Paper short abstract:

We draw on data from Malawi, Uganda and Zimbabwe to explore and reflect on the uncomfortable spaces created through the instrumentalization of lay health workers for the purpose of retaining and bringing women who default from Option B+ back into care.

Paper long abstract:

In the past four years, Malawi, Uganda and Zimbabwe, have adopted a universal 'test-and-treat' approach to the prevention of mother-to-child transmission of HIV (Option B+). Thousands of pregnant and breastfeeding women are routinely tested for HIV and immediately started on antiretroviral treatment for life after a positive diagnosis. Amongst this largely asymptomatic population, a relatively high number of HIV-positive women are not retained in care; they are labeled 'defaulters' or 'lost-to-follow-up' patients. These women give a range of reasons for not coming back to health facilities; often, they implicitly choose not to be traced by providing a false address at enrollment. Across rural and urban spaces, new strategies have sought to utilize lay health workers' liminal positionality -triangulated between the experience of living with HIV, belonging to local social ties, and being a caretaker- in order to track 'defaulters'. Many lay health workers, mostly women, are deployed for tracing, often without adequate guidance or training to protect confidentiality and respect patients' choice. Not being able to bring back a patient into care is perceived to be a professional failure and sometimes a loss of income. Lay health care workers need to develop individual strategies and pay their own way to track down 'defaulters' and bring them back into the system. We draw on data collected as part of a study looking at ART decentralization (Lablite) to reflect on the uncomfortable spaces created through the instrumentalization of lay health workers for the purpose of retaining and bringing patients back into care.

Paper short abstract:

This paper illuminates the conflicts that outreach workers contend with as they attempt to build relations of trust with their fellow sex workers at the same time as more aggressive surveillance procedures, like the introduction of biometric registration protocols, impart relations of distrust

Paper long abstract:

In recent times, community outreach workers serving sex workers in Kenya have been caught between two competing approaches: 1) an entrenched history of laboratory science and biomedical 'solutions' to STI prevention, treatment, and care led by Canadian academics—tracing back to chancroid studies in the 1980s and continuing today with respect to building blood repositories and phylogenetic exploration, and 2) newer discourses emanating from the Gates Foundation via a "South-to-South" collaboration that stress community-level surveillance and evidentiary procedures in the implementation of STI interventions. This paper illuminates the conflicts that these outreach workers contend with as they attempt to build relations of trust with their fellow sex workers at the same time as new and more aggressive surveillance procedures, like the introduction of biometric registration protocols, impart relations of distrust. In the name of greater accountability to funders, emerging juridical-like relations between clinicians and sex workers greatly undermine the abilities of these outreach workers to enact forms of care that sex workers deem to be crucial to the wellbeing of their community.

Paper short abstract:

I examine Yanomami health agents' experience of training as an act of translation that paradoxically aimed to join while separating globalised practices of biomedicine and Yanomami practices of shamanism, raising important issues about intercultural care and health agents' training courses

Paper long abstract:

In 2005, health authorities in Venezuela decided to revamp the longstanding Simplified Medicine Programme in Venezuela, implemented mostly in indigenous areas with few doctors. Rather than a matter of 'task shifting', the new programme follows from the state's renewed interest in indigenous peoples and an effort towards providing 'intercultural' health services. For health authorities, interculturality supposes respecting cultural difference, yet changing practices which result in illness according to the prevailing biomedical paradigm. From their perspective, the training of indigenous health agents operates as an 'educating translation' where doctors teach indigenous peoples who become representatives of biomedicine. In contrast, for the Yanomami health agents, the training course was an act of translation through which they could learn to walk 'the paths of health' and do like doctors, without achieving semantic commensurability or identity with doctors. Health agents acted as brokers of alterity: on the one hand, they were learning from the doctors and undergoing bodily transformations into health workers; on the other, they asserted the validity of their own systems of healing, while generally keeping their medical ontology concealed from the view of doctors. I examine several analogies made between schools, shamanic initiations and the training course, and also between clinical algorithms and shamans' healing paths. This case challenges the idea of training courses for health agents as a space of knowledge transmission, and exemplifies a strategy of translation in which versions of healing co-exist but do not mix, with comparative value for other intercultural contexts.

Paper short abstract:

This paper uses a biosocial approach to explain the variable forms of care and micro-politics in which Ethiopian community health workers (CHWs) engage, comparing across two contexts: urban CHWs deployed by NGO-government partnerships and rural CHWs deployed primarily by the government.

Paper long abstract:

Across localities, community health workers (CHWs) engage in various forms of care, in relation to locally distinct population health needs and goals. This variation and set of relationships are poorly understood largely due to a lack of comparative biosocial research. And yet CHWs participate--or perform--in more than the delivery of health care. CHWs are political actors. They form opinions on the inequalities they witness. They often desire social change. Even in contexts in which CHWs are not autonomously organized as political forces, such as in Ethiopia, they make small steps towards forming collectives to argue and seek better job conditions. Some emphasize that their job conditions are unfair, and that this impedes their capacities to improve community health and wellbeing. This paper explains the variable forms of care and micro-politics in which Ethiopian CHWs engage, comparing across two contexts: urban CHWs deployed by NGO-government partnerships to perform highly intimate forms of care alongside the roll-out of antiretroviral drugs; and rural CHWs deployed by the government to promote maternal- and child-focused primary health care. A biosocial approach aims in part to identify and understand links between population health, CHWs' capacities and experiences, and officials' and donors' attempts to encourage specific forms of care, discourage collective action, and make programs cost-effective. Such comparative analysis is highly needed to provide insight into the rapidly changing moral and political economies of CHW labor at local and global scales.

Paper short abstract:

Hopes invested today in community health workers echo those once invested in “traditional birth attendants.” In Malawi, TBAs once treated as stop-gap extensions of the modern state are now often vilified as dangerous non-moderns. Their experience raises cautions about health work at the boundary.

Paper long abstract:

"Global health" schemes today often place high hopes on community health workers, imagined to extend sensitive, appropriate, and inexpensive care to people in poor countries and remote places. These hopes are not novel. From the early twentieth century to the mid-1990s, so-called traditional birth attendants (TBAs) were imagined as agents who might extend safe motherhood practices beyond the reach of doctors and nurses. Programs to teach TBAs the rudiments of biomedical obstetric care proliferated. The rise and fall of TBA programs raises cautions about today's focus on CHWs.

In Malawi, birth attendants were registered (although never entirely), trained (although never at large scale), and supervised (although never consistently) for decades. Training programs largely ended by 2005; in 2007 TBA practice was outlawed. Although the ban was later reversed, the legal status of these attendants now varies among districts and is often unclear. In the aftermath, those who still work as TBAs are largely cut off from relations with government health workers and facilities.

How did these birth workers go from saviors to scoundrels? Drawing on ethnographic and archival research, and on interviews with birth attendants in Malawi, I argue that a managerial biomedical imaginary stabilized and homogenized a remarkably heterogeneous set of practitioners. TBAs were not just at the boundary between traditional and biomedical: the whole category was a product of bureaucratic boundary-drawing that never matched up with what was actually happening in practice. This imaginary made the hopes invested in TBAs possible—and their disappointment inevitable.

Paper short abstract:

This paper examines the sanitary and socio-political impact of the work of a Yanomami Health Agent, and his relation with the health system. It argues that community welfare relies more on the co-option of state resources by the people than on the State´s effort to sanitarize them.

Paper long abstract:

This paper examines the impact of the work of a Yanomami Community Health Agent in a group of previously unattended villages of the Upper Ocamo basin of the Venezuelan Amazon. It draws on fieldwork undertaken between 2007 and 2011, and combines an analysis of the effect of the Health Agent´s sanitary work on the general well-being of the village; the impact of his endowment with a paid job in the socio-political climate of the community and neighbouring villages; the gradual abandonment of supervision and support of his work by the regional health system, and the agent´s response to this. While the case shows that the transference of a first level of attention to community workers seems to have had a positive sanitary impact over a certain period of time, the lack of continued support to the Agent expresses a constitutional inertia of the State culture, which works against the declared welfare goals of the program. Providing a discussion of Kelly´s (2011) analysis of Yanomami state healthcare, it will argue that in the contentious interaction between health governmentality and indigenous agency, community welfare is better served by the people´s drive to co-opt state resources than by the State´s drive to sanitarize hinterland peoples.

Paper short abstract:

Results of ethnographic research regarding the role of Indigenous Health Agents (AIS) in Brazil suggest that AIS role is central to the production of the social field of intermedicality and that such community health workers emerge as new political subjects to act in inter-ethnic contexts.

Paper long abstract:

Brazilian National Indigenous Health Care Policy (PNASPI) has established the principle of "differentiated attention" (atenção diferenciada) for the promotion of health care services that take into consideration cultural diversity and epidemiological and sociocultural specificities. According to PNASPI, training courses for health workers are strategic for guaranteeing differentiated attention in indigenous villages. This paper summarizes results of ethnographic research regarding the role of Indigenous Health Agents (AIS) on the Munduruku Indians Reserve Kwata-Laranjal, municipality of Borba, Amazonas, Brazil. It contributes to understanding the AIS's role within the hegemonic medical model in a pluralistic medical context. The analysis includes data from 8 months of participant observation and interviews conducted from 2009 to 2011. Semi-structured interviews were conducted with 31 of the 35 AIS to obtain data regarding education, gender, age, years employed, etc. Open interviews were realized for the registering of narratives with regard to routine responsibilities, experiences and difficulties. According to our findings, there are several obstacles that interfere with their activities and are primarily caused by operational and management problems of the Indigenous Health Care Subsystem (SASI). We conclude the Indigenous Health Agents' performance is essential to the operation of health services and that their role transcends strictly technical activities. They play a central role of articulation between biomedical and indigenous knowledge in an intermedical context and such community health workers emerge as new political agents in interethnic contexts.

Paper short abstract:

This paper compares the role of indigenous health workers in Western Amazonia as cultural mediators between shamanic popular medicine and health services in the 1980s and now. The rise of both indigenous movements and shamanism in Latin America call for consideration of this cultural mediation in the new health goals for integrated primary health care.

Paper long abstract:

In this paper I review the involvement of Amazonian indigenous health workers in shamanic popular medicine in two surveys conducted in the Peruvian Upper Amazon in the early 1980s and in 2013-4. In the first survey, as sons or nephews of shamans, health workers mediated conflicting views of health and illness and helped patients negotiate parallel quests for therapy. Three decades later, the rise of both indigeneity and shamanism and the prevailing hospital model of health care in Amazonia have produced a superficial integration of health services yet a deeper cultural divide. Analyzing the changing modalities of “delivering health care” in the two periods, I show that indigenous health workers are more actively and explicitly engaged in cultural translation and the production of difference. As popular shamanic medicine, now re-claimed as ‘indigenous’, continues to spread in the sprawling urban shanties of Amazonia, rich and poor alike practice extensive ‘healer shopping’ across the hospital-shaman divide. Traditional midwives however are still excluded in a binary system of care as they were thirty years ago in Peru, while in the Ecuadorian and Bolivian Amazon, their role is acknowledged in health services. Regardless of the concept of medical pluralism having fallen into academic disrepute, I argue that medical anthropological studies of the indigenous health workers’ role as cultural mediation can throw light on the new policies of participatory engagement of local healers in the delivery of primary care for all. Notions of covert or overt agency, tacit or explicit knowledge need to be addressed.