ASA2016: Footprints and futures: the time of anthropology

(P03)
Trust and uncertainty in therapeutic encounters
Location Science Site/Maths CM219
Date and Start Time 07 July, 2016 at 09:00
Sessions 3

Convenors

  • Kate Hampshire (Durham University) email
  • Heather Hamill (University of Oxford) email

Mail All Convenors

Short Abstract

This panel considers the role of trust (inter-personal, institutional, trust in technologies, etc.) - as well as mistrust, doubt, misplaced trust - in therapeutic encounters and transactions, against a global context of healthcare deregulation, fragmentation, uncertainty and risk.

Long Abstract

Any therapeutic encounter or transaction depends (arguably) on a degree of trust being established, be it inter-personal trust (e.g. between patient and doctor/healer), institutional trust (e.g. trust in healthcare or regulatory systems) and/or trust in medicines or other technologies/techniques. However, in a global context of increasing deregulation and fragmentation, navigating the resultant complex, uncertain and often digitally-mediated healthcare landscapes becomes a considerable challenge, with potentially serious risks if trust is misplaced. Trust is a key element in many pressing contemporary global health concerns: for example, in relation to pharmaceuticals (and particularly the growing threat of antimicrobial drug resistance), we might think about how people obtain, evaluate and manage multiple sources of information, confront risks of counterfeit medicines or navigate the often opaque world of unregulated internet pharmacies. In this panel, we invite contributions that consider the role of trust (as well as mistrust, doubt and misplaced trust) in therapeutic encounters and transactions around the world. We particularly welcome papers that combine rich empirical data with novel theoretical approaches from across (and even beyond) the full range of anthropological enquiry.

This panel is closed to new paper proposals.

Papers

Theorising trust and risk in medicinal transactions in Sub-Saharan Africa: combining ethnography and behavioural game theory

Authors: Kate Hampshire (Durham University)  email
Heather Hamill (University of Oxford)  email

Short Abstract

We report on a project that combines the richness of ethnographic enquiry with Behavioural Game Theory to understand how trust/mistrust in medicines operates in Ghana and Tanzania, where widespread counterfeiting and inadequate regulation lead to huge uncertainty and risk.

Long Abstract

Medicines, which have played such a major role in reducing disease burden over the last half century, are now at the centre of a major global public health crisis. Widespread counterfeiting and unprecedented global traffic of pharmaceuticals have created significant trust problems for patients, retailers, manufacturers and others, particularly where regulation is weak, with serious risks for individual and public health. In this paper we report preliminary findings and reflections from a research project, conducted in Ghana and Tanzania, that aims to bring analytical clarity to this pressing global public health problem. Our question is: how, under conditions of uncertainty and informational asymmetry, do actors (consumers and providers) come to trust and distrust particular medicines, and how does this shape practice? Our goal is to bring together the richness of ethnographic enquiry with the powerful analytical approaches offered by Signalling Theory (a variant of Behavioural Game Theory) in order to enhance our understanding of the mechanisms that foster the production of trust in medicinal transactions in sub-Saharan Africa.

Trust in crisis: Ebola and the politics of separation

Author: Hannah Brown (Durham University)  email

Short Abstract

This paper explores how possibilites to trust others changed in the Ebola epidemic

Long Abstract

The Ebola outbreak in West Africa transformed all kinds of social connection, from the intimate to the governmental. The epidemic was characterised by the introduction of new forms of separation that aimed to curtail the spread of the disease. These have huge implications for possibilities for trust in intimate, governmental and therapeutic relations. Drawing upon ethnographic fieldwork in Sierra Leone, Liberia and Guinea, this article explores the effects of these forms of social separation. In doing so, this paper contributes to anthropological literature on the constitution of forms of detachment and separation within social relations.

Diabetes management in the context of poverty and uncertainty

Author: Misheck Nkhata (Durham University)  email

Short Abstract

This paper explores diabetes management practices in low resource settings

Long Abstract

Diabetes is growing concern in low and middle income countries, with the WHO estimating that more than 80% of diabetes deaths occur in these countries. Yet our anthropological understanding of diabetes experiences, management and care practices are most based on ethnographic research in the Global North, while African research is still mostly concerned with infectious diseases: HIV, TB, malaria and - recently of course - Ebola.

In contexts characterised several barriers to diabetes management (drug, staff and infrastructure shortages, financial costs), high levels of mortality and poverty, uncertainties emerge with regard to perceptions of causes, access to care and efficacy of care. Partly as a result, patients alternate or concurrently use biomedical, traditional and/or faith healing practices.

This paper raises anthropological questions of what is at stake in the management of diabetes of diabetes in this context by focusing on trust endowed on measuring devices and the results they produce, trust on efficacy and effectiveness of diabetes management practices (diet, physical activity) and trust on their bodies to know and manage diabetes. These questions are explored using concepts of body, embodiment and self.

Encounters on the frontiers of biomedicine: communication between patients and clinicians in Ethiopia's primary health care system

Authors: Edward Stevenson (UCL)  email
Melkamu Bedimo (Bahirdar University)  email

Short Abstract

Direct observation of encounters between patients and health workers reveals aspects of communication that are not captured by post-hoc evaluations. Based on a study in Ethiopia, we investigate the implications of patients’ education for successful communication in the clinic.

Long Abstract

For people in rural settings with little access to schooling, clinics and hospitals may feel like very alien environments. Recent research suggests that certain routines important to navigating health systems - such as waiting in line, and how to address figures of authority - are learned in schools. Greater familiarity with these routines makes the experience of navigating biomedical systems more predictable and reliable, and should instill confidence. While this idea is supported by survey research, it has yet to be tested by direct observations in clinical settings. We observed 30 encounters between clinicians and patients in rural communities near Bahir Dar, Ethiopia. Six patients (20%) had some school experience (range 1-8 years), the remainder had no formal education. We analyzed transcripts of conversations to investigate differences in communication for patients with schooling compared to those without: for example, the length of the conversations, and patients' readiness to ask questions of the clinician. We focus on one clear instance of miscommunication, between a clinician and a woman (without schooling) whose child was diagnosed with malaria. The variation in styles of communication we observed was not reflected in interviews conducted after each clinical encounter, in which patients consistently rated their levels of satisfaction as high. This study calls into question the validity of research that evaluates the successful communication in clinical settings on the basis of retrospective interviews, and draws attention to the social distance that separates patients and medical providers in some of the settings where global health needs are highest.

From Personal Pain to Medical Truths: The Remarkable Rise of Complementary and Alternative Medicine in Israel

Author: Maayan Roichman (Tel Aviv University )  email

Short Abstract

This paper explores a medical community established on mistrust of the Western medical system. It examines how mistrust is articulated vis-à-vis both the suffering body and the medical institutions, and how it becomes a central aspect of the remarkable rise of alternative medical methods in Israel.

Long Abstract

Writing about the body, anthropologists have referred to pain within the Western biomedical model as the limit of one's agency (Asad, 2003), an inexplicable event (Kleinman, 1995), as though it were a 'lightning bolt' (Luhrmann, 2007). Thus, the suffering body has become a central site of uncertainty and mistrust in many cultures, where the biomedical model is prominent.

Following extensive fieldwork among complementary and alternative physicians and patients in Israel, I examine how mistrust was evoked and practiced within illness narratives, clinical encounters, professional training, and daily activities in the field. I demonstrate how this mistrust was generated in specific biographical intersections of pain and uncertainty. In these situations, the suffering subjects find themselves searching for ethical explanations for their pain and fail to find them within the mainstream medical systems.

I suggest that the interplay between the suffering body and mistrust serves as a key aspect both in undermining the biomedical's once indisputable legitimacy, and in the formation of new healing methods, medical communities, and epistemologies of trust and mistrust towards the body and the 'medical truth'. The result is an ethnographic interrogation of the ways in which mistrust shapes even the most individual experiences such as pain, and their contribution to community consolidations. It shows how practices and beliefs of mistrust soon become the basis for the disaffiliation from the mainstream medical systems and affiliation with "alternative" ones.

Negotiating trust in Ayurvedic practice

Author: Alžběta Wolfová (Charles University in Prague, Faculty of humaninites)  email

Short Abstract

Drawing upon ethnographic research among one Ayurvedic community in the Czech Republic, I discuss the construction and role of the trust in patient-healer interaction. I am interested in how trust is negotiated and how different strategies of trust establishment influence the success of the treatment.

Long Abstract

Drawing upon field-work among one Ayurvedic community in the Czech Republic, I discuss the construction and role of trust in Ayurvedic practice. Through the presentation of three case studies of Ayurvedic practitioners, I compare different strategies of trust establishment. It has been argued that the personalized character of alternative medicines` practice, as opposed to depersonalization in the field of Western medicine, is one of the reasons for growing consumption of these types of medical treatments. Furthermore, where the medical practices lack institutional support the other mechanisms of authorisation and trust establishment emerge and take on a greater significance. In this context I am interested in how different forms of this presumably personalized Ayurvedic medical practice work in terms of success in treatment based on different kinds of trust construction. In quite non-regulated CAM (complementary and alternative medicine) environment in the Czech Republic most of the CAM practitioners are free to design a treatment themselves. This situation results in a large diversity in treatment and patient-healer relationships, even among one particular medicine` community. Simultaneously the absence of regulation is related to the flourishing of multiple kinds of uncertainty within the field. By examining different mechanisms of trust construction and its effects, I aim to discuss the questions like how is trust negotiated in these settings and what actors are involved in its establishment? How do the different forms of trust enactment influence the treatment?

Trust and mistrust on the limits of care

Author: Adam Brisley (The University of Manchester)  email

Short Abstract

This paper explores how the theoretical irreducibility of care is limited in UK general practice medicine by economic concerns and acts of clinical prioritisation, and highlights the role of ‘trust’ in ensuring that the limits of care appear advantageous rather than arbitrary.

Long Abstract

The irreducibility of 'care' has been celebrated in recent years as scholars have tried to explain what makes 'the logic of care' uniquely resistant to the pervasive influences of neoliberal governmentality. It is argued that care is not a product but a process, the guiding values of which cannot be reduced because they are located in the perennially incomplete lives of patients (Mol 2008). Care appears in contemporary work as a harmonious process - 'a matter of various hands working together… towards a result' (2008: 21). What is absent from this work is any sense of how the theoretical irreducibility of care is limited in practice by economic concerns and acts of clinical prioritisation. As a result, the current model of care is incapable of explaining why debates about healthcare are populated with stories of contestation and mistrust.

The paper analyses the work of several Manchester-based general medical practitioners. It shows how the irreducibility of care was carefully made to appear finite via notions about what was not in the best interests of the patient, as well as via clinical priorities and ideas about risk and resource distribution. The paper argues that care could only be achieved through acts of truncation and cutting but - because these acts involved complex moral, financial and clinical assemblages - limiting care was often prone to contestation. The paper explores the role of trust (in the motivations of patient or doctor) as pivotal in ensuring the limits of care mutually appeared advantageous rather than arbitrary.

Trust and the credibility in therapeutic encounters between parents and clinicians caring for children with respiratory tract infections

Author: Christie Cabral (University of Bristol)  email

Short Abstract

In therapeutic encounters between clinicians and parents of children with cough both evaluate the credibility of the other. Trust and credibility are key to the success of these encounters and their lack may contribute to higher antibiotic prescribing rates.

Long Abstract

Respiratory tract infections (RTI) are the most common reason for parents to take their child to a clinician. Antibiotics are frequently prescribed for RTI in children, contributing to the development of antimicrobial resistance (AMR). Drawing on empirical data from connected studies with parents and clinicians about consultations for children with RTI, I will examine the key role played by trust and credibility in these therapeutic encounters. When parents consult for a child with a RTI, they assess the credibility of the medical evaluation carried out by the clinician. Credibility is judged on whether or not clinicians are perceived as listening to and taking seriously the parent's description of their child's illness and whether or not the physical examination conforms to the parent's expectations. If parents judge that a medical evaluation is not credible, they distrust the diagnosis and treatment advice and view the consultation as a wasted encounter, often re-consulting a different clinician or at a different service (e.g. A&E). A minority of parents also miss-trust clinician's rationale for not prescribing antibiotics. Drawing on public discourses about the need for rationing in the NHS, they believe that when clinicians decide not to prescribe antibiotics, it is because clinicians are saving the antibiotics for worse cases or the vulnerable elderly. In their turn, clinicians evaluate the competence of parents to manage a child with RTI, in particular to spot signs of deterioration. If they do not trust a parent to re-consult if needed, they prescribe antibiotics just in case.

Being 'fobbed off' and the problem of trust between women with endometriosis and their doctors

Author: Véronique Griffith (Durham University)  email

Short Abstract

This paper looks at results from an ethnographic study that shed light on how health professionals and patients negotiate endometriosis in the UK. Results show that women with endometriosis, lack trust in their doctors due to multiple experiences of not being believed.

Long Abstract

Endometriosis, an epidemic and a chronic disease affecting over 176 million women worldwide, is defined as the ectopic placement of endometrial-related tissue, and is characterized by extremely painful menstrual periods, chronic pelvic pain, pain during sexual intercourse and infertility.

This ethnographic study, conducted in the North-East of England, shed light on how health professionals and patients negotiate endometriosis. Methods utilized include: semi-structured and unstructured interviews of 35 women and 30 medical professionals, participant observation, and use of online materials.

Results of the study show that lack of trust remains a key issue determining the relationship between women with endometriosis and their healthcare providers. Women with endometriosis often feel that they are not believed by treating professionals. Hence their clinical interaction and relationship lack trust.

Women with endometriosis experience multiple episodes of being dismissed in clinic visits. Due to these multiple negative experiences with doctors, women with endometriosis report hesitancy in accessing new doctors as well as concerns that doctors are not to be trusted with certain kinds of information. The findings suggest that women with endometriosis' experiences of being 'fobbed off' are linked to: 1. Difficulty in receiving a diagnosis, and 2. Stigma linked to endometriosis.

The clinic visit then remains a space where women with endometriosis often lack trust in their doctors.

This panel is closed to new paper proposals.