Biomedical techniques in context: on the appropriation of biomedical procedures and artifacts

Communicative trust in therapeutic encounters: users' experiences in public healthcare facilities and community pharmacies in Maputo, Mozambique

Interactions between healthcare users and providers are an essential but often problematic element in therapeutic processes. In many settings worldwide, there has been a general recognition of the importance of adopting care approaches that understand patients as active agents, moving away from traditional paternalistic forms of interaction. Research shows that improving the quality of communication in therapeutic encounters fosters mutual understanding and cooperation in healthcare processes, helping to create the grounding conditions for building trusting relationships. But what are the communicative mechanisms through which trust in healthcare providers is cultivated? Going beyond the traditional 'doctor-patient' dyad analysis, and using data from a mixed-method study on medicine use in Maputo, Mozambique, this paper explores healthcare users' experiences and interpretations of their interactions with public healthcare professionals (medical doctors and prescribing nurses) and community pharmacy workers (pharmacists, technicians and other attendants). The analysis evolves around various communicative and relational aspects, emphasised by users as meaningful and underpinning different qualities of care, competence, integrity and trustworthiness. These attributes were assessed based on a combination of verbal conversation and information exchange, together with the use of other (non-verbal) situationally valued artefacts such as biomedical tools and communicative rituals performed by providers. This study shows that despite healthcare providers' different attributes of competence and authority, it is mainly their communicative performances during interactions that influence whether (symbolic) trust has the space to evolve or crystallise. Moreover, while performing certain rituals may be an effective form of communication, the lack of other (verbal and non-verbal) communicative elements during the interaction may compromise patient trust in what is being prescribed or advised. Efforts to improve the quality and responsiveness of healthcare services centred around citizens' needs should take users' perspectives into account and pay particular attention to these communicative and relational dimensions.

Aligning in the dark: Variable and shifting (user-) settings in developing point-of-care diagnostics for tuberculosis and HIV

To be effective, healthcare technologies should be attuned to particular contexts of use. This article examines how such attuning is articulated in global innovation practices for tuberculosis and HIV diagnostics, and to what effect. It examines the development of point-of-care (POC) diagnostics - promised to be designed for users outside laboratories or in resource constrained settings - to study what developers and implementers do to align diagnostic technologies to the POC. Fieldwork among global health actors involved in diagnostic development, including manufacturers, donors, industry consultants, international organizations, policymakers, regulators and researchers, is combined with fieldwork among users of diagnostics in India, including decision-makers, NGOs, program officers, laboratory technicians and nurses. The article adds to STS's theory of alignment and user interaction, where the setting and user to which developers and implementers of global health diagnostics align are multiple, varied, emerging and keep shifting. The characteristics of a local user setting include multiple engaged and imagined user settings, but also the settings of developers, of global intermediaries, competitors and diseases. As such, alignment is happening across multiple dimensions and scales and has an important temporal dimension. The results reveal how alignment happens to some extent in the dark, characterized by uncertainty about the elements that should align. Standardizing elements, politics and scarce resources cause frictions in the temporalities of aligning and over what constitutes a well-aligned diagnostic.

Understanding physicians' professional knowledge and practice in research on skilled migration

Research on the integration of migrant professionals into high-skilled labor markets either focuses on differences between nation states which may be exacerbated by national closure or it celebrates the global versatility of professional knowledge, especially in the natural and health sciences. Building on a pragmatist approach to professional knowledge, the article argues that professional knowledge should not be seen as either universal or local, but both the institutionalized and the incorporated aspects of cultural capital are characterized by 'local universality'. Professionals recreate professional knowledge in specific 'local' situations by relating to universal standards and to internalized 'libraries' of situated expert experience. While the more common notion of knowledge as a socially contested resource continues to be relevant for research on skilled migration, professional knowledge should also be seen as emerging in situations in response to socio-material problems. These problems can be structured by the nation-state, but they can also be transnational in nature.

Assisted reproductive technologies in Ghana: transnational undertakings, local practices and 'more affordable' IVF

The article sketches the origins and development of IVF in Ghana as a highly transnational undertaking. Movements are from and to Africa, involving human beings (providers and users), and also refer to other entities such as technologies, skills and knowledge. None of these movements are paid for using public money, neither are they subsidized by international health organizations. Currently, 'more affordable' IVF is being introduced into Ghana, on initiative of the first Association of Childless Couples of Ghana (ACCOG), in collaboration with the Belgium based non-profit organization the Walking Egg (tWE), representing another form of transnational networking. The article underlines the scarcity of well-trained embryologists in Ghana, which turns the embryologists' expertise and skills into a scarce and precious commodity and guarantees this expertise becomes a major challenge for the directors of the private clinics. Next to local Ghanaian couples, the clinics also attend to transnational reproductive travellers, including women and men from neighbouring countries and Ghanaians in the diaspora returning to their country of origin. Their manifold motivations to cross borders and visit the IVF clinics in Ghana provide insight into the structural conditions impeding or facilitating the use of assisted reproductive technologies at different local sites. Transnational movements also include the flow of new procreation practices (such as surrogacy and the use of donor material), which (re-)shape existing cultural and societal notions regarding kinship and the importance of blood/genetic ties. Finally, the article lists a number of thematic and theoretical issues which require further exploration and studies.

'You cannot do IVF in Africa as in Europe': the making of IVF in Mali and Uganda

In sub-Saharan Africa, many gynaecologists and embryologists agree that 'you cannot do IVF in Africa as in Europe'. Based on empirical data from anthropological fieldwork, this article contrasts the establishment of IVF provision in a private fertility clinic in (francophone, Muslim-dominated) Mali with one in (anglophone, Christian-dominated) Uganda. Outlining the history of setting up IVF procedures at each site, the author shows the distinct ways in which the respective clinics have found to juggle structural challenges. The question of how religious moral concepts are integrated in the way in which assisted reproductive technology is practised at the two sites is also considered, revealing the moral ambivalences of practitioners and patients, donors and surrogates. By contrasting the processes of setting up IVF therapeutics in a Malian and a Ugandan clinic, the author shows that sub-Saharan African countries, although sharing similar historical positioning in global power topographies, structural and political shortcomings, nevertheless exhibit a range of developments and societal answers in response to the challenges, both moral and structural, inherent in establishing assisted reproductive technology-based infertility treatment.

Tuberculosis is a threshold: the making of a social disease in post-Soviet Georgia

In this article I use Margaret Lock's concept of local biology as a standpoint to view tuberculosis as a threshold where distinctions between social and biological aspects of disease are negotiated. I conceptualize tuberculosis as a threshold in two ways: first as a passageway, and second as a space for navigating the limits of tolerance to therapeutics. The article is based on ethnographic research about responses to tuberculosis in post-Soviet Georgia. I focus on how health professionals and patients make claims to social aspects of illness by recuperating historical examples for tuberculosis treatment as a moral commitment to society, and in the context of emergent patient-centered treatment services.