Ethnography of Health for Social Change: Impact on public perception and policy

Introduction

This special issue addresses a core problem of social science: the relationship of research to public perception and policy. It focuses on the potential impact of ethnographic research on the way its audiences see health problems, conduct their professional and personal lives, and become politically active. How can ethnography foster public engagement in health issues?

Ethnography has an established role in health research. It elucidates the cultural logics driving health related behavior, and the unexamined assumptions that frame problems of relevance to health. It places these findings in historical, economic and political context in ways that quantitative research alone does not. And given the widespread use of narrative in mass media’s shaping of public opinion in the U.S., ethnographic narratives promise to make a distinct contribution to public perceptions and policy. Medical anthropology and sociology have long been employing ethnographic methods to answer specific health and medicine-related questions. They have had a demonstrable impact on professional and organizational practices as well as on our theoretical understandings of health and medicine. But what broader effects might ethnographic work, ranging from theoretical to applied, have on public discourse and policy agendas?

This is a question for cultural anthropology and qualitative sociology—fields that have called for self-examination regarding the public relevance of their work (Burawoy, 2009; Gans, 2010). It is also a question for qualitative public health and policy researchers, whose methodologies may be less established within their larger disciplines. In the U.S., national meetings of the American Anthropological Association, and academic publishers such as the editors of the journal Ethnography and of the University of California Press book series on Public Anthropology, strive to bring ethnography to bear on issues of public importance. Leaders in a movement within academia to promote public ethnography have defined it as “The type of research and writing that directly engages with the critical social issues of our time…Authors of such works passionately inscribe, translate, and perform their research in order to…emotionally engage, educate, and move the public to action.” (Tedlock, 2007) Yet there is little consensus on how to achieve this goal.

Articles in this special issue describe ethnographic research of relevance to health and consider the actual or potential impact of their findings on public debate and policy. In order to demonstrate cross cutting core issues, as well as the specificity and diversity of the ways that ethnographic research reaches larger publics in particular contexts, we deliberately include ethnographers working in geographically and thematically diverse settings.

Contributors to this issue cluster around three cross cutting topics in which ethnography has historically played a prominent role: 1) critical perspectives on global health; 2) marginalizing processes of poverty, stigma and violence; and 3) community based participation and advocacy.

First, global health initiatives have required the fine grained and interpretive perspective offered by ethnographers, which has led to indispensable insights among global health practitioners and agencies about the ways that concepts and interventions do, or do not, translate across borders, languages and cultural groups (Janes, 2010; Kleinman, 2010; Nichter, 2008). In fact, ethnographers are often able to explain counterintuitive outcomes when health interventions are transported from one locale to another.

Second, ethnographers have historically had unique access to marginalized groups, and attended to their on-the-ground lived experiences, illuminating both the local mechanisms by which larger policies or institutions negatively impact health, and the ways that marginalized groups attempt to adapt to and resist unfavorable policies and institutions (Hammersley & Atkinson, 2007; Kleinman, Das, & Lock, 1997). Third, when these groups or health organizations attempt to advocate for themselves against the larger structural forces that entrench health and social inequalities, ethnographers are often those who document this advocacy and its symbolic and material sources. The ethnographic stance of representing alternative world views lends itself to envisioning alternative politics and institutions. It also lends itself to participatory research in which research subjects shape the questions and products of health research itself (Israel, 2005; Minkler & Wallerstein, 2011).

The ethnographic record is rich with research that illuminates health inequalities and calls for social change as health intervention. Ethnographers are often called upon to assess the effects of professional and institutional practices on health outcomes. And a growing number of ethnographers are “studying up; ” analyzing the cultural frames and social practices of large institutions, professionals, scientists, marketers, journalists and policy-makers themselves. Yet the ways that their diverse ethnographies inform publics and policy makers have seldom been examined in a systematic way.

This special issue takes up the question of how ethnographic research can uniquely contribute to public perception and policy surrounding health issues. It poses this question to academic, theoretical ethnographers who pursue topics of public interest. To that end, this issue assembles the work of ethnographers who strive to illuminate the social mechanisms of health disparities, as well as an anthropologist-cum-magazine publisher, an online editor, a policymaker-cum-visual ethnographer, and a local and national health official who comment on these ethnographic perspectives from the point of view of the potential uses of ethnography in media and policy making.

Ethnographers and commentators in this volume draw on their work to address one or more of the following questions: 1) How have your findings been taken up in the public realm?; 2) Where do you think your work could go further in its impact?; 3) What are the challenges and risks of achieving a broad, public impact with ethnography?; and 4) What gives ethnography leverage in public debate? In addressing these questions, the papers in this issue help us envision the promise, and, in some cases, the risks of ethnographic methods and description in inciting social change.

Critical perspectives on global health

The first set of articles in this issue examines the unique role of ethnography and ethnographers in shaping the field of global health. Given the historical use of ethnography to describe health practices in the global South, it is not surprising that ethnography has left its mark on global health agendas, and that it promises to have formative influence on national and international health priorities in the future. These articles are notable for their dual ethnographic lens, which focuses both up, on the cultural fields and practices of global health policy makers, and focuses down, on those who feel the impact of global health policy.

Fassin (2013) discusses ethnography in global health research, contrasting multi-sited ethnography with multi-layered, “vertical” approaches that shift levels of analysis, moving between the world views of actors on the ground and their overarching political, economic and institutional contexts. To illustrate how a vertical approach can affect social change he describes the “afterlife” of his own ethnographies in the form of translation and commentary by readers. He portrays this “afterlife” as yet another stage of ethnographic work, and ethnography as a “living object:” both a resource and a forum for public debate, such as of the South African government’s position on the need to subsidize antriretroviral medication.

Pigg (2013) also describes the mechanisms by which ethnography illuminates global public health agendas, showing how “just sitting” by participant-observers can be an important source of insight about ground level dynamics that are not considered by NGO health promotion efforts. As Pigg writes, “Ethnography is both a mode of attentiveness, and openness to being taken off course,” one that makes it possible to render visible the “structural, political-economic, and discursive global workings” of the systems in which global health takes part. She ends with a call to view global health as a “social field” unto itself, one that ethnographers can help to make more self-reflexive.

Nambiar (2013) illuminates the work of ethnographers working inside national policy, describing how health reformers in India drew on ethnography to re-conceptualize healthcare inequalities and interventions. Nambiar provides a hopeful note that policy makers might assimilate the contextual nuance of ethnographic health research and translate it into systems design, calling attention to her own participation in health reform planning, and the participation of other ethnographers, as agents in this assimilation.

Marginalizing processes of poverty, stigma and violence

Another area in which ethnographers have historically had a notable impact is in research on economically and socially marginalized groups. They have revealed the violent impact of this marginalization on individuals and local institutions. In the second section of this issue, ethnographers working at the margins explain how their efforts have and can make visible that which by definition is hidden from view, and enable new political responses to hierarchical systems.

Pine (2013) describes her “somatic solidarity” with Honduran Nurses in Resistance to the violence of a neoliberal coup. Vividly describing the bodily threat that this violence posed to her as an ethnographer documenting the aftermath of the coup, she draws an analogy between Honduran nurses who resisted political assaults on their patients’ health “with their own bodies,” and her own role, as a politically engaged ethnographer, in stopping violence with her research.

Holmes (2013) brings us to the US-Mexican border, with an on-the-ground account of the deadly trek that undocumented Mexican migrants are forced to take in search of work. As Holmes points out, a face-to-face ethnographic description of the mortal risks of this border crossing calls attention to the health effects of immigration policies and international trade agreements, such as the North American Free Trade Agreement, that are making local sources of industry and employment in Mexico unsustainable. These policies have a body count, and Holmes’ ethnography demonstrates the public health and moral imperative to acknowledge and resist their structurally violent effects.

Lee (2013) provides a rich ethnographic account of a low income African American man who survived his gunshot wounds only to find himself stuck in a “pill hustle,” seeking relief of his chronic pain amidst a growing street trade in prescription opioids. As Lee points out, the plight of gunshot wound sufferers is hidden, but it is an important driver of clinical dilemmas and pharmaceutical economies in American inner cities. Ethnography has a unique role in making this phenomenon visible, along with the interpersonal and structural violence that creates and marginalizes it.

Lindemann (2013) shows how ethnography of groups that are hidden from public view – in this case, practitioners of Bondage Discipline, and Sadomasochism (BDSM) – can have unexpected implications for health policies and interventions. Only through ethnography did she discover the ways in which professional identities and “purifying disourses” protect the health and safety of BDSM practitioners, by employing their guild-like social structure. The organizational strengths of groups that are stigmatized and at risk for injury, infection or arrest can thus be seen as a public health resource.

Ethnographic advocacy and community based participation

Because participant-observation puts ethnographers into intimate contact with the groups they study, they often develop collaborative, multidisciplinary and participatory modes of working that directly implicate them in bringing about social change as a part of their research. In the third section of this issue, ethnographers who collaborate politically with their research participants reflect on the complexities of this engagement. Their engagement has required analysis not only of people who are subject to health inequalities, but has also required an ethnographic gaze on policy makers, housing and welfare benefits officials, correctional officers, school system and public clinic administrators.

Messac, Ciccarone, Draine and Bourgois (2013) present four cases of collaborations between ethnographers and quantitative researchers that led to clinical and policy interventions to improve the quality of life and of health care for poor, non-white people who are HIV positive, drug dependent, homeless and/or incarcerated. As the authors persuasively argue, what is needed to succeed in such collaborations is “good enough” ethnography that is informed by critical theory of social structures and inequality. Through such collaborations, the seemingly apolitical persuasiveness of “evidence based medicine” can be harnessed to render structural inequality legible for clinicians and policy makers, and accessible for intervention.

Ginsburg and Rapp (2013) examine ethnographers’ personal engagement with the political projects of their research participants, in what they term “entangled ethnography.” Here they lay bare the degree to which participant observers are personally implicated in the outcomes of the disability rights movements they study, describing themselves as mothers of children with diagnoses of learning disabilities, who have a personal stake in the outcome of the cultural and political innovations around disabilities rights that they document. They demonstrate how entangled ethnographers can play pivotal roles in the social transformations that ensue from “envisioning alternative politics and institutions” of diversity and inclusion.

Hansen (2013) sounds a cautionary note about such entanglement with her account of a video self-documentary therapy group in a public mental health clinic. The video group members’ filming the role of creative arts therapies in their own recovery coincided with the public hospital system’s reduction of support for psychotherapies, in favor of “evidence based” pharmacological, apparently cost-effective, interventions. The consequences for group members of reduced funding for therapy, and of their effort to videographically advocate for such therapy, made visible both the “iron cage” of clinical bureaucratization and the risks to patients of working in a participatory ethnographic mode.

Lessons from and for ethnography

This issue on Ethnography of Health for Social Change closes with the reflections of an ethnographer who has decades of experience in global and domestic health advocacy, as well as pragmatic advice for ethnographers seeking to enhance their social impact from a journalist, from an ethnographer who founded a popular anthropology magazine, a Federal health officer, and a policy maker-cum-visual ethnographer. They all call on ethnographers to attend as carefully to the context and motives of their audiences as they do to the context and motives of their study participants.

Hopper (2013), a self-identified public ethnographer, offers three sobering accounts of solid ethnographic evidence relevant to, and/or commissioned by, policy makers, that policy makers then ignored because it did not fit within reigning political agendas. Yet, he argues, while we cannot congratulate ourselves on the inroads that ethnographic data has made in improving policy, without ethnographic documentation of injustices and failed policies, advocates would have no conceptual basis for their work.

In our concluding essay (Martin, Litchfield, Mandefro et al. 2013), Martin, an ethnographer well established in the academy, discusses her motivation for founding a popular audience magazine that translates cutting edge ethnography for lay persons. Its expansion of ethnographic audiences is evident in the journal’s selection for the national secondary school curriculum in the United Kingdom. Journalist Litchfield points to a universe of online publications that has opened up via the internet. If ethnographers can master these new venues, he argues, ethnography will have a golden age of dissemination to publics hungry for the level of detail and analysis that it uniquely provides. Visual ethnographer and former Special Advisor to the U.S. Veterans Administration Mandefro discusses her techniques for distilling ethnographic narrative into concise forms that nonetheless convey complexity and nuance to policy makers. Finally, U.S. Centers for Disease Control Officer Parvez argues that to influence policy makers, ethnographers should publish mixed-method papers in the traditionally quantitative journals read by policy makers and health administrators.

Toward an enhanced impact of ethnography

In this era of facile media dissemination of narrative (which paradoxically coincides with the silent suffering of many people without access to this media), ethnographers of health answer a call to document what researchers using other methods cannot. It is our hope that this dialogue among ethnographic sociologists, ethnographic anthropologists, policy makers and journalists will help to enrich the theoretical, methodological and representational tool boxes of all concerned. In addition, we hope that this Special Issue serves as one step toward greater visibility of this kind of work beyond ethnographers, further expanding the range of ethnography’s impact.