Graduation Year

2023

Document Type

Dissertation

Degree

Ph.D.

Degree Name

Doctor of Philosophy (Ph.D.)

Degree Granting Department

Anthropology

Major Professor

Roberta D. Baer, Ph.D.

Co-Major Professor

Heide Castañeda, Ph.D.

Committee Member

Daniel H. Lende, Ph.D.

Committee Member

Asa Z. Oxner, M.D.

Committee Member

David A. Wein, M.D., M.B.A.

Keywords

assemblage theory, structural vulnerability, opioid use disorder, Hepatitis C Virus

Abstract

This dissertation demonstrates that a critical, clinically applied anthropology is possible by testing a hypothesis that a syndemic intervention, and use of a structural vulnerability assessment tool, can achieve improved healthcare outcomes. A critical, clinically applied anthropology integrates social scientists into healthcare delivery, alongside biomedical providers, through the co-creation of new diagnostic and patient care pathways that utilize anthropological methods (ethnographically informed care, syndemics, thematic/mixed methods data analysis) and advance anthropological theory (biomedicine and culture, structural violence, structural competency/vulnerability, ontology, assemblage theory, and entanglements) to decrease healthcare inequities.

Medical anthropology has previously engaged biomedicine and other attempts at a clinical anthropology have occurred in the past. Previous efforts around an applied clinical anthropology largely focused on closing perceived culture gaps between physician and patient models of disease and illness, often with an implicit attempt to improve patient compliance. The role of culture as an explanatory variable, as well as the complicit role of clinical anthropology within biomedicine were rightly criticized. Critical approaches to healthcare delivery recognized that structural vulnerabilities were more likely to explain observed health outcome inequities. In addition, the prior approaches may have missed the real interesting loci of cultural analysis at the point of co-created meaning in pathway creation. A new clinical anthropology must move beyond being relegated to teaching outdated cultural competency concepts in medical schools and, instead, demonstrate value by informing care delivery. This follows models of other disciplines with a praxis and theoretical approach, such as psychology and physics.

Healthcare delivery and biomedicine is a complex system highly intertwined in a capitalist/post-capitalist landscape. That precarious landscape is filled with potential diagnoses that must be extracted and built out to achieve better patient health outcomes. Ontological approaches and the process of creating meaning between patients, providers and social scientists represent opportunity for ethnographically informed care and the design of testable hypotheses. Existing assemblages must be described, unentangled and the becoming of new assemblages must be examined to imagine other ways of delivering healthcare.

Syndemic descriptions can be found in the anthropological literature (two diseases linked by a social force and described locally through ethnography). Tests of syndemic interventions have been limited or non-existent. A syndemic description and linked syndemic intervention represents one way to contextualize, engage, and treat patients through a critical, clinical anthropology approach.

In this dissertation, I test a syndemic intervention designed to treat patients entangled in an ongoing syndemic of opioid use disorder (OUD), hepatitis C virus (HCV) infection, and structural vulnerability. A co-located HCV and OUD and co-located HCV and harm reduction treatment model were designed via anthropological integration into a clinical space, achieving the largest known cohort of HCV cure among people on medication for opioid use disorder and amongst people still using drugs.

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