Valuing health

Eileen Moyer, Vinh-Kim Nguyen

17 Apr 2019

How do we value health, and how are practices of valuing shaped by matters of scale, geopolitical location, and individual positionality? How do age and quality of life intersect with these valuation practices? What health-related affordances come into being as a consequence of people’s abilities to stake claims based on kinship, wealth or status, or nationality? Who gets excluded as a consequence of shoddy public health systems, predatory insurance schemes, and profit-centred pharmaceutical companies? How does a growing reliance on metrics and short-term profits foreclose possibilities for valuing deeper social, political, and economic drivers of health, both good and bad? This issue of MAT combines a range of written and photographic work to examine the contexts that shape how health is valued, variously attending to issues of kinship, social relations, traditional medical practices and religion, nationality, and language. 

Mara Buchbinder’s article on ‘aid-in-dying’ in Vermont examines communication around end-of-life care for people with less than six months left to live. Through a focus on the sociality of language used in clinical interactions she builds a theory of language ideology relating to practices of clinical disclosure of possibilities for assisted death. How one values acts of disclosure is tied to one’s views on patient rights, including the right to die with dignity, and informed choice; these ‘disclosure ideologies’ reflect broader social ‘values regarding privacy, relationality, autonomy, and medical authority’ (p. 8). Our responses in the face of failing health and impending mortality reflect not only how health is valued but also wider social norms, ethics, and morality. Buchbinder argues that ‘the moral stakes of such disclosures are more complex than the question of one’s “right” to information, and instead depend on uncertainties surrounding the performative context of informing’ (p. 12).

Expressing some ambivalence about its usage, Alejandro Cerón coins the term ‘neocolonial epidemiology’ to explore mechanisms that limit the possibility for public health practitioners in Guatemala to adhere to principles of epidemiology that should enable professionals to address the structural causes of poor health. Cerón partly attributes these failures to economic issues, ranging from the underfunding and fragmentation of public health facilities in Guatemala to failures to professionalize epidemiology at the national level. Also key to his explanation is the limitation on epidemiological practices that emerges in relation to global health metrics and a donor focus on disease response over prevention. Through his article, we come to see the insidious consequences of a devaluation of public health in Guatemala: chronic underfunding, structural adjustment, and audit cultures.

Also based on research in Guatemala, Jillian Moore, Caitlin Baird, and Peter Rohloff ask tough ethical questions related to the provision of dialysis for people in need within a meagre health care system in a country with a poor social welfare infrastructure. Rather than delivering health, the intervention seems only to prolong illness, putting substantial economic and care responsibilities on both patients and their families and communities. The authors ask: Should we only value life at the individual level, or should we also consider the consequences for the family, community, and wider public health care system when medical technologies are used to prolong illnesses while requiring substantial economic and time commitments from others to succeed? 

Utilizing classical anthropological and sociological theories on exchange, Eva Krah examines a seeming paradox: how Mamprusi healing practices in Northern Ghana stubbornly resist becoming subject to monetization and commodification in an otherwise neoliberal context. Her study not only offers an important contribution to the literature on gift exchange, it also argues that anthropologists must push beyond simplistic characterizations of how neoliberalization voraciously swallows local practices. Her careful analysis shows how health is persistently valued within the context of a local moral economy, despite increasing pressures felt by healers to participate in a cash economy.

Clare Herrick’s think piece asks us to consider why, despite evidence of their growing burden on society, NCDs, or noncommunicable diseases, have so far failed to compel global action proportionate to their magnitude. Responding to a recent discussion on the topic in the Lancet, Herrick argues that there is more to the problem than a simple failure of terminology. Instead, she suggests that ‘inaction represents the failure of “NCDs” to resonate with the public and to create the kinds of meanings, values, and sense of crisis that make people anxious enough to care and politicians accountable enough to act’ (p. 96). Here, Herrick points to something alluded to in the articles by Cerón and Moore, Baird, and Rohloff: the entwinement of valuation practices with crisis framings. Diseases or health problems that are valued as a threat get more immediate attention and (usually) more money, despite possible consequences for the wider public health system.

This issue also features two photo essays that push the boundaries of the genre for us at MAT. Anthropologist Jerome Crowder shares coauthorship with his late father to explore his journey with chronic illness and eventual death. The elder Crowder’s positionality as a relatively well-insured older white male in the United States helps the younger Crowder to ask questions relating to the ethics and costs of extending life for some. Crowder reflects on the value of life with ever-decreasing health, wondering where the boundaries are regarding expensive and invasive medical interventions and ever-growing caregiving responsibilities. The intimacy of the family photographs raises questions relating to positionality and objectivity, which are touched on by the authors but are also sure to leave readers with food for thought.

Also pushing us to sit with uncomfortable questions is Emily Yates-Doerr’s photo essay, which expertly oscillates between the United States’ border, where young Guatemalan children have died in government custody, and a seeming Guatemalan idyll, where her own children are treated with respect and dignity. The injustice at the border is made all the more stark by the comparison, inviting us to ask: why are the lives of some children valued more than others?

The issue is rounded out by Joelle M. Abi-Rached’s book review of As the World Ages: Rethinking a Demographic Crisis, by Kavita Sivaramakrishnan. Fittingly for the theme running through this issue, Sivaramakrishnan’s book examines how ageing populations are valued differently around the world, and how Western crisis framings shape competing paradigms in South Asia and Africa.

Finally, we remember the life and work of Deanna Jeanne Trakas, who introduced medical anthropology to Greece, where she spent most of her academic life. She contributed multiple pieces to Medische Antropologie, MAT’s predecessor, as well as a think piece to MAT’s inaugural issue of December 2014. The remembrance, authored by her colleague and friend Sjaak van der Geest, paints a moving picture of a dedicated scholar and generous colleague.