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Neurochemical selves or social prescription? by Pauline Garvey

XinyuanWang15 December 2018

Social Prescribing Brochure available at https://www.hse.ie/eng/health/hl/selfmanagement/donegal/programmes-services/social-prescribing/social-prescribing-brochure.pdf

In an academic article in the early 2000s sociologist Nikolas Rose asks ‘How did we become neurochemical selves? How did we come to think about our sadness as a condition called “depression” caused by a chemical imbalance in the brain and amenable to treatment by drugs that would “rebalance” these chemicals?’[i]. During the decade from 1990-2000 Rose charts high rates of prescribing psychiatric drugs in Europe, Japan and the United States. In Europe growth in the value of prescription drugs rose by over 125% while growth in sales of similar drugs in the United States rose by over 600%. He notes that a decline in prescriptions for hypnotics and anxiolytics was matched by a rise in prescriptions for anti-depressants of about 200% (2003: 46).

There is, however, another trend that is gathering momentum on the international stage and which couldn’t be more different than the trends that Rose documents.  Social prescription takes an altogether different approach to health and embeds it in social networks and cultural activities. It is defined by the NHS as ‘helping patients to improve their health, wellbeing and social welfare by connecting them to community services which might be run by the council or a local charity[ii]. In Ireland the Health Service Executive webpage speaks directly to the reader and defines it as a free service that ‘helps to link you with sources of support and social activities within your community. These include Physical activity, Reading groups/books for health, Self-help programmes such as the Stress Control Programme, Men’s Sheds, Community gardening, Arts and creativity’. Social Prescribing is for you if you feel that you need some support to mind your health and wellbeing, you feel isolated, stressed, anxious or depressed, you simply feel you need the service[iii]

In a comparable project called Local Asset Mapping Project (LAMP) run through St James’s Hospital in Dublin their webpage again addresses the reader directly and conjures the scenario: ‘Imagine visiting your doctor and as well as getting a prescription for a pill, you get an electronic  prescription designed especially for you, with a list of all the local businesses and services around you that might improve your health – that is the vision of LAMP’[iv]. The LAMP project points out that wellbeing is determined by ‘good health behaviours’ such as exercise, nutrition, minimal alcohol consumption and good social networks, but notes that traditional medical consultation does not address this adequately’.   As if to echo these arguments, just two weeks ago the Irish Longitudinal Study on Ageing at Trinity College Dublin (TILDA) presented their most recent findings regarding ‘Change in life circumstances’ for Ireland’s over 50s between 2009 and 2016. They found that quality of life peaks at 68, and therefore shouldn’t be thought of in a linear way (ie as a steady decline) but also that fundamental to quality of life is social connnectedness. Quality of life improves with age for the majority of their sample, but only if social engagement is strong. [v]

As an anthropologist the holistic approach to health and wellbeing makes perfect sense. My respondents do not organise their lives ‘in silos’ (see LAMP), and how one feels ripples into all aspects of life, in the same way that everyday experiences are integral to how people think about their wellbeing, happiness – and age. Some respondents occasionally talk in neurochemical terms -particularly when wondering how to get a good night’s sleep, but the majority of their time and energy is devoted to their busy lives.  One of my informants aged in her early 80s resisted joining Active Ageing groups because she did not consider herself elderly. Another woman said ‘I’m 78 but I feel 60, I feel younger, not older’. In the course of my research I have met some retired men and women who are lonely, isolated or bored but many others take to retirement with vigour and enthusiasm. What interests me is whether these activities such as knitting, writing or meeting friends for coffee are reflected upon as ‘good health behaviours’. What are the social trends that social prescription is tapping into, or indeed leading?  Meanwhile as I conduct me research the benefits of social embeddedness seem clear. As one man told me since retiring from work he has never been so busy.

[i] Rose, N. (2003) ‘Neurochemical Selves’ Society 41 (1): 46–59.

[ii] https://www.england.nhs.uk/contact-us/privacy-notice/how-we-use-your-information/public-and-partners/social-prescribing/

[iii] https://www.hse.ie/eng/health/hl/selfmanagement/donegal/programmes-services/social-prescribing/

[iv] http://www.ehealthireland.ie/Case%20Studies/Local-Asset-Mapping-Project-at-St-James-Hospital/

[v] https://tilda.tcd.ie/news-events/2018/1812-w4-key-findings/

The Purple Month — by Alfonso Otaegui

Alfonso ManuelOtaegui10 October 2018

As a member of the Anthropology of Smartphones and Smart Ageing research project, I am doing fieldwork among migrants working in Santiago de Chile. Among the many diverse migrants who live in this city, I chose to work with Peruvian migrants. Peruvians are the largest immigrant group in Chile: they represent 25.2% of the migrant population, according to the 2017 census. Many of them have been living in this country for over fifteen or more years, and most of them live in Santiago (65.2% of migrants live in the Metropolitan Region).

During the first weeks of my fieldwork, I asked a Peruvian colleague –who was also living far away from his country– on advice about meeting his countrymen here in Chile. He advised me to approach Christian confraternities. Confraternities –in this case Peruvian– are groups of people who honor their local Catholic devotions. I started then to frequent a catholic church in the center of the city, which is famous for being welcoming and supportive of migrants. There I met Peruvians belonging to several different confraternities. Some of these confraternities honor Peruvian Marian devotions, such as the Virgin of Chapi, from the southern city of Arequipa, or the Virgin of La Puerta, from the northern city of Otuzco. Others honor Peruvian saints such as San Martin de Porres or Santa Rosa de Lima. All of them were as proud of their devotions as welcoming to my ethnography.

Among all of the confraternities, I decided to join the most diverse in terms of regional origin, including even non-Peruvians: the Hermandad del Señor de los Milagros (Confraternity of the Bearers of The Lord of Miracles). This devotion originates in Lima in the seventeenth century and, although the largest confraternity can be found in the capital city of Peru, there are local confraternities –such as the one I joined in Santiago– all over the world, from São Paulo to New York (even in Hamamatsu, Japan). “Wherever there is a Peruvian there is the Lord of Miracles”, so I’ve heard them quote of Monseñor Hidalgo, the spiritual guide of the main confraternity at the Nazarenas church in Lima.

The brothers and sisters have been very kind to me and have allowed me to join them in several activities along the year, such as regular meetings, spiritual retreats and ‘polladas’ (traditional funding events where chicken dishes are sold). The biggest event of the year is the Lord of Miracle’s procession at the end of October, called the purple month, due to the typical color that identifies this devotion as seen at a number of activities (shorter processions, masses, retreats, etc). The main procession, lasting eight hours, takes place on the last Sunday of October. As a sign of the place of Peruvians in Chile, the procession goes from the Cathedral of Santiago to the migrants’ church, gathering thousands of devotees. I was invited to join one of the groups of thirty people carrying the 1.5 tons image. ‘Carrying’ is not only a body technique one needs to master (the hands at a certain position, the steps following the music) but also an honor. Besides, ‘carrying’ is a complex concept whose meaning linked to faith and community I am just starting to grasp.

 

 

 

 

 

 

 

 

Most of the miracles I have been told about are in fact related to health: a surgery that went well, a disease that was beaten against all odds, a tumor that turned out to be benign. As far as I can understand, prayers and processions do not substitute medical procedures. I see in the chains of prayers, the dedication of a procession stages, and the participation in funding activities a sense of community, a display of collective care. What is interesting for our study in the ASSA project, is that this particular devotion is not only an expression of belonging, of tradition continued abroad, but it also opens the door to the study of the relation between faith and health.

References

Institituo Nacional de Estadísticas Chile. 2018. Síntesis resultados Censo 2017. Santiago: Instituto Nacional de Estadísticas Junio / 2018.

 

 

 

Dr. Google will see you….anytime.

DanielMiller4 October 2018

Given that I suspect almost everyone you know at least occasionally uses google to look up health related information, at least sometimes, there is not a great deal of research on the consequences – though I have no access to google’s own research. This has therefore been a major focus of my work on digital technologies and health here in Ireland. What are the main conclusions so far?

Most noticeable is the way googling exacerbates differences in class and educational background. There is a pronounced spectrum. At one end are those, often without medical backgrounds, who would comfortably use google to track down the latest medical journals, because they are trained in research. At the other end are those who simply look at the items that come at the top of their google search, which are often scare stories, rumours or commercial sites. As one pharmacist noted `They just type it into google and probably read the first couple of articles that come up. So whatever’s most recent. They don’t differentiate NHS from random.’ This can be very frustrating to medical practitioners when it leads to their patients locating the problem in the latest online speculation, rather than starting with the practitioner’s own analysis.

This spectrum is complex because of several contradictory factors. A surprising number of people in this town mention that there is someone with medical training, within their extended family, who may mediate their searches. There is also a well educated section who use googling as a kind of anti-medical-establishment resource seeking out alternative and complementary treatments, which they feel deal with issues and consequences that are neglected by bio-medical establishments.

At both ends of the spectrum most people see equally strong positive and negative consequences of googling. They feel more knowledgeable, and in control of their treatment, but they also see googling as a cause of considerable stress and anxiety. They note that pretty much any symptom could potentially indicate cancer or some other life threatening condition. Some therefore limit their googling. Many people are wary of informing doctors of their searches for fear they will be seen as a nuisance or a challenge to the doctor’s authority. Googling may be a factor in deciding whether to see a doctor, but it also employed subsequent to visits to the doctor in order to better understand terminology, medicines and procedures. Pharmacists may actively guide people in their googling. Those who differentiate trusted sources of information mostly choose the US Mayo clinic or the UK NHS site rather than any Irish sites, and also favour specialist sites dedicated to their particular conditions. Unlike early evidence from other fieldsites in our project, such as in our recent blog post about Cameroon, there is little use of YouTube here for health information.

To conclude, google appears to provide equal information to all, but in practice, it may extend class and educational differences and create problems of online health literacy. Well-educated people become still better informed, while poorly educated people are left even more confused and anxious. The obvious solution is kite-marking those sites backed by established professional bodies. This does nothing to prevent a preference for complementary health sources, but does ensure a more equal playing field for those who, to use a common expression here, think of online as Dr. Google.

The dilemma of life-saving medicines in China – by Xinyuan Wang

XinyuanWang20 September 2018

Author: Xinyuan Wang

Last summer, a film about illness and medicine achieved phenomenal success among Chinese audiences. Some friends of mine who had watched the film suggested that I take some tissues or even towels along to the cinema, assuming, , half-jokingly, that many would cry during the film. But they were quite right, in the cinema there were people sitting all around me wiping tears during the film, and talking highly of it with tears in their eyes after the cinema was over.

The film, Dying to Survive,  tells the tale of a health supplements peddler Yong who smuggles illegal medicine from India to sell to leukaemia patients in China at more affordable prices. Why are Chinese people all so touched by a film about an illegal medicine smuggler?

In the film, even though the protagonist Yong initially goes into the trade by chance and was purely motivated by making money – “I don’t want to become a saver, I just want to make money” as he claimed, Yong started to become more altruistic as he gradually realizes how many lives he could save by the cheaper medicine. The film was inspired by a real-life incident in China: in 2015, a man called Lu Yong was charged for importing and selling a cheaper, knockoff version of Gleevec, a leukaemia medication. Lu himself suffered from leukaemia and began purchasing Gleevec tablets produced by an Indian pharmaceutical company for other patients who couldn’t afford the “real” drug. The indictment was later quashed after the patients that had benefited from Lu’s actions petitioned the court to lessen the sentence and release him. In recent years, the Chinese government had realized this problem and had make some effort to reduce the price of ‘life-saving’ medicines. So, the film is also in line with the state policy.

As shown in the film, an old lady said: “one bottle of genuine medicine cost me 40,000 CNY (around 4,500 pound), I have been sick for 3 years, and I have been eating these pills for 3 years. In order to buy this medicine, my family had to sell the house, my family has been totally dragged down. Which family does not have a patient? Can you guarantee that you will not get sick for a lifetime? I don’t want to die, I want to live.”

A 45-year-old woman whose mum died two years ago because of cancer, told me: “I just can’t stop crying, when the old lady in the film said ‘Can you guarantee that you will not get sick for a lifetime? I don’t want to die, I want to live’,” she adds, “everybody who has experienced a major illness themselves, or of their family member or good friends can feel for the film. You would never imagine the desperate feelings about losing somebody you love dearly just because you can’t afford the saving-life medicine.”  Indeed, even though there is life-saving medicine, there is no life-saving money. In the film, the only sincere line a deceitful drug dealer uttered was “there is one illness in the world which you can never cure – poverty.”

Satirical films such as this unveil and spotlight the social concern that no Chinese would not bear to ignore – that for normal people, a major disease can potentially tear a family down both mentally and financially. Dying to survive has sparked and leveraged tremendous discussion over many topics nationwide, which is unprecedentedly in China’s film history. Without a doubt, the film has touched a few sour points of Chinese medical care from the high price of imported medicine to major illness insurance policy (da bing yi bao). Each aspect requires thorough investigation in order to understand the situation.  If you are interested in the film, here is the trailer with English subtitles. https://www.youtube.com/watch?v=on82VId28l4

The Internet of Health in Yaoundé – by Patrick Awondo

ShireenWalton12 September 2018

Author: Patrick Awondo

Over the last decade, Internet penetration rate in Cameroon has more than doubled, from around 10% in 2007 to 21-30% in 2017 (these figures leave aside small and medium-sized cities, and do not take into account connection-sharing practices that are part of people’s daily habits). The internet boom, made possible by the democratization of smartphones (which 80% of the population now have) has impacted significantly upon behavioural habits and the ways in which individuals and groups live at different stages of their lives. Among the areas chiefly affected by such changes, health is attracting attention in the digital landscape because it is the subject of unprecedented publicity, and is considered to offer many affordances to people.

In Yaoundé as in other African capitals, health remains a significant problem, but also, is undergoing  ongoing processes of change, and permanent questioning. In the smartphone age, health is an area of intense social activity. Three types of issues in the online health context deserve attention for the importance of the activities they generate:

  1. The variety of access to online health resources
  2. The diversity of information and forms of access offered by the Internet
  3. Challenges related to the density of supply, and what our colleague, Daniel Miller, perceives as inequality in interpretation, and the ability to appreciate in a fair and balanced way, the different “resources” of health online.

The variety of access to health resources

Generally speaking, people in Yaoundé use the Internet in contexts of/for health either to publicize health resources, that is to say, to present information that aims to simultaneously improve access to health through good practices. Or, to find the right information about very specific health problems. The latter is undertaken through a range of sites and links dedicated to specific health issues. Specific health issues can include pandemics such as malaria, tuberculosis or HIV / AIDS, which are priority public health problems usually treated by public health actors. However, people also turn to the Internet to search for diseases that have no visible presence in public health discourses, and which generally lack in public awareness – such as Typhoid fever, as well as certain female health issues such as ovarian cysts, dermatological problems, and infertility. These issues are addressed in forums, and blogs, but more and more, via dedicated Whatsapp groups that are often created by individuals with such concerns. There are also many health bloggers from Cameroon and the Cameroonian diasporas. Some are not always of Cameroonian descent or nationality, but blog membership appears most strong when individuals are Cameroonians or presented as originating from the country.

Overall, there are different ways of accessing the  internet of health in Yaoundé. Informants could be classified into 3 categories:

  1. those who watch YouTube for health
  2. those who Google-search health problems
  3. those who follow specialized health blogs

Health-searching practices on YouTube

Amongst my young informants, (19-31 years), the practice of searching for information on YouTube seems to be fairly common. Informants describe a typical double scenario, whereby they have a health concern, for various reasons that may be related to a lack of economic means, or the inability to join a health service. In this case, they will introduce on YouTube the name of one or more symptoms, which they hope a video will help inform them about. A 31-year-old security officer at a mobile phone operator explained how she regularly used YouTube on her smartphone to get video responses mainly about intimate grooming techniques, and a set of problems related to gynaecology. Interested in plant medicine, she regularly follows a “youtubeuse” specialized in herbal care for women. Many under-educated people like this female informant with limited income, but also among people with higher levels of education follow the youtubeurs of Cameroon almost daily. Other informants in the same social category stress that seeing a specialised doctor can be difficult in Yaoundé because of the high rates that these specialists practice. About 10,000 XAF consultation is already 10% of the salary of a security guard as our informant.

These high prices are not those charged in public hospitals, where a specialist costs half the price in private. Another factor determining the choice of Youtubeurs health advice is to be found in the strong competition that plant medicine imposes on modern Western medicine in Yaoundé. This appeal of alternative, natural therapies can be found amongst all social strata.

Those who “Google read” health on the Internet

During interviews and observations in one Yaoundean clinic, it appeared that searches on Google densified as a large part of the population access the Internet via the smartphone (specifically, the android phone, which is most popular here). Healthcare professionals in this capital’s leading private clinics point to the fact that a growing number of patients in consultation rooms are talking about diagnostic elements previously sought on the Internet, or afterwards in order to be able to make analogies by comparison.

The issue of individuals making their own comparisons with official health advice is intriguing. In another clinic, a 40-year-old teacher explained his reliance on seeking health information on Google through the dual need to better understand the disease from which his son had suffered from for 6 months at the time of the interview, but also, to compare the information received during diagnosis with that available on the Internet. If the case of this Father is not isolated, it reveals the complexity of different persons and needs that are engaged in via the search for health information on Google.

So while some informants point out curiosity and the primary need for knowledge of the disease or to understand the symptoms, this informant took to researching online for secondary purposes, to in some sense validate the official medical diagnosis. Another 44-year-old informant, a married, bookstore employee and Mother of two who lives in mvog-Ada, stressed the fact that the availability of the internet is a key factor in explaining its popularity and usage. Suffering from a Glaucoma, she went to an Ophthalmologist in a public hospital. The latter professional indicated that surgery was inevitable. Frightened and seeking reassurance, she turned to Google from her office to access information about her own illness. For this informant and for the first mentioned above, the search for information becomes a way to access a second opinion on the diagnosis of the doctor, especially in the case of serious diseases.

Health blogs and their followers

At the beginning of August, I was walking in the streets of Mvog-ada, the low-income neighborhood, when I was accosted by a group of people ;  two young men, a man, and a young woman, all wearing a green T-shirt on which read the name of a company that distributes herbal medicines. The group explained to me how they had created an online site with an active blog through which to communicate and sell their products. Like this distribution company, many groups have online blogs that are subscribed to by many Cameroonians. As a rule, these Blogs are put online from Cameroon and in particular the two big cities that are Yaoundé and Douala. But some of the blogs are often domiciled in Europe, particularly in France.

Such blogs cover broad health issues ranging from exclusively female problems (such as intimate care practices, ovarian problems, and so forth) to major pandemics (Malaria, Typhoid Fever, Cholera). There is also a very large number of sites dedicated to plant medicine. These plant medicine sites, still called herbalists, are very successful in the online contexts.

In sum, health on the Internet seems to play a major role in Cameroon, affecting the way people access health information on the one hand, and the way in which this – and also non-Internet accessed medical information such as doctors’ diagnoses – is evaluated. These last observations highlight two types of concerns: on the one hand, the difference between specialized and non-specialized information (also professional and non-professional); on the other hand, the issue of inequalities, linked to the ability of informants to analyze ‘good’ and ‘bad’ news offers. This brings us back to the classic issue of the reproduction of (health) inequalities related to economic context and education levels, and how these factors influence the use or non-use of information and the evaluation of their quality and/of efficacies.

 

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.

Conducting a health check in rural Japan

LauraHaapio-Kirk22 August 2018

Earlier this month I was invited to help in an annual health check in a rural town in Kochi prefecture. I had wanted to find a rural comparative site to my main fieldsite of Kyoto, so when Dr Yumi Kimura, a researcher at Osaka University, invited me to participate in the health check, this seemed like the perfect opportunity to establish myself in a rural community. I arrived in Kikuyama* on a Sunday afternoon along with my research assistant, Lise Sasaki, and about 50 other researchers, students, doctors, and dentists. The five-hour train and bus journey from Kyoto ran alongside sparkling clear turquoise rivers winding their way through lush mountains.

We were first briefly taken to a scenic spot to view rice terracing; breath-taking luminous green tumbling down the mountainside. But that was the limit of our sightseeing; we soon got down to business. We were expecting to welcome about 300 people to the health check over the next five days so we spent that Sunday afternoon preparing. The health check was to take place in a large hall adjacent to the town’s health clinic. We set up distinct areas for different kinds of medicine and tests, including areas for dentists, cardiologists, gynaecologists, mobility and dexterity tests, dementia tests, driving tests, blood tests, and a space for general practitioners to give consultations at the end of the visit. The area where Lise and I were stationed featured a machine called InBody which we used to measure body fat and muscle percentage.

The machine works by running a small electric current via electrodes placed on the fingers and ankles. Over the course of the week, while we attached and removed electrodes, we had a chance to chat with people about their health. This was a great opportunity to meet a large number of people in a short space of time and to establish myself as a known person to this community. Many were very surprised to see a foreigner, and some even asked to touch my hair, telling me it was the first time they had seen someone with fair hair and skin up close. Given the hectic nature of the health check we were only able to have long conversations with a few people, most were limited to about five to ten minutes. However, we managed to get a sense of the topics that were most insistent and frequently occurring in relation to health: work, food, luck, and community. Identification of these key topics will direct my conversations that are scheduled during my return trip in October, when I am planning to conduct more in-depth interviews and also do filming. Without participating in the health check I feel it would have taken much longer to build up trust with this rural community, especially as a foreigner, but now we have many invitations to visit people in their homes.

I will save a longer discussion of the above mentioned topics for a blog post after my second visit to the site, but for now I will briefly explain why the topic of work appears so pertinent to understanding how health is conceived in this community. Most people we met were rice farmers or foresters, often still working well into their 80s. The foresters had extremely big hands which were often missing fingers, and the rice farmers were deeply tanned from spending their days in the fields. This is hard work which leaves its mark on the body, yet when asked what is the secret to staying healthy and energetic (genki) in old age nearly everyone said that daily work is key. Men and women appeared to be equally committed to farming, while all of the foresters were male. For some farming had been a life-long career, and for others they had taken it up after retiring from other jobs. While the physical nature of strenuous work appears to benefit the physical health of these strong elderly people, I am particularly fascinated by how the sociality of work affects people’s emotional and mental health. Farming requires communication, not only with suppliers and buyers, but also with fellow farmers about how to cooperate and to manage seasonal fluctuations. People also mentioned that they socialise with people who do the same work: a rice farmer will go and have sake now and then with fellow rice farmers in their association. The significance of work for health in later life appears to be about more than staying active or having an income, it seems to be central to maintaining a sense of belonging within a community. I look forward to further exploring this topic, along with the others, in the months to come.

 

Text and Illustrations by Laura Haapio-Kirk

*A pseudonym is used in order to protect privacy.

The Challenge of Menopause – Daniel Miller

DanielMiller3 August 2018

Photo (CC BY) Daniel Miller

For a project concerned with health and mid-life, menopause is an obvious target. What specifically does an anthropological perspective add, first to understanding menopause and second to envisaging a positive digital intervention? One key anthropological component, which is the comparative perspective, will have to wait until the team completes its research, but from my Irish fieldsite there are many possible insights. The challenge is firstly that no two women have the same experience. Menopause can start in your 30s or 50s. It can be almost symptom-free or have dramatic effects, some of which may never end.

The anthropologist will focus on the way medical issues are inextricable from the social context. The effect can be on close relationships. As a pharmacist told me, Sometimes they come and say ‘I’m ready to kill my husband I think I’m going crazy’ very reassured when you say it could be the menopause”. Or women report that vaginal dryness makes it too painful to have sex. Women have told me that their mothers never mentioned menopause to them, or that they do or do not feel they can discuss the topic with their sister or close friends. Mostly they report that menopause is a topic that can only be broached through jokes. The impact might also be on wider relationships, such as to one’s work: “You might say to your colleague `could you just take over for a moment’ and then not explain why you would disappear, because you had a flush and you needed to remove yourself”.

Then there is the relation to wider medical authorities. Concerns about HRT or addictive sleeping pills may mean they prefer to consult complementary medicine rather than doctors. Knowledge seems to be a complete lottery, where some are well aware of the potential effects on bone density while others have never had anyone suggest this is something they might look into. Listening to women, within an ethnography, also alerts one to the considerable differences in perspective. One woman will give a feminist perspective about the need to rethink menopause as a celebration of a natural process, rather than merely a medical problem. While another, who is undergoing IVF and is desperate to have children, sees nothing to celebrate.

For us, the ASSA team, it is important that this same alertness to the social and wider context should manifest itself as the anthropological contribution towards delivering that will be of genuine benefit. One of the lessons from this research is that we need to see smartphone apps less as autonomous interventions and more as potential hubs. Different women will respond to different levels of information. There are those who are turned off by text and just want visuals, contrasted to those who want to read the medical journals. In my research so far, women have split equally between those who would prefer a discussion forum based on complete anonymity, to those who would only want to discuss these issues with people they can identity and feel some sort of relation to. In making relevant information more accessible all these factors need to be taken into account, but first and foremost comes listening to what a broad range of women say.

 

Avoiding Stress in Kampala’s “Jobless Corners” – by Charlotte Hawkins

ShireenWalton30 July 2018

Author: Charlotte Hawkins

Our health depends on how we conduct ourselves, what we eat, what we drink. …Alcohol has compromised a lot of health in Uganda today.  

(Elder in Kampala fieldsite, Godown)

A nationwide study by the World Health Organisation in 2016 found 10% of Uganda’s adult population have problems related to alcohol[1]. Excessive alcohol consumption can be a contributory factor to diseases such as cancer, mental illness and diabetes, as well as accidents, domestic violence, and other detrimental effects on family life. The drinking habits of some people in my chosen fieldsite, a low-income area in Kampala, are both a cause and consequence of socioeconomic problems in the home and beyond.

Drinking for leisure has long been ethnographically recorded as part of everyday life in Kampala (Southall and Gutkind, 1957: 22; Wallman, S and Bantebya, G 1996: 83). Today, gathering points are centred around bars serving home brews, waragi, ‘war gin’, or ajono, millet beer, and branded beers, whisky and gin. Groups of men, and a few women, sit around a large shared pot with long drinking straws. It is a chance to laugh, relax, tell stories and bond; what one community leader termed a “narrative exchange of ideas”. The home brews also offer an opportunity for women to make an income; small factories like those photographed below can be found across the country.

Women brewing waragi in Kampala fieldsite (above) and rural Northern Uganda (below)

Public drunkenness, “morning to sunset”, is the subject of censure. An elder in Godown thinks that drinking alcohol should be criminalised before 6pm, as it is in neighbouring Kenya. However, he also recognises that people resort to drinking out of frustration and boredom, with a lack of employment opportunities or “what to do”. As another pointed out, “you know if there’s no employment, people tend to start drinking, drinking without proper feeding”. The local councillor, whose job is to resolve disputes in Godown, finds that “over drinking” is the main cause of conflict, husbands beating wives who have lost patience with their spending. As the women’s leader in Godown explained, they are often left to provide for their families alone:

Their husbands drink. They don’t even help them. They just take. Now their place they call it ‘jobless corner’. Even those who are working, who work at night, they come very early in the morning to go and join them. So the little money they make from work, they spend it on drinking.

In some families, alcohol is bought at the expense of children’s education, further perpetuating the inaccessibility of employment. Laura Haapio-Kirk’s recent ASSA blog post examined the paradoxical relationship between overworking, stress and health in Japan. In Uganda, it is the absence of formal work opportunities which perpetuates a cycle damaging to personal, familial and communal health.

References

  • Southall, A and Gutkind, P (1957) Townsmen in the Making: Kampala and its suburbs, East African Studies. East African Institute of Social Research, Kampala, Uganda.
  • Wallman, S., Bantebya-Kyomuhendo, G., 1996. Kampala women getting by: wellbeing in the time of AIDS, Eastern African studies. James Currey ; Fountain Publishers ; Ohio University Press, London : Kampala : Athens.

[1] http://www.who.int/substance_abuse/publications/global_alcohol_report/msb_gsr_2014_3.pdf,

Work, stress, and health in Japan

LauraHaapio-Kirk4 July 2018

Photo (CC BY) Laura Haapio-Kirk

“Because of my job it is not easy to feel Im living a healthy life. If you have a stressful life or stressful job it is a cause of ill-health. Work gives you stress but you need work to be healthy.”

This quote is from Tomoko san, a teacher who is near the age of retirement but is not considering retiring any time soon. She works six days per week and lives alone, her adult daughter living in another city. We met in the botanical garden and, after feeding turtles, we chatted overlooking a small lake and ate rice crackers that she had brought. We talked about health and in particular its relationship to stress which has surfaced as the most commonly cited source of ill-health in my conversations with people so far. She works hard and acknowledges that work stress, particularly social stress from colleagues and parents of students, causes ill-health. But at the same time she recognises that routine and purposeful work keeps her healthy. Her quote above is interesting because it captures this idea of work as both the main cause and prevention of ill-health, expressed in different ways by all of my informants. The routine and stimulation provided by work, especially of interacting with younger colleagues, has been cited as a way that people feel like they might retain their youth and stay healthy.

Diminished mental health, widely recognised by my informants under the umbrella term “stress”, does not appear to be as much of a priority to address as bodily health and fitness. Work and social relations are simply accepted as stressful because of a deference to hierarchical structures within social life. Colleagues often may not leave work until after their boss and then, if they are required to go drinking together, they also cannot leave the bar until their boss wants to. If a boss is insensitive to the exhaustion of their colleagues, this is known as power hara or power harassment. This kind of intense pressure from social bonds is often accepted as a source of stress and ill-health which people can do little about. As one informant told me with a sense of resignation “we (Japanese) have a lot of stress in daily life”. Unsurprisingly the mindfulness trend seen in Europe is also popular in Japan. However one of my informants said that mindfulness is just trendy and that people don’t really practice such activities in their daily lives. Japanese cultural activities such as tea ceremony and flower arranging (ikebana) are also supposed to be a form of paying attention and mindfulness, but as someone told me “ordinary people want to learn (such things) because its cool. For us, the mind is not so important, lifestyle is much more important. Mental health is not visible, whereas your body is, so people easily forget to take care of their mental health. How we look is very important.” One woman in her 40s confirmed these sentiments when she told me that the invisibility of mental health means that people often ignore warning signs and then reach burn-out stage. This is what happened to her while working as a designer, a job which often required 14-hour days. She subsequently quit the profession entirely and is now working as an administrator for a medium-sized company, where she feels less pressure to work excessively and therefore her health has returned.

Another person I have been getting to know is Hiroshi san, a 66-year-old nurse who also works 6 days per week. He tried retirement for 3 months but found that he wasn’t writing the novel he had planned to write, and instead felt anxious that others were doing more than him and being more productive, so he returned to work. For him, his peers are rivals who he feels in direct competition with, and retirement means dropping out of the race. Other people have told me that they don’t want to retire because it’s not healthy, they will just end up watching tv all day long, which they feel will shorten their lives. Work and “ikigai”, or purpose in life, are so bound up with health in Japan, yet in every conversation I’ve had people cite work as their main cause of stress and stress as their main cause of ill-health. This is a paradox I wish to further explore in the coming months.

Author: Laura Haapio-Kirk

Note: all names used are pseudonyms.