Somatosphere welcomes you to the April edition of “In the Journals.” Scroll through our monthly round up of new research across anthropology, STS and social science journals.
Culture, Medicine, and Psychiatry
Clinical Ethnographies of the Politics and Poetics of the US Healthcare Crisis
Liza Buchbinder, Seth M. Holmes, Rebecca Newmark, Bonnie Wong, Philippe Bourgois
The confluence of the COVID19 pandemic, the Supreme Court’s overturning of Roe vs Wade, the televised murder of George Floyd, and the rise of populist hate-speech under Donald Trump highlights how political ideologies, racism, and social structural inequities negatively impact health and medicine. As US-based medical providers, scholars, and advocates, we are keenly aware of the ways in which policies and social forces influence bodily well-being. COVID-19 continues to lay bare the divisions between haves and have-nots. High death rates in the U.S. compared to similarly wealthy countries (Bilinski et al., 2023), a monetized for-profit health system that disproportionately affects poor and racialized communities (Dranove & Burns, 2022), and a deeply polarized political climate all harm health and well-being.
This special issue offers an ethnographic snapshot and critical archive of the era’s turmoil since COVID-19. Composed of health practitioners and researchers who are also social scientists and humanist observers, the authors in this special issue draw on ethnography to address the poetics and politics of intimate spaces of healing. This engaged scholarship builds on interdisciplinary traditions at the nexus of anthropology and medicine.
‘Hallucination’: Hospital Ecologies in COVID’s Epistemic Instability
Scott Stonington, Roi Livne, Zoe Boudart
Historians and ethnographers have described biomedicine as a modernist project that imagines accumulating ever-more stable knowledge over time. This project broke down in heavily hit hospitals at the onset of the COVID-19 pandemic in the U.S., when bureaucratic, physical and knowledge structures collapsed. A combination of terror, a partially characterized disease entity and clinicians′ inability to operate without disease models drove them to draw on rapidly changing and contradictory information via social media, changing medical practice minute-to-minute. The result was a unique form of knowing described as “hallucination”: a hyperreal, unstable ecology of imagined viral particles distributed in physical spaces, transforming with each text message and tweet. The nature, experience and practice of this ecology sheds light on what happens when instability comes to otherwise stable places.
Learning Language, Un/Learning Empathy in Medical School
Seth M. Holmes
This article considers the ways in which empathy for patients and related solidarity with communities may be trained out of medical students during medical school. The article focuses especially on the pre-clinical years of medical school, those that begin with orientation and initiation events such as the White Coat Ceremony. The ethnographic data for the article come from field notes and recordings from my own medical training as well as hundreds of hours of observant participation and interviews with medical students over the past several years. Exploring the framework of language socialization, I argue that learning the verbal, textual and bodily language of medical practice contributes to the increasing experience of separation between physicians and patients. Further considering the ethnographic data, I argue that we also learn a form of empathy limited to performance that short circuits clinical care and the possibility for solidarity for health equity. The article concludes with implications for medical education and the medical social sciences and humanities.
Jeremy Levenson, Shamsher Samra
The field of medical action extends beyond the clinical encounter. Rather, clinical encounters are organized by wider regimes of governance and expertise, and broader geographies of care, abandonment and violence. Clinical encounters in penal institutions condense and render visible the fundamental situatedness of all clinical care. This article considers the complexity of clinical action in carceral institutions and their wider geographies through an examination of the crisis of mental health care in jails, an issue of significant public concern in the United States and much of the world. We present findings from our engaged, collaborative clinical ethnography, which was informed by and seeking to inform already existing collective struggles. Revisiting the concept of “pragmatic solidarity” (Farmer in Partner to the poor: a Paul Farmer reader, University of California Press, Berkeley, 2010) in an era of “carceral humanitarianism” (Gilmore in Futures of Black Radicalism, Verso, New York, 2017, see also Kilgore in Repackaging mass incarceration, Counterpunch, June 6–8, http://www.counterpunch.org/2014/06/06/repackaging-mass-incarceration/, 2014), we draw on theorists who consider prisons to be institutions of “organized violence” (Gilmore and Gilmore in: Heatherton and Camp (eds) Policing the planet: why the policing crisis led to Black lives matter, Verso, New York, 2016). We argue that clinicians may have an important role in joining struggles for “organized care” that can counter institutions of organized violence.
Corpses in Clinical Space and the Preposterous Temporality of Pandemic Care
Sheyda M. Aboii
Articulations of the chasm between ideal and attainable forms of care surfacing throughout the coronavirus (COVID-19) pandemic have highlighted the proliferation of unceremonious deaths associated with inequitable conditions. This paper reconsiders the preposterous temporality of pandemic care by following corpses in and out of clinical space. Written from the perspective of a MD/PhD student’s encounter with a corpse replacing the patient on the medicine ward prior to pandemic onset, this paper asks how corpses might interrupt narratives of clinical care. Sifting through Eugène Ionesco’s 1954 play “Amédée,” Édouard Glissant’s rejection of the tragic heroine, Achille Mbembe’s positing of viscerality as autopsy, and David Marriott’s theorization of blackness as corpsing among other engagements, I conceptualize how corpses might refigure clinical spaces as preposterous realms wherein distinctions between a before and after falter. Considering the continuities between an apparent before and after, I argue that the contemporary concerns punctuating the pandemic as a unique period in time might not be as contemporary as they first appear. Taking cues from literary analysis and fictional works, I engage the corpse as a figure that prompts a rethinking of what might constitute ideal as well as failed care. I argue that corpses in clinical space signal a critique of the ideal narrative arc, one that centers the medical provider as heroine/hero in the midst of tragedy. Turning to the corpse as an interruptive figure, I ask what this dominant narrative might ultimately demand of its cast of characters—protégé, provider, and patient.
Kimberly L. Sue
In this article, I describe the dilemmas of working as a physician-ethnographer within the Rikers Island jail healthcare system before and at the beginning of the COVID-19 epidemic in April 2020. The Rikers Island jail system in New York City has been in the national spotlight as a space of violence, trauma, and death amidst calls to decarcerate by community members and abolition advocates. This article is a personal reflection on the labor and subjectivity of healthcare providers and their positionality to multiple axes of structural and interpersonal violence while attempting to provide care in carceral institutions. I observe how COVID-19 functioned as an additional form of structural violence for incarcerated people. Clinical ethnography remains an essential tool for understanding complex social phenomena such as violence. However, physician-ethnographers working in these spaces of structural violence can have unique and conflicting constraints: tasked with providing evidence-based medicine but also simultaneously participating in an unusual form of labor that is an amalgamation of care, social suffering, and punishment. Despite and across at-times conflicting roles and obligations, I propose that these fragmented subjectivities can foment social criticism, propel advocacy toward decarceration, and produce a critically engaged dialogue between fields of anthropology and medicine toward a goal of health justice.
Intimacy, Anonymity, and “Care with Nothing in the Way” on an Abortion Hotline
Jennifer Karlin, Caroline C. Hodge
This essay is an ethnographic account of a volunteer, anonymous hotline of physicians and advanced practice providers who offer medical advice and guidance to those who are taking medications on their own to end their pregnancies. Attending to the phenomenology of caring on the Hotline reveals a new form of medical expertise at play, which we call “care with nothing in the way.” By operating outside the State’s scrutiny of abortion provision, the Hotline offers its volunteers a way to practice abortion care that aligns with their professional and political commitments and that distances them from the direct harm they see caused by the political, financial, and bureaucratic constraints of their clinical work. By delineating the structure of this new regime of care, these providers call into question the notion of the “good doctor.” They radically re-frame widely shared assumptions about the tenets of the ideal patient–doctor relationship and engender a new form of intimacy–one based, ironically, out of anonymity and not the familiarity that is often idealized in the caregiving relationship. We suggest the implications of “care with nothing in the way” are urgent, not only in the context of increasing hostility to abortion rights, but also for a culture of medicine plagued by physician burnout.
Carolyn Sufrin
Anthropologist-clinicians who engage in both ethnographic inquiry and clinical practice confront methodological, ethical, and epistemological predicaments that can challenge and enhance the moral practice and ethics of care inherent both to healing and to ethnography. Clinician-ethnographers often find themselves practicing within harmful systems that they also critique, such as hospitals or carceral institutions. This paper analyzes the dual practice of obstetrical care and ethnography in a county jail and a county hospital. These intertwined roles involve wrestling with sometimes conflicting vocational and ethical obligations to heal, to protect privacy, to address bodily consequences of systemic oppressions, and to critique the systems that mete human suffering. Developing a consciousness of clinical-ethnographers’ complicity, rather than disavowing it, can be aligned with approaches of abolition medicine to reimagine more just forms of healing.
Lior Tal, Yehuda C. Goodman
According to psychiatry, Attention-Deficit/Hyperactivity Disorder (ADHD) is a chronic condition beginning in early life. Psychiatry advocates for early diagnosis to prevent comorbidities that may emerge in untreated cases. “Late”-diagnosis is associated with various hazards that might harm patients’ lives and society. Drawing on fieldwork in Israel, we found that ‘midlife-ADHDers,’ as our informants refer to themselves, express diverse experiences including some advantages of being diagnosed as adults rather than as children. They share what it means to experience “otherness” without an ADHD diagnosis and articulate how being diagnosed “late” detached them from medical and social expectations and allowed some to nurture a unique ill-subjectivity, develop personal knowledge, and invent therapeutic interventions. The timeframe that psychiatry conceives as harmful has been, for some, a springboard to find their own way. This case allows us to rethink ‘experiential time’—the meanings of timing and time when psychiatric discourse and subjective narratives intertwine.
East Asian Science, Technology and Society: An International Journal
Frédéric Obringer
Medical knowledge, representations of illness and health, and diagnostic and therapeutic practices in the Chinese world intrigued, to varying degrees, the Portuguese Jesuits who reached Japan as early as the seventeenth century, then the Jesuits of the China Mission and the doctors of the Dutch East India Company in the eighteenth century, and finally the European scientists, diplomats, and soldiers who visited the Far East in the nineteenth century. More generally, as we know, the same was true of agriculture (or agronomy), botany, the art of gardening, architecture, porcelain, zoology, etc. These contacts resulted in numerous texts presenting these various “Chinese techniques and sciences,” the nature, status, and scope of which varied considerably depending on the informant and the period (Barnes Citation2005; Bivins Citation1999).
Lucia Candelise
The evolution of “traditional” medicines frequently involves transnational circulation, appropriation, and the redefinition of their knowledge and techniques by local cultures. This dynamic is particularly evident in therapeutic practices originating from Chinese medicine, such as acupuncture and moxibustion, massage, and the prescription of remedies derived from the Chinese pharmacopoeia. This article focuses specifically on the context of France, examining how knowledge and know-how related to Chinese medicines have been constructed and how they circulate between the mid-twentieth century and the beginning of the twenty-first. Furthermore, this article explores how Chinese medical thought and practices developed during different historical periods were also conditioned by the professional orientation and intellectual aims of the different key figures of this medical knowledge. By analysing individual itineraries (Jami 2017) of these key figures, this article shows how a distinct medical knowledge and practice, identified as “French Traditionalist Acupuncture,” emerged in France influenced the medical landscape of acupuncture practices throughout Europe up to the present day.
Victor Kumar
In the United States today, acupuncture and Chinese medicine are so connected that the terms are almost interchangeable. Yet, when acupuncture first came to prominence in the American medical community in the 1820s, it was seen as a European innovation and associated with physicians in Paris and London. In contrast to the cultural models of therapeutic action so prevalent today, medical manuals and textbooks of the nineteenth century tended to classify acupuncture as a form of “practical medicine,” an empirically effective technique without a definitive theoretical basis. This paper traces a genealogy of the different ways in which acupuncture has historically been recognized in the United States. Particular attention is paid to the period of “acupuncture fever” in the 1970s, the appearance of acupuncture in American medical texts in the late nineteenth century, and the initial wave of discourse around acupuncture in the 1820s. This paper demonstrates an ongoing historical tension between framing acupuncture in terms of a complex system of cultural concepts and framing it as a simple and practical therapy whose efficacy is most clearly felt in the space of the clinical encounter.
Jialiang Cui, Jialing Wu
For people with mental health issues (MHIs), the experience of being at home is widely recognised as a universal aspiration. Yet, research on home in the mental health context has largely marginalised the role of transitional accommodation. This paper examines how residents construct the idea of home and how homelike qualities are enacted and sustained in transitional accommodation in Hong Kong, where such services remain the primary response to the (temporary) housing needs of people with MHIs. With the support of a panel of experts with lived experience of MHIs and transitional accommodation, we conducted in-depth interviews using both visual and verbal methods with 60 residents across 16 hostels. Findings revealed that external, relational, and socially connected qualities of home were more likely to be prioritized by residents. Participant accounts also reflected a broad continuum in how transitional accommodation is perceived in relation to home, ranging from full acceptance to firm rejection. Four themes, including safety risk coming from inside, spaces for extending family connection, dimensional interpretations of personal space, and living with a diminished sense of ownership, are discussed, highlighting the influence of personal, socio-cultural, and political contexts in the homemaking process. The paper underscores the need for more culturally and contextually sensitive research on at-homeness and offers insights into improving the design and delivery of transitional accommodation services.
Eunice Y. Park, Jodi H. Barnet, Kristen C. Malecki, Thomas R. Oliver
Social capital is known to function as a protective buffer during disasters and crises. This study examines the relationship between neighborhood-level sense of community–a social capital indicator–and mental health before and after widespread COVID-19 vaccine distribution. It uses health survey data from community-dwelling adults in Wisconsin (n = 2048), a series of longitudinal analyses (Generalized Estimating Equation), adjusting for demographic and socioeconomic status, between neighborhood sense of community and mental health across two timepoints. Before the vaccines, participants with strong sense of community showed significantly lower prevalence of symptoms of depression (PR = 0.81; 95 % CI = 0.70, 0.94; p = 0.004) and anxiety (PR = 0.88; 95 % CI = 0.79, 0.99; p = 0.03), compared to participants with neutral sense of community. After the vaccines, however, the protective effect drastically diminished for both depressive symptoms (PR for interaction = 1.76; 95 % CI = 1.38, 2.25; p < 0.001) and anxiety symptoms (PR for interaction = 1.42; 95 % CI = 1.16, 1.73; p < 0.001). This study yields intriguing and somewhat paradoxical findings that challenge a conventional assumption that social capital–as measured by sense of community at the neighborhood level–protects people during an infectious disease outbreak. The results highlight that neighborhood-level sense of community functioned as a protective buffer early in the pandemic but offered significantly less protection once there was a sense of normalcy with loosened pandemic restrictions and more in-person socializing. Such nuanced results offer insights on the multifaceted nature of social capital, particularly complex and dynamic role of neighborhood sense of community, which may provide insights for future interventions during challenging times.
Ruoyu Dong, Yanqing Xu, Rui Zhu
Rapid urbanization has led to a significant increase in artificial light at night (ALAN), raising concerns about its potential adverse effects on human health. Yet, evidence on the relationship between ALAN, sleep, and mental health remains limited. In this study, we utilized the Extended Time-Series of Global NPP-VIIRS-like Nighttime Light Data and population distribution maps to estimate population-weighted ALAN at the census tract level across 500 major U.S. cities from 2013 to 2019. We also obtained the prevalence of frequent mental distress and short sleep duration from the SDOH database. A Two-Stage Least Squares (2SLS) model was applied to investigate the causal relationships between ALAN, sleep, and mental health, as well as heterogeneity across differing educational and urbanization levels. The findings revealed that: (1) Population-weighted ALAN was significantly associated with both sleep and mental health, with a ten-fold increase in O-ALAN corresponding to an 8.05 % (±0.04 %) rise in mental distress prevalence and a 4.99 % (±0.07 %) increase in short sleep duration prevalence; (2) higher education levels intensified the negative impact of ALAN on mental health but mitigated its effect on sleep; and (3) higher urbanization levels amplified ALAN’s adverse effects on both sleep and mental health. This study is the first to examine the relationship between population-weighted ALAN and sleep and mental health outcomes while accounting for economic endogeneity, offering a comprehensive view of ALAN’s impact on health.
Ediomo-Ubong Nelson
Studies have shown that medication-taking experiences are mediated by intricate social, affective and material entanglements. However, less attention has been accorded the role of place in the sociomaterial relations of these experiences. Using four examples drawn from a mixed qualitative methods study with people who use drugs living with chronic non-cancer pain in Nigeria, this study shows that medication-taking experiences are not stable but always relative to the spatio-temporal contexts of their enactment. Consistent with the logic of ‘enabling places’, the study produced findings showing that the actor-networks in different places afforded various resources that mediated medication-taking experiences. Medication-taking experiences were not reducible to simple encounters between bodies and pharmacology; instead, they were constituted through social, affective and material resources of network associations the availability of which made particular places enabling on particular occasions. To conclude, the study calls for the creation of enabling places by transforming actor-networks in ways that enable positive medication-taking experiences.
Anna Stone, Tiffany Cheng, Robert J Coplan
Spending time alone in nature has been found to benefit well-being, but the mechanisms underlying this relation are understudied. The current study validated an assessment of the construct of connectedness to nature in solitude (CNIS) and evaluated a model linking CNIS, time spent alone in nature, and indices of well-being. Participants were N = 812 emerging adults (Mage = 19.45, SD = 1.87) attending university in southeastern Ontario, Canada. Participants completed a series of self-report measures assessing CNIS, time alone in nature, affinity for solitude, nature connectedness, loneliness, aloneliness, and life satisfaction. Factor analysis of the 7-item CNIS Scale indicated a one-factor solution. Regression analyses indicated that at low levels of CNIS, time alone in nature was significantly and positively related to loneliness and aloneliness, but at higher levels of CNIS, this relation was attenuated. The current study provides initial evidence for the importance of CNIS as a moderator of the links between time alone in nature and well-being.
Sarah A. Lovell, Christina Ergler, Mary Kensington
High rates of intervention in birth is a significant health issue. Primary birth centres are midwife-led sites for care with lower rates of intervention in birth than hospitals. Yet hospital births dominate birthplace decision-making in New Zealand. In-depth interviews with 24 health workers associated with four primary birth centres aim to identify how confidence in a primary centre birth is built. Thematic analysis demonstrates how midwives discursively and visually re-centred birth as a normal physiological process challenging hospital as the taken-for-granted place for care. We conclude that midwives’ neurohormonal understandings of birth builds responsiveness to the birth-place ontologies of clients.
Structural drivers of health among transgender women in the United States: A nationwide study
Tonia C. Poteat, Sabriya L. Linton, Andrea L. Wirtz, Carmen Gutierrez, … Sari L. Reisner
Residential segregation and gentrification are associated with a variety of health outcomes. However, few studies in this area have included transgender women, who experience well-documented health inequities. This analysis sought to assess the effects of racialized economic segregation and gentrification on psychological distress and self-rated health (SRH). Ethnoracial identities included 57 % White, 19 % Black, and 9 % Latine (of any race). The highest tertile of racialized economic advantage (vs the lowest) was associated with increased risk of serious psychological distress (RR = 1.28; 95 %CI = 1.02, 1.61) and higher risk of poor-to-fair SRH (RR = 1.51; 95 % CI = 1.10,2.08) in multivariable models, while gentrification showed no significant association with either outcome. These findings are consistent with prior research indicating that minoritized populations may not derive health benefits from residing in more socially and economically advantaged neighborhoods. Future research is needed to better understand the experiences of transgender women who may be exposed to transphobia in both advantaged and disadvantaged neighborhoods.
Claire Wicks, Susan McPherson, Cara Booker, Antonella Trotta, … Emily T Murray
Recent research in the United Kingdom (UK) has highlighted a potential ‘coastal effect’, whereby residents of coastal areas may be subject to poorer health outcomes, including mental health. This study sought to investigate the coastal effect by comparing the risk of experiencing diagnosed and undiagnosed mental distress in both coastal and inland English adult residents. Data from waves 10–13 (2018–2023) of Understanding Society, a nationally representative population study, were extracted for analysis. Respondents were categorised by residential area (coastal or inland), mental health status (no mental distress, diagnosed mental distress, and undiagnosed mental distress), and age category (young adult (16–24 years) (n = 3,615), working age adult (25–65 years) (n = 18,011) and older adult (66+ years) (n = 6,923)). The results of multinomial regression revealed that after adjusting for sex, ethnicity, tenure and household income, young adults residing in the most deprived coastal areas had three times the risk of experiencing undiagnosed mental distress compared to young adults from equally deprived inland areas (RRR: 3.42, 95%CI: 1.24, 9.36). In contrast, older adults in the most deprived coastal areas had approximately one-third of the risk of experiencing undiagnosed mental distress compared with their inland peers (RRR: 0.13, 95%CI: 0.13, 0.95). This research highlights the striking mental health inequality in coastal young adults and calls for investment in both short-term interventions to support mental health and long-term investment in coastal infrastructure and youth mental health services to prevent future generations from experiencing similar mental health disparities.
Does nature make us less lonely? Analysis in Bulgaria’s five largest cities
Iana Markevych, Clemens Baumbach, Marco Helbich, Angel Burov, … Angel M. Dzhambov
Loneliness is prevalent and increases risks of disease and premature death. We aimed to investigate whether greater exposure to nature is associated with less loneliness in urban Bulgarian adults, and whether the association was modified by sociodemographic factors. Residing in areas with more urban green space, higher green space quality, and green space window view and spending more time in green and blue space were associated with lower loneliness scores. Living in low or high compared to medium level NDVI settings or in areas with higher tree cover density was associated with higher loneliness scores. Sociodemographic factors modified some of these associations. Our findings underscore the importance of extending and improving structured urban green spaces in Bulgarian cities.
Nicole Stephan, Sheela S. Sinharoy, Rachel Waford, Madeleine Patrick, … Bethany A. Caruso
Research indicates that women and girls face gender-specific stressors related to sanitation that affect their mental health, and women’s decision-making agency may play a role in this relationship. This study aimed to quantitatively assess the association between women’s sanitation-related decision-making – overall, within the household, and within the community – and well-being in two urban municipalities in Bangladesh. This paper is a secondary analysis of cross-sectional survey data collected from 1449 women in Meherpur and Saidpur, Bangladesh from March–April 2022. We measured well-being using the World Health Organization Well-being Index [WHO-5] and primary exposures included women’s sanitation-related decision-making and access to an unshared latrine. Decision-making was measured using the Agency, Resources, and Institutional Structures for Sanitation-related Empowerment (ARISE) scale; the full-scale score was utilized in the first analysis and the five individual factor scores were used in the second. Linear regression models were employed to assess the associations between decision-making and well-being scores, controlling for life stage, socioeconomic level, perceived social support and self-reported physical health. Analyses were conducted with city as a fixed effect and also stratified by city. Mean well-being scores were moderate in both cities, with approximately 20 % of respondents reporting poor well-being. On average, women generally agreed that they had a role in sanitation-related decision making (mean score = 2.66 on a 1–4 scale, with higher scores indicating stronger agreement that they had the ability to make sanitation-related decisions). In the full models using the full decision-making scale score, results indicated a positive association between the overall decision-making scale score and well-being (β = 0.73, p = 0.02). In full models using decision-making factor scores, we observed a positive association between well-being and individual decision-making factor scores for the ability to influence community-level sanitation decisions (β = 1.10, p = 0.0002) and to make small household sanitation decisions (β = 1.07, p = 0.006). Conversely, the ability to participate in community-level sanitation decisions was negatively associated with well-being (β = −0.68, p = 0.02). The ability to participate in household sanitation decisions and make large household sanitation decisions were not associated with well-being. Access to an unshared latrine was not associated with well-being in fully adjusted models. The relationships between decision-making factors and well-being varied in analyses stratified by city. Women’s involvement in sanitation-related decision-making likely varies based on the extent of their participation, the nature of the decisions, and a range of contextual and household- or individual-level factors (e.g., socioeconomic level, age, education). To effectively improve women’s well-being, sanitation programs must be informed by context-specific research exploring sanitation-related decision-making and its mediators among the populations of interest.
Journal of Critical Public Health
Articulating place: Towards a conjunctural analysis of public health
Colin Lorne, Michael Lambert
‘Place’ is again circulating as a policy solution to improve health, wealth and wellbeing. But while place-basedpolicymaking is quickly becoming ‘common sense’, we stress the need to think conjuncturally about the changing place of health. By conceptualising places as open articulations—rather than straightforwardly local territories—much wider geographies come into view. In dialogue with decentred approaches to public health which take seriously competing policy narratives, we therefore situate place-based policymaking within ongoing struggles over places and their pasts. To develop our argument, we look at public health through the lens of Wigan, north west England, which has become an unlikely ‘exemplar’ for place-based reforms. Framed by different, often contradictory, narratives of loss, control, and hope, it may be the talk of the town, but we reject the politics of self-responsibilisation implicit within recent attention towards purportedly ‘left behind’ places. Instead, we foreground how Wigan has been shaped by wider forces and relations such as de-industrialisation, postcolonialism, austerity and state restructuring, as well as the COVID-19 pandemic. By locating the many crises, contradictions and antagonisms conditioning public health in this conjuncture, we can start to articulate political alternatives and identify possibilities for making policy otherwise.
Gerry McCartney, Jennie Popay
Place-based approaches to reducing health inequalities have become increasingly common in the UK. It is likely that this is because area deprivation indices have highlighted spatial areas, rather than social groups, for policy focus; and because local agencies have until recently at least had a greater policy focus on reducing health inequalities than national government. Place-based approaches at the neighbourhood level have been characterised by a combination of civic-level, community-centred, and service-based interventions. We identify several important factors that limit their effectiveness for reducing health inequalities, including: socioeconomic and power relationships that are unrestricted by spatial boundaries; most disadvantaged individuals not living in areas with the highest deprivation scores; a pre-existing gradient in community capacity which many community development approaches exacerbate; stigmatisation of areas with high deprivation scores; and the potential for partnership approaches to undermine genuine community-led organisation and challenge. We argue that for place-based approaches to be successful in reducing health inequalities, they must challenge economic and power relationships that exacerbate inequalities and catalyse emancipation of currently disempowered and alienated communities.
Unionization rates and health in Canadian provinces, 2000 – 2020
Ian Hudson, Anupam Das, Mark Hudson
This paper examines one possible, but understudied, institution that might have an impact on health: unionization. We outline four distinct, although complementary, pathways through which unions might influence population health outcomes based on two axes: the levers that unions can potentially pull to influence any policy environment (collective bargaining and political action) and the manner in which health can be influenced in a society (the Social Determinants of Health and health care). We test whether unionization rates have an impact on total, preventable, and treatable mortality using panel data on Canadian provinces between 2000 and 2020. We find that unionization rates are negatively associated with all three measures of mortality.
Kathrin Lauber, Nason Maani, Olivia Brown, Rebecca Glover
Across human and planetary health, the concept of crisis provokes a sense of exceptionalism and sudden diversion from a supposed ‘normal’ state of affairs. By approaching crises as socially constructed rather than objectively occurring phenomena, we open up paths of enquiry that can help us to understand what it means to promote, use, or suppress the framing of an issue as a crisis. Actors can create or exploit crisis narratives to define the crisis and specific solution(s) in their interest. Identifying and critically interrogating different crisis framings, however, represents a key challenge. In this paper, we analyse four case studies from across human and planetary health: obesity, climate change, antimicrobial resistance, and the cost-of-living. Adopting an interpretive lens to interrogate these ‘crisis imaginaries’, we interrogate how crises are constructed through, and reflected in, discourse. We build on existing frameworks to better develop methods to critically evaluate crisis conceptions and understand how these may drive (and be driven by) the commodification of narratives in public health. In paying particular attention to power dynamics, we demonstrate how crisis narratives may obscure longstanding inequities. We conclude by providing recommendations to better inform consideration of the drivers, trade-offs, and wider implications of crisis framing.
Justin Waring, Simon Bishop, Bridget Roe
Across high income countries, policy makers seek to reform their health systems to promote public health, address long-term care needs, and reduce the burden on acute care. Policy narratives articulate a model of health system governance premised on multi-agency collaboration and service integration. Combining decentred theory with the negotiated order thesis, this paper examines how local policy actors interpret and negotiate the dilemmas presented by such reform in the context of their customary ways of working. Reporting on the findings of a three-year study of the introduction of Sustainability and Transformation Partnerships in the English health and care system, we focus on how policy actors negotiate the dilemmas manifest around the vision and priorities for, and the governance of, health system change. In each area, we show that structural interests and governing traditions shape actors’ orientation towards system change. This results in tensions that are resolved (or not) through localised negotiations between policy actors, which vary according to whether they were open or closed, structured or emergent, and whether they had a significant or limited impact on system governance. The paper shows that health systems reform is contingent upon how local policy actors translate and negotiate policy narratives.
Psychiatric Care as an Other-than-Human Entanglement: Anthropological Reflections on Forest Therapy
Anna Hänni
What can we learn about the therapeutic landscapes of in-patient psychiatric care by focusing on the invisible, the seemingly unimportant? To explore how mental affliction and caregiving acts are connected to other-than-human dimensions and sensory experience, I analyse the role of trees and forests in a Swiss in-patient psychiatric clinic. Using ethnographic vignettes and introducing the forest as a therapeutic landscape, I discuss the role of trees in a ward’s day-to-day life, a psychiatric sufferer’s modes of self-perception in the forest, and a physiotherapist’s active ‘tinkering’. My central argument addresses a problematic element in the research on psychiatric care in Switzerland: it is largely devoid of anthropological attentiveness to sensory perception and the atmospheric. I propose an alternative view where the experiences of illness, recovery, and violence are fundamentally co-created by a sensory context—including its marginalised, nonhuman, and atmospheric dimensions—and a conceptual framework informed by an anthropological adaption of feminist notions of ‘matters of care’ as well as sensory and ecological anthropology.
Simone Grytter, Adam Bencard
In this article we examine how patients of elective orthopaedic surgery might transform the understanding of their body’s fixability over time. The article builds on an ethnographic fieldwork at an elective orthopaedic unit in Denmark and follow-up interviews with two patients eighteen months after their surgery. Through the affective theoretical framework of Lauren Berlant’s Cruel Optimism, we discuss how the patients experience the part-loss of functionality. We trace the transformations in their expectations of their body through their use of metaphors. Drawing on Alan Bleakley’s division of the metaphors of the body into ‘body-as-machine’ and ‘body-as-ecology’, we argue that patients end up describing their bodies through both these metaphors, and come to understand their bodies as not being fixable, but as being in ongoing process.
Carla Naomi Vaucher
Congenital heart defects (CHDs) are the most common type of major birth defects worldwide. Yet globally, access to high quality treatment is very limited and uneven with most patients living in places without adequate diagnostic or treatment. Based on ethnographic engagement with Beninese and Togolese children undergoing surgical treatment in Switzerland through a humanitarian medicine programme, this paper explores the multiple temporalities and experiences of chronicity at play in the lived experiences of families with children with CHDs in a context of profound health inequalities. These temporal experiences encompass the various promises of a cure made to them, ensuring continued investment in their child’s health, experiencing a sense of rebirth, and navigating the potential risks of future complications. The article highlights how families facing CHDs in underserved regions encounter distinct forms of chronicity compared to those in more privileged areas. It identifies four kinds of chronicity in the families’ lived experiences: symptom-related, procedural, follow-up, and emotions-related.
Tait Mandler, Mariana Rios Sandoval, Michael Lim Tan, Anita Hardon
Our worlds and lives are awash with industrially-produced chemicals. This dizzying array of chemicals includes compounds, interactions, and health effects that are poorly, if at all, understood. While the vast majority of both natural and social science research continues to focus on the toxicities of single compound or classes of compounds, we propose a theoretical and methodological framework to attend to cumulative toxicities—known, unknown, interacting and in flux—in everyday life. Our approach builds on the empirical, methodological, and theoretical work of urban political ecology (UPE), anthropology of embodiment, and science and technology studies (STS), and uses radical cartography and ethnographic methods to gain insight into urban pollution’s complex and uneven entanglements, which are inseparably chemical, social, and ecological. We are developing this approach in three phases: ethnographically attending to the sensorial experiences and embodied knowledges of those most affected; creatively and cartographically producing representations and evidence; and identifying and supporting existing modes of action and harm reduction practices. Currently transitioning between the first and second phase, here we also share fresh insights from our recently wrapped grand tours of collective explorations.
Reckless Local and Ill-Fated Stranger: Reimagining Vietnamese National Sentiment during COVID-19
Shani Tra
Since the beginning of the COVID-19 pandemic in Vietnam, the media has meticulously covered disease prevention and reported on infection cases. This article will explore the current and shifting gender relations of Vietnam’s state and societal expectations by comparing Patient 17, a female Vietnamese citizen, and Patient 91, a British male pilot. While Patient 91 has received sympathy and international acclaim, Patient 17 has been heavily criticised and shunned from Vietnamese society. Through these case studies, I seek to understand how individual patient cases reflect the nuances of nationalism in Vietnam and how online citizens interpret the quintessential traits of Vietnamese character. Drawing on media analyses from an online news outlet, I delve into themes of media representation, gender, class, and race. By exploring how media coverage and online commentators shape perceptions of these patients, I aim to shed light on how patient stories can transcend individual experiences and become emblematic of broader societal ideals.
After Antibiotics – Events, Episodes and the Veterinization of UK Livestock
Stephen Hinchliffe
As antimicrobial use is more tightly regulated, animal medicine is under pressure. Drawing on UK fieldwork with veterinarians, farmers, and animal health providers, this article examines how animal health practices are being reorganized. It argues that antimicrobial reductions have not driven the systemic changes some predict. Instead, the antibiotic era’s legacy persists, shaping preventive efforts and reinforcing data-driven control. As veterinary roles are marginalized, the illusion of mastery over animal life endures. It is an illusion that risks undermining progress on antimicrobial resistance by reinforcing, rather than challenging, dominant forms of biopolitical control.
Therapeutic Trajectories of Kenyan Queer Men with Anal Warts: Iatrogenesis in a Time of Homophobia
Matthew Thomann et al.
Human papillomavirus (HPV)-related anal infection is high among African gay, bisexual, and other men who have sex with men (MSM). In Kenya, queer men living with HPV-related anal warts often avoid health facilities, fearing homophobic retaliation from providers. In this paper, we present data collected over 24 months of ethnographic research, foregrounding the therapeutic trajectories of 35 men with advanced cases of anal warts requiring surgical intervention. The therapeutic trajectories we present here help to make visible how iatrogenesis exceeds the clinic’s socio-spatial, temporal, and institutional confines and spills out into the intimate, social, and political spheres of human existence.
Kurt Cassar
In Malta, palliative care is often seen by nurses, policymakers and others as care of doing nothing. In my study, I demonstrate how nurses working in a palliative care unit attend to what, in the Maltese language, are called ċuċati: seemingly trivial acts that, even within palliative care, are often not recognized as legitimate forms of care, yet have a profound effect on patients’ well-being. In this article, I highlight a paradoxical relationship between the ċuċati and formal recognition. Formal recognition, while providing a means to legitimization, also risks depersonalizing the ċuċati, potentially undermining nurses’ intent to improve patients’ well-being.
F’Malta, il-kura palljattiva spiss titqies minn infermieri, dawk li jfasslu l-politika u oħrajn, bħala ħidma li ma tiswa xejn. Fl-istudju tiegħi nitfa dawl fuq kif l-infermiera li jaħdmu f’sala tal-kura paljattiva, jattendu għal, li bil-Malti jissejħu “ċuċati”; azzjonijiet li jidhru trivjali, li għalkemm spiss ma jitqiesux bħala forom leġittimi ta’ kura, anke fil-kura paljattiva, tabilħaqq iġorru profondità fil-ħajja tal-pazjenti. F’dan l-artiklu, niddeskrivi r-relazzjoni paradossali li tidher teżisti bejn iċ-ċuċati u rikonoxximent formali. Għalkemm il-formalità toħloq spazju biex dawn il-forom ta’ kura jiġu rikonoxxuti, jeżisti wkoll r-riskju li iċ-ċuċati jiġu depersonalizzati, potenzjalment itelfu l-intenzjonijiet li l-infermiera jkollhom biex itejbu l-ħajja tal-pazjenti.
Beyond Body Parts: The Uterus as a Symbol of Self in the USA
Ophra Leyser-Whalen
Utilizing a symbolic interactionist lens in analysis of 16 in-depth interviews with 13 women and three men who had used fertility treatments in the United States, I reveal how the uterus was a powerful symbol for those struggling with infertility as they drew upon cultural norms and co-created meaning through interactions with multiple others. The uterus represented more than a biological body part; it symbolized the cultural power of biomedicine and created biographical disruptions that affected people’s self-perceptions as women, mothers, wives, and lovers. Findings further uncover the relationship between science, medicine, culture, and identity and the body.
Juan Pablo Zabala et al.
We analyze the ways in which different researchers and health professionals in Argentina (physicians, biochemists, epidemiologists) develop their arguments against mass vaccination against COVID-19. In particular, we explore how these positions are related to the mobilization of scientific knowledge-or arguments compatible with scientific reasoning-and to issues related to other interests (professional, political, economic, among others). Our aim is to advance the understanding of a potentially contradictory position: that of researchers and health professionals who hold positions that contradict some of the principles that hegemonically articulate the professional field.
Shao-hua Liu
Taiwan, internationally acclaimed for its early success in COVID-19 control, credits its robust system of medical epidemiologists as pivotal. This article examines how these physicians were caught between the professionalism of global health initiatives and the challenges of local governance in a structurally unequal world. These dynamics shaped their roles as both members of transnational networks upholding professional principles and national scientists representing a state eager for “global citizenship”–a vision championed by UN agencies and international organizations. The conflation and disruption of biological citizenship, nationally and globally, together influenced the identity negotiation of Taiwanese medical epidemiologists.
Diagnostic Moments in the Rare Disease Life Narratives of Mitochondrial Disease Patients in Germany
Jacquelyne Luce
I draw on interviews I conducted in Germany with four individuals who were eventually diagnosed with mitochondrial disease, a category of rare neurogenetic disorders. Rather than the diagnosis of mitochondrial disease serving as a threshold between a before and after, I show how multiple ″diagnostic moments″ generate and shape mitochondrial disease life narratives as affected individuals embody emergent medical knowledge and navigate scientific unknowns. Attending to the plurality of diagnostic moments in rare disease life narratives illuminates the fragmented temporalities and incoherencies of illness experiences, which are often erased by an emphasis on a singular diagnostic moment.
Ich stütze mich auf Interviews, die ich in Deutschland mit vier Personen geführt habe, bei denen schließlich eine mitochondriale Erkrankung, eine Kategorie seltener neurogenetischer Erkrankungen, diagnostiziert wurde. Anstatt die Diagnose einer mitochondrialen Erkrankung als Schwelle zwischen einem Vorher und einem Nachher zu betrachten, zeige ich, wie mehrere “diagnostische Momente” Lebensgeschichten über mitochondriale Erkrankungen generieren und prägen, während betroffene Personen aufkommendes medizinisches Wissen verkörpern und sich mit wissenschaftlichen Unbekannten auseinandersetzen. Die Beachtung der Vielzahl diagnostischer Momente in Lebensges-chichten über seltene Erkrankungen verdeutlicht die fragmentierten Zeitlichkeiten und Inkohärenzen von Krankheitserfahrungen, die oft durch die Betonung eines einzelnen diagnostischen Moments verschwinden.
Sensing Rhabdomyolysis: Building Sensorial Knowledge in Inherited Metabolic Disorders in Poland
Małgorzata Rajtar
Sensations have emerged as an increasingly important topic in anthropological studies of health and disease. In this article, I draw from ethnographic research conducted among people living with selected rare inherited metabolic diseases (IMDs) and their caregivers in Poland, focusing specifically on recurrent rhabdomyolysis, a long-term complication that affects energy-consuming organs and muscles. Employing insights from sensorial and medical anthropology, I examine how people with IMDs and their caregivers, as parent-patient units, build anticipatory sensorial knowledge that enables them to attend to bodily sensations symptomatic of elevated creatine kinase levels, which are characteristic of rhabdomyolysis.
Immigrants to Health: Negotiating Liminality and Belonging with Cystic Fibrosis in Germany
Stefan Reinsch
Cystic fibrosis is a rare genetic disease that significantly reduces life expectancy. Therapy can delay the progression of the disease, but it is onerous, time-consuming and makes the disease more visible, creating a sense of not belonging to the healthy peer group that young people desperately want. Recent, very expensive advances in therapeutic interventions have dramatically reduced both the therapeutic load and the visibility of the condition. Drawing on a long-term ethnographic study in Germany, I explore how this changes the ways people with cystic fibrosis negotiate belonging, which is experienced as a metaphorical immigration into the world of the healthy.
Ilaria E. Lesmo
Public representations of rare diseases often depict patients as neglected and isolated. In response, initiatives promoting patient involvement have emerged, with illness narratives considered as key tools. However, the relationship between narratives and involvement remains underexplored. Based on ethnographic research conducted in Piedmont (Italy), I explore the narratives of two patients, which are deeply entangled with spiritual and religious perspectives, and explore the forms of involvement that emerged within the clinical space. I suggest that, depending on how moral and structural conditions intertwine, patients may be differently legitimized: roles of “experts of experience” or “implicated actors” arose within the field.
Yi-Hui Christine Huang, Qinxian Cai, Xiaohui Wang, Jie Sun
This study examined how institutional trustworthiness shapes public attitudes toward the health policy across Mainland China, Taiwan, and Hong Kong. Using stratified quota sampling to recruit participants from each region (Ntotal = 4812), we applied Protection Motivation Theory (PMT) to explore the roles of threat appraisal (perceived probability and unfamiliarity) and coping appraisal (self-efficacy and response efficacy). Our findings showed that response efficacy was the strongest mediator in promoting favorable attitudes across all regions. Perceived probability was positively related to policy attitudes in all regions, while perceived unfamiliarity was negatively associated with attitudes in Mainland China only. Self-efficacy was not a significant mediator, suggesting that beliefs in personal ability were less impactful than the perceived effectiveness of the policy. These findings underscore the pivotal role of institutional trustworthiness and perceived effectiveness of health measures in public health communication. They also highlight the importance of addressing region-specific differences in risk perception to enhance public support for health policies. Furthermore, the results support PMT and shed light on the paradoxical effects of different dimensions of risk perception on policy attitudes.
Xiaoguang Li, Xiaoxian Guo
Throughout human history, pandemics have repeatedly revealed a persistent pattern of disease-related stigma. This phenomenon highlights the critical need to address this recurring social challenge. In light of the most recent COVID-19 pandemic, it is evident that there are vital lessons to be learned. This study examined whether pandemic-recovered individuals (PRIs) faced disease-related stigma and experienced psychosocial distance by utilizing representative social survey data, including a vignette experiment on social interaction. The findings demonstrated that PRIs were subject to disease-related stigma as participants in this study exhibited significantly reduced willingness to engage socially with hypothetical PRIs during the pandemic. This psychosocial distance was particularly pronounced among individuals with higher levels of education, social status, and social capital. To prepare for future pandemics, societies must draw on these lessons and mitigate psychosocial distance by strengthening formal institutions and improving the dissemination of accurate information.
Aloysius Odii, Eleanor Hutchinson, Obinna Onwujekwe, Prince Agwu, … Dina Balabanova
Corruption in the health systems of low- and middle-income countries (LMICs) is fuelled by many factors, including health system failures, practical norms, informal rules, and social networks. Researchers have historically scrutinized these factors in isolation, often failing to grasp the intricate interconnections and the combined manner in which they manifest. In this ethnographic study, we present evidence from Nigeria’s healthcare system, where these factors converge, fundamentally reshaping the structure and operation of the healthcare system away from those set out in policy. Our study entailed three months of simultaneous participant observation at six Primary Health Centres in Enugu, Nigeria by four researchers. Following this, we conducted in-depth interviews with healthcare workers and their managers, and focus group discussions with service users. Our findings show that informal payments and rent-seeking, are widespread. Failures to provide basic infrastructure, staff and commodities means that healthcare providers have to use informal means to raise money in order to address these deficiencies. These practices are deeply embedded in reciprocal obligations among staff members, coordinated by groups who collaborate and engage in sustained interactions. Over time, their shared norms and networks are underpinned by informal agreements when and how to charge patients and allocating collected resources. Under this situation, healthcare facilities metamorphose from the ideal of primary health facilities as a setting in which care is provided according to need, into a ‘marketplace,’ where access to care and health commodities is profoundly shaped by economic imperatives and intricate social processes. The findings of this study suggest that any single “silver bullet” approach, such as solely focusing on norms, and health system failures, is likely to have minimal impact. Instead, policy makers should seek innovative ways through which more equitable access to care can be achieved in the current context.
Marwân-al-Qays Bousmah, Mohammad Abu-Zaineh, Simon Combes, Bruno Ventelou
Has the quest for efficiency in OECD health systems impacted the social gradient of health? We examined the cross-dynamics of the health system equity-efficiency nexus among OECD countries in the past two decades. We find evidence for a bidirectional causality between health system efficiency and equity. An increase in health system efficiency leads to an increase in socioeconomic inequalities in health; a result particularly salient in countries with predominantly private health service provision. Interestingly, decreases in socio-economic inequalities in health are likely to lead to higher health system efficiency, especially in countries where the health system relies predominantly on public provision. The pursuit of efficiency gains in OECD health systems has not been a precondition for socioeconomic equity in health. Adverse effects of efficiency-seeking interventions on health equity are particularly apparent in the private provision of healthcare. However, addressing health inequalities provides a plausible route to enhance efficiency.
Libor Potočár, Michal Kozák, Tormod Bøe, Tilmann von Soest
Research investigating social inequalities in mental health and well-being across the life course is scarce. Moreover, a comprehensive examination of underlying pathways linking early life disadvantage to subsequent mental health inequalities is needed. This nationally representative prospective cohort study in Norway followed 3072 individuals from adolescence (mean age 15 years, 1992) to midlife (43 years, 2020). Using latent growth curve modeling, we examined the magnitude and life course development of social gradients in self-reported internalizing problems (symptoms of depression and anxiety), externalizing problems (problematic alcohol use and conduct problems), and psychosocial well-being (loneliness and self-esteem). Family disadvantage in adolescence was assessed by parental educational attainment and living situation. Parenting practices, including behavioral monitoring, warmth, educational investment, social support, and psychological overcontrol, were examined as mediators. Results showed that living with both biological parents was consistently linked with better mental health and psychosocial well-being, with these advantages persisting into midlife. In contrast, lower parental educational attainment was associated with deteriorated psychosocial well-being and externalizing problems during adolescence, but these inequalities diminished with age. Importantly, individuals from advantaged families experienced more nurturing, supportive, and involved parenting, which accounted for a substantial portion of observed mental health disparities during adolescence. Altogether, our findings highlight the importance of early social disadvantage for mental health and well-being across the life course, underscoring the critical role of parenting practices in shaping these trajectories.
The patient double bind: Seeking outsiders while creating insiders
Patricia Satterstrom, Fletcher Dementyev, Maura Danehey, Chancey B. Herbolsheimer, Timothy J. Vogus
Including patients and their ideas is critical for helping organizations better serve patients. Yet patient partners are often tokenized, which limits the scope and impact of their contributions. In this 23-month longitudinal inductive study of patient participation in multidisciplinary healthcare change teams in three outpatient clinics, we explore the microprocesses that impact patient contributions and the teams’ responses to them. We selected a healthcare organization that was committed to using best practices and evidence-based methodologies when designing, launching, and supporting multidisciplinary teams that included patients and aimed to create more patient-centered clinics. To understand how patients contributed and how their contributions were received by the team, we followed patient-team interactions throughout 142 meetings – supplemented with observations, interviews, and archival data. We observed that, while teams welcomed patients, the patients faced recurring cycles of marginalization, narrowing, and redefining what it means to be a patient member of the team. When patients contributed like staff team members or provided convergent incremental patient perspectives on staff-centered projects, their contributions were more likely to be accepted; whereas when patient contributions diverged–challenged and/or offered alternatives to staff assumptions, priorities, and processes–they faced resistance. We mapped three pathways for patients: 1. Empowerment to Exit, 2. Empowerment to Acceptance, and 3. Team Reframing to Patient Adaptation. By delving into how well-intentioned interactions reshaped patient contributions, we develop new theory to better understand how patients and staff may be limited in their ability/mindset to become more patient-centered.
Jinho Kim, Taehoon Kim
Adolescent dating violence victimization is a prevalent but often underexamined form of early relational trauma, with potential long-term consequences for mental health. This study investigates the longitudinal association between adolescent dating violence victimization and depressive symptoms in adulthood and explores the mediating roles of subsequent violence-related experiences and lifestyle factors. Using data from the National Longitudinal Study of Adolescent to Adult Health, we analyzed a sibling subsample (N = 1,474) followed through Waves I to V. Sibling fixed effects models were employed to account for unobserved family-level confounders. Mediation analyses using multivariate bootstrapping assessed the indirect effects of later violence involvement and health-related behaviors. Adolescent dating violence victimization was significantly associated with increased depressive symptoms in adulthood, even after controlling for shared family background. This relationship appeared stronger for males, though gender differences were not statistically significant. Mediation analyses revealed that violence-related experiences—particularly perpetration—and lifestyle factors—particularly sleep problems—partially explained the observed association, accounting for approximately 25 % of the total effect. These findings underscore the long-term mental health risks associated with exposure to dating violence in adolescence and highlight the importance of early, trauma-informed interventions. Addressing continued violence involvement and health-risk behaviors may help mitigate the enduring psychological consequences of adolescent dating violence victimization.
Lina Maria Ellegård, Gustav Kjellsson, Roxanne Kovacs, Yuejun Zhao
This study explores socioeconomic disparities in how patients trade off quality against other features when choosing their primary care provider. We use a unique registry dataset linking the choices of individuals who recently moved to a new market, and therefore need to select a new provider, with detailed individual-level measures of socioeconomic status (SES) and provider-level measures of patient satisfaction, clinical quality and travel distance in a large Swedish region. We find significant disparities in patient choice based on SES, as high-SES individuals are consistently more likely to select higher quality providers. However, the results also suggest that most of the SES disparities in observed quality are linked to differences in the availability of high-quality providers within an acceptable travel distance. Our findings suggest that patient choice can widen, rather than reduce, disparities in population health by SES – if spatial inequalities in access to high-quality care are not addressed beforehand.
Family physicians’ power and team-based care: Lessons from a 60-year-old primary care clinic
Coralie Darcis, Marc-André Pigeon, Haizhen Mou
The article focuses on the tension between team-based care approaches that emphasize interprofessional collaboration and existing power imbalances between family physicians and other health care providers. It contributes to the literature on the implementation of team-based care models in primary care clinics by adopting a governance perspective, often overlooked in these transitions. While existing research has acknowledged power imbalances between family physicians and other health care providers, it has paid less attention to how governance mechanisms may shape these dynamics. Through an in-depth case study of a 60-year-old Canadian primary care co-operative, we address this gap and explore how these power issues play out in a context of collaborative governance and shared decision-making. The methodology is qualitative, relying mainly on data from 42 interviews, as well as on observations and document analysis. On the one hand, the research reveals that some governance mechanisms play an important role in team-based primary care settings, helping attenuate the tension and facilitating collaboration between providers. On the other hand, it shows that, even in a long-standing team-based care model promoting equality between health care professionals and between providers and patients, power imbalances persist. The research illustrates the cultural anchorage of medical domination, highlighting (i) the importance of looking at one organisation’s informal norms and cultural context when implementing team-based approaches to care, as well as (ii) the critical need for interprofessional education to actively engage with and address the underlying power dynamics that exist within health care settings.
Binaya Chalise, Cari Jo Clark, Shivani Bhattarai, Subash Thapa
This study investigates the association between Chhaupadi practice and violence against women through the lens of structural violence and patriarchy theories. Data from the 2019 Nepal Multi-Indicator Cluster Survey was used to compute propensity score matching, creating a balanced sample with equal numbers of women practising Chhaupadi and their counterparts. We then estimated the average marginal effect of the practice on domestic violence, accounting for matching weights and clustering standard errors at the matched pair stratum. The results indicated that women who practised Chhaupadi had a 14.3 % (p < 0.001) higher probability of experiencing intimate partner violence and a 12.2 % (p < 0.001) higher probability of violence from mothers-in-law, compared to women who did not. These findings are robust across various matching models and sensitivity analyses. Our results highlight how deeply embedded socio-cultural norms, such as menstrual seclusion, perpetuate systemic gendered inequities and vulnerabilities, exacerbating women’s exposure to physical violence within intimate and familial relationships.
Hong Yu Liu, James Hayton
In recent years, considerable academic attention has been devoted to the use of new technology in the healthcare sector. However, there is limited empirical knowledge about how everyday professional work is affected or how professionals actually experience these changes. This article assesses the introduction of the da Vinci surgical robot in the colorectal surgery department of a National Health Service Hospital in England. It argues that the impact of technology on healthcare workers is not predetermined by the characteristics of a technology and should be understood as a combination of positive and negative experiences in specific, highly contextualised workplace settings. Benefits to patients of the da Vinci surgical robot are clinically promising, but its implementation continues to be difficult, and the trade-offs look much different for varying employee groups. Our ethnographic method enables us to present this finding in granular detail: the da Vinci surgical robot can improve the morale and occupational health of the healthcare professionals in this hospital, yet negative impacts such as anxiety associated with conducting new operation procedures are commonly experienced by surgical team members. This article covers themes such as recruitment, preparation, and training, and offers much-needed insights into the long-term development of the healthcare workforce in England and beyond.
P.P.M. Mos, A.F.H. Hoogenboom, N.J.A. van Exel, V.T. Reckers-Droog
Social care supports individuals with functional impairments to live at home independently and participate in society for as long as possible. The demand for social care continues to rise, driven by increased longevity and demographic ageing. In the Netherlands, local decision-makers enjoy discretion to allocate the limited social care budget in view of local needs. The aim of this study is to examine their viewpoints on what matters in the allocation of scarce social care resources in the Netherlands.
We conducted a Q-methodology study among decision-makers (n = 25) employed in one of 15 municipalities in the Netherlands. Participants ranked 39 statements reflecting the underpinnings of decisions on the allocation of social care resources and explained their ranking in an interview. We used factor analysis followed by varimax rotation to identify clusters in the rankings. We then used the resulting factor arrays and interview transcripts to interpret the clusters as viewpoints. We identified four viewpoints among participants, representing views of sufficientarianism (providing support up to a basic level of needs), egalitarianism (providing equal support to as many as possible), welfarism (fostering access to high-quality social care), and communitarianism (highlighting the responsibility of informal caregivers to provide support).
The findings of this study suggest that differences in viewpoints between local decision-makers may arise from differing notions of distributive justice. While local differences may—to some extent—fall within decision-makers’ discretion, considerable differences in resource-allocations decisions on social care in the Netherlands may have consequences for horizontal equity in access.
T.J. Price, V.J. McGowan
Health inequalities are a form of violence, produced and sustained by political, economic, and social structures that systematically disadvantage certain communities. Drawing on qualitative data from 194 participants in six English towns, this study develops the Cycle of Social Violence, a novel theoretical framework that conceptualises how structural, slow, and symbolic violence interact to create and perpetuate health inequalities. Participants’ narratives illustrate how structural violence, driven by neoliberal economic policies creates the material conditions for poor health. These harms unfold over time as slow violence, extending their impacts and making their effects difficult to trace to specific causes. Symbolic violence then legitimises and obscures these injustices, reinforcing narratives that blame individuals rather than structural forces. The interaction of these three forms of violence produces a self-perpetuating cycle that deepens inequalities and erodes resistance to systemic harm. This study highlights how these dynamics manifest in deindustrialised and economically deprived communities, where declining public services, insecure work, and stigma reinforce poor health outcomes. Breaking the cycle of social violence requires policy interventions that incorporate the lived experience of people in affected communities and that go beyond surface-level regeneration to address the root causes of economic and social deprivation.
Susan Thieme, Sony K.C., Christine Bigler
This study investigates the perceptions of health workers in Nepal’s mental health sector regarding their experiences related to emancipation and justice. The research highlights the mental health gap in general, and that specifically faced by children and adolescents in Nepal. Factors contributing to this gap include a shortage of mental health professionals, societal stigma, and limited awareness of mental health challenges. Through 18 semi-structured, in-depth interviews and two focus group discussions conducted between 2022 and 2023, the study captures the insights of various professionals, including psychiatrists, nurses, and representatives of organizations, about their roles in fostering change within Nepal’s mental healthcare landscape. The findings illustrate how these individuals navigate their engagement in a still-evolving field, reflecting on their motivations, challenges, and the relational dynamics at play.
We apply an emancipatory and justice framework by interlinking the four stages of emancipation with three dimensions of justice, namely the distributive, procedural, and recognitive.
The research elucidates the interconnectedness of individual experiences with broader structural forces, emphasizing how health workers strive for equity and recognition of mental health in a context marked by social inequalities. The research recognizes the pioneering work of these practitioners, and contributes to providing a nuanced understanding of the transformative potential of mental health workers and their ongoing struggles for justice within the sector.
Inka Laisi
This study examines professional isolation in Finnish public primary healthcare and how general practitioners (GPs) craft their work in health centres and in the doctor’s consulting room in particular. Consulting rooms are often places of isolation and loneliness but simultaneously arenas of independence and autonomy. The data consisted of 16 interviews of Finnish doctors, out of whom 13 worked in public health centres or were specialising in general practice at the time of the interview and three worked in hospitals. This study shows how institutional material-discursive practices that create the consulting room isolate the GP and how this generates feelings of loneliness, as well as how GPs aim to make the workplace more inhabitable through crafting themselves as independent and autonomous doctors or through crafting the environment to enable collaborative relationships. Through this kind of crafting, the GPs create professionally sustainable jobs and roles for themselves in the public primary healthcare organisation.
Inequality, Trust and Fear: Migrant Healthcare During the COVID-19 Pandemic and Beyond
Alexis Hawthorne, Alicja Bobek, Lina Sandström
Many migrants are considered to be disadvantaged regarding their social, economic and health outcomes. During the COVID-19 pandemic these inequalities grew starker, especially in healthcare, as migrants were at increased risk of exposure and had a reduced ability to seek care or access support. This paper will explore these issues through the analysis of narrative interviews gathered during a large-scale, cross-European project which explored the experiences of 740 marginalised individuals, including migrants, during the COVID-19 pandemic. We build upon Beck’s concept of the ‘risk society’ by exploring the ways in which neoliberal states have created exposure to risk; however, we also adopt a critical approach in examining how risk is not distributed equally. The following themes were revealed: first, migrants were often more exposed to the virus due to their occupational status. Second, migration status had an impact on access to healthcare, with undocumented migrants especially vulnerable. Third, the intersection between health crises and trust was identified: on the one hand, migrants lack of trust in host country institutions affected their engagement with services; on the other, they also experienced a lack of trust in them, as they were often perceived as a ‘risk’ in relation to the virus.
The Changing Discourse of Healthism: A Contextual Analysis
David Armstrong
This article uses bibliometric and thematic analyses to explore the origins and influence of Crawford’s 1980 paper on healthism and the medicalisation of everyday life. The construct of healthism was built on some important concepts such as medical dominance/power, medicalisation, alternative medicines, lifestyles and health behaviour that had only first emerged during the previous decade. In the new millennium, however, healthism has become more associated with new ideas such as appearance and neoliberalism and with wider debates about self-responsibility. This shift in context was also found in the patterning of citations to the paper. After an initial slow accumulation of citations, the number grew rapidly from about 2005. With increasing involvement of patients in their own care management (especially for long-term conditions) and the promotion of more shared decision-making in clinical encounters, the role of self-responsibility in the healthism literature increasingly reflects the emergence of a ‘subjectified’ individual.
Tobias Olofsson
By connecting an uncertain present to a potential future, predictions and other forms of projected futures construct meaningful contexts on which actors can lean when seeking to act in the face of uncertainty. This article outlines the background and careers of many, and often contradicting, futures that informed the collective work to define and represent Covid-19 in Sweden during the first half of 2020. Through an analysis of press briefing transcripts, in-depth interviews with centrally placed informants, and a timeline of Covid-19–related events, debates, and policies in Sweden, this article outlines how enactments of Covid-19 evolved over time—from straightforward comparisons to past experiences, to repurposed models intended to make the pandemic calculable, to survey-based extrapolations produced by the Public Health Agency. The article demonstrates how a combination of contextual factors and a continuously evolving knowledge base led some enactments to become more influential than others, allowing them to influence evolving decisions and strategies. The article highlights the role of competing voices and perspectives in the collective epistemic work performed during the pandemic and explores Covid-19 as a multiple entity composed of a patchwork of data and assumptions. Depending on what futures informed them, these enactments varied from catastrophic and dystopian, to hopeful promises of an eventual return to normality.
Luca Chiapperino, Nils Graber, Francesco Panese
This article explores the development of T cell-based therapies in Switzerland. These therapies, which elicit the immunological potential of each patient to respond to tumor development, constitute a major promise for so-called ‘precision oncology’. We document how immunological concepts, technologies, and practices are articulated given the centrality of genomics in ‘precision oncology’. We consider ‘precision immunotherapies’ to probe whether and how change ensues in these established sociotechnical regimes of biomedicine. The case of genomics and immunology in oncology offers a unique insight into the conditions of possibility for change in such regimes. How does the present new wave of cancer immunotherapies challenge, integrate, and complement the centrality of genomics in ‘precision oncology’? What are the specific processes that make possible the convergence, competition, or co-existence of distinct conceptions, infrastructures, and programs of innovative cancer medicine? Drawing from observations and interviews with researchers and clinicians, we qualify these sociotechnical processes as hybridizations. Bringing together different sociotechnical regimes of biomedical research is conditional to the articulation of core concepts, technologies, and translational practices of genomics and immunology. Pivotal to this objective are neoantigens, cell surface proteins originating from the somatic genetic mutations of tumors and which activate a patient’s immune response. While neoantigens are an unstable entity in experimentation, they offer a conceptual and material substrate to renegotiate the dominance of cancer genomics, and initiate the production of a new, hybrid regime of ‘immunogenomic precision’ in oncology.
Noortje Marres, Matías Valderrama Barragán
This article presents a situational analysis of the expert advice offered by Independent SAGE, a group of scientists that formed in May 2020 in the UK to provide advice on the Covid response. Based on interviews with the group’s members and partners, we argue that through its interventions Indie SAGE demonstrated an important alternative approach to linking science and politics in a time of emergency. They showed that the only way to ensure that policy and decision-making on Covid-19 was grounded in knowledge was by making expert advice public. Indie SAGE’s decision to ‘go public’ was a response to the political situation in the UK, one in which scientific advice, in particular public health expertise, was being ignored, sidelined and contested as such. We identify four rationales for making expert advice public: openness, calling out, translation, and responsive engagement. We describe associated modes of intervention that Indie SAGE adopted in relation to different critical situations of Covid-19. Distinctive about their advice, we argue, is its prioritization of situational adequacy. Much of it was explicitly oriented towards addressing practical and existential challenges experienced by particular social groups, professions and everyday publics. We argue that this way of making science public in an ‘ontological’ register acquires critical importance in a political situation like the UK Covid response, which was marked not just by disagreements about science but growing contestation of science as such. In this respect, our study holds a wider lesson for the understanding of the role of evidence in public politics. To advocate for evidence-based governance, as Indie SAGE did, is not necessarily to endorse a post-political vision of government. When science is contested in a time of emergency, making evidence public becomes a key means for responding to the demands of situations. It is not only pragmatic but a critical accomplishment.
Survivors, users, or peers? Translating identities and decolonizing mental health in China
Zhiying Ma
In recent years, new identities have emerged for psychiatric “patients” in China, such as “users,” “survivors,” and “peers.” This article draws on my long-term research on and engagement with the country’s mental health field to explore the emergence of these identities as translations of globally circulating ideas and practices. Rather than viewing them as mere derivatives of Euro-American originals, I demonstrate that they are strategic translations initiated by activists and academics to resist the hegemony of biomedical and institutional psychiatry, and that they have created opportunities for policy and service reform, recognition, and empowerment. However, my analysis also reveals that the global and local authority these translations leverage has produced exclusion and marginalization. In particular, the mandate for self-advocacy against institutions underlying activists’ promotion of the user and survivor identities could overlook people’s vulnerability, dependency, and differences in communities. Meanwhile, attempts by academics like me to establish peer supporters as recognized paraprofessionals within the system could reproduce existing hierarchies and generate new frictions among persons with lived experience. I suggest that academics, activists, and other stakeholders involved in translating identities in the Global South should critically examine the processes and their potentially oppressive power effects, to reflect on our gatekeeping roles and center the diverse leadership of impacted individuals, and to boldly experiment with new forms of translation together for continuous (self-)decolonization.
Linda E. Guzman, Kristen M. Fite, Hannah E. Frank, Ruben G. Martinez, Ana J. Bridges
This qualitative study explores barriers to accessing treatment for Major Depressive Disorder (MDD) among Latino adults in the United States, with a novel focus on how these barriers were described based on participants’ preferred language. Fifty Latino individuals (n = 24 primarily Spanish-speaking; n = 26 primarily English-speaking) participated in Zoom interviews and completed a demographic survey and the patient health questionnaire-9 MDD self-report measure in their preferred language. Thematic analysis of interview data identified barriers across three levels: individual (e.g., stigma, service literacy, treatment readiness, caretaking responsibilities), provider (e.g., language barriers, cultural humility, perceived care quality), and clinic (e.g., cost, time constraints, waitlists, geographical access). While many challenges were shared across groups, key differences emerged. Spanish-speaking participants emphasized the importance of bilingual providers and described feelings of mistrust, communication fears, and concerns about emotional safety when language concordance was absent. English-speaking participants described prioritizing working with bicultural providers who demonstrated cultural humility and a nuanced understanding of possible intergenerational and structural stressors. Structural barriers, such as cost and scheduling, were often compounded by emotional experiences such as shame and mistrust, underscoring the need for both system-level and culturally responsive solutions. These findings reinforce the need for equity-informed strategies that attend to the intersection of language, culture, and structural barriers to MDD treatment.
Ntombenhle Mkhize, Sue-Ann Meehan, Graeme Hoddinott
In South Africa, neuropsychiatric disorders rank third in their contribution to overall burden of disease. Stigma, lack of mental health awareness, and limited access to health services and to appropriate treatment contribute to the high level of unmet need for treatment of neuropsychiatric conditions. Little is known about how young adults make decisions to access mental health services and how their adult family members influence these decisions. This study explored young adults’ perceptions of the influence their adult family members on their own mental health service uptake. We conducted semi-structured in-depth interviews with a convenience sample of 21 people (18–24 years) from KwaZulu-Natal Province (KZN). Thematic analysis of interviews found that: young people had partial knowledge of mental health conditions and services; both adult family members as well as peers and other community members influenced mental health care seeking behaviours. Participants who had accessed mental health services attested to their long-term benefit. Transition to adulthood was a time of mental health challenges. The results point to the need to scale up community-level awareness on mental health conditions in rural South Africa. This can include targeted education interventions to increase knowledge of mental health, and ways to adjust to the stresses of the transition to adulthood. More research is needed to further understand the gendered dimensions of peers’ influence of mental health service uptake.
R. N. Gurbuz-Dogan, A. Ali
There is some evidence that Sufi music as a receptive music therapy might be beneficial for treatment of common psychological disorders, and mental well-being. The aim of this study was to test the feasibility of Sufi music intervention for adults with mild to moderate levels of depression and anxiety, attending Turkish community centres in England. This was a pilot randomised controlled trial of a 4-week Sufi makam music intervention with 60 participants conducted in two Turkish community centres in the UK with assessments at baseline, mid-intervention (2 weeks), post intervention (4 weeks) and at 2 weeks follow-up. The recruitment and retention rates in the intervention arm during the four weeks were 94.5% and 93.3%, respectively. The intervention was acceptable for most of the participants. According to analysis of clinical outcomes, Sufi music intervention was not associated with any clinical improvement in the music group relative to the control group when the means were compared at T3. However, when the results were adjusted for baseline scores as control variables in the linear regression, anxiety levels of the music group were significantly lower than the control group at the end of trial (p = .013), and mental and spiritual well-being had a statistically significant increase in the music group at the end of trial (p = .002; p < .001, respectively). The Sufi music therapy intervention was found to be feasible, acceptable and convenient to deliver, and the recruitment and retention rates in the intervention group were high. Furthermore, assessment of the clinical outcomes suggests that the intervention may reduce anxiety and improve mental and spiritual well-being.
5E Mental Health? Notes on an emerging style of thought
Nikolas Rose
A new style of thought is emerging in debates around psychiatry and mental health, which I term ‘5E Mental Health.’ This goes beyond the well-known and much-criticized ‘biopsychosocial’ approach, and entails a fundamental challenge to the deeply socially embedded ‘psychiatric complex.’ It aims to map the biosocial mechanisms through which ‘social determinants’ give rise to the ailments that have become the province of clinical psychiatry. Those ailments are: embodied: brought forth not just by the brain but by the whole organism; extended: realized by the organism in interaction with the material and interpersonal environment; emplaced: always shaped in relation to a specific milieu and what it affords or disaffords; experienced: made meaningful by and to the individual (and to others) in language, meaning, memory, salience; and enacted: not just passively received but shaping an active agentive way of being with others, a form of life. These are the tractable pathways through which adverse social experiences give rise to those ailments conventionally diagnosed and treated in individual clinical encounters. It is possible and plausible to enact small-scale local changes in forms of life that can act on these pathways. This requires mental health professionals to work collaboratively with architects, planners, local and national policy makers, and, crucially, those who have experience of mental distress and psychiatric services. It thus requires a paradigm shift in the work of psychiatrists, mental health professionals, and policy makers that is as radical and fundamental as that entailed in the closure of the asylums.
