Non-Communicable Diseases: A Medical Anthropological Perspective

           The rising global population, increasingly sedentary lifestyles, and unhealthy diets have led to a significant increase in risk factors for non-communicable diseases over the past few decades resulting in a drastic surge in deaths caused by NCDs all over the world according to the World Health Statistic 2012 Report (World Health Statistics). Although the WHO report explains the increasing occurrence of a few risk factors of NCDs as the sole cause of the rising death rate due to NCDs, it is important to take on a medical anthropological perspective in order to gain a more holistic view of the problem. For instance, in the cases of the hunter-gatherers in North America, the significant change in morbidity due to NCDs was not exclusively determined by the named NCD risk factors in the WHO report. A complete understanding of the sudden change was only found after close ethnographic and epidemiological studies of the population. The extensive studies resulted in the discovery that genetic adaptations to a hunter-gatherer diet caused significant health problems when they changed to a diet of starchy and processed foods. When trying to find a solution to this important global health problem of the 21^st century, a medical anthropological perspective needs to be used in order to gain a far-reaching understanding of the global health problem.

The rising rates of non-communicable diseases has been determined a major global health problem of the twenty first century according to the WHO World Health Statistics report for 2012. While the rate of deaths from infectious diseases is expected to decline over the next twenty years, the number of deaths caused by NCDs has been projected to escalate, possibly reaching 55 million annual deaths by the year 2030 (World Health Statistics). The United Nations has already recognized this issue as a major global health challenge and has begun taking steps to address the problem. They plan to strengthen health systems to provide better treatment of NCDs, to monitor the number of NCDs, and to attempt to decrease the incidences of NCDs through the reduction of NCD risk factors.

The main four NCDs are cardiovascular disease, cancer, chronic respiratory disease, and diabetes and they account of a majority of deaths worldwide. The introduction to the section on NCDs in WHO’s report begins, “Of the estimated 57 million global deaths in 2008, 36 million (63%) were due to noncommunicable diseases (NCDs). Population growth and increased longevity are leading to a rapid increase in the total number of middle-aged and older adults, with a corresponding increase in the number of deaths caused by NCDs.” (World Health Statistics). Although increasing longevity has prompted the rate of deaths caused by NCDs to increase, other factors have been influential in causing this global health problem. The WHO report also mentions, “In 2008, around 80% of all NCD deaths (29 million) occurred in low- and middle-income countries. In addition, a higher proportion (48%) of all NCD deaths in low and middle-income countries are estimated to occur in people under the age of 70 – compared with an estimated 26% in high-income countries and a global average of 44%.” (World Health Statistics). In developing countries, the problem of longevity is clearly not a main cause of deaths by NCDs because a much higher percentage of deaths occur in people under age 70 in comparison to developed countries. Speculations behind the high numbers of deaths caused by NCDs in developing countries mainly blame the lack of adequate health care in these countries to diagnose and treat NCDs. In order to understand the problem, all of the factors causing the problem need to be fully understood.

Clearly a solution to this rising problem needs to be found. In order to alleviate the problem, it should be addressed from a medical anthropology perspective. Ethnographic studies of communities need to be performed in order to completely understand the root of the problem. The rising rate of deaths by NCDs has many complicated causes and the only way to fully understand how all the factors interrelate requires the use of ethnographic work by a medical anthropologist. Once the cause of the problem can be understood in communities, steps can be taken to prevent the deaths caused by NCDs from rising.

The medical anthropology academic article, Chronic health effects of dispossession and dietary change: Lessons from North American hunter‐gatherers by Russel Lawrence Barsh from the journal, Medical Anthropology: Cross-Cultural Studies in Health and Illness describes the biochemical reasons behind the rising rates of morbidity due to NCDs in the Inuit and North American Indian hunter-gatherer population over the past several decades. The article explores the relationship between the recent significant change in diet of the Inuit and North American Indian hunter-gatherers and the simultaneous change in morbidity patterns. The past advantageous metabolic adaptations to a hunter-gatherer diet have become detrimental to health when changing to a diet of store bought foods, which are high in refined starches, sugars, and saturated fats. The effects of this diet change, along with other risk factors associated with modernity, have caused the recent change in morbidity pattern due to non-communicable diseases, such as non-insulin-dependent diabetes mellitus, cardiovascular disease, and cancer.

The leading cause behind the escalation of NCDs in the hunter-gatherer population include biochemical reasons causing health problems from the recent drastic change of diet according to the article, although other NCD risk factors are included as factors of the recent change in the morbidity pattern. The hunter-gatherer diet consists mainly of nuts, seeds, green leafy vegetables, and fish and wildlife as a protein source (Russel). The shift from hunting-foraging to domestic meats results in a drastic increase in saturated fatty acid intake because domestic animals contain a significant amount of more fat than fish or wildlife. The increase in saturated fatty acid intake paired with a reduced consumption of seeds, nuts, fish, and leafy vegetables causing a vitamin E deficiency, a lipoprotein antioxidant, resulted in the increase of cardiovascular disease in the Inuit and North American Indian hunter-gatherers (Russel). Also, the shift in diet from natural foods taken directly from the environment to processed foods resulted in the exposure to many carcinogens. The article stated, “Industrialization has exposed Inuit and other hunter-foragers to a wide range of novel toxic and carcinogenic materials, while removing many of the protective nutrients from their diets.” (Russel).Previously, this group received little to no exposure to carcinogens because of their hunter-forager diet consisting of all natural foods taken directly from the environment. When they switched to a modern diet of processed foods, in particular processed meat, they began to be exposed to carcinogens that their bodies were not accustomed to causing an increase in cancer rates. Finally, the recent diet change led to a significant increase in occurrence of non-insulin-dependent diabetes mellitus, NIDDM, in the hunter-forager community. Genetic factors have been proven to play an important role in the increasing rate of NIDDM cases in the hunter-forager population. For instance, the article mentioned a “gene locus governing rates of IRF synthesis and iron uptake is linked with the expression of gene loci involved in glucose and lipid metabolism.” (Russel). The frequency of this allele proved beneficial for the customary hunter-forager diet. When the change to a low-iron and high density store-bought food diet occurred, the rates of NIDDM and anemia significantly increased due to the genetic predisposition to favor the hunter-forager diet. Clearly, the recent change in diet triggered the change in morbidity pattern due to the genetics of the Inuit and North American Indian hunter-gatherers.

Although many biochemical reasons in the change in diet can explain the change in morbidity pattern in this group, the author made a point to mention that other risk factors for NCDs have also increased recently in this group and have also contributed to the problem. The health impacts of dietary change have also been aggravated by behavioral factors resulting in the escalation of NCDs and thus the increase in morbidity. Behaviors such as alcohol and tobacco use and reduced physical activity are also risk factors for NCDs and have played a role in the recent change in morbidity. The increase in alcohol use amongst this group has been theorized to be caused by “modernization” which introduces new status symbols, such as alcohol consumption (Russel). The increase in alcohol intake and tobacco use have already been clearly identified as NCD risk factors, therefore the increase in these behaviors in the hunter-forager community also contributed to the increase in NCD occurrences.

The causes behind the increase in morbidity in the Inuit and North American Indian hunter-gatherer population require complex research and analysis to gain a complete and accurate understanding. The holistic approach used by the anthropologist of this article explores all possible causes, including cultural, scientific, and historical reasons for the problem. This same holistic approach can be applied to other communities around the globe that also have experienced an increase in deaths caused by NCDs.

A medical anthropological perspective would frame this problem differently than the approach used by the World Health Statistics Report 2012. The World Health Statistics stated a clear approach to the solution in their 2012 report. The approach they outlined included the acknowledgement of the rising number of deaths caused by NCDs, especially in developing countries, and the problem’s contribution to poverty and hunger in developing countries. The plan of action shaped by the WHO comprised of developing “a comprehensive global monitoring framework and recommendations for a set of voluntary global targets for the prevention and control of NCDs” and “to collaborate with the Secretary-General of the United Nations in submitting a report to the United Nations General Assembly in 2012 on options for strengthening and facilitating multisectoral action for the prevention and control of NCDs through effective partnership.” (World Health Statistics). WHO plans to approach the problem by finding ways to reduce NCD risk factors, strengthen health systems to provide better treatment, and improve the monitoring of NCDs globally. The WHO regions will be individually monitored to watch the process of the individual regions in the hopeful reduction in the rates of NCDs over time. Their plan fails to include several aspects that a medical anthropologist would include when framing the problem.

A medical anthropological perspective would take a holistic approach to framing this problem, instead of looking at just the diseases and risk factors like the approach used by WHO. A medical anthropological perspective would include looking at all physical, social, and mental aspects of health, illness, and healing in order to frame the problem and find a solution. To do this, contextualization and comparisons would be used to help frame the problem. Instead of grouping the problem globally like the World Health Statistics, a medical anthropologist would contextualize the NCDs within the uniqueness of individual communities. The perception of the NCDs varies greatly based on the culture and the health belief systems of each individual community. When grouping individual cultures and communities into the large WHO regions, the varying cultures within those large regions are ignored in the World Health Statistics approach. A medical anthropological perspective would frame the problem by individually studying the communities where NCD rates are particularly high to create a complete understanding of the diseases and the reasons for the escalating occurrences of NCDs within that culture. The studying of the individual cultures would be performed through participant observation in order to interact fully with the community and gain a thorough understanding of the issue within a particular culture. Then, to interpret the data from the participant observation, comparisons to other cultures will be used to link the details from the immersion to the big picture meaning. Finally, from the thorough research described, a medical anthropologist could frame the problem and determine a unique solution to the rising rates of NCDs within each particular community.

Several medical anthropology concepts addressed in class can be used to shed light on new aspects of this problem allowing for further analysis and possibly finding a solution. First, the importance of ethnographic studies can be used to redefine the problem and create a better understanding of the rising NCD rates within particular communities. Ethnographic studies by medical anthropologists can help shed light onto the causes of the rise in number of deaths caused by NCDs and the reasons why the NCD risk factors are increasing within specific communities. The health systems of communities depend heavily on their culture, therefore to understand the health system of a community an understanding of the community from participant observation and ethnographic work is vital. Health systems can be very complex and vary greatly from culture to culture. They consist of healers, therapies, sufferers, and a health belief system. The health belief system of a community is important to understand because it consists of the etiology, diagnosis, and prescription or treatment of a disease. The health belief system thus determines what governs a disease and what the treatment of a disease requires. In some cultures, the etiologies behind diseases such as cancer or cardiovascular disease may not fully be understood resulting in the people of those communities not reducing risk factors for those diseases. For instance, if their health belief system’s etiology for lung cancer does not include smoking, they will not know to reduce or stop smoking in order to lower their risk of getting lung cancer. Understanding the health belief system of a community will help shed light on how to solve this problem by learning how to reduce the NCD risk factors within that community.

The prescription, or treatment, and diagnosis of a disease are both determined by the health belief system of a community. Treatment and diagnosis are key to reducing the global death rates caused by NCDs. Early diagnosis of NCDs correlates with a higher survival rate for most NCDs, therefore it is important that the health systems of a community understand the early signs and symptoms of a disease. Certain signs and symptoms have different symbols or meanings within a culture, which can also affect whether a disease is properly diagnosed. In order to understand these symbols, cultural understanding must exist in order to educate the community in proper diagnosis and treatment. The treatment of NCDs can also vary greatly from culture to culture because the treatment is also determined by the unique health belief system of a culture. Medical pluralism exists in most communities creating a complex and dynamic treatment process for diseases and adding yet another important factor to consider. Cultural awareness through ethnographic research plays an important role in finding a solution to reduce NCD risk factors and improve the treatment of NCDs within a community. The previously mentioned example of the hunter-forager community exemplifies the importance of cultural context when addressing this problem and attempting to find a solution.

After applying these medical anthropology concepts to this global health problem, I have a much more thorough understanding of the concepts and their applications. I now clearly understand how the health belief system of a culture determines the outcome and the treatment of a disease in a community. The unique culture of a community includes their health belief system, which is important to understand in order to understand a disease within a community. After seeing the application of the importance of ethnographic work through participant observation, contextualization, and comparisons for my selected problem, I have a thorough understanding of the steps taken by a medical anthropologist when researching a problem within a particular community. Also, I noticed the significance of in-depth and detailed ethnographic work when trying to determine the complex causes of a problem within a community when reading my chosen article about the Inuit and North American Indian hunter-forager population.

When addressing the increasing occurrences of NCDs from a medical anthropological perspective, this global health problem is re-defined and new light is shed on how to address this problem. A medical anthropological perspective exemplifies the importance of how cultural understanding of individual cultures plays a crucial role in addressing global health problems, including my chosen problem. Instead of grouping large regions of the world and attempting to fix the problem in these large regions through monitoring NCD rates and strengthening health systems of a large and diverse area, a medical anthropological perspective pays attention to specific cultures within the large regions. The medical anthropological perspective uses ethnographical studies and medical anthropology tools to understand the problem within a culture. It addresses the problem within an individual culture rather than trying to tackle the problem in a diverse region. When the causes of the problem are analyzed within a particular culture, a solution specific to that community can be found that will produce the most beneficial results.

The rising death rate due to NCDs has already been determined a major global health problem of the twenty-first century. Deaths caused by NCDs already make up a much larger number of global deaths than infectious diseases, and the deaths from NCDs are only expected to rise in the future. A solution to this problem needs to be found in order to help reduce the annually increasing deaths from NCDs, especially since some can be prevented through decreasing NCD risk factors. From the example of the rising number of deaths within the hunter-forager community in the article, the importance of contextualization and cultural understanding when addressing this problem can clearly be seen. In order to prevent the predicted increase in deaths caused by NCDs, a medical anthropological perspective needs to be used to analyze the problem within individual cultures to create a valuable and unique solution for the individual communities and an overall global reduction in the deaths cause by NCDs.

-Allison Binkerd

Bibliography

Russel, Lawrence Barsh (1999): Chronic health effects of dispossession and dietary change: Lessons from North American hunter‐gatherers, Medical Anthropology: Cross-Cultural   Studies in Health and Illness, 18:2, 135-161

"World Health Statistics 2012." WHO. World Health Organization, 2012. Web.             <http://www.who.int/gho/publications/world_health_statistics/EN_WH S2012_Full.pdf>.

AN ANTHROPOLOGICAL DISSECTION OF POST-TRAUMATIC STRESS DISORDER IN CAMBODIAN REFUGEES

Cambodia is a low-income Southeast Asian country, with a population of 13 million, an estimated 85% of Cambodians live in rural areas and 33% of the population is subsisting on working wages of less than $1 US dollar per day (Guhadasan & Pises, 188). Due to scarcity of material resources and the global community’s belated response to social crises, the access to healthcare has become a privilege enjoyed by few because of its conditional nature determined by an individual’s capacity to pay. Access to healthcare is out of reach for many Cambodians, these facts are evident in the World Health Organization’s (WHO) report that continues to rank Cambodia very low in health indicators in comparison to other Southeast Asian countries. In this paper, I aim to address the medical inequality surrounding mental health diagnosis and treatment. In regards to post-traumatic stress disorder (PTSD) diagnoses, internationally recognized mental health assessment tests do not take cultural and historical contexts into consideration and this relationship has led to few resources allocated to mental health throughout the world. The World Health Organization (WHO) estimates that 75-85% of people in developing countries do not receive institutional mental health treatment and almost 33% of countries have no specific budget for mental health services. Writing from the medical anthropology perspective, I intend to focus on the historical context and social realities that characterize the rural Cambodian’s response to conflict-related PTSD occurrences. The urgency of this matter can no longer be ignored.

HISTORICAL CONTEXT

In 1975, Pol Pot and the Khmer Rouge took control of Cambodia and radically transformed the country. For three-and-a-half years, the Khmer Rouge implemented radical socioeconomic changes in order for Cambodia to make a “super great leap forward into socialism” (Hinton, Hinton, Eng & Choung, 386).  People were forced to relocate into rural areas and institutions were dismantled as the cities were emptied. Targeted as enemies of the state, doctors and lawyers fled the country or died from malnutrition or disease. It is estimated that approximately two million people died during the “reign of terror”, a product of continuous labor on starvation rations and psychological disturbances as speech, religion, travel, and communication were restricted. In 1979, the Vietnamese invaded and ended the Pol Pot period, leaving a decade-long civil war battle between guerrilla factions for control of the country. While “nearly a quarter of Cambodia’s 8 million inhabitants had died of disease, starvation, overwork, and execution” the world turned a blind eye to the atrocities that were occurring on the ground (Hinton, Hinton, Eng & Choung, 386).  The only response by world powers would be minimal international assistance and fierce sanctions by most western nations.

In 1991, the Vietnamese left Cambodia and the United Nations drafted a peace agreement between all factions to prepare for the elections of 1993. Despite these steps toward recovery, the destruction on Cambodia’s infrastructure and human resource capacity was so devastating that even today; the country is still working toward reconstruction. As a result of the exiting of legal and medical professions, access to medical care is out of reach for many Cambodians, with a majority of the population working on wages akin to extreme poverty, the choices come down to sustenance or medical expenses. According to the global health watch, about 20% of all healthcare financing comes from general revenues; the rest of medical expenditures are out-of-pocket (Global Health Watch, 64).

THE DEFINITION OF MENTAL HEALTH

Although mental illness is commonly thought of as the domain of developed countries, it is prevalent in resource-poor settings such as Cambodia, where their impact is compounded by a lack of medical training, diagnosis, and effective treatments. The WHO defines mental health as a “state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (Global Health Watch, 154). Mental health instability can be attributed to numerous factors; including food insecurity, unemployment, occupational health, conflict, lack of adequate housing, and mental healthcare services. It is within these social and economic factors that inequalities fester and continue to grow. It is well documented that widening inequalities “negatively affect the poorer and more marginalized sections of society to a greater degree” (Global Health Watch, 154). Within the rural communities of Cambodia where access to basic medical services is a hardship, the traumas inflicted as a result of conflict are remedied primarily by traditional healers who “have been, and continue to be, the mainstay of mental health care in many low-income countries” (Global Health Watch, 157).

In the article, “PTSD and Key Somatic Complaints and Cultural Syndromes among Rural Cambodians”, the reader examines the results of a needs assessment survey in rural Cambodia as part of a project labeled Victims of Torture (VoT). The purpose of the project was to document the experiences of the local people under the Khmer Rouge and to identify villagers with significant distress and provide the appropriate medical services. According to the article, little is known about mental health in Cambodia. Previous research was conducted using the Harvard Trauma Questionnaire (HTQ), which was deemed by researchers as not culturally sensitive in the context of rural Cambodia. Using a standard assessment tool labeled “C-SSI”, researchers sought to “assess somatic symptoms and cultural syndromes that are a key part of the response to trauma among Cambodian refugees but are not among the Diagnostic and Statistical Manual of Mental Disorders (DSM) PTSD symptoms” (Hinton, Hinton, Eng, & Choung, 385). While concept of theoretical importance defines the symptoms that we examine in the PTSD definition found in the DSM, it is important to examine the clinical utility of such assessment tests. To assume that a standardized assessment test can be implemented with the same success around the world is wholly inaccurate, local ideologies regarding health and wellness vary according to conditions, culture, and lived experiences.

CULTURAL FEATURES OF PTSD

The C-SSI assessment aims to identify somatic symptoms and cultural syndromes experienced by Cambodian refugees that are part of their response to trauma but not defined in the DSM PTSD symptoms. By examining the “biology of the trauma, ethnophysiology, cultural syndromes, metaphoric resonances, and trauma associations” researchers hope to holistically aid the Cambodian refugees who are suffering from PTSD (Hinton, Hinton, Eng, & Choung, 387). Some features of the test involve the assessment of dizziness, orthostatic dizziness (dizziness from standing), neck soreness, and heart weakness. To Cambodians, these symptoms are of more concern than the clinical markers used to diagnosis PTSD, which examines re-experiencing symptoms, avoidance symptoms, and hyperarousal (Hinton, Hinton, Eng, & Choung, 385).

In the case of dizziness, the historical context is important to consider. During the Pol Pot period, Cambodians were forced into slave labor while simultaneously starving to death, this caused “great dizziness”, Cambodians were often beaten by the Khmer Rouge or forced into watching executions and corpses as punishment; this form of torture brought a renewed sense of fear, nausea, dizziness. The most common form of slave labor was being forced to carry large loads of dirt at the neck on a pole; this caused extreme neck soreness and discomfort (Hinton, Hinton, Eng, & Choung, 391). Researchers have found that the cultural and historical context may be important in terms of diagnosis and treatment;“if a Cambodian now experiences one of these trauma-linked somatic symptoms for any reason… that somatic symptom may bring to mind the trauma event that featured the somatic symptom” (Hinton, Hinton, Eng, & Choung, 393).

KYÂL ATTACKS & HEART WEAKNESS

Cambodians believe in a potentially pathogenic element called Kyâl. In a healthy individual, Kyâl flows throughout the body alongside blood and exists by passing through every pore in the body, exiting by the action of burping and flatulence. When Kyâl is disturbed it surges upward in the body, causing dizziness, blurry vision, headaches, nausea, neck soreness, shortness of breath, cold bodily extremities, and energy depletion (Hinton, Hinton, Eng, & Choung, 394). These “Kyâl attacks” are greatly feared by all Cambodians. Another SSI syndrome is heart weakness. For Cambodians, “breathing is thought to be driven by a piston-like action of the heart" (Hinton, Hinton, Eng, & Choung, 395). Heart weakness, which is thought to precipitate cardiac arrest, is of major concern to Cambodians and a deep stressor for individuals who are faced with issues that contribute to stressful existences such as extreme poverty and malnutrition. Rural Cambodian refugees have drastically different trauma ontology than that of western populations. Local PTSD diagnoses are comprised of heavy importance on certain somatic symptoms such as dizziness, orthostatic dizziness, and neck soreness; and incidences of unique cultural syndromes, such as Kyâl attacks, Kyâl overload, and heart weakness (Hinton, Hinton, Eng, & Choung ,399).

MEDICAL ANTHROPOLOGICAL CONCEPTUALIZATION OF CAMBODIAN PTSD

It has been well-documented in medical research that there has been continuity in trying to address the issue of “culture against the success of the diagnostic construct of PTSD and even against the general psychiatric conception of trauma” (Rechtman, 2). In Margret Lock’s essay “Medical knowledge and Body Politics”, Lock explains the discourse of medicine and culture in relation to historical narratives. “People everywhere have amassed knowledge and practices designed to preserve health, account for the occurrence of illness, and provide therapeutic relief” (Lock: 190). The body is a biological entity and also a manifestation of history. It is a site of resistance and conformity to culture. Lock argues that medicine has currently become a part of society and its form and purpose is shaped by societal values, customs, and language.

Health, wellness, and healing are embedded within individual experience and are affected by cultural and social context. In class we learned that “It is not always just about the individual, it’s about how we experience the world around us and how other people treat us and these are embedded into our beliefs systems and cultures” (Cade Cannon, lecture). In regards to mental health treatment, the idea of legitimacy is significant because the social perception of suffering determines whether it is medicalized or stigmatized.

In rural Cambodia, where researchers know PTSD exists in mass quantities, an explanatory model of the occurrence of PTSD is vital to understanding what part of the population is tormented by this disorder. The local perception of PTSD is different in terms of semantics and behavior toward the illness. Local healthcare providers focus on culturally-defined symptoms such as heart weakness and dizziness; and I should note that lack of medical terminology does not invalidate the suffering of the rural Cambodians who experience PTSD. It is not clear if the emphasis on traditional healers in the case of mental distress is a product of financial restriction to institutional healthcare or simply cultural preference; the impact of socioeconomic status is vast and individualized so perhaps we may never be able to fully understand. The context of perception is important simply because it helps identify local ideologies about health and the hierarchy of resort in the pursuit of wellness.

The restriction of impoverished populations to healthcare is another stark example of biopolitics at work; which is defined as regulation through power of health and life. In the face of conflict, whole families were forced to flee into the forests and to take shelter among the foliage in an effort to preserve their own life and protect their loved ones. The government assassinated all medical professionals and educated individuals, anyone who they saw as a threat to control the whole population’s access to health and human rights to life. People were starved, beaten, overworked and forced from their families in an effort to work toward socialism and political gain. The medical anthropology concepts of biopolitics have played an immense role in my own understanding of the lack of healthcare services in Cambodia. With little access to a salary worthy of comfortably providing for a family, citizens of Cambodia (rural or otherwise) are subjected to structural violence’s of their government and international agencies.

After examining the implementation of mental health and PTSD assessment in Cambodia, I have come to understand that the politics of social change starts at the ground. The incidence of PTSD in Cambodian refugees is well-documented in countries such as France, Australia, and the United States but little has been documented in Cambodia itself. (Rechtman, 2). The incidence of mental health disturbances in Cambodia isn’t even mentioned in the WHO statistics, they cite that “The number and density of psychiatrists are the most widely available and reliable indicators of the human resources available to mental health services”, however as we have learned from this paper, the sheer number of individuals who utilize the medical system does not reflect the actual need for the services (WHO statistics, 122).

CONCLUSION

In order for mental health problems to be remedied, effective responses “need to take place at individual, local, national, and international levels, and involve all members of society as well as health professionals” (Global Health Watch, 159). The extreme poverty in Cambodia restricts the rural refugees from utilizing life-sustaining healthcare treatments. In a country where nearly a third of the population subsists on less than US$1 dollar a day and average annual out of pocket expenditure is US$49 dollars per person, biomedical assistance will always be a privilege enjoyed by the wealthy and the continuation of unfair biopolitics will persist. During the next few decades, as these countries develop and the burden of conflict-related PTSD occurrences begins to subside, the contribution of mental disorders to the family unit will become increasingly apparent in the psyche of future generations. Consequently, there is a major need for healthcare professionals, medical faculties and aid agencies to start to consider and to act on, these problems now.

BIBLIOGRAPHY

1.      World Health Organization (2012). World Health Statistics Report. Geneva: WHO. Available at:http://www.who.int/gho/publications/world_health_statistics/EN_WHS2012_Full.pdf

2.      Global Health Watch (2011). Global Health Watch 3: An Alternative World Health Report. Available at:http://www.ghwatch.org/sites/www.ghwatch.org/files/global%20health%20watch%203.pdf

3.      Hinton, D. E., Hinton, A. L., Eng, K.-T. and Choung, S. (2012), PTSD and Key Somatic Complaints and Cultural Syndromes among Rural Cambodians: The Results of a Needs Assessment Survey. Medical Anthropology Quarterly, 26: 383–407. doi: 10.1111/j.1548-1387.2012.01224.x

4.      Margaret Lock, 2002, “Medical Knowledge and Body Politics.” In Exotic No More: Anthropology on the Front Lines, ed. Jeremy MacClancy (Chicago: University of Chicago Press), 190-208.

5.      Cannon, Cade. "What is Medical Anthropology" University of Washington, Architecture Hall Room No.147, Seattle, WA. 08 2012. Lecture.

6.      Rechtman, R. (2006). The survivor’s paradox: Psychological. Taylor and Francis Group, 13(1), 1-11.

7.      Trankell, I. (2004). French colonial medicine in Cambodia: reflections of governmentality. Anthropology And Medicine, 11(1), 91-105.

 

Malnutrition and Famine in Africa

Cassie Oh

We have always heard about the ongoing malnutrition in third world countries like those in Africa. Have we ever thought about what the insider views were like as a researcher or even as an individual living there? Parker Shipton is an anthropologist of African Studies who wrote an article called “African Famines and Food Security: Anthropological Perspectives” explaining and analyzing the issue of famines and their affect on communities and anthropologists’ research. I believe this was a great reading on not only learning about what a famine really is but also knowing how to grasp the problem in a medical anthropology perspective. Its importance on questioning the who, what, where, how & why of the problem and how to tackle with possible answers to these questions strengthens this paper for future plans to take care of it.

The problem I am focusing on is malnutrition and famine in Africa. Because of the harsh climate, famine proceeds which affects the communities who farm for their main source of food. This is a problem because due to the environment deteriorating, basic needs for good health start to vanish as well. Therefore, it is addressed in the medical anthropology perspective through the studying mortality as a result from the famine. The case studies in the article questions the cause, effects, possible preventions and remedies for this issue which are perfect to start out with in studying the issue through  an anthropological perspective. Shipton’s article mainly explains the debates on the causes of famines and analyzes the impacts made upon the communities and anthropologists through case studies. He embraces the idea on how to make possible resolutions through research and a higher organization of methods for farmers in Africa. The goal of this paper is to re-introduce the definition of famine in Africa and bring a better understanding of how to strategize a solution while maintaining the agrarian culture there.

The article not only provided specific details and how famines happen and what we can do for it, but just simply putting out a definition to work with. Shipton did a great job in defining what a famine is according to the perspective of an anthropologist. He mentioned that “[a] definition of famine must denote breadth and severity without suggesting that everyone starves or suffers in the same way or at the same time: I suggest ‘severe shortage or inaccessibility of appropriate food (including water), along with related threats to survival, affecting major parts of a population.’” (Shipton 358). I believe this was a great way to introduce the issue because one should know a proper way to define a problem in order to plan a way to solve it. The fact that he made it more specific helps medical anthropologists know what exactly is causing it and who it affects so that they can conclude with a higher efficacy on reducing or preventing the health problem. Representations of a famine can vary and produce many different ways to go about on helping. Shipton’s definition helped me to focus better on the other factors of a famine and the affects of a larger population. An example of a cultural shift due to the famine is when Shipton mentions the need for loosening the definition of food. Their culture had certain foods that are core to their everyday lives, which were the crops that they grew themselves. However when push comes to shove,  one must use basic survival skills to get by. Shipton explains that although it did not extend to cannibalism, people did search for other edible resources such as wild animals and insects. He emphasized that “[c]ultural rules about foods warp and loosen in hunger, but they do not just wither away” (Shipton 369). Clearly it shows that these people do not just eat anything. Traditional eating may not be the same but individuals still make their way in holding onto their culture. Through this method, individuals still make sure they get their nutrients and general health leveled. Not only will this give a more practical way of possibly preventing famine but it demonstrates that through these survival skills people can endure longer in a crisis like this. They look after their well being along with applying their beliefs into their actions when getting food. This may not work for everyone but I believe it is a start in addressing some strategies to make the issue into a less critical level.

To add to the explanation of the cultural shift and effects in society, it is also a good example on strategizing a more practical way to go about this issue. The article left me with a broader sense of how to attack this problem in a progressive way. I definitely agree Shipton’s analyses on how to reduce and prevent famines. For example, his idea of how to promote the methods of preventing food shortages was a concept called  social investment. “It includes aspects of kinship, friendship, and patronage; and it encompasses both dyadic reciprocities and concentric redistribution (including ceremonial exchanges, and tribute-or tax-fed relief)” (Shipton 368). Not only does it encourage a positive social connection between the community members but it does give a beneficial value to their health overall with attempts to decrease food shortages. I really liked this idea because it demonstrated a mixed view through the medical aspect and social & cultural aspect of it. Through this collected investment within the community, individuals will be able to allocate whatever resources they have in a more organized manner.

Global health and medical anthropology work hand in hand. However, global health focuses more on the health and medical anthropology focuses on social factors along with the health. How a medical anthropologist would frame this problem is through social factors while taking into account the health of the group of people. Global health would specify more on the environment and any biological factors that affect their health. Medical anthropologists would look at those as well as how the issue is affecting the social aspect of their lives. According to World Health Statistics, some indicators they look at include risk factors and main causes of the issue. In a medical anthropology perspective, this issue is addressed through in depth focus on the African culture of farming in relation to the famines occurring as well as the societal effects of it. This article supports this perspective by indicating that culture and society are highly influenced by issues of health, health care and related issues. World Health Statistics would see that the location is one of the main causes of famine, thus resulting in malnutrition and death as huge risk factors. These factors presented how the African agrarian culture has been affected by the specific location of their grounds and the famines that are a consequence of it.

Several ideas that we’ve learned from lecture definitely tie into this article. Concepts like perceptions, representations and power through socioeconomic status helped redefine this issue. The debates on the different reasons of the famine gave a better understand on how important perceptions are. The debates were deciding “…whether to point the finger at natural hazards like droughts and floods, or to blame human oppression, exploitation, and bad management—the human-made ‘political economy of colonialism, markets and states” (Shipton 355) It is clear that there are different views on how this issue came about and of course different attack methods to try and resolve it. The fact that this agrarian culture is a core piece in these people’s lives make it an important factor to consider, which helped my understanding of the concept of socioeconomic status when we discussed about it in class. If farming gave the people what they need for food and water, their status economically would have been fine. However, now with the famine their status has been reduced to a troubling level of survival. Life and death have a very thin line between them with the disappearing fruitful land. In addition to the different perspectives, Janzen’s readings went into detail about the meaning of medical anthropology, which clearly relates to malnutrition going on in Africa. Janzen’s explanation of medical anthropology “…includes the community’s access to the resources that maintain or restore health, or the exclusion from such resources by the community’s power structure” (Janzen 2). This supports the article’s emphasis on the lack of resources as a result of the famine which in the end comes down to people losing their lives. As one can see, these concepts helped wrap my mind around the center of medical anthropology and how this article executed the point of perspectives in a global health issue.

I would say my understanding of the medical anthropology perspective has been more redefined after applying it to the malnutrition and famine issue in Africa. At first I just addressed it as a health issue affecting a large group of people. Now after learning about perceptions and the cultural aspects of it, I can see a bigger picture on the different factors resulting from this famine. The fact that these people have the agrarian culture, it is more difficult for them to resolve food shortages and famine. Farming and growing their own crops have been part of their daily lives and is in general what keeps them alive. To live in a location that is prone to dying land and harsh weather not only puts their lives at risk but makes it harder for them to leave when they already lack resources. This cultural aspect demonstrates how medical anthropologists can think of strategies to help maintain their food system and tradition. In addition to maintaining it, Shipton indicates several strategies on how to go about their cultivation without relocating themselves. “The three most important prevention strategies observed are diversification of livelihood; consolidation of savings into illiquid, indivisible, or incontestable forms; and social investment” (Shipton 364). This is clear that the views from medical anthropology focus on how to sustain health while understanding the social aspect of the problem. Perceptions matter because people outside of Africa who are not familiar with its traditions and lifestyle may not understand why Africans have to deal with agrarian culture when they can transition to another one. Different cultures and methods on keeping oneself healthy demonstrate how important it is to understand these approaches.

Desperation increases as the food shortages persist. “ [Famines] blur cultural distinctions between persons and property, and destitution redraws the lines between the saleable and unsaleable” (Shipton 372). Through this unfortunate shift in tradition, individuals suffer not only physically, but socially as well. Shipton had an outsider perspective when describing an experience with elderly rural Luo women who said “… some of their prostitute daughters in towns had remitted them money or purchased food from towns; some mothers, having once done the same, had even tutored them in the trade to begin with” (Shipton 372). This displays not only the severity of the effects of the famine but an example of a concept of outsider perspective we have discussed in class. Shipton put himself in the situation listening to the women experiencing the famine without fully understanding the meaning of their relation with culture and is told what they do out of the feeling of hopelessness. Scrimshaw’s article on “Culture behavior and health” demonstrates the cultural context on the affects of a group of people’s health. He explains the concept of the outsider perspective which “…conveys a structural approach, or something as seen without understanding its meaning for a culture” (Scrimsaw 44). Scrimshaw’s article connects with Shipton’s experience in observing the African communities in their acts of desperation which starts to temporarily change their cultural ways (which in this case is their value of social interactions).

It is interesting to see how a global health issue can be dissected into different anthropological perspectives while applying the medical aspect to it.  Although malnutrition is nothing new in our world, Shipton’s article presents an easier grasp of the issue through refining the definition of famines and bringing ideas of ways on how to prevent them and help communities get educated on what they can do as well. The importance of this article and paper is to reach out to the public with a more straightforward message on the affects of famine to the people in Africa. It relates to class material on the concept of perception and identifying a global health issue through the analysis of medical anthropology. Will there be much change in the future? There might be or might not be. Nevertheless, our research in combining health and society will only bring us closer to our goal to remove the issue from the global scale at least and to create a better strategy in maintaining the health we need.

Works Cited

Janzen, John M. "Introducing Medical Anthropology." The Social Fabric of Health: An Introduction to Medical Anthropology. Boston: McGraw Hill, 2002. N. pag. Print.

Scrimshaw, Susan. "Culture, Behavior and Health." International Public Health: Diseases, Programs, Systems, and Policies. By Michael H. Merson, Robert E. Black, and Anne Mills. Sudbury, MA: Jones and Bartlett, 2006. 43-64. Print.

Shipton, Parker. "AFRICAN FAMINES AND FOOD SECURITY: Anthropological Perspectives." Understanding and Applying Medical Anthropology. 2nd ed. Vol. 19. Mountain View, CA: Mayfield Pub., 1998. 353-82. Print.

Final Review: Outsourcing Pharmaceutical Trials

Pharmaceutical Trials

In the last 30 years clinical trials of the pharmaceutical and biotech industries have paralleled the ever globalizing world. The continual emphasis that is placed on globalization is translated into the medical field in the form of internationally shared clinical data. Although the practice of medicine lies within the field of science, it encompasses more than the celebration of raw data being pooled at a global level; yet the outsourcing of pharmaceutical trials remains at large. This exponential growth of outsourcing in the pharmaceutical industry provides an opportunity to evaluate the relationship between data oriented corporate protocols and human beings that the trials are conducted on.

 In this review I will follow Petryna’s style of objectively assessing clinical trials by discussing the benefits and limitations within this segment of the pharmaceutical industry. I will also attempt to clarify that raw data is not king when discovered through unethical, and immoral circumstances. By analyzing clinical trials in a medical anthropology framework, new conclusions can be drawn to bring needed change to the ‘magic bullet’ philosophy of the pharmaceutical industry.  Using medical anthropology to describe the global health problem of clinical trials offers the ability to see the multi-faceted nature of this problem along with the possible contextualized solutions.    

Paradigms of Expected Failure

In the article Paradigms of Expected Failure by Adriana Petryna, attention is drawn to the problems of outsourcing pharmaceutical trials while acknowledging the limited benefits.  Through critical study with a medical anthropology framework Petryna brings to light how biopowers known as the “big pharma” (which are the four major pharmaceutical companies) are setting up clinical trials in places such as Eastern Europe and Latin America to gather data which can then be used to gain patents from the United States Food and Drug Administration or the European Medicines Agency. The practice of outsourcing harnesses the power of testing populations with minimal to no pharmaceutical drug history therefore making the citizens the perfect clinical subjects. At the same time that these companies are maximizing their personal gain, they are providing a local social good. This dialectic nature of clinical trials remains one the biggest obstacle when attempting change in the pharmaceutical industry. By highlighting ethical dilemmas present in the field of clinical trials Petryna discusses how these unethical operational protocols are affecting the social network of communities and nations, and how they unfairly direct problems of the clinical trials away from the big pharma and onto the individual; the beginning of the paradigm of expected failure. The paradigms of expected failure, or the inability to predict safety outcomes of clinical trials, is outsourced along with pharmaceutical testing and are a calculated way for the big pharma to refuse a majority of complications that participants incur after clinical trials are over. Of the many questions that surround clinical trials Petryna focuses on the problems within operational models and the systems that are in place for human protection. With these two main themes in mind, the essay concludes with Petryna’s vision of future changes that could be implemented which would tie in the goals of the pharmaceutical companies in a way that improves the rights for humans who agree to participate in clinical trials.

Medical Anthropology and Outsourced Clinical Trials

            Along with the article Paradigms of Expected Failure I reviewed what the Global Health Watch publication had to say about the outsourcing of pharmaceutical clinical trials as a global health problem. While many of the claims were the same between these two articles there were some notable differences. In Petryna’s article her main focus was on the treatment of the community and clinical subjects that participated in trial medicine and how changes in policy could create a better environment for them. In the World Health Watch article the main theme was how the power of the four major pharmaceutical companies influences policies and people to make detrimental choices. Because of differing main themes the structure of the articles are different. In the World Health Watch article the beginning discusses how consumerism and advertising lead people to the “more choice façade”, which is the idea that by advertising prescription drugs as a consumer you feel like they are giving you information for you to make a more educated decision but in actuality it’s another method of propaganda. Then the article continues with how the genuine scientific inquiry has been removed from clinical trials leading to inaccurate data. Editors of the British Medical Journal have supported this by stating that they “turn down 90% of articles submitted because of poor research quality”(World Health Watch 281).  After establishing the core problems in the operational portion of clinical trials the World Health Watch concludes with how these problems affect communities and individuals that participate in clinical trials. Although the structure of both the World Health Watch and Paradigms of Expected Failure were different and resulted in different possible solutions, both can be viewed as beneficial analyses of a global health problem in need of a multi-layered revolution.  

Redefining Clinical Trials through Medical Anthropology

                Medical Anthropology studies problems in an organized manner that sorts observations into categories of concepts such as perspective and power. The ethnographic research that was produced by Global Health Watch and Petryna have discussed these concepts through identifying individual and scientific perspectives and the biopower relationship between the big pharma and international governments. When researching the different perspectives of a problem there are two broad categories that are evident; the individual perspective and the power perspective, in this case the scientific perspective. Often in the case of clinical trials individuals have the opinion that this clinical health care that they are receiving is a “local social good” (Petryna). Despite the fact that these clinical trials are present for a limited time, it is possible that this trial medicine is the only form of health treatment that they have ever received in their lives.  This opinion spreads throughout the community and when there is good intended dispute put forward by a doctor about the approaches that pharmaceutical companies are taking, it is the doctor that is shunned and not the company. The persuasive power of a local doctor is little compared to the propaganda and advertisement put forward by the billion dollar company facilitating the clinical trial. The scientific perspective is held by the biopowers, i.e. the big pharma. This perspective focuses on clinical trials as strictly a business; humans as test subjects, raw data as the sole focus, both of which abide by a robotic corporate conduct with limited ethical boundaries. By definition the pharmaceutical industry is a biopower, they are playing in two markets, the field of medicine and the field of consumerism. By intertwining these two fields there become times were profitability and supply and demand become more important that the medical need for prescription medications. Unfortunately this is the point that has been reached and we are seeing the problems in the clinical trials that are outsourced.

Practical Alterations of the Clinical Trial Industry

                After studying the outsourcing of pharmaceutical trials with a medical anthropological framework there are a few potential changes that would benefit the humans participating in trial medicine with little effect on the pharmaceutical industry therefore making these changes useful as well as necessary.  In Paradigms of Expected Failure, Petryna has three recommendations which she discusses as the most important changes needing to be implemented now. First, returning the “science of drug development”(Petryna) back to the clinical trial industry. By returning the core principles of scientific discovery to clinical research there will be less room for researchers to skew data, or be faced with unethical choices. Second, Petryna encourages that less emphasis should be placed on the discursive nature of the pharmaceutical industry and rather an emphasis on the “behind the scene” type flaws. These rifts that are present in places where “invisibility and visibility confront each other”(Petryna), describe the moments where data is collected and in return a prescription drug is created. Third, there must be comparative analysis that is done in different nations with different “systems of accountability and law”(Petryna). Through thorough comparative analyses that transcend the USA or EU conclusions can be drawn on the status of clinical trials worldwide and how to better approach change within this pharmaceutical stronghold. The world Health Watch has four alterations that would improve the clinical trial industry. First, rewarding pharmaceutical companies based on the health outcomes of new drugs rather than mere projections formed from the company. Providing incentives based on the outcome of a drug is the most reasonable change in my opinion. There should only be a reward based on proof that a new drug is beneficial and needed. Second, policy reform that makes it easier for generic drugs to be made and distributed to nations that cannot afford to pay more than the cost of a generic drug. In underdeveloped countries that cannot afford non generic medications, the pharmaceutical industry is denying individuals to the right of health care and a quality of life that they themselves enjoy based on an economic form elitism.  Third, to stimulate a market in which prescription drugs are being discovered for the greatest medical needs. When only “1 percent of the medications being produced are for neglected medical disease”(Global Health Watch) there is an obvious disconnect between medical need and medical extortion based on profitable afflictions, i.e. musculoskeletal aches and pains.  Fourth, to disassociate the relationship between drug research and development (R&D) and the cost of said medications on the market. Patients should not have to pay more for medications because of the cost to develop said medications; because of this principle many individuals are withheld medical treatment because of financial limitations. I think that if these seven achievable goals were implemented in the operational systems of the clinical trial industry it would be possible to reform the clinical trials and re-present them in an ethical light to the international medical community.  

Reshaping Personal Opinion of Medical Anthropology

As I continue to study global health problems it becomes clearer to me that medical anthropology is a dynamic field that is continually shaped by the problems that it analyzes and discusses. Specifically after studying the outsourcing of clinical trials, I have learned that how data is gathered is equally as important as the data itself.  Prior to taking this class, being a science major, my thoughts were under the influence that getting accurate data is unequivocally the most important pursuit of a scientist.  I can now acknowledge that in an idealized laboratory setting this may be possible but when the social context of medicine becomes involved there are more unknown variables than known variables accounted for. This problem presents an opportunity for medical anthropology to study the problem in an objective framework to come to conclusions that facilitate cooperation between those with opposing views. It is clear to me that this form of mediation is beneficial to any global problem where biopowers, policy makers, and lay people are involved.

After studying this global health problem I have concluded that the outsourcing of clinical trials at this moment is a market in which unethical treatment of humans is occurring. I will concede to the point that clinical data is necessary to the production of any prescription drug, but I will not accept the inefficient systems that are currently in place to protect human test subjects.  I stand by what the Adriana Petryna and the Global Health watch have outlined as ways to improve the outsourcing of pharmaceutical trials, and if these changes are implemented I have no doubt that the pharmaceutical clinical trial industry can become a useful international asset within the medical field.

Bibliography

Petryna, Adriana

  2009. Paradigms of Failure. Springer Science+Business Media B.V. Retrieved December, 2012, from

Shukla, Abhay, et. al.

  2011. Global Health Watch 3: An Alternative World Health Report. London: Zed Books Ltd.

Assisted Reproductive Technology: A Medical Anthropology Perspective. By: Crystal Vergin

Assisted Reproductive Technology: A Medical Anthropology Perspective

            New reproductive technologies (NRTs) are a growing field in the Global Health arena. While the NRT’s may not pose a problem in the form of malaria or tuberculosis, they are of concern. As with any new technology, assisted reproductive technologies (ARTs) have the potential to create health inequalities. Not all techniques and technologies are available to all people in all parts of the world. New reproductive technologies are, according to Global Health Watch 3, are “a broad constellation of technologies aimed at facilitating, preventing or otherwise intervening in the process of reproduction”(2011). I will examine some of the barriers patients face when seeking out these ARTs, particularly in vitro fertilization (IVF) within the Middle Eastern context. Medical anthropology theory and tools will be applied to this complex global health concern, especially the ethnographic work of Marcia C. Inhorn. The ethnographic fieldwork of anthropology allows individual perspectives to come to light that might not otherwise have been seen; through this perspective various inequalities are verified or discounted. Biopower, gender, access and global flows will also be more closely.

GENDER DYNAMICS

Gender plays a dynamic role in the use and access of reproductive technology. Women bear the most of the reproductive burden, and certainly with the increasing use of surrogates women play a major role in the reproscape, but men must not be left out of the equation. ARTs often require gametes from both sexes, meaning that it is not just oocytes (eggs) that require donation but also sperm. Often it is married couples who seek out ARTs and this is definitely so in the Middle Eastern context. Therefore, both genders are users of the ARTs and in the Middle Eastern context it is couples that seek these technologies together. Power struggles between genders may also contribute to inequalities when considering the new reproductive technologies.

 Women may not have the agency to choose what reproductive technologies that they do and do not use because of religious or cultural norms that put women at a disadvantage in the power dynamic. One example of is the AIDS epidemic in Africa. If women were allowed to choose protection in the form of condom use without the threat of being ostracized or abused, outcomes may be much different. Open to speculation is the capacity of Huda, the infertile woman in Inhorn’s article, we are never told how she feels about the use of a donor egg being implanted in her uterus, we only hear her husband’s perspective (2011). Medical anthropology is concerned with the issue of gender because women may carry the most reproductive burden but may also have the least amount of choice in what reproductive technologies they use. The male role in the access of ARTs is much larger than that of females, especially in the Middle Eastern context. Through more detailed ethnographic work anthropology may be able to get at the heart of this inequality to offer solutions to women without agency.

ACCESS AND RELIGION

            Access to NRTs is another way in which inequalities are magnified. Access to ARTs and NRTs also drives reproductive tourism. Recently discussed in class, medical tourism took form in the context of North Americans seeking inexpensive cosmetic surgery in Costa Rica. Here, we discuss a repro tourism in the Middle Eastern context. Existing literature has cited eight factors contributing to reproductive tourism, out of which, four are directly related to access. For example, services may be unavailable do to lack of gametes, equipment or medical specialization; procedures may be considered unsafe in certain countries, or some patients may not receive services based on expense to national healthcare programs, marital status, sexual orientation or age. Besides the former reasons some countries prohibit certain services for religious or ethical reasons (Inhorn, 2011).

           In the context of the Middle East religion plays a large role in the availability and use of ARTs and NRTs.  The vast majority of patients seeking these reproductive therapies in the Middle East are Muslim. Within the Islamic tradition there are two paths the Sunni and Shia. Religious opinion on the ARTs differs between the two. Both sects offer fatwas- non-legally binding authoritative decrees. The first fatwa on ARTs was announced in 1980, two years after the first test tube baby was born in the UK (Inhorn, 2011). The Sunni position permits IVF (in vitro fertilization) but only using eggs from the sperm of the husband of a couple; no third party is allowed involvement. In other words, no donor sperm or eggs are to be used. Not only does this break the sanctity of the marriage for Muslims, a donor gamete calls paternity into question. According to Inhorn, Sunni Muslims agreed in interviews that no third party should be introduced into a marriage. A child born of a donor gamete would not know their nasab or linage, which “confuses kinship, paternity, descent and inheritance.” This can be psychologically damaging for the child (Inhorn, 2011).

 Shia religious authorities mostly agree with Sunni authorities excepting for the form of individual religious reasoning known as, ijtihad. This reasoning has brought about disagreement and raised questions: (1) the third-party rule has been called into question. (2) In the case of male infertility should the donor gamete go by the donor’s name? (3) Should anonymous donation be allowed? (4) Should temporary marriages be allowed to avoid adultery? This type of temporary marriage is allowable for Shia’s but not for Sunni’s (Inhorn, 2011). The Shia religious thinkers raise these questions but Inhorn found that even some Sunni couples used donor gametes despite the fatwa against it and were able to keep this a secret through repro tourism (2011). From this is it is clear that ARTs are socially represented as both acceptable and taboo. The couple interviewed in Inhorn’s article, were willing to accept the social and religious taboo of using a donor gamete. The Husband Hatem, rationalized that because his sperm was being used to fertilized the consensual donor egg, this form of IVF was acceptable from his point of view. It is interesting to note that Hatem the husband of the couple interviewed is the one to speak for both him and his wife. Medical anthropology researches much further than biomedicine. Anthropology examines more than just the clinical data of biomedicine, but is capable of highly contextualizing both data and individual perspectives and representations. In Rachel Chapman’s article this allowed for the reality of the situation in Mozambique to come to the surface and for the problem of perinatal care to be explained in terms that led to better outcomes for the community. Recently we discussed in class anthropology’s synthetic quality that sets it apart from other disciplines. Anthropologists don’t merely pull apart an issue to look at its parts, rather the parts are closely examined to see how they function, then put back with the whole to see how all the parts function together (Lecture, A. Ceron, 12/12). Through this process global flows are taken into account, whereby we can see the biopolitics at the macro and micro levels.

POLICY AND THE REPRO SCAPE

The biopolitics of ARTs has reached an international level. Many countries have enacted policy regarding ARTs; these policies are also tied to the availability and access of ARTs. Some Western nations including Great Britain, Canada, Norway and Italy, have legislation prohibiting the donation of gametes, especially by anonymous donors and surrogacy. This means that Western Europeans seeking “white” donor gametes are flocking to Eastern Europe where policies are more lenient (Inhorn, 2011). Young women in post- soviet bloc countries sell their bodies in whatever way they can to survive. Inhorn mentions the parallels between sexual tourism and reproductive tourism; this is a prime example of body commodification.

       This entire process is historical, and global, we can see movement at various levels producing a both a global flow and a “glocal” culture. Within Appadurai’s framework Inhorn proposes the use of the “reproscape” to encompass “a kind of ‘meta-scape’ combining numerous dimensions of globalizations and global flows”(Inhorn, 2011). Cultural anthropologist Arjun Appadurai is a major theorist of globalization. Inhorn references Appadurai’s theory of global movements that are characterized by “scapes.” Globalization, according to Appadurai is characterized by the movement of images (mediascapes), people (ethnocacapes) and other “scapes,” these follow complex trajectories that move at different speeds across the globe (Inhorn, 2011).           

        The buying and selling of gametes on the open market, links the commodification of bodies with the issue of human rights. While we may not think of the gamete market in these specific terms we see it almost every time we read a classified section of a newspaper. I see ads in the UW Daily asking for egg donors of a specific ethnic background and/or eye and hair color, age, height and sometimes even a GPA. It is this transfer of human DNA on a global scale that Ruth Deech questions in her article, ‘Reproductive Tourism in Europe’ (2003,425, as cited in Inhorn, 2011).

            The couple in Inhorn’s article could be labeled reproductive tourists; they travel from Syria in some secrecy to Beirut for IVF treatments. While their families know that they are traveling for “treatment” they do not know what sort of treatment. It is clear from the interview that Huda (wife) suffers as a childless woman living in a large extended family surrounded by her relative’s children while she has none of her own (Inhorn, 2011). Across cultures and history it is general knowledge that infertility has been and still is considered both an illness and a sickness. Biomedicine has the ability to categorize and medicalize infertility into a disease.

            Medical anthropologists are equipped with the tools needed to further explore the global “reproscape” as it grows and changes with the demands of infertile couples around the world. Inhorn’s article points to the anthropologists’ ability to collect ethnographic information, a key role anthropology should play (2011). In addition anthropologists can do more than ethnographic investigation, we can see the whole and it’s parts. We know that health cannot be divorced from social contexts, that what may true in one context is not true in another. If we look to highly contextualize a scenario as Rachel Chapman’s article encouraged us to do we may be capable of discovering clearer paths to answering global health questions.

Bibliography

Ceron, Alejandro. “ Untitled Lecture, A 215.” Lecture, University of Washington, Seattle, WA, December 7,2012.

Chapman RR. 2003. "Endangering safe motherhood in Mozambique: prenatal care as pregnancy            risk". Social Science & Medicine (1982). 57 (2): 355-74.

Deech, Ruth. 2003. Reproductive tourism in Europe: Infertility and human rights. Global          Governance 9: 425–32.

Global health watch 3: an alternative world health report. 2011. London: Zed

Inhorn, Marcia C. “Globalization and gametes: reproductive ‘tourism,’ Islamic bioethics, and Middle Eastern modernity.” Anthropology & Medicine Volume Number, no. 18 Issue Number 1 (2011): Pages 87-103.