'Hallucination': Hospital Ecologies in COVID's Epistemic Instability.

Historians and ethnographers have described biomedicine as a modernist project that imagines accumulating ever-more stable knowledge over time. This project broke down in heavily hit hospitals at the onset of the COVID-19 pandemic in the U.S., when bureaucratic, physical and knowledge structures collapsed. A combination of terror, a partially characterized disease entity and clinicians' inability to operate without disease models drove them to draw on rapidly changing and contradictory information via social media, changing medical practice minute-to-minute. The result was a unique form of knowing described as "hallucination": a hyperreal, unstable ecology of imagined viral particles distributed in physical spaces, transforming with each text message and tweet. The nature, experience and practice of this ecology sheds light on what happens when instability comes to otherwise stable places.

Stigmatizing and discriminatory attitudes toward people living with HIV/AIDS (PLWHA) among general adult population: the results from the 6th Thai National Health Examination Survey (NHES VI).

Background: Thailand has an ongoing action plan to reduce human immunodeficiency virus (HIV) discrimination and stigma. We aimed to monitor the level of stigmatizing and discriminatory attitudes toward people living with HIV/AIDS (PLWHA) among the general adult population and to investigate its related factors. Methods: This study was based on data from the 6th Thai National Health Examination Survey, a large-scale country-wide survey in 2019-2020. We used a multistage sampling technique and included 11 843 adults aged 20 to 59. We collected data through face-to-face interviews which included six items related to HIV stigma domains. We weighted all analyses to account for the probability of sampling the Thai population aged 20 to 59 years. Results: We found that anticipated stigma had the highest percentage of negative stigmatizing attitude responses (78.5%), followed by perceived stigma (66.6%), fear of HIV infection (54.4%), and social judgment (28.2%). Regarding the UNAIDS global indicator for discriminatory attitude, 48.6% of respondents had negative perceptions to questions about experienced stigma or discrimination. Multiple logistic regression showed that factors associated with discriminatory attitudes toward PLWHA were being aged 20-39 (adjusted odds ratio (aOR) = 1.32, 95% confidence interval (CI) = 1.18-1.47) or 50-59 (aOR = 1.23, 95% CI = 1.09-1.40) compared to being aged 40-49, being Muslim compared to Buddhist (aOR = 1.73, 95% CI = 1.46-2.06), being married compared to being single (aOR = 1.15, 95% CI = 1.04-1.28), holding certificate degree or higher compared to not studying or studying at a primary level (aOR = 0.81, 95% CI = 0.68-0.97), living in the Northeast (aOR = 1.27, 95% CI = 1.12-1.45) and Bangkok (aOR = 1.30, 95% CI = 1.12-1.51) compared to living in the North, having no HIV/AIDS infected relative or acquaintance compared to having an HIV/AIDS infected relative or acquaintance (aOR = 1.56, 95% CI = 1.41-1.73), and not obtaining an HIV test compared to obtaining it (aOR = 1.10, 95% CI = 1.02-1.19). Conclusions: We found that HIV stigmatizing and discriminatory attitudes toward PLWHA decreased, but remained concerning among Thai adult people. A public education and awareness campaign, as well as an intervention to reduce HIV-related stigma and discrimination in the country's health care facilities, must still be maintained.

PrEP stigma among current and non-current PrEP users in Thailand: A comparison between hospital and key population-led health service settings.

Background: Pre-exposure prophylaxis (PrEP) has demonstrated effectiveness in high-risk populations. PrEP service in Thailand became free of charge under the Universal Health Coverage (UHC) in 2021. The National Health Security Office launched a pilot project in 2020 to ensure sustainable service delivery, and the national monitoring and evaluation (M&E) framework was adopted to evaluate early phase implementation. We carried out a cross-sectional survey as part of the M&E process to investigate PrEP stigma among current and non-current PrEP users from both hospital and Key Population Led Health Services (KPLHS) settings in Thailand. Methods: Between August and October 2020, an online cross-sectional survey was conducted. A link for a self-administered questionnaire was distributed to all active PrEP centers and PrEP clients were then recruited by PrEP providers. Descriptive and univariate analysis using Chi-square were applied in the analyses. Attitudes toward PrEP were ranked from the most negative to the most positive. The negative attitude can be interpreted as PrEP stigma. Results: This study included 513 PrEP clients (355 from hospitals and 158 from KPLHS). In both settings, respondents' attitudes toward PrEP were generally positive, but some potential stigma was observed. 31.8% of hospital PrEP clients and 9.5% of KPLHS clients agreed that PrEP users should keep their pills hidden from others. Almost half (44.5%) of hospital clients and 18.4% of KPLHS clients agreed that PrEP users are often viewed negatively by society. More than 20% of hospital clients and 12% of KPLHS agreed that PrEP users frequently experience difficulties when their partner/lover/family find out that he or she is on PrEP. Respondents from the hospitals had slightly higher PrEP stigma than those from KPLHS. Conclusions: According to our findings, at the policy level, the campaign to provide PrEP education to all groups of people should be continued in order to promote a positive view of PrEP and reduce PrEP-related stigma among the general population, which is critical for successful PrEP implementation.

'Acute-on-chronic': Emergency Affect and the One-way Staircase of Pharmaceutical Escalation.

The opioid epidemic in the United States is often portrayed as leading to a "pendulum swing" from indiscriminate prescribing toward appropriate use. This portrayal imagines rational-ethical physicians trying to resist irrational-manipulative patients and pharmaceutical companies. Drawing on an ethnography of pain management in U.S. hospital and clinic settings, I suggest instead that chronic pain generates a constantly renewed "emergency affect," a mutual experience for providers and patients that polarizes decisions toward either medication escalation or patient abandonment. Understanding this "emergency affect" can help provide a path forward through the opioid epidemic to embrace the discomfort of pain management.

"Making Moves" in a Cardiac ICU: An Epistemology of Rhythm, Data Richness, and Process Certainty.

Ethnographers of clinical rationality often assume that the goal of biomedical practice is to eliminate uncertainty to produce definitive diagnoses. In this ethnography of an academic cardiac intensive care unit (CCU) in the United States, bodies are conceived instead as ever-changing constellations of problems that make diagnostic certainty irrelevant and require clinicians to construct and reconstruct temporary models to facilitate action. They suspend their uncertainty to "convince themselves" enough to "make moves" on patients, driven by the relentless tempo of critical illness. This necessitates a practice-oriented model of professional rationality that can account for the flow of time, with implications beyond the biomedical.

The first nationwide survey of MD-PhDs in the social sciences and humanities: training patterns and career choices.

BACKGROUND: While several articles on MD-PhD trainees in the basic sciences have been published in the past several years, very little research exists on physician-investigators in the social sciences and humanities. However, the numbers of MD-PhDs training in these fields and the number of programs offering training in these fields are increasing, particularly within the US. In addition, accountability for the public funding for MD-PhD programs requires knowledge about this growing population of trainees and their career trajectories. The aim of this paper is to describe the first cohorts of MD-PhDs in the social sciences and humanities, to characterize their training and career paths, and to better understand their experiences of training and subsequent research and practice. METHODS: This paper utilizes a multi-pronged recruitment method and novel survey instrument to examine an understudied population of MD-PhD trainees in the social sciences and humanities, many of whom completed both degrees without formal programmatic support. The survey instrument was designed to collect demographic, training and career trajectory data, as well as experiences of and perspectives on training and career. It describes their routes to professional development, characterizes obstacles to and predictors of success, and explores career trends. RESULTS: The average length of time to complete both degrees was 9 years. The vast majority (90%) completed a clinical residency, almost all (98%) were engaged in research, the vast majority (88%) were employed in academic institutions, and several others (9%) held leadership positions in national and international health organizations. Very few (4%) went into private practice. The survey responses supply recommendations for supporting current trainees as well as areas for future research. CONCLUSIONS: In general, MD-PhDs in the social sciences and humanities have careers that fit the goals of agencies providing public funding for training physician-investigators: they are involved in mutually-informative medical research, clinical practice, and teaching - working to improve our responses to the social, cultural, and political determinants of health and health care. These findings provide strong evidence for continued and improved funding and programmatic support for MD-PhD trainees in the social sciences and humanities.

Locating global health in social medicine.

Global health's goal to address health issues across great sociocultural and socioeconomic gradients worldwide requires a sophisticated approach to the social root causes of disease and the social context of interventions. This is especially true today as the focus of global health work is actively broadened from acute to chronic and from infectious to non-communicable diseases. To respond to these complex biosocial problems, we propose the recent expansion of interest in the field of global health should look to the older field of social medicine, a shared domain of social and medical sciences that offers critical analytic and methodological tools to elucidate who gets sick, why and what we can do about it. Social medicine is a rich and relatively untapped resource for understanding the hybrid biological and social basis of global health problems. Global health can learn much from social medicine to help practitioners understand the social behaviour, social structure, social networks, cultural difference and social context of ethical action central to the success or failure of global health's important agendas. This understanding - of global health as global social medicine - can coalesce global health's unclear identity into a coherent framework effective for addressing the world's most pressing health issues.

On ethical locations: the good death in Thailand, where ethics sit in places.

In this article, I use ethnographic data on end-of-life care in Northern Thailand to address the relationship between ethics and place. My analysis is based on fieldwork conducted in 2007-2008, consisting of twenty in-depth oral life-histories of dying patients; ninety-five interviews with patients, family members and caretakers; fifty-four interviews with providers, administrators, civil society leaders and other key informants; as well as participant-observation of care of patients at the deathbed. In Northern Thailand, many feel that it is ethical to withdraw life support in the home, but unethical to withdraw it in the hospital. This is because the place of death is partly responsible for the quality of rebirth. Hospitals, on one hand, are powerful for saving lives; but as places to die, they are amoral, dangerous, devoid of ceremonial history and haunted by spirits. Homes, on the other hand, are optimal for dying because they are imbued with moral power from a history of beneficial ceremony and family living. Hospitalized patients at the edge of death are often rushed home by ambulance to withdraw life support in the more ethical place. I argue that the two places can be considered different ethical locations, because each is inhabited by a unique ethical framework governing withdrawal of life support. This concept has implications for the contemporary globalization of bioethics and for understanding practices that arise around ethically charged decisions.

Facing death, gazing inward: end-of-life and the transformation of clinical subjectivity in Thailand.

In this article, I describe a new form of clinical subjectivity in Thailand, emerging out of public debate over medical care at the end of life. Following the controversial high-tech death of the famous Buddhist monk Buddhadasa, many began to denounce modern death as falling prey to social ills in Thai society, such as consumerism, technology-worship, and the desire to escape the realities of existence. As a result, governmental and non-governmental organizations have begun to focus on the end-of-life as a locus for transforming Thai society. Moving beyond the classic outward focus of the medical gaze, they have begun teaching clinicians and patients to gaze inward instead, to use the suffering inherent in medicine and illness to face the nature of existence and attain inner wisdom. In this article, I describe the emergence of this new gaze and its major conceptual components, including a novel idea of what it means to be 'human,' as well as a series of technologies used to craft this humanity: confession, "facing suffering," and untying "knots" in the heart. I also describe how this new subjectivity has begun to change the long-stable Buddhist concept of death as taking place at a moment in time, giving way for a new concept of "end-of-life," an elongated interval to be experienced, studied, and used for inner wisdom.