Silent Violence

Silent Violence engages the harsh reality of malaria and its effects on marginalized communities in Tanzania. Vinay R. Kamat presents an ethnographic analysis of the shifting global discourses and practices surrounding malaria control and their impact on the people of Tanzania, especially mothers of children sickened by malaria. Malaria control, according to Kamat, has become increasingly medicalized, a trend that overemphasizes biomedical and pharmaceutical interventions while neglecting the social, political, and economic conditions he maintains are central to Africa’s malaria problem. Kamat offers recent findings on global health governance, neoliberal economic and health policies, and their impact on local communities. Seeking to link wider social, economic, and political forces to local experiences of sickness and suffering, Kamat analyzes the lived experiences and practices of people most seriously affected by malaria—infants and children. The persistence of childhood malaria is a form of structural violence, he contends, and the resultant social suffering in poor communities is closely tied to social inequalities. Silent Violence illustrates the evolving nature of local responses to the global discourse on malaria control. It advocates for the close study of disease treatment in poor communities as an integral component of global health funding. This ethnography combines a decade of fieldwork with critical review and a rare anthropological perspective on the limitations of the bureaucratic, technological, institutional, medical, and political practices that currently determine malaria interventions in Africa

Private practitioners and their role in the resurgence of malaria in Mumbai (Bombay) and Navi Mumbai (New Bombay), India: serving the affected or aiding an epidemic?

The increased emphasis on privatization of the health care sector in many developing countries by international financial institutions and national governments expects an expanding role for private health care practitioners in the management of major communicable diseases such as tuberculosis, malaria, acute respiratory infections (ARIs) and sexually transmitted diseases (STDs). Largely unexamined in the Indian context, however, is the socio-cultural context, the micro-level political environment in which private practitioners carry out their activities, and the quality of care they provide to their patients. Examining these aspects is significant given the impressive growth of the country's private health sector during the past decade. This paper reports the results of an ethnographic study carried out in Mumbai (Bombay) and Navi Mumbai (New Bombay), India on private general practitioners (GPs) and their role in the management of malaria at a time when these two neighboring cities were in the midst of the worst malaria epidemic in over 60 years. Described are the characteristics of a sample of 48 private practitioners from the two cities, and their clinics. This is followed by a discussion of the data gathered through untructured interviews with practitioners and patients, and complemented by observational data on doctor-patient encounters gathered at 16 clinics over a 9-month period. The findings of the study suggest that many practitioners in Mumbai and Navi Mumbai were poorly qualified and did not play a supportive role in the two cities' public health departments to bring the epidemic under control. The majority of the practitioners adopted diagnostic and treatment practices that were not consistent with the guidelines laid down by WHO and India's National Malaria Eradication Programme. Very few practitioners, especially those practicing in low-income areas, relied on a peripheral blood-smear test to make a diagnosis. Practitioners whose clientele was mostly the poor commonly resorted to giving one-day treatment to febrile patients that included injectable antimalarials and broad spectrum antibiotics. Such practitioners justified their mode of diagnosis and treatment by asserting that they were only responding to the demands placed on them by their patients who could not afford a blood-smear test or a full prescription. The paper argues that practitioners who acquiesced to patient demands were at once exacerbating the health problems of their patients and jeopardizing the prospects for the epidemic to be brought under control. Driven primarily by the need to retain the patronage of patients and maintain one's popularity in a highly competitive health arena, many providers practiced medicine that was unethical and dangerous. The paper concludes by discussing the ramifications of this study for malaria control in Mumbai and Navi Mumbai, and highlights a few salient health policy issues concerning the growth of the private health sector in India and its regulation.Urban malaria Malaria therapy Private practitioners Private health sector Regulation Consumer Protection Act India

Silent Violence

Silent Violence engages the harsh reality of malaria and its effects on marginalized communities in Tanzania. Vinay R. Kamat presents an ethnographic analysis of the shifting global discourses and practices surrounding malaria control and their impact on the people of Tanzania, especially mothers of children sickened by malaria. Malaria control, according to Kamat, has become increasingly medicalized, a trend that overemphasizes biomedical and pharmaceutical interventions while neglecting the social, political, and economic conditions he maintains are central to Africa’s malaria problem. Kamat offers recent findings on global health governance, neoliberal economic and health policies, and their impact on local communities. Seeking to link wider social, economic, and political forces to local experiences of sickness and suffering, Kamat analyzes the lived experiences and practices of people most seriously affected by malaria—infants and children. The persistence of childhood malaria is a form of structural violence, he contends, and the resultant social suffering in poor communities is closely tied to social inequalities. Silent Violence illustrates the evolving nature of local responses to the global discourse on malaria control. It advocates for the close study of disease treatment in poor communities as an integral component of global health funding. This ethnography combines a decade of fieldwork with critical review and a rare anthropological perspective on the limitations of the bureaucratic, technological, institutional, medical, and political practices that currently determine malaria interventions in Africa

Pharmacies, self-medication and pharmaceutical marketing in Bombay, India

Studies of pharmaceutical practice have called attention to the role played by pharmacists and pharmacy attendants in fostering self-medication and medicine experimentation among the public. Left undocumented is the extent to which clients passively follow the advice of pharmacy personnel or question their motive or expertise. While research has focused on pharmacists and pharmacy attendants as agents encouraging self-medication and medicine experimentation, adequate attention has not been paid to pharmacist-client interactions that are sensitive to the social, cultural, and economic context in which medicine sales and advice occur. This paper highlights the context in which pharmacy attendants engage in "prescribing medicines" to the public in Bombay, India. An ethnographic description of pharmacies and pharmaceutical-related behavior in Bombay is provided to demonstrate how reciprocal relationships between pharmacy owners, medicine wholesalers and pharmaceutical sales representatives (medreps) influence the actions of pharmacy staff. Attention is focused on the role of the medicine marketing and distribution system in fostering prescription practice, pharmacy "counter-pushing" and self-medication. In documenting the profit motives of different players located on the drug sales continuum, it is argued that the economic rationale and the symbiotic relations that exist between doctors, medreps, medicine wholesalers and retailers, need to be more closely scrutinized by those advocating "rational drug use".pharmacies self-medication prescription pharmaceutical marketing Bombay India

Community response to artemisinin-based combination therapy for childhood malaria: a case study from Dar es Salaam, Tanzania

Background. New malaria treatment guidelines in Tanzania have led to the large-scale deployment of artemether-lumefantrine (Coartem®), popularly known as ALu or dawa mseto. Very little is known about how people in malaria endemic areas interpret policy makers' decision to replace existing anti-malarials, such as sulphadoxine-pyrimethamine (SP) with "new" treatment regimens, such as ALu or other formulations of ACT. This study was conducted to examine community level understandings and interpretations of ALu's efficacy and side-effects. The paper specifically examines the perceived efficacy of ALu as articulated by the mothers of young children diagnosed with malaria and prescribed ALu. Methods Participant observation, six focus group discussions in two large villages, followed by interviews with a random sample of 110 mothers of children less than five years of age, who were diagnosed with malaria and prescribed ALu. Additionally, observations were conducted in two village dispensaries involving interactions between mothers/caretakers and health care providers. Results While more than two-thirds of the mothers had an overall negative disposition toward SP, 97.5% of them spoke favourably about ALu, emphasizing it's ability to help their children to rapidly recover from malaria, without undesirable side-effects. 62.5% of the mothers reported that they were spending less money dealing with malaria than previously when their child was treated with SP. 88% of the mothers had waited for 48 hours or more after the onset of fever before taking their child to the dispensary. Mothers' knowledge and reporting of ALu's dosage was, in many cases, inconsistent with the recommended dosage schedule for children. Conclusion Deployment of ALu has significantly changed community level perceptions of anti-malarial treatment. However, mothers continue to delay seeking care before accessing ALu, limiting the impact of highly subsidized rollout of the drug. Implementation of ACT-based treatment guidelines must be complemented with educational campaigns to insure that mothers seek prompt help for their children within 24 hours of the onset of fever. Improved communication between health care providers and mothers of sick children can facilitate better adherence to ALu's recommended dosage. Community level interpretations of anti-malarials are multifaceted; integrating knowledge of local beliefs and practices surrounding consumption of anti-malarials into programmatic goals can help to significantly improve malaria control interventions.Anthropology, Department ofArts, Faculty ofReviewedFacult

Soft targets or partners in health? Retail pharmacies and their role in Tanzania's malaria control program

The retail sector has been at the center of recent policy debates concerning its role in malaria control programs in Africa. This article closely examines the perspectives of owners and managers of retail pharmacies and drug shops in Dar es Salaam, toward the dominant public health discourse and practices surrounding the deployment of artemisinin-based combination therapy (ACT) as a way forward in malaria control. Drawing on fieldwork conducted between May-August 2007, and July-August 2009, involving in-depth interviews and participant observation in pharmacies and drug shops in Dar es Salaam, the article describes the social realities facing people who manage retail pharmacies, the nature of their interactions with customers, the kinds of antimalarials they sell, and their perspective on how the new malaria treatment guidelines have affected their business. Findings suggest that for most pharmacy owners and managers, it is 'business as usual' concerning the sale of conventional antimalarials, with a majority reporting that the introduction of ACT in public health facilities had not negatively affected their business. Implications of the research findings are examined in the context of proposed interventions to make pharmacy owners and managers more socially responsible and adhere to government health regulations. The article makes a case for actively involving pharmacy owners and managers in decision making processes surrounding the implementation of new treatment guidelines, and training programs that have an impact on their business, social responsibility, and community health. In considering regulatory interventions, health planners must explicitly address the concern that retail pharmacies fill an important role in the country's health care system, and that the complex nexus that drives the global pharmaceutical market often governs their operations at the local level.Tanzania Malaria New antimalarials Retail pharmacies

Estimating the rheology parameters of icy satellites from observed surface deformations

Multivariate analysis for association between number of attempts and occurrence of any TIAEs without esophageal intubation with immediate recognition, and severe TIAEs without esophageal intubation with delayed recognition. (DOCX 15 kb