Anthro 3283 Test 2 WashU

Fadiman on Lia

""I do not know if Lia would be able to walk and talk today had she been treated by Arthur Kleinman instead of by Neil Ernst and Peggy Philip. However, I have come to believe that her life was not ruined by septic shock or noncompliant parents but by cross-cultural misunderstanding" Understanding the culture differences could have shaped the treatment, could have been a more collaborative approach to her illness.

Cultural Clarifiers

"Culture, in these cases, was identified as strange and unfamiliar, as that which was decidedly not normal." • What should they do? • "Identifies the patient's difference itself as a problem that is ultimately behind health disparities. It places part of the blame for health disparities on the patient's culture and implies that if only 'they'...acted more like 'us', inequalities would disappear" (175) "The recognition of cultural difference, then, is not designed to challenge the culture of biomedicine or the social norms that have produced it, but to overcome the obstacles created by the patient's culture. " Localizing difference between people and compliance, did not get to the core of what really mattered, power relationship of biomedical encounter Differences in power exacerbated the relationship between patient and provider

Saran Wrap

"It felt as if there was this layer of Saran Wrap or something between us, and they were on one side of it and we were on the other side of it. And we were reaching and reaching and we could kind of get into their area, but we couldn't touch them. So we couldn't really accomplish what we were trying to do, which was to take care of Lia." - Neil, one of Lia's physicians Physicians wanted Lia to live a life free of seizures The idea that the parents wouldn't comply caused a clash of culture and a clash in understanding the illness overall.

Fadimans statement

"It was also true that if the Lees were still in Laos, Lia would probably have died before she was out of her infancy, from a prolonged bout of untreated status epilepticus. American medicine had both preserved her life and compromised it. I was unsure what had hurt her family more."

Arthur Kleinman's statements

"Looking back over a career of forty years of publishing on how medical education and clinical practice can improve the quality of care by attending more closely to experiences of illness and caregiving, I am ambivalent now about the application of ideas long associated with me concerning suffering and caregiving as cultural practices. In the early 1970s, at a time of rapid growth of high technology, reductionism, and bureaucracy in medicine, there was rising anxiety that clinicians were failing to treat their patients as individuals who possessed a richly human background and social context for their lives and disorders." But by the 1990s, I had become increasingly uncomfortable with the way the illness/disease distinction was being used. Eliciting the explanatory model, I came sadly to realize, had often become a conversation stopper in a consultation, a mechanical task that assumed that dynamic meanings could be fixed as a single, unchanging, material thing in the patient's record. On clinical rounds which I conducted with medical residents at Harvard hospitals, and in many other teaching hospitals, trainees presented cases in which the explanatory model took on the status of the CBC and electrolytes, as if it were also a material substance. What was meant to humanize care by providing greater space for lay voices and practices appeared to be doing just the opposite. It unintentionally reduced complex, vivid lives into limiting and biased cognitive stereotypes."

Nancy Scheper-Hughes, Death Without Weeping, 196,

"Modern medicine has transformative qualities as doctors, nurses, pharmacists, and other health professionals contribute to the process whereby more and more forms of human discontent are filtered through ever expanding categories of sickness, which are then treated, if not "cured," pharmaceutically...Medicine is, among other things, a technical practice for "rationalizing" human misery and for containing it to safe quarters, keeping it "in its place," and so cutting off its potential for generating an active critique

Jose Muñoz, Cruising Utopia

"Queerness is that thing that lets us feel that this world isn't enough."

--Gayle Rubin, "Thinking Sex," (NINETEEN EIGHTY-FOUR)

"Right-wing opposition to sex education, homosexuality, pornography, abortion, and pre-marital sex moved from the extreme fringes to the political centre stage after 1977, when rightwing strategists and fundamentalist religious crusaders discovered that these issues had mass appeal. Sexual reaction played a significant role in the right's electoral success in 1980. Organizations like the Moral Majority and Citizens for Decency have acquired mass followings, immense financial resources, and unanticipated clout. The Equal Rights Amendment has been defeated, legislation has been passed that mandates new restrictions on abortion, and funding for programs like Planned Parenthood and sex education has been slashed. Laws and regulations making it more difficult for teenage girls to obtain contraceptives or abortions have been promulgated."

Bernadette as a Young Woman

"She'd cry for her medicina. That's what she called it . . . It's not that I didn't know any different [the difference between drugs and "legitimate" medicine]. It's that I wanted her to feel better. That's all that mattered. And I was afraid she was going to die. I was afraid, and the only thing you feel like you can do is help get them high." • Desire to help ease her mother's pain she began scoring • "[t]hey shared it, "hustled" for money or drugs when the other was in need, and took care of each other when one was feeling ill.

Mortal Danger

"The border environment is diverse. Mountains, deserts, lakes, rivers and valleys form natural barriers to passage. Temperatures ranging from sub-zero along the northern border to the searing heat of the southern border efect [sic] illegal entry trafc as well as enforcement eforts. Illegal entrants crossing through remote, uninhabited expanses of land and sea along the border can fnd themselves in mortal danger"

Garcia pg 128

"The dependencies produced through heroin became a part of the relational mix that is kinship, and the circulation of heroin became the substance through which care was performed and through which affective ties between Eugenia and Bernadette were reaffirmed. But they were reaffirmed at the cost of further fragmentation, and perhaps even further subjections."

Rubin: Sexual Essentialism

"The idea that sex is a natural force that exists prior to social life and shapes institutions...eternally unchanging, asocial, and transhistorical." • Explosion of works that show how preoccupation with regulated and policing things like homosexuality and prostitution are incredibly new; even our rigid understanding of "heterosexuality" is pretty new

Enumeration & Categories (Ian Hacking)

"The subversive effect of this transition was to create new categories into which people had to fall, and so to create and to render rigid new conceptualizations of the human being." • Statistical enthusiasm 1820s-1840s • Statistics a moral science Sexuality was the nexus at which populations reproduce and became the key to understanding population

The Pastoral Clinic: Addiction and Dispossession along the Rio Grande

"This book starts from the idea that this particular geography of addiction encloses multiple forms of spatial and existential ruin, sedimented and entangled through time." (7)q

Jenk's view on structural and social conditions that produce health inequalities.

"This use of culture not only blames inequality on those who differ from the norm, but runs the risk of naturalizing and reinforcing the social order, making disparities seem inevitable and masking the conditions that produce them" We are not getting to the disparities overall

Garcia

"Thus while relapse is understandable and even expected (at least from the medical point of view), the relapsed addict is ultimately assigned blame for the relapse and is therefore seen lacking the will to recover."

Ethics of Writing & Representation

"What does it mean to write a "maternal genealogy" of drug addiction where, in both cases, there is a kind of sacrifice of the daughter? • How can a feminist ethics and politics respond to the figure of the sacrificed daughter? • What does the incarceration of Bernadette and the death of Michelle signal in terms of the gendered politics of blame and shame in the context of drug addiction? • And what is my role, as an anthropologist, in drawing these out?

Angela Jenks, "What's the Use of Culture?"

"What is the culture that cultural competency refers to, and how does it intersect with other understandings of difference, including race, ethnicity, and nationality? (and religion). What are the implications of identifying culture as both a problem behind, and solution to, health disparities?" What happens when culture includes markers of difference. Patients' culture sometimes becomes an obstacle to health care

US Post-WWII War Anxieties: the Sexual Menace

'Homosexual menace' and 'sex offender' conflated in law and policing (i.e., conflating sexual assault and consensual sodomy; both were illegal) • Homosexuals are communists! Non- familial sex = communism + political weakness • Objects of federal witch hunts and purges (e.g., root out homosexuals working for the government) • Even in queer meccas - New York and San Francisco - police raids, street sweeps, etc. • And not just "homosexuals" - prostitution and obscenity, etc. • Protect our children from queers!!!!

Michel Foucault (1926-1984)

- created problematization -simultaneous naming of problem (often official) and in naming a problem there is a process of defining the problem and what it means and how to address problem -just b/c named AIDs a problem doesn't mean successfully addressed -same with guns - can name but don't necessarily address it -king james= tobacco problem, should be prohibited (now he's problematizing it) -we all agree it's a problem, it's how you problematize it Power was based on knowledge, and knowledge is produced through iterations of power. • One of the most influential (continental) philosophers ever • Was particularly concerned with the "power/knowledge" • Particularly focused on the modern history of France, understanding the ruptures that characterize "modernity" • Ideas shaped the humanities and social sciences more than probably any other thinker in the past century How shape and contour of knowledge shifted, intellectual history, and what changed

Cultural Competence Model

1) Cultural awareness "My centred analysis" "Other-centred analysis" cultural knowledge, cultural sensitivity, cultural competence

Why Syndemics Emerge

1. Changing political and economic conditions 2. Shifting ecological and environmental conditions 3. Altering demographics and changing social behavior 4. Expanding patterns of globalisations 5. Ongoing microbial adaptation 6. Breakdown of public health protective services 7. Increasing access to technology

The Regan Era

1982: federal support for low-income housing all but ceased • Decreased funding for public health issues, like TB, STIs, and mental health • Community Development Block Grant program - to support low- income communities - slashed by a third from $6.1B to $2.8B • Generous tax cuts for the wealthy and increase in military spending cut overall federal resources for health

Rural / Addiction

1990s, Española Valley "ground zero" of heroin trafficking and addiction • Many studies of addiction occur in urban spaces, particularly major US cities • Garcia studying addiction at a time when drug use had been steadily increasing across the US • "Rural ghetto" • Meth labs in unlikely places - farmhouses, chicken coops (think: Breaking Bad) • And unlikely addicts - retired farmers to Evangelical teens • Studies link to -- ease in manufacturing substances; open space • But Garcia asks: why is there are there wide open spaces? • Economic conditions, poverty, intimate violence

The cost of the syndemic of TB, HIV, and homicide among low-income New Yorkers during this time was

54,700,000,000 to $166,000,000,000 vs. $9,900,000,000 in budget cuts does not do justice to how much it costs to treat people

The Melancholic Subject

A move away from seeing melancholia as purely pathological • Especially in queer theory • Garcia wants to see Alma as a melancholic subject in relation to her (and her community's) history of dispossession - their LOSS • Of which, addiction is the contemporary manifestation - a manifestation that addicts themselves come to understand as "endless," much like the process of melancholia

Refugee

A person who has been forced to leave their country in order to escape war, persecution, or natural disaster Moral boundary placed between types of migrants, particularly who is deserving of unquestioned support from the international community in terms of economic, social, and health aid • Refugee: legitimacy; ability to make claims on states for rights and services • States become "responsible" • Codifed in the 1951 UN Convention on the Status of Refugees • However, is still depending on a judgment about the situation of a particular country, not outside of interest, power, and geopolitical confgurations, particularly of the host country

The Turn Towards Care

A series of important works started emerging in the mid- 2000s, focusing specifically on the moral (value-based) aspects of caring and caregiving • But this was not a turn away from the structural - ethnographies of care grappled heavily with questions of power, economy, kinship, politics, and violence • Someone who we've talked about at length thus far this semester was particularly important in cementing this new object of study

Cultural Iatrogenesis

A situation in which the knowledge and abilities of health professionals have become so mythologized that individuals lose the capacity to heal themselves. The "ultimate evil of medical progress" • Suffering, loss, uncertainty, pain, death are all healthy facets of life • Cultural iatrogenesis refers to when otherwise healthy non-medical practices, mechanisms, practices for these normal aspects of life a broken down • Culture is over-medicalized and centuries of practices to deal with them are pathologized and represented as in need of medicine

Making Up People

A term coined by Hacking which refers to the ways in which scientific classification may bring into being a new kind of person, conceives of and experienced as a way to be a person. We create kinds of people that did not exist beforehand. The poor • The criminal • The mad • "Does there exist, in our day, a greater number of mad people than 40 years ago?" • Better institutions and better diagnoses? • For Hacking: the avalanche of printed numbers Need category of people, have to decide what counts, mad / healthy Start understanding themselves as fundamentally specific, experiencing themselves and changes how they understand themselves in the world • "Disease, madness, and the state of the threatening underworld, les misèrables, created a morbid and fearful fascination for numbers upon which the bureaucracies fed. Insttituionalize / diagnose people based on categories

HIV

A virus that attacks and destroys the human immune system. Most trace emergence of HIV in NYC to the 1970s - MSM and injection drug users • AIDS cases in particular peaked in 1993 and then declined with the availability of ARVs • By late 1980s, ~200,000 NYC residents living with HIV • Important: during this time 41% of NYC AIDS cases were related to injection drug use (vs. 25% nationally) • This makes the cutting of addiction services even more severe for the epidemic • Increase in crack use at this time as well; methadone ineffective for treatment - but a little irrelevant given how much those programs were cut • Also blanket layoff of health educators; cuts in school health services; lack of comprehensive primary care

Multiaxal Models of Suffering

A way of understanding structural violence and its contribution to human suffering 1. Geographically broad 2. Historically deep • Gender, race, and socioeconomic status have limited explanatory power on their own, but must be considered simultaneously • (One may think: hmmm...pretty sure Kimberlé Crenshaw - who coined the term intersectionality - said that in 1989) undertsand history in a complex deep way and understand power dynamics

Rubin: Sexual Value System

According to this system, sexuality that is 'good', 'normal', and 'natural' should ideally be heterosexual, marital, monogamous, reproductive, and non-commercial. It should be coupled, relational, within the same generation, and occur at home. It should not involve pornography, fetish objects, sex toys of any sort, or roles other than male and female. Any sex that violates these rules is 'bad', 'abnormal', or 'unnatural'. Bad sex may be homosexual, unmarried, promiscuous, non-procreative, or commercial. It may be masturbatory or take place at orgies, may be casual, may cross generational lines, and may take place in 'public', or at least in the bushes or the baths. It may involve the use of pornography, fetish objects, sex toys, or unusual roles

Acéphie Joseph

Acéphie Joseph was twenty-six when she died of AIDS in Haiti. She acquired the disease in a brief sexual relationship with a soldier when she was nineteen. She couldn't afford medications or treatment for her disease and left an infant daughter, also infected. Shortly after she died, her father hanged himself. From one point of view, Acéphie died because of "fate" and poor personal choices. Farmer suggests, however, that any analysis of Acéphie Joseph's story must be historically deep and geographically broad. One beginning point might be 1956 when Acéphie's family was forced out of their ancestral home and farmland in a fertile valley because the regime, in cooperation with international aid groups, built a dam that flooded the valley. Uncompensated for their loss, the Josephs were forced onto barren land and into penury. At age 19—about the time for her to bring in income for the family—Acéphie was courted by a soldier. Although her family knew the soldier was already married, he was one of the few men in the area with a steady income. Acéphie felt she had no other choice, no other chance to rise out of poverty. The relationship was brief because the soldier became ill shortly thereafter and died. Acéphie hadn't known he was HIV-positive, but she was already infected. There was no effective medical treatment during the late 1980s, but she wouldn't have been able to afford it anyway. Or the story could begin in 1804, when Haiti was established as the world's first black republic and the United States boycotted it for fifty years and then supported various military dictators who over the years left the country impoverished. Or the story could begin in Africa when Acéphie's ancestors were rounded up and sold into slavery. We will not understand the death of Acéphie Joseph without understanding the wider context, including the active involvement of the United States and other Northern nations in impoverishing her country over two centuries.

Back to Foucault

Against the repressive hypothesis: "natural libido yearning to break free of social constraint" • Not about uniform, pre-existing biology, but are constituted in particular socio-political contexts - new sexualities are constantly produced • Does not mean that biology has nothing to do with sexuality, it simply means that sexuality cannot be reduced to pure biology • But also note: what is considered NORMAL is usually that which is see Chasing careers that make us work hard

Garcias analysis

Alma's and Joseph's commitment to the past and to certain losses, in particular, has not precluded them from living in the present. It is through the experience of melancholy that Alma and Joseph are, in my view, living a moral life—that is, a locally and interpersonally engaged life, however precarious these engagements may be. I would add that seeing and experiencing the world and the past as painful—and to not appropriate, forget, or sublimate this pain for other purposes—is likewise a way of living in the world. In other words, there is meaning in melancholia, meaning in wounds that haven't healed, perhaps may never heal. (108)

Tuberculosis

An infectious disease that may affect almost all tissues of the body, especially the lungs Between 1978-1992, TB rates increased EVERY YEAR • This is after almost a yearly decline for about a century • 52,000 excess TB cases • During the financial crisis, the DOH cut its TB control program • In 1988, 89% of of patients discharged from Harlem Hospital - with the highest TB rates it the city - were lost to follow-up • Increase in multi-drug resistant TB as well • Reduction in public assistance, Medicaid • From 1982 to 1992, the city's homeless population grew from 7,584 to 23,494; many people ended up in shelters or were criminalized and put in jail

The Spirit Catches You and You Fall Down

Anne Fadiman (1997) 150,000 Hmong fled Laos since 1975 (in 1996) • Lia born at the Merced Community Center, 1982 • Taking placenta home • Reading/signing discharge • Quag dag peg - the spirit catches you and you fall down (believed that a spirit caused her to convulse) • Three months old • Older sister slammed door in front of her • Eyes rolled up, arms jerked over her head, and she fainted • Txiv neeb - mixture of concern and pride Social worker of Lia's family: "They felt Lia was kind of an anointed one, like a member of royalty. She was a very special person in their culture because she had these spirits in her and she might grow up to be a shaman, and so sometimes their thinking was that this was not so much a medical problem as it was a blessing" --> the seizures served as a mixed connotation. - Jeanine Hilt, social worker Of the other ~40 American medical professionals, Hilt was the only one who asked what they thought caused Lia's illness During the next few months of her life, Lia had ~20 seizures • Were skeptical of American biomedicine, but had an experience with one of their sons in which biomedicine helped • This is not lead them to abandon Hmong cultural practices and understandings of the cause of illness • But rather it was thought to complement their own customs and understandings • So they took her to the hospital in Merced • No set hospital budget for interpreters; instead hired a variety of Hmong medical professionals in the hope they could translate in addition to doing their main job

Suffering: Explaining v. Making Sense

Are these stories of suffering emblematic of something other than two tragic and premature deaths?" • Many ways in which we "make sense" of suffering through narrative - films, novels, poems; a "universal" activity in Farmer's terms • A different thing to "explain" suffering: "one must embed individual biography in the larger matrix of culture, history, and political economy"

Handmaiden to Biomedicine?

At the same time, others were developing models for similar questions • In a searing critique of Kleinman, anthropologist Nancy Scheper- Hughes argued for a "critically" applied medical anthropology • "must be an anthropology of affliction...praxis must not be left in the hands of those who would only represent the best interests of biomedical hegemony." If anthropology is making anthropologists becoming cultural broker, there are tools are used to reinforce and legitimize biomedicine overall rather than taking a step back or understanding power relations in biomedicine. It instead impels biomedicine as a hegemony. • Question of the "double agent"

Experiments With Care

Back to neoliberal model • "What to do in the absence of care as it is construed in the traditional sense—that is, the care of a doctor or of a parent?" • "But the exclusion of the poor from the forms of care that only the rich, or the richer, have at their disposal does not eliminate the possibilities of care altogether." • Adela; Pauline and Michael; Bernadette and Eugenia • The Q&A, the response

National CLAS Standards

Became increasingly Institutionalized • March 2005, the governor of New Jersey signed a bill that requires physicians to receive cultural competency training • Have physicians learn about minority groups and their circumstances • Increase awareness of cultural beliefs that may influence care • Emerging field - differences around best practices; lack of evidence about effectiveness of certain cultural competency models Very indeterminate field, hard to define what culture is Empathy modules

Syndemics Case 1: NYC, 1975 (Freudenberg et al. 2006

Beginning in 1975, New York City had a political and fiscal crisis • Without resources to pay its operating expenses; borrow money; pay its operating expenses • Hmmmm. 1975. I know about another fiscal crisis then! • Same one: worldwide recession due to the oil crisis & geopolitical situation in the Middle East • This was compounded with city fiscal and tax policies that could not meet the growing need • Demographic shifts: less money, more people in need of social services robust system of health services at a particular time, growing need and reliance of robust network for social services, but no money to put into them For the city not to go bankrupt, asked other cities to send bankers, went to President Ford, (adamant and said no)

Endless

Being pushed into remembering she is at perpetual risk • Endlessness, hopelessness, depression • Does a model that wanted to destigmatize addiction actually propel addictive experience forward? • If what I have is without end, what is the point of attempting recovery, I will always be this way, I will always feel this pain, I will always need escape

Ethnocentrism

Belief in the superiority of one's nation or ethnic group, their form of life is the best way, and judging others and saying others are inferior for not following a particular way of life. Boas and his students would be harsh critics of ethnocentrism • Ethnocentrism occurs when one thinks the beliefs, language, practices, etc. of one's own culture are the natural, absolute, or ultimate forms • Other cultures are seen as inferior in relation to this standard, and the "superior culture" is forced on others • In medical anthropology, the most obvious form of ethnocentrism we will encounter is the idea that Western biomedicine is the only proper way to treat all illnesses and diseases One idealogical framework shouldnt be imposed on others With regards to medical anthropology, biomedicine becomes ethnocentric.

Garcia, The Pastoral Clinic Part II

Bernadette and Eugenia • Ethics of kinship based on intergenerational heroin use • Jennifer: heroin wounds "sustain her connections to the family members she has loved—and lost—to heroin overdose" • Disrupt popular representations of addictive experience cutting people off from important social and kinship ties • Garcia shows "how heroin works through, and provides endurance for, ties of blood and property, of inheritance" (114). • How intergenerational heroin use is a "life-affirming project" but also results in "injury, loss, and even death."

Not-So-Secret Weapon

Between 2000-2013, ~11.7 million people were apprehended trying to cross the border to US via Mexico • ~5.3 million people arrested - New Mexico to Yuma Sector, including Yuma County Line • "This terrain is that federal agency's not-so-secret weapon, and the migrant injuries and death toll provide evidence that it is a painfully efective one" (de Léon 2015: 21)

(Non)Compliance of the story

Between the ages of 18 months and 4.5 years, Lia was admitted to MCMC 17 times; more than a hundred emergency room visits • Various times over the course of this period, Lia's parents were directed to give her: Tylenol, Tegretol, Benadryl, Pedizole, Vi-Daylin Multi-vitams with Iron, Alupent, Depakene, and Valium • Parents noticed that various medications made Lia worse - began administering medication as they saw appropriate • Doctor's notes: "Are no longer giving Phenobarb because parents insist it causes diarrhea shortly after administration...Reluctant to give med but has been giving Phenobarb & Tegretol but refuses to give her Dilantin. State it changes "spirit" & makes face look different." • "Non-compliant mother, non-compliant mother, non-compliant mother Physicians found that the parents were not giving her the regiment of care, felt that the regiment was making her worse overall. Doctors used patients complaining about nasty side-effects • But by and large, there is trust in this normative physician-patient relationship that the doctor is right about why the person is sick and offers the treatment in good faith • Here, however, such a relationship couldn't be presumed • Lia's parents - and Fadiman generalizes this to the Hmong broadly do not hold biomedicine to be the be all and end all of illness explanation

Homicide

Between the late 1975 and 1993, homicides rate increased • Total of 26,980 homicide victims • NYPD cuts • Cuts in youth programing • Substances/crack cocaine increases

Agamben, Homo Sacer

Bios: biographical, feshy life; inclusion in social and political spheres (polis), fully biographical human, human experience • Zoe: bare life, purely biological life; excluded from social and political spheres/polis • in many cases, the object of humanitarian aid • Polis marks the boundary between human/non-human

Boas and Anti-Racism

Boas argued that the sweeping generalizations by the evolutionists weren't scientifically valid • Said anthropological research was being distorted in the "cause of scientific racialism" • For Boas, "race involves the inheritance of similar physical variations by large groups of mankind" (anti racist turn in american anthropology) • For Boaz, race = inheritance of physical phenotype; culture = shared system of beliefs/practices that are different, not inferior There were practices of scientific racism (trying to prove scientifically that some people were innately inferior to others) ex: use of skulls to measure intelligence "Anthropology provides no scientific basis for discrimination against any people on the ground of racial inferiority, religious affiliation or linguistic heritage" (denouncing Nazism) Detach culture from race, and separate those completely Surface phenotypic characteristics have nothing to do with inferiority, instead we have to understand people's culture. No differential capacity in humans, they are formed in different environments and cultural particularities. Anti-racism was important.

Space of Exception

Border zones as a space of exception • "physical and political locations where an individual's rights and protections under law can be stripped away upon entrance" • "The Border Patrol will improve control of the border by implementing a strategy of 'prevention through deterrence.'" • Mention of the environment removed in later policy documents (i.e., 2012-2016 Border Strategic Plan) • Basically stationing border patrol guards and surveillance in easier-to-traverse areas, forcing migrants to travel through the most hazardous parts of the Sonoran desert • "Rather than shooting people as they jumped the fence, Prevention Through Deterrence set the stage for the desert to become the new "victimizer" of border transgressors."

Syrian Refugee Crisis (2015)

By September of 2015, more than 487,000 people arrived on various Mediterranean shores in Europe in that year alone • Many of them Syrians feeing their country's civil war (began in 2011) • ~429,000 Syrians applied for Europe later that year • With more than 1M more expected, European Commission called it the "largest global humanitarian crisis" • EU Policy: claim refugee status in country of arrival (probably Italy or Greece) - some of the poorest of EU members Refugees had to claim asylum in the first country they set foot on , and E.U. madea geopolitical cause to make this law. Ex. Italy and Greee - very poor economic infrastructure to take care of refugees,

Compliance

Can include activities like medical interpreters • Recruitment of minority medical professionals Biomedicine isn't enough to deal with health issues of minorities, cultural competency would respond to health disparities but was a difficult thing to do. • Implementation of diversity education • Creation of ethnically specialized clinics • The idea behind it: biomedicine is not up to caring for a diverse patient group - particularly visible minorities, women, LGBTQ, immigrants • Hope that such care might increase patient "compliance" for provider recommendations 1) Changing demographics 2) Health Disparities 3) Mandates and regulations (CLAS standards, Affordable Care Act, Act VI of the Civil Rights, Joint Commission) 4) Business imperative (increase patient compliance, reduce people who are not showing up for long term care)

Briggs and Martini-Briggs ("Preparing for a bacteriological invasion" MAIN ARUGMENT

Cholera, although it can kill an adult through dehydration in half a day, is easily treated. Yet in 1992-93, some five hundred people died from cholera in the Orinoco Delta of eastern Venezuela. In some communities, a third of the adults died in a single night, as anthropologist Charles Briggs and Clara Mantini-Briggs, a Venezuelan public health physician, reveal in their frontline report. Why, they ask in this moving and thought-provoking account, did so many die near the end of the twentieth century from a bacterial infection associated with the premodern past? It was evident that the number of deaths resulted not only from inadequacies in medical services but also from the failure of public health officials to inform residents that cholera was likely to arrive. Less evident were the ways that scientists, officials, and politicians connected representations of infectious diseases with images of social inequality. In Venezuela, cholera was racialized as officials used anthropological notions of "culture" in deflecting blame away from their institutions and onto the victims themselves. The disease, the space of the Orinoco Delta, and the "indigenous ethnic group" who suffered cholera all came to seem somehow synonymous. One of the major threats to people's health worldwide is this deadly cycle of passing the blame. Carefully documenting how stigma, stories, and statistics circulate across borders, this first-rate ethnography demonstrates that the process undermines all the efforts of physicians and public health officials and at the same time contributes catastrophically to epidemics not only of cholera but also of tuberculosis, malaria, AIDS, and other killers.

Chouchou Louis

Chouchou moves in with a pregnant woman named Chantal Brise. The election of a supposedly pro-democratic leader named Father Jean-Bertrard Aristide initially brought hope to poor Haitians, but sure enough the violent regime was quickly reinstated once again. A comment made by Chouchou regarding road conditions is misunderstood as an insult to the coup by a n out-of-uniform soldier on a truck en route to the town of Hinche. At the following checkpoint, Chouchou is seized and beaten. He is then held prisoner in the military barracks in Hinche for several days. Chouchou spent the remainder of his life living in fear of the coup and of a second arrest. His worst nightmare came true when he was visiting his sister. No reason was given for his arrest as he was tortured at the next military checkpoint by soldiers and the attaches. Chouchou is beaten beyond the point of recognition. His family was able to locate him and carry him back to Chantal, however it was too late to save him from his slow and painful death, which took three days. f bureaucrats and soldiers seemed to have unconstrained sway over the lives of the rural poor, the agency of Ac?phie and Chouchou was, correspondingly, curbed at every turn. These grim biographies suggest that the social and economic forces that have helped to shape the AIDS epidemic are, in every sense, the same forces that led to Chouchou's death and to the larger repression in which it was eclipsed. What is more, both were "at risk" of such a fate long before they met the soldiers who altered their destinies. They were both, from the outset, victims of structural violence. Acéphie Joseph's and Chouchou Louis's stories illustrate some of the mechanisms through which large-scale social forces crystallize into the sharp, hard surfaces of individual suffering. Such suffering is structured by historically given (and often eco nomically driven) processes and forces that conspire-whether through routine, ritual, or, as is more commonly the case, these a view from below hard surfaces- to constrain agency For many, life choices are structured by racism, sexism, political violence, and grinding poverty.

The Model of Chronicity

Chronic model of illness for addiction - once addicted, always addicted; there is no "true" recovery, regardless of how long one has been clean • Attempting to avoid overt moralism of addictive experience • Move away from stigmatizing and marginalizing drug users • Addiction Severity Index (ASI): the more frequent the condition, the higher the score - more eligible to receive treatment • Even with this reliance on "chronicity," drug recovery is still understood as a problem of personal choice or will • Twelve Steps: individual choice; personal power; capacity for reason; personal autonomy; responsibility for actions

Co- Infection

Concurrent infection a critical factor when weighing disease progression and treatment options variety of afflictions • For example, co-infection with HIV and TB is associated with faster disease progression, more intense symptoms, and higher viral/pathogenic loads than if one was infected with just one pathogen • HIV accelerates the transition from latent to active TB; TB increases the development of HIV infection • Treatment efficaciousness goes down and becomes more expensive

Culture is?

Cultural competency pocketbook - alphabetized list of different "cultural" groups and pertinent information regarding their "culture" • But culture so often is used as a politically- correct term for other ways of marking difference - like race, religion, and nationality • This sets up the assumption that people of the same race or religion necessarily share the same "cultural" beliefs • Example of a black South African physician being used as the racial concordance doctor for an American clinic's "black unit"; the assumption that two Muslim women necessarily share all of the same views about piety, practice, worldview • Walking a line between essentializing culture and providing "useful" information

Cartesian Dualism

Descartes's view that all of reality could ultimately be reduced to mind and matter. A legacy of Descartes' philosophy - one that continues to be a mainstay of clinical biomedicine - is the rigid separation of mind and body • The body is a "material" substance, palpable, real, natural, organic - it is the body and its breakdown/damage that is in the domain of science • The mind is an intangible substance, elusive, inorganic - the mind holds the realm of the unreal/unknowable, separate from the workings of the organic body • Body can be "seen," "known" • Is "it" in the body or is "it" in the mind? Divides real body from unreal mind, places pathology and deviations from normalcy in body into physical body, as if the mind is disconnected.

Geyla Frank, "On Embodiment"

Diane DeVries, born in 1950 congenital amputee • Underwent numerous surgeries during childhood • Stopped wearing prosthetics during puberty • After lived an independent life • Religious practice, accident, marital difficulties, at the time of the article, a counselor at a transitional living facility

Back to Techniques of the Body

Diane's desire for freedom in her body was paradoxical to those around her - prostheses would both make her "look" more normal and make it easier to do everyday bodily practices • However, the prostheses were suffocating to her sense of freedom • She learned an array of bodily techniques to live without prostheses, inhabiting her body more freely in her experience • "And then it gets to be very natural, if you can do it good."

Cultural Difference

Differences between human communities are culturally and not biologically patterned Back to the problem of culture • Confuse structural violence with cultural difference • "In their culture, in their nature" • Culture of violence; culture of poverty fallacies • Rubric of "cultural difference" essentializes and individualizes structural and historical conditions chidren forced into culture of poverty, cannot exit from culture keeps people in cycle

How Categories Fail, in Life and Public Health

Epidemiologists measuring MSM HIV prevalence: • cross-dressers (34.4%) • travesti • homosexuals (11.7%) • gigolos (6.5%) • sanky panky • bisexuals (6.1%) • heterosexuals (8.2%) • HALF of all MSM self-identified as heterosexual • Sex with women was uniform across all groups - the last three groups, all participants; for homosexuals, 55.8%; and cross-dressers, 31.3% • Rate of condom-use significantly lower with women than men: stigma; norms about masculinity; fear

--Alma

Es que lo que tengo no termina [It's just that what I have has no end]." Pain and desire to escape (monochronicity) pastoral collides with chronicity and pushes subjectivity on people and forces endless reflection on a loss

The Promise

Eugenia's trailer raid - 3oz black tar heroin, $5000 + drug paraphernalia • Bernadette present (harsher sentence); Eugenia not • The "commitment she and her mother forged long ago—a commitment to ease each other's pains...produced by and treated with heroin" • Responsibility, care • But also, in caring for her mother it was clear that Bernadette's relationship with her own children was threatened

Clips from "The Affair"

Exact same scenes from different perspectives Memory of people at the exact same space and time, have radically different experience of each other.

Tierra Amarilla: Yellow Earth

First settled as a land grant in mid- 1600s • Spanish and later Mexican settlers were allotted land for a home; plot for farming; share common land for pasture, timber, hunting • Individual land private property; collective land commons • New Mexico became part of the US in 1848, widespread dispossession • Treaty of Guadalupe - supposed to protect titles secured before the war • Heirs of Tierra Amarilla lost over half a million acres

The Crisis was the Treatment

For Lia's parents, the treatment was causing more harm than the actual seizures • For Lia's physicians, the seizures were the crisis • Impasse in how both were understanding the situation • Physicians used to having the power - status, education, etc. - in such patient relationships; many Westerners almost childlike in relation to the physician • Lia's parents saw biomedicine as a culture, one of the many ways to understand and treat • Resulted in state removal of Lia from her parents' care

DISCIPLINE - ANATOMO-POLITICS

Foucault argues that biopower can be split (make live or let die) • Techniques for control over *individual bodies*, discipline body • Aims for docility • Examples: educational institutions, military, factory work, prison, etc. • Cultivation of specific human capacities exercised over individual bodies • Standardization / examination

Health Realities for Undocumented Immigrants in France

France, 1998 "Illness clause" -"Conditions of Entry and Residence of Foreigners" • Grants legal residency for immigrants in France if they have illnesses of life- threatening potential, and would probably be denied adequate care in their home country; MSF highly infuential in getting it passed • In conducting an ethnography of immigrants in France (sans papiers) Miriam Ticktin saw many migrants turn toward physical injury and purposeful infection • Immigrant rights worker at HIV/AIDS workshop: "Isn't it terrible? We almost wish for illness when we talk to sans papier."

The Real Cause (the relationship between mind and body? what does it mean to inhabit a body? How do we individually experience the world and ourselves? How does our lived experience, in our bodily forms, profoundly influence how we understand the world?)

From "The Mindful Body: A Prolegomena to Future Work in Medical Anthropology (1987)", Nancy Scheper-Hughes and Margaret Lock: • Grand rounds • Middle-age woman suffering from chronic and debilitating headaches • Husband an alcoholic, physically abusive; virtually housebound for the past 5 years looking after her senile and incontinent mother-in-law; constantly worried about her son, who is failing high school • Growing restless with the line of clinical questioning, one of the students interrupted the professor: • "But what is the real cause of the headaches?"

The Axis of Gender

Gender inequality • Sexism • Sexual assault • Maternal morality • All intersecting especially with socioeconomic status - what Farmer refers to as "poor" or "poverty" throughout

Georgia O'Keeffe, "Black Mesa Landscape, New Mexico / Out Back of Marie's II," (1930)

Georgia O'Keeffe created serene works to reflect the world around her. Close-up flowers, a signature motif, are so magnified that the petals and blooms become abstracted into sweeping shapes and swaths of color. A celebrated icon herself, O'Keeffe carved out her own style apart from the chaotic modern art scene of the time and paved the way for many women artists to come.

Syrian Refugees in Germany

Germany responded with "ambivalent hospitality" (Holmes and Castañada 2016) • Germany's history • By October of 2015, Germany had admitted more refugees in than any other country in Europe • Syrian family deserving because they were forced to flee civil war • Regardless, still face anti- immigrant and anti-Islam rhetoric in Germany

Why Care?

Given our emphasis on structural, social, political, and historical understandings of health and illness, you may ask: why care? • Care emerged as a critical site of inquiry for anthropologists and sociologists in the late 90s and early 2000s • What does care offer - as an object of study, as a practice, even as an ethics

What Happened to Lia

Had a massive seizure that left her in a permanent coma, until she died in 2012 • Had nothing to do with parents' non- compliance of medications; like Lia's parents thought, the medications potentially made it worse • The medication Depakene weakened her immune system, making it harder for her body to fight the sepsis • Lia's brain was destroyed by septic shock • Septic shock caused the seizures

Kleinman on Caregiving as Moral Experience

Has written for about 15 years his journey in care with his wife Joan, who lived with dementia for the last 10 years of her life • Kleinman documented the daily struggles and PRACTICES of caregiving • Argued that caring is a fundamentally moral act - that is, it is at the intersection of values (what really matters) and emotion -- and is expressed through practice

Winthrop Cohen

Hero of World War II in the Pacific, who came to you in his 60s, some years ago, and was depressed. But didn't you, when you looked over your notes more recently, conclude that by calling him depressed you were missing something essential? KLEINMAN: I missed the moral statement. Here was a decorated solder, who had, in his own words, been turned into a killer, committing several atrocities. The worst was that he'd killed an unarmed Japanese doctor who had been treating Japanese wounded. Think of how hard it is for a guy who's been treated as a hero to say, ''I killed a doctor up close, who looked in my eyes, and made me feel I was a real killer.'' There are some things you can't say. The rest of his life was an encounter with that atrocity, a constant attempt to deal with it, and finally, a kind of giving up. That produced a very severe clinical depression. But the clinical depression was in the context of the tragedy. And maybe the illness, the fact that he really did become depressed, allowed him to speak.

Displacement & Decline

Housing costs soaring • Gentrification • Suburbanization/white flight • Freeze on public assistance, affecting nearly $1M dependent on welfare • 1970-76: NYC lost just under half a million manufacturing jobs; EFBC layoffs eliminated 1 in 5 city jobs

- Miriam Ticktin,"Where Ethics and Politics Meet

How does the French state reconcile the denial of papers to immigrants who are perceived to be economically burdensome with the decision to give papers and social services to immigrants who are sick? Stated otherwise, why is it that illness is allowed to travel across borders, whereas poverty cannot?"

Returning to Death Without Weeping

Hunger and thirst are mindful and embodied states, as they come trailing their own metaphorical meanings and symbolic associations." • For Scheper-Hughes, you can't separate mind & body in this dualistic way • Both are in constant relation • Today we will focus on two theories of embodiment: • Practice/Technique • Phenomenology Focusing on whats real and whats unreal

Nervoso

Idiom of distress" • "As for me, I'm always sick; I have weak nerves." • Trembling, chills, fainting, shaking, sleeplessness, weakness, irritability, • Anger nerves, fear nerves, worrier's nerves, falling down nerves, overwork nerves, sufferers' nerves • How to treat nerves? • Medication: tonics, nerve pills, tranquilizers, sleeping pill People had to pay for medical care, use little resources they have to treat nerves This was a massive conundrum, no connection

Anti-Psychiatry Movement (1960s—70s)

Increasingly illuminating the abuses of the mentally ill in psychiatric institutions • Not all mental illnesses are a medical condition; a response to the stresses and strains of modern life Restructure of mental health in the world, rollback of government healthcare, • E.g., Homosexuality a DSM diagnosis until 1974, when it was renamed "sexual orientation disturbance," removed in 1986 • Argued for de-institutionalization of the mentally ill; re-integration back into the community • But also came at a time of an increase in neoliberal economic policies - less publicly funded health services available for those in the "community" No longer a concentration of power in institutions • Enter the problem of community mental health care, responsibilization, intersection of county jails + mental health care.

Techniques of the Body: Ensemble

Instrument for Mauss • Or natural technical object • But before there is "instrumental techniques"—that is, skillful/efficient ways of carrying out an action—there is "the ensemble of the techniques of the body" (76). • "The constant adaptation to a physical, mechanical, or chemical aim (e.g., when we drink) is pursued by a series of assembled actions, and assembled for the individual not by himself alone but by all his education, by the whole society to which he belongs, in the place he occupies in it" (76) Ways we use our bodies are extremely amazing.

Disease and Illness

Kleinman argued there was a difference between illness and disease • Illness: "refers to how the sick person and the members of the family or wider social network perceive, live with, and respond to symptoms and disability. Illness is the lived experience" of bodily distress (how they feel, emic) • Disease: "is the problem from the from the practitioner's perspective. In the narrow biological terms of the biomedical model, this means disease is reconfigured only as an alteration in biological structure or functioning" (etic) Cross-cultural collision happen in medical practice because people believe illness and disease are the same thing.w

Biological Life

Life that separates the living from the nonliving (e.g., that separates plants from rocks). Life in this sense is not uniquely human but is that which we share with all other living things. Resolute focus on "biological life" and only "biological life" - or, in Agamben's terms, bare life; sometimes referred to as "the politics of life itself." • Biological life - physical, organic body - is seen as "apolitical" • Illness Clause does not immediately include work permit • Disqualifies them from participation of social, economic, and political life • But grants them residence based on the fact of their biological life being at stake

What do the CLAS standards look like? (LEARN)

Listen with sympathy and understanding to the patient's perception of the problem Explain your perceptions of the problem and your strategy for treatment. Acknowledge and discuss the differences and similarities between these perceptions. Recommend treatment while remembering the patient's cultural parameters. Negotiate an agreement. It is important to understand the patient's explanatory model so that medical treatment fits in their cultural framework. Institutionalizing these process in biomedical sphere, challenges include power dynamics, theoretical models vs. actual practise, principles become harder to actually practise.

The Pastoral (Aesthetic)

Literary and artistic style attentive to landscape • New Mexico a kind of pastoral ideal, without people • Williams, The Country and the City, critique • Experience of dispossession "covered over" by the New Mexico pastoral landscape • Spatial language for deep-rooted and complex nature of addiction Intracices of rural health get left out - difficult to do so without subsistence and farming, erases the experience of what actual rural farming looks like

Habitus (Mauss)

Long tradition of thinking about Habitus: most notably Aristotle and Bourdieu • Taken-for-granted practices & dispositions we employ and refine everyday • Mauss: "these 'habits' do not just vary with individuals and their imitations, they vary especially between societies, educations, properties and fashions, presitges" (73). • We should not just characterize this as a route repetition of a given task, but as techniques—that is, "the techniques and work of collective and individual practical reason" (73) How we learn to use our bodies are determined by education and formation and things that we learn Mauss argued that the ways in which we cultivate our bodily dispositions allow us to technically carry out particular things

The Paradox of Health / "Care"

Lots of people interested in healthcare • But where is the care in contemporary health practice? • Even in elite settings, the practice of caring - of being "with" someone - is not a mainstay of medical education • Physician's are not evaluated in how effectively they care for their patients' illnesses, they are evaluated on how efficient they are at treating their diseases • The internal paradox of health/care much more about health (defined biologically) than it is about care

Rubin: Sex Negativity

Many in the West consider sex to be dangerous, destructive, negative • Unless it is done in a particular context - i.e., marriage or long-term partnership • Especially okay if done in both marriage and solely for the purposes of PROCREATION • Sex is distilled down to its utility in reproduction • That is, sex's "natural" purpose • Obviously, the fact of queer bodies totally disrupts that • But also notice that as same-sex couples become accepted and are considered "normal," they are more often to be considered "normal" and "good" in a coupled, normative, relationship that mirrors a heterosexual couple • Queer people on the fringe of this normativity of the couple form, or have different gendered and bodied expressions, or are non-monogamous, experimental, etc. are judged differently

Rebellion

Many rebellions in relation to dispossession • One of the most famous, Reies Lopez Tijerina • + armed insurgents stormed local courthouse - a symbol • The Courthouse Raid prompted the governor to call the National Guard, send tanks, small aircraft • Largely depicted as "anarchy" rather than a social justice issue • Importantly, this isn't just Garcia "explaining" historical and structural conditions - talking about dispossession is woven into everyday narrative and materiality life for many Hispano

What does all this have to do with global health?

Mark Padilla, "Limits"

Economic Necessity, Sexual Identity, and Stigma Management

Martín: "I've gone for about 10 or 12 years without work. So, you know, here in the Dominican Republic things are really hard, so since there are some opportunities with some guys who come from abroad, and they offer you money or something to be with them, you grab it, you understand? It's the easiest way to get money. That's what's going on." • Orlando: "Well, sometimes I even have to tell them [regular clients] that I have an uncle that's been feeling bad, that I have to go for a week to the country, but it's a lie because it's to be with my girlfriend. And sometimes I tell my girlfriends that I—I have a job, that I'm painting a house really far away and that I won't be back until really late, so I won't be able to go by their house, but it's a lie, since that's when I'm with my friends, right?

Technique, Instrument, Tradition

Mauss: "I made...the fundamental mistake of thinking that there is technique only when there is an instrument" (75). • Definition of technique: "an action which is effective and traditional" • No technique and no transmission of technique without tradition • Mauss argues that this separates humans from non-human animals: "the transmission of his techniques and very possibly their oral transmission" (75) ex: 3 ways of performing a dance move, based on where they were trained. Our bodily movements being corrected are destabilizing

Not Just About Infectious Disease

Mental health issues - depression, stress, anxiety, etc. • Chronic conditions like diabetes • As well as intimate partner violence, substance use, etc. • Can interact with other forms of marginality than just socio- economic status as we've discussion - citizenship, race, gender, sexuality, among others (interestingly: all keywords for this class)

HIV in the DR

Mid-1980s, found that tourists were the most likely cause of transmission to Dominicans • Men who consider themselves heterosexual who engage in sex-for- money transactions at the highest risk for infections • 20 years later: no sustained HIV preventions interventions for Dominican sex workers • At the time, the Caribbean showed prevalence rates second only to sub- Saharan Africa • The AIDS epidemic is labelled in the Caribbean as a "heterosexual epidemic

Deservingness

Migrant Crisis Voluntary Choice Economic Refugee Crisis Involuntary Force Political

Ansel Adams, "Moonrise, Hernandez, New Mexico," (1941)

Moonrise, Hernandez, New Mexico is a black and white photograph taken by Ansel Adams, late in the afternoon on November 1, 1941, from a shoulder of highway US 84 / US 285 in the unincorporated community of Hernandez, New Mexico

Practice

Most bodily dispositions are not natural for Mauss • Learned, acquired, practiced • They do not exist on different planes: i.e., the social influences the biological and vice versa • E.g., "the fact that we wear shoes to walk transforms the positions of our feet: we feel it sure enough when we walk without them" (74). ex: learning how to swim, maximize efficiency of freestyle stroke

Hegemony

Most closely associated with Marxist theorist Antonio Gramsci • Hegemony is not about subjugation through "active" force or coercion • Rather, it represents subtle, unquestioned, naturalized, "common sense" facets of everyday life that people "choose" to participate in, even when it has the effect of subjugating them or reinforcing a relation of domination "By the time people start lining up in clinics and waiting long hours for three minute consultations and a prescription, it is not because they have been "forced" to do so; and once inside those clinics they do not have the doctor's social and medical views thrust on them. They go because to a great extent they have already come to share those views

Mourning and Melancholia

Mourning: the "natural" process of mourning the loss of a significant person or "abstraction" • The process of mourning is painful, but eventually ends • The mourner is able to let go of the lost object • Melancholia: an endless mourning—the mourner is not able to let go of the lost object, and instead "incorporates it" • Incorporating the lost object keeps them "alive" inside of the subject, a ghost lives inside you • For Freud, it is pathological; if one does not expel the lost object, there is no room for a another, potentially present and fulfilling, object

Addiction Services Agency

NYC Mayor John Lindsay created the ASA in 1967 in response to the heroin epidemic • From 1971-73, NYC increased its census of methadone patients by 170% • Significantly decreased waiting time • During those two years: drug arrests, burglary & grand larceny reports, and reported cases of serum hepatitis all fell significantly • This was eliminated in 1976 due to this financial crisis; would save the city $10M; government $40M It worked to at least solve the financial crisis: by 1981, NYC was able to re-enter to public credit market

Lending, again

New York City bankers decided to stop lending the city money • Could have caused defaulting on loans • Threat of declaring bankruptcy • Turned to the federal government; turned down - remember the burgeoning economic theories at this time? • DC thought of NYC as a city that doesn't balance its books well and "coddles" its poor citizens

Arthur Kleinman's quote in Winthrop Cohen

Once the condition is described in terms of repressed or dissociated trauma, the refigured experience comes to seem a confirmation of the theory. In fact, it is all a huge tautology. That's where I was, caught in a professional loop that left me deaf to Winthrop Cohen's complaint: what was a stake for him was the soul and not the trauma, the moral crisis and not the Oedipal conflict."

Culture

One major definition: the enduring behaviors, ideas, attitudes, values, and traditions shared by a group of people and transmitted from one generation to the next (associated with civlization, high society sense of being civilized) • Given its complexity, "culture" as we use it today has many definitions (way that people use culture in medicine and illness varies) • For some, it refers to practices, behaviors, symbols, ways of life, beliefs, meaning, making etc. • It has so many meanings, the question is raised if it is helpful • For some it should be studied scientifically; for some it is more interpretive • Culture, until quite recently, was interchangeable with civilization - i.e., being "cultured" meant being civilized • It was used in this singular sense • We have already covered the history of unilineal evolutionism and the damage that the idea of "civilization" has done

Statistical Enthusiasm

Over the span of about 25 years: 1. Sickness had become subject to the statistical laws of Nature 2. Immense amount of data being accumulated and understood 3. Bureaucracies created to collect information about people; arrange populations in a well-organized data bank 4. Need to create classifications of which people would be counted in groups Sickness becomes central, people need to be counted into how they fit into a specific category Therefore bureaucracies can create classifications to count / group people

Castañeda

People can be driven out of their home countries by economic desperation—that is, forcibly displaced by material factors aside from war and natural disasters— and some have argued that the idea of voluntary migration ignores the realities of structural violence that push people out of their home countries. Immigration is fundamentally determined by social, economic, and political inequalities. This reality is particularly important because when immigrants' circumstances are viewed as a choice, they are less likely to be viewed by policy makers as inherently deserving of social and health services."

Effects of Medicalization

People come to localize much larger structural conditions as failings of their individual bodies • Failing that can be remedied by medication • Naturalizes the social order, inequality, and the political-economic reproduction of hunger Make hunger something to be "treated" • Obscures exploitation, history, class relations, the violence of everyday life Rather than seeing sickness as profoundly socially produced condition and chared by people, obscuring of those conditions and nerves have to be treated by tranquilizer rather than hunger.

WHO 1995 - Quoted by Farmer

Poverty wields its destructive influence at every stage of human life, from the moment of conception to the grave. It conspires with the most deadly and painful diseases to bring a wretched existence to all those who suffer from it." • "The world's poor are the chief victims of structural violence—a violence which has thus far defied the analyses of many seeking to understand the nature and distribution of extreme suffering.

Briggs and Martini-Briggs ("Preparing for a bacteriological invasion")

Poverty, hygiene, sanitation, health education, cholera, structural adjutment, race, culture, knowledge, discourse, representation, statistics, international health organizations, geographies of blame, biomedical compliance, noncompliance, modern, traditional, Third World Bank, IMF, social inequality Media social reality that is divorced, attention to language

The art of using the human body

Primacy of education for Mauss • A "prestigious imitation" • One imitates a given action based on how one sees it being performed by others successfully • Imposed from without • Social: the prestige of the person doing the act skillfully that one imitates Physical, psychological, social, • Psychological/biological: the imitative action itself • All three—social, psychological, biological - makes it whole

"Extreme Suffering"

Primacy of the economic • "None of this is to deny the ill effects of sexism or racism, even in the wealthy countries of North America and Europe. The point is merely to call for more fine-grained and systemic analyses of power and privilege in discussions of who is likely suffer and in what ways.

Back to Rubin and Why Queer Theory Matters to Global Health

Public health categorizations are not value-neutral but very often reflect the socio-political context in which they were created • Relying on normative assumptions about sexual practice - that, for instance, people are either "gay" or "straight" - then fundamentally alter how things are counted, and how we view epidemiological data • We tend to think of these numbers as resolutely objective, but measuring human experience and practice through categories and enumeration misses what queer theory reminds us - that what is represented as the normative, natural world doesn't even come close to being adequate

What do you call the problem? 2. What do you think has caused the problem? 3. Why do you think it started when it did? 4. What do you think the sickness does? How does it work? 5. How severe is the sickness? Will it have a long or short course?

Quag dab peg. That means the spirit catches you and you fall down. 2. Soul loss. 3. Lia's sister Yer slammed the door and Lia's soul was frightened out of her body. 4. It makes Lia shake and fall down. It works because a spirit called dab is catching her. 5. Why are you asking us these questions? If you are a good doctor, you should know the answers yourself.

But...doesn't this all sound so, um, incredibly white?

Queer of Color critique • Queer theory dominated both by white men and women (particularly the former) • Reduces the history of queer struggle to the white, affluent man (think: Stonewall, AIDS activism, etc.) • Other forms of queerness - especially for folks of color - don't necessary share the same history, and whose lived experiences of marginalization are often excluded, obscured, remain un- represented • Being able to say "f uck it" to normativity relies on EXISTING PRIVLEDGE (socio-economic and racial, in particular) • It's easy for many gay white men to denounce the church for its oppressive tendencies; but for alternative versions of queerness, the church may offer community and spiritual support

The Axis of Race or "Ethnicity"

Race/racism • Example of South African infant mortality & race • "deafening silence" on class - "race as a substitute for class" • 2016 CDC Study of Race + Maternal Morality • Race/class debate • Farmer: "it is the black poor...that are being left out" "The PRMR for black women with at least a college degree was 5.2 times that of their white counterparts"

Relapse

Rare for Garcia to return to work and see the same patients she cared for during the previous shift • Extremely high rates of relapse at the clinic • Stayed for a few days, leave, sometimes in violation of their parole • Nearly 90% "self-discharge" rate at the clinic: "we can't help those who don't want to be saved" • Marisa: "I have everything to lose" if she didn't get clean, but left a week later. • "With so much to lose, why didn't she stay?"

Some Take-Aways from Diane

Returning back to the question of Cartesian dualism - the materialist conception of the body as either abnormal or normal by "organic" standards • The radical individuality of a body as it cultivated through collective practices - embodiment and bodily practice is at once individual and collective (Mauss) • Attention to embodiment should decenter any notion that one can know what it means to inhabit the body of another • Presence/absence of her legs • Self-image; beauty; self-love • Many "normal" bodies perhaps never experience the fullness of Diane's bodily experience, her freedom and radical acceptance of the body she inhabited Dont assume what is like to be in someone else's body

Scene in Cultural Competency

Role-play • Leila, trainee, interpreting into Arabic • Treatment for thyroid cancer • Doctor recommends surgery • Patient says she needs to consult with her husband, who makes the medical decisions • Doctor asks, "Why do you need to talk to your husband?" • The facilitator reminded Leila that the topic of the day was "cultural" issues, and asked if what the doctor said was not culturally sensitive

Transformation and Rupture: Modernity

Rupture at the end of the 18th century • Transformation occurring during the 19th century • French Revolution (1789-99) • Dawn of modernity • Age of "Enlightenment" • Reason, logic, science against unreason, magic, the supernatural • Also the time when most political ideals - that continue to this day - were born: liberty, freedom, individual autonomy, democracy • Move away from the sovereign monarch toward representative government Enchanted, magic, and supernatural --> envelop world and could be used to explain why things happened secular

Alma in pastoral clinic

Said that focusing on the past was a problem, went to Evangelical Church for cure. Clinic said that you would still have problems and still be addicted

The Violence of Everyday Life

Scheper-Hughes shows that for many women, their work - whether on the plantation, as domestic workers, etc. - made childcare nearly impossible on wages of about $1 a day • Infant death incredibly common as breastfeeding was very difficult given the conditions of labor and the mothers' own malnutrition; diarrhea and dehydration extremely common; buying powdered milk was pushed by physicians • Scheper-Hughes describes mothers as seeing some of their children "too weak" to survive, assuming they will die; others had a "knack for life"

Sugar, again

Scheper-Hughes traces the transformation of production and labor for Northeast Brazil's monocrop: sugar • From 16th century colonization and slave plantation labor to contemporary sugar production/factories • Transition from the plantation economy to modern sugar production & expansion resulted in mass evictions as plantations grew • The Alto was a magnet for rural migrants who were evicted, as it was within commuting distance to some of the large plantations

Medical Nemesis

Searing critique of the increasing reach and institutionalization of biomedicine (satirical tone, tirade against biomedical enterprise) • Argued that biomedicine is iatrogenic in many senses - that is, disease caused or induced by medical treatment • Illich proposed three kinds of medical iatrogenesis (clinical, social, cultural)

Gay Sex Tourism

Significant gay sex tourism industry began in 1970s • Gay life fluctuates depending on presence of foreigners • Travel agencies in New York; internet sites, information on gay businesses, cruising spots, and opportunities to arrange social & sexual encounters with Domincans (eclipsed today, no doubt, by Tinder and Grindr) • Many gay tourists come just for sex tourism

Political Economy of DR

Since early 1980s, informal sector has employed more men than any other sector of the economy • Expansion of tourism sector; privatization of industries; reduced agricultural exports; proliferation of free-trade zones, which employ mostly women • 30 years of political hegemony by former President Balaguer • Rise to power in 1966 backed by the US • A familiar story; Cabezas (1999): "heavily subsidized, sanctioned, and guided by the US, the UN, the World Bank, and the Organization of American States in its effort to develop an investment climate favorable for the development of international tourism"

Politics of Representation

Stuart Hall, Cultural Studies participants in a culture, give meaning to people, objects, events things "in themselves" rarely have a single, fixed meaning "Even something as obvious as a stone can be a stone, a boundary marker, or a piece of sculpture, depending on what it means" (ex: two stones could be used as a soccer 'net') It is by our use of things and what we say, think, and feel about them - how we represent them - that we give them a meaning If representations are, by their definition, not stable or singular, and are made in and through human interaction and practice, they are not outside operations of power make meaning through practices, multi referential quality Different people hold that a same object represents different things

Think about how you "take" care in everyday life

Supporting, reassuring, being present for friends and family • How you do or don't take care of yourself • How caring and caregiving is so often associated with moral virtue - that it is good to care about someone or something • How many in this room aspire to a live of being care-givers - how identity or a sense of a moral life is tied to the ability to care for another

Arthur Kleinman

Taiwan research - argued that healers and patients have different explanatory models of illness Arthur Kleinman, Harvard psychiatrist and anthropologist of China • Famous 1988 book, The Illness Narratives • Kleinman argued that physicians need to take alternative cultures' understandings of illness seriously if they wanted to provide better care • Narrative was key

Death Without Weeping (Scheper-Hughes)

Takes place in mid 80s in Brazil, in a shantytown (Alto de Cruzerio) "When lives are dominated by hunger, what becomes of love?" • Scheper-Hughes explores the political- economic and historical conditions of widespread famine in Northeast Brazil • One of her most controversial arguments was that normative motherhood and mother love is only possible for those with the luxury to know their children will live Tendency among Brazilian mothers to assume that there was good possibility that their baby would not live to be 2 year old Innate biological bond, death of infant is a horrible experience Women did not publically grieve death of infants (hence name of book) because conditions of everyday life were that infants would die of malnutrition and hunger Asks people to rethink what motherhood is, scarcity is woven into everyday life • In Scheper-Hughes' view, the material conditions of everyday life were such that infant death became an ordinary feature of life for many women - death without weeping

Kleinman on Care 4:38-7:55

Taking for granted that partners will take care of each other system of care of relations extraordinary parts of society - care is important, caregiver resources are important, woman and minorities are often involved in caretaking but their support is limited nothing to do with policy

REGULATION - BIOPOLITICS

Techniques of the regulation of life processes/mechanisms in and among POPULATIONS • Aims for optimization according to statistically-determined/acceptable norms (e.g., longevity of life, fertility rates) • Examples: public health apparatus, social demography, epidemiology, etc. • Statistics - key • Acts not on individual bodies but regulates environment/population Ex: protecting other people by washing your hands (exercise of biopower, relies on bodily discipline and eye for protecting population).

Immigrant v. Refugee: The Paradox of Choice

The different classification of different types of migration - "voluntary" or "involuntary" • "Involuntary" usually associated with refugee status: i.e., immigrants had no choice given persecution in home countries • "Voluntary" usually associated with migrants (many times referred to as "illegal"): i.e., economic opportunity Why migrants are choosing / being forced to immigrate effects how they can access services • Why the language of "choice" and "intention" is problematic • The individual

A Note on Method

The experience of suffering, it is often noted, is not effectively conveyed by statistics or graphs" (262). • Anything but anecdotal - many see ethnographic scenes as "anecdotes" and not "evidence" • Ethnography as a method vs. other qualitative and quantitative methods

4 pillars of reaganomics

The four pillars of Reagan's economic policy were to reduce the growth of government spending, reduce the federal income tax and capital gains tax, reduce government regulation, and tighten the money supply in order to reduce inflation Wealthy people invest and the money trickles down to those who are not wealthy

Kleinman 2012

The market model seems to have infiltrated so thoroughly into human lives and medicine that in certain circles—policy making and analysis, hospital and clinic administration, and even clinical work— economic rationality with its imperative of containing costs and maximising efficiency has come to mute the moral, emotional, religious, and aesthetic expressions of patients and caregivers...models from economic psychology, behavioural economics, and business studies, based on the narrowest calculations of what a "rational" person would choose as most costeffective, are now routinely applied to clinical decision making and the organisation of care.

Addendum to Biopower: society must be defended

The same year History of Sexuality came out, Foucault was also giving lectures entitled Society Must be Defended • Questions about population have and continued to be about racial purity & the question of degeneration • Foucault argued that the move toward population coincided with the idea that degeneracy would occur if the "sub-race" could reproduce • The theory of degeneracy becomes the ultimate anxiety for the biopolitical state: the non-normativity of the "sub-race" • Problem of racial purity • What does this sound like????

Society Must Be Defended

The same year History of Sexuality came out, Foucault was also giving lectures entitled Society Must be Defended • Questions about population have and continued to be about racial purity & the question of degeneration • Foucault argued that the move toward population coincided with the idea that degeneracy would occur if the "sub-race" could reproduce • The theory of degeneracy becomes the ultimate anxiety for the biopolitical state: the non-normativity of the "sub-race" • Problem of racial purity • What does this sound like????

Phenomenology

The study of individuals' own unique, first-person, conscious experience. Branch of philosophy concerned with EXPERIENCE and the meaning we give to our experiences, which shape how we understand and inhabit our worlds 1ST person subjective understanding of the world, how our bodies are affected by sound, light, affected by minute attunements to how we experience something • Subjective and first person perspective • Sensation, affective, bodily - seeing, hearing, touching, perception, imagination, desire, etc. • FOCUS ON LIVED EXPERIENCE

Gayle Rubin, "Thinking Sex" (1984)

The time has come to think about sex. To some, sexuality may seem to be an unimportant topic, a frivolous diversion from the more critical problems of poverty, war, disease, racism, famine, or nuclear annihilation. But it is precisely at times such as these, when we live with the possibility of unthinkable destruction, that people are likely to become dangerously crazy about sexuality."

Geographies of Addiction

There is a connection between geography and illness. There is a link between who becomes addicted and memories of dispossession and land loss. Heroin addiction tells the relationship between the Us and Mexico in terms of colonization and land use history. Presence of syringes in physical place and in everyday life • "This book starts from the idea that this particular geography oof addiction encloses multiple forms of spatial and existential ruin, sedimented and entangled through time." (6) • Memories of dispossession and loss of land • "That place as it is experienced, remembered, and narrativized should become a central site of understanding addictive experience." Something fundamental about where we come from, we are formed from a particular landscape People were forced to be present at New Day and it became a space of contradiction, they were there in a coerced way but they also wanted to recover In 1990s, the place became ground zero, "breaking bad" effect, addiction in rural areas

How these intersect

This economic juncture then intersects with: a burgeoning AIDS epidemic, increase in addiction (especially crack cocaine), and a rising homicide rate in NYC. From 1970-1980 New Yorkers below the poverty line grew by 20%, even though the overall population of NYC decreased by 10%

Scheper-Hughes, Death Without Weeping, 202-3

To acknowledge hunger, which is not a disease but a social illness, would be tantamount to political suicide for leaders whose power has come from the same plantation economy that has produced the hunger in the first place. And because the poor have come to invest drugs with such magical efficacy, it is all too easy for their faith to be subverted and used against them. If hunger cannot be satisfied, it can at least be tranquilized, so that medicine, even more than religion, comes to actualize the Marxist platitude on the drugging of the masses." "Hunger and thirst are mindful and embodied states, as they come trailing their own metaphorical meanings and symbolic associations."

Culture Problems

To distance itself from race, "culture" has become seen as internally homogeneous and bounded • To the point where it can become reified Culture becomes "thingified" dissolved into isolate, descrete things that become bounded Ironically, even though culture would help us deessentialize difference, race promulgated the essentialization of difference, reduces amorphous interchangeable things into descrete localized thing that can be studied, understood, and applied. • In this way, reducing culture to a bounded, localized "thing," it has the effect of essentializing difference in a new way • If difference is essentialized - like it was when race was tied to biological inferiority - "what the use of culture?" Angela Jenks asks • The fear is that trying to teach "cultural competence" has just this possibility - of reifying, essentializing, and decontextualize difference, the exact opposite of its aims

"Normal, productive, satisfying lives"

Using a prosthetic, for her medical professionals, would determine the level of "normalcy" for her life • The choice between a dependent person with institutional care and an independent person who can take care of themselves • At 12, occupational therapist confounded by her "non-wearing" - "we do feel that a substitute...which resembles those of a normal arm is advantageous and that the advantage will be more obvious in the future."

Examples of Biopower

Vaccinations • Family Planning • School Nutrition Programs • Physical Education Programs • Pre-Exposure Prophylaxis (PrEP) (bodily discipline, operating with view towards optimizing population and making people live overall)

Responsibility

WHO (1946): "Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures" • Alma-Ata (1978): "Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures.

Biomedicine as Culture

We often think of biomedicine as value-neutral and scientific • Detached from all human values; evidence-based; rational • Many anthropologists would hold that, when humans are involved in general, it is very hard if not impossible to be completely value-neutral (biases in interacting with people) • Regardless of good intentions, bias, judgement, assumptions abound when people interact with one another • This does not mean that biomedicine is "bad," it simply means that we need not give it blanket authority • Biomedicine is incredibly effective and life-saving, but can also have unforeseen consequences when it is seen as "hegemonic"

Costs of "Cost-Effectiveness"

We talked about the changing metrics in the era of global health: move toward overall cost-ofillness (productivity; days lost, etc.) • Using conservative estimates: • TB excess cases: $500M (others higher: $900M-$2.4B) • Homicide: $17.7B • AIDS: $2.3B for direct costs; $1.8B for preventable cases of AIDS; $666M for preventable HIV cases; loss of life costs for AIDS, $31B

Ethics of Addiction

Weighing obligation and concern for kin - biological and social • Practices of care that are "not always remedial and which bring unexpected, even dangerous, consequences" (121) • Implicated in the life of someone else, who is implicated her life too • Butler: constituted in relationality - "implicated, beholden, sustained by a social world that is beyond us and before us

The Point

What does this boil down to? • Individualizes culture—becomes about "individual personality traits" (about something collective and shared) • Bias is NOT SEEN as STRUCTURALLY or SOCIALLY produced • Culture has the effect of individualizing the larger structural, historical, and political-economic forces that PRODUCE health disparities in the first place • Ironic given that culture is seen at least theoretically as a "collective" phenomenon • People, especially those not affected by it, are uncomfortable talking about racism - cultural competency makes people feel "more comfortable" • Talking about cultural competency "hurts a little less" than talking about race - "a little more palatable," in the trainee's words • Culture can be apolitical in a way race never is

Marcel Mauss, Techniques of the Body

What is a technique? • A particular way of skillfully executing a task • Not everyone uses the same techniques to complete the same task • Does a technique need an instrument? • Examples at the outset: • Swimming • Digging • Marching Not actively thinking about movements, why we hold things. Things become habitualized

Beyond Co-Morbidity

When this co-infection has a synergistic reaction with adverse social, political, and economic conditions - most frequently among marginalized communities - scholars (marginalization) how two diseases accelerate morbitiy, happen in ecologies (socio-economic status, structural violence) --> leads to co-morbitiy have called this a syndemic • Co-infection of this kind are more likely to occur under conditions of inequality that we have been talking about - poverty, stigma, structural violence, and racism • The concept of a syndemic moves beyond biomedical understandings of "co-morbidity" to show how social & political-economic conditions exacerbate disease clustering Merrill Singer ( Lowering HIV risk among ethnic minority drug users)

Race after Culture?

While emphasizing culture in this moment was an anti-racist move, it had the effect of making it difficult to talk about racism • In Kamala Visweswaran's (2009: 60) words, "The Boasian desire to separate race from negative cultural values, and therefore racism, is understandable, and, some would say, laudable. Yet, in separating race from racism (that is, race conflict or persecution), [they] left no means for anthropologists to understand how racism produces the objective reality of race at any given historical moment." Racism still exists in both interpersonal and structural capacities in today's world Hard to analyse the presence of racism Racism doesn't go away because race isn't tied to biological inferiority (omnipresence of culture)

Interpretive Medical Anthropology

While medical anthropology as a sub-discipline was forming in the 1970s, 80s, and 90s, Kleinman's approach was associated with an "interpretive medical anthropology" frame • By focusing on the question of narrative, and the power of stories in general, Kleinman was seen to be at the forefront of the "interpretive" approach • Many medical anthropologists critical of his approach from an early stage, and in their eyes, he was seen as a clinically applied medical anthropologist at the time.

Pg 160

While the dual stigmas of homosexuality and sex work motivate men's use of numerous strategies for ensuring discretion with wives, partners, and community members as a means of maintaining one's status as "un hombre normal" (a normal man), traditional public health approaches are largely incapable of capturing these nuances of men's intimate experiences or the ways that their risk behavior is shaped by large-scale transformations in gender, sexuality, and work."

6. What kind of treatment do you think the patient should receive? What are the most important results you hope she receives from this treatment? 7. What are the chief problems the sickness has caused? 8. What do you fear most about the sickness?

You should give Lia medicine to take for a week but no longer. After she is well, she should stop taking the medicine. You should not treat her by taking her blood or the fluid in the backbone. Lisa should be treated at home with Hmong medicines and by sacrificing pigs and chickens. We hope Lia will be healthy, but we are not sure we want her to stop shaking forever because it makes her noble in our culture, and when she grows up she might become a shaman. 7. It has made us sad to see Lia hurt, and it has made us angry at Yer [Lia's sister] 8. That Lia's soul will never return.

Explanatory Model

a patient's views about health and illness and its treatment multiple explanations for a given affliction The difference between disease and illness represent two different EXPLANATORY MODELS of affliction (popular sector, professional sector, folk sector) • Both have an explanation for cause and cure • Many times they are at odds • For Kleinman, physicians need to take other explanatory models seriously if they want to try and avoid what happened to Lia

Practise MC: In Arthur Kleinman's explanatory model framework, "disease" refers to:

a) a patient's life history b) a patients explanation of their disease c) *alteration in biological or functioning* d) a folk sector understanding of disease e) an illness narrative

Giorgio Agamben's figure of bios refers to

a) bare life b) life excluded from the polls c) life without citizenship d) *flesh, biographical life* e) life without rights

Practise MC: In the Spirit Catches You and You Fall Down, what did Anne Fadiman argue that killed Lia Lee in the end?

a) biomedical hegemony b) non-compliant parents c) *cross-cultural misunderstanding* d) lack of translation support e) incompetent doctors

Nanchy Schepher-Hughes utilizes which of the following frameworks in Death Without Weeping

a) embodiment b) political economy c) critical medical anthropology d) hegemony e) *all of the above*

In "suffering and structural violence", paul farmer argues for the importance of:

a) making sense of suffering b) statistics c) *explaining suffering* d) graphs e) narratives

Practise MC: Of the following, what would critical medical anthropologists be most likely to focus on in the case of Lia Lee?

a) physician-patient relationship b) clinical mediation of cross-cultural misunderstanding c) *production and maintenance of biomedical power* d) cultural competency e) syndemics

According to Angela Garcia, the biomedical model of chronicity assumes:

a) that addiction is curable with treatment b) that addiction is a matter of personal responsibility c) that addiction is a moral failing of the addict d) *that an addict will always be an addict, regardless of when they last used.*

Critical Medical Anthropology

an approach to the study of health and illness that analyzes the impact of inequality and stratification within systems of power on individual and group health outcomes Critical medical anthropology must focus on power relations in addition to interpretive and narrative approaches to disease • Must practice a radical critique of the "tenacious assumptions of western medicine" • Only translating to increase "compliance" reinforces biomedicine as a hegemonic form, and does not question its very foundations Not doing analytical work of what biomedicine was, disengage from biomedicine and its framework to be able to practise a radical critique to reconstruct a radical from of medical practise. • "Disengaging" from biomedicine allows for a more radical critique

______________ is one of the two or three most complicated words in the English language.

culture

US-Mexico Border

explosion of writing and documenting - simultaneously fascination and fear • "Immigration pornography" • 1994 NAFTA - North American Free Trade Agreement • We know a little about this old guy • "drowning in a pinche montón of subsidized gringo corn" (how it affected mexican workers ) • Crashed agricultural economy; many peasant farmers out of work

Franz Boas

father of modern American anthropology; argued for cultural relativism and historical particularism Born in Germany in 1858, he was the founder of American cultural anthropology, (social anthropology, society + structure) • Was important in making long- term ethnographic fieldwork a mainstay in anthropology • Until this point, many unilineal evolutionists where "armchair anthropologists" American anthropology defined culture, which became the inquiry. • Did ethnographic fieldwork among the Kwakiutl of Northwest Canada and US (imperial data collection) • Also deeply influenced by Rudolf Virchow

Health Services New York

hit very hard by these cuts • Over the next two years, the Dept of Health's budget was cut by 20% and had lost 28% of its workforce • 7/20 district health centers closed • Cut $1M from its methadone program • Cut 14/19 Health Educators • Closed 20/75 child health stations • Closed 6/14 chest clinics • Beds in municipal hospitals fell by 16% by 1980; number of days of care dropped by 23% • Closed ALL 50 of its community- based clinics

Joseph

in vietnam war came back and used drugs with previous vets suffered with long history of dispossession area became gentrified

Clinical Iatrogenesis

injury done to patients by ineffective, unsafe, and erroneous treatments Medicine causing physical harm rather than healing • Incompetence or carelessness/malpractice • "Side-effects" - drug toxicity, surgery, physical manipulation, etc. • Banning of alternatives • Populations turned into experimental subjects, etc

Cf. African Migrants in Europe

involuntary

Paul Farmer

physician and medical anthropologist treated TB in Haiti with his group, did a study to see whether belief in sorcery had anything to do with their recovery, it didn't. Group that was given money and food along with their medication all recovered. Arthur Kleinman student • Founder of Partners in Health, a major international non-profit health organization that focuses on structural solutions to health problems - building hospitals, infrastructure, hires and trains local staff, provides long-term care • Author of some of the most widely-read medical ethnographies, especially AIDS and Accusation, Infections and Inequalities, Pathologies of Power

Structural Competency

recognizing the institutions that shape cultural expression, opportunities, privilege, discrimination & racism Increasing move, by physician-anthropologists like Helena Hansen, Seth Holmes, Sam Dubal, Josh Neff et al. to teach physicians STRUCTURAL COMPETENCY • The larger structural, political-economic, historical conditions (like the ones we spoke about at length in GLOBAL and will continue to) that produce health disparities in the first place

Pictures

romanticism with pastoral clinic

Queer Theory?!

social theory about gender and sexual identity; emphasizes the importance of difference and rejects ideas of innate identities or restrictive categories Not simply about sexual orientation • About a fundamental questioning of the structures of normativity in the contemporary world • Queer theories denaturalize facets of the world taken to be granted as "natural" - bodies, practices, ways of being in the world, gender, sex, sexuality • Focus on deconstructing categories: who defines them, who is excluded by them, who polices them, etc.

Social Iatrogenesis

the deliberate obscuring of political conditions that render society unhealthy Medical monopoly - no alternatives to biomedical knowledge/practice • Institutionalization • "Medical practice sponsors sickness by reinforcing a morbid society that encourages people to become consumers of curative, preventive, industrial and environmental medicine."

What is Cultural Competency?

the enabling of health care providers to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients broad and generalized, cultivating empathy and humility and increased understanding in the patient. Arthur Kleinman's The Illness Narratives was a crucial model for cultural competence • Increasingly incorporated into medical schools & medical training broadly • Focuses on attempts to increase physician awareness to "cultural" difference • Also based on increasing empathy, humility, curiosity, respect, etc. in physician-patient encounters • Patient advocacy groups demand greater awareness • Legal organizations; civil rights legislation

Ethnography

the method by which researchers attempt to understand a group or culture by observing it from the inside, without imposing any preconceived notions they might have Long-term immersion (in a given place) • Combination of participant observation, interviews, archival research, surveys, and sometimes demographic and epidemiological data • Combines a variety of evidence rather than just relying on one form • Some say ethnography is useless because of the sample size; others say it is more robust than purely quantitative measures for social issues, which can't capture experience and practise in the same way

Cultural Relativism

the practice of judging a culture by its own standards developed by Margaret Mead and Ruth Benedict people are formed in a radically different environment with radically different histories, hence their fundamental forms of life are going to be different. Have to denature that there is an innate progress with humans, and examine culture by its own standards, not juding cultures against a universal standard. Argued that characteristics similar to all humans (like trade or kinship) look different in different cultures • Different environments and different histories produce different cultural traits • Historically, because they were different from Euro-Americans, they were seen as "primitive" • Societies were the result of their own particular histories, and should be studied on their own terms • Cultural relativism, then, refers to the orientation that there is no "standard" or "ultimate" culture against which to judge all others; rather, cultures are unique and different, and should not be judged ("inferior, savage, barbaric, primitive") against other cultures

Sovereign Power

the supreme power of an independent state to regulate its internal affairs without foreign interference Monarch • Centralization • Power can be held by, and exercised through, the sovereign • negative • The right of the sword • "The very essence of the right of life and death is actually the right to kill: it is at the moment when the sovereign can kill that he exercises his right over life" (24

Medicalization

the transformation of a human condition into a matter to be treated by physicians Institutions that are integrated into society, but we dont think about their social mechanisms Irving Zola and Ivan Illich very influential, launched a group of sociologists who studied institutions, and crystallized medicalization • The increasing tendency for all adverse aspects of the human experience to be rendered as a MEDICAL PROBLEMS to be treated with MEDICAL KNOWLEDGE A process by which ordinary facets of human experience becoming rendered as medical problems and only medical problems which can only be solved by medical treatment • Gives increasing amount of power and control to medical institutions • Obscures the structural conditions of disease

Definition of Representatino (cont).

things rarely have one singular, fixed meaning humans produce meaning through language in language, we symbolize things - we can linguistically represent something that is not present whether it be real or imagined Language is not like a mirror- representations change over time and between people, repreentations are being made over through practice and interactions; representations are thus not stable meaning is produced by the practice, the "work" or representation. It is constructed

Representation

to describe or to depict it, to call it up in the mind by description or portrayal or imagination; to place a likeness of it before us in our mind or in the senses; as for example in the sentence "This picture represents the murder of Abel by Cain" also means to create meaning my symbolizing, to stand for, to be a specimen of, or to substitute for

Think about how central CARE is to the possibility of life

• A baby, a child, an adolescent, an adult • In times of both bodily and existential crisis AS WELL AS in times of normality • A baby cannot live without a variety of certain types of care - food, warmth, attention, etc. • Even as an adult, when our bodies deteriorate, things happen, and we become damaged, we need care: sometimes bodily/medical; sometimes psycho-social or emotional; sometimes we just need someone there

To avoid bankruptcy...

• Appointed an Emergency Financial Control Board (EFBC) • To balance the city's budget, especially so it could borrow money again • EFBC demanded cuts in city services; city workers; redistribution of responsibilities from the city to the state; tax increases • At this time, NYC budget: $13B • Needed to cut $200M per year for 3 years

Biopower

• Diffusion of power, "capillary" • Power no longer held by a person (like the sovereign) • Positive/productive • Normalizing

Bugarrón and sanky panky

• Forms of self-identification used by male sex workers • Sanky panky: young, "well-built" men who made a living hustling in heavy tourist areas • Masculine embodiment & performance + spatial: at the beach • Bugarrón: deeper history in the DR; refers to a sex worker who is a top & whose ordinary life is much like "normal" men - i.e., heterosexual • Situational identities veiled in public/family/social contexts • But fluid: sometimes people would switch between categories if working in a different place (the beach)

Rubin: Back to Victorian Morality

• In both England and the US, late 19th century • Educational and political campaigns to encourage chastity, eliminate prostitution, discourage masturbation • Crusaders targeted 'obscene' literature, nude paintings, music halls, abortion, birth control information, public dancing • The morality apparatus included social, medical, and legal enforcement • Rubin argues that the legacies of this are still with us: "deep imprint on attitudes about sex, medical practice, child- rearing, parental anxieties, police conduct, and sex law.

A Decent Life

• Lisa: "I needed heroin, and it was there. It made me feel like things were possible. Being high was the only time I felt like things were possible. You think about your future when you're high, and it doesn't look so bad. You even think about quitting. You can't even think about quitting when you're strung out. But when you're high you think, I can do this. I can do anything." • Garcia: "In the absence of heroin, there is nothing but "bad feeling," the collective weight of years of damage: physical, emotional, financial, and familial. In heroin's embrace, the bad feeling dissipates, and the addict is released into feelings of love, serenity, and possibility: the possibility of living clean.

History of Sexuality, Vol 1.

• Perhaps his most famous work • Published in 1976 • Looked at the explosion of discourse about sexuality and its control in the early 19th century • Against the repressive hypothesis • Actually a discursive explosion about sexuality - scientific advancements, implementation of policy and controls • This shift was a move away from seeing looking a people as "subjects" and more so as a POPULATION • Thus very concerned with sexuality, reproduction, and death

Dominican Republic ~2005

• Tourism: fastest growing industry - central to the gov't economic development strategy • Population ~9.3 million; ~ 3million tourists a year • Completely changed the physical, social, and political landscape of the country • Question of "influence of foreign vices on the moral foundation of society" • Gay sex tourism in particular

Other Histories of Conquest

• Two Native American Pueblos: Ohkay Owingeh (pre-Hispanic name, San Juan) and Santa Clara • Pueblo Revolt: 1680 against Spanish colonists • Hispanos: casinos and poverty • Statue of leader of Pueblo Revolt (Po'Pay) vs. Spanish conquistador don Juan de Oñate - brutality also remembered by Native Americans • Racialized/racist stereotypes of both groups • 30,000 residents: 81% Hispanic or Latino; 8.7% American Indian or Alaska Native

Is Care So Obviously Always So Unambiguous?

• While Kleinman's intervention was important, many scholars pointed to the fundamental ambiguity of care: that it can result in violence, loss, destruction, and even death • Remember Ticktin's Casualties of Care (2011) from "Immigration"? • In that case, the possibility of receiving care (as a citizen) meant exposing oneself to danger, violence, disease • Remember the entire first part of the class(lol)? Weren't all those interventions kinds of CARE?

Illegal to Die?

• William Farr: no one could die without a death certificate • "Cause of death" had to be uniform - had to a discrete category to be counted • WHO - need to count uniformly diseases, "correct diagnosis" • What would Angela Garcia's interlocutor Alma be said to have died from? How would she have been counted? • (Overdose. Substance Abuse Disorder.) • Is that enough?