Melbourne School of Population and Global Health - Theses
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ItemInterrupting knowledge, decolonising care: understanding mental health with a refugee-run NGO in Sydney, Australia( 2017)Any expression of medical pluralism will reflect the organisation and hierarchisation of its traditions of knowledge. My thesis attends to moments in which diverse understandings of mental affliction are negotiated, and sometimes even silenced, in the networks and relationships surrounding a Sydney NGO. Here, alongside this NGO run for and by people from Central Africa, I explore approaches to questions of what mental affliction is, various notions of who (mis)understands it, and how afflictions and their percieved misunderstanding are dealt with. In the process, the category of ‘mental health’ emerges and disappears, is challenged and negotiated, within jostling epistemological frames of understanding. To examine this therapeutic landscape, I prioritise modes of analysis that are sensitive to the fluctuating complexities of caring for community through existing, yet not always equitable, structures for such care. I draw on affect theory’s slowness and attunement to the unseen, often unarticulated forces that unfold in encounters, conversations and in what is articulated (Stewart 2017: 192). Affective scenes provide an access point to each chapter's textured study of the refugee-migrant community health assemblage, which is examined in terms of: historical context (Chapter One), NGO sector development (Chapter Two), education (Chapter Three), belief (Chapter Four), faith (Chapter Five), and care (Chapter Six). Through such attention, this thesis asks after what medical pluralism looks like when a group of people with histories of a range of healing traditions—psychiatry, cosmopolitan medicine, religious faith healing, and spiritual cleansing of curses—move to Australia? How were these different knowledge traditions treated and talked about? And how could one meaningfully study these pluralities?—what would anthropological research and ethnographic writing, as modes of knowledge creation, come up against in trying to engage with plural traditions of knowledge? Through representational sensibilities, moments of ethnographic attention and narratives that circle back and interrupt themselves, this thesis builds an argument for ambivalence towards conclusive uses of knowledge. Ambivalence is presented as a counter to the kinds of simplified understandings of diversity that are often salient in the migrant health and community development sector, and that are shown, through this ethnography to beget subtle, structurally violent effects. I frame such ambivalence as an act of care. Part examination of the tensions “between fragmentation and connectedness-in-the-making” (Biehl and McKay 2012: 1210), part portrait of the tensions held in suspense when crafting an ethnography of knowledge(s), my work seeks to contribute to the decolonisation of knowledge and care.
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ItemNeuroscience’s brain: a study of material, practice and imagination in neuroscience’s expanding scope( 2017)This thesis is a brain-based study of neuroscience. While human beings have studied the brain and considered its role in what makes a human being since at least the ancient Greeks, neuroscience is a very specific contemporary formation. Within the project laid out by the field to understand the human mind in terms of the brain, what is considered to be within the scope of research on the brain includes a growing range of complex human phenomena. This ethnographic study explores the growth of neuroscience and considers the factors that sustain its entry into the investigation of an ever-broadening research scope. The thesis is an ‘object ethnography’ that explores neuroscience as a particular cultural world through a focus on the brain as neuroscience’s object. The research involved participant observation in behavioural and cognitive neuroscience laboratories and interviews with neuroscientist key informants in a major metropolitan Australian city, as well as an analysis of popular neuroscience books written by key neuroscientist writers. My central argument is that ‘neuroscience’s brain’ provides an evolving multidisciplinary field with coherence and with the ability to expand into the study of increasingly complex human issues. Through my ethnographic data I show: first, how neuroscience’s brain addresses organisational needs by bringing together a diverse group of scientists and providing them with space within the field where they are able to develop their particular areas of interest; second, how the brain, conceived of as both mind and body, embodies tensions between the material and immaterial that are used productively to drive neuroscientific work forward; third, how the brain facilitates the mixing of neuroscientific knowledge with other domains of knowledge through its status as a particularly human kind of scientific object. Neuroscience’s brain provides concrete explanations of human behaviour, allows materiality to be extended into areas where the material is not yet able to go, and through mixing with other systems of meaning, is seen to provide a compelling frame within which human life can be imagined. By focusing on the brain and drawing on theories of objects from medical anthropology and Science and Technology Studies (STS) that emphasise the material, processual and imaginative, I show how an approach to understanding the human is taking shape in the work of neuroscience, and in neuroscientists’ broader articulations of their object beyond the laboratory. The thesis provides an alternative account of the links between brain, human, and neuroscience; links that, within a neuroscience explosion, are taken to be natural and self-evident.
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ItemLife beyond control: youth, diabetes and care in contemporary Chile( 2017)In this dissertation I ethnographically explore how young Chileans with type 1 diabetes strive to construct good lives while negotiating the limits of a neoliberal approach to diabetes care. The study foregrounds my informants’ efforts to find health in illness, as they aim to live rich lives with diabetes, process that is often reduced or hidden from view within the biomedical understanding of the responsible and autonomous adult diabetic patient. The stories take place, both inside and outside of hospitals, in Chile’s capital city: Santiago. The study takes on a socio-cultural construction of youth, where the macro- and micro-level impacts upon young people’s experiences, while allowing for fluidity and transformation. I thread my informants’ experiences within Chilean history, tracing complex interactions between youth, family, precarity, biomedicine, and the state. I argue that growing up with diabetes constituted a troubling and ongoing process for young people, where their understanding of a good life escaped the limits of diabetes metabolic control. I explore their negotiations with and juggling of diabetes care with competing desires and obligations in relational terms, as they co-created partnerships with other companions. While I examine the entanglements and difficulties my informants faced, I highlight that they were not willing to abandon their illness, deciding instead to stay with its trouble. This represented a realistic alternative to sustain diabetes care or begin again with it, devising paths to be healthier in the future. Having supportive and attentive companions was essential in finding health in illness. This study highlights the role of health practitioners and the health system as partners, showing that, sometimes, they could become troubling ones. I depart from the assumption that only patients who achieve metabolic goals can live well, suggesting instead that a good life with diabetes should tie together biological and social life amid trouble. I problematize the emphasis on disease progression, autonomy and individual responsibility in diabetes care, pointing out its limits and unforeseen consequences. This approach tended to distance young people from clinicians, reducing their possibilities to work together. I contribute to an empirically and theoretically rich analysis that provides a more complex view on the experience of being young and having a chronic condition, threading Chilean history and state decisions with my informants’ experiences. This dissertation will be of interest to medical anthropologists, sociologists of health and illness, health professionals working with young people, hospital officials, and policy makers concerned with health systems and the reduction of health inequalities. Finally, it will be of interest to patients’ organizations, families, and young people themselves.
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ItemA phenomenological study into African refugee men’s wellness seeking behaviours, inclusive of community, spirit and ancestral connections.( 2017)AIM: To inform counselling with African male refugees in Tasmania, Australia, through the elaboration of African-derived approaches to problems. A secondary aim was to critique and re-inform Western counselling approaches and cultural assumptions. DESIGN: Phenomenology was selected to facilitate close engagement with participants’ life-worlds, and African interpretive frameworks were investigated to assist with data analysis. Reliability was enhanced through triangulation techniques such as sequencing the literature review after the Tasmanian data collection phase, followed by field work in South Africa. The study spanned over ten years which provided opportunity for personal transformation and trust-building with participants. METHOD: Phenomenological interviewing was the primary method, with the orienting question enquiring about “Approaches to Problems”. Participants (N=46) comprised 27 male and three female refugee entrants to Tasmania, Australia; and eight female and eight male residents of South Africa. Participants were selected through purposive sampling by place, augmented by trust-balling. Participant-observation in community activities emerged as a secondary method, and researcher experience was analysed heuristically. After publishing the results of interviews and two consensus groups in Tasmania, the researcher conducted three field trips to South Africa and recorded participant perceptions, behaviours, social exchange, and spirit resources. RESULTS: Thematic analysis yielded family-focussed communities of interconnectedness with a vibrant, social universe, inclusive of animal, plant, physical and spirit entities. Complex, layered cultural norms centred around this theme of connectedness supported life-long development and education, and informed African approaches to problems. CONCLUSIONS: Western research and therapeutic approaches informed by experimental science, and Western assumptions of individualised human existence, present multiple barriers to Africans seeking help. De-centred, fluid, and externally-oriented constructions of identity, inclusive of multiple centres of self, are required to enable full consideration of African experience. Such constructions of identity may assist in shaping counselling with western clients by their subversion of western counselling assumptions.
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ItemMedical tourism and hospital(ity) in Mumbai: imprints of the global commodification of health( 2016)Internationally, healthcare has been intensively privatised and commercialised over the past three decades. Medical tourism has emerged in this context as an economic development strategy for many developing nations, and provisional remedy for patients in developed countries facing rising costs and long waiting periods to access healthcare at home. This study is based in India and is predominantly ethnographic. As such, it is grounded in local realities, with a close eye to how everyday interactions and actions are shaped by significant global interconnections. The research findings have been directly shaped by the daily interactions of living and studying the footprint of medical tourism in five private hospitals in Mumbai, the city itself and, the wider nation of India. My primary fieldwork took place across the greater city of Mumbai, the capital city of the Indian state of Maharashtra over a 12-month period between March 2009 and February 2010. This extended period was preceded by an earlier scoping visit to the city in late 2008 to determine the viability of the project. The study offers a microcosmic view of broader economic patterns occurring within and between nations with healthcare services swiftly transitioning to another global commodity like any other product for commercialisation, consumption and exploitation. The focus of the research was primarily located within five hospitals but was also dispersed throughout the greater city of Mumbai in consultancy rooms, cafes, university lecture halls, private homes, hotels, smaller not-for-profit hospitals and a range of other spaces from rickshaw to boulevard. The research is further entangled and engaged across less spatially definable locales; across the transient domains of the Internet, media and macro-micro policy sphere. International organisations, industry and governments have all made claims of medical tourism’s facilitation of economic development in developing countries. However, little is known about the complex and diverse implications of the medical tourism industry for developing countries such as India. The research is primarily analytical, conducted within an interdisciplinary frame, with a theoretical reliance on the academic areas of critical medical anthropology and a human rights-based approach to development. In the context of this research, these theoretical approaches have been selected to understand the area of enquiry (medical tourism) from a local, place-based perspective within a developing nation. In combination, they cover the issues of political economy, power, development, equity, health and human rights within the context of the ever-growing practice of transnational medical tourism. The thesis offers in-depth, thick descriptions of daily encounters at five tertiary institutions in Mumbai, and places this ethnographic work in the wider political economy with a focus on the impact of medical tourism on inequalities experienced in the international delivery of health and healthcare services. The focus of the study is not on the patients, instead paying close attention to the institutions and healthcare workforce engaging in medical tourism in India. The ethnography was conducted during a period of time (2008 to 2010) of intensive commercial transition in the tertiary healthcare sector of India. Thus, the study presents a critical analysis of the dominant ideologies, understandings and representations of medical tourism across social institutions and actors at the time. The enquiry engages in how discourses of medical tourism, embedded in structural and hierarchical networks of power and neoliberal ideologies, serve to mask social and economic inequities in healthcare. It also describes how medical tourism is contributing to the transformation of understandings of health and healthcare for the healthcare workforce, the organisations they work within and the broader society.
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ItemControlling diabetes or keeping life under control?: Experiences and understandings of a group of Sri Lankan migrants in Australia with type two diabetes( 2014)Diabetes is a key public health priority and a major health concern for many migrant communities including the Sri Lankan community here in Australia. Understanding people’s comprehensions of the disease and its management is essential to successfully address any related issues in order to avoid premature deaths and high public health costs. According to many health reports published over the past years Sri Lankan migrants have been identified as having a significantly higher prevalence of type two diabetes in Australia compared to the general Australian population. This ethnography revolves around a group of first generation Sri Lankan migrants with type two diabetes in Australia. This thesis relates their story of encountering and dealing with difficulties and complexities of migrant life while having to build a ‘successful’ life in Australia and also having to concurrently manage a chronic illness. While arguing that understanding of diabetes management cannot be just reduced or confined to level of compliance to medical advice and blood sugar measurement readings on the glucometer, I point out in the research that the stories of Sri Lankans with diabetes in a developed country are different to the stories of other South Asian migrants with diabetes living elsewhere in the world as examined in other studies. I show how Sri Lankans, despite possessing several socio economic and cultural advantages in the land of settlement, still encountered significant challenges to manage diabetes effectively. I demonstrate in the thesis how each person’s socio cultural ‘baggage’ they bring to Australia during migration from their motherland, affects their transplanted lives and how it in turn affects their health care seeking behavior concerning managing diabetes. I demonstrate that aspects that affect the Sri Lankans’ perceptions and actions regarding the management of diabetes derive from personal history, their attachment to the collective cultural history of the community, their aspirations of upward social mobility coupled with attaining a higher standard of living as well as from the pressure caused by the differences in their conceptualization of ‘control’ from that of the doctors. This thesis will be of interest to medical anthropologists, sociologists and social science researchers of migration and migrant health; health care providers particularly teams who provide diabetes care to migrant patients; and community health care workers. It will also be of specific interest to migrants with diabetes living in Australia and in other Western societies, who might be interested to understand the experiences and challenges of living with a chronic illness through the insights of a group of Sri Lankan migrants in Melbourne living with diabetes.
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ItemGonna drink, get drunk: a history and ethnography of alcohol in Rarotonga, Cook Islands( 2002-11)This thesis describes the place of alcohol in the lives of people from Rarotonga, Cook Islands. It incorporates historical and ethnographic analyses to provide the broad context of drinking by people aged from their teens to late thirties. The historical component of this study describes specific accounts of alcohol consumption, and situates these with regard to changes that occurred in Rarotonga from the early 19th century. Prior to contact with Papa’a (Europeans), people of Rarotonga neither produced nor consumed alcoholic beverages. Thus, the use of alcohol was a phenomenon intimately bound up with global exploration, proselytisation and trade. I trace historical changes in the distribution of power, resources, religious practice, and social discourse, and show how alcohol practice, distribution, and trade was linked to these changes from missionary contact onward. This history informs the ethnography of contemporary drinking practices. Individual and group practices and understandings of alcohol are described. I also describe the contribution of state policy, commercial interests, government institutions, and religious organisations to the place of alcohol in Rarotonga. Alcohol is a transformative substance that changes the comportment of drinkers. But its effect is ambiguous, and recognised as such. ‘Drunken’ behaviours are often explained as originating in concerns and desires that pertain in sobriety. Thus, the status of alcohol consumption as an explanation for specific behaviours is equivocal, and contested. Drinking is a means by which relationships between friends, kin and strangers are initiated and/or maintained. The particular significance of alcohol to the maintenance of (drinking) relationships is not only due to social constructions of meanings and practices associated with drinking; pharmacological effects of alcohol increase the social salience of drinking. Drinking both alters bodies and alters relationships between drinkers. In this sense, it embodies social meanings and understandings of drinking practice. Finally, I suggest that in Rarotonga, the association of drinking with emotional experience and behaviour is also, in part, attributable to the ‘embodied’ experience of alcohol. The form of emotional experience, and the form of embodied experience of alcohol, are similar. These are associated with one another through analogy (and so by the social construction of each) by embodied experience.
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ItemThe narrative construction of identity and the medical student-patient encounter( 2013)My argument is that medical students and patients use stories to construct their identities in relation to one another, both within their encounters and when they talk about them. Identities are constructed in particular social contexts, shaped by relations of power and customary practices associated with embedded cultural values. Patients and students play an active part in shaping their own identities, as they comply with those in powerful positions, but also perform acts of resistance. Students struggle to integrate the values and practices expected of their emerging professional identity with those of their established identities. Some patients tell of empathic experiences, in which they are aware of students’ anxiety and intervene to relieve their discomfort; some also make judgements about a student’s moral character. Patients may participate actively in clinical teaching, but at times, they feel treated like passive objects. There are potential benefits and harms from patients’ involvement in medical education, yet when doctors and students enlist them, they often neglect to gain valid consent. When these practices are defended, patients are represented as adversaries; students’ learning is given precedence when their interests are seen as being in conflict. Students’ learning about communication and clinical relationships is often heavily based around simulated or peer-to-peer encounters. Despite some advantages, this approach may distort students’ expectations of authentic patient encounters and shape their identities in unknown ways. Encounters with real patients are more complex; learning about the doctor-patient relationship through authentic patient encounters would help students learn to listen to their stories, and appreciate what they accomplish, including the production of identity.
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Item‘Art is us’: Aboriginal art, identity and wellbeing in Southeast Australia( 2007)Aboriginal arts practices in the southeast of Australia have, since the early years of colonisation, been rarely considered within the realm of authentic Aboriginal arts practices. Such attitudes were a reflection of the colonial encounter and associated attempts to assimilate the Aboriginal population with the White. This thesis explores Aboriginal arts practices and asserts that there has always been Aboriginal art in the southeast and that, despite the overwhelming effects of colonisation, the work of Aboriginal artists provides a distinct and definite counter-history to that endorsed by the dominant culture. Using published historical and contemporary accounts and recent interviews from Aboriginal artists and arts workers, this thesis investigates the continuation of the knowledge and practice of southeast Australian Aboriginal art and its connection to culture, identity and wellbeing. It explores the corresponding adaptations and changes to these practices as Aboriginal people contended with the ever-expanding European occupation of the region from 1834 onwards. This project adopted a collaborative research methodology, where members of the Aboriginal arts community were consulted throughout the project in order to develop a study which had meaning and value for them. The collaborative approach combined an analysis of historical data along with the stories collected from participants. By privileging the Aboriginal voice as legitimate primary source material, alternative ways of exploring the history of Aboriginal art were possible. Although the story of Aboriginal art in the southeast is also one of tensions and paradoxes, where changes in arts practices frequently positioned art, like the people themselves, outside the domain of the ‘real’, the findings of this project emphasise that arts practices assist people with connecting and in some cases reconnecting with their communities. Aboriginal art in the southeast is an assertion of identity and wellbeing and reflects the dynamic nature of Aboriginal culture in southeast Australia.