Out-of-Sync Cancer Care: Health Insurance Companies, Biomedical Practices, and Clinical Time in Colombia

Waiting for Care and Community Organizing for Serious Health-Related Suffering in Kerala, India

We explore the temporalities that shape and alleviate serious health-related suffering among those with chronic and terminal conditions in Kerala, India. Drawing on ethnographic fieldwork between 2009 and 2019, we examine the entanglements between waiting for care within dominant institutions and the community organizing that palliates this waiting. Specifically, people navigate multiple medical institutions, experience loneliness and abandonment, loss of autonomy, and delays and denials of recognition as they wait for care. Community palliative care organizations offering free, routine, home-based care provide samadhanam (peace of mind) and swatantrayam (self-determination) in lifeworlds mired with chronic waiting. We document how community care sustains an alternative politics of shared time, untethered from marketized notions of efficiency and productivity toward profits. In so doing, we cast in high relief community healthcare imaginaries that alleviate serious health-related suffering and reconfigure Global North-centric perspectives.

Untimely care: How the modern logics of coverage and medicine compromise children's health and development

How do families manage when health care systems do not "cover" and clinicians do not acknowledge their children's condition? This article presents an ethnographic study in the Northeastern region of the United States with 20 families with children diagnosed with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS)/Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). Two of the 20 families had moved to the U.S. seeking care. The for-profit structure of the U.S. health care system resulted in costly and lengthy therapeutic journeys to access a diagnosis and adequate treatments. In the U.S., PANS/PANDAS coverage depends on legislation, advocacy, clinical characteristics of each child, and how for-profit insurance companies react to an increased demand for a given service. Many medical professionals, both in the U.S. and in other countries, refuse to acknowledge the condition or offer effective treatments that lack "acceptable" evidence. We argue that the financial logic behind coverage exists across modern health care systems and imposes restrictions and exclusions that impede access to care. Thus, untimely care, the time gap from PANS/PANDAS symptoms to diagnosis and treatment is the result of the modern logics that structure medicine and coverage. The results of this study illustrate how modern medicine and coverage fail to protect families with children with PANS/PANDAS against catastrophic expenses and often block care that would prevent developmental disruptions and losses, avoid much suffering, and even save costs to health care systems. New and controversial conditions like PANS/PANDAS highlight the importance of separating the financial logics behind proposals such as "universal health coverage" from the provision of comprehensive forms of care that acknowledge uncertainty and prioritize action and flexibility.

Anthropology of new chronicities: illness experiences under the promise of medical innovation as long-term treatment

In the introduction to the special issue, Greco and Graber discuss the concept of chronicity and the ways it is used in the contributions to the special issue. Historians have shown that the concept of chronic disease has its origins in policy and has always been fluid and vague; however, the classic literature in sociology and nursing has focused on modelling the evolution of chronic disease rather than on examining the concept itself. In the introduction, chronicity is explored in the ways in which it is transformed by medical innovation. Innovations in biomedicine promise to turn terminal and acute conditions in chronic and to render chronic conditions curable. Even when such promises are not fulfilled, they change the context of the illness and the experiences of patients. In such a context a specific work is required from patients, in terms of adherence to the treatments, but also in terms of pursuing experimental treatments that could make their condition chronic. The introduction offers a critical exploration of the concept of chronicity, highlighting both its fluid definition and the changes linked to medical innovation, and the ways in which it shapes the temporalities and experiences of illness in complex ways that cannot be reduced to simplified schemas and trajectories.

Vaccinal chronicity: immunotherapy, primary care, and the temporal remaking of lung cancer's patienthood in Cuba

The Cuban biotechnology industry is producing cancer immunotherapy, in particular, therapeutic vaccines that actively stimulate the immune system to stabilise the tumour. These products aim to transform metastatic malignancies into a chronic disease. Since 2010, this therapeutic concept has been integrated within a public health experiment, consisting of the large distribution of immunotherapies, including in primary healthcare centres, to enhance access and assess its effectiveness on a wider population of patients. Such experimental intervention, consisting of post-marketing clinical trials, has focused only on lung cancer, one of the most widespread and lethal cancers on the island. Combining interviews with ethnographic observations focusing on care performed by professionals, patients, and their relatives, this paper analyses the experience of lung cancer chronicity under this type of immunotherapy in Cuba. It shows how a certain form of continuity is made between prophylactic and therapeutic vaccination to shape a new temporality of cancer care, through the integration within primary care, constant access to biotechnology, and multiple care practices directed to strengthen the immunotherapy's efficacy. If vaccinal chronicity remains fragile due to its experimental dimension and the fact that long-term survivorship is still an exceptional phenomenon, lung cancer patienthood is deeply transformed through a shared effort of the people and the state to provide more stable, meaningful, and inclusive care.

Taming Time: Configuring Cancer Patients as Research Subjects

This article explores how incurable cancer patients in the affluent Danish welfare state are recruited to clinical trials. We show that patients' impending death constitutes their potential for being configured as research subjects. To produce valuable data, patients who enroll in trials and health care professionals must engage in daily "time practices" that prolong the threshold between life and death. When death becomes inevitable, the limit of configuring dying cancer patients as research subjects is reached. Navigating this temporal logic, health care professionals balance the boundary between patients' instrumental worth as research subjects and their intrinsic worth as dying cancer patients. Whereas previous studies have critically uncovered how clinical trials operate at socioeconomic margins, we point to the ways in which clinical trials operate through temporal margins. We argue that clinical trials are dependent on configuring marginal societal spaces and marginal bodies from which to produce knowledge.

Game-changing? When Biomarker Discovery and Novel Forms of Patient Work Meet

I analyze the promised efficacy of Pembrolizumab, an immunotherapy regime under clinical trial for patients with metastatic colorectal cancer. Drawing on anthropological fieldwork with patients and health professionals in a gastrointestinal cancer clinic in London, UK, I tease out the dynamics through which scientists and clinicians assemble personalized technologies to halt cancer growth in patients' bodies; what patients undergo in order to participate in these innovations; and the constraints that restrict the efficacy of these treatments. Beyond examining the treatment possibilities that clinical trials offer, I illuminate some of the gaps made visible when personalization happens from below.

Medical labour under neoliberalism: an ethnographic study in Colombia

OBJECTIVES

In order to increase the knowledge about the impacts of neoliberal market forces on physician's labour, this article's objectives are to analyse how and why the labour of physicians is transformed by neoliberalism, and the implications of these transformations for patient care.

METHODS

Ethnographic investigation is carried out through semi-structured interviews with 20 general practitioners at public and private facilities in Colombia. The interviews were contrasted with national studies of physician's labour since the 1960s. A "mock" job search was also simulated. The analysis was guided by Marxian frameworks. The study was approved by a Human Research Ethics Committee, and informed consent was obtained from all participants.

RESULTS

The overpowering for-profit administration of the Colombian healthcare system imposes productivity mechanisms on physicians as a result of a deregulated labour market characterized by low salaries, reduced and self-funded social security benefits, and job insecurity. Overworked physicians with reduced autonomy become frustrated for not being able to provide the care their patients need according to clinical standards.

CONCLUSIONS

Under neoliberal conditions, medical labour becomes exploitable and directly productive through its formal and real subsumption to Capital. The negative consequences of a progressive loss in physician's autonomy unveil the incompatibility between neoliberal health systems and people's health.

Prevention and control of HPV infection and HPV-related cancers in Colombia- a meeting report

The Human Papillomavirus (HPV) Prevention and Control Board is an independent multidisciplinary board of international experts that disseminates relevant information on HPV to a broad array of stakeholders and provides guidance on strategic, technical and policy issues in the implementation of HPV control programs. In response to drastic drop of vaccine coverage following the adverse event crisis in Carmen del Bolivar, Colombia, the HPV Prevention and Control Board in collaboration with the Colombian National Cancer Institute and Colombian League Against Cancer convened a meeting in Bogota, Columbia (November 2018). The goal of the meeting was to bring together national and international group of experts to report the disease burden, epidemiology and surveillance of HPV and HPV-related cancers, to discuss the successes and especially the challenges of HPV vaccination and screening in Colombia, as well as the lessons learnt from neighbouring countries. The meeting provided a platform to confer various stakeholder's perspectives, including the role of the Colombian healthcare system and to catalyse various parts of the public health community in Colombia into effective action. The conclusion of the meeting included following suggestions to strengthen HPV prevention and control: 1) Re-introducing school-based vaccine programs, 2) Integrating primary and secondary prevention programs, 3) Developing an innovative crisis communication plan targeting healthcare workers, teachers and general population, 4) Building trust through efficient and timely communication, 5) Building strong relationship with media to ensure a stable vaccination campaign support, and 6) Promoting empathy among healthcare professionals towards patients to build trust and communicate effectively.

Primary Health Care for Universal Health Coverage? Contributions for a Critical Anthropological Agenda

Forty years after the Alma-Ata declaration, the WHO has reaffirmed its commitment to Primary Health Care (PHC). We argue that this renewed interest in PHC is being coopted by the neoliberal agenda on health via its application to Universal Health Coverage (UHC) reforms as part of the Sustainable Development Goals (SDGs). We offer an overview of classic anthropological studies on PHC, and more recent ones on UHC, as a way to propose some research foci and a set of questions for emerging critical anthropological research. Lastly, we suggest the careful reading of five recently published articles in Medical Anthropology.

Reliable information for cancer control in Cali, Colombia

BACKGROUND

The Cali Population Cancer Registry (RPCC) has been in continuous operation since 1962 with the objective of producing valid statistics on the incidence of cancer, its patterns, trends and survival rates.

METHODS

During the period 2008-2012, 23,046 new cases were registered and during 2011-2015 there were 12,761 cancer deaths. The trend of the rates was described with the APC average annual change rate and with the Joinpoint analysis. We analyzed the individual data of 38,671 adults (15-99 years) diagnosed with cancer between 1995-2009, and we calculated the standardized net survival by age for the 14 most common cancer body sites, using the Pohar-Perme method.

RESULTS

Prostate and breast cancer were the first cause of cancer morbidity. The incidence rates in these were susceptible to early detection, tumors stabilized after decades of growth, while an increase in the incidence of colon cancer and papillary thyroid carcinoma was observed. The incidence rates of cervical and stomach cancer and conditions related to infectious agents decreased, although the number of absolute cases increased, due to the growth and aging of the population. Gastric cancer was responsible for the highest number of cancer related deaths. The types of cancer related to tobacco consumption (lung, oral cavity, esophagus, pancreas, urinary bladder) showed low numbers and a tendency to decrease. During the period 2000-2004, the 5-year net survival improved for cancers of the breast, cervix, prostate, melanoma and thyroid, although in the period 2005-2009 a stagnation was observed. In stomach, liver and lung cancer, the 5-year net survival was less than 15%. The 5-year overall survival in children was 51.0% (95% CI: 47.5, 54.3) and in adolescents 44.6% (95% CI: 36.0, 52.8).

COMMENT

RPCC has been an advisor to the Colombian government in the evaluation of CPRs in the country and its data has contributed significantly to different aspects of cancer control in Colombia.