Tesis Susanna Rance Aborto en Bolivia

CHANGING VOICES: ABORTION TALK IN BOLIVIAN MEDICAL SETTINGS
A Thesis In Two Volumes
VOLUME II
Susanna Rance
A thesis submitted for the Degree of Doctor of Philosophy to the Department of Sociology, University of Dublin (Trinity College)
May 2003
DECLARATION
This thesis has not been submitted as an exercise for a degree at this or any other university.
This thesis is entirely my own work.
I agree that the Library of the University of Dublin, Trinity College, may lend or copy this thesis upon request.
..............................................
Susanna Rance, La Paz, May 2003 srance@entelnet.bo
Changing Voices
Table of Contents, Volume II
VOLUME II: TABLE OF CONTENTS

Page KEY TO TRANSCRIPT NOTATIONS KEY TO SPEAKERS CITED i) Key to Speakers, A to Z ii) Key to Speakers, AA to XX iii) Note on Translation of Categories of Professional Formation KEY TO ABBREVIATIONS iii iv iv v vi viii
CHAPTER 10. AUDIENCING HOSPITAL STORIES

10.1 10.2 The Problematic Relationship Actor-Audience, Text as Actant 10.2.1 10.2.2 10.2.3 10.2.4 10.3 First-year students: We are a human person Interns: If there has been good conduct, or not Residents: Everyone should have just one language Obstetricians: Although you insist its the same patient
1 2 6 8 12 14 16 19 23
Negotiating Professional Boundaries 10.4 Never-Ending Stories
CHAPTER 11. CONTRARIWISE AND OTHERWISE

11.1 11.2 11.3 11.4 It seems that you dont understand! Strangeness and the Authors Vision A Hybrid Methodology Ironic Use of Deadpan Understatement 11.4.1 11.5 Its all negative
25 26 27 28 31 33 36 36 38 39 40 42 45 47
Alternation: from Epistemology to Strategy 11.5.1 Deconstruction and reconstruction
11.6
Performing Consensus and Conflict 11.6.1 11.6.2 11.6.3 The Gringa Boliviana story Conflict and transformative action Why are people so nice?
11.7 11.8
Abortion: The Vanishing Topic Semiotic Action-Research
REFERENCES
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Table of Contents, Volume II
Page
APPENDICES
APPENDIX 1 APPENDIX 2 APPENDIX 3 APPENDIX 4 APPENDIX 5 APPENDIX 6 APPENDIX 7 APPENDIX 8 APPENDIX 9 Contextualisation of transcript excerpt introducing Chapter 1, Doing Abortion Contextualisation of transcript excerpt introducing Chapter 2, Mapping the Field Contextualisation of transcript excerpt cited in sections 3.2.3 and 3.2.5 of Chapter 3, March of the White Coats Contextualisation of transcript excerpt introducing Chapter 4, White on White Contextualisation of transcript excerpt introducing Chapter 5, The Empty Bed Contextualisation of transcript excerpt cited in section 6.6 of Chapter 6, Sociology of a Syringe Contextualisation of transcript excerpts cited in sections 7.3, 7.3.1 and 7.4 of Chapter 7, Changing Voices Contextualisation of transcript excerpts cited in sections 8.2 and 8.4 of Chapter 8, Managing Pain Contextualisation of transcript excerpts cited in sections 9.1 and 9.2 of Chapter 9, One Woman, Five Stories
80 81 84 91 98 122 129 149 160 172 176 182 191 195 196 198 199 200 205 207
APPENDIX 10 Contextualisation of transcript excerpts cited in section 10.3 of Chapter 10, Audiencing Hospital Stories APPENDIX 11 Contextualisation of transcript excerpt introducing Chapter 11, Contrariwise and Otherwise APPENDIX 12 Translated excerpts from Bolivian Ministry of Health 1999 policy document, National Programme for Sexual and Reproductive Health APPENDIX 13 United Nations Population Fund 1996. Paragraph 8.25, Programme of Action adopted at the ICPD, Cairo, 5 13 September 1994 APPENDIX 14 Translated excerpt from the 1972 Bolivian Penal Code, Title VIII, Crimes against Life and Bodily Integrity, Chapter II, Articles 263269 on abortion APPENDIX 15 Translated excerpt from the 1985 Bolivian Political Constitution, Article 3 on State and religion APPENDIX 16 Translated excerpt from the Bolivian Medical Colleges 1993 Code of Ethics, Article 15 on therapeutic abortion APPENDIX 17 Register of materials used for analysis. APPENDIX 18 Excerpts from a 1999 Ipas publication including the organisations mission statement (Hord, CE 1999. ICPD Paragraph 8.25: A Global Review of Progress). APPENDIX 19 Dra. Bertha Bastos personal account of medical education and stages in formation.
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Key to Transcript Notations
KEY TO TRANSCRIPT NOTATIONS

System developed by Jefferson (1985), adapted by Andrade, Aguilar, Bradby and Nina (1995), and further adapted by SR (transcripts listed in Appendix 17).
Transcripts of recordings: word//[in middle of turn] //[at beginning of turn] {words}
Indicates that word is cut off here Turn interrupted at this point by the next turn This turn interrupts the previous turn Phrase or part of phrase pronounced simultaneously with similarly marked phrase which precedes or follows it
underlined words or syllables Spoken with emphasis CAPITALS ::::: [.] [2] ['] [''] ['''] [words] [??] [[indications]] X, XX Spoken loudly Indicates prolongation of preceding vowel or consonant Pause, less than one second Pause lasting two seconds, etc. Intake of breath: short, middling, prolonged Words in square brackets are uncertain in the transcript Words which could not be transcribed (inaudible) Indications of gestures, etc. added by transcriber Names of people, institutions, places omitted to protect anonymity Female speaker Male speaker
Transcripts of fieldnotes and jottings:

Fieldnotes and jottings are transcribed as written, except for speakers pseudonyms (see Key to Speakers), pseudonyms for hospitals and place names, and the insertion of round brackets - (words) - to mark SRs ethnographic notes, phrases summarised or uncertain at time of noting, indications of gestures, etc.. words... words - Verbatim transcription of dots or dashes appearing in fieldnotes, indicating tailing off, cutting-off or incompleteness of a speakers utterance, or of SRs jottings made at the time. words Verbatim transcription of an underlining appearing in fieldnotes, indicating SRs analytic attention to the words underlined.
______
Verbatim transcription of symbol appearing in the margin of fieldnotes, indicating SRs drawing of special attention to the element marked. Verbatim transcription of a line appearing in fieldnotes, indicating passage to next speaker, movement to another place, or a gap in note-taking.
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Key to Speakers
KEY TO SPEAKERS
To identify the 48 research subjects cited in the thesis narrative, I use correlative A-Z initials for the first 25 pseudonyms, and then AA-VV for the next 21 introduced. This alphabetical coding can be used to trace each persons first and subsequent appearances in the thesis narrative (which is not necessarily the same as the order of their appearance in the Appendices of transcripts). Two speakers (my daughter and son) are identified by name with their consent, and X and XX mark different speakers with momentary or anonymous interventions. Medical professionals gender differentiation is signalled as in Spanish, by giving male doctors the title Dr. (Doctor) and female doctors Dra. (Doctora). My interventions as researcher are marked SR.
(i)
Pseudonym
Key to Speakers, A to Z
Initials Gender Status in interactions cited
Dr. Antunes Bertha Bastos Dra. Campos Dr. Dvila Elba Dra. Fuentes Dr. Gonzles
Dr. A B Dra. C Dr. D E Dra. F Dr. G
M F F M F F M
Dr. Harb
Dr. H
Ignacio Dra. Jurez Karen Dr. Losada Mrs. Mayta Mrs. Nina Mrs. Ortega Mr. Ortega
I Dra. J K Dr. L Mrs. M Mrs. N Mrs. O Mr. O
M F F M F F F M F F F M F
Nurse Paredes Nurse P Mrs. Quiroga Rayda Dr. Salinas Dra. Tania Tamayo Mrs. Q R Dr. S T
Director of State Hospital. Intern friend doing rotas in General Hospital; research collaborator with whom I discussed relations between sociology and medicine. First-year medical resident on State Hospital gynaecology ward. Protagonist of two Empty Bed case presentations. Staff gynaecologist and academic coordinator of residents training; research collaborator in State Hospital. Fifth-year medical student participating in teaching session in gynaecology outpatients clinic, State Hospital. Former chief of Insurance Hospital gynaecology ward; collaborator as coordinator of Insurance Scheme Reproductive Health Programme. Staff gynaecologist; academic coordinator of residents training; research collaborator in Insurance Hospital; protagonist of the dossier One Woman, Five Stories. Obstetrician who attended my childrens births; my personal gynaecologist; former coordinator of Mother-Child Health Programme; research collaborator as director of Maternity Hospital. First-year medical student from a country bordering on Bolivia; research collaborator in Medical School study. Third-year medical resident researching obstetric applications of misoprostol; research collaborator in the Maternity Hospital. Colleague from the USA on project visits to Insurance Hospital. Third-year medical resident in Insurance Hospital; protagonist of the dossier One Woman, Five Stories. Woman whose pregnancy was interrupted in the Insurance Hospital; protagonist of the dossier One Woman, Five Stories. Woman consulting with Dr. Dvila in gynaecology outpatients clinic, State Hospital, with whom I negotiated consent for observation. Woman awaiting a therapeutic abortion in the State Hospital. Husband of Mrs. Ortega, who refused my requests for consent to consult his wifes medical history file in the State Hospital. Nurse who entered Dr. Dvilas gynaecology outpatients clinic in the State Hospital during my observation session. Woman awaiting surgery in gynaecology ward, Insurance Hospital. Intern I spoke to after gynaecology ward round, Insurance Hospital. Chief of Insurance Hospital gynaecology ward, who invited me to give a presentation on my research to his staff. Public health specialist; collaborator as counterpart for Gender ViceMinistry in Gender and Health course for Medical School teachers; postgraduate student in Gender and Development programme.
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Key to Speakers
Pseudonym
Initials
Gender
Status in interactions cited
Ms Ulloa Vctor Dr. Walters Mr./Dr./Nurse X, Dra. Yapita Mrs. Zamora
Ms U V Dr. W
F M M
Mr./Dr. Nurse X Dra. Y F Mrs. Z F
Woman interviewed while recovering from a D&C following pregnancy loss on the Insurance Hospital gynaecology ward. Intern participating in a story dossier discussion exercise in the Maternity Hospital. Staff gynaecologist in Insurance Hospital; MVA technology innovator; protagonist of the story dossier Managing Pain. Used to indicate different people who intervene momentarily in transcribed interactions, or who are anonymous in the thesis narrative. Medical resident who performed MVA procedure on Insurance Hospital gynaecology ward. Woman who had to stay another day on the Insurance Hospital gynaecology ward after the last in a series of three MVA procedures.
(ii) Key to Speakers, AA to XX

Pseudonym Initials Gender Status in interactions cited
Nurse Ayala Dr. Balda Mrs. Calisaya Mrs. Daz Head Nurse Elena Elas Dr. Fernndez Mrs. Gong Dra. Helga Haber Licenciada Irma Illanes Dr. Justiniano Kiko Dr. Luna Dr. Maidana Dr. Navia Olga Porfirio Dr. Quisbert Dr. Rojas
Nurse AA Dr. BB
F M
Mrs. CC F Mrs. DD Nurse EE Dr. FF F F M
Mrs. F GG Dra. HH F Lic. II Dr. JJ KK Dr. LL F M M M
Dr. MM M Dr. NN OO PP Dr. QQ Dr. RR M F M M M
Nurse in series of three Insurance Hospital MVA procedures who showed residents how to clean MVA syringes. Medical resident who was called to wash MVA syringes on the Insurance Hospital gynaecology ward. Woman who asked me to accompany her during the first in a series of three MVA procedures on the Insurance Hospital gynaecology ward. Woman who complained of pain during the second in a series of three MVA procedures on the Insurance Hospital gynaecology ward. Head Nurse of Insurance Hospital gynaecology ward whom I interviewed about ward use of MVA and Cytotec. Staff gynaecologist in the State Hospital who did research on MVA and trained residents in its use in that hospital and in his private clinic. Woman who screamed with pain in an Insurance Hospital MVA procedure; protagonist of A Dossier of Pain. First-year resident on Insurance Hospital gynaecology ward; protagonist of A Dossier of Pain; friend of European origin. Social worker in Insurance Hospital; protagonist of the story dossier One Woman, Five Stories. Chief of State Hospital gynaecology ward, who deemed Mrs. Mayta an interesting case. First-year medical student who participated in Medical School discussion exercise on the story dossier One Woman, Five Stories. First-year resident who participated in dossier discussion exercise in the Maternity Hospital with peers whom he called los sufridos. Senior staff obstetrician in Insurance Scheme Maternity Hospital who participated in the dossier discussion transcribed in Appendix 10. Junior staff obstetrician in Insurance Scheme Maternity Hospital who participated in the dossier discussion transcribed in Appendix 10. First-year medical student who participated in a story dossier discussion in a Medical School anatomy cubicle. First-year medical student who participated in a story dossier discussion in a Medical School anatomy cubicle. Junior staff obstetrician in Insurance Scheme Maternity Hospital who participated in a story dossier discussion. Senior staff obstetrician in Insurance Scheme Maternity Hospital who participated in a story dossier discussion.
Changing Voices
Key to Speakers
Pseudonym
Initials
Gender
Status in interactions cited
Mrs. Suxo Dr. Tapia Vincente Dr. XX
Mrs. SS Dr. TT VV Dr. XX
F M M
Woman whose GP consultation I observed in a 1995 ethnographic study; protagonist of vignette presented in Mombasa conference. General practitioner whose clinic I observed in a 1995 ethnographic study; protagonist of vignette presented in Mombasa conference. First-year medical student who participated in a story dossier discussion in a Medical School anatomy cubicle. Used to indicate different people who intervene momentarily in transcribed interactions, or who are anonymous in the thesis narrative.
iii) Note on Translation of Categories of Professional Formation1

Categories indicating speakers status or stage in professional formation are translated using terms close to the original terms in Spanish. In Medicine, from the lowest to the highest levels, these go as follows: First-year medical students (Estudiantes de primer ao), attending Anatomy, Histology and Embryology lectures, group classes and practices. Fifth-year medical students (Estudiantes de quinto ao) still attend undergraduate classes in the Medical School, with some hospital visits and training sessions in therapeutic settings. This stage is retrospectively called pre-internship (pre-internado) by teachers (see Appendix 19 for Dra. Bertha Bastos account of medical education). Interns (Internos/as) are sixth-year undergraduate students doing group rotas through different services in teaching hospitals, prior to final Medical School examinations. On passing these exams, they are graduates (egresados/as), but not yet licensed doctors. Their level is similar to that of PreRegistration House Officers (PRHOs) in the UK and Ireland. However, subsequent requirements for professional registration differ. In Bolivia, interns have to fulfil several months practice in a provincial health centre (ao de provincia) in order to qualify. In the UK and Ireland, PRHOs have to fulfil six months of hospital practice in Surgery, and six months in Medicine. Medical residents (residentes mdicos/as) are qualified doctors training to be specialists, in a threeyear programme in a teaching hospital. Their training combines intensive work on the wards, academic sessions, a research project, and the overseeing of interns. The level of first-year residents is similar to that of Junior House Officers (JHOs) in the UK and Ireland. In their second and third years, residents level is similar to that of registrars or Senior House Officers (SHOs) Staff gynaecologists, staff obstetricians (gineclogos/as de planta, obstetras de planta) are qualified specialists with salaried employment in a hospital. Many have their own private practice, and some own private clinics. Their responsibilities include training and supervising residents and interns. A senior specialist is often accompanied on duty by a more recently qualified (junior) colleague. Ward chiefs (jefes de servicio) are specialists in charge of a hospital service.
1 I am indebted to Dra. Bertha Bastos and to Dr. Harriet Lupton for their respective explanations about professional levels and stages in medical education in Bolivia, and in the UK. For further details of the UK system, see Applying for a Job, British Medical Journal Careers Supplement 15th June 2002, p. s192.
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Key to Speakers
Hospital directors (directores de hospital) are executive directors employed by the Ministry of Health (State Hospital) or National Insurance Scheme (Caja Nacional de Salud). Supervisor (supervisora) is the term I use for Dra. Fuentes, coordinator of the National Insurance Schemes Reproductive Health Programme, who visited the hospital to monitor its gynaecology services. Consultants is the term I use for higher-ranking specialists (especialistas) who are called to the hospital when needed to advise on particularly interesting or problematic cases. Social workers and registered nurses are formally addressed as Licenciada, meaning university graduate. Head Nurses in charge of wards (Matron or Ward Sister in UK and Irish usage) were habitually addressed by colleagues as Doa followed by their first name (e.g. Doa Irma), indicating respect for a senior woman.
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Key to Abbreviations
KEY TO ABBREVIATIONS
A-B ADN ANT CA C-A CDA CH CEDOIN Aborto (Abortion) Accin Democrtica Nacionalista, National Democratic Action (political party) Actor Network Theory Conversation Analysis Carcinoma (cancerous tumour) Critical Discourse Analysis Clinical History (in Spanish, HC, Historia Clnica) Centro de Documentacin e Informacin, Centre for Documentation and Information CSO D&C DFID DHS Dra. ESAR Common-sense objection Dilation and curettage (in Spanish, legrado, legrado instrumental, or raspaje) Department for International Development Demographic and Health Survey Doctora, woman doctor Fundacin para la Educacin en Salud Reproductiva, Foundation for Education in Reproductive Health GP H-I ICPD INE IPAS, Ipas IUD IWHC Lic. LMP MVA NGO ODA OED SSK SWOD TAI TWOD POA UMSA UNFPA USAID WHO General Practitioner H-Y, Hypochondriac (Hipocondraco/a) or Hysterical woman (Histrica) International Conference on Population and Development Instituto Nacional de Estadstica, National Institute of Statistics Formerly International Projects Assistance Services, IPAS. From 1998, just Ipas. Intra-uterine device (in Spanish, DIU, dispositivo intrauterino) International Womens Health Coalition Licenciada, woman university graduate Last Menstrual Period (in Spanish, FUM, Fecha de Ultima Menstruacin) Manual Vacuum Aspiration (in Spanish, AMEU, Aspiracin Manual Endouterina) Non-governmental organisation Overseas Development Administration The New Shorter Oxford English Dictionary (1993) Sociology of Scientific Knowledge The Saving Women Device Tratamiento del Aborto Incompleto (Treatment of Incomplete Abortion) The Truth Will Out Device Programme Of Action Universidad Mayor de San Andrs (La Paz State University) United Nations Fund for Population Activities United States Agency for International Development World Health Organisation
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Chapter 10. Audiencing Hospital Stories
CHAPTER 10. AUDIENCING HOSPITAL STORIES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Intern V: SR: Mhm [2] Now thinking [.] about the exercise itself. [.] Lets say, the fact of seeing: [.] on one sheet, five different stories. [.] Um:: [2] this, for you: [1] can it have some u:se, for anything::, does it have any sense, doesnt it have any sense, [2] Yes. Personally, [1] er: I think th- [.] that: weve passed through and were already at the end:- were already on the final stretch to [.] graduate as surgical doctors, [1] and::: er- its useful to us [1] from the point of view of controlling, [.] how: [.] we do it here, in the hospital:, of controlling some medical his:tories and the way: [.] that those same indications are carried out [1] by the nurses, [2] and that: our patients: [.] find: [.] find: out, [.] their families as well: as themselves, about: the: procedure that is going to be done [1] for each one of our patients, [.] and that they should be awa:re [.] that what is being done, [1] is: [.] the best: [.] that it can be. [2] [[continues his intervention for one minute]] [1] To me- [.] it helps me. [1] To know what I must NOT do [[strikes the dossier sheet]]. Its a stor- a woman with five stories, [1] to- [.] have treatment [.] thats more [.] humane. [4] In this chapter, I show my dialogic application of the story dossier method: the audiencing (Fiske 1994) of contrasting hospital narratives in group discussions with medical students and teachers. As part of a 1998 action-research project in a State university medical school, I presented the page of stories concerning Mrs. Maytas therapeutic pregnancy interruption to reader-audiences who could construct, apprehend, and bring meaning to and interact with the text in question (Denzin 1997:244). In the recorded excerpt transcribed above,1 Vctor (V), an intern (sixth-year undergraduate student) participating in a Maternity Hospital discussion exercise, interprets the dossier as promoting (self) control in hospital procedures (lines 6-9, 12-13 ), adequate information to patients and their families about medical procedures and their benefits (lines 8-11), and humane treatment (lines 13-14). In the previous chapter, I discussed elements that shaped the creation of this story dossier: ward round presentations referring to hospital pregnancy interruptions, the political significance of documenting Mrs. Maytas case, my decision to expose resident Dr. Losadas account of moral conflict, and self-censorship regarding Cytotec (the technology used to induce Mrs. Maytas second-trimester abortion). Before analysing the discussion exercises, I turn to institutional considerations that led to the selection of this dossier for use in the medical school. My Ipas employers constituted a primary audience for both the dossiers I produced, and theirs was the
1
Excerpt from Transcript GPIN.2:7, 13/8/02.
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decision to authorise presentation of One Woman, Five Stories - but not A Dossier of Pain in the exercise I designed.
10.1
The Problematic Relationship
Negotiation among actors involved in research has a crucial impact on what can be investigated, reported and disseminated: [T]he definition of useful research, and therefore of the research objectives, is a political matter (Schrijvers 1991:175, my italics). Researchers may be given grants, sponsored to attend conferences, or provided access to research settings with the implicit understanding that their work will reflect favourably on the sponsor and/or follow the preferred political agenda. Many sensitive topics are mined with specific agendas that researchers must tread carefully to avoid becoming ejected (Adler and Adler 1993:258, my italics). In using a grounded theory approach (Strauss 1987), I attempted to enter field settings with an open mind, prepared to build my analysis on the basis of locally encountered categories and phenomena. Finding evidence of medical discourse and practice that challenged governmental and institutional norms, in my 1997 contract research report I addressed issues that were polemical for the organisation that employed me. Providing the written comments that I requested on this report, an Ipas representative expressed the following concerns: I return to my previously expressed question regarding the decision to study the five issues: incomplete abortion, MVA, therapeutic abortion, misoprostol use and postabortion contraception. Please clarify if and how these issues are relevant to the overall project. My concerns regarding the way this is expressed in the project final report are political, given that a) in Bolivia MVA is not an approved procedure (according to national norms); b) misoprostol is not approved for the use described here;2 and c) that therapeutic abortion is not a component of our larger project. In addition, the donor agency expressed a high level of concern about the political sensitivity of the topic of the overall project in a project where all contracts and agreements are for postabortion care. As presently described here, one could mistakenly presume that these three issues are of programmatic relevance to the project. (Ipas Interoffice Memorandum 5/3/98, my italics.) I developed the two story dossiers included in the 1997 report on the basis of field events that could not have been anticipated at the start of my research. The topics raised in both were
2
See 9.5, Cytotec: The Missing Link, in Chapter 9, One Woman, Five Stories.
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problematic for Ipas. The author of the above comments argued that therapeutic abortion was taboo within the Bolivian context. She held that political opposition made it difficult enough to keep postabortion care on the public agenda, without entering the contentious terrain of abortion procedures. My position, in line with that of the 28th September Campaign to Decriminalise Abortion in Latin America and the Caribbean,3 was that raising professional awareness about aborto impune (non-punishable abortion) was a legitimate advocacy strategy. Manual Vacuum Aspiration (MVA) was also a polemical issue for Ipas. In the early 1990s, following a pilot MVA training project in the Insurance Hospital, the organisations activities were questioned and they were almost obliged to close down activities in Bolivia. MVA became the object of an unwritten veto by the Health Ministry, on the grounds that the instruments could be used to induce abortion.4 Despite this governmental position, I found that MVA was being used covertly in the State Hospital, and with institutional restrictions in the Insurance Hospital on the gynaecology wards where I did fieldwork. Health authorities and hospital directors, acknowledging the technologys potential for cutting costs, operating lists and beds occupied, opted for turning a blind eye to its implementation. Womens pain in MVA procedures was also problematic for Ipas. When I presented findings from my 1997 research to colleagues in the US central office, they concurred that pain was a sensitive issue at Ipas, both a big issue and a non-topic.5 MVA was marketed as an appropriate technology for countries such as Bolivia, and support was growing in governmental circles for its adoption, with a view to maximising scant health sector resources. However, as my data showed, anaesthesia was not being adequately utilised in MVA procedures. Pain was a barely admitted obstacle to the technologys acceptability, both for women treated and for nursing staff. For the Medical School discussion exercise, I would have preferred to use the dossier on pain. The juxtaposition of Mrs. Gongs representation of the MVA procedure as like a nail, inside (lines 23 of her narrative in the dossier in Chapter 8), and Dr. Walters rhetorical question [W]hat pain could she have? (lines 5-6 of his dossier text), forcefully indicated medical negation of a womans account of her experience. At the time of the pain episode, I interpreted these narratives as competing and mutually exclusive versions of reality.6 During my two years of fieldwork, I witnessed many instances of callous handling of bodies dead and living by Medical School
3 4
See footnote in 9.1, An Interesting Case, in Chapter 9, One Woman, Five Stories. See the introductory section of Chapter 6, Sociology of a Syringe. 5 Notes written at the time in Field Notebook 6, 23/9/97. 6 See 8.4, A Dossier Of Pain, in Chapter 8, Managing Pain.
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students and teachers. Bertha Bastos, my intern friend, asserted that medical knowledge could invalidate a patients account of pain: SR: From a sociological point of view, its considered that doctors also observe from their subjectivity. And that there isnt a hierarchy of knowledge that the patients and doctors constructions have the same value and validity. Bertha: That cant be so. For example, a patient with a gall bladder problem, who exaggerates his pain... while the doctor does an evaluation and knows that such pain cannot exist because it is known studies have been done.7 In the Medical School discussion exercise, I wished to present evidence that could challenge such physiological truths. Given Ipas concern about the topics of both dossiers, which could be considered the most suitable case for treatment, therapeutic abortion or pain in an MVA procedure? One response was neither, and the Ipas representative cited above suggested that made-up accounts might be sufficient: Do the stories have to be true?.8 As I replied on that occasion, fieldwork convinces me ever more of the aphorism that truth is stranger than fiction (Potter 1996:173). Encouraged by positive responses to staff training materials that incorporated my ethnographic data from a former study,9 I sought to edit dossier narratives whose authenticity would jump off the page, their turns of phrase too singular to have been invented. Through their very oddness, transcribed stories, with all their internal contradictions, can appear more real than scripts designed expressly for workshop exercises. Although these latter creations may also be based on qualitative research, their tailoring to make an unambiguous point can produce stereotyped narratives which lack verisimilitude (Denzin 1997:10),10 making neither good social science nor good literature.11 The feature of authenticity was noted by medical students participating in dossier exercises. Theyre real events. Its all true! exclaimed a woman first-year student, in a discussion facilitated
Notes written afterwards in Field Notebook 11, 13/5/98. See Appendix 11 for bilingual transcript of notes. Notes written during telephone conversation in Ipas Notebook 7, 6/5/98. 9 Transcripts from an earlier hospital study (Rance 1993) were used to prepare a manual (Secretara Nacional de Salud/IPAS 1995) and a video (Ipas/Ministerio de Salud 1998) for health workers on postabortion care. 10 Verisimilitude: a texts ability to reproduce (simulate) and map the real (Denzin 1997:10). 11 As an example of unambiguous stereotypes created by authors using my ethnographic data, I cite a translated excerpt from a socio-drama in a manual for health workers: The doctor says to the nurse, still without looking at the patient or saying anything to her, Does she admit that she induced it? Nurse: No, doctor. She denies having done anything to herself, but I suspect that she went to a healer to get the abortion done. Doctor: Well, it seems we have no Xylocaine. Its good that our patients have a lot of resistance to pain. Nurse: Yes, doctor. The doctor starts the MVA procedure, still without speaking to the patient. (Ipas 1998. Module: Treatment and Communication between the Patient and the Provider of Postabortion Care, unpublished draft, p. 9.)
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in an anatomy dissection cubicle by Ignacio, a classmate.12 Her conviction contrasted with the scepticism of medical teachers who questioned the truth of these same stories.13 In any case, participants at all levels used authenticity as a parameter for accepting, doubting or rejecting my data. The Ipas representative was eventually persuaded of the importance of real stories. The question remained: which dossier could be used? The institutional position was that showing the pain dossier in the medical school would be politically dangerous. I was given permission to use the dossier on therapeutic abortion, with one condition: If you are directing the discussion, we feel that it can serve as an excellent teaching tool. However, the concern about the document being misinterpreted or disseminated by students keeping the page in the future remains. We believe that there could be serious very negative consequences for all of Ipass programs if that were to happen. Therefore, our recommendation/authorization for use is as follows: You may use these five interpretations of the event. However, any copies of the document that are handed out in class MUST BE RETURNED to you prior to the completion of the discussion.14 Thus it was that I came to present the story dossier on Mrs. Maytas pregnancy interruption, rather than the one on Mrs. Gongs pain in an MVA procedure. Ultimately, this outcome was favourable to my political agenda. Into the Medical School, de contrabando, I was able to smuggle evidence of a therapeutic abortion in a Bolivian teaching hospital and have it discussed by students and teachers. This kind of negotiation, with unpredictable results for all concerned, is characteristic of the Problematic Relationship between researchers, sponsoring institutions, funders, and policymakers. Wengers overall assessment is that [w]hile some researchers manage to establish a good working relationship with the contracting agency (Mamak, 1978; Stretton, 1978) this is usually achieved only as the result of careful negotiation and cannot be taken for granted. Orlans (1967) (...) commented that givers and recipients of social research funds are often troubled by misunderstandings
12 13
Notes taken at the time in Field Notebook 11, 19/5/98. See 10.2.4 (below), Although you insist its the same patient. 14 E-mail message from Ipas to SR, 11/5/98.
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and a sense of unfulfilled expectations that may lead readily to moral recriminations and noted that money does not come free (pp. 3-5). (Wenger 1987:2-3) Discussions with Ipas concerning my 1997 research report concerned methodological issues as well as topic. The shift from interpretative repertoires to narratives was criticised as demonstrating inconsistency: Page 12, point 4 also mentions the goal of advancing in the search for new categories and methods of analysis, which you later describe. This seems to represent a change in methodology of data collection. This should be mentioned here particularly since that would normally be seen as a sign of methodological weakness in public health quantitative or qualitative studies.15 Ipas approval of my 1998 action-research project was conditioned to the planning of interviews and dossier exercises with medical students, trainee specialists and teachers at pre-determined levels. This signified forfeiting some flexibility in my method, which involved mapping the field in the course of research by tracking key collaborators through their natural networks.16 Pressure to comply with project indicators left me insufficient time to carry out sessions with other first-year groups who heard of the exercise and asked me to bring it to their anatomy cubicles. It also influenced my adoption of a generalising approach, comparing the tendencies noted at four stages of medical formation. This produced a clean-cut, if somewhat homogenised finding of a progressive narrowing of medical criteria concerning valid voices and truths in a critical hospital event.
10.2
Actor-Audience, Text as Actant
Over three months, concurrently with observations and interviews, I presented the dossier to 30 participants in seven groups and pairs of first-year students, interns (sixth-year students rotating through hospital services),17 residents (trainee specialists), and medical teachers. The discussion exercise constituted a particular application of the practice of audiencing. Rather than conceptualising each group as a market segment, site of acculturation, or constituent element in a
15
Ipas Interoffice Memorandum to SR, RE: Request for Comments on Research Report: Medical Discourses, 5/3/98. 16 See 2.2.1, Collaborators, participants and subjects, in Chapter 2, Mapping the Field. 17 See Appendix 19 for Bertha Bastos personal account of medical education and stages in the undergraduate Study Plan.
Changing Voices
way of living (Fiske 1994:194), I approached the sessions as scenarios for performative interactions between groups of peers and the story dossier. The actor-network I attempted to engineer linked reader-audiences with text-as-actant, rather than spectating audiences and researcher-actor with script (Dugdale 1999:127).18 For the initial dossier discussion, a group of 19 white-coated first-year students19 sat facing each other on wooden benches in the anatomy dissection cubicle which had become my operational base20 in the Medical School. The corpse had been returned to the metal sarcophagus in the corner. Formaldehyde fumes still burned my eyes and throat, and the air was thick with the familiar, sickly stink that clung to clothes and hair. I had followed the advice of Ignacio, a student research collaborator,21 to hold the session in the groups habitual learning environment rather than in an alien classroom setting. He suggested that they might be put on the defensive by being moved elsewhere: When youre in your own home you feel really free.22 On planning the exercise, I envisaged my intervention as minimal. All I did during the hour-long session was to present the activity as part of my action-research project on Humane Treatment and Medical Education, hand out copies of the dossier sheet headed by the question: How do you interpret the stories and the differences between them?, and ask participants to read it individually, discuss it in small groups, and then all together. At the end I did a five-minute round of the whole group with a cassette recorder, recording each participants response to the frame analysis question (Goffman 1997:153): What have we been doing here?23 What, if any, has been the point of this exercise?. I declined to give my interpretation of the stories, and this detached approach provoked questions from students which I countered negatively, using responsibility-abdicating dont know and cant say responses (a variant of the NO-NO strategy):24
It is standard procedure of semiotic analysis to explore how it is that readers are constituted by textual moves of one kind or another. It is therefore not breaking new ground to argue that this text is performing its reader in a particular way (Dugdale 1999:127). 19 There were ten women and nine men in the group. 20 For discussions of such military metaphors in fieldwork narratives, see 2.2, Mapping From Within, in Chapter 2, Mapping the Field, and 4.2, Reviewing Researcher Access, in Chapter 4, White on White. 21 Ignacio, a first-year student, was a research collaborator during my Medical School fieldwork. Coming from a country bordering on Bolivia, like me he was an outsider, and his peers regularly drew attention to his nationality. Ignacio expressed interest in my research from the start, and contributed to it in many ways, such as inviting me to accompany him on two visits to the General Hospital mortuary and informing me of internal conflicts in the Medical School. He appropriated my research methods by recording and transcribing interviews with students, teachers, the hospital mortician, and also with me, as part of an anatomy group study that I supervised on the handling of corpses. 22 Translation of notes written afterwards in Field Notebook 11, 19/5/98. 23 For Goffmans critique of the frame analysis question What is it thats going on here?, see my Introduction, p. 6 (Goffman 1997:153). 24 See 7.2, Doctors Interpretative Dilemmas, in Chapter 7, Changing Voices.
18
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Student 2: SR: SR: Student 4: SR: Student 5: SR: Student 1: SR: SR: Student 3: Student 2: Student 1: SR:
(10.55 a.m.. 19 students, each has the page. They read in silence.) Do we have to find that one of the stories is the true one? No its a question of personal inspiration! (11.00 a.m.. SR gives 20 minutes for the discussion in six groups.) What do we have to do? Say how each story was? How their feelings were? You have to get out your feelings on reading the stories. Where was the dermoid tumour? Couldnt they wait until she had the baby and only then take the tumour out? The doctors said the pregnancy was incompatible with the tumour. But if for you that question is important, you have to talk about it in your group. Has she got other children? Because if she has it would be better for her to abort. That, you have to talk about in your group. Do we have to say which of the stories is the true one? You have to say what you feel about the stories, subjectively. Do we have to analyse the stories one by one? Do a subjective interpretation what each one feels your coincidences and differences. What does NPO mean? I think it means Nil By Mouth. But Im not a doctor either. Its what I copied from the clinical history. I dont know!
10.2.1
First-year students: We are a human person
In this discussion,25 the first-year students raised issues of the stories competing truth status (lines 2, 15), feelings expressed by different speakers (lines 5-6), clinical and ethical dilemmas (lines 89), social considerations in the decision to interrupt Mrs. Maytas pregnancy (lines 12-13), analytic method (line 17), and clarification of medical terminology (line 20). Their questions, produced after five minutes of individual reading, alluded to points on which I had reflected for weeks in the process of creating the dossier. In retrospect, I could well have acknowledged the pertinence of the students requests for clarification.
25
Notes taken at the time in Field Notebook 11, 19/5/98.
Changing Voices
At the time, however, I gave defensive responses aiming to turn the students attention away from me as presenter, and towards group discussion of the texts. I demanded that they provide subjective interpretations, expressing their feelings about each story, and noting coincidences and differences within each group (lines 3, 7, 16, 18-19). I refused to discuss facts concerning the dermoid tumour and Mrs. Maytas children, deflecting their discussion back to the groups (lines 10, 14). In my final response about the NPO indication in the medical history notes (N.VO in the Spanish original, lines 21-22),26 I reverted to the position of radical naivety adopted at other moments in fieldwork,27 temporarily disavowing the knowledgeable semi-insider status that I had negotiated within the Medical School as researcher, dossier author, and session organiser. In saying Im not a doctor either (line 21), I demagogically claimed equal status with the students, and implied that they required no further information to interpret the texts as they stood. While I ostensibly pursued dialogic goals and methods, this transcript shows how I blocked dialogue with participants in using them as audience for the text. My unique statement was the dossier which I attempted to introduce as a non-human actant (Saetnan 1995:52) substituting my role as human actor. This dehumanising strategy conflicted with my action-research focus on Humane treatment in medical education (Rance 1999). I now find it to be illustrative of ActorNetwork Theorys linking of actants and actors - the thing-symbols named participants - as quasiobjects-quasisubjects (Verran 1999:154 n.24 citing Latour 1993:89). Asking Ignacio, my student-collaborator, to moderate the groups discussion, I removed myself from the debate and observed the students from outside their circle. I adopted the stance of phenomenological positivism applied in focus groups where facilitators tap participants subjectivities, maintaining their own out of reach (Cunningham-Burley et al 1999:190). In keeping my pro-choice views out of the discussions, I also safeguarded the niche I had negotiated for my Medical School interventions. By directing each groups attention towards their internal discussions, I vainly tried to obtain data uncontaminated by my presence.28 As I go on to show, these students subscribed to the humanising rhetoric of my projects title, reiterated by the intern Vctor in the transcript commencing this chapter (lines 15-17): [[[S]trikes the dossier sheet]]. Its a stor- a woman with five stories, [1] to- [.] have treatment [.] thats more [.] humane.
26
Maternity Hospital director Dr. Harb later informed me that an alternative to N.VO Nada por Va Oral the abbreviation I had copied from Mrs. Maytas medical history file - was NPO, from the Latin Nil Per Os (nil by mouth), an abbreviation also used in English. Personal communication, February 2002. 27 See 6.6, Knowing Nurses, in Chapter 6, Sociology of a Syringe. 28 Notes taken at the time, Field Notebook 11, 19/5/98.
Changing Voices
My purportedly non-interventionist approach carried a strong agenda. The concepts I hoped to promote were epistemological symmetry, the relative status of medical authority, and the feasibility of therapeutic pregnancy interruption even in the face of religious objections. The first-years responded to the dossier exercise como enseados (as if they had been taught: a Hispanic expression sceptically alluding to performance of a pre-given script, like stooges). Their discussion was moderated by the student-facilitator Ignacio (I), who also intervened in the debate: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Student 2: Student 4: Student 2: Student 2: Student 3: Student 1: Student 2: Student 3: Student 1: Facilitator I: (shouts) Silence please! Its an abortion with a lot of children involved the mother is the one who supports the family the father only has occasional jobs. The child has a right to live too! But you cant value one life above another. The most practical thing is to do an abortion. But Ignacio, doesnt it seem absurd to you the gynaecologist, the terms he uses with the woman, that she cant understand! He just says abortion. The woman thinks hes only going to remove the tumour. The mother doesnt understand! How can you tell a mother to choose. Weve considered all that. Its all been said. Everyone has seen it, from what theyve studied. If it had been a better-off person The doctor went for the quickest solution. The social worker went for the social angle. The last doctor sees the spiritual side. The woman within her state of practical ignorance, or her total ignoranceTheyre not working as a group! It shouldnt be called a hospital. Each one goes off on their own tack. I have a friend, his mother died in childbirth. Which comes first, the chicken or the egg? We have to look at the reality of Bolivia or of Latin America. I think that a matriarchy exists. Its very hard but thats the reality. What do you prefer? For one to die, or five? If the mother dies or if six die, right. Thats not so much the basic issue. The theme here isnt so much abortion. Its that each one gives their opinion from their point of view. The father feels obliged to work If I have six children then five have to go out to work. Its a different point of view. He works out of necessity, but you say out of personal initiative. What about if it has no father and no mother(They all shout at once.)
Facilitator I: Youre getting off the point!
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Here too, the students raised several issues that I had considered in editing the dossier: social considerations influencing abortion decisions (lines 1-2, 12, 23, 25-26), ethics of informed consent (lines 5-7), disunity of the medical team (lines 11-15), the relevance of lived experience (lines 16, 22, 25-26), and Death-death as bottom-line argument against relativism (Edwards et al. 1995, lines 19-20). To my satisfaction, one woman student voiced an argument that is central to my thesis: The theme here isnt so much abortion. Its that each one gives their opinion from their point of view (lines 20-21). In berating a classmate for getting off the point (line 24), Ignacio, as facilitator, made a bid for his understanding of frame, text and context (Goffman 1974; Kendon 1992; Schegloff 1997). I could not have asked for a more willing audience. In this first exercise, my pro-choice agenda and relativist thesis encountered significant support. In the concluding comments which I recorded, several students referred to humane treatment, which was the topic of my study and a tenet of national health policy (Ministerio de Salud y Previsin Social 1999:48): 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 SR: SR: [[addressing a woman student who had left the cubicle momentarily when I put the question to the group and started recording.]] Olga, the question was, what have we been doing here, what has this exercise been for? [2] Student OO: What has this exercise been for? [2] Er:: [.] for us to realise that:::: [2] like it or not, were all individualists any- anyhow, because we respond [] to the::- to the way in which weve grown up:- to:- to our ideas, with which weve already been formed. [] Thats why we see that: lets say: in one: [1] from:- from:- in one and the same person, [.] with one and the same situation, [] you can get er:- not just five different opinions. [.] But: you can get thousands of different opinions! [1] Thats it. [3] Anyone else, [.] to finish? [3] Yes? [.] Yes, Porfirio? has served to put us in a future position in which were going to put ourselves. [] That is, what would we choose at that moment? [.] [] What:: as doctors, [.] will- as::- were going to be doctors at that moment, but in the end well still be human beings. [] And were going to put ourselves on those two planes. [] We dont know what we are going to choose. But this dynamic serves us to [.] reflect about that theme. [] What are we going to do at the moment when were going to be doctors? [] If its going:- if the humanistic side is going to win, or if the winner will be the- the scientific side? [] But essentially, [.] I would say that we are [.] a Student PP: Um:: [2] this:: dynamic work that weve done, developed in- just now, []
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22 23 24 25 SR:
29
human person, [.] and that we are going to do [] at that moment at least, my idea is to do the best that can be done, as much for th- [] the person thats involved at that moment, as for their family. [2] Thank you. [2].
These responses indicate two readings of the dossiers significance that emerged in the first-years comments. The first, given by Olga (OO), alluded to the salutary effect of realising about human particularity: [W]ere all individualists any- anyhow (line 5). With her statement [Y]ou can get thousands of different opinions (lines 9-10), Olga challenged not only the validity of one universal interpretation of a given situation such as a privileged medical truth but also the sufficiency of just five versions as presented in the dossier (line 9). She diverged from the habitual interpretation of competing versions, finding narrative plurality in equally valid stories whose polyphony did not necessarily involve confrontation (Bakhtin 1984:6). 30 The second reading was given by Porfirio (PP), who also took the session to be a salutary exercise, emulating a real-life dilemma that students might face in their future careers. The opposition he postulated was between two planes: the humane and scientific sides of medicine (lines 15-17, 2021), which parallel Mishlers lifeworld and medical voices (Mishler 1984:13-14). The encounter I orchestrated between text-as-actant and audience-as-readers was interpreted by Olga, Porfirio, and other participants as a morally charged intervention, imparting awareness of plurality, promotion of humane values we are [.] a human person (lines 21-22) -, and conducive to the improvement of medical practice for patients benefit.
10.2.2 Interns: If there has been good conduct, or not Having found it impossible to organise meetings with interns within the medical school, I held two one-hour sessions crammed into busy shifts, with a total of eight interns rotating through Maternity and General Hospital services. Like the first-years, these sixth-year students interpreted the exercise as a lesson in humane treatment that acquired practical significance in the light of their ongoing medical duties. In his response cited at the start of this chapter, Vctor took the dossier to be instructive to interns nearing the end of undergraduate training (lines 4-7 of the introductory
29 30
Translated excerpt from Transcript GP1.1:3-4, 19/5/98. [A] plurality of consciousnesses, with equal rights and each with his own world, combine but are not merged in the unity of the event (Bahktin 1984:6 cited in Shotter 1992:17, italics in the original). See 8.4, A Dossier Of Pain, in Chapter 8, Managing Pain.
12
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transcript). Discussion of the narratives could serve to promote control of medical and nursing practice (lines 6-8), the giving of information to make patients aware that treatment received was the best possible (lines 8-11), and orientation to prevent doctors from committing moral or technical errors (lines 12-13). To my final recorded questions, What has this been useful for? and What did you get out of it?, two interns replied:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
31
Intern 1:
I think that:: m:: [.] um it was basically focused on the job they have t- er:: [.] er:: [.] the- the professionals, as much as the:::: the woman affected, right? [.] [] Um:: [.] thats to say, its focused according [.] to:- to the: criterion, to the knowledge of each person. [] From what it says he:re, the criterion of the- of the doc:tor, the criterion of the social worker, the criterion of the nurse, the criterion of the doc- of the medical resident, and the person affected! [] Its: [.] I think, more than anything, to [.] see: [.] u:::m [.] if (...) there is or if: there has been good conduct, [.] or not. [.] Eer:: [.] in each one of- of these actions. [1] Or- [.] if there is [.] any: [.] any error at:- at any::- at any step. [.] [[in a low tone]] Anything. [.] thats all.
SR: Intern 1: Intern 2:
Mhm:? [1] Its:: {[??]} {Well,} I think- as my companion says, this goes:: [1] this is related to every::: [.] profession that t- that people have! [] But always dedicated to one and the same aim, right, for:- the good of the pa- of the patient and: that: all- all the things that:: are do:ne in the hospital come out well, [] and:: [.] with this [?] knowledge of the patient, [[the baby in the adjacent ward starts to cry more loudly]] what it is that is going to be do::ne, [] how its going to be do:ne, and what is::- the consequences that this can have, and according to that make a decision. [3].
While the first-years had imagined future dilemmas, the interns (sixth-years) focused on practical matters they had encountered in hospital services. They concentrated on the medical job in hand (lines 1-2), criteria of different health workers (lines 3-6), interests of the woman/person/patient being treated (2, 6-7, 15), and correct and incorrect medical practice- if: there has been good conduct, [.] or not (line 8). Defence of the good of the patient (line 15) was loaded with concern
31
Translated excerpt of Transcript GPIN.1:3, 3/8/98.
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for the visible success of hospital interventions (line 16), a self-legitimating position expressed still more strongly at higher levels (Bosk 1979:114).32
10.2.3 Residents: Everyone should have just one language The next two sessions were with residents undergoing specialist training in the Maternity Hospital. They had gone through six years of undergraduate studies concluding with a years hospital internship, and several months pre-registration practice in a provincial health centre. Through a competitive selection process influenced by family connections as well as academic achievement, they had won places in the Insurance Schemes coveted residency programme. This was an elite group with the potential to go far in the profession. The written autobiographical accounts I later elicited from 33 medical students and professionals A critical event in my medical formation - referred to arbitrary disciplinary measures and public humiliation dispensed by teachers (Rance 1999a:70-80; Rance 1999b:6), practices frequently noted in studies of medical education (Wolf et al. 1991; Harth et al. 1992; Lebenthal et al. 1996). Residents took their in turn in exercising authority sometimes abusively over interns rotating through hospital departments. Within this regime, residents were conceded no right to complain about gruelling shifts and the harsh conditions of their apprenticeship. Nearing the promised land, they were long-suffering pilgrims: los sufridos, as resident Dr. Luna ironically commented in a Maternity Hospital dossier discussion.33 My use of a religious metaphor carries echoes from my notes on a telephone conversation in 1998 with Maternity Hospital director Dr. Harb, a gynaecologist-obstetrician with over thirty years professional experience. When I mentioned my finding of systematic exclusion of supernumeraries from the first year of medical studies onwards, Dr. Harb defended this practice as indicative of a healthy culture of competitiveness, part of the professional mystique, a rite of passage which every (paradigmatically masculine) medical student had to face: [H]e has to pay his dues. If thats what he wants, itll cost him dear! He has to pass through many tests. Its like an initiation ritual. Like in some religious sects, in freemasonry... you have to pass through water, through fire... you have to pass through narrow gates.
32
[A]ttendings must both explain their failures that is, they must neutralize or divest failures of their negative meanings and they must also make their successes highly visible. (Bosk 1979:114) 33 Transcript GPR.2:5, 4/8/98.
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I carried out the dossier exercise with a group of one male and three female residents, and with a pair (one woman and one man), all struggling to pass through the last narrow gate leading to their qualification as specialists. In sessions lasting under an hour, squeezed into hectic duty schedules in the Maternity Hospital, these six residents, like their junior colleagues, raised issues of humane treatment, consideration for patients needs, medical ethics, and professional responsibility. They called for uniting practical and sentimental elements in medicine. Two new issues emerged at this level. One was residents exploitation as a permanently exhausted work force, named by Dr. Luna (Dr. LL) as los sufridos (the sufferers). The other was a demand for order, and hegemonic status of one correct medical criterion:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Resident Dr. Luna:
[6] I think that he:re [] [.] work teams should be formed. [1] In this case the social worker should speak first with the doctor. [.] Before giving any criterion [2] Because the social worker [1] kno:ws about her:- about her: [1] about her profession, [.] but she doesnt know about medicine! [1] so:- [1] everyone [.] should: [2] have just on:e language. [2] And give that to a patient. [.] Thats why its not appropriate lets say, [] for on:e doctor to give his version, and another a different one! [] The one who comes out confused is the:- the patient herself, who received two different pieces of information. [] Thats why [.] criteria of service should be handled![.] And not personal criteria. [1] Because many times, they get- it leads: to confusion afterwards. [2] I think that from this [.] it has to be concluded that:: [2] no-one understands anyone else, and that everyone has their own version [.]
Resident: Resident Dr. Luna:
[[laughs]] that suits them! [.] [[laughs]
15
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Dr. Luna, like his peers, argued for the primacy of just one language: the medical criterion, to be received by other staff and transmitted to the patient (lines 5-6). In line with doctors frequent exclusion of paramedical staff from the category of professionals,34 Dr. Lunas bid for medical hegemony35 was achieved by shedding doubt - with repeated hesitations and pauses (lines 3-5) - on the professional status of social work. Dr. Luna called on SWOD, the Saving Woman Device, to argue for compliance with medical authority for the patients good so that she would not come out confused (lines 6-10). He ended on an ironic note, provoking a laugh from his female colleague, as he linked the notion of plural consciousnesses, each with his own world (Bakhtin 1984:6), to the pragmatic observation that everyone pursued their own convenience by adhering to a particular version (lines 12-14).
10.2.4 Obstetricians: Although you insist its the same patient As I have shown in this chapter and the two that precede it, I developed the dossier method with the aim of jolting doctors to reflection about alternatives to medical discourse.36 Through my selection of texts in One Woman, Five Stories, I juxtaposed different dimensions and meanings of Mrs. Maytas pregnancy interruption: the nurses notes on foetal expulsion, gynaecologist Dr. Gonzles clinical explanation, resident Dr. Losadas reflections on its religious significance, Mrs. Maytas account of the babys baptism and burial, and social worker Irma Illanes justification in terms of the familys economic situation. This symmetrical presentation constituted a radical assault on the hegemony of doctors discourse. Its subversive effect was signalled by medical teachers who demanded a return to the truth status of one, correct version of the event: their own, as represented by gynaecologist Dr. Gonzles. The vehemence with which they asserted this position conjures up the spectre of a counter-argument (Billig 1988:19-24), the postmodern challenge to expert knowledge:
34
In a recorded group discussion, Vctor, an intern, interpreted the dossier as expressing a total discrepancy between: [] [1] four- [1] two professionals, [1] the woman herself, [3] and: inoperativeness [2] on the part of the medical resident (Transcript GPIN.2:2, 13/8/98). 35 [H]egemony does not imply a dominant, or even necessarily existent, pattern of behaviour. The hegemonic ideal does not imply conformity of behaviour, but does imply the suppression, or de-legitimizing, of other models. (Saetnan 1995:183 n.9 citing Lie 1995) 36 The dossier discussions were ostensibly aimed at stimulating what Woolgar terms benign introspection. This kind of reflexivity perhaps more accurately designated reflection entails loose injunctions to think about what we are doing (Woolgar 1988:22, italics in the original). This innocuous proposal masked my far from benign intent to provoke subversive confusion, by presenting a proliferation of discourses (Butler 1990:33-34), whose symmetrical juxtaposition implicitly jolted medical discourse off a pedestal of privilege. See the final footnote of 1.2.2, Intellectual auto/biography: Letting go, in Chapter 1, Doing Abortion.
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[I]f we think in terms of ontological politics, then information is no longer given to anyone. The stories professionals might tell have lost their self-evidence. And what is more, it is not only the representations of reality in information circulating as words and images that have become contestable, but also the very material shaping of reality in diagnosis, interventions and research practices. (Mol 1999:85-86, italics in the original) It was at the highest professional level that I encountered most resistance to the dossier method. The insistence on one correct, medical version was most pronounced among the specialists who participated in the exercise. These were two pairs of male obstetricians whom Maternity Hospital director Dr. Harb designated to collaborate with me on different days, in brief encounters snatched from on-duty hours. (Although these doctors were specialists in gynaecology and obstetrics, I name them here as obstetricians because it was in that professional capacity that they worked in the Maternity Hospital.) In each case, a senior doctor was accompanied by a younger colleague. I took notes at the time, since neither pair granted me permission to record their comments.
37
In the following excerpt from my fieldnotes on the first session, the younger doctor, Dr. Quisbert (Dr. QQ), joined the session after his senior colleague, Dr. Rojas (Dr. RR), had already spoken:
37
Appendix 10 contains the bilingual transcript of the second session, a dossier discussion with obstetricians Dr. Maidana (Dr. MM) and his junior colleague, Dr. Navia (Dr. NN).
17
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Transcript A: (14h03. I ask for Dr. Quisbert to be called in, although Dr. Rojas does not consider this to be necessary: he already spoke in both of their names, it seems). Dr. QQ: Its not comprehensible. It seems theres no relation. For the tumour, it wasnt necessary to operate. It cant be properly understood. What the social worker says is the least relevant it seems she hasnt understood because shes talking about her problems not about the current situation. The residents problem is out of place because he talks about Good Friday. SR: Dr. QQ: SR: Dr. QQ: Why do you say that the social workers part has nothing to do with it? Shes not talking about the current problem, of the moment. Why she had to be operated on How do you explain the differences? It seems not to be the same situation. Although you insist its the same patient. More information is lacking, more data. The resident theres no relation between what he says, and the patient. Dr. Quisberts categorical affirmations contrasted with the more exploratory, questioning utterances made by undergraduate students and residents. I interpret his reiteration of it seems (parece, in lines 3, 5, 13) as a gesture of courtesy avoiding offensively direct negations of the dossier evidence, and of the social workers capacity to understand the situation rather than as a preface to tentative suggestions (my own use of parece in my notes transcribed in line 2 was ironic rather than courteous). As well as observing the incomprehensibility, irrelevance and incompleteness of the information provided (lines 3-5, 7, 10), Dr. Quisbert shed doubt on its authenticity: It seems not to be the same situation. Although you insist its the same patient (lines 13-14). These responses refuted my supposition of the undeniability of my evidence, which I bolstered with the rhetoric of detail to support witness category entitlement (Potter 1996:165). Given their scepticism, did these specialists attribute any value at all to the dossier exercise? In a mood of some exasperation, I put three leading questions in this vein to Dr. Rojas (Dr. RR) and Dr. Quisbert (Dr. QQ). Dr. Rojas gave the following replies:
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Transcript B 1 2 3 4 5 6 7 8 9 10 11 12 13 14 SR: Dr. RR: Dr. RR: SR: SR Dr. RR: Is there any value in reading this sheet with the different stories? Of course. The most important thing is the contradiction which exists. Although the gynaecologist doesnt say if the foetus is alive or not the social workers version has nothing to do with it. Its wrongly said! Theres a lot of contradiction with the concept of the gynaecologist. [[Remaining 6 lines of Dr. Rojas intervention omitted in this excerpt.]] What conclusion do you draw from the differences between the five stories? There may be different criteria, but they have to arrive at just one conclusion, for the benefit of the patient, and her baby. The criterion has to be just one. Is the exercise of any use? Yes as a mental exercise so that they have a criterion, for discrimination of different concepts. As this discussion shows, the dossier was mutually understood to be a didactic instrument: both the obstetricians and I took it as imparting a lesson to others. In my terms, it served for medical professionals to relativise the authority and unity of their own discourse. For Dr. Rojas (Dr. RR), a member of my prime target audience, it served to teach residents to discriminate between correct and incorrect medical criteria when discussing a clinical case.
10.3
Negotiating Professional Boundaries
In my first recorded interview with resident Dr. Losada about Mrs. Maytas pregnancy interruption, he shifted among technical, normative and pragmatic repertoires. For the dossier, I selected a similarly three-voiced narrative indicating tensions between his religious convictions, professional duty, and personal feelings. When discussing Mrs. Maytas case on the ward, Insurance Hospital gynaecologists rarely deviated from the technical repertoire. For the gynaecologists dossier narrative, I also chose a text in Dr. Gonzales technical voice. In the dossier discussions, specialists judged that this was the correct register for alluding to such a matter, and that it should be unanimously adopted by medical and paramedical staff. They categorised Dr. Losadas personal reflections as unscientific. These
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judgments suggest a medical code for appropriateness of voice to safeguard professionalism, which I here attempt to decipher. In the Maternity Hospital dossier discussion between the first pair of obstetricians (Transcript A, above), Dr. Quisbert (Dr. QQ) categorised the residents Good Friday revelation38 as his personal problem, as being out of place (line 7), and as bearing no relation to the patient (lines 14-15). These criticisms indicate Dr. Quisberts contingent definition of matters relevant to a clinical case. In each of the seven groups to whom I presented the dossier, one or more participants observed that the resident was not speaking in a professionally appropriate way.39 Before obstetrician Dr. Quisbert joined the discussion, his older colleague, Dr. Rojas, had said: The residents concept is philosophical. He hasnt got a medical criterion its more personal.40 Two weeks later, I repeated the exercise with a second pair of Maternity Hospital obstetricians, Dr. Maidana and Dr. Navia. Dr. Maidana, the senior of the two, declared a similar position to that voiced above by his professional peer, Dr. Rojas: Dr. Maidana: The resident does not give an explanation of a scientific type, not even gynaecological. It seems more an interview that is very sentimental, more from the moral and religious point of view not scientific. (The interview) does not seem as if it were done in a hospital, (but) by chance, in any place. A resident in the third year has the capacity to be able to give correct explanations in a scientific form he talks rather in a religious form. Its a counter-position. In medicine, we do not take much account of religious aspects. It has to be of a scientific nature.41 The Maternity Hospital obstetricians postulated a division between a legitimately medical point of view patient or case-focused, scientific, gynaecological and a personal one, irrelevant to a professional discussion, in which a doctor referred to a problem of his own from a philosophical, sentimental or religious stance. While taking note of these in vivo codes (Strauss 1987:33-34), the
38
See 9.2, A Dossier of Life and Death and 9.4, Backstage Emotions in Chapter 9, One Woman, Five Stories. 39 In the first-years session, one male participant supported the idea of a medical/religious dichotomy, and another disagreed: I think not: [1] I think it should be more between the medical and the humane, because:for- what are we going to put religion in? [] More, it would be medical and humane. [4] Nothing more (Translated excerpt of Transcript GP1.1:2, 19/5/98). 40 Translated excerpt of Transcript AGD.1:4, notes made at the time in Field Notebook 12, 5/8/98. 41 Translated excerpt of Transcript AGD.2:3, jottings made at the time in Field Notebook 13, 18/8/98. See Appendix 10 for the bilingual transcript of field jottings. Comparison between the Appendix text and the excerpt cited on this page provide an indication of minimal editorial changes made when citing jottings in the thesis narrative.
20
Changing Voices
exclusion of moral discourse from medical education and practice was not a constant in my data: I found that scientific and moral elements were both foundational to the professional ethos. As an alternative to situating the voice of the lifeworld (Mishler 1984) outside the boundaries of medical discourse, the voice of medicine can be deconstructed to allow for the incorporation of a personal repertoire. Roberts and Sarangi include a personal experience mode informal, moral, highlighting the rhetoric of lay accounts as one of three modes of talk in medical settings (Roberts and Sarangi 1999:486). Within doctors three interpretative repertoires, I included a pragmatic voice: a personal, confessional style of expression alluding to the speakers feelings, and to problems in the negotiation of everyday contingencies.42 Proposals to extend the boundaries of professional discourse are substantiated in a classic Peruvian text still used in Latin American medical schools, that argues for doctors alternation between scientific and moral modes of understanding. In The Doctor, Medicine and the Soul, humanist essayist Honorio Delgado ([1952]1992) holds that the scientific basis of medical formation allows doctors to forestall imaginative deviations in verifying and discarding hypotheses. However, a scientific approach is insufficient for physicians to apprehend the concrete and singular reality offered by each patient, and to guide their own moral conduct. Doctors contact with the suffering of others constitutes a school of moral perfection, refining their understanding through sentiments which are both sound and superior, of greater depth and significance than those of the profane (Delgado 1992:26-31).43 Medical specialists in my study reproduced these complementary constructions of their profession, using Changing Voices in different situations. Doctors were permitted to make emotionally charged declarations of moral convictions speaking individually or collectively - so long as these did not compromise the professions public standing as law-abiding, and obedient to Catholic doctrine. Examples of legitimised personal expression appear in the interview with State Hospital director Dr. Antunes cited at the start of Chapter 1.44 In the latter part of that interview, Dr. Antunes used the first person singular and addressed me in the informal voice, t, to refer to the pragmatically delicate matter of discriminating between women hospitalised with spontaneous or induced abortions. He later reverted to the first person plural to vehemently express a normative position, negating institutional practice of abortion and opposing its legalisation. He qualified this
42
See 7.1, Origins of an Interpretative Application and Fig. 7.2, Doctors Three Interpretative Repertoires, in Chapter 7, Changing Voices. 43 Profano: profane, secular. Used in Hispanic medical discourse to differentiate lay people from doctors. 44 See introductory section of Chapter 1, Doing Abortion, and Appendix 1 for complete text of the interview with Dr. Antunes.
21
Changing Voices
with SWOD rhetoric, arguing for compassionate medical care for women with infected abortions we cant leave her alone, and we treat them and assuming a professional obligation to attend to our people. Doctors principled objections in the dossier discussions, rather than targeting resident Dr. Losadas confession of personal values per se, were directed towards his transgressive selfrevelation that put the professions reputation at risk. I interpret doctors location of the residents problem outside medical boundaries primarily as a move to censor his declared infringement of Catholic doctrine prohibiting abortion. When a woman-decided induced abortion was discussed by doctors in a public transcript (Scotts 1990:26),45 a normative register was called for.46 When the topic was a medically-decided pregnancy interruption, public discourse was to remain technical. By incorporating Dr. Losadas confessional account within the dossier, I made a displacement in the language game (Lyotard 1984:10) that upset tacitly established medical order. A similar reaction of censure might have been provoked by publicly presenting doctors discussions concerning (illegally) induced abortions in terms of their technical quality.47 The dossier discussions with specialists served to clarify three areas in which my feminist, prochoice position conflicted with their collegiate one: the assertion of one medical opinion as hegemonic; the exclusion of personal, sentimental expressions from professional discourse; and the denial of hospital practice of therapeutic abortion. This last-mentioned position was declared by Dr. Navia, the younger obstetrician in the second session: It doesnt seem to me that a hospital would accept the interruption of a pregnancy. In all hospitals in Bolivia, human life has to be protected. Its the first time I hear theres an interruption.48 The Maternity Hospital obstetricians performed professionalism not only by affirming the authority of one medical criterion, but also by voicing scepticism or outright rejection of the dossiers textual evidence. Comparing interpretations of the dossier across four levels of professional formation, I identified a progressive narrowing of medical criteria concerning valid voices and truths in a critical hospital event. My agenda of cutting medicine down to size49 proved feasible with undergraduates, who performed as willing audiences prepared to consider alternatives to professional discourse. Real doctors, however, rejected the dossiers location of medical narratives on the same plane as
45 46
See 9.4, Backstage Emotions, in Chapter 9, One Woman, Five Stories. See 1.7.1, In Other Words, in Chapter 1, Doing Abortion. 47 Technical aspects of induced abortion were discussed by doctors in Bolivia, but in hidden transcripts (Scott 1990:26), such as those among members and allies of a clandestine network of medical practitioners trained to provide high quality, low-cost abortion services. 48 Translated excerpt of Transcript AGD.2, pp. 2-6, notes taken at the time, 18/8/98. 49 See 1.8, Researching What? in Chapter 1, Doing Abortion.
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Changing Voices
paramedical and lay accounts. Thus, meanings escaped prescription, and my authorial control was effectively undermined. This finding confirmed an effect of Denzins Storied, Performance Approach to Narrative, cited at the end of the Introduction to this thesis: This approach embraces experimental, experiential and critical readings that are always incomplete, personal, self-reflexive and resistant to totalizing theories. It understands that readers and writers are coproducers of the text that is being written and read. This understanding requires a move away from (...) scientific postpositivist forms of narrative enquiry (...). A texts meaning is best given in coperformances, when audiences and readers-as-performers interact in and over the same text. This messy approach conceptualizes audiences (and readers) as processes that outlast any given media event (see Fiske, 1994, p. 196). (Denzin 1997:246-247) Had I carried out further sessions with first-years who expressed interest in the exercise, I might have over-estimated the scope of the dossier methods potential. Critical responses from higher levels led me to question its wider applicability as a sociological contribution to medical education (Arsenau 1995; Coombs et al. 1990). I concluded the exercise with heightened awareness of difference between my disciplinary approach and that of the profession I studied.
10.4
Never-ending stories
At the time of writing this chapter, a political battle broke out between the UK Labour government and the Conservative opposition, sparked by the revelation of hospital dramas concerning a 94year-old womans treatment in an emergency service.50 Media debates addressed several issues broached in the story dossier discussions: conflicting versions of an event, the significance of one womans experience, the status of stories as fact or fiction, confidentiality, privacy and public exposure, technical and humane aspects of health care, pressures on health workers, use of anecdotal evidence, and different kinds of storytelling. Never-ending stories was the title given to a Conservative MPs critique of the exploitation of individual stories to orchestrate political attacks (Guardian 24/1/02). In the same issue of The Guardian, a journalistic contribution - Rival claims: the Rose Addis case - set out the versions of key actors in the event with no further comment. This piece used a method similar to the story
50
See the Guardian Unlimited Webpage for references to the Rose Addis case from January 24th 2002.
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Changing Voices
dossier, with direct quotes from the patients daughter, a hospital executive, and a Downing Street spokesman (Guardian 24/1/02). The question Which story is the true one?, posed repeatedly in the Medical School discussions and in the Rose Addis debates, tends to accentuate entrenched positions that defend only one voice as valid. I would now be inclined to introduce future dossier discussions by outlining some alternative interpretative frameworks. Accounts are not necessarily rival, not every story is a war of words (Guardian 27/1/02), and the yarns we spin (Guardian 26/1/02) may tangle or interweave in unpredictable ways.
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Changing Voices
Chapter 11. Contrariwise and Otherwise
CHAPTER 11. CONTRARIWISE AND OTHERWISE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Bertha:But I am trying to explain to you why the Doctor explained it that way it seems that you dont understand! SR: I understand that this forms part of his model. But you in medicine learn a type of language, a terminology, and to say Thats how it is. In sociology, we learn to question the terms and to say: Why would it be called like that? How could it be called otherwise?. Its not a destructive thing but of curiosity, of examining how reality is constructed in different ways. B: But you are researching among us, among the doctors! And youre learning how we explain things. SR: Yes, but Im more interested in the negotiation between you and other people like the users of the services (I dont say patients because that emphasises submission, dependency and a lesser hierarchy faced with medical power) try to validate their version of reality in the interaction what happens and who succeeds in validating their version of the facts. I could do this same work in a fishery, a beauty salon or a restaurant what interests me is human interaction and the management of power relations between people of different social groups. B: But you have to see that the patients almost always enlarge or diminish the condition they have. They do not tell you the truth. SR: That supposes that there is a condition out there that is objectively demonstrable. That any person can recognise as true. In sociology we do not give greater hierarchy to that medical version of the facts. We consider the knowledge of the user as equal to that of the doctor, in status. B: SR: (--- ?) (saying goodbye) I hope you do not get totally disgusted with sociology!
25
Changing Voices
In this final chapter, I draw some conclusions regarding the methods and effects of my research, the contribution of my thesis to medical sociology, and the potential for practising sociology with medicine (Bury 1986:165 citing Horobin 1985;1 Llovet and Ramos 1995:51). The seven-year thesis exploration confronted me with differences, not just in medicine (Berg and Mol [eds.] 1998), but also in the gamut of possible relations contrariwise and otherwise2 - between the two disciplines.
11.1
It seems that you dont understand!
The introductory transcript is of notes I wrote after a conversation in 1998 with Bertha Bastos (B), an intern I had met that year during my Medical School fieldwork. Having qualified as a doctor in 2001, Bertha figures as Dra. Bastos in Appendix 19, her personal account of medical education and stages in formation. Here (as elsewhere in the thesis narrative) I call her Bertha, because we were talking informally as friends, walking in the street. In this concluding passage of our conversation, reconstructed in my notes,3 Bertha signalled my incomprehension of her explanation concerning a legal medicine class she had invited me to observe that morning: [I]t seems that you dont understand! (lines 1-2). I contrasted sociological and medical approaches to defining terms and constructing reality (lines 3-7). Bertha alluded to my research among doctors as requiring preferential attention to medical explanatory models (lines 89). I replied that my interest lay in doctors negotiation with others in relations of power (which I conceptualised at that time in poststructuralist terms). I located my exploration of human interaction in wider social frameworks, beyond the field of medicine (lines 10-16).
In the transcribed excerpt, my voice gained greater space than Berthas, a feature I have signalled at other points in my thesis.4 I represented my sociological intervention as innocuously knowledgeseeking rather than subversively transformative: In sociology, we learn to question the terms and to say: Why would it be called like that? How could it be called otherwise?. Its not a destructive thing but of curiosity, of examining how reality is constructed in different ways (lines 6-7).
Although Bury (1986) cites Horobin 1985, he does not provide the corresponding bibliographic reference. I have been unable to locate the text mentioned, but my search indicates that DF Horrobin may be the author alluded to. 2 I know what youre thinking about, said Tweedledum: but it isnt so, nohow. Contrariwise, continued Tweedledee, if it was so, it might be; and if it were so, it would be; but as it isnt, it aint. Thats logic. (Lewis Carroll [1872] 1962:235, Through the Looking Glass) 3 Notes made in Field Notebook 11 after the conversation, 16/5/98. See Appendix 11 for complete text. 4 See the introductory section of Chapter 4, White on White.
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Changing Voices
Significantly, I could not recall Berthas last intervention, and gave myself the final word in my version of the conversation. Rather than using the adversary method (Moulton 1989) 5 to prove points against others, I now seek dialogue with the authors with whom I find most affinity at this ending-point in my thesis. I acknowledge contributions gleaned from their work, and point out some differences in the approach I evolved. These comments are located within a framework putting epistemological and methodological alternation before allegiance to fixed notions of self, theory or method.
11.2
Strangeness and the Authors Vision
In my selective application of grounded theory methodology, the in vivo codes (Strauss 1987:3334) of research subjects received attention as being remarkable to the researcher, a gringa sociologist who was granted access to Bolivian hospitals and medical schools over a period of two years. The dimensions of abortion talk addressed in each chapter emerged from my interrogation of data, as I explicitly or implicitly contrasted what I found with what could or should have been there (Atkinson 1990:162).6 In this sense, the authorial narrative of knowledge-construction is inseparable from the actors, actants and issues represented. Foregrounding of the authors vision, rather than of the topics and contexts named by those studied (Schegloff 1997), is characteristic of auto/biographical method (Stanley 1992; 1996), critical autobiography (Jackson 1990; Church 1995), and some cultural studies of health and illness (Stacey 1997).
Unlike the last four authors referenced, I carried out fieldwork as ethnic as well as professional outsider to my research settings. My strangeness was noted by others in research encounters,7 and I also drew attention to strangeness encountered from my perspective (Atkinson 1984:169-172). I fed these impressions back to doctors studied, and to wider audiences of health sector professionals. Why did hospital doctors discriminate between abortions done by women, and pregnancy interruptions (anonymously) performed for therapeutic reasons? How did the white coat
5
The aim of the Adversary Method (...) is to show that the other party is wrong. (...) The Adversary Paradigm prevents us from seeing that systems of ideas that are not directed to an adversary may be worth studying and developing, and that adversarial reasoning may be incorrect for nonadversarial contexts. (Moulton 1989:12,17, italics in the original) 6 A great many ethnographic, interpretative accounts () trade on contrasts between what everyone (including the ethnographer, in many instances) regards as normal, and the supposedly unusual features of a given setting. Likewise, they may be organized in terms of a contrast between actual states of affairs, and what is portrayed as reasonable under similar circumstances. (Atkinson 1990:162) 7 See 4.1.1, Profession and ethnicity, in Chapter 4, White on White, and 7.3.1, Partner, couple or pair? in Chapter 7, Changing Voices.
27
Changing Voices
acquire significance as a metonym for the doctors protest march? How was my attempt to request informed consent for observation interpreted by a woman consulting in a gynaecology outpatients clinic? On what basis did medical teams on ward rounds come to present cases around beds that were empty? Who ended up washing Manual Vacuum Aspiration (MVA) instruments, and how was the ward rule The one that uses it, cleans it established and broken? How could a gynaecologist refute a womans account of pain in an MVA procedure? Why would specialists reject multiple evidence of a therapeutic pregnancy interruption in a teaching hospital?
Recalling doctors responses to such interrogations, I cite an observation made by Dr. Salinas (Dr. S), Insurance Hospital gynaecology ward chief, in the discussion following my Changing Voices presentation to his staff:
Dr. S: Er: [.] to me the only thing that called my atte:ntion, [.] is tha::t [1] in all [.] the:- [.] in all the interpreta:tion of the wo:rk, in the conclusions and recommendations, [2] as if there were [.] a: [.] mm: [.] an idea [.] of fo:rcing [.] and saying, Well, why do you not accept abortion? [.] In an open form, all: of you. [.] But [.] unfortunately:, [.] we have: [1] no:rms:, we have regula:tions. [2]8
Dr. Salinas adequately captured the spirit of my intervention in medical territory. In presenting purportedly descriptive analyses of doctors talk, I implicitly demanded a transformation in their approach to abortion. Dr. Salinas named his individual reading of my counter-discourse (Billig et al. 1988:19-24), and argued against it in normative terms on behalf of an institutional collective. My response through this thesis is to acknowledge my transformative agenda, to challenge the italicised statement we have: [1] no:rms:, and to deconstruct the medical we and the normative voice as contingent and negotiable.
11.3
A Hybrid Methodology
The particular contribution of this thesis to the sociology of medicine lies in its deconstruction (Derrida 1972 cited in Kamuf 1991:108; Cameron 1985:140; Elam 1994:5)9 of topic, method, and
See 7.4, Doctors Reactions: A Perfect Fit, in Chapter 7, Changing Voices, and Appendix 7 for the full bilingual transcript of the discussion. 9 See the Introduction for complementary definitions of deconstruction.
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Changing Voices
authorial voice (Atkinson 1990). While I often appealed implicitly to modernist metanarratives,10 I set out not to know a priori what the context was (Schegloff 1997:171), not to predetermine the dimensions of my topic, and not to bring a pre-given critical framework down on my data (van Dijk 1993).
In my Introduction, I mapped a discourse graphic with arrows pointing inwards towards a questionmark incognito (Fig. 1). I focused chapters on discourse-arrows named by medical research subjects, and by myself as author: not-doing, field, white coat, gringa, bed, syringe, pain, living being, pareja, and just one language - a gynaecological criterion - as valid to define a hospital event. All these and more were abortion in particular Bolivian medical settings and encounters. None encapsulated the topic, and each spoke of it in different terms. My question in the Introduction Researching What? - was provisionally answered by eleven chapter-vignettes, a pattern of story-crystals displayed on the plane of a field mapped from within (Marcus 1994:567). The arrow-dimensions of my topic, presented in successive chapters, were identified by mixing ingredients from ethnography, ethnomethodology, discourse and narrative analysis. This produced a methodological salad, a metaphor I appropriate in an affirmative rather than a derogatory sense (Daz Martnez 2002a:35).11 I initially applied methodological hybridity as demonstrated in Talk, Work and Institutional Order: Discourse in Medical, Mediation and Management Settings (Sarangi and Roberts [eds.] 1999), using a combination of ethnography and discourse analysis to generate and triangulate data.12 The editors of this volume recommend using feedback from medical counterparts to supplement their analyses (Cicourel 1999). Hybridity and triangulation are proposed as ways for researchers to obtain extended data sets (Atkinson 1999) and insider medical knowledge to enrich their own interpretations (Sarangi and Roberts [eds.] 1999:70).
My application of methodological hybridity became broader and more exploratory than the modes alluded to in the previous paragraph, and I came to use indefinite triangulation for dialogic rather than purely cognitive ends (Cicourel 1974:195-204).13 I made changes in my methodological approach in response to particular research situations and audience-readings. I found that interpretative strategies that furthered my understanding or political agenda were differently
10
See 1.4, Doing Abortion In Bolivia, in Chapter 1, Doing Abortion: [W]hat were absolutes or universalities under modernism become particular positions under postmodernism; shorn of their automatic authority but still active (Jordan 1997:496). 11 The incorporation of methods and findings originating in different perspectives does not imply making methodological salads. It is possible to respect the original identity of each perspective and at the same time, to maintain a critical, integrated vision of the social order of the clinical institutions that allow one to see and understand how the doctor-patient relationship functions (Miller, 1997). (Daz Martnez 2002a:35) 12 Contributors to Section 1, Medical practices and health care delivery, are Atkinson, Erickson, CookGumperz and Messerman, and Cicourel. Contributors to Section 3, Methodological debates, are Silverman, Hak, Gumperz, and Roberts and Sarangi. (Sarangi and Roberts [eds.] 1999: 61-224, 389-503) 13 See 2.4, Data Analysis and Triangulation, in Chapter 2, Mapping the Field.
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received by audiences that were critical, and those that were defensive of the medical profession. My relations with doctors became less instrumentally focused, and more open to negotiated interaction in medical territory (Rance 2000b).14 I moved from sharing transcripts with research collaborators, to discussing preliminary findings, and organising discussion exercises (Rance 1999a; 1999b). The final object of my inquiry was not a truth out there to access, but the process and effects of mutually constitutive, trans-disciplinary performances.
I gradually moved from an empiricist discourse approach towards a literary critical perspective focusing on the rhetorical production of sociological accounts, starting with my own (Atkinson 1990:10-34). The exercise of transposing transcript notations in translation involved a detailed rereading of selected data from this critically reflexive perspective. This led me to analyse my interventions in the early interviews as influenced by the poststructuralist paradigm that shaped my initial thesis proposal. Despite my declared intention to frame interview questions with reference to research subjects language as registered in observation, I often introduced my own theoretical categories which were then appropriated by interview subjects in their replies. There were conflicts and ruptures between my ethical pursuit of dialogue and transparency about my interests and goals, the effort to produce objective analysis of medical discourse, and my action-research agenda of provoking doctors reflexive criticism of their own language and practice.15
What did I gain from combining eclectically, partially, subjectively elements of different paradigms in my research? First, a respect for the principle of symmetry (Potter and Wetherell 1987), the base line of methodological relativism (Collins 1983), that allows talk to be heard and mapped, at least initially, without regard for truth or falsity. Grounded theory, ethnomethodology and conversation analysis intensified my practice of registering and citing detail, not just for witness category entitlement (Potter 1996:165-166), but also to substantiate the construction of meaning in situated encounters. I learned to take others talk seriously as argumentation (Billig 1999), and not to reify my own discourse, in similarly understanding it as persuasive rhetoric (Atkinson 1990:83).
A principle I gleaned from postmodernism was the validity of superficiality: mapping, navigation, horizontal browsing, attention to relations and effects, the sufficiency of the flat planes of page, screen, text. I spread my research thin, mapping a wide field without digging thoroughly into any point on the surface. This lateral mode of exploration can be contrasted with excavating endeavours
14
In October 2000, in a Buenos Aires seminar on Complementation of Medical and Social Sciences, I presented a paper whose title translates as Improving the quality of postabortion care: Strategies for sociological intervention in medical territory(Rance 2002). 15 See the transcript in Appendix 3 for examples of such conflicts in a recorded interview with Dr. Dvila.
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Changing Voices
that mistrust outward appearances and delve into the depths behind language, under the skull, in the heart, underlying forces, unconscious motivations, profound feelings. Nevertheless, while attempting to put the romantic rhetoric of emotional sociology on hold, I often naturalised inner experience to get the reader or the audience to feel the passion of the circumstance under consideration (Gubrium and Holstein 1997:58-59).16
Drawing reflexive criticism into the thesis narrative (Woolgar 1988; Potter 1996:231), I struggled with the search for an authorial voice. Like the doctors I studied, I used the Changing Voices of my thesis title to pursue effects with particular audiences, present or projected. I forged17 shifting selves in the words and deeds of the moment, taking up the voice of an essentialised subject at some points, and at others letting my personae float in imagined spaces between body and name.
In writing, I alternated between soft, emotionally expressive narratives, and hard, distancing accounts using detailed citations and references to bolster facticity (Potter 1996:117). Through this division, I reproduced Gender and Science associations between empathy, subjectivity and femininity on the one hand, and detachment, objectivity and masculinity on the other (Keller 1985). I found that the rhetoric of discourse analysis achieved greater acceptance with medical professionals, while that of ethnography appealed more to undergraduate medical students and feminists. Some peer reviewers in the field of medical sociology found the auto/biographical thread in my accounts superfluous, and distracting from my discourse analytic arguments. Without declaring fixed loyalty to any one rhetorical mode, I took voice to be an artifact, forged in interaction.
11.4
Ironic Use of Deadpan Understatement
Within an overarching bid for subjectivity, I sought to de-naturalise my narrative through the use of reflexive criticism, a method that is corrosive to all authoritative accounts, including that of the current analyst and writer (Potter 1996:231-232). Such textual practices have been qualified as insane (Craib 1997:10), ideologically irresponsible (Eagleton 1991:198), and dangerous from different critical perspectives:
16
See for example 6.4, Outing the Researcher, in Chapter 6, Sociology of a Syringe, and 8.1, Epiphany, in Chapter 8, Managing Pain. 17 Forging carries associated meanings of fabrication, counterfeit, invention, and beating into shape (OED).
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Changing Voices
The danger of this approach, emphasized by some social analysts (for example, Parker, 1992), is that criticism may be blunted by the concern for a fully symmetrical management of factual versions or by the turn to reflexivity. The rich and powerful will carry on exploiting the poor and powerless while researchers, bewitched by reflexivity, explore their textual navels (cf. Edwards et al., 1995). The reflexive workers response to this is that ones textual navel is an excellent start point for considering the constitution and mystification of power. (Potter 1996:232)
While agreeing with Potters response, I suggest an alternative argument to counter warnings about blunted criticism and complicity with exploitative systems. Sociologists of medicine including those committed to descriptive approaches - rarely abstain altogether from inferring criticism of doctors discourse and practice, although their strategies are often oblique rather than direct. Sudnow sets out to show the relevance of a sociological perspective in his classic study of the social organisation of dying. He defines the sociological perspective as an objective one - an ethnomethodological stance of impassive scrutiny - that does not specifically aim to perform transformations on the object (Sudnow 1967:v, 9). Despite his claim to distanced appraisal, Sudnow does make suggestions for addressing prominent problems of interaction between bereaved and nonbereaved persons in US society (Sudnow 1967:11).
In his narrative, Sudnow signals the problems he observed without resorting to evaluative comment, or to an ethnographic rhetoric of strangeness (Atkinson 1990:113).18 His naming of phenomena as sociologically interesting, instructive, striking, significant, useful to consider, or relevant to note (Sudnow 1967:35-53) often serves to convey a stoically controlled reaction of bemused horror. One particularly grotesque incident is qualified by Sudnow as a rather unfortunate circumstance: a nurses unwittingly callous act in exposing the corpse of an extremely malformed, stillborn infant to the shocked grandmother of the dead baby (Sudnow 1967:84, scare quotes in the original). The rhetoric of deadpan understatement,19 used by Sudnow and other descriptive analysts, is a pseudo-literal strategy carrying ironic, critical effect. My naming of this discourse contains its own negation (Billig et al. 1988:19-24): to signal a facial or verbal expression as deadpan summons a contrary rhetoric of engaged emotion as an appropriate mode for conveying something shocking or
18
Atkinson notes the achievement of ironic effect through the apparently detached ethnographic narrative of When Prophecy Fails (Festinger et al.1964): There is no textual marking of the events as bizarre, incredible or out of the way. The narrator is only minimally present: a few phrases and terms are placed in quotation marks, and there is sparing use of evaluative comment (Atkinson 1990:113). 19 Deadpan a., n., adv., & v. A. adj. Expressionless, impassive, unemotional, detached, impersonal. E20. (OED)
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Changing Voices
hilarious.20 Through the juxtaposition of negatively charged citations of data and dry authorial turns of phrase, authors can implicitly appeal to readers assumed empathy with the medically (mis)treated. In displaying the bare facts of a clinical encounter, bolstered by titles and subtitles drawn from in vivo codes, medical sociologists can achieve underhand ridicule of professional behaviour, together with inference of the epistemic privilege of lay accounts.
11.4.1 Its all negative
To illustrate use of this device, I reproduce the last of four vignettes incorporating data from a 1995 study that I presented to an international meeting on expanding postabortion care services (Rance 2000): 21
Figure 11.1 Ethnographic Vignette Illustrating Ironic Use of Deadpan Understatement Thats our guarantee Mrs. Suxo (Mrs. SS), aged 29, is consulting with general practitioner Dr. Tapia (Dr. TT) in a peri-urban State health centre. The reason given for consulting is that she has had no period since an abortion two years previously. At that time, Mrs. Suxo had requested an IUD from this same provider. Dr. Tapia had told her to come back when her menstruation returned. Dialogue during the 35-minute consultation: Dr. TT: Mrs. SS: Dr. TT: No menstruation? No. But I had some bleeding after being hit. Anti-tetanus vaccine? Pap? [Does gynaecological examination]. You knew your belly was growing. Dont wear a tight girdle, thats why your baby does not grow well. Youre 6 months pregnant. After that well give you an IUD. Mrs. SS: Yes yes yes! Thats what I wanted. You told me to come back when I had my period. Dr. TT: Thats our guarantee. Otherwise, the baby comes out with the Copper T in its hand. Mrs. SS: Its your fault. If I do not get my period, how am I supposed to know?
20
I noted my own use of this strategy in the first paragraph of 5.2.1, Rectangular planes as sites of knowing (Chapter 5, The Empty Bed). I initially made a deadpan citation from first-year student Ignacios account putting cadavers before teachers as elements that made him happy with the Medical School. I later qualified his phrase as a delightful blooper, to explicitly convey the hilarity it provoked in me, rather than ironically inferring ridicule of it (Freres Alvarez 1998). 21 Parras and Rance 1997 cited in Rance 2000a. Presentation to the AVSC/Ipas International Workshop: Taking Postabortion Services to Scale, Mombasa, 15-18 May 2000.
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Changing Voices
From its very title, Thats our guarantee, this vignette invited the audience to focus critically on Dr. Tapias justification of his delay in inserting the IUD requested two years earlier by Mrs. Suxo after an abortion, a medical act that led to another unwanted pregnancy. The opening notes on context situated Mrs. Suxo as active instigator of two consultations with Dr. Tapia. The doctors strategy of continuing with a chain of closed, clinical queries, taking no account of Mrs. Suxos allusion to violence (with its agent deleted), proved disturbing to gender-aware health professionals in the audience. Dr. Tapias warning about the baby coming out clutching an IUD22 invited ridicule of a doctors appropriation of a lay myth to justify withholding a contraceptive method . Mrs. Suxos direct attribution of blame to Dr. Tapia for causing her already advanced pregnancy, in a singularly assertive patient-to-doctor challenge,23 achieved resonance in this international meeting on postabortion care services. Later in my presentation, I pointed to contrasts between international protocols for postabortion care, and the treatment dispensed by Dr. Tapia.24 However, the act of showing the vignette, in itself, elicited audience reactions of dismay, amusement, indignation, and technically informed criticism.
Such indirect moves to provoke criticism may be well received in anti-medicine circles (Osborne 1994), but they tend to raise the hackles of doctors and others defending the health systems alluded to. The Bolivian delegation at the Mombasa meeting included representatives of Ipas (my former employers), DFID (funders of the Ipas project), another US reproductive health agency, the Ministry of Health, the Bolivian Society of Obstetrics and Gynaecology, and a national network of health sector non-governmental organisations (NGOs). With the exception of the DFID representative, who subsequently named me external evaluator of the Ipas project, my colleagues on the country delegation were critical of my presentation in the session on Womens Rights and Needs. On the account of one NGO delegate, they saw it as letting down the side and giving Bolivian postabortion care services a bad name.
In other versions of this much-cited myth, the baby is born with the IUD incrusted in its head. In the Spanish original, Mrs. Suxos challenge to Dr. Tapia was still more forceful, since she used the second person singular, t mode of address, which slid from informality to rudeness: Es tu culpa (Its your fault). 24 In each of these consultations, the provider had the opportunity to go on from diagnosing a pathology, to understanding aspects of the womans social situation, to offering appropriate support, and ultimately to preventing further damage to her health and wellbeing. This ideal situation did not occur in any of the four consultations. National policies on postabortion care, reflecting the spirit of the Cairo and Beijing consensus documents, were not carried into these medical encounters. () In Mrs. Suxos case, family planning services (...) to avoid repeat abortions had not been offered in her last consultation with the same provider when she explicitly requested them. Dr. Tapia had not complied with her request for an IUD, offered alternative contraception, or informed her about the risk of conception before her menstruation returned. This negligence led directly to another unwanted pregnancy. Dr. Tapia made no comment on Mrs. Suxos allusion to her partners violence. She was offered no further support. (Rance 2000:5-6)
23
22
34
Changing Voices
This negative response echoed the reported comments of some doctors to a research presentation I gave in the Medical School, incorporating ethnographic vignettes. To my query about her colleagues reactions, Dra. Tania Tamayo, a public health specialist, replied:
They said, Its all negative. You get to feel wounded! They think theyre the kings of medicine... They feel theyre being alluded to! They dont like other people getting in there to say anything. They dont accept other people. They expect everyone to say their career is the greatest. Theres no-one above a doctor. Its hard, if you dont reach that moment of self-criticism, to the point of saying: What am I doing!.25
Ethnographic vignettes achieve critical effect by appealing to audiences assumed values. They serve to confirm prior notions of the already convinced, but prove inflammatory to sceptics or members of professions alluded to in the texts. Whenever I presented such extracts of field data, doctors demanded more contextual information, and objected to the selection of fragments of conversation. They accused me of stereotyping their profession, and of not showing nice provider examples to balance the bad provider ones. They reacted defensively to the inference that one encounter could represent an entire system: So youre saying that our whole quality of care programme is a disaster!.26 Taking these arguments into account, I conceded that the use of exemplars, while purporting to show what was possible within a health system at a given moment, slid into inferences of representativity and generality that could not be sustained (Atkinson 1990:84-92).
Trans-disciplinary dialogue is hampered by the scepticism that sociology transmits, an attitude that can readily harden into a doctrinaire cynicism (Strong 1979:201). There is an almost invariable tendency to link analysis with devaluation and to take discovery as if it were always disclosure... the grey mood and the unflattering anticipation are occupational afflictions of the searching sociological mind (Strong 1979:201 citing Halmos 1973:293). Irony, a hallmark of the sociological approach,27 makes deadpan understatement - criticism in the guise of mere description - a far from innocent rhetoric. Notwithstanding my claim to research and write
Notes written at the time of a telephone conversation with Dra. Tania Tamayo, Field Notebook 16, 25/2/99. 26 Comment received from a male doctor following a presentation to an audience of health sector professionals (Rance 2001). 27 Within sociology, irony is not confined to the ethnographic genre. Indeed, it has been argued that it is especially characteristic of sociology in general. (Atkinson 1990:158)
25
35
Changing Voices
primarily for doctors, and my attempt to minimise the use of irony, I have appealed to this textual convention at several points in my thesis.28
11.5
Alternation: from Epistemology to Strategy
I pointed above to doctors adverse reactions to the presentation of ethnographic vignettes that through deadpan understatement, inferred ironic critique of medical practice. While effective for preaching to the converted, this method proved inappropriate for promoting dialogue between sociology and medicine.
In the course of my research, I experimented with two other forms of data analysis and presentation: interpretative repertoires (Changing Voices) and a story dossier (One Woman, Five Voices). In this section, rather than defending one of these methods as more valid than the other, I shall suggest their alternating use as a form of sociological intervention in medical territory (Rance 2002). I now conceptualise alternation not only as an inevitable element in knowledgeconstruction, as discussed in my first chapter (Collins and Yearley 1992:302),29 but also as a methodological strategy for trans-disciplinary dialogue. To substantiate this proposal, I compare doctors responses to my presentations of Changing Voices and One Woman, Five Stories. I draw some conclusions concerning different applications and effects of deconstruction, understood as a practice that keeps the act of naming and defining as a site of contestation (Elam 1994:5).
11.5.1 Deconstruction and reconstruction
From a sociological perspective, interpretative repertoires can be said to deconstruct medical discourse on two levels. Firstly, they draw on fragments of text extracted from different interactions. Secondly, they undo the notion of a unitary professional position and separate it into three voices (technical, normative and pragmatic).
However, when I presented doctors with a descriptive analysis of their changing voices, they took the three repertoires as reinforcing and reconstructing their discourse, hence their favourable responses to the method. This analytic framework validated their discursive variations, and their
28
See for example 3.4.2, Insight Into Medicine, in Chapter 3, March of the White Coats, and 5.2, Patients as Audio-Visual Aids, in Chapter 5, The Empty Bed. 29 See 1.4.1, Epistemological pluralism, in Chapter 1, Doing Abortion.
36
Changing Voices
capacity to adopt appropriate repertoires at different moments. It also provided them with a defensive instrument to counter accusations of hypocrisy and double morality,30 frequently made against doctors in Bolivia with reference to their contradictory statements about abortion. In this sense, the use of repertoires promoted a notion of medical integrity, which I parody as One Doctor, Three Voices. In contrast, the story dossier sociologically reconstructs a critical event from different narratives.31 It incorporates extracts that crystallise the discourse of each actor, and juxtaposes them on one page to map out a picture of the event. Nevertheless, analysing doctors negative reactions to this artifice, I attribute their rejection to the effective deconstruction of their professional authority. The dossier ignored the hegemonic status of medical knowledge and cut it down to size just as I set out to do at the start of my research32 - placing the gynaecologists account on the same plane as that of other, less qualified actors. It had the offensive effect (Potter 1996:106-108) of relativising and challenging medical knowledge.33 Moreover, the selection of one textual extract to typify the discourse of each actor shrank and froze it into a unitary position. The gynaecologist was implicitly stereotyped as (appropriately) technical, and the resident as (inappropriately) sentimental. The dossier text-as-actant provoked doctors to assert binary difference between correct and incorrect performances of professionality.
Weighing up the relative advantages and disadvantages of the two methods from the perspective of my transformative agenda, I note that interpretative repertoires had the undesirable effect of magnifying and validating medical knowledge. For this very reason, Changing Voices was enthusiastically appropriated by doctors. I conclude that this method can be used to promote consensus with doctors regarding the variable and contingent nature of their declarations on particular issues, including abortion.
The story dossier approach, on the other hand, achieved my desired goal of cutting medicine down to size. In doing so, One Woman, Five Voices needled doctors to annoyed reaction, because it radically undermined their authority as experts. I conclude that this method can be productively used to generate conflict with and within the medical profession, regarding contrasting versions of critical events.
30 31
See 7.1, Origins of an Interpretative Application, in Chapter 7, Changing Voices. I am indebted to Brian Torodes observation of the deconstruction of medical discourse in interpretative repertoires, and the reconstruction of lifeworld discourse in the story dossier. Personal communication, 25/11/97. 32 See Cutting Medicine Down To Size in the Introduction. 33 See Potter 1996:106-108 for a discussion of offensive and defensive rhetoric in fact construction.
37
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Thus, rather than opting for one method or the other, I propose alternating between the two as a transformative strategy. As a topical case in the Bolivian context, I take the example of therapeutic abortion as an issue meriting further discussion with doctors. Obstetricians participating in dossier exercises rejected textual evidence of its practice in teaching hospitals. At the time, I surmised that the dossier method was not appropriate at the highest professional level. What strategy could I use to counter their resistance?
Building on doctors appropriation of interpretative repertoires, a preliminary intervention would be to fracture the assumed unity of medical discourse on abortion, through a new set of Changing Voices drawn from my data on therapeutic pregnancy interruption. Hospital practice of therapeutic abortion would figure as a technical and pragmatic possibility. The normative voice [W]e DO NOT [.] DO [.] ABORTION34 and We base ourselves on norms that are already written35 would be removed from a position of unique validity.
Interpretative repertoires would thus be used as an explanatory formula to achieve some degree of consensus on discursive variation, before turning to the potentially conflictive story dossier format. Space could be opened to acknowledge the different voices of gynaecologist Dr. Gonzles and resident Dr. Losada, in a further discussion of the dossier on Mrs. Maytas therapeutic pregnancy interruption. I propose this alternating method as a sociological contribution to trans-disciplinary dialogue in a range of fields medicine, nursing, social work, and many others - concerning medical, paramedical and lay discourse, and the relations between them.
11.6
Performing Consensus and Conflict
Writing about the Bolivian delegation in Mombasa (in 11.3, above) brought me memory flashes of scenes linking me with these institutional actors and others, through fifteen years of involvement in the field of reproductive health. As Gringa Boliviana a nickname announcing the paradox of my original and adopted nationalities36 - I have been afforded space and support to intervene in groundbreaking areas of rights advocacy.
34 35
See transcript excerpt introducing Chapter 1, Doing Abortion. Notes made in Field Notebook 13 at the time of a dossier discussion with Maternity Hospital obstetricians, 18/8/98. See Appendix 10 for the bilingual transcript of my notes. 36 See 4.1.2, A joke on the gringuita, in Chapter 4, White on White. I am indebted to my friend and mentor Ren Pereira Morat, former head of Bolivias National Population Council (CONAPO) where I worked from 1998 to 1991, for giving me my Gringa nickname, for providing me with my first opportunity to work with the Bolivian government, and for critically supporting my activities over the years.
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Changing Voices
11.6.1 The Gringa Boliviana story Since my teenage years, I have activated37 with a number of organisations and networks promoting rights-related causes. Soon after arriving in Bolivia in 1980, I joined a group producing underground bulletins denouncing abuses of successive military dictatorships. In 1981 I joined the feminist cell (Frente de Mujeres) of a left-wing party opposing those regimes. In 1988, as social communicator with the National Population Council (CONAPO), a technical unit within the Ministry of Planning, I organised debates on the then taboo issue of family planning.
In 1991 I was a co-founder of the National Committee for the Defence of Reproductive Rights. In 1993, I was a governmental delegate at preparatory events for the International Conference on Population and Development (ICPD). In 1994 I set up the first of four regional Working Groups on unwanted pregnancy and abortion. In that same year, I was a non-governmental delegate at the Cairo ICPD.
In 1997 I participated in the organisation of the first national meeting on Masculinities. In 2000, I joined national and international networks opposing the US Congress Gag Rule which prohibited recipients of USAID population funds from carrying out abortion-related activities. Later that year, with a Bolivian advocacy collective, I took up sexual rights issues, supporting the cause of transvestite citizenship in political and cultural events.
Throughout this process, I have developed a profile as researcher, university teacher, project coordinator, and technical evaluator of postabortion care services. Although my critical interventions have left some burnt bridges and spoiled relations, I maintain a niche as gringa activist whose professional contributions are sought and acknowledged in various sectors.
I originally intended to keep this curriculum vitae out of the thesis, justifying my reticence on several counts. First, I wanted my research to stand on its own merits, without summoning extraacademic credentials to bolster the significance of my interventions. Secondly, I now read much of my ostensibly transgressive reproductive rights activism in Foulcauldian terms, as collusive with bio-power: population control with a female gendered face, the individual rights paradigm of the Cairo Programme of Action (Hawkins 2002:70).38 Thirdly, in terms of empirical relevance, my
37
In Bolivia and other Hispanic contexts, activar, traditionally used as a transitive verb, has also been appropriated intransitively by activists to signify a mode of acting-up with transformative goals. 38 A dominant perception is that the ICPD POA represents a radical break from neo-Malthusian population policy, in its assertion that programmes that are demographically driven and intended to act directly on fertility are inherently coercive and abusive of a womans right to choose the number and spacing of her
39
Changing Voices
performances as activist rarely figured among features of topic and context named by participants in the interactions I analysed. Nevertheless, I balanced these reservations about scene-setting39 against my supervisors suggestion that I tell the Gringa Boliviana story, to continue with the torturous process of slow auto/biographical disclosure (Sharff 1982:119).40 I leave the preceding paragraphs - a dynastic script (Hankiss 1981:205)41 in imagined inverted commas - as a prelude to a discussion of conflict and consensus in research relations.
11.6.2 Conflict and transformative action
My story involves Ipas, the US-based NGO for which I did successive consultancies between 1993 and 1998, and whose Bolivian project I have evaluated since 2000 for DFID, the UK government funder. In the period of my contract research, my status as Gringa Boliviana was a card dealt by all players involved with varying effects. It often proved advantageous for Ipas, and for the Bolivian government as project partner, to work with a consultant who had long-standing relations with a range of institutional networks. At some moments, however, I used these relations to lever support for interventions that conflicted with Ipas or governmental policy. As freewheeling gringa,42 I alternately asserted my institutional affiliation, and promoted radical rights agendas with other activists. This performance of autonomy provoked dilemmas confronting ethics and politics:
Ethics has to do with application of a system of moral principles to prevent harming or wronging others, to promote the good, to be respectful and to be fair. Politics has to do with the methods and strategies used to gain a position of power and control. Ethics and politics are intertwined in sensitive research, especially that performed in community settings. (Sieber 1993:14, my italics)
children (McIntosh and Finkle 1985:227). The International Womens Health Coalition (IWHC) took the lead in formulating this feminist position in the lead up to ICPD. However, far from being anti-Malthusian, the policy position which seeks to provide a common ground for multiple womens voices, effortlessly melds a quasi liberal-radical feminist agenda with the neo-Malthusian population orthodoxy. (Hawkins 2002:70) 39 See 6.2, Scene-Setting: Too Much, Too Little?, in Chapter 6, Sociology of a Syringe. 40 [S]low disclosure reminiscent of slow torture! Sets you up as having the whole story to disclose to your audience. (Barbara Bradby, comments on Chapter 6, 8/7/02) 41 This account too can be analysed as the script of a dynastic strategy in which my present, good situation is a linear consequence of positive traditions. (1.2, A Personal Abortion Story, in Chapter 1, Doing Abortion) 42 Former allies turned critics of my freewheeling gringa performances have openly and covertly labelled me maverick, Quixote, ruinous, and spoiled.
40
Changing Voices
In sensitive research (Renzetti and Lee [eds.] 1993) indeed, in any kind of research - ethics and politics may be messily tangled rather than harmoniously intertwined. In naming community settings, Sieber refers somewhat euphemistically to locations marked by social inequality where researchers have some advantages. In such contexts, by taking an ethical approach, researchers can moderate their power-seeking urges in order to avoid harming research subjects, construed as vulnerable (Salinas Mulder et al. 2000; Rance and Salinas 2001b:14-15). However, when negotiating with sponsors, funders or gatekeepers who temporarily have the upper hand, researchers may adopt a political stance, seeking to gain power and control. In these situations, researchers strategic interests may conflict with sponsors notions of good, respect and fairness.
While relations with Ipas were generally smooth in the early years, I have alluded to some tensions and arduous negotiations that developed with my former employers.43 Areas of conflict included topics I chose to include in my 1997 research presentation and report; the change in methodology adopted during that year; the obligation to predetermine numbers of interviews and levels of groups addressed in my 1998 action-research in the Medical School; authorisation to present a dossier of real stories on a polemical theme to students and teachers in that setting; and adverse reactions by the Bolivia delegation to my presentation at the Ipas co-sponsored Mombasa meeting.
In political terms, I found it understandable that Ipas representatives should defend their institutional interests. Using the same logic, as activist, consultant and researcher, I did not cede to moral recriminations about promoting particular agendas. While recognising that money does not come free (Wenger 1987:5), I did not consider that s/he who paid the piper necessarily called the tune. Ipas contracted me, but their project partners the Ministry of Health and DFID supported my methods and disclosure of my findings.
Official restrictions on MVA use, and institutional barriers to studying the technology, were removed sixteen months after I presented my 1997 research report. In January 1999, the Ministry of Health approved MVA trials in two regional hospitals. In a February 1999 memorandum to Ipas, I reiterated recommendations from my 1997 report concerning MVA, pain management and anaesthesia, which were relevant to their new project. The Gender Vice-Ministry published my 1998 Medical School research report, incorporating the One Woman, Five Stories story dossier, and included it among books launched at an International Womens Day event (Rance 1999a). A 1999 DFID evaluation qualified my Medical School research as one of the main unexpected
43
See 7.3, Discussable and Taboo Topics, in Chapter 7, Changing Voices; 10.1, The Problematic Relationship, in Chapter 10, Audiencing Hospital Stories; and 11.4, Ironic Use of Deadpan Understatement (above) in this chapter.
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Changing Voices
successes of the Ipas project. In 2000, DFID contracted me as external evaluator of the project in which I had formerly participated.
I cite these outcomes this time using an antithetical script of triumph over adversity (Hankiss 1981:205) - to indicate the potential for transformative action, weaving an uneasy path between institutional politics and rights advocacy. In the next section, I continue with the theme of consensus and conflict, and draw some conclusions about the tangled relations between personal and professional agendas in the field of medicine.
11.6.3 Why are people so nice?44
One member of the Bolivian delegation in Mombasa (11.3, above) was Dr. Dvila, the gynaecologist who had been my main research collaborator in the State Hospital three years earlier. I contrast the account of conflict with fellow-delegates concerning my Mombasa presentation with a harmonious portrayal of my relations with Dr. Dvila, taken from notes made during my 1997 fieldwork:
Dr. Dvila himself spoke Aymara and I had previously heard him expressing positions defending indigenous culture and identity and condemning imperialist violations of Bolivian womens reproductive rights. In other observations I had seen him take an active interest in references to Andean traditional medicine made by women consulting. His approach to me as gringa researcher was simultaneously friendly and challenging, supportive and critical. I felt comfortably equal with him, knowing he set me certain limits but quickly opened spaces for my fieldwork wherever he could. We had a regular exchange of literature, ideas and invitations to events of mutual interest.45
At other points in my fieldnotes, I alluded to the relative ease of my relations with Dr. Dvila and with Dr. Gonzles, his counterpart in the Insurance Hospital. I attributed this not just to interpersonal affinity, but also to my careful negotiation of access, attention to research ethics, and information sharing throughout fieldwork. I drew attention to certain incidents as testifying to cordial and productive research relations: when Dr. Dvila summoned me to his students
44
I borrow this subtitle from Paynes analysis of sociologists representations of harmony in field settings (Payne 1995:30). 45 Excerpt from draft of Chapter 4, White on White, 2001.
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Changing Voices
presentation on abortion,46 when Dr. Gonzles introduced me to residents visiting the Insurance Hospital as our sociologist companion (nuestra compaera sociloga),47 and when my friendship with Bertha Bastos survived a heated discussion about medical versus lay truths.48
Reflexive criticism (Potter 1996:231) leads me to look beyond this self-congratulatory rhetoric and re-examine my constructions of people in the field as nice (Payne 1995:30). I return to my positive scene-setting for the observation in Dr. Dvilas outpatients clinic, cited in the penultimate paragraph. Attributing such representations to the incomers need to seek social support, Payne asks: is it really credible that sociologists have this ability to get on with everybody? He invites researchers to look sceptically at (self-)flattering portrayals of the ease with which they gained access, peoples niceness towards them (and each other), and insiders acceptance of the outsiders presence (Payne 1995:30).
My construction of relations with Dr. Dvila as comfortably equal lends itself to closer scrutiny. I interrupt this nice story with notes on his handling of another consultation at the end of the morning surgery:
When I switched off the cassette recorder before leaving, he took on an authoritarian, even aggressive tone with the next patient, a woman de pollera49 of over 50 who had come for a cancer check and was lying on the gynaecological examination table. He threw questions at her in a brusque manner and expressed prejudice and suppositions about her sexual and reproductive life.50
Here, I am exploring something other than the notion of real and contrived selves as contingent upon performance in social situations (Goffman 1959:254-255; 1997:l). I am looking instead at the tendency for authors to produce favourable portrayals of research collaborators and their relations with them, and at the discomfort that can ensue on both sides when idealised representations break down. I take issue with authors whose complicity with the medical profession seems overly marked (Bosk 1979), and also question the unremitting doctor-bashing stance evidenced in some critical exposs (Millman 1976). Nevertheless, at different moments I have adopted these positions and other intermediate ones, within the gamut of possible relations contrariwise and otherwise between sociology and medicine.
46 47
See the introductory section of Chapter 2, Mapping the Field. Notes written at the time in Field Notebook 3, 16/4/97. 48 See Appendix 11 for transcript of notes on this conversation. 49 See 4.1.1, Profession and ethnicity, in Chapter 4, White on White. 50 Notes made at the time in Field Notebook 1, 10/12/96.
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My pursuit of harmonious relations with Bolivian doctors collapsed dramatically four years after my fieldwork ended. In 2001, I supported a 19-year-old nieces complaint about medical negligence surrounding her babys death during labour in a public hospital. The ensuing medical audit implicated a former research collaborator, who was by then the hospitals director.51 This critical event jolted me back out of relativism and into anger and pursuit of justice. Between these two stances wandered the limpho ghost52 of reciprocal loyalty to the doctor who for months had allowed me to track him through his daily rounds. Reverting to notions of misplaced trust (Parsons 1951:435-453),53 I felt betrayed at the hospital directors failure to ensure that my niece received some medical explanation about her babys death before leaving the hospital. I infer this doctors own sense of betrayal from the words of another gynaecologist, who told me that professional colleagues had commented: If Susanna says she doesnt want to do harm, why is she distributing those letters of complaint like pamphlets?. By that point, my former research collaborator and I, no longer performing niceness, had located ourselves on opposite sides of the provider/user fence.
At the epiphanic moment of the babys death and throughout the year that followed, the partial connections (Strathern 1991) among my roles collided, generating conflict with former allies. As researcher, I continued to give presentations to medical audiences. As relative of a health service user, I became embroiled in a lengthy audit process, taking the case with my niece to health authorities, independent committees, pressure groups, and finally to the Ombudswoman (Defensora
My (19 year old) niece L's baby died shortly before birth on Monday. She and her partner/classmate E had got pregnant in their last year of school, and despite all the problems, very much wanted the baby. L had gone for antenatal checks and had scans and all seemed well right up to a couple of days before the birth (9 months). Then on Friday she had a fall (slipped over at home) and went to the hospital (quite nice new adolescents' centre at the Womens Hospital). Her woman doctor she liked a lot wasn't there and she didn't feel confident about seeing another doctor (having had negative experiences in the General Hospital and another State health centre). She went home and decided to go back on Monday. She went into labour at 3-4 a.m. Monday, was in the hospital by 7, the doctor who admitted her said he heard the baby's heartbeat, but an hour later it couldn't be heard. There was an excessive delay in getting her attended and a scan done and eventually she gave birth at 3 p.m. but the baby had been dead some hours (not clearly determined how many) before that. She is still in hospital, had two blood transfusions and is very upset and wants OUT because she can't stand hearing women in labour and seeing babies all around. I got the director of the hospital (one of whose projects I'm evaluating, and he is Dr. X, one of my main research collaborators) to get in there right from the start - when J, L's mum, first phoned me on Monday at 11 a.m. and I went in - and to follow up what was happening. E and I went to see him yesterday but we haven't had a satisfactory explanation yet. They are not (being) clear about whether the baby was still alive when she entered hospital on Monday. The doctors wanted to do an autopsy but we said no. I am insisting on responsibility of the specialist doctor who was on duty, since the one who said he heard the heartbeat was in training and the director says he may have got it wrong. So... L may be out of hospital today, we will collect the baby from refrigeration, do a wake in the house, and soon after have the burial. (E-mail message from SR to Barbara Bradby, 22/2/01) 52 Limpho: unbaptised soul of an aborted foetus that inhabits a member of the aborting womans household. See footnote on the penultimate page of 9.2, A Dossier of Life and Death, in Chapter 9, One Woman, Five Stories. 53 See 7.6, Interpreting Individual Contradictions, in Chapter 7, Changing Voices.
51
44
Changing Voices
del Pueblo). As consultant for DFID, I continued to evaluate postabortion care services, including those in the hospital being audited.
In this episode and others, I found performances of consensus and conflict to be contingent, with no fixed attitude on my part or on that of doctors. Divisions between sociology in, of and with medicine seemed less and less clear. Many researchers are too heavily implicated in the use of medical services to claim a clean distance from the profession. As individuals, they and their families need doctors at certain moments. As health service users, they are apt to evaluate and judge medical professionals. As sociologists, they aim to study them, and also influence their discourse and practice (Strong 1979:203, 213). 54 These roles can cross and combine in messy ways:
[A]lthough professional scepticism may account for a good deal of the distortion that creeps into our analysis, there are other factors which are surely also present. One of these is the fact that sociologists, as well as being students of medicine, are not infrequently its patients as well. Given the natural importance to them of their own health and the somewhat bureaucratic and impersonal nature of those medical services which are, these days, available to the professional middle-class, may harbour distinctly personal grudges against medicine. Such feelings are likely to be amplified where particular sociologists are members of subordinate groups within our society or have chosen to act as their representative. (Strong 1979:201)
11.7
Abortion: The Vanishing Topic
In acknowledging the partiality of my approach, what can I offer audiences seeking new knowledge about abortion talk in Bolivian medical settings? In the course of my research, my focus shifted from abortion per se to trans-disciplinary relations between sociology and medicine. The theme of study became those relations, and the methods used to explore them. Just as Button signalled the vanishing technology as an effect of Actor Network Theory (Button 1993:23-24),55 to a certain extent I vanished abortion and exited at a point of radical indeterminacy.
54
The collection by Davis A. and Horobin G. of personal accounts of their illnesses by medical sociologists (Medical Encounters. Croom Helm, London, 1977) is a fascinating mixture of analysis and animosity. (Strong 1979:213) 55 See 6.5, Actors and Actants, in Chapter 6, Sociology of a Syringe.
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Death and Furniture arguments (Edwards et al. 1995)56 may be summoned to claim that my thesis should not fail to engage with the hard fact that one woman dies each day in Bolivia from abortion complications, and that it cannot deny the solidity of metal curettage instruments and plastic aspiration syringes. From certain public health and feminist perspectives, Saving Women can be construed as a vital necessity and a moral imperative, not a discourse to be questioned.57 In the heat of violent, bloody, and lethal events, I also alternate into materialist critiques of semiotic analysis, as enunciated by Foucault in an interview on Truth and Power:
Neither the dialectic, as logic of contradictions, nor semiotics, as the structure of communication, can account for the intrinsic intelligibility of conflicts. Dialectic is a way of evading the always open and hazardous reality of conflict by reducing it to a Hegelian skeleton, and semiology is a way of avoiding its violent, bloody, and lethal character by reducing it to the calm Platonic form of language and dialogue. (Foucault cited in Fontana and Pasquino 1977:56-57, my italics)
I grappled with precisely this dilemma in the pain dossier. The epiphanic (Denzin 1989:15-18) encounter with contradictory accounts of Mrs. Gongs treatment with MVA led me to abandon interpretative repertoires (Gilbert and Mulkay 1984) and map a battle among discourses (Foucault 1975) concerning this critical hospital event. However, the concept of agent-displacement (Sykes 1985) took me beyond an oppositional analysis of the four narratives, to an understanding of speakers collaborative protection of the gynaecologists interests.58 Discourse analysis generated an effective mode of argumentation, and a credible alternative to the affirmation of Mrs. Gongs experience as undeniably real.
The adversary method (Moulton 1989) can be subverted by identifying points of dialectic referentiality between apparently opposed arguments. Commonality is paradoxically enabled by difference, as I noted in an earlier abortion study where health service providers and users made contradictory declarations within the same interview (Rance 1995:112-114). I commenced my research aware of threads of discourse common to parties on both sides of the abortion debate (Ginsburg 1989:222) - or rather, on all sides. If speakers change what they say about a topic
See 8.2, Pain, Death and Furniture, in Chapter 8, Managing Pain. For a discussion of the Saving Woman Device (SWOD), see 7.2, Doctors Interpretative Dilemmas, in Chapter 7, Changing Voices. The discourse of Saving Women from injury or death from unsafe abortion is current in the publications of the Centre for Reproductive Law and Policy (CRLP), a major feminist advocacy organisation; and in press releases and coverage of the Women on Waves Foundations floating abortion clinic, that docked off Ireland at the start of its voyage. (See Guardian and New York Times Webpages from August 2001, for example: (http://www.nytimes.com/2001/08/26/magazine/26ABORTION.html). 58 See 8.4, A dossier of pain, in Chapter 8, Managing Pain.
57 56
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according to context, conflicting positions may converge at certain moments. This possibility was indicated by Vincente, a first-year medical student participating in a group dossier discussion: Er... look, with regard to this specific theme of this lady and everything that happened to her? I think that the most feasible thing was... that this abortion should have been done, regrettably. I am religious, Im against abortion, but in this case.... 59
My experience mirrored Ginsburgs in Contested Lives: The Abortion Debate in an American Community, as I too encountered the hostility that can be provoked by chipping away at the smooth walls of assumed oppositions. Like Ginsburg, I met with suspicion from colleagues and fellow activists, and wondered with them if I had gone native among the doctors and pro-lifers (Ginsburg 1989:222-223).60 Mapping the field in virtual and real terrains,61 I found that tenets that had long sustained my pro-choice activism were dissolving into uncertainty. I could no longer situate myself in a truth-wielding stance vis--vis a homogenised adversary. A hard core of anti-abortion militants were indeed ready to shoot doctors in the back to defend foetal rights, but there were many people addressing issues of fertility and infertility, pregnancy, miscarriage, foetal death and childbirth, with whom I found affinities linking our research and politics.
11.8
Semiotic Action-Research
Actor Network Theory (Law 1992; Latour 1992) led me away from a rigidly oppositional mode, and towards a conceptualisation of consensus and conflict concerning abortion as mutually
59
Translated excerpt of Transcript GP1.1:2-3, recorded group discussion, 5 female and 6 male first-year medical students,19/5/98. 60 After I returned from the field and began to present my work in public, the reactions of colleagues raised new problems for me. It is one thing, I learned quickly, for an anthropologist to offer the natives point of view when the subjects are hidden in the highlands of New Guinea and have little impact on the lives of the assembled audience. It is quite another to describe the world view of people from the same culture whom some people in my audiences considered to be the enemy. I tried to think of the mission of Boas and Mead to break down cultural stereotypes when I found myself fielding occasionally hostile responses from colleagues. Some explained to me their concern that I had gone native and become a right-to-life advocate. One skeptic suggested that my data were simply not true. I started wondering if I had been overly optimistic, reading too much into the words of my interpreters, hoping that the commonalities I was seeing were evident to them in ways more significant than the tentative demonstrations and confessions of recognition that I had witnessed. (Ginsburg 1989:222-223) 61 One virtual exchange was my 1997-1998 e-mail correspondence with US art student Jessica Moore, who posted flyers in Dublin with photos of womens faces, their mouths blanked out with a quote from Bishop Joseph Cassidy: The most dangerous place to be at the moment is in the mothers womb. A real encounter disarming my prior notion of pro- versus anti-choice actors was my 1999 visit to the Clnica Pre-Vida (PreLife Clinic) in the Bolivian city of Santa Cruz de la Sierra. The clinics director turned out to be Dr. Osvaldo (Chato) Peredo, former member of Che Guevaras guerrilla movement, now practising past lives regression and other alternative therapies with the Asociacin de Medicinas Convergentes (Association of Convergent Medicines).
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constitutive. The quirkiness of ANT, its mad humour and fantastic virtuality, inspired flying leaps in my conceptualisation of the links between doctors and abortion. Following applications of ANT to asthma (Prout 1996), atherosclerosis (Mol 1999b) and anaemia (Mol and Berg 1994; Mol 1999b),62 my chapter-arrows point to performances of abortion linking human and non-human actants: doctors, coats, nurses, beds, women treated, syringes, and foetuses.
Actor Network Theory does not engage with pre-given notions of social structure and relations: Social relations do not necessarily precede medicine. They also follow from it and they can be found inside it. Whoever wants to study society may go, too, to the sites we studied, for there it is in all its ambiguity, ambivalence, shifts and balances, efforts at coordination, conflicts, and compromises (Mol and Berg 1999:11).
ANTs semiotically derived perspective makes no assumption that specific links or nodes in the network are guaranteed, as it were by a form of semantic cohesion given in the order of things; instead both links [and] nodes have to be uncovered by the analyst. They could be otherwise (Law 1995:3, my italics). There may not be an overall pattern in a network,
[f]or by now we know that these stories do not necessarily add up. Do not necessarily come to a point. That we may need to give up single narratives in favour of many small stories. () Perhaps there is no single and coherent pattern. Perhaps there is nothing except practices. Stories performing themselves and seeking to make connections. Practical and local connections. Specific links. (Law 1995:12-13, underlining in the original)
The mutually referential vision of ANT does not easily fit our traditional notions of politics. Which means that new conceptions of politics need to be crafted (Mol 1999a:85). Ontological politics pursue temporary alliances and destabilising moves rather than radical change. They generate more questions than answers, and it is also possible that these questions will evaporate and well enact and undergo, yet again, a shift in our theoretical repertoire, finding other ways of diagnosing the present (Mol 1999a:87).
The performance of this thesis effectively led me to craft a new conception of abortion politics. My
Studying the performances of anaemia reveals their multiplicity. But this multiplicity does not come in the form of pluralism. It is not as if there were separate entities each standing apart in a homogeneous field. So anaemia is multiple, but it is not plural. The various anaemias that are performed in medicine have many relations between them. They are not simply opposed to, or outside, one another. One may follow the other, stand in for the other, and, the most surprising image, one may include the other. () Alternative realities dont simply coexist side by side, but are also found inside one another. (Mol 1999a:85)
62
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first destabilising move was to disarm the textual unity and solidity of abortion. I then pursued temporary alliances with doctors, and involved medical students and teachers in deconstructive exercises which generated more questions than answers. Inspired by Mols (1999a) Ontological Politics and Cussins (1999) Ontological Choreography, I coin my own term: Semiotic ActionResearch. This refers to collaborative work on language for transformative ends, drawing on method rather than substance, relational strategising rather than the antagonistic assertion of facts, rights and wrongs.
As a form of radical semiotics, Actor Network Theory has been criticised for its symmetrical treatment of human and non-human actors as indeterminate and unpredictable, and for its conceptual obscurity (Abercrombie, Hill and Turner 2000:4-5). Recovering the principle of epistemological alternation applied throughout my thesis, I take my own difficulty in grasping the complexity of ANTs relational materiality as an indication of the insufficiency of paradigmatic coherence as a framework for understanding. I embrace the inter-linking of rigour and imagination in qualitative research, and sacrifice some clarity in the cause of creative exploration. In a rhetorical bid for alternation into semiotic out-there-ness (Potter 1996:150-151), I conclude by jumping from Derridas destabilizing jetty to a simply stating jetty (Derrida 1990:84), brandishing his assertion:
Deconstruction is neither a theory nor a philosophy. It is neither a school nor a method. It is not even a discourse, nor an act, nor a practice. It is what happens, what is happening today in what they call society, politics, diplomacy, economics, historical reality, and so on and so forth. Deconstruction is the case. (Derrida 1990:85)63
63
I am indebted to Geraldine Cullihy for bringing this text to my attention. Personal communication, Dublin, 17/7/02.
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Appendices
APPENDICES
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Appendix 1
Appendix 1 Contextualisation of transcript excerpt introducing Chapter 1, Doing Abortion

Excerpt of transcript of recorded interview with the following characteristics: Participants: Date and time of interaction: Place: Source of notes on context: Number and date of transcript: Context: The transcript excerpt which follows is from a recorded interview which I (SR) requested with Dr. Antunes (Dr. A), while I was waiting to meet with two gynaecologists suggested by him as potential research collaborators in the hospital. Dr. Antunes was very busy and had a series of visits and interruptions in the course of the morning. His office was being renovated and a worker was painting the outside of the door which was ajar. A group of male doctors and administrative personnel were grouped around a table at the far end of the office. Female receptionists, secretaries and nurses entered and left the office periodically, some of them staying in the anteroom just outside. Despite the lack of privacy and the rather agitated atmosphere, Dr. Antunes agreed to give the five-minute interview I requested, which actually lasted a total of 8 minutes. He first suggested postponing it until after the weekend but I insisted and he accepted. When I started to record, he took the cassette recorder from my hands and held it before him in both hands throughout the interview, switching it off and on again on the occasion of one interruption by a male medical colleague. In this way he effectively demonstrated his decision to give the recorded interview. The excerpt here selected and translated is of 1.5 minutes of transcript, starting 5.5 minutes into the interview. Dr. Antunes (Dr. A), director of State Hospital SR as researcher 6/12/96, 11.55 a.m. 12.05 p.m. Dr. Antunes office in the State Hospital Field Notebook 1, notes summarised 9/12/96, edited 10/7/02 2.1, 9/12/96 to 11/12/96
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SR: And what do you think about the question of the Mother-Child Insurance [.] of inclu:ding or not including treatment of complications of abortion within the Insurance Scheme. [3] Dr. A: [[in a very low tone, like a whisper]] But it would be a great marvel for it to be- [.] if that were to enter. But that gives way to a lot of susceptibility. [] [.] [[in a very low tone]] I believe that that: [.] gives way to a lot of susceptibility because if it includes: [2] er:: [1] practising the abortion [1] listen to me well [3] if it includes [.] practising the abortion [1] they would be thinking that [] the Maternity Insurance were [.] were [[in a low voice]] paying for or legalising abortion. [.] [[in an increasingly loud tone]] And with that we [.] do NOT [.] agree, [.] with legalising abortion. [] [.]
SR: Y qu opina Uste:d de la cuestin del Seguro de Maternidad y Nie:z [.] que se inclu:ya o no se inclu:ya la atencin a complicaciones del aborto dentro del Seguro. [3] Dr. A: [[en tono muy bajo, como susurro]] Pero sera una gran maravilla que se- [.] que ingrese esto. [] [.] Pero esto da para mucha susceptibilidad. [] [.] [[en tono muy bajo]] Yo creo que esto: [.] da para mucha susceptibilidad porque si se incluye: [2] eh:: [1] realizar el aborto [1] esccheme bien [3] si se incluye [.] realizar el aborto [1] estaran pensando de que [] el Seguro de Maternidad estara [.] -ara [[en tono bajo]] pagando o legalizando el aborto. [.] [[en tono cada vez ms fuerte]] Y en eso NO [.] estamos [.] de acuerdo [.] en [.] legalizar el aborto. [] [.]
We are AGAINST the legalisation of abo:rtion. Nosotros estamos en CO:NTRA de la legalizaci:n del abo:rto. NO. [.] NO. [.] [[in a lower tone]] [.] What we are doing is struggling AGA::INST abortion [.] doing family planning on that level. [] [.] So- [] I believe that it ought to be thought about [.] it is being made to enter within the Maternity Insurance, PERfect because that way [.] the- the- the- the- mother [] [.] but [.] of abortion [.] in process [.] not an induced abortion. [.] We know that an abortion [.] is a crime. SR: Mh-hm. [] But [.] lets say [.] when the woman enters [.] sometimes theres a lot of diff::iculty [.] in kno:wing [.] if its an abortion thats sponta::neous or indu:ced. [4] Dr. A: Thats [the] problem. [.] Im telling you. [.] This [.] has to be taken with great [.] care. [.] And- and- thats a problem [] [.] that:: [3] [[in a very low tone]] the government has to see to. [[en tono ms bajo]] [] Lo que s estamos luchando CO::NTRA el aborto [.] haciendo la planificacin familiar a ese nivel. [] [.] -tons- [] [.] yo creo que se debe pensar [.] se est haciendo [1] que entra dentro del Seguro de Maternidad perFECTO porque as [.] lala- lala madre [] [.] pero [.] del aborto [.] en curso [.] no un aborto provocado. [.] Sabemos que un aborto [.] es un crimen. SR: Mh-hm. [] Pero: [.] digamos [.] cuando ingresa la mujer [.] a veces hay mucha dificulta::d [.] para sabe:r [.] si es un aborto espont::neo o induci:do. [4] Dr. A: Ese es [el] problema. [.] Yo te digo. [.] Esto [.] hay que tomar [.] con muchas [.] pinzas. [.] Y- y- ese es un problema [] [.] que:: [3] [[en tono muy bajo]] el gobierno tiene que ver.
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SR:
Right:
SR:
Ya:
Dr. A: [[in a low tone]] Here [on] this level we are operative, [.] [] [1] if they accept it within the Maternity Insurance [.] welcome. [1] Because we [[in a loud tone]] DO NOT [.] DO [.] ABORTION [.] []
Dr. A: [[en tono bajo]] Aqu [a] este nivel nosotros somos operativos, [.] [] [1] si es que lo aceptan [.] dentro del Seguro de Maternidad [.] bienvenido. [1] Porque nosotros [[en tono fuerte]] NO [.] HACEMOS [.] EL ABORTO [.] []
W- [.] we are AGA::INST the- [.] legalisation E- [.] estamos EN CO::NTRA DE la [.] de [.] of abortion, once again I repeat it because about legalizar el aborto, nuevamente lo repito porque this I want [] you to be VERY clear [.] eso yo quiero [] que sea Usted BIEN claro [.] we are [1] AGA:NST legalising abortion. SR: [1] Mm. estamos EN [1] CO:NTRA de legalizar el aborto. SR: [1] Mm.
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Appendix 2
Appendix 2 Contextualisation of transcript excerpt introducing Chapter 2, Mapping the Field

Excerpt of transcript of interaction observed and recorded by SR with the following characteristics: Participants: Dr. Dvila (Dr. D), staff gynaecologist and academic coordinator of residents training, principal research collaborator in State Hospital. Group of five fifth-year medical students, four men and one woman, Elba (E) who presented the case history. SR as researcher. Date and time of interaction: Place: Source of notes on context: Number & date of transcript: Context: This transcript is of a participant observation that I (SR) did with Dr. Dvila (Dr. D) and a group of fifth-year undergraduate medical students, during consultations combined with a teaching session prepared on Dr. Dvilas initiative, in the third of four months fieldwork in the State Hospital. This session focused on the treatment of incomplete abortion and a discussion on abortion with the interns, one of whom, Elba (E), presented a case history. I had telephoned Dr. Dvila early that morning with the intention of postponing my observation session for another day, because I was exhausted from the weeks activities. However, Dr. Dvila immediately said that he was expecting me, and that his students had prepared for the session on abortion with my presence in mind. I went to the gynaecology outpatients clinic, without taking my white coat because I had anticipated another kind of dynamic more of a classroom nature for the teaching session. Dr. D immediately had me shown into the consulting room. He was demonstrating the insertion of an IUD with a woman who was lying on the gynaecological examination couch. For the next two hours, I alternated periods of recording and moments at which I made fieldnotes. The excerpt transcribed below corresponds to the first five minutes of a total of 46 minutes recorded during the two-hour session. Reflecting on this event, I was struck by Dr. Ds demonstration of will to collaborate with my research. I was also alarmed by the invasive nature of the consultations combined with a teaching session. I imagined the impact for the women consulting of being examined in the presence of a group of students. I felt that this situation would have made requests for these womens consent for my presence something of an absurd formality. Friday 14/2/97, 10:07 - 12:11 a.m. Dr. Ds gynaecology outpatients clinic, State Hospital Field Notebook 2, notes summarised 17/2/96, edited 15/7/02 3.7, 17/2/97 - 11/2/97
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Start of Transcript 3.7 [[Before the recording, there are 13 minutes of consultation combined with teaching activities. In the first 14 seconds of the recording, laughs and jokes can be heard from SR, Dr. D and the students, generated by my request to those present to record the session.
Inicio de la Transcripcin 3.7 [[Antes de la grabacin, transcurren 13 minutos de consulta combinada con actividades de docencia. En los primeros 14 segundos de la grabacin se escuchan risas y bromas de SR, Dr. D y los estudiantes, generadas por mi solicitud a los presentes para grabar la sesin.
My request gives rise to jokes from Dr. D about Mi pedido da lugar a chistes por parte del Dr. D sobre mis fines de espionaje para la CIA y my intent to spy for the CIA and the la actividad subversiva de un estudiante subversive activity of a Peruvian student. peruano. Then a serious atmosphere is restored and Dr. D Luego se vuelve a reestablecer un ambiente de situates us within the pre-established theme for seriedad y Dr. D nos ubica en la temtica preestablecida para la sesin docente.]] the teaching session.]] Dr. D: Well. [2] -so were going to:: deal with the: the theme of: [1] of abortion, from: [2] any point of view, [.] I, what I would like, for you to analyse it after reading the history, [1] for you to tell me what you think of those: [1] of what we have found, right, in reality. [1] Its a patient [??] how is it? [1] well [commence]. What- what patient is it? [1] E: Its a pa{tient} Dr. D: {Well} summarised, now. [2] E: Its a patient of nineteen years, [[for 8 seconds, all that can be heard is the occasional sound of papers being rustled]] Dr. D: Well who did the- who did the clinical history? {[???] know.} {[[The sound of papers being rustled continues.]]} E: [[reads from clinical history]] Nineteen ye:ars, [.] tra:der, concubine, [1] Dr. D: Bueno. [2] -tonces vamos a:: tocar el: el tema del: [1] del aborto, desde: [2] cualquier [1] punto de vista, [.] Yo lo que quisiera que lo analicen despus de leer la historia, [1] que me digan qu piensan ustedes de esos: [1] de lo que hemos constatado, no, en la realidad. [1] Se trata de una paciente [??] cmo es? [1] [comenz]aremos. Qu- qu paciente es? [1] E: Es una pacien{te}
Dr. D: {Bien} resumido noms. [2] E: Es una paciente de diecinueve aos,
[[durante 8 segundos slo se escucha el ruido ocasional de papeles que se hojean.]] Dr. D: Quin ha hecho pues la- quin ha hecho la historia clinica? {[???] saber.} {[[Sigue ruido de papeles que se hojean.]]} Es1: [[lee de historia clnica]] Diecinueve a:os, [.] comercia:nte, concubina, [1]
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Appendix 2
born in Umapampa, [1] lives in Altamira, in Zone C.i [2] And [??] motive of consultation, for genital haemorrhage and pain in the lower abdomen. [2]
nacida en Umapampa, [1] vive en Altamira, en la Zona C. [2] Y [??] motivo de consulta, por hemorragia genital y dolor en abdomen inferior. [2]
Um: regarding the history, she recounts that [2] Em: respecto a la historia, ella relata que [2] the clinical condition begins on one fourth of el cuadro clnico se inicia un da cuatro de February approximately [.] [] febrero aproximadamente [.] [] at one in the morning, after a wardrobe fell down on her [2] and [.] subsequently [.] a pain begins of colic type, of great intensity [1] localised in the hypoga:stric region with irradiation to the: dorsal lumbar region. [1] Which was not modified by posture. [1] This pain is accompanied by genital haemorrhage in great quantity, [.] with coagulation [.] and a bad odour. [1] When this condition did not abate the patient approached Altamira Hospital from where she was referred to this hospital centre. [1] And after being assessed [.] [[rustles papers]] er: her admission is decided. [2] Regarding the family precedents, [3] er [.] she mentions that the companion with whom: she finds herself [.] er living// Dr. D: //Shes a concubine? E: Shes a concu{bine.} Dr. D: {Shes a concu}bine. E: Yes. [1] Companion healthy, [1] she has three children, [1] of five, {four and a year and a half}. Dr. D: {[[Gives inaudible instructions about instruments to male students practising internal examination on woman lying on the gynaecological couch.]]} [2] a la una de la maana, luego que se le cay un ropero encima [2] y [.] posterior a eso empieza [.] un dolor tipo clico de gran intensidad [1] localizado en regin hipog:strica con irradiacin a la: regin dorso lumbar. [1] Que no se modificaba con las posturas. [1] Ese dolor es acompaado de hemorragia genital en gran cantidad, [.] con cogulos [.] y maloliente. [1] Al no remitir el cuadro la paciente acudi al Hospital Altamira de donde es remitida a este centro hospitalario. [1] Y despus de ser valorada [.] [[hojea papeles]] eh: se decide su internacin. [2] En cuanto a los antecedentes familiares, [3] eh [.] menciona que el compaero con el: que se encuentra [.] eh viviendo// Dr. D: //Es concubina? E: Es concu{bina.}
Dr. D: {Es concu}bina. E: S. [1] Compaero sano, [1] tiene tres hijos, [1] de cinco, {cuatro y un ao y medio}. Dr. D: {[[Da indicaciones inaudibles sobre instrumentos, a estudiantes practicando examen interno a mujer echada en la mesa ginecolgica.]]} [2]
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E: On her mother [1] on her mother three caesarians were practised [??] [[inaudible due to the sound of papers being rustled]] [dys]tocial. [.] The father is living, apparently healthy, she has ten siblings, apparently healthy. [2]
E: A su madre [1] a su madre se le practicaron tres cesareas [??] [[inaudible por ruido de papeles que se hojean]] [dis]tcicos. [.] El padre vivo, aparentemente sano, tiene diez hermanos aparentemente sanos. [2]
In the personal precedents, non pathological, [.] En los antecedentes personales no patolgicos, er the patient [.] followed schooling to the grade [.] eh la paciente [.] curs el grado de of fourth year primary, [.] escolaridad hasta primero bsico, [.] she is Catholic [.] her dwelling is rented and consists of adobe rooms [[For four seconds, papers being rustled can be heard, and the distant voice of Dr. D giving instructions to the students who continue practising the gynaecological examination.]] E: with plastered walls, it has drinking water, electricity [.] but no drainage. {[2]} {[[The distant voice of Dr. D can be heard talking with the students who are practising the examination.]]} E: Diet is predomi- with a predominance of carbohydrates. [2] Personal pathological precedents, [1] imm:unisations comple:te, [.] no traumatisms, [1] [??]. [1] Mentions processes of [??]ism, repeated [tonsi]llitis [.] when she was a girl. [2] [[in a loud tone, calling Dr. D who continues to supervise the students in the practice of the gynaecological examination]] Shall I continue, Doctor? [[For three seconds, the distant voice of Dr. D can be heard.]] E: Gyneco-obstetric precedents. [.] Menarche at twelve years, [.] current menstrual rhythm [1] five in thirty, [1] gestation four for three, caesarians zero, abortions [1] one, spontaneous. [1] LMPii [.] first [.] of: {[2]} es catlica [.] su vivienda rentada y consta de cuartos de adobe [[Durante 4 segundos, se escucha papeles que se hojean y la voz lejana de Dr. D dando indicaciones a los estudiantes que siguen practicando el examen ginecolgico.]] E: con paredes revocadas, tiene agua potable, luz [.] pero no alcantarillado. {[2]} {[[Se escucha voz lejana de Dr. D hablando con los estudiantes quienes practican el examen.]]} E: La alimentacin es predomi- a predominio de carbohidratos. [2] Antecedentes personales patolgicos, [1] in:munizaciones comple:tas, [.] sin traumatismos, [1] [??]. [1] Menciona procesos de [??]ismo, [amigda]litis a repeticin [.] cuando era ni[a]. [2] [[en tono alto, llamando a Dr. D quien sigue asesorando a los estudiantes en la prctica del examen ginecolgico]] Sigo Doctor? [[Durante 3 segundos, se escucha voz lejana de Dr. D.]] E: Antecedentes ginecobsttricos. [.] Menarca a los doce aos, [.] ritmo menstrual actual [1] cinco por treinta, [1] gesta cuatro para tres, cesareas cero, abortos [1] uno, espontneo. [1] FUM [.] uno [.] de: {[2]}
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{[[distant voices of Dr. D and students can be heard]]} E: [[hesitating]] Octo:-ber [.] October ninety six [1] and [.] date of last birth twelfth of [1] August ninety five. {[3]} {[[distant voices of students and Dr. D can be heard]]} E: Does not report use of: [1] contraceptive methods. [2] The start of- [.] of her sexual relations was at twelve years, in a voluntary manner. [.]
{[[se escuchan voces lejanas de Dr. D y estudiantes]]} E: [[hesitando]] octu:-bre [.] octubre del noventa y seis [1] y [.] fecha del ltimo parto doce de [1] agosto del noventa y cinco. {[3]} {[[se escuchan voces lejanas de estudiantes y Dr. D]]} E: No refiere uso de: [1] mtodos anticonceptivos. [2] El inicio de- [.] de sus relaciones sexuales fue a los doce aos, de manera voluntaria. [.]
Never had a PAP done [.] and neither did she Nunca se realiz un PAP [.] y tampoco ever [.] do mammary checks. [.] Does not know nunca [.] hizo control mamario. [.] No sabe about family planning. [2] sobre planificacin familiar. [2] On physical examination, presents moderate general state oriented in the three spheres [1] with pale hydrated skin and mucous membranes. [1] [??], arterial pressure one hundred/sixty, cardiac frequency eighty- [.] eighty six per minute, respiratory frequency twenty [.] per minute, [1] temperature thirty seven point eight degrees. [2] Head normocephalous, {[3]} Al examen fsico, presenta regular estado general orientada en las tres esferas [1] con piel y mucosas plidas hidratadas. [1] [??], presin arterial cien/sesenta, frecuencia cardaca ochenta- [.] ochenta y seis por minuto, frecuencia respiratoria veinte, [.] por minuto, [1] temperatura treinta y siete puntocho grados. [2] Cabeza normocfala, {[3]}
{[[distant voice of Dr. D can be heard calling to {[[se escucha voz lejana de Dr. D llamando a E]]} E]]} Dr. D: Lets stop for a little while. E: Right. [4] Dr. D: [[to one of the men students who is practising the examination]] Lets see. Now youre surely looking for [??]. [[For 18 seconds, the distant voices of Dr. D and the men students can be heard.]] Dr. D: [[to men students]] Umm: [.] Where is the: [[For 7 seconds, distant voice of Dr. D talking with the men students]] Dr. D: Un ratito pararemos. E: Ya. [4] Dr. D: [[a uno de los estudiantes hombres que practica el examen]] A ver. Ahora seguramente est buscando [??]. [[Durante 18 segundos, se escuchan voces lejanas de Dr. D y los estudiantes .]] Dr. D: [[a estudiantes ]] Este: [.] Dnde est la: [[Durante 7 segundos, voz lejana de Dr. D hablando con los estudiantes ]]
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Dr. D: [[to students grouped around his table for the case presentation]] You already know that this is a pa:tient [2] E: Nineteen years of age Dr. D: Of nineteen years of age [1] who commenced her sexual activity very precociously at twelve years, [.] and who at this stage of life already has three children:, [.] and who was pregnant with a: fourth [.] and who suddenly presents: the same old story, [1] that she got fallen on: [.] by the wardrobe, that she fell, {[3]} {[[sound of papers being rustled for three seconds and distant voice of male student]]} Dr. D: and [2] who [.] comes with a threat- [.] with a [.] diagnosis of [1] abortion [.] [[coughs]]. [.] We dont know why they:: they sent her from: from Altamira Hospital. E: Because it says they didnt ha:ve instruments. 1st male student (St1): Yes, they didnt have instruments. [1] Dr. D: Ay. [3] Right. [1] -so they didnt have instruments. [.]
Dr. D: [[a estudiantes agrupados alrededor de su mesa para la presentacin del caso]] Ustedes ya saben que se trata de una pacien:te [2] E: Diecinueve aos de edad Dr. D: De diecinueve aos de edad [1] que ha comenzado su actividad sexual muy precozmente a los doce aos, [.] y que a estas alturas de la vida ya tiene tres hijos:, [.] y que estaba embarazada de un: cuarto [] y que de pronto presenta: la historia de siempre, [1] que le ha cado: [.] el ropero, que ella se ha cado, {[3]} {[[ruido de papeles que se hojean y voz lejana de estudiante hombre ]]} Dr. D: y [2] que [.] viene con ame- [.] con un [.] diagnstico de [1] aborto [.] [[tose]] [.] No sabemos por qu le:: la remitieron de: del Hospital Altamira. E: Porque dice que no ten:an instrumen{tal}. St1: {S,} no tenan instrumental. [1] Dr. D: Ay. [3] Ya. [1] -tonces no tenan instrumental. [.]
But when she comes here, [.] she comes already Pero cuando viene ac, [.] viene ya with a bit of a fever, [2] She comes with fever, con un poco de fiebre, [2] Viene con fiebre, isnt that right? no es cierto? St2: Yes Dr. D: Umm::: and its done to her [.] what must be done! Or arent- or are you: [.] in disagreement [.] with: [.] the treatment [???.] [3] St2: S Dr. D: Este::: y se le hace [.] lo que se debe hacer! [.] O no- o estn: [.] en desacuerdo [.] con: [.] el tratamiento [???]. [3]
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St3: No, its the: [2] That treatment [.] er: [.] that was [.] that was proposed [for] the patient, [.] is the: [1] is the habitual: treatment [.] that [.] that generally [??] in incom- incomplete abortions. [2] Dr. D: Mm in all of them? [.] St3: No. Not all [.] Dr. D: But? St3: Not in all of them. Dr. D: Mm:. (4)
St3: No, es el: [1] [] Ese tratamiento [.] eh: [.] que se ha [.] que se planteaba [para] la paciente, [.] es el: [1] es el tratamiento habitual: [.] que [.] que en general [??] en los abortos incom- incompletos. [2] Dr. D: Mm en todos:? [.] St3: No. [.] No todos [.] Dr. D: Sino? St3: No en todos. Dr. D: Mm:. [4]
i ii
Pseudonyms for place names. LMP, Last Menstrual Period, in Spanish FUM, Fecha de Ultima Menstruacin.
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Appendix 3
Contextualisation of transcript excerpts cited in sections 3.2.3 and 3.2.5 of Chapter 3, March of the White Coats
Excerpt of transcript of recorded interview with the following characteristics: Participants: Dr. Dvila (Dr. D), staff gynaecologist and academic coordinator of residents training, principal research collaborator in State Hospital SR as researcher. Date and time of interaction: Place: Source of notes on context: Number & date of transcript: Context: This transcript is of an interview that I (SR) requested with Dr. Dvila to talk about some aspects noted in previous observation sessions. This was our first re-encounter after the end of year holidays, and Dr. Dvila was still on leave. First we discussed matters concerning the Working Group on unwanted pregnancy and abortion. My questions in the interview were guided by points I had identified in fieldnotes and transcripts. During the interview, Dr. Dvilas wife passed twice through the adjoining room. When his young son came into the surgery, I momentarily suspended the recording. I lost some of the recording by not noticing when the first side of the cassette had finished. The excerpt here selected and translated corresponds to 7 minutes of recording, starting 40 minutes into the 55-minute recorded interview, which was part of an encounter lasting an hour and a half. After the interview, we talked for twenty minutes about opportunities for me to observe teaching sessions. Dr. Dvila suggested organising a session on the topic of abortion, to be filmed on video, with pre-intern students commencing their 5th year of medical studies. I expressed reticence about the use of video but was won over by Dr. Dvilas enthusiasm for the technology. We talked about taking advantage of spaces in undergraduate and postgraduate teaching to influence the transformation of aspects of biomedical culture (such as the impersonal management of the ward round), which we both constructed as having a negative effect on doctor-patient relations. We confirmed our appointment in the State Hospital for February 2nd, so that Dr. Dvila could introduce me to the residents on duty in the emergency service where I wanted to do an observation session. Friday 31/1/97, 3.15 4.45 p.m. Dr. Dvilas private surgery on the ground floor of his house. Field Notebook 2, notes translated and summarised 31/1/97, edited 18/7/02 3.6, 31/1/97 - 5/2/97
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[6] SR: [] We:ll. [1] And to finish, [.] is there anything that:: [.] you would like to a:sk, li:ke,
[6] SR: [] Bue:no. [1] Y para terminar, [.] hay alguna cosa que:: [.] t quisieras pregunta:r, as:,
about: what I- Im do:ing, the re:search: and: [.] sobre: lo que yo- yo estoy hacie:ndo, la [] the observation and things like that? investigaci:n: y: [.] [] la observacin y estas cosas? [7] [7] Dr. D: One time what thing would I like to ask, Dr. D: Una vez qu cosa quisiera preguntar, [.] [.] [] [[smiling]] now its my turn! {[[laughs [] [[sonriendo]] ahora me toca a m! {[[re loudly]]} fuerte]]} SR: {[[laughs]]} Dr. D: [[laughs]] Mm:: [4] What is the fundamental objective? [.] SR: [] To impro:v:e [.] the access and qua:lity [.] of postabortion services. [1] Right:? [.] Its:- its: [.] [] a bit, the slo:gan of the project of IPAS:. [.] Right? [.] Er [.] MY rese:arch is within that. [.] Within the framework of the IPAS project, [2] which is to: [.] bro:aden [.] er: [.] the access and coverage [.] of [.] postABO:RTION services. [.] [] So: to me whats of interest is seeing [.] what factors can have in:fluence [.] [] so that people can [.] or cant [.] use the ser:vices: [.] and have [.] a: [.] a care which is adequate [.] for their needs, right? [1] [] And I, THAT is what I am addressing [1] er [1] but NOT [.] NOT SO: MUCH [.] concentrating myself [.] on the aspect of interviews with the women, with the patients, with the users [.] [] [.] BUT [.] with people [.] who provide the services:. [.] To see: [.] how [.] you [.] conceive of your work, [.] how you manage it, how you talk, how: [1] [] you communicate with peopl:e [.] and how you see [.] the view of your own work, right? [.] [] SR: {[[risas]]} Dr. D: [[risas]] Mm:: [4] Cul es el objetivo fundamental? [.] SR: [] Mejora:r: [.] el acceso y la calida:d [.] de servicios postaborto. [1] No:? [.] Es:- es: [.] [] un poco el le:ma del proyecto de IPAS:. [.] No? [.] Eh [.] MI investigaci:n est dentro de eso. [.] Dentro del marco del proyecto de IPAS, [2] que es para: [.] amplia:r [.] ah: [.] el acceso y la cobertura [.] de [.] servicios postABO:RTO. [.] [] Entonces: a m me interesa ver [.] qu factores pueden influi:r [.] [] para que la gente pueda [.] o no pueda [.] usar los servi:cios: [.] y tener [.] un: [.] una atencin adecuada [.] a sus necesidades, no? [1] [] Y yo ESO lo estoy abordando YO [1] eh [1] pero NO [.] NO TA:NTO: [.] concentrndome [.] en el aspecto de entrevistas con las mujeres, con las pacientes, con las usuarias [.] [] [.] SINO [.] con gente [.] que provee los servicios:. [.] Para ve:r [.] cmo [.] ustedes [.] conciben su trabajo, [.] cmo manejan, cmo hablan, cmo: [1] [] se comunica con la gente: [.] y cmo ven [.] la ptica de su propio trabajo, no? [.] []
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For me its very important. [.] [] Because YOU have the side of power. [1] [] Right? You ha:v:e [.] after all [.] erm [.] you have had more access to educa:tion, to forma:tion, [.] [] to professional status, [1] to the link with profess:ional [.] organisations:, [.] [] contacts with the power of the sta:t:e, [.] ri:ght? [.] You: [.] can have influence [.] a lot, [.] I think, [.] also as teachers, [.] [] on the ru:nning of the exercise of medicine here. [1] Right? You have power. [1] And thats why it interests me li:ke [.] mm [.]di:aloguing and understa:nding that a bit! [??,] [.] [] precisely to see those po:ssible spaces for change, right? For transformation. [1] Thats what interests me. [.] [] Because for me, [1] when there is an: [.] excellent service, people will go. They will approach. [.] They will want to go. [1] [] Right?
Para m es muy importante. [.] [] Porque USTEDES tienen el lado del poder. [1] [] No? Ustedes tie:nen: [.] noms [.] ahm [.] han tenido ms acceso a la educaci:n, a la formaci:n, [.] [] al estatus profesional, [1] al vnculo con organismos: [.] profesiona:les, [.] [] contactos con el poder estata:l:, [.] no:? [.] Ustedes: [.] pueden influir [.] mucho, [.] yo pienso, [.] tambin como docentes:, [.] [] en la ma:rcha del ejercicio de la medicina aqu. [1] No? Tienen poder. [1] Y por eso a m me interesa como: [.] mm [.] dialoga:r y entende:r un poco eso! [??], [.] [] justamente para ver esos espacios posi:bles de cambio, no? De transformacin. [1] Es lo que a m me interesa. [.] [] Porque para m, [1] cuando hay un: [.] excelente servicio, la gente va a ir. Va a acudir. [.] Va a querer ir. [1] [] No?
So for me, theres mu:ch more weight [.] on the -tonces para m, hay m:ucho ms offer than on the demand. [2] peso [.] en la oferta que en la demanda. [2] Much more it interests me [.] that: [.] the [.] offer should improve, [1] so that there is an increase in the demand. Mucho ms me interesa [.] que: [.] la [.] oferta mejore, [1] para que haya un incremento en la demanda.
I dont say that people HAVE to go and use the Yo no digo que la gente TIENE que ir a usar los services just because they have to! Right? [.] servicios porque s! No? [.] Because they have other o:ptions in [.] [] traditional health, in A:ndean health, Andean medicine, right? [.] [] Porque tiene otras opcio:nes en [.] [] en salud tradiciona::l:, en salud andi:na, medicina andina, no? [.] []
And it will depend on each person if they use or Y depender de cada persona si usa o no [.] [] not [.] [] the biomedical services. [2] los servicios biomdicos. [2] -so for me, [.] the biomedical services have to improve [.] to constitute themselves [.] [] as a more interesting alternative for people. [1] -tonces para m, [.] los servicios biomdicos se tienen que mejorar [.] para constituirse [.] [] en una alternativa ms interesante para la gente. [1]
Thats what interests me. [.] Its broadening the Eso es lo que a m me interesa. [.] Es ampliar o:ffer a bit. un poco la ofe:rta. [3] [3]
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Dr. D: Improving it. [1] SR: Yes! [1] Dr. D: Yes, improving it, right? SR: Yes! Dr. D: To improve it we have to find [.] [] our errors:. [.] SR: Mm:: Dr. D: Like, see them. [.] Know them. SR: Mm [.] Dr. D: Mm. [1] SR: And not only errors but [.] as I see it, cultural differences. [2] And not only of ethnic culture but of [[laughing]] medical culture! [] [.] Right? [.] Culture of health. [1] That: [.] just as you:, as you show when you relate to people, you recognise too that they come from another system too [.] [] of health. [.] [] And: that they also know things about traditional medicine, isnt that right? [1] Dr. D: Yes, thats how it is.
Dr. D: Mejorarla. [1] SR: [1] S:!
Dr. D: S, mejorarla, no? SR: S!
Dr. D: Para mejorarla tenemos que encontrar [.] [] nuestros errores:. [.] SR: Mm::
Dr. D: As, verlos:. [.] Conocerlos:. SR: [.] Mm
Dr. D: Mm. [1] SR: Y no solamente errores sino [.] como yo veo, diferencias culturales. [2] Y no slo de cultura tnica sino de cultura [[riendo]] mdica! [] [.] No? [.] Cultura de salud. [1] Que: [.] como t:, como demuestras cuando tratas con la gente, t reconoces tambin que viene de otro sistema tambin [.] [] de salud. [.] [] Y: que conoce tambin cosas de la medicina tradicional, no es cierto? [1] Dr. D: S, as es.
SR: And that that option [.] of going [.] to you:r SR: Y que esa opcin [.] de ir [.] a tu: [.] consulta [1] no es [.] la nica forma de [.] consultation [1] is not [.] the only form of looking after their health. [1] atender su salud. [1] There are others! [1] -so if they go [.] its for something, isnt that right? [6] Dr. D: Also, it would have to be seen: [1] the rela:tion [1] analyse it a bit mor:e [1] from a social point of view [1] Hay otras! [1] -tonces si va [.] es por algo, no es cierto? [6] Dr. D: Adems, habra que ver: la relaci:n [1] analizar un poco ms: [1] desde un punto de vista social [1]
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like [.] what [.] what is signified by the relation [1] doctor-pat:ient. [3] Tha::t:: [.] if theres a [.] if if:: [.] the fact [1] that [.] a person [.] asks another about something that [.] is [.] bothering them, [2] thats to say, [1] any person, right? [1] Already they are already acting [.] with power. SR: Tha:ts it. [3] Dr. D: Already theyre with {power.} SR: {Aha:} [.] SR: {Theyre giving you power.} Dr. D: {A lot, because the} other [.] the other [.] [] is: [.] is: needy. [.] SR: [[sighing]] Right. Dr. D: Yes. [2] So: [2] um: [.] we have to try to be [2] like priests! [2] Bu::t [2] well thats the ideal! [.] SR: Mh. [1] Dr. D: [[taking in a long breath]] But it would have to be seen too, how a:r:e [.] how a:r:e the providers of health! [1] Maybe the providers of health also are si:ck. [2] Theyre sick: because [1] because:: [.] they: have [.] [] they have to work in a load of pla::ces because the mo::ney doe:snt go far enough for them [.] [] or because:: [[laughing]] the boss [?] [[laughs]] pressures them a lo:t, [.] [] in the end [1] that aspect too would have to be analysed. [1]
cmo [.] qu [.] qu significa la relaci:n [1] mdico-pacien:te. [3] E::se:: [.] si hay un [.] si si:: [.] el hecho [1] de que [.] una persona [.] pregunta a otra de algo que [.] le est [.] molestando, [2] o sea, [1] cualquier persona, no? [1] Ya est actuando [.] con poder. SR: E:so. [3] Dr. D: Ya est con {poder.} SR: [.] SR: {Aja:} {Te est dando poder.}
Dr. D: {Mucho, porque el} otro [.] el otro [.] [] est: [.] est: necesitando. [.] SR: [[suspirando]] Ya.
Dr. D: S. [2] Entonces: [2] este: [.] nosotros tenemos que tratar de ser [2] cmo sacerdotes! [2] Pero:: [2] eso es pues el ideal! [.] SR: [1] Mh.
Dr. D: [[aspira largamente]] Pero habr que ver tambin cmo est:n: [.] cmo est:n: los prestatarios de salud! [1] De repente los prestatarios de salud tambin estn enfe:rmos. [2] Estn enfer:mos porque:: [1] porque:: [.] tienen: [.] [] tienen que trabajar en montn de pa::rtes porque no: les alcanza el dine::ro [.] [] o porque:: [[riendo]] su jefe los [?] [.] [[risas]] ajusta mu:cho, [.] [] en fin [1] ese aspecto tambin habra que analizar. [1]
If theyre well pai:d, or theyre not [.] because Si estn bien paga:dos, no estn [.] porque the health sector is converting itself [.] [] into a el sector salud se est convirtiendo [.] [] en un
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sector: [.] that is mi:litant, combative:, [.] in search of improvements in salaries:. [1] Because [1] private medicine [1] private medicine, er of- lucrative, [1] has been reduced a lot. [1]
sector: [.] combati:vo, peleador:, [.] en busca de mejoras salariales:. [1] Porque: [1] la medicina privada [1] la medicina privada: eh: de- lucrativa, [1] se ha reducido much:simo. [1]
And me:dicine:: [.] has become mor:e [.] Y la: la medici:na:: [.] se ha hecho ms: [.] its not a doctor, more its a salaried worker. [1] no es un mdico, ms es un asalariado. [1] Its a salaried worker [??]. [.] Es un asalariado [??]. [.] And every salaried worker [.] thats to say, at a: Y cada asalariado [.] o sea en un: given moment [.] can:: [1] maybe momento dado [.] puede:: [1] de repente they get to care little. [2] le importa poco. [2] The sam:e they earn [.] if they attend one patient [1] or if they attend ten. [1] O:r [.] or what do they do? [2] -so [.] those aspects: have to:: [.] [] have to::: um: be improved. [1] They have to [.] consciousness has to [?] be raised [1] and there just must be a search for some me:thod. [1] Because if:: [.] if the providers of health [1] are not satisfied, [2] well: er:: the matter gets: [.] a little difficult. [2] SR: [] And thi:s latest medical: stri:ke, the demonstra:tion: and all: [.] has been [.] exceptional, right? [.] In history here. [2] Dr. D: Yes:. [1] Yes. [2] Unfortunately there is::: is involvement [1] in some organisations: [1] of political aspects:. [2] That should not be done. [1] Thats to say:, [.] and political in the sense of:: um [.] [] of::: [1] If you are in power [.] now, [1] Im going to ruin you. [1] Igual: gana [.] si atiende un paciente [1] o si atiende diez. [1] O: [.] o qu hace? [2] -tonces: [.] esos aspectos: tienen que:: [.] [] tienen que::: este: mejorarse. [1] Tienen que:: [.] se tiene que [?] hacer tomar conciencia [1] y debe noms buscar alg:n m:todo. [1] Porque si:: [.] si los prestatarios de salud [1] no estn satisfechos, [2] pues: eh:: el asunto se pone: [.] un poquito difcil. [2] SR: [] Y esta: ltima: hue:lga mdica:, la manifestaci:n: y todo: [.] ha sido [.] excepcional, no? [.] En la historia aqu. [2] Dr. D: S:. [1] S. [2] Infelizmente se::: se involucran [1] en algunas organizaciones: [1] aspectos polticos:. [2] Que no deberan hacerse. [1] O sea:, [.] y polticos en el sentido de:: este [.] [] de::: [1] Si t ests en el poder [.] ahora, [1] te voy a arruinar. [1]
And if: Im going to be there tomorrow, [1] Im Y si: yo voy a estar maana, [1] yo also going to ruin you, thats to say tambin te voy a arruinar, o sea el revanchismo. revengefulness. SR: Mm. [.] Mm. SR: Mm. [.] Mm.
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Dr. D: And without seeing [.] the damage thats Dr. D: Y sin ver [.] el dao que being done. se est haciendo. [.] [.] SR: Mhm. [.] Dr. D: It wou:ld be:: [.] well, [.] to try to:: [2] well do a unionism:: umm:: thats real! [2] Pure! [1] Right? [2] That- that tha:t implies well um: [1] [[with a long sigh]] a series of [.] [] of other: activities, right? [1] A series of activities. [[The interview is interrupted for one minute (15 seconds recorded, the rest unrecorded) when Dr. Ds son enters, Dr. D introduces us, they talk briefly and his son leaves the surgery.]] SR: Mjm. [.] Dr. D: Ser:a:: [.] bueno, [.] tratar de:: [2] hacer pues un sindicalismo:: este:: real! [2] Puro! [1] No? [2] Eso- eso e:so implica pues este: [1] [[suspirando largamente]] una serie de [.] [] de otras: actividades, no? [1] Una serie de actividades. [[Se interrumpe la entrevista durante un minuto (15 segundos grabados, el resto sin grabar) cuando entre el hijo de Dr. D, Dr. D nos presenta, ambos conversan brevemente y su hijo sale del consultorio.]]
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Appendix 4
Appendix 4 Contextualisation of transcript excerpt introducing Chapter 4, White On White

Excerpt of transcript of recorded interaction with the following characteristics: Participants: Dr. Dvila (Dr. D), staff gynaecologist and academic coordinator of residents training, principal research collaborator in State Hospital. Mrs. Nina, woman consulting in gynaecology outpatients clinic. SR as researcher. Date and time of interaction: Place: Source of notes on context: Number & date of transcript: Context: This transcript is of the first part of a recorded participant observation session that I (SR) carried out during Dr. Dvilas gynaecology outpatients clinic. The time and place of the session had been suggested four days earlier by Dr. Dvila in our first conversation in his private surgery. On arriving at the clinic I found queues of women, some standing and awaiting numbered tickets for consultations, and others sitting on benches outside the surgery doors. The women were called to the consultations by their last names: Mrs. N. Dr. Dvila had me shown in. He asked almost immediately, And your white coat?, a condition for observation that had also been set by doctors in a previous study (Parras and Rance 1997). Dr. Dvila had accepted my proposal that I should request consent for observation and recording from each woman consulting and from other people entering the clinic, although he commented that this seemed unnecessary. From the start of the session, Dr. Dvila involved me in the consultations, asking me to pass him slides and forms for PAP smears, and to go to the door and call the women in. He laughed when I escaped, as he said, from one consultation with a man he was about to examine (the partner of a woman he had attended in a previous clinic) who had penile herpes. By the time I left, Dr. Dvila had seen a total of six patients during the clinic that morning. He said this was few in relation to the twelve he normally attended. This allowed him to dedicate considerable time to each one. When I switched off the cassette recorder before leaving, he assumed an authoritarian, quite aggressive tone with the last patient who was lying on the gynaecological examination couch, a woman de pollera of over 50 who had come for a cancer check and was lying on the gynaecological examination table. He threw questions at her brusquely and expressed prejudice and suppositions about her sexual and reproductive life. Transcript 3.4, from which this excerpt is taken, is of the recorded interaction between Dr. Dvila (Dr. D), myself (SR), and the fifth woman he attended, Mrs. Nina (Mrs. N), a woman de pollera aged 30. The translated excerpt that follows if of the first half of her 31-minute consultation. Tuesday 10/12/96, 11.00 11.30 a.m. Dr. Dvilas gynaecology outpatients clinic, State Hospital Field Notebook 1, notes summarised 14/1/97, edited 20/7/02 3.4, 27/1/97
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Start of Transcript 3.4 Dr. D: [[leafing through papers, in a low tone as if talking to himself, reads the first and last names of the next patient]] SN. [2] SR: [[to Dr. D]] [??]?
Inicio de la transcripcin 3.4 Dr. D: [[hojeando papeles, en voz baja como hablando solo, lee el primer nombre y el apellido de la prxima paciente]] SN. [2] SR: [[al Dr. D]] [??]?
Dr. D: [[continues as if talking to himself]] SN. Dr. D: [[sigue como hablando solo]] SN. [[to SR]] Yes! [[For five seconds, footsteps can be heard of Dr. D as he goes to the surgery door, opens it and calls the first and last names of the patient.]] Dr. D: SN? [[For 12 seconds, sounds can be heard from the doorway, footsteps, and a brief, inaudible exchange between Dr. D and Mrs. N. Both enter and approach the table of the consulting room.]] SR: [[to Mrs. N]] Excuse me Madam, Im called Susanna Rance, Im doing a study with the hospital [.] to support the service. Mrs. N: [[sighing]] Right. SR: And Im obse:rving and recording some consultations. [[a SR]] S! [[Durante 5 segundos, se escuchan los pasos de Dr. D quien va a la puerta del consultorio, la abre y llama el nombre y el apellido de la paciente.]] Dr. D: SN? [[Durante 12 segundos, se escuchan ruidos desde la puerta, pasos, y un breve intercambio inaudible entre Dr. D y Sra. N. Ambos entran y se acercan a la mesa del consultorio.]] SR: [[a Sra. N]] Disculpe Seora, me llamo Susanna Rance, estoy haciendo un estudio con el hospital [.] para apoyar el servicio. Sra. N: [[suspirando]] Ya. SR: Y estoy observa:ndo y grabando algunas consultas.
All place names in transcripts are pseudonyms.
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Mrs. N: Right. SR: You havent got a problem, I can sta:y? [.] And reco:rd? Mrs. N: Ahh: SR: If: if you dont like it, I can go out too.
Sra. N: Ya. SR: Usted no tiene problema, me puedo queda:r? [.] Y graba:r? Sra. N: Ahh: SR: Si: si no le gusta, puedo salir tambin.
Mrs. N: Right. [.] Ah [.] I have a problem with: Sra. N: Ya. [.] Ah [.] yo tengo problema de: {[?]} SR: {If you want:} Mrs. N: a bit, with: health. SR: [[in a louder and more emphatic tone]] Er [.] no [.] Im reco:rding [.] the consultations of all the people who come to talk with the doctor, [.] [] right? Mrs. N: Ahh: right SR: and its:: [.] a study to support the se::rvice, so there can always be [1] attention to:: the patients, right? [] Mrs. N: Ri:ght. SR: and to know [.] what things concer:n them [.] and: [.] all that, right? And [.] so if you have any doubt I can go out. [.] Theres no problem too. Mrs. N: R::ight. [] [.] Er: [.] I have a problem with [1] health, right, thats to say:: with:: {[?]} SR: {Si quiere:} Sra. N: un poquito de: salud. SR: [[en tono ms fuerte y enftico]] Eh [.] no [.] estoy graba:ndo [.] las consultas de todas las personas que vienen a conversar con el doctor, [.] [] no? Sra. N: Ahh: ya SR: y es:: [.] un estudio para apoyar el servi::cio, para que haya siempre [1] la atencin a:: las pacientes, no? [] Sra. N: Y:a. SR: y saber [.] qu cosas les preocu:pa [.] y: [.] todo eso, no? Y [.] entonces si Usted tiene cualquier duda yo puedo salir. [.] No hay ningn problema tambin. Sra. N: Y::a. [] [.] Este: [.] yo tengo problema de [1] salud, no, o sea:: de::
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SR: Yes. Mrs. N: my wo:mb, {all that,} SR: {Yes:, well} Mrs. N: right now for example I have:: [[she sighs, touching her neck]] I dont know, yesterday the wi:n:d blew on me, I dont know, {[?]}// SR: //[[in loud and emphatic tone]] {That} youll be telling to the doctor. Only Im as:king you, [] if you agree that I should stay here [1] during the consulta:tion. [.] Mrs. N: Ahh: right. SR: If I can sta:y, [.] or you prefer that I [.] that I go out. [1] Mrs. N: Also you can go out, er, I havent:: [.] you know, about ano- problems of another: , of [.] thats to say: [.] I mean to sa:y [.] problems of:: [.] personal! [.] That, you want: to know? SR: No no! [] If you are bothered that I should be here? [.] Mrs. N: N:o. SR: in the consultation?
SR: S. Sra. N: mi matr:z, {todo,} SR: {S:, pues} Sra. N: ahorita por ejemplo tengo:: [[suspira, tocando su cuello]] no s, ayer me sopl el vie:n:to, no s, {[?]}// SR: //[[en tono alto y enftico]] {Eso} le va estar contando al doctor. Solamente le pregun:to, [] si Usted est de acuerdo en que me quede aqu [1] durante la consu:lta. [.] Sra. N: Ahh: ya. SR: Si me puedo queda:r, [.] o Usted prefiere que me [.] que me salga. [1] Sra. N: Tambin puede salir, este, no tengo:: [.] sabe, de o- problema de otro:, de [.] o sea: [.] quiero deci:r [.] problemas de:: [.] personal! [.] Eso quiere: saber Usted? SR: No no! [] Si a Usted le molesta que yo est aqu? [.] Sra. N: N:o. SR: en la consulta?
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Mrs. N: No. SR: Because if you like I can go out. [.] Mrs. N: N:o. SR: And if you agree I stay:[.] and I can record. Mrs. N: Stay: here, just. SR: [[in relieved tone]] Thank you. Mrs. N: All right. [[For seven seconds, the sound can be heard of papers that Dr. D is leafing through.]] Dr. D: [[prolonged laughter]] Mrs. N: [[joins in with laughs]] SR: [[laughing]] Hes laughing, the Doctor is! Mrs. N: {[[laughs increasingly loudly]]} SR: {[[laughs increasingly loudly]]} {[[laughing]] {How can I go out, right?!} Mrs. N: {[????]} the lady [??] [[continues laughing]] Dr. D: {[[joins in with laughs]]}
Sra. N: No. SR: Porque si quiere Usted yo puedo salir. [.] Sra. N: N:o. SR: Y si est de acuerdo me quedo: [.] y puedo grabar. Sra. N: Qu:dese noms aqu. SR: [[en tono aliviado]] Gracias. Sra. N: Ya. [[Durante 7 segundos, se escucha ruido de papeles que hojea Dr. D.]] Dr. D: [[risas prolongadas]] Sra. N: [[se suma a las risas]] SR: [[riendo]] Se re el Doctor! Sra. N: {[[se re cada vez ms fuerte]]} SR: {[[se re cada vez ms fuerte]]} {[[riendo]] Cmo puedo salir, no?!} Sra. N: {[????]} la Seora [??] [[sigue riendo]] Dr. D: {[[se suma con risas]]}
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SR: {[[joins in with laughs]]} [[laughing]] Its that I didnt explain myself well, right? Mrs. N: {[[laughs]]} {[[laughs]]} Yes.
SR: {[[se suma con risas]]} [[riendo]] Es que no me he explicado bien, no? Sra. N: {[[risas]]} Dr. D: {[[risas]]} S. SR: [[a Sra. N]] Qu dice? Sra. N: [[risas]] Dr. D: [[en tono bajo, a SR]] [te] falta [explicar] [??] SR: [[en tono alto, riendo]] No::? Sra. N: {[[risas]]} Dr. D: {[[risas]]} SR: {[[risas]]} [[a Sra. N]] Me tiene que ensear. [.] A ver, [[riendo]] cmo se pide permiso? Sra. N: {[[risas y suspiros]]} SR: {[[risas y suspiros]]} [1] Dr. D: [[riendo]] Tengo [.] problemas! [[se re]] SR: [[riendo]] Se r:e noms el Doctor! [[risas y suspiros]]
Dr. D:
SR: [[to Mrs. N]] What do you say? [[laughs]]
Mrs. N:
Dr. D: [[in a low tone, to SR]] [you] need [to explain] [??] SR: [[in a loud tone, laughing]] Ri::ght? {[[laughs]]} {[[laughs]]} {[[laughs]]} [[to Mrs. N]] You have to
Mrs. N:
Dr. D:
SR:
teach me. [.] Lets see, [[laughing]] how does one ask for permission? Mrs. N: {[[laughs and sighs]]} SR: {[[laughs and sighs]]} [1] Dr. D: [[laughing]] I have [.] problems!! [[laughs]] SR: [[laughing]] He just lau:ghs, the Doctor does! [[laughs and sighs]]
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Mrs. N: [[laughs and sighs]] Ay: [??] I dont know, well, what it is youre asking so-//
Sra. N: [[risas y suspiros]] Ay: [??] no s pues qu es lo que est preguntando entons-//
SR: [[in a loud tone]] //No, {I [???] no:thing. [.] SR: [[en tono alto]] //No, {yo [???] na:da. [.] You just: [.] are going to talk and} Mrs. N: {[???]} Dr. D: {[?????]} SR: and I [.] only [.] want [.] to be here, right? [1] {[[laughs]]} {[[laughs]]} Ustedes noms: [.] van a conversar y} Sra. N: {[???]} Dr. D: {[?????]} SR: y yo [.] solamente [.] quiero [.] estar aqu, no? [1] Dr. D: {[[risas]]} Sra. N: {[[risas]]} SR: Pero no me he expli// Dr. D: [[a Sra. N]] //O le hace asustar a [.] la gringuita! [.] [[risas de SR y Sra. N]] Dr. D: Bien!
Dr. D:
Mrs. N:
SR: But I didnt expla// Dr. D: [[to Mrs. N]] //Or you make her frightened, [.] the gringuita! [.] [[laughs from SR and Mrs. N]] Dr. D: Well!
Mrs. N: [[laughing and sighing, in a low tone]] Sra. N: [[riendo y suspirando, en tono bajo]] the gringuita [[laughs and sighs]] {[[laughs]]} {[[laughs]]} la gringuita [[risas y suspiros]] {[[risas]]} {[[risas]]}
SR:
SR:
Mrs. N: [1]
Sra. N: [1]
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Dr. D: [[smiling]] How many years old are you, Mrs. N? Mrs. N: Ah Im [1] thirty. [7] Dr. D: Where do you live? [.] Mrs. N: By the Truck Stop Ive been living just for [.] a short time but I havent got an address. [[in a very low tone that becomes a whisper, with a nervous laugh]] Yes::, just an empty plot of land it is. Dr. D: Mm. [2] Do you work? [1] Mrs. N: M [.] Yes [.] as a maid I work [.] {like} Dr. D: {Maid?}
Dr. D: [[sonriendo]] Cuntos aos tiene, Sra. N? Sra. N: Ah yo tengo [1] treinta. [7] Dr. D: Dnde vive? [.] Sra. N: En la Parada de Camiones estoy viviendo recin hace [.] poco tiempo pero no tengo direccin. [[en tono muy bajo que se vuelve susurro, con una risa nerviosa]] S:: lote vaco noms es. Dr. D: Mm. [2] Trabaja? [1] Sra. N: M [.] S [.] de empleada trabajo [.] {as} Dr. D: {Empleada?}
Mrs. N: [.] also sometimes I wash clo:thes an:d Sra. N: [.] tambin hay veces lavo ro:pas y: [2] Dr. D: all right:. [.] Single, married, {concubine} Mrs. N: {I h- in:} concubine. [.] I have two children. [1] Dr. D: Where was the place of birth? [.] [2] Dr. D: -ta bien:. [.] Soltera, casada, {concubina} Sra. N: {T- en:} concubino. [.] Tengo dos hijos. [1] Dr. D: Dnde ha nacido? [.]
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Mrs. N: U:mm: [.] Munaypampa.1 Dr. D: NO, YOU you you you Mrs. N: Me:, in the countryside I was born. Dr. D: Whe:re? Mrs. N: Jurez Province:: [.] Calapata. [.] Dr. D: Hows that? Mrs. N: Calapata. Dr. D: Calapata?
Sra. N: E:mm: [.] Munaypampa. Dr. D: NO, USTED Usted Usted Usted Sra. N: Yo: en el campo he nacido. Dr. D: D:nde? Sra. N: Provincia Jurez: [.] Calapata. [.] Dr. D: Cmo? Sra. N: Calapata. Dr. D: Calapata?
Mrs. N: Yes. [.] We belong to Canton Cristbal Sra. N: S. [.] Pertenecemos a Cantn Cristbal Mrquez. [2] Dr. D: I dont know it. Whereabouts is that? Mrs. N: Its over on that side. [] Er: [.] facing Mount Inti. [1] Dr. D: Ah. [.] Whats it called? Mrs. N: Er:: [.] Jurez Province XM an::d Dr. D: Yes. Canton. Mrs. N: Canton Cristbal Mrquez. But {it has} Dr. D: {Cristbal Mrquez}? Mrquez. [2] Dr. D: No conozco. Por dnde es eso? Sra. N: Es aquel lado. [] Ehh: [.] frente al Cerro Inti. [1] Dr. D: Ah. [.] Cmo se llama? Sra. N: Eh:: [.] Provincia Jurez y:: Dr. D: S. Cantn. Sra. N: Cantn Cristbal Mrquez. Pero {tiene} Dr. D: {Cristbal Mrquez}?
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Mrs. N: Yes. [For six seconds, Dr. D writes.] Dr. D: [[in an almost inaudible tone, talking to himself]] Right. [[in direct, emphatic tone]] Why have you come? [1] Mrs. N: Mm: [.] Ive come to consult about my wo:mb, there are times I feel [] [.] thats to say they hurt, my ki:dneys [1] orthat part [.] First I had myself put in um: [2] a copper T but:: [.] it was there about two months: [.] a bit more it was there. [.] Mh. [.] A::nd I had that taken out of me up over the::re [.] mm [.] whats it called that: surgery [.] mm [.] Villa Asuncin. [.] Thats it. [.] Dr. D: Right. Mrs. N: I dont know. [.] In there I had it taken ou:t of me and: Dr. D: [??] Mrs. N: Right. [.] So: [.] I had it taken ou:t an:d after tha::t [.] a short while ago: [.] [[in a low tone]] I got some descharge [.] a lot [??].
Sra. N: S. [Durante 6 segundos, Dr. D escribe.] Dr. D: [[en voz casi inaudible, hablando solo]] Ya. [[en tono directo y enftico]] Por qu viene? [1] Sra. N: Mm: [.] yo vengo a consultar de matr:z:, hay ratos me siento: [] [.] o sea me duele los rio:nes [1] oesa parte [.] Primero me he hecho colocar ahm: [2] T de cobre pero:: [.] estaba como dos meses: [.] un poco ms estaba. [.] Mh. [.] Y:: me he hecho sacar eso all arri:ba:: [.] mm [.] cmo se llama ese: consultorio [.] mm [.] Villa Asuncin. [.] As. [.] Dr. D: Ya. Sra. N: No s. [.] En ah me he hecho saca:r y: Dr. D: [??] Sra. N: Ya. [.] Entonces: [.] Me he hecho saca:r y: de ah:: [.] hace poco: [.] [[en tono bajo]] m:e ha venido unos flojos [.] fuerte [??].
I dont know what part its called, this pa:rt:: [.] no s qu parte se llama esta pa:rte:: [.]
over the::re [1] in the:: [.] whats it called that:? all:: [1] en el:: [.] qu se llama ese:?
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Dr. D: Mh. Mrs. N: And it gives me itchiness. Dr. D: Because its that. Mrs. N: And [.] first here it hurt me. Thats to say: [] er- after my period like a: blow that it gave me there Dr. D: Mh Mrs. N: So- after that [1] er: [.] like that I made it pa:ss me, pa:ss [.] then: [1] that came on me. [1] And ever so often. [.] Th:other day I came. [.] It was on strike [.] Dr. D: Mh. Mrs. N: No-one was there. []. [1] [[in a very low tone]] Thats it. Now [] Ive come. [.] To consult oneself, what it is that Ive got. [1] [??] those things. [.] Dr. D: Right. But what- [.] [[enunciating very clearly]] what [.] wha:t [[uses the familiar t form for the first time, pronouncing very clearly]] are you principally coming for, why? [] Because you have di:scharge, or because it hu:rts you, or- [.] why. Mrs. N: Because mm:- it hu:rts mme:, thats to say first the ki::dneys:
Dr. D: Mh. Sra. N: Y me hace escosin. Dr. D: Porque es eso. Sra. N: Y [.] premero aqu me ha dolido. O sea: [] ah- despus de mi perodo como un: golpe que me ha dado ah Dr. D: Mh Sra. N: Entons- de eso [1] eh: [.] as he hecho pasa:rme, pasa:r [.] despus: [1] me ha venido eso. [1] Y seguidamente. [.] Lo:otro da he venido. [.] Estaba en paro [.] Dr. D: Mh. Sra. N: Nadie haba. []. [1] [[en tono muy bajo]] Eso es. Ahora: [] he venido. [.] A consultarse, qu es lo que tengo. [1] [??] esas cosas. [.] Dr. D: Ya. Pero qu- [.] [[enunciando muy ntidamente]] por qu [.] p:or qu [[recurre al tuteo por primera vez, enunciando muy ntidamente]] vienes principalmente, por qu? [] Porque tienes flu:jo, o porque te due:le, o- [.] por qu. Sra. N: Porque mm:- mm:i duele, o sea a principio los rio::nes:
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Dr. D: Wh:- where does it hurt you, show me [[in a low tone]] where does it hurt you Mrs. N: [[firmly]] Here. [1] Dr. D: The tummy. Mrs. N: Yes. [] And [.] do:wn there in the vagina: it makes me itchiness. Dr. D: It itches you. Mrs. N: Yes. [1] Dr. D: And that is:: [.] what most worries you. Mrs. N: Tha:t: most wor{ries me} Dr. D: {Yes?} Mrs. N: an::d [.] whats it called [.] [] and [.] like [.] cold that comes in:to me [1] like. [5] Mrs. N: And also I have headaches so:::metimes, li:ke [.] as though [.] doped I go round. [6] Dr. D: Since more or less a month:? [.] That. [.] Two months. [1]
Dr. D: D:- dnde te duele, mostrme [[en tono bajo]] dnde te duele Sra. N: [[en tono firme]] Aqu. [1] Dr. D: La barriga. Sra. N: S. [] Y [.] abajo: a la vagina: me hace escosin. Dr. D: Te escuece. Sra. N: S. [1] Dr. D: Y eso es:: [.] lo que ms te preocupa. Sra. N: E:se: ms me preo{cupa} Dr. D: {S?} Sra. N: y:: [.] qu se llama [.] [] y [.] as [.] fro que me e:ntra [1] as. [5] Sra. N: Y tambin tengo dolor de cabeza hay ra:::tos as: [.] como que [.] atuntada andu. [6] Dr. D: Hace ms o menos un mes:? [.] Esto. [.] Dos meses. [1]
no way, I dont know, I fee::l pain in my bo:nes ni hacer, no s me s::iento dolor de hue:so
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Mrs. N: Yes, one month after my period ca- period came to me on the fourtee:nth [1] mm:: after my period- my period [3] pa:ssin:g abou:t eight day:s like. [1] It came to me. [3] Dr. D: Right. [4] [[in loud and direct tone]] HOW are you urinating? [2]
Sra. N: S un mes despus de mi perodo me ha- perodo me ha veno cato:rce [1] mm:: despus de mi perodo- mi perodo [3] pasa:n:do un:os ocho d:as as. [1] Me ha venido. [3] Dr. D: Ya. [4] [[en tono fuerte y directo]] COMO ests orinando? [2]
Mrs. N: Er:m: [.] tha:t [.] my urine is strong [1] Sra. N: Eh:m: [.] e:se [.] mi orn es fuerte [1] the [.] odour is really strong, thats to say there are times it unchanges, [] its the colour of pineapple, at times its the colour of te:a, [] at times it seems purple too [] like. Dr. D: P:[??] these two last days [1] Mrs. N: Yes, {well} Dr. D: {There} it is. O{dour?} Mrs. N: {Like that} it is. Dr. D: How have you urinated? Arent you urinating at every moment? Mrs. N: Im no::t uri{nating} Dr. D: {Dont you} get the call to urinate at every moment? Doesnt it bu::r:n: you when you urinate? [1] el [.] olor es bien fuerte, o sea hay ratos desvara, [] es color de pia, hay ratos es color de t:, [] a veces parece morada tambin [] as. Dr. D: P:[??] estos dos ltimos das [1] Sra. N: S, {pues} Dr. D: {Ah} es. O{lor?} Sra. N: {As} es. Dr. D: Cmo has orinado? No ests orinando a cada rato? Sra. N: N::o estoy ori{nando} Dr. D: {No te} llama a orinar a cada rato? No te a::r:de: cuando orinas? [1]
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Mrs. N: [[sighing]] It does:nt burn me. [1] Dr. D: No? {No} Mrs. N: {No.} Dr. D: does it hurt you? [.] Mrs. N: [] Befo:re, before {???} Dr. D: {NO NO NO, NOW} well. {Now.} Mrs. N: {Now} Dr. D: Befo:re, [[in a low tone, as if talking to himself]] already is no:t of much interest. [[in a regular tone]] Now. [.]
Sra. N: [[suspirando]] N:o me arde. [1] Dr. D: No? {No} Sra. N: {No.} Dr. D: te duele? [.] Sra. N: [] A:ntes, antes {???} Dr. D: {NO NO NO, AHORA} pues. {Ahora.} Sra. N: {Ahora} Dr. D: A:ntes, [[en voz baja, como hablando solo]] ya: no: interesa mucho. [[en tono regular]] Ahora. [.]
Mrs. N: Now it doesnt, it doesnt bu:rn me but Sra. N: Ahora no, no me a:rde sino rather:: [1] Before my period: [.] thats to say [.] que:: [1] Antes de mi perodo: [.] o sea [.] before my period came it::: hurt me, thats to say [.] in- [.] since I work, I do, [] in my work they dont e:ven: give me to s- [.] not even to tlike [.] pass water, my:: [.] lady [.] [] thats to say What have you don::e? shell be saying to me then, so- I ha:v:e to bear it, so- for that reason [.] [] thats to say, li:ke [.] its like I:: [] [.] like as if [.] a:ir is in my- inside my my antes que me bajaba mi perodo mi::: dola, o sea [.] en- [.] como trabajo yo, [] en mi trabajo no me da n:i: para s:- [.] ni para tas [.] desaguar, mi:: [.] seora [.] [] o sea Qu has hecho::? me dicer ps entons- me to:ca: aguantar entons- de ese motivo [.] [] o sea como: [.] como qui mi:: [] [.] como que [.] a:ire est en mi- dentro de mi mi
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stomach here so- from the umbilicus it rose up to me here. [.] Here I felt bad. [.] [] After: [.] that: [1] er I::um [.] I took herbal te::as [.] like. [] So that:: [.] that a:ir um [.] ALREADY I WAS ALL RIGHT: [.] after that, [.] that: [.] thing cam:e to me. [3] Thats to say more before i:t used to swell me up here [.] where the womb is [.] there [.] like as if: like Im blown up. [2] So [.] er I
estmago aqu entons- del ombligo me suba aqu. [.] Aqu me senta mal. [.] [] Despus: [.] eso: [1] eh me::m [.] he tomado mate::s [.] as. [] Para que:: [.] ese a:ire ehm [.] YA ESTABA BIEN: [.] despus de eso, [.] es:a [.] cosa me ha: venido. [3] O sea ms antes mi: hinchaba aqu [.] donde el matrz [.] ah [.] as como: como que estoy enflado. [2] Entonces [.] eh yo he
wouldnt make me make me swell up. Af:ter [1] que no me se me hinchar. Despus: [1]
Here the second side of cassette 3.1 ends (up to here, there have been 7 minutes of recording 3.4). [[The recording is cut for a few seconds while SR changes the cassette.]]
Termina el segundo lado del cassette 3.1 (hasta aqu, van 7 minutos de la grabacin 3.4). [[Se corta la grabacin durante unos segundos mientras SR cambia el cassette.]]
Start of the first side of cassette 3.3 [16] Dr. D: [[in an emphatic and direct tone]] When did the period come? [1] Mrs. N: Er: fourteenth of::: m:: [.] Dr. D: November. Mrs. N: November.
Se inicia el primer lado del cassette 3.3 [16] Dr. D: [[en tono enftico y directo]] Cundo ha bajado la menstruacin? [1] Sra. N: Eh: catorce de:::m:: [.] Dr. D: Noviembre. Sra. N: Noviembre.
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Dr. D: Thats to say, its just about to come now, right? Mrs. N: Yes, its just// Dr. D: //Every month it comes?
Dr. D: O sea, ya va a bajar ahora, no? Sra. N: S, ya va// Dr. D: //Cada mes baja?
Mrs. N: Every month. One {day: it does:, [??]} Sra. N: Cada mes. Un {d:a s:, [??]} Dr. D: {How- How many da}ys does it last? How many days does it last? [.] Mrs. N: Er: [.] four days. Dr. D: [[repeats in almost inaudible tone, talking to himself while he notes down]] Four down to you for the FIRST TIME? [.] How many years old were you? Mrs. N: I was: ele:ven years old. Dr. D: Eleven. Early you got it! Mrs. N: [[in a low tone, sighing]] Yes:: Dr. D: And how many kids have you had? Mrs. N: Er:: [.] Ive had two:. Dr. D: TWO? Mrs. N: [[in a very low tone]] Mm: {[?] after:} Dr. D: {Cunt- Cuntos d}as dura? Cuntos das dura? [.] Sra. N: Ehh: [.] cuatro das. Dr. D: [[repite en voz casi inaudible, hablando solo mientras anota]] Cuatro te ha bajado la PRIMERA VEZ? [.] Cuntos aos tenas? Sra. N: Yo tin:a o:nce aos. Dr. D: Once. Temprano te ha bajado! Sra. N: [[en voz baja, suspirando]] S:: Dr. D: Y cuntas wawas has tenido? Sra. N: Eh:: [.] he tenido dos:. Dr. D: DOS? Sra. N: [[en voz muy baja]] Mm: {[?] despus:}
days. [2] [[in emphatic tone]] When did it come das. [2] [[en tono enftico]] Cundo
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Appendix 4
Dr. D: {[??]} Af{ter?} Mrs. N: [[in a very low tone]] {Ive had} two abortions:. Dr. D: Two abortions! Mrs. N: [[in almost inaudible tone]] Yes. Dr. D: Yes? [1] And did you have it [1] Mrs. N: Mm: [.] no. [1] Or:{:[.]} Dr. D: {[??]} Mrs. N: I had it taken out of me. [.] Dr. D: The two {times?} Mrs. N: {[?]} Yes. [[in a very low tone that becomes almost inaudible]] The two times. Because I didnt hav:e [.] [in]su:ran:ce: [.] my little daughter was only three months:, Dr. D: Yes Mrs. N: And after three months that: I: had it taken out of me again I got pregnant [[in it taken out of me. [1] My daughter was going to su:ffer. [.]
Dr. D: {[??]} Des{pus ?} Sra. N: [[en tono muy bajo]] {He tenido} dos abortos:. Dr. D: Dos abortos! Sra. N: [[en voz casi inaudible]] S. Dr. D: S? [1] Y vos te has hecho [1] Sra. N: Mm: [.] no. [1] O:{:[.]} Dr. D: {[??]} Sra. N: yo me he hecho sacar. [.] Dr. D: Las dos {veces?} Sra. N: {[?]} S. [[en voz muy baja que se vuelve casi inaudible]] Los dos veces. Porque no ten:a [.] [se]gu:ro:s: [.] mi hijita tena apenas tres meses:, Dr. D: S Sra. N: Y despus de tres meses que: me he hecho sacar de vuelta me he embarazado [[en he hecho sacar. [1] Mi hija iba a sufri:r. [.]
taken out of you, or all by itself did it come out? sacar, o solito se ha salido?
almost inaudible tone, sighing]] and again I had voz casi inaudible, suspirando]] y de vuelta me
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Appendix 4
Dr. D: Ri:ght. [2] Thats to say [.] four times youve got pregnant, youve had two kids [1] two abortions. THE LA:ST, [.] the la:st, what was it? [.] That fail- that abortion, or [.] birth. [1] Mrs. N: Mm: [.] it was:nt [.] a birth, but it {was [?]} Dr. D: {Abortion.} Mrs. N: Abortion. Dr. D: Whe:n: was that? Mrs. N: [] Thats to say, just like that it appethats how that was. [.] Mm [.] when she was three months my daughter, at: four months already I was: pregnant, I was. Dr. D: Right. And? Mrs. N: After [.] that I had it taken out of me, [.] like at: two months I had it taken out of me. Dr. D: Right. When was that? [.] Mrs. N: That was: like: [.] My daughter is four years old. [1] Dr. D: Right. Four years ago? Mrs. N: Yes:.
Dr. D: Y:a. [2] O sea [.] cuatro veces te has embarazado, has tenido dos wawas [1] dos abortos. LO U:LTIMO, [.] lo :ltimo, qu ha sido? [.] Ese frac- ese aborto, o [.] parto. [1] Sra. N: Mm: [.] n:o era: [.] parto, sino que {ha [?]} Dr. D: {Aborto.} Sra. N: Aborto. Dr. D: Cu:n:do ha sido eso? Sra. N: [] O sea, as ha apareas ha sido eso. [.] Mm [.] cuando estaba de tres meses mi hija, a los: cuatro meses ya estaba: embarazada yo. Dr. D: Ya. Y? Sra. N: Despus de [.] eso me he hecho sacar, [.] como de: dos meses me he hecho sacar. Dr. D: Ya. Cundo ha sido eso? [.] Sra. N: Eso ha sido: as: [.] Mi hija tiene cuatro aos. [1] Dr. D: Ya. Hace cuatro aos? Sra. N: S:.
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Dr. D: Or after, another one did you have? [.] Mrs. N: N:o. I havent had//
Dr. D: O despus, otro ms has tenido? [.] Sra. N: N:o. No he tenido//
Dr. D: //Its- since that time, again you havent Dr. D: //Es- desde esa vez ya no te has got preg{nant?} Mrs. N: {An:d [.] right.} [] I had it put in me for that, so as not to have one, Dr. D: {Yes} Mrs. N: {I di}d:- [.] a copper T, in Grover Hospital they put it in me. Dr. D: And:? Mrs. N: An:d after: with:: Doctorita Mara [.] Lpez I had it put in me. [2] After I: [.] {she [??]} Dr. D: [[almost shouting]] {HOW LONG} DID YOU USE IT? Mrs. N: Ah: [.] two ye:ar: [.] and a bit more than- [.] like {five mo:n-} Dr. D: {Two years.} Mrs. N: No. Dr. D: Right. {Up until} Mrs. N: {Four months.} em{barazado?} Sra. N: {Y: [.] ya.} [[suspira]] Me he hecho colocar por eso para no tener, Dr. D: {S} Sra. N: {he he}cho:- [.] T de cobre en el Hospital Grover me han colocado. Dr. D: Y:? Sra. N: Y: despus: a:: la Doctorita Mara [.] Lpez me he hecho colocar. [2] Despus me: [.] {ella [??]} Dr. D: [[casi gritando]] {CUANTO TIEMPO} HAS USADO? Sra. N: Ah: [.] dos a:o: [.] y un poco ms de- [.] co{mo cinco me:-} Dr. D: {Dos aos.} Sra. N: No. Dr. D: Ya. {Hasta hace} Sra. N: {Cuatro meses.}
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Appendix 4
Dr. D: whe:n [.] until- up- until whe:n? [2] Until when? When did you have it taken out of you? Mrs. N: I had it taken out of me in October. Dr. D: Up until October of this: [.] now already- now do you want to get pregnant? [1] Mrs. N: N::o! Im taking care of myself like that, {just.}
Dr. D: cu:ndo [.] hasta- hace- hasta cu:ndo? [2] Hasta cundo? Cundo te has hecho sacar? Sra. N: Me he hecho sacar en octubre. Dr. D: Hasta octubre de este: [.] ahora ya- ahora quieres embarazarte? [1] Sra. N: N::o! Me estoy cuidando as {noms.}
Dr. D: {How} are you taking care of yourself? Dr. D: {Cmo} te ests cuidando? Mrs. N: Like that counting the days. Dr. D: Yes? [[in a low tone]] How do you count the days? Mrs. N: Thats to say, fifteen day:s [.] I count, at times twelve day:s, like that. Dr. D: And? Mrs. N: But:: [.] {Im} Dr. D: {And what happens?} Sra. N: As contando los das. Dr. D: S? [[en tono bajo]] Cmo cuentas los das? Sra. N: O sea, quince d:as [.] cuento, hay ratos doce d:as, as. Dr. D: Y? Sra. N: Pero:: [.] {estoy} Dr. D: {Y qu pasa?}
Mrs. N: Thats to say: [.] Im not: [.] either Im Sra. N: O sea: [.] no: [.] tampoco estoy not taking any pill, all this. Dr. D: Lets see. Now [.] now [.] for when do you expect your menstruation? [.] tomando ningn pastilla, todo esto. Dr. D: A ver. Ahora [.] ahora [.] para cundo esperas tu menstruacin? [.]
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Mrs. N: Er [.] I expect it for [1] fif:teenth, fourteenth, around then. Dr. D: Now can you have relations, or not? [1] Mrs. N: N:: [1] Dr. D: [[in a low tone]] Right now if your husband [1] er: [.] says to you [1] lets have relations. [2] Can you have it [.] so as not to get yourself preg:nant, [.] to get yourself preg:nant, how [??]? Mrs. N: Mm: [1] Yes, but: [.] as Im not:: [.] twhen it is:: [.] p:assing, the period, [1] [] the Doctorita told me, youre going to take care of yourself, she {told me.} Dr. D: {When} its passing? [.]
Sra. N: Eh [.] espero para [1] qui:nce, catorce, por ah. Dr. D: Ahora puedes tener relaciones, o no? [1] Sra. N: N:: [1] Dr. D: [[en tono bajo]] Ahorita si tu marido [1] e:ste [.] te dice [1] "tenemos relaciones". [2] Puedes tenerlo [.] para no embaraza:rte, [.] para embaraza:rte, cmo [??]? Sra. N: Mm: [1] S, pero: [.] como no:: [.] tcuando est:: [.] p:asando el perodo, [1] [] l:a Doctorita me ha dicho, te vas a cuidar, me ha {dicho.} Dr. D: {Cuando} est pasando? [.]
Mrs. N: When your period is passing you take Sra. N: Cuando est pasando tu perodo te vas care of yourself, she told me. Dr. D: Thats to say when you are- [.] menstruating, [1] youre not going to [.] have relations? [1] Mrs. N: When I am menstruating I can have relations, but when alre:ady its passed me, [.] I cant have relations, because: a cuidar, me ha dicho. Dr. D: O sea cuando est- [.] menstruando, [1] no vas a [.] tener relaciones? [1] Sra. N: Cuando estoy menstruando puedo tener relaciones, pero cuando ya se me ha:ya pasado, [.] no puedo tener relaciones, porque:
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Dr. D: Thats to say, five [.] day:s only [1] [] It lasts you four days, your menstruation? Mrs. N: Yes. [1] Dr. D: And those four days only you can hav:e [1] relations, then [1] all the {month,} Mrs. N: {[?]} Dr. D: NOTHING? [1]
Dr. D: O sea, cinco [.] d:as noms [1] [] Te dura cuatro das tu menstruacin? Sra. N: S. [1] Dr. D: Y esos cuatro das noms puedes tener: [1] relaciones, despus [1] todo el {mes,} Sra. N: {[?]} Dr. D: NADA? [1]
Mrs. N: [] N::o! Thats to say, twelve days: [.] Sra. N: [] N::o! O sea, doce das: [.] to m:e she told that, well, up to fifteen she told me. [2] Because:: [1] you cant be[.] maybe// Dr. D: //AND AFTER THE FIFTEENTH? [2] Mrs. N: One can have rela{tions.} Dr. D: {Thats to say,} now you can have them? Mrs. N: [[in an almost inaudible tone]] Yes:. [1] Dr. D: Like that you take care of yourself. [1] Mrs. N: Yes. m:e ha dicho ella pues, hasta quince me ha dicho. [2] Porque:: [1] n:o puedes estar[.] por ah// Dr. D: //Y DESPUES DEL QUINCE? [2] Sra. N: Se puede tener rela{ciones.} Dr. D: {O sea,} ahora puedes tener? Sra. N: [[en voz casi inaudible]] S:. [1] Dr. D: As te cuidas. [1] Sra. N: S:. maximum youre going to take care of yourself, mximo te vas a cuidar,
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Dr. D: [[in an almost inaudible tone, as if talking to himself]] Right. [3] So [.] you are using the method of rhy:thm, right? That would be it [.] [[while noting down what he is saying]] me:thod of rhy::thm. [1] Mrs. N: Yes. [sighs] After I had it taken out of me [??] but, she gave me like a little pill, [.] she prescribed it to me so you dont- [] er- [.] because: they say that quickly one gets pregnant when the copper T is taken out. [1] Dr. D: And? Mrs. N: An:d [.] I took it, but:: Dr. D: What little pill? Mrs. N: Tha:t was: m::- I dont know what it was called that little pill to::- [.] little tiny ones. [2] Dr. D: Which? Mrs. N: [??] a little ta:bl:et: [.] Dr. D: Yes. [.] Each day? [1] Mrs. N: Yes, Each night youre to take it//
Dr. D: [[en voz casi inaudible, como hablando solo]] Ya. [3] Entonces [.] ests usando el mtodo del r:itmo, no? Eso sera, [.] [[a tiempo de anotar lo enunciado]] m:todo del r::itmo. [1] Sra. N: S. [[suspira]] Despus que me he hecho sacar [??] pero, me ha dao as una pastillita, [.] me ha recetado para que no te- [] eh- [.] porque: dice que rpido se embaraza cuando se saca el T de cobre. [1] Dr. D: Y? Sra. N: Y: [.] he tomado, pero:: Dr. D: Qu pastillita? Sra. N: E:sa era: m::- no s qu se llamaba esa pastillita para::- [.] chiquititos. [2] Dr. D: Cul? Sra. N: [??] una ta:ble:ta: [.] Dr. D: S. [.] Cada da? [1] Sra. N: S, Cada noche vas a tomar//
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Dr. D: //Each- [.]Did you take it? All the {month?} Mrs. N: {I} took it. All- [.] all the month I took that, after [1] [] thats to say, it gave me lik::- [.] dizziness it gave me, then I left that. [.] Dr. D: Mhm: Mrs. N: Youre to come back, she told me it called that hospital, whats it called that hospital, [.] [] There Ill give it to you, she told me. But: [.] I havent gone back again because: [1] it gave me like di:zziness: [.] it was bad for me [???] it was bad for me. [.] Dr. D: Mm Mrs. N: Thats why I left it. [1] But- [1] [] and [1] Dr. D: Ve:ry well. [1] So now: youre taking care of yourself with the method of rhythm, right? Mrs. N: Yes. [1]
Dr. D: //Cada- [.] Has tomado? Todo el {mes?} Sra. N: {He} tomado. Tod- [.] todo el mes he tomado eso, despus [1] [] o sea, me ha dado com::- [.] maros me ha dao, despus lo he dejado eso. [.] Dr. D: Mjm: Sra. N: Vas a volver, me ha dicho se llama ese hospital, qu se llama ese hospital, [.] [] Ah te voy a dar, me ha dicho. Pero: [.] ya no he vuelto porque: [1] me ha dado como m:areos: [.] me haca mal [???] me haca mal. [.] Dr. D: Mm Sra. N: Por eso he dejado. [1] Pero- [1] [] y [1] Dr. D: Mu:y bien. [1] Entonces ahora: te ests cuidando con el mtodo del ritmo, no? Sra. N: S. [1]
[??]. [.] Thats to say in the: [.] clinic: [.] whats [??]. [.] O sea en el: [.] clnica: [.] qu
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Appendix 5
Appendix 5 Contextualisation of transcript excerpt introducing Chapter 5, The Empty Bed

Excerpt of SRs transcribed field notes on interactions with the following characteristics: Participants: Dr. Gonzles (Dr. G), staff gynaecologist and academic coordinator of residents training, principal research collaborator in Insurance Hospital. Mrs. Mayta (Mrs. M), awaiting oncological surgery following a therapeutic interruption of pregnancy in the hospital. Mrs. Quiroga (Mrs. Q), awaiting gynaecological surgery. Three other women visited in their beds on the ward round. Nurse, medical resident, and intern Rayda (R), all women. SR as researcher. Date and time of observation: Place: Source of notes on context: Number & date of transcript: Context: This transcript is of fieldnotes written at the time of the gynaecology ward round which I accompanied on the invitation of Dr. Gonzles, my principal collaborator in the Insurance Hospital. Just before the ward round, on the initiative of Head Nurse Elena Elas, for the first time I attended the daily change of medical shifts (cambio de turno) in the gynaecology ward classroom. This session was led by Dr. Salinas, the ward chief. When it ended, Dr. Salinas introduced me to the group of doctors and residents, saying: Shes going to accompany us. He asked me to give a talk two days later to all the ward staff, to present some of my research findings. I left the classroom with Dr. Gonzles, a nurse, and two women whom I took to be residents, to accompany them on the ward round. This transcript is of notes I took at the time of the ward round and just afterwards, in view of those present. Before leaving with Dr. Gonzles for the operating theatre, I spoke to Rayda, who turned out to be an intern. Monday 31/3/97, 8.10 8.30 a.m. Gynaecology ward, Insurance Hospital Field Notebook 3, notes summarised 21/4/97, edited 22/7/02. A.X9.1, 21/4/97
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Start of Transcript A.X9.1, notes from Field Notebook 3: Dr. G starts the medical visit with nurse and 2 residents.i Dr. G: (1st bed visited) 16 weeks of pregnancy. Tumour. Dermoid. (to SR:) Medical Council. Interruption of pregnancy. Pregnancy of high risk. Its in the pages of the daily report... Oncology. _____ Dr. G: (to Mrs. M) How are you A little bleeding You know Transfer to Oncology Youre not to get pregnant Reproductive Health
Inicio de la transcripcin A.X9.1, apuntes del Cuaderno de Campo 3: Dr. G empieza la visita mdica con enfermera y 2 residentes . Dr. G: (1ra cama visitada) 16 semanas de embarazo. Tumor. Dermoide. (a SR:) Junta mdica. Interrupcin de embarazo. Embarazo de alto riesgo. Est en las hojas del informe diario... Oncologa. _____ Dr. G: (a Sra. M) Cmo est Sangradito T sabes Transferencia a Oncologa No hay que embarazarse Salud Reproductiva
She mustnt have another unwanted pregnancy, Que no tenga otro embarazo no deseado, another abortion. Dangerous. _____ Mrs. M: All right doctor ________ Dr. G: Her risk card (NOTE: check) _____ We include her as incomplete abortion. ____ Nurse: She is Doctor on Methergin __ Dr. G: Dermoid tumour. otro aborto. Peligroso . _____ Sra. M: Ya doctor _____ Dr. G: Su carnet de riesgo (NOTA: chequear) _____ Le incluimos como aborto incompleto. _____ Enfermera : Ella est Doctor con Methergin -Dr. G: Tumor dermoide.
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Mrs. M x Pregnant resident Dr. G Nurse
Mrs. M x Embarazada RM Dr. G Enfermera
resident
SR
RM
SR
Dr. G: (to Mrs. M) Youve got up? A little bleeding? Little? Right. _____ A little more orientation. ____________________ (Next bed) Dr. G: (to pregnant woman resident) 35 years. Bleeding. Pelvic tumour Biopsy _____ Nurse: Metronidazol. _____ Dr. G: (to ) A little bit of patience. Metronidazol in pessaries. _____ Dr. G: (to ) Have someone come and give blood in case we decide on the intervention. _____ Dr. G: (examines same in the bed) A little bleeding ... Seventh day
Dr. G: (to Mrs. M) Te has levantado? Sangradito? Poco? Ya. _____ Un poco ms orientacin. ________________________ (Prxima cama) Dr. G: (a Residente Mdica embarazada) 35 aos. Sangrado. Tumor plvico Biopsia _____ Enfermera: Metronidazol. _____ Dr. G: (to ) Un poquito de paciencia. Metronidazol en vulos. _____ Dr. G: (a ) Alguien que venga a dar sangre - por si decidimos la intervencin. _____ Dr. G: (examina a misma en la cama) Sangrecita ... Sptimo da
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Operatedii : All right Doctor. : - - go to the bathroom Cramp in my leg It doesnt pass in me Dr. G: Ferrous sulphate Dizziness? : A little... Dr. G: Well see the haemoglobin, how it is. Bland diet. Take out little stitches. Keep resting Today is the 31 . _____ : Doctor? _____ Dr. G: ... _____ : I want... _____ Dr. G: (speaks very rapidly) Ask for an appointment for check-up. (8.14) : All right Doctor. This Friday. (Rapid exchange) : (complains as Dr. G takes out stitches) Dr. G: Loosen up now.
st
Operadita : Ya Doctor. -- ir al bao Calambre en la pierna No se me pasa Dr. G: Sulfato ferroso Mareos ? Un poco...
Dr. G: Veremos la hemoglobina como est. Dieta blanda. Sacar puntitos. Mantener reposo Hoy da es 31. _____ : _____ Dr. G: ... ________ : Yo quiero... _______ Dr. G: (habla muy rpido). Pide una cita para control. (8.14) : Ya Doctor. Este viernes. (Intercambio rpido). : (se queja cuando Dr. G saca puntos) Dr. G: Sueltita noms. Doctor?
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Analgesic. (SR and in previous bed exchange gestures of empathy with who is complaining). (Bed # ) Dr. G: (to SR) Shes from another service, from surgery... _____ (Bed # -) Dr. G: She has done to herself... (a ) Where do you work? (rural worker) _____ : Doctor, am I going to have - days? _____ Dr. G: - - yet. You have to be tranquil.iii Do you work Saturdays? : No. Monday to Friday.
Calmante. (SR y en cama anterior intercambian gestos de empata con que se queja.) (Cama # -) Dr. G: (a SR) Es de otro servicio, de ciruga... _____ (Cama # -) Dr. G: Ella se ha hecho .. (a ) Dnde trabajas ? (campesina) _____ : Doctor, voy a tener - das?. _____ Dr. G: - - todava. Tiene que estar tranquilita. Sbado trabaja? No. Lunes a viernes. _____ Dr. G: Se va a abrigar bien. Se va a cuidar. _____ (Cama # - Dr. G saluda y sale. ____________________ ( Sala 9) # - cama vaca - se paran al pie de la cama.)
_____ Dr. G: Youre going to wrap yourself up well. Youre going to take care of yourself. _____ (Bed # Dr. G greets and leaves. ____________________ ( Ward 9) (# empty bed they stand at the foot of the bed.)
Dr. G: (to SR) They are patients who are going Dr. G: (a SR) Son pacientes que se van to be operated downstairs... a operar abajo...
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_________ Dr. G: (to SR) Do you want to enter the operating theatre? SR: I do too, if you allow me to. Dr. G: - - pupils who are going to arrive from the interior of the country... but I dont see them _____ (Dr. G writes at foot of empty bed. Puts papers on bed.) ______________ (Patient enters in a hurry.) Mrs. Q: Here I am! Here I am! Sorry (to Dr. G:) Ive got my period. Nothing to do with it? Dr. G: No its programmed. (To R who is leaving:) See you Rayda. (SR asks Rayda if she is a resident.) R: Intern SR: Of what year? R: Final year. ___________ We go down operating theatre... SR: (to Rayda) Does the visit really end there? R: The Doctor only passes it in his ward.
_________ Dr. G: (a SR) Quiere entrar a quirfano ? SR: Tambin, si me permiten. Dr. G: - - alumnos que van a llegar del interior del pas... pero no los veo _____ (Dr. G escribe a pie de cama vaca. Pone papeles en cama. __________ (Paciente entra apurada.) Sra. Q: Aqu estoy! Aqu estoy! Perdn (a Dr. G:) Estoy con mi perodo. Nada que ver? Dr. G: No - est programada. (A R, saliendo:) Nos vemos Rayda. (SR pregunta a Rayda si es residente.) R: Interna SR: De qu ao? R: Ultimo ao. _________ Bajamos quirfano... SR: (a Rayda) Acaso la visita se termina all? R: El Doctor slo pasa de su sala.
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SR: His ward? R: Its passed by 3 doctors at once on Wednesdays - grand round, there is. ______________________________ End of Transcript A. X9.1
SR: Su sala ? R: Pasan 3 doctores a la vez el mircoles - visita general hay. _____________________________ Fin de la transcripcin A.X9.1
Notes I initially supposed that both women were residents, but at the end of the round I found that one of them, Rayda, was an intern. ii Diminutive form, operadita, used in Spanish original. iii Diminutive form, tranquilita, used in Spanish original.
i
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Appendix 6
Appendix 6 Contextualisation of transcript excerpt cited in section 6.6 of Chapter 6, Sociology of a Syringe
Excerpt of transcript of interview recorded by SR with the following characteristics: Participants: Nurse Elena Elas (Nurse EE),i Head Nurse of Insurance Hospital gynaecology ward; SR as researcher. Date and time of interview: Place: Source of notes on context: Number & date of transcript: Context: This was the first interview I (SR) requested with Nurse Elena Elas (Nurse EE), on the day I returned to the hospital for the final stage of fieldwork. This followed almost a month of my absence from the hospital because of illness (paratyphus). It fell three days after the general elections won by ADN (Accin Democrtica Nacionalista), the party of former military dictator General Hugo Banzer. My wish to interview Nurse Elas (Doa Elena) was generated by a recorded interview that I had done earlier that morning with staff gynaecologist Dr. Walters. He had mentioned that a barrier to the wider use of Manual Vacuum Aspiration (MVA) was nurses resistance to the technology because of the extra work it meant for them, disinfecting the instruments and cleaning up blood spattered in the treatment rooms. I requested the interview with Doa Elena and waited for an hour in the nurses station until she had time for me. She was especially busy because she was due to go on holiday leave two days later. We did the interview with the sporadic presence of various other paramedical workers, and visitors. I tried to complete it in the shortest possible time because Doa Elena was very busy and there were frequent interruptions and a lot of noise. The transcript below corresponds to the totality of the 11-minute recorded interview with Nurse Elas. Wednesday 4/6/97, 10.15 11.23 a.m. Nurses station, gynaecology ward, Insurance Hospital Field Notebook 4, notes summarised 12/6/97, edited 23/7/02 14.1, 12-13/6/97
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Start of Transcript 14.1 SR: Right! [] so [.] mm: [.] I wanted to ask you [.] about: the use of MVA, of manual aspiration Nurse EE: Ah, right SR: in the Hospital. [] And:: what it signifies for the personnel, especially in Nursing, [] the use [.] or non-use of this me{thod} Nurse EE: {Ah, right} SR: especially for the treatment of incomplete abortion. [.] Nurse EE: Mostly they do:nt [.] they dont do it in incomplete abortions. [1] The majority of times they do it [.] [] on: patients who have for example: anembryonic diseases: or: trophoblastic diseases. [.] In those {cases} SR: {Mm} Nurse EE: they do it [.] to se:nd um: [.] all thats: [.] obtained [.] to Pathology its sent [.] for bio:- o:r to do a biopsy. SR: Right Nurse EE: To determine [.] from what cause
ii
Inicio de la Transcripcin 14.1 SR: Ya! [] -tonces [.] mm: [.] yo quera preguntarle [.] sobre: el uso del AMEU, de la aspiracin manual Lic. EE: Ah, ya SR: en el Hospital. [] Y:: qu significa para el personal, especialmente de Enfermera, [] el uso [.] o no uso de este m{todo} Lic. EE: {Ah, ya} SR: especialmente para el tratamiento del aborto incompleto. [.] Lic. EE: Mayormente no: [.] no hacen en abortos incompletos. [1] La mayora de las veces hacen [.] [] en: pacientes que tienen por ejemplo las: enfermedades anembrionadas: o: l:as enfermedades trofoblsticas. [.] En esos {casos} SR: {Mm} Lic. EE: hacen [.] para envia:r ahm: [.] todo lo: [.] obtenido [.] a Patologa se enva [.] para: bio:- o: para hacer una biopsia. SR: Ya Lic. EE: Para determinar [.] de qu causa
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is: the: SR: Right Nurse EE: the: [.] well the: [.] the degeneration, like of the tissue, right? SR: Aha Nurse EE: of that degenerated pregnancy, its a degenerated pregnancy, it would be SR: Right Nurse EE: It is not: a normal pregnancy. Mm
es: el: SR: Ya Lic. EE: el: [.] pues el: [.] la degeneracin, eso del tejido, no? SR: Aj Lic. EE: del embarazo ese degenerado, es un embarazo degenerado, sera SR: Ya Lic. EE: No es: un embarazo normal. Mm
SR:
SR:
Nurse EE: Uh- in those cases they do it. [] And [.] also they do it when theres a lot of bleeding, like haemostasisiii, in an emergency, so as: not to wait for the patient [] uh: to bleed herself away until she goes to the operating theatre, because in theatre they dont do it to them immediately, they rarely accept them from us when theyre emergency cases. [] Because always theyre busy, the theatres. [.] {In} SR: {Mhm} Nurse EE: those cases, yes, here also
Lic. EE: Ah- en esos casos hacen. [] Y [.] tambin hacen cuando hay mucho sangrado, como hemostasia, de urgencia, para: no esperar a que la paciente [] eh: se desangre mientras vaya a quirfano, porque en quirfano no les hacen inmediatamente, rara vez nos aceptan cuando son casos de urgencia. [] Porque siempre estn ocupados los quirfanos. [.] {En} SR: {Mjm} Lic. EE: esos casos s, aqu tambin
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they use: MVA SR: Right Nurse EE: for those cases. [.] SR: And why would it be that theyre no longer using it so much for:: incomplete abortion? [.] Nurse EE: No, they do:nt use it, not at all. SR: Aha Nurse EE: Mhm SR: Because its: {[??]} Nurse EE: {ON RARE OCCA:SIONS} they used it [.] on rare occasions they used it. SR: Yes Nurse EE: [] It seems tha::t [1] they have the idea: that if it were to be used, if they learn, some other doctors, that, [.] er:: [] they would do it even in their surgeries: [.] if they had that, thats why it seems that its: like restricted, [] only for those cases of:: [.] haemorrhages: in cases of: pregnancies like [1] anembrio:nic, mo:lar,iv
emplean el: AMEU SR: Ya Lic. EE: para esos casos. [.] SR: Y por qu ser que ya no estn utilizando tanto para:: aborto incompleto? [.] Lic. EE: No, no: usan, nada. SR: Aj Lic. EE: Mjm SR: Porque es: {[??]} Lic. EE: {RARA VE:Z:} usaban [.] rara vez usaban. SR: S Lic. EE: [] Parece que:: [1] tienen la idea: de que si es que se usara, si aprenden algunos otros mdicos eso, [.] eh:: [] haran hasta en su consultorios: [.] teniendo eso, por eso parece que es: as restringido, [] slo para estos casos de:: [.] hemorragias: en casos de: embarazos as [1] anembriona:dos, en mo:la,
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SR: Mm: Nurse EE: like degenerated, right, a degenerated pregnancy. SR: Right Nurse EE: Thats it. [.] Because always they first do MVA on them here [.] [] and afterwards only in the afternoon they go to: theatre for their curettage,v {fo:r} SR: {Ah:} Nurse EE: further clea:ning, in: theatre. SR: Ah, right Nurse EE: First of all, always here the MVA, with MVA they resolve: it SR: Ah, right Nurse EE: the anembryonic ones. [.] SR: Right. [1] Right. But from the point of view of the nurses, lets say, [1] which of the methods has more advantages? [.] From the point of view of you: all. Nurse EE: Mm:: curettage in theatre, n:because this MVA is a little bit traumatic here, []
SR: Mm: Lic. EE: as degenerados, no, un embarazo degenerado. SR: Ya Lic. EE: Eso. [.] Porque siempre les hacen primero AMEU aqu [.] [] y despus recin en la tarde van al: quirfano para su legrado, pa{ra:} SR: {Ah:} Lic. EE: limpie:za posterior, en: quirfano. SR: Ah, ya Lic. EE: Primeramente siempre aqu el AMEU, con AMEU resuelven: SR: Ah, ya Lic. EE: los anembrionados. [.] SR: Ya. [1] Ya. Pero desde el punto de vista de las enfermeras, digamos, [1] cules de los mtodos tiene mayores ventajas? [.] Segn el punto de vista de ustedes:. Lic. EE: Mm:: el legrado en quirfano, n:porque esto del AMEU es un poquito traumtico aqu, []
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the patients: [.] a:re without anaesthesia:, directly they do it to them []
las pacientes: [.] est:n: sin anestesia:, directamente les hacen []
with local: anaesthesia in the ne:ck of the womb con anestesia local: en cue:llo sometimes:, some little pricks and nothing more, directly! [] But that is not an anaesthesia: nor of- complete relaxation! [.] [] So they feel mu:ch pain [2] much pain. Mu:ch they complain, the patients. SR: M:hm: [.] And as regards the hygiene of the i:nstruments: Nurse EE: That is d- its s- its sterilised here, for half an hour with: [.] with: bleach, its [??] [.] At two per cent its used, [] for half an hour theyre sterilised [.] the {ca} SR: {Right} Nurse EE: nnulae. The syringe, not. [] Its not sterilised, the syringe is not sterilised, {right?} SR: {Aha} a veces:, unos pinchacitos y nada ms, directo! [] Pero eso no es un anestesia: ni de- relajamiento completo! [.] [] As que siente mu:cho dolor [2] mucho dolor. Mu:cho se quejan las pacientes. SR: M:jm: [.] Y en cuanto a la higiene de los instrume:ntos: Lic. EE: Eso se de:- se e:-se esteriliza aqu, por media hora con: [.] con: lavandina se [??] [.] Al dos por ciento se usa, [] por media hora se esterilizan [.] las {c} SR: {Ya} Lic. EE: nulas. La jeringa, no. [] No se la esteriliza, la jeringa no se esteriliza, {no?} SR: {Aj}
with::: [deter]gent [??] [.] sodium hypochlorite! con::: [deter]gente [??] [.] hipoclorito de sodio!
Nurse EE: The ca:nnulae, [] and:: [.] the::: [.] Lic. EE: Las c:nulas, [] y:: [.] el::: [.] the cannulae! in themselves. SR: Right: [.] Nurse EE: And their adaptors too {are} las cnulas! en s. SR: Ya: [.] Lic. EE: Y sus adaptadores ms {se}
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SR: {Yes:} Nurse EE: sterilised in: that {sodium hypochlorite.} SR: {Ri:ght.} [.] [] But [.] does that mean more work for Nursing? That type of: {sterilisation?} Nurse EE: {Er: n:o:t} mu:ch. Only that they wait, its- here the:- the one who takes charge: directly is the one doing cubicles. The one who is in charge of [?]. So she is the one who already knows, SR: Mhm Nurse EE: [] she sterilises [.] for ha:lf an hour, half an hour she ca:lls: them, they do the MVA, []
SR: {S:} Lic. EE: esteriliza en: ese {hipoclorito de sodio.} SR: {Ya:.} [.] [] Pero [.] eso significa ms trabajo para Enfermera? Este tipo de: {esterilizacin?} Lic. EE: {Eh: n:o:} mu:cho. Slo que esperan, es- aqu la:- la que se encarga: directamente es la de cubculos. La que est a cargo de [?]. Entonces ella es la que ya sabe, SR: Mjm Lic. EE: [] esteriliza: [.] m:edia hora, media hora les lla:ma:, hacen el AMEU, []
and: the doctor who u:ses [.] all the instruments, y: el mdico que utili:za [.] todo el instrumental, he in person has to wa:sh, [] dry: and [[smiling]] return everything clea:n, well lubricated the syringe, all that, [] in person, [[laughing]] right, to Nursing! SR: Yes! Nurse EE: We: [.] the nurse does not occupy herself with the cleaning after use. SR: Ah:, {right} Nurse EE: {The} doctor in person [.] does the clea{ning.} l en persona tiene que lava:r, [] seca:r y [[sonriendo]] devolver todo li:mpio, bien lubricada la jeringa, todo eso, [] en persona, [[riendo]] no, a Enfermera! SR: S:! Lic. EE: Nosotros: [.] la enfermera no se ocupa del aseo despus del uso. SR: Ah:, {ya} Lic. EE: {El} mdico en persona [.] hace el a{seo.}
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SR: {And:} why was that determination made? Nurse EE: Because they have to clean we::ll, since they are with gloves, directly they come here and they clean it and they lubricate it, -so they know how to lubricate and how to handle the syringe, we dont know very well how to handle the syringe, becthey [.] [] un- adjust its bu::ttons, some things they have nh [.] behind that, [] and they in person SR: Right Nurse EE: Like that. SR: Ah{a:} Nurse EE: {Sin}ce the beginning it was: implanted that method of: Ah:, right
SR: {Y:} por qu se ha tomado esta determinacin? Lic. EE: Porque ellos tienen que limpiar bie::n, como estn con guantes, directamente ellos vienen aqu y lo asean y ellos lo lubrican, -tonces saben cmo lubricar y cmo manejar la jeringa, nosotros no sabemos muy bien manejar la jeringa, porellos [.] [] de- ajustan sus boto::nes, unas cosas tienen ellas nj [.] detrs de eso, [] y ellos en persona SR: Ya Lic. EE: As. SR: Aj{:} Lic. EE: {Des}de un principio se ha: implantado ese mtodo de: Ah:, ya
SR:
SR:
Nurse EE: the one who uses it, [.] does! [.] the Lic. EE: el que usa, [.] hace! [.] el cleaning. [.] For the cleanliness {of the instruments} SR: {Right, right} Nurse EE: they use, like. SR: Right. [.] [] And:: Doa Elena, when aseo. [.] Por la limpieza {del instrumental} SR: {Ya, ya} Lic. EE: que usa, as. SR: Ya. [.] [] Y:: Doa Elena, cuando
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some times its used for example, Cytotec [1] Right:? Nurse EE: Right SR: To reso:lve some interru::ption in the {se} Nurse EE: {Right} SR: cond trimester Nurse EE: THEY WAIT! They wai:t unti::l its produced er: the birth or the abortion, then they g- go down to theatre. [1] Those patients always in theatre are done. SR: Ah:, right Nurse EE: In theatre always. SR: Right: Nurse EE: Because they need rel:relaxation more: [1] so the patient tranquil[???] and they can do the cleaning com{plete, right?} SR: {Ah:, right} [.] But what has it signified for you, as nurses, the introduction of: this:- this medication? [1] Nurse EE: Its to help to dilate in: big pregnancies, so!
alguna vez se utiliza por ejemplo Cytotec [1] No:? Lic. EE: Ya SR: Para resolve:r alguna interrupci::n de {se} Lic. EE: {Ya} SR: gundo trimestre Lic. EE: ESPERAN! Espe:ran a que:: se produzca eh: el alumbramiento o el aborto, despus ba- bajan a quirfano. [1] Esos pacientes siempre en quirfano hace. SR: Ah:, ya Lic. EE: En quirfano siempre. SR: Ya: Lic. EE: Porque necesita relajam:relajamiento ms: [1] para que la paciente tranquil[???] y puedan hacer la limpieza comple{ta, no?} SR: {Ah:, ya} [.] Pero qu ha significado para ustedes, como enfermeras, la introduccin de: esta:- este medicamento? [1] Lic. EE: Es para ayudar a dilatar en: embarazos grandes, pues!
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SR: Mm Nurse EE: To help that. It he:lps. [.] [] Because sometimes with: induction only, it does no:t give a result. It does not SR: {Mm:} Nurse EE: {give} a result. But putting in that: me- that medication, it does. [.] We help more the dilatation of the neck of the womb, so that it can give [1] eliminate the product, right? thats already bad. [.] Or is dead. [.] Dead product. [] Mostly they do it in: dead, retained foetuses and which are already: [] um::: of:: several months of:: [.] pregnancy, right? SR: Mm Nurse EE: Of some age. [.] [??] [.] SR: Right Nurse EE: Thats it. SR: [] Although at some moment:: er:: given the: resolution of the Medical Council italso its used: to interrupt a pregnancy, {isnt that right?} Nurse EE: {Ah yes.}
SR: Mm Lic. EE: Para ayudar eso. Ayu:da. [.] [] Porque a veces con: induccin noms, no: da resultado. No SR: {Mm:} Lic. EE: {da} resultado. Pero colocando esa: me- ese medicamento, s. [.] Ayudamos ms a la dilatacin del cuello, para que pueda dar [1] eliminar el producto, no? que ya est mal. [.] O est muerto. [.] Producto muerto. [] Mayormente hacen en: fetos muertos retenidos y que son ya: [] ahm::: de:: varios meses ya de:: [.] embarazo, no? SR: Mm Lic. EE: De edad. [.] [??] [.] SR: Ya Lic. EE: Eso. SR: [] Aunque en algn momento:: eh:: previa la: resolucin de la Junta Mdica satambin se utiliza: para interrumpir un embarazo, {no es cierto?} Lic. EE: {Ah s.}
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SR: [??.] Nurse EE: But on rare occasions that is SR: Almost not [.] Mhm: Nurse EE: Mostly they come already with their dead [2] retained eggs,vi with abortions already incomple:te, [.] [] in those cases where already they are quite advanced pregnancies it is put into them the [.] [] induction [.] and Cytotec so that [] it can eliminate complete, because if they were to take that directly to theatre, [.] [] it comes out piece by piece and: {that is} SR: {Ah:, right} Nurse EE: so: traumatic, so terrible that they should take out a: little foetus like that, piece by piece, n:: [.] SR: Right Nurse EE: Its: for that that they do it to them [] They have generally- they have to eliminate so that afterwards they take her to: theatre. SR: Right: Nurse EE: [They start.] SR: Mhm: [2] Lets say when you say that [.] uhm [.] traumatic:, [.] does that mean
SR: [??.] Lic. EE: Pero rara vez es eso SR: Casi no [.] Mjm: Lic. EE: Mayormente vienen ya con sus huevos muertos [2] reteni:dos, con abortos ya incomple:tos, [.] [] en esos casos cuando ya son embarazos ya avanzaditos se les coloca el [.] [] la induccin [.] y el Cytotec para que [] pueda eliminar completo, porque si llevaran eso directamente a quirfano, [.] [] sale pedazo por pedazo y: {eso es} SR: {Ah:, ya} Lic. EE: tan: traumtico, tan terrible que saquen a un: fetito as, pedazo por pedazo, n:: [.] SR: Ya: Lic. EE: Es: por eso que les hacen [] Tiene generalmente- tiene que eliminar para que luego le lleven a: quirfano. SR: Ya: Lic. EE: [Empiezan.] SR: Mjm: [2] Digamos cuando Usted dice que [.] ahm [.] traumtico:, [.] significa
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lets say for the patient, {for the nur:} Nurse EE: {for the pa:tient}, SR: se herself
digamos para la paciente, {para la misma enfer} Lic. EE: {para la pacie:nte}, SR: me:ra:
Nurse EE: Thats it- [[laughing]] the ones who Lic. EE: As es- [[riendo]] las que see [??] piece by piece, [the head:] [.] No! SR: Right: Nurse EE: When theyre big, like that it is. [.] SR: So for you all it has been like: [.] a benefit [.] the introduction of this medi{cation?} Nurse EE: {Right} [.] Ah yes, yes. So they can {he} SR: {Yes:} Nurse EE: lp to eliminate. SR: Right. [] And s- since how many years is it being used, the Cytotec? Nurse EE: This year only recently [?] SR: ONLY RECENTLY! Nurse EE: Yes, only recently. SR: Yes:! vemos [??] pedazo por pedazo, [la cabeza:] [.] No! SR: Ya: Lic. EE: Cuando son grandes, as es. [.] SR: Entonces para ustedes ha sido como: [.] un: beneficio [.] la introduccin de este medica{mento?} Lic. EE: {Ya} [.] Ah s, s. Para que puedan {ayu} SR: {S:} Lic. EE: dar a eliminar. SR: Ya. [] Y ha- hace cuntos aos que se est utilizando el Cytotec? Lic. EE: Este ao recin [?] SR: RECIEN! Lic. EE: S, recin. SR: S:!
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Nurse EE: Only recently, yes yes. [] It was used:, the laminaria. [.] Some: little {sticks.} SR: {Ah::} Nurse EE: Tha:t was what was {used} SR: {Tha:ts it} Nurse EE: But since this year recently it is being used, that [???] SR: Yes:. Ri::ght Nurse EE: Yes. [.] Because it is not- the laminaria alwaysvii
Lic. EE: Recin, s s. [] Se usaba: la laminaria. [.] Unos: tronqui{tos.} SR: {Ah::} Lic. EE: E:so era lo que se usa{ba} SR: {E:so} Lic. EE: Pero desde este ao recin s est emplendose eso [???] SR: S:. Ya:: Lic. EE: S. [.] Porque no- la laminaria siempre-
and now already it cant be found the laminaria, y ahora ya no se encuentra la laminaria, its for that it seems that they have: introduced this Cyto{tec.} SR: {No more,} it cant be found, {the the} Nurse EE: {No more!} SR: mina{ria?} Nurse EE: {They loo:k:,} but all over the place, the relatives have to go and buy SR: Yes? Nurse EE: [They say that] no, they dont find it. es por eso parece que han: introducido este Cyto{tec.} SR: {Ya no} se encuentra {la la} Lic. EE: {Ya no!} SR: mina{ria?} Lic. EE: {Bu:sca:n} pero por todo lado, los familiares tienen que ir a comprar SR: S? Lic. EE: [Dicen que] no, no encuentran.
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SR: Be{fo:re though it was not} Nurse EE: {[???]} SR: so difficult! Nurse EE: Yes, { right now no.} SR: {In the phar}macies they sold it! Nurse EE: Already there is not any [[laughs]] SR: Already there is not any? Nurse EE: They search a lot to be able to find it. SR: And why would that be? [1] Nurse EE: We dont know! [1] SR: Or {would it be that they are trafficking} Nurse EE: {There is no explanation} SR: with that, that theyre spe:culating, {or:} Nurse EE: {May}be! Right? [.] But already there is no laminaria, already they {cannot} SR: {Right!}
SR: A:n{tes pero no era} Lic. EE: {[???]} SR: tan difcil! Lic. EE: S, {ahorita no.} SR: {En las far}macias vendan! Lic. EE: Ya no hay [[re]] SR: Ya no hay? Lic. EE: Buscan mucho para poder hallar. SR: Y por qu ser eso? [1] Lic. EE: No sabemos! [1] SR: O {ser que estn traficando} Lic. EE: {No hay ninguna explicacin} SR: con eso, que estn especula:ndo, {o:} Lic. EE: {Tal} vez! No? [.] Pero ya no hay la laminaria, ya no {pueden} SR: {Ya!}
Nurse EE: get hold of it. [] For that they have Lic. EE: conseguir. [] Por eso han introduced Cytotec. introducido el Cytotec.
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SR:
Because
SR: Porque Lic. EE: [[a un hombre, Sr. X, que le est llamando desde la puerta abierta]] PERDON! [.] [[a SR]] Per- perdn un momentito SR: S s Lic. EE: [[llamando al mdico, Dr. X]] Pe- pero le da- damos permiso al seor? Porque [] Dr. X: Le dice que:: {[?]} Lic. EE: [[llamando al Sr. X]] {El} mdico es el que tiene que anotar en hoja de evolucin, no- no podemos dar Sr. X: [[al Dr. X]] Muchas gracias! [[Durante 9 segundos, se escuchan ruidos y voces simultneas, slo parcialmente audibles]] SR: [[a Lic. EE]] Porque parece que era un mtodo bastante prctico, no:? Lic. EE: S SR: la laminaria? Lic. EE: Era, era
Nurse EE: [[to a man, Mr. X,viii who is calling her from the open door]] SORRY! [.] [[to SR]] S- sorry, just a moment SR: Yes yes Nurse EE: [[calling the male doctor, Dr. X]] B- but do we g- give permission to the gentleman? Because [] Dr. X: Tell him that:: {[?]} Nurse EE: [[calling Mr. X]] {The} doctor is the one who has to note it in the case evolution form, we canno- we can not give Mr. X: [[to Dr. X]] Thank you very much! [[For 9 seconds, sounds and simultaneous voices can be heard, only partially audible]] SR: [[to Nurse EE]] Because it seems that it was a really practical method, right? Nurse EE: Yes SR: the laminaria? Nurse EE: It was, it was
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SR: And also its something: from na:ture, isnt that {right?} Nurse EE: {Yes:} SR: Its something::- from where would they bring that, eh? Nurse EE: Ay I dont know, it was a little stick like that: [.] a little stick. SR: Yes:. [.] That swells itself, right? Nurse EE: Yes:, yes yes SR: Yes Nurse EE: With the moisture in:: the:: neck: of the womb it starts to: [.] increase in volume and that makes it dilate, the neck of the {uterus,} SR: {Ah: right:} Nurse EE: [???] SR: Yes. So: [.] it has disappeared, this has, and they have started to use the Cytotec. [.] [] But when the patients [.] or the- the relatives go to buy Cytotec, do they find it just, easily? [.] Nurse EE: Yes! Because they bring it. They bring it to: [???] They indicate it to them, the doctors [??] that its to: [????]
SR: Y adems es algo: de la naturale:za, no es cier{to?} Lic. EE: {S:} SR: Es algo:: de dnde traern, no? Lic. EE: Ay no s, era un tronquito as: [.] un tronquito. SR: S:. [.] Que se hincha, no? Lic. EE: S:, s s SR: S Lic. EE: Con la humedad de::l:: cuello: empieza a: [.] aumentar de volumen y eso hace que se dilate el cuello del {tero,} SR: {Ah: ya:} Lic. EE: [???] SR: S. As que: [.] ha desaparecido esto, y han empezado a usar el Cytotec. [.] [] Pero cuando las pacientes [.] o las- los familiares van a ir a comprar Cytotec, encuentran noms fcilmente? [.] Lic. EE: S! Porque traen. Traen para: [???] Les indican los mdicos [??] que es para: [????]
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SR: Right, right. [.] Right [.] Right! Anything more that you want to express about the question of the: treatment of incomple:te abortion, all this? Any sugge:stion, recommenda:tion? [2] Nurse EE: Well [.] the: [.] it seems that its failing, something: in the [.] the pla:nning, the methods that theyre using, or: [.] there are a lot of people who are not co:ming [1] to do the:- [.] family planning, theyre not, it may be that theyre instru:cted, that its explai:ned to them, [] they do not:: accept it sometimes! [.] {They do not} SR: {Mm:} [.]
SR: Ya, ya. [.] Ya [.] Ya! Alguna cosa ms que quiere expresar sobre la cuestin del: tratamiento del aborto incomple:to, todo estoAlguna sugere:ncia, recomendaci:n? [2] Lic. EE: Pues [.] el: [.] parece que est fallando algo: de la [.] la planificaci:n, los mtodos que estan usando, o: [.] hay mucha gente que no est vinie:ndo [1] a realizar el:- [.] la planificacin familiar, no, puede ser que les instru:ye, se les expli:ca, [] no:: aceptan a veces! [.] {No se} SR: {Mm:} [.]
Nurse EE: have themselves put i:n not even an Lic. EE: hace coloca:r ni siquiera un intrauterine device, [??], back they- [.] come with an: abortion. SR: Mhm: Nurse EE: Thats it. [.] That would be it. [.] SR: Right. [.] And that: what would they have to do with it for example the husbands? [.] Of: the ladies? Nurse EE: Lets see, the- the husband is the one who refuses, does not wa:nt to accept dispositivo, [??], vuelven a- [.] venir con un: aborto. SR: Mjm: Lic. EE: Eso. [.] Eso sera. [.] SR: Ya. [.] Y eso: qu tendrn que ver por ejemplo los esposos? [.] De: las seoras? Lic. EE: A ver, el- el esposo es el que se niega, no quie:re aceptar
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that into her they put:- that she uses pills or: that a que le pongan:- a que use tabletas o: que they put into her a [.] device! [.] SR: Mm [2] Nurse EE: It depends too on the culture of each: [.] husband. SR: Mm Nurse EE: Some men out of ignorance say that the- the woman is there to have children! And: Mm le coloquen un [.] dispositivo! [.] SR: Mm [2] Lic. EE: Depende tambin de la cultura de cada: [.] esposo. SR: Mm Lic. EE: Algunos hombres por ignorancia dicen que lala mujer es para tener hijos! Y: Mm
SR:
SR:
Nurse EE: [???{????]} SR: {[] And do you see it as necessa}ry the lady can {use a: method?} Nurse EE: {Yes: Because afterwards} they have problems. SR: What type of problems? [.] Nurse EE: Its said that they complain, [.] as it stays, the little threads, it seems that there is- [.] [[laughing]] the pro:blem! [2] I do no:t know. SR: In what sense? That he {no:tices, or
Lic. EE: [???{????]} SR: {[] Y Usted ve necesa}rio la seora pueda {usar un: mtodo?} Lic. EE: {S: Porque despus} tienen problemas. SR: Qu tipo de problemas? [.] Lic. EE: Dice que se quejan, [.] como queda los hilitos, parece que ah es- [.] [[riendo]] el proble:ma! [2] N:o s. SR: En qu sentido? De que se {fi:ja, o
always that: they speak with the husband so that siempre que: hablen con el esposo para que
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that it bo:thers him, or what?} Nurse EE: {[????] in: having relations well it sticks into you! SR: That they notice? Or: {that they get annoyed?} Nurse EE: {N:: n::} That it bothers him, the {man! [??] the man, yes!} SR: {Ah, it bothers him, they say?} Nurse EE: Yes, I think so! But Im not- [] I am no:t so su:re, right, but {the ladies} SR: {Ah:} Nurse EE: sometimes do not wa:nt to have it put into them while [the men ??]. SR: Ah:, right. Nurse EE: [??] SR: Right, right. [3] Right. [2] Nurse EE: And sometimes always we call the husband, that: [.] the doctor for example says Have her call the husband too to consult if: were going to use or not the: SR: Right:.
le mole:sta, o qu?} Lic. EE: {[????] al: tener relaciones pues se te mete! SR: De que se fije? O: {que se moleste?} Lic. EE: {N:: n::} Que le moleste al hom{bre! [??] al hombre, s!} SR: {Ah, le molesta, dicen?} Lic. EE: S, yo pienso que s! Pero no- [] no: estoy tan segu:ra, no, pero {las seoras} SR: {Aj:} Lic. EE: a veces no quie:ren hacerse colocar mientras [los hombres ??]. SR: Ah:, ya. Lic. EE: [??] SR: Ya, ya. [3] Ya. [2] Lic. EE: Y a veces siempre llamamos al esposo, que: [.] el mdico por ejemplo dice Que llame al esposo ms para consultar si: vamos a usar o no el: SR: Ya:.
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[[For 11 seconds, sounds of the telephone and others, simultaneous voices including that of Nurse EE, which are only partially audible.]] SR: Right. So, Doa Elena. Any thing more that you want to comment? OrNurse EE: [[laughing]] That only! SR: Very good! [.] Right, thank you! Nurse EE: Not at all SR: Thank you
[[Durante 11 segundos, ruidos del telfono y otros, voces simultneas incluyendo la de Lic. EE, slo parcialmente audibles.]] SR: Ya. As Doa Elena. Alguna cosa ms que quiere comentar? OLic. EE: [[riendo]] Eso noms! SR: Muy bien! [.] Listo, gracias! Lic. EE: De nada SR: Gracias
End of Transcript 14.1
Fin de la Transcripcin 14.1
As her colleagues on the ward did, I addressed Head Nurse Elena Elas as Doa Elena. In Hispanic contexts, Nurse is a respectful title used to preface a womans first name. It is more formal than Seora which can preface first or last names. ii trophoblastic a. (Embryol. & Med.) relating to or consisting of trophoblast L19. trophoblast n. (Embryol & Med.) a layer of cells or a membrane surrounding an embryo, which supplies it with nourishment and later forms most of the placenta L19. (OED) iii haemostasis n. M19. Med. Stoppage of bleeding; stoppage or esp. prevention of the flow of blood. (OED) iv molar adj. Med. Of the nature of a mola or false conception. rare. E19. (OED) v Legrado is translated as curettage. Common medical terminology in English is D&C, dilation and curettage. vi Medical terminology for this in English is a missed abortion. vii laminaria n. M19 Any brown seaweed of the genus Laminaria, with long thin flat fronds; collect. seaweed of this genus. Also called oarweed, kelp. (OED) In Bolivia and other Andean countries, a processed form of this seaweed is sold in pharmacies, in short, smooth, round sticks. When inserted in the cervix, these absorb bodily fluid, expand, and provoke dilation. viii X (Mr. X, Dr. X, etc.) is used to identify different people who intervene momentarily in transcribed interactions, or who are anonymous in the thesis narrative.
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Appendix 7
Contextualisation of transcript excerpts cited in sections 7.3, 7.3.1 and 7.4 of Chapter 7, Changing Voices
Transcript of recorded discussion with the following characteristics: Participants: Dr. Losada (Dr. L), third-year medical resident; Dr. Salinas (Dr. S), head of gynaecology ward, Insurance Hospital; Three women medical residents: RM1, RM2, and Dra. Helga Haber (Dra. HH), European friend of SR; Licenciada Irma Illanes (Lic. II), social worker; Karen, colleague on project visit from USA; SR as researcher. Date and time of discussion: Place: Source of notes on context: Number & date of transcript: Friday 11/7/97, 12.50 13.00 p.m. Gynaecology Ward Classroom, Insurance Hospital Field Notebook 5, notes summarised 17/7/97, edited 24/7/02 12.3, 17, 20 and 21/7/97
Context: This transcript is of a recorded discussion following SRs presentation of preliminary research findings to Insurance Hospital gynaecology ward staff. After the presentation, I requested and received the consent of those present to record their comments and questions, as input to validation of the research data and methodology. Those present were Dr. Salinas (Dr. S), the ward chief; three male residents including Dr. Losada (Dr. L); four women residents including Dra. Helga Haber (Dra. HH), a friend of European origin; social worker Licenciada Irma Illanes (Lic. II); Karen (a colleague on a project visit from the USA) and another woman representative of IPAS; and myself (SR) as researcher. No nurses were present, despite repeated invitations made by SR and the social worker Lic. Illanes.
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Start of Transcript 12.3 [[During the first eight seconds of the recording, what is heard are only partially audible interventions by SR, a medical resident and a resident, Dr. Losada (Dr. L). Dr. L continues with the first comment on SRs presentation:]] Dr. L: [?] its that:: if it:: [.] was a matter of finding out if it was induced or no:t, each- ['] it was as part of a study! [.] To justify as well what it was::- uh: Reproductive Health And so, as a: [1] result of that study, [1] i:t was arrived at that [1] the women were in fact using [.] abortion as a: method of family planning! [.] [] So it was no- it was not [2] th- the like there it sense, [1] because the treatment is the same, being done, abortion! [.]
Inicio de la Transcripcin 12.3 [[ Durante los primeros ocho segundos de la grabacin, se escuchan intervenciones slo parcialmente audibles de SR, una residente mdica y un residente , Dr. Losada (Dr. L). Dr. L prosigue con el primer comentario sobre la presentacin de SR:]] Dr. L: [?] es que:: si se:: [.] trataba de averiguar si era inducido o no: cada- [.] era como parte de un estudio! [.] Para justificar tambin lo que era::- ah_ Salud Reproductiva. Y entonces, como: [1] resultado de ese estudio, [1] se: lleg de que [.] las mujeres estaban noms utilizando [.] el aborto como: mtodo de planificacin! [.] [] Entonces no e- no era: [2] el- el como all sentido, [1] porque el tratamiento es el mismo, estaba haciendo el aborto! [.]
says, To know, for what?, a:pparently without dice Conocer, para qu?, a:parentemente sin [.] but [2] a- well to de:monstrate tha:t [.] it was [.] sino [2] a- pues para demostra:r que: [.] s se
[] And it is being u:sed: [.] and so- there had to [] Y se est utiliza:ndo: [.] y entons- se deba be alternatives offered in all this, right? [] It WAS NOT [.] er:- [.] knowing to say then, We discri:minate her, we do not attend her. [] Thats to say [.] it seems to me that a little bit the ide:a when that is proposed, [1] er[.] it might seem without sense, truly, For what are finding out [.] [] if its: ofrecer alternativas en todo esto, no? [] NO ERA [.] eh:- [.] conocer para decir entonces, La discrimina:mos, no la atendemos. [] O sea [.] me parece que un poquito la ide:a cuando se plantea eso, [1] eh[.] pareciera [??] sin sentido, verdad, Para qu estamos averiguando [.] [] si es:
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provoked or induced! [.] The: objective at that time in finding o:ut, was precisely to say, [1] It is being used as a method of planning and so- there must be done some:thing, it has to be used, plan- [] already like to- ju:stify [.] after what came with: Reproductive Health and all this, right?
provocado o inducido! [.] E:l objetivo de ese entonces al averigua:r, era justamente para decir, [1] Se est utilizando como mtodo de planificacin y entons- se tiene que hacer a:lgo, se tiene que usar el plan- [] ya como pa- justifica:r [.] despus lo que ha venido con: Salud Reproductiva y todo esto, no?
Thats to say [1] er- when one sees like co:ldly, O sea [1] eh- cuando uno ve as friame:nte, a bit like:- it seems [2] without sense the thing, bu:t I believe that the idea was another one. [.] {Nothing more [?]}. SR: {Very well.} Excellent. Thank you. [] Uh I am going to give you afterwards copies [.] of all these overheads [.] so that:[.] you can read them with more time, [.] and [????] you can make them. [.] Because: I need this kind of input// medio que:- parece [2] sin sentido la cosa, pero: creo que la idea era otra. [.] {Nada ms [?]} SR: {Muy bien.} Excelente. Gracias. [] Ah [.] yo les voy a dar despus copias [.] de todas estas transparencias, [.] para que: [.] las puedan leer con ms tiempo, [.] y [????] los pueden hacer. [.] Porque: yo necesito este tipo de insumo//
Dr. S: //Evidently. [[He turns and addresses the Dr. S: // Evidentemente. [[Se voltea y se dirige staff members present to stimulate their participation. Copies of the overheads are handed out to all those present.]] a los miembros del personal presentes para estimular su participacin. Se reparten copias de las transparencias a todos/as los/las presentes.]] [???] [4] We offer the wo:rd, [2] to: co:mment [3] er: [2] to make questions, [2] in relation [1] to these conclu:sions [.] of Susannas. [3] [[Turning round to address the staff]] If anyone has- [4] Well. I am going to sta:rt [1] Well. First I want:: [3] to congra:tulate [.] [???] [4] Ofrecemos la pala:bra, [2] para: comenta:r [3] eh: [2] para hacer pregu:ntas, [2] en relacin [1] a estas conclusio:nes [.] de Susanna. [3] [[Voltendose para dirigirse al personal]] Si alguien tiene- [4] Bueno. Yo voy a empeza:r [1] Bueno. Primero quiero:: [3] felicita:r [.]
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Susanna [2] this::- this work that you have done Susanna [2] esta::- este trabajo que has hecho [1] reflects [2] er: [.] the truth [2] with reference to the management [.] of incomplete abortion. [2] Er: it reflects [2] an interpretation: of yours, [.] per:sonal, [.] very clear [2] with regard to these approaches: [.] humane, [1] related [1] er: [.] the aspect of nursing, [2] of Social Service, [1] [1] refleja [2] eh: [.] la verdad [2] en cuanto se refiere al manejo [.] del aborto incompleto. [2] Eh: refleja [2] una interpretacin: tuya, [.] person:al, [.] bien clara [2] en cuanto a estos enfoques: [.] humanos, [1] relacionados [1] eh: el aspecto de enfermera, [2] de Servicio Social,
with: [1] er: [.] the a::spect [.] of me:dicine, [1] [.] con: [1] eh: [.] el aspecto:: [.] m:dico, [1] and the humane aspect. [2] We believe that it is: [1] y el aspecto humano. [2] Creemos que es: [.] the: faithful reflection [2] of everything: tha:t [.] el: fiel reflejo [2] de todo: l:o que happens [.] in this service. [2] Er: [.] to me the only thing that called my atte:ntion, [.] is tha::t [1] in all [.] the:- [.] in all the interpreta:tion of the wo:rk, in the conclusions and recommendations, [2] as if there were [.] a: [.] mm: [.] an idea [.] of fo:rcing [.] and saying, Well, why do you not accept abortion? [.] In an open form, all: of you. [.] But [.] unfortunately:, [.] we have: [1] no:rms:, we have regula:tions [2]. Another thing that calls my attention [.] is that: [2] uh: [.] the decision of the woman. [.] I believe that you are right, [.] you know, [.] its another cu:lture, [.] unfortunately, [.] in our environment still [.] predominates machis:mo, [2] that the woman always depends on the:- on her partner, [1] and [.] of course on a decision. [.] The ideal would be that: [.] our women should have a level: [1] of culture, [1] so that they alone should decide. [.] That should be. [.] It should be a norm. [2] sucede [.] en este servicio. [2] Eh: [.] a m lo nico que me ha llamado la atenci:n, [.] es que:: [1] en todo [.] el:- [.] en toda la interpretaci:n del trabajo:, en las conclusiones y las recomendaciones, [2] como si hubiera [.] una: [.] mm: [.] una idea [.] de forza:r [.] y decir, Bueno, por qu no aceptan el aborto? [.] En forma abierta, todos:. [.] Pero [.] lamentablemente:, [.] nosotros tenemos: [1] no:rmas, tenemos reglame:ntos [2] Otra cosa que me llama la atencin [.] es que: [2] eh: [.] la decisin de la mujer. [.] Creo que tienes razn, [.] t sabes, [.] es otra cultu:ra, [.] lamentablemente, [.] en nuestro medio todava [.] prevalece el machis:mo, [2] que la mujer siempre depende del:- de su pareja, [1] y [.] por supuesto de una decisin. [.] Lo ideal sera que: [.] nuestras mujeres tengan un nivel: [1] de cultura, [1] para que ellas solas decidan. [.] Eso debera ser. [.] Debera ser una norma. [2]
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Simply that omment, [1] and to congra:tulate [.] Simplemente ese comentario, [1] y felicita:r [.] that a:ll [.] that you have said [.] is true. [2] Thank you. que to:do [.] lo que has dicho [.] es cierto. [2] Gracias.
SR: [4]
SR: [4]
Dr. S: [[addressing the staff]] Anyone more [.] asks: [.] [[to Dr. Losada]] Doctor? [3] Dr. S: Well! [2] SR: I beg you really, Im- Im: very interested in that you can [????], comment, di:ffer, right? [.] I need that trtruly really as input for my final report. I dont want: [.] for me to stay all alone: [.] with the analysis [??]. As he says, the Doctor, its something subjective thats mine, [.] I [.] am a person outside the area of medicine, [1] I need the criteria of you all [.] really, to enrich the work, [???] to the women [???]. [4] RM1: [[First medical resident]] Eh:: [.] I would like [??] [.] the majority of the abortions that come: [.] are: as incomplete abortion [.] and its difficult to deter- uh- to arrive at a diagnosis or to identify if its spontaneous to all the women. [1] The problem occurs [.] when the patient co:mes, [.] and already on entry she says that
Dr. S: [[dirigindose al personal]] Alguien ms [.] pide: [.] [[al Dr. Losada]] Doctor? [3] Dr. S: Bueno! [2] SR: Les ruego realmente, me- me: interesa muchsimo todo lo que puedan [??]ar, comentar, discrepa:r, no? [.] Necesito eso dede veras como insumo para mi informe final. No quiero: [.] quedarme yo solita: [.] con el anlisis [??]. Como dice el Doctor, es algo subjetivo mo, [.] yo [.] soy una persona fuera del rea mdica, [1] yo necesito los criterios de ustedes [.] realmente, para enriquecer el trabajo, [???] a las mujeres [???]. [4] RM1: [[Primera residente mdica]] Eh:: [.] quisiera [??] [.] la mayora de los abortos que vienen: [.] son: como aborto incompleto [.] y es difcil deter- ah- de llegar a diagnosticar o de identificar si es espontneo a todas las mujeres. [1] El problema ocurre [.] cuando la paciente vie:ne, [.] y ya de entrada ella dice que
or provoked:, [1] the way of treating is the same o provocado:, [1] el trato es igual
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it has been an abortion: [.] provoked. [.] [] The ha sido un aborto: [.] provocado. [.] ['] La discrimination is not on our part. [1] The way of treating the patients is the same. ['] The discrimination is from Nu:rsing, [1] and:: the Coverage Rights Office. [.] ['] Certainly, in- what is do:ne is [.] to inform the patient [.] that they are in an extra-ordinary risk:, [.] and the co:st that would be implied by a curettage here in the Hospital. [2] And the:- obviously the patient es discriminacin no es por nuestra parte. [1] El trato a las pacientes es el mismo. ['] La discriminacin es desde Enfermer:a, [1] y:: Vigencia de Derechos. [.] ['] Ciertamente, en- lo que se ha:ce: es [.] informarle a la paciente [.] que est en un riesgo extraordinario:, [.] y el co:sto que implicara un legrado aqu en el Hospital. [2] Y l:- obviamente la paciente es
the one who decides if she is: capable to- [.] pay la que decide si est: capacitada para- [.] pagar [.] or not pay the cost, which is much more high [.] o no pagar el costo, que es mucho ms alto [.] that in any other place, right? [.] The way of treating is the same, obviously, the same! [2] Bu:t uh:- th- the: problem exists in the Coverage Rights Office. [8] [[Inaudible comments from Dr. Salinas and Dr. Losada.]] We:ll. [.] que en cualquier otro lado, no? [.] El trato es el mismo, obviamente, el mismo! [2] Pe:ro eh:- e- el: problema existe en Vigencia de Derechos. [8] [[Comentarios inaudibles de Dr. Salinas y Dr. Losada.]] Bie:n.
treatment of medicine, personnel, and all that: is trato mdico, personal, y todo eso: es
SR: [1]
SR: [1]
Lic. II: [[Social Worker Lic. Irma Illanes]] Clarifying that of: [?] the risks [???]ary! [3] Irma [.] Can you again explain this:-?
Lic. II: [[Trabajadora Social Lic. Irma Illanes]] Aclarando lo de: [?] los riesgos [???]arios! [3] Irma [.] Puedes volver a explicar esto:-?
SR:
SR:
[.] I didnt understand very well. Lic. II: That the discrimination is [.] not [.] so:: much from Nursing as from
[.] No he entendido muy bien. Lic. II: Que la discriminacin no [.] es [.] ta:nto de Enfermera como de
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the Coverage Rights Office, what the Docto:ra said, [] but rather [.] on the pa:rt of the- of the Code of Social Security [1] in which it is mentioned in one clause [.] the problem of the risks that are extra-ordinary! [5] Dra. HH [[European medical resident, friend of SR]] Uh I wanted in reality to make the same: [.] comment, I am new in the service, but: [.] this point that:- about
Vigencia de Derechos, lo que ha dicho la Docto:ra, ['] sino ms bien [.] de pa:rte de- del Cdigo de Seguro Social [1] en el que est mencionado en un acpite [.] el problema de los riesgos extraordinarios! [5] Dra. HH: [[residente mdica europea, amiga de SR]] Eh quera en realidad hacer el mismo: [.] comentario, yo soy nueva en el servicio, pero: [.] este punto que:- sobre
incomplete abortion and the normative point, [''] el aborto incompleto y el punto normativo, [''] it seems to me that it is rather the: [.] pragmatic. me parece que es ms bien el: [.] pragmtico. [.] ['] Thats to say as pragmatic, all of us say here, We:ll, we attend them all equal. ['] But that is pragmatic. The normative is that the National Insurance Scheme does no::t ['] co:ver [1] the: uh: lets say, whats it called the treatment [''] of an abortion [.] uh: induced in another place. [1] Right? And that we have to just [.] uh [.] ex:pose it here en normative, that [.] that is the nor:m. ['] Now that it pleases us or does not please us, that is another point. That is the subjective point, right? But [''] that- th:- the norm remains in curren- uh:: [[laughing]] in current coverage, and not only Coverage Rights! {But in cov:erage} RM?: {[[laughs]]} Dra. HH: [''] and [.] uh it- it- even we practise it, because in the- in the: little time that I have been in the service, we: have seen cases [''] that::: well: uh::- thats to say, [.] ['] O sea como pragmticos, todos decimos aqu, Bue:no, les atendemos a igual. ['] Pero eso es pragmtico. Lo normativo es que la Caja Nacional de Salud no:: ['] cu:bre [1] los: eh: digamos, qu se llama el tratamiento [''] de un aborto [.] eh: inducido en otro lado. [1] No? Y eso tenemos que noms [.] eh [.] ex:ponerlo aqu en normativo, que [.] eso es la nor:ma. ['] Ahora que nos guste o no nos guste, eso es otro punto. Ese es el punto subjetivo, no? Pero [''] eso- l:- la norma sigue vigent- eh:: [[riendo]] en vigencia, y no solamente Vigencia de Derechos! {Sino en vigen:cia} RM?: {[[se re]]} Dra. HH: [''] y [.] eh se- se- hasta la practicamos, porque en las- en el: poco tiempo que he estado en el servicio, he:mos visto casos [''] que::: bueno: eh::- o sea,
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there has not been discrimina:tion in a personal sense to th- these persons, but there has been n- [''] it has been explained away: to another place, so [.] that is the norm and [.] ['] [[leafing through papers]] it remains in current coverage. ['] That would be [.] to add to that. [[in a lower tone, searching for the point on sheets distributed to participants with copies of overheads.]] And there was another thing thatwhat little thing more that I wanted to say [[for 4 seconds, he searches among the sheets [[??!]] [[10]]
no se ha discrimina:do en sentido personal a l- estas personas, pero s se ha n- [''] se les ha explicado que eso es entonces [.] eso es la norma y [.] ['] [[hojeando papeles]] sigue en vigencia. ['] Eso sera [.] para aadir a eso. [[en voz ms baja, buscando punto en hojas repartidas a asistentes con copias de transparencias]] Y haba otra cosa quequ cosita ms que quera decir [[durante 4 segundos, busca entre hojas [[??!]] [[10]]
to them that that is the norm and they have gone la norma y se han ido: a otro lado,
distributed.]] No. I cannot remember! [[laughs]] repartidas]] No. No me recuerdo! [[re]]
Dr. S: [[to Dr. Losada]] You wanted to speak? Dr. S: [[a Dr. Losada]] Queras hablar? [2] Dr. L: No. [.] Its all right. Dr. S: No? [1] [[laughs from participants]] SR: [[to Dr. Losada]] Doctor Losada, any observation: [.] thatRM?: [[inaudible comments from women medical residents]] Dr. L: [[to SR]] No, its all right [.] [2] Dr. L: No. [.] Est bien. Dr. S: No? [1] [[risas de participantes]] SR: [[to Dr. Losada]] Doctor Losada, alguna observacin: [.] queRM?: [[comentarios inaudibles de Residentes Mdicas]] Dr. L: [[a SR]] No, est bien [.]
it has been, it seems to me a:- good impre:ssion, ha sido, me parece un:- buena impresi:n,
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and its:- the- [.] what you have seen in the service, right? [2]
y es:- la- [.] lo que Usted ha visto dentro del servicio, no? [2]
SR:
And that concurs more or less with your SR:
Y eso concuerda ms o menos con su
vision, or do you have any discre:pancies, things that: you think that I am not reflecting [??]? Dr. L: No, its all right! [.] Its all right. [4] Dra. HH: [??] [[laughs from women present]] Dra. HH: [[smiling]] [[to SR]] In your [[telephone rings and RM? answers]]
visin, o tiene algunas discrepa:ncias, cosas que: piensa que no estoy reflejando [??]? Dr. L: No, est bien! [.] Est bien. [4] Dra. HH: [??] [[risas de mujeres presentes]] Dra. HH: [[sonriendo]] [[a SR]] En tus [[suena telfono y contesta RM?]]
Dra. HH: recommendations concerning [.] the: Dra. HH: recomendaciones en cuanto [.] a la: active promotion without: [.] requesting the:: the:: [.] consent of the husband, precisely what he said, the Doctor, ['''] [.] uhm: [3] I am n::ot so much in agreement that that stays alo:ne. [.] Thats to say, I am in agree:ment that it should not be an obstacle, right? If the woman says, I already do not want to have children. I want a:a method [''] [.] and neither does anyone do it, right, that they dema:nd that he comes, the hu:sband, thats to say:- its:- the other- [.] pragmatic, precisely, thats to say ['] uh: [she] gets lost. ['] But I believe that [.] as a recommenda:tion [.] ['] and as a promocin activa sin: [.] pedir el:: el:: [.] consentimiento del esposo, justamente lo que dijo el Doctor, ['''] [.] ehm: [3] N::o estoy tan de acuerdo que eso se queda so:lo. [.] O sea, estoy de acue:rdo que no debera ser un obstculo, no? Si la mujer dice, Yo ya no quiero tener hijos. Quiero un:un mtodo [''] [.] y tampoco nadie lo hace, no, que exi:ja que venga el mari:do, o sea:- es:- el otro- [.] pragmtico, justamente, o sea ['] eh: se pierda. ['] Pero yo creo que [.] como recomendaci:n [.] ['] y como
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programmatic approach, we have to just uh:: involve the men in contraception! ['] [.] If we close our eyes as women, ['] [.] Thats to say if the ma:n does not and contraception and having kids, [''] uh: thwe are going to keep them back another: five hundred centuries more! ['] So no: [.] for me that would not be the policy. The policy would be rather [.] to gi:ve counselling to the me:n! Involve the men. ['] Not, thats to say:- no::t [.] no:t to say, Well, decides, and the man well let him do what pleases him! [] No:: no it does not seem to me that that is the approach that- thats to say, in the long run, further beyond, right? So I believe that this is a little: [.] it would have to be used, that, if:: [2] all th{at:} {Yes}
enfoque programtico, tenemos que noms eh:: involucrar a los hombres en la anticoncepcin! ['] [.] Si nos cerramos los ojos como mujeres, ['] [.] O sea si el ho:mbre no concepcin y anticoncepcin y tener wawas, [''] eh: va- los vamos a atrasar otros: quinientos siglos ms! ['] Entonces no: [.] para m no sera la poltica. La poltica sera ms bien [.] da:r consejera a los ho:mbres! Involucrar a los hombres. ['] No, sea:- no:: [.] no: decir, Bueno, decide, y el hombre bueno que haga lo que le guste!" [''] No:: no no me parece que ese es el enfoque que- o sea, a lo largo, ms all, no? Entonces creo que esto es un poco: [.] habra que emplear eso, s:: [2] todo e{se:} {S}
I believe that we cut ourselves in our own flesh. creo que nos cortamos en la propia carne. participate: in the:- in what concerns conception participa: en el:- en lo que es
its a matter for the woman and only the woman es asunto de la mujer y solamente la mujer
right? Im talking already of [[laughs]] of ideals no? Estoy hablando ya de [[re]] de ideales
SR:
SR:
Dra. HH: point of vi{ew} Dr. L: {Yes,} I believe that it is not:- it is not family planning is the decision of the the couple to know and decide [.] ho:w many and whe:n to have the family. [.]
Dra. HH: punto de vi{sta} Dr. L: {S,} creo que no es:- no es decisin de planificacin familiar es la decisin de la la pareja de saber y decidir [.] cu:ntos y cu:ndo tener la familia. [.]
the decision of the woman, right? It is said that: la mujer, no? Se dice que: couple, [1] it is: [.] written like that, that is up to pareja, [1] est: [.] escrito as, que es de
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Thats to say, it is not at any moment that I know of:, only related to the woman, but its a treatment of the couple.. ['] Thats why within the methods it goes so: much for the woman, so much for the male. [.] Right? [.] There is not only [?] of the woman. ['] [.] Dra. HH: Yes, but: here it is in the:- [.] uh: I am referring to the recommendations of: of Susanna, [''] o:bviously we hav- thats to say, there have been seen cases, right, of ladies that do not have for example a partner who at times they come. So just the same she is given a method. [.] We are not going to say, We::ll, so she is not eligible. But:: ideal it would be [.] to involve the man. [1] In: in the process. [2] [??] Well.
O sea, no es en ningn momento que yo sepa:, solamente relacionado a la mujer, sino es tratamiento de pareja. ['] Por eso dentro de los mtodos va ta:nto para la mujer, tanto para el varn. [.] No? [.] No hay slo [?] de la mujer. ['] [.] Dra. HH: S, pero: aqu est en las:- [.] ah: me estoy refiriendo a las recomendaciones de: de Susanna, [''] o:bviamente hemo- o sea, se ha visto casos, no, de seoras que no tienen por ejemplo una pareja que a veces vienen. Entonces igual se le da un mtodo. [.] No vamos a decir, Bue::no, entonces no es eligible". Pero:: ideal sera [.] que se involucre al hombre. [1] En: en el proceso. [2] [??] Well.
participates. [1] Thats to say, uh they say:- yes, participa. [1] O sea, ah dicen:- s,
SR: [3]
SR: [3]
Dr. S: Very well! [1] Uh so: er: [.] I believe that there are no more comments, [1] we thank you: [2] and::: [2] with Karen already we have spoken [2] [''] the- [.] for the future of MVA, right? [2] So we hope: [.] well be commu:nicating [.] sending you the information, [2] and:: [.] well! Continuing with this method. [5]
Dr. S: Muy bien! [1] Ah entonces: eh: [.] creo que no hay ms comentarios, [1] le agradecemos: [2] y::: [2] con Karen ya hemos hablado [2] [''] el- [.] por el futuro de AMEU, no? [2] As que esperamos: [.] comunica:rnos [.] enviarle la informacin, [2] y:: [.] bueno! Continuar con este mtodo. [5]
[[end of Transcript 12.3]]
[[fin de la Transcripcin 12.3]]
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Appendix 8
Contextualisation of transcript excerpts cited in sections 8.2 and 8.4 of Chapter 8, Managing Pain
Transcript of interview recorded by SR with the following characteristics: Participants: Date and time of interview: Place: Source of notes on context: Number & date of transcript: Context: I requested this recorded interview with Dr. Walters (Dr. W) on the day I went to the hospital to ask Dr. Gonzles for a final interview, and to give the staff invitations to a meeting of the Working Group on unwanted pregnancy and abortion. I had had a conversation with Dr. Walters an hour earlier, on entering the gynaecology ward classroom to observe the morning change of duty shift. At that moment, he had spoken in very positive terms about the more frequent use of Manual Vacuum Aspiration (MVA) on the ward since our last encounter. After this conversation, I spoke to my medical resident friend Dra. Helga Haber (Dra. HH) and did a recorded interview with her. I remained worried about her accounts of pain management and other aspects of MVA use. A short while afterwards, I looked for Dr. Walters to ask him for an interview about the matter. He accepted immediately and we went to the ward classroom for a recorded interview which lasted 11 minutes, here transcribed in its totality. Just before I commenced recording, Dr. Walters had mentioned the presentation I had given to ward staff two weeks earlier. He had been absent on that day, but I had given him copies of my overheads, on which he started to comment. Dr. Walters (Dr. W), staff gynaecologist, Insurance Hospital; SR as researcher. Friday 25/7/97, 9.29 9.40 a.m. Gynaecology ward classroom, Insurance Hospital Field Notebook 5, notes summarised 1/8/97, edited 27/7/02 13.2, 1/8/97
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Start of Transcript 13.2
Inicio de la Transcripcin 13.2
SR: What thing do you want to comment to me SR: Qu cosa quiere comentarme first, what you have thought a bit about what you have seen of my preliminary results? [2] Dr. W: Uh: [.] it seemed very interesting to me, un th- contribution [.] ['] that you have made, [.] ['] and:: the truth is that: [.] that gives an impulse [1] and an:: [1] an incentive so that: the others:- the medical staff of the service [.] ['] uh:: should think first [.] about this method, [1] that is [.] really of: a lot of goodness and: less: [.] less risk, right? [2] From that:: it has been possible to observe that in this latest season the i:ncidence of: MVA [1] ['] has- has: increased. [1] Wwe are doing it, already they are more conscious, [.] ['] I see that its been encouraged at the level of the residents, [2] [''] uh: to do it, and they among themselves are: [1] fighting to do it! [2] And:: [.] with the supervision of us:, its:its being done with very good results. Patients that ['] are:: going away on the same da:y, [.] are admitted by Emergencies, [.] or another case, right? ['] We had a case of a: hydiatiform [.] mola, [.] ['] that:: [2] almost by routine should be done by curettage [1] an: uterine instrumental curettage [.] ['] following the MVA. primero, lo que ha pensado un poco de lo que ha visto de mis resultados preliminares? [2] Dr. W: Eh: [.] me ha parecido muy interesante, ah l: aporte [.] ['] que Usted ha hecho, [.] ['] y:: la verdad es que: [.] eso da un impulso [1] y un:: [1] un aliciente para que: los otros:- los: mdicos de planta del servicio [.] ['] eh:: pensemos primero [.] en este mtodo, [1] que es [.] realmente de: mucha bondad y: menos: [.] menos riesgo, no? [2] De ah que:: se ha podido observar que en esta ltima temporada la incide:ncia del: AMEU [1] ['] ha- ha: incrementado. [1] Eestamos haciendo, ya estn ms conscientes, [.] ['] veo que se ha incentivado a nivel de los residentes, [2] [''] eh: para hacer, y ellos se andan: [1] peleando por hacer! [2] Y:: [.] por la supervisin nuestra:, est:se est haciendo con muy buenos resultados. Pacientes que ['] se estn:: yendo en el mismo d:a, [.] son internadas por Emergencia, [.] que otro caso, no? ['] Hemos tenido un caso de una: mola [.] hidiatiforme, [.] ['] que:: [2] casi de rutina se debe hacer un legrado [1] un:: legrado uterino instrumental [.] ['] posterior al AMEU.
they do not need hospitalisation, except in some no necesitan hospitalizacin, salvo en alguno
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But: [.] since: were on [.] on: [1] on stri:ke [.] with the: nurses, it was not possible to do it. ['] We are giving her dis:charge, at any rate, to this patient. [.] [''] And:: we are going to be observing her, how:: she develops afterwards. [.] There is not at this moment any bleeding, [2] ['] so- I believe it [.] is going to be: advisable that we check more later, the problem of her trophoblastic disease, right? [.]
i
Pero: [.] como: estamos en [.] en: [1] en pa:ro [.] con las: enfermeras, no se ha podido hacer. ['] La estamos dando de al:ta, de todas maneras a esta paciente. [.] [''] Y:: la vamos a ir observando como:: luego evoluciona. [.] No hay en este momento ningn sangrado, [2] ['] -tons- creo que [.] va a ser: conveniente que la controlemos posteriormente ms el problema de su enfermedad trofoblstica, no? [.]
SR: Mm: [.] ['] And with regard: to MVA with: SR: Mm: [.] ['] Y en cuanto: al AMEU con: incomplete abortion, how has it gone for you all? Dr. W: We have done:: uh:: [.] uh three cases. [2] Very well. [1] Thats to say ['] [.] it is done the intervention, [.] ve:ry little pain, el aborto incompleto, cmo les ha ido? Dr. W: Hemos hecho:: eh:: [.] eh tres casos. [2] Mu:y bien. [1] O sea ['] [.] se hace la intervencin, [.] m:uy poco dolor,
['] it is not used, the paracervical block, because ['] no se utiliza el bloqueo paracervical porque the neck of the womb is half open, [2] and:: and el cuello est entreabierto, [2] y:: y you see, they go away happy:! [.] They go away ve, se van felices:! [.] Se van content:! You see? And we too. [''] Uh:: we are more content, right? from that we fr::[''] uh:: [.] free up a bit the part of programming of the operating theatre. [.] SR: Mhm: Dr. W: Right? SR: Mhm [.] ['] Right. And: how is that being managed a bit of the ve:rbal anaesthesia, the acco:mpaniment, the con{trol of pain} contentas:! Ve? Y nosotros tambin. [''] Eh:: estamos ms contentos, no:? de as des::[''] eh:: [.] desocupamos un poco la parte de programacin de quirfano. [.] SR: Mjm: Dr. W: No? SR: Mjm [.] ['] Ya. Y: cmo se est manejando eso un poco del anestesia verba:l, el acompaamie:nto, el con{trol del dolo:r}
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Dr. W: {But [.] uh::} [1] I in particular to them: [.] to them I am explai:ning to the [.] ['] That it is a me:thod that a:lways the method [1] that was:::- that was invented:, or it was:: [.] done the study of it for this. [.] ['] But: m: [.] there are some patients who understand and others who do not. [.] ['] The ones who do not, sur:ely [.] because since there are so many people that are around the patient, [.] [''] thats to say people who are obse:rving, ['] that are in teaching, ['] [.] it ca:n cause that- that nervous tension, and: [.] ['] But: [.] I have been able to observe myself:, on a level: private for example, [.] ['] that:: [.] [1] does not have: any problem! [1] She submits herself to the intervention without risk and without [''] without major nervous problem! Because we are [.] ['] doctor-patient! [.] Maybe the husband. [1] Or the nurse [.] right? ['] But here, [.] we- we are about, some- some ten: persons around the p:atients, all of us want to collaborate, [2] and: and that itself gives her a little bit of [.] overprotection to the patient and she does not tolerate it very well, in many cases. [2] Thats what ['] we could comment with regard
Dr. W: {Pero [.] eh::} [1] Yo particularmente les: [.] les estoy explica:ndo a las [.] ['] Que es un m:todo que sie:mpre el mtodo [1] que se:::- que se ha inventado: o se ha:: [.] hecho el estudio para esto. [.] ['] Pero: m: [.] hay algunas pacientes que comprenden y otras que no. [.] ['] Las que no, seguramen:te [.] porque como hay tanta gente que est alrededor de la paciente, [.] [''] o sea la gente que est observa:ndo, ['] que est en enseanza, ['] [.] pue:de ocasionar ese- esa tensin nerviosa, y: [.] ['] Pero: [.] he podido observar yo: a nivel: privado por ejemplo, [.] ['] que:: [.] [1] no tiene: ningn problema! [1] Se somete a la intervencin sin riesgo y sin [''] sin mayor problema nervioso! Porque estamos [.] ['] mdico paciente! [.] Tal vez el esposo. [1] O la enfermera [.] no? ['] Pero aqu, [.] ha- habemos como unos- unas diez: personas alrededor de las p:acientes, todos queremos colaborar, [2] y: y eso mismo le da un poquito de [.] sobreproteccin a la paciente y no tolera muy bien, en muchos casos. [2] Es lo que ['] podramos comentar al respecto
patients about what it involves, the intervention. pacientes de qu se tra:ta la intervencin. has been done without anaesthesia! Because its se ha hecho sin anestesia! Porque es
to them:- it seems that it would hurt them more. les:- parece que les doldra ms.
well explained, the patient absolutely does not:: bien explicadas, la paciente absolutamente no::
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to the:- to the paracervical anaes{thesia.}
de la:- del anestesia paracervi{cal.}
SR: {Right:.} Now [1] perhaps it might be that SR: {Ya:.} Ahora [1] quizs sera de que some of these people [1] ['] were to give constant accompaniment to the patient during the procedure. Lets say that they were at her si:de, that to her they were ta:lking, explai:ning, {making her brea:the,} Dr. W: {Yes. That is what is being} done. ['] That, right? algunas de estas personas [1] ['] d acompaamiento constante a la paciente durante el procedimiento. Digamos que est a su la:do, que le est charla:ndo, explica:ndo, {hacindole respira:r,} Dr. W: {S. Eso es lo que se est} haciendo. ['] Eso, no?
SR:
SR:
Dr. W: Mm SR: Having so many peo:ple there, some:{one would have to be there, isnt that right?} Dr. W: {So:meone has to be there. [.] Of cou:rse.} Thats it. Well I have been doing that, when they do: the:: clea:ning or the I treat them with ki:ndness:, giving affection, more co:nfidence, ['] [.] and: its worked! Its worked. SR: Mm:
Dr. W: Mm SR: Habiendo tanta ge:nte, al:{guien tendra que estar, no es cierto?} Dr. W: {A:lguien tiene que estar. [.] Cla:ro.} Eso. Bueno yo he estado haciendo eso, cuando ha:cen la:: limpie:za o la las trato con cari:o:, haciendo afecto, ms confia:nza, ['] [.] y: ha resultado! Ha resultado. SR: Mm:
aspira:tion, the: residents. [2] I explai:n to them, aspiraci:n los: residentes. [2] Yo les expli:co,
Dr. W: ['] But in others, for example yesterday Dr. W: ['] Pero en otras, por ejemplo ayer in an: incom:plete abortion that screamed tremendously, ['''] [1] m: until:: well, the people that were there outside c- cleared out, right? But: it is not like that! It is: n:ot [.] worth so: much. Because the neck of the womb was open! [.] en un: aborto incom:pleto que grit tremendamente, ['''] [1] m: hasta que:: bueno, la gente que estaba ah afuera s- se ha [des]ocupado, no? Pero: no es as! N:o es: [.] para tan:to. Porque el cuello estaba abierto! [.]
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SR: Mm: Dr. W: It entered, a cannula size ten!ii [2] Thats to say, what- what pain could she have? SR: Mm
SR: Mm: Dr. W: Entr una cnula de diez:! [2] O sea quequ dolor poda tener? SR: Mm
Dr. W: Right? ['] But shes very sensitive, the- Dr. W: No? ['] Pero es muy sensible lathe patient. SR: Mhm: Dr. W: Even though I spo:ke to her, if everyone was there:, [.] ['] the husband was outsi:de, the husband was walking around chewing his nai:ls, [.] [''] He says What have you done to my wi:fe! Why did she scream [[laughing]] so: much! SR: Right: Dr. W: Right? [.] But:: it was achieved and already:- and today she is leaving, we kept her in for: [.] preventively! [.] Right? SR: Right [1] Right, right [2] Dr. W: The method continues to be good, [.] ['] the: problem is that:: [.] that there is t- one:one: only: [2] only one ca:nnula for example of size six:, or only one cannula of [''] of -so we have to [1] fi:nish and wait twenty minutes for it to be sterilised, so th:la paciente. SR: Mjm: Dr. W: Pese a que le he habla:do, si todo el mundo estaba ah:, [.] ['] el esposo estaba afue:ra, el esposo andaba mascndose las u:as, [.] [''] Dice Qu le han hecho a mi espo:sa! Por qu ha gritado [[riendo]] ta:nto! SR: Ya: Dr. W: No? [.] Pero:: se logr y ya:- y hoy da se est yendo, la hemos mantenido por: [.] por prevencin! [.] No? SR: Ya: [1] Ya, ya [2] Dr. W: El mtodo sigue siendo bueno, [.] ['] el: problema es que:: [.] que hay t- una:un: solo:: [2] una sola c:nula por ejemplo del nmero seis:, o una sola cnula del [''] del -tonces tenemos que [1] termina:r y esperar veinte minutos a que se esterilice, entonces e:-
four, [.] of four millimetres theres one only, [''] cuatro, [.] de cuatro milmetros hay uno solo, ['']
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that is the problem, what we would like is to have [''] more cannulae! [1] Right? [.] SR: {Mm} Dr. W: {More} cannulae. SR: Mm: [.] Dr. W: And well, and:: and not to wait for them to be ste:rilised! Right? [2] SR: Mhm:
ese es el problema, lo que nosotros quisiramos es tener [''] ms cnulas! [1] No? [.] SR: {Mm} Dr. W: {Ms} cnulas. SR: Mm: [.] Dr. W: Y bueno, y:: y no esperar que se esterili:cen! No::? [2] SR: Mjm:
Dr. W: To open it and right away to u:se it and Dr. W: Abrir y:: de una vez utiliza:r y to do [your job!] [.] That will be talked about with IPAS surely, they are going to:they are going to see: the work that is being done here, right? [2] SR: And::: as you unfortunately were not there the day that: I gave my presentation of res{ults} Dr. W: {Yes::} SR: prelimina{ry,} Dr. W: {Thats it} SR: but I dont know what: you heard a:fterwards:, any co:mmentary:, [.] hacer [tu labor]! [.] Eso se hablar con IPAS seguramente, ellos van a:van a ver: el trabajo que se est haciendo ac, no? [2] SR: Y::: como Usted lamentablemente no estaba el da que: yo he dado mi presentacin de resul{tados} Dr. W: {S::} SR: prelimina{res,} Dr. W: {As es} SR: pero no s qu: ha escuchado despu:s:, algn comenta:rio:, [.]
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Dr. W: No no, absolutely not, no: I have not
Dr. W: No no, en absoluto, no, no: he
heard [??]. But I have- read:: your [1] summary, escuchado [??]. Pero lo he- le:: su [1] resumen, it was very i:nteresting, [2] like I tell you its an estaba muy interesa:nte, [2] como le digo es un i:mpulse so that we continue wo:rking, SR: Mm [.] Dr. W: and we take into account the: defects that {we} SR: {Mm:} Dr. W: have as well! In the form of expressing ourselves, right? SR: Mhm: Dr. W: with the patients themselves. SR: Right: [1] Dr. W: I think that: [.] to u:s it serves a lot, that. [2] impu:lso para que sigamos trabaja:ndo, SR: Mm [.] Dr. W: y nos demos cuenta de los: defectos que tenemos {noso} SR: {Mm:} Dr. W: tros tambin! En la forma de expresarnos, no? SR: Mjm: Dr. W: con las mismas pacientes. SR: Ya: [1] Dr. W: Creo que: [.] n:os sirve mucho a nosotros eso. [2]
SR: And is there: any thing that you remember, SR: Y hay: alguna cosa que recuerda, from those little sheets, like in particular, that surpri:sed you, had an i:mpact on you, any thing that you remember especially? [.] Dr. W: At this moment, [1] the recommendations! Right? de estas hojitas, as en particular, que le ha sorprendi:do, le ha impacta:do, alguna cosa que recuerda en especial? [.] Dr. W: En este momento, [1] las recomendaciones! No?
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SR: Mhm: Dr. W: That they should have [.] well, thatexception [1] we should:: be [.] tr- trained, [1] as well as receiving: more: uh information, right? And its what is happening, there doesnt exist information. SR: Mhm: [.] Dr. W: Its a ne:w method that:: even though its sim:ple, but:: since:- since it creates more work, [2] well they dont take it into account. Its better to send it in the afternoon, right? [.] Mm
SR: Mjm: Dr. W: Que deben tener [.] bueno, queexcepcin [1] debemos:: ser [.] en- entrenados, [1] por otro lado recibir: mayor: eh informacin, no? Y es lo que est sucediendo, no existe informacin. SR: Mjm: [.] Dr. W: Es un mtodo nue:vo que:: si bien es sen:cillo, pero:: como:- como crea mayor trabajo, [2] pues no lo toman en cuenta. Es mejor enviarlo en la tarde, no? [.] Mm
that they should:: [.] that all the staff [.] without que debe:: [.] que todo el personal [.] sin
SR: [.]
SR: [.]
Dr. W: But:: [.] already they are six MVAs that were done yesterday! SR: Mm:: [2] Dr. W: Today there is::- there is going to be done another one more now. SR: Right: [2]
Dr. W: Pero:: [.] ya se estn conscientizando! seis AMEUs que se han hecho ayer! SR: Mm:: [2] Dr. W: Hoy da se est::- se va a hacer otro ms ahora. SR: Ya: [2]
becoming aware! Like I tell you, look, there are Como le digo, mire, son
Dr. W: Even though we have the strike, but: [.] Dr. W: Pese a que tenemos el paro, pero: [.] it is- [.] it is being done, {right?} se est- [.] se est haciendo, {no?}
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SR: {Right} Dr. W: And they are being mobilised, the beds! SR: Right: [.] Dr. W: ['] After the:: informa:tion [.] what other thing was I commenting:? [.] I do not they should: have, the patients, right? [1] Its very important. [2] And: in some way I would like it to be don- that they should have privacy, as well! Because it cannot be done [.] ['] in a way that is so open. You have seen the cubicles we have, they are o{pen!} SR: {Yes:, well} [.] Yes [.] Dr. W: Right? [1] So it seemed to me that he who enters an interve:ntion [2] sosurrounded by:- by by [.] by fi:ve or seven persons, ['] feels bad! Right? That there should be a li:ttle bit of [1] of privacy for the patient. And for the selfsame party, [.] for him who is doing it as well! SR: Mm: [1] Dr. W: Because he feels [.] pressured, ['] and there is no lack of someone who says Doctor, I want you to sign this for me, when one is [.] doing the intervention, ['] thats to say, ['] [.]
SR: {Ya} Dr. W: Y se est movilizando las camas! SR: Ya: [.] Dr. W: ['] Despus de la:: informaci:n [.] qu otra cosa comentaba:? [.] No deben: tener las pacientes, no? [1] Es muy importa:nte. [2] Y: de alguna manera a m me gustara que se hag- que tengan privacidad, tambin! Porque no se puede hacer [.] ['] en forma tan abie:rta. Ha visto los cubculos que tenemos, son a{biertos!} SR: {S:, pues} [.] S [.] Dr. W: No? [1] Entonces me ha parecido que el que entra a una intervenci:n [2] entonsrodeada de:- de de [.] de ci:nco o siete personas, ['] se siente mal! No? Que debe haber un poqui:to de [1] de privacidad para la paciente. Y para el mismo parte, [.] para el que est haciendo tambin! SR: Mm: [1] Dr. W: Porque se siente [.] presionado, ['] y no falta alguien que dice Doctor, quiero que me lo firme esto, cuando uno est [.] haciendo la intervencin, ['] o sea, ['] [.]
remember: [2] Th:- the form of treatment! that:: me acuerdo: [2] E:- el: trato! que::
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theres n:o [.] idea of what is being done, right? n:o hay [.] idea de lo que se est haciendo, no? SR: Right [2] Dr. W: -so uhm::: we need a little bit of:: of instruction, information, [.] and study in this, fo:r the personne:l [.] that is paramedical, [[someone knocks on the classroom door]] Dr. W: residents and: interns, [2] so that we can uh: polish it! in a form [.] thats a:dequate, this method, right? [.] SR: Mhm Dr. W: And that it comes out for us [.] a hundred per cent! SR: Mm Dr. W: Right? SR: Right SR: Ya [2] Dr. W: -tonces: ehm::: necesitamos un poquito de:: de instruccin, informacin, [.] y estudio en esto, a:l persona:l [.] paramdico, [[tocan la puerta del aula]] Dr. W: residentes y: internos, [2] para que podamos eh: pulir! en forma [.] adecua:da este mtodo, no? [.] SR: Mjm Dr. W: Y que nos salga [.] cien puntos! SR: Mm Dr. W: No? SR: Ya
Dr. W: Thats what I could [.] comment to you Dr. W: Es lo que yo podra [.] comentarle SR: Right Dr. W: And from here on to some time ahead well see: statistics! SR: Thats it! SR: Ya Dr. W: Y de aqu a un tiempo ms veremos: estadsticas! SR: Eso!
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Dr. W: [[smiling]] Right? SR: Thats it!
Dr. W: [[sonriendo]] No? SR: Eso!
Dr. W: If theyre noting it down, so [??] in the Dr. W: Si estn anotando, entonces [??] en las clinical {his} SR: Mhm Dr. W: tories, ['] we dont have the computer that before they gave us [.] to note down these cases, ['] but I believe that its::- its going:: [.] its going to be possible to do a study of these cases. SR: Mhm Dr. W: Right? [2] SR: Very well. Dr. W: Very well [1] [?] I congratulate you and I thank you a lot for your interest [1] in supporting us! SR: Right [[laughing]] {Thank you!} Dr. W: {Right?} historias {clni} SR: Mjm Dr. W: cas, ['] no tenemos la computadora que antes nos daban [.] para anotar estos casos, ['] pero creo que se::- se va:: [.] se va a poder hacer un estudio de estos casos. SR: Mjm Dr. W: No? [2] SR: Muy bien. Dr. W: Muy bien [1] [?] la felicito y le agradezco mucho por su inters [1] de apoyarnos! SR: Ya: [[riendo]] {Gracias!} Dr. W: {Ya?}
End of Transcript 13.2
Termina la Transcripcin 13.2
Notes i trophoblastic a. (Embryol. & Med.) relating to or consisting of trophoblast L19. trophoblast n. (Embryol & Med.) a layer of cells or a membrane surrounding an embryo, which supplies it with nourishment and later forms most of the placenta L19. (OED) ii Canula de diez, a ten-millimetre diameter cannula.
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Appendix 9
Appendix 9 Contextualisation of transcript excerpts cited in sections 9.1 and 9.2 of Chapter 9, One Woman, Five Stories
Transcript of fieldnotes made by SR on interactions with the following characteristics: Participants referred to in notes: Mrs. Mayta (Mrs. M), woman who had undergone a therapeutic abortion in the Insurance Hospital. SR as researcher. Dr. Losada (Dr. L), third-year medical resident. Dr. Gonzles, principal research collaborator in the Insurance Hospital. Date and time of interactions: Place: Source of notes on context: Number & date of transcript: Context: I made these fieldnotes on Wednesday April 2nd 1997 between 9.25 and 10.08 a.m., sitting near the windows in the hallway outside the gynaecology ward of the Insurance Hospital. They were written at two different moments, just after conversations with Mrs. Mayta (Mrs. M). I had met Mrs. Mayta for the first time two days previously on the ward round. After the round I requested and received her permission to consult her medical history folder, which I did that same morning. Earlier on the day I made the fieldnotes transcribed below, I had requested a recorded interview with medical resident Dr. Losada (Dr. L) who was in charge of Mrs. Maytas treatment. After interviewing him, I approached Mrs. Mayta to ask her about her experience of the treatment. We had two conversations, and immediately after each one, I wrote the notes which follow. Wednesday 2/4/97, 9.15 10.05 a.m. Gynaecology ward and hallway just outside it, Insurance Hospital. Field Notebook 3, notes summarised 13/5/97, edited 28/7/02 A.XPZ.02, 13/5/97
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(9.25 - 9.35, notes afterwards, on 6th floor.) Mrs. M: (to SR) - I thought they were going to take out just the tumour from one side - No, I was in agreement - I had sorrow for the baby - The Doctor knows --- interrupt - like a birth... My husband took it to the Cemetery, we buried it, they baptised it The Lord can get angry
(9.25 - 9.35, apuntes despus, en el piso 6.) Sra. M: (a SR) Yo pens que iban a sacar el tumor noms de un lado No, yo estaba de acuerdo Tena pena por el beb El Doctor sabe --- interrumpir como parto... Mi esposo lo ha llevado al Cementerio, lo hemos enterrado, le han bautizado El Seor se puede enojar Yo nunca he hecho esas cosas El Dr. Losada se ha sacrificado por m Ha correteado Nosotros de pollera sabemos aguantar Mi parto as noms sabe ser, de una hora ____________
- I never have done those things - Dr. Losada sacrificed himself for me - He ran around - We who wear the pollerai know how to bear it My births, just like that they used to be, of one hour ____________
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(Conversation with Mrs. Mayta, patient of Bed #, she continued on the ward ... She came in walking and sat on the bed. I approached to ask her how she had got on with her treatment. She didnt look at me until the end.) _________ (While we were talking, Dr. Gonzles called me from the corridor. He was going downstairs with some forms about attention in reproductive health, with numbers of abortions, IUDs, etc.. He wanted to show me He said that I should wait for him that he would be back in 5 minutes.) __________ (She keeps calling me Doctoritaii although I tell her my name. __________ (10.04: For the past 10 minutes Ive been talking with Mrs. Mayta on the 6th floor, near the window We talk about her treatment and recovery. I speak to her: You have to take care of
(Conversacin con Sra. Mayta, paciente de la Cama #, segua en la sala... Entr caminando y se sent en la cama. Me acerqu para preguntarle cmo le haba ido con su tratamiento. No me mir hasta el final.) _________ (Cuando estuvimos hablando, me llam el Dr. Gonzles desde el pasillo. Estaba bajando las gradas con unos formularios de atencin a salud reproductiva, con nmero de abortos, DIUs, etc.. Me quiso mostrar Me dijo que le esperara que volvera en 5 minutos.) __________ (Me sigue llamando Doctorita aunque le digo mi nombre). __________ (10.04: Desde hace 10 minutos converso con Sra. Mayta en el 6to piso, cerca de la ventana Hablamos de su tratamiento y recuperacin. Le hablo: Tiene que cuidarse
yourself now so as not to get pregnant quickly. ahora para no embarazarse rpido. She has heard of a thing that is inserted inside so as not to get pregnant. Before a little nuniii told her 15 days after menstruation, Ella ha escuchado hablar de una cosa que se coloca adentro para no embarazarse. Antes - una monjita le dijo 15 das despus de la menstruacin,
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you are not to have relations Then, 15 days you can sleep. But her husband did not take any notice She didnt do that.) ______ She says that some say that [the IUD] does harm I say to her to some women it does not give them any problem To others, it does. That we are different... that if it causes her problems she can have it taken out again like a poultice its not for life.)
iv
no hay que tener relaciones Despus, 15 das puede dormir. Pero su esposo no haca caso Ella no ha hecho eso.) ______ (Ella dice que algunas dicen que [el DIU] hace dao Yo le digo - a algunas mujeres no les hace ningn problema A otras, s. Que somos diferentes... que si le causa problemas lo puede hacer sacar otra vez como un parche no es para toda la vida.)
End of Transcript A.XPZ.02
Fin de la Transcripcin A.XPZ.02
Pollera: Wide, layered skirts traditionally worn by Andean indigenous women. Doctorita: A diminutive that can be variously interpreted as inferring familiarity, affection, or the innocuous nature of the woman doctor referred to. iii Monjita: A diminutive that can be variously interpreted as inferring familiarity, affection, or the innocuous nature of the nun referred to.. iv Parche: Poultice impregnated with a curative animal or vegetable substance, used in Andean traditional medicine. I used this simile to simplistically convey the possibility of having an IUD inserted and having it removed again.
ii
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Appendix 10
Appendix 10 Contextualisation of transcript excerpts cited in section 10.3 of Chapter 10, Audiencing Hospital Stories
Transcript of field jottings made by SR on interaction with the following characteristics: Participants referred to in jottings: Dr. Maidana (Dr. MM), senior staff obstetrician in Maternity Hospital affiliated to National Insurance Scheme. Dr. Navia (Dr. NN), junior staff obstetrician in Maternity Hospital affiliated to National Insurance Scheme. SR as researcher. Date and time of interaction: Place: Source of notes on context: Number & date of transcript: Tuesday 18/8/98, 14.15 14.35 p.m. Paediatrics ward waiting room, Maternity Hospital. Field Notebook 13, notes summarised 13/5/97, edited 29/7/02. A.XPZ.02, 13/5/97
Context: I made these field jottings at the time of an encounter with Dr. Maidana (Dr. MM) and Dr. Navia (Dr. NN) in the waiting room of the Maternity Hospital paediatrics ward. A week earlier, I had given a Changing Voices research presentation to medical, paramedical and administrative staff on the invitation of the director Dr. Harb, my main research collaborator in that hospital. After the presentation, I requested Dr. Harbs help to locate some hospital doctors with whom I could carry out story dossier discussion exercises. He introduced me to Dr. Maidana, whom I had seen several times on previous visits to the hospital. He offered to do the session the following week with another obstetrician who would be on duty then.
I arrived at 13h on the agreed day and looked for Dr. Maidana, who was having lunch. Several staff members recognised me from the presentation and greeted me. The head nurse went to tell Dr. Maidana that I was waiting for him. He came out and we went to look for Dr. Navia, who immediately agreed to accompany us.
On my suggestion, we went to the paediatrics ward waiting room. I explained about the exercise and left them the story dossier sheets to read. I estimated that it would take them ten minutes to read and discuss it, and they agreed that that time would be sufficient. The jottings transcribed below were made when I returned to the waiting room after ten minutes.
At the end of the session, I asked Dr. Maidana and Dr. Navia if they would participate in a further exercise, writing an auto/biographical account: A critical event in my medical formation. Dr.Maidanas final intervention concerned an incident he had just remembered that was relevant to the proposed exercise.
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(14.15, notes made at the time.)
(14.15, apuntes tomados en el momento.)
Dr. MM: The five stories make it seem as if they were of five different patients. The point of view of the gynaecologist and the diagnosis is very directed towards induced abortion. The indication of a dermoid tumour is not very strong. I do not find why the pregnancy comes to be interrupted. It does not seem... to hold the Medical Council in a hospital... they are more firm in defence of life. In a hospital, this type of decision is not taken in the Reproductive Health programme above all for a cyst that does not have so much importance.
Dr. MM: Los cinco relatos hacen parecer que fueran de otros cinco pacientes. El punto de vista del gineclogo y el diagnstico est muy dirigido al aborto inducido. La indicacin de un tumor dermoide no es muy fuerte. No hallo por qu se llega a interrumpir el embarazo. No parece... hacer la Junta Mdica en un hospital... son ms firmes en defensa de la vida. En un hospital, no se toma este tipo de decisiones en el programa de Salud Reproductiva sobre todo para un quiste que no tiene tanta importancia.
Dr. NN: What the social worker says is very directed. There is not an explanation to the patient alternatives are not given. It is directed towards an abortion. The woman says I thought that they were going to take out the tumour just from one side. I had sorrow for the baby. But the social worker says another thing. Its contradictory. She says We who wear the pollera know how to bear it. The woman because of the social condition for that maybe it was not explained...
Dr. NN: Lo que dice la trabajadora social est muy dirigido. No se explica a la paciente no se da alternativas. Est dirigido a un aborto. La mujer dice Pens que me iban a sacar el tumor noms de un lado. Tena pena por el beb. Pero la trabajadora social dice otra cosa. Se contradice. Dice Nosotros de pollera sabemos aguantar. La mujer por la condicin social por eso quizs no se ha explicado...
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Dr. MM: The resident does not give an explanation of a scientific type not even gynaecological it seems more an interview that is very sentimental more from the moral and religious point of view not scientific. (The interview) It does not seem as if it were done in a hospital By chance in any place. A resident in the third year... has the capacity to be able to give correct explanations in a scientific form he talks rather in a religious form. Its a counter-position - in Medicine, we do not take much into account - religious aspects... It has to be of a scientific nature. The report of the nurse is not in agreement with the norms that (she should know, a) registered nurse she changes the concepts says obitus knowing that it does not occur at 16 semanas. An obitus (has to be) above 20 weeks. It says curettage... to extract the placenta Normally it is done to take out the placental remains - They do not explain for what cause she has to go down urgently to theatre -
Dr. MM: El residente no da una explicacin de tipo cientfico ni siquiera ginecolgico parece ms una entrevista muy sentimental ms desde el punto de vista moral y religioso no cientfico. (La entrevista) No parece que fuera realizado en un hospital Al azar en cualquier lugar. Un residente de tercer ao... tiene la capacidad de poder dar explicaciones correctas en forma cientfica l habla ms bien en forma religiosa. Es una contraposicin en Medicina, no tomamos muy en cuenta - aspectos religiosos... Tiene que ser de carcter cientfico. El informe de la enfermera no est de acuerdo a las normas que (debe conocer una) Licenciada en Enfermera cambia los conceptos dice bito sabiendo que no sucede a las 16 semanas. Un bito (tiene que ser) encima de 20 semanas. Dice legrado... para extraer la placenta Normalmente se hace para sacar los restos placentarios - No explican por qu causa tiene que bajar urgente a quirfano
Dr. NN: It seems a dermoid tumour with little feet
Dr. NN: Parece un tumor dermoide con patitas
(they both laugh)
(ambos se ren)
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Dr. MM: Is it a hospital? It does not seem to me that a hospital would accept the interruption of a pregnancy More still with a Medical Council In all the hospitals of Bolivia... (it should be) protected, human life -
Dr. MM: Es un hospital? No me parece que un hospital acepte la interrupcin de un embarazo Ms con Junta Mdica En todos los hospitales de Bolivia... (se debe) precautelar la vida humana Es la primera vez que escucho que hay que interrupcin (.....?)
It is the first time that I hear that it has to be interruption (.....?)
SR: Has it any utility, the exercise?
SR: Tiene alguna utilidad el ejercicio?
Dr. MM: This hospital does not have norms for attention, conduct each service does what it can It does not adhere to an internal regulation of a hospital. The patient should be attended with one norm alone the gynaecologist the social worker to lead the patient in only one direction.
Dr. MM: Este hospital no tiene normas de atencin, conducta cada servicio hace lo que puede No se rige a un reglamento interno de un hospital. A la paciente se la debe atender con una sola norma el gineclogo la trabajadora social encaminar a un solo lado a la paciente.
Dr. NN: To speak only one language.
Dr. NN: Hablar un solo idioma.
Dr. MM: That the resident should adhere to the norms of the hospital That he should learn correctly (Giving) various points of view - - instead of helping the patient confuses her That they should have programmes of teaching that take into account all the
Dr. MM: Que el residente se rija a las normas del hospital Que aprenda correctamente (Dar) varios enfoques - - en lugar de ayudar a la paciente la confunde Que tengan programas de enseanza que tomen en cuenta todos los
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aspects scientific psychic moral for the integral formation of the resident. It has to be modified, the system of teaching that is not in accordance with reality. The resident is the man who already is a specialist he must have concepts that are more clear more based on professional ethics. The doctor has to leave to one side his religious beliefs first, the profession -
aspectos cientfico psquico moral para la formacin integral del residente. Hay que modificar el sistema de enseanza que no est de acuerdo con la realidad. El residente es el hombre que ya es especialista debe tener conceptos ms claros ms basados en la tica profesional. El mdico tiene que dejar de lado sus creencias religiosas primero la profesin
SR:
SR:
(Have you not both seen situations like that, in (No han visto situaciones as, en which they have been handled, different approaches?) que se han manejado diferentes enfoques?)
Dr. NN: There are! But more in small things
Dr. NN: Hay! Pero ms en cosas pequeas
Dr. MM: In treatment. Not in conducts like that, aggressive this type of aggressions. Before it was worse.
Dr. MM: En el tratamiento. No es conductas as agresivas este tipo de agresiones. Antes era peor.
Dr. NN: We base ourselves on norms that are already written
Dr. NN: Nos basamos en normas ya escritas
Dr. MM: In a hospital always we go protecting human life
Dr. MM: En un hospital siempre vamos precautelando la vida humana
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Dr. NN: Including when there are foetuses that are deformed in Medical Councils it is difficult to decide.
Dr. NN: Incluso cuando hay fetos malformados en Juntas Mdicas es difcil decidir.
Dr. MM: (They are seen, the) possibilities to live. (It is tried, to) correct the defects a measure that is aggressive because of another tumour pathology - - life of the baby - -
Dr. MM: (Se ven las) posibilidades de vivir. (Se trata de) corregir los defectos una medida agresiva por otro tumor patologa - - vida del beb - -
Dr. NN: -
Dr. NN: Todos los tumores son compatibles con la vida del beb - -
All the tumours are compatible with the life of the baby - -
Dr. MM: Even cancer is compatible with pregnancy. (I give forms for the stories collect Friday 14h from directors office)
Dr. MM: Inclusive el cncer es compatible con el embarazo. (Doy formularios para relatos recoger viernes 14h de Direccin)
Dr. MM: Right now I have just remembered an incident from when I was in first year!
Dr. MM: Justo ahora me acabo de acordar de un incidente de cuando estaba en primer ao!
End of the transcript of notes A.GPD.2
Fin de la transcripcin de apuntes A.GPD.2
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Appendix 11
Appendix 11 Contextualisation of transcript excerpt introducing Chapter 11, Contrariwise and Otherwise
Excerpt of transcript of field notes on interactions registered by SR with the following characteristics: Participants: Bertha Bastos (B), intern friend and research collaborator SR as researcher and friend SRs 12-year-old son Amaru Villanueva Date and time of interaction: Place: Source of notes on context: Number & date of transcript: Friday 15th May 1998, 10.30 11.30 p.m. Walking on the street, urban residential zone Field Notebook 11, notes made 15-16/5/98, edited 30/7/02 S.1, 22/6/99
Context: These fieldnotes were written half an hour and then five hours after a conversation in the street with Bertha Bastos (B), an intern friend I had got to know through fieldwork in the Medical School, with whom I had ongoing discussions about relations between sociology and medicine.
That evening we had gone bowling and to eat hamburgers together with my twelve-year-old son, Amaru. The three of us were walking back along the main avenue of a residential street in the southern zone of the city. Bertha was smoking a cigarette and we walked and talked together before getting our respective taxis home.
Bertha initiated the conversation transcribed below, bringing up the topic of a legal medicine lecture that I had observed with her class in the Medical School that morning, on Berthas suggestion and invitation.
I wrote the notes here transcribed and translated on returning home at 11.45 p.m. that night, and on waking at 5.10 a.m. the following morning.
Parts of my notes were in English, and I present these in the left-hand column with no parallel translation. The text originally in Spanish is presented in the right-hand column, with an English translation running parallel.
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Start of Transcript S.1
(11.45 p.m. Just got back from bowling and McDonalds with Bertha and Amaru. The last hour was a rather disturbing and surprising conversation between me and Bertha, with which Amaru appeared to be bored stiff at the time, but afterwards reacted with amazement at how squarei she seemed to him, and great surprise when I said she was actually one of the more open students Id met. Ill try to remember parts of the conversation which struck me:)
B: It seems that you did not like the class this morning.
B: Parece que no te gust la clase de esta maana.
SR: Its not a question of whether I liked it or not it interested me, as a form of expressing the medical model.
SR: No es cuestin de que me haya gustado o no me interes, como forma de expresar el modelo mdico.
B: What do you mean by that?
B: Qu quieres decir con esto?
SR: Well, for example professional protection against litigation, lawsuits for medical negligence... and the informed consent form which has more the function of safeguarding the interests of the doctor, than the rights of the patient.
ii
SR: Bueno, por ejemplo la proteccin gremial en contra del litigio, los juicios por negligencia mdica... y el formulario de consentimiento informado que tiene ms la funcin de precautelar los intereses del mdico, que los derechos del paciente.
B: But this form is much better than others that I have seen, which as he said, are like registrations in a hotel.
B: Pero este formulario es mucho mejor que otros que yo he visto, que como dijo l, son como registros en un hotel.
SR: But all the same, the language is not
SR: Pero de igual manera, el lenguaje no es
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understandable for many people who are users of the services. Still less for those who do not know how to read and write.
entendible para muchas personas usuarias de los servicios. Menos an para los que no saben leer y escribir.
B: So what would you do? The doctor would have to give a class to each one
B: Entonces, cmo haras t? El mdico tendra que dar una clase a cada uno
SR: Put it in language which is more simple and clear. And put a note saying that if the person doesnt know how to read and write that theres an obligation to explain everything and to verify the comprehension and the informed consent of the person.
SR: Ponerlo en un lenguaje ms sencillo y claro. Y poner una nota diciendo que si la persona no sabe leer y escribir que se debe explicar todo y verificar la comprensin y el consentimiento informado de la persona.
I have seen that in the Insurance Hospital, in a case of therapeutic abortion, in which the woman and her partner had a lot of doubts about the procedure.
Yo he visto eso en el Hospital del Seguro, en un caso de aborto teraputico, en que la mujer y su pareja tenan muchas dudas sobre el procedimiento.
And the resident, seeing that, made them sign an informed consent form not so much to ensure their comprehension and agreement, but rather to protect himself against a possible lawsuit.
Y el residente, viendo eso, les hizo firmar un formulario de consentimiento informado no tanto para asegurar su comprensin y acuerdo, sino ms bien para protegerse en contra de un posible juicio.
Other things I noted in the class today were: the Otras cosas que not en la clase hoy, fueron: el use of slides without any attempt to protect the identity of people by covering their eyes; the repeated projection of images of medical pornography, the child with an immense tumour in his face showing it unnecessarily several times, as if to impress and frighten; and also the references to the subjective nature of what uso de diapositivas sin ningn intento de proteger la identidad de las personas, tapando sus ojos; la proyeccin repetida de imgenes de pornografa mdica, el nio con un tumor inmenso en la cara mostrndolo innecesariamente varias veces, como para impresionar y asustar; y tambin las referencias a lo subjetivo de lo que
the patient reports, versus the objective nature refiere el paciente, versus lo objetivo of the medical diagnosis. del diagnstico mdico.
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B: But it cant be any other way! We know that the great majority of patients either enlarge or diminish what they have. Doctors divide into symptoms and signs the symptoms are what the patient reports. And the signs are what the doctor really observes, objectively.
B: Pero no puede ser de otra manera! Sabemos que la gran mayora de los pacientes, o agranda o achica lo que tiene. Los mdicos dividen en sntomas y signos los sntomas son lo que el paciente refiere. Y los signos son los que realmente observa el mdico, objetivamente.
SR: From sociology, its considered that the doctor also observes from his subjectivity. And that there is not a hierarchy of knowledge that the constructions of the patient and the doctor have the same value and validity.
SR: Desde la sociologa, se considera que el mdico tambin observa desde su subjetividad. Y que no hay una jerarqua de conocimientos que las construcciones del paciente y del mdico tienen igual valor y validez.
B: That cant be. For example, a patient with a problem of the gall bladder, who exaggerates his pain whilst the doctor
B: Eso no puede ser. Por ejemplo, un paciente con un problema de vescula, que exagera su dolor - mientras que el mdico
evaluates and knows that such pain cannot exist valora y sabe que tal dolor no puede existir because its known studies have been done. porque se conoce se ha hecho estudios.
SR: But the patient will have his reasons for representing his pain in this way.
SR: Pero el paciente tendr sus razones por representar su dolor de esa manera.
B: But what can we do? We have to programme surgery giving priority to the most urgent cases. You, what would you do?
B: Pero qu podemos hacer nosotros? Tenemos que programar cirugas priorizando a los casos ms urgentes. T, qu haras?
SR: As a sociologist, its not up to me to
SR: A m como sociloga, no me compete
programme surgery. I would be more interested programar cirugas. Me interesara ms in knowing how that person constructs their pain and what they seek with that representation. saber cmo esta persona construye su dolor y qu busca con esta representacin.
B: And what would you do, with a patient who B: Y qu haras, con un paciente que consults for a problem of vision who says consulta por un problema de la vista que dice
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that he sees the small letters and not the big ones? What would you say?
que ve las letras chicas y no las grandes? Qu diras?
SR: I would not have to fix his problem with vision, or know if what he says is true or not. I would be more interested in talking to him to
SR: Yo no tendra que arreglar su problema de la vista, ni saber si lo que dice es cierto o no. Me interesara ms charlar con l para
know how he constructs his reality, his eyes, the saber cmo construye su realidad, sus ojos, el fact of seeing well or badly; if he wants to wear hecho de ver bien o mal; si quiere usar glasses or not; if there are people who are pressuring him to wear them; if he thinks that he is not going to look good with glasses; etcetera. It is not my problem to resolve his problem with vision. lentes o no; si hay gente que le est presionando para que los use; si piensa que no se va a ver bien con lentes; etctera. No es mi problema, solucionar su problema de la vista.
B: But what do you want us to do? To talk to him about that?
B: Pero qu quieres que hagamos nosotros? Qu le conversemos sobre esto?
SR: No you do what you have to do, within your medical model. But I as a sociologist see things in another manner and my work is different.
SR: No ustedes hacen lo que tienen que hacer, dentro de su modelo mdico. Pero yo como sociloga veo las cosas de otra manera y mi trabajo es diferente.
B: But you are attacking our way of doing things!
B: Pero t ests atacando nuestra forma de hacer las cosas!
SR: I dont say that its good or bad. Only that its a particular model, a special way of
SR: No digo que est bien ni mal. Slo que es un modelo particular, una forma especial de
constructing and treating the human body and construir y tratar el cuerpo humano y that its very different from the sociological model. que es muy diferente del modelo sociolgico.
B: But youre not understanding what the doctor wanted to say this morning! Thats how signs and symptoms are registered, as subjective y objective. In what other way can it be done?
B: Pero no ests entendiendo lo que quera decir el Doctor esta maana! As se registran los signos y sntomas, como subjetivo y objetivo. De qu otra manera se puede hacer?
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SR: Im telling you that there are other ways of constructing reality. Just as you cannot think like a sociologist, nor can I think like a doctor.
SR: Yo te estoy diciendo que hay otras formas de construir la realidad. Tal como t no puedes pensar como sociloga, yo tampoco puedo pensar como mdico.
B: Yes, but it cannot be denied that... (I think that here she tried to assert the superiority of the medical vision).
B: Si, pero no se puede negar que .. (pienso que aqu trataba de aseverar la superioridad de la visin mdica).
SR: Its that there are different ways of constructing and seeing reality! Im not saying that one is better or worse than the other but that both occur.
SR: Es que hay diferentes maneras de construir y ver la realidad! No estoy diciendo que una es mejor o peor que la otra sino que ambas se dan.
(16-5-98. 5.10 a.m. on waking)
B: But I am trying to explain to you why the Doctor explained it that way it seems that you do not understand!
B: Pero yo te estoy tratando de explicar, por qu el Doctor lo explic de esa manera parece que no entiendes!
SR: I understand that this forms part of his model. But you in medicine learn a type of language, a terminology, and to say thats how it is. In sociology, we learn to question the terms and to say: Why would it be called like that? How could it be called otherwise?
SR: Entiendo que esto forma parte de su modelo. Pero ustedes en medicina, aprenden un tipo de lenguaje, una terminologa, y a decir as es. En sociologa, nosotros aprendemos a cuestionar los trminos y a decir: Por qu se llamara as? Cmo se podra llamar de otra manera?
Its not a destructive thing but of curiosity, of examining how reality is constructed in different ways.
No es una cosa destructiva sino de curiosidad, de examinar cmo se construye la realidad de diferentes maneras.
B: But you are researching among us, among the doctors! And youre learning how we explain things.
B: Pero t ests investigando entre nosotros, entre los mdicos! Y ests aprendiendo cmo nosotros explicamos las cosas.
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SR: Yes, but Im more interested in the negotiation between you and other people like the users of the services (I dont say patients because that emphasises submission, dependency and a lesser hierarchy faced with medical power) try to validate their version of reality in the interaction what happens and who succeeds in validating their version of the facts.
SR: Si, pero ms me interesa la negociacin entre ustedes y otras personas como las usuarias de los servicios (no digo pacientes porque esto enfatiza la sumisin, la dependencia y una jerarqua menor frente al poder mdico) tratan de hacer valer su versin de la realidad in la interaccin qu pasa y quin logra hacer valer su versin de los hechos.
I could do this same work in a fishery, a beauty salon or a restaurant what interests me is human interaction and the management of power relations between people of different social groups.
Yo podra hacer este mismo trabajo en una pesquera, un saln de belleza o un restaurant lo que me interesa es la interaccin humana y el manejo de las relaciones de poder entre personas de diferentes grupos sociales.
B: But you have to see that the patients almost always enlarge or diminish the condition they have. They do not tell you the truth.
B: Pero tienes que ver que los pacientes casi siempre agrandan o achican el cuadro que tienen. No te dicen la verdad.
SR: That supposes that there is a condition out there that is objectively demonstrable. That any person can recognise as true.
SR: Esto supone que hay un cuadro ah fuera que es objetivamente demostrable. Que cualquier persona puede reconocer como cierto.
In sociology we do not give greater hierarchy to En sociologa no damos mayor jerarqua a that medical version of the facts. We consider the knowledge of the user as equal to that of the doctor, in status. esa versin mdica de los hechos. Consideramos los conocimientos del usuario como iguales a los del mdico, en status.
B: --- ?
B: --- ?
SR: (saying goodbye) I hope you do not get totally disgusted with sociology! ____________
SR: (despidindose) - Espero que no te disgustes del todo con la sociologa! ____________
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Appendix 11
Amaru reacted strongly to Berthas attitude as rigid, arrogant, and unable to see other constructions of reality outside or alternative to the medical model. He said I believe in science, but there are other ways of describing realities and phenomena, including illnesses.
I was struck by Berthas sense of being attacked, on having a critical vision of medical discourse presented. How she clung to a notion of medical superiority and patients unreliability. I hope this doesnt ruin our friendship! I felt the end of the conversation and the farewell were a bit abrupt. Ill see her on Wednesday in the legal medicine video and ask how she felt about the conversation. ________
All this makes me think that showing the dossiers while the exercise can serve to highlight the relativity of medical discourse could also serve to emphasise the falsity, distortion and lack of knowledge of other participants, from a medical point of view. Its a pity I cant use the pain dossier for me, thats the one that most brings the point home picking up what Bertha said about the impossibility of a certain kind of pain backed up by studies done on nerve paths, etc..
I think this conversation showed up a major facet of medical education: the teaching of a positivistic model, faith in the superiority of medical knowledge, and warnings of patients unreliability and manipulative behaviour used to get ahead on the operating lists.
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Appendix 11
______
This makes me think especially of the part in the medical history where it says: Fuente de informacin: paciente confiableiii (I take this to mean, for purposes of the medical version of events).
End of Transcript S.1
Cuadrada in Spanish, literally and figuratively square. Professional does not adequately express the associations of gremial in the original. This adjective comes from the noun gremio, often used by doctors in Bolivia to refer to their profession as a craft or union-like fraternity: el gremio mdico. gremio, m. lap; body, society, company, guild, corporation; fraternity; trade-union (Cuys xxx). iii Fuente de informacin, source of information. Paciente confiable, patient trustworthy.
ii
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Appendix 12
APPENDIX 12
Translated excerpts from Bolivian Ministry of Health 1999 policy document, National Programme for Sexual and Reproductive Health
Ministerio de Salud y Previsin Social. Coordinacin del Programa Nacional de Salud Sexual y Reproductiva. Unidad de Atencin a las Personas. Programa Nacional de Salud Sexual y Reproductiva 1999 2002. La Paz, 1999
A12.1
Excerpt on maternal mortality from Section III. Demographic, economic, political, social, cultural, educational context, pp. 33 34;
A12.2 A12.3
Excerpt on abortion from Section III, ibid., pp. 35 36; Excerpt on problems affecting sexual and reproductive health and services from Section VI. Priority Problems, p. 40;
A12.4
Excerpt on basic principles and approaches from Section IX. Principles, Vision, Mission, Objective, Results and Indicators of the Programme, p. 48.
A12.1
Excerpt on maternal mortality from Section III. Demographic, economic, political, social, cultural, educational context, pp. 33 34:
4. Maternal mortality
According to a direct estimate made by the DHS 94 study, the rate of maternal mortality for the period 1989 1994 was 390 deaths per 100,000 live births. In urban areas the mortality rate reached 262, while in rural areas it was 563 deaths per 100,000 live births. By region, in the high plateau it reached 591 (346 urban and 929 rural), 286 in the valleys and in the plains, 166 deaths per 100,000 live births. On observing the type of mortality, it was ascertained that 61.7% occurred during pregnancy, 22.8% in childbirth and 15.5% postpartum.
Three quarters of these deaths are produced in pregnancy, with greater frequency than in childbirth and postpartum (haemorrhage, abortion, hypertension, etc.). It is evident that pregnant women younger than 19 and older than 34, like women who have very short intervals between pregnancies (less than 24 months), increase the risk of dying. The majority of maternal deaths are produced at home. Unpublished data from the then National Health Secretariat estimated that in 1995 abortion was responsible for between 27 and 35% of maternal mortality.
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Appendix 12
A12.2
Excerpt on abortion from Section III, ibid., pp. 35 36:
6. Abortion
As in many countries of the world, abortion constitutes a serious public health problem in Bolivia. The Penal Code considers abortion as a crime against life and bodily integrity, establishing penalties depriving liberty and other greater ones when abortion is followed by lesions or death. Abortion is permitted when the life or health of the woman are endangered if the pregnancy continues or if the pregnancy is the result of rape, abduction not followed by marriage, abuse or incest (The Population Council 1995). The penalisation which the legislation establishes for practitioners and for the woman who requested it, together with the absence of comprehensive studies, prevents more precise knowledge regarding the national dimensions and repercussions of this problem for the rights, health and life of Bolivian women, and for this same reason, makes it difficult to link actions addressing it on its different levels.
Data on Bolivia estimate that approximately 115 abortions are produced daily and between 40,000 and 50,000 annually. The principal factor underlying the decision to abort is unwanted pregnancy. Given the illegal nature of abortion in the country, the majority of abortions are clandestine and practised by unqualified persons, which gives rise to conditions of risk for health.
The complications derived from induced abortion vary, depending on whether the woman resides in the rural or urban area, on her educational status and socio-economic level, as has been demonstrated by studies in other countries (The Alan Guttmacher Institute, 1994).
It is calculated that of all pregnancies produced worldwide, some 20 to 30% terminate in induced abortions. In 1986 the number of abortions practised in Bolivia was estimated at 42,000. Rates have been found of 600 deaths per 10,000 abortions practised in the country (compared with 0.5 per 100,000 in the United States, according to a study from the same year). This would give us an approximate figure of 252 women who die yearly in the country due to the complications of these interventions.
A12.3
Excerpts on problems affecting sexual and reproductive health and services from Section VI. Priority Problems, p. 40:
1. Relating to the sexual and reproductive health of the population:
Maternal morbidity and mortality associated with complications of the reproductive cycle (pregnancy, childbirth and postpartum). Morbidity and mortality of women associated with gynaecological cancers (cervico-uterine and mammary).
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Appendix 12
Morbidity and mortality of women associated with complications of unwanted pregnancy (induced abortion). Morbidity in adolescents, adult women and men, associated with risk behaviours (sexually transmitted diseases, HIV and AIDS). Mistrust of the services offered by the network of establishments. Unsatisfied demand for family planning. Lack of knowledge about sexual and reproductive rights.
2. Relating to the supply of sexual and reproductive health services:
Insufficient and weak situation of management systems at different levels: central departmental, district and local; expressed in: Weakness in the development of systems for leadership and management of the programme at different levels (weak sectoral leadership). Insufficiency in the development and application of programmatic orientation, technical and administrative norms and protocols for care. Limited integration of general services with those pertaining to sexual and reproductive health (including the availability of checks for STDs and HIV/AIDS. Influence of biomedical and assistential approaches in the management of services. Weakness in gender, ethnic (limited capacity for intercultural dialogue) and generational perspectives. Insufficiency in the application of specific plans within the network of public services. Insufficiency in the provision of human resources, equipment and materials for management tasks.
A12.4
Excerpt on basic principles and approaches from Section IX. Principles, Vision, Mission, Objective, Results and Indicators of the Programme, p. 48.
1. Basic principles and approaches
In recognition of the just aspirations of the Bolivian population to levels of sexual and reproductive health which are compatible with human, sexual and reproductive rights, expressed in numerous political and legal instruments and honouring the commitments made in important international and national forums, through this Programme the following principles and basic approaches are taken up and appropriated:
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Appendix 12
The recognition of reproductive health as a general state of physical, mental and social well-being in all aspects relating to the reproductive system, its functions and processes.1 In consequence, reproductive health involves the capacity to enjoy a satisfactory and risk-free sex life, as well as the capacity to procreate and the freedom of decision about whether or not to do so, when and with what frequency. This state implicitly entails the right of men and women to obtain information and have access to family planning methods of their choice which are safe, efficient, acceptable and economically attainable, as well as other methods of their choice for the regulation of their fertility, which are not legally prohibited, and the right of women to have access to health care services which promote risk-free pregnancies and births.
Recognition that reproductive health care includes sexual health, whose objective is the development of life and personal relations and not merely advice and care concerning reproduction and sexually transmitted diseases.
Recognition of sexual and reproductive rights, which embrace certain internationally recognised human rights, which refer to the right of couples and individuals to freely and responsibly decide the number of their children, the spacing and timing of births, to have access to the necessary information and means to do so, and the right to achieve the highest level of sexual and reproductive health. The right of each person to adopt decisions relating to reproduction without suffering discrimination, coercion or violence.
The importance of giving full attention to promoting relations of mutual respect between men and women and particularly, to the satisfaction of additional needs and services for adolescents so that they can assume their sexuality in a positive and responsible manner.
The provision of quality services, which implies the opportune and sufficient offer of information and orientation, the development of environments and mechanisms favouring free choice, the delivery of services by trained and motivated providers, respect for privacy and confidentiality, an integrated approach to care.
Promotion of individual responsibility, citizens participation, shared responsibility and management, which seeks to involve individuals in making decisions which are relevant to aspects connected with their health and with the care of the populations health.
Respect for culture and diversity, which demands differentiated attention in recognition of the populations cultural models and values for social life and organisation.
Authors note: Here and elsewhere, this national policy document directly cites excerpts from the United Nations ICPD 1994 Programme Of Action.
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Appendix 13
APPENDIX 13
United Nations Population Fund 1996. Programme of Action adopted at the International Conference on Population and Development, Cairo, 5 13 September 1994. Paragraph 8.25 (pp. 70-71):
8.25. In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental organizations are urged to strengthen their commitment to womens health, to deal with the health impact of unsafe abortion1 as a major public health concern and to reduce the recourse to abortion through expanded and improved family-planning services. Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. Post-abortion counselling, education and familyplanning services should be offered promptly, which will also help to avoid repeat abortions.
Unsafe abortion is defined as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both (based on World Health Organization, The Prevention and Management of Unsafe Abortion, Report of a Technical Working Group, Geneva, April 1992 [WHO/MSM/92.5]).
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Appendix 14
APPENDIX 14 Translated excerpt from the Bolivian Penal Code, Title VIII, Crimes against Life and Bodily Integrity, Chapter II, Articles 263269 on abortion (Bolivia. Cdigo Penal, pp. 92 - 93):
CHAPTER II
ABORTION
Article 263.- (ABORTION).- He who should cause the death of a foetus in the maternal womb or should provoke its premature expulsion, shall be sanctioned:
1) With deprivation of liberty from two to six years, if the abortion should have been practised without the consent of the woman or if she were less than sixteen years old.
2) With deprivation of liberty from one to three years, if it should have been practised with the consent of the woman.
3) With confinement from one to three years of the woman who gave her consent.
The attempt on the part of the woman is not punishable.
Article 264.- (ABORTION FOLLOWED BY LESION OR DEATH).- If the abortion with the womans consent should have been followed by lesion, the penalty shall be deprivation of liberty from one to four years; and if death should ensue, the penalty shall be augmented by half.
If abortion without consent should result in lesion, a penalty shall be imposed on the author of deprivation of liberty from one to seven years; if death should occur, deprivation of liberty shall be applied from two to nine years.
Article 265.- (ABORTO HONORIS CAUSA).- If the crime should have been committed to save the honour of the woman, either by herself or by third parties, with her consent, confinement shall be imposed from six months to two years, with the penalty aggravated by a third if death should ensue.
Article 266.- (NON-PUNISHABLE ABORTION).- If the abortion should have been the consequence of an offence of rape, abduction not followed by marriage, abuse or incest, no sanction will be applied, provided that the penal lawsuit has been commenced.
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Appendix 14
Neither will it be punishable if the abortion should have been practised with the purpose of avoiding a danger for the life or health of the mother and if this risk could not be avoided by other means.
In both cases, the abortion must be practised by a physician, with the consent of the woman and judicial authorisation where corresponding.
Article 267.- (UNINTENTIONAL ABORTION).- He who through violence should have given rise to abortion without intending to cause it, but with the pregnancy being in evidence or with knowledge of it, shall be penalised with confinement from three months to three years.
Article 268.- (BLAMEFUL ABORTION).- He who should blamefully have caused an abortion will be liable to provide labour for up to one year.
Article 269.- (HABITUAL PRACTICE OF ABORTION). He who should habitually dedicate himself to the practice of abortion shall be liable to deprivation of liberty from one to six years.
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Appendix 15
APPENDIX 15
Translated excerpt from the Bolivian Political Constitution, Article 3 on State and religion (Bolivia 1985. Constitucin Poltica del Estado, p. 6):
ARTICLE 3. The State recognises and sustains the Apostolic Roman Catholic religion. It guarantees the public exercise of all other cults. Relations with the Catholic Church will be governed by covenants and agreements between the Bolivian State and the Holy See.
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Appendix 16
APPENDIX 16 Translated excerpt from the Bolivian Medical Colleges Code of Ethics, Article 15 on therapeutic abortion (Colegio Mdico de Bolivia 1993. Cdigo de Etica Mdica in Estatutos y Reglamentos 1993 p. 111):
Art. 15
The interruption of a pregnancy will only proceed by therapeutic indication agreed by a medical council and with due authorisation from the patient or her direct relatives.
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Appendix 17
APPENDIX 17
Register of Materials Used For Analysis

17.1 Register of Appendices A - H submitted in spiral-bound volumes with preliminary contract research report, February 1997. Translations of contents follow: all materials are in Spanish. Speakers are identified with lettered and numerical codes in these Appendices. This register incorporates pseudonyms used in the thesis when applicable.
Appendix A Tables charting variations in 40 contextualised discursive constructions of therapeutic abortion, corresponding to five medical research subjects in the State Hospital, December 1996 January 1997: Dr. Dvila, staff gynaecologist and head of residents training: Graph: Variations in 20 discursive constructions of therapeutic abortion over the two-month period; Comparison of 20 contextualised discursive constructions of therapeutic abortion. Dr. Antunes, hospital director: 10 discursive constructions Dra. Campos, first-year medical resident: 4 discursive constructions Dr. X, first-year medical resident: 2 discursive constructions Dr. Justiniano gynaecology ward chief: 4 discursive constructions
Appendix B Tables showing contextualisation of the 40 discursive constructions of therapeutic abortion registered in Appendix A.
Appendix C Two clippings from national newspapers referring to therapeutic abortion, 22nd January and 6th February 1997.
Appendix D Scheme for the analysis of 20 contextualised discursive constructions of therapeutic abortion, by diverse research subjects in the State Hospital, registered in field notes made on unrecorded observations and interactions.
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Appendix 17
Appendix E Scheme for the analysis of 103 contextualised discursive constructions of abortion, by four research subjects in the State Hospital, from transcripts of recorded interactions: Dr. Dvila, staff gynaecologist and head of residents training: 32 discursive constructions in 5 interactions. Dr. Antunes, hospital director: 31 discursive constructions in 1 interaction Dra. Campos, first-year medical resident: 10 discursive constructions in 1 interaction Ms Ulloa, secretary, hospitalised in gynaecology ward: 30 discursive constructions in 1 interaction
Appendix F Selected fieldnotes referring to therapeutic abortion, transcribed from 10 entries in Field Notebook 1 between December 6th and 17th 1996
Appendix G Two selected excerpts referring to therapeutic abortion from an e-mail message sent on December 6th 1996 from SR to Ipas, transcribed on 15th February 1997.
Appendix H 11 transcripts of recorded observations and interactions, 6th December 1996 to February 14th 1997, with the following research subjects: Dr. Dvila, staff gynaecologist and head of residents training, State Hospital: 7 transcripts (3.1-3.7) Dr. Antunes, director of State Hospital: 1 transcript (2.1) Dra. Campos, first-year medical resident, State Hospital: 1 transcript (4.1) Ms Ulloa, secretary, hospitalised in gynaecology ward, State Hospital: 1 transcript (5.1) Mrs. X, sociologist: 1 transcript (6.1)
17.2
Register of appendices I - L submitted in spiral-bound volumes with first year contract research report, September 1997
Appendix I 13 transcripts of recorded observations and interactions with staff and women hospitalised in the Insurance Hospital gynaecology ward between April 2nd and July 25th 1997, with the following research subjects: Dr. Losada, third-year medical resident: 2 transcripts (10.1, 10.2) Licenciada Irma Illanes, social worker: 2 transcripts (11.1, 11.2) Dr. Salinas, gynaecology ward chief: 3 transcripts (12.1 12.3) Dr. Walters, staff gynaecologist: 2 transcripts (13.1, 13.2) Head Nurse Elena Elas: 1 transcript (14.1) Dra. Helga Haber, first-year medical resident: 1 transcript (15.1) Mrs. Gong, women hospitalised in gynaecology unit: 1 transcript (XPM.1) Mrs. X, woman hospitalised in gynaecology unit: 1 transcript (XPC.1)
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Appendix 17
Appendix J 16 transcripts of selected fieldnotes from Field Notebooks 2 5, from entries made between 25th March and 30th July 1997, on observations and interactions in the Insurance Hospital with the following research subjects: Dr. Gonzles, staff gynaecologist and head of residents training: 7 entries transcribed (A.X9.00 A.X9.5) Licenciada Irma Illanes, social worker: 1 entry transcribed (A.X11.1) Dr. Salinas, gynaecology ward chief: 1 entry transcribed (A.X12.1) Dr. Walters, staff gynaecologist: 1 entry transcribed (A.X13.1) Dra. Helga Haber, first-year medical resident: 1 entry transcribed (X.15.1) Mrs. Mayta, women hospitalised: 2 entries transcribed (A.XPG.02, A.XPG.03) General observations: 2 entries transcribed (A.OBS.1, A.OBS.2)
Appendix K Copies of overhead transparencies with preliminary results of research in State Hospital, presented at Population Council meeting on quality and accessibility of abortion services, New York, March 1997.
Copies of overhead transparencies with preliminary results of research in Insurance Hospital, presented to staff of gynaecology ward, Insurance Hospital, July 1997.
Appendix L Selection of clippings from national newspapers referring to abortion, the medical profession, health workers and medical education, 13th September 1996 to 3rd August 1997.
17.3
Register of appendices M - Q submitted in spiral-bound volumes with second year contract
research report, September 1998:
Appendix M 12 transcripts of recorded interviews with students in the Medical School of La Paz State University (UMSA) between 17th March and 19th May 1998: X, woman student repeating first year: 1 transcript (EY.1) Ignacio, first-year student: 5 transcripts (ES.1-3, ES-SR.1-2) X, male first-year student: 1 transcript (EN.1) XX, male first-year student: 1 transcript (EH.1) XX, female first-year student: 1 transcript (EE.1) XXX, female first-year student: 1 transcript (ET.1) X, male fifth year student: 1 transcript (ER.1) Group of first-year students, 5 women, 6 men: 1 transcript (GP1.1)
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Appendix 17
Appendix N Reduced selection (for contract research sponsors use) of clippings from national newspapers referring to the medical profession, health sector reform, higher education and medical education, 25th July 1996 to 2nd August 1998
Appendix O Fuller selection (for researchers use) of clippings from national newspapers referring to the medical profession, health sector reform, higher education and medical education, 25th July 1996 to 2nd August 1998
Appendix P 19 transcripts of recorded interactions, and fieldnotes on discussions with interns, residents and teachers in the Medical School, State university (UMSA), La Paz and three associated teaching hospitals, between 5th May and 18th August 1998: X, male intern: recorded interview, 21/7/98 (INhV.1) X1, male intern: recorded interview, 21/7/98 (INhY.1) X2, male intern: recorded interview, 21/7/98 (InhH.1) X, female intern: recorded interview, 23/7/98 (INmG.1) Dra. Jurez, medical resident: recorded interview, 19/6/98 (R1mV.1) Dr. X1, medical resident: recorded interview, 19/6/98 (R1hE.1) Dr. X2, medical resident: recorded interview, 19/6/98 (R1hF.1) Dra. X1, medical resident: recorded interview, 21/7/98 (R1mF.1) Dra. X2, medical resident: recorded interview, 23/6/98 (R3mL.1) Dr. X3, resident: recorded interview, 23/7/98 (R1hJ.1) Dr. XX, teacher: recorded interview, 5/5/98 (DO.1) Dra. XX, anatomy teacher, research collaborator: recorded interview, 12/5/98 (D1mA.1) Dr. Harb, director of Maternity Hospital: recorded interview, 17/7/98 (D2hB.1) Group of interns, 3 men, 1 woman: recorded group discussion, 3/8/98(GPIN.1) Group of interns, 3 women, 2 men: recorded group discussion, 13/8/98 (GPIN.2) Group of medical residents, 3 women, 1 man: recorded group discussion, 26/6/98 (GPR.1) Pair of medical residents, 1 man, 1 woman: recorded discussion, 4/8/98 (GPR.2) First pair of obstetricians, notes on discussion, 5/8/98 (AGD.1) Second pair of obstetricians, notes on discussion, 18/8/98 (AGD.1)
Appendix Q
33 first person narratives: "A Critical Event In My Medical Formation", written by first year students, interns, residents and teachers of the medical school, State University (UMSA), La Paz and associated teaching hospitals between 12th June and 25th August 1998:
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Appendix 17
Female 1st year student, 28 years, 12/6/98 Female 1 year student, 16 years, 12/6/98
st st
Female intern, 25 years, 7/8/98 Male intern, 25 years, 7/8/98 Male intern, 25 years, 7/8/98 Female intern, 26 years, 19/8/98 Female intern, 25 years, 20/8/98 Male intern, 25 years, 20/8/98 Female intern, 26 years, 20/8/98 Female resident, 29 years, 29/6/98 Female resident, 30 years, 25/8/98 Female resident, 33 years, 29/6/98 Male resident, 25 years, 29/6/98 Male resident, 27 years, 29/6/98 Male resident, 31 years, 23/8/98 Male teacher, 56 years, 18/8/98 Male teacher, 45 years, 19/8/98 Male teacher, 44 years, 20/8/98 Male teacher, 54 years, 23/8/98 Male teacher, 47 years, 24/8/98 Male teacher, 48 years, 25/8/98
Female 1 year student, 18 years, 12/6/98 Male 1 year student, 18 years, 12/6/98
st st
Male 1 year student, 18 years, 12/6/98 Female 1 year student, 18 years, 12/6/98
st
Male 1 year student, 20 years, 12/6/98

st st
Male 1 year student, 18 years, 12/6/98 Male 1st year student, 20 years, 12/6/98 Male 1 year student, 18 years, 12/6/98
st
Female 1st year student, 19 years, 12/6/98 Male 1 year student, 18 years, 12/6/98
st
Female 1 year student, 18 years, 12/6/98

st
Male 1st year student, 19 years, 12/6/98 Male 1 year student, 21 years, 18/7/98
st
17.4
17 Field Notebooks, 23rd August 1996 28th August 1999 (notes summarised in typed, spiral-bound volume): 1. 2. 3. 4. 5. 6. 7. 8. 9. 23/8/96 19/1/97 21/1/97 27/3/97 28/3/97 16/4/97 16/4/97 9/6/97 15/6/97 19/9/97 22/9/97 21/11/97 24/11/97 19/12/97 27/12/97 8/3/98 9/3/98 29/3/98 10. 30/3/98 5/5/98 11. 5/5/98 25/6/98 12. 26/6/98 8/8/98 13. 10/8/98 28/10/98 14. 29/10/98 27/11/98 15. 29/11/98 2/2/99 16. 5/2/99 22/5/99 17. 24/5/99 28/8/99
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Appendix 18
APPENDIX 18
Texts reproduced from Hord, CE 1999. ICPD Paragraph 8.25: A Global Review of Progress. Chapel Hill, NC: Ipas
A.18.1 Ipas Mission Statement (unnumbered page preceding Acknowledgements) A.18.2 Excerpt from Chapter One, Adapting Policies, p.3 A18.3 Excerpt from Chapter Three, Researching Best Approaches, p.8
A18.1
Ipas Mission Statement
Ipas works globally to improve womens lives through a focus on reproductive health. Our work is based on the principle that every woman has a right to the highest attainable standard of health, to safe reproductive choices, and to high quality health care. We concentrate on preventing unsafe abortion, improving treatment of its complications, and reducing its consequences. We strive to empower women by increasing access to services that enhance their reproductive and sexual health.
Ipas technologies, training, research and technical assistance:
support the development of women-centred reproductive health policies; improve the quality and sustainability of services; ensure the long-term availability of reproductive health technologies; and promote womens active involvement in improving health care.
A18.2 Excerpt from Chapter One: Adapting Policies (box, p. 3) Bolivia is a striking example of policy change. In the 1960s, Bolivia had the highest maternal mortality rate in Latin America, yet contraception was taboo. Family planning grew in acceptance during the 1980s and, as a result of nationwide advocacy leading up to and following Cairo, Bolivias reproductive health policy is now one of the most progressive in the region.1 As of early 1999, the government plans to cover the cost of emergency treatment for first trimester hemorrhage, including incomplete abortion, in the national health insurance plan.
Camacho, Alma Virginia; Rance, Susanna; Abernathy, Marian; Escbar, Alexia. From The Blood of the Condor to Cairo: Abortion and Reproductive Health Policy in Bolivia. Paper presented at the American Public Health Association meeting, November 1 1995.
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A.18.3
Excerpt from Chapter Three: Researching Best Approaches (p. 8) Studies on Postabortion Care ....
In Bolivia, where government policy has changed in favour of reproductive health since
ICPD, very little data exist on the extent and quality of postabortion care in public sector hospitals, though the costs of treating abortion complications are estimated to be 30-40% of total hospital obgyn costs. An opinion survey conducted among public sector health professionals in 1998 indicated that they identify incomplete abortion as a frequent cause of maternal mortality for women locally, and that an overwhelming number support the introduction of MVA in public sector hospitals to improve the quality and efficiency of postabortion care services.2 Based on this study and information about the success of a similar approach in Peru, the Ministry of Health (MOH) has decided to introduce MVA for postabortion care in tertiary level hospitals throughout the country.3
Friedman, Alison; de la Quintana, Claudia; Jov, Gretzel; King, Tim D.N. Diagnstico de los Servicios de Atencin Postaborto (APA) en el Sistema Boliviano de Salud Pblica. Informe de los Resultados de Investigacin al Ministerio de Salud y Previsin Social (MSPS). Carrboro, NC: Ipas, 1999. 3 Personal communication with Dr. Guillermo Cuentas, Bolivia, February 1999.
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Appendix 19
APPENDIX 19 Dra. Bertha Bastos auto/biographical account of medical students hospital training
Editorial note: In the final month before submitting my thesis, I wrote to my friend Bertha Bastos, whom I had met in 1998 when she was an intern in her sixth year of undergraduate medical studies. I asked her to write me an account of medical students education and hospital training, and to clarify my doubts about divisions between years, and the categories Intern and Pre-Intern. I also asked her about some abbreviations she had mentioned as being in current use among hospital staff.
By this time, Bertha Dra. Bastos, already a qualified doctor, in her late thirties had emigrated to North America in search of personal and professional opportunities. We corresponded by e-mail in an informal vein. In a message sent on July 20th 2002, Bertha responded with this narrative, which I transcribe below in a translated version, with her informed consent. In editing the account on July 29th 2002, I made some changes in punctuation to aid readability. In the edited text, inverted commas ( ), dots (), and round brackets (()) correspond to punctuation in the original, while italics and phrases in square brackets ([]) are my additions:
About your enquiries: the Pre-Internship is really the fifth year of Medicine and the Internship is the sixth year. However, in the pensum it figures like this: Medicine, five years and one of Internship. And a curious thing when you are in the fifth year, no-one calls it Pre-Internship, and when you are in the Internship no-one calls it sixth year. Only when you are in Internship they say to you, When you were in Pre-Internship you should have learned all the things that now I have to teach you Thats when you realise that the fifth year was Pre-Internship
About the stages in formation, Ill give you the whole Study Plan (valid since 1984). The period is annual, it has always been so since I was studying. I think that before it was by semesters (but Im not sure). This Plan was approved by Resolution HCU No. 155/85, October 3rd 1985:
Undergraduate Study Plan for Students of Medicine, Bolivia, since 1985

FIRST COURSE Histology Embryology Anatomy SECOND COURSE Physiology-Biophysics Microbiology Biochemistry Public Health I Parasitology Weekly hours of Theory 3 2 2 Total 7 5 2 5 2 2 Total 16 Weekly hours of Practice 3 3 12 18 6 2 3 2 2 15
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Appendix 19
THIRD COURSE Pharmacology Pathological Anatomy Physiopathology Medical Psychology Medicine I Surgery I
Weekly hours of Theory 3 4 3 1 5 2 Total 18 4 3 2 2 2 2 15 3 5 1 2 1 2 2 15
Weekly hours of Practice 3 4 3 1 5 1 17 5 3 2 3 3 2 18 3 3 1 3 3 3 16
FOURTH COURSE Medicine II Surgery II Neurology-Neurosurgery Psychopathology-Psychiatry Traumatology-Orthopaedics Public Health II Total FIFTH COURSE Medicine III Surgery III Legal Medicine Gynaecology Obstetrics Paediatrics Public Health III Total
Rotating Internship
One calendar year according to the Rotating Internship Regulation Undergraduate Degree in Medicine (Licenciatura en Medicina)
COURSE Public Health I Medicine I Surgery I Medicine II Surgery II Public Health II Medicine III Surgery III
CONTENTS Biostatistics-Demography Semiology, Laboratory, General Radiology Surgical Technique Cardiology, Pneumology, Rheumatology, Infectology, Immunology, Tropical Medicine. General Surgical Pathology. Surgery of face and neck. Surgery of thorax. Cardiovascular surgery. Epidemiology, Environmental Health, Sanitary Administration. Nephrology, Haematology, Endocrynology, Gastroenterology. Abdominal Surgery and Urological Proctology, Ear, Nose and Throat (Otorrinolaringologa), Ophtalmology, Anaesthesiology.
The fifth year is very hard, but nothing compares with Internship (you already know, I think youre tired of hearing me say that). From the third year you already have experience in the hospital, thats to say with the patients (now clients of health), and obviously with the doctors and their respective personalities, principally and effectively with the latter.
Nevertheless, you can do nothing (with the patients), only learning to do the clinical history, that you finish learning to do in Internship, unfortunately. Its not that its difficult, however I dont know why the doctors, above all those in the General and Insurance Hospitals, have an issue with
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that. You have to do it to the taste of each one of them, and in each speciality it always varies in some aspect, they hassle you a lot but really a lot with the spelling and grammar.
So well, as I was telling you, in third year you already have contact with the action, Im referring to the fact that by then you dont have classes only in the Medical School, but you already go to the hospitals. In the fourth year, they already give you patients, thats to say that they designate one to you they dont give them to you but its already your responsibility. But always concerning the Clinical History (CH), thats to say if the patient for example has a heart condition, your teacher isnt interested in your knowing how to prescribe for them or how to help them in relation to their pathology. What interests them is that the CH should be well done, with good spelling, on good paper, and for example if they have a scar on their back and you didnt put it in the CH, youre lost, get it? What they (the teachers) do is get you to do the greatest observation concerning the body of the patient.
In the fifth year you already do some shifts in the hospital, for example in Emergencies, and you already do surgery on dogs, of course that last thing is not very frequent, I luckily had to do it only once.
I was forgetting to tell you that in the third year you already practise with your actual classmates, for example in Surgery I, they inject you and you have to do injections, and theres a practice where you put the injection yourself in your own calf (that is really impressive, I can tell you, I still remember it now).
Also in fifth year you go into births, although its more theory they give you, than the practice which they make you see.
The subject I liked best was Legal Medicine, we had a teacher who was very good in his field and in others too, he was a very cultured and well-prepared man. Nevertheless, it was in that course that I saw the videos I told you about, do you remember? Documentaries, short films and videos that were somewhat morbid to say the least. We saw, for example, a man in the electric chair, in all the process of his death, really morbid. You also get to see rapes, even a murder by a Satanic sect, cruelty to animals, accidents on big highways, all in all, many things that maybe take years to forget. About all that you have to do a piece of work to present, only that I dont remember the treatment given to that work because I never did it, I think you had to give your points of view about it.
About the abbreviations, I dont understand very well what you want. I imagine that its what I commented to you on some occasions: a HY [HI] is a hysteria [histeria], for example a woman comes in whos fainted or with nervous attacks, without stimulus or organic pathology, and we say among ourselves, Shes got a HY, meaning that she is hysterical. A little rat [ratita] is the person
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who takes rat poison supposedly to commit suicide, those are the patients that interns most flee from, since it is really gross.
From any year in Medicine they say Doctor or Doctora, but only the patients, and its enough for you to be wearing an overall [mandil]. Some doctors, very few, call you Doctora in the Internship, and when you already graduate, well you have earned that right That about the patients, they use it to gain your attention (in their logic), its like saying Colonel to an officer [cabo] when they want to take you to the Transport Police for some demeanour
I think that is what I have to tell you, I hope to have helped you with what you wanted, if not, please let me know, OK?
Bertha.
210

Tesis Susanna Rance Aborto en Bolivia

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Tesis Susanna Rance Aborto en Bolivia

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CHANGING VOICES: ABORTION TALK IN BOLIVIAN MEDICAL SETTINGS

A Thesis In Two Volumes

This thesis is entirely my own work.

Susanna Rance, La Paz, May 2003 srance@entelnet.bo

Table of Contents, Volume II

VOLUME II: TABLE OF CONTENTS

CHAPTER 10. AUDIENCING HOSPITAL STORIES

Negotiating Professional Boundaries 10.4 Never-Ending Stories

CHAPTER 11. CONTRARIWISE AND OTHERWISE

Alternation: from Epistemology to Strategy 11.5.1 Deconstruction and reconstruction

Abortion: The Vanishing Topic Semiotic Action-Research

Table of Contents, Volume II

Key to Transcript Notations

KEY TO TRANSCRIPT NOTATIONS

Transcripts of recordings: word//[in middle of turn] //[at beginning of turn] {words}

Transcripts of fieldnotes and jottings:

Dr. A B Dra. C Dr. D E Dra. F Dr. G

I Dra. J K Dr. L Mrs. M Mrs. N Mrs. O Mr. O

Status in interactions cited

Ms Ulloa Vctor Dr. Walters Mr./Dr./Nurse X, Dra. Yapita Mrs. Zamora

Mr./Dr. Nurse X Dra. Y F Mrs. Z F

(ii) Key to Speakers, AA to XX

Mrs. CC F Mrs. DD Nurse EE Dr. FF F F M

Mrs. F GG Dra. HH F Lic. II Dr. JJ KK Dr. LL F M M M

Dr. MM M Dr. NN OO PP Dr. QQ Dr. RR M F M M M

Status in interactions cited

Mrs. Suxo Dr. Tapia Vincente Dr. XX

Mrs. SS Dr. TT VV Dr. XX

iii) Note on Translation of Categories of Professional Formation1

Chapter 10. Audiencing Hospital Stories

Excerpt from Transcript GPIN.2:7, 13/8/02.

Chapter 10. Audiencing Hospital Stories

The Problematic Relationship

Chapter 10. Audiencing Hospital Stories

Chapter 10. Audiencing Hospital Stories

Chapter 10. Audiencing Hospital Stories

Chapter 10. Audiencing Hospital Stories

Actor-Audience, Text as Actant

Chapter 10. Audiencing Hospital Stories

Chapter 10. Audiencing Hospital Stories

First-year students: We are a human person

Notes taken at the time in Field Notebook 11, 19/5/98.

Chapter 10. Audiencing Hospital Stories

Chapter 10. Audiencing Hospital Stories

Facilitator I: Youre getting off the point!

Chapter 10. Audiencing Hospital Stories

Chapter 10. Audiencing Hospital Stories

Chapter 10. Audiencing Hospital Stories

SR: Intern 1: Intern 2:

Translated excerpt of Transcript GPIN.1:3, 3/8/98.

Chapter 10. Audiencing Hospital Stories

Chapter 10. Audiencing Hospital Stories

Resident Dr. Luna:

Resident: Resident Dr. Luna:

[[laughs]] that suits them! [.] [[laughs]

Chapter 10. Audiencing Hospital Stories

Chapter 10. Audiencing Hospital Stories

Chapter 10. Audiencing Hospital Stories

Chapter 10. Audiencing Hospital Stories

Negotiating Professional Boundaries

Chapter 10. Audiencing Hospital Stories

Chapter 10. Audiencing Hospital Stories