Dysfunctional Health Systems in the US and Stigmatized Biologies

Avalon Valencia

Medical Anthropology 215

Final Paper

            The access to healthcare in the United States has left many people of lower incomes/poverty, questioning what options they have to receive any medical or dental benefits. The government funded program Medicaid, once regarded as the “cure all solve all” solution for people without private health insurance, is now viewed by many policy reformists as the facade of larger problems. People who are on Medicaid do not get the resources or medical attention that people with private insurance usually get, or they get quicker and less personalized attention. In the case of a young Mexican girl in the article I chose, Raquel, her teeth were rotting and her Medicaid accepting dentist chose to pull out her teeth instead of repair them. When she went to a dentist who was better trained for serving Medicaid patients, he discovered that her teeth actually could have been saved. Raquel wouldn’t have had so many complications if the first dentist had taken the proper amount of time and care to do the teeth repairing procedure instead of the removal in the first place.

This case brings up a large problem of inequality and access to healthcare that we are currently facing. This problem stems across groups of people who are enrolled in private insurance, people who are enrolled in Medicaid, and people who are uninsured. In this case we have been focusing largely on Medicaid and will focus on other supplemental healthcare programs and the links between what services they provide and how they are provided. In some cases like Raquel’s, the distributer of the Medicaid (Denti-Cal) only pays medical professionals 30-40% of what they would receive from a private insurer. Raquel’s teeth were not saved due to the small amount of turnaround the dentist was receiving to take care of the problem. With the unequal distribution of payouts from government-funded programs for people who can’t afford private insurance, it’s hard to guarantee equal treatment.

It is also interesting to find out that funding for private insurance not only comes from those who have it and have to pay for it, funding also comes from those who have Medicaid and no insurance. Their tax dollars and other fees essentially pay for services that they never get to use. The problem within our current healthcare system in the United States is something that I chose to look at through a medical anthropological perspective because of the way that the subject is being handled by our politicians. The decisions that are made by politicians affect our nations’ people disproportionately and send money into places that are not always seen by the general population. As stated in the Global Health Watch 3, “Medicine in the US is nothing but the result of our politics on the largest scale.” We are not running a system that is beneficial for anyone except those who can afford not to care. Those who can afford not to care about the money they are able to put out for health services are the ones who are the voices for everyone else.

Given the specific nature of the article I have chosen to work with, I will not only focus on the overarching subject of dysfunctional health systems in the US, or the sub focus of Medicaid, I will also focus on “stigmatized biologies.” Medical anthropologists use these terms to describe how although there are individual medical as well as governmental policy matters to be taken care of in America’s healthcare system, the increasingly developing category of stigmatized biologies is hindering certain communities from advancing in these areas. “Stigmatizing a biology” to some people might mean that they exploit some children and help others, but especially in this case, it goes deeper than the surface; it gives right to immigrant caregiving practices interact with Denti-Cal policies over farmworker children’s lifetimes, to “lock in” long-term effects of early tooth decay. Public health scholar, Krieger, has already come up with her plan of action based on things she has found unsuccessful in helping disadvantaged people. “Her model critiques biomedical and psychosocial approaches focused exclusively on endogenous biological responses for ignoring the social determinants of health.” “Embodiment” she said, is a “conceptual tool, to examine the conjoint biological and social determinants of health. Further explanation of the complexities within the proposed framework are best explained as follows:

“Proposing a ‘multilevel’ framework, Krieger urges attention to the interplay between the biological and the sociopolitical at multiple levels. She proposes that scholars analyze the specific pathways through which social disadvantage materializes as illness and disability. The concept of embodiment reveals racial disparities in health as not genetically determined but, rather, as the mutable and embodied expression of discrimination itself. She shows, for example, how the excess risk of hypertension among African Americans is the physical embodiment of myriad social and material factors—including residential and occupational segregation, exposure to toxic substances, interpersonal discrimination, the targeted marketing of commodities, and inadequate health care. Her model unmasks population patterns of health and disease as ‘biological expressions of social relations.’ Yet even more provocatively, her approach allows for the cumulative interplay between biological development and social structure, taking into account the long-term health effects of inequalities embodied early in life.”

           

            The inability to guide oneself through the heavily stigmatized social circumstances that fall within having an oral disease would be hard for any young child, but for a young, Mexican, female, immigrant child, the path to comfort is a lot longer. Getting back to long-term discoveries within others who have possessed an oral disease under similar circumstances, periodontal diseases have been known to lead to heart disease, stroke, and pancreatic cancer. More research in the physical aspects of anthropology have shown that the pre-mature loss of teeth can adversely affect a child’s self-esteem, speech development, ability to eat, and in severe cases, the permanent shape of the cavity itself; Medicare doesn’t cover these things. No one covers these things. There is hardly enough funds to cover the invasive and insensitive procedures that are already limited to those in disadvantaged communities, like those of Mexican farmworkers, that it’s hard for families to do anything else but accept what “help” they have been given, and be grateful for it. America has convinced them that they are doing better with their help, than if they were anywhere else, even though medical anthropological studies have shown that children who are Raquel’s age and living in Mexico, reportedly have no severe oral problems like the ones she had experienced. It’s the young children who come from Mexico, into America, whose families are trying to adjust, that continually, have this problem.

            As discussed in class, differences within cultures heavily impact a family’s ability to function in new environments. Their practices and ways of raising healthy kids vastly change when they are put into an environment where their previous resources are not as readily available. Due to the intense nature of fieldwork: the long hours on the job, the labor, and the responsibility to constantly juggle work with raising kids and providing for them all while trying to deal with language barriers and discrimination in education, medical, and healthcare settings, it’s almost impossible for parents to know how to adapt to this version of “American culture” right away. Reports on studies of children whose teeth were removed under the Denti-Cal program revealed that the majority of children were being given a bottle for too long, and with liquids that were too rich in sweetener and damaging their teeth at an alarming rate. The added ingredients in many juices and even sometimes if a child was given too much milk, were too much for their developing teeth. In Mexico, they were given more natural ingredients, so when dealing with this issue in America, parents weren’t necessarily aware that what they had previously been doing, wasn’t going to work anymore, and was hurting their children.

            This leads me into my next concept of the immense power brought on by the power of representation. Under the dysfunctional reforms in the US healthcare system, traditionally disadvantaged and marginalized groups are represented under failing systems like Medicaid. As previously mentioned, when children would have issues with their teeth, they would first off, have trouble finding a dentist who would accept the Medicaid coupon (due to the extremely low rate of profit they would make) and second, they would have trouble knowing if the dentist was doing their absolute best to treat their child. A case study was mentioned in the article about the Yakima Valley, about an alarming number of migrant and immigrant children, who were facing serious oral problems due to their lack of healthcare and lack of awareness. The only representation they had was their label that was assumed under their medical coupons, which is heavily stigmatized as low income, poor, Spanish-speaking, liabilities to the government and everyone around them who pays tax dollars to fund what other people consider a “generous hand out.” What people don’t understand is that they aren’t getting even half of what they pay in tax dollars in services, while others who have private insurance, never have to even think about what kind of service they are going to get, because once you have that private insurance number and provider name, no doctor or dentist is going to second guess the quality of service he/she is going to provide.

From a conceptual perspective, my understanding of medical anthropology has changed after applying my concepts to my selected problem of dysfunctional healthcare systems in the US because I was able to see the faults within the realms of (insensitivity to) cultural differences,

power of representation, and power and resource allocation. People were not given equal access to healthcare, in this case dental care, and it resulted in a vast amount of the Mexican farmworker children across heavily farmworking populated areas, to become affected by oral problems. These concepts allowed me to view each area at fault in ways that allowed me to see the micro-level of how they affected young children like Raquel, but also allowed me to apply them to larger groups being studied like the kids affected in the Yakima Valley. Through a practical perspective, I was able to see how the US can do a better job at allocating resources and reducing stigma toward those with Medicaid and other alternative insurances to ensure better care for all citizens.

Sources:

Horton, S. and Barker, J. C. (2010), Stigmatized Biologies:. Medical Anthropology Quarterly, 24: 199–219. doi: 10.1111/j.1548-1387.2010.01097.x

Global Health Watch 3

HIV/AIDS and Poverty: Discourse of Hunger

Yasmin Habib
Final Paper

Introduction

    In the WHO 2012 report, HIV infection morbidity and mortality was identified as prevalent global health issues affecting various populations all across the world. According to the WHO 2012 report, the Global HIV/AIDs epidemic has impacted multiple lives, especially those in developing nations.   In 2010, an estimated total of 2.7 million people were newly infected with HIV, and in 2011 a total of 1.5 million people died of AIDS ( pg 14). The reports also shed light on attempts made to address the issue through antiretroviral treatments . WHO reports “ In 22 countries in sub-Saharan Africa, a  rate of decline has been observed over the past decade, but the number of cases in this region still accounts for 70% of all those who acquire HIV infection globally. At the end of 2010, there were an estimated 34 million people living with HIV – an increase on previous years. As access to antiretroviral therapy in low- and middle-income countries expands (16 times more people were treated in 2010 than in 2003), the population living with HIV will continue to climb as fewer individuals die from AIDS-related causes” ( pg 14).  Although the availability of the treatment appears to be positive at first glance, a medical anthropology perspective would reveal complexities and underlying issues which are being undermined and potentially dismissed by the report. This can be observed by comparing WHO’s 2012 report on the issue to Anthropologist’s Ippolytos Kalofono’s report on the issue.


Article Summary & Medical Anthropology Perspective
In an ethnography  published in Medical Anthropology Quarterly entitled “All I Eat is ARV’s”, Ippolytos Kalofonos from the University of Washington conducts a project which focuses on individuals living with HIV/AIDs primarily in Chimoio, the capital of  Manica Province. The author went about conducting his research by completing the project in three stages. First he collected both quantitative and qualitative information 6 weeks prior to the availability of the drug. Then he continued to do the same thing 8 weeks while the drug was available, and finally 12 months after the drug became available.  Kalofonos points out that after the antiviral treatment first became available to the public of Mozambique for free in 2004, the usage of the treatment has increase by 1500 percent. According to statistics of course, ( and his research) this has led to what appears to be a significant increase in the number of “lives saved”. Meaning that now, in comparison to before the treatment became available, there are more people living longer with the virus and people experiencing dramatic recoveries.  Yet throughout his work, Kalofonos identifies what he calls “ The Paradox of AIDS Treatment Interventions in Central Mozambique”(1).  He explains that hunger emerged to be a key theme amongst all the patients who were taking advantage of the treatments. You see, it was discovered that the treatment  required that patients increase their caloric intake, therefore patients found themselves tormented by hunger throughout their day.  As Kalofono’s  indicates, this turned out to be problematic in a nation already dealing with  poverty and extreme hunger. Similar to the case of the Play Pumps,  a lack of understanding of how the intervention program would impact the community in the long run led to more problems. The author states, “ HIV/AIDS interventions did not adequately anticipate or account for the impact of hunger among the people whose lives were being saved, leading to competition for scarce food resources” ( 4).  Therefore “Discourses of hunger serve as a critique of these shortcomings, and of the wider political economy underlying the HIV/AIDS epidemic” ( 4).

According to the author, in other words, there needs to be a better understanding of the co-existence of extreme hunger and AID’s in South East Africa. As the disease takes its toll on the individual, the body requires more and more nutrients.  If it does not receive these nutrients, the immune system is suppressed thus speeding up the progression of the disease. As these individuals  are forced to go out in search of food and work ( usually prostitution) , they hasten the progression of the disease even more and continue to spread the virus. It is easy to see why, in this case, a drug which adds on the caloric requirements can only deepen the problem.  Another way to also understand it is that hunger can indirectly cause HIV/AIDS  because healthy, but hungry individuals are more likely to participate in dangerous sexual activities ( transactional sex), thus exposing themselves to infection and spreading the disease in that way.  And so we see how the vicious cycle works and why understanding hunger plays and important role in understanding how the problem of  HIV/AIDs in Southeast Africa should be tackled.

Comparison to WHO
Although The World Health Organization’s report on the issue provided plenty of important basic and numerical facts, a brief comparison of the WHO report and the ethnography will reveal that it missed a lot of other significant points. As we discussed in class at the beginning of the quarter, Paul Farmer associated the definition of “Global Health”  with “ messy social realities”, and WHO’s report certainly failed to address this aspect even though it is a report concerned with Global Health. Statistics and the proper presentation of these statistics can serve as important tools which can be used to analyze raw data. But to a medical anthropologist, this tool can only be used as a starting point in understanding the “messy social realities” it is a part of.  In other words, WHO’s representation of the moralities caused by HIV infections and the results of the antiretroviral therapy de-contextualizes the social reality.

A medical anthropological perspective, like the one presented in the article addresses not only the statistical facts involved, it also attempts to contextualize these facts and critically analyze the social, political and economic implications of these facts.  Furthermore medical anthropology allows for the voices of the people and members of these affected communities to speak out and present their viewpoints on their illnesses and the provided interventions. In Kalofono’s work, the voices of the patients are heard immediately as they are being interviewed. They reveal that although they are grateful to regain their health thanks to the antiretroviral treatments, the hunger seemed to embody a sense of injustice for them when they say “ someone else is eating in my place”. You see in the case of Mozambique, the local government and the various nongovernmental agencies involved only provided enough food for one person each month. But as the program accepted more and more people who now needed even more food than usual because of the treatment, there was a decrease in the amount of food available. And so the voices of the people along with these facts point to a lack of consideration by NGO’s  of the significance of hunger in relation to the HIV/AIDs epidemic. When an organization such as WHO, which hold great power in the representation and understanding of a disease, bases it’s reports merely on the biological conditions being treated, the underlying ( and perhaps even more important) social, political, and economical issues are dismissed, and the people are left to be tormented by their hunger. As the author states this leads to “ local forms of solidarity [being] undermined as disease-related distinctions determine eligibility for scarce resources” (4) .  The vicious cycle mentioned in the earlier section takes its toll on the community and the problem continues to worsen regardless.  In the long run then, one problem is merely being replaced by another.

Three Concepts
In class, we also discussed other concepts in relation to medical anthropology would could shed light on this particular issue. One of the most important ones includes that of Power.  As indicated by the professor, power is the ultimate determinant of health. In this case, the people need their medications, yet the medications lead to a different and cruel form of torture ( hunger and starvation). Those in power, and those in control of the distribution of these medications are also the ones with the obligation to understand and the underlying issue of hunger which torments the community and leads to other less obvious yet equally severe complication ( competition for scarce resources).  This is because they have the loudest voices and thus, the Power to address these issues on a political scale and work on intervention programs which lead to more practical economic and political solutions as well as the biological ones.

    Interconnected with Power, another concept discussed in class which sheds light on this issue is that of Representation ( briefly mentioned earlier). The important thing to note about representation in this case is who has a say in the representation of the patients and what does this indicate in terms of where the focus will be  when the question of intervention comes up? As mentioned earlier, WHO’s representation of the disease and the antiretroviral treatment plays a huge role in the kind of attention this issue receives. And this all goes back to the Power that such an organization holds on a global scale. Yet WHO does not directly voice the opinions of the people, rather it presents de-contextualized statistics that have led to a dismissal of the underlying important aspects of this issue.  As was mentioned in class,  the form of suffering which  is legitimized can determine whether it is medicalized or merely stigmatized. In this case, the legitimization of extreme hunger in relation to the HIV epidemic in Southeast Africa  could easily be determined by the representation of the issue by the loudest, thus most powerful organizations.
The final concept which sheds light on this topic is that of historical context. In class we mentioned that “ while the body is a biological entity, it is also the manifestation of history.” This is certainty true for the case of HIV/AIDs in Central Mozambique. Chimoio gained it’s independence from Portugal in 1975 which led to “ a period of ambitious social programs…” yet the “optimism of independence was halted by a war of destabilization… in 1977”( 5).  It is because of this that the area experienced cuts in the available resources, especially food. And as was mentioned earlier, hunger can be both a consequence and a cause of HIV/AIDs. Of course to understand where the hunger came from, one must take a close look at the history of the nation in relation to politics and the economy.

Conclusion: Conceptual and Practical
     In conclusion, both the WHO 2012 report on the issue of HIV /the antiretroviral treatment  and Kalofono’s work presented interesting perspectives on the issue. While WHO provided necessary data in understanding the disease and it’s treatment, it is the medical anthropology perspective which considers the historical, social, political, and economic implications of the global health issue. On a more practical level, the medical anthropology perspective can offer ideas on solutions to the problem. As mentioned, extreme hunger presents itself as a root problem in this nation, and in order to understand how the HIV/AIDs epidemic should be handled, government and non governmental agencies need to consider the it’s close relationship to poverty and hunger. These agencies must first address what seems like such a basic issue (hunger) which could help to ultimately lead to a decrease in the prevalence of the disease in the nation.

Bibliography

1) http://onlinelibrary.wiley.com/doi/10.1111/j.1548-1387.2010.01109.x/full
2) WHO2012 Report

The Social Implications of Assisted Reproductive Technologies

The Social Implications of Assisted Reproductive Technologies

Introduction

One of the most rapidly evolving technologies in the realm of biomedicine is the broad category of new reproductive technologies. Over the past decades, new reproductive technologies have expanded across national borders. Yet this rise has also been accompanied by a wide array of social, legal, and ethical issues. In this essay, I will focus on a specific subcategory within NRTs called assisted reproductive technologies (ARTs). Through insights from an article about men’s experience of infertility and ARTs in the Middle East, I will examine the perceptions of those impacted by ARTs and their implications through a medical anthropology perspective. As ARTs are less based around a specific problem, but rather their ethical, societal, and political implications, I will lastly propose ways in which we should approach them as a society based on the insights offered through medical anthropology.

ARTs: A Bio-social Issue

Assisted reproductive technologies are the most visible and recognized of medical technologies according to Global Health Watch 3. Their origins can be traced to 1978, when the first in vitro fertilization (IVF) was performed (Inhorn 2008). According to the World Health Organization’s glossary of ART terminology, ARTs are defined as “all treatments or procedures that include the in vitro handling of both human oocytes and sperm or of embryos for the purpose of establishing a pregnancy. This includes, but is not limited to, in vitro fertilization and embryo transfer, gamete intrafallopian transfer, zygote intrafallopian transfer, tubal embryo transfer, gamete and embryo cryopreservation, oocyte and embryo donation, and gestational surrogacy.” Today, there is an entire industry based on ARTs. This has caused ethical problems and significant social impacts, however, particularly for women. Global Health Watch 3 asserts that the ART industry “has exploited the social pressures on women to have children. It claims to offer women new choices when in fact it increases the pressure on women to use these technologies, despite the high costs, poor success rates and risks to their health.” Global Health Watch 3 maximizes on the issues of third-party reproduction (surrogacy and gamete donation), which have become increasingly globalized as surrogates and reproductive body parts cross national boundaries. This raises even more ethical questions – can commercial surrogacy be a livelihood, especially for disadvantaged women? How do trade laws apply to the ART market? These concerns are reflective of the transnational commodification of bodies and reproductive technologies. Overall, the rise of ARTs has challenged traditional notions of birth and family structure in unprecedented ways.

The Male Experience of ARTs

The implications of the stigmas attached to male infertility in Egypt and Lebanon are the focus of the article I’ve chosen. In it, anthropologist Marcia C. Inhorn describes the findings from two of her studies which examine the experience of infertility of Middle Eastern men. She asserts that male infertility affects more than half of all cases of childlessness, yet is deeply hidden in many parts of the world. This is due to the associations of masculinity, virility, and paternity attached to being able to impregnate a woman. Inhorn’s methods for her most recent study involved interviewing 220 men of Lebanese, Syrian, and Lebanese-Palestinian men in two IVF clinics in central Beirut. Out of these, 120 were infertile cases, while the other 100 were fertile controls (in which infertility was attributed to the woman). The qualitative information gleaned from this study was also compared to her earlier study of infertility in Egypt conducted in similar fashion. Through interviews with these men, Inhorn explored how the stigmas attached to male infertility in the pronatalist societies of Egypt and Lebanon have caused male infertility to be surrounded by secrecy.

She proceeds to describe the perceived causes of infertility in Middle Eastern men, which are indicative of the social context in which it male infertility is situated. Inhorn notes that infertility in men is more prevalent and severe in the Middle East than in the United States and Western Europe, making up at least sixty to seventy percent of patients studied in the clinic. Among the Lebanese physicians she interviewed, the most common explanation for this was the genetic repercussions of the relative prevalence of interfamilial marriage, due to its preference in the Muslim religion. Infections, high caffeine and tobacco consumption, and environmental toxins from air pollution are other causes Inhorn notes as probable causes. However, the men themselves did not ascribe the cause of their infertility to their smoking, but to factors beyond their control, such as lack of nutrition, emotional stress, religious reasons, and the civil war in Lebanon, the last of which Inhorn states as the most commonly cited reason for male infertility among Lebanese men. There was also a common theme of infertility being “from God” among those who identified themselves as being religious. These suggested causes are illustrative of the men’s culture-specific perceptions of their condition.

Inhorn then expands on the social impact of the most promising ART for male infertility – introcytoplasmic sperm injection (ICSI). ICSI requires only one viable spermatozoon to be retrieved, which is then injected into the ovum directly to cause fertilization. For infertile Muslim men, this is the only option to have their own biological children, as Sunni practices prohibit the use of surrogates and third-party donation of gametes. There are strong cultural sentiments against donor sperm in particular, as men’s biological paternity is highly valued in Islamic beliefs. However, ICSI is not without its own repercussions in Muslim Lebanese culture. ICSI carries with it a stigma that it is sinful, or haram, as many assume that the process involves donor gametes. Thus, there are worries among couples considering the procedure that stigmas could surround their child if they were revealed to be produced through ICSI. Additionally, there are potential marital dilemmas that could occur as ICSI brings new possibilities. One such possibility is that among older married couples, husbands may feel the desire to divorce their wives, whose eggs have degenerated, and marry a younger woman in order to increase their chances of producing a child (Inhorn 2004). While Inhorn notes that the majority of couples she interviewed in IVF clinics were in stable marriages, she had also interviewed several 40-something women experiencing marital crises brought about by ICSI technology. As technologies such as ICSI are spreading in a globalized world, Inhorn calls for the need to understand the local cultural context in which these new reproductive technologies are being deployed, as they inevitably carry implications unique to the cultural context.

ARTs: A Medical Anthropology Perspective

                Medical anthropology lends much to the understanding of the larger impact of assisted reproductive technologies. ARTs are biomedical technologies, but at the same time have a strong influence on societal perceptions. ARTs are also deeply gendered, as there are separate technologies for men and women, each with their own stigmas and implications. This is not acknowledged by the Global Health Watch report, however, which discusses only women in its section on ARTs. It mentions the impact of surrogacy and egg retrieval on women, while the experiences of men are omitted entirely. This may be reflective of the general invisibility of male infertility in most societies – a process loosely connected to hegemony in that male infertility does not immediately come to mind when discussing infertility. In this case, men, associating fertility with the validating and empowering trait of masculinity exercise their control by hiding what is perceived as an emasculating condition. Another reason for the omission of male infertility may be the fact that women are put at greater risk through ARTs through egg-retrieval procedures and surrogacy, making it reasonable that the report should pay greater attention to concerns about this. Nevertheless, the report marginalizes the experiences of men with infertility by acting as if it does not exist, reinforcing the social invisibility of male infertility. Ethical, social, and cultural issues are present in ARTs for men as well, as demonstrated in the article, and must also be addressed in order to holistically approach the challenges to family structures and roles posed by ARTs.

                A concept that medical anthropology lends to illuminate the impact of ARTs is medicalization. ARTs have essentially medicalized infertility into a condition that requires treatment. Global Health Watch 3 states that language such as “right to parenthood” conflates parenthood with normalcy, presenting it as a state to be desired. This has increased pressures on infertile women to use biomedical technologies in order to have children. Medicalizing infertility, however, can also be a validation of experience. In the article on male infertility, Inhorn states that the medicalization of male infertility in Lebanon has normalized the condition of male infertility, making it “like any other medical condition.” Many Lebanese men in her study insisted that male infertility had nothing to do with manhood, in contrast to Egyptian men from an earlier study who had equated infertility with emasculation (Inhorn 2004). For them, medicalization of their condition was a validating experience that led to greater social acceptance in their cultural community. This emphasizes the understanding of ARTs as “liberating” technologies with significant social ramifications.

In relation to this, the concept of biopolitics offers another way to understand the influence of ARTs. By medicalizing infertility, industries which develop these technologies increase the pressure to use ARTs, as mentioned in Global Health Watch 3. The logical “solution” to being unable to have a child is now recourse to assisted reproductive technologies, rather than non-biomedical options such as adoption. Thus, a framing of the influence of ARTs can be that industries developing them seek to profit by compelling people to use their technologies.

Another concept that adds new understanding to ARTs is social representations. Social representations play a large part in the prevalence and reception of ARTs in that they determine whether or not these technologies will be accepted. Rachel Chapman’s article “Motherhood in Mozambique” shows how representations of pregnancy in a particular community influenced women’s health decisions (Chapman 2003). In the same way, infertility is socially represented as an emasculating condition in parts of Middle Eastern society, leading men to conceal their condition. A Lebanese physician is quoted in the article, “It’s a deficiency if you can’t have children. I do think people feel this. I would assume they do, because it’s a secret kind of thing, male infertility.” At the same time, medical knowledge and social representations shape each other in a cyclical relationship. We can view ARTs as both shaping and being shaped by social representations; ARTs influence perceptions about infertility, but are also responsive to current representations of infertility in society.

Through applying these medical anthropology concepts to the issue of ARTs, I now see that there is interconnectedness between them. I saw that medicalization can have both a “positive” or “negative” impact depending on the social context. In situations where the condition causes shame and confusion, medicalizing it can help society accept the condition as legitimate, which then makes it easier for individuals to accept it themselves. At the same time, industries producing biomedical technology can exert biopolitical power over individuals through medicalizing their condition, increasing the pressure to use their products. Thus, industries shape social perceptions of what is “normal” and what must be addressed biomedically, based on their own economic motives. This is an example of how medical knowledge and social perceptions continually shape each other. It is also demonstrative of how biopolitics influence social representations, as biopolitics help shape medical knowledge.

Practical Implications

                Now that the medical anthropology perspective of ARTs has been explored, we can examine the implications for how to approach assisted reproductive technologies. It is important to understand the medicalization of infertility through ARTs to keep it in perspective of larger social issues, as medicalizing infertility carries political, economic, and ethical implications. Because ARTs present infertility as a disease, it increases pressure on those who are unable to have a child by addressing it medically, which may turn couples away from non-biomedical options, such as adoption, to producing their own child through ARTs. This has led to a high demand for ARTs, spurring on the rapid development of new technologies. However, it is important to remember that these technologies benefit a relative few in a limited way, as only the socio-economic elite have access to them. Global Health Watch 3 suggests, “We must judge the value of the reproductive technologies in the context of the social, political, and economic setting…” Significant funds and resources are being put into the development and marketing of these technologies when life-saving health care technologies are still not available to many in the world. This raises questions of whether spending resources in areas that do not benefit those in the most need encroaches on their right to health. It may be wise to remember that infertility is a medicalized condition, one that should be kept in perspective of the greater issues plaguing those less privileged. Yet the use of ARTs is also driven by the social representations of infertility in each culture, as many perceive being able to have a child to be a rewarding or validating achievement. In any case, it is evident that ARTs will continue to have a large presence in the global economic and social stage.

Conclusion

                ARTs are at the same time biomedical and social technologies, offering new opportunities to both infertile men and women through medical technology. This is not without its effects on society, as we have seen how medicalization and social representations of infertility have substantial impacts on health decisions and perceptions. The Global Health Watch report’s omission of male infertility is illustrative of these forces at work, both demonstrating and reinforcing the social invisibility of male infertility by omitting it from its assessments. We have also seen in the article on male infertility in the Middle East that these forces interact on the local cultural level, where culture-specific perceptions play an important role in people’s notions of ARTs. ARTs are altogether socially complex technologies, given the wide array of perceptions surrounding infertility and parenthood in each culture. As the global use of assisted reproductive technologies will expand even further, we must continually be aware of the significant influence of ARTs in shaping societal perceptions of family, parenthood, and natural birth.

 

Bibliography

Chapman, Rachel. 2003. “Endangering safe motherhood in Mozambique: prenatal care as pregnancy risk.” Social Science & Medicine 57:355-374

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

Inhorn, Marcia. 2004. “Middle Eastern Masculinities in the Age of New Reproductive Technologies: Male Infertility and Stigma in Egypt and Lebanon.” Medical Anthropology Quarterly, New Series, 18: 162-82

Birenbaum-Carmeli and Marcia C. Inhorn. 2008. “Assisted Reproductive Technologies and Culture Change.” Annu. Rev. Anthropol 37:177-96

Zegers-Hogschild et al. 2009. “Glossary of ART Terminology.” World Health Organization. 

Neoliberalism in the American Health Care System

When first looking through the Global Health Watch Report 3 I was especially interested in the section discussing dysfunctional health systems. What I found to be so interesting was the fact that all of the three countries that were determined to have extremely flawed and dysfunctional health systems were countries that had strong roots in neoliberalism. Throughout the quarter there have been many videos and articles that reinforce the assertion that the policies of neoliberalism, despite what some may say, are direct barriers to the struggle for equitable quality care. The Global Health Watch Report 3 identified and examined the health care systems of three very powerful countries in depth: India, China, and the United States of America. I found it especially noteworthy that even though the United Sates is acknowledged by most to be the richest nation in the world it lags behind in health care. Even though the United States government has attempted to improve the American health care system the continued privatization of the health sector prevents any real lasting change.

  The problem India, China, and the United States have in common is that all these countries are allowing and even encouraging the use of neoliberal ideology as a basis for health care. In the United States Americans have seen that the proliferation of free market policies in health care has, over the last couple decades, failed to stem the rising costs of health care, and has resulted in extreme inequality in relation to access and treatment, and has disrupted the traditional patient-physician relationship. This issue is an important aspect of the social and cultural context of health, disease and healing in the United States. The shift to for-profit care has seriously altered the way health care is perceived and delivered. Evidence indicates that neoliberalism and the supposed goals of health care are incompatible. Health care deals with issues of individual trust and common good. Healing is supposed to be “a special kind of human activity governed by an ethic that serves those ends and not the self-interests of physicians, insurance plans, or investors” (Pellegrino, 1999:246). In the current American system of health care there is a constant battle between what is just and what is profitable, a battle in which what is just does not always take priority. The articles I read helped me to examine the dichotomy between what medicine is socially represented to be, a just system that prioritizes the best interests of the patient, and what it has become, an institution run much like a business that seeks to maximize profits. The articles also helped me better understand the system of knowledge production behind these social representations.

The article I drew the most information from was “Managed Care or Manage Inequality?” This article primarily discusses how managed care and the American health care system as a whole has become big business. It seeks to debunk the belief that privatization is compatible and even beneficial to health care needs. Instead the article, critiques the growing dominance of market-based medicine. It discusses how market-based medicine has not resulted in improved quality of care, lower costs, or improved equity in matters of access and outcomes. The article affirms that, “allowing market forces to dictate the shape of health care delivery in this country ensures that inequalities continue to grow.” The second article I read was titled “Wall Street and Health Care” and went into more detail on the economic history of how the American Health Care system became what it is today. This article also concluded that even though “market-driven healthcare” has often been advertised as the solution to the problems in the American health care system it has actually been shown to undercut the autonomy of physicians and the services given to patients.

 A medical anthropology perspective would frame this problem in terms of how Americans experience their health care system, as opposed to focusing on the inner workings and economics of the American health care system like the Global Health Watch 3 does. Medical anthropology would want examine more critically the underlying reasons why Americans have decided to apply neo-liberal ideologies to their health care system. A medical anthropologist would want to better understand why neoliberalism appeals to many Americans, both in terms of history and in terms of culture. A medical anthropologist would want to address how people experience illness and healing within the United States’ system of health care. Medical anthropology would be more concerned with examining the social structure of health and health care. Then, medical anthropology would want to scrutinize how different social groups are specifically affected by a market-based system of health care.

 One concept that clearly applies to this issue is the concept of neoliberalism. The articles primarily address the top-down definition of neoliberalism, which says that neoliberalism is a dominant policy-making rule set that represents a return to the free market liberalism of the 19^th century. In the United States it is especially evident that this rule set has come to dominate the way most issues are addressed. The second commandment of neoliberalism calls for the privatization of public services. In most other countries health care is considered a right and is offered as a public service. In the United States health care has become a commodity from which profit may be derived, in accordance to the commandments of neoliberalism. Neoliberalism is weaving its way deeper and deeper into the social fabric of the United States.

Another important aspect of this issue is the role of social representations. In the United States doctors are represented as the primary givers of care. Doctors are seen as care takers and people that can be trusted to act in the best interests of their patients. The fact is that in the current system of health care is a system in which doctors can also be businessmen acting in the interest of gaining money from drug and biotech companies, managed care organizations, or insurance companies. In addition, many people do not realize the extent of the power insurance companies and managed care organizations have to determine the type of care a patient is likely to receive. This relates directly to the issue of knowledge production. Why don’t people question the compatibility of business and health care? Even amid calls for reform to the American health care system legislation to expand the Medicare program to cover everyone and thereby establish a social insurance system was never considered. Instead, despite the reforms passed under the Obama administration, the American health care system will continue to run on a market-based system. The big businesses of health care and the lobbyist it employs have been able to mostly convince the American public that a market-based system of health care is what is most beneficial to all. This argument stems from the logic that privatizing forces companies to better serve their customers and employees; though in reality what privatizing does is force companies to maximize profits for their shareholders through any means possible.

Biopower, the governing of people through their bodies, is also medical anthropology concept that sheds light on an additional facet of this issue. Health care and the way in which it is administered is a direct example of biopower. Health care agencies have the power to determine how many times an individual may visit the doctor’s office, how easy it will be for him or her to access more than just primary care, and how affordable his or her medications will be. Until recently insurance companies were allowed to discriminate against people with pre-existing conditions and they are still allowed to charge women higher insurance rates. Fundamentally health care agencies have power over the bodies of all the people they serve and all the people they do not serve. This is an enormous amount of power to give to companies that are ultimately subjects to the will of the free market.  

 This article’s critique made me realize the value of deeply examining an issue using anthropological tools and terms. It also made me reflect on the downfall of continued support for neoliberal policies. Examining the issue of health care in the United States of America made me reflect more on the pervasiveness of biopower. It made me conclude that to live in society is to submit to biopower. Thinking about health care through the lens of biopower made me realize that as more neoliberal policies are put in place more biopower will be give to the free markets, and power that would usually be in the hands of government would go to big business. Examining this issue also made me think more critically about knowledge production and about its role in big business and government.

            From a practical perspective these articles convinced me that neoliberalism and the development of market-based health have created a system that does not prioritize the well being of its patients, but the bank accounts of its stockholders. I found that it would be useful for the United States government to employ medical anthropologists to critique the current system of health care and better determine what the role of markets should be in health care. There should be more transparency when it comes to issues of such great consequence. Citizens have a right to understand how their healthcare is being run and by whom. Reading this information on the American health care system has convinced me that if more people understood the inner workings and economics of this system more people would call for true reform.
            Neoliberalism can be dangerous when applied to systems that are supposed to serve the common good, since neoliberalism by design is meant to benefit only a select few. Governments should understand that neoliberalism fails to narrow gaps in inequality, and may in fact increase inequality. It is no coincidence that the three most dysfunctional health care systems the Global Health Watch 3 decided to focus on were from countries that are all products, in one way or another, of neoliberal policies.

Bibliography

Rylko-Bauer, B. and Farmer, P. (2002), Managed Care or Managed Inequality? A Call for Critiques of Market-Based Medicine. Medical Anthropology Quarterly, 16: 476–502. doi: 10.1525/maq.2002.16.4.476