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- Convenors:
-
Karolina Kuberska
(University of Cambridge)
Lorelei Jones (Bangor University)
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- Stream:
- Health, Disease and Wellbeing
- Sessions:
- Monday 29 March, -
Time zone: Europe/London
Short Abstract:
How can we explain, and narrow the gap between grand visions outlined in policies and the wishes of people seeking healthcare? What trade-offs are made in trying to reconcile divergent healthcare-related priorities? If caring for health is a responsibility, who does this responsibility belong to?
Long Abstract:
As understandings of health, disease, and wellbeing are influenced by an increasingly complex landscape of competing cultural, social, political, technological, and economic agendas, it is worth exploring the understandings of responsibility driving these interests from an anthropological perspective. Many of these agendas are articulated through categories that do not readily translate into each other, creating opportunities for frictions and misunderstandings. Nonetheless, various new health policies and programmes are regularly created and rolled out, sometimes with little input from those expected to implement them. An important example is that of "patient-centred care": it might be an often-used phrase, but how it fits into expectations of meeting numerical patient targets at a regional or national level is often obscured. How can we describe, explain, and narrow the gap between grand visions outlined in policies and the wishes of individuals seeking basic healthcare? What trade-offs are made as a result of healthcare professionals, policymakers, and patients trying to reconcile divergent priorities? Can anthropological input help to organise healthcare delivery systems in ways that are not only more efficient and less prone to adverse effects but also more humane? If caring for health is a responsibility, who does this responsibility belong to?We invite papers exploring the tensions of different priorities driving healthcare policies and ways of implementing them, with the notion of responsibility as an analytical lens. Papers discussing healthcare delivery in non-Euro-American contexts are particularly welcome.
Accepted papers:
Session 1 Monday 29 March, 2021, -Justin Dixon (LSHTM) Salome Manyau (Biomedical Research and Training Institute) Clare Chandler (London School of Hygiene and Tropical Medicine) Faith Kandiye
Paper short abstract:
Based on ethnographic research in two clinics and a hospital in Harare, Zimbabwe, this paper explores how antibiotic prescribing practices labelled ‘irrational’ are a consequence of competing imperatives layered into the biomedical scripts and architectures of global health.
Paper long abstract:
Rising concerns around antimicrobial resistance (AMR) have led to a renewed push to rationalise and ration the use of antibiotics. As ‘AMR’ has crystallised as a policy object and travelled, it has carried particular imaginings of ‘responsible’ antibiotic use that exalt frugality and restraint, with attempts to convert people into ‘stewards’ of these threatened commodities. However, these relatively recent concerns with antimicrobial stewardship enter a longer historical trajectory in which the scripts, systems and architectures of global health have progressively pharmaceuticalised care in LMICs and squeezed out modes of caring beyond the provision (or withholding) of medicines. Based on ethnographic research in two clinics and a hospital in Harare, Zimbabwe, this paper explores the significance of antibiotics in local care practices and what it means to use them ‘responsibly’ amidst severe resource constraints. We found clinicians were well aware of AMR and committed, in theory, to the need to use antibiotics sparingly. Yet being ‘responsible’ in practice often meant using antibiotics beyond indication to ‘cover’ for multiple uncertainties, expectations and gaps in the system, and as metaphorical ‘explosives’, ‘guns’ and ‘bleach’ to combat severe infection. That antibiotics have taken on such broad, anticipatory roles, we contend, highlights both the naivety of many stewardship interventions and how vulnerable and exposed they could leave clinicians and their patients. We consider in turn what it would take to build a fuller picture of patients and illness back into health systems such that alternative ways of caring beyond medicines become possible.
Eva Vernooij (Utrecht University) Francess Koker (Kings Sierra Leone Partnership) Alice Street (University of Edinburgh)
Paper short abstract:
This paper explores how clinicians, patients’ relatives and anthropologists affect diagnostic pathways and distribute responsibility when a young pregnant woman presents with fever in a government referral hospital in Sierra Leone.
Paper long abstract:
This paper examines how diagnostic tests structure patients’ diagnostic navigations across different levels of the health system in Sierra Leone. By following 15 patients presenting with fever in the country’s largest referral hospital, we analysed patients’ diagnostic pathways before, during and after their visit to the hospital. Our research revealed that diagnostics are just one part of the diagnostic process. Through a detailed discussion of the diagnostic pathway of a young pregnant women presenting with fever, who is send back and forth between two referral hospitals, we show how responsibility for diagnosis was distributed across different people (patients, patient’s relatives, nurses, clinicians, laboratory workers, procurement agencies and record keepers) and across different spaces (e.g. hospital triages, consultations, hospital laboratories, private laboratories and wards). We found that diagnosis is not a singular event, rather it emerges over time. Often, patients were reported by health workers as “being managed” for the initial diagnosis, and received treatment until tests could be done to allow a differential diagnosis. For admitted patients, this process could take several weeks when tests were unavailable, either because of stock outs of tests or limited funds by patients. The majority of the admitted patients and their relatives claimed they had not been informed about test results or diagnosis, at times because there was no final diagnosis made. Additionally, we reflect on the ethical queries and hesitations we encountered about our own responsibility in affecting the diagnostic pathways of patients when conducting “participant-observation” in severely resource-constrained settings.
Cassandra Yuill (City, University of London)
Paper short abstract:
This paper considers the (re)emergence of midwifery-led care in Europe and the entanglements of policy, care implementation, responsibility and human rights in maternal health, highlighting anthropology’s potential as a tool for reconciling the complexities of evolving maternity care delivery.
Paper long abstract:
Despite vast improvements in maternity care and lowered rates of maternal and infant mortality, there are worrying trends being reported in maternal health. Disproportionate rates of maternal and infant mortality increasingly cut along racial and economic lines. Obstetric violence and birth trauma are pressing issues, while rates of caesarean sections and obstetric interventions continue to rise. In response, maternal health policies increasingly focus on promoting models of ‘patient-centred care’, seeing choice in care as a means for re-establishing agency amongst women and improving services. Midwifery-led care has come back into prominence, given promising evidence that it can improve health outcomes and provide equitable, respectful and cost-effective care. However, maternity care practices are publicly and professionally contested and enmeshed in notions of safety, responsibility, autonomy and medicalisation. Midwifery-led care, often situated at the periphery of, or in tension with, obstetrics, faces socio-political, economic and practical barriers to implementation, even in countries where midwifery is fully integrated into the health system. As midwifery practice, or being ‘with woman’, and patient control increase, who is ultimately responsible for pregnant women’s care, and can this be shared? This paper considers the (re)emergence of midwifery-led care in Europe and the entanglements of policy, care implementation, responsibility and human rights in maternal health. I draw from ethnographic research on place of birth in East London and experiences working in a multidisciplinary team focussed on wider midwifery-led care integration in Europe, highlighting anthropology’s potential as a tool for reconciling the complexities of evolving maternity care delivery.
Karolina Kuberska (University of Cambridge)
Paper short abstract:
Hospitalised people with dementia who wear special hospital wristbands are vulnerable to having their condition revealied to those who can interpret the identifier. The goal of this paper is to explore the stigmatising potential of a special hospital wristband for patients with dementia.
Paper long abstract:
A significant proportion of elderly patients admitted to hospitals also have dementia and may display dementia-related behaviours, which makes their care more challenging to clinical staff. Many hospitals have systems of visual identification for such patients in the form of e.g. stickers placed above their beds. These visual identifiers, while often useful, do not always help to prevent problems arising when patients with dementia walk about the hospital and become lost. One of the design interventions proposed to address this particular issue was using visual identifiers that can be placed on the patient, such as blue hospital wristbands. Similar interventions were successfully rolled out in a number of NHS trusts in England but a range of ethical concerns have been raised around their use, from issues with informed consent to disclosure of diagnosis. A number of voices suggested that wristbands of this kind have the potential to stigmatise patients with dementia by revealing their condition to those who can interpret the identifier. The goal of this paper is to explore the stigmatising potential of a special hospital wristband for patients with dementia in two contexts. The first includes a comparison with other visual identifier systems used in hospital settings that do not raise such criticisms. The second involves broader understandings of living with dementia that deemphasise medicalisation of processes typical of aging. By exploring the stigmatising potential of a special hospital wristband, it is possible to reveal frictions at the intersection of various agendas that simultaneously normalise and denormalise dementia.