Readings for Medical Anthropology – Flashcards

THESIS: Cultural studies of contemporary biomedicine should focus on the dynamics, tensions and exchanges between local and global worlds of knowledge, technology and practice CONNECTIONS: Interesting argument in comparison to Latour's (1983) regarding laboratories and the dissemination of scientific knowledge, Martin's (1998) regarding power as a rhizome, and Foucault's regarding capillary power -- I think Good's (1995) argument here places more stress on power dissemination as a linear object as opposed to capillary or rhizomic power structures (Emily Martin 1998)

THESIS: Argues that beliefs about illness are always closely linked to specific therapeutic interventions and thus cannot be understood apart from their culturally constituted systems of knowledge and action. He sketches out an ecological model for comparing healthcare systems cross-culturally by focusing on the external and internal factors that affect the healthcare system. A key aspect of Kleinman's ecological model is distinguishing between three types of clinical realities: folk, professional and popular cultures. CONNECTIONS: Relevant for how anthropologists approach cross-cultural analysis of health care systems and universal therapeutic structures.

Hidden Hearts & Bright Faces THESIS: Wikan argues that the Western construction of the public versus the private, with the private being a safe and relaxed environment cannot be applied to Balinese society. Rather than differentiating between the public and private, we should center on person-in-place to analyse how people perceive and experience space. The important thing to take away from this article is how space is construed differently in different cultures. As opposed to the West, in Bali the home is where one has to watch out - after all you let people into your intimate lives, this gives them all sorts of knowledge and leverage to harm you with. This issue is complicated by the fact that the Balinese are morally obliged to always maintain a bright face and to not show anger, jealousy etc. Therefore, one never knows what guests are thinking and the Balinese have to take every precaution to perform the required behaviors in order to not offend the guests (which might in turn lead to them using black magic and harming you). Wikan refutes Geertz and Geertz' (1975) observations that a sharp distinction is present between the public and private domains of Balinese life. Furthermore, Clifford Geertz argued that witchcraft is unrelated to Balinese personhood and should be studied as such. Wikan responds to that by saying that witchcraft plays an integral role in how people perceive their relationships with others vis a vis themselves. She uses the case study of Issa, who took her to visit and pray with a widow as a case example of how the imperative to keep a bright face goes past the public/private dichotomy. "Person-in-space" describes a paradigm that Wikan proposes in order to look at how space is constructed and perceived. This is not only dependent on the space itself, but it is a question of who is in it with what, whom, when and how.

Television, Disordered Eating, and Young Women in Fiji THESIS: In Fiji, Western media images of thin, successful women (like Zelda) have worked synergistically with globalization and the transformation from an agrarian based society into a cash economy to increase the rate of eating disorders. In Fiji Western media images are used as a guide and the notion of a thin body has become associated with securing a successful future, amidst uncertainty about how to live life in a changing, globalizing world. Becker conducted her ethnography three years after the introduction of TV to a rural community in Western Fiji and found an increase in eating disorders amongst young girls during this time, whereas prior to 1990 cases of Anorexia and Bulimia Nervosa were highly rare. Becker shows how media, a changing economy and globalisation act synergistically to play a role in this process. Importantly: there is considerable ambivalence to the extent in which a thin tall body is actually perceived as ideal'. Becker suggest that this ambivalence comes from Fijian youth having to craft an identity which adopts Western values about productivity and efficiency in the workplace while simultaneously selling their Fijian-ness (an essential asset to their role in the tourist industry). Self-presentation is thus carefully constructed so as to bridge and integrate dual identities. That these identities are not consistently smoothly fused is evidenced in the ambivalence in the narratives about how thin a body is actually ideal." CONNECTION: Personhood: Becker (2004) argues that in Fiji the means of projecting personal identity have gradually shifted from mind and character to an increasingly visual and consumeristic focus "Traditionally, in Fijians, identity had been fixed not so much in the body as in family, community, and relationships with others, in contrast to Western-cultural models that firmly fix identity in the body/self." (P.551) CONNECTION: Fijian explanations for idolising tall thin bodies are notably different from Western explanations and therefore a Western-based therapy might not work at all in this context. Demonstrates the need to look at sociocultrual context and historical roots behind disordered thinking in order to develop therapeutic strategies CONNECTION: Shows how social relations are inscribed on the body/ how the body constitutes a so die for social relations CONNECTION: Neoliberalism & self-transformation from Gibbon et al. (2010).

Condoms and Cosmology THESIS: Taylor points out how the rejection to use condoms by men and women from Rwanda has deep roots in their concept of personhood. The refusal to use condoms is related to the concept that sex is an interchange of both partners' bodily fluids. A moral person is produced by gifts, by their constant interaction with other individuals through reciprocal dynamics of giving and receiving. The Rwandan concept of physical well-being is related with the importance of the flow of bodily fluids. The "flow" is seen as a way of receiving and giving. When blockage occurs the body can only receive and as a consequence reciprocity dynamics cannot be completed. In this sense, "blockage" of this flow represents the biggest risk. Thus, Taylor argues that anything perceived to cause blockage (for example a condom) will be intensely rejected by Rwandans. Taylor (1990) argues that personhood is constructed differently in Rwanda than in the West. He claims that the Western conception of a person is as an entity that is perceived as an individual being (thus, society = sum of individuals). In Rwanda, however, Taylor argues that personhood is perceived to be built through a constant process of giving/receiving gifts (thus the individual cannot be understood apart from society). CONNECTION: Risk perception. Rwandan understanding of personhood also affects the perception of risk as a matter of singularity or plurality. In health issues people consider risk as dependent on not only on what they do but also on what others do. CONNECTION: Marcel Mauss, The Gift: Through interchange of things individuals adopt obligations with the other person, the obligation of giving back and receiving. This obligation of reciprocity between donor and recipient creates a social bond. Not being able to reciprocate has social awful consequences. Mauss' The Gift also relates in important ways to one method of making sense of organ exchange (Jo Cook's lectures).

Soul Loss THESIS: In order to understand soul loss, we need to grasp not only what soul loss means to people but also what it feels like, since cultural ways of seeing and feeling tie into experiences of personal distress, contributing to the nature and frequency of culturally recognized forms of suffering Desjarlais explores the ways in which the aesthetic sensibilities of the Yolmo of Nepal influence how and why villagers suffer from soul loss, what soul loss feels like and why this form of illness prevails in this area. He explains that soul loss can take several forms, but focuses on a loss of spirit (bla), understood as the vital essence of a living person, the volitional impetus to engage in life. Its loss does not cause death, but in an illness constituted by a lethargic slumber in which the person does not want to eat, work, talk, or sleep. He provides 3 case studies of soul loss (one of a woman who falls on the way to a funeral, one of a child and one of a recently married woman) and cites different explanations for each case. Desjarlais concludes the chapter by providing an explanation of why soul loss seems to be affecting the Yolmo of Nepal more than other ethnically Tibetan societies. He argues that in the case of Yolmo the basic tenets of Buddhism - i.e. the acknowledgment of change, decay, and death, and the stress on suffering, purity, and right mindfulness - have fused with Yolmo patterns of experience so that they have taken a particular intensity. Notions of loss are indeed particularly relevant to the everyday concerns of Yolmo villagers, because of the present threats to local collectivities constituted by antagonism between the families and by the economic situation, forcing males to depart in search of a job. And since the physiology of the body mirrors the physiology of households and villages, bodies tend to assume a sensibility of loss when distressed. ^Not sure I agree with this conclusion... CONNECTION: Buddhism and depression CONNECTION: Notions of personhood and TSCYAYFD CONNECTION: Combining methodological approaches: phenomenology with cross-cultural analysis. He seems to be against Interpretivism (by saying there is a need to go beyond patient's accounts. Interpretivists typically prize and doesn't question the insider's view, simply trying to reconstruct it faithfully)

Clinical Paradigm Clashes THESIS: Calabrese argues that traditional Navajo healing, which involves communal rituals and altered states of consciousness is a legitimate form of therapy, even though it is very different from Euro-American psychotherapy. Drawing from his work with the Native American Church (NAC), he challenges our cultural assumptions of what makes effective psychotherapy and asks that we consider alternative paradigms when judging interventions for clinical and political decisions. All therapeutic intervention is influenced by culturally relative ideological and metaphysical assumptions. In Western psychiatry, these assumptions include commitment to individualism, tolerance of certain psychoactive chemicals like alcohol and tobacco but not others and 'normal' sexuality GOOD QUOTE: "patients are not homogeneous, neither should psychotherapeutic intervention be reduced to a "one size fits all" therapy manual. Human diversity includes deep cultural psychiatric differences" Calabrese explores 10 areas of cultural difference in relation to psychotherapeutic approaches to intervention: (1) Individualist dyad (relationship between client and therapist in Euro-America) versus communal group process (2) The role of the healer: In Euro-America, therapeutic efficacy is on the therapist (not sure I agree). In NAC the healer is more of a guide, with the individual playing a central role in gaining insight (3) The expectation of calm self disclosure to a professional stranger (4) Time (1 hour for psychotherapy, 6-7 for peyote ritual) (5) Secular versus spiritual intervention (6) Change as a rational decision versus ecstatic experience/ hypnotic suggestion (7) Individualised narratives (n Euro-American therapy) versus performed narratives (that rely on narratives with fixed myth and symbolic structure) (8) Psychotherapeutic intervention as remedial-stigmatized (only see shrink when something is wrong- an act of failure) versus preventative-valorised (therapeutic intervention is a preventative measure and an opportunity for development) (9) Dualist separation of meaning-centred and pharmacological interventions (mind/body dualism in Euro-America) versus integration of mind and body (10) Trust in synthetic versus natural drug forms CONNECTION: Role of spirituality in healing. MBCT and Peyote ritual both have religious roots as psychotherapeutic interventions. Both present a move away from 'rational' discussion (i.e. analysing the validity of beliefs) too. CONNECTION: Big pharma and socially acceptable drug use being a product of sociocultural morality and rationality. CONNECTION: Foucault. Calabrese describes peyote as providing a sort of panoptical gaze to oversee an individual's actions relative to moral expectations (like a super-ego) CONNECTION: Cartesian mind/body dichotomies CONNECTION: Personhood in a social context. Links well with Becker's work on eating disorders as the synergistic results of globalisation. With the rise of globalisation can we really be so sure that the cultural differences Calabrese describes are reflected in Westerners? Or is he describing medical hegemony? CONNECTION:

Foucault & The Medicalisation Critique **See your own notes, these ones are subpar** Lupton interrogates the notion of medicalization as it has been taken up by orthodox critics and Foucauldian writers to explore the ways a Foucauldian perspective can contribute to understandings of power in relation to medical knowledge and practice and the medical encounter. She argues that the writings of Foucault and his followers tend to present a world in which individuals' lives are profoundly experienced and understood through the discourses and practices of medicine and its allied professions. Equally she claims that orthodox critics tend to simplify the complexity of the role played by medicine. In this paper, the Foucauldian perspective on the practices of the self are taken into consideration in order to overcome both the orthodox critique to medicalization and the Foucauldian notion of docile body. These two approaches agree that medicine is a dominant institution that in Western Societies has come to play an increasingly important role, shaping the way we think about and live our bodies. For orthodox critics, medicalization is typically represented as negative, repressive and coercive process that limits the autonomy and encourages the dependency of lay people. These critics argue for the possibility that medical power must be diminished in favour of greater autonomy on the part of lay people. On the other hand, the Foucauldian understanding of subjectivity and the body as constructed through medical discourses and practices calls into question the assumption that de- medicalization is a source of freedom and greater autonomy for lay people. For Foucault, demedicalizing the body may well lead to different modes of subjectivity and embodiment. The best claim against the orthodox critique of medicalisation in the whole article (in my opinion) comes from how Lupton applies Foucault's notion of capillary power to demonstrate how it is impossible to remove power from members of the medical profession and hand it over to patients. Power is not a possession of particular social groups, but it is relational, a strategy which is invested in and transmitted through all social groups. Lupton's advice is to take up Foucault's later interests in the practices of the self and engaging in a phenomenological analysis of the experiences people have in the context of medical care. Neither the orthodox critique nor the Foucauldian perspective has adequately taken into account the mutual dependencies and the emotional and psychodynamic dimensions of the medical encounter, preferring to rely upon a notion of rational actor. Recognition of the irrational and contradictory aspects of the relationship that lay people have with members of medical profession may help to tease out the complexity of power.

The Biotechnical Embrace THESIS: Science, biotechnology and biomedicine cannot be separated from the society in which they are found (i.e. they are culturally relative). However, attention must also be paid to their place in the wider global system. Physicians, patients and the public are subject to constantly changing ideas ('regimes of truth') surrounding appropriate treatments. The enthusiasm for biomedicine comes from the cultural production of ideas surrounding the potentiality of biotechnological advances for success despite there being little evidence to demonstrate therapeutic efficacy. Good focuses on oncology departments to demonstrate how clinical narratives connect to public imaginations of experimental biomedicine to shape patient expectations and experiences. In particular, she discusses ABMT therapy (Autologous bone marrow transplant) as an example of the biotechnical embrace. The use of ABMT treatment was initially controversial as it was expensive to carry out with questionable efficacy. Due to the price of the treatment, many patients were refused coverage leading to several lawsuits being brought against insurance companies. The demand from the public spurred researchers to continue to development the treatment. once clinical studies showed that mortality rates had dropped, AMBT was introduced as a standardised procedure for metastatic breast cancer.This demonstrates how public and individual patients invest in the potentiality of experimental biomedicine. Despite the initial mortality rates resting at 30%, patients demanded access to treatment leading to its development and implementation as standard practice and this demonstrates how individuals embrace biotechnology as well as being embraced by it. Good also looks at the ways patients use humour to navigate the ambiguities of experimental treatments. Whilst the biotechnical embrace is rooted in the desire for hope, individuals do not wholly adhere to this ideal and patients use ironic humour to voice the cynicism they felt regarding the efficacy of the treatments. Good warns that we must be sensitive to how the marketing of biotechnology influences the practices of medicine in low-income settings. She recognises that all societies face ethical questions regarding how best to serve all patients. These questions arise more profoundly in low-income societies where the medical imaginary that privileges experimental biomedicine could create a demand for biotechnologies that are not economically sustainable. CONNECTION: Her article in 1995 (week 1), which also uses the case study of oncology to demonstrate the ways in which exchanges between patients and providers create medical cultures. CONNECTION: Twilight sleep shows the downside to the biotechnical embrace. Women demanded access to treatment that led to hesitant physicians needing to embrace the technology, despite its limited efficacy. Took public tragedy to recognise this. CONNECTION: Relates to Martin's work on the ambiguities and displacement in pharmaceutical uptake in USA. Both studies demonstrate the ways that patients interact with the ambivalences and ambiguities of medical (in one case pharmaceutical, in the other experimental) treatment. Also relates to Petryna and Kleinman's study on the pharmaceutical nexus. CONNECTION: Good's final 'warning' of the global uptake of the biomedical embrace is widely relevant throughout the course: technologies, an alternative (less pejorative) approach to medicalisation, organ trafficking, big pharm outsourcing of clinical trials, as well as Myland and Bolstand's study on breastfeeding amongst HIV+ mothers.

Real-Time Fetus THESIS: Ultrasound imaging (at least in the case in which it is used as a precursor to amniocentesis screening in New York-based prenatal genetic testing clinics) acts to personify (make 'real') developing foetuses, turning what are essentially black-and-white blobs on a screen into a baby -a life. In short, ultrasound turns the experience of early pregnancy (which usually does not include feeling any signs of foetal movement) into a quantifiable, 'real' pregnancy, knowable through the use of technology, not embodied experience. In this context women become more directly faced with the status of a developing embryo as a person. The impact this personifying aspect of ultrasound has on how women embody pregnancy is complex. However, it certainly appears to act as both a source of joy as well as a source of anxiety for women (and their partners) about the health status and vulnerability of their unborn children. She sets the goal of exploring the complex implications of sonographic personification: essentially, while the act of getting an ultrasound is often portrayed (particularly within public media) as a joyous and pleasurable occasion (which it often is), the personifying aspect of sonography means that the act of getting an ultrasound often introduces just as much anxiety. In essence, once an ultrasound personifies what is growing inside a woman as real -as a life -women often express added anxiety about the vulnerability of their unborn child and the potential for things to go wrong. CONNECTIONS •The obvious connection here is to Foucault and his notion of the medical gaze, biopower, etc. •Barbara Duden's book, Disembodying Women (1993). She is a medical historian and writes on the roles that visualisation technologies have played in shaping how we 'know' the foetus. Also see The Woman Beneath The Skin (1991). • Joseph Dumit's (2003) work on the power of visualisation technologies in brain scans to influence how those with mental illnesses think about and embody their conditions •Tine Gammeltoft's (2007) study on pregnant women's use of obstetrical ultrasound imaging in Hanoi. Gammeltoft's study suggests that the power sonography has to personify the foetus may be peculiar to the West (or at least not taken up with similar vigour in Hanoi).

An Anthropology of Structural Violence THESIS: Farmer's central thesis is that to understand modern epidemics and how they are rooted in misery and inequality, we need to understand the ways in which they are rooted in history and political economy. He defines structural violence as a form of systematic control and manipulation emanating from those in power and argues that an unfair economic and social order perpetuates and justifies the continuation of these dynamics. Farmer exposes the dismal situation in Haiti: its extreme poverty, completely collapsed healthcare system and the daily life struggle of its population. Key to Farmer's argument about structural violence is his suggestion that it is crucial for researchers to take the historical, geographical, and biological contexts in to account in order to understand the nature of structural violence in Haiti. According to Farmer, structural violence is directly linked to racism, slavery, and social and gender inequalities. He uses the case studies of tuberculosis and HIV as two diseases that kill the poor disproportionately. Farmer on defining structural violence: "the concept of structural violence is intended to inform the study of the social machinery of oppression" (2004:307) Farmer positions himself as a CMA, pointing out the important role that anthropologists have to play in uncovering systems of structural violence since anthropologists often conduct fieldwork in poor countries. He argues there is a great opportunity to unveil the causes of inequality and domination by having a real and contextualised picture of the situation. Farmer remarks the importance of using a combination of ethnographically visible events with a broad geographical context and deep historical analysis. In the article he gives a short historical account of Haiti (see notes) CONNECTION: Obviously to other CMA work like NS-H and Phillipe Bourgois, who argue that the term "structural violence" used by Farmer needs to be better defined to make ethnographers realise the importance of looking at the deep causes of suffering. They also suggest that it's necessary to look at the discursive power and to include in the concept of class the issues of gender and race. CONNECTION: Didier Fassin, who hasn't aligned himself with CMA appreciates the importance of bearing in mind the historical background but he believes that contemporary ethnography should also take into account present events in order to build up a real picture of the situation. CONNECTION:Power & neoliberalism as a method of control

THESIS: The racial disparities found in the US health care system are grounded in institutional racism found in the professional ideologies of medicine, which lead to power imbalances between ethnic minorities and medical elites. Institutional racism is multifaceted and includes both covert and overt displays of racism. The article looks at: (1) how the training of medical students and the organisation of medical institutions creates racial disparities in health care provision and; (2) how institutional racism creates conditions whereby ethnic minorities become over diagnosed with particular illnesses. The authors discuss how medical training teaches students to embody the medical gaze and go on to show how the associated need to streamline illness narrative into medical diagnoses can act as a form of structural inequality when patient's narratives don't fit into the medical machine. They suggest that these patients (often ethnic and racial minorities) are more susceptible to being mis-served and underserved by the medical institution, more likely to find themselves diagnosed with psychotic disorders (as opposed to affective) and less likely to receive adequate medication and medical attention because of time constraints put on the medical establishment CONNECTION: Strong connection to Foucault's medical gaze: the authors here argue that medical students must learn to embody the medical gaze as they discern what is relevant to the clinical encounter. In doing so, they learn to dismantle patient's lives and reconstitute their concerns about their illness into medically meaningful narratives that allow physicians to provide a diagnosis and treatment plan. Medical narratives must be streamlined to get rid of irrelevant data and so the social side of a patient's life is often regarded as inadmissible evidence. This does not mean that patients are ignored, but their narratives are built for them by clinicians. CONNECTION: Obviously structural inequalities, power dynamics etc. Other studies that have looked at the impact of training medical students like "Learning Medicine" by Good & Good (1993) on the biotechnical embrace and the role of the "soteriological" (affect) in suffering and salvation that infuse medical practice. Also relevant here is Atul Gawande's "Education of a Knife" in "Complications" (2008) and Jerome Groopman's "How Doctors Think" (2008) CONNECTION: Race & psychiatry (see pages 411-416). CONNECTION: Also could relate to the medicalisation week with the production of biomedical power. Mattingly's ethnography (paradox of hope) demonstrates the struggles of families to construct narratives that complement and work with the clinical narratives provided for them.

Syndemics & Public Health THESIS: Singer and Clair's main purpose here is to introduce the concept of the syndemic as a "big picture" way of understanding disease in public health. The idea of syndemics is a move away from rigid biomedical classifications of diseases as discrete, bounded entities unlinked to the social context. The concept of a syndemic allows us to articulate the ways in which diseases are intertwined with each other and with the social conditions and biopsychological consequences of disparity, discrimination, and structural violence. Singer and Clair use the notion of syndemics to explore how different diseases act together to create systems where illness progresses much more swiftly. They cite a number of examples, all of which highlight the importance of understanding how diseases interact with each other and with social conditions to produce excess morbidity and mortality in a population.The example of co-infection with HIV and TB is given, where having HIV makes TB worse, and having TB can accelerate the immune system destruction that occurs with HIV. People with TB and HIV progress to death much faster than those with only one of these conditions. At the social level, o TB is given as an example of the interaction of sociopolitical forces and disease: poverty increases the likelihood of acquiring TB infection, due to poor nutrition and repeated exposure to the bacteria, and difficulties accessing care and adhering to treatment plans. Syndemic can be conceptualised at 3 different levels, all with negative health consequences: (1) Population (diseases clustering in a a location or population) (2) Biological (biological interaction between 2 pathogenic agents can occur within 1 individual to create additional negative health consequences) (3) Social (this relates to structural inequities. Looking at how epidemics that interact at the biological and are sustained at population level are caused by harmful social conditions and injurious social connections) Singer and Clair (2003) cite the case study in syndemical research (the Syringe Access, Use, and Discard study in 3 New England cities). They suggest that there is the presence of a large number of serious infectious and other diseases among injection drug users and a notable rate of co-infection by two or more of these diseases. Individuals who reported high numbers of diseases were more likely to be homeless. This case shows how syndemics works on multiple levels (it also shows the rationale of current public health efforts on reducing risk instead of prosecuting offenders) They conclude by suggesting that recognising the existence of syndemics makes clear the need for a biosocial re-conception of disease, with a more holistic approach that emphasizes interrelationships and the influence of contexts. CONNECTIONS: Paul Farmer (2003, 2004) and structural violence CONNECTIONS: Really interesting connection to be make to Fassin (2011) "This Is Not Medicalisation" who also uses the case of Exchange Programs amongst intravenous drug users, but in his case it is used to illustrate the complexities of medicalisation. This study supports Fassin's work, showing the current rationale taken up by PH workers. CONNECTIONS: These writers align themselves with CMA, through their discussion of the intersection of health, politics, power, inequality, poverty and human rights

Where It Hurts THESIS: Cohen conducts a detailed ethnography in Chennai. and suggests that ethical arguments either against (purgatorial ethics) or for (ethical publicity, i.e. rationalist ethics) organ trade in India need to expand to encompass more than just the dyad of seller-buyer. The logics of the two orthodox arguments obscure the context of poverty, indebtedness, economic entrepreneurship and construction of female agency where organ transactions are situated. KEY: He argues that understanding the organ trade in Chennai necessarily involves understanding the inextricable links between gender, citizenship and organ surgery (the 'operability' of female bodies). Surgical operations in Chennai is a central modality of citizenship, which Cohen defines as the performance of agency in relation to the state. In other words, having an operation becomes a dominant and pervasive means of attempting to secure a certain kind of future: to be someone with choices is to be operated upon, to be operated upon is to be someone with choices. "Operation" is not just a procedure with certain risks, benefits, and cultural values; it confers the sort of agency I am calling citizenship." CONTEXT: Cohen's study takes place in Chennai (nicknamed by locales "Kindeyvakkam"). While it is neither the poorest nor most impoverished area of India, it was chosen because it is a fertile ground for organ harvesting as health care innovations are more pronounced in Southern India. The study takes place in light of India passing the 1994 Transplantation of Human Organs Act. The act made the selling of solid organs unambiguously illegal, authorized the harvesting of organs from the bodies of persons diagnosed as brain dead, and forbade the gift of an organ from a live donor other than a parent, child, sibling, or spouse. Exceptions were allowed but had to be approved by Authorization Committees set up in each state that implemented the Act to ensure that the donor was some kind of relation or close friend -but easily circumvented TWO MOMENTS OF SCARE: kidney scars have "two moments" for women: (1) a recent past , where the scar marks their successful efforts to get out of extreme debt and support their family, and (2) an indebted present when it has come to mark the limits of that success. The scar reveals both the inevitability of one's own body serving as collateral and the limits to this collateralization. One has only one kidney to give, but the conditions of indebtedness remain (141). CONNECTION: Obviously, this article should be discussed as an opposition to Marcel Mauss argument about the gift. Although Cohen does not propose that the rationalist argument outlined in this paper is better (the one about the ownership of our own body); it is worth to think in relationship to that. CONNECTION: The construction of femininity as related to the concept of biological citizenship (Sahra's class -- Petryna and Rabinow in particular). CONNECTION: Singer & Clair's discussion of syndemics: how poverty, debt and illness co-occur (bound to be more susceptible to illness with only one kidney, right?)

The Global Traffic in Human Organs THESIS: This paper is ethnographic and reflexive essay on the transformations of the body and the state under conditions of neoliberal economic globalism in the context of organ donation. Scheper-Hughes uses this paper to raise the central question, "Under what social conditions can organ harvesting and distribution for transplant surgery be fair, equitable, just, and ethical?" While she doesn't answer this question, the case studies she uses to illustrate the ambiguities and ambivalences of organ trading suggest her position is that the trade has an ingrained unethical nature to it. Scheper-Hughes, acting as an anthropologist-ethnographer for The Bellagio Task Force on Organ Transplantation, Bodily Integrity and the International Traffic in Organs, conducted research on the social context of transplant surgery for the Task Force in Brazil, South Africa and India. She also cites evidence from organ harvesting of prisoners in China. "Transplant surgery as it is practiced today in many global contexts is a blend of altruism and commerce, of science and magic, of gifting, barter, and theft, of choice and coercion. Transplant surgery has re- conceptualized social relations between self and other, between individual and society, and among the "three bodies"—the existential lived body-self, the social, representational body, and the body political. Finally, it has redefined real/ unreal, seen/unseen, life/death, body/corpse/cadaver, person/nonperson, and rumor/fiction/fact." She argues that global capitalism has resulted in the commodification of human beings, their labour and their reproductive capacity. Human organs have also been turned into commodities. Flow of organs generally follows the flow of capital - "from south to north, from third to first world, from poor to rich, from black and brown to white, and from female to male". CONNECTIONS: To virtually everything: an obvious comparison of structural violence, CMA and power between Mauss (1990), Sharp (2000) Cohen (1999) could be made (I think she aligns herself different from both writers -instead suggesting that the trade is necessarily unethical...I think?). Also related to discussions of neoliberalism, Foucault's notion of the governance of vital characteristics (life and death), the medicalisation of death and dying (brain death, etc.) and personhood/ corporeality (how transplant surgery has reconceptualised notions of the body in relation to society, the self and other and the "three bodies" she discusses in her paper with Lock (1987): body-self, the social body and the body politic.

The Commodification of the Body & Its Parts THESIS: This article is really about the objectifying affects of the medical gaze on the human body. Sharp argues that through metaphors that surround a hist of medical practices (including organ donation) the medial establishment asserts a dualistic separation of body and self, which facilitates the depersonalisation—and, thus, dehumanisation—of persons-as-bodies. This process ultimately allows for the commodification of the body and its parts. She highlights the importance of anthropology in addressing how the body is fragmented, for what purpose, and by whom; how such processes may obscure, augment, or alter constructions of personhood and /or the social worth of human bodies. Turning to a discussion of commodities, she argues that anthropology has understood commodities often are not simply things-in-and-of-themselves, or objects whose worth lies merely in their exchange value. Rather, as Mauss (1967) argued, exchange goods are frequently entangled in a host of meanings framed by sociopolitical concerns, and thus they are symbolically charged by their sociality as well as by their links to hierarchy and power. Following Davis-Floyd & St. John 1998, Sharp argues that driven by a highly "technocratic" approach, clinical medicine frequently monopolizes access to the human body, so that competing understandings are devalued and silenced. Sharp warns that once issues of property ownership and autonomy take center stage, they displace competing cultural constructions of the body, other possible reactions to the dilemmas of biotechnologies, and, finally, the shaping of alternative ethical responses She first discusses the commodification of the pregnant body (interesting for you), particularly in relation to ownership of the products of the pregnant body (placenta, stillborns, etc.), definitions of the foetus as autonomous/part of pregnant woman, the social positioning of conjoined twins, and surrogacy: THE FOETUS Raises troubling questions about uniqueness and autonomy: Is the fetus part of the female body or a separate entity? Within the United States, shifts in definitions of its social worth are inevitably framed by the abortion debate. She raises the interesting point of conjoined twins, which offer an especially vivid example of competing cultural readings: as Thomasma et al (1996) make clear, a sacrificed twin may be described as a murder victim, appendage, unjust aggressor, or organ donor, an array that exposes multiple definitions of personhood, social worth, and the economic value for an unusual category of the fragmented body (301). SURROGACY Surrogacy raises a host of concerns: the most pronounced focus on reproductive rights and autonomy in a realm overrun with the language of commerce. Others express concerns that surrogacy ultimately preys on the bodies of disenfranchised women in financial need, an issue that is mystified by the language of gift exchange (Ragone 1994; cf Malm 1992), which connects interestingly to organ donation. ORGAN DONATION Sharp positions herself with those who argue the organ-as-commodity side of the ethical debate: Although organs are frequently described as "gifts of life" (an expression that originates in the blood industry and that likewise is used to describe surrogacy), it is, in fact, a multi-million dollar medical industry where clients in need pay steep fees for the procurement, preparation, transportation, and surgical replacement of body parts. This rhetoric of gift exchange disguises the origins of commercialized body parts, silencing in turn any discussion of the commodification process. Even anonymous donation, portrayed as an act of great social kindness, has its darker side, for as Fox & Swazey (1992) explain, many organ recipients suffer terribly from "the tyranny of the gift" in their intense desire to repay, as it were, this debt of life. CONNECTIONS: Sharps analysis of competing claims made to a body (illustrated in the following quote) illuminates the ambivalences in conceptualising organ donation/ trade that Cohen discusses (one party seeing it as a gift, the other as a commodity): "Shifting meanings and transformative processes similarly characterize the fetishization of human body parts: For example, a dead woman's transplantable heart may simultaneously embody the essence of a lost loved one, be transformed into a gift for a recipient in need, and be the coveted object of a surgeon's desires. The theme of ambivalence, and of border zones and their crossings, are thus central to this article's concerns" CONNECTIONS: Medicalisation (of the human body, feminist critics, Lupton 1997), neoliberalism and role in controlling bodies, Foucault (on Cartesian dualisms and objectification supported by medical gaze)

Mindfulness Training as a Clinical Intervention THESIS: This review is a summary of the literature of mindfulness meditation as a clinical treatment from the 1970's onwards. The author acknowledges the increasing popularity of mindfulness meditation as an intervention and discusses both its success as an intervention and the ways in which empirical research has room to grow. This paper is a review of the studies that have investigated the efficacy of mindfulness-based interventions in stress-reduction. Baer describes Mindfulness-Based Stress Reduction and and how it has been used as the basis for MBCT in dialectical behaviour therapy (DBT) and acceptance and commitment therapy (ACT). She then moves to summarising the conceptual approaches that articulate how mindfulness skills may be helpful in treating clinical conditions, noting how they have been found to promote cognitive change, self-management, relaxation and acceptance. MBCT differs from traditional CBT as it refrains from evaluating thoughts and does not include the evaluation of thoughts as rational or distorted. Finally Baer (2003) offers a review of the empirical literature on the effects of mindfulness training, addressing the issue of how individuals who practice these skills may experience reductions in a variety of symptoms, citing the work of Kabat-Zinn et al. (2003), Kristeller and Hallett (1999) and Teasdale et al. (2000). All of these studies support the notion that MBCT may help to alleviate a variety of mental health problems and improve psychological functioning. CONNECTION: Obeyesekere on depression in Buddhism.

THESIS: Kirmayer & Minas (2000) take on a review of work that has been done thus far in cross-cultural psychiatry. They claim cultural psychiatry has evolved along 3 lines in its concern with understanding the impact of social and cultural differences on mental illness and its treatment: (1) cross-cultural comparative studies (Kraepelin 1904, etc.), (2) efforts to resound to the mental health needs of culturally diverse populations (related to local notions of citizenship and the history of migrations), and (3) looking at ethnographic studies of psychiatry themselves as the product of specific cultural histories (Kleinman 1966, etc.) and using this new arena to explore the hidden assumptions and limitations of current psychiatric theory and practice. The authors spend a good deal of time on the second evolutionary line in cultural psychiatry, looking at how different models of citizenship influence mental health. They cite case studies from England, France, Canada, Australia, the US, Japan, Sweden, and a number of low-income countries, claiming that psychiatry has a short history for this latter group, often revolving around disintegrating mental hospitals bequeathed by departed colonial powers. CONNECTIONS: Drugs, Big Pharma and personhood as well as the global scale of drugs consumption (Ecks, Rose, Martin); Foucault on knowledge and power and the Hasid Antinomian in Anthropology of Psychiatry (Littlewood).

Depression, Buddhism, and the Work of Culture in Sri Lanka THESIS: Obeyesekere argues that while depressive affect is universal, the paradigm of cultural understanding it is situated in varies cross-culturally. He suggests that term "depression" is a Western cultural conception, in which a constellation of symptoms is defined as illness and that in Buddhist Sri Lanka, depressive affects are part of a larger cosmological understanding of the universe and one's place within it. He claims that for the Buddhist, "to exist is to suffer." Therefore her a rues that depressive affect isn't locally constituted as mental illness (even though it exists) but rather as bound up with existential aspects of living. METHODOLOGY: He designed a questionnaire for 13 upasakas who regularly mediated to investigate their typical activities during sil (a week-long period of intense meditation). Illustration of how "the pain of mind and sorrow was articulated in Buddhist terms and expressed in the activity of sil and meditation Obeyesekere focuses on asubha bhavana (foulness meditation), as it is the most common form of mediation practiced in Sri Lanka. This type of mediation aims to reduce desire and attachment for the body and make the meditator feel that his body is something that is his yet is outside of him. Thus, the degeneration of the self through meditation like asubha bhavana is of a similar order to the degeneration of the self in depression because of the lowering of self-esteem and worth that is characteristic of both "One man's Buddhism is another man's depression" Obeyesekere criticises the methodology of psychiatric epidemiology for treating symptoms in isolation from their cultural context and argues that while this may facilitate 'measurement', the entities being measured are 'empty of meaning.' CONNECTION: Jo Cook's (2010) work on MBCT amongst Buddhists in Thailand, Kirmayer and Minas (2000) on cross-cultural psychiatry, Kleinman and Good (1985) on culture and depression (agree with Obeyesekere that dysphoria does not equal depression in Buddhist context --- this is a criticism of Western empirical science in a similar vein to orthodox criticism of medicalisation in Lupton 1997) CONNECTION: Other interpretivist anthropologists like Good and Kleinman - shares critiques of anthropologists/ epidemiologists/ psychiatrists/ public health officials who seek to operationalise symptoms of dysphoria (but this critique relies on the argument that people live in distinct cultural worlds unintelligible to each other, which Cook disagrees with)

Biopower Today There is a lot here so I'm not doing to go in depth for this flash card. Review in detail yourself. Argues that we've moved towards vital politics, biosocialities and biological citizenship and that we need to see the modes of subjectivation at stake in biomedical and biotechnical developments -it's not just about controlling populations but also about controlling subjects THESIS: Rabinow and Rose aim to provide conceptual clarification of the terms "biopower" and "biopolitics" based on Foucault's development of them. They compare how Agamben and Negri 's philosophical viewpoint differs from Foucault and their own. Rabinow and Rose argue that 'biopower', in contemporary states is a relation between 'letting die' and 'making live'. These are strategies for the governing of life. This is closer to Foucault's argument than Agamben and Negri who focus more on exceptional forms of biopower in conditions of absolute dictatorship combined with certain technical resources, and leading to murderous 'anatomopolitics' - a politics of death. R&R argue that the terms are useful in contemporary analysis, if used in a precise fashion (like Foucault), then it can be a "key part of the analytical toolkit", when looking into our 'near future'. They use 3 topics (race, reproduction and genomic medicine) to illustrate what is necessary to precisely apply biopower (a originally historical term) to contemporary analyses, making clear how these 3 topics are intertwined and transform each other rather than being all about power and control. CONNECTIONS: Useful case studies on race (connection to race and psychiatry and structural violence - think DelVecchio Good et al. (2005) on medical training), reproduction and genomic medicine. CONNECTIONS: Rabinow and Rose's (2006) conception of biopower links nicely to the studies on organ transplanting (vital characteristics of 'letting die' and 'making live') CONNECTIONS: Links to DelVecchio Good's work on the 'Biotechnical Embrace' i.e. the medical imaginary AND "Economies of hope" - Rose and Novas as well as Fassin's 'Another Politics of Life is Possible'.

BRCA Patients in Cuba, Greece and Germany THESIS: By analysing and comparing three ethnographic examples of the interplay between genomic medicine, public health and breast cancer through the lens of deconstructive and feminist approaches (Cuba, Greece and Germany), the authors argue that normative 'neoliberal' patient subjects are only partially reproduced in situated contexts, and are neither stable nor homogeneous. Indeed, different actors and publics engage differently with transnational as well as culturally local discourses and health practices. The authors conclude that these three case studies demonstrate how the global expansion of BRCA genetics in different medical arenas necessarily entails a renegotiation with local structural factors, social norms, and embodied daily practices. It is therefore impossible to talk of an inevitable, hegemonic and uniform spread of neoliberal ideology and proactive responsible patienthood. CUBA: In Cuba, the notion of embodied health risk must be understood within the expansion of 'community genetics', an arena which emerged from the long standing project of family and community medicine. While family histories and hereditary factors were a point of reference for some women, the notion of 'genetic risk' was not widely acknowledged. Attention was not focused on individual lifestyle or genetic factors that reflected a moral discourse about preventive monitoring of personal health. Rather, risk factors were understood as standing outside of the individual control of persons, such as ozone depletion or the effects of pollution. This - it is argued - needs to be understood in the context of Cuba's structural conditions: not only there is no significant culture of health activism around breast cancer, but there is also no public health basis for routine clinical genetic testing, and little resources for mammography screening for those identified at risk. Here ideas of individual responsibility co-exist with an ongoing emphasis on health at the level of the family, community and state. GREECE: Developments in preventive and genetic medicine have been based on the rhetoric of 'progress' and 'hope.' However, this is challenged by the public health system's shortcomings and inequities, with many women - especially those living in rural areas - lacking access to quality services for breast care are well aware of. Within this context, an important role is played by the prevention centre for breast and cervical cancer organized by an Orthodox Christian Convent in the spirit of religious philanthropy. Women in Greece referred to predisposition to the disease as rooted in the family history, connected to notions of nature and heredity. Embodied risk is thus here a key factor underlying and supplementing other causes such as diet, and overshadowing external factors such as environmental pollution and excessive use of chemicals for agriculture. Ultimately therefore, in Greece it is not that there is no desire to know about one's genetic risk and embrace genetic medicine, but there is concern with having to become active consumers of an uneasy knowledge that does not provide any reassurance. GERMANY: BRCA diagnostic techniques have become part of institutional health care practices since the 1997, but despite the national discourse following globalising 'neoliberal' rhetoric, individual patients only partially reproduce, or even subvert these dominant norms. Women are strongly encouraged by breast cancer centres to be active in their own risk management (to be 'responsible selves'). Consequently, the risk factors that are more addressed in the counselling sessions are those that can be individualized - genetic and lifestyle factors - rather than external environmental factors. The author could indeed divide the majority of women interviewed in two types of patients: the 'informed risk-manager' and the 'care-seeking client'. The first group is constituted by women who perceive themselves as genetically at risk persons and act as active decision-makers, by informing themselves, and calculating costs and benefits of different options, sometimes even going against doctors' recommendations The second group is instead constituted by women who chose to delegate their decision making to 'good doctors'. CONNECTIONS: Lots of cool connection to risk perception. German case relates particularly well to Lazarus (1994) in showing how people do not take up the neoliberal valorised 'autonomous rational agent' universally. CONNECTION: The ways in which people demand certain technologies that may not be economically viable in their context (i forget the readings, but there is definitely one here!) and repel technologies (medicalisation) CONNECTION: Huntington's disease documentary ("do you really want to know") introduces a comparison for how people interact with testing technologies when treatment isn't available.

Another Politics of Life is Possible THESIS: Fassin suggests that we're not quite beyond biopower -biomedicine is used by the state in diverse and hidden ways. But he also claims here that we need to bring in the concepts of inequalities and 'life as lived through the body' -concepts which aren't brought to the forefront in Foucault's notion of biopower. His overarching argument is that there is a need to recognise how 'biolegitimacy' has become a key feature in the moral economies of Western societies. Seeing life under bipolar through the value-laden lens of biolegitimacy allows us to begin conceptualising inequality within biopolitics, as Foucault never did. The focus on biolegitimacy places emphasis on constructing meaning and values instead of forces and strategies which control it. To use the Foucauldian metaphor, it is moving away from the 'rules of the game' to its stakes. In discussing the 'Humanitarian Exception' - Fassin says we are asking, who should live, and in the name of what? Fassin's aim is "ultimately, to get back to where [Foucault] left biopower before he limited politics to its technologies and morals to an ethics." Fassin claims Foucault did not conceptualise 'biopolitics' as a politics in which 'life as such' was the object. He did not consider the 'meaning and value' of an individual's life to be as salient in this concept as the technologies and policies used by states to govern. Instead, Foucault restricted the term to refer to the regulation of the population, and abandoned the terms to move on to his work on 'governmentality'. Fassin provides descriptions of "4 shifts" in the development of the concept of "biopolitics" from Foucault's initial employment of the term. 1) Politics is not only about rules of the game of governing but also about stakes. 2) Contemporary societies are characterized by the legitimacy attached to life, rather than just power over life 3)Intervention in lives is a production of inequalities rather than a normalising process. 4) The "politics of life" is not only a question of governmentality and technologies, but also of meaning and values. Fassin is interested in exploring what "life" as a concept is. He approaches 'life' as the course of events, which occurs from birth to death. Here, life can be shortened by political or structural violence or prolonged by health and social policies. It can give place to cultural interpretations and moral decisions. It is life that is lived through a body (not only through cells) and as a society (not only as a species). CONNECTION: Fassin's application of 'biopower' to 'rejecting into death' is applied to how certain races and classes have been historically 'rejected into death', such as AIDS in Africa, and TB being called the "miner's disease". Fassin refers the Mbembe's (2003) term "Necropolitics", and considers Biehl's work on 'Vita, the zone of abandonment' in Brazil - forgotten people abandoned and waiting for death. All readings on structural violence (S-H, Farmer, etc. are relevant here). CONNECTION: Also important links here to Rabinow and Rose's (2006) work on untangling Foucault's notions of biopower/ biopolitics. While the writers come to different conclusions, both take up their primary aim as exploring whether contemporary societies have moved 'beyond biopolitics' and both argue we need to move in the direction of exploring how biopower is subjectified (biosocialities and biological citizenship) and carried out on unequal terrain (biolegitimacy) CONNECTION: "One might say that the ancient right to kill and let live was replaced by a power to make live and reject death." this quotes ties in nicely with the weeks on organ transplanting and Big Pharma --- all technologies that aim to introduce agency into the management of life and death.

The Pharmaceutical Person THESIS: Martin explores the USA's contemporary relationship with tablets and capsules and concludes that we have an ambivalent relationship with drugs (she uses the term pharmakon to denote this ambivalence). Pharmaceuticals are both remedy and poison, but our knowledge of the 'bad' effects are displaced by pharmaceutical corporations, hiding or de-emphasising the negative biomedical and social impact of the drugs. She calls for consumers to become more attentive to these displacement strategies. There is actually quite a bit in this article I don't agree with - the psych dynamic critique, etc. A really good opportunity to critically engage with this reading. CONNECTIONS: TONS! See notes. The general social-constructivist critique in medical anthropology that highlights the inequality caused by pharmaceuticals. Those that can afford medicines can become 'pharmaceutical persons', those that cannot are more likely to be drug-trial subjects. However, inequality reinforced by pharma is not simply resolved by providing more drugs for marginalised communities -- see 'Pharmaceutical Citizenship' (Ecks). CONNECTION: Her notion of the pharmaceutical person is similar to Rose's (2003) notion of the 'neurochemical selves'

Pharmaceutical Citizenship THESIS: Calling upon fieldwork from the context of India, Ecks argues that people with depression are constituted as 'marginal' in the sense of 'being deprived of medication', and explores how the biomedical promise of an effective pharmacological treatment becomes a promise of 'pharmaceutical citizenship'. What are the effects of antidepressants in the Indian context? Ecks raises this question in relation to the theme of 'marginality'. Marginality, as expounded by international health and biomedicine at large, is seen as a form of social inequality that should, in principle, be abolished. Whenever one speaks of 'marginality', one speaks of a state of injustice. To call a person or a group 'marginal' normally entails an ethical mandate to remove such marginality. Thus Ecks highlights that being depressed is seen a symptom of being socially marginalized, and untreated depression is seen a symptom of being marginalized from pharmaceutical networks. Ecks analyses Indian pharmaceutical advertisements that he collected in 2003, to highlight that all of the people in the adverts look like attractive, smiling, fair-skinned South Asians. The medication seems to bring one back into society without stigma or visible mark (242). They suggest that the drug removes both depression and all forms of marginality One response that might be drawn from the understanding of depression promoted by the World Bank (as a symptom of being marginalised from pharmaceutical networks) is that antidepressant medications should be made available—or, at least, easily affordable—for as many marginalized people as possible. This view is typical of a 'monoculture of happiness' which defines happiness in terms of consumerism (here, the consumption of pharmaceuticals). However, for many social-controctivist critics, the prescription of antidepressants for the ills of marginality is seen to amount to only a quick fix at best, and a new form of exploitation by pharmaceutical companies at worst. An antidepressant, this critique runs, is nothing but a fetishized commodity that diverts our attention away from unequal relations between humans and humans, while disguising them as relations between things and humans. However, Ecks problematises this view too by citing Latour. For Latour, the social-constructivist critique of science works like a kind of 'potent euphoric drug' (Latour 2004, p. 163) for those who use it, because it is always right. In the case of antidepressants, the obvious social science critique is to call them 'fetishes' of medicine, development, and pharmaceutical industries. What should be done, in Latour's view, is to see matters of fact as matters of concern for all those participating. Ecks concludes that if Latour's point is to be applied, however, we have to find a way to think about mental health that neither reduces it to the proper distribution of medicines, nor simply rejects medicines as fetishized commodities (245). Ecks then moves on to discuss the Kass Report, a report that took on a nuanced discussion of medical technologies with the goal of making people not just well, but 'better than well'. This report argues that by itself, the expansion of antidepressants is not seen as an ethical problem, as long as they relieve 'true' suffering. The ethical dilemma only arises when people who do not 'truly' suffer start taking these pills. The most pressing ethical problem, then, is to distinguish between "TRUE" (objective, clinically proven) suffering, and merely subjective, inauthentic suffering. Ecks comments that the term 'true' plays a pivotal role in the Report's line of argument: it suggests a 'true' life is life with other people, a deeply committed social life. Ecks critiques the report for overlooking that this definition of authentic happiness is already mediated by the presence of mood-brightening drugs. If 'authentic happiness' is rooted in social ties, what does 'social' mean? The very definition of 'social ties' used in the Kass Report is based on an implicit exclusion of drugs. 'Social' is then a space where non-human substances are not admitted to enter and where only relations between humans are allowed (247). Ecks supplies an example of local expressions of distress in the form of the local Bengali term mon kharap ('bad mind') (248). Strengthening one's ties to family and friends as a relief from mon kharap are also seen as important, but not as important as practices that help to focus one's mind. Going back to the discussion of Latour (2004) Ecks argues that not only pills have to be re-admitted into the picture, but also gods and transcendent entities. A purely sociocentric view will not hold (cf. Chakrabarty 2000, p. 16) (250). CONCLUSION: Ecks argues that medical anthropologists should not be too quick to separate human actors (patients, doctors, etc.) from non-human actors (for example, antidepressants). Instead, it might be more fruitful to follow pharmaceuticals around and to study their power of not only transforming the bodies and moods of individuals, but of transforming social relations as well (Whyte et al. 2002; Ecks 2003). After critiquing the Kass Report and citing the Bangali example of mon kharap he concludes that that the global monoculture of happiness does not only come in the guise of things like antidepressants, but also in the guise of a sociocentric ideology that propagates social ties as the only path to true happiness. Promises of demarginalization through 'pharmaceutical citizenship' are key elements in this ideology. Critiques of commodity fetishism, with its stress on social ties, might inadvertently deepen this monoculture (251). CONNECTIONS: Left, right and centre: this is a KEY REFERENCE. Briefly: medicalization and how depression has become medicalised through pharmaceutical advancements; technology, Structural violence/marginalization, neoliberalism, depression/ suffering, big pharma

The Pharmaceutical Nexus **Theres a lot in this reading, which I'm not covering here, see notes** THESIS: Petryna and Kleinman point out the paradox of Big Pharma: namely, that effective life-extending technologies coexist with lost life chances in areas (often poor) where essential medications remain unavailable. The authors explain this paradox by calling upon the notion of the moral economy that is based in a specific political economy guided by the globalization of pharmaceutical enterprises. They highlight the main factors that sustain such paradox. They use the notion of the 'pharmaceutical nexus' to illuminate the complexities of global clinical trials by illustrating ethical variability. CONNECTIONS: Tons...this chapter relates to biopower (Rabinow and Rose); Biosocialities (Gibbon and Novas 2008), Politics of Life (Fassin) and biological citizenship (Petryna) and pharmaceutical citizenship (Ecks). CONNECTIONS: In this book are all the ethnographies that Sahra suggest in relation to Big Pharma. Particularly important is Petryna's chapter about ethical variability, by which the anthropologists discuss how the application of the same standards of regulation may reproduce inequality, and how situations of humanitarian crisis enable pharmaceutical industries to lose their standards. CONNECTIONS: Connection could also be made to Turner (1967) "A Ndembu Doctor" in relation to the bit of this article about pharmaceuticalization and healing.

Moral Models in Anthropology Argues that anthropology is fundamentally still a science and scholastic in nature -that our duty as ethnographers is to try and objectively describe to the best of our ability the emic realities of those we study. On this view, advocacy is often viewed as detrimental because it necessarily compromises the ethnographer's ability to be objective. While few anthropologists would suggest that neutral objectivity is possible or even desirable, a number have argued that the values behind objectivity -values of passive disengagement, impartiality in reporting, and descriptive focus on those we study (as opposed to the agent's interactions with them) -are still values that should be promoted in fieldwork. For instance, D'Andrade (1995) argues that the promotion of such values is both the most effective way of producing as-accurate-as-possible knowledge and the only way of preserving anthropology as an intellectually valued academic discipline. Underlying assumption: objectivity is the optimal way of illuminating the worlds in which we conduct fieldwork and, on a more basic level, that objectivity is something worth striving for Ethnographic application: Hastrup & Elsass (1990)

The Primacy of the Ethical Scheper-Hughes (1995) argues that anthropologists have a moral responsibility to act as advocates for the people they study. She cites a number of reasons behind this view: (1) Her own personal experience in the field to claim that active engagement in the moral/political aspects of fieldwork can "enrich" the ethnographer's understanding of the community and "expand...theoretical horizons" (Scheper-Hughes 1995:410-11). (2) She holds that the fact that we professionally "make our living observing and recording" does not exempt us personally "from the human responsibility to take an ethical (and political) stand on events we are privileged to witness" (Ibid. 411). (3) Lastly, Scheper-Hughes sees the position that the ethnographer is in as a powerful one having the potential to make a difference to the lives of those being studied. On this view, the responsibility anthropologists accept when conducting fieldwork is to act as "negative workers," exposing the oppressive power structures that keep the subaltern oppressed and "collude[ing] with the powerless to identify their needs against the interests of the bourgeois institution." Underlying assumptions: First, that there is always a determinable right and wrong in fieldwork and that the ethnographer knows which is which; second, that "power" is inherently "evil" and must be apprehended; third, that the ethnographer is more qualified than her readers to make determinations about the morality of her fieldwork; fourth, that the ethnographer is in a position to determine who needs help (and who wants it); and lastly, that active engagement (in the moral/political sense) is the most effective way to "help." Ethnographic application: Farmer (2003)

Pathologies of Power Perhaps one of the most well known examples of critically engaged approach to medical anthropology is Paul Farmer's (2003) work with tuberculosis and HIV/AIDs in Haiti. As an anthropologist-physician, he combines ethnographic work with advocacy to illuminate what he feels is the true source of disease amongst impoverished Haitians: structural violence. "Racism and related sentiments...underlie the current lack of resolve to address [the distribution of AIDS and tuberculosis] squarely. It is not sufficient to change attitudes, but attitudes do make other things change" (Farmer 2004:317). Thus, through the lens of active engagement, activism is necessary in order to make visible the links between "violence, suffering, and power" so that we may aid those being oppressed through structural violence (Ibid. 318).

Will to Live João Biehl's (2007) ethnography, Will to Live, provides just one example of how an anthropologist can navigate the treacherously moral territory of fieldwork. His ethnography represents over ten years of research and addresses the impact that a 1996 Brazilian public health policy that established universal access to free antiretroviral therapies has had on those living with HIV/AIDS. He synthesises multiple methodologies and perspectives to try and paint a well-rounded and contextualised picture of the successes and failures of the Brazilian policy. His approach is neither wholly advocative nor coolly disengaged. Unlike Scheper-Hughes, he doesn't define his responsibility as ethnographer as meaning he must be a "negative worker" (Scheper-Hughes 1995:420). Rather, he represents the "state, corporate, scientific and nongovernmental institutions" as well as "the plight and singularity of the abandoned AIDS patient" (Biehl 2007:4-5). His focus is not on uncovering the inherent evil of any "bourgeois institution," but on representing the sheer complexity of AIDS. Above and beyond D'Andrade's objectivism, he recognises the necessarily moral/political significance of his fieldwork and uses this position to unabashedly illuminate the contradictions and complexities of Brazil's policy in a way that is both heart-wrenchingly humanistic and impartially descriptive. His focus on thick, uninterrupted description from multiple perspectives indicates an appreciation for quality ethnography as a valuable contribution that only the ethnographer, who often painstakingly devotes years to patiently accumulating an understanding of the field, is in a position to make. In his own words, "ethnography captures the human force that is capable of acquiring sufficient consistence for turning a situation around...and transforms it into a map of the present world: a broken world, full of rifts that deepen yet also a world of previously unimaginable possibilities" (Biehl 2007:405). Will to Live demonstrates what I believe is the primary obligation of any anthropologist conducting fieldwork in climates of poverty, violence and suffering that we so often find ourselves: "to expose the difficulties, the contradictions, the conflicts of interest in a situation in order that false hopes of easy solutions should not mislead" (Firth 2002:162). Biehl advocates for HIV/AIDS sufferers by producing quality ethnography that does just that, not by making his primary focus political engagement. IMPORTANT: This ethnography contrasts Epstein (1996) by revealing that there is great variability in the extent to which people can be activist-citizens and advocate for their own health. Poor are stigmatised as 'non-compliant' but in reality forms of structural violence mean ARV treatment programs aren't always easy/possible for the poor to follow. In this case, activism represents a massive success in one sense because it resulted in access to free ARTS but massive failure in another sense because of inability of therapies to reach those most marginalised.

Learning Medicine

Study cited in Delvecchio Good et al. (2005) White psychiatrics were found to be more likely to diagnose black male patients as schizophrenic and white patients as having affective disorders. Furthermore, the black schizophrenic patient is thought to be more dangerous and violence becomes linked to schizophrenia even though it is not part of the diagnostic criteria (Whaley 1998). The conflation of schizophrenia, blackness and violence demonstrates how clinical judgements and treatment decisions made by individuals who are not overtly racist can have a discriminatory impact on patients that results in racial disparities in the health care services provided. Patients diagnosed with psychotic disorders, as opposed to affective disorders, are less likely to receive psychotherapy and more likely to receive medication.

His argument rests on a notion of culture that requires people to be unintelligible to each other -Jo doesn't think this is the case. MBCT provides a good example. A central tenant of MBCT is about changing one's relationship to thoughts -seeing them as JUST thoughts, not facts, but 'clouds in the sky.' This central tenant behind MBCT is a loaded cultural proposition rooted in Buddhist meditation in THERAVADA tradition. Yet MBCT necessitates a dedicated engagement and investment in these 'culturally loaded' tenants (Clark). The shift in theoretical focus to the self has been very successful cross-culturally in MBCT which provides evidence that culturally loaded propositions can be taken up and used beneficially outside their context of origin. Based on this evidence it becomes difficult to argue that people live in distinct cultural worlds unintelligible to each other, the central tenant behind Obeyesekere's notion that "one man's Buddhism is another man's depression" 3 MARKS OF EXISTENCE IN BUDDHISM: IMPERMANENCE (ANITYA), NON-SELF (ANATMAN) AND "DUHKA" -which has been roughly translated as 'suffering' or 'unsatisfactoriness', an imperfect translation of the sanskrit word which is meant to ply how nothing in the physician or even emotional realm can bring lasting, deep satisfaction. In Buddhism, all sentient beings share these 3 characteristics and the goal, through meditation is to gain a full understanding to them to bring an end to suffering. Obeyesekere (1985) conflates 'duhka' with depression because both make allowances for suffering as part of the Buddhist cosmology, even after he and Good and Kleinman are so careful to critique psychiatric epidemiologists for doing something similar. This implies a model of culture EXTERNAL to the subject, focused on the person and not the SELF therefore the interpretivist approach misses something key: the phenomenology of duhka which is vastly different from the phenomenology of depression Phenomenological aspect of critique is similar to Desjarlais (1992) if you want to understand soul loss, can't just ask what it means but HOW IT FEELS

Meditation in Modern Buddhism Using her own experience as a 'mae chee' (lay nun), Cook conducts an ethnography and phenomenology of Buddhist meditation, analysing subjectivity, inter-subjectivity and embodiment of ethics in Thai Buddhist practice. She argues that the denigration of the self in meditation is of a different order from the denigration of the self in depression (against Obeyesekere (1985)).

Injectionists: The Attraction of Technology Provides and ethnographic example of the globalising effects of biomedicine and medicalization Explores why injection usage has been so ubiquitous in Ugandan medicine and determines it is because the materiality of an injection fits with local conception of disease as something localised to blood. Ugandan model of treatment requires a patient's body to be pierced, therefore injections are ubiquitous because they align with local model of therapeutic intervention.

An Anthropology of Biomedicine (particularly the chapter: Biosocial Variation & Local Biologies) Explore the concept of local biologies Challenge the prevailing assumption behind clinical trials: that there is a universal, comparable human biology. They suggest instead that biology is influenced by particular environmental and social histories. They raise the paradox that the factors that make trials on developing populations possible may also be problematic.

This Is Not Medicalisation THESIS: The power and negative effects associated with medicalization have become so ubiquitous that they are often exaggerated- or at least not subjected to critical scrutiny. Fassin argues that theorists need to work towards decoupling medicalization and pathologization, which Fassin argues are too often erroneously used interchangeably. While in some instances medicalization can lead to patholoigzation, Fassin uses the case study of intravenous drug use in France to illustrate that in others it can contribute to depathologization instead. CASE STUDY: Intravenous drug use in France and shift in approach in 1980s from focus on criminalising drug use (as a public health initiative) to a focus on the dangers of needle-sharing and promoting policy for needle exchange and methadone maintenance. Medicalization can only go so far in explaining this transformation, since the medical establishment was deeply entrenched in both transformations (first, medicalizing drug use as addiction; second in medicalizing drug users in relation to infectious risk) This case shows how other analytical tools may be necessary to unpack the impact of the social positioning of illnesses on populations and individuals CONNECTIONS: Could be really interested in a discussion of the rise of risk awareness in tandem with epidemiology/ public health (even though that occurred slightly earlier).

One of the first sociologist-philosophers to develop the notion of medicalization- used in reference to the 'iatrogenic consequences' of biomedicine

One of the first feminist critics to develop the notion of medicalization- used in reference to paternalistic structure of biomedicine that propagates inequalities inherent in the clinical encounter

Lazarus (1994) conducted a cross-sectional ethnography in the U.S., looking at what women from different social classes "want" out of their pregnancies. She concludes that while upper- and middle-class women were often concerned with exerting their own autonomy during pregnancy, poor women "neither expected nor desired this autonomy" (Lazarus 1994:25). Some preferred to submit to expert authority; others did not but recognised that without health insurance they had fewer choices and that passivity led to better care than noncompliance (Lazarus 1994:32). For these women the risks imposed by a lack of continuity of care were far more salient than the risks of passively accepting medical authority. This trend seems to pose a problem for the concept of the autonomous rational agent. Whether preferring to submit to expert authority because of a belief that "doctor knows best" or having no other option but to submit, using the lens of reflexive modernity requires us to categorise the poor women in Lazarus' study as subservient. This conclusion is not only classist, but doesn't adequately capture the broader systems of structural violence that limit the freedom these women have to exert personal autonomy (a concept that has been taken up by Foucault in great detail).

Illich (1975) Conrad (1975)- hyperkinesis Schneider (1978)- drinking Bell (1987)- menopause Epstein (1988)- homosexuality Zola (1991)- Ageing Young (1995)- Trauma Davis-Floyd & Sargent (1997)- P&C "I can't stand believing evil Zoro yawns daily!"

Develops the notion of somatic individuality brought forth by Rose and Novas 2000 further (as the tendency to define key aspects of one's individuality in bodily terms [...] and to understand that body in the language of contemporary biomedicine (Rose 2004:18)) by discussing its application to neurochemical selves. He develops somatic individuality term in relation to 'psychological individuality', which represents a view of the self as being fundamentally dependent upon a 'deep internal space shaped by biography and experience' and the source of individuality Argues that a new form of individuality (somatic individuality) is supplementing or replacing the psychological individual. Rose is primarily interested in how somatic individuality developed, i.e. how we have have become 'neurochemical selves' - how we have come to think about our sadness as a condition called 'depression' caused by a chemical imbalance in the brain, etc.

Drugs for Life Provides a case study on pharmaceuticals and personhood Argues that in the USA we are defining health as requiring drugs to reduce life-long risk Shows how DTC ads succeed by undermining the authority of doctors. In this sense, it relates to both Martin's (2006) and Eck's (2005) work on pharmaceutical marketing. However Dumit's representation of pharmaceutical corporations can be critiqued as being unidimensional and hegemonic

AIDS Activism in the US Case study on clinical trials and health activism. Epstein documents the strong therapeutic activism (almost militant) from the gay community and mass willingness to particulate in clinical research and trials. He shows how this transformed AIDS from a death sentence to a condition that could be lived with Therefore it is a sort of success story for health activism influencing the quality of therapeutic intervention available to sufferers.

AIDS Activism in W Africa Case study on clinical trials and health activism - to be compared with Biehl (2007) and Epstein (1996). Indigenous activism emerged around 2000 THROUGH the presence of clinical trials -> hope of gaining access to healthcare through trials Nguyen (2011) illuminates the role of 'therapeutic pioneers' in activism (charismatic individuals who were good at telling their stories about living with HIV/AIDs). He argues that therapeutic pioneers were vital to getting resources from foreign health development agencies

Genetic Risk & The "Somatic Individual This article is essentially about the normalisation of the risky subject Rose and Novas explore the implications of molecular genetics for the ways in which we are governed and govern ourselves, suggesting the key impaction has been the development of the person "genetically at risk". They call this the creation of the 'somatic individual' They argue that genetic risk is linked to practices of subjectification and 'contemporary regimes of the self' where 'activism and responsibility are not only desirably but virtually obligatory' as part of an individual's 'life project' They critique the idea of 'geneticization' and genetics as eugenics because of autonomy and obligation imbued in individuals - it therefore doesn't have basis in fatalistic logic

Biosociality In this essay Rabinow develops the notion of biosociality as a way of thinking through the implications of contemporary genetics "It is not hard to imagine groups formed around the chromosome 17, locus 16 [...] with a guanine substation" In retrospect, Rabinow has admitted that his initial conception of biosociality hasn't quite happened and thus claims it is often relied on too heavily by anthropological analysts. However, he thinks it is still a useful concept for TWO KEY ASPECTS: (1) Contemporary genetics challenges nature/culture distinctions because nature can be intervened through knowing one's genome (2) Thinking about identity practices that have emerged based on the notion of genomic knowledge

Biosocialities The authors develop the notion of 'biosocialities' to illumine the 'spaces, practices, and persons' biosociality has failed to account for as well as shed light on the way different biosocialities are brought to bear in a comparative arena Biosocialities as a term illuminates the variability of bio-social configurations around genomic information

BRCA genetics, gender activism and institutional medicine in UK Her doctoral work provides a case study to use when complicating biosocialities Sahra studies the process of mobilisation behind the rapid discovery/ testing/ application of BRCA genetic knowledge into standard health care practices. She suggests that this has led to the creation of 'anticipatory patients' (that is, a new class of patients who fear being 'at risk' - a fear propagated by (1) breast cancer activism and (2) institutional culture of NHS offering testing to those 'at risk') that has been extraordinarily mobilising in pushing those 'at risk' to get tested THe logic of anticipatory inhabits is relevant here Also, Gibbon raises important issues surrounding the gendered aspects of BRCA activism - emphasis on caring for others/ self permeates the languages surrounding activism

New Predictive Genetics & Huntington's Disease She explores the role of narrative in constituting and revealing risk identities, arguing that accounts aren't retrospective, but 'therapeutic emplotments that guide future action' and also discusses the 'limbo-ness' of embodying prognosis and living in the temporal gap between testing and knowing This case is a good application of Rose & Novas' (2000) idea of the creation of the 'at-risk' neoliberal individual, that is the somatic individual. Also relates to notions of personhood/ambiguous subjectivity

Genetics & Alzheimers Case study which complicates biosocialities Despite hundreds of millions of dollars invested in medical research, no effective treatment has been discovered for Alzheimer's disease, the most common form of dementia. The Alzheimer Conundrum exposes the predicaments embedded in current efforts to slow down or halt Alzheimer's disease through early detection of presymptomatic biological changes in healthy individuals. Margaret Lock highlights the limitations and the dissent implicated in this approach. She stresses that one major difficulty is the well-documented absence of behavioral signs of Alzheimer's disease in a significant proportion of elderly individuals, even when Alzheimer neuropathology is present in their brains. This incongruity makes it difficult to distinguish between what counts as normal versus pathological and, further, makes it evident that social and biological processes contribute inseparably to aging. Lock argues that basic research must continue, but it should be complemented by a realistic public health approach available everywhere that will be more effective and more humane than one focused almost exclusively on an increasingly frenzied search for a cure. Alzheimer's is not about 'identity-making' but unmaking of persons

Looks at genomics and the making of bioavailable populations in India. Rajan examines the multiple 'over-determinations', that is, inequalities in the global outsourcing of clinical trial and the role of international bioethical regulation in positioning Indian participants as 'experimental subjects'

Global infertility and the globalisation of NRTs: illustrations from Egypt Inhorn uses the Egyptian context to demonstrate that IVF is not a culture-free solution to infertility Rather, she applies Appardurai's notion of the 'indiginization of technologies' to show how local understandings inform what might otherwise be seen as a culture-free technology (IVF) In Inhorn's study local understandings of reproductive biology, gender dynamics and class-based barriers to access all affect have IVF is taken up

Asian Biotech: Ethics and Communities of Fate The authors are concerned with the ways biotechnoloigse are entwined with sovereign reason, neoliberal logic and collectivist ethics. Through conducting fieldwork they illuminate the in an Asian context biotechnology is seen as a national project. They highlights how in this context biotech isn't seen as a dystopian reinforcement of state power, but as an ethical formulation of the role of the state Their book is a compilation which brings together ethnographic case studies on biotech endeavors such as genetically modified foods in China, clinical trials in India, blood collection in Singapore and China, and stem-cell research in Singapore, South Korea, and Taiwan. Their book complicates studies of biosocialities in a global context by showing how we need to look at biopower as well

The Heart of What's The Matter: The Semantics of Illness in Iran Good presents a study on how Iranians interpret and communicate depressive symptoms in relation to elements and themes already thematized in Iranian culture- these symptoms of depression cross-cut the pre-established categories of Western psychiatry. Good says the same 'mental illness' may play different roles in different societies - knowing the social, cultural, political, economic, miler is essential to understanding MI in context The study is a classic critique of the primacy given to the Western diagnostic and labelling system in the biological approach to answering whether mental illness is universal. The classic critique goes: "we have knowledge, they have culture"

Culture & Depression Agree with Obeyesekere that dysphoria does not equal depression in Buddhism --- this a a criticism of Western empirical sciences They interpret understand willful dysphoria in Buddhist meditation as a step on the road to salvation therefore claim suffering is cultivated and of a differently quality than depression in the West (don't say depression doesn't exist, just that it is understood differently -isn't pathologized)

First distinguished illness from disease DISEASE- is an objectively measurable pathological condition of the body. Tooth decay, measles, or broken bones are examples. ILLNESS- is an experience of discontinuity in states of being and perceived role performance. Illness may, in fact, be due to a disease. However, it may also be due to a feeling of psychological or spiritual imbalance. By definition, illness is rooted in personal perception and is highly culturally-ingrained.

"A Category of the Human Mind: The Notion of Person, The Notion of Self" Root of anthropological interesting in distinctions between person/self/body Mauss here insisted that conceptions of the person are NOT always stagnant or even individually-focused, as Western culture often assumes, but instead culturally and historically constituted -constantly subject to change. This culturally-bound approach to defining personhood provided the foundation for most subsequent anthropological writing on the subject. Modern anthropologists tend to approach what it means to be a person in a society through a 3-fold analytical approach of understanding cultural notions of "The Body", "The Person" and "The Self", where "The Body" refers to the physical person, "The Person" refers to how personhood is socially defined and positioned and "The Self" refers to the meaning-centred first-person approach to understanding oneself. This approach places personhood as a distinct phenomenon from "humanhood, where being human doesn't necessarily imply that one is a person. The distinction of personhood from humanhood is illustrated clearly throughout social history, where, for example, different understandings of the personhood of animals, women, foetuses and slaves have been catalysts for social upheaval. What is required for personhood varies cross-culturally and throughout history and has at times included nonhuman persons (Wooden Iroquois masks, deities and spiritual beings) and excluded certain groups of humans

The Gift

The Effectiveness of Symbols Key reference in discussing symbolic healing. Here Levi-Strauss explores how it is that symbolic healing may actually work by analysing a song sung during difficult deliveries in the Cuna tribe in Panama : SYMBOLS i.Cuna neles (shamen) sing a special song that has the purpose of facilitating. The aetiology is that Muu, the power responsible for the formation of the foetus has exceeded her function and captured the soul of the mother (to be). The shaman fights against this abuse of power, aided by his spirit helpers, to get Muu to release the soul of the mother. HOW SYMBOLS WORK FOR HEALING" i.The song evokes a psychological response, which allows his patient to relax. Once relaxed the childbirth goes easier. Specifically the myth works on the imagination to produce a psychological and physiological response; "the song constitutes a psychological manipulation of the sick organ and it is precisely from this manipulation that a cure is expected. HOW SYMBOLS IMPACT UNDERSTANDING OF ILLNESS i.The incoherent and arbitrary pains of the patients' situation are put into a comprehensible and meaningful framework that the patient can deal with. Thus myth is a concrete interpretation or representation for a more abstract concept. "Once the sick woman understands, however, she does more than resign herself; she gets well." Symbolic healing functions to place the individual's woes in a cosmic space.

The Concept of Therapeutic Emplotment Cheryl Mattingly discusses linguistic symbols and healing through the concept of therapeutic emplotment, the creation of story-like structures through therapist-patient interactions which encourage the patient to see therapy as integral to healing. Therapeutic emplotment' develops from two philosophical strains: one emphasizing the connection of speech to actions, the other the linguistically mediated nature of human experience. Mattingly highlights potential of narratives to create experiences in clinical practice. With therapeutic emplotment, narratives become 'tools' in the hands of health professionals to shape the interaction with patients with a long-term illness and are constructed by them together.

Explain, many organ recipients suffer terribly from "the tyranny of the gift" in their intense desire to repay, as it were, this debt of life.