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In seeking to explore the meaning of chronic and chronicity, the association with infertility is neither immediate nor evident. However, this paper explores this relationship by analyzing the idea of infertility in relation to chronicity. In the linkages that come forth the idea of chronic lifestyle emerging from certain ways of being and living, as well the imaginings associated with the chronic body become important nodes of exploring the relationship between infertility and chronicity. Most importantly, the role that time plays in marking the chronic state is seen to be especially potent in the practice of infertility treatment, and the narratives that emerge around its temporal inevitability. The rhetoric that marks the diagnosis and prescription of treatment is often based on the identification of the body as susceptible to reproductive decline and failure, due to the contingencies of modern living. This often translates into a more sustained involvement with ARTs, which may or may not fulfil the required desire for a child. In this paper I seek to analyse the ways in which practitioners of infertility medicine create an image of an affliction that borders on chronicity. In the process, I question the idea of both chronic diseases and chronicity by looking at how illness is imagined in narratives that IVF specialists create in public, and through the idea of a cure for infertility. By analysing data collected through ethnographic fieldwork, this paper aims to build on the idea of the chronic as inevitable within clinical discourse and practice. [ABSTRACT FROM AUTHOR]

Emergency Contraceptive Pills (ECPs) are increasingly available over the counter as a form of hormonal birth control in India. As use of ECPs is increasing over time, this paper draws on ethnographic research in Dehradun, in Uttarakhand (Northern State) to highlight the everyday material conditions under which women create narrative around choice and agency regarding these ECPs. Women viewed ECPs as better options than abortion, appreciated the sense of empowerment these provided them because they could be consumed in houses where women had limited 'space and privacy;' and finally that ECPs and their advertisements could act as 'agents of social change.' Feminist scholarship on reproduction demonstrates that choice is a form of agency that is enacted within certain constraints. Using this framework, the research here highlights how women create narratives about ideas of contraceptive choice and notions of 'empowerment' when talking about ECPs and their advertisements. In revisiting the dilemma about women's agency and choice, this paper builds on Rosalind Gill's concept of 'critical respect' to propose 'critical ethnographic respect' as an ethnographic tool to help read women's responses and respectfully contextualise the materiality from within which these narratives emerge. [ABSTRACT FROM AUTHOR]

Drawing on ethnography of one family's life with diabetes in a poor settlement in Delhi's suburbs, this paper examines the relationship between emotional structures of care and kinship in the face of chronic illness. While anthropologists have argued for a relational understanding of care and discussed how, in India, modernity and social transformations have resulted in crises of familial care, less attention has been paid to the emotional terrains of care and its difficulties as they unfold in concrete relationships over time. This paper demonstrates how emotional intensities define the possibilities, limits, and ambivalence of kin care for the chronically ill. Described as care without heart, this mode of attention implies a continuation of care labour that maintains kinship ties and holds the possibility of kin futures, but is disinvested emotionally and feels unsatisfactory. The analytic of care without heart expresses a particular mode of care by which persons navigate dominant moral regimes around gendered family responsibilities and imperatives of love in relationships, but without fully subscribing to them. Care without heart at once signifies an inadequate form of care, invokes North Indian normative moral regimes around family care responsibilities and emotions, and acknowledges the shortcomings of these regimes and norms of relatedness. [ABSTRACT FROM AUTHOR]

This commentary discusses the methodological utility of ethnography within the medical space. Whilst a general consensus affirms that ethnography aligns with qualitative approaches, as identified within the existing medical literature, here, we demonstrate how quantitative [positivist] methods can also be incorporated. This paper begins by contextualising ethnographic approaches within medical contexts by demonstrating its empirical value within the existing literature. Next, we discuss the interconnection between the practice of 'doctoring' and ethnographic research, whereby doctors themselves use forms of inductive and deductive reasoning to treat and manage patients in their everyday context. This philosophical discussion not only links to the everyday practice of medical practitioners, but also critically reflects on the role of the first author, as a diagnostic radiographer. Lastly, this paper identifies the virtues of ethnographic research for medical students and/or medical doctors whereby the combination of qualitative and quantitative methods (within an ethnographic methodology) can lead to new empirical and methodological insights, enabling the creation of alternate research strategies and evidence. This methodological strategy may be best considered amongst medical students and/or early career medical researchers, but we also anticipate it to resonate and open further discussion with experienced medical practitioners and researchers transnationally. [ABSTRACT FROM AUTHOR]

This paper presents qualitative field research conducted at a radiology department in the USA. It examines 'the radiologist at work' and analyses the intersubjective ground for her individual diagnostic intentions and personalized strategies for enacting diagnostically-relevant experiences via imaging technology. The paper incorporates the radiologists' use of 'enactive proofs'—observations and professional memories made explicit through their interaction with medical imaging technology and other practitioners in the field. The observations strongly support the development of enactive phenomenology and provide a critique of representationalism and of the primacy of inference in cognition. The results demonstrate the crucial role of shared intentions, providing insight into expert performance in the form of concrete dealings with imaging technology, habituality, the origin of mistakes, multilayered communication, and discovering new ways for improving professional praxis. The findings have much to offer to philosophy, anthropology and radiological practice. [ABSTRACT FROM AUTHOR]

In this era of personalisation a patient's molecular profile plays an increasingly central role in development and delivery of personalised medicine. This paper sets out to explore the sociocultural implications of mainstreaming BRCA genetic testing in the treatment of advanced ovarian cancer patients, who carry a BRCA1 or BRCA2 gene mutation. It draws on ethnographic research conducted by between April-June 2016 in a large tertiary London hospital. Participant observation was conducted across two sites. For the first two weeks participant observation was conducted in the traditional genetic testing setting in two separate clinics. From thereon, participant observation was conducted in the clinical encounters of treating patients in the ovarian cancer clinic. In addition, face-to-face interviews were conducted with medical oncologists who worked in the clinic. Contributing to the fields of cancer genetics, personalised medicine and medical material culture studies in medical anthropology the paper seeks to further discussions about the interactions and relationships unfolding between medical objects and subjects across the landscape of cancer care. It highlights the importance of clinic-based ethnography to examine the complexities of identities and technologies as they intersect with the themes of suffering and hope in new and contradictory ways for BRCA-positive patients with late-stage disease. The paper argues that a BRCA mutation is not only central to the political economy of hope but takes on a more materialist nature as it becomes an embodied practice that moves in and beyond the clinic. [ABSTRACT FROM AUTHOR]

Throughout the history of bareback sex (condomless sex between men), 'subjects' have been created, particularly through scientific literature, to characterise the men who engage in the sexual practice. For example, a gay man who does not use a condom may be framed as a pathologised subject. This paper first presents this history. Afterwards, by relying upon ethnographic data such as interviews collected from fieldwork research done in Toronto in 2014 with young gay men who have bareback sex, it shows exactly how these young gay men related themselves to those subjects. Then, it focuses on the pre-exposure prophylaxis (PrEP) Truvada as a new HIV prevention technology. Although PrEP can allow condomless sex to occur while diminishing the risk of HIV transmission, at the time of the research, none of the young gay men were interested in using this tool despite being the subjects for whom the drug is tailored. This paper argues that PrEP and subjectivity are coproduced and can have conflicting meanings. This contradiction of meanings is a result of the various representations and symbols of bareback sex and the men who engage in the practice that have been produced throughout the history of bareback sex. [ABSTRACT FROM AUTHOR]

Drawing on the work of Ivan Illich, our special issue reanimates iatrogenesis as a vital concept for the social sciences of medicine. It calls for medicine to expand its engagement of the injustices that unfold from clinical processes, practices, and protocols into patient lifeworlds and subjectivities beyond the clinic. The capacious view of iatrogenesis revealed by this special issue collection affords fuller and more heterogeneous insights on iatrogenesis that does not limit it to medical explanations alone, nor locate harm in singular points in time. These papers attend to iatrogenesis' immediate and lingering presences in socialities and structures within and beyond medicine, and the ways it reflects or reproduces the racism, sexism, and ableism built into medical logics. [ABSTRACT FROM AUTHOR]

Health care systems as well as bodies of medical knowledge are dynamic and change as the result of political and social transformations. In recent decades, health care systems have been subjected to a whole assemblage of regulatory practices. The local changes undertaken in Denmark that are being explored here are indicative of a long-term shift that has occurred in many welfare states intended to make public services in the Global North more efficient and transparent. Departing in prolonged field work in Danish general practice and the anthropological literature on audit culture, this paper suggests that the introduction of regulatory practices has enhanced the need for triage as a key organising principle. The term triage literally means separating out and refers to the process of sorting and placing patients in time and space. The paper suggests that an increasing introduction of triage feeds into a reconfiguration of diagnostic work, where the clinical setting is gradually becoming more intertwined with the governing domains of policy, and the work of the secretary is gradually becoming more intertwined with that of the doctor. Finally, the paper argues that an increasing regulation of general practice poses an ethically charged challenge to existing welfare politics of responsibility between the state and the public, as it makes it increasingly difficult to negotiate access to care. [ABSTRACT FROM AUTHOR]

In public health there is increased focus on evaluating 'complex' interventions for health improvement, examining how their multiple components interact dynamically with the contextual system in which they are delivered. Amid this complexity framing are calls for methodologies that can facilitate contextual understanding as part of the evaluation process, including ethnography. However, while ethnography's attention to 'context' has been recognised as valuable for evaluation, few questions have been raised about the possible tensions of aligning what are quite different expectations for knowledge making in evaluation and in ethnography. This paper introduces a special section illustrating empirical examples of conducting ethnography for and with evaluation of 'complex' health interventions. Central to these experiences, this paper argues, are the concepts of time and temporality through which experience, change and knowledge making are invariably structured. It considers the different expectations for time and temporality in ethnographic and evaluation research, and how the 'long conversation' of ethnography aids interpretation of an intervention's interaction with the pasts, presents and possible futures of people's health experiences. Furthermore, in understanding time not as linear and constant but experienced through a series of encounters, ethnography highlights the spaces in between action and change, vital for understanding the complex dynamics of a health intervention in context. Through temporality, this paper and the related empirical papers present an intricate exploration of the challenges and productive opportunities posed by the use of ethnography for and with evaluation. [ABSTRACT FROM AUTHOR]

The paper introduces the Baanashada Dumarka, a Somali fertility therapy carried out by a spirit medium, known locally as 'Alaqad. Baanashada is aimed at women whose fertility issues are believed to be caused by spirits. The study also explores a component of the Baanashada, namely, the use of tiire (Rotheca myricoides), or the butterfly bush. Although Rotheca myricoides is known to possess a number of medicinal components as confirmed by studies of modern science, so far, there exist no studies on its potential (or lack of) fertility effects. Hence, the alleged fertility benefits of the butterfly bush need examining. The author is aware of at least one recent case that a Somali woman from Europe died of herbs placed in her cervix by a traditional healer in Somaliland. This piece of information indicated not only the role of herbal medicine in fertility practices, but also the popularity of traditional reproductive medicine beyond border, class or educational background. Yet, current research into Somali women's health focuses mainly on Female Genital Mutilation (FGM), examined often without the context of wider cultural practices. This paper, however, suggests that rituals, beliefs and material culture play a paramount role in women's practices. For example, as explored elsewhere, the wagar, a wooden and sacred object made of the African olive, is critical for fertility practices. The current paper illuminates further the significance of reproduction practices in Somali society and the potential continuity of traditions associated with the perpetuation of kinship. It concludes that fertility rituals are part of a wider context of interaction with sacred landscapes, objects and archaeological sites, often associated with past legends in the Horn of Africa. [ABSTRACT FROM AUTHOR]

Reducing the maternal mortality rate (MMR) is an important part of Mexico's commitment to the Millennium Development Goals, and the country has made great strides towards achieving this goal. However, researchers have questioned to what extent the focus on improved MMR and other indices of maternal health has contributed to an emphasis on improved statistics rather than quality care, and the effect this has had on the quality of reporting. While public health officials and hospital administrators alike agree that improved obstetric reporting is necessary, there is little discussion regarding the accuracy of the data that are submitted and the institutional pressures that may contribute to the production of inaccurate data. Using ethnographic research collected in Tulum, Quintana Roo, this paper explores how biomedical childbirth functions as a source of legitimization for the state while simultaneously providing the means for the presentation of an ideal subjecthood, one that situates birthing women and healthcare personnel as properly attenuated to the norms and needs of the modern Mexican state. By highlighting the point of disjuncture between women's experiences and the formal ‘reality’ created through hospital texts, this paper explores the place of biomedical birth as a producer of and legitimization for Mexican public health policy. [ABSTRACT FROM PUBLISHER]

Based on ethnographic research carried out in the Buenos Aires Metropolitan Area, this paper examines the views of social actors on the psychoanalytically-oriented psychotherapy focused on marginalized populations. From Foucault's perspective on the forms of truth-telling, the aim of this paper is to analyze, as a preliminary research report, treatments according to the native ways of speaking and listening, which dominate the description of therapeutic experiences of patients who come to the treatment without any professional intermediation. The neoliberal transformations of the past decades in Argentina changed both the landscape of the public health system and the daily lives of marginalized people. Considering such changes, this paper examines the ways in which verbal actions (speaking and listening) take place in psychotherapy and mark the course not only of treatments but also the temporal rhythms of their development, and their various levels of efficacy. Finally, the discussion focuses on how ways of speaking and listening in treatments are modeled not only by institutional dynamics but also by the characteristics these verbal activities take in everyday life under the logics of power that prevail over them. [ABSTRACT FROM AUTHOR]

This paper explores the moral implications of treatment of young people with functional somatic symptoms. Based on an ethnographic field study at a Danish pain clinic for youngsters (age 8 to 18), the paper seeks to unearth the cultural, moral values that clinical practice steers by and upholds, and the implications this has for the assessment and management of ill body-selves. Through an exposition of the general practice of the clinic and an investigation of two specific cases of youngsters, it is found that the assessment of symptoms and selves and the goals of treatment are informed by cultural ideals of 'the good self' and 'the good life' in which agency and work ethic – both pertaining to the notion of individual responsibility – figure as prevalent virtues. The study underpins the findings of other researchers who have found that ideals of individual autonomy and responsibility for own life and health permeate the Western health care system and the discourses of ill individuals. The contribution of this article is to portray in ethnographic detail how such a cultural ethics manifests in practice and what implications this have for the treatment of young people with functional symptoms at a specific location and in specific cases. The two cases illustrate that the underlying norms and values can give rise to very different moral assessments of symptoms and selves within the same diagnostic category. [ABSTRACT FROM AUTHOR]

Acupuncture and other forms of so-called alternative treatments, originating outside the West, have increasingly become an integrated part of the repertoire of medical practices widely used in health care remote from their places of origin. The main aim of this paper is to elucidate the cultural translation of Chinese medical concepts in a Western, acupuncture setting located far from China. Drawing on material from ethnographic fieldwork in acupuncture schools in Norway, this study discusses how concepts used in Chinese acupuncture are taught and interpreted for biomedically oriented students. The paper concentrates on the concept of jingluo ('circulation tracts', 'meridians') which the schools considered to be vital in order to conduct acupuncture. Similar to several other Chinese medical concepts, jingluo presents claims about the body that significantly differ from biomedical assumptions. The paper adds novel resources and insights to the research concerning medical conceptions, in that it applies the perspective of 'finitism' as developed in the field of sociology of knowledge by Barnes, Bloor and Henry (1996) in its analysis. It presents an analysis of five empirical examples demonstrating how a variety of interpretations of jingluo - many of them from different fields and some of them contradictory - were involved in establishing jingluo. Finally, by examining examples of Chinese concepts of the body, the paper seeks to contribute to the wider field of the anthropology of the body as well as to add to our understanding of the ways in which medical pluralism and globalisation of acupuncture unfolds. [ABSTRACT FROM AUTHOR]

Presently, there is a general understanding that health, illness and rehabilitation should be studied in a relational context, and that people's experiences, perceptions and practices in relation to health and recovery are formed relationally and contextually. The aim of this paper is to consider and discuss how men experienced their marital relationships, after being diagnosed with cancer. The empirical material is based on the authors' ethnographic fieldworks, including participant observation and interviews with men who have or have had cancer. The analysis is informed by the anthropologist Michael Jackson's notion of intersubjectivity and his argument that intersubjectivity continually and dialectically moves between the complementary poles of compassion and conflict. We demonstrate how the men appreciated their partners' support and care, but also that the cancer disease and the treatment could cause marital friction and tension. Due to their new life circumstances and subject positions, the men continuously shifted between the poles of compassion and conflict, struggling for balance and control, including negotiations of how to perform their masculinity. [ABSTRACT FROM AUTHOR]

Alternative health care and holistic spiritual practices have become increasingly popular in many Western countries, especially among women, who often claim them to be deeply transformative. This paper presents an ethnographic study of women's tantric retreats in Northwest Europe that aimed to help women reconnect with their vital sexual energy, rediscover the sacredness of their female bodies, and possibly heal from damaging and even traumatic experiences regarding their femininity and sexuality. It draws on Turner's influential view on ritual as a liminal space in order to account for the transformative potential of these workshops. Specifically, it applies Hinton and Kirmayer's flexibility hypothesis, which suggests that healing rituals shift people's mode of being-in-the-world, including their cognitive, emotional, and physical state or stance, towards openness to new ways of being. First, it highlights different ontological domains where shifts took place, notably somatic state, self-image and relationality. Subsequently, it identifies the main modalities that were used for enabling transformation: the embodiment of the metaphor of the goddess/the divine as present in each woman and the use of intimate, loving touch and meditative awareness. The process of transformation and healing elucidated in this way engaged the physical, emotional and cognitive levels as interacting dimensions, relying foremost on the activation of a vital energy that both gave participants a deep sense of self and connected beyond the self. [ABSTRACT FROM AUTHOR]

On paper, Niger's maternal healthcare system is extensively outlined by policies which assure access to certain services and create hierarchical referral chains. In practice it remains intensely improvisational: actors in the system must frequently make up the next steps to giving and receiving care, often outside the existing policies and procedures. Although population health in Niger has improved since the recently enacted gratuité des soins policy (which guarantees free access to certain material and child health services), care on the ground is still dictated by difficult circumstances and scarce resources. Health workers often lack the required medications and supplies; nevertheless, they must find ways to deliver services. Patients seeking maternal health services are frequently dissatisfied with the care they receive and so move forward of their own volition, by negotiating with health workers or by looking for services elsewhere. This research builds on recent scholarly work on improvisation, and asks us to further look at the ways that improvisation can be informed by the identity of the actors. Examining case studies of women from the Fulani ethnic group illustrates how particular cultural differences can inform improvisation. Analysing improvisation can also have policy implications; identifying typical points of departure from the official maternal health care system can reveal points where Niger can bolster its commitment to a universally high quality of care. [ABSTRACT FROM AUTHOR]

Ethnographic inquiry into Ayurvedic commodification in Kerala revealed the prevalence of a distinct regional pharmaceutical market dominated by physician-manufacturers, oriented towards supplying classical medicines to Ayurvedic doctors. This stands in sharp contrast to mainstream Ayurveda that is observed to have undergone biomedicalization and pharmaceuticalization. This paper argues that Kerala's classical-medicine-centric pharmaceutical market constitutes an alternative modernity because it provided Kerala Ayurveda with a different route to modernization impervious to the biomedical regime, as well as endowing it with the institutional power to safeguard its regional identity. Although physician-entrepreneurs are its key architects, it is sustained by value regimes shaped by a unique regional medico-cultural milieu. Even when industrially produced, classical medicines remain embedded within Ayurveda's socio-technical network; unlike proprietary drugs sold as individual product-identities through non-Ayurvedic channels, they travel together as a pharmacopeia, distributed through exclusive doctor-mediated agencies. This clinic-centric distribution format is best conceptualized as an open-source business model as it made low-margin generics viable by packaging them with therapies and services. Besides ensuring better access and affordability, it provided resistance to pharmaceuticalization and intellectual property concentration. By keeping the doctor in the loop, it prevented medicines from degenerating into de-contextualized commodities; the service component of Ayurveda therein preserved went on become the unique selling point in the health-tourism market. The tourism-inspired proliferation of Brand Kerala eventually triggered a paradigm shift in mainstream Ayurveda – shifting focus from ‘pharmaceuticals’ to ‘services’ and from ‘illness’ to ‘wellness’. Furthermore, interacting with hybrid Ayurvedas in transnational markets, Kerala Ayurveda co-produces new alterities countervailing the structurally dominant biomedical paradigm. [ABSTRACT FROM PUBLISHER]

This paper seeks to understand the outbreaks and the development of grisi siknis, a form of mass spirit possession among the Miskitu of north-eastern Nicaragua. Earlier documented outbreaks typically involved a few adolescents, however, in recent years, violent large-scale epidemics have taken place, involving many people of all ages. This has coincided with recent developments in Miskitu society marked by conflicts, contradictions and tense social relations. The anthropological field technique of participant-observation was used. The research took place during 11 months from 2005 to 2008 in the port town of Puerto Cabezas. A total of 38 informants were interviewed. Group discussions, narratives and informal and semi-structured interviews were carried out, as well as participation in healing rituals. The paper shows that socio-economic, cultural, personal as well as environmental factors all contribute to outbreaks of grisi siknis. The affliction has previously been considered a ‘culture-bound syndrome’ only occurring among the Miskitu. However, when viewed in a more contemporary context and cross-cultural perspective, grisi siknis shows similarities with other forms of involuntary mass spirit possession, particularly in the ways it is manifested, experienced and appears to be spreading. The paper argues that the phenomenon should no longer be considered a ‘culture-bound condition’ but in fact a Miskitu version of involuntary mass spirit possession. Further research that seeks to understand other forms of involuntary mass spirit possession should emphasize the social, personal and environmental context as well as cross-cultural comparisons in order to encompass fully the role of culture in relation to illness and suffering. [ABSTRACT FROM PUBLISHER]

Medical herbalism is the most widespread and the most ancient form of medicine. This paper offers an account of medical herbalism in Malawi, and discusses the role of medicines - both plant and animal substances - in the social life of the matrilineal peoples of Malawi. It aims to counter the widespread tendency to interpret medical practices in Africa solely in terms of a spiritual or religious metaphysic. After critiquing some early approaches to African medicine, the paper discusses the nature and role of medicines in Malawi, the main forms of therapy, and the relation of medicine to the ancestral shrines. [ABSTRACT FROM AUTHOR]

This paper deals with the role of earth shrines in generating and maintaining social order and cohesion in a Dogon village on the Bandiagara escarpment (Mali, West Africa), in a context of scarcity. Earth shrines are erected at significant points in the landscape and in remote times symbolised the foundation of the territory. They form part of the ritual control of space by reinforcing, through sacrificial practice, a symbolic boundary that encloses and protects the village space. Through their yearly reactivation, this practice firstly enables the Dogon to strengthen their relationship with their god, their ancestors and the spirits that own the place and, secondly, it aims to renew social relationships and maintain the cohesion and continuity of the society whilst simultaneously conveying a sense of well-being. This paper examines the materiality, efficacy and activation principles of Dogon earth shrines that operate through the intervention of complementary living substances: millet and blood. These earth shrines function on an ontological principle of containment by which people protect themselves, act and dwell in the world. That is to say, they endow active principles and play a part in forming a local cosmology in a harsh and changing world. [ABSTRACT FROM AUTHOR]

This paper examines the grid of sentiment that structures medical travel to India. In contrast to studies that render emotion as ancillary, the paper argues that affect is fundamental to medical travel's ability to ease the linked somatic, emotional, financial, and political injuries of being ill 'back home'. The ethnographic approach follows the scenes of medical travel within the Indian corporate hospital room, based on observations and interviews among foreign patients, caregivers, and hospital staff in Mumbai, New Delhi, Chennai, and Bangalore. Foreign patients conveyed diverse sentiments about their journey to India ranging from betrayal to gratitude, and their expressions of risk, healthcare costs, and cultural difference help sustain India's popularity as a medical travel destination. However, although the affective dimensions of medical travel promise a remedy for foreign patients, they also reveal the fault lines of market medicine in India. [ABSTRACT FROM AUTHOR]

This paper draws from two years of fieldwork investigating the social course of illness among Pakistani Muslims in East London, exploring how chronic illness is communicated and negotiated in local worlds disrupted by migrancy. It examines episodic short stories about dreams, premonitions and uncanny coincidences that were prominent within the illness narratives of migrant Pakistani Muslims, recalling and throwing light on complex questions concerning subjective constructions of misfortune, the personal and social meanings of illness and the relationships between narrative and selfhood. The ethnography identifies a strong normative context of communication about ill health and bad news, within which revelation through the mode of the supernatural takes on added significance. Recurrent motifs in the dreams emphasize the connectedness between family members scattered across migratory contexts, and the reawakening of moral obligations in families. Whilst medical anthropology has understood descriptions of dreams and other uncanny experiences as 'subjunctivising tactics' serving to maintain alternative plots about the source and outcome of illness, in the Islamic context the narrating of supernatural encounters can have transformative effects, re-organising praxis and conferring legitimacy to certain forms of moral selfhood. The paper therefore argues that the notion of the 'subjunctive mode' imposes the analysts' own system of logic and that there is a need to understand the interpretive frameworks present in the illness narratives in their own terms. [ABSTRACT FROM AUTHOR]

Why do patients and others confronted with cutaneous leishmaniasis (CL) – a parasitic skin disease – in the hinterland of Suriname, South America, provide a dazzling variety of aetiological explanations for one single illness? And how do these explanations reflect local knowledge of and interest in the origin of illness? In this article, we explore these questions using the concept of 'not-knowing', as introduced by Murray Last in 1981. One of Last's conclusions is that 'don't knows' or 'don't cares' reflect people's disinterest in medicine. The aim of this article, however, is to draw attention to another aspect of not-knowing: it may lead to a proliferation of explanatory assumptions, unhindered by precise knowledge. In other words, multiple explanations mask not-knowing, which is from a methodological point of view a rarely observed element in social science research and constitutes an important addition to Murray Last's well known argument. The paper describes findings based on anthropological fieldwork carried out between September 2009 and December 2010 at the Dermatology Service in Suriname's capital Paramaribo and among 205 CL patients and 321 inhabitants in various communities in the hinterland. As this article shows, both knowing and not-knowing are rooted in the various contexts of people's daily lives and reflect their historical, socio-cultural, occupational, educational, biological, environmental, and public health-related conditions. Public health authorities should explore not-knowing more seriously in their efforts to prevent illness, since knowing about not-knowing is valuable in the design of health education and prevention programmes. [ABSTRACT FROM AUTHOR]

Cultural psychiatrists and medical anthropologists have collaborated to help clinicians screen for culture-related issues in patient explanatory models of illness and to enhance the clinical processes of engagement, diagnosis, and treatment planning. This effort prioritises patient perspectives on suffering and healing to counter the trend of symptom-based interviews which assume biologically determined models of mental disorders. The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the Cultural Formulation Interview (CFI), a semi-structured questionnaire for eliciting patient explanatory models. This paper analyses specific linguistic meanings and practices that could account for patient perceptions of improved rapport with clinicians, clinician perceptions of improving information gathering, and cultural models of health and illness during the DSM-5 field trial piloting the CFI. Twenty-seven audiotapes were analysed through the Roter Interaction Analysis System (RIAS), a standardised method for examining medical interviews based on ethnographic studies of small-group communication. After an introduction with procedural and reassurance statements to orient communication, the CFI's open-ended questions elicited patients' opinions on interpersonal, environmental, and biomedical information. Clinicians made facilitation and activation statements for patients to speak more and informed patients about what to expect. Patients constructed cultural models of illness that weaved interpersonal, environmental, and biomedical information. Clinicians and patients made rapport-building statements to each other. A RIAS-derived patient-centred score indicates that CFI sessions addressed patient concerns. Our work offers a way to analyse the discursive construction of culture in health settings and patient-centredness through detailed examinations of linguistic meanings and practices. [ABSTRACT FROM AUTHOR]

This paper situates the ethnography of avian flu within the geo-political context of a new epidemiologic transition. Drawing on anthropological experience and insight, this paper examines areas of enquiry in which an ethnographic approach could contribute to a better implementation of prevention and control measures. Within the context of newly emerging diseases and accelerated globalization, the task of ethnography needs to extend far beyond the local. This paper reveals two major global issues that the ethnography of epidemiologic transition must take into consideration: (1) Global agro-industrial capitalism, and (2) global politics in the context of international health organizations and multi-national drug companies. The case of Thailand poses a question of how the strength of ethnographic practice could be deployed to account for the reality of the global-local interface of the new epidemiologic transition. [ABSTRACT FROM AUTHOR]

Multi-level marketing (MLM0), a business model in which product distributors are compensated for enrolling further distributors as well as for selling products, has experienced dramatic growth in recent decades, especially in the so-called global South. This paper argues that the global success of MLM is due to its involvement in local health markets. While MLM has been subject to a number of critiques, few have analyzed the explicit health claims of MLM distributors. The majority of the products distributed through MLM are health products, which are presented as offering transformative health benefits. Based on interviews with MLM distributors in Ghana, but focusing on the experiences of one woman, this paper shows that MLM companies become intimately entwined with Ghanaian quests for health by providing their distributors with the materials to become informal health experts, allowing their distributors to present their products as medicines, and presenting MLM as an avenue to middle class cosmopolitanism. Ghanaian distributors promote MLM products as medically powerful, and the distribution of these products as an avenue to status and profit. As a result, individuals seeking health become a part of ethically questionable forms of medical provision based on the exploitation of personal relationships. The success of MLM therefore suggests that the health industry is at the forefront of transnational corporations’ extraction of value from informal economies, drawing on features of health markets to monetize personal relationships. [ABSTRACT FROM AUTHOR]

In recent years, there has been growing emphasis on the need to develop ways of capturing 'complexity' in the evaluation of health initiatives in order to produce better evidence about 'how' and under what conditions such interventions work. Used alone, conventional methods of evaluation that attempt to reduce intervention processes and outcomes to a small number of discrete and finite variables, are typically not well suited to this task. Among the research community there have been increasing calls to take more seriously qualitative methods as an alternative or complementary approach to intervention evaluation. Ethnography has been identified as being particularly well suited to the purpose of capturing the full messiness that ensues when health interventions are introduced into complex settings (or systems). In this paper we reflect on our experience of taking a long term multi-site, multi team, ethnographic approach to capture complex, dynamic system processes in the first phase of an evaluation of a major area-based community empowerment initiative being rolled out in 150 neighbourhoods in England. We consider the utility of our approach for capturing the complexity inherent to understanding the changes that ensue when the initiative is delivered into multiple diverse contexts/systems as well as the opportunities and challenges that emerge in the research process. [ABSTRACT FROM AUTHOR]

Ethnography is increasingly being used in the evaluation of quality improvement and change initiatives in healthcare settings, particularly in the form of 'focused' and 'rapid' ethnographies. This new ethnographic genre is tailored to suit narrower enquiries within clinical pathways. However, the application of ethnography to the evaluation of quality improvement is not straightforward or free from reductionist bias, particularly in hospital settings where interventions take place during a limited period of time and instigate change in busy and sensitive settings. This paper discusses problems and emergent solutions involved in conducting an ethnographic process evaluation of co-design projects in lung cancer and intensive care unit services in two hospitals in England. The mixed-methods ethnographic evaluation consisted of observations of the co-design process and triangulation of findings with interviews, questionnaires, participant reflective diaries and service improvement logs. Limitations of observational time and distance from 'the field' were overcome by making most of the pre- and post-event observational periods, situating quality improvement within the wider context of clinical practice, achieving attunement with local clinical cultures and engaging participants in collaboratively guiding observational and interview design. This approach led to a focused ethnographic evaluation that accommodated ethnographic principles to obtain rich insights into quality improvement processes despite the limitations of short-timeframes and the hospital setting. [ABSTRACT FROM AUTHOR]

This paper describes the appearance and subsequent disappearance of ‘Barrow Man’ and uses anthropological and social psychological theory to examine the socio-cultural, psychological and economic conditions for the existence of the phenomenon. It argues that these conditions were the result of both specific local labour market circumstances and of the effects of global political changes, and argues that to talk about ‘Barrow Man’ as if it was a psychiatric diagnosis was to identify a moral construct as a mental disorder. It also argues that at the same time the phenomenon was expressive of certain core values that were not readily acknowledged in everyday clinical practice and that it might therefore best be understood as an institutional category. [ABSTRACT FROM PUBLISHER]

This collection of essays opens a critical examination of compassionate acts responding to social suffering in the intensely complex moral context of a rapidly changing and globalizing China. Jeanne Shea describes self-compassion among older women in China as a post-revolutionary response to changing opportunities and resistance to consumerism. Khun Eng Kuah-Pearce's essay frames the Buddhist organizations as NGOs and shows compassion being mobilized and its acts being spiritual-philanthropic, not political. The next three papers illuminate the complexity of mobility in a moral sea of changing values. Even as modernity facilitates movement of people away from suffering, the grinding of entangled moral experiences within the mobile group can be the cause of suffering. Shu-Min Huang critiques ‘cultural petrification’ as the diasporic Yunnan Chinese community in Thailand attempt to preserve the cultural forms and procedures of the world they left behind. Likewise, Richard Madsen shows that the idea of a universalized cultural heritage fails in the face of the ‘micro-ecologies’. And yet the modern impulse to universalize beyond China has important implications for transnational compassion and cooperation. The work of the humanitarian organization Médecins Sans Frontières in China, discussed by Kuah-Pearce and Guiheux, challenges the universality of global humanitarian actions. Following the series of essays threaded across intersections of compassion, suffering, and a morally-divided China, the collection closes by looking at the West. Iain Wilkinson discusses the origins of social suffering as a focus of the social sciences, as well as the difficulties of making engaged compassion its task in a morally-divided world. [ABSTRACT FROM AUTHOR]

The aim of this paper is to convey the relevance of a Gramscian perspective in medical anthropology, stressing his anti-essentialist way of reasoning about ‘nature’. The author claims that Gramsci's understandings of the bodily life of the state can deconstruct naturalized realities in ways that are helpful for the ethnographer engaged in the political anthropology of embodiment and the management of health, persons, and life itself. The paper is presented in three parts. An attempt is made, first, to frame the relevance of Gramsci for Italian medical anthropology and second, to explore the components of the Gramscian concept of ‘second nature’ within the perspective that he himself calls ‘an anthropology’. Third, an example is given of how the proposed Gramscian insights could inform an ethnography on the biopolitical aspects for the early detection of Alzheimer's disease, which is currently being carried out in Perugia. [ABSTRACT FROM PUBLISHER]

The paper describes, for the Hausa farmers of Gidan Jatau in northern Nigeria, the distinct ways in which they see and understand (a) their close and distant environment and (b) their bodies' anatomy and physiology. These ways result in 'another geography' - of both space and being - which, however, may no longer now have the resonance it had in the early 1970s when the author lived in Gidan Jatau for two years as a guest. At that time, the spiritual dimensions of daily life were deemed important to the health and prosperity of each person and to the farmstead as a whole. The argument is made that the urban-centred literature on the bori possession-cult neglects the ordinary, anonymous spirits of house and field. Any serious archaeology of the landscape will need insights into this 'alternative geography' if it is truly to 'read' a lost countryside from the traces left by its religious past; the paper also explains why some traces, such as shrines, may not be where they are expected to be. [ABSTRACT FROM AUTHOR]

This paper is a comparative ethnography of the therapeutic practices at two different spa locations: Caldas da Imperatriz, SC, Brazil, and Termas da Sulfurea in Cabeco de Vide, Portugal. The comparison reveals the existence of contrasting 'explanatory models' held by the spa-goers as well as by the official medical systems. In the Portuguese context this model is highly medicalized; in the Brazilian case, spa treatments are viewed as 'alternative' or 'complementary' therapy and are also related to religious philosophies. Each model corresponds to a different idiom expressing certain experiences and world views, one focusing on 'pains' (dores) and the other on 'energy' (energia), the former leading to the rationale of 'curing', the latter to the notion of 'energizing'. In this paper the author intends to analyze and contrast the categories found in these models, which originate from different conceptions of health, illness and healing for Brazilian and Portuguese spa-goers. [ABSTRACT FROM AUTHOR]

This paper focuses on psychiatric medication experiences among a sample of North American university students to explore a new cultural and social landscape of medication 'compliance.' In this landscape, patients assume significant personal decision-making power in terms of dosages, when to discontinue use and even what medications to take. Patients carefully monitor and regulate their moods, and actively gather and circulate newly legitimated blends of expert and experiential knowledge about psychiatric medications among peers, family members and their physicians. The medications too, take a vital role in shaping this landscape, and help to create the spaces for meaning-making and interpretation described and explored in this article. In concluding the article, the authors claim that two popular academic discourses in medical anthropology, one of patient empowerment and shared decision-making and the other of technologies of self and governmentality, may fail to account for other orders of reality that this paper describes - orders shaped and influenced by unconscious, unexpressed and symbolic motivations. [ABSTRACT FROM AUTHOR]

To social anthropologists an affinity with psychotherapy lies in the view that this discipline is a social science. Increasingly, social anthropologists offer comments and analyse their own data using psychotherapeutic or psychoanalytic frames of reference. At the same time, a methodological crisis has developed in ethnography. This is a crisis of how to carry out an ethnographic enquiry in a disciplined manner without either claiming to be a detached observer on the one hand or explaining away the subjective experiences of informants or clients with too much interpretation on the other. The aim of this paper is to address this crisis and to suggest ways in which ethnographers can use techniques from one type of psychotherapy, namely systemic or family psychotherapy in order to access social and psychological aspects of the lives of their informants. The paper achieves this by describing systemic psychotherapy and its theoretical foundations in the ethnographic work of Gregory Bateson. It then reviews the mainly medical anthropology literature in which the connection between psychotherapy and anthropology has been discussed. While this literature has suggested a narrative and a performative approach to ethnographic data and, therefore, to informants, it has not extended the analytic frame to include the ethnographer him/herself within these frames. Clinical case material is presented to demonstrate how such an inclusion is central to the practice of systemic psychotherapy and to show that this type of material is ethnographic. The techniques of double description, hypothesising and circular questioning are described and demonstrated, and it is argued that adapting these to an ethnographic enquiry will enhance the validity of the anthropological project. [ABSTRACT FROM AUTHOR]

This paper argues that uncommon use of time and space in a closed ward of a mental hospital is strongly related to culture, social dynamics and power relations. Space is differentiated and continuously re-embodied through awareness of and participation in events, interaction and forces. The time perspective is centred on patterns of improvement and regression of the illness. Past and future form an indissoluble part of these patterns. Through ethnographic material, gathered during anthropological fieldwork in the ward, this paper demonstrates that time and space form a complex web and are enmeshed with aspects of social life in and outside the ward, so that it is problematic to conceive whether uncommon use of both can be ascribed to mental illness or to social situations. [ABSTRACT FROM AUTHOR]

The article discusses various reports published within the issue, including one by Cardarello on stigma related to Brazilian children given up for international adoption, one by Varley on reproductive issues related to Islamic families in Pakistan and one by Marchesi on immigrants' reproduction in foreign countries.

This paper develops the concept of reproductive governance as an analytic tool for tracing the shifting political rationalities of population and reproduction. As advanced here, the concept of reproductive governance refers to the mechanisms through which different historical configurations of actors – such as state, religious, and international financial institutions, NGOs, and social movements – use legislative controls, economic inducements, moral injunctions, direct coercion, and ethical incitements to produce, monitor, and control reproductive behaviours and population practices. Examples are drawn from Latin America, where reproductive governance is undergoing a dramatic transformation as public policy conversations are coalescing around new moral regimes and rights-based actors through debates about abortion, emergency contraception, sterilisation, migration, and assisted reproductive technologies. Reproductive discourses are increasingly framed through morality and contestations over ‘rights’, where rights-bearing citizens are pitted against each other in claiming reproductive, sexual, indigenous, and natural rights, as well as the ‘right to life’ of the unborn. The concept of reproductive governance can be applied to other settings in order to understand shifting political rationalities within the domain of reproduction. [ABSTRACT FROM PUBLISHER]

An in-depth case study of integrated health and social care provides the empirical basis for this exploration of tensions between ethnography and evaluation. The case study, developed from a two year period of fieldwork, is based on ethnographic data of individuals' experiences of living with multiple long-term conditions, their experiences of integrated care, and integrated care commissioning practices. Narrative and phenomenological analysis show how temporal aspects of ethnographic fieldwork contribute to producing knowledge of patients' experiences. However, tensions emerge when attempting to bring learning from these experiences into discussions about evaluations of services. Data generated from fieldwork are seen as both too 'big', in terms of quantity of details, and too 'small', in terms of generalisability. Scale is also of concern, as tensions between ethnography and evaluation play out in questions of relevance. Ethnography foregrounds embodied, day-to-day lived experience, bringing the minutiae of daily life into sharp focus whereas evaluators need a wider angle to foreground larger objects of interest; organisations, budgets, services. A further source of tension between ethnography and evaluation emerges in defining interventions as distinct from context, when the conceptual boundary required to distinguish the shape of the intervention within a social world blurs and dissolves under the close gaze of an immersed ethnographer, problematizing attempts to inform causation. Concerns are raised that without greater dialogue about the nature of knowledge produced by patients' experiences, these experiences are at risk of being marginalised and de-centred. [ABSTRACT FROM AUTHOR]

Shrines associated with the deity Tongnaab in the Talensi region of northern Ghana formed the centre of a precolonial regional cult that encompassed a variety of peoples in the savannas of the Volta basin. Despite attempts by the British colonial state to destroy the shrines and to suppress ritual activity in the Tong Hills, by the 1920s the cult was spreading beyond its heartland into the Akan forest and the Gold Coast to the south. There it became known as Nana Tongo, one of a wave of anti-witchcraft healing movements. This paper examines the material culture and the mechanics of this history of ritual mobility and metamorphosis. It reflects upon the connection between the metaphysical concept of 'shadow' and the physical substance of earth, both of which were transported in a portable shrine called a bo'artyii and used to empower satellite medicine shrines. As these items traversed cultural frontiers they were subject to local reinterpretation and transformation. [ABSTRACT FROM AUTHOR]

The ancient cultural tradition in the middle belt region of northern Ghana, with its stone circle and house mounds, contains varied material culture. The unique contextual arrangements of the material culture within the stone circle mounds and the diverse ceramic art forms, as well as their ethnographic analogues in West Africa, indicate the mounds' association with past shrines that have multiple functions, including curative purposes. The archaeology of the mounds and ethnographic associations related to past indigenous medical practices is reviewed and discussed. This paper will also consider how some of the figurines through which the Koma tradition has achieved 'fame' possibly functioned as physical representations of disease, perhaps underpinned by intentions of transference from afflicted to image. The notions of protection and healing are also examined with reference to the resorted and disarticulated human remains sometimes recovered from the sites. [ABSTRACT FROM AUTHOR]

This paper discusses the relationship between people and shrines in the Afro-Brazilian religion Candomble. One of its main points is that shrines cannot be described solely as a particular instance or token of a general formula or type. The power of the shrine is also partially the result of extraordinary and unexpected events of cure and personal formation and transformation, often defined as 'miracles' that bond together shrines and their caretakers. Through these events, new places, objects and substances are recognized as or incorporated into shrines. In other words, the power of the Candomble shrine is also a result of its historicity. [ABSTRACT FROM AUTHOR]

This paper examines the twin German institutions of the Kur (spa), and the 'lay' licensed healing practitioner or Heilpraktiker. Through an ethnography of a Heilpraktiker and his Ayurvedic spa in a small catholic village in Germany, where patients arrive in person or as body parts by post, it examines the poly-therapeutics of the practitioner, who seems to combine in his being a dizzy array of diagnostic and therapeutic possibilities. It argues that the while the Ayurvedic spa can be seen as a kind of variation of the traditional German Kur, the Heilpraktiker's poly-therapy has to draw upon the special nature of the practice of medicine in Germany, symbolised in part by the very figure of the Heilpraktiker. It attempts to show that the practitioner's panoply of therapies is partly a symptom of an epistemic impasse at the heart of biomedicine, leading patients on an itinerant quest toward different therapeutic locales, such as the Kur, or to different therapeutic possibilities, such as the ones offered by the Heilpraktiker. But while the Kur and the Heilpraktiker would be either fringe or alternative in the Anglo-American world, in Germany the Kur is part of orthodox medicine, and the Heilpraktiker is a legal entity; and the two together re-draw and make fuzzy what elsewhere seem to be clearly drawn boundaries between medicine and the spa, between pleasure and therapy, and medicine and alternative medicine. [ABSTRACT FROM AUTHOR]

This paper is about the changing shape of health tourism in a Czech spa town. The research focuses on balneotherapy as a traditional Czech healing technique, which involves complex drinking and bathing therapies, as it is increasingly being incorporated into the development of a Czech health tourism industry. Today, the health tourism industry in Marianske Lazne is attempting to 'harmoniously' combine three elements - balneology, travel and business activities. One detects subtle shifts and consequent incongruities as doctors struggle for control over the medical portion of spa hotels. At the same time, marketing groups are creating new packages for a general clientele, and the implementation of these new packages de-medicalizes balneotherapy. Related to the issue of the doctor's authority in the spa, the changes occurring with the privatization of tourism entails the entrance of 'tourists' to Marianske Lazne who are not necessarily seeking spa treatment but who are still staying at spa hotels. There is a general consensus among spa doctors and employees that balneotherapy has become commodified. Thus, while balneotherapy remains a traditional form of therapy, the commercial context in which it exists has created a new form of health tourism. [ABSTRACT FROM AUTHOR]

In this paper the author explores notions of illness and health among a particular group of spirit mediums in Havana: the Sociedad de Estudios Psicologicos Amor y Caridad Universal. For its members and leaders, the development of mediumship is not just therapeutic but prophylactic. And traumas (of spirits and persons) must not simply be acknowledged but metabolised through the execution of good mediumship. More importantly, people's existences are chemically and psychologically entangled with those of their protective spirits, making of their 'selves' systems, rather than bounded essences. The author argues that such concepts of personhood offer alternative modes of understanding the self in relation to forms of otherness, including dysfunction and pathology. [ABSTRACT FROM AUTHOR]

By often taking as its focus the experience of illness in itself, medical anthropology has sometimes neglected the meanings that patients may assign to the diagnostic procedures that they are expected to undergo. This paper puts into anthropological perspective the author's experiences working as an assistant psychologist in two British memory clinics for the detection and treatment of dementia, using comments by patients to illustrate the significance that one aspect of these procedures - cognitive testing - had for them. These comments suggest that the meanings that patients construct with regard to such testing are complex and cannot be understood if one persists in seeing it as a neutral diagnostic tool without broader implications. It is argued that a strong association made by many patients between the cognitive tests and their childhood school experiences informs their reactions for better or worse. It is important to acknowledge the implications of this active interpretation of medical procedures if the memory clinic experience is not to become an alienating and infantilising one. [ABSTRACT FROM AUTHOR]

Currently, the life expectancy of black Americans is about five years shorter than that of white Americans when factoring for gender. Poor patient compliance is often used as an explanation for why black people have worse health outcomes. The proof, however, is anecdotal and relies primarily on discourses about black people's general dysfunction. Black patients often respond in kind to problems they experience with health care access. They often conclude that the medical professionals they work with are racist. In most cases, neither of these explanations is correct. This paper argues that behavioral explanations for health care disparities shift attention away from structural issues, namely health care rationing and the limits of therapeutic medicine. The lack of an open discussion about the structural issues is part of the reason the goal initiated by the Clinton administration to end racial disparities by 2010, Healthy People 2010, largely failed. [ABSTRACT FROM AUTHOR]

Most research on migrants examines what makes them ill. Inspired by Antonovsky's salutogenic approach, this study shifts the perspective and asks why migrants stay healthy. At the centre of interest are sub-Saharan Africans living in Switzerland who consider themselves and/or are considered by others as mastering problems affecting their health. The mixed Swiss-African research team explored meanings of health and resilience in 20 case studies in Zurich and Basel and five group discussions in Bern, Biel and Geneva. The data show that migrants with resilient trajectories have a dynamic and multi-dimensional understanding of health. Moreover, they have learnt to interpret difficulties as 'stress': a popular illness concept in Switzerland and Europe but less known in their home countries. The paper argues that resilience is closely related with the appropriation of 'stress' as an illness concept: it not only gives meaning and helps to explain diffuse symptoms of ill-health, it also offers an agenda for action and contributes to their feeling of social belonging in the host country. These findings have important implications for policy and practice in the rapidly changing field of migration and health. [ABSTRACT FROM AUTHOR]