3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item Building a culture of research in clinical medicine: an ethnography of professional aspiration, privilege and crisis at the intersection of hospital and University in South Africa(2019) Van Der Wiel, ReneeThis thesis is an ethnography of a group of medical doctors in South Africa who produce clinical research based on their patient practice. These clinician-researchers are scarce around the globe but praised as contributing indispensable clinical insights to research in an aim to improve healthcare. In South Africa government and professional bodies recently took action to expand and racially transform this elite of knowledge producers with the aim of remedying the country’s healthcare, perceived as being in crisis. My ethnography centres on the University of the Witwatersrand (Wits), specifically its School of Clinical Medicine, its associated teaching hospitals, and its attempts to grow a so-called culture of research among doctors. It is a reflection on the relationship between clinical practice and knowledge production at the intersection of resource-insecure public hospital and research-intensive university — both powerful state institutions with competing demands for doctors. Drawing on interviews and participant-observation I describe and analyse the aspiration, contestation, contingency, and actual work of research production among local clinicians. Overall this thesis indicates that the resource-insecure context in which clinicians produce knowledge creates the opportunity for and the value of their research. But this context simultaneously limits the scale, translation, and social good of their research, undermines the valour and expertise of clinician-researchers, and in cases bifurcates their knowledge production from their clinical experiences. This undercuts the pervasive imaginary of doctors’ clinical insights as fundamentally valuable to clinical research; and the potential of their research to improve healthcare for a population with a unique demographic and epidemiology by providing locally-embedded evidence for best practice, rather than relying on research from the global north. My evidence also indicates that publicly claimed professional aspiration to create a more inclusive democratic scientific community of doctors sits in tension with the often unacknowledged professional privilege many doctors have in the dispersed labour of research and does not fully reflect the unequal professional experiences and engagement that research doctors have in relation to gender, race, language, and locality. I argue that attempts to build a culture of research in clinical medicine sit uneasily within its larger institutional structures and historical context. My ethnography of “studying up” is relatively uncommon in South African anthropology. But I demonstrate that profession is a useful lens through which to study the relationship between power, knowledge, and human suffering, including the brutalisation of professionals, in post-apartheid institutional life. The thesis also highlights the personal and epistemological challenges of doing interpretivist research among a professionally-privileged, research-literate community that places great value on instrumental knowledge production.Item An ethnography of adults living with aphasia in Khayelitsha.(2010-11-09) Legg, Carol FrancesThis thesis is concerned with the experience of aphasia in Khayelitsha, a township on the outskirts of Cape Town characterised by poverty, violence, limited resources and a culture and language that differs from the setting of most speech and language services in South Africa. It is based on three years of intermittent fieldwork that entailed participant observation of the everyday life of five adults living with aphasia and interviews with participants, kin and healthcare workers in various settings. Grounded in sociocultural theory, this thesis has aimed to provide an ethnographic account of cultural frameworks of interpretation of communication impairment following stroke and of the daily reality of life for adults living with aphasia in this setting. An exploration of causal notions in this setting provided interesting commentary on social and cultural processes and how people, caught up in these processes, search for meaning and for cure. Participants entertained plural notions of causation of aphasia and explored numerous therapeutic avenues. The wide variation in causal notions included biomedical causes, social and behavioural determinants, and the influences of supernatural powers, such as witches and ancestors. Similarly participants experienced aphasia through multiple healing systems, including traditional, biomedical and religious therapy options. All however seemed to be ambiguous sources of help. Whilst encounters with the health system presented serious challenges to participants, traditional and religious avenues for help were obscured by a burgeoning and not always ethical open market offering miracle cures. An articulation of the circumstances of this group of adults provided further commentary on the influence of the social context on aphasia. In a context where sociopolitical processes have had a disintegrating effect on social cohesion, questions of support, care and security were of primary concern. Prejudices towards the elderly and women were more acutely felt and vulnerability, isolation, insecurity and fluidity of circumstance emerged as overarching themes. The central argument in this thesis is that the genesis of these experiences can be found in contextual factors in Khayelitsha, such as poverty, inequality, urbanisation and changing cultural paradigms. These emerging themes highlight the disjunctions between the medical alignment of the discipline of speech language therapy in South Africa and the capacity for socially-engaged practice. They also highlight the socio-cultural complexity of the experience of aphasia, specifically the influences of culture and poverty. There is thus theoretical and clinical relevance in using anthropological objectives to explore the world of the adult living with aphasia and the interface between context and service provision. Interventions and healthcare communications that will make a meaningful difference to adults with aphasia in a setting such as Khayelitsha are proposed.