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Health Workers in Medical Missions to Madiha (Kulina)

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Health Workers in Medical Missions to Madiha (Kulina) THE REFERENTIAL FUNCTIONS OF AGENCY: HEALTH WORKERS IN MEDICAL MISSIONS TO MADIHA (KULINA) INDIANS IN THE BRAZILIAN AMAZON by Christian Dave Frenopoulo Gorfain Bach. Filos., Universidad Católica del Uruguay, Uruguay, 1996 Lic. Cs. Antrop., Universidad de la República, Uruguay, 2000 M.A., University of Regina, Canada, 2005 Submitted to the Graduate Faculty of the Kenneth P. Dietrich School of Arts and Sciences in partial fulfillment of the requirements for the degree of Doctor of Philosophy University of Pittsburgh 2012 UNIVERSITY OF PITTSBURGH KENNETH P. DIETRICH SCHOOL OF ARTS AND SCIENCES This dissertation was presented by Christian Dave Frenopoulo Gorfain It was defended on July 23, 2012 and approved by John Frechione, Ph.D., Senior Research Associate Professor, Department of Anthropology Christopher Keane, Sc.D., Assistant Professor, Department of Behavioral and Community Health Sciences Joseph Alter, Ph.D., Professor, Department of Anthropology Dissertation Advisor: Kathleen DeWalt, Ph.D., Professor, Department of Anthropology ii Copyright © by Christian Dave Frenopoulo Gorfain 2012 iii THE REFERENTIAL FUNCTIONS OF AGENCY: HEALTH WORKERS IN MEDICAL MISSIONS TO MADIHA (KULINA) INDIANS IN THE BRAZILIAN AMAZON Christian Dave Frenopoulo Gorfain, PhD University of Pittsburgh, 2012 This dissertation presents the results of a study of health workers in a medical mission in the Brazilian Amazon. The study aims to scrutinize health mission workers’ perceived capacities and abilities to deliver itinerant biomedical health services to Madiha (Kulina) Indians in the Brazilian Amazon. Participant observation with the health mission workers involved accompanying them in medical mission trips to Madiha villages and settlements in the Upper Purus River region. Madiha are hunters and manioc horticulturalists. The research shows that health mission workers participate in three social spaces during a mission journey. In the work space, they perform rigid role behaviors that emphasize biomedical technical procedure and the use of imported technical practices and knowledge. In their domestic space, located on the boat that they use for living and traveling, their behaviors emphasize ethnic similarity and a self-assumed status as trustees of the Madiha population’s health welfare. In the population’s domestic spaces, they attempt to participate in activities that can award them a status as equals to the villagers. The analysis of their interactions in these spaces suggests that their capacities and abilities are constructed according to a foreign/local polarity. The polarity underscores their iv missionary status as expert outsiders who need to engage in active efforts to achieve legitimacy among the patient population. Throughout the day, they constantly switch their positioning relative to one another and to the villagers, in order to navigate the ambiguity of their missionary status. In this way, they inhabit the various domestic and work spaces differently, cross- referencing each space with alternating behaviors. The dissertation attempts to contribute to the theory of human agency in anthropology by proposing that agency configurations are not properties of social actors, but circumstantial indexes of relative position in specific types of relationships. Agency is comprehensible relative to role arrangements. In this sense, agency would have two referential functions. Agency would indicate an actor’s position relative to resources and relative to other actors. Thus, agency attribution is an interpretation of the value of actions and of the relative status of actors. v TABLE OF CONTENTS ACKNOWLEDGEMENTS ................................................................................................ XXVII PREFACE .............................................................................................................................. XXIX 1.0 INTRODUCTION ........................................................................................................ 1 1.1 INTRODUCTION: AN INFANT DEATH IN BOAÇU VILLAGE ............... 1 1.2 THE PROBLEM .................................................................................................. 3 1.3 THE SETTING .................................................................................................... 4 1.4 HYPOTHESIS ..................................................................................................... 8 1.5 CONTRIBUTION................................................................................................ 9 1.6 SYNOPSIS OF CHAPTERS ............................................................................ 11 1.7 TERMINOLOGY .............................................................................................. 12 1.7.1 Ability and capacity ....................................................................................... 12 1.7.2 Intention and intentionality .......................................................................... 13 2.0 THEORY .................................................................................................................... 14 2.1 THE EMANCIPATORY MODEL: AGENCY AS A PROPERTY.............. 15 2.1.1 Patient resistance as a sign of agency ........................................................... 17 2.1.2 Patient compliance as a sign of agency ........................................................ 18 2.1.3 Patient ambivalence as a sign of agency ...................................................... 22 2.1.4 Liberal humanism: agency as a property of the acting self ....................... 23 vi 2.2 FORMATION OF THE AGENT ..................................................................... 26 2.2.1 Ortner: articulation of political position and intention ............................. 26 2.2.2 Mahmood: habitual practices of the acting self .......................................... 29 2.2.3 Discussion: The correspondence between position and intentionality is not universal ...................................................................................................................... 33 2.3 REFERENTIAL FUNCTION OF AGENCY IN HEALTH CARE RELATIONS ....................................................................................................................... 38 2.3.1 The “agency relation” ................................................................................... 38 2.3.2 Parsons’ model of the health care relation .................................................. 42 2.4 REFERENTIAL FUNCTION OF AGENCY IN ROLES ............................. 46 2.4.1 Strathern: agency in reciprocal role relations ............................................ 47 2.4.2 Latour: agency and the interpretation of roles ........................................... 50 2.5 COMPOSITE MODEL: THE REFERENTIAL FUNCTIONS OF AGENCY ...............................................................................................................................53 2.5.1 Traits are indicators of relative role ............................................................ 54 2.5.2 Two types of agency: capacity and ability ................................................... 55 2.5.3 Intentionality and the directionality of action ............................................ 58 2.5.4 Intentionality indicates status ....................................................................... 62 2.5.5 Functionality indicates role........................................................................... 64 3.0 METHODOLOGY AND TECHNIQUES ............................................................... 67 3.1 RESEARCH QUESTIONS ............................................................................... 68 3.1.1 Hypothesis ...................................................................................................... 70 vii 3.1.2 Research question 1 Indicators of counter-role orientation: Status and intentionality ............................................................................................................... 71 3.1.3 Research question 2 Indicators of utility: Resources and functionality ... 73 3.2 PARTICULARISTIC APPROACH: CASE STUDY OF TWO DAYS ....... 74 3.2.1 Justification .................................................................................................... 76 3.2.2 Two dates: March 18 and March 21 ............................................................ 77 3.2.3 Other field locations ...................................................................................... 77 3.3 TECHNIQUES ................................................................................................... 78 3.3.1 Observations of health care interactions ..................................................... 78 3.3.2 Participant observations ............................................................................... 81 3.3.3 Use of photographs ........................................................................................ 82 3.3.4 Semi-structured interviews with Base Post workers .................................. 82 3.3.4.1 Interview guide .................................................................................... 83 3.3.4.2 Duration ............................................................................................... 85 3.3.4.3 Interviewees ......................................................................................... 85 3.3.4.4 Dates ..................................................................................................... 85 3.3.4.5 Interview locations
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