Hospital Ethnography

Hospitals are designed as spaces of improvement. Yet an accumulation of infrastructural projects can lead over time to the emergence of a layered landscape made up of multiple incongruous planned spaces. This article focuses on Madang General Hospital in Papua New Guinea as one example of such a landscape. Here, deteriorating colonial buildings jostle against new gleaming constructions built with donor funds. The layered effect of the postcolonial landscape draws attention to enduring racial and class inequalities; the colonial past is rendered present in the buildings of the future. Drawing on recent work on affect in anthropology and cultural geography I argue that this landscape impresses affects of hope and disappointment on the people who inhabit it and shapes ambivalent attachments to national and state futures. This double movement of improvement and decay is analysed as a process of ruination that is intrinsic to modern spaces of improvement.

By building on the emerging anthropology of clinics in crisis, this chapter will explore how hospitals are observed and imagined to operate as sites which mirror and perpetuate the social segregations and structural inequalities associated with Shia-Sunni hostilities in Gilgit Town, the capital of northern Pakistan’s semi-autonomous Gilgit-Baltistan region. In so doing, I explore the complex ways that Shia and Sunni health infrastructures and the services they provide are mimetic and generative of broader forms of discord and conflict. The chapter first discusses the rise of sectarian hospitals in Gilgit Town, whereby medical services have come to operate as unique sites of Shia and Sunni sectarian capital formation; processes which draw their impetus from insecurity, violence and warfare. Then, through ethnographic case study analysis of the ‘Sunni’ Kashrote Government City Hospital, my analysis foregrounds how to an increasing and often exclusive degree, public sector hospitals have been socially, bureaucratically and politically configured as sectarian medical infrastructures, and addresses the contestations and concerns associated with this process. The chapter concludes with a discussion of the significance of sectarian medical infrastructures as dynamically heterotopic sites of experience, identity affirmation, and boundary-making. Through critical exploration of the ways that Shia and Sunni hospitals serve as spaces of sectarian inclusion and safety, or, inequity and exclusion, my research illuminates the diverse ways that health services in Gilgit Town have come to occupy a central role in Gilgitis’ political and sectarian imaginations.

L'articolo offre una panoramica della storia degli studi e degli aspetti teorico-metodologici dell'etnografia dell'ospedale, sulla base di tre numeri monografici dedicati ad essa nelle riviste “Social Science & Medicine” (2004),  “Anthropology and Medicine” (2008)  e “Journal of Contemporary Ethnography” (2008), che hanno segnato la ripresa del dibattito disciplinare dell'antropologia medica su questo proficuo ambito di ricerca.

Artists and novelists have rarely been considered as ethnographers in the medical social sciences. This article pursues the idea that ethnographically informed artistic works can be viewed as critical cultural texts alongside sociological and anthropological studies of surgery. It is proposed that art provides fresh perspectives on topics of interest in health sociology and medical anthropology while simultaneously expanding our engagement with ethnographic representation. Discussion revolves around a video installation incorporating images of heart surgery by contemporary artist Bill Viola and a recent novel by Ian McEwan detailing the day-in-the-life of a neurosurgeon. Considering an emerging re-engagement, particularly in contemporary art that artists are having with medical themes, and a concurrent `ethnographic turn' in art practice, it seems timely to recognize the potentially critical contribution of non-social scientist ethnographers to our understanding of a rapidly changing medical culture.

The hospital's ambiguous relationship to everyday social space has long been a central theme of hospital ethnography. Often, hospitals are presented either as isolated "islands" defined by biomedical regulation of space (and time) or as continuations and reflections of everyday social space that are very much a part of the "mainland." This polarization of the debate overlooks hospitals' paradoxical capacity to be simultaneously bounded and permeable, both sites of social control and spaces where alternative and transgressive social orders emerge and are contested. We suggest that Foucault's concept of heterotopia usefully captures the complex relationships between order and disorder, stability and instability that define the hospital as a modernist institution of knowledge, governance, and improvement. We expand Foucault's focus on the disciplinary, heterotopic qualities of the hospital to explore the heterotopia as a space of multiple orderings. These orderings are not only biomedical. Rather, hospitals are notable for the intensity and heterogeneity of the ongoing spatial ordering processes, both biomedical and other, that produce them. We outline an approach to heterotopias that traces the contingent configuration of hospital space through relationships between the physical environment, technologies, and persons, while simultaneously considering the kinds of spatial imaginings, hopes for the future, and emotional responses that are rendered possible by those configurations. We provide three thematic frameworks through which the heterotopic and contingent qualities of hospital spaces might be explored: boundary work, generating scale, and layered space.

Evoquant incontestablement le charme d’une distance sublimante, l’île semble toujours avoir attisé la curiosité du continent qui l’envisage, tour à tour, comme un fragment isolé, arraché du monde par des eaux belliqueuses, ou comme un microcosme autonome et utopique. Mais qu’en est-il du regard de l’ilien ? Partage-t-il cette vision polarisée, ou vient-il remettre en question un éloignement et un isolement inhérents à la perception continentale des îles, tout comme le suggère the sea of islands d’Epeli Hau’ofa? Que l’île exacerbe la distance ou la dissolve, cette thématique n’en reste pas moins centrale à toute discussion autour de l’iléité. Comment celle-ci se manifeste-t-elle dans une île française de l’Océan Indien à la fois DOM, RUP, postcoloniale, post-esclavagiste et postdépartementale, et dont les littératures ressassent de façon lancinante ou sporadique les topoï du malaise, de l’oubli et de la quête identitaire ? Du fait d’un contexte historique qui problématise la possibilité d’ancrage dans une île perçue comme un fardeau imposé par la traite, l’île de la Réunion se profile en effet dans les œuvres littéraires à la fois comme un lieu et un non-lieu.
A la lumière de l’hétérotopologie de Michel Foucault, nous nous proposons d’examiner le rapport qu’entretiennent l’île et l’îlien dans deux des cinq romans en français de l’auteur réunionnais Axel Gauvin : L’aimé (1990) et Cravate et fils (1996). Après avoir contextualisé notre étude, nous poursuivrons par l’analyse d’un espace-microcosme particulièrement révélateur de ce rapport : l’hôpital de Saint Denis, chef-lieu du département. Par inférence métonymique, nous verrons en quoi l’île devient ainsi la manifestation privilégiée d’un espace hétérotopique entre lieu et non-lieu.

This course provides an interdisciplinary sociological and anthropological exploration of medical systems, with a special emphasis on Canadian healthcare. By adopting critical social science approaches to explore healthcare services and health, illness and well-being at individual and societal levels, students will gain an in-depth understanding of the social determinants of health, and the role played by medical systems in remedying or even worsening population health disparities and inequalities.

The first half of the course explores the evolution and recent history of Canada’s medical systems, with attention paid to the development, policy and operations of Medicare. We will then discuss the contribution of religious healing and complementary and alternative medical systems for Canadians’ sense of wellbeing and their health and healing practices. The second half of the course will introduce and critically evaluate the beliefs that shape the social acceptability and provision of particular medical services, inform health decision-making, access and use, animate provider-patient interactions and treatment processes, and determine outcomes. In the area of medical systems research and theory, special attention will be paid to the social construction of health, illness and medical knowledge, biomedical hegemony and its effects for medical pluralism, and the hierarchies, politics and ethical challenges associated with medical service provision. Then, in order to emphasize the diverse ways that clinical medicine is subjectively understood and experienced, the course will draw on an innovative array of ethnographic studies of health, healing and healthcare systems, and those that prioritize patients’ and providers’ points of view in particular.

With regard to patients’ navigation and experience of these same systems, the course will assess how the social determinants of health - such as how they concern economic standing, gender, ethnicity, and race - impact health at individual and societal levels. Efforts will also be made to identify the health inequities, deprivations and disadvantages that are over-distributed among and experienced by First Nations, Inuit and Métis, ethnic minority and LGBTQ+ communities. As importantly, the course will investigate how health beliefs, experiences, practices and even medical ethics are shaped and conveyed by culturally specific illness representations, treatment accounts, and narratives.

Throughout the course, attention will be paid to the ways the aforementioned issues intersect with the COVID-19 pandemic.

In questo articolo viene descritta un’indagine etnografica svolta da Helle Johannessen (University of Southern Denmark) sull’uso della medicina complementare e alternativa in oncologia, alla quale l’Autrice prese parte in qualità di assistente di ricerca. Attraverso la lettura retrospettiva di due Day Hospital oncologici viene presentato un esempio di “etnografia dell’ospedale”, le cui coordinate teoricometodologiche costituiscono il retroterra di una riflessione sulle implicazioni del posizionamento del ricercatore all’interno di un reparto, rispetto agli altri soggetti
presenti. Ad essere discussa qui è l’opzione metodologica basata sull’assimilazione del ricercatore ad una compagine sanitaria da una prospettiva resa peculiare dal fatto che, in questo caso, tale condizione non derivava da una scelta calibrata sulle
esigenze della ricerca, e anzi in parte contraddiceva gli intenti etnografici inizialmente
ponderati. L’articolo esplora le modalità attraverso le quali l’ambiguità
promanata dal camice bianco ha indotto una marginalizzazione delle relazioni interpersonali con i soggetti cui era rivolto l’interesse analitico primario, i pazienti oncologici, esemplificando una delle difficoltà che possono annidarsi dietro tale posizionamento. La descrizione delle strategie adottate per fronteggiare i problemi di metodo che ne sono scaturiti non si risolve in una semplice azione di distanziamento
dall’istituzione biomedica, ma si fa testimonianza dell’esistenza di meccanismi disciplinanti che l’autorità medica ha proiettato sull’impianto globale della ricerca, in forme spesso non palesi ma efficaci, le quali assurgono a loro volta a degno
oggetto di indagine.

Medical anthropology involves up-close, person-centered, and ethically engaged examination of the complex cultural dynamics that underpin and give rise not only to health and wellbeing, illness and death, but also the medical systems on which we rely for treatment and cure. This introductory course will first discuss the history and development of medical anthropology as a sub-discipline of sociocultural anthropology. We will briefly explore the multiple directions that medical anthropology
has taken since its inception, and the interdisciplinary approaches, concepts, and theories so central to contemporary anthropologists’ research, outreach, and activism. We will also discuss the field-based
methods used by medical anthropologists – and ethnographers in particular – to investigate how cultural forces shape issues of health, illness, and medicine.

The course will next focus on recent theoretical and ethnographic developments, such as the evolution of meaning-centered and critical medical anthropology approaches. Special attention will be paid to
anthropologists’ efforts to explore how bodies, health and illness, and also medical services and systems are at the nexus of – and bear the effects of - intersecting neoliberal and capitalistic forces. In addressing the ways that social, political, and economic systems give rise to health (in)equity and (in)justice, we will gain insights to the socially important and applied ways that ethnography pulls into view otherwise obscured or invisible experiences, and the forms of suffering and signs of hope these entail. To this end, we will work together to review critical theories and ethnographic case studies of health and medicine in North America and around the world.

The novel coronavirus is profoundly impacting population health and welfare across the globe, forcing patients, medical providers, and healthcare systems to find ways to rapidly adjust to COVID-19’s complex risks and constraints. The crisis has led to especially severe effects and outcomes for vulnerable persons and healthcare systems.

Women’s sexual and reproductive (SRH) and maternal and newborn (MNH) health, already badly impacted by inattention and disinvestment in many parts of the world, are now even more dangerously deprioritzed and neglected due to the effects of social distancing, lockdowns, and overloaded health systems. Equally worrying is the growing evidence that women in better-resourced settings such as the United States are now also facing similar gaps in care, and are more likely to experience the pandemic-linked health hazards and harms that result.

With many of COVID-19’s short and long-term effects for SRH/MNH still poorly understood, medical anthropologists are uniquely positioned to help fill in the gaps and answer emerging questions about the pandemic’s impacts on women’s health and healthcare services and systems. Not least, our work holds the power to raise necessary attention concerning social, political, and organizational efforts to protect women and newborns from the worst of the pandemic, especially those made most vulnerable by the crisis.

In this spirit, the first and second rounds of our online special collection gathered together the work of medical anthropologists whose research, advocacy and activism concern COVID-19’s impacts on SRH/MNH.

By adopting critical and action-oriented approaches, the contributors provide compelling insights into the contextual forces and dynamics at stake in health system and community-level responses to the pandemic as they draw women and their newborns closer to care, further estrange them from the services they need, or, under the pretext of protocol adherence and risk-reduction, separate babies from their mothers. More than this, they show how the pandemic’s challenges are variably experienced, with different cultural, political and geographic sites giving rise to unique forms of need and vulnerability. We see that women of color, those with lower socioeconomic status, and those in under-resourced settings face some of the most challenging circumstances every day, but especially in these times. Their already reduced access to healthcare services is amplified and reinforced by limited access to privilege that would allow them to access alternative care or forms of support.

Neste artigo, objetivo tecer uma etnografia da vida social de morado- res permanentes de um hospital psiquiátrico, espírita e asilar, a fim de compreender, no devir institucional, algumas formas particulares de viver e experimentar a institucionalização. Busco observar vivências que subsistem à rotina comum obrigatória para identificar a possível presença de auto-organizações daqueles que vivem o/no local insti- tucional. A ala escolhida dentro de um hospital localizado no interior do estado de São Paulo foi o “Lar Abrigado”, um anexo que possui seis casas e, atualmente, abriga vinte e um moradores. Optei por esta ala porque nela vivem moradores permanentes que, devido ao longo pe- ríodo de internação, têm pouco ou nenhum contato com familiares ou outros responsáveis e, por este motivo, mesmo após os proces- sos de reforma psiquiátrica, continuam a habitar o Hospital de forma permanente. O trabalho etnográfico naquele ambiente começou em 2016, mas os dados trazidos nesta pesquisa foram refletidos após um intenso convívio no mesmo ambiente por 90 dias seguidos, em 2018.

Anthropologists studying voluntary-anonymous systems of blood donation have noted the ways in which they facilitate imaginings of national relatedness and integration. This paper focuses on family replacement systems in Papua New Guinea, where blood donated by a patient's relative replaces the units taken from the bank, in order to examine what kinds of relational imaginings are possible when blood is transacted between people who know one another. Patients in Madang Hospital are led to believe that it is their responsibility to obtain blood donations from their relatives within a kinship obligation system. However, articulations of kinship exchange with a biomedical blood economy are not as straightforward as hospital workers suggest. Instead the hospital emerges as a crucial, but hidden, mediator in these transactions. Doctors conceal from patients the fact that blood group incompatibilities mean blood intended for a specific person may be redirected elsewhere. The obviation of this 'biomedical technology' thus enables the hospital to harness patients' 'relational technologies' of gift exchange to feed the institution's blood economy. In contrast to anthropologists' common focus on blood donation, here attention is drawn to the role of recipients in negotiating different regimes of extraction.

The Anthropology of Global Public Health represents a critical, interdisciplinary, and applied sub-discipline of Sociocultural and Medical Anthropology. Broadly speaking, Global Public Health is defined as an area of research and practice that is focused on improving issues of health and health equity. Global Public Health practices, policies, and interventions are increasingly characterized by transcultural and transnational approaches, which emphasize the social determinants of health experienced by peoples from diverse backgrounds, and respond to the specific needs of local
populations, healthcare settings, and therapeutic traditions.

In turn, the scholarly and engaged Anthropology of Global Public Health occurs at the intersection of the Social Sciences, Medicine, Public Health, and Health Studies. Anthropologists’ work is informed by the concepts, analytical frameworks, and issues associated with Development, Globalization, International Relations, and Conflict Studies. This course will provide students with a comprehensive overview of Anthropological research on Global Public Health with a special focus on the Global South. Critical attention will be paid to roles played by governments, neoliberal policies and reforms, and nongovernmental interventions in shaping Global Public Health and its efforts to reduce health disparities, inequalities, and morbidity and mortality rates.

Oxytocin, a uterotonic that works to induce labor, expedite delivery, and reduce post-partum hemorrhage, has in recent decades become a key component of Pakistan’s public health sector’s arsenal of essential drugs. Despite ample proof of oxytocin’s life-saving properties, there is growing global evidence of its increasingly widespread counter-protocol uses, and the life-threatening complications these produce. With the literature for South Asia predominantly focused on the ways that its misuse results from the knowledge and practice deficits typical of untrained or low-skilled birth attendants working at the community level, we know far less about oxytocin’s misapplications by skilled providers in hospital settings. Through ethnography of oxytocin’s actual uses in government hospitals in northern Pakistan, my paper attempts to correct this gap, and explores the drug’s non-medical advantages and sometimes-dire medical disadvantages. By analyzing its correlations with uterine rupture, post-partum hemorrhage, and birth asphyxia, for instance, my research may explain why high local rates of obstetric injury, illness, and death persist even despite Gilgiti women’s near-total recourse to hospitals for labor and delivery. Equally, in considering oxytocin’s use against the backdrop of the hospital and its shortfalls, my paper confirms that non-medical or medically inappropriate forms of oxytocin use were neither isolated nor unusual clinical events, but quotidian extensions of the structural violence inherent to Pakistan’s public health services.

Drawing on historical and ethnographic research conducted in Intensive Care Unit (ICU) in Latvia, this paper seeks to examine the nature of healthcare workers' (HCW) compliance with handwashing guidelines. Although it is a cornerstone of good infection control practice and defines patient wellbeing, the rate of such compliance is rather low. Surveillance environment which is used as the main tool for ensuring compliance creates feeling of anxiety and oppression. Therefore healthcare workers see handwashing requirements as a part of hierarchical power struggle rather than a part of good infection control practice and patient wellbeing. In this paper it is argued that refusal to wash hands is not due to lack of education, time or wish to care but a conscious resistance strategy.

Anthropological and STS scholars of biomedical work have traditionally explored contexts where inconsistencies and lacunas in diagnostic knowledge production are fundamentally problematic for medical practitioners and have consequently focused on the social and political processes by which such epistemic uncertainties are resolved. This article draws on ethnographic material from a Papua New Guinean hospital where diagnostic uncertainty is not rendered problematic and where the open-endedness of the diagnostic process gives rise to new forms of medical expertise and practice. The paper focuses on the medical record as an artefact of not-knowing that both documents and performs uncertainty as a valuable resource. It shows that medical records can operate as either technologies of 'opening' that multiply opportunities for pragmatic action within a hospital space or as technologies of 'closure' that move people and documents between spaces. Practices of not-knowing and knowing are therefore shown to be interdependent and interchangeable 'moments' of bureaucratic-biomedical work.

Following three decades of international financial institutions implementing austerity measures in sub-Saharan Africa, many health systems remain chronically underfinanced. During this period, countries like Tanzania have moved from a post-independence vision of a strong social sector providing free care for citizens, to a model of increased privatization of public health facilities, shifting the burden of self-financing to individual health facilities and the constituents they serve. Drawing on longitudinal ethnographic research and document analysis undertaken between 2008 and 2017 within three publicly-funded hospitals in north-central Tanzania, this article examines the actions and perspectives of administrators to explore how novel shifts towards semi-privatization of public facilities are perceived as taken-for-granted solutions to funding shortfalls. Specifically, hospital administrators used "side hustle" strategies of projectification and market-based income generating activities to narrow the gap between inadequate state financing and necessary recurrent expenditures. Examples from publicly-funded hospitals in Tanzania demonstrate that employing side hustles to address funding conundrums derives from perverse incentives: while these strategies are supposed to generate revenues to sustain or bolster services to poor clients, in practice these market-based approaches erode the ability of publicly-funded hospitals to meet their obligations to the poorest. These cases show that neoliberal ideas promoting health financing through public-private initiatives offer little opportunity in practice for strengthening health systems in low income countries, undermining those health systems' ability to achieve the goal of universal health care.

Drawing on the work of Ivan Illich, our special issue reanimates iatrogenesis as a vital concept for the social sciences of medicine. It calls for medicine to expand its engagement of the injustices that unfold from clinical processes, practices, and protocols into patient lifeworlds and subjectivities beyond the clinic. The capacious view of iatrogenesis revealed by this special issue collection affords fuller and more heterogeneous insights on iatrogenesis that does not limit it to medical explanations alone, nor locate harm in singular points in time. These papers attend to iatrogenesis’ immediate and lingering presences in socialities and structures within and beyond medicine, and the ways it reflects or reproduces the racism, sexism, and ableism built into medical logics.

In the past 20 years, the hospital has become a privileged field site for medical anthropologists. But what is a hospital? Is it only an architectural formation that allows for the practice of contemporary biomedicine? A space permeable and clearly delimited, structured and open, unpredictable and opaque, medical and non-medical, the modern hospital constantly undergoes rapid technological and economic change. It harbours the traces of past medicines and produces memories and emotions for those who have resided, worked there or supported close ones undergoing treatment and care. This special issue approaches the research object « hospital » by linking specific hospital places to the professional practices exercised in its realms, be they medical, nursing, bureaucratic or managerial. Taken together, the contributions incite to study hospitals not only as ethnographic field sites, but also as singular anthropological locations, in order to understand how each hospital exists in its particularity – for patients, professionals and families – and how it arranges medicine and care. In the degree that we detach our ethnographic view from the problems specific to hospital medicine, it becomes possible to apprehend the productions and proprieties of hospitals as such.

In Gilgit, capital of the Gilgit-Baltistan region in northern Pakistan, leucorrhea - vaginal discharge known in the vernacular as safaid pani, or 'white water' - serves as both a medical diagnosis and signifier of the chronicity of the reproductive, social, and emotional burdens endured by women. While ethnomedical providers explained safaid pani as resulting from relatively benign forms of 'weakness', which required minimal dietary or ethno-botanical recourse, allopathic physicians approached discharge as evidence of numerous pathologies that necessitated protracted and sometimes also expensive treatments. Physicians' clinical assessments were not solely biomedical, but also integrated informal folk and formal ethnomedical theories of causation. Clinical diagnoses that affirmed leucorrhea as a pathophysiology substantiated women's belief that it was proof of the destructive effects of sustained social inequity, peril, and distress on the body, and the uterus in particular. Women and their treating providers recognized the power of the (dys)functional uterus to not only threaten women's reproductive wellness but also their social, marital, and familial status, which hinged on their ability to become pregnant and give birth, to sons especially. Because of the ailing uterus's expansive importance, weeping wombs served as a potent source for women's claims making and calls for attention and care.

Through the medium of a hospital ethnography, this paper explores the debilitating impacts of the 2010 monsoon floods on Gilgit-Baltistan's public health sector, and interrogates how its escalating harms coalesced with long-standing state neglects to generate medical precarity and loss, and spark debate concerning Pakistan's responsiveness and commitments to this politically marginalized and remote region. In Gilgit Town, the region's administrative capital, the state's failure to adequately prepare for and offset the floods' direct and indirect effects had catastrophic consequences for public sector hospitals, where healthcare providers worked without sufficient resources, treatment options were greatly diminished, and patients experienced significantly higher risks and worsened health outcomes. In providing ethnographic snapshots of the ways that the floods and disaster-related governance gaps shaped service provision at the region's primary referral hospital, the paper centralizes healthcare providers' accounts of the inadequacy of Pakistan's response to the crisis, and their claims that the state's failure to protect them from the floods' worst effects was symptomatic of its historic lack of care for Gilgit-Baltistan and its peoples.

Using data collected over nearly three years of ethnographic fieldwork in the Gilgit-Baltistan region of northern Pakistan, my paper explores hospital spaces, clinical services and treatment encounters as conduits for the expression and propagation of conflictive Shia-Sunni sectarianism. Where my prior research has investigated the political etiologies (Hamdy in Am Ethnol 35(4):553-569, 2008) associated with Gilgiti women's experiences of childbirth during 'tensions', as Shia-Sunni hostilities are locally known, this paper focuses on healthcare providers' professional and personal navigations of an episode of conflict whose epicentre was at the District Headquarter Hospital, Gilgit-Baltistan's foremost government hospital. Through critical evaluation of the impacts of Shia-Sunni tensions on the social, administrative and clinical practices and consequences of medicine, my paper analyses the complex ways that clinics in crisis serve as zones of contact (Pratt in Profession 91:33-40, 1991) and abandonment (Biehl in Soc Text 68(19):131-149, 2001; Subjectivity: ethnographic investigations, 2007), in which neglect and harm are directed along lines of sectarian affiliation to produce vulnerability, spectacular violence and death for healthcare providers and patients.

What and where is ethics in gene therapy? Historical debates have identified a set of ethical issues with the field, and current regulatory systems presume a discrete ethics that can be achieved or protected. Resisting attempts at demarcation or resolution, we use the notions of “ordinary” or “everyday” ethics to develop a better understanding of the complexities of experimental gene therapy for patients, families, and practitioners and create richer imaginings of ethics in the gene therapy sphere. Drawing on ethnographic research in several clinical trials, we show that patients/parents can acquire some control in difficult medical situations, and practitioners can attune their care to their patients’ needs. The human provenance of gene therapy practice, and the irreducible sociality of ethics, means that understanding the ethics of this medical field also requires understanding the everyday worlds and relationships of those at its heart.

As I write this review, I keep the fanning pages of Tom Rice’s wonderful book, Hearing and the Hospital, open with my old stethoscope. It’s looking a little tatty now, my stethoscope that is. The smooth plastic tubing (carefully chosen burgundy) has started to wear away, leaving black marks and grimy dust collects in available crevices. These are traces of hospitals past and medical work in a previous career. As Rice discusses in his book, the stethoscope can become for medical students and doctors an autobiographical object, around which memories and associations are made, turning into “a storied instrument” (p89) ...

In this introduction to the special issue, we follow the journey of global AIDS medicines into diverse health facilities in East Africa, which for decades have been subjected to neoliberal reform processes and increasing fragmentation. The introduction explores the multifaceted and multidirectional connections between global processes and their manifold articulations and experiences “on the ground.” We sketch how individuals, families, and communities dealt with HIV/AIDS-related illness and death before the scale-up of life-prolonging antiretroviral therapy programs, and describe the global policy processes that led to an influx of large volumes of donor support for AIDS treatment programs. We argue that global AIDS medicines have caused dramatic changes in institutional set-ups and care practices. The pharmaceutical medicines travel to the local health care settings with “baggage”: protocols and guidelines on who to treat and why, with strict guidelines on how to ensure adherence; and new notions of responsible and therapeutic citizens. This special issue elucidates the frictions, negotiations, and ambiguities that have shaped the incorporation of global AIDS medicines in local healthcare settings.

In the last few decades infrastructures have become increasingly visible in the social sciences, following a much longer engagement by historians. Recent anthropological work on infrastructure often adopts a practice-orientated approach, which focuses on the ways in which they are shaped through entangled material and social relations. In this paper I argue that such an approach can be strengthened by attention to the sensory and imaginative dimensions of infrastructure, which helps to articulate the vibrancy and fragility of such sociomaterial assemblages. I do so in order to suggest new methodological directions for the history of infrastructure. In order to illustrate my argument I use the case study of an infrastructure which once existed through large technical systems under city streets, and now is constructed on much smaller scales in buildings such as hospitals; pneumatic tube systems. Pneumatic tube systems highlight the durability of infrastructures over time. They are used nowadays to move materials which cannot be uploaded, scanned or printed; materials which come with traces of the personal, whether this is a piece of human tissue or trash. Following the practices of pneumatic tube systems ethnographically highlights the multisensory nature of infrastructures, which refuse to stay buried and quiet. Focusing particularly on sound, I look at examples of how sounds and listening practices signal infrastructures working smoothly as well as moments of breakdown and blockage. Working with infrastructures entails sonic skills, which becomes part of professional practice. I suggest that as well as making infrastructures more visible in our historical and anthropological engagements, we should also make them more audible. Often we tend to attribute sensory qualities to nature rather than technologies. Attending to the sensory dimensions of infrastructure however helps to understand more about their temporality and affects, which forwards our understanding of the role of infrastructural technologies in the modernization of society. In making this methodological plea, I suggest that sensory methods have as much relevance for historical studies as for the social sciences where they are more commonly used, and that both anthropology and history can learn from working closely alongside each other in their studies of the infrastructural arrangements of social life.

Using data collected over nearly three years of ethnographic fieldwork in the Gilgit-Baltistan region of northern Pakistan, my paper explores hospital spaces, clinical services and treatment encounters as conduits for the expression and propagation of conflictive Shia-Sunni sectarianism. Where my prior research has investigated the political etiologies (Hamdy in Am Ethnol 35(4):553–569, 2008) associated with Gilgiti women’s experiences of childbirth during ‘tensions’, as Shia-Sunni hostilities are locally known, this paper focuses on healthcare providers’ professional and personal navigations of an episode of conflict whose epicentre was at the District Headquarter Hospital, Gilgit-Baltistan’s foremost government hospital. Through critical evaluation of the impacts of Shia-Sunni tensions on the social, administrative and clinical practices and consequences of medicine, my paper analyses the complex ways that clinics in crisis serve as zones of contact (Pratt in Profession 91:33–40, 1991) and abandonment (Biehl in Soc Text 68(19):131–149, 2001; Subjectivity: ethnographic investigations, 2007), in which neglect and harm are directed along lines of sectarian affiliation to produce vulnerability, spectacular violence and death for healthcare providers and patients.

In their studies of doctors and hospitals, ethnographers have shown that medicine is practiced in local contexts. They have not, however, fully explored the processes involved when medical practitioners move between clinical settings. This article contributes to the study of medical work by looking at the adjustments international medical graduates must make to practice in Australian hospitals. These doctors are interesting to study ethnographically because, like many skilled migrants, they encounter workplaces similar, and simultaneously unfamiliar, to those they have known before. Drawing on the work of Merleau-Ponty, I develop the concept of “adjustment” as a movement between habit and the moment. My findings reveal how adjustment is both discursive and bodily, tied up with status and performance. Also, by focusing on the adjustments of migrant doctors, my study highlights the taken-for-granted aspects of medical practice and the environmentally situated nature of medical work.

This paper contributes to studies of healthcare worker migration and, more broadly, to the study of occupational adjustment, with an analysis of finely detailed sensorial data. It focuses upon doctors, who are increasingly on the move around the world, working in hospital environments different from those in which they have trained. A number of unexamined questions remain in relation to how medical practitioners shift their work across contexts, in particular the tactile nature of adjustment, which has been under-explored in health sociology. This paper examines a procedural skill; a skill in which tools have become almost natural extensions of the doctor’s hands. It focuses upon what happens when doctors travel overseas and find unfamiliar equipment, and their habitual practice is interrupted. The paper argues that by studying overseas doctors’ bodily adjustment during such moments of mismatch, we learn more about the environment of the doctors’ past and present. It suggests that by looking at the rupture between habit and the unfamiliar, we also understand something about the ways in which we adjust to the unexpected.

In Gilgit, capital of the Gilgit-Baltistan region in northern Pakistan, leucorrhea -- vaginal discharge known in the vernacular as safaid pani, or 'white water' -- serves as both a medical diagnosis and signifier of the chronicity of the reproductive, social, and emotional burdens endured by women. While ethnomedical providers explained safaid pani as resulting from relatively benign forms of 'weakness' , which required minimal dietary or ethno-botanical recourse, allopathic physicians approached discharge as evidence of numerous pathologies that necessitated protracted and sometimes also expensive treatments. Physicians' clinical assessments were not solely biomedical, but also integrated informal folk and formal ethnomedical theories of causation. Clinical diagnoses that affirmed leucorrhea as a pathophysiology substantiated women's belief that it was proof of the destructive effects of sustained social inequity, peril, and distress on the body, and the uterus in particular. Women and their treating providers recognized the power of the (dys)functional uterus to not only threaten women's reproductive wellness but also their social, marital, and familial status, which hinged on their ability to become pregnant and give birth, to sons especially. Because of the ailing uterus's expansive importance, weeping wombs served as a potent source for women's claims making and calls for attention and care.

Drawing on fieldwork undertaken between 2004 and 2013 in Gilgit Town, the multi-sectarian capital of the Gilgit-Baltistan region of northern Pakistan, this brief explores how, even while they work under the aegis of a “avowedly nondenominational” (Miller 2015: 4; see Khan 2010: 66), “non-communal” (AKRSP 1990: 3) Muslim humanitarianism that professes to uplift and protect insaaniyat – or, humanity itself – philanthropic actors can sometimes engage instead in practices that differentiate and exclude prospective beneficiaries on the basis of sect.

Healthcare providers on the maternity ward utilize the partograph, meant to track women's labor progress until delivery, in a plethora of ways that diverge from or even undermine the intended purposes of the document. This talk discusses the ways in which providers used the document to accomplish diverse ends.

The large number of international medical graduates (IMGs) working in Australia, and many other countries around the world, have received significant attention from the media, governments and academia. These institutions utilise a number of classificatory schemes in order to categorise IMGs. Such classification is often stigmatising, yet goes largely unquestioned. In this paper I show that the ‘official naming’ of IMGs in Australia, as well as the naming of IMGs by staff in hospitals, is historically, politically and socially produced. Following Bourdieu's call to also study how the classified classify, the paper goes on to examine ways in which IMGs name and categorise each other, drawing on ethnographic research. I argue that IMGs use classification themselves, strategically, in order to modify their marginalised position within the ‘social space’ of the hospital. The article questions taken for granted assumptions about classified groups such as IMGs and leaves an opening for change.

Many doctors migrate to find work opportunities elsewhere. Before being allowed to practice, these doctors, commonly referred to as International Medical Graduates (IMGs), must gain local registration, which can take considerable time. During this process many IMGs linger on the margins of hospitals, without medical employment. We follow this understudied group of IMGs in Melbourne, Australia, to understand their life on the margins of medicine. This takes us into hospital places on the fringes of clinical activity: a cafeteria, tutorial room and hospital library. We argue that these places are important for the doctors in retaining and strengthening their sense of professional identity in precarious circumstances. The IMGs find creative ways to inhabit familiar settings, creating their own pathways, to find their way into the local medical system. This analysis is in contrast to more common Foucauldian interpretations of hospitals that present the institution as having a structured, disciplining effect on its inhabitants.

Until recently in South Korea, the central dilemma facing children with ageing parents was how and by whom their parents should be cared for. In accordance with the norm of filial piety, the eldest son used to take responsibility. However, with the recent proliferation of long-term care hospitals, this arrangement is changing. These institutions, which play the combined role of rehabilitative hospital, long-term care centre, and nursing home, admit elderly people who do not require active medical intervention. The government's promotion of these hospitals, centred on deregulation, ambiguity around their function, and the lack of alternative care facilities, has led to an expansion of the sector and consequently to the 'nursing hom(e)fication' of many of these institutions. While these hospitals ease the pressures associated with an ageing population, their mainstreaming has had an impact on healthcare, medicine, and the lives of elderly people. The hospital field has become commercialised, medical practice is being transformed, and the dignity of elderly people is being lost through hospitalisation. In this new care regime, filial piety itself is undergoing transformation-from an ideology underpinning the domestication of care, to the market idiom of service compliance. In this article, I introduce these hospitals and investigate how their growth has brought about a Korean style of elderly care commodification, revealing the undercurrents of healthcare privatisation and the neoliberalisation of welfare.

thearticlepresentsanethnographyofthesociallifeofpermanentresidentsinternedinaSpiritistpsy- chiatric hospital in the interior of the State of São paulo (Brazil), focussing their participation in a “healing ritual” known as passe. it describes the ways of living and sociabilities that emerge in a compulsory daily routine, in order to identify agency and expressions of subjectivities and desires. although they are in a hospital wing composed of individual residences, institutionalisation is a major characteristic of their lives, such that their histories often inter- twine with a life in institutions. their residential life is marked by a compulsory religious and medical routine that imposes a moral order on their actions. through ethnographic research, we seek to understand their social practices that diverge from the normative order imposed by the hospital routine of enforced medications and participation in the Spiritist healing ritual of the passe. rather than engaging in the ritual performance, these long-term residents resist through the enactment of alternative goals and desires. long-term institutional experience and excessive medication contribute to other subjectivities and goals within the walls of the institution and its mandatory rituals.

This paper examines the emotional labor performed by researchers when undertaking ethnographic research in hospitals. Drawing on emotion work theory to situate emotions at the center of qualitative and interdisciplinary research, I provide a methodological reflection based on a 20-week long ethnography at a Canadian pediatric hospital I conducted in the context of a research project examining risk communication of antimicrobial resistance. I argue that the emotional labor in which hospital ethnographers engage starts long before the fieldwork and carries on throughout the project and into the data analysis and writing of results. I divide these instances of emotional labor into four categories: gaining and maintaining access to the field site, resolving ethical concerns, managing relations with participants, and witnessing human suffering. This paper addresses a gap in the literature regarding the various barriers that hospital ethnographers encounter as I reflect upon the challenges I faced and the emotional labor I intuitively engaged in and provide advice for researchers on how to navigate these barriers.

The 1996 Health Care Consent Act of Ontario (Canada) is a law that regulates medical decision making. Therefore, it also gives indications on how end of life decisions should be made. The goal of the law was to ensure and protect patient's autonomy and avoid medical paternalism, especially at the end of life. Throughout this article, I would like to argue that one of the consequences of the 1996 Health Care Consent Act of Ontario is to promote individualism. Therefore, this law makes it improbable to attain a shared decision model. More specifically, the way the 1996 Health Care Consent Act is currently written, a proxy is assigned as a decision-maker for someone who is deemed incompetent. However, it also ensures that the proxy will be the only one with the burden of that decision. This argument will be supported by providing a qualitative description of three cases that I have encountered during my six-month fieldwork in the Intensive Care Unit (ICU) of a hospital located in Ontario. This paper offers a reflection upon the consequences of using an alternative decision maker (proxy) to withdraw life support.

In Balochistan, Pakistan, hospitals are not the desired location for childbirth, but an affective economy of obstetric care, deceit, and clinical tactics of control has emerged, redirecting women away from midwives toward biomedical obstetrics. This economy manifests in forms such as coercing expectant mothers to deliver in the clinic rather than the home by generating fear in them and their kin through a narrative of imminent maternal and child harm. Drawing from ethnographic research, I show why Baloch midwives’ ethical expertise and affective responses to iatrogenically induced emergencies haunt the postcolonial state and constrain biomedicine’s haunting expectations of hospital/clinical births.

This article explores collaborative aspects of clinical decision-making, based on a focused ethnography and video recordings of meetings in clinical practices in two wards for gastro-intestinal diseases at the surgical department of a large Norwegian university hospital. By studying clinicians' communication during patient introduction, handling uncertainties and surprises, collecting information, and negotiating acceptance, we elaborate on how collaborative teamwork in the hospital ward is developed. Further, by drawing on detailed studies of meetings, in which patients are not physically represented, we explore ways in which a 'collective clinical gaze' of each patient is constructed on the basis of documents, memory , and a consensus-directed discussion among cli-nicians who are present. Although electronic patient record systems and the like are expected to produce firm bases for clinical decision-making, our analysis suggests that more emphasis should be put on how clinicians in their daily practice establish collectively based validity of any decision being made.

Internationally, healthcare has been intensively privatised and commercialised over the past three decades. Medical tourism has emerged in this context as an economic development strategy for many developing nations, and provisional remedy for patients in developed countries facing rising costs and long waiting periods to access healthcare at home. This study is based in India and is predominantly ethnographic. As such, it is grounded in local realities, with a close eye to how everyday interactions and actions are shaped by significant global interconnections. The research findings have been directly shaped by the daily interactions of living and studying the footprint of medical tourism in five private hospitals in Mumbai, the city itself and, the wider nation of India.The study offers a microcosmic view of broader economic patterns occurring within and between nations with healthcare services swiftly transitioning to another global commodity like any other product for commercialisation, consumption and exploitation.

Dissolving the Solid Body:
An Ethnography of Birthing in an Australian Public Hospital
(PhD Thesis)

Based on ethnographic fieldwork undertaken in the maternity unit of an urban Australian public hospital, this thesis explores metaphors derived from material density as major ordering principles in western understandings of the world, and argues that logics of solidity and fluidity underpin lines of contestation in scientific, academic, and biomedical/health discourses.

Through an exploration of social and scientific understandings of the human body, the thesis argues that the body as a fluid, dynamic phenomenon is frequently understood, in biomedical culture, through a logic that is inherently ‘solid’. Solid logic is privileged over fluid logic in hospital environments, which has particular consequences for maternity and birthing care.

While medicalised birthing has contributed to improvements in maternal and infant safety and well-being across the western world, inappropriately medicalised birth can be both traumatising and iatrogenic. Feminist contestations to the medicalisation of pregnancy and birth, and obstetric resistance to these contestations, can be seen as contestations between epistemologies centered on (more) fluid or (more) solid understandings of the world.

Risk management is shown to be reliant on strategies of material and symbolic solidification, often to the detriment of the inherent fluidity of the maternal body. Constructions of individual autonomy rely on the construction of a bounded body that is often in contradiction with experienced biological corporeality. The thesis argues that fluid logic offers space for maternal corporeality, however the individual autonomy required by the western health consumer is only achievable within a framework of solid logic.

Ethnographic engagement with pregnant and birthing women, their partners and families, midwives, obstetricians and other hospital professionals allows for an analysis of embodied and discursive beliefs and practices. The rich complexities of technologised birthing are highlighted in explorations of clinical encounters and key decision making moments in birthing and maternity care.