BIOMEDICAL DISENCHANTMENTS: PRACTICES, DISCOURSES, AND IMAGINARIES OF TRANSNATIONAL BIOMEDICALIZATION IN RURAL ETHIOPIA BY STEPHANIE MARGRIT RIEDER DISSERTATION Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Sociology in the Graduate College of the University of Illinois at Urbana-Champaign, 2016 Urbana, Illinois Doctoral Committee: Associate Professor Zsuzsa Gille, Chair Associate Professor Claire Laurier Decoteau, University of Illinois Chicago Associate Professor Brian Dill Associate Professor Assata Zerai ABSTRACT This dissertation examines practices, discourses, and imaginaries of biomedicine within hospital spaces produced by transnational processes in a rural Ethiopian community. I examine how Ethiopian and volunteer American physicians navigate intersections of globalized standards and technologies with site-specific clinical realities and sociopolitical structures to provide patient care and engage in professionally-satisfying endeavors. Extending sociological theories of biomedicalization into this postcolonial space constructed by unpredictable mobilities of global health technologies, but largely disconnected from formal networks of biocapital reveals biomedical imaginaries of physicians in tension with severely limited material and symbolic resources. The instability that characterizes biomedicine in Gelel, Ethiopia, is evident in physician practices and discourses in two community hospitals, representing different forms of institutional governance and fraught engagements with national and international policies and resources. Data were collected between July 2013 and March 2014 in the form of participant observation in the wards, operating rooms, and clinics of the hospitals, qualitative interviews with Ethiopian and American physicians, hospital administrators, NGO coordinators, and other medical staff, and community member surveys. This dissertation contends that biomedicalization in these spaces is a variegated construct of neoliberal capitalism and thus produces disenchantments and contradictions evident within the embodied and socially embedded practices understood through analysis of the integration of globalized macroinstitutional structures and local clinical realities. Contemporary medical missions allow American volunteers to participate in one- to two-week projects in a particular mode of “global health” practice and produce boundaried clinical enclaves and novel forms of biomedical subjects. These processes work through frontier imaginaries and utilize spaces of exclusion and technologies of modularity that further enmesh Gelel’s biomedical processes and practitioners in particular moral and bio- economies. The tensions that emerge from these various friction-laden interactions of individuals, communities, resources, and imaginaries are productive of variegated biomedicalization itself and reinforce the inequalities and exclusions that promote “global health” projects. ii Dedication This dissertation is dedicated to those who practice medicine as a daily form of social justice in Ethiopia and elsewhere. iii Acknowledgements This project could not have been undertaken without the support and generosity of the Ethiopian and American physicians, surgeons, and staff that opened their wards, operating rooms, and homes to me, often sharing stories and feelings about difficult situations. Their dedication to their patients, creativity and innovation in clinical situations, and willingness to go above and beyond for their colleagues were inspiring. I am eternally grateful for their willingness to let me into their lives and their patience as I asked countless questions. I am likewise grateful to Yohannes Bibisu, for his friendship, translation, and taekwondo coaching. His patience and support were unwavering and his faith in the significance of our questions and concerns were motivating even when circumstances seemed daunting. Additionally, the administrative and faculty support at the local campus of Wellega University was an immense help to me during my time in Ethiopia. A sincere thanks to Teka Shifera and Debala Mamo for assistance with community surveys, as well as for candid conversations regarding sociology in Ethiopia. Thank you also to the Wellega University local campus social science department and Gurmessa Beka in particular, with whom discussions about methods and research were very helpful. I offer my sincerest gratitude to the members of my committee: Dr. Zsuzsa Gille, Dr. Claire Decoteau, Dr. Brian Dill, and Dr. Assata Zerai for their guidance and support. In addition, thank you to other faculty members and mentors that provided invaluable help and wisdom over the years: Dr .Donald Crummey, Dr. Norman Denzin, and Dr. Dang Ho, among many others. I am greatly indebted to those who provided funding for this project in its many stages: University of Illinois Urbana-Champaign Department of Sociology, University of Illinois Urbana-Champaign Medical Scholars Program, University of Illinois Urbana-Champaign College of Medicine, and Illinois Program for Research in the Humanities (IPRH). Thank you to my IPRH colleagues for their insight and feedback. This project, and indeed my life as a scholar, has been greatly enriched by long-standing relationships with my intrepid writing group members: Parthiban Muniandy and Erin Castro. Their inspiration, feedback, and encouragement from the beginning of this journey has shaped me in many forms and their friendship has buoyed me through many a writer’s block and theoretical dilemma. Additionally, friends and colleagues, particularly those in the Medical Humanities and Social Sciences and the Sociology Department have helped me remember the reasons that medicine is incomplete without social science and have been wonderful colleagues over my graduate school career: Francisca Mata, Rachel Smith, Kristen Ehrenberger, Elise Duwe, Jenn Baldwin, Rico Chenyek, Valeria Bonatti, Francisco Guerra, Courtney Cutherbertson, Becky Gresh, Michelle Schmidt, Katherine Magerko, and others. iv Thank you beyond words for the love and support of my parents, Susan and Hanspeter Rieder. They have made me the person I am and continue to offer me encouragement and strength through their insights, senses of humor, and confidence in me. Also, thanks to my brother, Chris Rieder. Finally, much gratitude to my loving and encouraging partner, Jeff Horwat, who believes in me and offers unwavering support. v Table of Contents Chapter 1: Introduction ……………………………………………………………. Page 1 Chapter 2: Conflicts, Hybridities, and Coevolution: Social and Historical ……….. Page 66 Contexts of Biomedicine in Ethiopia Chapter 3: Health is Relative: Variegated Biomedicalization in Ethiopia ………... Page 91 Chapter 4: Even if You Know the Theory: Informality, Innovation, and ………… Page 124 Discontents in Ethiopian Biomedicine Chapter 5: Clinical Frontiers and Modular Medicine: Constructions of .……......... Page 152 spaces, subjects, and technologies in American medical missions Chapter 6: At Some Point You Need to Do Something: Evangelical ethics ……… Page 186 and dialectics of medical mission projects Chapter 7: Conclusion ……………………………………...……………………... Page 219 Appendix A: Qualitative Interview Measure for Ethiopian Physicians …..………. Page 240 Appendix B: Pre-Arrival Survey for American Volunteer Physicians .…………… Page 242 Appendix C: Qualitative Interview Measure for Visiting Physicians .……………. Page 244 Appendix D: Qualitative Interview Measure for Non-Governmental …………….. Page 245 Organization Members Appendix E: Survey Measure for Community Members ………..………………... Page 246 Appendix F: Brief Qualitative Interview Measure for Patients.………….………... Page 251 References ………………………………………………………………………… Page 252 vi CHAPTER 1 Introduction In a storeroom across the hallway from the main operating room in a hospital in rural Ethiopia, five suitcases and a large cardboard box filled with supplies were kept under a blue tarp, waiting for the return of an American surgical team. Having been asked by the team leader to do an inventory of their contents, I talked with the operating room manager about getting the boxes out. He told me emphatically that no one had touched them since two team members had inventoried them in April, eight months before. Opening the first suitcase, I noticed two blood pressure cuffs and while realizing the utility for making sure the team has these available when they arrived, I also knew how useful these would have been for the hospital staff in the time the team was gone. There were a few medications including ciprofloxacin, bisacodyl, acetaminophen, and ibuprofen, all of which are readily available in the hospital.1 Purchasing these medications locally would benefit either the hospital or the local pharmacies and probably cost less than purchasing them in the United States. Indeed, by bringing suitcases of medications donated in the United States, this team and others denied the hospital and the Ethiopian pharmaceutical sector the opportunity to make a profit from these same medications. The next suitcase was full of gloves of all sizes, some latex and some not. I grimaced as I thought of the hospital’s general surgeon’s latex allergy and how his hands broke out because of the unreliable supply of latex-free gloves in the hospital. I browsed through a third and fourth suitcase. One had a number of supplies in it, but notably suture of all different kinds. There was more suture in that 1 Ciprofloxacin is an antibiotic; bisacodyl is a laxative; acetaminophen