Ethnography for Public Health Interventions, Essay Example

Ethnography is a potentially very powerful tool for gaining information that can be used to inform public health interventions. Based on rich, thick description, ethnography enables researchers to obtain much in-context information about how people live their lives, what they believe, and therefore how they are likely to respond to health interventions. Ethnography has many strengths, but its fundamental power is that of narrative, the ability to understand the story of a particular population. There are disadvantages to ethnography as well, since it can be subjective and tends to convey a great deal of information. Overall, however, ethnography is an invaluable and vital tool for gaining the kind of information needed to design the most efficacious public health interventions.

By using ethnography to inform health interventions, policymakers can go beyond health care as such to design interventions that improve the way people live, helping them to be more truly and fully healthy.[1] As such, ethnographies have an important role to play in the search for social justice in biomedicine, often making them intrinsically political. Through the use of ethnography, researchers can come to better understand the people they are working with. In the context of public health policy, this helps to ensure that interventions are designed and implemented in a culturally relevant and appropriate fashion, one that does not privilege hegemonic models, such as Western and patriarchal narratives, over subaltern models, such as indigenous and feminist narratives.[2] Humans are meaning-makers and world-creators, and it is essential to understand this if one is to truly help people as efficaciously as possible.[3]

Dominant paradigms of medicine generally treat of biomedical technologies as if they were context-free, in sociocultural terms. Whether antiretroviral drugs for the treatment of AIDS or chemicals for the treatment of water against parasitic worms, all biomedical interventions are reliant on empirical scientific variables rather than social and cultural ones—or so the received wisdom goes. The problem, however, is that people are not blank slates when it comes to society and culture. How people will respond to a given intervention depends very much on the degree to which it is calculated to address their needs and take their perspectives and beliefs into account. Failure to do this will compromise the efficacy of the intervention, leading to wasted resources and opportunity.[4]

A case in point of the importance of attending to social and cultural context is that of a landmark study on deworming children in Kenya, and the general reaction to it. This study determined that by provisioning young Kenyan children with deworming medication, school attendance increased by about 10 percent.[5] The deworming medication was extremely cheap, which would enable it to be distributed to Kenyan families in the necessary quantities, and it resulted in better school attendance as well as better health. The problem: a follow-up study by the very same authors found that other families who knew the families who had benefited from the deworming were actually less likely to adopt the treatment for their own children. Friends of families who had had their children treated also tended to rate the efficacy of the medicine as lower. While the authors did not ascertain the exact reason for this, these puzzling findings are a very clear reminder of the need for ethnographic research. A skilled ethnographer with a sufficient rapport with the people in question could doubtless have unraveled the mystery, and very probably could have anticipated the problems with a lack of trust in the medication that arose among those other families.[6]

A similar case of Western assumptions conflicting with indigenous values and ways of knowing is an incident that occurred in the small Ghanaian village of Taha. The people of Ghana, like populations in much of West Africa and other parts of tropical sub-Saharan Africa, have long suffered from the so-called guinea worm, a parasite that uses aquatic snails as its secondary host and causes great pain when it emerges from people. A program to eradicate the worm has been underway for many years, and it has achieved astonishing success. Accordingly, one would think that when a pair of workers with this program in Ghana went to Taha to treat the water with chemicals designed to kill guinea worms, they would be met with a warm reception, rather than an angry and armed mob. It would be too easy to dismiss the reactions of these Ghanaian villagers as the benighted response of a pre-scientific people to modern medicine. But as with so much of human behavior, no matter how inscrutable it may appear upon first brush, there is far more than meets the eye.[7]

As Moran-Thomas explains, in Northern Ghana traditional conceptions see the worms as entirely natural. Not only are they believed to be innate, they are believed by many to be natural parts of human bodies. So natural are infestations of the guinea worm, so much a part of ordinary, regular life, that it is not at all uncommon for people to mark their absence as a cause for concern. Not having worms may even be reason to seek spiritual explanations in order to ascertain what is wrong. In Northern Ghana, it is quite common for people to interpret the worm as a message from displeased ancestors, a message that must be received by attempting to placate the ancestors. It may also be interpreted as evidence of witchcraft, since after all, different people have worms leave their bodies at different times. Similar conceptions of the perceived naturalness of worm infestations have been found in Kenya, where the Luo people see parasitic worms as having their place in an overall circle of life. Instead of something to be eradicated, the Luo, like the people of Northern Ghana, see the worm as a part of existence to be coped with. The fact that the worms, while painful when they emerge from the body, do not cause death has also been frequently pointed out by many local peoples.[8]

What this review of indigenous attitudes about the worm and conceptions of overall health demonstrates is the seminal importance of considering this human perspective in any efforts to help people. The campaign to eradicate the guinea worm was undertaken in the 1980s by the steering committee of the World Health Assembly, and President Carter joined and became a prominent spokesman. The campaign has achieved remarkable success, promoting water purification efforts to destroy the parasites by interrupting their life cycle. While the campaign itself is commendable, the reactions of local peoples demonstrate that it has not been as successful in engaging with the very people it is trying to help as it perhaps could be.[9] The campaign has proceeded from a Western biomedical model of ‘disease,’ wherein the worms are seen simply as parasitic infestations which must be gotten rid of. Without disputing the merits of this perspective as such, it is still quite evident that it is not shared by many populations in the affected areas. Beyond doubt, then, it is important to consider the impact of these indigenous knowledge systems, and this is something that ethnography is uniquely well positioned to facilitate.

It was not until 2005 that it became relatively feasible to obtain a blood test for HIV, when at last the government was able to extend some access to voluntary counseling and testing (VCT) to facilities in the countryside that could test for HIV. Consequently, and given the proliferation of HIV, rural Malawians have ways of ascertaining whether or not someone is HIV positive without the use of a blood test, social diagnoses of a person’s symptoms that seek to pinpoint the ailment.[10] Weight loss is the key symptom rural Malawians pay attention to in order to tell if somebody has HIV or not. Weight loss is a relatively reliable symptom, if other factors can be accounted for. If someone is wealthy and is believed to eat well, but still manages to lose weight, this is a sure sign they have HIV. Rural Malawians will say that somebody has a “weak body” or “a body like a child’s,” variations on the theme of weight loss.[11] Another thing rural Malawians will look for is sores: individuals with sores on their bodies and their faces in particular are likely to have HIV. Rural Malawians also pay attention to hair, and with good reason: the medical literature has established that change in coarseness of hair or hair loss are common symptoms of HIV, and rural Malawians have picked up on this.[12]

Gossip is fundamental to the diagnosis of HIV without a blood test. Rural Malawians will gossip, comparing observations and pooling collective knowledge. This enables them to fill in gaps in their own knowledge about the person in question and their likely sexual history. Resulting pools of knowledge constitute virtual case studies, and can be quite detailed, “including who saw the person at the STD clinic or who paid for the trip to the hospital.”[13] Without this ethnographic data, attempts to design a public health intervention to reduce HIV transmission in rural Malawi would neglect an important source of information and knowledge among the population in question.

The case of the AIDS epidemic in the Caribbean presents another example of the importance of ethnography in understanding significant variables for the design of a public health intervention. Padilla presented ethnographic data on a high-risk population, male sex workers in the Dominican Republic. Significantly, although these sex workers catered to gay male clients from the US and other foreign countries, they did not generally describe themselves as gay or homosexual. One of these individuals, a man named Ricardo, became so successful in providing sex work to foreign tourists, male and female, that he opened his own agency. Ricardo was married and had an infant daughter, but this did not stop him from running his business from his home.[14]

What the ethnography revealed was the fluidity of Dominican male sex workers’ sexual identities. They did not see themselves as gay per se, and often dated women, but they were still perfectly willing to take clients who were gay men. Without this kind of context-specific knowledge, any attempts to curb the proliferation of HIV/AIDS in the Dominican Republic would be severely curtailed in their efficacy. In fact, the ethnography also highlighted the degree to which sex workers like Ricardo stressed the importance of using condoms to prevent HIV transmission, highlighting the knowledge of individuals within this high-risk population.[15] The lesson, then, is clear: the use of ethnographies facilitates understanding of populations, an understanding that is absolutely vital if a health policy intervention is to be successful. Only by truly understanding the population in question is it possible to ascertain the degree to which a particular intervention will be helpful, harmful, or simply ineffective.

Ethnographies have also the power to give a sense of scale. Multi-sited ethnographies, in particular, can help policymakers to understand the problem from the ground up as well as from the top down. Ethnography can highlight and lay bare the degree to which interventions are bound up with embedded narratives of normative value systems, which can reveal ways in which they are lacking and need to be readjusted if they are to truly help those they are intended to help. Ethnography can also point to structural factors and economic factors that may be relevant.[16] Examples of these are easy to come by from the case studies already presented: for example, the importance of the Dominican Republic’s shift to a more tourism-based economy in recent decades with regards to the prevalence of HIV/AIDS.

Ethnographies can help in another crucial way too: correcting actual misconceptions of study populations. The conceptions of Ghanaians that guinea worms are simply a natural part of human physiology present one example: this was a clearly mistaken belief, albeit one held sincerely and with reasons that seemed very apt to the people in context. Returning to the example of rural Malawians and HIV, ethnography enabled researchers to identify some quite significant misconceptions that identify gaps in local knowledge. One misconception that is very common in Malawi is the idea that a single instance of sexual intercourse with an HIV-positive person will lead to one becoming HIV positive as well. Malawians have a proverb warning against HIV: “Lie together, die together.” This is an understandable misconception, and it is certainly a better misconception to have than some, but it would certainly benefit more Malawians to understand that it does not exactly work that way.[17]

Another misconception concerns time. Malawians commonly think that when symptoms of HIV manifest, the person contracted the disease quite recently, when in fact research has established that it can take some years for such symptoms to manifest. Conversely, Malawians commonly associate looking ‘fat’ with health, and so believe that since HIV tends to have a wasting effect, that if someone is fat then they cannot possibly have HIV. This is a serious misconception: after all, someone could be quite fat (by Malawian standards, anyway) and yet still have contracted HIV. Symptoms, again, can take years to manifest visibly, and in that time plenty of people who do not show symptoms and appear to be perfectly healthy may go on to infect other people.[18]

Ethnography has also identified some of the key reasons why Malawians, despite knowing full well that HIV is transmitted through sex, nevertheless continue to become infected. It is not a deficit in their knowledge, or either of the above misconceptions (certainly not the first) that are to blame. Official HIV prevention programs teach a message often given as the acronym ABC: Abstinence before marriage, Be faithful to your partner, and Condom use. Rural Malawians commonly understand this very well, and are under no illusions on this score. Even in rural areas, most people in Malawi have had plenty of access to official information warning them about HIV and risky sexual behavior. Why, then, do they still continue to get infected with the disease?[19]

The answer is that Malawians understand the ABCs, but find it less than desirable to follow them all of the time. Abstinence before marriage may sound commendable and it is certainly completely effective, but abstinence is not always desirable: human beings are sexual creatures, and the majority of Malawians, like other people everywhere, give the desire for sex as the key reason why they do not practice total abstinence before marriage, or even just total abstinence from potentially risky sexual encounters. In Malawi, much as in many, many other societies, it is simply not a realistic expectation that the vast majority of adults be abstinent from all sexual activity prior to marriage. Malawians commonly recognize that being faithful to one’s partner is all well and good, but again like other people practically everywhere, many Malawians have more than one sexual partner over the course of their lives, and also like other people everywhere, not all of them are faithful to their partners all of the time. Similar experiences apply to condom use, or lack thereof. The basic problem is not that Malawians are ignorant and uneducated, or even terribly reckless (all things considered): the basic problem is that they see the three elements of the ABC approach as some mix of unattainable and undesirable. If they followed the ABCs all of the time, Malawians reason, they would find life much less enjoyable and satisfactory. Realistically, strict adherence to the ABC approach is probably not something that one can expect of most peoples, given the degree to which contravening these three tenets is ubiquitous worldwide, social censure notwithstanding.[20]

For all of their many virtues in facilitating health interventions, ethnographies have important limitations as well. These disadvantages, though by no means prohibitive, should nonetheless be taken into account when designing and implementing health policy interventions. First, there are problems with sampling and site selection to be taken into account.[21] Say that a researcher is conducting an ethnography of ‘lower-class’ female sex workers with high rates of drug abuse. The researcher wishes to use this information to inform a health policy intervention for the purposes of helping these women to find a safer and healthier line of work, and to get quit of their addictions. One possible problem is that the researcher is only one person, while the vulnerable group in question is represented in many cities in the United States, to say nothing of other parts of the world.

Realistically, any one researcher will not be able to really get to know very many of these sex workers with drug problems: they may meet a great many, they may learn a great deal, but it is doubtful that they will be able to really know more than a relative handful. If for whatever reason those individuals they do meet and come to know are not representative of the population as a whole even in one large city, the researcher may have a skewed conception of what is really important in designing this intervention. This is all the more true when one considers the differences that may be present between representatives of this same population living in different cities, to say nothing of different countries. Other methods are designed to glean sufficient information to correct for sampling and site selection biases, and should certainly also be used. Nonetheless, again, this disadvantage is by no means a prohibitive one, and researchers should continue to utilize ethnographies in designing and implementing health policy interventions.

Another potential issue concerns the difficulties that ethnography sometimes presents with regards to handling data. Because ethnography is about particularities and the rich tapestry of lived experiences, it is not always very easy to use it as a basis for generalization.[22] Ethnography is based on extensive observation, interviews, and time spent in the presence of other people. While the information it provides is very rich, it can be a challenge to codify that information into a form of concrete data that can be readily distilled and used to guide health policy in very specific ways. In other words, the information provided by ethnography is very complex and very diverse, and this can make it challenging to sort out what aspects of the findings should be used to do what. However, with the proper diligence on the part of the researchers responsible for producing the ethnography in the first place, and the proper attention to detail on the part of those designing the health policy intervention, it is eminently possible to use ethnography to inform any intervention. The challenge is fundamentally one of comprehension, the ability to read a narrative and identify its overt and covert themes. Once one can do that, then it becomes very possible indeed to use an ethnography to design an optimal health policy intervention.

Subjectivity is another issue researchers must be prepared to confront. The data ethnography yields are generally quite subjective, something which, though not without its advantages, does have shortcomings as well.[23] Subjective data of the kind revealed by ethnographies are very useful in helping to cast light on how people live and think, so it is not as though they are not useful. Nonetheless, a problem with subjective data is precisely that they are value-laden and very particular: the subjective opinions and views of research subjects, while significant and relevant, are not the kind of data that one can take as objective in a scientific sense. Again, caution must be exercised on the part of the researcher if they are to come to the best and most informed conclusions. By exercising prudence and caution, the researcher can recognize subjectivities in their data and use the data in the most efficacious ways, without allowing subjectivity to assume an emphasis or form that is not meet for the purposes of the health policy intervention.

Another weakness: the presence of the ethnographer themselves. Since people do not speak and act the same way in all situations and with all people, it is highly likely that no matter how culturally sensitive and conscientious the ethnographer is, they will have some influence on what is being said and done, simply by virtue of being someone who is not known at first to those they are observing, and a researcher at that. This is an important effect that requires much time and diligence on the part of the would-be ethnographer to overcome as best as they are able, and of course there is absolutely no guarantee they will ever be able to overcome it entirely. A committed ethnographer who learns the local ways of doing things over a long period of time will be able to obtain better information, especially because over time they will see the same people interacting in more and more situations, and doing similar or different things in the same situations. This can compensate significantly for the effects of the presence of the ethnographer, but again, there is absolutely no guarantee that they will ever be able to overcome these issues entirely. A key point here is that “even in excellent ethnographies one almost never finds the back and forth of everyday talk.”[24]

Ethnography has many strengths as an approach for learning about a population that is to be targeted for a public health intervention. It provides a great deal of rich information in context, allowing the researcher to understand how the population in question views the world and the particular health malady at issue. This can inform comprehensive and culturally sensitive interventions, interventions that can provide for the needs of the population without inefficiency or clashes of cultural values. There are also disadvantages of the ethnographic approach, since it is subjective, produces a great deal of information, and because the researcher will have some influence. However, these disadvantages can be worked around, giving ethnography its proper place in the design and implementation of public health interventions.

Bibliography

Biehl, Joao, and Adriana Petryna. “Critical Global Health.” In When People Come First: Critical Studies in Global Health, edited by Joao Biehl and Adriana Petryna, 1-23. Princeton, NJ: Princeton University Press, 2013.

Biehl, Joao, and Adriana Petryna. “Overview.” In When People Come First: Critical Studies in Global Health, edited by Joao Biehl and Adriana Petryna, 133-139. Princeton, NJ: Princeton University Press, 2013.

Lock, Margaret, and Vinh-Kim Nguyen. An Anthropology of Biomedicine. Malden, MA: Blackwell Publishing, 2010.

Moran-Thomas, Amy. “A Salvage Ethnography of the Guinea Worm.” In When People Come First: Critical Studies in Global Health, edited by Joao Biehl and Adriana Petryna, 207-242. Princeton, NJ: Princeton University, 2013.

Padilla, Mark B. “The Limits of ‘Heterosexual AIDS’: Ethnographic Research on Tourism and Male Sexual Labor in the Dominican Republic.” In Anthropology and Public Health: Bridging Differences in Culture and Society, 2^ndedition, edited by Robert A. Hahn and Marcia C. Inhorn, 142-164. New York: Oxford University Press, 2009.

Quimby, Ernest. Doing Qualitative Community Research: Lessons for Faculty, Students and Communities. Sharjah, UAE: Bentham Science Publishers, 2012.

Watkins, Susan C., Ann Swidler, and Crystal Biruk. “Hearsay Ethnography: A Method for Learning About Responses to Health Interventions.” In Handbook of the Sociology of Health, Illness, and Healing: A Blueprint for the 21^stCentury, edited by Bernice A. Pescosolido, Jack K. Martin, Jane D. McLeod, and Anne Rogers, 431-448. New York: Springer, 2011.

[1] Ernest Quimby, Doing Qualitative Community Research: Lessons for Faculty, Students and Communities (Sharjah, UAE: Bentham Science Publishers, 2012), 112.

[2] Joao Biehl and Adriana Petryna, “Critical Global Health,” in When People Come First: Critical Studies in Global Health, ed. Joao Biehl and Adriana Petryna (Princeton, NJ: Princeton University Press, 2013), 16-17.

[3] Biehl and Petryna, “Critical Global Health,” 17.

[4] Margaret Lock and Vinh-Kim Nguyen, An Anthropology of Biomedicine (Malden, MA: Blackwell Publishing, 2010), 1500.

[5] Ctd. in Biehl and Petryna, “Critical Global Health,” 17.

[6] Biehl and Petryna, “Critical Global Health,” 18.

[7] Amy Moran-Thomas, “A Salvage Ethnography of the Guinea Worm,” in When People Come First: Critical Studies in Global Health, ed. Joao Biehl and Adriana Petryna (Princeton, NJ: Princeton University, 2013), 207-212.

[8] Moran-Thomas, “A Salvage Ethnography of the Guinea Worm,” 212-217.

[9] Moran-Thomas, “A Salvage Ethnography of the Guinea Worm,” 215-217.

[10] Susan C. Watkins, Ann Swidler, and Crystal Biruk, “Hearsay Ethnography: A Method for Learning About Responses to Health Interventions,” in Handbook of the Sociology of Health, Illness, and Healing: A Blueprint for the 21^st Century, ed. Bernice A. Pescosolido, Jack K. Martin, Jane D. McLeod, and Anne Rogers (New York: Springer, 2011), 438.

[11] Watkins, Swidler, and Biruk, “Hearsay Ethnography,” 438.

[12] Watkins, Swidler, and Biruk, “Hearsay Ethnography,” 438.

[13] Watkins, Swidler, and Biruk, “Hearsay Etnography,” 438.

[14] Mark B. Padilla, “The Limits of ‘Heterosexual AIDS’: Ethnographic Research on Tourism and Male Sexual Labor in the Dominican Republic,” in Anthropology and Public Health: Bridging Differences in Culture and Society, 2^nd ed., ed. Robert A. Hahn and Marcia C. Inhorn (New York: Oxford University Press, 2009), 142-147.

[15] Padilla, “The Limits of ‘Heterosexual AIDS’,” 144-151.

[16] Joao Biehl and Adriana Petryna, “Overview,” in When People Come First: Critical Studies in Global Health, ed. Joao Biehl and Adriana Petryna (Princeton, NJ: Princeton University Press, 2013), 136.

[17] Watkins, Swidler, and Biruk, “Hearsay Etnography,” 443.

[18] Watkins, Swidler, and Biruk, “Hearsay Etnography,” 443.

[19] Watkins, Swidler, and Biruk, “Hearsay Etnography,” 443.

[20] Watkins, Swidler, and Biruk, “Hearsay Etnography,” 443.

[21] Quimby, Doing Qualitative Community Research, 112.

[22] Quimby, Doing Qualitative Community Research, 112.

[23] Quimby, Doing Qualitative Community Research, 112.

[24] Watkins, Swidler, and Biruk, “Hearsay Ethnography,” 437.