Anthropologies of late modernity (also called postmodernity, postindustrial society, knowledge society, or information society) provide a number of stimulating challenges for all levels of social, cultural, and psychological theory, as well as for ethnographic and other genres of anthropological writing. Three key overlapping arenas of attention are the centrality of science and technology; decolonization, postcolonialism, and the reconstruction of societies after social trauma; and the role of the new electronic and visual media. The most important challenges of contemporary ethnographic practice include more than merely (a) the techniques of multilocale or multisited ethnography for strategically accessing different points in broadly spread processes, (b) the techniques of multivocal or multiaudience-addressed texts for mapping and acknowledging with greater precision the situatedness of knowledge, (c) the reworking of traditional notions of comparative work for a world that is increasingly aware of difference, and (d) acknowledging that anthropological representations are interventions within a stream of representations, mediations, and unequally inflected discourses competing for hegemonic control. Of equal importance are the challenges of juxtaposing, complementing, or supplementing other genres of writing, working with historians, literary theorists, media critics, novelists, investigative or in-depth journalists, writers of insider accounts (e.g. autobiographers, scientists writing for the public), photographers and film makers, and others.
Format: Journal
Pharmaceutical Citizenship
Among practitioners of biomedicine, to speak of people as ‘marginalized’ often amounts to saying that they do not have access to medical substances. Thus conceived, the best way to remove marginality seems to be to give medicines to those deprived of them. The peculiar relationship between marginality and pharmaceuticals is especially poignant in the case of antidepressant drugs, as these drugs appear to bring the patient ‘back into society’, but not any society, but middle-class consumer society. What is now special about antidepressants is that there is nothing special about them: antidepressants are like consumer items among thousands of other consumer items. This paper explores the relations between medicines and marginality with reference to the marketing of antidepressant drugs in Kolkata (Calcutta), India. Drawing on ethnographic fieldwork in the Kolkata metropolitan area from July 1999 to December 2000 and in August/September 2003, this paper examines how people with depression are constituted as ‘marginal’ in the sense of ‘being deprived of medication’, and how the biomedical promise of an effective pharmacological treatment becomes a promise of ‘pharmaceutical citizenship’. In view of Bengali notions of mental health as a state of detachment, the paper asks if pharmacological demarginalization holds the same promise in the Indian context that it holds in the West.
Anthropology’s Contribution to AMR Control
Anthropological study can provide important insights for addressing AMR. This paper describes anthropological approaches for understanding the context of increasing antimicrobial use around the globe as well as how important anthropological contributions to the study of infectious diseases can inform studies of AMR emergence and transmission. Four themes are followed to illustrate this: care; pharmaceuticals and markets; knowledge; and ecologies. Together, these accounts illustrate the complex stories behind our relations with microbes and antimicrobial medicines across the world today, and help us to study and anticipate consequences – intended or not – of both AMR and AMR control strategies globally.
As a clinician, you are not managing lab results, you are managing the patient
In response to widespread overuse of antimalarial drugs, the World Health Organisation changed guidelines in 2010 to restrict the use of antimalarials to parasitologically confirmed malaria cases. Malaria rapid diagnostic tests (RDTs) have been presented as a means to realize the new guidelines, and National Malaria Control Programmes, including that of Cameroon, are developing plans to introduce the tests to replace microscopy or clinical diagnosis at public health facilities across the country. We aimed to understand how malaria tests and antimalarial drugs are currently used as part of social interactions between health workers and patients at public and mission health facilities in Yaoundé and Bamenda and surrounding districts in the Northwest region of Cameroon. In May to June 2010, we held 17 focus group discussions with 146 health workers involved in clinical care from 49 health facilities. Clinicians enacted malaria as a ‘juggling’ exercise, involving attention to pathophysiology of the patient as well as their desires and medical reputations, utilising tests and medicines for their therapeutic effects as symbols in the process of care. Parasites were rarely mentioned in describing diagnostic decisions. These enactments of malaria contrast with evidence-based guidelines emanating from WHO, which assume the parasite is the central driver of practice. If RDTs are to be taken up in practice, public health practitioners need to pay careful attention to the values and priorities of health workers and patients if they are to work with them to improve diagnosis and treatment of febrile illnesses.
Introducing malaria rapid diagnostic tests at registered drug shops in Uganda
In Uganda, around two thirds of medicines are procured from the private sector, mostly from drug shops. The introduction of malaria rapid diagnostic tests (RDTs) at drug shops therefore has the potential to make a significant contribution to targeting antimalarial drugs to those with malaria parasites. We undertook formative research in a district in Uganda in preparation for a randomised trial of RDTs in drug shops. In May to July 2009, we interviewed 9 drug shop workers, 5 health workers and 4 district health officials and carried out 10 focus group discussions with a total of 75 community members to investigate the role of drug shops and the potential for implementation of RDTs at these health care outlets.
Drug shops were seen to provide an important service to community members, the nature of which is determined by responsiveness to client demands. However, drug shops hold a liminal status: in the eyes of different actors, these outlets are at once a shop and clinic; legitimate and illegitimate; and trusted and distrusted. Malaria treatment was found to be synonymous with diagnosis. Diagnostic testing was deemed useful in theory, and community members were curious about the results, with the expectation that a test would decrease uncertainty and help secure an end to illness. However, whether testing would be sought as a routine step in treatment decisions in practice is uncertain, since the appeal of the tests waned in light of their costs and potential for results to conflict with presumed diagnosis.
Interventions that increase awareness of multiple causes and management of malaria-like illness will be needed to support the new rationalisation for malaria treatment represented by parasitological diagnosis.
Guidelines and Mindlines
Why is malaria over-diagnosed despite access to simple diagnostic testing? Why does clinician knowledge not translate into practice? In this ethnographic study of two hospitals in Tanzania, Clare Chandler and her colleagues demonstrated that many non-clinical factors influence malaria diagnosis and treatment. Diagnosing non-malaria febrile illness is complicated, not because of a lack of access to diagnostic tools, or from a lack of clinician knowledge, but because of prevailing social spheres of influence. These social spheres have contributed to the development of clinician ‘mindlines’ that tend to inform diagnosis more than official ‘guidelines’. ‘Mindlines’ can best be understood as constructed rationales for clinician behaviour, that are “collectively reinforced” and act as “internalized tacit guidelines” (Gabbay and le May 2004: 1015) that outweigh impact on practice over official guidelines. Clinician practice is heavily influenced by social concerns and constraints, not by lack of knowledge or lack of appropriate diagnostic tools.
Four social spheres of influence were identified: First, malaria is seen as a safe and easy diagnoses to make in an environment with multiples constraints, and initial clinician training strongly promotes attention to malaria. This training, coupled with a policy environment that portrays malaria widely endemic, have led to the shared belief that to miss a malaria diagnosis is an ‘indefensible’ act. Second, the influence of peers strongly shaped diagnosis practices. Physicians understood malaria as easily recognizable, and misdiagnosing malaria was considered a potential source of humiliation. Third, malaria was perceived by clinicians as an ‘acceptable’ diagnosis for patients. Clinicians described feeling ‘pressure’ from patients for both a malaria diagnosis and for prescribing antimalarial medication. Fourth, quality of diagnostic support (resource management, motivation and supervision) were limited. Clinicians reported trusting their diagnostic skills over formal diagnostic testing, and resisted the idea that antimalarial drugs should only be prescribed in test-positive cases.
Works cited:
Gabbay, J. and A. le May. 2004. Evidence based guidelines or collectively constructed ‘mindlines?’ Ethnographic study of knowledge management in primary care. BMJ, 329(7473):1013.
Witchcraft, Bureaucraft, and the Social Life of (US) Aid in Haiti
In this article I discuss the unintended consequences of humanitarian and development assistance provided to “victims of human rights abuses” in Haiti in the years following the restoration of democracy in 1994. Such targeted aid was a component of international political and economic development aid intended to facilitate the nation’s postconflict transition. I argue that in much the same manner that witchcraft discourses signify moral struggles over the distribution of resources in small-scale societies, the cultures and moral economies of humanitarian and development aid—well-intentioned activities that nonetheless include opaque bureaucratic practices and competition over knowledge, scarce resources, and institutional territory—can produce similar phenomena as has been described regarding contemporary witchcraft. I draw on the literature on witchcraft, bureaucracy, and secrecy to analyze accusations of malfeasance, scapegoating, and violence directed toward both providers and recipients of humanitarian and development assistance. I characterize such processes occurring in relation to compassion economies by the term bureaucraft. [witchcraft; bureaucracy; bureaucraft; humanitarianism; democracy; insecurity; human rights; Haiti]
Antibiotics: The Epitome of A Wonder Drug
Antibiotics can truly be considered the epitome of the 20th century’s “wonder drugs.” This term was widely used in the 1950s, even in official documents, expressing the enthusiasm of patients, doctors, and policy makers for drugs that transformed once mortally feared bacterial infections into curable conditions.
Penicillin is the iconic antibiotic. Its introduction into clinical practice was widely celebrated and was the culmination of individual achievements, long running trends in science, and a supportive environment. In 1929 Alexander Fleming, at St Mary’s Hospital Medical School in London, reported his observation that the culture medium on which a penicillium mould had grown attacked certain bacteria. However, chemists and bacteriologists, then working largely separately, failed to isolate the active substance in the mould juice. Only in 1940 was the isolation achieved, at Oxford, where Howard Florey had created a multidisciplinary team. The team’s efforts were sustained by the interest and talent of, among others, Ernst Chain, a German refugee, and Norman Heatley, who developed key techniques for growing the mould and isolating the drug. But the financial support of the Rockefeller Foundation in the United States and the Medical Research Council in the United Kingdom was also crucial, as were the need created by the outbreak of war and the remarkable properties of penicillin itself. This confluence of factors led rapidly to laboratory scale production and the demonstration of penicillin’s clinical potential.
Antibiotics, Big Business, and Consumers
This paper explores a regulatory campaign to promote access to antibiotics in the United States during the 1950s, and explains it as a reaction to prewar deprivation. It tracks a decade-long attempt to prevent the drug industry from replicating a perceived pattern of big business behavior blamed for underconsumption. The Depression-era Temporary National Economic Committee (TNEC) had explained low consumption by artificially high prices associated with excess profits, excessive marketing and restrictive patents of large companies. In the post-War years a group of TNEC veterans (including Walton Hamilton, Irene Till and John Blair) campaigned to protect the drug market from these vices: through a FTC enquiry which led to a judicial investigation, and through the Kefauver hearings in Congress. This campaign culminated in the in radical increase of FDA powers in 1962, albeit triggered by the thalidomide scare. Ironically the problems of under-consumption were given institutional teeth just at the time that the novel problem of the over-consumption of antibiotics was becoming serious.
‘There is worse to come’
How is the future imagined via the politics and policy of AMR? What happens when the metaphors we employ to describe AMR are overwhelmingly linked to the ‘dark ages’ and the ‘impending apocalypse’? What work do these catastrophic formulations do? Do they garner public support? Do they impel more investment in ‘new’ antibiotics? In this article, Brown and Nettleton offer a compelling history and political economy for the emergence of this kind of rhetoric, arguing that what these metaphors really do is nurture the prevailing notion of the individual body at war with a dangerous and dirty bacterial world. What other kinds of futures are possible though? What would a more cooperative – rather than combative – juncture between the human and the microbial look like?
