Guest Blog: “Telemedicine in Ghana”

This week on the blog we are hosting a guest post by Heather Baily, a Doctoral student in Anthropology at Case Western Reserve University. Here, she presents some of her research on telemedicine in Ghana.

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In November 2015, Tanja Ahlin and Mark Nichter issued a “Take a Stand” statement in the Critical Anthropology for Global Health interest group (available here), calling for more anthropologists to study telemedicine. Telemedicine is the use of telecommunication tools, namely cell phones and computers, to exchange information regarding patient health. A recent report from the World Health Organization (2016) states that universal health coverage cannot be achieved without this form of e-health. Universal health coverage, as well as comprehensive primary health care, has been an overarching goal of the international health and global health community since the Alma Ata conference in 1978, but these goals are very difficult to achieve. Telemedicine is poised to help achieve greater health coverage and access, yet the field is still very new, particularly in resource-poor settings, and is evolving rapidly alongside cell phone technology.

In June of last year, I traveled to Ghana to investigate the ways in which telemedicine is being used there. Ghana is in the midst of scaling up a successful telemedicine pilot project into a national telemedicine program through Ghana Health Services. Public health administrators in the pilot project districts, as well as doctors and nurses who worked with the program, all spoke favorably of the new technology. Each clinic and hospital has a designated smartphone to be used for various medical communication purposes, including receiving calls from patients, over-the-phone consultation from doctors at the regional hospital call center, and direct contact with the other clinics and district health offices through encrypted instant messaging apps, such as WhatsApp.

Practitioners reported decreased maternal mortality since the implementation of this program, as well as an increase in utilization of local clinics and trust in the staff. In Ghana, once someone has completed medical training of any kind, such as a community health nurse or a registered midwife, they must complete their “national service,” a two-year contract in an assigned village. Typically, community health nurses are younger and not from the village in which they are assigned to work. A “small girl/boy” is a common term used in Ghana for a young person, indicating not only their age, but their social status and lack of social legitimacy. Thus, being able to access and connect a patient to a doctor at a hospital over the phone has helped the nurses achieve more legitimacy and overcome their “small girl/boy” status.

I draw from several areas of anthropological theory when examining the impacts of telemedicine in Ghana, specifically the anthropology of reproduction since my dissertation research focuses on obstetric care. The concept of authoritative knowledge is particularly useful in this case. Authoritative knowledge is knowledge that is given more weight than other types of knowledge, or ways of knowing, by collective assessment in a local setting and is displayed in everyday practices (Jordan, 1990; Davis-Floyd & Sargent, 1997; Ivry, 2010). This concept relates to legitimacy in the health care setting as authoritative knowledge shapes interactions between patients and caregivers, access to knowledge, and health care decision-making. Access to physicians may alter the hierarchy of who has authoritative knowledge, adjust healthcare seeking patterns, or disrupt local power structures and “knowing” about birth.

Science and Technology Studies provides a foundation from which to examine the historical contexts and meanings of technologies and how people interact with them. The introduction of a communication technology which links rural areas to clinicians at a regional hospital complicates questions of the way people interact with technology, especially as it regards obstetric care.  Rayna Rapp (1999) examined technologies used in assisting reproduction, which she calls “technologies of knowing.” In this study, she examined the production of knowledge as a result of new technology. Following this tradition, it is important to examine the intersections of technology, reproduction, and knowledge by investigating ways in which the introduction of a new technology changes how a patient might acquire and use knowledge.

Studying telemedicine from an anthropological perspective builds on our understanding of how people interact with technology, particularly when seeking healthcare treatments, and how technology can influence a universal human experience, such as pregnancy and childbirth. As telemedicine is widely regarded as the much-needed direction medical care is heading around the world, it is crucial to examine ways it can shape an individual’s interaction with a technology and with the community at large.


About Heather:

Heather Baily is a dual degree Ph.D./MPH student in Anthropology at Case Western Reserve University. She has a MA in Anthropology from CWRU and a BA in Anthropology and Sociology from Colorado State University. Her research investigates the intersections of new telecommunication technologies used in healthcare and local structures of reproductive knowledge and authority in Ghana.


References Cited:

Davis-Floyd, R., & Sargent, C. F. (1997). Childbirth and authoritative knowledge: Cross-cultural perspectives. Berkeley: University of California Press.

Ivry, T. (2010). Embodying culture: Pregnancy in Japan and Israel. New Brunswick, NJ: Rutgers University Press.

Jordan, B. (1990). Technology and the social distribution of knowledge: Issues for primary health care in developing countries. In J. Coreil and J. D. Mull, (Eds.), Anthropology and Primary Health Care pp. 98–120).

Rapp, R. (1999). Testing women, testing the fetus: The social impact of amniocentesis in America. New York: Routledge.

World Health Organization. (2016). Global diffusion of eHealth: making universal health coverage achievable. Report of the third global survey on eHealth. Geneva.

 

In the News: Health Disparities and Water Quality in the 2016 Rio Summer Olympics

 

August 2016 – The 2016 Summer Olympic games in Rio de Janeiro, Brazil has dominated news headlines in recent weeks. The athletics event, taking place from August 5 to August 21, featured 207 countries in the Parade of Nations as well as the first ever Refugee Olympic Team. It is the first time the games have been held in South America. But besides highlights on the events and spotlights on athletes’ training regimens and backgrounds, there is another stream of news stories surrounding the Olympic Games. These stories have focused on two key public health issues related to this year’s Games: health disparities and water quality issues.

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Rio’s Olympic beach volleyball venue is on Copacabana Beach. Photo from Marcio Jose Sanchez for AP.

Only two years ago the FIFA World Cup was making similar headlines in Brazil. As reported in 2014, and highlighted in this blog[1], there have been past concerns about access to quality healthcare despite the surge of funds for the World Cup event. These reports unmasked a problematic system of health disparities to a global audience. The Daily Californian[2] stated that many Brazilians were “unhappy that their government [was] funding stadium renovations instead of spending on more instrumental matters like improved health care and emergency services.” Reports relating to the current Olympics have painted a similar picture for the present health scene. As Reuters[3] reported in December 2015, the governor of Rio de Janeiro declared a state of emergency “as hospitals, emergency rooms and health clinics cut services or closed units throughout the state as money ran out for equipment, supplies and salaries.” According to CNN[4], the financial crisis has been causing difficulties in the “provision of essential public services and can even cause a total breakdown in public security, health, education, mobility and environmental management.”. While the state of emergency declaration provides a critical 45 million reais ($25.3 million) in federal aid and may facilitate the transfer of future funds, estimates state that Rio de Janeiro owes approximately $355 million to employees and suppliers in the healthcare sector alone, and the state needs over $100 million to reopen the closed hospital units and clinics.[5] While the city of Rio spent approximately $7.1 billion on improving toll roads, ports and other infrastructure projects, the Brazil Ministry of Health devoted only $5.7 million to address health concerns[6].

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The Christ the Redeemer statue is visible above the Santa Marta favela in Rio de Janeiro. Photo from Joao Velozo for NPR. 

In addition to these issues (and the high-profile Zika virus, which is causing health concerns in multiple countries[7]), concerns surrounding water quality and cleanliness in Brazil has garnered considerable attention. A recent scene involving the diving and water polo pools turning a swamp-green color because of an algae bloom left some athletes complaining of itchy eyes.[8] While the Olympic Games have brought international attention to the impact of water quality on the athletes and visitors, the residents of Rio have been dealing with theses concerns on a daily basis for much longer. With almost 13 million people living in and around Rio, the current sewage system is struggling to cope. One news report[9] notes that “about 50 percent of what Brazilians flush down the toilet ends up in the country’s waterways. Diseases related to contaminated water are the second leading cause of death for children under five in Brazil.” Tests performed in a variety of areas, including the sailing venue of Guanabara Bay, over the course of a year found high levels of “superbugs of the sort found in hospitals on the shores of the bay.” The possibility of hospital sewage entering the municipal sewage system remains a concern.[10]

An economic recession, compounded by water concerns, political unrest, and a presently faltering healthcare system all leave many Cariocas— citizens of Rio– who rely on the public health system in a challenging and hazardous situation across the social, medical, and political spheres. With hopes of local profits from the Olympic Games ranging in the billions of dollars, much is at stake for both residents and investors.[11] Despite the risks and tribulations, many residents welcome the international event and attention, and credit the Olympics for cultivating “several underutilized, often abandoned spaces have been transformed to ones that appeal and cater to local residents”. Many “beautification” projects leave residents hoping the installation of new art and the newly constructed spaces will leave a lasting impression on its residents and visitors long after the games end.[12]  Despite this optimism, the citizens of Rio are not impacted equally by the Games.[13] The improved infrastructures will likely benefit those who already have access to services. Tourism, and tourism cash, has been weak in the favelas, or shantytowns, which house at least 25% of the population in Rio. The infrastructure inequities have even bypassed some neighborhoods entirely, leaving those residents out of the celebrations.[14]

Overall, these Olympic Games promise once again to bring the world’s cultures together in competition and camaraderie, yet they do not do so without controversy. This global spectacle illuminates athletics and sportsmanship, as well as the intersections between cultural events, politics and nationalism, power and profit, and community health. These larger issues lead to questions about what will happen to the residents of Rio after the Games have drawn to a close.

 


[1] https://culturemedicinepsychiatry.com/2014/07/11/news-the-2014-world-cup-and-healthcare-in-brazil/

[2] http://www.dailycal.org/2014/07/08/uc-berkeley-faculty-graduate-students-look-world-cup-different-light/

[3] http://www.reuters.com/article/us-brazil-health-emergency-idUSKBN0U716Q20151224

[4] http://www.cnn.com/2016/06/18/americas/brazil-rio-state-emergency-funding-olympics/

[5]http://www.reuters.com/article/us-brazil-health-emergency-idUSKBN0U716Q20151224

[6] http://wuwm.com/post/let-s-do-numbers-money-spent-rio-olympics#stream/0

[7] http://www.nytimes.com/2016/01/29/world/americas/brazil-zika-rio-olympics.html?_r=0

[8] http://uk.reuters.com/article/uk-olympics-rio-diving-pool-idUKKCN10O0UW?feedType=RSS&feedName=sportsNews

[9] http://wuwm.com/post/rios-water-problems-go-far-beyond-olympics#stream/0

[10] http://edition.cnn.com/2016/08/02/sport/rio-2016-olympic-games-water-quality-sailing-rowing/index.html

[11] http://www.newsweek.com/rio-2016-who-stands-benefit-successful-olympics-453094

[12] http://www.kvia.com/news/rio-olympics-bring-beautification-projects/40884340

[13] http://www.npr.org/sections/thetorch/2016/08/11/487769536/in-rios-favelas-hoped-for-benefits-from-olympics-have-yet-to-materialize

[14] http://www.reuters.com/video/2016/08/14/olympic-infrastructure-causes-suffering?videoId=369565427

Book Release: Haraway’s “Staying with the Trouble”

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Image via Duke UP website

Debuting this September 2016 from Duke University Press is Donna Haraway’s Staying with the Trouble: Making Kin in the Chthulucene (available here.) Haraway’s text challenges the concept of the anthropocene, noting that in an age of ever-increasing environmental degradation, any centralization of the human detracts from the ill-effects of a “damaged earth” on all forms of life. Haraway posits a new term, the Chthulucene:, to describe the contemporary state of human and non-human existence. She argues that this new term highlights the multi-directional, tentacular ways in which life forms are bound together as kin in this new world. Moreover, this term encourages us to consider not human self-making, but rather sym-poiesis: the mutual entanglements of human and inhuman life as they “make” and define one another. The text unites an environmental approach with themes that resonate throughout Haraway’s work: including feminism, technoscience, kinship, and the destabilization of the “human” category.

This publication will be of interest to anthropologists spanning environmental studies, medical anthropology, and anthropological theory, as well as scholars of science and technology studies. Haraway’s commentary on “making kin”and the Chthulucene previously appeared in the open-access journal Environmental Humanities and is available in full here.


About the Author

Donna Haraway serves as Distinguished Professor Emerita at the University of California Santa Cruz in the History of Consciousness Department. In addition to Staying with the Trouble and many past publications, Haraway has also released a collection of her manifestos this year, entitled Manifestly Haraway. The collection is available here through the University of Minnesota Press.

Book Releases: New Texts on Sex Tourism, Biotechnology

This week, we are featuring two book releases from the University of Chicago Press. The first book is Gregory Mitchell’s Tourist Attractions: Performing Race and Masculinity in Brazil’s Sexual EconomyThis new book, published in December 2015, presents an ethnographic perspective on gay sex tourism in Rio de Janeiro, Salvador de Bahia, and the Amazon. Mitchell examines issues of race, masculinity, and sexual identity amongst both sex workers and sex tourists. In particular, he asks how men of various racial, cultural, and national backgrounds come to understand their own identities and one another’s within this complex series of commercial, sexual, and cultural exchanges. Details about the book can be found here.

About the author: Gregory Mitchell is assistant professor at Williams College, where he teaches in the Women’s, Gender and Sexuality Studies program and in the Department of Anthropology and Sociology.

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Image via UC Press website

The second book, debuting in September 2016, is Hallam Stevens’ Biotechnology and Society: An Introduction (cover image not yet available.) Each chapter of the text will address a different topic in the cultural and historical study of biotechnology, from gene patents, to genetically-modified foods, to genetic testing and disability, assisted reproductive technologies (ARTs), and the intersections of race, diversity, and biotechnologies. The text will be of equal interest to scholars of science and technology studies (STS), posthuman theory, and the history and culture of medical technology. Details about the book can be found here.

About the author: Hallam Stevens is assistant professor at Nanyang Technological University in Singapore. He teaches courses in the history of the life sciences and information technologies. He is the author of Life Out of Sequence: A Data-Driven History of Bioinformatics, also available here via the University of Chicago Press.

 

Blog Archive: Latour’s AAA 2014 Address

In this installment of the blog, we revisit one of our first conference features. This commentary piece examined Bruno Latour’s Distinguished Lecture address at the 2014 Annual Meeting of the American Anthropological Association in Washington, DC. You can access the original post here.


 

This year at the American Anthropological Association 2014 Meeting, Bruno Latour was invited to deliver the distinguished lecture. Entitled “Anthropology at the Time of the Anthropocene,” Latour discusses the rise in the term anthropocene to describe our current stage of natural history. Although the term makes reference to how “human” (anthro) our current age may be, Latour jests that this term was introduced by geologists, not social scientists. In the anthropocene, it is humans that play the defining role in our geological historical moment.

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via Wikimedia Commons

The assumption, Latour notes, is that human agency is the prime source of action that shapes the physical world. Humans are responsible for climate change, for pollution, for altering the literal, natural fabric of our world. Yet we know that not all humans have the same impact on our environment. As Latour quips, there is not “One Human” who is responsible for the changes we see in our climate or environment. We are simultaneously assessing human power as a plural, collective entity, as well as using this concept to suggest that the blame for global change does not fall evenly across all humans. As anthropologists and cultural theorists, we know how fragile human agency can be when we divide it amongst many contending social and cultural groups.

Is there another way to think about human action that does not problematically configure humans as both collective and individual, acting but not universally accountable for all human actions? Latour posits that rather than focusing solely on agency, with a strong emphasis on human intention and purpose when committing action, we could think instead about animation, or what forces–human and non-human– are in motion in a given social space. To do so, we can no longer assume that the human agent is a colloquial be-all-end-all.

How does this assertion speak to medical anthropology, social medicine, and medical humanities? At first, we might raise our brows at the discussions of geography, environment, and most of all the suspicion surrounding the primacy of human agency. Decentralizing the human agent, we might say, is perhaps the least humanistic approach to the study of human experience. Indeed, medicine is the care of humans by humans!

However, our human ability to question our own power and position in the universe, amidst other natural and non-human forces, is a mark of our species. Whether through philosophy, religion, or social science, humans have a proclivity for ruminating about our place in the material, corporal world. We crave knowledge about what sets us apart from non-human things, and how we are sometimes reliant on them. For scholars of medicine, such inquiries about our relationships with the physical universe is key. We consider the place of non-human agents in disease and care. We ask: why do physicians rely on certain tools? Why do patients see stethoscopes, thermometers, and scalpels as making a clinician legitimate in his or her practice? How are medical traditions made unique by their tools and pharmaceutical formulas? Could the layout of a hospital or clinic itself alter the way care is given?

In an age where technology permeates developed and developing societies, Latour’s suggestion to destabilize human agency is productive when considering medicine as a cultural object. We must think not only of ourselves, but the physical environments we live in and the material objects and devices we cannot seem to live without.

Many scholars understandably resist Latour’s idea that non-humans could have some primitive agency. Yet even if we do not assign agency to non-human tools, things, and environments, thinking seriously about their role in sociocultural systems is informative. Medicine is a lively site of exchange between patients and physicians, as well as practitioners and devices, patients and new medical innovations, and the built environments which house them. As Latour invites us to do, we should pause to consider humans within the midst of a rich material world around us that– like humanity itself– is constantly in motion.

 

In the News: Telemedicine in the United States

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The intersections between technology, medicine, and health are a frequent site of discussion at Culture, Medicine & Psychiatry. In our last issue of 2015, for instance, Yael Hashiloni-Dolev[1] examined the role of new medical technologies that enable posthumous reproduction, while Petersen and Traulsen[2] shed light on the nuanced social uses of psychoactive medications amongst university students. These articles underscore the centrality of technology in everyday human health behaviors, and on the cultural meaning of these new tools in local medical landscapes.

Another technological innovation altering the social world of medicine—one making headlines in recent months—is telemedicine. In the Journal of the American Medical Association[3] (JAMA), telemedicine has been described as “the use of telecommunications technologies to provide medical information and services,” often a shorthand “for remote electronic clinical consultation” via phones and internet applications.

In the December 2015 AARP Bulletin, author Charlotte Huff[4] remarked that over 1 million patients will use telemedicine services this year, and remote access to physicians by phone, video chat, and email is more and more commonly covered by American employers’ health insurance packages. A Reuters article[5] adds that in Texas, a telemedicine company is working to block a state law that would require physicians to see a patient in-person before consulting with them via phone, email, or other means. And in the New York Times[6], a physician observed that telemedicine may prove a useful tool for children and adolescents: many of whom have grown up in a digital culture of “oversharing” and would not balk at texting their physicians images of strange rashes or lesions on their bodies. As this new tool of health care delivery is negotiated in different societal arenas, so too are its implications increasingly worthy of anthropological attention.

Telemedicine is altering the social fabric of medicine in a number of significant ways. Here, we will outline two potential outcomes of telemedicine on medical exchanges facilitated by technology. First, telemedicine extends the professional reach of biomedical clinicians. Areas where biomedical care is inaccessible, or where only indigenous medical systems exist, may now fall under the electronic eye of a faraway practitioner. This has extraordinary consequences for the ubiquity of biomedicine and the consolidation of biomedical power. Second, and rather conversely, telemedicine empowers the patient in the clinical encounter. Because the physician or clinician is not physically present to examine the patient’s body, the patient themself is the one who touches a swollen throat, or flexes a stiff joint, and relays their response through phone or web camera. In sum, the patient gains greater control over bodily (and verbal) narratives that, unlike an in-person exam, the clinician does not have total access to.

The rise of telemedicine speaks to medical anthropologists, certainly, but it also presents a fascinating case more broadly for science and technology theorists and scholars in health communication. As the topic of telemedicine continues to capture the interest of medicine and the media, so too will it fall under the consideration of researchers piecing together the networks that bring patients and their caregivers together in novel ways.

[1] http://link.springer.com/article/10.1007/s11013-015-9447-6

[2] http://link.springer.com/article/10.1007/s11013-015-9457-4

[3] http://jama.jamanetwork.com/article.aspx?articleid=386892

[4] http://www.aarp.org/health/conditions-treatments/info-2015/telemedicine-health-symptoms-diagnosis.html#slide1

[5] http://www.reuters.com/article/health-case-to-watch-teladoc-idUSL1N14H0CT20151228

[6] http://well.blogs.nytimes.com/2016/01/18/using-phones-to-connect-children-to-health-care/?ref=health

 

Issue Highlight: Vol 39 Issue 4, Posthumous Reproduction

Our final issue of the year– Volume 39 Issue 4 December 2015– has just arrived. In our last blog post series for 2015, we begin with a three-part feature of the latest publications at the journal in this new issue. In addition to the article previews in this series, our readers can access the full issue here. In this post, we explore Yael Hashiloni-Dolev’s preliminary research on posthumous reproduction in Israel (full article accessible here.)


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Biomedicine, through its innovative application of technology, can reconfigure biological experiences in ways that alter or reinforce cultural beliefs surrounding life, death, reproduction, kinship, parenthood, and social roles. Most recently, this has become a central issue in the field of assisted reproductive technologies: where biomedical interventions potentiate new relationships between parents, families, and children. But while assisted reproductive medicine is often discussed in terms of generating life, these new generative technologies may also intersect with death in novel ways that challenge existing understandings of kinship and familial relationships.

Hashiloni-Dolev article studies Israeli lay perceptions of a new concept in assisted reproductive medicine called posthumous reproduction (PHR.) In sum, PHR entails the use of genetic material from deceased parents to conceive children after their deaths. This usually means a woman will opt to become artificially inseminated with a husband or partner’s sperm retrieved while the man was in a coma or vegetative state: however, it may also include the fertilization of a woman’s eggs, frozen while she was alive, and gestated in a surrogate mother. Even frozen embryos of two deceased parents (a mother and father) might be “adopted” and implanted into a female relative or another recipient, who subsequently gives birth to a child whose biological parents are no longer alive. This process also facilitates the possibility of posthumous grandparenthood, and indeed, some parents whose adult children have died may seek out PHR technologies (include allied technologies such as surrogacy) to produce grandchildren.

Israel is one of the few countries that permits some forms of PHR, and it is a progressive nation in terms of reproductive technologies: its state health system covers the costs of ARTs (assisted reproductive technologies) for couples who have difficulty conceiving. Although Israel does not permit all forms of PHR, it does allow for the collection of a man’s sperm upon a wife’s request to carry his child upon his death (what the author calls the “prototype scenario.”) In this regard, Israel served as a prime location for surveying participants and testing initial ideas about the public perception of PHR: a new frontier of ARTs yet to be studied in the anthropological literature.

Through 26 semi-structured interviews with newlywed or childless couples, Hashiloni-Dolev discovered that there were some inconsistencies between the Israeli PHR policies and the participants’ understanding of PHR technologies. For instance, the government stipulated that PHR could occur via the retrieval of sperm from a dying or recently deceased father upon the wife or female partner’s instruction. The policy states that the retrieval could occur given evidence of a man’s “presumed wish” that he would want his spouse or partner to carry his child after death. However, “wish” and “consent” were interpreted differently by men interviewed for the study. The men typically stated that while they would defer to their partner’s wishes to have a child after their death, they themselves were uncomfortable with the possibility of their partners having the child and being unable to “move on” should they pass away. In this instance, while the man’s presumed “wish” might not change a woman’s decision to retrieve his sperm posthumously, it does not mean the man would “consent” to the process if he were not already dead.

Conversely, consent becomes more complicated given the circumstances that typically surround the use of PHR. The man is presumably young, such that his female partner would be able to carry his child, and would have died suddenly: thus making it nearly impossible to obtain his consent unless he had already affirmatively offered it while still alive and healthy.

There were also issues related to the family life of a child born through PHR techniques. Both male and female participants worried about the emotional stability and security of children born out of such conditions, and expressed their concern with new policies being proposed that would allow for expanded posthumous grandparenthood rights. The participants believed that the decision to have children following the death of a spouse was between the couple, and was not between other family members. Likewise, many participants worried about the birth of a child as a living shrine to the deceased, rather than as a new and autonomous member of the family.

In these responses, it is clear that while both biomedical technologies and governmental policies may enable PHR to occur, the process is not always viewed in such liberal terms by individuals who could be most likely to use it. Posthumous reproduction thus supplies medical anthropologists and scholars of social medicine with a nuanced case of the cultural position of new technologies, and the concerns that individuals across cultures have with these new reproductive tools: particularly as they relate to consent, kinship, and the roles of parents.