Doctoral Dissertation Research: Between Community and Clinic: Households, Intermediaries, and Bureaucracy

Stanford University, Stanford CA

Investigators

Abstract

Stanford University doctoral student Anna West, with the guidance of Dr. James Ferguson, will conduct ethnographic research on citizenship, political subjectivity, and the state as it develops in the context of household-based health promotion, a practice found throughout the world but is especially prevalent in developing countries. The research will be conducted in Malawi, a sub-Saharan African country that is faced with a severe shortage of physicians and nurses and so must rely on community health workers to implement national and global health directives. Malawi's community health workers (CHWs), known as Health Surveillance Assistants, are secondary school graduates trained to deliver health education, provide basic curative care, and conduct disease surveillance in rural homes. The CHWs' routine interactions with women and men in rural households constitute an ongoing intimate encounter with the state, which is otherwise absent in many remote communities. The researcher will examine how these household-level health promotion encounters shape rural Malawians' homes and domestic practices, political subjectivities, and experiences of citizenship within broad ideological projects of national health and development. The investigator will conduct eighteen months of fieldwork combining village-based ethnography with community health workers and rural households in Malawi's Central Region, and institutional ethnography and archival research on the role of community health workers in Malawi's health system. She will explore three aspects of the health workers' encounters with households: (1) how the CHWs represent biomedical values and concepts of health in routine conversations; (2) how they position health responsibility; and (3) how they engage in disease surveillance and routine bureaucratic paperwork to generate a portrait of village health and rural homes that influences health policy and intervention design. Data will be collected through participant observation, semi-structured in-depth interviews, oral history interviews, and content analysis of health policy documents. The research is important because by focusing on the role of intermediaries and outreach workers in health and development projects, it will shed light on the local dynamics and consequences of translating large-scale global initiatives into routine service delivery. Findings also will contribute to social science literature on the interaction between health promotion, domesticity, and political subjectivities. Supporting this research also contributes to the education of a social scientist.