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PhD Candidate, Social Anthropology, York University, Toronto, ON
Abstract In this conference paper, I discuss methodological approaches to researching the networks of public health policy through the case study of the introduction of HPV vaccine programming in Ontario. Networks function as a tool to follow health policy narratives as they are developed across institutions; received, refuted or amalgamated by women in their everyday lives; and contested in everyday resistance and public advocacy. I examine the central notions of biological citizenship, risk, and gender across three thematic fields: (1) constructing risk, (2) negotiating risk and (3) resisting risk. These three fields by no means reflect an evolutionary trajectory. Instead, they bump up against one another and create creative frictions. My research is an endeavor to analyze how the networks of public health policy “organize individual realities, and the way they are narrated, contested, and lived as social trajectories” (Petryna, 2002).
n my research, which is in media res, I am conducting an ethnographic study – across multiple “fields”1 – of Ontario’s tripartite health prevention policy for cervical cancer. In this research, I am investigating the “networks” (Riles 2001, Strathern 1996) of public health policy. By networks, I am referring to “an apt image for describing the way one can link or enumerate disparate entities without making assumptions about level or hierarchy. Points in a narrative can be of any matter or form, and network seems a neutral phrase for interconnectedness” (Strathern 1996:522). 2 In the case of this research, networks function as a methodological tool to “follow” health policy narratives as they are developed across institutions; received, refuted or amalgamated by women in their everyday lives; and contested in everyday resistance and public advocacy. In doing so, I am examining the central notions of biological citizenship (Rose & Novas 2002, Petryna 2002), risk (Foucault 1995, 1980, 1988a, 1988b, 1989, 1990, 1991 & 1999, Douglas 1992, Lupton 1994 & 1999, Turner 1997, Nettleton 1997, Castel 1991), and gender (Butler 2007, Moore 1994, Sanders 2000, Hanson 2000) across three thematic fields: (1) constructing risk, (2) negotiating risk and (3) resisting risk. These three fields by no means reflect an evolutionary trajectory. Instead, they bump up against one another and create creative “frictions” (Tsing 2005). Throughout this paper I will discuss how each thematic field was developed, primarily from a methodological perspective, and how each field provides the framework for the three research questions I am exploring. And, speaking of frameworks, I will concurrently recount how I have drawn upon the anthropology of policy as a mechanism to track, navigate, and analyze the unpredictable and ever changing flow of traffic. By traffic I am referring to negotiation. Such negotiation involves tacking between “the dialectics of domination and resistance” (Lock & Kaufert 1998:5) in even what may appear to be the most mundane and routine medical encounters. Negotiation, as per Rapp (2000), can
1 For the purposes of this research project field is defined in multiple ways, highlighting fields of enquiry, methodological fields and fieldwork locations. 2 Strathern points out that her récit can be construed as “following Latour’s call for a symmetrical anthropology that gathers together modern and nonmodern forms of knowledge” (1996:517).
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Keywords Anthropology of policy, methodology, gender, risk, biological citizenship
‘Playing the Field’ Conference Proceedings | Social Anthropology | York University 2009 also be looked upon as the traffic between the risk discourses of the medical establishment and individual lived experience. Without the guide of anthropology of policy – a framework through which to “follow” the traffic of policy narratives, from “above” and “below”, as they unfold, unravel and tighten up - I am certain my research would not only be incoherent, but unmanageable. I would like to make it clear, however, that this research project is a not intended to evaluate scientific research and practices regarding cancer. Nor, is this research project an attempt to judge women who engage with or do not engage with Pap screens, HPV tests and the HPV vaccine. Instead, this is an endeavor to take a step back, from a social science of medicine perspective, and analyze how the networks of public health policy “organize individual realities, and the way they are narrated, contested, and lived as social trajectories” (Petryna 2002). Setting the critical context: HPV, cancer & Ontario’s cervical cancer prevention policy In order to contextualize my research project, it is crucial to outline Ontario’s current cervical cancer prevention policy. I will, however, only provide a cursory recounting due to time constraints and, as this is pretty technical, I do not wish to put everyone to sleep. The three-part prevention strategy incorporates regularized Pap tests, HPV DNA testing in cases of heightened risk and universal HPV vaccination of grade eight girls. It is recommended that Pap screens be taken every year until they are without abnormal results for a three-year period. As a result, Pap smears have become a regularized aspect of a women’s health care and synonymous with annual physicals (Kaufert 2000). In fact, Pap smears have become a ubiquitous sign of “femininity” (Bush 2000) and are rarely questioned in western society. Second, in addition to conducting regularized Pap smears, it is recommended that “high-risk” women – women who present with “abnormal” Pap tests --, undergo accompanying HPV DNA tests (Vanslyke et al. 2008:585, CCO 2005). Third, in the fall of 2007, the Ontario government announced that it would implement a provincewide, no-cost HPV vaccination program for grade eight girls in public schools. Similar programs have been implemented in the other Canadian provinces, all of which have adopted the Gardasil vaccine (Graveland 2009:1). This vaccine works to immunize individuals against four particular strains of the HPV virus. The vaccine immunizes against HPV strains six and 11 (which are linked to genital warts) and strains 16 and 18 (which are linked to cervical cancer). Ontario’s uptake rate of the vaccine has been sluggish compared to other provinces. Just under a half of eligible girls in Ontario were vaccinated in 2008. By comparison, nearly 70% of girls in British Columbia and “about 80% of eligible girls are receiving Gardasil in Prince Edward Island and Nova Scotia” (Graveland 2009:1). If a woman/girl is vaccinated against HPV, screening protocols still suggest undergoing regularized Pap smears once sexual activity has started. Sketching out methodological approaches & research questions: Following biological citizenship, risk & gender through the anthropology of policy So, how does one research a three-part cancer prevention strategy? How do you ground something as elusive and, concurrently, material as a policy? How do you navigate the congestion surrounding the traffic a policy creates? In my view, this research project requires a methodological approach that takes into account that health policy is created, articulated, performed and resisted across many metaphorical and physical sites. For the purposes of this research, policy is defined as not only “a piece of government legislation… [but] a general program or desired state of affairs or, alternatively, as a label to describe outcomes for what governments generally achieve” (Wedel et al. 2005:35). Anthropology of policy is often framed as studying the offices and languages of power – in other words, “the complex ways in which policies construct their subjects as objects of power” (Shore & Wright 1997a:xiii). However, anthropology of policy should not only examine the processes through which
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‘Playing the Field’ Conference Proceedings | Social Anthropology | York University 2009 policy is formulated, but also investigate how policy works to “influence people’s indigenous norms of conduct so that they themselves contribute, not necessarily consciously, to a government’s model of social order” (Shore & Wright 1997a: xiii &1997b:6). Pragmatically, this requires a “reconceptualization of ‘the field’; not as a discrete local community or bounded geographical area, but as a social and political space articulated through relations of power and systems of governance” (Shore & Wright 1997a: 14). Wedel, et al., (2005) describe the field as “often consist[ing] of loosely connected actors with varying degrees of institutional leverage located in multiple ‘sites’ that are not always even geographically fixed” (39). Policy is not developed, implemented or experienced in a governmental vacuum - various stakeholders, such as the scientific community, the mass media and, in this case, big pharma, help shape its form, content and delivery. And, of course, policy is then taken up, mediated and/or refuted by the individuals whose behaviors it aims to affect/effect. Hoeyer notes “policy emerges in the networks that give it social life, and so this is where the analyst must be placed to understand such framings and their implications” (2005:S72). Thus, for the purposes of my research, the concept of the field is widely framed and steers clear from anchoring premises. As Shore and Wright note engaging within the realm of anthropology of policy involves “studying through” and not “up” or “down” (1997b: 14). This does not, however, consist of framing policy making as a teleological process that moves in one discrete direction of crisis naming, proposed remedy, executing the remedy and post-mortem analysis as the prevailing “rational systems model” might suggest (Shore & Wright 1997b: 15). Instead, anthropology of policy provides a fluid framework through which to probe and unravel prevailing “common sense” as current day governance strategies (Shore & Wright 1997b: 17). As a result of the diffused and discursive nature of power, there is no central node through which Pap smears, HPV testing and HPV vaccines are administered throughout Ontario – these technologies are deployed in individual physician offices, labs, and a pastiche of school gymnasiums and sexual health clinics across the province. This necessitates conducting research in a dispersed manner that follows disparate networks (Riles 2001:3) that metaphorically stretch out across many fields. These networks can signify a bricolage of human and non-human elements converging and diverging depending upon the context (Strathern 1996:520). Networks hybridize women’s bodies; governmental policy; medical technologies, such as vaccines, DNA tests, speculums, cytology reports; the daily news and communications technology and so on. Therefore, my research is taking place across three thematic fields: (1) constructing risk, (2) negotiating risk and (3) resisting risk. I will now, very briefly, describe each thematic field through which I am operating and how each field inspired a related research question. As Martin states, while drawing on Baudrillard, my fieldwork is “fetch[ing]… [me] up in what has been called implosions, places where different elements of the system come into energetic contact and collapse in on themselves” (1992:11, emphasis in the original). Field – Constructing Risk: Research question: Since the linkage between HPV and cancer, how has HPV risk been formulated in scientific literature and the mass media and how has a gendered public health policy emerged from these knowledge nodes? I began the research project with a critical discourse analysis (CDA) of institutionally based narratives – those of medicine/science, official government health policy and the mass media as they come to bear upon Ontario’s cervical cancer prevention policy. This is a critical endeavor in contextualizing the narratives of women who negotiate biological citizenship and this “risk” landscape for themselves and their daughters and on-line activists who advocate against the vaccine. This phase of the research project focuses upon the tracking and
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‘Playing the Field’ Conference Proceedings | Social Anthropology | York University 2009 tracing of HPV knowledges. The CDA provides the groundwork to produce “situated accounts” of the “microphysics of power” as they play out in the everyday realm of women’s health discourse (Lock & Kaufert 1998:1). Situated accounts are akin to Haraway’s “situated knowledges” (1988:583-584). However, in explaining the concept of situated knowledges, Haraway stresses the importance of unpacking knowledge from above, “below” and laterally – subjugated knowledges should not be privileged over institutional knowledge. All facets of an issue, illness or policy must be scrutinized (Haraway 1988:583-584). In essence, the CDA is a form of mini-genealogy, which in itself is an articulation of resistance (Sawicki 1991:26). Field – Negotiating Risk: Research question: How are Ontariobased women enacting and mediating biological citizenship through cervical cancer risk negotiation in their everyday lives? As the CDA is underway, I am concurrently implementing the second part of the research project. This stage of the research focuses upon collecting and interpreting womens’ experiences (Lock & Kaufert 1998:1) as they come to bear upon Pap tests, HPV DNA testing and HPV inoculation. While there is a tendency to examine how cultural milieus/factors affect the development of science/medicine, there is less established scholarship looking at how medical technology works to assist in developing one’s sense of identity/self (Cussins 1996:575). Posner (1993) found that women engaged in Pap smears for divergent reasons than medical rationale. While physicians advocate for and perform these medical procedures as a means to weed out potential disease or, in other words to “look for trouble”, women look to Pap smears “to avoid trouble”, or, to avert disease (Posner 1993:60). However, Posner’s study tends to reinforce the fissure between medical and lay responses to medical technologies and homogenizes womens’ renderings of these technologies. Therefore, careful attention has been paid in the creation of interview schedules to allow “space” for the emergence of “the complexity of women’s responses to medicalization, which may range from selective resistance to selective compliance, although women may also be indifferent” (Lock & Kaufert 1998:2). In allowing for this “space” of complexity, I have followed Cussins’ lead. Cussins (1996), in a study of women’s narratives regarding assisted reproduction, emphasizes that objectification can, concomitantly, be tapped as a source of agency and a continually unfolding sense of self, particularly when a woman desires to take on the social role of a mother and is having biological difficulty in doing so. Thus, a “politics of ‘just say no’ is unconvincing” with regard to assisted reproductive technologies (Cussins 1996:576577) and this may be applicable to Ontario’s cervical cancer prevention policy and, particularly the vaccine.3 Objectification can bring about new forms of agency hitherto unrecognized or developed. As women are not necessarily subsumed by medical/political technologies, the mediation of biological citizenship, risk and cervical cancer falls within the realm of negotiation. I am analyzing this negotiation, or traffic, through women’s’ narratives for “text, textuality, derived from texto (Latin, to weave), constitutes the locus where bodies discursive and material weave fabrics of the self. The body of each text contains two other bodies which shape the text as it shapes them: the physical body and the body politic whose materiality the physical body symbolically represents” (SmithRosenburg 1989:102, emphasis in the original). Field – Resisting Risk: Research Question: How are grassroots, anti-Gardasil activists re-appropriating risk in their informational and digital bio-citizenship? 43 | Michelle Wyndham-West As Ontario has the lowest up-take rate of HPV inoculation of any province in Canada, grassroots resistance is easy to find. However, this resistance is not generally organized along group lines. Much of this resistance is taking place on the Internet in public, on-line 3 It is worth noting that there has been a push for the vaccine to be open for use by gay men (Gilbert 2007 & Roehr 2007).
‘Playing the Field’ Conference Proceedings | Social Anthropology | York University 2009 discussion forums, through Facebook pages and in videos submitted to You Tube. At this formative stage, on-line resistance to the HPV vaccine is discursive and primarily atomistic, although there are a few activist groups working through this medium, such as parent groups lobbying school boards and university student run groups. Political scientists would term this type of activism as “non-traditional” as it appears in spurts and does not take the form of firmly organized and collective action. Furthermore, this type of activism is often not taken seriously by policymakers and deemed “cheap talk”, both for the fact that inexpensive channels are used for communication and that these discussions will not affect policy (Chadwick 2006:121). In this phase of the research, I will be conducting CDA of various incarnations of this resistance. The “DIY culture” in electronic communication is particularly suitable for following resistance to a health policy for these mediums are not necessarily just personal vehicles, but “operate as spaces for expression and dialogue about political and social issues” (Harris 2008:482). Harris positions these on-line spaces as “counter-publics” or “parallel discursive arenas”, which is borrowed from Fraser’s work (1992) on feminist activism, for they allow a unique opportunity to produce and showcase alternate viewpoints, which are not given “airtime” in established media venues (2008:482). Conclusion In this research I aim to produce an ethnography of health policy in action across multiple, thematic fields. In essence, this involves tracing, collecting and analyzing renditions of the traffic health policy creates. Policy does not “sit” in a static state – it morphs, hybridizes and is subject to reassembling depending upon the context. Thus, this research project requires a methodological approach that takes into account that health policy is created, articulated, performed and resisted across many metaphorical and physical sites. This involves “studying through” and not “up” or “down” (Shore & Wright 1997b: 14). Pragmatically, studying through necessitates conducting research in a dispersed manner following disparate networks (Riles 2001:3). The three thematic fields I have discussed -- constructing, negotiating and resisting risk -- by no means reflect an evolutionary trajectory. Instead, they bump up against one another and create creative “frictions” (Tsing 2005). And, these frictions provide the basis for an ethnographic account of health policy as it is worked out on the ground and in the daily lives of Ontario-based women.
References Bush, Judith 2000 “It’s just part of being a woman”: cervical screening, the body and femininity. Social Science & Medicine, 50:429-444. Butler, Judith 2007 Gender Trouble: Feminism and the Subversion of Identity. New York: Routledge. Cancer Care Ontario 2005 Evidence-based series: section 1 – cervical screening: a clinical practice guide (May 20, 2005). Author: Toronto. Castel, Robert 1991 From Dangerousness to Risk. In The Foucault Effect: Studies in Governmentality. G. Burchell C. Gordon and P. Miller, eds. Pp. 281298. Chicago: University of Chicago Press. Chadwick, Andrew 2006 Internet politics: states, citizens, and new communication technologies. New York: Oxford University Press Cussins, Charis 1996 Ontological choreography: agency through objectification in infertility clinics. Social Studies of Science, 26:575-610. Douglas, Mary 1992 Risk and blame: essays in cultural theory. London: Routledge. Foucault, Michel 1977 Discipline & punish. New York: Vintage books.
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question in feminism and the privilege of partial perspective. Feminist Studies, 14, (3): 575-599. Harris, Anita 2008 Young women, late modern politics, and the participatory possibilities of online cultures. Journal of Youth Studies, 11, (5): 481-495. Hoeyer, Klaus 2005 Studying Ethics as Policy: The Naming and Framing of Moral Problems in Genetic Research. Current Anthropology, 46:S71-S90. Kaufert, Patricia 2000 Screening the body: the Pap smear and the mammogram. In Living and working with the new medical technologies: intersections of inquiry. M. Lock, A. Young and A. Cambrosio, eds. Pp. 165-183. Cambridge, UK: Cambridge University Press. 1998 Women, resistance, and the breast cancer movement. In Pragmatic women and body politics. M. Lock and P. Kaufert, eds. Pp. 287-309. Cambridge, UK: Cambridge University Press. Lock, Margaret and Kaufert, Patricia 1998 Introduction. In Pragmatic women and body politics. M. Lock and P. Kaufert, eds. Pp. 127. Cambridge, UK: Cambridge University Press. Lupton, Deborah 1994 Medicine as culture: illness, disease and the body in western societies. London: Sage Publications. 1999 Introduction: risk and socio-cultural theory. In Risk and Sociocultural Theory: New Directions and Perspectives. D. Lupton, ed. Pp. 1-11. Cambridge, UK: Cambridge University Press. Martin, Emily 1992 Flexible bodies: tracking immunity in American culture – from the days of polio to the days of AIDS. Beacon Press: Boston. Moore, Henrietta 1994 A passion for difference: essays in anthropology and gender. Cambridge: Polity Press. Nettleton, Sarah 1997 Governing the risky self: how to become
1980 Power/Knowledge: Selected Interviews and Other Writings, 1972-1977. New York: Pantheon Books. 1988a The Care of the Self. New York: First Vintage Books Edition. 1988 Technologies of the self. In Technologies of the Self: A Seminar with Michel Foucault. L. Martin, H. Gutman and P. Hutton, eds. Amherst: The University of Massachusetts Press. Publications Ltd. 1989 The birth of a clinic. London: Routledge. 1990 The History of Sexuality: An Introduction. New York: Vintage Books. 1991 Governmentality. In The Foucault Effect: studies in governmentality: with two lectures by and an interview with Michel Foucault. G. Burchell, C. Gordon and P. Miller, eds. Pp.87-104. Chicago: University of Chicago Press. 1999 Abnormal: Lectures at the College de France, 1974-1975. New York: Picador. Fraser, Nancy 1992 The Uses and Abuses of French Discourse Theories for Feminist Politics. In Revaluing French Feminism: Critical Essays on Difference, Agency & Culture. N. Fraser and S. Bartky, eds. Pp.177-194. Bloomington: Indiana University Press. Gilbert, Sky 2007 The promise of Gardasil. Xtra (Toronto), 606:10-11. Graveland, Bill 2009, March 2 HPV vaccine still a tough sell in some parts of Canada. Toronto Star: A1. http:// www.parentcentral.ca/parent/article/595295, accessed March 2, 2009. Hanson, Barbara 2000 The social construction of sex categories as problematic to biomedical research: cancer as a case in point. Health, Illness, and Use of Care: The Impact of Social Factors, 18:53-68. Haraway, Donna 1988 Situated Knowledges: the science
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healthy, wealthy and wise. In Foucault: Health and Medicine. A. Petersen and R. Bunton, eds. Pp. 207222. New York: Routledge. Novas, Carlos and Rose, Nikolas 2000 Genetic risk and the birth of the somatic individual. Economy and Society, 29, (4):485-513. Posner, Tina 1993 Ethical issues and the individual woman in cancer screening programs. Journal of advances in health and nursing care, 2, (3):55-70. Petryna, Adriana 2002 Life exposed: biological citizens after Chernobyl. Princeton University Press: Princeton. Rapp, Rayna 2000 Extra chromosomes and blue tulips: medico-familial interpretations. In Living and working with the new medical technologies: intersections of inquiry. M. Lock, A. Young and A. Cambrosio, eds. Pp. 184-207. Cambridge, UK: Cambridge University Press. Anthropology of Policy: Critical Perspectives on Governance and Power. C. Shore & S. Wright, eds. Pp.xiii-xiv. New York: Routledge. 1997b Policy: a new field of anthropology. In Anthropology of Policy: Critical Perspectives on Governance and Power. C. Shore and S. Wright, eds. Pp.3-39. New York: Routledge. Smith-Rosenburg, Carol 1989 The Body Politic. In Coming to Terms: Feminism, Theory, Politics. E. Weed, ed. Pp. 101121. New York: Routledge. Strathern, Marilyn 1996 Cutting the network. Journal of the Royal Anthropological Institute (n.s.), 2:517-35. Tsing, Anna 2005 Frictions: An Ethnography of Global Connections. Princeton: Princeton University Press. Turner, Bryan 1997 From governmentality to risk: some reflections on Foucault’s contribution to medical sociology. In Foucault, Health and Medicine. A. Petersen and R. Bunton, eds. Pp.ixxxi. New York: Routledge.
Riles, Annelise 2001 The network inside out. Ann Arbor: The University of Michigan Press. Roehr, Bob 2006 HPV vaccine for women nears approval, gay men’s study lags. Gay & Lesbian Times, no. 963:16-16 Rose, Nikolas and Novas, Carlos 2002 Biological Citizenship. London: London School of Economics web site. www.lse.ac.uk/collections/sociology/pdf/ roseandnovasbiologicalcitizenship.pdf, accessed January 30, 2009. Sanders, Todd 2008 Beyond bodies: Rainmaking and Sense Making in Tanzania. Toronto: University of Toronto Press. Sawicki, Jana 1991 Disciplining Foucault: Feminism, power and the body. New York: Routledge. Shore, Chris and Wright, Susan 1997a Preface and acknowledgments. In
Vanslyke, J.; Baum, J.; Plaza, V.; Otero, M.; Wheeler, C. and Helitzer, D. 2008 HPV and cervical cancer testing and prevention: knowledge, beliefs, and attitudes among Hispanic women. Qualitative Health Research, 18, (5):584-596. Wedel, Janine, Shore, Chris, Feldman, Gregory and Lathrop, Stacy 2005 Toward an Anthropology of Public Policy. ANNALS, AAPSS, 600:30-51.
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Michelle Wyndham-West is a
PhD candidate in the Social Anthropology department at York University. She is currently writing her dissertation. Her interdisciplinary research on the gendering of HPV, the vaccine and related policies in Ontario draws inspiration from post-structuralist social theory, social science approaches to risk and feminist praxis.
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