Special Issue 2016: The Clinic in Crisis

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To help kick off a new year of articles, books, and highlights, Springer is featuring the June 2016 special issue of Culture, Medicine & Psychiatry, The Clinic in Crisis: Medicine and Politics in the Context of Social Upheaval, as part of a larger group of Special Issues in Social Sciences. Each article in the special issue is available for free here until February 3, 2017.

Over the summer we spotlighted several original papers from this special issue:

  1. Salih Can Aciksoz’s Medical Humanitarianism Under Atmospheric Violence: Health Professionals in the 2013 Gezi Protests in Turkey
  2. Emma Varley’s Abandonments, Solidarities and Logics of Care: Hospitals as Sites of Sectarian Conflict in Gilgit-Baltistan
  3. Elly Teman, Tsipy Ivry, and Heela Goren’s Obligatory Effort [Hishtadlut] as an Explanatory Model: A Critique of Reproductive Choice and Control

Each highlighted article discusses medical neutrality in areas of political conflict and how clinical space can be an extension of violence. While many clinicians strive to maintain an environment of safety and neutrality in the hospitals and clinics, the locations are routinely entangled with positions of violent local and international political struggles. The ethnographic accounts in each of the featured articles address the concept of “medical neutrality” – the ethical norm that medicine should be practiced impartially – in the context of conflict and social unrest, and suggest medical neutrality may work as a tool that is deeply cultural, social, and political.

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Issue Highlight Vol 40 Issue 2: Global Health Diplomacy in Ethiopia

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Across the past few weeks, we have been spotlighting new articles from our June 2016 issue, which you can access in full here. The theme of this special issue is The Clinic in Crisis: Medicine and Politics in the Context of Social Upheaval. This week, we visit Lauren Carruth’s article “Peace in the Clinic: Rethinking ‘Global Health Diplomacy’ in the Somali Region of Ethiopia.” You can read the full article at this link.


In this article, Carruth argues that the politics of global health manifest not only at the scale of “interstate” interactions between governments, NGOs, and international assemblies, but at the local and interpersonal levels between individuals who are giving, receiving, and managing clinical care in “politically insecure” places. Through ethnographic research on two health programs in the Somali region of Ethiopia, the author argues that medical care provision can alternatively strain and strengthen political relationships between people across ethnic and social boundaries.

For instance, Somali people in Ethiopia often refused to seek medical services from the local clinic, Aysha Health Center. Somali patients complained that the Habesha (a native Ethiopian group) nurses were insensitive and uninterested in treating their health concerns. Many Somali informants offered up the same story as evidence: three mothers went to the clinic, and their three children had different ailments. Yet the Habesha nurses did not examine the children, and offered the same drugs to each of the mothers without diagnosing each patient. Somali patients also had difficulty securing a translator who could assist them in conversations with clinicians, who spoke Amharic. The Habesha clinic staff countered that the Somali patients were adverse to biomedical care, instead trusting native folk healers over the clinicians. They added that Somali patients would not adhere to the medication regimens or treatment plans that they recommended. In this case, the friction between Habesha caregivers and Somali patients intensified long-standing ethnic and political tensions at the local scale.

Carruth presents another case, however, where medical aid eases inter-ethnic relationships and ameliorate social rifts between opposing groups. She describes a mobile UNICEF clinic staffed by two Somali clinicians of the Ogaden clan operating in Ethiopia. Though these Somali clinicians were caring for fellow Somali patients, the patients descended from a less politically powerful line which did not have the dominant social standing of the Ogaden: a clan with significant regional power in Ethiopia. Though the patients were of opposing clans, such as the Issa, the two clinicians listened intently to the patients’ complaints, recalled their family lines when they returned for further treatment, and even offered resources like supplementary nutrition to ailing patients despite UNICEF limitations on what types of patients could receive these rations. The patients adored the mobile clinic staff, and the clinicians became integrated into the marginalized communities they served. This example, Carruth notes, highlights the potential for medical aid to facilitate positive and deeply personal relationships between factions in regions that have otherwise experienced significant social unrest.

Carruth concludes that in order to successfully deliver medical aid to places encountering social upheaval or unrest, it is critical to unite oppositional groups within clinical spaces themselves. Providing medical resources and building clinics alone, she notes, fails to address the need to facilitate positive relationships between individuals mired in conflict. Instead, to ease political and social tensions, Carruth posits that clinics and similar treatment centers can serve as sites of caring, communal exchange between otherwise opposed social groups.

Issue Highlight Vol 40 Issue 2: Reproductive Experiences Amongst Haredi Jewish Women

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Over the next few blog updates, we will be spotlighting new articles from our June 2016 issue, which you can access in full here. The theme of this special issue is The Clinic in Crisis: Medicine and Politics in the Context of Social Upheaval. In addition to articles that address the topics of societal unrest, political change, and human health, this installment also turns to how people navigate change and decision-making within the contexts of their own lives. Specifically, one article questions whether individual autonomy over medical decisions is a characteristic of medical care across cultural contexts. In Teman, Ivry, and Goren’s article “Obligatory Effort [Hishtadlut] as an Explanatory Model: A Critique of Reproductive Choice and Control,” we learn that the notion of reproductive choice and control does not cleanly map onto the procreative experiences of Haredi (ultra-Orthodox Jewish) women. To access this article in full, click here.


Reproductive technologies have expanded the range of procreative choices a woman and members of her family confront: should birth control be used to limit the number of children she wishes to have? Should assisted reproductive technologies (ARTs) be used to facilitate conception, or should a woman abort a fetus that has tested positive for a developmental or congenital ailment? The authors of this article suggest that in these discussions, another question has emerged. Are these decisions truly reflective of individual choice, or do individual mothers and members of their community perceive the reproductive course as one over which no person has ultimate control?

Amongst Haredi (ultra-Orthodox Jewish) women in both the United States and Israel, the authors observed another way that individuals framed their reproductive experiences. Rather than describing their procreative choices as a form of individual control over one’s life course, the Haredi women referenced hishtadlut, or obligatory effort: the notion that they were obliged to God to try to become pregnant, but not responsible for the outcome if they were unable to do so. In hishtadlut, women have “room for effort” in that they may flexibly interpret and enact what constitutes a serious attempt to become pregnant or maintain a healthy pregnancy per their religious duty to God to have children. In this explanatory framing, women recognize that they must consciously make choices that would enable God to enact a divine plan for them: however, they are not accountable for the outcome if, having invested the “effort,” God’s plan does not come to fruition or leads to the birth of a child with a developmental disability or congenital condition.

The concept of hishtadlut extended to the use of various reproductive technologies. For instance, there are many concerns about hereditary genetic illnesses like Tay-Sachs disease within the Haredi community. To ameliorate this issue, blood samples from young Haredi men and women enrolled in high school are collected and catalogued into an anonymous database. If two families are arranging a marriage between a son and a daughter, they are able to consult the database to confirm whether or not both individuals are genetic carriers of an illness. This prevents unions between two carriers who would have a greater likelihood of having a child with a genetic illness; thus a genetic carrier would be paired with a non-carrier spouse. Most women interviewed for the article agreed that this technological system facilitated the will of God, as it reduced the chance that a couple would face the difficulty of raising a disabled or an ill child. Here the technology is seen as a “blessing” from God, as it allows families and couples to avoid “heartbreak,” while bolstering a couple’s ability to have healthy children per God’s divine plan.

In other instances, technology is viewed as irrelevant out of the hishtadlut principle. For example, the Haredi women perceived genetic testing for fetal developmental or other congenital illnesses as having little purpose. In Jewish law, abortions beyond 40 days after conception are prohibited, and all fetal diagnostic testing occurs after this point in a woman’s pregnancy. Thus, the women held that the test was inconsequential, as God’s will for them and their fetus had already been ordained. If a baby was born with a disability, this was part of their fate as decided by God. Here “choice” is viewed as God’s choice for the mother and baby, rather than the mother’s own control over whether or not to give birth to a child with potential developmental or congenital conditions.

As Teman, Ivry, and Goren’s research illustrates, “choice” and “control” do not necessarily apply to the reproductive experiences of women and their families across cultures. Indeed, in a deeply religious community such as the Haredi Jews, “choice” is attributed to God while individual reproductive decision-making is cast as a means to allow God to work through individuals to enact divine will. Haredi women did not describe themselves as accountable for becoming pregnant (or having a healthy child), but they did feel obligated to use technologies and consciously make reproductive decisions or avoid certain interventions. These actions, they held, would enable God to direct their journey to motherhood and to fulfill their purpose as parents.

 

Issue Highlight Vol 40 Issue 2: Hospitals as Sites of Conflict in Pakistan

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In the coming blog posts, we will be highlighting new articles from our June 2016 issue, which you can access in full here. The theme of this special issue is The Clinic in Crisis: Medicine and Politics in the Context of Social Upheaval. This week, we will overview Emma Varley’s article “Abandonments, Solidarities and Logics of Care: Hospitals as Sites of Sectarian Conflict in Gilgit-Baltistan.” Read the full article here.


As our past blog highlights have suggested, the clinical space can both act as a site of political protest and serve to facilitate political unity. Varley’s article expands upon these themes by arguing that the clinic can also become a microcosm of inter-group tensions, wherein the hospital itself relays a picture of broader social conflict. Through her analysis of a crisis in a Pakistani hospital, Varley ethnographically demonstrates how Sunni-Shia conflicts manifest in the clinic, and how these tensions are navigated by health professionals employed there.

Varley recounts a shooting and raid which occurred at a hospital in Gilgit-Baltistan in January 2005. Shia gunmen had entered the regional hospital to hunt down Sunni male patients, aiming to retaliate after the assassination of a Shia leader killed by Sunnis. One women’s health ward, operated by nurses of the neutral Ismaili group, was left untouched after the nurses hid Sunni male patients. The nurses protected the men by insisting to the gunmen that there would be no male patients on a female ward: drawing both upon their social role as neutral Ismaili and their gendered role as caregivers of women, who were seen as uninvolved in the conflict at hand. Meanwhile, in a surgical theatre, physicians pretended as if the assassinated Shia leader on their operating table was still alive: hoping to placate the gunmen who threatened them until police or military forces could arrive to dispel the violence. Orderlies and other guards on the wards had, in some cases, fled: leaving clinical staff to defend or otherwise conceal the Sunni patients, and in other cases, fellow Sunni providers.

In reflecting on this incident, Varley notes that the hospital became an example of an “abandoned” space, one in which the necessary governmental protections and securities were not in place to ensure the safety of all patients and clinicians. The onus of protecting patients fell upon the clinicians who staffed the hospital: illustrating both the selflessness of individuals in assisting one another across oppositional group divides, and the potential for hospitals to become sites of medical and political refuge. This increased the trust between Shia providers and their Sunni colleagues in medicine. Conversely, the incident intensified professional divisions between Shia and Sunni providers, as Sunni clinicians later departed the larger regional hospital and took up employment in new Sunni health centers where they felt less at risk.

Though Varley reminds us that conflict is “corrosive” within medical professional relationships, it may also enable “renewed” feelings of trust between caregivers of opposing groups when political unrest unites them under a common aim. In sum, the hospital may serve a site of caregiving exchanges that expand beyond the bounds of medical encounters, as it becomes a sites of political action and negotiation between social groups.

Issue Highlight Vol 40 Issue 2: Medical Humanitarianism and Conflict in Turkey

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In the next few blog updates, we will be spotlighting new articles from our June 2016 issue, which you can access in full here. The theme of this special issue is The Clinic in Crisis: Medicine and Politics in the Context of Social Upheaval. This week, we will overview Salih Can Aciksoz’s article “Medical Humanitarianism Under Atmospheric Violence: Health Professionals in the 2013 Gezi Protests in Turkey.” Read the full article here.


Aciksoz’s article begins by painting a scene. In the summer of 2013, protests erupted throughout Turkey, leading to violent clashes between armed police forces and civilian protestors. Humanitarian health workers began to establish make-shift infirmaries near known sites of conflict to treat wounded protestors, yet soon themselves became targets of the police who directed tear gas and turned their weapons upon the infirmaries. Those tasked with quashing riots and subduing protests soon fixed their ire on the health professionals who cared for wounded protestors: viewing these clinicians not as neutral aid workers, but instead as complicit members of the uprisings they were attempting to quell. In time, emergency healthcare offered to protestors was deemed criminal activity by the Turkish government.

The author frames the Gezi Protests in terms of the security of medical spaces. Medical humanitarianism, he notes, is premised on the neutrality of care giving centers which serve as a “safe space” for medical aid to be delivered in times of “crisis” to anyone in need. However, this designation as a safe space relies on the authority of a state to recognize it as such. The Turkish government’s criminalization of the humanitarian infirmaries aligned health professionals with protestors, despite any claims to political neutrality. In Turkey, the ability for make-shift infirmaries to serve as neutral care centers was further threatened by the use of a particular weapon: tear gas and similar chemical weapons. An indiscriminate gas could transform entire physical areas– especially enclosed ones– into dangerous structures where all people were at risk of exposure. The use of gas by police forces inside clinics prevented these spaces from being both politically neutral and medically safe for patients and health professionals within.

The state’s designation of infirmaries as a site of criminal activity, and health professionals’ attendance to protestors as insurgent, did not always align with the accounts that Ackisoz collected from Turkish clinicians themselves. Even whenever health professionals confessed that they sympathized with the cause of the protestors, they nevertheless distinguished their political beliefs from their medical obligation. Many described their medical involvement with the protests as a natural response to crisis: as understandable as if they were responding to victims of an earthquake or other disaster. Yet their work also bordered on activism, as numerous clinicians sought to aid protestors after noting the failures of state-operated hospitals and ambulances to attend to the medical needs of all injured protestors.

In sum, Ackisoz argues that what constitutes “medical humanitarianism” borders on many other domains of society: on the state, on the government’s definition of both criminality and on appropriate use of force, on what constitutes political dissidence and whether or not “humanitarianism” is strictly neutral whenever any medical action has the potential to shed light on political failings. The article demonstrates that the ethnographic and social constructivist lenses are well-suited to the analysis of the troubled boundaries between politics and medicine, and between healing and the state in periods of upheaval.

 

Special Issue Highlight: The Anthropology of Autism, Part 1

The newly released June 2015 special issue of Culture, Medicine & Psychiatry addresses anthropological studies of autism from around the world, including the United States, India, and Italy. In this installment and the next entry on the blog, we will explore four articles published in the latest issue. This research spans the fields of disability studies, psychological anthropology, and medical anthropology, and touch on themes of identity, subjectivity, family caregiving, and community. Here, we will focus on two articles in this publication.


Parenting a Child with Autism in India: Narratives Before and After a Parent–Child Intervention Program

Rachel S. Brezis, et al.

Throughout India, there are limited social services and support networks for individuals with autism and their families. Furthermore, neurodiverse (and mentally ill) individuals have historically been cared for in private by family members in India, where they are hidden from the community and may be treated as a mark of shame on the household. However, despite these challenges, Indian parents of children with autism are increasingly seeking out professional programs that educate them about autism and appropriate caregiving strategies.

One such program in New Delhi, the Parent-Child Training Program (PCTP), evidences the changing view towards autism in India. The program aims to educate parents about autism and, in so doing, encourage them to educate others about the experience of raising a child with the condition. Parents bring their child to PCTP and learn alongside them. As the first program in India to provide such training, its examination proves essential in understanding the way that various populations (here in India) are now approaching the shifting landscape of autism.

Brezis and colleagues studied the PCTP to discover how the training was altering parents’ perceptions of autism and relationships with their children. They interviewed 40 pairs of parents at the beginning and end of the 3-month program, encouraging the parents to speak for five minutes without prompts regarding their child and their relationship to the child.

The authors found that parents who participated in the three-month program were less likely to describe their children in relation to an assumed “normality,” although mothers proved to be more likely than fathers to self-reflect on their relationship with their child. Similarly, while parents described their child’s behaviors no less frequently in the second and final interview, they did not note behavior in relation to other individuals’ behavior perceived as “normal.”

To learn more about this research, click here for a link to the article: http://link.springer.com/article/10.1007/s11013-015-9434-y

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Custodial Homes, Therapeutic Homes, and Parental Acceptance: Parental Experiences of Autism in Kerala, India and Atlanta, GA USA

Jennifer C. Sarrett

Like Brezis et al, Sarrett also investigates Indian caregiving and parental experiences of autism, while comparing this context to autism and the family in the United States. In both cases, Sarrett asks how the home as space and place impacts the meaning of disability for people with autism. She interviewed seventeen caregivers in Atlanta and thirty-one in Kerala, and observed seventeen families in Kerala and five families in Atlanta who had also participated in interviews. Sarrett concludes that though there are some similarities in the constellation of autism-specific and biomedical services that may be available to Keralite and American families, the arrangement of households themselves drastically changes the way autistic children are cared for in each location.

In Kerala, for example, mothers serve as both full-time child caregivers as well as domestic laborers, often spending long hours washing clothes by hand and cooking from scratch. Keralite children with autism have few interactive toys that are specifically geared to engaging them, few devices that may control their movements and behaviors (such as baby gates) or assist them in communication (such as an electronic device that voices requests for food or other needs.) Such tools are common in Atlanta households. However, they have consistent household care from mothers who manage all domestic labor with no outside employment.

Households with autistic children in Atlanta, meanwhile, are specifically retrofitted for the needs of the child. There are picture cards that children may use to show caregivers and parents an item of food that they wish to eat, as well as a calendar in the kitchen or office that marks doctors’ appointments and family events geared for socialization with the autistic child. Baby gates, cabinet locks, and other safety devices ensure the child does not come into contact with household dangers (such as kitchen knives and cleaning solutions.)

In sum, these tools are designed to change and improve the behavior of the child. The home itself is structured to be a therapeutic space: requiring material and financial resources that Keralite families do not have to physically adjust their households. Instead, Keralite families focus not on improving or altering an autistic child’s behavior, but rather emphasize consistent caregiving for the child. In both cases, however, parents are committed to creating an environment (be it material or social) in which a child with autism can be integrated into the activities of the household, and thus into the family’s social world. Despite cultural, and certainly resource, differences between Indian and American families, they share a common commitment to building home support systems for their developmentally disabled children.

Click here to access the full text of this article: http://link.springer.com/article/10.1007/s11013-015-9441-z


To access all of the articles in this issue, click here: http://link.springer.com/journal/11013/39/2/page/1

June 2015 Issue Preview: Guest Editor M. Ariel Cascio, on Global Autism Studies

Culture, Medicine & Psychiatry’s second installment of the year arrives June 2015. This special issue will address anthropological studies of autism throughout the world. To give our readers a preview of the upcoming issue, special issue guest editor M. Ariel Cascio, PhD joined our social media editor for an interview to discuss compiling the issue, what topics the articles will address, and new themes in the study of autism.


Can you tell us a little about the upcoming June 2015 special issue?

The special issue, “Conceptualizing autism around the globe,” shares anthropological (and allied field) research on autism in Brazil, India, Italy, and the United States. We talk about “conceptualizing” autism as a way to counter the idea that autism “is” or “means” one specific thing. Sometimes autism means the diagnosis measured by a certain instrument (such as ADOS), sometimes it means a more broadly defined set of characteristics (such as those in the DSM), sometimes it means an individual identity, and so many more things. The articles in this issue explore how autism is conceptualized at several different levels: in national policy, in treatment settings, and in the home.

What’s been your favorite part of working on the special issue?

I’ve just enjoyed the opportunity to greater familiarize myself with the group of scholars who are pursuing the anthropology of autism, and to work alongside scholars whose work I have long followed.

So how did you become interested in the study of autism?

I’ve been studying autism since 2008. I actually came to anthropology before I came to autism, and when I first began learning about autism, I saw it as rich for anthropological inquiry (isn’t everything!) because of anthropology’s strengths in focusing on lived experience, challenging deficit narratives of so-called “disorders,” and placing medicine and psychiatry in sociocultural context.

What was it like doing fieldwork in Italy? How do Italians see autism differently than other places in the world?

I’ve studied the autism concept more in Italy than in any other place in the world, and I’m very grateful to everyone there from whom I learned – autism professionals, family members of people with autism, and people on the spectrum themselves. I could hazard comparisons with the literature that address perceptions in other parts of the world – and some of these comparisons come through in the special issue – but for now I would like to focus on the strength of the rich description of the Italian context without external comparison. As my article in the special issue shows, autism professionals tended to take a social model of autism, focusing on creating environments that were tailored to the needs of people on the spectrum and structured to help them learn.

What are some of the challenges you’ve faced in studying autism?

As in many areas of inquiry familiar to readers of CMP, it can be challenging to communicate information about my study to people who study autism in other fields (clinical, psychological, social work, etc.). A lot of research about autism takes a positivist stance, whereas my research takes an interpretivist stance and focuses on autism as a concept whose meaning may vary rather than a diagnosis measured in a particular way. Nonetheless, I love talking about my research interests with a broad audience because in many contexts (especially in the U.S.), so many people have personal or professional interest in autism and we can always have interesting and stimulating conversations.

What’s something you think would surprise non-anthropologists about the anthropology of autism?

I would imagine non-anthropologists would be surprised by the anthropology of autism for the same reasons they might be surprised by anthropology (or medical anthropology) in general. For example, they might be surprised that anthropologists study autism all over the world, particularly if they think of the autism concept as something that represents a universal set of characteristics and experiences that are unaffected by context. The articles in this special issue really show that context matters in all conceptualizations of autism, from Brazil to the United States, from national policy to the family home.

Where do you see the anthropology of autism heading next?

I see the anthropology of autism becoming more inclusive. In her commentary, Pamela Block expresses optimism that the anthropology of autism will increasingly include researchers who identify as autistic themselves, and I agree. In addition to including more researchers with autism, I anticipate that the anthropology of autism will increasingly work to include participants with higher levels of support needs (those whom some people call “people with low-functioning autism”), and delve deeper into their lived experiences as well.


Many thanks to Dr. Cascio for sharing her insights! Look for the special issue on conceptualizing autism in June 2015, and be sure to check back for more previews of the issue, article features, and other blog entries about the new installment here on our website.