Sot. Sci. Med. Vol. 35, No. II, pp. 1359-1367, Printed in Great Britain. All rights reserved

LOCAL

1992

0277-9536192 $5.00+ 0.00 Copyright 0 1992Pergamon Press Ltd

KNOWLEDGE: RESEARCH IN INTERNATIONAL

CAPACITY HEALTH

BUILDING

MARY-JO DELVECCHIOGoon Department of Social Medicine, Harvard Medical School, Harvard University, Cambridge, MA 02138, U.S.A. Abstract-Processes of building research capacity in international health projects and their implications for anthropology are addressed using examples from the Applied Diarrhea1 Disease Research project funded by the United States Agency for International Development. Two aspects of training are examined: the way interdisciplinary methodsyualitalive and quantitative approaches-are presented to researchers, given the context of international health research culture; and how researchers’ local knowledge and local concerns in pursuing health research relevant to policy led them to become interested in anthropology. The consequences for anthropology’s place and product in future capacity building efforts in international health research are discussed. Key

words-international

health, research capacity building, local knowledge

INTRODUCTION This paper addresses processes of research capacity building in international health projects and their implications for anthropology and other social sciences relevant to public health. Iliustrative case material is drawn from the Applied Diarrhea1 Disease Research (ADDR) project, which is supported by funds from AID/Washington and managed by the Harvard Institute for International Development as prime contractor. The Johns Hopkins University School of Hygiene and Public Health and the New England Medical Center are sub-contractors on the project. I focus on two aspects of the training process with which I became familiar in my work for ADDR as a social science consultant on research design and analysis.* My first concern is how we frame and convey interdisciplinary methods to developing researchers, given the international health research cultures within which we work. My second concern, which has particular relevance for anthropology, grows out of my observation that many health researchers in developing countries with whom I worked developed a surprising interest in ‘anthropology.’ While there is general anxiety in the field about *I have been a staff social scientist to the ADDR project, Harvard Institute for International Development, Harvard University, since 1987. My work for ADDR included consullancies to individual research groups and involvement in proposal development and data analysis workshops in Asia. In order to maintain the confidentiality of the research groups discussed, none are identified by country or institution. Appreciation is expressed to all groups with whom I worked. Wome researchers in each country where ADDR has funded studies have been associated with government health institutes, but the majority have come from public or private universities.

anthropology’s relation to local cultures and local intellectuals, I have found that many health researchers with whom I have worked perceive the discipline as one which acknowledges the relevance of local knowledge and local concerns for health policy research [l]. ‘Local knowledge,’ a concept in anthropological theory coined by Clifford Geertz, poses local ways of knowing, perspectives and understandings over and against cosmopolitan, assumed to be universal, forms of knowledge. I use the notion of ‘local knowledge’ to frame how researchers new to international health projects conceptualize their own research interests that are generated by local contexts and concerns and by desires to explore local culture more explicitly. In addition, I discuss how these researchers relate their questions about local culture to the discipline of anthropology and to the use of qualitative methodologies in health research. I conclude with a discussion of considerations for the future as we present anthropology and social science in capacity building endeavors. AND INTERNATIONAL HEALTH RESEARCH CULTURE

THE ADDR PROJECT

The Applied Diarrhea1 Disease Project, the research program from which I draw my illustrations, seeks to improve the health of children in less industrialized countries through the production of knowledge applicable to diarrhea1 control programs and health policy activities. (See Trostle and Simon for a more detailed description of the ADDR project [2].) The ADDR Project funds studies of acute and persistent childhood diarrhea which are developed and carried out by university researchers from Asia, Africa and Latin America.? Although foreign scientific consultants advise grantees on design and 1359

1360

MARY-JO DELVECCHIO GOOD

analysis, ADDR-funded teams generate and implement their own projects. During the first 5 years of the program, funded studies have focused on home and clinical case management, food and fluid use, professional prescribing behavior, and clinical feeding trials. The ADDR Project’s purpose soon evolved to include enhancement of the research capabilities of the investigators, many of whom were in the early stages of their research careers. An interdisciplinary agenda also came to characterize many of the larger project’s efforts. Thus, the ADDR program came to have its own particular ‘culture,’ one which emphasized interdisciplinary research capacity building. One of the ADDR Project’s explicit goals has been to encourage research that combines the perspectives and methodologies of public health, biomedicine and the social sciences. The ADDR Project management, scientific staff, and technical advisory group themselves represent the project’s interdisciplinary agenda; these groups are comprised of individuals with expertise in public health and diarrhea1 disease, epidemiology, clinical medicine, nutrition, and the social sciences-anthropology, political science and sociology. This deliberate interdisciplinary agenda reflects the initial conceptual formulation of the project at AID. It also reflects the acknowledgement within the international health community that improvements in morbidity and mortality are hampered by the social, economic and cultural contexts in which diseases, such as childhood diarrhea, occur and are treated. The interdisciplinary approach of ADDR led to activities:

(1) the support and encouragement

of research designs that integrate public health, biomedical and social science frameworks and methods; (2) the support and encouragement of the creation of interdisciplinary research teams from the medical and social sciences; (3) the support and encouragement of training in interdisciplinary research through the process of doing research. For example, training community medicine physicians in survey research or qualitative interviewing and observation, and training social scientists in health research are legitimated activities.

Despite these explicit interdisciplinary goals, the process of encouraging an integrated research program initially posed some difficulties for the ADDR advisory group, as definitions about what constituted quality research training and quality research were debated. The debate focused on researcher autonomy in defining the field of inquiry, formulating research lADDR chose to fund a much wider range of studies of maternal response, including analyses of feeding, helpseeking behavior, emotional responses to childhood illness and death, symptom recognition and local concepts of diarrhea1 disease.

questions and creating research designs. A core issue was how the research endeavor was to be conceptualized. Some advisors preferred that new researchers follow designs previously used in studies conducted by leading diarrhea1 disease scientists. Advisors experienced in the medical sciences, public health and epidemiological research frequently encouraged a narrowing of focus in research designs. For example, in studying maternal response to diarrhea, some advisors urged that use of and knowledge about ORT be the central question, given its direct and obvious policy relevance.* Advisors with social science backgrounds often proposed that researchers be allowed to expand their field of inquiry to include a broader assessment of social and cultural contexts in which acute diarrhea threatened children’s lives. And many advisors felt that the local concerns and local knowledge of ADDR-funded researchers should be drawn upon in the formulation of research questions, designs and methods. For example, local researchers suggested that maternal experience with previous child deaths and child illness was a potentially important factor to understand home management of children’s diarrhea. In spite of these broad disciplinary distinctions, neither the medical nor social scientists on the ADDR technical advisory group consistently offered only one type of guidance; disciplinary boundaries were permeable.

QUANTITATIVGQUALITATIVE DISTINCTIONS Interdisciplinary efforts in international health are frequently accompanied by oversimplified methodological distinctions among disciplines. Disciplines are often characterized by whether they use ‘qualitative’ or ‘quantitative’ methods; at times broad disciplinary divisions between the biomedical and social sciences are represented in oppositional and methodiological terms. The oppositional distinctions, part of American research culture, produce an on-going discourse on the relative value of quantitative and qualitative research methods. One physician administrator from USAID who commented on ADDR activities referred to “the drive, the hunger for a ‘P’ value, for numbers” in medicine, thus justifying a preference for quantitative or epidemiological studies. This evaluative distinction between ‘qualitative’ and ‘quantitative’ methodologies and disciplines is part of the baggage from our contemporary research culture that a social science consultant carries to the field. George Foster, in discussing the problems of conducting appropriate research in public health at the World Health Organization [3] and Judith Justice, who analyzed the problem of anthropological contributions by foreign researchers to health policy projects in Nepal [4], identified a similar distinction in the evaluation of the quantitative and the ‘softer’ or qualitative sciences. They found that anthropological and qualitative studies were viewed as less rigorous in

Research

capacity

building

these international health research and policy contexts. Thus, in forums such as these, ‘quantitative’ methods have often become associated with biomedicine, public health and epidemiology; and ‘qualitative’ methods with the ‘soft’ social sciences, such as anthropology [3-51. In the 198Os, research models which did incorporate qualitative methods into largely quantitative research designs were frequently restrictive in their vision of what such methods might contribute [6-lo]. Qualitative methods were conceptualized as providing a rapid take on the ‘beliefs’ or ‘behaviors’ of a culture, to better enable epidemiologists to design questionnaires to measure etiology and risk factors associated with disease. Laudatory as these efforts were, the relationship of method to discipline was less clearly understood and the importance of qualitative disciplines in framing critical research questions was less valued. Indeed, anthropological researchers sought to address these limitations of perspective in a series of articles which raised questions about anthropology’s role in international health research [ 10, 111.Many offered alternative views on the contribution of anthropology, not as an adjunct but as an essential discipline, to understanding the experience and meaning of disease processes and child illnesses [7-8, l&19].* The qualitative-quantitative distinction has frequently been expressed as a litany with little relevance to the framing of critical concepts and research questions in public health. Yet this discourse colors how we present the social sciences in research training efforts such as those of ADDR. INTERDISCIPLINARY

CONSULTATIONS

As ADDR sought to develop interdisciplinary projects, it was not surprising that initial consultations and evaluations of interdisciplinary research designs brought out competing definitions of quality. Resolving these conflicts was a necessary part of deciding how to build the research skills of grant recipients. This competitive tension has been largely positive for ADDR-funded project development. New programs and creative research agendas are frequently generated when competing disciplines and organizations within which they are represented (such as WHO, USAID, the Centers for Disease Control, and consultants’ academic institutions) seek ways to collaborate and compromise while investing in researcher development. The incorporation of both qualitative and quantitative methodologies in research designs represents one example of such collaboration. Occasionally, when proposals are evaluated

*The AIDS pandemic has given a new impetus to multi-disciplinary research efforts, and because of the limits of biomedical interventions, anthropology has been viewed as a useful discipline in generating not only research but intervention models in promoting health behavior.

in international

health

1361

in terms of the competing standards of the particular scientific disciplines involved, researchers can become confused about what constitutes quality designs and methodologies and cautious about creating new ways to assess health problems and programs. Difficulties encountered in research capacity building tasks can also be compounded by local research cultures and status hierarchies in the institutions of potential grant recipients. Nevertheless, the qualitative-quantitative distinction characteristic of the research culture of many international health organizations appears less problematic for many researchers to whom we are ‘selling’ the interdisciplinary perspective. Nor surprisingly, qualitative and quantitative methods are frequently woven into their research designs. What benefit has the introduction of an interdisciplinarly and methodical mix brought to these researchers? How is the anthropological ‘product’-the qualitative aspect of the methodological mix-shaped by the needs and sensibilities of these researchers? What relevance does the qualitative-quantitative distinction hold for evaluating ‘local’ knowledge and its policy consequences? Where does anthropology as a discipline fit into this discourse? These questions may best be addressed through examining illustrative case material on the process of research training and development. The case data are drawn from my field notes and trip reports on my ADDR consultantancies and from interviews I conducted with ADDR-funded researchers. Following discussion of the case samples, I will return to the question of where anthropology as a discipline positions itself in the discourse on qualitative methods in international health research. LOCAL KNOWLEDGE

Physicians as ‘anthropoIogists’

“We hate medicine, we want to become anthropologists.” This impulsive statement was made to me by a young physician, a colleague of an ADDR-funded research group in an Asian country. The physician and his ADDR-funded colleagues had been referred to as ‘young revolutionaries’ by a senior psychiatrist and medical school administrator. When I queried the junior physician as to how they had acquired this label, he answered, “we hate medicine, we want to become anthropologists.” This response was at first baffling to me, although other university academics, physicians and district health officials who were present laughed knowingly and affectionately at his comment. The occasion for his remark came at the conclusion of my first consultant visit to the institution and my first working week with all the members of the research team (physicians, veterinarians, a statistician and a senior sociology professor-all university faculty members). Although I had previously advised the team leader, a physician who

1362

MARY-JO DELVECCHIO Goon

taught community medicine and physiology in the medical school, during an ADDR proposal development workshop, I was quite unclear as to what ‘anthropology’ meant in this context. Although most members of this ADDR-funded research team would not claim to ‘hate medicine,’ all appeared to have what we may call an ‘anthropological sensibility.’ They displayed a curiosity about their own culture which they wished to explore and analyze further through the pursuit of field research. On my second consulting visit one year later, the group’s local senior sociologist told me again that the young physician-researchers were ‘radicals.’ He explained, in a jovial manner, that the physician who was the team leader was ‘crazy.’ This physician enjoyed doing social science and public health research so much that “he prefers to be in the field and he does not even have a private medical practice.” (This is almost unheard of among the country’s medical faculty.) One surgeon-anatomist, who also taught community health and was deeply involved in the ADDR-funded research, expressed the hope that he would eventually acquire post-graduate training in medical anthropology. What did these researchers mean by “wanting to become anthropologists”? What did they imagine anthropology to be and how could it possibly address the problems of their concern, both as public health physicians and as individuals who wanted to expand their interdisciplinary research capabilities? The ADDR-funded researchers (physicians and veterinarians) attributed their ‘anthropological sensibility’ and interest in medical anthropology to personal field experiences, first as students in rural community health projects, and second as teachers of community health to medical students.* Students in selected medical faculties in this country spend 4-6 weeks per year during the first 2 years of training conducting village health surveys and working on rural health projects. The programs are relatively new, instituted during the past decade. The researchers’ personal experiences in village living, as medical students doing community health projects or as residents born and brought up in the village, also sharpened this sensibility. These experiences seemed to enhance their commitment to improving the health conditions of the rural population. In addition, these experiences fostered a curiosity about aspects of their own society which they did not quite understand and yet hoped to change. All genuinely enjoyed being in ‘the field.’

*I asked the ADDR team leader on a return visit about the young physician who told me previously he wanted to be an anthropologist. He had had exposure to social science research field training through the university’s field site initially established by the Ford Foundation a decade earlier, and he had worked with sociologists in research and development programs in the villages in the region. He maintained his social science interests throughout his medical training. He was not a member of the ADDR team, and had left the university faculty.

A second source of this anthropological sensibility appears to have been contacts with the local university social science community, in particular with a professor of rural sociology and village development. He was not only supportive of the university activities of these young men, but also advised them on their ADDR-funded research. His influence was apparent in the way the team members thought about their research in rural communities. The researchers drew on their ‘local’ knowledge which they gained from their community medicine field experience about causes of childhood diarrhea. They speculated about how they might create a health intervention project to improve sanitation and hygiene in rural communities in their catchment area. And they defined their research agenda with broad strokes. It was to be defined as neither simply a ‘health and behavior’ problem nor a ‘biomedical’ disease. These distinctions were neither salient nor relevant to them. Local definitions of major problems in child health captured the imagination of these young researchers. Although the international preference for attacking childhood diarrhea emphasized teaching and encouraging mothers to use oral rehydration therapy, these physicians were adamantly opposed to making this the primary focus of their applied diarrhea1 disease research. Nor did they wish to make it the central and sole message of an envisioned ‘health campaign’-the policy relevant intervention of their research program. They felt that the Ministry of Health had previously produced successful programs promoting the locally produced oral rehydration solutions. They wished to take their research in an alternative direction. They identified primary causes of childhood diarrhea as problems with household hygiene and village sanitation, and decided they would invest their efforts in promoting prevention rather than coping with consequences. They asked themselves how these problems could be most effectively addressed. Desirous of seeking locally based solutions which would be meaningful in the political and social context of the villages in their region, they identified traditional political channels and village religio-political leaders. Based on knowledge of the effective grass-roots organizational abilities of these leaders in creating a regionally powerful Islamic political party and in promoting family planning, they decided that these men had the potential to bring about changes in their communities which would improve child health and control childhood diarrhea. The researchers designed their ADDR-funded research project with this goal foremost in mind. Situated among the disciplines of public health in its international and local configurations, epidemiology, and anthropology, the research group was inclined to select a mix of qualitative and quantitative methods to address the substantive issues of their concern-childhood diarrhea, village hygiene and sanitation, and effective local intervention through

Research capacity building in international health village leaders. They were encouraged to incorporate a variety of methodologies by ADDR proposal reviewers and my consultancy. Thus, the final research design was complex, having both ‘quantitative’ and ‘qualitative’ components as well as an intervention. The project design began with qualitative interviews of mothers and village men and women who were religious and political leaders. A baseline survey and observational study of village households, focusing on hygiene, sanitation and concepts about etiology and treatment, constituted the second, quantitative stage. The third stage of the project included semi-structured interviews with the village religiopolitical leaders on hygienic practices and childhood diarrhea1 disease. The fourth stage was a diarrhea1 disease training program for the religio-political leaders; during the training the leaders would design their own health campaign for the villages. The fifth phase was the health campaign delivered by each participating religious leader, to increase community awareness about hygiene, sanitation and childhood diarrhea. The final stage of the project was a follow-up household and village survey to assess the effectiveness of the campaign in changing awareness and behavior. An assessment of the success of the campaign through informal interviews concluded the design. The researchers’ justification for this mixed approach was based not only on their own knowledge of village health and hygienic conditions, but also on a highly attuned sensitivity to the cultural dynamics of local communities. Yet, the sheer complexity of the research design and intevention was at times dismaying to outside reviewers. Undaunted, the team has pursued the project and the first five phases have been completed thus far. The team’s initial formulation of the research design, while steeped in a good degree of understanding of local village life, was largely limited to closed questions of a quantitative nature. They intended to ask villagers about the ‘names’ they used for diarrhea1 disease, about local models of etiology, and common hygienic behavior. The initial formulation of questions was highly formalized and structured. Although ‘anthropology’ legitimated these topics, the team was still unfamiliar with anthropological methods. And the ‘anthropological product’ which they first thought they would use was heavily influenced by the epidemiological training each received or was receiving. It took little encouragement on my part during the first consulting visit to enable these researchers to adopt additional qualitative methods which made sense to them in the context of their own field experiences. In the arena of village and household hygiene, they observed practices and facilities. Prior to the baseline survey, they incorporated semistructured interviewing of village leaders and of village mothers into their study. They utilized semistructured interviews and group discussions when evaluating the power of each rehgio-political figure.

1363

They observed how many villagers attended the Friday Mosque prayer meetings in making their assessment about whether a village religious leader would be desirable as a health promoter. They also spoke with villagers about other qualities of the religious leaders, whether they were considered by the villagers to be good advisors for families in trouble, whether they were considered to be kind and moral, whether they held the villagers’ respect. The unleashing of the team’s anthropological sensibility, through encouragement of systematic but open interviewing, allowed researchers to develop a set of criteria for inviting the religious leaders to join their health promotion project. As the project evolved over the year, the role of these leaders became clearer to the researchers. Villages were selected and categorized in part according to the level of influence each religious leader held in his community. As the training program was about to be launched, all but 3 of 29 leaders invited to participate had agreed to do so. This research group continues to explore the range of methods and concepts offered by the social sciences, including medical anthropology, for health research. Their commitment was demonstrated by a public university seminar which they held for over 100 participants from medicine, public health and social sciences, on ‘What is Social Medicine?’ They also continue to put faith in quantitative methodology and survey research. This faith was mildly disrupted when they were faced with the difficulties and limits of their first baseline survey and with problems encountered when using a ‘validated’ SES measure for the region designed by a foreign donor organization. Yet, the drive for numbers and a ‘P value,’ the fascination with computer analysis of data, and the very real concern of being able to address an international health audience which primarily respects quantitative methods, preserves the value of the quantitative aspects of the research project. Policy relevant research continues to be the foremost concern of this ADDR-funded team. Yet the anthropological sensibility of the group continues to fuel their curiosity about their own society, about village culture which is present at the boundaries of the university campus. This sensibility frequently sends them and their students back into the field. Interest in the ‘stories,’ and in the qualitative data they have collected through interviews and observations, has led them to ask how they can acquire additional research and analytic skills in medical anthropology. They view the discipline of anthropology as holding the key to interpreting and ‘making sense’ of the qualitative data. To their credit, this team has moved beyond framing their query solely in terms of methodologies [20]. As a group they are beginning to formulate plans about how they may best foster their intellectual development and further their conceptual abilities within the medical school and university context.

1364

MARY-JO DELVECCHIO Goon

Clinicians as field researchers Formulating research questions from prior clinical and field experiences poses curious challenges to research design, frequently leading to research foci which are complementary but not necessarily within the strictures of ‘normal’ scientific practice. The following two cases from South Asia illustrate how attention to local culture and nutritional practices may create the potential for innovation in research. The question of what local foods should be used for feeding children with diarrhea led researchers to turn to ‘anthropology’ as a complementary science to their biomedical and public health research. They felt this discipline would contribute to the formulation of additional research questions and would provide supportive data for the more biomedical and health policy dimensions of their work. The clinical scientist’s interest in anthropology During an informal discussion of his clinical nutrition research, a respected South Asian clinical researcher said to me that, ‘we need an anthropologist.’ Once again, the comment was curious, in part because it came from an esteemed ‘biomedical’ colleague. Why did this clinical researcher feel he needed an anthropologist for his highly regarded team? What in fact did he mean by anthropology? In this particular case, the clinician’s research group was doing a series of clinical studies to assess the efficacy of a local food in breaking the cycle of chronic childhood diarrhea, dehydration, and malnutrition. New work was being conducted at that time in several other countries as well, to evaluate the safety and efficacy of food based ORT, utilizing local foods in the respective societies [21]. Some diarrhea1 disease researchers in the international health community seemed to have some discomfort about the move toward non-standard treatments for dehydration. This discomfort may have been based on concern that international efforts continue to promote ORS which is not only highly effective but inexpensive and generally safe [22-241. Protocols and procedures, standards of research practice, and investments in promoting oral rehydration solutions, may have influenced how the innovative aspects of these food based ORT research efforts were perceived. They may also have coloured the response of the international diarrhea experts. The clinical researcher’s interest in having an ‘anthropologist’ involved with his group appeared to stem from his desire to explore local feeding practices of families and to build the case for the innovative aspects of food-based ORT on local knowledge and practices. He also appeared to wish that clinical findings be placed in the context of local culture. The ‘anthropological product’ in this case was not defined so much as a ‘method’ but as a perspective and ‘problem area’ to be researched and related to the clinical findings. In this clinical researcher’s under-

standing, anthropology would identify mothers’ understandings about food and nutrition, especially food used in diarrhea1 diets. It would identify food resources and usual local practices: thus, local knowledge and practice would shape the future of health policy interventions and activities. Another ADDR-funded researcher, a colleague of the clinical scientist, took up the task of pursuing this line of inquiry with her project. Highly knowledgeable about the communities in the university hospital’s catchment area, she designed a study which included qualitative key informant interviews and a household survey of reported dietary practices. Her interviewers also observed and recorded the quantity and type of food stores maintained in the house. Her work introduced baseline data on food resources and dietary use. Both of these physician-researchers envisioned anthropology as the discipline that privileges the ‘local’ dimensions of the problem. The challenge remains to link the privileging of ‘local’ culture to the formulation of interventions in the cycle of chronic diarrhea and malnutrition in children. Women as researchers Two South Asian female physicians, during a discussion of child diarrhea and home treatments, remarked to me that there was an inherent distortion in how contemporary international health research formulated the maternal role in child health. They identified this distortion as the neglect of the role of maternal emotional and physical health and childcare experiences in shaping a mother’s capacity to care for an ill child. In a separate context, a female research scientist, in field visits to mothers of young children before proposal development and project design, collected mothers’ stories of caring for children who were seriously ill with diarrhea. In collaboration with her team members she identified “maternal emotional response” and mothers’ previous experience with childhood diseases as potentially significant variables in understanding home treatment and help seeking for childhood diarrhea. These variables, and the concerns which led to their definition, found their way into the research design of the ADDR-funded project. This project also combined qualitative and quantitative methods. Questions designed to assess maternal response were incorporated into the household survey and in-depth interviews. They included mothers’ accounts of diarrhea1 episodes experienced by their children and mothers’ previous experiences with children who died. The task of designing appropriate questions was not easy; previously designed questionnaires and interview schedules were not of help. Thus, the field research team found it necessary to devise and revise questions and interview formats to effectively explore maternal responses. By the pretest stage, the team included two female physicians, a female anthropologist, several female inter-

Research capacity building in international health

viewers, the female research scientist as well as several male colleagues who administered the project. The team attempted to move beyond the usual questions about whether mothers knew about and used government promoted ORS or salt-sugar rehydration solutions made at home. The female researchers, particularly the project’s first anthropologist, pursued this task with tenacity. Studies of mothers’ beliefs and behaviors flourish in international health research. However, when local women scientists become centrally involved as primary researchers, conceptualizations of mothers as caretakers may take on a degree of complexity usually overlooked by health educators and policy makers responsible for encouraging mothers to adopt new health behaviors in the care of their children. The possibility that local women investigators produce alternative or innovative research designs and concepts about women, mothers and maternal behavior, requires careful examination as projects concerned with the ‘maternal factor,’ including Safe Motherhood, are increasingly funded. The anthropological sensibility of this particular ADDR-funded team and the presence of a Masters level anthropologist on the staff legitimized the exploration of mothers’ emotional responses as well as their cognitive notions about diarrhea and treatment relevant behavior. The collection of mothers’ ‘stories’ or accounts about their children’s diarrhea1 episodes and about experiences with children dying was also legitimized by the discipline of ‘anthropology.’ Anthropological sensibility spilled over the disciplinary boundaries of the research team; the ‘hard’ scientists and physicians found themselves intrigued with ‘anthropology’ as a discipline and with the results of the qualitative components of their ADDRfunded project data. Yet, the most difficult tasks were to analyze and interpret mothers’ stories and accounts of diarrhea1 episodes in their children. How, the team asked, should this qualitative data be analyzed, interpreted, presented in internationally acceptable form, and integrated with the quantitative household survey data in publications and papers? These are not easy tasks, and the team has devoted considerable investment to these efforts. However, the efforts were given legitimacy by anthropology as a discipline, which the team came to respect through the discipline’s relevant products, in particular publications on diarrhea1 disease in international journals. Team members have used qualitative and quantitative data in several project papers, including a paper on maternal emotional responses to diarrhea1 illness [25]. The medical model of data presentation continues to shape most analyses, and several papers based on the survey data have been submitted for publication or have been published in local medical journals [26-281. The success of one anthropological paper has led to a second, aimed at the country’s community of physicians. The team hopes to publish it in a local medical journal. Nevertheless, differences

1365

in publishing criteria between biomedical vs anthropological disciplines have made the ‘qualitativequantitative’ distinction of consequence. CONCLUSION: ANTHROPOLOGY AS PRODUCT AND ANTHROPOLOGY’S PLACE. A CONSULTANT’S PERSPECTIVE

Health researchers’ receptivity to anthropology is illustrated by the cases presented above, and by the enthusiasm of health policy makers and infectious disease researchers toward anthropology in addressing the AIDS pandemic [ 151.This receptivity requires us to seriously evaluate how we present anthropology, as discipline and method, in research capacity building efforts. In assessing the role of anthropology in marketing endeavors to promote contraceptives in South Asia, Mimi Nichter considered the ‘four p’s’ of social marketing-product, place, promotion and price. She also addressed the ethical issue of the role of anthropology in promoting health products through devising culturally appropriate marketing programs [29]. Nichter’s analysis is suggestive; social scientists in research capacity building are also involved in the marketing of anthropology to health researchers. It behooves us to assess how we frame the ‘p’s’ of anthropology; here I consider product and place.

If we focus on product, we might ask about the limits we impose as we frame our anthropological product. What indeed are we selling these researchers? Are we in danger of primarily selling method rather than the discipline? Are we selling the use of focus groups, key informants, qualitative research, openended interviews, and assorted other approaches, bereft of the theoretical and epistemological grounds from which the discipline’s methods derive? The discipline of anthropology shapes the way we frame problems; the kinds of knowledge, social institutions, and events to which we attend; and the approaches we take to analyzing and interpreting data whether it be from participant-observation, interviews, formal and informal discussions, or ethnographic and documentary analysis. In light of the ADDR experience, the audience for anthropology appears not only interested in methodology, but also in the kinds of knowledge that are sought through anthropological endeavors. This anthropological sensibility and interest in local culture may lead researchers to do ethnographies and community studies of some duration as well as the useful but more abbreviated forms of rapid inquiries [30, 311. Although many researchers, such as our ADDR-funded colleagues, have adopted the litany of qualitative-quantitative distinction of research methods, they appear to be little constrained by disciplinary conflicts and divisions. These distinctions may be more serious to those who have graduate education within the disciplines of medicine, epidemiology and anthropology. This willing eclecticism suggests that in presenting anthropology as one

1366

MARY-JO DELVECCHIO GOOD

of the critical social sciences relevant to health research, we need not limit our vision of its methodological and theoretical place to descriptive or exploratory phases of research or to work preceding the construction of survey instruments. Although it is tempting to emphasize methodologies in teaching and consulting, especially given anthropology’s traditional assumption that one learns a great deal about the discipline through experience in the field, we face the challenge of creating a balance that grounds method in theory and that allows researchers to develop interpretive and analytic skills as well as the ability to collect data [32]. If we assess the future place of anthropology in multidisciplinary projects in international health, we can benefit from the many studies conducted over the past decade. These have taken us beyond previous limits, where anthropology was often limited in its role to being an adjunct to biomedical or epidemiological inquiries. Recent studies in medical anthropology [ll-191, as well as renewed efforts to meld anthropology and epidemiology [6] may contribute to defining the future of anthropology’s place in international health, just as they have helped to define core issues in the study of health and disease. Such work may also begin to dissolve the qualitativequantitative litany and to reframe how method relates to theory and analysis. As illustrated by the ADDR case studies, the growing international interest in medical anthropology suggests that anthropology’s institutional place may also be expanding, albeit frequently into medical schools. A pivotal issue, noted by both Pelto and Rosenfield in this issue [32,33], is whether collaborative research efforts can be developed which not only integrate medical and social science perspectives but also cross departmental boundaries as truly interdisciplinary and joint efforts. In the first case presented above, a senior sociology professor from the arts and science faculty was an influential consultant for ADDR-funded physicians based in the medical faculty. In the second case, anthropological and social science methods were used by community medicine

*Among ADDR’s most interdisciplinary teams, one from Indonesia crossed departmental boundaries between the medical faculty and teaching hospital and the university, and included an anthropologist, a sociologist, an epidemiologist-physician, a statistician-physician, an internist and a pediatrician, Other similar interdisciplinary teams have been fielded by ADDR-funded projects in Peru, Thailand and Mexico. Several ADDR projects have also been initiated by social scientists whose primary affiliations were not with medical schools. An ethnographic study of childhood diarrhea and sibling care was conducted in Cameroon by a senior professor of anthropology, who also initiated a medical anthropology section within the Pan African Association of Anthropologists, A study of the determinants of changes in physicians’ prescribing practices in Mexico City was also conducted by a senior medical sociologist.

physicians who had social science training, but no social scientists were directly employed. In the third case, the ADDR-funded team was based in a medical school research unit; an anthropologist was hired specifically for the project at ADDR’s encouragement. She was central to the team. Other ADDRfunded teams are interdisciplinary and cross departmental and faculty boundaries, and several ADDR projects have been headed by senior social scientists.* I have argued throughout this paper that the anthropological conviction that human knowledge is inherently idiomatic and local is one shared by many health researchers in universities and medical schools throughout the world. The social sciences have often accepted the natural sciences’ view that knowledge is inherently universal, that the findings of research should be stated as universalistic knowledge claims, and that local deviations from universal knowledge should be rendered as ‘beliefs’ [34]. But these definitions of knowledge provide an epistemological boundary that must be crossed in order to ‘apply’ research findings to the practical exigencies of local communities. The researchers with whom I have worked sense intuitively that knowledge is inherently local, that representation of local knowledge must share its local nuances, and that scientific representation of local knowledge has special value for applied interventions. It is this intuition that leads such researchers to identify their interests with those of anthropology. ADDR’s interdisciplinary efforts encouraged and sought to build on this interest, as illustrated by the qualitative and quantitative methodologies incorporated in many studies. Although it is tempting to emphasize methodology in building research capacity, many researchers found that anthropology, as a discipline, also legitimized their desire to explore the meaning, causes and experience of disease and illness within local settings. It privileged local knowledge and made it compatible with the universalistic frameworks of international public health. This attention to local settings and the local culture of health, disease and treatment, has begun to lead researchers to formulate programs for intervention and action, with local priorities and constraints as guidelines. Research capacity building efforts provide possibilities for a two-way flow of knowledge and approaches to studying the health of populations. The ‘local knowledge’ gained from field experience by researchers newly engaged in studies such as those funded by ADDR suggests alternative ways of conceptualizing research problems, thus contributing to our cosmopolitan health sciences. These may include the formulation of different variables and cultural models as well as new approaches to intervention and health promotion. As the skills and capabilities of recipient researchers are enhanced, so too may the conceptual categories relevant to research in international health be expanded and broadened.

Research capacity building in international health Acknowledgements-Financial support for the Applied Diarrhea1 Disease Research Project (ADDR) at Harvard University is provided by means of a cooperative agreement with the U.S. Agency for International Development. Helpful comments on earlier drafts of this essay by James Trestle, the issue editor, and anonymous reviewers are gratefully acknowledged.

REFERENCES

1988.

18. Weiss M. G. Cultural models of diarrhea1 illness: conceptual framework and review. Sot. Sci. Med. 27, 5-16, 1988. 19. Coreil J. and Mull J. D. (Eds) Anthropological studies of diarrhoeal illness. Sot. Sci. Med. 27, 1988. 20. Geertz C. A report to the Ford Foundation concerning: A program for the stimulation of the social sciences in Indonesia. ms. August 1971. 21. Cereal-based Oral Rehydration Therapy for Diarrhoea. Report of the International Symposium on Cereal-based Oral Rehvdration Therauv, Arra Khan University, Facu-

2.

luty of Health Sciences,*Kar&hi Foundation, Geneva, 1990.

4. 5.

189-197,

1988.

13 Scheper-Hughes N. Culture, scarcity and maternal thinking: maternal detachment and infant survival in a Brazilian shanty-town. Ethos 13, 291-317, 1985. 14. Scheper-Hughes N. (Ed.) Child Survival: Anthropological Perspectives in the Treatment and Maltreatment Children. D. Reidel, Dordrecht, 1987.

of

15. Marshall P. and Bennett L. A. (Eds) Culture and behavior in the AIDS epidemic. Med. Anthropol. Q. 4, 1990: Anthroooloeical contributions to AIDS research. Med: Anthropol.

Q. 4, 3-5, 1990.

16 Farmer P. Sending sickness: sorcery, politics and changing concepts of AIDS in rural Haiti. Med. Anthropol. Q. 4, 627, 1990. 17 Mull J. D. and Mull D. S. Mothers’ concepts of childhood diarrhea in rural Pakistan: what ORT pro-

Pakistan. Aga Khan

22. ICORT

II Proceedings. Second International Conference on Oral Rehydration Therapy, Washington, DC. Pre-

oared for AID, Office of Health. Bureau for Science and Technology, 1986. 23. ICORT III Proceedings. Third International Conference on Oral Rehydration Therapy, Washington DC. Pre-

24.

1982.

6. Janes C. R., Stall R. and Gifford S. M. (Eds) Anthropology and Epidemiology. D. Reidel, Dordrecht, 1986. 7. Dunn F. L. and Janes C. R. Introduction: medical anthropology and epidemiology. In Anthropology and Epidemiology (Edited by Janes C. R., Stall R. and Gifford S. M.), pp. 3-34. D. Reidel, Dordrecht, 1986. 8. Trostle J. Anthropology and epidemiology in the twentieth century. In Anthropology and Epidemiology (Edited bv Janes C. R.. Stall R. and Gifford S. M.).,_ PP. __ 59-94. D. Reidel, Dordrecht, 1986. 9. de Zoysa I., Carson D., Feachem R. ef al. Perceptions of childhood diarrhoea and its treatment in rural Zimbabwe. Sot. Sci. Med. 19, 727-734, 1984. 10. Nations M. K., Epidemiological research on infectious disease: quantitative rigor or rigormortis: In Anthropology and Epidemiology (Edited by Janes C. R., Stall R. and Gifford S. M.), pp. 97-123. D. Reidel, Dordrecht, 1986. 11. Nichter M. Anthropology and International Health: South Asian Case Studies. Kluwer, Dordrecht. 1989. 12. Nations M. K. and Rehbun L. A. Angels with wet wings won’t fly: maternal sentiment in Brazil and the image of neglect. Culture Med. Psychiat. 12, 141-200,

I,.

gram planners should know. Sot. Sci. Med 27, 5347,

1. Geertz C. Local Knowledge.

3.

Basic Books, New York, 1983. Trostle J. and Simon J. Building applied health research capacity in less developed countries. Sot. Sci. Med. 35, 137991387, 1992. Foster G. M. World health organization behavioral science research: problems and prospects. Sot. Sci. Med. 24, 709-717, 1987. Justice J. Policies, Plans and People: Culture and Health Development in Nepal. University of California Press, Berkeley, 1986. Foster G. M. Applied anthropology and international health: retrospect and prospect. Hum. Organiz. 41,

1367

25.

26.

27.

28.

pared for AID, Office of Health, Bureau for Science and Technology, 1989. Personal communication with Dr Julius Richmond, Professor Health Policy, Emeritus, Harvard Medical School and John D. MacArthur Professor of Health Policy and Management, JFK School of Government, Harvard University. Malik I. A., Bukhtiari N., Good M. J. et al. Mothers’ fear of child death due to acute diarrhoea: a study in urban and rural communities in Northern Punjab, Pakistan. Sot. Sci. Med. 35, 1043-1053, 1992. Ahmed A., Malik I. A., Iqbal M., et al. The use of ORS (Nimkol) in management of childhood diarrhoea by mothers in the suburbs of Rawalpindi-Islamabad. P. Pak. Med. Assoc. 40, 178-182, 1990. Mahk I. A., Azim S., Good M. J. et al. Feeding practices for young Pakistani children, usual diet and diet durine diarrhoea. JDDR 9. 213-218. 1991. Mahk I. A. et al. The’effect of social conditions on the incidence of diarrhoea in children. J. Pak. Peds. Assoc., 1991.

29. Nichter M. The business of selling health: social marketing approaches to development. Paper presented at the Society for Applied Anthropology meetings, April 1989. 30. Scrimshaw S. and Hurtado E. Rapid Assessment Procedures for Nutrition and Primary Health Care. UCLA Latin American Center Reference Series, Vol. Il. University of California, Los Angeles, 1987. 31. Bentley M. E., Pelto G. H., Straus W. L. et al. Rapid ethnographic assessment: applications in a diarrhea management program. Sot. Sci. Med. 27, 107-105, 1988. 32. Pelto P. Developing applied medical anthropology in Third World countries: problems and actions. Sot. Sci Med. 35, 1389-1395,

1992.

33. Rosenfield P. The potential of transdisciplinary research for sustaining and extending linkages between the health and social sciences. Sot. Sci. Med. 35, 134331357, 1992. 34. Good B. Medicine, rationality and experience: an anthropological perspective. The 1990 Lewis Henry Morgan Lectures. Cambridge University Press, Cambridge. Forthcoming.