Knowledge Enacted: A Multiplicity Perspective
on Global Health Implementation
and Behaviour Change in Rural India
Jenna E Schmidt
Student ID: 11128194
Supervisor: Dr. Daniel H de Vries
Second Reader: Dr. Trudie Gerrits
MSc Medical Anthropology and Sociology
University of Amsterdam
26 June 2016
TABLE OF CONTENTS
SUMMARY
3
FOREWORD
4
TERMS, ACRONYMS, AND ABBREVIATIONS
5
INTRODUCTION
7
LITERATURE REVIEW
10
GLOBAL ASSEMBLAGE THEORY 11
ACTOR NETWORK THEORY 12
MULTIPLICITY 14
RESEARCH QUESTION AND OBJECTIVES
15
OVERVIEW OF CHAPTERS 16
METHODOLOGY
17
RESEARCH METHODS 17
LOCATION 19
LANGUAGE AND APPROACH 21
ETHICS 22
CHAPTER 1
23
THE MOVEMENT OF KNOWLEDGE/TRANSLATION AS A KEY PROCESS 23
HIV/AIDS 23
DURABILITY 25
SEX VS. SEXUAL REPRODUCTIVE HEALTH 25
LOST IN TRANSLATION 27
CONCLUSIONS ON TRANSLATION 28
CHAPTER 2
29
POSITIVE DEVIANTS: DYNAMIC COMMUNITY FIGURES 29
SUNITA CHARAN 30
KASTURI MOHAPATRA 32
SIBHA PRADAN 34
CONCLUSIONS ON POSITIVE DEVIANTS 36
CHAPTER 3
36
WHAT DOES KNOWLEDGE ‘DO’? 36
MSG AND HIV 38
MENSTRUATION 40
CONCLUSIONS ON WHAT KNOWLEDGE ‘DOES’ 42
CHAPTER 4
43
GENERATIONAL BEHAVIOR CHANGE AND GROWING PAINS 43 KALU AND ADOLESCENT HOPES 44 CONSTRICTION, FRUSTRATION 47 CONCLUSIONS ON GROWING PAINS 49
CONCLUSION
49
REFERENCES
53
SUMMARY
The objective of this paper is to take a network and multiplicity approach to global health by drawing on the theoretical perspectives of global assemblage theory, actor-network theory, and multiplicity. The data utilised was gathered during eight weeks of ethnographic fieldwork in rural villages within the Ganjam district of Odisha, India, as well as at the offices of the Netherlands-based funding and supervisory NGO. The global health programmes in question are Unite for Body Rights and its add-on, Unite Against Child Marriage, which were implemented over a period of five years in multiple countries and contexts, including my research site, Khallikote block. Twenty interviews were conducted with over one hundred participants representing stakeholders at different levels of community organisation as well as with Dutch and Indian NGO staff
members. The conceptualisation of knowledge as an object which is variously enacted, practiced, constituted, and reconstituted at different places and by different actors within the network is central to this paper. This multiplicity of knowledge is explored through stories which highlight processes essential and intrinsic to the configuration of the network in question. These processes include translation, dissemination and ownership by community champions, the interaction between knowledge, need, and infrastructure, and finally, the time needed for these shifts to take place. This paper intends to inspire reflection and add nuance to our understanding of global health rather than to evaluate or critique the programmes and organisations studied.
FOREWORD
This thesis represents the culmination of my studies in the MSc Medical Anthropology and Sociology at the University of Amsterdam. Many individuals have helped me along the way and none of this would have been possible with their time and support. I am extremely grateful to the staff of Simavi for providing me with support, connecting me to their local partner, providing feedback on my proposal, and answering any questions that came up along the way. A special thanks to Loan L. and Nanja M. for being there every step of the way and to Carola H., Jenni S., and Aika van der K. for taking the time to meet and discuss with me after I returned to Amsterdam.
Conducting research in India was a new and challenging experience for me and the support that I received from the VHAI staff was invaluable. Many thanks to Debananda for acting as my local supervisor, answering my never ending questions, and coordinating countless logistics. Additional thank you’s to Niranjan and Deepak for their support and kindness, especially during the time that I was ill. At the field office, Sudarshan, Sisir, and Tapon assisted me in countless ways and I wish to thank them for the effort and concern that they put into ensuring my safety and wellbeing. Also, for getting me safely to and from all of my interviews on the back of a motorbike, an experience that I will never forget. I am grateful to Pragati for working as my translator; this thesis would contain far fewer words if it were not for her efforts. Thank you to Mamta for taking care of me and teaching me how to get through daily life in India. And thank you to my four teenage roommates for inspiring me, making me laugh, and cooking me dinner every night. And of course, to each and every one of my participants for sharing their time and allowing me to see a glimpse of their lives.
Infinite thanks to my parents for supporting me emotionally, mentally, and financially throughout all of the ups and downs in the past year. And to my friends around the world for cheering me up and listening to me when I was lonely, frustrated, and sick in India. Finally, thank you to Danny de V. for going above and beyond as a supervisor and talking through things with me throughout the entire proposal, research, and writing process. I could easily fill many pages expressing my gratitude for everyone who came together to make this entire experience possible; my network has grown in so many wonderful and surprising ways.
TERMS, ACRONYMS, AND ABBREVIATIONS
ANC: Antenatal care.
Anganwadi: Anganwadi workers are responsible for the management of the Anganwadi Center. Workers are chosen from the community and receive four months of training on the topics of nutrition, childcare, and health. Their duties include reaching out to families regarding immunization, hygiene, and education for infants, toddlers, and pre-schoolers, as well as providing services to expectant and nursing mothers. An estimated 1.8 million Anganwadi workers serve about 58 million children and 10 million mothers in India (Aanganwadi.org, 2016).
ANM: Auxiliary Nurse and Midwife. Community health workers who provide comprehension health services and work above ASHA’s to guide the implementation government health initiatives through the village sub-centre (Malik, 2009).
ASHA: Accredited Social Health Activist. ASHA’s are female health workers selected from their community and trained to provide health-related knowledge, services, and support. ASHA’s counsel women during and after pregnancy, and promote good health practices among the wider community. They are provided with a basic drug-kit and expected to be a “fountainhead of community participation in public health programmes” in their local villages. Remuneration is through incentives and ASHA’s operate within a support network that includes community committees, ANM’s, Anganwadi workers, and the Ministry of Health and Family Welfare (National Health Mission, 2013a).
CHC: Community Health Centre. CHC’s are part of the rural health care system in India and act primarily as referral centres. CHC’s are supposed to staff four medical specialists responsible for surgery, gynaecology, paediatrics, and general medicine and should include an operating theatre, labour room, X-ray machine, and 30 beds for patients (Pal, 1999).
Child Marriage: According to the Indian Prohibition of Child Marriage Act, 2006, a child is “a person who, if male, has not completed twenty-one years of age, and if a female, has not completed eighteen years of age” and child marriage thus refers to “a marriage to which either of the contracting parties is a child” (Ministry of Law and Justice, 2007: 2).
GKS: Gaon Kalyan Samiti, formerly Village Health and Sanitation Committee. GKS groups are village level groups organized organized and funded by the National Rural Health Mission of India. They are responsible for health and sanitation related issues within the community (National Rural Health Mission, 2009).
Gram Panchayat: A group of villages which serves as a platforms for planning and policy implementation (Sapra, 2013: 108).
MSG: Mother Support Group.
PHC: Primary Health Centre. PHC’s are envisioned to be the ‘cornerstones’ of the rural healthcare service system and are intended to serve 20,000-30,000 people, equipped with one or more
Medical Officers, nursing facilities, and 6 beds. PHC’s are referral units for 6 sub-centres and in turn, refer patients to the CHC for more specialized care (Directorate General of Health Services Ministry of Health & Family Welfare, 2012).
PNC: Postnatal care.
SHG: Self-Help Group. SHG’s are women-run alliances designed to improve communities by providing assistance to other villagers as well as distributing funds (World Bank, 2016).
SRHR: Sexual Reproductive Health Rights.
UaCM: Unite Against Child Marriage Programme. UFBR: Unite for Body Rights Programme.
VHAI: Voluntary Health Association of India.
VHND: Village Health Nutrition Day. VHND’s take place once a month and are an opportunity for villagers to interact with health personnel, receive basic medicine and healthcare, and seek advice. Intended to provide encourage better health practices by providing services locally. Facilitated by ANM, ASHA’s, and Anganwadi workers (National Health Mission, 2013b).
INTRODUCTION
Saraswati comes from a poor family and like many poor families in rural India, her parents do not have sufficient money to survive in life; they make a deal with a man from their community for a loan of 5,000 rupees or about 65 euros. The man knows that this family is very poor and the economic conditions in Ganjam are not good, but he lends them the money anyway. Time passes and Saraswati’s parents cannot return the money, so the man makes them a condition: if you cannot return the money back to me, then I will marry your daughter and your debt will be forgiven. Saraswati is 12 years old and the man is 38 years old, but such things are not so uncommon in this part of the world. A local NGO called the Voluntary Health Association of India (VHAI) has held meetings about child marriage in her community through the Unite for Body Rights (UFBR) and Unite Against Child Marriage (UaCM) global health programmes. Saraswati has attended some of these meetings; she feels scared for her future, so she shares her story with some local youth club members. Other community members become involved and try to convince her family that the marriage must not take place, but they are unsuccessful. They reach out to the VHAI office and staff members come to persuade the family not to carry out the wedding but nothing happens; Saraswati’s family must repay their debt, so the wedding must go on.
The day of Saraswati’s wedding arrives and drama unfolds when VHAI staff make a bold intervention: police and media arrive at her family’s home and both the man and the marriage officiant are arrested and taken to jail, according to the terms of the Indian Prohibition of Child Marriage Act, 2006 (Ministry of Law and Justice, 2007). When this story is relayed to me in February 2016, six months have elapsed and both men remain in jail. One could say that this is quite obviously a story of the triumph of good over evil, that justice was served, and a life was saved. But pause, consider the broader consequences, the further implications, and suddenly it is more difficult to make a clear judgment. Saraswati has escaped one fate but her family remains poor and must also now bear a further burden of shame. Two men are in jail, the reputation and structure of their own families have been damaged, perhaps irreparably. Saraswati’s case nagged at the back of my mind throughout my fieldwork in India, especially in light of the fact that VHAI is externally funded by the Dutch Ministry of Foreign Affairs through an NGO called Simavi, a factor which adds a further layer of complexity to the situation.
I describe Saraswati’s story to a small group of senior Simavi staff during a debrief meeting after I have returned to Amsterdam, and when programme director Loan Liem responds, I see that it has clearly nagged at her mind as well:
I think it is difficult to talk about ‘what is Simavi doing about it’ because I was also faced by this case and I think I might have thought differently than [others], so I discussed at lengths with the staff about the Do Not Harm principle for the individual [and] we discussed it in the wider group as a whole because…VHAI took that case and they said it was their best case and everyone selected that case as the best case, as good work. And then, I also highlighted the other side: Now what does it mean for the girl? What does this mean for the parents? What would happen in your community if you have similar cases? But still, in the Indian context I feel all the partners — we have quite a big group, maybe twenty people or thirty — they said ‘no, this is the good way, how we should work’. So I kind of say ‘okay, I have the backside now, I want to highlight that’ but they will say ‘well this is right, we don't see that you should have done different’ [so] I let it go as well. But there was another thing, because later they also said they had similar cases and…they stopped the child marriage and the girl wanted to be married [so] she committed suicide… So we talk a lot about this Do No Harm principle, of the ‘how can you then prevent this kind of case?’, because you do your job and you follow the law but this is not what we want.
When Loan describes her interaction with Saraswati’s case, it is apparent that it has become more than just a story; it has been transformed into a mechanism of teaching, an example to stimulate thought, a source of knowledge. Surrounded in its own tensions, the case moves through contexts and takes on a new form in each setting. I have presented it in the introduction of this paper in order to help you, the reader, to enter a frame of mind which considers the tension and complexity inherent in the process of knowledge transfer and behavior change via global health programme implementation. Saraswati, her parents, the man, and the VHAI staff are all interacting with what at first appear to be the same objects — marriage, money, a law — but each enact these objects differently. Marriage is a different object to Saraswati than it is to the man, the child marriage law is a different object to her parents than it is the VHAI staff, and so on. In turn, the story itself becomes an object which is different and intertwined in tension at different points in the network through which it travels. This case encapsulates many of the concepts that will be discussed in the following pages — multiplicity, networks, assemblages, translation, tensions — and also illustrates the central problem which with this thesis is concerned.
Simavi funds and supports VHAI with the goal of behavior change and better health practices; as Saraswati’s case shows, however, this a process mired in ethical, cultural, and structural complexities. Outcomes, even when in line with the goals of the programme, take on lives of their
own and individual components are neither static nor stable. More often than not however, the practice of global health is framed in one of two ways. On one hand, NGO’s and aid agencies promote the idea that global health is a humanist exercise, altruistic work which helps to alleviate poverty, build local economies, improve health, and contribute to a better, more peaceful world (USAID, 2015). Within academia on the other hand, a range of critical perspectives can be found which view development discourse and practice “as nothing more than an apparatus of control and surveillance” and an attempt to extend and universalize Western powers throughout the globe (Cooper and Packard, 1997: 3). Global health and development is also framed as an arbitrary concept rooted in a meta-narrative which only serves to reflect the interests of its practitioners (Rapley, 2004: 350). Or, in another critique, the development perspective in practice is problematic because it assumes that structural change is simply a matter of “educating” people, or even just convincing them to change their minds (Ferguson: 1994: 178).
These dominant approaches may be categorized as perspectivalism, a concept coined by Annemarie Mol which refers to the assumption that the object being examined remains stable and unified although different parties may view and perceive of it differently (Jensen and Winthereik, 2005: 266). I argue that this perspectivalism approach can fail to capture how complicated, variable — and personal — global health programme implementation is. I consider the knowledge associated with the UFBR/UaCM programmes as an object which is constituted and reconstituted as it is shifted and translated by different actors through various networks. It is not just that different actors adopt alternate perspectives about the object, but rather that the object itself is enacted in different forms (Mol, 2002). This ethnography is thus concerned with knowledge as a mechanism of global health implementation through a multiplicity perspective and tells the story of my own experience traveling from the Netherlands to India to meet some of the stakeholders in two recently closed health programmes; all the while navigating through the complex networks and assemblages that both facilitate and obstruct programme implementation. My purpose in this paper is not to characterize or critique what I saw and experienced as representing one perspective or another, but instead to open the reader’s eyes to the way in which both human and non-human actors implicate and enact knowledge and behavior change in differing ways.
As noted above, central to this thesis is the conceptualization of knowledge as an object which is enacted and practiced variously in different contexts and by different actors. The knowledge which I refer to is the knowledge contained in the technical assistance that VHAI and Simavi have designed the UFBR and UaCM programmes to include. In the case of UFBR, which was
implemented initially, this is knowledge pertaining to Sexual Reproductive Health Rights (SRHR) and can include HIV/AIDS, STI’s, menstruation, birth spacing, contraceptives, gender based violence, and reproductive health in regards to antenatal (ANC) and postnatal (PNC) care (VHAI, 2015). The UaCM was an add-on pilot programme that followed the UFBR programmes and was concerned with community wide behavior change to end child marriage practices. The
knowledge central to this programme pertained to both SRHR as well as child marriage (Tewari and Biswas, 2016).
LITERATURE REVIEW: A NETWORK PERSPECTIVE
Conducting eight weeks of ethnographic fieldwork in India was a challenging and complicated task. Prior to departing the Netherlands, visas were secured for entry, flights were booked, canceled, and rebooked for transport, and immunizations were administered for health and safety. Ethical clearance and approval was granted for academic legitimacy, emails were exchanged between Dutch and Indian NGO staff to coordinate logistics, and online research was completed to gain background knowledge. I relied on bureaucratic systems, private companies, international banks, and modern communication technologies to ensure all pieces were in place.
Upon arrival, I was greeted with new networks to navigate and challenges to overcome. Language barriers made communication difficult and confusing, shifting time zones left me exhausted, and a new diet made me thin and lethargic. My traditional Indian wardrobe was intended to help me fit in, yet I saw a stranger when I looked in the mirror. My body physically adjusted to sitting cross-legged on the floor for hours at a time and sleeping on an unpadded cot. I moved from a state of independence and freedom in Amsterdam to one of heavy dependence, relying on VHAI staff for transportation, translation, meals, and assistance. Cultural competencies such as a firm handshake and formal introduction were replaced with locally appropriate responses, nodding namaste over praying hands. Things and people, new and different, took on altered meaning as I struggled to
adjust quickly. Motorbikes, bindis, buckets, flip-flops, humans, and cows: a bizarre network of material and non-material actors which both supported and hindered my ability to not only conduct research, but also to simply live comfortably in India.
Navigating through the multi-layered networks which I had suddenly become part of fostered an increasing awareness of the way in which in UFBR/UaCM programmes and the knowledge they intend to impart must also move across similar transnational, transcultural pathways. I therefore selected Global Assemblage Theory and Actor Network Theory as the overarching theoretical frameworks for this thesis, and a multiplicity perspective to examine knowledge as an object variously enacted. These explanatory frameworks complement each other well, and I conceptualize global assemblage theory as the overarching perspective which encompasses the complexity of the topic and Actor-Network theory as the more specific lens through which each piece is analyzed. In this way, one framework is nested within the other, as assemblages can be understood as comprising networks.
GLOBAL ASSEMBLAGE THEORY
Assemblage Theory originates in the complex writings of Deleuze and Guattari (1987), but more recently took new shape after having been re-appropriated for contemporary application by Stephen Collier and Aihwa Ong (2005). Collier and Ong’s Global Assemblage theory refers to configurations of ‘global forms’ and provides an explanatory framework for understanding an increasingly complex modern world (2005). In this sense, ‘global’ refers not to the assumption that global forms exist everywhere, but rather, that “they have a distinctive capacity for decontextualization and recontextualization, abstractability and movement, across diverse social and cultural situations” (Collier, 2006: 400). These forms may take the form of scientific facts, ‘techniques of rational calculation’, or systems of expert knowledge (Collier, 2006: 400).
In the case of my research, the global form in question is the knowledge that UFBR/UaCM programmes attempt to impart on local communities. Child marriage as an abhorrent, dangerous occurrence, the sexual and reproductive health rights of women, and the concept of empowered youth have been increasingly decontextualized and universalized as global health mechanisms — international and local NGOs, systems of governance, private foundations, etc. — disseminate
these ideas across the world. These concepts are not, however as static as they might appear, especially when they are made mobile and begin to travel through heterogeneous contexts. Collier introduces the global assemblage as an alternative to the categories of local (specificity) and global (abstraction), arguing that “in the space of an assemblage, a global form is simply one among a range of concrete elements…[and] the relationship between the elements in an assemblage is not stable; nor is their configuration reducible to a single logic” (Collier, 2006: 400). Rather, “an assemblage is structured through critical reflection, debate, and contest” (Collier, 2006: 400). In the case of this research, the various networks that I encountered and the tensions and transformations that arose as the knowledge is translated and disseminated represent the assemblage, and the knowledge itself represents the global form. It is important to note that although Collier describes global form here as a ‘concrete element’, the multiplicity perspective that I also adopt contradicts this, and I indeed describe the global form as variously enacted.
ACTOR-NETWORK THEORY
According to my theoretical conceptualization, endless networks exist within these assemblages and these networks can be best understood by drawing on Actor-Network theory (ANT). ANT is essentially a conceptual framework which considers the agency of human and non-human actors in the realization of sociocultural and technological changes and advances (Latour, 1996). ANT in conjunction with Global Assemblage theory helps to unpack the complexity that I constantly confronted while attempting to grasp the social and structural processes surrounding UaCM/UFBR implementation. According to Latour:
ANT is a simple material resistance argument. Strength does not come from concentration, purity, and unity, but from dissemination, heterogeneity and the careful plaiting of weak ties…resistance, obduracy and sturdiness are more easily achieved through netting, lacing, weaving, twisting of ties that are weak by themselves, and…each tie, no matter how strong, is itself woven out of still weaker threads (1996: 370).
These ties are not only the NGO staff and members of the target communities, but also the material objects with which they interact. Although some critics point to the ‘absurdity’ of appointing agency to non-human actors, this aspect makes ANT all the more relevant in its application to my research. The material aspects of the networks that I navigated in India were incredibly important — motorbikes, medical logbooks, mobile phones, medicines, informational pamphlets, airplanes, computers — and all contributed in their own ways to the realization or breakdown of programme
goals, as well as to the experiences and agency of the human actors involved. John Law encourages us to consider this very idea, asking “…is an agent an agent because he or she inhabits a set of elements (including, of course, a body) that stretches out into the network of materials, somatic and otherwise, that surrounds each body?” (1992: 384). The multi-sited nature of my research took me into many different communities and brought me face to face with many different stakeholders, each surrounded by different networks of materials which affected their ability or inability to act.
The terms and texts that circulate as ANT are, as Annemarie Mol explains ‘coordination devices’, and its strength lies in its adaptability — its capacity to “move topics and concerns from one context to another” (Mol, 2010: 265). These devices “…translate and betray what they help to analyse. They sharpen the sensitivity of their readers, attuning them/us to what is going on and to what changes, here, there, elsewhere” (Mol, 2010: 266). I mentally exhausted myself in India, trying to make sense of what I was seeing, hearing, and feeling. I read novels on my Kindle not only to pass hours of boredom, but to stop my mind from running through the mazes that it created in trying to draw conclusions and rationalize experiences. In some ways, ANT represents the same chaos that I struggled with, but reducing the chaos of my experience to an orderly theoretical perspective seems wrong — sometimes you need chaos in order to understand chaos.
Mol asserts that researchers involved in ANT are ‘amateurs of reality’ and “…their theoretical repertoires allow them to attune themselves to the world, to learn to be affected by it. Thus, ANT…helps to train researchers’ perceptions and perceptiveness, senses and sensitivity” (Mol, 2010: 262). The way I see it, I was an amateur of reality in India. I was constantly confused, crippled by my lack of language skills, and overwhelmed with doubt and uncertainty about the meaning of things. Every time I came to believe that I had mastered some cultural competency or figured something out, India would throw me another curveball. And so, I quickly learned to accept my confusion and frustration, seeing what I could see and focusing on details and complexities rather than grand conclusions. To this day, I remain unsure about the meaning of many incidents and wonder yet what exactly was said during each interview. These are the unanswerables, made relevant by my sensitivity to their very unanswerability, and doubly useful because they pushed me to be more sensitive to and observant of other details.
A story can be told in many ways and who it is that tells the story matters. I once lived with a host family in the Republic of Georgia; one day, when we were home alone, my host father grabbed me by my neck and tried to kiss me. This incident, and the consequences that followed it shaped my story of Georgia. Had I been a male, the story would be different and Gaela would simply be a fat, jovial, wine loving old man. I considered constantly how different my experience would be in India if I could change even one factor about my positionality— what if I were a man or I was twenty years older or I could speak the language or I had a research partner? How would that change the research, change my story? This internal positionality is not all that shapes a story; the external theoretical framework with which we choose to analyze it also transforms it. Had I, for example, chosen a post-development critique perspective, I would have pulled details from my data which support the argument that “…the goal of development is intimately linked to modernization…which entails the extension of the control of the Western world and its nationalist allies in the developing countries” (Rapley, 2004: 350). Surely I could have supported such a claim, and possibly drawn far clearer conclusions than I do using ANT. But, it would have meant extracting details from the chaos of their networks and as Latour explains, “One does not jump outside a network to add an explanation — a cause, a factor, a set of factors, a series of co-occurences; one simply extends the network further. Every network surrounds itself with its own frame of reference, its own definition of growth, of referring, of framing, of explaining” (Latour, 1996: 376). Thus, with the help of an ANT perspective, I present stories which challenge you, the reader, to reflect on the complexity and variability of global health program implementation (specifically in regards to knowledge and behavior change) as a social process mired in both accommodating and conflicting networks and assemblages.
MULTIPLICITY
Although global assemblage theory and ANT help sensitize us to the complexity of the situation, the further inclusion of the multiplicity perspective is essential because it helps us to understand the variability of objects across the network. Multiplicity is a radical idea because it challenges our dominant conception of objects as being stable entities viewed through differing
perspectives (Mol, 2002). It is essentially the idea that
…the object order is a precarious accomplishment which should be studied rather than assumed. An object (a disease for instance) is not a singular entity but a texture of
partially coherent and partially coordinated enactments. In Mol’s account, the ontology of an object is thus decentred to a multitude of practices. Objects do not exist in and off themselves but only through multiple situated practices (Jensen and Winthereik, 2005: 266).
Multiplicity is important to rounding out the theoretical and philosophical perspective of this paper because, in just one example, a Simavi program director in the Netherlands and a twelve-year-old girl in India can be understood to share the same network; however, marriage or sexual reproductive health as an object of knowledge is enacted differently by each one. I draw on this idea of multiplicity throughout this paper, but do so sparingly because the objective is to provoke thought, not provide an exhaustive list of the various enactments of knowledge. Indeed, ethnographers are limited in their ability to observe and analyze a number of variants because they are only able to observe a particular location for a limited amount of time (Mol, 2002: 51). Additionally, it is important to realize that “…attending to the multiplicity of reality is also an act. It is something that may be done — or left undone. It is an intervention. It intervention the various available styles for describing practices” (Mol, 2002: 6). Thus, multiplicity and the preceding concepts are the interventions which entreat you, the reader, to consider the complexity which surrounds the stories which follow in this paper.
RESEARCH QUESTION AND OBJECTIVES
The challenge of conducting research in India enhanced my awareness of process and I chose to orient this thesis as an ethnography concerned with the way in which knowledge travels across geographic, physical, social, and cultural spaces. I examine how knowledge can be understood through multiplicity and how it is mired in networks, describing these processes through the narratives of my participants as well as my own. My objective is to highlight the complexity of global health program implementation across multiple contexts, drawing attention to the ways in which various material, cultural, and social factors enact upon each other in a constantly shifting process of interaction. The central question that this thesis addresses is: How can the
implementation of a global health programme be understood through a multiplicity perspective?
Prior to arriving in India, my initial proposed research question had been: How are the discourses
and practices which are constructed and implemented by Simavi/VHAI being received by the targeted adolescents and their communities in Ganjam? Upon arrival in India however, it very
quickly became apparent that this vision of a research project would not be possible within such a short time frame and in consideration of the realities of the local context. My reliance on VHAI for transportation, support, and translation meant that I was accompanied to all interviews with by at least three staff members. Such a close association to the local NGO and my positionality as both an outsider and my ties (real and perceived) to Simavi in the Netherlands made the objective of capturing a diverse range community member’s perceptions superficial.
OVERVIEW OF THE CHAPTERS
In Chapter 1, the process of translation will be discussed. The use of a translator was crucial to my research but the translator I worked with only spoke English at what I would describe as an intermediate level of fluency. My daily struggles with translation and realizations of how this impacted my research findings as well as my own experience illuminated this process as an issue that is bigger than the interpretation of words from one language to the next. In the case of UFBR/UaCM implementation, knowledge traveled electronically across international borders with the assistance of modern communication technologies, but also physically, with people on planes, cars, buses, trains, motorbikes, bicycles, and even on foot. Understanding these processes is interesting and topical when we consider knowledge and information as being mobile, durable (or not), and relational (Law, 1992: 387); as different actors participate in the movement of knowledge, it is translated and enacted. As knowledge moves across geographic, cultural, and social boundaries, it is disseminated through and to individuals with differing levels of education and different cultural conceptualizations of the broader categories within which these topics fall (Law, 1992: 386). Translation can thus be understood to be a process impacting the way in which knowledge as an object is practiced and enacted.
Chapter 2 focuses on dynamic community stakeholders, whom I label as positive deviants and how they play a crucial role in the implementation and sustainability of UFBR/UaCM programmes. These individuals as well as the larger organizational structures they associate with take ownership of knowledge and share it further, participating in a constantly shifting process of receiving, sharing, and enacting. By telling the stories of these individuals and groups, I will illustrate how their status in the community and their personal drive to improve their lives and the lives of others is shored up by VHAI. Thus, we can understand the relationship between these figures and VHAI as being
symbiotic — they help with program implementation but program implementation also helps them to achieve their goals.
In Chapter 3, I present multiple anecdotes to illustrate what happens when new knowledge is brought into a community, arguing that knowledge serves to create a need, but if the social, cultural, and/or physical infrastructure does not exist to meet this need, then the behavior cannot change in practice. The stories that back this argument show firsthand how difficult and complex behavior change is, and also how deeply it is impacted by the material and human aspects of networks. Furthermore, this relationship between knowledge and practical behavior change illustrates the necessity for change to occur at many levels and the difficulty that NGOs face when working in poor settings with limited infrastructure. In reading this chapter, it is important to consider the question ‘what does knowledge do?’.
Finally, in Chapter 4, the matter of time is introduced. Although change in practice may not be occurring immediately, this process has implications for the future. At the same time, this slow process of change is wrapped up in tensions and frustrations, and the narratives and anecdotes in this chapter highlight what I perceived to be a slow, and often painful process of change.
Education levels have increased as well as access to communication and information, meaning that Indian adolescents can now see an alternative way of life, but not necessarily achieve it. Personal autonomy, gender equality, and a more ‘modern’ lifestyle are visible, but children remain tightly restricted by their parents who are cautious about change and remain bound by strict social pressures.
METHODOLOGY
RESEARCH METHODS
The majority of this research was conducted in India over a period of eight weeks, however the full research period began before I left the Netherlands, ending only after I had returned. My first meeting with Simavi in November 2015 marked the beginning of my immersion into the UFBR/UaCM network and I continued to communicate and meet with Simavi staff through June 2016. The research location was chosen by Simavi and through them, I was connected with VHAI.
Access to participants, programme activities, and reports, as well as on the ground support was provided by the staff of the VHAI-Aparajita office in Bhubaneswar and the Khallikote field office. Over the course of eight weeks, I conducted twenty interviews with over one hundred participants. These participants included NGO staff, adolescent girls and boys, Mother Support Group (MSG) members, Self-Help Group (SHG) members, Gram Kanchayan Samiti (GKS) members, gram
panchayat members, peer educators, Accredited Social Health Activists (ASHA), local government
officials, doctors, Anganwadi workers, Auxiliary Nurse and Midwives (ANM), and other community members. Participants were recruited by VHAI staff, and it was acknowledged that I was meeting with community members who actively participated in VHAI programme activities and had a positive relationship with the NGO.
These individuals were the NGO’s biggest allies, or ‘best people’ so to speak, and I was therefore potentially excluding the viewpoint of those who might have held negative opinions or were resistant to its presence in the community. This issue was difficult to address for two primary reasons. First of all, I relied entirely on VHAI to recruit participants; I could not speak the local language, I did not have personal access to their community directories, and I was such an outsider that attempting to locate my own participants would have been almost impossible in such remote areas and within such a short time frame. Second of all, both the participants and VHAI had their own motives to consider. As an organization, VHAI wants to present itself in a good light and to show the positive effects of its work. All local staff members were concerned that I was safe, happy, and having a productive research experience, but also aware of my association with Simavi, who funds and monitors their work. It seems reasonable to assume that these factors encouraged them to paint a positive picture of the local realities. Participants and non-participants also had their own motivations to consider; strong allies of VHAI had a stake in maintaining a positive relationship with the NGO and those who hold negative views or experience tension with VHAI’s presence would presumably want to avoid extra contact with them. It is possible to see these motives and resulting biases in a negative light, but upon reflection, I find them understandable and relatable. Attempting to make a good impression in front of a stranger or to provide a positive experience for a foreign guest is a very human reaction, and I cannot say for certain that I myself would act any differently if an anthropologist came to study my work or my community.
Interviews were primarily conducted in groups, but the term ‘focus group’ may be a misnomer as it implies a degree of structure and group-wide participation that was generally not possible in the local context. My assumption in using a focus group method was that multiple perspectives could be captured, whereas in actuality I often felt that I was capturing one perspective but in a group environment. Oftentimes, I found that only one or two members of a large group would actively participate in the interview, and although I pressed other group members to join in the discussion, their participation typically remained quite limited. I believe that the strongest contributing factor in this scenario is the collective nature of Indian culture, wherein the act of expressing yourself through an individual opinion is perhaps not as highly valued as it may be in the West. Many Indian women (and men as well) were quite shy and while they were interested to be a part of the interview group, they did not appear comfortable to speak openly with me or to challenge the statements of more outgoing participants. Interviews were typically conducted in homes, temples, offices, and Anganwadi centers; at times we sat in plastic chairs, but more often than not, we sat cross-legged on the ground.
LOCATION
This ethnography is multi-sited in the sense that I conducted research both in the Netherlands and India, and also because I conducted interviews in multiple different villages. Each village possessed its own community structures, priorities, and resources and thus each can be considered an individual site in its own right. These sites contain local networks but also comprise a larger network of Indian, Dutch, and other global components. While it is networks and assemblages that are being examined in this paper, the geographical location is a component which effected not only my experience, but also impacts the way in which actors enact, constitute, and reconstitute knowledge. The physical location also helps to determine what non-human components gain importance within the network and how human actors interact with each other and approach daily life. For this reason, I include a description of the primary research location and then contrast its briefly with Simavi as another research site.
The Khallikote block of Odisha’s Ganjam District lies two hours south of capital city Bhubaneswar and sits only forty kilometers from the Bay of Bengal, at the southernmost edge of locally-famous Chilika Lake. Leaving Bhubaneswar, the NH16 winds gently through vast stretches of farmland
where rocky outcroppings and small mountains rise abruptly in sharp juxtaposition to the pancake flat landscape. On the drive to the field office, we pass small roadside markets, coconut and mango plantations, and two toll booths, one abandoned and crumbling into the ground, and the next operating with busy lines of vehicles where prostitutes with bold, messy lipstick pound on car windows to solicit customers. Blink, and you might miss the turn off for Khallikote Block, an administrative division of the Ganjam district which includes twenty-six gram panchayats and 219 villages (Census of India, 2011). Exiting the NH16 to enter Khallikote, a police station sits on the left, followed by shocking green rice fields on the right which give way to dense, tangled mango forests. Next comes a roadside slaughter, where fat white chickens flop listlessly in wire cages beneath wooden counters while their peers are butchered above for waiting customers.
Past a few schools and through the main market and bus station, the road grows busier as it narrows into the densest part of town. Home to a population of roughly 10,000, Khallikote Block feels like a metropolis in comparison to the sleepy, far flung villages that it serves. The apartment where I stayed is located across from the Veterinary Dispensary, about 10 minutes’ walk to the field office. My four sixteen-year-old roommates slept together in one bedroom and I slept in the other. An empty common room which leads into the small kitchen separated our quarters. I had the luxury of a private bathroom with western-style toilet, a cot, a desk, and two plastic chairs. I describe these items as a luxury because it is more common in India to sleep on the floor, with only a mat and a thin pad. Although my cot was no softer than the ground, it was comforting to be away from the cockroaches that I saw skittering across the room when I woke up at night to use the bathroom. I took cold bucket showers, ate cross-legged on the floor, and dressed in the local style, but these efforts at ‘fitting in’ were always counterbalanced by all of the factors that made me different. Appearance, language, and culture are the most obvious but other things separated me as well — eating with a spoon, sleeping under a mosquito net, using a water filter, and taking anti-malarial pills before bed — each indicated how poorly adapted I was to the local environment.
Each morning, I passed brightly colored multistory houses which line the narrow, bumpy dirt road leading to the VHAI field office. Situated on the second level of a private home, the office contains a workspace, sleeping quarters, and a kitchen. Internet access was available only with the use of a dongle and the connection is slow and unreliable. The office is inconspicuous, simple, and practical.
In sharp contrast, the Simavi offices are located in Haarlem, reachable in 30 minutes by high speed train from the cosmopolitan city of Amsterdam. Brightly lit with modern workspaces and high speed internet, it is exactly how one might imagine the headquarters of a small, European NGO to look. Here, I shook hands with new acquaintances, communicated easily in English, and kept my shoes on at all times, but the biggest difference was the independence that I possessed in the Netherlands. I can do many things in the Netherlands that I could not do in India and this abrupt change from freedom to dependence effected my research experience in many ways.
The disadvantage to conducting this type of multi-sited research is that I spent a limited amount of time in each community and was not able to build long term rapport or take an in-depth look at daily life. The advantage however, is that I was able to gain more diverse perspectives and appreciate how remote and inaccessible the target communities are — a factor that clearly makes programme implementation far more difficult and complicated1. While a few villages were only 10
or 15 minutes from the field office, most took at least 40 minutes to reach. Traveling by motorbike through vast stretches of rural land allowed me to experience first-hand the scale of the challenge being undertaken and the importance of knowledgeable local staff who are able to navigate through a complex system of unmarked roads in varying condition.
LANGUAGE AND APPROACH
As the primary language in Odisha is Oriya and English is very limited, the assistance of a translator was essential. My translator, Pragati, was organized through VHAI and was herself a staff member at the field office. Due to her limited level of English proficiency, translations were not verbatim but rather summaries of participant responses. While I attempted to elucidate both questions and responses, I have no doubt that a great deal of detail and meaning was lost in the translation process. My translator’s own opinions and perspectives were often added in among the responses of the participants, and she casts a long shadow on the entirety of my research2. Interviews were
recorded electronically and transcribed. Although most interviews lasted about one hour, the time for translation, clarification, and interruptions (which were common) meant that I faced time restrictions which at times hindered my ability to probe deeper. I approached my research with a
1
See Annex: Photos, page 56
2See Annex: Photos, page 57
grounded theory perspective, choosing to allow fieldwork experience to guide me towards a suitable theoretical perspective. Grounded theory refers to the following process: “from the beginnings of their fieldwork, grounded theory ethnographers study what is happening in the setting and make a conceptual rendering of these actions. A grounded theory ethnographer likely moves across settings to gain more knowledge of the studied process” (Charmaz, 2006: 22). This approach paid off, as the network perspective and use of the concept multiplicity described previously emerged from what I saw, rather than being imposed through preconceptions.
ETHICS
Ethical clearance for this research was granted by the administration of the Medical
Anthropology and Sociology Department of the University of Amsterdam, with additional review and organizational clearance from both Simavi and VHAI. In order to receive such clearance, a research proposal was submitted for review to my academic supervisor and the fieldwork coordinators, as well as to Simavi and VHAI staff for input. The proposal included background information, research methodologies, ethical considerations, and consideration for clearance and access. In the field, informed consent was established verbally and recorded. Both my
respondents and my translator seemed to view the informed consent process as superfluous and unnecessary; I had to constantly remind my translator to read the short consent statement, a task she would do with a sigh of annoyance. The participants would typically nod dismissively, as if to say, ‘of course I consent, I showed up here to talk with you, didn’t I?’. Conceptualizations of privacy in India vary greatly from European or American standards, and indeed this was one of many cases where I saw my own values at odds with the local culture. For example, neighbors or other community members would often interrupt, watch, and/or join in during interviews, an occurrence that was disruptive only when it was a male entering a female group interview. The private interview space that I imagined creating was something that never came to be realized. Furthermore, local health care practitioners invited me to look through, and even photograph, patient files and record books. Although this would suggest an open and accessible research environment, willingness to share information does not necessarily go hand in hand with a willingness to give ‘honest’ answers, and I often wondered how often I was being told what participants thought I wanted to hear. In this paper, the names of NGO staff are used, but the names of community-level participants and village names have been changed.
CHAPTER 1
THE MOVEMENT OF KNOWLEDGE AND TRANSLATION AS A KEY PROCESS
During my research in India, I often thought back to an exercise that was presented in a first year sociology course during my bachelors: for a moment, try to imagine that you have just met a new person, and this person has never in their life seen or even heard of a television. You must now explain to them, using only your words and your own knowledge, what a television is and how it works. Odds are, the more you consider about the task, the more difficult it becomes. This is because our knowledge of ‘what a television is’ is based on a larger mental schema that includes our own firsthand experience watching TV coupled with varying levels of knowledge about other important components such as electricity, satellites, and so on (Bartlett, 1967). The point of the exercise is to recognize that our ability to understand a concept is not based solely on the transfer of information between individuals, but rather is deeply influenced by social, cultural, economic, and geographic factors which shape our understanding of the world — in other words, knowledge cannot be translated without considering the context and is shaped by the networks that surround it. Even if two individuals from different cultural contexts both speak the same language, some process of translation must occur in order for one to understand the other, and the process of translation contributes to the multiplicity of knowledge. In this chapter, I share my own observations of and experiences with the process of translation to highlight how important it is to consider as a component of programme design and implementation — as well as success or failure.
HIV/AIDS
A row of thin brown girls sit before me, wrapped in vibrant, jewel tone fabrics, black hair styled back with pins and barrettes. I am meeting with six adolescent peer educators from Kairasi village, ages ranging from 17 to 19. As often happened, the interview strays from the question that I had asked and a discussion begins between my translator Pragati, VHAI programme supervisor Mamta, and a few of the girls. Pragati tells me that one of the girls has asked a question about HIV/AIDS and they are answering it for her. Leaning back against the wall and stretching out my cramped legs, I sit quietly and wait for translation, watching with curiosity as the conversation shifts into an increasingly animated argument between Pragati and Mamta. Turning abruptly to me, Pragati asks, ‘you know about HIV/AIDS right?’. I discover that in trying to answer Kaberi’s question, Pragati
and Mamta have realized that there is a discrepancy in their respective explanations. The question is, ‘if an HIV-negative person has sex with 20 other people, all of whom are also HIV-negative, is it possible that this person will develop HIV?’ One believes that, yes, it is possible to develop HIV by having sex with many other people and the other disagrees, but both seem unsure. I explain that because HIV is a virus, it cannot ‘develop’ but rather is transferred through contact with the bodily fluids of an HIV-positive person. We move on with the interview but this small interaction sticks in my mind, a discrepancy illustrative of something worth investigating.
Pragati and Mamta have both been working with NGOs for a few years, and were responsible for trainings and activities specifically related to sexual reproductive health and HIV/AIDS during the implementation of UFBR and UaCM. How is this ‘misunderstanding’ then possible? Based on my conversations and interactions with both women, I believe that their confusion was not a result of poor training or misinformation but rather is related to their background knowledge about viruses and sexual health; in other words, the factors in their networks which influence the way knowledge of HIV/AIDS is practiced and enacted. My own ability to understand how HIV/AIDS ‘works’ centers most significantly around what I know about viruses generally and has been influenced by my interaction with specific material and human components of my own networks. I have been categorically lucky — Sexual Education courses were mandatory in both the 8th and 10th grades, and I followed Biology courses in both high school and college. Lessons from attentive and available instructors were supported by high quality textbooks, videos, graphics, and presentations. Doing additional research on the internet was easy and always accessible, and I could openly discuss the topics of HIV/AIDS and sexual reproductive health with my friends, teachers, and family.
Conversely, rural education systems such as those found in Ganjam district often lack adequate resources. Owning or even having access to a personal computer is a luxury and internet access is remains relatively slow and unreliable; the percentage of rural schools in India with computers was only 19.6% in 2014 (Pratham, 2014). I heard anecdotal evidence during my research which suggests that local teachers often pass over topics such as human anatomy and sexual reproductive health, which remain culturally taboo and sensitive. As a senior staff member from the UNICEF Bhubaneswar office explained to me, teachers deliberately pass over these lessons because they
do not feel comfortable speaking about them, leaving students with a lack of knowledge and perpetuating the idea that they are not acceptable topics to discuss. I did not study education in Ganjam, but my experience there gave me the impression that it is a context which lacks many of the material resources necessary to not only learn, but retain and maintain a ‘stable’ understanding of topics which are as complex as HIV/AIDS. Pragati and Mamta’s confusion over HIV/AIDS was most likely related to a lack of foundational understanding of human biology at a molecular level — specifically in regards to ‘scientifically established’ notions of how viruses function within the human body and this story relates Law’s conclusion that “…translation is contingent, local, and variable” (1992: 387).
DURABILITY
Furthermore, much of what VHAI teaches is conveyed through verbal trainings, and while some posters and handouts are available, it is not always easy for community stakeholders to accurately recall the information they have been taught. As Chandrama, an Anganwadi worker of 26 years from Pustapur explained to me, she did not know about HIV/AIDS, anemia, and sexual reproductive health issues until VHAI taught her about them, and has now learned new approaches in order to motivate parents to take up new health practices for their children. While she tells me that this has helped her in caring for her community, she adds that she wishes VHAI would provide her with printed books about these health issues so that she could read and review them, instead of always trying to remember the conversations. Anyone who has played a game of ‘telephone’ knows how fragile the process of verbal sharing is and how easily seemingly simple ideas can become lost in translation. As Law points out, “Thoughts are cheap but they don’t last long, and speech lasts very little longer. But when we start to perform relations — and in particular when we embody them in inanimate materials such as texts and buildings — they may last longer” (1992: 387). Thus, we see that a concept like HIV/AIDS that may be seen as universal and immutable is actually quite vulnerable to the process of translation.
SEX VS. SEXUAL REPRODUCTIVE HEALTH
Back in my pink apartment, with the day’s interviews over and the lunch eaten, Mamta naps on her mat in the corner and Pragati and I sit on my cot. This is the time when Pragati and I usually practice English but today she wants to discuss another topic: “you’ve had sex before, right?”. Yes, I explain
that I indeed have had sex and we discuss that this is generally accepted and considered to be quite normal where I come from, despite the fact that I am not married. I have opened a door, implicitly agreeing that I am willing to discuss this topic, and so her questions begin in earnest: “how many times have you had sex?”. Three hours later, we have covered the basics of sex, losing your virginity, oral sex, masturbation, and homosexuality. I try to be honest and open with her because I understand that she is anxious about not knowing what will happen once she is married — a worry she tells me keeps her up at night. Up until the age of 20, she believed that hugging and kissing were ‘sex’ and I am aware that I am a source of ‘expert knowledge’ for her — not because I am any kind of actual expert on the topic, but simply because I come from a cultural context where sex is frequently and openly discussed. Still, I feel compelled to censor and generalize my answers to a certain extent and I have to answer her questions in plain language, translating ideas into easy to understand concepts.
Pragati is one of the most educated girls in her community and her limited knowledge of sex as an intimate act tells me something about how taboo this topic remains in an area like Ganjam. For me, sex as an intimate act and sexual reproductive health are inextricably linked but I realize that when VHAI teaches about sexual reproductive health and rights, it is actually disassociated from sex, and the two could might actually be considered entirely different topics. Again, one might ask, how can someone teach about SRHR without understanding sex? As with the previous discussion of HIV/AIDS, there are of course risks involved in programme staff having what one might describe as a lack of in-depth knowledge. However, “translation is more effective if it anticipates the responses and reactions of the materials to be translated.” (Law, 1992: 388). The distance between VHAI staff and local community members is at once great and small; it is great in the context of rural India and their knowledge is in actually in-depth within this setting. However, the distance is also small in comparison to the possibility of a Dutch Simavi staff member conducting trainings. The tension here lies in the balance between too much expert knowledge and thus too much distance, and not enough expert knowledge and thus loss of important details and context. Each scenario carries its own risks and can affect the translation of information in different ways.
In a far less abstract sense, translation was also an obstacle in the literal sense of interpreting words from one language to another. Ethnographic research had always appealed to me because of how
personal it is, and I looked forward to building my thesis around the narratives of my participants. What I did not anticipate however, was that their words would be relayed to me as summaries, rather than verbatim quotes. I sat and watched in frustration during my interviews as words were quite literally lost before my eyes, a five-minute response reduced to a one minute summary. Fascinating stories and accounts became shortened, muddled, and precious interview time was eaten up by clarification and questions. I returned to Bhubaneswar during my final week and hired a ‘professional translator’, Mr. N, to go through key sections of my interviews. My hopes for verbatim quotes, unlocking the mysteries of what my participants really said were not realized however, and my doubt and confusion mostly increased.
LOST IN TRANSLATION
The Mother Support Group in M. Barida village told me a story that was both disturbing and inspiring, poverty at its worst and community engagement at its best — or so I interpret it, based on what I think I know. Pragati’s translation left me wanting to understand more and I had hoped that Mr. N’s translation would illuminate some details or at least paint a more vivid picture of what happened. Instead, comparison of the two translations showed only how subjective and personal the process of translation is. Pragati’s translation of this story is as follows:
Pragati: They give one example, six months ago they found a problem in their community, actually husband and wife had come from different place to their community and they had also children, a child, a girl...and that wife had some problem, they find a, you know, what you call that…in the stomach, like…like a kidney stone? Yes, yes they found that problem, they did not have sufficient money for treatment so what they do, to get money for the problem then what they do, the husband and wife, they sell their baby, you know child. Jenna: They sold their child?
Pragati: Yes, yes because they didn't have money for treatment. Then what did the community people did…
Jenna: Who did they sell the child too?
Pragati: Her parents was from different place but came to this community.
Jenna: Yes, but they sold the child, but who did they sell it to…who bought the child? Pragati: From Berhampur.
Jenna: Yes but what person bought the child? Why would you buy a child?
Pragati: She has also not children child, so he bought that baby and he gave some money to that family, because they didn’t have enough money for treatment so they got some money and they sold that baby.
Jenna: Okay and then what happened?
Pragati: And when they came to know that this thing has happened, with that husband and wife, then they call the media and they try to collect some money, they collect some money from village level and also they call media and they advertise it on Facebook actually, there is a problem and if anybody want to help, then we need your help, then they collect some money and again they bring that child back. They brought the child back.
Mr. N’s translation tells essentially the same story, but with different, and fewer, details:
An example of community mobilization was shared by the members. A family was residing in a rented house of the village. The wife fell sick. For treatment they sold their baby at Bhanjannagar. When this news was spread the women group invited media and govt. people. Lastly the sold baby was rescued.
It is not just that the two versions have more or less detail, but they actually leave a different impression; they are not the same object. Choosing to include one version versus the other affects the whole feeling of the section and including both, as I have done, raises questions. Which one is more accurate? Why did Pragati include the details about the social media
campaign while Mr. N did not? Was the discrepancy in cities a transcription mistake on my part? And most frustratingly, what did the participants actually say? They chose to share a story in a certain manner with certain details, and both translators relayed it to me in the way that felt was most appropriate. At the same time, I searched for details that I deemed important, such as who bought the baby, although this detail seemed to matter little to the translators or the
participants.
CONCLUSIONS ON TRANSLATION
The preceding three stories all illustrate the interaction between the process of translation and the object knowledge. Knowledge is continually translated and re-translated as it travels through the network of Simavi, VHAI, and the local communities, and it is different at different places within the network. HIV/AIDS, sex, and sexual reproductive health knowledge is enacted and practiced differently by individual actors in various contexts. Knowledge in one context to
another is no longer a singular object viewed from multiple perspectives, but rather a new object in relation to miscellaneous others (Mol, 2002). As Mol explains, “maybe there are many selves, implicated in many relations. They do not stand in opposition to a single outside world to which they belong and are strangers. They are, instead, implicated in different practices. Many selves and various others” (Mol, 2002: 134). Returning to the opening example of HIV/AIDS knowledge, I enact this object in one way, practicing it into my own reality based on the components of my own network. Pragati and Mamta also enact and practice it, but do so differently because they live in a context that is very different than mine. At the same time however, we have become enmeshed in the same network and these variations of knowledge thus come into contact with each other in an interdependent manner.
CHAPTER 2
POSITIVE DEVIANTS: DYNAMIC COMMUNITY FIGURES
“I will take this and steal your word of positive deviance” says Aika van der Kleij, Simavi programme manager of SRHR, as she moves to the door, hurrying to carry on with a busy day’s schedule. Loan Liem, senior programme officer SRHR and Carola Hofstee, programme officer SRHR are both shaking their heads, “Oh yeah that’s very Indian…everything is positive deviance…this is nothing new” says Loan. It is midday on a beautiful May day, sun pouring into the windows of the Simavi office. I have come here to share my preliminary findings and speak with the staff about UFBR/UaCM programmes. Although I am eager to hear their perspectives, I am intimidated by the prospect of asking them critical questions. It is moments like this when I consider myself to be uncomfortably close to my research; I intend to have a career in global health, and finding the delicate balance being a critical, questioning anthropologist and an inexperienced student who will soon be seeking employment is not always easy.
The concept of positive deviance is essentially an alternative perspective on the typically negatively connoted concept of deviance as a negative, punishable aberration. It refers to individuals who stray from the norm in a way that is beneficial to themselves and thus provide a model for uncommon, ‘good behaviors’ that other community members can similarly strive towards (Marsh, et al., 2004). These uncommon behaviors can vary in their distance from the norm; an Olympic athlete from humble beginnings and the first girl in her village to attend college are both positive
deviants, as their behaviors are, in their own capacity, exceptional as compared to the norm. I began to associate this idea with my observations early on, after a particularly compelling interview with Kasturi Mohapatra, an ANM of 25 years’ experience, and Loan and Carola’s recognition of the applicability of this idea to the Indian context was reassuring. It may not be the most novel explanatory framework but it is a well-recognized mechanism of social change that warrants further discussion. In this chapter, I use the stories of a few particularly dynamic and engaging community members (positive deviants) to illustrate how certain individuals serve as strong ties, bringing the network together and aiding in the success of UFBR/UaCM programmes; these individuals are crucial to the dissemination, practice, and enactment UFBR/UaCM programme knowledge.
SUNITA CHARAN
Sunita Charan was pregnant with her second daughter when her husband died ten years ago. Unsure how she would go on and aware of the precariousness of her situation, she did not hesitate when the local community leaders suggested that she undergo training to become an ASHA. We meet in her home in Biribattia, where she lives with her elderly parents and two daughters, Nayana and Ranjita. I am drawn to Sunita as soon as I meet her, charmed by her bright, white smile, almond eyes, and smooth brown skin that stretches over high cheekbones. She never stops smiling during our interview, telling me about her duties as an ASHA and how this job has allowed her to slowly build her house, bit by bit. The main room is meticulously clean and tidy, dresses and blankets hanging perfectly folded below a high shelf containing rice and household utensils. The walls remain bare concrete, unpainted, but a perimeter of decorative burgundy and orange tiles has been carefully installed.
As an ASHA, Sunita provides ANC and PNC support to the women in her community, registering new ANCs with the local ANM, providing advice from pregnancy until the baby is five years old, distributing iron tablets and hemoglobin tests, and accompanying women to the PHC or CHC for delivery. She is responsible for one panchayat, which contains five thousand people. The warmth with which she speaks about her work and the excitement in her tone gives me the impression that she genuinely enjoys her work. She is reticent to share any complaints when I ask her what she finds challenging about her work, instead telling me that she is happy to do her job and finds joy in helping women to deliver healthy babies. When I ask her what her relationship with her patients
