Carolyn Rouse

Patient and practitioner noncompliance: rationing, therapeutic uncertainty, and the missing conversation.

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 peoples 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.

Informing choice or teaching submission to medical authority: a case study of adolescent transitioning for sickle cell patients

Objectives. To understand how some of the top pediatric sickle cell centers are transitioning their adolescent patients from pediatric care given the diminished availability and quality of services in adult care. Design. The ethnographic research for this project was carried out over more than seven years. Patients, medical professionals, and disease advocates were interviewed and observed in clinics, homes, offices, at national meetings, and at sickle cell-related events. This paper focuses narrowly on adolescent transitioning programs that are designed to educate teenage patients about sickle cell disease (SCD) and treatments; how to communicate with medical professionals; and when it is appropriate to use healthcare services. This paper uses the experiences of a social worker in a pediatric hospital clinic as a lens for understanding the role patient education can play in improved outcomes. Results.Adolescent sickle cell patients are already skeptical about medical care. In transitioning meetings, legitimating that skepticism worked better than simply teaching them to submit to medical authority. One important strategy was to teach patients about what medical anthropologists and sociologists call the culture of medicine. By learning about how healthcare institutions operate, the social worker felt that they were better able to ask relevant questions, understand the limits of both the treatments and care, and to resist institutional demands without alienating themselves from the staff. Conclusion. For the past 15 years, cultural competency training has been considered one of the best approaches for improving patient care. The rationale for cultural competency is that if a physician understands a patient’s ‘culture’ he or she can better communicate with, and therefore treat, a patient. This research demonstrates that perhaps a better approach is for patients to be taught how medical professionals think and how healthcare institutions rationalize treatment options. In adult care, patient services are nominal and medical professionals have less time to develop relationships with patients. Given these constraints, enhancing self-advocacy through knowledge about the culture of medicine should be the focus.

Cultural Scripts: The Elusive Role of Psychotropic Drugs in Treatment

When I was asked by Michael Oldani to write the commentary for a series of papers on psychotropy, I was a bit surprised. I study health care disparities in the US through the lens of sickle cell disease, a very clear genetic disorder. With sickle cell, the social constructedness of the diagnosis is not an issue whereas in the case of mental illness category fallacy remains a primary concern. As anthropologists we are trained when entering the field to presume that behavior is either normative or a response to particular cultural pressures. Anthropologists do not tend to study people in the singular as if their behavior has a unique ontology. Our methods, therefore, make it virtually impossible to see mental illness as merely brain function gone awry. What makes psychotropy a conceptually rich and exciting intervention, although not new as Benjamin Campbell rightly points out, is that it takes us one step closer to an anthropological theory of the mind. Just to reiterate, Daniel Lord Smail identifies psychotropic mechanisms as, ‘‘The mood-altering practices, behaviors, and institutions generated by human culture’’ (p. 161). By acknowledging that behaviors and experiences have the power to change our brain chemistry—think trance or a day at the spa—psychotropy suggests specific objects of study for approaching the mind/body/culture conundrum. The take-away from this set of ethnographically rich papers is that FDA-approved pharmaceuticals should not be considered revolutionary. Rather these medications are simply a different set of tools for altering our moods and behaviors. Therefore, we need to dampen both our enthusiasm and apocalyptic fears of big pharma. SSRIs, stimulants, and sedatives are simply another cultural form in the service of normalizing behavior and making people feel better by first naming a disease and then delineating a course of action.

Markets of sorrow, labors of faith: New Orleans in the wake of Katrina

Markets of Sorrow, Labors of Faith: New Orleans in the Wake of Katrina is not easily classified as a book about public health. Then again, medical anthropologist Vincanne Adams has never confined her questions about health entirely to what we traditionally define as ‘health care’. Her other two books include an analysis of the symbolic economy of Sherpas and a detailed account of how Nepali physicians deal with the state. Having worked for 25 years in Asia, Adams found herself conducting fieldwork in New Orleans after the surprising death of her colleague Gay Becker. Partly to honour her colleague, Adams agreed to take on Becker’s National Institutes of Health funded study on the health and well-being of those affected by Hurricane Katrina in 2005. In Markets of Sorrow, Adams hones in on the corrupt and feckless handling of recovery efforts by for-profit companies. Rather than directly funding the victims, the government disbursed funds through companies that failed to effectively, efficiently and transparently distribute recovery aid. Those companies included most significantly ICF International, but also Blackwater, Halliburton, the Shaw Group, as well as regional banks and insurance companies. Adams writes:

Fashioning Markets: Muslimah Designers and Economic Empowerment

While few of us like overly didactic films, this one errs by revealing too little, too late, and then too quickly. It is not until the very end of the film that we learn these details. The film feels like raw data with most of the interpretation and all of the analysis, especially for a student audience, left to the viewer. What messages do the filmmakers wish us to take away? Is the film primarily a condemnation of pervasive social and economic inequality and neglect? Willets Point clearly has been neglected for years, lacking basic infrastructure and services. But why? Is it a condemnation of the Willets Point redevelopment plan in particular or all similar urban renewal projects? Not many people in the film seem to have much to say about the city’s plan; perhaps they lack the time and energy to think about it. Is Foreign Parts a piece of salvage ethnography meant to visually document a highly photogenic cultural scene before it disappears? It is a story of survival? Certainly the people profiled are scrappy survivors whose humanity comes across despite the bleakness of their personal plights and the environment they occupy. Foreign Parts is beautifully filmed and has won several awards, including the Opera Prima (for best first feature) and the Jury Prize in the “Filmmakers of the Present” competition at Locarno. It was also an official selection for the New York Film Festival. The filmmakers are skilled, and they have chosen a photogenic place and people to film. (Willets Point was also the setting for the 2007 fictional film Chop Shop by Ramin Bahrani.) Unfortunately, we did not find much anthropology in Foreign Parts, and with one exception we do not think it would be successful in the classroom, especially with undergraduates, and certainly never in its entirety. The pace is exceedingly slow, and it is only at the very end of its 80 minutes that the filmmakers provide a small amount of crucial contextual information. We doubt that most anthropology undergraduates would get that much out of it without a lot of guidance, supplemental reading, and patience. It might, however, be successfully used in an anthropological film course as an example of an almost purely observational film that could push students to think about the nature of “ethnographic” film. Paravel and Sniadecki’s approach is to let the data—the visuals, the sounds, the comments of a few—speak for themselves, without commentary or narrative structure. In conclusion, we found the film frustrating and at times tedious yet oddly captivating, largely due to its visual strength.