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A New Reflexivity: Why Anthropology Matters in Contemporary Health Research

and Practice, and How to Make It Matter More: A New Reflexivity

Article  in  American Anthropologist · April 2016

DOI: 10.1111/aman.12532

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 AMERICAN ANTHROPOLOGIST

PUBLIC ANTHROPOLOGY

A New Reflexivity: Why Anthropology Matters in

Contemporary Health Research and Practice, and How
to Make It Matter More
Svea Closser and Erin P. Finley

M any of medical anthropology’s leading lights are cur-

rently lamenting the undervalued place of ethno-
graphic work in public health and medicine. Vincanne Adams
commitment to rich, deep ethnographic work. We’ve also
spent decades thinking and writing about positionality, bias,
and validity. Most of us have a highly developed awareness
argues that in the field of global health, demands for random- of both the power and the limits of the work we do.
ized, controlled studies have become an “empirical tyranny” However, much qualitative work in public health and
(Adams 2010:48). João Biehl and Adriana Petryna assert that medicine falls short of anthropological standards; it is often
“ethnographic evidence consistently dies within the dominant carried out quickly and based primarily on interviews.
conceptual paradigms of global health” (Biehl and Petryna Participant-observation is rare. Many qualitative health
2013:16). researchers don’t know how to take field notes, and many
This argument seems incomplete to us. Based on our are MDs or other health care providers who never received
experience publishing and collaborating with health pro- in-depth training in qualitative research. Some have not
fessionals in two very different arenas—global polio erad- been trained to consider what validity and bias mean in the
ication and veteran-oriented health services research—we qualitative context.
have come to believe that anthropologists now have an un- Given all this, it is easy to understand why many within
precedented opportunity to contribute to the creation of public health and medicine might think qualitative methods
clinical and public health structures more deeply informed are flimsy. While it is true that such research is sometimes
by core anthropological concerns. Anthropological theory discounted in public health and medicine, one reason for
has a powerful grasp of the connection between broad-scale this is that some of it isn’t very good.
social structures and intimate lived realities, and its methods Anthropology has an enormous amount to contribute
are perhaps unequaled in capturing the nuances of context. here. Anthropologists’ commitment to truly informed
But making the most of anthropology’s particular ethnography brings valuable tools to the table—tools
strengths will require overcoming a series of challenges, in which many public health researchers are sincerely
particularly in how we as anthropologists communicate with interested. For example, in a recent collaborative research
other health professionals. In this commentary, we first dis- project, Svea Closser and a group of researchers studied
cuss our observations on anthropology’s unique value in con- health systems in eight districts in Sub-Saharan Africa and
temporary health research and practice and then offer a few South Asia (Closser et al. 2012, 2014). What particularly
suggestions for how to make the most of our contributions. caught public health officials’ attention were case studies
Ultimately, we contend that making sure that anthropology of ways to strengthen health systems. The case studies
has a place at the table with public health and medicine will were classic ethnography, written with a careful eye to
require a new reflexivity, a careful examination of the biases agency and power. The research project in question had
and conventions of our discipline. both quantitative and qualitative components, but it was
the ethnography, not the statistical analysis, that was picked
WHAT ANTHROPOLOGY BRINGS TO THE TABLE up and circulated by immunization planners.
Anthropologists have a sophisticated and rigorous
ethnographic approach Anthropology understands context
Let’s start with the obvious. Anthropology has a valuable set A particular strength of ethnographic work is its power to
of tools for understanding the world—tools that are needed illuminate cultural, political, and historical context. This
in public health and medicine. We have a long history of makes anthropology valuable for understanding human

AMERICAN ANTHROPOLOGIST, Vol. 000, No. 0, pp. 1–6, ISSN 0002-7294, online ISSN 1548-1433. 
C 2016 by the American Anthropological Association.

All rights reserved. DOI: 10.1111/aman.12532

2 American Anthropologist • Vol. 000, No. 0 • xxx 2016

behavior and experience, including health and illness, without cultural awareness are likely to fail. But anthro-
in an interconnected world where change is rapid and pology has the longest and most sophisticated history of
continual. engaging with that concept and seeking to understand it,
One example of anthropology’s particular relevance to warts and all. Moreover, many of the questions at the heart
questions facing contemporary healthcare is the problem of contemporary anthropology—like how cultural thinking
of understanding the adoption and spread of clinical prac- reflects structural circumstances, how culture changes over
tices for screening, prevention, and treatment. There is time, and how individuals navigate within culture to make
frequently a gap of years—sometimes decades—between high-stakes decisions—have immediate relevance for health.
identification of a practice that is useful and effective in Building on this kind of anthropological lens, another VA
reducing suffering and widespread use of that practice by anthropologist, Heather Reisinger, has been working with
providers. So striking is this gap that an entire interdisci- a team to study how a so-called tele-IC—a system linking
plinary field has sprung up to examine it, most commonly patients and care providers at rural intensive care units—
called implementation science. Despite the relative lack of works in practice. They found that integrating tele-ICUs
visibility of implementation science within anthropology, into rural hospitals was complex and potentially disruptive,
anthropologists have been in the forefront of growing the particularly because nurses and doctors at the rural hospi-
field (Huertin-Roberts et al. 2013). It has become a cen- tals reasonably feared that the tele-ICU was a mechanism
tral tenet of implementation science that, when it comes of surveillance and control (Moeckli et al. 2013). Their
to understanding what people do or do not do, context recommendations on, among other things, how to build
is all. supportive relationships rather than systems experienced as
For one example, we can look to the U.S. Department of “spies in the sky” were widely circulated at the VA and used
Veterans Affairs (VA), which maintains the largest integrated to help strengthen the fledgling initiative.
healthcare system in the United States and is also a significant
employer of anthropologists (Sobo 2013). Erin Finley and Anthropology turns its critical lens back on health
others have been using implementation science perspectives systems themselves
within the VA to study the adoption of new psychothera- Being an anthropologist at the table with public health and
pies demonstrated to help veterans with posttraumatic stress medical professionals does not necessitate losing a critical
disorder (PTSD). These therapies have demonstrated effec- perspective or becoming a cog in the wheel of problematic
tiveness in both clinical and real-world settings around the projects. Anthropologists have long critically examined the
world and are promoted in international guidelines, but until structures and practices of public health and medical institu-
recently they were rarely used by psychotherapy providers tions themselves (Justice 1986; Pfeiffer 2003; Singer 1995)
in the United States. The reasons for this include cultural and know full well that public health and medical projects
and contextual issues specific to the United States, like the may reinforce rather than alleviate inequalities. Frequently,
nature of training, organizational policy, and care providers’ public health and medical practitioners are aware of this, too.
beliefs about the treatments’ relative benefits and potential Our experience is that the problems we identify are ones that
harms (Cook et al. 2014; Finley et al. 2015). Lessons learned many public health practitioners, with their backgrounds in
from investigating these kinds of contextual factors are be- health inequalities and social justice, are open—enthusiastic
ing used to continually refine how the VA delivers therapy even—to learning more about.
for PTSD. A strong example of this is the thoughtful, critical work
Bringing an anthropological eye to context—to under- done by the Ebola Response Anthropology Platform. These
standing how clinics, health systems, and other kinds of social researchers (in their words) “scrutinise some of the assump-
organizations work and to identifying the characteristics of tions about current Ebola social mobilisation strategies”
those organizations that support innovation and growth— (Chandler et al. 2015:1275). They ask critical questions
can greatly increase the potential for positive change. about education strategies—for example, about whether
improved knowledge really will lead to behavior change.
Anthropology has great theory Some of these questions would feel familiar to most in pub-
Few of anthropology’s central concepts, including culture lic health. Yet the authors also push the envelope by looking
and ethnicity, have remained within the field. The ideas of critically at how and by whom Ebola messaging has been cre-
syndemics, medicalization, and stigma, to name just a few, ated and disseminated: they are productively critical about
are now fully embraced by most public health and medical the very structures of public health programs. Their work is
professionals. But it remains true that anthropologists typ- explicitly anthropological—few public health practitioners
ically understand and use these concepts with more depth think and write in quite this way.
and nuance. But many in public health and medicine are open to
For instance, cultural competence is valued, if not al- thinking in these terms. These anthropologists published
ways achieved, within modern medicine and public health— their critical observations in the Lancet, the flagship global
an outcome both of their humanistic orientation and of public health and medical journal, with an impact factor
decades spent realizing that health interventions delivered around 15 times that of the American Anthropologist.
 Closser and Finley • A New Reflexivity 3

ANTHROPOLOGY AT THE TABLE stigma discourages veterans from seeking care, however, is
So anthropology’s well-informed critical perspective has immediately and obviously useful.
a lot to offer public health and biomedical healthcare When we are able to apply our expertise to pressing,
delivery. What, then, of Biehl and Petryna’s argument actionable problems, we are more likely to find a receptive
that ethnographic evidence isn’t taken seriously in public audience for our work. As just one example, the VA values
health? its growing number of anthropologists to such an extent
We think they have a point. Anthropological research that the national head of health services research, Dr. David
is sometimes discounted or disregarded in public health and Atkins, attended the 2014 Society for Applied Anthropol-
medicine. Not always, to be sure—the discussion above con- ogy meeting to serve as a panel discussant. Atkins used his
tains a number of examples of times when anthropologists time at the podium to praise the work being done by VA
were heard and their thoughts widely disseminated—but anthropologists. At the same time, in comments published
too often. after the meeting, he made a point of saying that “insight is
We think the responsibility for this lies not just in global overrated” and “to truly be of value, anthropologists need to
health and medicine but also in anthropology, particularly turn their insights into recommendations for action or tools
in how anthropologists communicate their work. We need to help the people trying to understand and shape culture”
to communicate with applied health fields the same way we (2014).
would ask health professionals to communicate with our It is worth emphasizing that the ultimate value of
ethnographic participants: in thoughtful, culturally appro- anthropological work should not be judged only by its
priate language, with an eye to their needs and perspectives perceived utility among nonanthropologists. Ours is a
and the resources they have within reasonable access. When gloriously diverse discipline, and anthropologists can and
this is done, it is our experience that public health and med- should do anthropology for anthropologists. We must be
ical professionals listen. Ensuring that anthropology has a able to choose our own methods and areas of study and to do
place at the table, then, requires a concerted effort to adopt anthropology for its own sake. Nonetheless, there are times
a new reflexivity and to move the field forward in six key when it is appropriate to look first to what contribution we
ways. want our work to make and to focus our efforts on the area
of greatest need in a clear and demonstrable way.
Communicate in accessible language
Anthropologists often write for an audience of other profes- Ground our work in rigorous and transparent
sional anthropologists. We use language to signal affiliations, methodology
and we use particular words as shorthand for complicated The cultures of public health and medical research value
theoretical ideas. This works if all we want to do is write clear, transparent descriptions of methodology. At public
to each other (which is a perfectly laudable goal). But it health conferences, it is common for well over half of a pre-
doesn’t work if we want to communicate to people trained sentation to be devoted to methodology, empowering the
in other disciplines. Such writing makes it all but impossible audience to make their own judgment regarding the validity
for people like district-level health staff in poor countries and utility of the data. So when anthropologists write pa-
to engage with our work. If people are to listen to us, they pers or give presentations in which methodology is glossed
need to understand what we’re saying. over with just a passing reference to participant-observation,
Inspiring models of transparent, clear, compelling writ- their work is frequently—and unfortunately—written off by
ing exist. Claire Wendland’s A Heart for the Work (2010) is health practitioners as being perhaps not particularly rigor-
such a model, an elegant book that consistently avoids ob- ous or sophisticated.
fuscation without sacrificing theoretical rigor and that easily In some cases, an underlying problem is that anthro-
reaches across disciplinary boundaries. pologists may not always be as proficient with qualitative
methodology as we like to claim. As qualitative methods have
Work on problems with obvious relevance acquired greater authority, so too have they acquired a prolif-
Many anthropologists, even those who avoid jargon, have erating number of practitioners across a wide range of fields:
had the experience of explaining their work to health types sociology, business and marketing, organization science,
only to be met with glazed eyes. There are myriad questions folklore, communications, medicine, nursing, and so on.
of great fascination in anthropology—including those we’ve Anthropologists working in applied settings will—sooner
embraced in our own work—that do not directly facilitate rather than later—be asked to articulate their methodolog-
a more effective response to a given health concern. To ical choices and rationale to an audience quite capable of
take an example from Erin Finley’s work, the question of educated critique. To the extent that anthropologists choose
how the act of defining traumatic illness reflects cultural to emphasize methodological expertise as one of our contri-
approaches to suffering and violence may be interesting, butions beyond our own field, we need to be prepared to
but it does almost nothing to help front-line providers speak and act as experts.
figure out how to improve access to care for combat Being explicit about our methods can only be to
veterans. Developing a more nuanced understanding of how the good. Most obviously, it facilitates acceptance of
4 American Anthropologist • Vol. 000, No. 0 • xxx 2016

anthropological work in public health and medical journals. happening ten years ago or last month don’t really matter
But beyond that, explicit discussion of methodology, in terms of the larger patterns at play, which is what we
including positionality, methods of analysis, and potential are really interested in. But for health practitioners—who
biases, makes our work more robust. One great example are trying to do the best they can today, not ten years
of transparency in methods is the methodological appendix ago—writing about bygone political and funding struc-
in the collaborative ethnography The Secret (Hirsch et al. tures as if they are current makes anthropologists seem
2010). It is precise, comprehensive, and detailed enough sloppy and uninformed at best and completely clueless
that it can be used by others who want to adapt their at worst.
methods. The solution to this is not to throw out our old data.
The larger structures that caused problems ten years ago
Get the facts right are still very much alive, and history does often repeat it-
In conducting ethnographic work that focuses on health insti- self. But we should project our awareness that ten years
tutions, and then asking the people inside those institutions ago or even five years ago are not today. We should use
to take our results seriously, we face an enormously high bar the past tense and be alive to the political and economic
for accuracy. We are presenting our results to the natives. context of the time in which we are writing. When we
If any of the information that we relate in our analysis is speak to the carefully gathered facts of the current time, we
wrong, the natives will quickly—and fairly—write us off more immediately build a solid base upon which to be taken
as uninformed. Anthropologists who desire to engage with seriously.
health organizations and practitioners must demonstrate an
informed understanding of their workings and worlds in Be mindful of anthropological biases
order to be heard. If we were to argue at this point that the field of anthropol-
There is a structural problem to this, however, in that ogy has particular biases that influence its way of viewing the
most anthropologists working in academia have demanding world, it would likely seem both obvious and unpersuasive,
teaching schedules and squeeze in fieldwork over the for the field is so diverse that it is nearly impossible to charac-
summer months or winter break. There is often limited terize. Moreover, the relative perspective on whether “bias”
time to do participant-observation in the structures that is a bad thing also varies tremendously; one anthropolo-
provide healthcare. Health practitioners, in contrast, live gist’s bias is another’s umvelt, as becomes immediately clear
in these structures. In some cases, they created them. If when the question of whether anthropology should consider
anthropologists have the hubris to argue that they have itself a science arises. Nonetheless, it seems relatively safe to
new knowledge or perspectives to share, they must first say that most anthropologists care deeply about finding and
demonstrate that they know healthcare structures at least as speaking to truth, in all its myriad forms.
well as those working within them. Toward that end, we also urge anthropologists to be
It is therefore essential to be meticulous about our facts. mindful of their own biases, particularly those that might be
Even mild inaccuracies undermine our credibility. Precise considered shared cultural tendencies of the field. Though
descriptions alive to the nuances of context establish it. this is a warning that has been put forward before (Bolton
Many anthropologists, of course, do a beautiful job at this. 1995), it bears repeating. Common biases include those
Just one example is the work of Judith Justice, which grows emerging from our methodologies, particularly as outsiders
out of a commitment to informed ethnography. She double not always well integrated into the societies under study; our
checks all her information from multiple sources. She builds philosophical leanings, including the tendency to romanticize
relationships with health practitioners and runs her work by the exotic over the mundane and the marginal over the
them to make sure that her descriptions are correct. She has mainstream; and our professional conventions, which tend
a great reputation in public health—people listen to her— to preference the elegantly articulated over the ruthlessly
and her reputation is in large part built on the fact that she triangulated.
knows what she’s talking about. In short, while anthropology has done an admirable
In presenting factual information that will be taken job in the postmodern era of encouraging reflexivity at the
seriously, time and tense present a particular challenge individual level, we have not always been so active in ex-
(but one, happily, easily overcome). In too much medical amining our disciplinary biases and how they influence the
anthropological writing, we use the ethnographic present quality and utility of our work. Now would be an opportune
to describe fieldwork done as many as ten or even fifteen time to engage in a new reflexivity.
years ago. Use of the ethnographic present in such cases can
easily result in errors of fact and interpretation, describing
what once was but is no longer true. Again, the reasons Provide recommendations for action
for this are often structural; many of us have fascinating Describing problems is straightforward for anthropologists.
data we don’t have time to write up right away. We may Our theoretical background and our propensity to talk to
even tell ourselves that the particulars of whether this was people without much power give us a framework for quickly
 Closser and Finley • A New Reflexivity 5

seeing the ways that public health and medical institutions Bolton, Jonathan
uphold structures of inequality. 1995 Medical Practice and Anthropological Bias. Social Science
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can’t do much with our work if we refuse to tell them what Banteyerga, Ismaila Zango, Aminu Dukku, Patricia Omidian,
to do better. Sometimes, making recommendations—and Emma Varley, Pauley Tedoff, Adam Koon, Laetitia Nyiraziny-
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