'Having the card makes us feel worthless': the negative value of government-funded health insurance in India.

Since the 2000s, hundreds of government-funded health insurance (GFHI) schemes were introduced in India. These schemes are meant to prevent poorer households from incurring catastrophic health expenditures. Through GFHIs, policy-makers want to mobilize the decision-making powers of private consumers in a liberalized healthcare market. Patients are called upon to act as 'co-creators' of healthcare value by optimizing supply through demand. Based on long-term ethnographic fieldwork with insurance users in South India, we argue that GFHIs fail because people experience the value of insurance in drastically different ways that only partly overlap with how the policy assumes they value insurance. In addition, the hollow promises of health coverage can be experienced as so frustrating that signing up for health insurance actually makes people feel devalued.

"Demand Side" Health Insurance in India: The Price of Obfuscation.

In India, most healthcare expenses are patients' out-of-pocket payments to private sector providers. Catastrophic health expenditures drive millions of families deeper into poverty. To save poorer households, hundreds of government-funded health insurance schemes have been introduced since the 2000s. These "demand side" schemes suggest that treatments in the private sector will be fully reimbursed. Fieldwork in one of India's largest hospitals shows that GFHIs overpromise. GFHIs are designed to turn patients into co-creators of healthcare value, but instead they deepen individuals' lack of market transparency. Poor patients pay the price for the state's lack of trust in them.

Depression, Deprivation, and Dysbiosis: Polyiatrogenesis in Multiple Chronic Illnesses.

Biomedicine tends to treat "mental" illnesses as if they could be isolated from multiple social and somatic problems. Yet mental suffering is inseparable from complex somatosocial relations. Clinical fieldwork in a deprived area of the UK shows that nearly all the people treated for "depression" are chronically multimorbid, both in their bodies and in their social relations. Mental suffering is co-produced by poverty, trauma, and excessive medication use. Patients' guts are as imbalanced as their moods. Single vertical treatments make them worse rather than better. In the UK, patients in poorer neighbourhoods do not "lack access" to healthcare. If anything, they suffer from taking too many medications with too little integration. I conceptualize the bad effects of excessive interventions in patients with multiple chronic problems as polyiatrogenesis.

Multimorbidity, Polyiatrogenesis, and COVID-19.

To date, the strongest predictor for dying with COVID-19 is suffering from several chronic disorders prior to the viral infection. Pre-existing multimorbidity is highly correlated with socioeconomic inequality. In turn, having several chronic conditions is closely linked to multiple medication intake, especially in richer countries with good access to biomedical care. Owing to its vertical structure, biomedicine often risks giving multiple treatments in an uncoordinated way. Such lack of integrated care can create complex forms of iatrogenic harm. Multimorbidity is often exacerbated by a pharmaceuticalization of social deprivation in place of integrated care. In this article, I explore the possibility that clusters of over-medication are a contributing factor to higher death rates from COVID-19, especially in poorer areas within richer countries. Anthropological perspectives on the social embeddedness of multimorbidity and multiple medication use can expand our understanding of who is most vulnerable to SARS-CoV-2.

The social underpinnings of mental distress in the time of COVID-19 - time for urgent action.

We argue that predictions of a 'tsunami' of mental health problems as a consequence of the pandemic of coronavirus disease 2019 (COVID-19) and the lockdown are overstated; feelings of anxiety and sadness are entirely normal reactions to difficult circumstances, not symptoms of poor mental health.  Some people will need specialised mental health support, especially those already leading tough lives; we need immediate reversal of years of underfunding of community mental health services.  However, the disproportionate effects of COVID-19 on the most disadvantaged, especially BAME people placed at risk by their social and economic conditions, were entirely predictable. Mental health is best ensured by urgently rebuilding the social and economic supports stripped away over the last decade. Governments must pump funds into local authorities to rebuild community services, peer support, mutual aid and local community and voluntary sector organisations.  Health care organisations must tackle racism and discrimination to ensure genuine equal access to universal health care.  Government must replace highly conditional benefit systems by something like a universal basic income. All economic and social policies must be subjected to a legally binding mental health audit. This may sound unfeasibly expensive, but the social and economic costs, not to mention the costs in personal and community suffering, though often invisible, are far greater.

Disentangling Family Life and Hair Pulling: Trichotillomania and Relatedness.

Trichotillomania (hair pulling) remains a relatively unknown form of body-focused repetitive behavior (BFRB). Sufferers tend to conceal both the action and its effects from others because of stigmatization, which is strong in both public and domestic spheres. Negative responses from close family members can add significantly to the suffering. Based on fieldwork in the United Kingdom and United States, we explore how hair pulling troubles ties even among close family members. We show why ethnographic methods reveal impacts of hair pulling that structured assessments do not yet capture and argue for a more nuanced study of BFRBs through anthropologies of relatedness.

'It just opens up their world': autism, empathy, and the therapeutic effects of equine interactions.

Experiences of autism-spectrum disorder are now increasingly studied by social scientists. Human-animal relations have also become a major focus of social inquiry in recent years. Examining horse-assisted therapy for autistic spectrum disorders, this is the first paper that brings these fields together. Drawing on participant observation and interviews at a UK horse therapy Centre, this article examines how staff and the parents of riders account for the successes and limitations of equine therapy. To the respondents, horses 'open up' autistic children and make possible interactions that seemed impossible before. Horses were regarded as facilitating the emergence of apparently social behaviours, which included eye contact, pointing, and speech. Three key explanations emerged for therapeutic success: the sensorial, embodied experience of riding the horse; the specific movements and rhythms of the horse; and, the 'personality' of the horse. Equine therapy can be regarded as enabling a form of multispecies intersubjectivity, with the resonance between rider and horse seeming to make possible a new attunement between humans. Practices of equine therapy, and perceptions of its efficacy, serve in turn to attune social scientists to a version of empathy constituted through lively and sensorial interactions, as opposed to one that is restricted to particular kinds of humans.

"What is strange is that we don't have more children coming to us": A habitography of child psychiatrists and scholastic pressure in Kolkata, India.

The mental health of Indian school children could be expected to be a major topic of research. More people below 15 years are living in India than in any other country in the world, and India has undergone rapid social, economic, and demographic changes that have greatly increased the pressures on children to do well in school. Yet there is a striking dearth of research in this field. In this article we present the first-ever study focused on child psychiatrists in India. Based on long-term fieldwork and interviews with psychiatrists in the Kolkata metropolitan area, we present a habitography of how psychiatrists experience young people's problems. Child psychiatrists are greatly concerned about the nexus between heightened expectations of educational success and a rise of mental problems among young people. At the same time, they wonder why not many more children are coming to them with school-related complaints. To date, there is not enough research that could either confirm or disconfirm the psychiatrists' analysis of social changes, but some conclusions on the plausibility of their views can be drawn.

"We always live in fear": antidepressant prescriptions by unlicensed doctors in India.

In India, psychopharmaceuticals have seeped deep into both formal and informal pharmaceutical markets, and unlicensed "quack" doctors have become ready prescribers of psychotropics. These ethnographic insights trouble policies that aim at closing the treatment gap for psychiatric medications by "task shifting" to low-skilled health workers as if medications were exclusively available by prescription from public sector psychiatrists. This article describes what these doctors, known as rural medical practitioners (RMPs), know about psychotropics and how they use them in everyday practice. Unlicensed doctors learn about psychopharmaceuticals through exchanges with licensed doctors, through visits by drug companies' sales representatives, and through prescriptions brought by patients. Although the RMPs exist outside the margins of legitimacy, they are constrained by a web of relations with patients, licensed doctors, pharmacists, drug wholesalers, and government agents. The RMPs do not only prescribe but also dispense, which leads to conflicts with licensed medicine sellers. They "always live in fear" both because they are illegal prescribers and because they are illegal sellers of medications. The article shows that any form of strategic ignorance among policy makers about the local importance of informal practitioners in India can only lead to lopsided interventions.

The unlicensed lives of antidepressants in India: generic drugs, unqualified practitioners, and floating prescriptions.

Antidepressant uses have been rising rapidly over the past decades. Two main theories have been advanced to explain this. One claims that socio-economic change causes a global rise of depressive illness. The other holds that European and North American corporations are aggressively marketing antidepressants to expand their global reach. Both theories assume that multinational capitalism drives rising depression rates. Based on ethnographic data from India, this article shows that antidepressants are increasingly used in this country as well, but for reasons than have been little explored yet. Taking fluoxetine (Prozac) as the main example, it is argued that the spread of antidepressants in India is ;unlicensed' by Euro-American corporations in at least three ways: (i) drug marketing is driven by Indian generic producers; (ii) fluoxetine is given by practitioners who have no license to do so; and (iii) knowledge of fluoxetine is spread through unlicensed ;floating' prescriptions that patients take from one prescriber to another.

Welcome home, Descartes! rethinking the anthropology of the body.

For many scholars, the Cartesian mind/body split is one of the fundamental mistakes of the Western scientific tradition. Anthropologists who study notions of the body in cultures around the world regularly take Descartes as their point of departure. Many also suggest that breaking free from Descartes is politically liberating: if the mindful body could be rediscovered, society could move away from its materialist, positivist, and commodity-fetishizing ways. Beyond the Body Proper is anthropology's best and most comprehensive anti-Cartesian manifesto to date. This volume brings together some of the finest studies on the cultural and historical diversity of bodies and minds. Yet anthropologists' blanket rejection of the mind/body dualism seems politically self-defeating. If anthropologists want to criticize racism, gender hierarchies, or discrimination against disabled people, they need to believe that the mind is independent from the body. In other words, they need to uphold the Cartesian split.

The Ills of Marginality: New Perspectives on Health in South Asia.

Social marginality and ill health can form an unholy dyad: firstly, groups who suffer from chronic or infectious diseases often find themselves pushed to the margins. Secondly, people who are already on the edge of society tend to suffer more from illness than those at the centre. In development discourse, marginal people are defined as those who are 'not yet' on the same level as the developed mainstream and are in urgent need of aid from the centre. The papers in this special issue take a different approach by insisting that marginality is a radically relational concept: the centre and its margins constitute each other, and the boundaries between them are constantly shifting. The papers show that there are many types of marginality (based on geography, class, caste, sex/gender, ethnicity, etc.), and that each of them has different effects on the health of a particular group. Yet instead of speaking of a plurality of unrelated 'group identities', marginality preserves a sharp sense of unequal power relations between groups. The specific ethnographic contribution to the study of marginality comes from its attention to the point of view of marginal people. This is of critical importance since marginality puts health most under stress when it is clearly and steadily perceived in everyday life. This, in turn, makes it possible to show that living on the margins is not always and everywhere bad for health. While all of the papers present South Asian case studies, the insights and questions are relevant for the study of the ills of marginality in a global perspective.

Pharmaceutical Citizenship: Antidepressant Marketing and the Promise of Demarginalization in India.

Among practitioners of biomedicine, to speak of people as 'marginalized' often amounts to saying that they do not have access to medical substances. Thus conceived, the best way to remove marginality seems to be to give medicines to those deprived of them. The peculiar relationship between marginality and pharmaceuticals is especially poignant in the case of antidepressant drugs, as these drugs appear to bring the patient 'back into society', but not any society, but middle-class consumer society. What is now special about antidepressants is that there is nothing special about them: antidepressants are like consumer items among thousands of other consumer items. This paper explores the relations between medicines and marginality with reference to the marketing of antidepressant drugs in Kolkata (Calcutta), India. Drawing on ethnographic fieldwork in the Kolkata metropolitan area from July 1999 to December 2000 and in August/September 2003, this paper examines how people with depression are constituted as 'marginal' in the sense of 'being deprived of medication', and how the biomedical promise of an effective pharmacological treatment becomes a promise of 'pharmaceutical citizenship'. In view of Bengali notions of mental health as a state of detachment, the paper asks if pharmacological demarginalization holds the same promise in the Indian context that it holds in the West.

Bodily sovereignty as political sovereignty: 'self-care' in Kolkata, India.

This paper explores the potentials of applying Michel Foucault's notion of 'self-care' to issues in medical anthropology. While Foucault's writings on regimes of power/knowledge have had an enormous influence on medical anthropologists, his late works on the ethics of the self have not yet received much attention. This paper discusses Foucault's notion of self-care in relation to Ayurvedic interpretations of digestion in Kolkata (formerly Calcutta, India). In Kolkata, it is a widely held belief that attentive care of the self, and especially for the stomach, can set a person free from dependencies. Yet at the same time, 'modern' people are seen as unable to live up to the ethics of self-care. The parallel between bodily sovereignty and cultural/political sovereignty produces a discourse on 'lack of self-control' as one of the main reasons for continuing dependency in all spheres of life. How does Foucault's late work help to conceptualize these findings?

Towards an ethnography of Indian homeopathy.

Despite its large number of practitioners, medical anthropology has given little attention to Indian homeopathy. In historical accounts, homeopathy's popularity is explained by its position as a modern, yet non-colonial form of medicine, which became indigenized during the last 150 years. Other scholars argue that homeopathic concepts converge with Indian ideas on healing. However, few empirical data have been gathered on homeopathic practice in contemporary India. In this paper, we explore the perspectives of college-trained homeopaths in urban West Bengal. How strongly do they feel indebted to classical and canonical homeopathic writings? Can we observe attempts of indigenizing homeopathy by blending it with common ideas of Indian medical culture? While the homeopaths in our study report practising an orthodox version of homeopathy, we can also identify creative solutions when they are responding to their patients' expectations: conforming to the idea of single-remedy prescription by simultaneous use of placebos, short-cut homeopathic anamnesis, complementing homeopathic drugs with therapeutic nutritional advice, and developing a system of seasonal drugs are all evidence for silent hybridization of homeopathic and local ideas. In the homeopathic consultation, time pressure becomes a significant challenge and Bengali homeopaths grasp the most important homeopathic symptoms quickly.