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In public health there is increased focus on evaluating 'complex' interventions for health improvement, examining how their multiple components interact dynamically with the contextual system in which they are delivered. Amid this complexity framing are calls for methodologies that can facilitate contextual understanding as part of the evaluation process, including ethnography. However, while ethnography's attention to 'context' has been recognised as valuable for evaluation, few questions have been raised about the possible tensions of aligning what are quite different expectations for knowledge making in evaluation and in ethnography. This paper introduces a special section illustrating empirical examples of conducting ethnography for and with evaluation of 'complex' health interventions. Central to these experiences, this paper argues, are the concepts of time and temporality through which experience, change and knowledge making are invariably structured. It considers the different expectations for time and temporality in ethnographic and evaluation research, and how the 'long conversation' of ethnography aids interpretation of an intervention's interaction with the pasts, presents and possible futures of people's health experiences. Furthermore, in understanding time not as linear and constant but experienced through a series of encounters, ethnography highlights the spaces in between action and change, vital for understanding the complex dynamics of a health intervention in context. Through temporality, this paper and the related empirical papers present an intricate exploration of the challenges and productive opportunities posed by the use of ethnography for and with evaluation. [ABSTRACT FROM AUTHOR]

Reducing the maternal mortality rate (MMR) is an important part of Mexico's commitment to the Millennium Development Goals, and the country has made great strides towards achieving this goal. However, researchers have questioned to what extent the focus on improved MMR and other indices of maternal health has contributed to an emphasis on improved statistics rather than quality care, and the effect this has had on the quality of reporting. While public health officials and hospital administrators alike agree that improved obstetric reporting is necessary, there is little discussion regarding the accuracy of the data that are submitted and the institutional pressures that may contribute to the production of inaccurate data. Using ethnographic research collected in Tulum, Quintana Roo, this paper explores how biomedical childbirth functions as a source of legitimization for the state while simultaneously providing the means for the presentation of an ideal subjecthood, one that situates birthing women and healthcare personnel as properly attenuated to the norms and needs of the modern Mexican state. By highlighting the point of disjuncture between women's experiences and the formal ‘reality’ created through hospital texts, this paper explores the place of biomedical birth as a producer of and legitimization for Mexican public health policy. [ABSTRACT FROM PUBLISHER]

Studies of care-seeking behaviour have generally focused only on the medical facilities that are available within a country's national boundaries. However, a growing number of patients worldwide are pursuing medical services outside of their own countries. The burgeoning literature on 'medical tourism' tends to offer the perspectives of the treatment destinations, not the experiences of patients. This paper examines the international medical travel of patients from the capital-poor country of Yemen. Families in Yemen often sacrifice greatly to seek the advanced, trustworthy technological medicine that is unavailable locally. The paper draws on interviews conducted with 71 Yemeni medical travellers in India and Jordan, as well as a survey of 205 doctors in Yemen about their disclosure practices regarding terminally ill patients. While perhaps an attractive option in today's global world, the use of medical services abroad affects local perceptions: it perpetuates a lack of trust in local capabilities, invites criticism of the government for not providing care to its citizens and fosters the hope that a cure exists somewhere in the world. [ABSTRACT FROM AUTHOR]

Following the recognition that ‘culture matters’ in designing effective public health programs, this paper focuses on one refraction of culture within the so-called ‘homosexual’ community in India, to highlight how attention to local knowledge and its socio-economic underpinnings can impact the politics of health care. Drawing primarily on ethnographic fieldwork conducted from 1995–1997 and 2003 in the South Indian city of Hyderabad among hijras (the so-called third sex of India) as well as the wider community of MSM or ‘men who have sex with men’, the paper argues that public health framings of homosexuality often fail to pay attention to differential understandings of stigma and their socio-economic underpinnings, a failure that accounts in some measure for the ineffectiveness of prevention programs targeted at ‘high risk’ communities such as hijras and MSM. Focusing on the local moral economy of respect and shame as one pathway of stigma and contagion, and in particular on the differences in constructions of respect and shame between hijras and the wider community of MSM, this paper points at one small way in which understanding how culture matters can ultimately address the ineffectiveness of prevention programs and redress the inequalities in health outcomes between the various margins and centers of power. [ABSTRACT FROM AUTHOR]

Based on fieldwork and archival studies carried out since 1995, this paper is an analysis of the dialogue between the Jarwas and the outside world. The Jarwa tribal community on the Andaman Islands has a long history of voluntary isolation and pronounced hostility towards outsiders. This situation only started to change in the mid-1990s, when a young Jarwa was successfully treated at a local hospital. The Jarwas’ sudden fascination with modern medicine was less to do with its therapeutic powers than the fact that, on each visit, hospital staff gave them food, clothes, and various consumer items. This paper describes events in the Jarwas’ ‘junket to modernity’. Before discussing recent events, the paper first retraces the history of relations between the Jarwas and the outside world during the second half of the 19th century, when life on the Andaman Islands was dominated by a British Penal Settlement. In the face of epidemic outbreaks of pneumonia, malaria, and measles, tribal health has become a major concern for the Indian authorities. The paper discusses continuities and discontinuities in medical concerns with the tribal body, and argues that ‘marginalization’ must be understood as a practice of mutual constitution. [ABSTRACT FROM AUTHOR]

In the global effort against HIV and AIDS, prevention of mother-to-child transmission of HIV (PMTCT) in resource-poor countries is an issue of international importance. In Cameroon, a widely disseminated protocol defines the process to be followed by all pregnant women within the public health system before and after screening, whatever the result. The protocol as a representation of professional practices can be discerned in inscriptions made in files, registers and the carnet de santé that we use here as the cornerstone of our analysis. By granting it the status of a 'script' and intermediary object, we hypothesize that its purpose is to link together human and non-human actors around the PMTCT protocol in order to reduce the risk of mother-to-child transmission. However, as we show, representations and forms of interactions that are structured and reconfigured around it paradoxically contribute to the re-emergence of the risk of mother-to-child transmission of HIV. [ABSTRACT FROM AUTHOR]

In this paper I discuss the possibilities and limitations of the ethnographer participating in the different on-going activities and events in highly specialised healthcare systems. The concept of participant observation is based on a number of assumptions, particularly that the ethnographer will become one of 'them' to be able to follow the steps belonging to the accepted ethnographic research practice of doing fieldwork. The character of fieldwork in highly specialised healthcare systems does not fit well with this assumption. I suggest that we need to rethink the concept of participant observation and I propose negotiated interactive observation as a more appropriate way to describe ethnographic fieldwork in a setting such as the hospital or the clinic. [ABSTRACT FROM AUTHOR]

Increasing HIV testing is a necessary step toward control of the disease. Many experts suggest routinely offering HIV testing to specific population segments. We explore provider discourse regarding an HIV test implementation project with the aim of illuminating a structurally emergent clinician strategy for promoting testing and the socio-cultural factors underlying it. Twenty US Veterans Affairs Healthcare System clinical care providers were interviewed. Using standard anthropological text analysis techniques, themes, their relationships, and the significance of these for increasing appropriately targeted HIV test offers were established. Presenting the HIV test offer to their patients as if routine ('routinisation') supported providers' desire to do no harm by lessening the test's potential stigma. Offering the test helped providers maintain professional integrity: it empowered veterans to realise access to care and fit with providers' sense of honour and duty. Routinising HIV testing also helped providers to manage scarce time effectively. Findings can be leveraged to support routine screening's successful roll-out. The carefully managed introduction of routine HIV test offering policies will formalise and legitimise productive strategies of destigmatisation already being enacted by some front-line providers. The fact that routinisation strategies are in use although HIV testing is not actually routine attests to the potential power routinisation has to reduce HIV's stigma, increase HIV test uptake, and thereby improve access to care. What I've learned about tough questions is: The more routine you make them, the easier it is to get the questions answered, the less destructive it is to the relationship and that's the sort of paradigm I've come to believe in and will use now into the future. (Marvin K, MD) [ABSTRACT FROM AUTHOR]

Departing from what has in medical anthropology been termed the individual body, the social body and body politics, actor-networks in medical pluralism are investigated on the basis of a study of complementary and alternative forms of medicine (CAM) in Denmark, including participant-observation in 12 clinics of reflexology, biopathy and kinesiology, as well as interviews and informal conversations with more than 40 alternative practitioners and 300 patients of CAM clinics. In this study, several actor-networks that connect metaphorical models of the body, clinical technology, social relations and political structures of the Danish society are revealed: a technocrat network, a social-democratic consultancy network and a neo-liberal network. The co-existence of several actor-networks has phenomenological as well as structural implications. The implications for patients using several forms of therapy is important insofar as the patients' move between different actor-networks of healing implies switches between different experiences of body and self. Each of the actor-networks at the same time implies different positions in relation to the public healthcare system, and some actor-networks appear to be more compatible than others with the generalized and technical properties of public healthcare. [ABSTRACT FROM AUTHOR]

The objective of this study was to compare perceptions and practices in relation to human and livestock illness among the Luo in Western Kenya. Qualitative methods of data collection such as key informant interviews, open-ended, in-depth interviews, focus group discussions, narratives, and participant- and direct observations were applied. The study showed that there were significant parallels between human and livestock illnesses regarding terminology, perceptions of pathogenesis and treatment seeking practices. Even practitioners and their medications were often the same. The rationale behind pathogenesis in both cases was usually that illnesses resulted from some form of inhibition of flow through blockage or clogging of the various ‘channels’ in the body. Treatment aimed at decongesting or unblocking these channels so as to create openness that would guarantee normal flows and restore health. The study concludes that the domain of animal illness be taken more into account in human medical anthropological studies and vice versa. It further argues the case for considering these similarities when planning and implementing health care services. [ABSTRACT FROM AUTHOR]