Paper short abstract:

Antimicrobial stewardship (AMS) interventions are gaining traction as solutions to the problem of antimicrobial resistance (AMR) in healthcare settings. With the ethnographic case of PROA interventions in Spain, I explore how they may offer a territory to imagine change in healthcare work.

Paper long abstract:

In policy settings, antimicrobial resistance (AMR) is anticipated to have a crucial impact on the near future of healthcare across the globe. In an scenario in which antimicrobial drugs are framed as scarce and increasingly depleting resources, the implementation of antimicrobial stewardship (AMS) interventions has been proposed as a direct solution, particularly in high-income settings. I will draw my analysis from an ethnographic study of these interventions in the context of Spain —known as Programas para la Optimizacion de Antimicrobianos (PROAs)—, where the implementation of these programmes is increasingly encouraged in public hospitals and other healthcare settings by professionals and state officials alike. In this paper, I will argue that healthcare professionals (primarily clinicians, pharmacists and microbiologists) are not only drawn into taking part of PROA teams and activities in public hospital institutions due to an ethical mandate to preserve antibiotics and provide good care for patients, and a shared understanding of the past wrong-doing of overusing antibiotics that has drove us to today’s situation in regards to AMR. PROAs are also appreciated as an exhilarating opportunity to imagine institutional change; a distinct territory to rehearse other modes of engaging in healthcare work and work relationships. PROA, as one participant put it, delivers “a taste for good work” and carrying out a fulfilling kind of healthcare labour in an otherwise strained healthcare system and often reckless work environment.

Paper short abstract:

To understand the politics and materiality of technological innovations in healthcare systems, the paper examines the accessibility and care at a small telepsychiatry clinic in Tharparkar, Pakistan.

Paper long abstract:

The rising numbers of suicides in Tharparkar district in the last decade has led to numerous psy-interventions by public, private and development actors in Pakistan. One often-cited intervention is the telepsychiatry clinic. Operated within a private hospital (considering internet connectivity and smartphones are not common in the district) through a partnership between various public and private-sector organisations, the clinic is praised by these stakeholders as a novel solution to the problem of access to mental healthcare in Tharparkar, where, otherwise, a single government-appointed psychiatrist caters to the entire district’s two million population.

Previous works have shown how clinicians and policymakers have presented telepsychiatry as a way to ‘enhance access’ to therapeutic services (Pickersgill, 2019). The clinic’s management and funders also market the telepsychiatry service as a dynamic solution to the district’s rising suicide numbers. However, preliminary findings from my fieldwork–including observations and interviews with mental health actors in Tharparkar district–reveal that the telepsychiatry clinic is not thriving. The patient attendance is nominal and decreasing with time, and the quality of service is hindered by three infrastructural barriers: 1) the majority of the Thari people cannot afford travelling to the clinic; 2) the power supply and internet connection in the district is insufficiently stable; 3) people cannot afford to continue buying psychiatric medicines which are often prescribed via telepsychiatry services.

The paper highlights the material and political dimensions of telepsychiatry’s claim of ‘enhancing access’ and offer insights into the everyday workings of tech-led mental healthcare in southern Pakistan.

Paper short abstract:

In Scotland, Lyme-literate healthcare is a response to chronic Lyme disease as a contested illness. This unregulated healthcare system empowers patients into experts, doctors into rogue pioneers, and finances a private healthcare economy that challenges and dismantles the authority of the NHS

Paper long abstract:

Chronic Lyme disease is a contested illness (Dumes, 2020), an illness you have to fight to get (Dumit, 2006): NHS Scotland offers patients 21 days of antibiotics, after which they are labelled as 'healed', and ongoing symptoms are understood as evidence of a different medical complication. Patients who believe they are suffering from a chronic form of Lyme disease are therefore placed in the precarious situation of creating bottom-up strategies to access antibiotics and alternative forms of treatment. This is leading the contruction of a future healthcare system known as Lyme-literacy. In this initiative, patients assign expertise to and away from clinicians; organise on informal medical networks; and pay into an unregulated alternative healthcare system that spans the United Kingdom, Europe, and the United States.

Based on 12 months ethnographic fieldwork across Scotland, this paper reveals the powerful private healthcare economy currently profiting from chronic Lyme disease's uncomfortable category as a contested illness. I share the financial pathways that patients walk down as they experiment with antibiotics, herbs, food, and technologies of self-management to build allyship with their mitochondria. I discuss how polypharmacy narratives construct a healthcare that empowers patients into experts, Lyme-literate healthcare providers into rogue pioneers, and the ethics of experimenting on patient bodies in the name of creating a morally superior healthcare to replace biomedicine. This paper discusses how patients are already creating and financing future healthcare, its disparities in what "health" and "healing" means, and the important lessons this offers for how we cure and care.

Paper short abstract:

This paper explores doing healthcare reform in the NHS, through ethnographic research on the implementation of a quality improvement framework in English midwifery care. We look at what is (re)done in the process, as well as what is left undone and consequences of reform procedures.

Paper long abstract:

In recent years, England’s maternity services have been facing a reckoning – high-profile national inquiry reports into failings in care, stark inequalities in outcomes among women and their babies and acute staffing shortages – leading to calls for reform. Improvement now focuses on quality and safety, underpinned by national health policy to facilitate choice and compassionate, respectful care.

Maternity services in the National Health Service (NHS) are primarily provided by midwives, including intrapartum and birth care. Choice in place of birth in England includes settings that are midwifery-led, called ‘midwifery units’ (or ‘birth centres’). Midwifery units confer benefits for women, birthing people and their babies and are associated with improved outcomes. However, they too face questions of safety and viability as a birthplace option and, as part of the wider healthcare service, requirements to reform in line with national improvement initiatives.

We undertook ethnographic research on the regional implementation of a quality improvement framework for midwifery units and, through this lens, explore doing healthcare reform work in the NHS. We look at what is (re)done in the process, as well as what is left undone. Our discussion touches on redefining philosophies of care and midwifery as a profession in more holistic terms but also the “social consequences” of reform and assessment procedures (Strathern, 2000) and entanglements with the ‘heavy’ bureaucracy of the NHS. Finally, we consider how healthcare change in England might be done against the backdrop of ongoing challenges and with shifting notions of safety and wellbeing.

Paper short abstract:

Continuity of care (COC) is a high priority in mental healthcare. We explore this concept from the perspective of people living with severe mental illness. COC is often understood as absence of breaks or gaps in care, but we stress the need for embracing dis-continuity in Continuity of Care.

Paper long abstract:

This study addresses the increasing demand for Continuity of Care (COC) in mental healthcare. A need that is voiced by the political system, health care providers and care recipients as a response to fragmentation and specialization of health care. In mental healthcare, coordination of services and stability of patient-provider relationships is emphasized and COC is often defined in negative terms as the antipode to gaps, lags, inconsistencies, and interruptions in the delivery of healthcare.

In this study we explore diverse understandings of ‘relational continuity of care’ through the perspectives of the users of a community outreach treatment project for people with severe mental illness. Building on one year of interviews and observations of interactions between health care professionals and users, we explore how COC is an arena for the users to experiment with the situations in which they find themselves. For professionals, COC includes absence of breaks or gaps in care. Users, on the contrary, living with extraordinary conditions, experiment with agency during treatment by avoiding services because of extraordinary conditions. They find that breaks and gaps in care are a way to build and maintain self-control in a situation of despair, however they also worry about being excluded from the care program when avoiding services. We thus argue that conceptualization of COC should embrace dis-continuity in the notion of continuity.

Paper short abstract:

The contribution focuses on the benefits found among users, as well as on the barriers (economic, political, cultural), the challenges and the expectations, encountered by the first French nationwide experimental program to provide an alternative to the hospital for psychotic crisis management.

Paper long abstract:

In 2019, 1 in every 8 people around the world were living with a mental disorder. The UN SDG 3 is to “ensure healthy lives and promote well‐being for all at all ages”. However, the UN has only been measuring the suicide mortality rate as mental health outcome indicator, which is totally insufficient. Indeed, the scarcity of reliable data at a global level is a major issue. This is coupled with a gap in governance, resources and services, affecting high-income countries as well. If we consider France, the mental health system is experiencing a chronic lack of human resources, and a crisis of efficacy and sense, which make it increasingly inadequate to meet demand. In response to this situation, in the city of Marseille, the first and still the only nationwide experimental program to provide an alternative to the hospital for psychotic crisis management, has been operating since 2017. Recovery-oriented, it offers a non-medical, community-based approach, in which peer workers play a prominent role. The contribution we propose - based on two years of ethnographic activities - focuses on the benefits found among users, as well as on the barriers (economic, political, cultural) and challenges that its implementation encounters. Similarly, we will question the expectations the program is generating, since it is seen as a milestone for a transition to a mental health care system no longer exclusively based on hospitals and the use of drugs, but more oriented towards a bio-psycho-social approach and more respectful of human dignity.

Paper short abstract:

Drawing on a collaborative institutional ethnography conducted by anthropologists and clinicians, this paper tackles the unfolding of, and future of ‘Peer-supported Open Dialogue’, recently implemented in the UK’s NHS under the world’s largest randomised controlled trial of this innovation.

Paper long abstract:

‘Open Dialogue’ is a Finnish psychiatric innovation from the 1980s, garnering attention globally after reporting impressive rates of recovery, reduced hospitalisation, and minimal use of psychotropic medication. It is now being implemented in the UK’s NHS via a randomised controlled trial in response to perceived failures of the existing medical paradigm and calls for a social network approach to treating distress. Complementary but independent to this trial, an Anthropological Study of Peer-supported Open Dialogue was launched and a team comprising anthropologists (who trained in Open Dialogue) and clinicians (who trained in ethnography) became embedded in two trial sites (community mental health teams) to study its unfolding. My PhD project, affiliated with the aforementioned team, demonstrates tripartite engagement as an anthropologist, Open Dialogue practitioner, and peer.

During a time where NHS mental health services were perceived as dysfunctional in their use of resources, Open Dialogue’s promise to reorganise services in a clinically- and cost-effective way, enabled it to take hold. Open Dialogue itself views crisis as an opportunity to mobilise social networks polyphonously, enabling patients to regain agency. To deliver this therapeutic intervention, clinicians must then engage in ‘undoing’ their expert, solution-driven practices and respond tentatively and compassionately as ‘humans’.

What of anthropologists investigating innovations such as Open Dialogue that present as stable assemblages? How are the outcomes of such innovations evaluated and what of their sustainability into the future? This paper assesses to what extent healthcare systems are repackaging and circulating historical innovations when attempting to ‘undo’ their past.

Paper short abstract:

This paper argues that addiction is a continually changing family of problems created by forces and flows in the world. It imagines a future for addiction healthcare where narrow diagnostic models are foregone in favour of intervention targeted at these forces and flows.

Paper long abstract:

For years the “brain disease” model has been dominant in the addiction world. Social scientists have been calling for this model to be re-evaluated for years – and now many doctors and scientists are joining them. Treatments derived from it have some of the lowest efficacy rates and highest remission rates of any psychiatric problem. Which is why it is so important to look for new ways of defining it. This paper will look at how addiction has been conceptualised through history in an attempt to formulate a new way of thinking about for the future. It draws on ethnography conducted at an internet addiction rehab in the USA, as well as a famous essay by Tim Ingold on creativity, to argue that addiction is a continually changing family of problems arising from “fields of force and flows” in the world. The paper imagines a future for addiction healthcare – and mental healthcare more broadly – where narrow diagnostic models are foregone in favour of interventions calibrated towards these forces and flows.