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Applying ethnography to digital health aims; challenges and opportunities – by Charlotte Hawkins

LauraHaapio-Kirk10 August 2019

Author: Charlotte Hawkins

Photo (CC BY) Charlotte Hawkins

How can a holistic ethnographic understanding of ageing experiences, particularly related to health mobile phone engagement, contribute to an mHealth initiative and improve the accessibility of health services and information through mobile phones? This applied challenge in the ASSA project has initiated partnerships with digital health practitioners in most of our fieldsites – in particular, with collaborators working within existing phone practices. This aligned with our early finding across the fieldsites, that mobile phones are commonly used for health purposes, but through communication on apps evidently most popularly used, such as calls, Facebook and WhatsApp. In Kampala, I worked with The Medical Concierge Group (TMCG), a medical call centre founded by Ugandan medics to improve the accessibility, affordability and quality of healthcare. They offer a 24-hour toll-free phone line, SMS, WhatsApp and Facebook access to a team of doctors and pharmacists and have 50,000 interactions each month. At the time of fieldwork, they were in the process of researching the development a psychiatric call line, or ‘telepsychiatry’. This early stage of service development meant that TMCG were interested in and able to accommodate holistic ethnographic insight in their considerations.

Ethnographic insights included systematic information on 50 low income research participants’ existing mobile phone and mobile health practices as relevant to accessing TMCG services. For example, access to airtime and data is intermittent, with a tendency towards regular low-cost subscriptions. This suggests that calling or using the internet could be inaccessible to users at least once a day. Furthermore, 54% of participants had made health-related calls in the last month, and 27% of their previous three remittances were for health purposes, which confirmed an existing propensity to use mobile phones to support family health – but only across their own network of friends and relatives. Interviews with 50 respondents encountered during the wider ethnography also offered TMCG feedback on mental health perceptions, experiences and help-seeking preferences. These interviews were predominantly with older people, mostly older women, who would not typically opt to engage with research on mental health, and yet who represent an advisory position within their family or community. This also included interviews with health workers, including psychiatric clinicians at the local government hospital, and private health clinicians within the fieldsite. Research showed that treatment for mental illness was perceived to be unavailable, costly, or stigmatised. Often respondents said they prefer to handle mental health problems through prayer or counselling within their community, with hospital treatment sought only once problems become severe. This suggested that optional, confidential, accessible or community-based mental health services could be useful for low-income people in Kampala, if advertised accordingly.

Initially, the wide-reaching interview responses were considered thematically, from causality to treatment seeking, and condensed into representative quotes for presentation back to the team. More recently, alongside the team, these themes have been expanded to inform a draft publication in psychiatric journals, which TMCG hope to use seek further funding. We also hope to further disseminate findings in accessible formats amongst other digital and mental health service providers in Kampala. As familiar to many applied medical anthropologists, translating interpretive, subjective and relativist ethnographic information within positivist, objective and universalist medical paradigms brings challenges, such as risking that complex human experiences and perceptions are reduced into ‘practical’ or digestible concepts (Kleinman, 1982; Scheper-Hughes, 1990). However, this assumes that the health practitioners and their discipline are not open to understanding their patient’s everyday realities, which has not been the case in this instance, perhaps reflecting a particular affinity between anthropology of digital health – appropriation of phone based health services is entirely dependent on their relevance and usefulness for their target populations.

The on-going collaborative process has also highlighted what anthropology might learn from the research and writing processes of health disciplines, for example: ensuring findings are widely disseminated and thus accessibly written; avoiding anecdotal, emotive or biased claims; and ensuring that quantitative statements, “many people said xxx”, are qualified and backed-up. The collaboration has  also confirmed that the flexibility of anthropological research and richness of qualitative insight potentially has much to offer health programmes, to ensure their contextual relevance. In ethnographic research, we have the privilege of time, which comes with in-depth insight, and familiarity with the community – time and understanding which we can offer usefully to other audiences. The data provided can perhaps confirm a hunch of a practitioner from the area but can also surprise them. When documented and publicised, the data encourages practitioners to both tailor their approach, but also allows them to share the specific requirements of their target population, encouraging others to do the same – or hopefully even to offer funding to support them.

 

REFERENCES

Scheper-Hughes, N. Three Propositions for a Critically Applied Medical Anthropology. (1990) Social Science & Medicine 30 (2): 189-97.

Kleinman A. The teaching of clinically applied medical anthropology on a psychiatric consultation-laison service. In Clinically Applied Anthropo1ogy: Anthropologists in Health Science Settings (Edited by Crisman N. and Maretzki T.) Reidel. Dordrecht, 1982.

 

‘Ikigai’ – what is your purpose in life? By Laura Haapio-Kirk

LauraHaapio-Kirk25 July 2019

Photo (CC BY) Laura Haapio-Kirk.

I went to meet Wada san* on his land in the heart of the mountains of Tosa-cho, where he grows the plant sasaki, common in Shinto ceremonies and used to decorate altars. He keeps ducks who help him to take care of his rice by eating weeds and harmful insects, and by fertilising the rice crop. He knows the paths and trees in his forest as well as a city person would know the streets and buildings of their neighbourhood. School children often come here to learn about nature and see how we can work with it, such as by making beautiful things out of wood, or healing ourselves with plant remedies. He told us that the plants that are able to grow and thrive here in the mountains, growing up through other vegetation, have the strength to survive and therefore when you eat them you too gain some of that vitality. Along with my research assistant Lise Sasaki and two friends, we spent several hours walking and talking together about happiness and the things in life that give a sense of purpose, in Japanese termed ikigai. While this is quite an abstract term, Wada san was able to explain his ideas through vivid analogies to the landscape that surrounds him.

“What is happiness? Human being’s happiness… I’ve heard that it is health. But after that, its whether or not you find the job you want to devote your life to. I have lived through many jobs and have picked up skills throughout. Now I use those skills to do what I do, my passion. My life story, my life history is written in the mountains, and is remembered by the mountains. Working in an office, once you retire someone else will take on your job. But in this rural area the trees I have planted will grow and remain here, and the trees will be cut down and I will plant them again. It will be a cycle. Not only that cycle, but here – (shows us the rings of a cut tree) you can see how much it has grown, how much it has lived. The trees, even if they are chopped, they will live on as someone else’s house or in another form. It reincarnates as several things. Trees live once in the mountains, giving us oxygen and giving to us our life. And it lives that way. But in its second life, it is transformed into our homes, giving us comfort. We can’t see the oxygen, but it produces it – let’s say it was living in the mountains for 50 years and then it was chopped down and lived as a house for 50 years. Then it has lived for 100 years.”

Wada san explained that trees, like humans, are naturally wild, but that with the right kind of nurture they can find their way in the world. He said that when we are becoming an adult we have to choose our path in life and our role in society – trees are the same. For many people I have spoken to the idea of ikigai is linked to the satisfaction you gain by fulfilling your role in society, especially when you see your positive impact on others. Whether through making delicious bean paste sweets and sharing them with people, or in taking workshops to become a better teacher for your students, people agree that one element of ikigai is about trying your best in serving others.

Everyone has a different definition of ikigai. For some people it refers to dreams and ambitions, such as pursuing a career as an artist, for others it is about doing daily activities which align with one’s interests such as learning English, or for others it is more about the thing in life that you could not live without, such as your children. For some people it is about enjoyment of life, for others it is about the fulfilment of obligations, and some people are in between – a sense of ikigai can come in both difficult and joyous moments and it is more about an underlying feeling of immersion in life.

The English translation of “purpose in life”, it seems, is completely inadequate for understanding the broad range of meanings that ikigai can have in Japan. In England we often talk about life dreams, or working towards goals that we want to achieve. But it seems that people here think about life purpose in a more subtle way, through trying your best day-to-day and being fully present in whatever you are doing. Wada san explained that we must live in the now, rather than waiting for happiness in the future. I think this is an important lesson for us all, especially for people living hectic city lives far removed from the cycles and rhythms of nature. We can often get caught up in our to-do lists and anxieties rather than being fully aligned with our passions and the flow of life.

Human beings are always worried, human being all have anxiety. If your passion wins over, you’re okay. If anxiety takes you over, you can’t take a step. You think life and death are far apart? They’re next to each other. You can die anytime you know? It’s up to you whether you stay anxious or live to the fullest, with passion.” 

Thank you to Wada san for sharing your time, wisdom, and inspiring passion for nature with us.

 

*Wada san is a pseudonym because this man preferred to remain anonymous.

Pandora turned 70 and she just opened the box again. By Marília Duque

LauraHaapio-Kirk3 July 2019

Photo (CC BY) Marilia Duque.

Author: Marilia Duque

I am packing up to leave my field site after a 15-month ethnography with older people in Sao Paulo. One thing I learned is that a smartphone is not smart by default. Most of the time, especially for older people, a smartphone could be a stupid little thing that releases a new set of problems they now have to deal with, just like a Pandora’s box.

The character of Pandora can be perfectly represented by a 70-year-old lady I met who just received her box in the form of a gift from her son. This pandora’s box contained many gifts: a telephone, camera, calendar and computer and they were all hidden inside a Samsung Galaxy phone. Pandora’s husband warned her: “You should never turn this on. We are not supposed to steal technology from the youngsters”. Pandora then left the smartphone inside its box for weeks until she found out she was not invited to her old school annual reunion. The explanation they gave to her? “It was all set up through our WhatsApp group, dear”. In a mix of rage, sorrow and curiosity, Pandora immediately opened her smartphone’s box and turned it on.

As in the Greek myth, our Pandora also released some plagues and devils she now has to deal with. In her case, she faced fear, low self-steam, and anxiety. She first experienced fear of breaking the device, fear of being charged for something she was not using, and fear of erasing something important, like the pictures of her youngest grandson’s swimming competition. She then experienced a lost of self-esteem because her smartphone’s display was set to sleep after just 30 seconds of inactivity and she just didn’t have the proper time to think about what to do before the screen turned off. And when she asked her son for some help, he simply had no patience to explain to her what was happening. Instead, he took her smartphone from her hands, reset the sleep mode to 5 minutes and gave it back to her saying “it is intuitive, even children are supposed to learn how it works”.  Pandora still doesn’t use her smartphone to its full potential, but a friend from her church has downloaded WhatsApp for her. She has finally joined her old school friends’ group and also her charity group, her meditation group and her family group. Now Pandora experiences anxiety because she has to manage so many messages that just keep coming without interruption. Pandora doesn’t understand that the connection is on 24 hours a day, 7 days per week, but she can choose not to be.

Curiosity was what made Pandora open her smartphone’s box and turn it on for the first time. But it is also curiosity which is the only thing that can save her. With curiosity (and with a little help from her friends), Pandora can dig deeper into her smartphone until she finds a solution – ‘hope’. It is hope that was left remaining in Pandora’s box. She will make ten mistakes for each thing she does right. She will be annoyed because she can enlarge the font size and the display size of her smartphone, but this will disrupt her WhatsApp screen lay-out and she will feel lost again. Even so, with time, she will become more confident to try new things and make new mistakes and learn with them. In doing that, Pandora will discover that one more gift was left inside her smartphone. Pandora will finally experience the smartness of her smartphone. A smartness that is only achieved in practice, when the smartphone provides a solution for someone’s need or desire.

Fear, low self-steam and anxiety will still exist. But Pandora won’t have time to pay much attention to them. She is now checking Google Maps for the easiest way to go to a museum with her friends. She is deciding to take an Uber so she can improve her English with Duolingo during the trip. She is experiencing that fraction of smartness that makes her think that her smartphone was actually a gift from the gods to mankind. A gift she had the curiosity to open and the courage to keep it on.

Mothers and Daughters in Milan & beyond

ShireenWalton22 March 2019

Milan fieldwork, May 2018

Among the themes that have emerged from my research on ageing in Milan over the last 14 months, relationships between women and their Mothers have been particularly prominent. I have been exploring the significance of physical proximity, distance, and smartphones in examining how care is enacted in these relationships, amongst women of different ages and backgrounds. The following examples illustrate some aspects of this work.

Elena (55) and her 80-year old Mother, Maria, are both from a nearby northern Italian city where Maria lives alone following the death of her husband, Elena’s Father, three years ago. Elena, who is married, without children, lives and works full-time in Milan. Maria has a range of physical mobility issues, meaning that she is largely house-bound. She refuses to accept help from care workers (known as Badanti, in Italian, who are often from other countries), for the encroachment she says she feels this would pose to her autonomy. Maria does not appear to trust Badanti and dislikes the idea of ‘strangers’ inhabiting her home space so intimately: “These carers are caring for the money after all, are they not?” She explains. “For them it’s a job. They don’t really care”. The ‘real caring’, following Maria’s definitions, is carried out by her daughter Elena, who, not having any siblings, bears full responsibility for her Mother’s care. Maria does not have a smartphone, so Elena calls the house phone up to three times a day from Milan to check in. At the weekend, Elena drives the two-hour round trip to provide weekly shopping and carry out basic household chores. The two women share in each other’s company, and Elena will often stay overnight on the Saturday. Elena herself, back in Milan, faces a range of problems of her own, including pending unemployment, and a marriage under strain.

Photo (CC BY) Shireen Walton, Milan fieldwork.

Elena’s situation is not uncommon in Italy, and elsewhere. Studies have highlighted the anxiety, depression, and emotional strain often experienced amongst children, particularly daughters, who are primary carers for elderly parents (Amirkhanyan AA, Wolf DA. 2006). These pressures characterise, for instance, what has become known as the ‘Sandwich Generation’ (Chisholm 1999; Riley and Brown 2005) of presently middle-aged women caring ‘upwards’ to parents and ‘downwards’ to younger children. From Maria and Elena’s nigh-on co-dependent relationship, one sees how what makes ageing so complex and intense a social experience is how the physical conditions of ageing bring about the modulating of roles, without altogether subverting or eradicating existing ones. ‘At a certain point” Elena explains, “you swap – daughters become Mothers and vice versa.” The relationship in reality is not as clear-cut or one-directional as Elena’s swapping over analogy implies. Instead, the layering of the Mother-daughter relationships thickens, and intensifies as the denial of change sets in. Maria appears to be very much still “the Mamma” in charge of the family home, whilst Elena effectively ‘project manages’ her Mother’s care. Never actively acknowledged between the two women is how ageing has modulated their relationship.

Where international migration is involved, daughter-Mother relationships play out in different ways. Kemala is from a small village in North-East Indonesia. She came to Italy ten years ago to study and work. She now lives in Milan with her husband and two children. Despite the distance, Kemala feels deeply connected with her childhood upbringing in Indonesia, and particularly with her Mother, who at 75 still runs the rice-packing business she had established in the village forty years ago. Despite this, Kemala has always found the intense sociality of her natal village context stifling. The youngest of eight children, she felt, from an early age, a need to leave, by pursuing education and upwards social and transnational mobility. Kemala has returned to Indonesia with her young children, but is unable able to do this often. Kemala’s wariness towards “too much” hometown sociality is reflected in her WhatsApp usage. Strikingly aware of what constitutes her “equilibrio” (equilibrium), Kemala chooses when and how she participates on family WhatsApp groups. She responds on the transnational family group (consisting of over 30 people) only on important occasions such as select birthdays, or Eid. Knowing that this group exists however, and that “everyone is there”, she confesses, provides comfort to her being physically far. She speaks with her Mother one-two times a week via WhatsApp on her sister’s phone in the village, since her Mother does not have a smartphone.

Kemala engages in care, but on a crafted, individual basis that she deems important for maintaining her sense of balance between countries and socio-cultural groups. She explains how “the distance helps. It creates a kind of a safety barrier, and behind this barrier, I quietly live my life.” Kemala’s use of smartphones recalls in part Ahlin’s (2018) notion of ‘frequent calling’ in the ethnographic context of transnational Indian families, whereby regularly keeping in touch constitutes notions of ‘good care at a distance’. The frequency of calling with Kemala, however, is modulated by her notion of self-care. For Kemala, (self-)care is constituted through distance, or rather the smartphone’s socio-technological capacity for facilitating ‘distant-closeness’ (Van House 2007). Meanwhile, the pervasive guilt that Kemala feels about honouring her individual commitment to social distance, and in being physically away from her village and ageing relatives, shows up in her everyday life in Milan. Over the months of participating in community activities together, I notice how she breaks into tears at what appear to be the slightest things that link her to Indonesia, to her village culture, but especially to her Mother.

Photo (CC BY) Shireen Walton. Milan fieldwork.

As Kemala continues to crafts her life in the present, this is done at the intersection of her emotional proximity but physical distance to her kin and village, and her determination to facilitate the best life she can as a Mother herself to children born and growing up in Italy.

Elena, Kemala and their relationships with their Mothers reveal how individuals navigate their wellbeing in complex ways on– and offline via a range of practices rooted in kin relations, social-cultural contexts, and normative expectations. The smartphone, highly present for some, less so for others, facilitates a capacity for virtual presence, distant-closeness and ‘care at a distance’, while physical distance for some enables self-care in the pursuit of individual wellbeing. This is particularly significant in cases of co/dependent Mother-daughter relationships, and contexts of intense family and/or cultural sociality.

Milan fieldwork photos 2018-2019 (CC BY) Shireen Walton

Milan fieldwork photos 2018-2019 (CC BY) Shireen Walton

Milan fieldwork photos 2018-2019 (CC BY) Shireen Walton

References

Ahlin, T. (2018): Frequent Callers: “Good Care” with ICTs in Indian Transnational Families, Medical Anthropology, DOI: 10.1080/01459740.2018.1532424

Amirkhanyan AA, Wolf DA. (2006). Parent care and the stress process: Findings from panel data, The Journals of Gerontology Series B-Psychological Sciences and Social Sciences, 61(5): 248–255.

Chisholm, J. F. (1999). The Sandwich Generation. Journal of Social Distress and the Homeless, 8(3), 177-180.

Riley, L, D and Bowen, C. (2005). ‘The Sandwich Generation: Challenges and Coping Strategies of Multigenerational Families’. The Family Journal: Counselling and Therapy for Couples and Families. Vol 13., No.2. Pp.52-58

Van House, N. A. (2007). Flickr and Public Image-Sharing: Distant Closeness and Photo Exhibition. CHI’07 extended abstracts on human factors in computing systems, New York, ACM Press.

Ageing Actively in Focus – By Shireen Walton

ShireenWalton8 January 2019

Books about ageing are currently in the spotlight. As discussed by Daniel Miller in an earlier blog post from February 2018, philosopher Kieran Setiya has looked at mid-life, from theoretical and practical perspectives. Another more recent work comes from journalist and author Carl Honoré, who in (B)older: Making the Most of our Longer Lives (2018) suggests a rethinking of ageing as a positive feature of the human experience, to be increasingly acknowledged and enjoyed more than ever before in history – a bonus not a burden.

Image (CC BY) Shireen Walton

What these books have in common is a call to shift our thinking about ageing from a negative; to consider the positive aspects of later life, and to rebrand ageing along ‘active’ lines, recalling the European Union’s emphasis on ‘active ageing’. In Italy, a country with the second (after Japan) oldest population in the world, active ageing receives much public policy and media attention. One avenue through which I came in to contact with these initiatives is through Auser, a nation-wide NGO in Italy founded in 1989. The organisation has branches all over the country, and the Lombardy region headquarters is in Milan – located in zone 2 where I am based for my research. Auser’s mission statement is ‘promoting the active ageing of the elderly and enhancing their role in society’ from  an inclsive perspective: ‘addressed primarily to the elderly, but open to relations of dialogue between generations, nationalities, different cultures.’

Auser website (English version)

Attending one of their meetings in Milan in December, I learnt about some of the main ways that ageing is being envisioned; towards skills-acquiring and sharing; a push towards enjoying life through ‘Active Welfare’, a concept the organisation defines as follows:

“Perhaps we will all have to work on building a model of “active welfare” based on financial resources adapted to social needs, built on an integrated system of subjects and public and private interventions, where through informal networks, the State, the Third Sector and individual citizens all work to build the social welfare of people, thus strengthening the concept of community and of social cohesion.”  [Auser mission statement, website]

Auser December meeting, Milan December 2018. Image (CC BY) Shireen Walton

I do not want to detract from these optimistic and significant attempts to combat ageism, but as ethnographer, I have to also investigate, specifically, what possibilities are/could be available to who – locally, regionally, nationally? From the middle-aged Italians in this fieldsite, I hear a great deal about the devastating economic situation in Italy since the 2008 economic crash, which makes the idea of retiring for many seem nigh on impossible, particularly if sufficient structures of in-family care are not in place due to transnational family lives and financial pressures. Active ageing is is also difficult to envisage amongst some of the individuals, families and groups I am working with from countries such as Egypt, Afghanistan and Peru, many of who currently imagine their futures as continuous work(ing). Noor, 45, a schoolteacher from Alexandria, explains how she “hopes my children will take care of me, as I take care of them…if we are together, Inshallah, we will all be fine.” How, I wonder, will her 15-year old daughter take care of her Mother in years to come? What might potential future Grandparenting be like for Noor, as an Egyptian single Mother living in Milan in her 60s?

Image (CC BY) Shireen Walton

Ali, Hazara (44), from west Kabul works a number of jobs, including as a night-time lorry driver. His wife and children are currently in another northern European country with his wife’s family. Ali explained the following: “Of course for the future having money is fundamental, but it is also important if you are a helpful person, and do good things for people; for your family, for your people (Hazara), and for humanity.”

Image (CC BY) Shireen Walton

Noor’s investment in Italy seems to be long-term; her ever-strengthening language proficiency, her children growing up in Italy, attending school and speaking fluent Italian, the death of her parents in recent years back in Alexandria and her own severance from the rest of the family in Egypt means that she feels she is here to stay, intent on growing old near her children. For Ali, currently working in Italy and visiting his family when he can, the geographies of his and his family’s future remains unknown.

My ongoing task then is to consider how people are ageing in – and away from – their homelands, aided by smartphone connections, but in many cases lacking public voice, and/or not involved in many of the dominant culture’s organisations and groups dedicated to ageing, health, and wellbeing. I am continuing to explore about these issues in line with broader conversations about contemporary citizenship, the role of technology, the state and NGO’s, migration trajectories & biographies, and the ongoing categorisation of peoples into strategic kinds of subjects (Giordano 2014). The approach reflects my commitment to studying ageing across cultural lines here in Milan.

References

Giordano, C. (2014). Migrants in Translation: Caring and the Logics of Difference in Contemporary Italy. University of California Press.

Let’s laugh together – by Marilia Duque

XinyuanWang26 December 2018

Author: Marilia Duque

Marilia (left) with her friend

One year of fieldwork and I must say, I am here laughing alone whilst I remember all the good times I had with my informants. At first I could have argued that most of them were fighting against the stigmas of ageing. On one hand, it means that they were trying their best to hide their physical limitations in order to keep their independence and their autonomy. On the other hand, it also means they were trying to adapt to the model of successful ageing, the image of respectful old people who are healthy, productive and socially engaged. Yes, they are always alert and fighting for their space and that resistance can result in a kind of self-surveillance, with a zero-tolerance with those who try to make fun of old people.
But wait until you are accepted by the group, wait until they feel comfortable with your presence and you will be surprised. They laugh at old people all the time. They recognize their frailties and they make fun of them. I was at an event with old people last week, and an old lady was stealing the scene, dancing with her very long hair, when one jealous old woman whispered to me “her geriatric diaper will fall”. After a while, when the lunch was served and a long queue of old people had formed, one of them said laughing, “where is the senior row? I have priority”. They also make jokes of issues like impotence, lack of memory, deafness, insomnia and their difficulties with technology. They address with humour the amount of time they spend in hospitals, all they have to do to pay their health insurance, how young people think they are stupid and how they feel tired after they have to pretend they were not “that old”.
We shared incredible moments together when they were not old people anymore. They were just human beings facing some difficulties in life and getting old day after day, just like me and anyone else.

Retirement and its malcontent in Yaoundé – by Patrick Awondo

ShireenWalton15 November 2018

Author: Patrick Awondo

The question of retirement in Yaoundé requires first and foremost an understanding of the precariousness of employment and its widespread informalisation across the country, making the idea of retirement per se almost impossible. One of the questions asked by informants is often “what does retirement mean in a country where work is scarce”? Approaching the question of retirement in Cameroon, 3 types of reactions are generally involved.

The first and the most frequent is that “Retirement is not a punishment!” Nearly all of my interlocutors have expressed sentiments such as this at the mention of retirement ; an idea reflecting wider public discourse concerning the retirement of civil servants who have a hard time accepting it, as well as a view from a section of society which views negatively the fact that retirement-age officials are dropping out of duties that should be the responsibility of other younger people.

A second reaction expressed my my informants is to highlight how retirement is necessary, despite the challenges it poses in the context. In discussion, informants raised context as an important factor determining retirement experiences, in a country where only 15% of workers have a payslip. Retirement is therefore a fact that concerns a limited number of people from an official point of view. There is also a notably pessimistic discourse about retirement, especially for those who live and are currently experiencing it. The present moment in Cameroon thus appears to be a complex moment in which the experience of the end of work is combined with a decrease in material resources and precariousness. A final category of discourse highlights the alternative facts that allow us to have a less pessimistic look at retirement. These 3 attitudes and points of view on the retirement can be an entry to initiate a reflection on the way in which this moment of life is expressed in Cameroonian society. Overall, informants in Yaoundé emphasise the ambivalence of retirement.

“Retirement is not a punishment! “

To understand the significance of this popular expression in Yaoundé we must consider the context of work patterns in the country. The labor market in Cameroon is characterised by a high unemployment rate, as well as underemployment[1]. Unemployment is highest among 15-24 year olds (10.3%) and 15-34 years old (8.9%) than among the general population (5.7%). In addition to this, is youth unemployment, which varies with the level of education and is especially higher among higher education graduates (27.1%). Youth unemployment rate is higher in urban areas (15.5%) than in rural areas (4.3%), and is 8.5% for males and 23.5% for females.

In the Cameroonian context, the state remains the largest employer in the formal sector because informal employment is more widely represented, and covers more than 70% of working people. In such a context, the number of de facto retirees is limited insofar as the number of civil servants is itself relatively low, since the State can not absorb all graduates and job-seekers.

Another much more specific issue has been raised in the discussions on retirement in Cameroon in recent years. In 2009, the Association of Public Service Retirees (AREFOP) publically denounced the problems faced by people at the end of their careers along the following lines :

  • the improvement of pensions of retirees in the face of increased purchasing power: “Where have our contributions to the land credit passed for decades?     “How many of us have retired without benefiting from a single honor when they served the nation with loyalty?” Ask the retired officials.
  • Preservation of health insurance
  • The possibility of accessing bank credit etc. «  Why do banks don’t ant to give credit to pensioners at least as far as school advances are concerned? »

These points subsequently led to a media-based controversy over retirement issues. A particular grievance was the long waiting lines in which people came to collect their certificates in the offices of the National Social Insurance Fund (CNPS), the body responsible for social security and pensions. These controversies led to reforms and an administrative reorganization, which reduced expectations and conditions for pensioners’ pensions.

The impossible retreat

 A second series of arguments often mentioned is related to the specific situation of the labor market. Some statistics can help illuminate this issue. In the year 2017, according to the data of the CNPS[1], 7,415 files of Pensions Old Age Disability Deaths were filed during the year and 97,48% were liquidated of which 85,47% in less than 15 days and 8.36% in more than 45 days. The pending files represent 2.04% of the total files filed. The number of PVID beneficiaries is up slightly by 1.6% (from 109,304 in 2016 to 111,006 in 2017). If we consider that Cameroon has more than 23 million inhabitants, of which half active, then 111 006 residents represents a derisory figure. The generic question of retirement as having entailed access to work, and therefore to a pay slip, and later to a retirement pension therefore appears inadequate as a framework for understanding the experience of later life in Cameroon.

The happy few

 There is however an alternative viewpoing about retirement – one which emphasizes its need after long years of “good and loyal” services, and acknowledges the possibility of it being a time for flourishing. This discourse is the result of two categories of informants : people who have worked in a manner that is appropriate for the context, that is, with a regular salary and benefits, and another category of people employed in the formal private sector, who have made a very good living and who have invested in retirement – particularly seen in the field of real estate. Informants mention building several houses for instance, whose monthly rent will be an end-of-career investment. These people are a small group but are a growing happy few retirees in Cameroon who participate in the middle and upper middle-class life style in Cameroon, which is currently expanding, but constitute an overall minority.

Notes

[1] https://www.cnps.cm/images/AnnuairestatistiqueCNPS2017.pdf#page17

Sharing is caring: communities of abundance in rural Japan – by Laura Haapio-Kirk

LauraHaapio-Kirk22 October 2018

Harvested corn. Illustration by Laura Haapio-Kirk

Last week I returned from ten days among the wonderful people of my rural fieldsite in Kochi prefecture. The vibrant green rice terraces I had been mesmerised by back in August are now the colour of gold, and in the fields small pyramids of drying rice are beginning to appear. It is harvest season and I was able to experience first hand, as people kept telling me, how Kochi is truly a land of abundance. I was given bags of chestnuts and yuzu lemons, and large Japanese pears (nashi); people here are adamant about sharing the fruits of their labour. The gifting of food binds the community and is, as one woman told me, important for creating a feeling of wealth without money: “Even if we have no money here in Kochi, we have abundance because we can grow so much delicious food and we love to share it.”

Community is sustained in this small rural town through a number of institutional initiatives, such as group activities for elderly residents, or regular workshops in the town hall, for example for new mothers. But it is also through these informal networks of reciprocal giving that community is made. The building and sustaining of community is especially important to people here because Japan’s ageing and shrinking population is felt most acutely in rural areas. It is not rare to come across abandoned schools which have been repurposed as community spaces, and indeed entire empty villages. Yet, I have also come across another quite different picture – young people and families moving into this rural town in search of a slower pace of life and self-sustainability. I have met numerous families who left behind jobs in cities both in Japan and abroad, to start new lives in a place where they feel safe; both protected by a community that looks out for each other, and as a number of people have told me, far enough away from the site of the Fukushima nuclear disaster of 2011 for the food to not be contaminated.

Akaushi – a famous breed of local cow. Illustration by Laura Haapio-Kirk.

This group of relatively recent immigrants, who have mostly arrived within the last eight years, are active on Facebook community groups where they buy and sell clothing, and post about local events. I have been told that local people are less active on Facebook, but perhaps more reliant on one-to-one messaging through Line. However, I have come across local people practicing traditional crafts who share their work on social media. For example, one woodworker in his sixties who uses Instagram to promote his products has customers as far as Tokyo. He told me “It is important for us to be active online because this is how we can reach the rest of Japan and the world, and show the beautiful things that we make here from nature.” Indeed, one of the first people to move to this community eight years ago blogged about her experience and inspired others to follow her move from urban to rural living. Blogs and social media are one way that people in rural Japan can influence a wider perception of the rural from being depopulated and dying, to re-populated and thriving. Social media also provides an opportunity for local people to build and develop their community in new ways. As my bags of fruit demonstrate, they have always had an extraordinary tradition of sharing.

The challenges of staying active – by Maya de Vries

ShireenWalton25 September 2018

Author: Maya de Vries

10 years ago, in a Russian store at the city center of Jerusalem, I bought an A3 size poster from the communist time, with a drawing of an old lady who looks like a farmer, holding a book. The short text beside her image read: If you stop reading books, you might forget the language.

Recently in my field site of Dar al Hawa I found myself remembering this poster when visiting the elderly club, a central place in my field site, as I observed a variety of practices that aim to keep them sharp and vital.

One of the most challenging problems in the elderly club is to find suitable activities for the members. They need to be activities that both men and women can do; not too physical, because many are suffering from pains in their legs and can’t walk a lot, some have hearing problems, or cannot breath well. Hence, many of the activities are ‘just’ talks – it is easier for them to sit and listen. However, there can still be difficulties in establishing the time and place with lecturers as sometimes they call in the morning of the lecture to cancel. When a lecturer stands them up like this or if there is no other organized activity in the club, their alternative is an independent Quran lesson, which is quite different from the religion lesson that they have every few weeks with the local Iman. They take out larger volumes of the Quran and start reading aloud, each one in his/her turn. Hala, a member in the club who is volunteering in the Israeli welfare department and coordinates some of the club’s activities, leads the reading session and corrects them as they read. It is not easy to read correctly from the Quran,  as ech part has its own chants. The exercise is productive not just of the sense of community but also isa practice which helps stimulate memory (Collier, 2017).

The books were donated by one of the club’s members, and are large in order to make reading easier. From the perspective of our projects work on smartphones, in a site where religion plays a core role in daily life, the small screen of the smartphone poses a problem – even if they are able to change the size of the font. However, people here do find relevant uses for the technology. For example, most of them have downloaded an app that reminds them when to pray during the day.

Quran reading lessons seem to be physically passive, since they take place while sitting. However, praying in Islam is quite a physical experience, as the person praying needs to first take off his/her shoes, following this he/she may enter the mosque and begin praying. Praying also involves all kinds of physical positions such as sitting, leaning to the ground, standing up, turning the head to the side – these movements are frequently repeated. The entire group went inside the mosque to pray, some sat on the floor as is custom, while others who physically cannot get down to the floor took plastic chairs. For almost an hour, they all prayed, regardless of any physical limitations, and in a way, were challenging their bodies through the prayer. It is easy to forget that prayer is far more than just words. It is an immersion of the person physically and mentally within their religious practice, and for older people, it remains the structure to much of their life. So when thinking about the impact of the smartphone on people’s lives, one has to be continually aware of how much, and how, this is mediated by religion.

References:

https://www.medicalnewstoday.com/articles/320377.php 

The place of WhatsApp in the ecology of care – by Marilia Duque

LauraHaapio-Kirk26 August 2018

Author: Marilia Duque

Dr. Gusso uses WhatsApp Business at Amparo Health Clinic (Photo: Marilia Duque)

In 2015 a PwC research report suggested that the Brazilian m-health market would reach $ 46.6 million while a GSMA report forecasted that 45.7 million Brazilians would benefit from mobile health projects (see here). In 2017 the scenario was even more optimistic. According to Statista, Brazil was expected to become the largest m-health market in Latin America with revenues of around $ 0.7 billion. These numbers explain the impressive amount of m-Heath startups and startup Incubators I’ve seen in Sao Paulo (see Eretz.bio, for example). But they don’t explain why after 7 months of fieldwork I still couldn’t find the people who are actually using these m-health apps. Instead, I found an intensive use of WhatsApp among my informants, filling the gaps in communication and making a huge impact on the ecology of care which we address in this project.

For example, every day early in the morning, Ms. M (54) sends a good morning message through WhatsApp to four lady-friends older than her. “It is like volunteer work because I know they are lonely and that message will make them happy and socially connected”, she explained. Ms. D (66) also starts her day sending a WhatsApp message. But in her case, the message is sent to her only daughter who lives in France, as a sign that she spent the night well. She is supposed to send this message every day before 10am otherwise her daughter will call a friend to check on her. “Some people say my daughter abandoned me, but the truth is that she is closer than many of my friends’ children who just live nearby”.

That is the same in the case of Dr. J., a physician who works in Sao Paulo and uses WhatsApp to take care of his 93 year-old father. After having a stroke, his father moved to Dr. J. brother’s house located two hours away.  Dr. J. created a WhatsApp group to talk to his brother and to his father’s caregiver. He gives her all the instructions she needs, and she updates him with information such as what his father ate, how he slept, how much water he drank, how much he exercised and how he was feeling. After a few months, he could tell how improved his father was and he explained how WhatsApp helped him and his family to feel safe and engaged.

Dr. K. also uses WhatsApp to provide care at distance. He works in my field site as a generalist providing ambulatory care to old people. WhatsApp allows him to give orientation about what to do when patients don’t feel well, and he can also ask them to go to his office if necessary. In many cases, he said, he can solve problems providing only care at distance. Dr. K. believes that the simple fact that the patients know they can use WhatsApp to contact him makes them feel safe and comfortable.

WhatsApp is also helping clinics to manage people’s health. Amparo Health, for example, is a clinic that uses WhatsApp Business to connect patients to doctors. The patient pays a monthly fee to have access to low-cost exams and to specialists like ophthalmologists, gynecologists, dermatologists, nutritionists and psychologists. What is new here is that all procedures and exams are coordinated by a generalist, who is available on WhatsApp. Dr. Gusso, the head physician at Amparo Health, explains that because the clinic business model is based on membership, they have no interest in demanding unnecessary exams or appointments. Doctors are paid by the hour and not by performance and that includes time to answer WhatsApp messages during the morning and afternoon. At the end of the day, he said, they are using WhatsApp to provide care at a distance, helping people to stay healthy, to feel safe and to save money. Prevent Senior, a health insurance company, also uses WhatsApp to make patients’ lives easier. In cases where treatments require on-going medication, patients can use WhatsApp to ask for new prescriptions. They can receive their prescriptions at home or they can go to the doctor office to get them, but with no need to schedule an appointment.

WhatsApp is the primary method of communication for 96% of Brazilians with access to smartphones. And among my informants older than 60 years old, that is also the app they use the most. Now imagine what can be achieved if WhatsApp features are explored to make the communication between health insurance companies, doctors, patients, caregivers, family and friends healthier too.