An anthropological writing (March 10th, 2023) by Tongtong (Petra) Yang for the course Anthro 216GH: Case Studies in Global Health with Professor Felicity Aulino
What is Structural Violence?
Kleinman et al. (1997) created the concept of social suffering. Farmer (2004) wrote about structural violence that pain and suffering is caused by the institutions, policies, and systems’ constraint of choices of certain groups.
Structural violence is important because we can use it to analyze how violence in global health issues was created by race, gender, class, ideologies, and other systems of oppression and institutions in action. While sufferings of individuals are important, seeing the pain geographically broad and historically deep can offer insight into the engine of the suffering. Analyzing the policies and systems limiting the agency of LGBTQIA+ people can help us understand where their suffering from psychological disorders come from: bashing, stigma about HIV/AIDS, criminalization, no marriage allowed, discrimination at workplace, daily stress to hide identity, and more.
Structural violence can be applied in global health interventions by analyzing the health concerns and suffering with regard to how individuals’ choices are limited and relevant policies and systems, then designing, running, reviewing, and evaluating the interventions addressing these mechanisms. In DOT treatment for TB in rural Bangladesh, this means that:
– to address poverty, paying the shasthya shebikas for their work, offer food to meet nutritional needs, and refine water and sanitation;
– to address lack of health literacy, providing households with basic health education;
– to meet basic health needs, analyze the current health system and collaborate with the government to run health insurance;
– to understand other contributors to the suffering caused by systems, analyze how race and ethnicity, political ideologies, gender and patriarchy, and other types of oppression created the TB situation.
(ideas in italics are those I did not find in the BRAC’s TB Program report and might have been investigated)
What is Social Construction of reality/knowledge?
Berger and Luckmann (1996) created social construction of reality/knowledge. It is that all we know, despite perceived as objective, is socially constructed, specifically through habituation, institutionalization, and legitimation. Habituation is the process of learning through practicing routines to the point that the routine/action becomes a habit. Institutionalization is the process of establishing ways in which things are done and thus the way to do things, and maintaining “authority over the individual.” Legitimation is the process by which the institutions are justified through telling the new generations the institutional history while they are socialized.
This concept is important because it reminds us to examine our knowledge by thinking how it is embedded in the society, habituated, and institutionalized, and who defined and are defining the knowledge. When pharmaceutical companies developed the medicines and the clinics sell the medicines at certain prices, our knowledge of “we can access the medicines and health only by purchasing this medicine at this price” is habituated by seeing people around us buy medicines at a price and us buying more and more medicines; and institutionalized by pharmaceutical companies and clinics setting the needing-meds and being-healthy way as “buying meds at this fixed price and keeping yourself healthy,” also by limiting other ways to access meds and health.
This concept can be applied in global health interventions by analyzing what constitutes habituation, institutionalization, and legitimization within the region and health situation; designing the program addressing these constituents; and refining and evaluating the intervention with these constituents as part of the criteria. For HIV Care in Rwanda, this application means first analyzing the history of Rwanda politics, economics, and healthcare, how HIV and other health problems have been treated and the pros and cons of these interventions, the governmental and NGO relationships in the interventions, and the daily routines of local people of different generations and what they know and are used to about HIV care (by observation and interviewing). Second, designing the program responding to these analyses. Third, keep analyzing and refining in the intervention process by maintaining a good communication network. Fourth, assess the results of care and present the new knowledge formed (personal and institutional) after the intervention and new reality’s implications about healthcare, economics, politics, and the local life.
(ideas in italics are those I did not find in the Partners in Health: HIV Care in Rwanda 2010 report and might have been investigated)
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What is multi-drug resistant (MDR)-TB? What characteristics of tuberculosis transmission and treatment lead to drug resistance? Why is a biosocial lens particularly useful for understanding this disease and designing interventions?
Multi-drug resistant (MDR)-TB is the tuberculosis (caused by Mycobacterium tuberculosis) strain resistant to at least INH and RIF in the multiple drug chemotherapy treatment. MDR-TB occurs when naturally occurring mutants become favored during the course of inadequate therapy or being transmitted the drug resistant strain TB directly. It spreads by breathing in the air which TB bacteria is put into by coughing, sneezing, speaking, and singing. A biosocial lens is useful for understanding MDR-TB by looking into the biological, social, political, economic, historical, and environmental processes which led to the emergence and transmission of MDR-TB, which is more likely to happen in certain communities.
In 1990s Tomsk, Russia, TB and MDR-TB drug resistance emerged and stayed most in communities where social forces – of political changes, breakdown of health services, alcohol addiction, overcrowded and underfunded hospitals, overcrowded prisons and detention centers, poverty (unemployment and homelessness), and socioeconomic unequal access to care – were prominent. People facing these challenges were unable to complete 6 months of treatment for regular TB. More transmissions of TB and the drug-resistant strain happened in overcrowded areas. Homeless people were also vulnerable to MDR-TB after social services offering food and shelter disappeared. Before the ambulatory treatment program, people were unable to complete 18-24 months of inpatient treatment with second-and third-line medications given under direct observation and management of side effects for MDR-TB. Interventions including DOTS, DOTS-Plus, and Sputnik addressed these challenges. Social processes in the midst of a global health problem are important and a biosocial lens including the social theories can help stakeholders and others understand the problem and design interventions.