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- Convenors:
-
Jennie Gamlin
(University College London)
Audrey Prost (University College London)
- Location:
- FUL-210
- Start time:
- 11 September, 2015 at
Time zone: Europe/London
- Session slots:
- 2
Short Abstract:
This panel brings together contributions on theory and practice in research and interventions from anthropology and global health to discuss the consequences and effects of policies and programmes on the wellbeing (in the broadest sense) of people they are designed to benefit.
Long Abstract:
We invite papers that look critically at the unintended social, emotional and health (in the broadest sense) consequences of global health research and interventions.
From a theoretical position or using empirical data, papers may discuss the negative consequences of well-intentioned national health policies or programmes on, for example, gender equality, access to care, quality of care or emotional, social, cultural or physical wellbeing.
We are also interested in discussing how large scale research impacts upon the localities where it is done, potentially leading to changes in families or communities, effecting individual attitudes to health or social issues, in ways that go beyond the aims, scope and proposals of the project itself. Empirical research that has been conducted in the wake of large research programmes is of particular interest.
We also invite papers that explore how clinical encounters may have unintended and unanticipated consequences, for example acting as a deterrent to future care seeking or impacting negatively on the social or family level. In some cases these unintended consequences have been described as 'violent', 'discriminatory' or 'culturally damaging'. What are the theoretical underpinnings of these interpretations, and should we consider how to incorporate a greater anticipation of 'unintended negative effects' into ethical reviews? To what extent can macro factors be held responsible for these negative consequences and what are the local factors that work to mitigate and exacerbate them?
Accepted papers:
Session 1Samuel Beaudoin (University Laval)
Paper short abstract:
This paper aims to show how global health research, public policy interventions as well as community groups’ claims have actively participated in the refining of the categories of stillbirth and bereaved parents. This process made unintended consequences on the wellbeing of those they are designed to benefit.
Paper long abstract:
The point I am making is that the definition and classification of stillbirth have real and unintended consequences, some of which participate in what Ian Hacking calls the «looping effect» of human classification. I illustrate my point with data from Quebec in relation to the emergence of stillbirth as a global health issue. My analysis shows the following looping effect. The definition of «stillbirth» in opposition to that of «live birth» contributes to the classification of human/non human. In Quebec, the product of stillbirth is not considered a human being. Yet, three global changes have occurred in the past decades about stillbirth and bereaved parents. 1) Between 1990-2000 the basic hospital's strategy facing a stillbirth has moved from shielding parents to supporting them. 2) Between 2000-2010 the «virtual community pregnancy loss support group» gradually grew in importance. 3) The Lancet Journal in 2011 and the following WHO 2014 Every newborn action plan, made stillbirth a global health issue priority. Since 2008, these changes led Quebec public health authorities to consider perinatal mourning as a public problem. In 2012, a public petition requested a paternity leave following perinatal death. Still, no birth and no death certificates are issued following a stillbirth in Quebec. «Bereaved parents» remain a contradiction in terms, with new problems. My analysis is based on long term research on data produced both by medical boards and public health authorities, as well as on open data from a website of parents having experienced such losses.
Nehla Djellouli (University College London) Maria Cristina Quevedo-Gomez (Universidad Javeriana)
Paper short abstract:
While formulating a national plan - influenced by international organisations - to tackle HIV in Colombia, the voices of locals affected by HIV were silenced. This resulted in implementation barriers in Cartagena; a participatory approach is thus needed in policymaking to include local stakeholders.
Paper long abstract:
With the highest prevalence of HIV/AIDS in the world after sub-Saharan Africa, the Caribbean region is greatly affected by the epidemic. The disease burden is linked to social determinants specific to the region - such as social inequalities, sexual tourism, machismo culture and stigma - leading to detrimental social, economic and health repercussions across the region. This paper focuses on the example of Cartagena, one of the largest Colombian cities, significantly affected by the disease and its determinants. Although a national plan to tackle the epidemic was formulated, with the influence of international organisations, did the plan fit the local needs in Cartagena?
Through participatory research, barriers to implementation and possible solutions were investigated in a first fieldwork in Cartagena in 2006-2007 with 27 interviews of stakeholders and 13 life stories of local people living with HIV/AIDS. A follow-up fieldwork took place in June 2013 with 10 participants, either policymakers, policy implementers, NGO representatives or local inhabitants.
Barriers identified included: the gap between the national plan and locals' cognitions; stigma and discrimination; lack of cooperation from the Church, educators and local politicians; corruption; hindrances to access of HIV prevention and treatment; low economic and human resources; and numerous changes in leadership and staff. Several achievable solutions to overcome implementation barriers were discussed with participants. However, implementation efforts can only be successful and democratic with the inclusion, during policy formulation and implementation, of all stakeholders from all levels of governance to ensure that local needs are met and attainable actions identified.
Christine McCourt (City, University of London)
Paper short abstract:
Macro-level policy goals on maternal and infant health such as the MDGs remain out of reach in many places. This paper will discuss and review our research in the context of wealthy, middle income and resource constrained countries to question received wisdom about the benefits of global MCH policies.
Paper long abstract:
Macro-level policies on maternal and infant health, from WHO's global level to national health policies at state level have been intended to bring about improvements in maternal and infant morbidity and mortality and to promote better health. However, big policy goals such as the MDGs remain out of reach in many places.
There has been a consistent bias in such policies towards top-down planning following a largely technocratic imperative. Assumptions were made about risk, safety and wellbeing that were not always well founded or evidence-based. Among these policies has been the exclusion of traditional midwives, and even an overlooking and undervaluing of formally qualified midwives in many countries, together with an emphasis on hospital birth. These policies are not affordable in many countries and further to this, there is a lack of evidence for the greater safety of hospital birth for healthy pregnant women. Additionally, the problem of disrespect and abuse of mothers in maternity facilities is increasingly being discussed, while many healthcare professionals suffer stress and burnout relating to over-stretched services.
Recently, robust research evidence has begun to emerge on three fronts: the safety of well-organised out of hospital birth; the safety of midwife led care and services and the potential value of traditional midwives and other categories of maternity supporters or workers. This paper will discuss and review our research in the context of wealthy (UK), middle income (Brazil) and resource constrained countries (Malawi & Sudan), to question received wisdom about the benefits of global MCH policies. Macro-level policy goals on maternal and infant health such as the MDGs remain out of reach in many places. This paper will discuss and review our research in the context of wealthy, middle income and resource-constrained countries to question received wisdom about the benefits of global MCH policies.
Calum Blaikie (Austrian Academy of Sciences)
Paper short abstract:
This paper examines some of the unintended consequences arising from the mainstreaming of Tibetan medicine in the Indian Himalayas, focusing on its effects on the social and economic dynamics of healing and on patterns of drug production and procurement
Paper long abstract:
The Government of India rolled out the National Rural Health Mission (NRHM) in 2005 as a flagship programme for improving health standards in underserved regions through integrated, low cost and community-based initiatives. This ambitious programme can be understood as India's attempt to address its poor performance on many key indicators, while aligning its policies more closely with Global Health discourse and practice. A decade later, the NRHM has yielded many encouraging results, but certain aspects remain poorly understood. Notable amongst these is the 'mainstreaming' of traditional medicine services into primary healthcare, which was heralded as a low cost and locally adaptable solution for a range of health problems, as well as a boost to the herbal products industry.
This paper examines some of the unintended outcomes of the mainstreaming of Tibetan medicine in Himalayan India. It focuses upon the changing ways healers perceive their roles, relate to one another and their patients, and procure their medicines. How is the NRHM perceived differently by practitioners involved in the scheme and those excluded from it? What impact has it had on treatment seeking behaviour and moral economies of healing? How is growing public sector demand shaping medicine production and affecting the natural resource base? Exploring these issues provides a solid ethnographic basis from which to reflect upon the unanticipated effects of national schemes on the structure and dynamics of medical traditions at the local level, and upon the positioning of traditional medicine systems in Global Health more broadly.
María del Pilar Torres Pereda (National Institute of Public Health)
Paper short abstract:
This mixed methods quasi experimental evaluation on the Mexican Non-Contributory Social Pension Program, shows mixed results. While results suggest that the program have an impact beyond the economic sphere, impacting even the mental well-being, delivery processes must be revisited due to unintended effects.
Paper long abstract:
In 2007, a non-contributory pension program was launched in rural areas of Mexico. The program consisted in a non-conditional cash transfer of US$40 monthly to all older adults (OA) aged 70 and over. We evaluate the effect of the program on mental well-being of its beneficiaries.
Quantitative and qualitative methods were used in this quasi experimental mixed method evaluation. Using ethnographic methods, the qualitative component was designed to explore possible causal pathways of such effect. For this component 129 semi structured interviews with beneficiaries, relatives of beneficiaries and key actors in communities were developed and four non participant observations the payment points were done. Additionally in 6,000 households a survey was carried on.
After a year of exposure, the program had a significant effect on reduction of depressive symptoms (b = 20.06, CI95% 20.12; 20.01) and an increase in empowerment experiences: elderly participated in important household decisions, they participated in household decisions pertaining to expenses where reciprocity was a central element on these findings. Nevertheless observation of the payment day revealed unintended social, emotional and health consequences for elderly. Structural violence was perceived uncovered in the formal program processes of the intervention delivery.
These results suggest that a non-conditional transfer in older ages have an impact beyond the economic sphere, impacting even the mental well-being, nevertheless delivery processes must be revisited.
Jennie Gamlin (University College London)
Paper short abstract:
Health, social and cash transfer programmes based largely on a philosophy of ‘asistencialismo’ make up the ‘development’ strategy that aims to improve the lives of Mexico's indigenous communities. In response to this welfareism self belittling attitudes of entitlement and dependency emerge.
Paper long abstract:
Like most indigenous communities, the Mexican Huichol people are classified as 'highly marginalised' and this entitles them to financial and other donations, some conditional, from the ministry of social development as well as specific programmes such as the 'crusade against hunger'. Over the years this as included three generations of toilets, concrete for their floors, corrugated iron sheets for their roof, food and blanket handouts. After more than forty years of 'development' programmes, many communities have become dependent on hand-outs and have repositioned themselves as families in relation to the state as people who, because of their indigenous origins and condition of often extreme marginalization they are entitled to as many forms of economic and social support as possible.
In this paper I will argue that this self-derogatory attitude is a form of symbolic violence that operates against them on an individual and community level and is in turn utilized by the state to stigmatise their poverty. This belittling attitude is one of the many unintended consequences of a approach that does not seek to deal with the long term and structural determinants of poverty and ignores the indigeneity of communities, instead aiming to incorporate indigenous families into the lowest ranks of mestizo society. This then begs the question of whether these symbolic and structural forms of violence are actually 'unintended', or simply form part of a wider concerted effort to undermine indigenous and autonomous lifestyles in order to maintain the existing racial and economic hierarchy.
Elsa Fan (Webster University)
Paper short abstract:
What do global health interventions do? What do they enable in unanticipated ways? This paper examines the scaling-up of HIV testing among MSM in China, and how this intervention turns tests into commodities and procurement into profit. In doing so, I consider possibilities for future interventions.
Paper long abstract:
In 2007, the Bill and Melinda Gates Foundation launched a $50 million HIV/AIDS program in China to target HIV prevention in vulnerable populations; most notably, among men who have sex with men (MSM). The foundation came at an opportune moment in the HIV/AIDS community just as donors began reprioritizing their funding away from the epidemic. By 2009, however, this program had become highly contested and controversial, culminating in a New York Times article that described the practice of payments in return for HIV tests from gay men as part of this initiative. The report foregrounded three important trends emerging from this program: the turn to scaling-up testing as a form of prevention; the deployment of community-based organizations (CBOs) to facilitate testing; and the use of "incentives" to encourage testing among MSM. In this paper, I examine the impacts and the effects (both intended and unintended) this program has had on the broader HIV/AIDS landscape and MSM population in China. In particular, I explore how this program has transformed HIV tests into commodities and their procurement into profit. I am less interested in "what went wrong" rather than what it is these interventions do. That is, what have these interventions enabled in unanticipated ways? And how do these unintended impacts help us rethink our intended aims? In raising these questions, I consider potential challenges and possibilities for future interventions in global health.
Amy Kaler (University of Alberta)
Paper short abstract:
Using 15 years of observational journals, we demonstrate how global guidelines concerning HIV prevention, testing and treatment have been taken up by rural Malawians in unexpected ways.
Paper long abstract:
The Malawi Journals Project is one of the longest-running observational field studies in sub-Saharan Africa, ongoing since 1999. Through the journals, rural Malawians have chronicled their individual, household and community-levels response to the evolving AIDS pandemic, from the days when AIDS was a poorly-understood death sentence, through the advent of behavior change campaigns and HIV testing, to the emergence of the treatment era as antiretroviral medications arrive. Over the same period, these communities have also been saturated by global policy prescriptions and interventions concerning HIV risk, prevention, testing and treatment, emanating from the world opinion leaders in global health and filtering down through village clinics and NGO activities. In this paper, we examine the disjunctures between global norms and local interpretations thereof, as Malawians adopt, adapt, and query these official discourses, re-interpreting them in creative and pragmatic ways adapted to local life projects and social conditions. We illustrate not only the unintended ambiguities of AIDS interventions, but also how these ambiguities move towards consensus as time goes by. We argue that this longitudinal observational journal method provides not only empirical insights but also theoretical contributions to the study of unintended consequences of global health policies.