1
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Bundy H. "Don't fuss at our staff": A moral economy of volunteerism in South Carolina safety net clinics. Soc Sci Med 2024; 347:116706. [PMID: 38489962 DOI: 10.1016/j.socscimed.2024.116706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 02/05/2024] [Accepted: 02/19/2024] [Indexed: 03/17/2024]
Abstract
In South Carolina, a state that has foregone Medicaid expansion, working poor residents often rely on safety net clinics for medical care. This care often occurs far from major hospitals, in different, inferior, spaces where limited services are provided in lesser circumstances. The temporary and conditional aid provided in these clinics is meant as a last resort, but often serves as the only source of care for many working poor patients, who must manage the effects of sustained precarity and protracted immiseration with conditional aid provided by volunteers. Here I explore the function that volunteering plays in regulating patients' utilization, and ability to contest, the quality of safety net care. Using ethnographic examples and interview data I show how the needs of patients-referred to in the clinics as "clients"-are managed and contained by a moral economy of volunteer care. These reciprocal obligations of debt and duty preclude working poor patients from making demands of, or lodging complaints against, the free clinics' staff, due to their capacity as volunteers, and leaves the state's safety net effectively unassailable to accusations of inefficacy or neglect. Consequently, patients must defer care, ignore episodes of maltreatment, and ration and share prescription medications, lest they be considered recusant or deemed not sufficiently appreciative of the volunteer staff dedicating their time to them. As a result of this moral economy, the plight of the state's uninsured working poor residents goes under-recognized as the safety net absorbs their cases, hiding the attritional nature of the ostensibly free care they receive and ration.
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Affiliation(s)
- Henry Bundy
- Department of Social Sciences and Health Policy, Wake Forest University, 475 Vine Street, Winston-Salem, NC, 27101, USA.
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2
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Martínez-Rodríguez A, Martínez-Faneca L, Fabrellas N. Construction of nursing knowledge in commodified contexts: Views and experiences of nurses regarding primary care. Nurs Inq 2023; 30:e12579. [PMID: 37427491 DOI: 10.1111/nin.12579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 06/17/2023] [Accepted: 06/23/2023] [Indexed: 07/11/2023]
Abstract
The commodification of health care, particularly primary care, presents challenges to care and knowledge development. The purpose of this study is to examine how nurses perceive and develop their knowledge in a commodified context. A mixed-methods study was conducted that included a closed-question survey and in-depth interviews with nurses in public primary care in Catalonia. There were 104 valid responses to the questionnaire and 10 in-depth interviews. The main findings of the survey were related to workload and limited time for nursing care. Six themes emerged from the in-depth interviews: (1) limited time for nursing, (2) feelings of burnout, (3) awareness of patient and family satisfaction, (4) organizational factors that favor nurses' needs, (5) organizational factors that hinder nurses' needs, and finally (6) public administration requirements. Participants perceive excessive workload and time constraints and feel that this affects their nursing care and their physical and mental health. However, nurses purposefully use knowledge patterns to cope with the problems associated with commodification. Nurses have multidimensional, contextualized, and integrated knowledge that allows them to optimize their care based on the needs of their patients. This research examines many challenges related to nursing practice and the nursing discipline and opens the door for further research that encompasses all areas of nursing.
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Affiliation(s)
- Ana Martínez-Rodríguez
- Departament d'infermeria fonamental i mèdicoquirúrgica, Facultat de Medicina i Ciències de la Salut, Escola d'Infermeria, Universitat de Barcelona, Barcelona, Spain
- August Pi i Sunyer Campus Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Laura Martínez-Faneca
- August Pi i Sunyer Campus Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Núria Fabrellas
- Departament d'infermeria fonamental i mèdicoquirúrgica, Facultat de Medicina i Ciències de la Salut, Escola d'Infermeria, Universitat de Barcelona, Barcelona, Spain
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3
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LaRusso M, Gallego-Pérez DF, Abadía-Barrero CE. Untimely care: How the modern logics of coverage and medicine compromise children's health and development. Soc Sci Med 2023; 319:114962. [PMID: 35584978 DOI: 10.1016/j.socscimed.2022.114962] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/22/2022] [Accepted: 04/03/2022] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Maria LaRusso
- Human Development and Family Sciences, University of Connecticut, USA
| | - Daniel F Gallego-Pérez
- Department of Physical Medicine & Rehabilitation, University of North Carolina School of Medicine, USA
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4
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Smith-Morris C, Juaréz-López BM, Tapia A, Shahim B. Indigenous sovereignty, data sourcing, and knowledge sharing for health. Glob Public Health 2022; 17:2665-2675. [PMID: 35358022 DOI: 10.1080/17441692.2022.2058049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In this article, we consider the impacts of the COVID-19 pandemic on Indigenous Peoples (IPs) by reporting on information-gathering work across two non-governmental and Indigenous organisations to compensate where federal systems failed. Strategies IPs have employed to understand and respond to the pandemic, and described here, include: collaborative efforts across communities intra- and inter-nationally; open-source data platforms; and small-scale epidemiological research. Our review exposes the informational politics faced by Indigenous organisations and communities, and their struggle to pursue needed resources or protections while avoiding the critiques of 'post-neoliberal' and 'science denialism'. We conclude by suggesting ways that Indigenous communities improve our understanding of their needs during public health crises, and maintain both informational and medical self-governance.
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Affiliation(s)
- Carolyn Smith-Morris
- Department of Anthropology, Southern Methodist University, Dedman College of Humanities and Sciences, Dallas, USA
| | | | | | - Bheshta Shahim
- Department of Anthropology, Southern Methodist University, Dedman College of Humanities and Sciences, Dallas, USA
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5
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Chan IL. Translating international health policies into lived realities: Maternal health, social support programs, and obstetric violence in highland Peru. WOMENS STUDIES INTERNATIONAL FORUM 2022. [DOI: 10.1016/j.wsif.2022.102600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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6
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Jabbar H, Menashy F. Economic Imperialism in Education Research: A Conceptual Review. EDUCATIONAL RESEARCHER (WASHINGTON, D.C. : 1972) 2022; 51:279-288. [PMID: 38250711 PMCID: PMC10798664 DOI: 10.3102/0013189x211066114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
In this review, we explore economic imperialism, a concept that captures the phenomenon of a single discipline's power over so many facets of social life and policy-including education. Through a systematic search, we examine how economic imperialism has been conceptualized and applied across fields. We uncovered three key, interconnected elements of economic imperialism that hold relevance for education research. First, economics has colonized other disciplines, narrowing the lens through which policymakers have designed education reforms. Second, an overreliance on economic rationales for human behavior neglects other explanations. Third, a focus on economic outcomes of education has subjugated other important aims of education. We share implications for researchers to use economic theory in ways that are interdisciplinary but not imperialist.
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7
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Health and immigration systems as an ethnographic field: Methodological lessons from examining immigration enforcement and health in the US. Soc Sci Med 2021; 300:114498. [PMID: 34893355 DOI: 10.1016/j.socscimed.2021.114498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 10/07/2021] [Accepted: 10/18/2021] [Indexed: 11/22/2022]
Abstract
The complexity of health systems and their social, political, and economic contexts has resulted in a call for multidisciplinary research that can appropriately examine the relationships and interactions surrounding health systems. Anthropologists, who have a disciplinary training that emphasizes social structures and human relationships, are well-suited to conduct health systems research. However, there remains a gap in anthropologically-ground methodological approaches for conducting in-depth, qualitative research that simultaneously conceptualizes and maps out a health system and examines connections between health systems and other social structures, such as immigration enforcement systems. Without such methodological approaches, limitations in examining a health system and its constituent elements will persist, and health and social scientists will miss opportunities to identify links between different factors in a health system and outside the system itself. In this article, I use ethnographic research examining the health-related consequences of immigration enforcement laws and police practices in the United States to show how to examine relationships between multiple social systems. In doing so, I provide an example for how to conduct in-depth, qualitative health systems research by merging theoretical frameworks in health sciences and anthropology to demonstrate how medical anthropologists can conceptualize a health system as a social field for ethnographic inquiry. Overall, I argue that such an approach permits anthropologists a way to conduct rigorous health systems research that emphasizes relationships and reveals potentially hidden interactions.
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8
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Closser S, Mendenhall E, Brown P, Neill R, Justice J. The anthropology of health systems: A history and review. Soc Sci Med 2021; 300:114314. [PMID: 34400012 DOI: 10.1016/j.socscimed.2021.114314] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 12/17/2022]
Abstract
Ethnographies of health systems are a theoretically rich and rapidly growing area within medical anthropology. Critical ethnographic work dating back to the 1950s has taken policymakers and health staff as points of entry into the power structures that run through the global health enterprise. In the last decade, there has been a surge of ethnographic work on health systems. We conceptualize the anthropology of health systems as a field; review the history of this body of knowledge; and outline emergent literatures on policymaking, HIV, hospitals, Community Health Workers, health markets, pharmaceuticals, and metrics. High-quality ethnographic work is an excellent way to understand the complex systems that shape health outcomes, and provides a critical vantage point for thinking about global health policy and systems. As theory in this space develops and deepens, we argue that anthropologists should look beyond the discipline to think through what their work does and why it matters.
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Affiliation(s)
- Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Rm E5545, Baltimore, MD, 21205, USA.
| | - Emily Mendenhall
- Science, Technology and International Affairs Program, Edmund A. Walsh School of Foreign Service, Georgetown University, USA
| | - Peter Brown
- Department of Anthropology, Emory University, USA
| | - Rachel Neill
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Judith Justice
- Institute for Health and Aging, School of Nursing, University of California, San Francisco, USA
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9
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Mulligan JM, Weil M. A Eulogy for Jane Robinson: A Social Autopsy of Uncare Policies. Med Anthropol Q 2021; 36:27-43. [PMID: 34350615 DOI: 10.1111/maq.12664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 12/01/2022]
Abstract
Shortly after losing her health insurance in 2018, Jane Robinson died of a treatable respiratory infection. This article argues that Jane's death occurred at the nexus of two different approaches to care: the necropolitics of uncare and the micropolitics of generative care labor. Both of these approaches to care increased Jane's health and social vulnerability, in turn quickening her death. We adopt the necropolitics of uncare framework to identify and name the harmful policies and attitudes of disregard that control access to life saving medical care. In the micropolitics of care in Jane's life, she became the safety net for others, which left little over when her health began to deteriorate. This social autopsy reveals that her care networks were insufficient to undo the uncare enshrined in state policy. Jane's unnecessary death foreshadowed the excess mortality that the United States has experienced from COVID-19.
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Affiliation(s)
- Jessica M Mulligan
- Health Policy and Management Department, Providence College, Providence, RI
| | - Madeline Weil
- Health Care Programs, NORC at the University of Chicago, Bethesda, MA
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10
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Abstract
As a result of reforms aimed at adjusting it to the market economy, the Polish health care system has become a complicated mix of public and private services. Using as an example maternity services, I show how private services allow a subtle process of patient selection to emerge, contributing to the fragmentation of public care. The process of selection is based on social relations formed between health care providers and patients through the use of private services. This has a negative impact on women who do not have the social or financial resources to engage in private services.W wyniku reform mających na celu dostosowanie do gospodarki rynkowej, opieka zdrowotna w Polsce przekształcona została w skomplikowaną mieszaninę usług publicznych i prywatnych. Na podstawie świadczeń położniczych, pokazuję, w jaki sposób prywatne usługi zdrowotne stały się "oknami" pozwalającymi na subtelną selekcję pacjentów. Selekcja ta oparta jest na relacjach społecznych nawiązywanych pomiędzy lekarzem/położną a pacjentką przy okazji korzystania z prywatnych usług i prowadzi do fragmentaryzacji opieki publicznej. Proces ten szczególnie negatywnie wpływa na kobiety, których zasoby społeczne i finansowe nie pozwalają na korzystanie z prywatnych usług zdrowotnych.
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Affiliation(s)
- Maria Węgrzynowska
- Department of Midwifery, Centre for Postgraduate Medical Education, Warsaw, Poland
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11
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Fleming MD, Shim JK, Yen I, Thompson-Lastad A, Burke NJ. Patient Engagement, Chronic Illness, and the Subject of Health Care Reform. Med Anthropol 2020; 40:214-227. [PMID: 32946278 DOI: 10.1080/01459740.2020.1820500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In the United States, in the wake of health care reform, health care systems have been subject to intensifying demands to increase patient engagement, a term that refers broadly to participation in care. We draw from ethnographic research in urban health care safety-net settings in California to examine efforts to increase patient engagement among chronically ill, marginalized patients who have long been disconnected from outpatient care. We suggest that the work of engagement in this context involved getting people to accept the norms of biomedicine while also reworking these norms to account for the complex circumstances of their lives.
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12
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Dao A. What it means to say "I Don't have any money to buy health insurance" in rural Vietnam: How anticipatory activities shape health insurance enrollment. Soc Sci Med 2020; 266:113335. [PMID: 32932002 DOI: 10.1016/j.socscimed.2020.113335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/29/2020] [Accepted: 08/25/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Amy Dao
- Department of Geography and Anthropology, Cal Poly Pomona. 3801 W. Temple Ave, Pomona, CA, 91768, United States.
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13
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Lee AA, James AS, Hunleth JM. Waiting for care: Chronic illness and health system uncertainties in the United States. Soc Sci Med 2020; 264:113296. [PMID: 32866715 PMCID: PMC7435333 DOI: 10.1016/j.socscimed.2020.113296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 11/17/2022]
Abstract
Structures of power and inequality shape day-to-day life for individuals who are poor, imposing waiting in multiple forms and for a variety of services, including for healthcare (Andaya, 2018a; Auyero, 2012; Strathmann and Hay, 2009). Constraints, such as the age requirements for Medicare, losing employer-provided health insurance, or the bureaucracy involved in filing for disability often require people to wait to follow recommendations for medical treatments. In 2016–2017, we conducted 52 narrative interviews in St. Louis, a city with significant racial and economic health inequities and without Medicaid expansion. We interviewed people with one or more chronic illnesses for which they were prescribed medication and who identified as having difficulties affording their prescriptions. Throughout the interviews, participants frequently recounted 1) experiences of waiting for care, along with other services, and 2) the range of strategies they utilized to manage the waiting. In this article, we develop the concept of active waiting to describe both the lived experiences of waiting for care and the responses that people devise to navigate, shorten, or otherwise endure waiting. Waiting is structured into healthcare and other social services at various scales in ways that reinforce feelings of marginalization, and also that require work on the part of those who wait. While much medical and public health research focuses on issues of diagnostic or treatment delay, we conclude that this conceptualization of active waiting provides a far more productive frame for accurately understanding the emotional and physical experiences of individuals who are disproportionately poor and made to wait for their care. Only with such understanding can we hope to build more just and compassionate social systems. Poor and chronically ill people wait to receive medical care and social services. People wait actively, making decisions to manage the repercussions of waiting. The idea of delaying care is inadequate to explain realities of illness and poverty. Waiting broadens and deepens structural vulnerability for marginalized people.
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Affiliation(s)
- Amanda A Lee
- Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8100, St. Louis, MO, 63110, USA; University of Arizona, School of Anthropology, 1009 E. South Campus Drive, Room 210, Tucson, AZ, 85721, USA
| | - Aimee S James
- Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8100, St. Louis, MO, 63110, USA
| | - Jean M Hunleth
- Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8100, St. Louis, MO, 63110, USA.
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14
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Manelin EB. Health Care Quality Improvement and the Ambiguous Commodity of Care. Med Anthropol Q 2020; 34:361-377. [PMID: 32767465 DOI: 10.1111/maq.12608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 06/24/2020] [Accepted: 07/01/2020] [Indexed: 11/26/2022]
Abstract
Quality of care has become a major concern of the U.S.'s health care system in recent decades thanks to an energetic social movement and, more recently, interest from health insurers. Ethnographic research at a primary care clinic engaged in an array of quality improvement efforts revealed that physicians navigate two incommensurable views of quality: one aligned with the metric-oriented quality movement, and the other based on a humanistic vision of their professional role. Against the backdrop of a financialized health care system, these two views represent "differentiated ties" with respect to health care as a commodity. Furthermore, they are used to justify a broad division of labor where support staff and clinic leaders relieve physicians of responsibility for managing, implementing, and reporting quality efforts. These differentiated ties reveal the fundamental ambiguity of health care as a commodity, the resolution of which is a central-albeit implicit-motive of the quality movement.
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15
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Martínez-Rodríguez A, Martínez-Faneca L, Casafont-Bullich C, Olivé-Ferrer MC. Construction of nursing knowledge in commodified contexts: A discussion paper. Nurs Inq 2020; 27:e12336. [PMID: 31976615 DOI: 10.1111/nin.12336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 11/15/2019] [Accepted: 11/17/2019] [Indexed: 01/24/2023]
Abstract
This original article outlines a theoretical path and posterior critical analysis regarding two relevant matters in modern nursing: patterns of knowing in nursing and commodification contexts in contemporary health systems. The aim of our manuscript is to examine the development of basic and contextual nursing knowledge in commodified contexts. For this purpose, we outline a discussion and reflexive dialogue based on a literature search and our clinical experience. To lay the foundation for an informed discussion, we conducted a literature search and selected relevant articles in English, Spanish, and Portuguese that included contents on patterns of knowing, commodification, and nursing published from 1978 to 2017. Globalization, commodification, and austerity measures seem to have negative effects on nursing. Work conditions are worsening, deteriorating nurse-patient relationships, and limiting reflection on practice. Nurses must develop knowledge to challenge and participate in institutional organization and public health policies. Development of nursing knowledge may be difficult to achieve in commodified environments. Consequently, therapeutic care relationships, healthcare services, and nurses' own health are compromised. However, by obtaining organizational, sociopolitical, and emancipatory knowledge, nurses can use strategies to adapt to or resist commodified contexts while constructing basic knowledge.
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Affiliation(s)
- Ana Martínez-Rodríguez
- Departament d'infermeria fonamental i mèdicoquirúrgica, Facultat de Medicina i Ciències de la Salut, Escola d'Infermeria, Universitat de Barcelona, Barcelona, Spain.,Hospital Clínic de Barcelona, Barcelona, Spain
| | | | | | - Maria Carmen Olivé-Ferrer
- Departament d'infermeria fonamental i mèdicoquirúrgica, Facultat de Medicina i Ciències de la Salut, Escola d'Infermeria, Universitat de Barcelona, Barcelona, Spain
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16
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González-Agüero M, Chenhall R, Basnayake P, Vaughan C. Inequalities in the Age of Universal Health Coverage: Young Chileans with Diabetes Negotiating for Their Right to Health. Med Anthropol Q 2019; 34:210-226. [PMID: 31637732 DOI: 10.1111/maq.12555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 09/10/2019] [Accepted: 09/23/2019] [Indexed: 01/05/2023]
Abstract
While universal health coverage (UHC) has been praised as a powerful means to reduce inequalities and improve access to health globally, little has been said about how patients experience and understand its implementation locally. In this article, we explore the experiences of young Chileans with type 1 diabetes when seeking care in Santiago, within Chile's UHC program, which sought to improve people's access to health care. We argue that the implementation of UHC, within a structurally fragmented health system, did not lead to the promised equitable health care delivery. Although UHC aimed to equitably provide universal care, locally it materialized in heterogeneous configurations forcing individuals into positions of precarity and generating new inequalities. Furthermore, for the young people in the study, UHC intersected with their health insurance and socioeconomic status, impacting on the health care they could access, consequently making diabetes care and management a difficult challenge.
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Affiliation(s)
| | - Richard Chenhall
- Melbourne School of Population and Global Health, The University of Melbourne
| | - Prabhathi Basnayake
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne
| | - Cathy Vaughan
- Gender and Women's Health Unit, Melbourne School of Population and Global Health, The University of Melbourne
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17
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Kline N. When deservingness policies converge: US immigration enforcement, health reform and patient dumping. Anthropol Med 2019; 26:280-295. [PMID: 31550907 DOI: 10.1080/13648470.2018.1507101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
As immigration and health policy continue to be contentious topics globally, anthropologists must examine how policy creates notions of health-related deservingness, which may have broad consequences. This paper explores hidden relationships between immigration enforcement laws and the most recent health reform law in the United States, the Patient Protection and Affordable Care Act (ACA), which excludes immigrants from certain types of health services. Findings in this paper show how increasingly harsh immigration enforcement efforts provide health facilities a 'license to discriminate' against undocumented immigrants, resulting in some facilities 'dumping' undocumented patients or unlawfully transferring them from one hospital to another. Due to changes made through the ACA, patient dumping disproportionately complicates public hospitals' financial viability and may have consequences on public facilities' ability to provide care for all indigent patients. By focusing on the converging consequences of immigrant policing and health reform, findings in this paper ultimately show that examining deservingness assessments and how they become codified into legislation, which I call 'deservingness projects', can reveal broader elements of state power and demonstrate how such power extends beyond targeted populations. Exercises of state power can thus have 'spillover effects' that harm numerous vulnerable populations, highlighting the importance of medical anthropology in documenting the broad, hidden consequences of governmental actions that construct populations as undeserving of social services.
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Affiliation(s)
- Nolan Kline
- Rollins College, Anthropology, Winter Park, Florida, USA
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18
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Abstract
Drawing on archival evidence, I document the emergence and florescence of three free health clinics in Chicago in the late 1960s. I trace the centers' forceful removal by the city's Board of Health, and their subsequent replacement by Federally Qualified Health Centers (FHQCs). I argue that the demise of the free centers is exemplary of a broader trend in US health policy of regulating and diminishing the health care options of poor Americans. By highlighting the stark contrast between Chicago's free health centers of the 1960s and the health care services offered by contemporary FQHCs, I reveal a gradual shift from health care rights to accessing care in the US health care safety net.
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Affiliation(s)
- Jessica Jerome
- Department of Health Sciences, DePaul University , Chicago , Illinois , USA
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19
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Farfán-Santos E. Undocumented Motherhood: Gender, Maternal Identity, and the Politics of Health Care. Med Anthropol 2019; 38:523-536. [PMID: 30917082 DOI: 10.1080/01459740.2019.1587421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Undocumented Mexican immigrants have had to regularly confront a prohibiting health care system despite alienation, marginalization, and the threat of deportation. In this article, I explore the impact of political exclusion and alienating discourses on the health habitus of undocumented Mexican mothers through the narrative of one mother, Marta Garza, who finds herself at the painful intersection of political and medical alienation. Marta's narrative reflects an analytical framework that centers undocumented motherhood as a space of necessary resilience and strain, wherein she is forced to advocate for her children's health despite prohibitive barriers and dangerous potential consequences.
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Castillo CG. What the Doctors Don't See: Physicians as Gatekeepers, Injured Latino Immigrants, and Workers' Compensation System. ANTHROPOLOGY OF WORK REVIEW 2018. [DOI: 10.1111/awr.12149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Saxton DI, Stuesse A. Workers' Decompensation: Engaged Research with Injured Im/migrant Workers. ANTHROPOLOGY OF WORK REVIEW 2018. [DOI: 10.1111/awr.12147] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Stuesse A. When They're Done with You: Legal Violence and Structural Vulnerability among Injured Immigrant Poultry Workers. ANTHROPOLOGY OF WORK REVIEW 2018. [DOI: 10.1111/awr.12148] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Kline N. Life, Death, and Dialysis: Medical Repatriation and Liminal Life among Undocumented Kidney Failure Patients in the United States. POLAR-POLITICAL AND LEGAL ANTHROPOLOGY REVIEW 2018. [DOI: 10.1111/plar.12269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fleming MD, Shim JK, Yen I, Natta M, Hanssmann C, Burke NJ. Caring for “Super‐utilizers”: Neoliberal Social Assistance in the Safety‐net. Med Anthropol Q 2018; 33:173-190. [DOI: 10.1111/maq.12481] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 04/18/2018] [Accepted: 04/26/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Mark D. Fleming
- Department of AnthropologyHistory and Social Medicine University of California San Francisco
| | - Janet K. Shim
- Department of Social and Behavioral SciencesUniversity of California San Francisco
| | - Irene Yen
- Department of MedicineUniversity of California San Francisco
| | - Meredith Natta
- Department of Social and Behavioral SciencesUniversity of California San Francisco
| | | | - Nancy J. Burke
- Public HealthUniversity of California Merced
- Department of Anthropology, History and Social MedicineUniversity of California San Francisco
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McCullough K, Dalstrom M. I am insured but how do I use my coverage: Lessons from the front lines of Medicaid reform. Public Health Nurs 2018; 35:568-573. [DOI: 10.1111/phn.12525] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Laverty L, Harris R. Can conditional health policies be justified? A policy analysis of the new NHS dental contract reforms. Soc Sci Med 2018; 207:46-54. [PMID: 29730549 DOI: 10.1016/j.socscimed.2018.04.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 04/16/2018] [Accepted: 04/24/2018] [Indexed: 10/17/2022]
Abstract
Conditional policies, which emphasise personal responsibility, are becoming increasingly common in healthcare. Although used widely internationally, they are relatively new within the UK health system where there have been concerns about whether they can be justified. New NHS dental contracts include the introduction of a conditional component that restricts certain patients from accessing a full range of treatment until they have complied with preventative action. A policy analysis of published documents on the NHS dental contract reforms from 2009 to 2016 was conducted to consider how conditionality is justified and whether its execution is likely to cause distributional effects. Contractualist, paternalistic and mutualist arguments that reflect notions of responsibility and obligation are used as justification within policy. Underlying these arguments is an emphasis on preserving the finite resources of a strained NHS. We argue that the proposed conditional component may differentially affect disadvantaged patients, who do not necessarily have access to the resources needed to meet the behavioural requirements. As such, the conditional component of the NHS dental contract reform has the potential to exacerbate oral health inequalities. Conditional health policies may challenge core NHS principles and, as is the case with any conditional policy, should be carefully considered to ensure they do not exacerbate health inequities.
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Affiliation(s)
- Louise Laverty
- Department of Health Services Research, Institute of Psychology Health and Society, University of Liverpool, UK.
| | - Rebecca Harris
- Department of Health Services Research, Institute of Psychology Health and Society, University of Liverpool, UK.
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Getrich CM, García JM, Solares A, Kano M. Buffering the Uneven Impact of the Affordable Care Act: Immigrant-serving Safety-net Providers in New Mexico. Med Anthropol Q 2017; 32:233-253. [PMID: 28556358 DOI: 10.1111/maq.12391] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 05/16/2017] [Accepted: 05/17/2017] [Indexed: 11/30/2022]
Abstract
We conducted a study in early 2014 to document how the initial implementation of the Affordable Care Act (ACA) affected health care provision to different categories of immigrants from the perspective of health care providers in New Mexico. Though ACA navigators led enrollment, a range of providers nevertheless became involved by necessity, expressing concern about how immigrants were faring in the newly configured health care environment and taking on advocacy roles. Providers described interpreting shifting eligibility and coverage, attending to vulnerable under/uninsured patients, and negotiating new bureaucratic barriers for insured patients. Findings suggest that, like past efforts, this recent reform to the fragmented health care system has perpetuated a condition in which safety-net clinics and providers are left to buffer a widening gap for immigrant patients. With possible changes to the ACA ahead, safety-net providers' critical buffering roles will likely become more crucial, underscoring the necessity of examining their experiences with past reforms.
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Affiliation(s)
| | | | - Angélica Solares
- Clinical and Translational Science Center, University of New Mexico
| | - Miria Kano
- Comprehensive Cancer Center, University of New Mexico
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The problem of choice: From the voluntary way to Affordable Care Act health insurance exchanges. Soc Sci Med 2017; 181:34-42. [DOI: 10.1016/j.socscimed.2017.03.055] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 03/23/2017] [Accepted: 03/25/2017] [Indexed: 11/19/2022]
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Dao A, Mulligan J. Toward an Anthropology of Insurance and Health Reform: An Introduction to the Special Issue. Med Anthropol Q 2016; 30:5-17. [PMID: 26698645 DOI: 10.1111/maq.12271] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This article introduces a special issue of Medical Anthropology Quarterly on health insurance and health reform. We begin by reviewing anthropological contributions to the study of financial models for health care and then discuss the unique contributions offered by the articles of this collection. The contributors demonstrate how insurance accentuates--but does not resolve tensions between granting universal access to care and rationing limited resources, between social solidarity and individual responsibility, and between private markets and public goods. Insurance does not have a single meaning, logic, or effect but needs to be viewed in practice, in context, and from multiple vantage points. As the field of insurance studies in the social sciences grows and as health reforms across the globe continue to use insurance to restructure the organization of health care, it is incumbent on medical anthropologists to undertake a renewed and concerted study of health insurance and health systems.
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Affiliation(s)
- Amy Dao
- Department of Sociomedical Sciences, Columbia University
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Dillon PJ, Basu A. African Americans and Hospice Care: A Culture-Centered Exploration of Enrollment Disparities. HEALTH COMMUNICATION 2016; 31:1385-1394. [PMID: 27007165 DOI: 10.1080/10410236.2015.1072886] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Over the past decade, scholars and practitioners have called for efforts to reduce disparities in the cost and quality of end-of-life care; a key contributor to these disparities is the underuse of hospice care by African American patients. While previous studies have often relied on interviewing minority individuals who may or may not have been terminally ill and of whom few were using hospice care services, this essay draws upon the culture-centered approach to report the findings of a grounded theory analysis of 39 interviews with 26 African American hospice patients (n = 10) and lay caregivers (n = 16). Participants identified several barriers to hospice enrollment and reported how they were able to overcome these barriers by reframing/prioritizing cultural values and practices, creating alternative goals for hospice care, and relying on information obtained outside the formal health system. These findings have implications for understanding hospice experiences, promoting hospice access, and improving end-of-life care.
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Affiliation(s)
| | - Ambar Basu
- b Department of Communication , University of South Florida
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Tesser CD, Norman AH. Differentiating clinical care from disease prevention: a prerequisite for practicing quaternary prevention. CAD SAUDE PUBLICA 2016; 32:e00012316. [PMID: 27783750 DOI: 10.1590/0102-311x00012316] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 07/20/2016] [Indexed: 11/22/2022] Open
Abstract
This article contends that the distinction between clinical care (illness) and prevention of future disease is essential to the practice of quaternary prevention. The authors argue that the ongoing entanglement of clinical care and prevention transforms healthy into "sick" people through changes in disease classification criteria and/or cut-off points for defining high-risk states. This diverts health care resources away from those in need of care and increases the risk of iatrogenic harm in healthy people. The distinction in focus is based on: (a) management of uncertainty (more flexible when caring for ill persons); (b) guarantee of benefit (required only in prevention); (c) harm tolerance (nil or minimal in prevention). This implies attitudinal differences in the decision-making process: greater skepticism, scientism and resistance towards preventive action. These should be based on high-quality scientific evidence of end-outcomes that displays a net positive harm/benefit ratio.
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Affiliation(s)
- Charles Dalcanale Tesser
- Centro de Ciências da Saúde, Universidade Federal de Santa Catarina, Florianópolis, Brasil.,Centro de Estudos Sociais, Universidade de Coimbra, Coimbra, Portugal
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Leem SY. The anxious production of beauty: Unruly bodies, surgical anxiety and invisible care. SOCIAL STUDIES OF SCIENCE 2016; 46:34-55. [PMID: 26983171 DOI: 10.1177/0306312715615971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This study is based on ethnographic fieldwork at a plastic surgery clinic in Seoul, South Korea. Examining the three phases of plastic--consultation, operation and recovery--I show how surgeons work to shape not only patients' bodies but also expectations and satisfaction. Surgeons do so in part to assuage their own anxieties, which arise from the possibility of misaligned beauty standards and unforeseen anatomies, as well as the possible dissatisfaction of the patient. I offer the concept of 'surgical anxiety', which occurs in relation to inherently unruly patient bodies in which worries, fear, frustration, self-pity, cynicism, anger and even loneliness are symptomatic. The unpredictability and uncontrollability of patients' bodies, which generates anxiety for both patients and surgeons, work to constrain the power of plastic surgery and making it inherently vulnerable. This study also pays attention to the invisible work of taking care of surgical anxiety, as practised by female staff members, and surgeons' dependence on these workers. My focus on anxiety is a kind of remedy for the predominant concern with 'ambivalence' in constructivist science and technology studies; rather than continue to highlight the power differentials between experts/practitioners and lay people/patients, this study illuminates surgical anxiety as their shared vulnerability. Thus, this study proposes a new politics of care in technoscience and medicine, which begins with anxiety.
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Jung Y, Kwon S. The Effects of Intellectual Property Rights on Access to Medicines and Catastrophic Expenditure. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2015; 45:507-29. [PMID: 26077858 DOI: 10.1177/0020731415584560] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Since the introduction of Trade-Related Aspects of Intellectual Property Rights (TRIPS) in 1995, there has been considerable concern that poor access to essential medicines in developing countries would be exacerbated because strengthening intellectual property rights (IPR) leads to monopoly of pharmaceutical markets and delayed entry of lower-cost generic drugs. However, despite extensive research and disputes regarding this issue, there are few empirical studies on the topic. In this study, we investigated the effect of IPR on access to medicines and catastrophic expenditure for medicines, using data from World Health Surveys 2002-2003. The index of patent rights developed by Ginarte and Park (1997) was used to measure the IPR protection level of each country. Estimates were adjusted for individual and country characteristics. In the results of multilevel logistic regression analyses, higher level of IPR significantly increased the likelihood of nonaccess to prescribed medicines even after controlling for individual socioeconomic status and national characteristics associated with access to medicines. This study's finding on the negative impact of IPR on access to medicines calls for the implementation of more active policy at the supra-national level to improve access in low- and middle-income countries.
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Affiliation(s)
- Youn Jung
- Institute of Health and Environment, Seoul National University, Seoul, Republic of Korea
| | - Soonman Kwon
- School of Public Health, Seoul National University, Seoul, Republic of Korea
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Abadía-Barrero CE. Neoliberal Justice and the Transformation of the Moral: The Privatization of the Right to Health Care in Colombia. Med Anthropol Q 2015; 30:62-79. [PMID: 25335474 DOI: 10.1111/maq.12161] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Neoliberal reforms have transformed the legislative scope and everyday dynamics around the right to health care from welfare state social contracts to insurance markets administered by transnational financial capital. This article presents experiences of health care-seeking treatment, judicial rulings about the right to health care, and market-based health care legislation in Colombia. When insurance companies deny services, citizens petition the judiciary to issue a writ affirming their right to health care. The judiciary evaluates the finances of all relevant parties to rule whether a service should be provided and who should be responsible for the costs. A 2011 law claimed that citizens who demand, physicians who prescribe, and judges who grant uncovered services use the system's limited economic resources and undermine the state's capacity to expand coverage to the poor. This article shows how the consolidation of neoliberal ideology in health care requires the transformation of moral values around life.
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Affiliation(s)
- César Ernesto Abadía-Barrero
- Department of Anthropology and Human Rights Institute University of Connecticut and Centro de Estudios Sociales, Universidad Nacional de Colombia.
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35
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Mulligan J. Insurance Accounts: The Cultural Logics of Health Care Financing. Med Anthropol Q 2015; 30:37-61. [DOI: 10.1111/maq.12157] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Suskind AM, Zhang Y, Dunn RL, Hollingsworth JM, Strope SA, Hollenbeck BK. Understanding the diffusion of ambulatory surgery centers. Surg Innov 2014; 22:257-65. [PMID: 25143440 DOI: 10.1177/1553350614546004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Outpatient surgery is increasingly delivered at freestanding ambulatory surgery centers (ASCs), which are thought to deliver quality care at lower costs per episode. The objective of this study was to understand potential facilitators and/or barriers to the introduction of freestanding ASCs in the United States. METHODS This is an observational study conducted from 2008 to 2010 using a 20% sample of Medicare claims. Potential determinants of ASC dissemination, including population, system, and legal factors, were compared between markets that always had ASCs, never had ASCs, and those that had new ASCs open during the study. Multivariable logistic regression was used to determine characteristics of markets associated with the opening of a new facility in a previously naïve market. RESULTS New ASCs opened in 67 previously naïve markets between 2008 and 2010. ASCs were more likely to open in hospital service areas that were urban (adjusted odds ratio [OR], 4.10; 95% confidence interval [CI], 1.51-10.96), had higher per capita income (adjusted OR, 3.83; 95% CI, 1.43-10.45), and had less competition for outpatient surgery (adjusted OR, 2.13; 95% CI, 1.02-4.45). Legal considerations and latent need, as measured by case volumes of hospital-based outpatient surgery in 2007, were not associated with the opening of a new ASC. CONCLUSIONS Freestanding ASCs opened in advantageous socioeconomic environments with the least amount of competition. Because of their associated efficiency advantages, policy makers might consider strategies to promote ASC diffusion in disadvantaged markets to potentially improve access and reduce costs.
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Affiliation(s)
| | - Yun Zhang
- University of Michigan, Ann Arbor, MI, USA
| | | | | | - Seth A Strope
- Washington University School of Medicine, St Louis, MO, USA
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Fletcher RA. Keeping up with the Cadillacs: What Health Insurance Disparities, Moral Hazard, and the Cadillac Tax Mean to The Patient Protection and Affordable Care Act. Med Anthropol Q 2014; 30:18-36. [PMID: 25132244 DOI: 10.1111/maq.12120] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A major goal of The Patient Protection and Affordable Care Act is to broaden health care access through the extension of insurance coverage. However, little attention has been given to growing disparities in access to health care among the insured, as trends to reduce benefits and increase cost sharing (deductibles, co-pays) reduce affordability and access. Through a political economic perspective that critiques moral hazard, this article draws from ethnographic research with the United Steelworkers (USW) at a steel mill and the Retail, Wholesale and Department Store Union (RWDSU) at a food-processing plant in urban Central Appalachia. In so doing, this article describes difficulties of health care affordability on the eve of reform for differentially insured working families with employer-sponsored health insurance. Additionally, this article argues that the proposed Cadillac tax on high-cost health plans will increase problems with appropriate health care access and medical financial burden for many families.
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Ellison J. First-Class Health: Amenity Wards, Health Insurance, and Normalizing Health Care Inequalities in Tanzania. Med Anthropol Q 2014; 28:162-81. [DOI: 10.1111/maq.12086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Willging CE, Sommerfeld DH, Aarons GA, Waitzkin H. The effects of behavioral health reform on safety-net institutions: a mixed-method assessment in a rural state. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2014; 41:276-91. [PMID: 23307162 PMCID: PMC3987948 DOI: 10.1007/s10488-012-0465-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In July 2005, New Mexico initiated a major reform of publicly-funded behavioral healthcare to reduce cost and bureaucracy. We used a mixed-method approach to examine how this reform impacted the workplaces and employees of service agencies that care for low-income adults in rural and urban areas. Information technology problems and cumbersome processes to enroll patients, procure authorizations, and submit claims led to payment delays that affected the financial status of the agencies, their ability to deliver care, and employee morale. Rural employees experienced lower levels of job satisfaction and organizational commitment and higher levels of turnover intentions under the reform when compared to their urban counterparts.
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Affiliation(s)
- Cathleen E. Willging
- Pacific Institute for Research and Evaluation, Behavioral Health Research Center of the Southwest, 612 Encino Place NE, Albuquerque, NM 87102, USA
| | - David H. Sommerfeld
- Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive (0812), La Jolla, CA 92093-0812, USA
| | - Gregory A. Aarons
- Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive (0812), La Jolla, CA 92093-0812, USA
| | - Howard Waitzkin
- Department of Sociology, University of New Mexico, MSC 05 3080, 1070 Social Sciences Building, 1915 Roma NE, Room 1103, Albuquerque, NM 87131-0001, USA
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Bochi G. Exploring pluralism in oral health care: Dom informal dentists in northern Lebanon. Med Anthropol Q 2014; 29:80-96. [PMID: 24474241 DOI: 10.1111/maq.12066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article describes a pluralistic regime of oral health provision in a rural part of northern Lebanon, where dental care came from two main sources: professionally trained dentists and "informal" Dom dentists with Syrian nationality. Relying on a combination of interviews and ethnography, I offer a multivocal view of oral health services that incorporates data from patients and formal and informal providers. I argue that informal dentistry constituted an interstitial and translocal mode of dental care. In the northern Lebanese Biqa Valley, close to the Syrian border, the local articulation of neoliberal health governance created opportunities for heterodox practices in oral health. The organization of informality was predicated on the presence of the open border between Syria and Lebanon, which favored patterns of flexible cross-border mobility. In this context, informal dentistry was not alternative, but supplementary and lateral in relation to official forms of oral health provision.
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Horton S, Abadía C, Mulligan J, Thompson JJ. Critical Anthropology of Global Health "takes a stand" statement: a critical medical anthropological approach to the U.S.'s Affordable Care Act. Med Anthropol Q 2014; 28:1-22. [PMID: 24395630 DOI: 10.1111/maq.12065] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The Affordable Care Act (ACA) of 2010--the U.S.'s first major health care reform in over half a century-has sparked new debates in the United States about individual responsibility, the collective good, and the social contract. Although the ACA aims to reduce the number of the uninsured through the simultaneous expansion of the private insurance industry and government-funded Medicaid, critics charge it merely expands rather than reforms the existing fragmented and costly employer-based health care system. Focusing in particular on the ACA's individual mandate and its planned Medicaid expansion, this statement charts a course for ethnographic contributions to the on-the-ground impact of the ACA while showcasing ways critical medical anthropologists can join the debate. We conclude with ways that anthropologists may use critiques of the ACA as a platform from which to denaturalize assumptions of "cost" and "profit" that underpin the global spread of market-based medicine more broadly.
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Affiliation(s)
- Sarah Horton
- Department of Anthropology, University of Colorado, Denver
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de la Luz Ibarra M. Frontline activists: Mexicana care workers, subjectivity, and the defense of the elderly. Med Anthropol Q 2013; 27:434-52. [PMID: 24123259 DOI: 10.1111/maq.12051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In this article, I focus on Mexican immigrant women who, as care workers in various care settings in the wealthy city of Santa Barbara, California, attempt to defend aging Americans patients from devaluation and harm. To understand why vulnerable women defend more privileged citizens of the nation, I address Mexicana subjectivity. I argue that neoliberal policies have created multiple vulnerabilities for Mexican women and it is in formal care contexts where these vulnerabilities intertwine with that of their patients. Workers' feelings of shame, complicity, and empathy help explain a defense of the Other. A significant form of defense is informal sector family-based care. This article is based on ethnographic fieldwork conducted between 2009 and 2011.
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Kim T, Haney C, Hutchinson JF. Exposure and exclusion: disenfranchised biological citizenship among the first-generation Korean Americans. Cult Med Psychiatry 2012; 36:621-39. [PMID: 23054295 DOI: 10.1007/s11013-012-9278-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Based on fieldwork with a highly uninsured and underinsured Korean American population, this article maps how the current healthcare system in the United States disenfranchises those of marginal insurance status. The vulnerability of these disenfranchised biological citizens is multiplied through exposure to disproportional health risks compounded by exclusion from essential healthcare. The first-generation Korean Americans, who commonly work in small businesses, face the double burden of increased health risks from long, stress-laden work hours and lack of access to healthcare due to the prohibitive costs of health insurance for small business owners. Even as their health needs become critical, their insurance status and costly medical bills discourage them from visiting healthcare institutions, leaving Korean Americans outside the "political economy of hope" (Good, Cult Med Psychiatry 52:61-69, 2001). Through an ethnographic examination of the daily practice of doing-without-health among a marginalized sub-group in American society, this paper articulates how disenfranchised biological citizenship goes beyond creating institutional barriers to healthcare to shaping subjectivities of the disenfranchised.
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Affiliation(s)
- Taewoo Kim
- Department of Anthropology, Chonnam National University, Gwangju, 500-757, South Korea.
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Vargas I, Unger JP, Mogollón-Pérez AS, Vázquez ML. Effects of managed care mechanisms on access to healthcare: results from a qualitative study in Colombia. Int J Health Plann Manage 2012; 28:e13-33. [PMID: 22865727 DOI: 10.1002/hpm.2129] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 06/22/2012] [Accepted: 07/06/2012] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Managed competition has underpinned most health sector reforms aimed at improving access and efficiency, in Latin America and other countries. The aim of the paper is to analyse barriers to healthcare that emerge from the introduction of managed care mechanisms in Colombia. METHODS Qualitative, exploratory, and descriptive-interpretative research was carried out on the basis of case studies of four healthcare networks, comprised of insurers and their providers. Individual semi-structured interviews were conducted with a theoretical sample of informants (managers, professionals, and users), between 24 and 61 per network. The final sample size was reached by saturation of information. An inductive thematic content analysis was conducted. The study areas were two municipalities of Colombia, in which most of the population live in poverty. RESULTS A number of managed care mechanisms that act as barriers to access were identified by all informants, regardless of area and type of insurance regime. These mechanisms act directly on the patient (authorizations, fragmented insurance) or on the providers (purchasing mechanisms or limits to medical practice). The predominant mechanism appears to be related to the type of agreement established between insurers and providers. The reason for these barriers, according to informants, is insurers' search for profitability. As a consequence, there is delay in or no access to adequate treatment. This is particularly evident in secondary care. CONCLUSION A variety of managed care strategies that effectively hinder access to healthcare have been introduced by insurers, casting doubt on the usefulness of their application in low-income countries and profit-making contexts.
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Affiliation(s)
- Ingrid Vargas
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain.
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Chapman SLC, Wu LT. Food, class, and health: the role of the perceived body in the social reproduction of health. HEALTH COMMUNICATION 2012; 28:341-350. [PMID: 22746270 PMCID: PMC3527688 DOI: 10.1080/10410236.2012.688009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The association between social class and cardiovascular health is complex, involving a constant interplay of factors as individuals integrate external information from the media, health care providers, and people they know with personal experience to produce health behaviors. This ethnographic study took place from February 2008 to February 2009 to assess how cardiovascular health information circulating in Kansas City influenced a sample of 55 women in the area. Participants were primarily Caucasian (n = 41) but diverse in terms of age, income, and education. Themes identified in transcripts showed women shared the same idea of an ideal body, young and thin, and associated this perception with ideas about good health, intelligence, and morality. Transcript themes corresponded to those found at health events and in the media that emphasized individual control over determinants of disease. Women's physical appearance and health behaviors corresponded to class indicators. Four categories were identified to represent women's shared beliefs and practices in relation to class, cardiovascular disease, and obesity. Findings were placed within an existing body of social theory to better understand how cardiovascular health information and women's associated beliefs relate to health inequality.
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Affiliation(s)
- Shawna L Carroll Chapman
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA.
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Dalstrom MD. Winter Texans and the Re-creation of the American Medical Experience in Mexico. Med Anthropol 2012; 31:162-77. [DOI: 10.1080/01459740.2011.589417] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Special issue part I: 'Deservingness' and the politics of health care. Soc Sci Med 2011; 74:855-7. [PMID: 22245382 DOI: 10.1016/j.socscimed.2011.10.044] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 10/05/2011] [Accepted: 10/06/2011] [Indexed: 11/20/2022]
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Willen SS, Mulligan J, Castañeda H. Take a stand commentary: how can medical anthropologists contribute to contemporary conversations on "illegal" im/migration and health? Med Anthropol Q 2011; 25:331-56. [PMID: 22007561 DOI: 10.1111/j.1548-1387.2011.01164.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Of the estimated 214 million people who have migrated from poorer to richer countries in search of a better life, between 20 and 30 million have migrated on an unauthorized, or "illegal," basis. All have health needs, or will in the future, yet most are denied health care available to citizens and authorized residents. To many, unauthorized im/migrants' exclusion intuitively "makes sense." As scholars of health, social justice, and human rights, we find this logic deeply flawed and are committed to advancing a constructive program of engaged critique. In this commentary, we call on medical anthropologists to claim an active role in reframing scholarly and public debate about this pressing global health issue. We outline four key theoretical issues and five action steps that will help us sharpen our research agenda and translate ourselves for colleagues in partner disciplines and for broader audiences engaged in policymaking, politics, public health, and clinical practice.
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Affiliation(s)
- Sarah S Willen
- Department of Anthropology, University of Connecticut, USA
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Willen SS. How is health-related "deservingness" reckoned? Perspectives from unauthorized im/migrants in Tel Aviv. Soc Sci Med 2011; 74:812-21. [PMID: 21821324 DOI: 10.1016/j.socscimed.2011.06.033] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 06/10/2011] [Accepted: 06/16/2011] [Indexed: 11/18/2022]
Abstract
Do unauthorized im/migrants have a right to health? Do they deserve health care, or health protection, or access to the social determinants of good health? Are they party to prevailing social contracts, or does their exclusion from mainstream systems of health promotion, prevention, and care "make sense"? Questions like these, which generate considerable attention in multiple spheres of scholarship, policy, and public debate, revolve around an issue that merits substantially greater consideration among social scientists of health: health-related "deservingness." In addition to putting the issue of health-related deservingness squarely on the map as an object of analysis, this article further argues that we cannot focus solely on those with power, influence, and public voice. Rather, we also must investigate how deservingness is reckoned in relation to--and, furthermore, from the perspectives of-- unauthorized im/migrants and members of other groups commonly constructed in public and policy discourse as undeserving. Additionally, we must consider the complicated relationship between universalizing juridical arguments about formal entitlement to health rights, on one hand, and situationally specific, vernacular moral arguments about deservingness, on the other. The paper analyzes findings from a 29-month mixed-methods study conducted in Tel Aviv, Israel, that approached unauthorized im/migrants as subjects, rather than simply objects, of ethical deliberation. Participants' conceptions of health-related deservingness are investigated using two sources of data: (1) quantitative findings from a self-administered, closed-ended survey conducted with 170 im/migrant patients at an NGO-run Open Clinic (2002-2003), and (2) qualitative findings from the larger ethnographic study of which the survey was part (2000-2010). The study findings both (1) contradict commonly circulating assumptions that unauthorized im/migrants are "freeloaders," and (2) highlight the need for rigorous investigation of how unauthorized im/migrants, among other marginalized and vulnerable groups, conceptualize their own relative deservingness of health-related concern and investment.
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Affiliation(s)
- Sarah S Willen
- University of Connecticut, Department of Anthropology, 354 Mansfield Road, Unit 2176, Beach Hall, Storrs, CT 06269-2176, USA.
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Viladrich A. Beyond welfare reform: reframing undocumented immigrants' entitlement to health care in the United States, a critical review. Soc Sci Med 2011; 74:822-9. [PMID: 21745706 DOI: 10.1016/j.socscimed.2011.05.050] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 05/22/2011] [Accepted: 05/25/2011] [Indexed: 11/27/2022]
Abstract
This article addresses the main scholarly frames that supported the deservingness of unauthorized immigrants to health benefits in the United States (U.S.) following the passage of the Personal Responsibility Work Opportunity Reconciliation Act (PRWORA), known as the Welfare Reform bill, in 1996. Based on a critical literature review, conducted between January 1997 and March 2011, this article begins with an analysis of the public health rhetorics that endorsed immigrants' inclusion into the U.S. health safety net. In this vein, the "cost-saving" and "the effortful immigrant" frames underscore immigrants' contributions to society vis-à-vis their low utilization of health services. These are complemented by a "surveillance" account that claims to protect the American public from communicable diseases. A "maternalistic" frame is also discussed as a tool to safeguard families, and particularly immigrant mothers, in their roles as bearers and caretakers of their American-born children. The analyses of the "chilling" and the "injustice" frames are then introduced to underscore major anthropological contributions to the formulation of counter-mainstream discourses on immigrants' selective inclusion into the U.S. health care system. First, the "chilling effect," defined as the voluntary withdrawal from health benefits, is examined in light of unauthorized immigrants' internalized feelings of undeservingness. Second, an "injustice" narrative highlights both the contributions and the limitations of a social justice paradigm, which advocated for the restoration of government benefits to elderly immigrants and refugees after the passage of PRWORA. By analyzing the contradictions among all these diverse frames, this paper finally reflects on the conceptual challenges faced by medical anthropology, and the social sciences at large, in advancing health equity and human rights paradigms.
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Affiliation(s)
- Anahí Viladrich
- Queens College & The Graduate Center, The City University of New York, Flushing, New York City, NY 11367, USA.
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