The politicizing clinic: insights on 'the social' for mental health policy and practice.

PURPOSE: In this paper, we explore how Brazilian socially sensitive therapy can respond to care-users' desire to change the social and political forces shaping their lives. We use this case to demonstrate the limits of the "social determinants of health" agenda which, when operationalized, tends to leave questions of lasting structural change aside. METHODS: We report on mixed methods ethnographic and epidemiological results from the 1982 Pelotas (Brazil) birth cohort study, a prospective study of 5914 children. Ethnographic analysis explored the cyclical relationship between schooling, mental health care, conceptualizations of mental distress, social and political engagement, and experiences with diverse forms of discrimination. Epidemiological bivariate and multivariate analyses examined differences in socio-political participation and the reporting of discrimination at different time-points for participants who used therapy with those who did not. Effect modification analysis tested the hypothesis that the socially empowering effects of therapy were greater for marginalized and minoritized youth. RESULTS: Most young people living in situations of precarity experienced therapy, particularly when based in schools, to be a blame-inducing process. A more fulfilling and impactful therapeutic experience took shape when young people were able to shift the focus away from symptom reduction and behavioral management toward narrative life analyses, social debate, and political agency. Use of socially sensitive therapy was statistically associated with increased political participation and reporting of discrimination after controlling for confounders. The empowering effects of therapy were greater for those with less formal education and family income, but not for young people who identified as black, brown, or non-white. CONCLUSION: The findings underscore the importance of considering agency, sociality, and politics when theorizing "the social" in clinical practice, and health and social policy.

The Politics of Clinic and Critique in Southern Brazil.

Drawing on a historical ethnography of how Brazil's post-dictatorial psychiatric reforms have shaped young people's lives, this paper builds on Eve Sedgwick's analysis of the hermeneutics of suspicion to show that narrow applications of Foucault's biopower concept nurture forms of resistance to bio-reductionism centred primarily on epistemic deconstruction. To unsettle this hermeneutic, I put young people's theories of power into conversation with Georges Canguilhem's concept of the milieu and with feminist scholars' work on prefigurative politics. I introduce the concepts of threading and unthreading to consider how one subject of biopower, the child-like biobehavioural figure, was continuously being threaded within a specific milieu and in relation to another key figure: the elite angst-ridden 'storm-and-stress' adolescent. Young people's subsequent unthreading and reweaving politics, flourishing in co-construction with what I call the politicizing clinic, illustrate how decolonial pedagogies can incrementally change the patterning of social life.

Adolescent Sex and Psyche in Brazil: Surveillance, Critique and Global Mental Health.

Drawing on a historical ethnography conducted in Southern Brazil, this article explores how public health programs for adolescent reproductive and mental health have emerged in Brazil and begun to intersect with the growing field of "global mental health" (GMH). The story I recount begins not in the 2010s with the rapid rise of expert interest in adolescent health within GMH, but in the 1990s, the decade when young teens in Brazil were first coming into contact with practices and approaches in research, schools and clinics that have both underpinned and critiqued the production of an adolescent mental and reproductive health sub-field. In parsing what young women's encounters with the then newly-emerging questionnaires, measurement tools, school-based programs and clinical practices came to mean to them, I use a genealogical approach to consider how histories of education reform, population control, psychoanalysis, social medicine, the transition to democracy, feminism and grass-roots politics all entered the fold, shaping the way adolescent sex-and-psyche materialized as a contested object of expertise. I end by exploring what this case can teach global mental health advocates and social theorists about practices of critique.

"Playing the numbers game": evidence-based advocacy and the technocratic narrowing of the Safe Motherhood Initiative.

Based on an ethnography of the international Safe Motherhood Initiative (SMI), this article charts the rise of evidence-based advocacy (EBA), a term global-level maternal health advocates have used to indicate the use of scientific evidence to bolster the SMI's authority in the global health arena. EBA represents a shift in the SMI's priorities and tactics over the past two decades, from a call to promote poor women's health on the grounds of feminism and social justice (entailing broad-scale action) to the enumeration of much more narrowly defined practices to avert maternal deaths whose outcomes and cost effectiveness can be measured and evaluated. Though linked to the growth of an audit- and business-oriented ethos, we draw from anthropological theory of global forms to argue that EBA-or "playing the numbers game"-profoundly affects nearly every facet of evidence production, bringing about ambivalent reactions and a contested technocratic narrowing of the SMI's policy agenda.

Contested leadership and the governance of COVID-19 in Brazil: The role of local government and community activism.

Strong public health governance and leadership driven by scientific evidence, community participation, and attention to social and structural determinants of health are key to effective covid-19 containment. Given the failure of the federal government in Brazil to adopt effective public health measures, state and municipal governments, as well as community activists, have stepped in to fill the void. This essay examines the synergistic role that local governments, public universities, public health institutions and mutual aid initiatives have played in Brazil to advance pandemic control and mitigate the damaging effects of central government policies and neglect. Drawing on literature, media reports, and insights from journalists and activists based in Rio's favelas, we show how grass roots groups take actions that bear complex and vital relationships with local governments, NGOs, universities, and public health institutions. Effective local public health governance goes beyond technical public health responses and involves strategies for countering chronic marginalisation and disempowerment of local communities which open new pathways for creative intermunicipal collaboration, social change, power redistribution. It remains to be seen if actions and emerging networks at the local level can exert pressure on national government while not further exacerbating the polarising politicisation of the pandemic.

Contraceptive medicalisation, fear of infertility and teenage pregnancy in Brazil.

In Brazil, as in many other countries, teenage pregnancy is widely recognised as a public health problem. Buttressed by a public health science of the economics of teenage pregnancy that emphasises the postponement of parenthood as key to poverty reduction, young people's lack of appreciation for medical knowledge of contraceptives is most often credited for failed attempts to reduce teenage pregnancy. Based on a longitudinal ethnographic study conducted in Pelotas, Brazil, with young people over the course of 10 years, our study found that young women who became teenage parents did not lack medical knowledge but were, rather, highly medicalised. Not only were they intensely concerned with the ill-effects of oral contraceptives on possible future fertility, they also engaged in intricate routines of contraceptive-use as a way of testing and safeguarding their fecundity. Our analysis attends to the way these practices are shaped by the problematisation of the economics of teenage pregnancy, as well as by the gendering of cultural norms relating to the transition to adulthood. We theorise the results by considering how contraceptive medicalisation enabled some women to engage with the authority of normative society, while developing a potent off-stage critique of this authority and of what they considered to be discriminatory messages imbedded in scientific discourses on teenage pregnancy.

Risk of psychological distress following severe obstetric complications in Benin: the role of economics, physical health and spousal abuse.

BACKGROUND: Little is known about the impact of life-threatening obstetric complications ('near miss') on women's mental health in low- and middle-income countries. AIMS: To examine the relationships between near miss and postpartum psychological distress in the Republic of Benin. METHOD: One-year prospective cohort using epidemiological and ethnographic techniques in a population of women delivering at health facilities. RESULTS: In total 694 women contributed to the study. Except when associated with perinatal death, near-miss events were not associated with greater risk of psychological distress in the 12 months postpartum compared with uncomplicated childbirth. Much of the direct effect of near miss with perinatal death on increased risk of psychological distress was shown to be mediated through wider consequences of traumatic childbirth. CONCLUSIONS: A live baby protects near-miss women from increased vulnerability by giving a positive element in their lives that helps them cope and reduces their risk of psychological distress. Near-miss women with perinatal death should be targeted early postpartum to prevent or treat the development of depressive symptoms.

Psychiatry and politics in Pelotas, Brazil: the equivocal quality of conduct disorder and related diagnoses.

The world-wide emergence of categories for diagnosing mental health problems in children and youth such as conduct disorder is often attributed to the globalization of a highly biomedical form of psychiatry. In Brazil, a small group of therapists are resisting biomedicalization by keeping psychodynamic traditions alive and aiming to transform psychotherapy into a resource for politicized youth empowerment. Nevertheless, clinical practices demonstrate an increased use of biomedical diagnoses and therapeutic routines. On the basis of fieldwork with therapists and teachers, and a nine-year-long ethnography of young people, this article explores the localized effects of these potentially contradictory developments. Results show that the growth of biomedical practices alongside politicized therapeutic approaches is not indicative of underlying ambiguities but has, rather, emerged from the purposefully equivocal nature of Brazilian social, medical, and professional life. The article uses this Brazilian case study to critically debate theories of medicalization in the anthropology of psychiatry.

Re-imagining global health through social medicine.

The conceptual and practical work done by social medicine and global health have often overlapped. In this paper, we argue that new efforts to apprehend 'the social' in social medicine offer important insights to global health along five lines of critical analysis: (1) reconfigurations of the state and new forms of political activism, (2) philanthrocapitalism and the economisation of life, (3) The economy of attention, (4) anthropogenic climate change, and (5) the geopolitics of North and South.

Collapsing the vertical-horizontal divide: an ethnographic study of evidence-based policymaking in maternal health.

Using the international maternal health field as a case study, we draw on ethnographic research to investigate how public health researchers and policy experts are responding to tensions between vertical and horizontal approaches to health improvement. Despite nominal support for an integrative health system approach, we found that competition for funds and international recognition pushes professionals toward vertical initiatives. We also highlight how research practices contribute to the dominance of vertical strategies and limit the success of evidence-based policymaking for strengthening health systems. Rather than support disease-and subfield-specific advocacy, the public health community urgently needs to engage in open dialogue regarding the international, academic, and donor-driven forces that drive professionals toward an exclusive interest in vertical programs.

Pierre Bourdieu and transformative agency: a study of how patients in Benin negotiate blame and accountability in the context of severe obstetric events.

This paper explores the social and institutional processes that constrain and enable obstetric patients in Benin to critically evaluate quality of healthcare and to stimulate positive changes in the health system. Based on qualitative data collected as part of a hospital auditing system, the paper analyses semi-structured patient feedback interviews and their function as a primary mechanism through which critical patient evaluation can develop constructively. Using a Bourdieuan framework, we explore the dynamic social conditions that give rise to transformative agency and institutional change. Our results show that hospitals are often permeated with the habitus of employment, kinship and reproductive social fields, through which a number of social, economic and healthcare conflicts, power struggles and blame-inducing interactions emerge. These conflicts generally serve to keep patients quiescent and passive when it comes to developing critical statements of quality of care. In a subset of cases, however, these conflicts are transformed by patients and their family members into opportunities for modifying the values and practices of each habitus in new and creative ways. The active negotiation of social conflict and blame enabled a minority of patients actively to divert blame from themselves and to develop and maintain critical healthcare evaluations.

Psychiatry, Sex, and Science: The Making of "Adolescent" Motherhood in Southern Brazil.

Research linking teen motherhood to psychoneurodevelopmental causes and pathologies has proliferated in the past two decades. In Brazil, a psychodevelopmental project of teen motherhood has gained traction despite many experts' long-standing commitment to psychodynamic psychiatry and social epidemiology, generating epistemic tension rather than substitution. Drawing on historical ethnography conducted in Southern Brazil, I explore how this project materialized through the co-production of epistemic struggles, remedial interventions, and ontological politics. In showing how this co-production became interwoven with incremental changes in young women's emotions, sexualities, relationships, and bodies, I describe how one particular "kind" of teen motherhood emerged and became entangled with both psychiatric knowledge-production and the angst of working-class political agency. In giving women a contested psychiatric language with which to rework their social-moral worlds, I argue that science did more than conceptualize teen childbearing in pathological terms; it contributed to its troubled transformation.

"Guilty until proven innocent": the contested use of maternal mortality indicators in global health.

The MMR - maternal mortality ratio - has risen from obscurity to become a major global health indicator, even appearing as an indicator of progress towards the global Sustainable Development Goals. This has happened despite intractable challenges relating to the measurement of maternal mortality. Even after three decades of measurement innovation, maternal mortality data are widely presumed to be of poor quality, or, as one leading measurement expert has put it, 'guilty until proven innocent'. This paper explores how and why leading epidemiologists, demographers and statisticians have devoted the better part of the last three decades to producing ever more sophisticated and expensive surveys and mathematical models of globally comparable MMR estimates. The development of better metrics is publicly justified by the need to know which interventions save lives and at what cost. We show, however, that measurement experts' work has also been driven by the need to secure political priority for safe motherhood and by donors' need to justify and monitor the results of investment flows. We explore the many effects and consequences of this measurement work, including the eclipsing of attention to strengthening much-needed national health information systems. We analyse this measurement work in relation to broader political and economic changes affecting the global health field, not least the incursion of neoliberal, business-oriented donors such as the World Bank and the Bill and Melinda Gates Foundation whose institutional structures have introduced new forms of administrative oversight and accountability that depend on indicators.

Methodological aspects of the 1993 Pelotas (Brazil) Birth Cohort Study.

This paper describes the main methodological aspects of a cohort study, with emphasis on its recent phases, which may be relevant to investigators planning to carry out similar studies. In 1993, a population based study was launched in Pelotas, Southern Brazil. All 5,249 newborns delivered in the city's hospitals were enrolled, and sub-samples were visited at the ages of one, three and six months and of one and four years. In 2004-5 it was possible to trace 87.5% of the cohort at the age of 10-12 years. Sub-studies are addressing issues related to oral health, psychological development and mental health, body composition, and ethnography. Birth cohort studies are essential for investigating the early determinants of adult disease and nutritional status, yet few such studies are available from low and middle-income countries where these determinants may differ from those documented in more developed settings.

Psychiatry, bio-epistemes and the making of adolescence in southern Brazil.

Drawing on an ethnographic study in southern Brazil, this paper explores how therapists' attempts to "resist bioreductionist" pharmaceutical use both succeed and crumble. Using a comparative framing, I show that pharmaceuticalization can become an anesthetizing "lid" that interacts with young people's polarizing micro-politics and is an outgrowth of multi-generational medico-political family histories. This lid, however, is not air-tight and exceptionalities are born out of these very same histories. I argue that both pharmaceuticalization and exceptions to it emerge not through "resistance" to biopsychiatric logics but from the transformative possibilities that the patterned co-production of social, political, and psychiatric life affords.

"Lives in the balance": The politics of integration in the Partnership for Maternal, Newborn and Child Health.

A decade ago, the Partnership for Maternal, Newborn and Child Health (PMNCH) was established to combat the growing fragmentation of global health action into uncoordinated, issue-specific efforts. Inspired by dominant global public-private partnerships for health, the PMNCH brought together previously competing advocacy coalitions for safe motherhood and child survival and attracted support from major donors, foundations and professional bodies. Today, its founders highlight its achievements in generating priority for 'MNCH', encouraging integrated health systems thinking and demonstrating the value of collaboration in global health endeavours. Against this dominant discourse on the success of the PMNCH, this article shows that rhetoric in support of partnership and integration often masks continued structural drivers and political dynamics that bias the global health field towards vertical goals. Drawing on ethnographic research, this article examines the Safe Motherhood Initiative's evolution into the PMNCH as a response to the competitive forces shaping the current global health field. Despite many successes, the PMNCH has struggled to resolve historically entrenched programmatic and ideological divisions between the maternal and child health advocacy coalitions. For the Safe Motherhood Initiative, the cost of operating within an extremely competitive policy arena has involved a partial renouncement of ambitions to broader social transformations in favour of narrower, but feasible and 'sellable' interventions. A widespread perception that maternal health remains subordinated to child health even within the Partnership has elicited self-protective responses from the safe motherhood contingent. Ironically, however, such responses may accentuate the kind of fragmentation to global health governance, financing and policy solutions that the Partnership was intended to challenge. The article contributes to the emerging critical ethnographic literature on global health initiatives by highlighting how integration may only be possible with a more radical conceptualization of global health governance.