Category Archives: Faculty interviews

Bridges and Barriers: The Ins and Outs of Strategic Storytelling

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© 2016 University of North Carolina at Chapel Hill School of Medicine

Dr. Raúl Necochea is currently an assistant professor in the Department of Social Medicine at the UNC School of Medicine as well as an adjunct assistant professor in the Department of History. Inspired by stories from his OB/GYN mother and questions of unethical sterilizations in his native Peru, Necochea wrote A History of Family Planning in Twentieth Century Peru, which was published in 2014. His book tries to capture the different lived experiences of people regarding family planning. Each chapter represents a different vantage point including those of clinicians, intellectuals, feminists, the Catholic church, and men and women who were seeking abortions. At stake were notions of individual autonomy, the future of gender relations, and national prosperity.

“When I went in to write this book about the history of family planning in my home country of Peru,…I had some vague idea of what it was going to be about; it was going to about family planning and it was going to involve Peru and it was going to involve the 20th century…Once I had that figured out, [I thought] okay, I have all this now, [so] what is the best story that I can tell with all this?”

Grabbing a copy of his book, A History of Family Planning in Twentieth Century Peru, from his office’s book nook, Raúl Necochea settled in his desk chair and briefly sifted through the pages. When reflecting on his role as a historian, Dr. Necochea knew he was tasked with telling and uncovering yet “another story of abuse and negligence of people” who shouldn’t have been susceptible. Although Dr. Necochea recalls always having a particular interest in family planning, his research journey began at the start of his grad career, which was situated within the plight of a Peruvian scandal.

“Right around the mid 1990s, there was a scandal in Peru over some surgical sterilizations that were performed on women seemingly without their consent. They were mainly poor women, indigenous women, mainly women who lived in rural areas, traditionally the women who had always been the last to [be] served by the government and the medical profession.”

Representing a repetitive pattern of victimization, Dr. Necochea was challenged with revitalizing an old tale. Why were the same people still vulnerable and victimized? How were the same trends regarding contraceptive access reproduced? What actors were consistently involved? These probing questions guided Dr. Necochea’s role as an active historian, researcher, and storyteller.

When talking about projects, Dr. Necochea believes creating research projects is a valuable tool to experience. He views it as a bridging opportunity between professors and students to experience the value and importance of research and allow students to explore their interests deeper. “I think that the experience of writing and doing research on your own is really valuable…I mean, oftentimes the way in which we present research to students sort of makes it seem as though our expertise…is there for you to simply accept and consume, but the experience of actually producing the knowledge that goes into books or articles, that’s a very different process.” Dr. Necochea’s advice to students who hope to create their own research project encompasses the idea of producing knowledge through passion. He demonstrated his passion by drawing attention to the needs of the community in Peru. He also spoke about his identity as a Peruvian and the role it played in navigating the exploration of his research. Dr. Necochea stated that being Peruvian “opened a lot of doors for [him], not only speaking the language but being able to navigate and understand the people there. There’s nothing like being a local to open those doors and get others to say what you understand.”

“Beyond [ethnicity], there’s other markers that make you into the right or wrong messenger for some stories. The whole time that I wrote this story for example, I was always worried about the fact that I was a man studying a topic that is primarily about contraception for women”

In addition to his ethnicity, other aspects of his identity played a pivotal role in his research on sexual and reproductive health, especially with regard to gender. Conflicted about the role of men in conversations regarding modern contraceptives and family planning, concepts primarily marketed for women, “being a man was always in the back of [his] mind as a barrier to negotiating some of these conversations that [he] had to have.”

Alongside his identity, Dr. Necochea’s upbringing helped bridge the barrier of potential ideological differences between himself and his research participants. “Another thing that sort of played in my favor is who I am, which is not only a man but also a man who has been educated at a fairly conservative high school [in Lima]” he explained. This high school was a Catholic institution that was very renowned in Lima. Many of the participants in Dr. Necochea’s research had conservative viewpoints and were strong activists of the Catholic church, so his educational background provided a common ground, a sense of trust, and a bridge for critical dialogue. Ultimately, “it created sort of a level of confidence that [he] would not have had otherwise.”

Snapshot of Necochea's archival adventures. Reflective of one of his practical research challenges, "being indoors reminded [him] of how resource-poor archives can be." Pictured

Snapshot of Necochea’s archival adventures. Reflective of one of his practical research challenges, “being indoors reminded [him] of how resource-poor archives can be.” Pictured is one of the buildings of the Regional Archive of Puno, in southern Peru, 4000 meters above sea level.

During his time in Peru, Dr. Necochea faced many unexpected research challenges. He gave us interesting insight into navigating practical and ethical barriers while in the field. On the practical side, he learned that accessing archives would be much more difficult in Peru than in the US or Canada; but, in order to pursue the study, he would have to adjust.

“What I would find is that people were not returning my calls…or the facilities would be closed arbitrarily, or the materials that were supposed to be there were not there…Materials would be scattered around in different places. Archives would close, as in ‘we no longer have the possibility of serving the public because, [we’ve] run out of money’…It [was] a situation I encountered very often and it’s not a situation that is uncommon in developing countries– archived materials [that] ought to be available for public education and research often suffer from lack of funds.”

Dr. Necochea also discussed some of the ethical dilemmas he faced while in the field. He often had to interview individuals with whom he disagreed on the issue of family planning. Sometimes he was able to “make bridges [with individuals] when there [was] a respectful understanding of difference.” Other times, it was not so simple. In one example, he had conversations with physicians who flippantly recalled forced sterilizations they had performed and a pharmaceutical representative who ended up going on an anti-indigenous rant.

“Sometimes not everything can be planned in those situations, and you can be surprised in a bad way…you start to question your own sense of composure. Like, did I really do the right thing in not telling this guy he’s an ass and that I’m out of here or something like that? Or do I just finish my drink and then be on my way? Do I stay in touch with these people, all of whom want to stay in touch? “I mean, what do you do? It becomes a little bit of an ethical conundrum too about how do you stay connected to the field, which is another anthropological thing.”

In order to overcome his own biases, which could also act as barriers to his research, Dr. Necochea found that it was important “[to be] comfortable being sort of alien in a different cultural space. That’s a mainstay of anthropological work and it’s one of the things that has happened to [him] often by having to travel to different places for archives.” Despite being “mainly in archives, you have to be in situations in which you are the odd person out because of the nature of the different archives where [he] was. That attitude of being comfortable with uncertainty helps make you a good observer when you’re on the edge of a different culture.”

Through his research, Dr. Necochea was able to overcome barriers and create powerful bridges by telling a story that ensured voices were heard on a research topic in which he was extremely invested in. Yet, the story does not end here and Dr. Necochea’s research will continue on. Looking towards the future, he plans to write his next book on the “history of cervical cancer in Peru and possibly Latin America.” He “came across a couple of sources from the 1950s of physicians with ties to the government who were speaking out against the use of intrauterine devices for women…[and] started to get very curious about how this particular fear sort of became articulated at different levels — [specifically] at the level of government experts and also at the level of lay people.”

“More needs to be done to end social problems that have health implications, and a law is not gonna change that. We need something more–community participation in changing people’s minds like minds were changed earlier in the 20th century about birth control. That takes a great deal more work than just saying ‘Oh that’s wrong.'”

Now it is our turn. Now is the time to turn the page and bookmark the innovated projects of the future. Now is the time to research our own stories that encompass our passions, our interests, our backgrounds, and our various identities. Each story will bring its own barriers and challenges, however, it will also build bridges and enable us to make connections to the world around us. Dr. Necochea told his story, which story will you tell?

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Gems about Dr. Necochea

Tar Heel Bred: “I’m a big fan of this place [and] organizationally what UNC is and stands for. I mean, public education for one — I’m very proud of the fact that I can contribute to training of people who are so grounded in this space of this state and who get some kick ass education and experiences and opportunities to go as wide as they can.”

Elements of Anthropology: “I really enjoy ethnographic tales where anthropologists sort of reflect on their position of being on the edge of something and being able to understand its differences and similarities with other places.”

Favorite Quote: “The restricted use of anovulatories* […] does not infringe on the terms of the [Humanae Vitae] Encyclical, according to the judgment of authorized experts in morality” – Juan Landázuri, Archbishop of Lima (1955-1990) and Cardinal (1962-1990)

* – contraceptive pill

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Is Medical Anthropology “All in Your Head?” An Interview with Dr. Mara Buchbinder

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An Introduction

Photograph of Dr. Mara Buchbinder

Dr. Mara Buchbinder’s most recent book, All in Your Head: Making Sense of Pediatric Pain, offers an exciting perspective on pediatric pain by focusing on the intricate dynamics of a small clinic in California she refers to as the “West Clinic”. By following the lives of several adolescent patients, families, and clinicians, she identifies numerous variables which contribute to making sense of pediatric pain. The book challenges its audience to recognize the social expectation which culture has linked to definitions of pain. This interview on her newest academic feat was conducted by a team of undergraduate Medical Anthropology minors.

“Because the mind is the province of imagination, ‘”all in your head'” may also suggest that the pain is made up, […] the invention of a self-defeating mind, or, worse the fabrication of a malingerer.”

Sources of Inspiration

When did you decide you wanted to go into medical anthropology?

M.B.: I had this really fantastic opportunity to do an interdisciplinary undergraduate thesis project at Dartmouth College. I developed this idea based on my summer research at The Children’s Hospital, Boston to make visual illness narratives of adolescents with type 1 diabetes. For my senior project, I produced a video component about what it was like [for these adolescents] to live with type 1 diabetes. I loved doing that and it got me very excited about going to graduate school and doing research. That’s what actually got me into medical anthropology.

What inspired you to write about this topic? Why did you choose to focus on pediatric pain?

M.B: I have always been interested in children’s health issues and how families manage children’s chronic health problems. What I found really compelling me about medical anthropology was the focus on people’s narratives about illness. That is why I wanted to look at pediatric issues. In terms of the focus for my dissertation research, I happened to find out about this clinic and it seemed like a very interesting research opportunity because it was unique in the way that it was set up and the the kinds of pain that it dealt with.

“What really compelled me about medical anthropology was the focus on people’s narratives about illness.”

The Project

All in Your Head: Making Sense of Pediatric Pain

Image of the cover of Dr. Buchbinder’s book, “All in Your Head: Making Sense of Pediatric Pain”

What were some of the challenges you faced in the writing and research behind All in Your Head?

M.B.: One thing that was a little challenging was that I didn’t leave home to do this project. [In anthropology,] there’s an expectation that you will go somewhere else and experience a foreign culture. Initially, I had a hard time getting my research off the ground and thinking “Am I in the field now?” and “What is the field? What defines the limits of the field?”. I also had methodological challenges and had to adjust the research design. It was sometimes difficult to recruit families to participate, but I incorporated more of what I saw as low-hanging fruit. Most families let me observe their clinical appointments with physicians, so I did a lot of that.

With respect to writing, I think it was challenging that so much of what I saw in the clinic was very particular. The patient population was very privileged and didn’t really reflect the socio-demographics of the surrounding area. I struggled because I was talking about a type of health care that a lot of people didn’t have access to. I thought about how to set up the story so that it would reflect on larger themes, even though it’s not representative of the American health care system. There was a patient that I had recruited for my study but didn’t end up going to the clinic because her state insurance wasn’t accepted. I decided to write a chapter about her experience because it showed what happened when people didn’t have access to the clinic.

“I’d say a really high percentage of them could get better… if their parents would let them.”

-Nina Herrera, clinical coordinator, West Clinic

In Chapter 4, “Treating the Family”, you focus on how the West Clinic team assumptions of normative family roles relate to explanatory models behind treatment decisions. Can you expand on how other normative assumptions contributed to treatment decisions?

M.B.: I think that a lot of the decisions about restoring functioning were motivated by ideas about what defines success in adolescence, and so a lot of the decisions were oriented toward, getting kids into college. There was a lot of talk about getting [them] into college and getting them back into their high-achieving tracks. Of course, sometimes I think the clinicians helped families and patients get off that track, and that was also part of what they did. But I think sometimes they were implicitly motivated by middle class values about education and achievement and success.

In Chapter 5, you begin with a quote by George Beard about American nervousness “Without civilization there can be no nervousness…”. In what ways does this quote relate to the West Clinic patients’ experiences with navigating their roles in civilization as both patients and humans?

M.B.: I was very drawn to historical work on diseases that affect certain socioeconomic groups. Much of the discussion in the clinic meetings was about the culture of stress facing today’s adolescents. I think it’s true that adolescents today are under a lot of stress, but there’s a particular class privilege that marks the kind of stress that these kids are experiencing that is quite different from that of working class teenager in certain parts of the country. I got really fascinated with Beard’s work on nervousness because it is kind of a byproduct of modernization and civilization growth. There was something similar going on with the way people talk about what is going on with the West Clinic patients, which I think is very interesting.

Moving Forward

“I think there’s been growing interest in thinking about complementary and alternative treatments.”

What do you think are next steps in the field of pediatric pain research?

M.B.: I think there’s been growing interest in thinking about complementary and alternative and integrative treatments, and there are big funding and structural constraints with incorporating those into pediatric pain treatment. That is one place where people should probably be devoting more attention. Generally speaking, the financial issues are big because pediatric pain is really underfunded. And actually, pain in general is underfunded by the NIH. That is a challenge for future research. I would like to see more interest in the productive side of language and the productive possibilities of using particular types of metaphors to explain things to pediatric patients. I think that [research] could be very generative and low cost. Low cost, high yield I would say.

Thank you Dr. Buchbinder for speaking to us about your new book.

Fun Facts

Favorite book: Rayna Rapp’s Testing Women, Testing the Fetus: The Social Impact of Amniocentesis in America

Current research: Cultural impact of Vermont’s physician aid-in-dying law

Advice for students entering the field of medical anthropology: To think collaboratively and interdisciplinary – how insights from medical anthropology can enhance approaches to health problems from other disciplines such as public health and clinical medicine.

For information about Dr. Buchbinder’s previous book, Saving Babies? The Consequences of Newborn Genetic Screening, click here.

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Peter Redfield on his latest book “Life In Crisis: The Ethical Journey of Doctors Without Borders”

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1. How did the idea for Life in Crisis: The Ethical Journey of Doctors Without Borders came about? What inspired you?

I had friends who had worked for Médecins Sans Frontières (MSF) so I’d heard about them for some time. I thought it would be an interesting subject in part because the phrase sans frontières — “without borders” — later became a tagline for globalization. Historically this is the group that popularized that expression, if with rather different aims than to open markets. The organization’s core movement in France began to engage a “borderless” world of sorts in the early 1970’s, imagining that doctors should be able to reach patients anywhere, overcoming all barriers. I wanted to look at what it means to practice medicine with this global ambition in mind: How to take biomedicine (i.e. the sort of healing taught in medical schools) and move it anywhere in the world and try to make it work.

I’d also just finished my first book and started to teach at UNC. I was meeting a lot of undergraduates who wanted to do something good in the world — to make a difference, to live a meaningful life. Whether they were actively thinking about it or not, many of them were likely going to work in the world of NGOs, nonprofits, etc. So I wanted to look at such engagement once you put it in practice, into motion. What happens when your great idea actually takes off?

While there have been lots of things written about MSF in French, at the time there was little in English, even at a journalistic level. There was not a great deal of analysis in an anthropological sense (although now there is much more). Over the last dozen years, global health has emerged as a key term. Even the School of Public Health changed its name! Looking at MSF is a way to try and think about global health, or one version of it in practice. To see it in motion over time, to see what it means to try to be global in the most literal sense of direct cross-border mobility as opposed to having “international” relationships in the nation-to-nation sense. Historically, one of MSF’s claims (which is exaggerated but has a kernel of truth) is that the group can go anywhere in the world in 48 hours. That’s the kind of infrastructure for emergency response they sought to realize, and to a certain extent they succeeded. They can go to most places in the world relatively quickly, and as long as everything cooperates — all the people and things — they can set up an operation. There’s a similar conception of the “global” in global health, which tends to focus on particular projects and campaigns as opposed to general system building in a given nation state (unlike the older international health). It likewise generally shares MSF’s secular, medical focus on “saving human lives”. This notion of biomedicine as a response to human suffering reveals complex technical and ethical issues, particularly when cast at a global scale.

I should also note that MSF is no longer really a French organization; it became European in the 1980s and has increasingly grown transnational. Indeed the French part is a minority at this point. The dominant language across MSF has increasingly become English, which is also the dominant language of aid, trade etc., often in an asymmetrical way. At the same time most people involved with the group believe strongly in human equality, value diversity and don’t want to mimic colonial empire. So there are several kinds of globalization at work, not all of which neatly line up. That’s anthropologically interesting.

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Mara Buchbinder on her latest book “Saving Babies? The Consequences of Newborn Genetic Screening”

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1. How did the idea for this project come about?

It was a question of being in the right place at the right time. I was brought on to the project after the initial investigators, who were two professors of sociology at UCLA, had developed this idea to study the impact of newborn screening in the clinic. They had learned that newborn screening was in this new phase of development where the state had just rolled out screening tests for a large number of disorders. They were really interested in doing something around the idea of medical uncertainty and this seemed like a perfect target for exploring some of those ideas, because it was really unclear what the impact of screening asymptomatic children for such a large number of disorders was going to be. At the time that this was getting off the ground, I was a graduate student. I was working on my dissertation research and I started out working on the newborn screening project as a research assistant. Over time, one of the investigators got busy with other projects, and I ended up taking on a bigger role, and working more closely with Stefan Timmermans, who co-authored the book with me.

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