Tesis Susanna Rance Aborto en Bolivia Copy

CHANGING VOICES:

ABORTION TALK IN BOLIVIAN MEDICAL SETTINGS

A Thesis In Two Volumes

VOLUME II

Susanna Rance

A thesis submitted for the Degree of Doctor of Philosophy to the

Department of Sociology,

University of Dublin (Trinity College)

May 2003

DECLARATION

This thesis has not been submitted as an exercise for a degree at this or any other

university.

This thesis is entirely my own work.

I agree that the Library of the University of Dublin, Trinity College, may lend or copy this

thesis upon request.

..............................................

Susanna Rance, La Paz, May 2003

[email protected]

Changing Voices Table of Contents, Volume II

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VOLUME II: TABLE OF CONTENTS

Page

KEY TO TRANSCRIPT NOTATIONS iii KEY TO SPEAKERS CITED iv

i) Key to Speakers, A to Z iv ii) Key to Speakers, AA to XX v iii) Note on Translation of Categories of Professional Formation vi KEY TO ABBREVIATIONS viii CHAPTER 10. AUDIENCING HOSPITAL STORIES 1

10.1 The Problematic Relationship 2

10.2 Actor-Audience, Text as Actant 6

10.2.1 First-year students: ‘We are a human person’ 8

10.2.2 Interns: ‘If there has been good conduct, or not’ 12

10.2.3 Residents: ‘Everyone should have just one language’ 14

10.2.4 Obstetricians: ‘Although you insist it’s the same patient’ 16

10.3 Negotiating Professional Boundaries 19

10.4 Never-Ending Stories 23

CHAPTER 11. CONTRARIWISE AND OTHERWISE 25 11.1 ‘It seems that you don’t understand!’ 26

11.2 Strangeness and the Author’s Vision 27

11.3 A Hybrid Methodology 28

11.4 Ironic Use of Deadpan Understatement 31

11.4.1 ‘It’s all negative’ 33

11.5 Alternation: from Epistemology to Strategy 36

11.5.1 Deconstruction and reconstruction 36

11.6 Performing Consensus and Conflict 38

11.6.1 The Gringa Boliviana story 39

11.6.2 Conflict and transformative action 40

11.6.3 ‘Why are people so nice?’ 42

11.7 Abortion: The Vanishing Topic 45

11.8 Semiotic Action-Research 47

REFERENCES 50

Changing Voices Table of Contents, Volume II

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Page APPENDICES 80 APPENDIX 1 Contextualisation of transcript excerpt introducing Chapter 1, Doing Abortion 81

APPENDIX 2 Contextualisation of transcript excerpt introducing Chapter 2, Mapping the Field 84

APPENDIX 3 Contextualisation of transcript excerpt cited in sections 3.2.3 and 3.2.5 of Chapter 3, March of the White Coats 91

APPENDIX 4 Contextualisation of transcript excerpt introducing Chapter 4, White on White 98

APPENDIX 5 Contextualisation of transcript excerpt introducing Chapter 5, The Empty Bed 122

APPENDIX 6 Contextualisation of transcript excerpt cited in section 6.6 of Chapter 6, Sociology of a Syringe 129

APPENDIX 7 Contextualisation of transcript excerpts cited in sections 7.3, 7.3.1 and 7.4 of Chapter 7, Changing Voices 149

APPENDIX 8 Contextualisation of transcript excerpts cited in sections 8.2 and 8.4 of Chapter 8, Managing Pain 160

APPENDIX 9 Contextualisation of transcript excerpts cited in sections 9.1 and 9.2 of Chapter 9, One Woman, Five Stories 172

APPENDIX 10 Contextualisation of transcript excerpts cited in section 10.3 of Chapter 10, Audiencing Hospital Stories 176

APPENDIX 11 Contextualisation of transcript excerpt introducing Chapter 11, Contrariwise and Otherwise 182

APPENDIX 12 Translated excerpts from Bolivian Ministry of Health 1999 policy document, National Programme for Sexual and Reproductive Health 191

APPENDIX 13 United Nations Population Fund 1996. Paragraph 8.25, Programme of Action adopted at the ICPD, Cairo, 5 – 13 September 1994 195

APPENDIX 14 Translated excerpt from the 1972 Bolivian Penal Code, Title VIII, Crimes against Life and Bodily Integrity, Chapter II, Articles 263–269 on abortion 196

APPENDIX 15 Translated excerpt from the 1985 Bolivian Political Constitution, Article 3 on State and religion 198

APPENDIX 16 Translated excerpt from the Bolivian Medical College’s 1993 Code of Ethics, Article 15 on therapeutic abortion 199

APPENDIX 17 Register of materials used for analysis. 200

APPENDIX 18 Excerpts from a 1999 Ipas publication including the organisation’s mission statement (Hord, CE 1999. ICPD Paragraph 8.25: A Global Review of Progress). 205

APPENDIX 19 Dra. Bertha Bastos’ personal account of medical education and stages in formation. 207

Changing Voices Key to Transcript Notations

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KEY TO TRANSCRIPT NOTATIONS System developed by Jefferson (1985), adapted by Andrade, Aguilar, Bradby and Nina (1995), and further adapted by SR (transcripts listed in Appendix 17). Transcripts of recordings:word- //[in middle of turn] //[at beginning of turn] {words} underlined words or syllables CAPITALS ::::: [.] [2] ['] [''] ['''] [words] [??] [[indications]] X, XX ♀ ♂

Indicates that word is cut off here Turn interrupted at this point by the next turn This turn interrupts the previous turn Phrase or part of phrase pronounced simultaneously with similarly marked phrase which precedes or follows it Spoken with emphasis Spoken loudly Indicates prolongation of preceding vowel or consonant Pause, less than one second Pause lasting two seconds, etc. Intake of breath: short, middling, prolonged Words in square brackets are uncertain in the transcript Words which could not be transcribed (inaudible) Indications of gestures, etc. added by transcriber Names of people, institutions, places omitted to protect anonymity Female speaker Male speaker

Transcripts of fieldnotes and jottings: Fieldnotes and jottings are transcribed as written, except for speakers’ pseudonyms (see Key to Speakers), pseudonyms for hospitals and place names, and the insertion of round brackets - (words) - to mark SR’s ethnographic notes, phrases summarised or uncertain at time of noting, indications of gestures, etc.. words... words - Verbatim transcription of dots or dashes appearing in fieldnotes, indicating tailing off,

cutting-off or incompleteness of a speaker’s utterance, or of SR’s jottings made at the time. words Verbatim transcription of an underlining appearing in fieldnotes, indicating SR’s analytic

attention to the words underlined. ✰ Verbatim transcription of symbol appearing in the margin of fieldnotes, indicating SR’s

drawing of special attention to the element marked. ______ Verbatim transcription of a line appearing in fieldnotes, indicating passage to next speaker,

movement to another place, or a gap in note-taking.

Changing Voices Key to Speakers

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KEY TO SPEAKERS To identify the 48 research subjects cited in the thesis narrative, I use correlative A-Z initials for the first 25

pseudonyms, and then AA-VV for the next 21 introduced. This alphabetical coding can be used to trace each

person’s first and subsequent appearances in the thesis narrative (which is not necessarily the same as the

order of their appearance in the Appendices of transcripts). Two speakers (my daughter and son) are

identified by name with their consent, and X and XX mark different speakers with momentary or anonymous

interventions. Medical professionals’ gender differentiation is signalled as in Spanish, by giving male doctors

the title ‘Dr.’ (Doctor) and female doctors ‘Dra.’ (Doctora). My interventions as researcher are marked SR.

(i) Key to Speakers, A to Z

Pseudonym Initials Gender Status in interactions cited Dr. Antunes Dr. A M Director of State Hospital. Bertha Bastos B F Intern friend doing rotas in General Hospital; research collaborator

with whom I discussed relations between sociology and medicine. Dra. Campos Dra. C F First-year medical resident on State Hospital gynaecology ward.

Protagonist of two ‘Empty Bed’ case presentations. Dr. Dávila Dr. D M Staff gynaecologist and academic coordinator of residents’ training;

research collaborator in State Hospital. Elba E F Fifth-year medical student participating in teaching session in

gynaecology outpatients clinic, State Hospital. Dra. Fuentes Dra. F F Former chief of Insurance Hospital gynaecology ward; collaborator as

coordinator of Insurance Scheme Reproductive Health Programme. Dr. Gonzáles Dr. G M Staff gynaecologist; academic coordinator of residents’ training;

research collaborator in Insurance Hospital; protagonist of the dossier ‘One Woman, Five Stories’.

Dr. Harb Dr. H M Obstetrician who attended my children’s births; my personal gynaecologist; former coordinator of Mother-Child Health Programme; research collaborator as director of Maternity Hospital.

Ignacio I M First-year medical student from a country bordering on Bolivia; research collaborator in Medical School study.

Dra. Juárez Dra. J F Third-year medical resident researching obstetric applications of misoprostol; research collaborator in the Maternity Hospital.

Karen K F Colleague from the USA on project visits to Insurance Hospital. Dr. Losada Dr. L M Third-year medical resident in Insurance Hospital; protagonist of the

dossier ‘One Woman, Five Stories’. Mrs. Mayta Mrs. M F Woman whose pregnancy was interrupted in the Insurance Hospital;

protagonist of the dossier ‘One Woman, Five Stories’. Mrs. Nina Mrs. N F Woman consulting with Dr. Dávila in gynaecology outpatients clinic,

State Hospital, with whom I negotiated consent for observation. Mrs. Ortega Mrs. O F Woman awaiting a therapeutic abortion in the State Hospital. Mr. Ortega Mr. O M Husband of Mrs. Ortega, who refused my requests for consent to

consult his wife’s medical history file in the State Hospital. Nurse Paredes Nurse P F Nurse who entered Dr. Dávila’s gynaecology outpatients clinic in the

State Hospital during my observation session. Mrs. Quiroga Mrs. Q F Woman awaiting surgery in gynaecology ward, Insurance Hospital. Rayda R F Intern I spoke to after gynaecology ward round, Insurance Hospital. Dr. Salinas Dr. S M Chief of Insurance Hospital gynaecology ward, who invited me to

give a presentation on my research to his staff. Dra. Tania Tamayo

T F Public health specialist; collaborator as counterpart for Gender Vice-Ministry in Gender and Health course for Medical School teachers; postgraduate student in Gender and Development programme.


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Pseudonym Initials Gender Status in interactions cited Ms Ulloa Ms U F Woman interviewed while recovering from a D&C following

pregnancy loss on the Insurance Hospital gynaecology ward. Víctor V M Intern participating in a story dossier discussion exercise in the

Maternity Hospital. Dr. Walters Dr. W M Staff gynaecologist in Insurance Hospital; MVA technology

innovator; protagonist of the story dossier ‘Managing Pain’. Mr./Dr./Nurse X,

Mr./Dr. Nurse X

Used to indicate different people who intervene momentarily in transcribed interactions, or who are anonymous in the thesis narrative.

Dra. Yapita Dra. Y F Medical resident who performed MVA procedure on Insurance Hospital gynaecology ward.

Mrs. Zamora Mrs. Z F Woman who had to stay another day on the Insurance Hospital gynaecology ward after the last in a series of three MVA procedures.

(ii) Key to Speakers, AA to XX Pseudonym Initials Gender Status in interactions cited Nurse Ayala Nurse

AA F Nurse in series of three Insurance Hospital MVA procedures who

showed residents how to clean MVA syringes. Dr. Balda Dr. BB M Medical resident who was called to wash MVA syringes on the

Insurance Hospital gynaecology ward. Mrs. Calisaya Mrs. CC F Woman who asked me to accompany her during the first in a series of

three MVA procedures on the Insurance Hospital gynaecology ward. Mrs. Díaz Mrs.

DD F Woman who complained of pain during the second in a series of three

MVA procedures on the Insurance Hospital gynaecology ward. Head Nurse Elena Elías

Nurse EE

F Head Nurse of Insurance Hospital gynaecology ward whom I interviewed about ward use of MVA and Cytotec.

Dr. Fernández Dr. FF M Staff gynaecologist in the State Hospital who did research on MVA and trained residents in its use in that hospital and in his private clinic.

Mrs. Gong Mrs. GG

F Woman who screamed with pain in an Insurance Hospital MVA procedure; protagonist of ‘A Dossier of Pain’.

Dra. Helga Haber

Dra. HH F First-year resident on Insurance Hospital gynaecology ward; protagonist of ‘A Dossier of Pain’; friend of European origin.

Licenciada Irma Illanes

Lic. II F Social worker in Insurance Hospital; protagonist of the story dossier ‘One Woman, Five Stories.

Dr. Justiniano Dr. JJ M Chief of State Hospital gynaecology ward, who deemed Mrs. Mayta an interesting case.

Kiko KK M First-year medical student who participated in Medical School discussion exercise on the story dossier ‘One Woman, Five Stories’.

Dr. Luna Dr. LL M First-year resident who participated in dossier discussion exercise in the Maternity Hospital with peers whom he called ‘los sufridos’.

Dr. Maidana Dr. MM M Senior staff obstetrician in Insurance Scheme Maternity Hospital who participated in the dossier discussion transcribed in Appendix 10.

Dr. Navia Dr. NN M Junior staff obstetrician in Insurance Scheme Maternity Hospital who participated in the dossier discussion transcribed in Appendix 10.

Olga OO F First-year medical student who participated in a story dossier discussion in a Medical School anatomy cubicle.

Porfirio PP M First-year medical student who participated in a story dossier discussion in a Medical School anatomy cubicle.

Dr. Quisbert Dr. QQ M Junior staff obstetrician in Insurance Scheme Maternity Hospital who participated in a story dossier discussion.

Dr. Rojas Dr. RR M Senior staff obstetrician in Insurance Scheme Maternity Hospital who participated in a story dossier discussion.


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Pseudonym Initials Gender Status in interactions cited Mrs. Suxo Mrs. SS F Woman whose GP consultation I observed in a 1995 ethnographic

study; protagonist of vignette presented in Mombasa conference. Dr. Tapia Dr. TT M General practitioner whose clinic I observed in a 1995 ethnographic

study; protagonist of vignette presented in Mombasa conference. Vincente VV M First-year medical student who participated in a story dossier

discussion in a Medical School anatomy cubicle. Dr. XX Dr. XX Used to indicate different people who intervene momentarily in

transcribed interactions, or who are anonymous in the thesis narrative. iii) Note on Translation of Categories of Professional Formation1 Categories indicating speakers’ status or stage in professional formation are translated using terms close to

the original terms in Spanish. In Medicine, from the lowest to the highest levels, these go as follows:

First-year medical students (Estudiantes de primer año), attending Anatomy, Histology and

Embryology lectures, group classes and practices.

Fifth-year medical students (Estudiantes de quinto año) still attend undergraduate classes in the

Medical School, with some hospital visits and training sessions in therapeutic settings. This stage is

retrospectively called ‘pre-internship’ (pre-internado) by teachers (see Appendix 19 for Dra. Bertha

Bastos’ account of medical education).

Interns (Internos/as) are sixth-year undergraduate students doing group ‘rotas’ through different

services in teaching hospitals, prior to final Medical School examinations. On passing these exams,

they are graduates (egresados/as), but not yet licensed doctors. Their level is similar to that of Pre-

Registration House Officers (PRHOs) in the UK and Ireland. However, subsequent requirements for

professional registration differ. In Bolivia, interns have to fulfil several months’ practice in a

provincial health centre (año de provincia) in order to qualify. In the UK and Ireland, PRHOs have

to fulfil six months of hospital practice in Surgery, and six months in Medicine.

Medical residents (residentes médicos/as) are qualified doctors training to be specialists, in a three-

year programme in a teaching hospital. Their training combines intensive work on the wards,

academic sessions, a research project, and the overseeing of interns. The level of first-year residents

is similar to that of Junior House Officers (JHOs) in the UK and Ireland. In their second and third

years, residents’ level is similar to that of registrars or Senior House Officers (SHOs)

Staff gynaecologists, staff obstetricians (ginecólogos/as de planta, obstetras de planta) are

qualified specialists with salaried employment in a hospital. Many have their own private practice,

and some own private clinics. Their responsibilities include training and supervising residents and

interns. A senior specialist is often accompanied on duty by a more recently qualified (junior)

colleague.

Ward chiefs (jefes de servicio) are specialists in charge of a hospital service.

1 I am indebted to Dra. Bertha Bastos and to Dr. Harriet Lupton for their respective explanations about professional levels and stages in medical education in Bolivia, and in the UK. For further details of the UK system, see ‘Applying for a Job’, British Medical Journal Careers Supplement 15th June 2002, p. s192.


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Hospital directors (directores de hospital) are executive directors employed by the Ministry of

Health (State Hospital) or National Insurance Scheme (Caja Nacional de Salud).

Supervisor (supervisora) is the term I use for Dra. Fuentes, coordinator of the National Insurance

Scheme’s Reproductive Health Programme, who visited the hospital to monitor its gynaecology

services.

Consultants is the term I use for higher-ranking specialists (especialistas) who are called to the

hospital when needed to advise on particularly interesting or problematic cases.

Social workers and registered nurses are formally addressed as Licenciada, meaning university graduate.

Head Nurses in charge of wards (Matron or Ward Sister in UK and Irish usage) were habitually addressed by

colleagues as ‘Doña’ followed by their first name (e.g. Doña Irma), indicating respect for a senior woman.

Changing Voices Key to Abbreviations

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KEY TO ABBREVIATIONS

A-B Aborto (Abortion)

ADN Acción Democrática Nacionalista, National Democratic Action (political party)

ANT Actor Network Theory

CA Conversation Analysis

C-A Carcinoma (cancerous tumour)

CDA Critical Discourse Analysis

CH Clinical History (in Spanish, HC, Historia Clínica)

CEDOIN Centro de Documentación e Información, Centre for Documentation and

Information

CSO Common-sense objection

D&C Dilation and curettage (in Spanish, legrado, legrado instrumental, or raspaje)

DFID Department for International Development

DHS Demographic and Health Survey

Dra. Doctora, woman doctor

ESAR Fundación para la Educación en Salud Reproductiva, Foundation for Education in

Reproductive Health

GP General Practitioner

H-I H-Y, Hypochondriac (Hipocondríaco/a) or Hysterical woman (Histérica)

ICPD International Conference on Population and Development

INE Instituto Nacional de Estadística, National Institute of Statistics

IPAS, Ipas Formerly International Projects Assistance Services, IPAS. From 1998, ‘just Ipas’.

IUD Intra-uterine device (in Spanish, DIU, dispositivo intrauterino)

IWHC International Women’s Health Coalition

Lic. Licenciada, woman university graduate

LMP Last Menstrual Period (in Spanish, FUM, Fecha de Ultima Menstruación)

MVA Manual Vacuum Aspiration (in Spanish, AMEU, Aspiración Manual Endouterina)

NGO Non-governmental organisation

ODA Overseas Development Administration

OED The New Shorter Oxford English Dictionary (1993)

SSK Sociology of Scientific Knowledge

SWOD The Saving Women Device

TAI Tratamiento del Aborto Incompleto (Treatment of Incomplete Abortion)

TWOD The Truth Will Out Device

POA Programme Of Action

UMSA Universidad Mayor de San Andrés (La Paz State University)

UNFPA United Nations Fund for Population Activities

USAID United States Agency for International Development

WHO World Health Organisation

Changing Voices Chapter 10. Audiencing Hospital Stories

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CHAPTER 10. AUDIENCING HOSPITAL STORIES

SR: Mhm [2] Now thinking [.] about the exercise itself. [.] Let’s say, the fact of seeing: 1

[.] on one sheet, five different stories. [.] Um:: [2] this, for you: [1] can it have 2

some u:se, for anything::, does it have any sense, doesn’t it have any sense, [2] 3

♂Intern V: Yes. Personally, [1] er: I think th- [.] that: we’ve passed through and we’re already 4

at the end:- we’re already on the final stretch to [.] graduate as surgical doctors, [1] 5

and::: er- it’s useful to us [1] from the point of view of controlling, [.] how: [.] we 6

do it here, in the hospital:, of controlling some medical his:tories and the way: [.] 7

that those same indications are carried out [1] by the nurses, [2] and that: our 8

patients: [.] find: [.] find: out, [.] their families as well: as themselves, about: the: 9

procedure that is going to be done [1] for each one of our patients, [.] and that they 10

should be awa:re [.] that what is being done, [1] is: [.] the best: [.] that it can be. [2] 11

[[continues his intervention for one minute]] [1] To me- [.] it helps me. [1] To 12

know what I must NOT do [[strikes the dossier sheet]]. It’s a stor- a woman with 13

five stories, [1] to- [.] have treatment [.] that’s more [.] humane. [4] 14

In this chapter, I show my dialogic application of the story dossier method: the ‘audiencing’ (Fiske

1994) of contrasting hospital narratives in group discussions with medical students and teachers. As

part of a 1998 action-research project in a State university medical school, I presented the page of

stories concerning Mrs. Mayta’s therapeutic pregnancy interruption to reader-audiences who could

‘construct, apprehend, and bring meaning to and interact with the text in question’ (Denzin

1997:244). In the recorded excerpt transcribed above,1 Víctor (V), an intern (sixth-year

undergraduate student) participating in a Maternity Hospital discussion exercise, interprets the

dossier as promoting (self) control in hospital procedures (lines 6-9, 12-13 ), adequate information

to patients and their families about medical procedures and their benefits (lines 8-11), and humane

treatment (lines 13-14).

In the previous chapter, I discussed elements that shaped the creation of this story dossier: ward

round presentations referring to hospital pregnancy interruptions, the political significance of

documenting Mrs. Mayta’s ‘case’, my decision to expose resident Dr. Losada’s account of moral

conflict, and self-censorship regarding Cytotec (the technology used to induce Mrs. Mayta’s

second-trimester abortion). Before analysing the discussion exercises, I turn to institutional

considerations that led to the selection of this dossier for use in the medical school. My Ipas

employers constituted a primary audience for both the dossiers I produced, and theirs was the 1 Excerpt from Transcript GPIN.2:7, 13/8/02.


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decision to authorise presentation of ‘One Woman, Five Stories’ - but not ‘A Dossier of Pain’ – in

the exercise I designed.

10.1 The Problematic Relationship

Negotiation among actors involved in research has a crucial impact on what can be investigated,

reported and disseminated: ‘[T]he definition of useful research, and therefore of the research

objectives, is a political matter’ (Schrijvers 1991:175, my italics). ‘Researchers may be given

grants, sponsored to attend conferences, or provided access to research settings with the implicit

understanding that their work will reflect favourably on the sponsor and/or follow the preferred

political agenda. Many sensitive topics are mined with specific agendas that researchers must

tread carefully to avoid becoming ejected’ (Adler and Adler 1993:258, my italics).

In using a grounded theory approach (Strauss 1987), I attempted to enter field settings with an

open mind, prepared to build my analysis on the basis of locally encountered categories and

phenomena. Finding evidence of medical discourse and practice that challenged governmental and

institutional norms, in my 1997 contract research report I addressed issues that were polemical for

the organisation that employed me. Providing the written comments that I requested on this report,

an Ipas representative expressed the following concerns:

I return to my previously expressed question regarding the decision to study the five issues:

incomplete abortion, MVA, therapeutic abortion, misoprostol use and postabortion

contraception. Please clarify if and how these issues are relevant to the overall project. My

concerns regarding the way this is expressed in the project final report are political, given

that a) in Bolivia MVA is not an approved procedure (according to national norms); b)

misoprostol is not approved for the use described here;2 and c) that therapeutic abortion is

not a component of our larger project. In addition, the donor agency expressed a high level

of concern about the political sensitivity of the topic of the overall project in a project

where all contracts and agreements are for postabortion care. As presently described here,

one could mistakenly presume that these three issues are of programmatic relevance to the

project. (Ipas Interoffice Memorandum 5/3/98, my italics.)

I developed the two story dossiers included in the 1997 report on the basis of field events that

could not have been anticipated at the start of my research. The topics raised in both were 2 See 9.5, ‘Cytotec: The Missing Link’, in Chapter 9, One Woman, Five Stories.


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problematic for Ipas. The author of the above comments argued that therapeutic abortion was

taboo within the Bolivian context. She held that political opposition made it difficult enough to

keep postabortion care on the public agenda, without entering the contentious terrain of abortion

procedures. My position, in line with that of the 28th September Campaign to Decriminalise

Abortion in Latin America and the Caribbean,3 was that raising professional awareness about

aborto impune (non-punishable abortion) was a legitimate advocacy strategy.

Manual Vacuum Aspiration (MVA) was also a polemical issue for Ipas. In the early 1990s,

following a pilot MVA training project in the Insurance Hospital, the organisation’s activities were

questioned and they were almost obliged to close down activities in Bolivia. MVA became the

object of an unwritten veto by the Health Ministry, on the grounds that the instruments could be

used to induce abortion.4 Despite this governmental position, I found that MVA was being used –

covertly in the State Hospital, and with institutional restrictions in the Insurance Hospital – on the

gynaecology wards where I did fieldwork. Health authorities and hospital directors,

acknowledging the technology’s potential for cutting costs, operating lists and beds occupied,

opted for turning a blind eye to its implementation.

Women’s pain in MVA procedures was also problematic for Ipas. When I presented findings from

my 1997 research to colleagues in the US central office, they concurred that pain was ‘a sensitive

issue at Ipas’, both a ‘big issue’ and a ‘non-topic’.5 MVA was marketed as an appropriate

technology for countries such as Bolivia, and support was growing in governmental circles for its

adoption, with a view to maximising scant health sector resources. However, as my data showed,

anaesthesia was not being adequately utilised in MVA procedures. Pain was a barely admitted

obstacle to the technology’s acceptability, both for women treated and for nursing staff.

For the Medical School discussion exercise, I would have preferred to use the dossier on pain. The

juxtaposition of Mrs. Gong’s representation of the MVA procedure as like ‘a nail, inside’ (lines 2-

3 of her narrative in the dossier in Chapter 8), and Dr. Walters’ rhetorical question ‘[W]hat pain

could she have?’ (lines 5-6 of his dossier text), forcefully indicated medical negation of a woman’s

account of her experience. At the time of the pain episode, I interpreted these narratives as

competing and mutually exclusive versions of reality.6 During my two years of fieldwork, I

witnessed many instances of callous handling of bodies – dead and living – by Medical School

3 See footnote in 9.1, ‘An Interesting Case’, in Chapter 9, One Woman, Five Stories. 4 See the introductory section of Chapter 6, Sociology of a Syringe. 5 Notes written at the time in Field Notebook 6, 23/9/97. 6 See 8.4, ‘A Dossier Of Pain’, in Chapter 8, Managing Pain.


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students and teachers. Bertha Bastos, my intern friend, asserted that medical knowledge could

invalidate a patient’s account of pain:

SR: From a sociological point of view, it’s considered that doctors also observe

from their subjectivity. And that there isn’t a hierarchy of knowledge – that

the patient’s and doctor’s constructions have the same value and validity.

Bertha: That can’t be so. For example, a patient with a gall bladder problem, who

exaggerates his pain... while the doctor does an evaluation and knows that

such pain cannot exist – because it is known – studies have been done’.7

In the Medical School discussion exercise, I wished to present evidence that could challenge such

physiological truths. Given Ipas’ concern about the topics of both dossiers, which could be

considered the most ‘suitable case for treatment’, therapeutic abortion or pain in an MVA

procedure? One response was ‘neither’, and the Ipas representative cited above suggested that

made-up accounts might be sufficient: ‘Do the stories have to be true?’.8 As I replied on that

occasion, fieldwork convinces me ever more of the aphorism that truth is stranger than fiction

(Potter 1996:173). Encouraged by positive responses to staff training materials that incorporated

my ethnographic data from a former study,9 I sought to edit dossier narratives whose authenticity

would jump off the page, their turns of phrase too singular to have been invented. Through their

very oddness, transcribed stories, with all their internal contradictions, can appear more ‘real’ than

scripts designed expressly for workshop exercises. Although these latter creations may also be

based on qualitative research, their tailoring to make an unambiguous point can produce

stereotyped narratives which lack verisimilitude (Denzin 1997:10),10 making neither good social

science nor good literature.11

The feature of authenticity was noted by medical students participating in dossier exercises.

‘They’re real events. It’s all true!’ exclaimed a woman first-year student, in a discussion facilitated

7 Notes written afterwards in Field Notebook 11, 13/5/98. See Appendix 11 for bilingual transcript of notes. 8 Notes written during telephone conversation in Ipas Notebook 7, 6/5/98. 9 Transcripts from an earlier hospital study (Rance 1993) were used to prepare a manual (Secretaría Nacional de Salud/IPAS 1995) and a video (Ipas/Ministerio de Salud 1998) for health workers on postabortion care. 10 Verisimilitude: a text’s ‘ability to reproduce (simulate) and map the real’ (Denzin 1997:10). 11 As an example of unambiguous stereotypes created by authors using my ethnographic data, I cite a translated excerpt from a ‘socio-drama’ in a manual for health workers: ‘The doctor says to the nurse, still without looking at the patient or saying anything to her, “Does she admit that she induced it?” Nurse: “No, doctor. She denies having done anything to herself, but I suspect that she went to a healer to get the abortion done.” Doctor: “Well, it seems we have no Xylocaine. It’s good that our patients have a lot of resistance to pain.” Nurse: “Yes, doctor.” The doctor starts the MVA procedure, still without speaking to the patient.’ (Ipas 1998. ‘Module: Treatment and Communication between the Patient and the Provider of Postabortion Care’, unpublished draft, p. 9.)


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in an anatomy dissection cubicle by Ignacio, a classmate.12 Her conviction contrasted with the

scepticism of medical teachers who questioned the truth of these same stories.13 In any case,

participants at all levels used authenticity as a parameter for accepting, doubting or rejecting my

data.

The Ipas representative was eventually persuaded of the importance of ‘real stories’. The question

remained: which dossier could be used? The institutional position was that showing the pain

dossier in the medical school would be ‘politically dangerous’. I was given permission to use the

dossier on therapeutic abortion, with one condition:

If you are directing the discussion, we feel that it can serve as an excellent teaching tool.

However, the concern about the document being misinterpreted or disseminated by

students keeping the page in the future remains. We believe that there could be serious very

negative consequences for all of Ipas’s programs if that were to happen. Therefore, our

recommendation/authorization for use is as follows: You may use these five interpretations

of the event. However, any copies of the document that are handed out in class MUST BE

RETURNED to you prior to the completion of the discussion.14

Thus it was that I came to present the story dossier on Mrs. Mayta’s pregnancy interruption, rather

than the one on Mrs. Gong’s pain in an MVA procedure. Ultimately, this outcome was favourable

to my political agenda. Into the Medical School, ‘de contrabando’, I was able to smuggle evidence

of a therapeutic abortion in a Bolivian teaching hospital and have it discussed by students and

teachers.

This kind of negotiation, with unpredictable results for all concerned, is characteristic of the

‘Problematic Relationship’ between researchers, sponsoring institutions, funders, and policy-

makers. Wenger’s overall assessment is that

[w]hile some researchers manage to establish a good working relationship with the

contracting agency (Mamak, 1978; Stretton, 1978) this is usually achieved only as the

result of careful negotiation and cannot be taken for granted. Orlans (1967) (...) commented

that ‘givers and recipients of social research funds are often troubled by misunderstandings

12 Notes taken at the time in Field Notebook 11, 19/5/98. 13 See 10.2.4 (below), ‘“Although you insist it’s the same patient”’. 14 E-mail message from Ipas to SR, 11/5/98.


6

and a sense of unfulfilled expectations that may lead readily to moral recriminations’ and

noted that ‘money does not come free’ (pp. 3-5). (Wenger 1987:2-3)

Discussions with Ipas concerning my 1997 research report concerned methodological issues as

well as topic. The shift from interpretative repertoires to narratives was criticised as demonstrating

inconsistency:

Page 12, point 4 also mentions the goal of advancing in the search for new categories and

methods of analysis, which you later describe. This seems to represent a change in

methodology of data collection. This should be mentioned here – particularly since that

would normally be seen as a sign of methodological weakness in public health quantitative

or qualitative studies.15

Ipas’ approval of my 1998 action-research project was conditioned to the planning of interviews

and dossier exercises with medical students, trainee specialists and teachers at pre-determined

levels. This signified forfeiting some flexibility in my method, which involved mapping the field in

the course of research by tracking key collaborators through their ‘natural’ networks.16 Pressure to

comply with project indicators left me insufficient time to carry out sessions with other first-year

groups who heard of the exercise and asked me to bring it to their anatomy cubicles. It also

influenced my adoption of a generalising approach, comparing the tendencies noted at four stages

of medical formation. This produced a clean-cut, if somewhat homogenised finding of a

progressive narrowing of medical criteria concerning valid voices and truths in a critical hospital

event.

10.2 Actor-Audience, Text as Actant

Over three months, concurrently with observations and interviews, I presented the dossier to 30

participants in seven groups and pairs of first-year students, interns (sixth-year students rotating

through hospital services),17 residents (trainee specialists), and medical teachers. The discussion

exercise constituted a particular application of the practice of audiencing. Rather than

conceptualising each group as a market segment, site of acculturation, or constituent element in a

15 Ipas Interoffice Memorandum to SR, ‘RE: Request for Comments on Research Report: Medical Discourses’, 5/3/98. 16 See 2.2.1, ‘Collaborators, participants and subjects’, in Chapter 2, Mapping the Field. 17 See Appendix 19 for Bertha Bastos’ personal account of medical education and stages in the undergraduate Study Plan.


7

‘way of living’ (Fiske 1994:194), I approached the sessions as scenarios for performative

interactions between groups of peers and the story dossier. The actor-network I attempted to

engineer linked reader-audiences with text-as-actant, rather than spectating audiences and

researcher-actor with script (Dugdale 1999:127).18

For the initial dossier discussion, a group of 19 white-coated first-year students19 sat facing each

other on wooden benches in the anatomy dissection cubicle which had become my operational

base20 in the Medical School. The corpse had been returned to the metal sarcophagus in the corner.

Formaldehyde fumes still burned my eyes and throat, and the air was thick with the familiar, sickly

stink that clung to clothes and hair. I had followed the advice of Ignacio, a student research

collaborator,21 to hold the session in the group’s habitual learning environment rather than in an

alien classroom setting. He suggested that they might be put on the defensive by being moved

elsewhere: ‘When you’re in your own home you feel really free’.22

On planning the exercise, I envisaged my intervention as minimal. ‘All’ I did during the hour-long

session was to present the activity as part of my action-research project on ‘Humane Treatment and

Medical Education’, hand out copies of the dossier sheet headed by the question: ‘How do you

interpret the stories and the differences between them?’, and ask participants to read it individually,

discuss it in small groups, and then all together. At the end I did a five-minute round of the whole

group with a cassette recorder, recording each participant’s response to the frame analysis question

(Goffman 1997:153): ‘What have we been doing here?23 What, if any, has been the point of this

exercise?’. I declined to give my interpretation of the stories, and this detached approach provoked

questions from students which I countered negatively, using responsibility-abdicating ‘don´t know’

and ‘can’t say’ responses (a variant of the NO-NO strategy):24

18 ‘It is standard procedure of semiotic analysis to explore how it is that readers are constituted by textual moves of one kind or another. It is therefore not breaking new ground to argue that this text is performing its reader in a particular way’ (Dugdale 1999:127). 19 There were ten women and nine men in the group. 20 For discussions of such military metaphors in fieldwork narratives, see 2.2, ‘Mapping From Within’, in Chapter 2, Mapping the Field, and 4.2, ‘Reviewing Researcher Access’, in Chapter 4, White on White. 21 Ignacio, a first-year student, was a research collaborator during my Medical School fieldwork. Coming from a country bordering on Bolivia, like me he was an outsider, and his peers regularly drew attention to his nationality. Ignacio expressed interest in my research from the start, and contributed to it in many ways, such as inviting me to accompany him on two visits to the General Hospital mortuary and informing me of internal conflicts in the Medical School. He appropriated my research methods by recording and transcribing interviews with students, teachers, the hospital mortician, and also with me, as part of an anatomy group study that I supervised on the handling of corpses. 22 Translation of notes written afterwards in Field Notebook 11, 19/5/98. 23 For Goffman’s critique of the frame analysis question ‘What is it that’s going on here?’, see my Introduction, p. 6 (Goffman 1997:153). 24 See 7.2, ‘Doctors’ Interpretative Dilemmas’, in Chapter 7, Changing Voices.


8

(10.55 a.m.. 19 students, each has the page. They read in silence.) 1

♀Student 1: Do we have to find that one of the stories is the true one? 2

SR: No – it’s a question of personal inspiration! 3

(11.00 a.m.. SR gives 20 minutes for the discussion in six groups.) 4

♀Student 2: What do we have to do? Say how each story was? How their feelings 5

were? 6

SR: You have to get out your feelings on reading the stories. 7

♀Student 3: Where was the dermoid tumour? Couldn’t they wait until she had the baby 8

and only then take the tumour out? 9

SR: The doctors said the pregnancy was incompatible with the tumour. But if 10

for you that question is important, you have to talk about it in your group. 11

♂Student 1: Has she got other children? Because if she has – it would be better for her 12

to abort. 13

SR: That, you have to talk about in your group. 14

♀Student 4: Do we have to say which of the stories is the true one? 15

SR: You have to say what you feel about the stories, subjectively. 16

♀Student 5: Do we have to analyse the stories one by one? 17

SR: Do a subjective interpretation – what each one feels – your coincidences 18

and differences. 19

♂Student 2: What does NPO mean? 20

SR: I think it means ‘Nil By Mouth’. But I’m not a doctor either. It’s what I 21

copied from the clinical history. I don´t know! 22

10.2.1 First-year students: ‘We are a human person’

In this discussion,25 the first-year students raised issues of the stories’ competing truth status (lines

2, 15), feelings expressed by different speakers (lines 5-6), clinical and ethical dilemmas (lines 8-

9), social considerations in the decision to interrupt Mrs. Mayta’s pregnancy (lines 12-13), analytic

method (line 17), and clarification of medical terminology (line 20). Their questions, produced

after five minutes of individual reading, alluded to points on which I had reflected for weeks in the

process of creating the dossier. In retrospect, I could well have acknowledged the pertinence of the

students’ requests for clarification.

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


9

At the time, however, I gave defensive responses aiming to turn the students’ attention away from

me as presenter, and towards group discussion of the texts. I demanded that they provide subjective

interpretations, expressing their feelings about each story, and noting coincidences and differences

within each group (lines 3, 7, 16, 18-19). I refused to discuss facts concerning the dermoid tumour

and Mrs. Mayta’s children, deflecting their discussion back to the groups (lines 10, 14). In my final

response about the ‘NPO’ indication in the medical history notes (N.VO in the Spanish original,

lines 21-22),26 I reverted to the position of ‘radical naivety’ adopted at other moments in

fieldwork,27 temporarily disavowing the ‘knowledgeable semi-insider’ status that I had negotiated

within the Medical School as researcher, dossier author, and session organiser. In saying ‘I’m not a

doctor either’ (line 21), I demagogically claimed equal status with the students, and implied that

they required no further information to interpret the texts as they stood.

While I ostensibly pursued dialogic goals and methods, this transcript shows how I blocked

dialogue with participants in using them as audience for the text. My unique statement was the

dossier which I attempted to introduce as a non-human actant (Saetnan 1995:52) substituting my

role as human actor. This dehumanising strategy conflicted with my action-research focus on

‘Humane treatment in medical education’ (Rance 1999). I now find it to be illustrative of Actor-

Network Theory’s linking of actants and actors - the ‘thing-symbols’ named ‘participants’ - as

‘quasiobjects-quasisubjects’ (Verran 1999:154 n.24 citing Latour 1993:89).

Asking Ignacio, my student-collaborator, to moderate the group’s discussion, I removed myself

from the debate and observed the students from outside their circle. I adopted the stance of

‘phenomenological positivism’ applied in focus groups where facilitators tap participants’

subjectivities, maintaining their own out of reach (Cunningham-Burley et al 1999:190). In keeping

my pro-choice views out of the discussions, I also safeguarded the niche I had negotiated for my

Medical School interventions. By directing each group’s attention towards their internal

discussions, I vainly tried to obtain data uncontaminated by my presence.28 As I go on to show,

these students subscribed to the humanising rhetoric of my project’s title, reiterated by the intern

Víctor in the transcript commencing this chapter (lines 15-17): ‘[[[S]trikes the dossier sheet]]. It’s a

stor- a woman with five stories, [1] to- [.] have treatment [.] that’s more [.] humane’.

26 Maternity Hospital director Dr. Harb later informed me that an alternative to N.VO – ‘Nada por Vía Oral’ – the abbreviation I had copied from Mrs. Mayta’s medical history file - was NPO, from the Latin ‘Nil Per Os’ (nil by mouth), an abbreviation also used in English. Personal communication, February 2002. 27 See 6.6, ‘Knowing Nurses’, in Chapter 6, Sociology of a Syringe. 28Notes taken at the time, Field Notebook 11, 19/5/98.


10

My purportedly non-interventionist approach carried a strong agenda. The concepts I hoped to

promote were epistemological symmetry, the relative status of medical authority, and the feasibility

of therapeutic pregnancy interruption even in the face of religious objections. The first-years

responded to the dossier exercise ‘como enseñados’ (as if they had been taught: a Hispanic

expression sceptically alluding to performance of a pre-given script, like stooges). Their discussion

was moderated by the student-facilitator Ignacio (I), who also intervened in the debate:

♂Facilitator I: (shouts) Silence please! It’s an abortion with a lot of children involved… the 1

mother is the one who supports the family… the father only has occasional jobs. 2

The child has a right to live too! But you can’t value one life above another. The 3

most practical thing is to do an abortion. 4

♀Student 1: But Ignacio, doesn’t it seem absurd to you… the gynaecologist, the terms he uses 5

with the woman, that she can’t understand! He just says ‘abortion’. The woman 6

thinks he’s only going to remove the tumour. 7

♂Student 1: The mother doesn’t understand! 8

♀Student 2: How can you tell a mother to choose. 9

♀Student 3: We’ve considered all that. It’s all been said. Everyone has seen it, from what 10

they’ve studied. If it had been a better-off person… The doctor went for the 11

quickest solution. The social worker went for the social angle. The last doctor sees 12

the spiritual side. The woman – within her state of practical ignorance, or her total 13

ignorance…They’re not working as a group! It shouldn’t be called a hospital. Each 14

one goes off on their own tack. 15

♂Student 2: I have a friend, his mother died in childbirth. 16

♀Student 3: Which comes first, the chicken or the egg? We have to look at the reality of Bolivia 17

– or of Latin America. I think that a matriarchy exists. It’s very hard… but that’s 18

the reality. What do you prefer? For one to die, or five? If the mother dies – or if 19

six die, right. That’s not so much the basic issue. The theme here isn’t so much 20

abortion. It’s that each one gives their opinion from their point of view. 21

♂Student 2: The father feels obliged to work… 22

♀Student 4: If I have six children… then five have to go out to work. 23

♂Facilitator I: You’re getting off the point! 24

♂Student 2: It’s a different point of view. He works out of necessity, but you say out of 25

personal initiative. What about if it has no father and no mother- 26

(They all shout at once.) 27


11

Here too, the students raised several issues that I had considered in editing the dossier: social

considerations influencing abortion decisions (lines 1-2, 12, 23, 25-26), ethics of informed consent

(lines 5-7), disunity of the medical team (lines 11-15), the relevance of lived experience (lines 16,

22, 25-26), and ‘Death-death’ as bottom-line argument against relativism (Edwards et al. 1995,

lines 19-20). To my satisfaction, one woman student voiced an argument that is central to my

thesis: ‘The theme here isn’t so much abortion. It’s that each one gives their opinion from their

point of view’ (lines 20-21). In berating a classmate for ‘getting off the point’ (line 24), Ignacio, as

facilitator, made a bid for his understanding of frame, text and context (Goffman 1974; Kendon

1992; Schegloff 1997).

I could not have asked for a more willing audience. In this first exercise, my pro-choice agenda and

relativist thesis encountered significant support. In the concluding comments which I recorded,

several students referred to humane treatment, which was the topic of my study and a tenet of

national health policy (Ministerio de Salud y Previsión Social 1999:48):

SR: [[addressing a woman student who had left the cubicle momentarily when I 1

put the question to the group and started recording.]] Olga, the question 2

was, what have we been doing here, what has this exercise been for? [2] 3

♀Student OO: What has this exercise been for? [2] Er:: [.] for us to realise that:::: [2] like 4

it or not, we’re all individualists any- anyhow, because we respond [‘’] to 5

the::- to the way in which we’ve grown up:- to:- to our ideas, with which 6

we’ve already been formed. [‘] That’s why we see that: let’s say: in one: 7

[1] from:- from:- in one and the same person, [.] with one and the same 8

situation, [‘] you can get er:- not just five different opinions. [.] But: you 9

can get thousands of different opinions! [1] That’s it. [3] 10

SR: Anyone else, [.] to finish? [3] Yes? [.] Yes, Porfirio? 11

♂Student PP: Um:: [2] this:: dynamic work that we’ve done, developed in- just now, [‘’] 12

has served to put us in a future position in which we’re going to put 13

ourselves. [‘’] That is, what would we choose at that moment? [.] [‘] 14

What:: as doctors, [.] will- as::- we’re going to be doctors at that moment, 15

but in the end we’ll still be human beings. [‘’] And we’re going to put 16

ourselves on those two planes. [‘] We don’t know what we are going to 17

choose. But this dynamic serves us to [.] reflect about that theme. [‘] What 18

are we going to do at the moment when we’re going to be doctors? [‘’] If 19

it’s going:- if the humanistic side is going to win, or if the winner will be 20

the- the scientific side? [‘] But essentially, [.] I would say that we are [.] a 21


12

human person, [.] and that we are going to do [‘] at that moment at least, 22

my idea is to do the best that can be done, as much for th- [‘] the person 23

that’s involved at that moment, as for their family. [2] 24

SR: Thank you. [2]. 25 29

These responses indicate two readings of the dossier’s significance that emerged in the first-years’

comments. The first, given by Olga (OO), alluded to the salutary effect of ‘realising’ about human

particularity: ‘[W]e’re all individualists any- anyhow’ (line 5). With her statement ‘[Y]ou can get

thousands of different opinions’ (lines 9-10), Olga challenged not only the validity of one universal

interpretation of a given situation – such as a privileged medical truth – but also the sufficiency of

‘just five’ versions as presented in the dossier (line 9). She diverged from the habitual interpretation

of ‘competing versions’, finding narrative plurality in equally valid stories whose polyphony did

not necessarily involve confrontation (Bakhtin 1984:6). 30

The second reading was given by Porfirio (PP), who also took the session to be a salutary exercise,

emulating a real-life dilemma that students might face in their future careers. The opposition he

postulated was between ‘two planes’: the humane and scientific sides of medicine (lines 15-17, 20-

21), which parallel Mishler’s lifeworld and medical voices (Mishler 1984:13-14). The encounter I

orchestrated between text-as-actant and audience-as-readers was interpreted by Olga, Porfirio, and

other participants as a morally charged intervention, imparting awareness of plurality, promotion of

humane values – ‘we are [.] a human person’ (lines 21-22) -, and conducive to the improvement of

medical practice for patients’ benefit.

10.2.2 Interns: ‘If there has been good conduct, or not’

Having found it impossible to organise meetings with interns within the medical school, I held two

one-hour sessions crammed into busy shifts, with a total of eight interns rotating through Maternity

and General Hospital services. Like the first-years, these sixth-year students interpreted the

exercise as a lesson in humane treatment that acquired practical significance in the light of their

ongoing medical duties. In his response cited at the start of this chapter, Víctor took the dossier to

be instructive to interns nearing the end of undergraduate training (lines 4-7 of the introductory

29 Translated excerpt from Transcript GP1.1:3-4, 19/5/98. 30 ‘[A] plurality of consciousnesses, with equal rights and each with his own world, combine but are not merged in the unity of the event’ (Bahktin 1984:6 cited in Shotter 1992:17, italics in the original). See 8.4, ‘A Dossier Of Pain’, in Chapter 8, Managing Pain.


13

transcript). Discussion of the narratives could serve to promote ‘control’ of medical and nursing

practice (lines 6-8), the giving of information to make patients ‘aware’ that treatment received was

the best possible (lines 8-11), and orientation to prevent doctors from committing moral or

technical errors (lines 12-13). To my final recorded questions, ‘What has this been useful for?’ and

‘What did you get out of it?’, two interns replied:

♂Intern 1: I think that:: m:: [.] um it was basically focused on the job they have t- er:: 1

[.] er:: [.] the- the professionals, as much as the:::: the woman affected, 2

right? [.] [‘] Um:: [.] that’s to say, it’s focused according [.] to:- to the: 3

criterion, to the knowledge of each person. [‘’] From what it says he:re, the 4

criterion of the- of the doc:tor, the criterion of the social worker, the 5

criterion of the nurse, the criterion of the doc- of the medical resident, and 6

the person affected! [‘’] It’s: [.] I think, more than anything, to [.] see: [.] 7

u:::m [.] if (...) there is or if: there has been good conduct, [.] or not. [.] E- 8

er:: [.] in each one of- of these actions. [1] Or- [.] if there is [.] any: [.] any 9

error at:- at any::- at any step. [.] [[in a low tone]] Anything. [.] that’s all. 10

SR: Mhm:? [1] 11

♂Intern 1: It’s:: {[??]} 12

♂Intern 2: {Well,} I think- as my companion says, this goes:: [1] this is related to 13

every::: [.] profession that t- that people have! [‘’] But always dedicated to 14

one and the same aim, right, for:- the good of the pa- of the patient and: 15

that: all- all the things that:: are do:ne in the hospital come out well, [‘’] 16

and:: [.] with this [?] knowledge of the patient, [[the baby in the adjacent 17

ward starts to cry more loudly]] what it is that is going to be do::ne, [‘] how 18

it’s going to be do:ne, and what is::- the consequences that this can have, 19

and according to that make a decision. [3].20 31

While the first-years had imagined future dilemmas, the interns (sixth-years) focused on practical

matters they had encountered in hospital services. They concentrated on the medical job in hand

(lines 1-2), criteria of different health workers (lines 3-6), interests of the woman/person/patient

being treated (2, 6-7, 15), and correct and incorrect medical practice- ‘if: there has been good

conduct, [.] or not’ (line 8). Defence of the good of the patient (line 15) was loaded with concern

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


14

for the visible success of hospital interventions (line 16), a self-legitimating position expressed still

more strongly at higher levels (Bosk 1979:114).32

10.2.3 Residents: ‘Everyone should have just one language’

The next two sessions were with residents undergoing specialist training in the Maternity Hospital.

They had gone through six years of undergraduate studies concluding with a year’s hospital

internship, and several months’ pre-registration practice in a provincial health centre. Through a

competitive selection process influenced by family connections as well as academic achievement,

they had won places in the Insurance Scheme’s coveted residency programme. This was an elite

group with the potential to go far in the profession.

The written autobiographical accounts I later elicited from 33 medical students and professionals -

‘A critical event in my medical formation’ - referred to arbitrary disciplinary measures and public

humiliation dispensed by teachers (Rance 1999a:70-80; Rance 1999b:6), practices frequently noted

in studies of medical education (Wolf et al. 1991; Harth et al. 1992; Lebenthal et al. 1996).

Residents took their in turn in exercising authority – sometimes abusively – over interns rotating

through hospital departments. Within this regime, residents were conceded no right to complain

about gruelling shifts and the harsh conditions of their apprenticeship. Nearing the promised land,

they were long-suffering pilgrims: ‘los sufridos’, as resident Dr. Luna ironically commented in a

Maternity Hospital dossier discussion.33

My use of a religious metaphor carries echoes from my notes on a telephone conversation in 1998

with Maternity Hospital director Dr. Harb, a gynaecologist-obstetrician with over thirty years’

professional experience. When I mentioned my finding of systematic exclusion of

‘supernumeraries’ from the first year of medical studies onwards, Dr. Harb defended this practice

as indicative of a healthy culture of competitiveness, part of the professional mystique, a rite of

passage which every (paradigmatically masculine) medical student had to face: ‘[H]e has to pay his

dues. If that’s what he wants, it’ll cost him dear! He has to pass through many tests. It’s like an

initiation ritual. Like in some religious sects, in freemasonry... you have to pass through water,

through fire... you have to pass through narrow gates.’

32 ‘[A]ttendings must both explain their failures – that is, they must neutralize or divest failures of their negative meanings – and they must also make their successes highly visible.’ (Bosk 1979:114) 33 Transcript GPR.2:5, 4/8/98.


15

I carried out the dossier exercise with a group of one male and three female residents, and with a

pair (one woman and one man), all struggling to pass through the last narrow gate leading to their

qualification as specialists. In sessions lasting under an hour, squeezed into hectic duty schedules in

the Maternity Hospital, these six residents, like their junior colleagues, raised issues of humane

treatment, consideration for patients’ needs, medical ethics, and professional responsibility. They

called for uniting ‘practical’ and ‘sentimental’ elements in medicine. Two new issues emerged at

this level. One was residents’ exploitation as a permanently exhausted work force, named by Dr.

Luna (Dr. LL) as ‘los sufridos’ (the sufferers). The other was a demand for order, and hegemonic

status of one correct medical criterion:

Resident Dr. Luna: [6] I think that he:re [‘] [.] work teams should be formed. [1] In this 1

case the social worker should speak first with the doctor. [.] Before 2

giving any criterion [2] Because the social worker [1] kno:ws about 3

her:- about her: [1] about her profession, [.] but she doesn’t know 4

about medicine! [1] so:- [1] everyone [.] should: [2] have just on:e 5

language. [2] And give that to a patient. [.] That’s why it’s not 6

appropriate let’s say, [‘] for on:e doctor to give his version, and 7

another a different one! [‘] The one who comes out confused is 8

the:- the patient herself, who received two different pieces of 9

information. [‘’] That’s why [.] criteria of service should be 10

handled![.] And not personal criteria. [1] Because many times, they 11

get- it leads: to confusion afterwards. [2] I think that from this [.] it 12

has to be concluded that:: [2] no-one understands anyone else, and 13

that everyone has their own version [.] 14

♀Resident: [[laughs]] 15

Resident Dr. Luna: that suits them! [.] [[laughs]16


16

Dr. Luna, like his peers, argued for the primacy of ‘just one language’: the medical criterion, to be

received by other staff and transmitted to the patient (lines 5-6). In line with doctors’ frequent

exclusion of paramedical staff from the category of professionals,34 Dr. Luna’s bid for medical

hegemony35 was achieved by shedding doubt - with repeated hesitations and pauses (lines 3-5) - on

the professional status of social work. Dr. Luna called on SWOD, the Saving Woman Device, to

argue for compliance with medical authority for the patient’s good so that she would not come out

‘confused’ (lines 6-10). He ended on an ironic note, provoking a laugh from his female colleague,

as he linked the notion of plural consciousnesses, ‘each with his own world’ (Bakhtin 1984:6), to

the pragmatic observation that everyone pursued their own convenience by adhering to a particular

version (lines 12-14).

10.2.4 Obstetricians: ‘Although you insist it’s the same patient’

As I have shown in this chapter and the two that precede it, I developed the dossier method with the

aim of jolting doctors to reflection about alternatives to medical discourse.36 Through my selection

of texts in ‘One Woman, Five Stories’, I juxtaposed different dimensions and meanings of Mrs.

Mayta’s pregnancy interruption: the nurse’s notes on foetal expulsion, gynaecologist Dr. Gonzáles’

clinical explanation, resident Dr. Losada’s reflections on its religious significance, Mrs. Mayta’s

account of the baby’s baptism and burial, and social worker Irma Illanes’ justification in terms of

the family’s economic situation.

This symmetrical presentation constituted a radical assault on the hegemony of doctors’ discourse.

Its subversive effect was signalled by medical teachers who demanded a return to the truth status of

one, correct version of the event: their own, as represented by gynaecologist Dr. Gonzáles. The

vehemence with which they asserted this position conjures up the spectre of a counter-argument

(Billig 1988:19-24), the postmodern challenge to expert knowledge:

34 In a recorded group discussion, Víctor, an intern, interpreted the dossier as expressing ‘a total discrepancy between: [‘’] [1] four- [1] two professionals, [1] the woman herself, [3] and: inoperativeness [2] on the part of the medical resident’ (Transcript GPIN.2:2, 13/8/98). 35 ‘[H]egemony does not imply a dominant, or even necessarily existent, pattern of behaviour. The hegemonic ideal does not imply conformity of behaviour, but does imply the suppression, or de-legitimizing, of other models’. (Saetnan 1995:183 n.9 citing Lie 1995) 36 The dossier discussions were ostensibly aimed at stimulating what Woolgar terms ‘benign introspection. This kind of reflexivity – perhaps more accurately designated “reflection” – entails loose injunctions to “think about what we are doing”’ (Woolgar 1988:22, italics in the original). This innocuous proposal masked my far from benign intent to provoke ‘subversive confusion’, by presenting a proliferation of discourses (Butler 1990:33-34), whose symmetrical juxtaposition implicitly jolted medical discourse off a pedestal of privilege. See the final footnote of 1.2.2, ‘Intellectual auto/biography: Letting go’, in Chapter 1, Doing Abortion.


17

[I]f we think in terms of ontological politics, then information is no longer given – to

anyone. The stories professionals might tell have lost their self-evidence. And what is

more, it is not only the representations of reality in information circulating as words and

images that have become contestable, but also the very material shaping of reality in

diagnosis, interventions and research practices. (Mol 1999:85-86, italics in the original)

It was at the highest professional level that I encountered most resistance to the dossier method.

The insistence on one correct, medical version was most pronounced among the specialists who

participated in the exercise. These were two pairs of male obstetricians whom Maternity Hospital

director Dr. Harb designated to collaborate with me on different days, in brief encounters snatched

from on-duty hours. (Although these doctors were specialists in gynaecology and obstetrics, I name

them here as obstetricians because it was in that professional capacity that they worked in the

Maternity Hospital.) In each case, a senior doctor was accompanied by a younger colleague. I took

notes at the time, since neither pair granted me permission to record their comments.37

In the following excerpt from my fieldnotes on the first session, the younger doctor, Dr. Quisbert

(Dr. QQ), joined the session after his senior colleague, Dr. Rojas (Dr. RR), had already spoken:

37 Appendix 10 contains the bilingual transcript of the second session, a dossier discussion with obstetricians Dr. Maidana (Dr. MM) and his junior colleague, Dr. Navia (Dr. NN).


18

Transcript A:

(14h03. I ask for Dr. Quisbert to be called in, although Dr. Rojas does not consider this to

be necessary: he already spoke in both of their names, it seems).

Dr. QQ: It’s not comprehensible. It seems there’s no relation. For the tumour, it

wasn’t necessary to operate. It can’t be properly understood. What the

social worker says is the least relevant – it seems she hasn’t understood –

because she’s talking about her problems – not about the current situation.

The resident’s problem is out of place – because he talks about Good

Friday.

SR: Why do you say that the social worker’s part has nothing to do with it?

Dr. QQ: She’s not talking about the current problem, of the moment. Why she had

to be operated on…

SR: How do you explain the differences?

Dr. QQ: It seems not to be the same situation. Although you insist it’s the same

patient. More information is lacking, more data. The resident – there’s no

relation between what he says, and the patient.

Dr. Quisbert’s categorical affirmations contrasted with the more exploratory, questioning

utterances made by undergraduate students and residents. I interpret his reiteration of ‘it seems’

(parece, in lines 3, 5, 13) as a gesture of courtesy – avoiding offensively direct negations of the

dossier evidence, and of the social worker’s capacity to understand the situation – rather than as a

preface to tentative suggestions (my own use of ‘parece’ in my notes transcribed in line 2 was

ironic rather than courteous). As well as observing the incomprehensibility, irrelevance and

incompleteness of the information provided (lines 3-5, 7, 10), Dr. Quisbert shed doubt on its

authenticity: ‘It seems not to be the same situation. Although you insist it’s the same patient’ (lines

13-14).

These responses refuted my supposition of the undeniability of my evidence, which I bolstered

with the rhetoric of detail to support witness category entitlement (Potter 1996:165). Given their

scepticism, did these specialists attribute any value at all to the dossier exercise? In a mood of some

exasperation, I put three leading questions in this vein to Dr. Rojas (Dr. RR) and Dr. Quisbert (Dr.

QQ). Dr. Rojas gave the following replies:


19

Transcript B

SR Is there any value in reading this sheet with the different stories? 1

Dr. RR: Of course. The most important thing is the contradiction which exists. 2

Although the gynaecologist doesn’t say if the foetus is alive or not – the 3

social worker’s version has nothing to do with it. It’s wrongly said! There’s 4

a lot of contradiction with the concept of the gynaecologist. [[Remaining 6 5

lines of Dr. Rojas’ intervention omitted in this excerpt.]] 6

SR: What conclusion do you draw from the differences between the five 7

stories? 8

Dr. RR: There may be different criteria, but they have to arrive at just one 9

conclusion, for the benefit of the patient, and her baby. The criterion has to 10

be just one. 11

SR: Is the exercise of any use? 12

Dr. RR: Yes – as a mental exercise – so that they have a criterion, for 13

discrimination of different concepts.14

As this discussion shows, the dossier was mutually understood to be a didactic instrument: both the

obstetricians and I took it as imparting a lesson to others. In my terms, it served for medical

professionals to relativise the authority and unity of their own discourse. For Dr. Rojas (Dr. RR), a

member of my prime target audience, it served to teach residents to discriminate between correct

and incorrect medical criteria when discussing a clinical case.

10.3 Negotiating Professional Boundaries

In my first recorded interview with resident Dr. Losada about Mrs. Mayta’s pregnancy interruption,

he shifted among technical, normative and pragmatic repertoires. For the dossier, I selected a

similarly three-voiced narrative indicating tensions between his religious convictions, professional

duty, and personal feelings.

When discussing Mrs. Mayta’s case on the ward, Insurance Hospital gynaecologists rarely deviated

from the technical repertoire. For the gynaecologist’s dossier narrative, I also chose a text in Dr.

Gonzales’ technical voice. In the dossier discussions, specialists judged that this was the correct

register for alluding to such a matter, and that it should be unanimously adopted by medical and

paramedical staff. They categorised Dr. Losada’s personal reflections as unscientific. These


20

judgments suggest a medical code for appropriateness of voice to safeguard professionalism, which

I here attempt to decipher.

In the Maternity Hospital dossier discussion between the first pair of obstetricians (Transcript A,

above), Dr. Quisbert (Dr. QQ) categorised the resident’s Good Friday revelation38 as his personal

problem, as being ‘out of place’ (line 7), and as bearing no relation to the patient (lines 14-15).

These criticisms indicate Dr. Quisbert’s contingent definition of matters relevant to a clinical case.

In each of the seven groups to whom I presented the dossier, one or more participants observed that

the resident was not speaking in a professionally appropriate way.39 Before obstetrician Dr.

Quisbert joined the discussion, his older colleague, Dr. Rojas, had said: ‘The resident’s concept is

philosophical. He hasn’t got a medical criterion – it’s more personal’.40

Two weeks later, I repeated the exercise with a second pair of Maternity Hospital obstetricians, Dr.

Maidana and Dr. Navia. Dr. Maidana, the senior of the two, declared a similar position to that

voiced above by his professional peer, Dr. Rojas:

Dr. Maidana: The resident does not give an explanation of a scientific type, not even

gynaecological. It seems more an interview that is very sentimental, more

from the moral and religious point of view – not scientific. (The interview)

does not seem as if it were done in a hospital, (but) by chance, in any place.

A resident in the third year has the capacity to be able to give correct

explanations in a scientific form – he talks rather in a religious form. It’s a

counter-position. In medicine, we do not take much account of religious

aspects. It has to be of a scientific nature.41

The Maternity Hospital obstetricians postulated a division between a legitimately medical point of

view – patient or case-focused, scientific, gynaecological – and a personal one, irrelevant to a

professional discussion, in which a doctor referred to a problem of his own from a philosophical,

sentimental or religious stance. While taking note of these in vivo codes (Strauss 1987:33-34), the 38 See 9.2, ‘A Dossier of Life and Death’ and 9.4, ‘Backstage Emotions’ in Chapter 9, One Woman, Five Stories. 39 In the first-years’ session, one male participant supported the idea of a medical/religious dichotomy, and another disagreed: ‘I think not: [1] I think it should be more between the medical and the humane, because:- for- what are we going to put religion in? [‘] More, it would be medical and humane. [4] Nothing more’ (Translated excerpt of Transcript GP1.1:2, 19/5/98). 40 Translated excerpt of Transcript AGD.1:4, notes made at the time in Field Notebook 12, 5/8/98. 41 Translated excerpt of Transcript AGD.2:3, jottings made at the time in Field Notebook 13, 18/8/98. See Appendix 10 for the bilingual transcript of field jottings. Comparison between the Appendix text and the excerpt cited on this page provide an indication of minimal editorial changes made when citing jottings in the thesis narrative.


21

exclusion of moral discourse from medical education and practice was not a constant in my data: I

found that scientific and moral elements were both foundational to the professional ethos.

As an alternative to situating the ‘voice of the lifeworld’ (Mishler 1984) outside the boundaries of

medical discourse, the ‘voice of medicine’ can be deconstructed to allow for the incorporation of a

personal repertoire. Roberts and Sarangi include a ‘personal experience mode’ – informal, moral,

highlighting the rhetoric of lay accounts – as one of three modes of talk in medical settings

(Roberts and Sarangi 1999:486). Within doctors’ three interpretative repertoires, I included a

pragmatic voice: a personal, confessional style of expression alluding to the speaker’s feelings, and

to problems in the negotiation of everyday contingencies.42

Proposals to extend the boundaries of professional discourse are substantiated in a classic Peruvian

text still used in Latin American medical schools, that argues for doctors’ alternation between

scientific and moral modes of understanding. In The Doctor, Medicine and the Soul, humanist

essayist Honorio Delgado ([1952]1992) holds that the scientific basis of medical formation allows

doctors to ‘forestall imaginative deviations’ in verifying and discarding hypotheses. However, a

scientific approach is insufficient for physicians to ‘apprehend the concrete and singular reality’

offered by each patient, and to guide their own moral conduct. Doctors’ contact with the suffering

of others constitutes a ‘school of moral perfection’, refining their understanding through

‘sentiments which are both sound and superior’, ‘of greater depth and significance than those of the

profane’ (Delgado 1992:26-31).43

Medical specialists in my study reproduced these complementary constructions of their profession,

using ‘Changing Voices’ in different situations. Doctors were permitted to make emotionally

charged declarations of moral convictions – speaking individually or collectively - so long as these

did not compromise the profession’s public standing as law-abiding, and obedient to Catholic

doctrine. Examples of legitimised personal expression appear in the interview with State Hospital

director Dr. Antunes cited at the start of Chapter 1.44 In the latter part of that interview, Dr. Antunes

used the first person singular and addressed me in the informal voice, tú, to refer to the

pragmatically ‘delicate matter’ of discriminating between women hospitalised with spontaneous or

induced abortions. He later reverted to the first person plural to vehemently express a normative

position, negating institutional practice of abortion and opposing its legalisation. He qualified this

42 See 7.1, ‘Origins of an Interpretative Application’ and Fig. 7.2, ‘Doctors’ Three Interpretative Repertoires’, in Chapter 7, Changing Voices. 43 Profano: profane, secular. Used in Hispanic medical discourse to differentiate lay people from doctors. 44 See introductory section of Chapter 1, Doing Abortion, and Appendix 1 for complete text of the interview with Dr. Antunes.


22

with SWOD rhetoric, arguing for compassionate medical care for women with infected abortions -

‘we can’t leave her alone, and we treat them’ – and assuming a professional obligation ‘to attend to

our people’.

Doctors’ principled objections in the dossier discussions, rather than targeting resident Dr.

Losada’s confession of personal values per se, were directed towards his transgressive self-

revelation that put the profession’s reputation at risk. I interpret doctors’ location of the resident’s

‘problem’ outside medical boundaries primarily as a move to censor his declared infringement of

Catholic doctrine prohibiting abortion. When a woman-decided induced abortion was discussed by

doctors in a public transcript (Scott’s 1990:26),45 a normative register was called for.46 When the

topic was a medically-decided pregnancy interruption, public discourse was to remain technical. By

incorporating Dr. Losada’s confessional account within the dossier, I made a displacement in the

language game (Lyotard 1984:10) that upset tacitly established medical order. A similar reaction of

censure might have been provoked by publicly presenting doctors’ discussions concerning

(illegally) induced abortions in terms of their technical quality.47

The dossier discussions with specialists served to clarify three areas in which my feminist, pro-

choice position conflicted with their collegiate one: the assertion of one medical opinion as

hegemonic; the exclusion of personal, ‘sentimental’ expressions from professional discourse; and

the denial of hospital practice of therapeutic abortion. This last-mentioned position was declared by

Dr. Navia, the younger obstetrician in the second session: ‘It doesn’t seem to me that a hospital

would accept the interruption of a pregnancy. In all hospitals in Bolivia, human life has to be

protected. It’s the first time I hear there’s an interruption’.48 The Maternity Hospital obstetricians

performed professionalism not only by affirming the authority of one medical criterion, but also by

voicing scepticism or outright rejection of the dossier’s textual evidence.

Comparing interpretations of the dossier across four levels of professional formation, I identified a

progressive narrowing of medical criteria concerning valid voices and truths in a critical hospital

event. My agenda of ‘cutting medicine down to size’49 proved feasible with undergraduates, who

performed as willing audiences prepared to consider alternatives to professional discourse. ‘Real’

doctors, however, rejected the dossier’s location of medical narratives on the same plane as

45 See 9.4, ‘Backstage Emotions’, in Chapter 9, One Woman, Five Stories. 46 See 1.7.1, ‘In Other Words’, in Chapter 1, Doing Abortion. 47 Technical aspects of induced abortion were discussed by doctors in Bolivia, but in hidden transcripts (Scott 1990:26), such as those among members and allies of a clandestine network of medical practitioners trained to provide high quality, low-cost abortion services. 48 Translated excerpt of Transcript AGD.2, pp. 2-6, notes taken at the time, 18/8/98. 49 See 1.8, ‘Researching… What?’ in Chapter 1, Doing Abortion.


23

paramedical and ‘lay’ accounts. Thus, meanings escaped prescription, and my authorial control was

effectively undermined. This finding confirmed an effect of Denzin’s ‘Storied, Performance

Approach to Narrative’, cited at the end of the Introduction to this thesis:

This approach embraces experimental, experiential and critical readings that are always

incomplete, personal, self-reflexive and resistant to totalizing theories. It understands that

readers and writers are coproducers of the text that is being written and read. This

understanding requires a move away from (...) ‘scientific’ postpositivist forms of narrative

enquiry (...). A text’s meaning is best given in coperformances, when audiences and

readers-as-performers interact in and over the same text. This messy approach

conceptualizes audiences (and readers) as processes that outlast any given media event (see

Fiske, 1994, p. 196). (Denzin 1997:246-247)

Had I carried out further sessions with first-years who expressed interest in the exercise, I might

have over-estimated the scope of the dossier method’s potential. Critical responses from higher

levels led me to question its wider applicability as a sociological contribution to medical education

(Arsenau 1995; Coombs et al. 1990). I concluded the exercise with heightened awareness of

difference between my disciplinary approach and that of the profession I studied.

10.4 Never-ending stories

At the time of writing this chapter, a political battle broke out between the UK Labour government

and the Conservative opposition, sparked by the revelation of ‘hospital dramas’ concerning a 94-

year-old woman’s treatment in an emergency service.50 Media debates addressed several issues

broached in the story dossier discussions: conflicting versions of an event, the significance of one

woman’s experience, the status of stories as fact or fiction, confidentiality, privacy and public

exposure, technical and humane aspects of health care, pressures on health workers, use of

‘anecdotal evidence’, and different kinds of storytelling.

‘Never-ending stories’ was the title given to a Conservative MP’s critique of the exploitation of

individual stories to orchestrate political attacks (Guardian 24/1/02). In the same issue of The

Guardian, a journalistic contribution - ‘Rival claims: the Rose Addis case’ - set out the versions of

key actors in the event with no further comment. This piece used a method similar to the story

50 See the Guardian Unlimited Webpage for references to the Rose Addis case from January 24th 2002.


24

dossier, with direct quotes from the patient’s daughter, a hospital executive, and a Downing Street

spokesman (Guardian 24/1/02).

The question ‘Which story is the true one?’, posed repeatedly in the Medical School discussions

and in the Rose Addis debates, tends to accentuate entrenched positions that defend only one voice

as valid. I would now be inclined to introduce future dossier discussions by outlining some

alternative interpretative frameworks. Accounts are not necessarily ‘rival’, not every story is a ‘war

of words’ (Guardian 27/1/02), and the ‘yarns’ we spin (Guardian 26/1/02) may tangle or

interweave in unpredictable ways.

Changing Voices Chapter 11. Contrariwise and Otherwise

25

CHAPTER 11. CONTRARIWISE AND OTHERWISE

Bertha:But I am trying to explain to you why the Doctor explained it that way – it seems 1 that you don’t understand! 2

SR: I understand that this forms part of his model. But you in medicine learn a type of 3 language, a terminology, and to say ‘That’s how it is’. In sociology, we learn to 4 question the terms and to say: ‘Why would it be called like that? How could it be 5 called otherwise?’. It’s not a destructive thing – but of curiosity, of examining how 6 reality is constructed in different ways. 7

B: But you are researching among us, among the doctors! And you’re learning how 8 we explain things. 9

SR: Yes, but I’m more interested in the negotiation between you and other people – 10 like the users of the services (I don’t say ‘patients’ because that emphasises 11 submission, dependency and a lesser hierarchy faced with medical power) – try to 12 validate their version of reality – in the interaction – what happens and who 13 succeeds in validating their version of the facts. I could do this same work in a 14 fishery, a beauty salon or a restaurant – what interests me is human interaction and 15 the management of power relations between people of different social groups. 16

B: But you have to see that the patients almost always enlarge or diminish the 17 condition they have. They do not tell you the truth. 18

SR: That supposes that there is a ‘condition’ out there that is objectively demonstrable. 19 That any person can recognise as true. In sociology we do not give greater 20 hierarchy to that medical version of the facts. We consider the knowledge of the 21 user as equal to that of the doctor, in status. 22

B: (--- ?) 23 SR: (saying goodbye) – I hope you do not get totally disgusted with sociology! 24


26

In this final chapter, I draw some conclusions regarding the methods and effects of my research, the

contribution of my thesis to medical sociology, and the potential for practising sociology with

medicine (Bury 1986:165 citing Horobin 1985;1 Llovet and Ramos 1995:51). The seven-year thesis

exploration confronted me with differences, not just in medicine (Berg and Mol [eds.] 1998), but

also in the gamut of possible relations – contrariwise and otherwise2 - between the two disciplines.

11.1 ‘It seems that you don´t understand!’

The introductory transcript is of notes I wrote after a conversation in 1998 with Bertha Bastos (B),

an intern I had met that year during my Medical School fieldwork. Having qualified as a doctor in

2001, Bertha figures as Dra. Bastos in Appendix 19, her personal account of medical education and

stages in formation. Here (as elsewhere in the thesis narrative) I call her Bertha, because we were

talking informally as friends, walking in the street.

In this concluding passage of our conversation, reconstructed in my notes,3 Bertha signalled my

incomprehension of her explanation concerning a legal medicine class she had invited me to

observe that morning: ‘[I]t seems that you don´t understand!’ (lines 1-2). I contrasted sociological

and medical approaches to defining terms and constructing reality (lines 3-7). Bertha alluded to my

research among doctors as requiring preferential attention to medical explanatory models (lines 8-

9). I replied that my interest lay in doctors’ negotiation with others in relations of power (which I

conceptualised at that time in poststructuralist terms). I located my exploration of ‘human

interaction’ in wider social frameworks, beyond the field of medicine (lines 10-16).

In the transcribed excerpt, my voice gained greater space than Bertha’s, a feature I have signalled at

other points in my thesis.4 I represented my sociological intervention as innocuously knowledge-

seeking rather than subversively transformative: ‘In sociology, we learn to question the terms and

to say: ‘Why would it be called like that? How could it be called otherwise?’. It’s not a destructive

thing – but of curiosity, of examining how reality is constructed in different ways’ (lines 6-7).

1 Although Bury (1986) cites Horobin 1985, he does not provide the corresponding bibliographic reference. I have been unable to locate the text mentioned, but my search indicates that DF Horrobin may be the author alluded to. 2 ‘“I know what you’re thinking about,” said Tweedledum: “but it isn’t so, nohow.” “Contrariwise,” continued Tweedledee, “if it was so, it might be; and if it were so, it would be; but as it isn’t, it ain’t. That’s logic”’. (Lewis Carroll [1872] 1962:235, Through the Looking Glass) 3 Notes made in Field Notebook 11 after the conversation, 16/5/98. See Appendix 11 for complete text. 4 See the introductory section of Chapter 4, White on White.


27

Significantly, I could not recall Bertha’s last intervention, and gave myself the final word in my

version of the conversation.

Rather than using the adversary method (Moulton 1989) 5 to prove points against others, I now seek

dialogue with the authors with whom I find most affinity at this ending-point in my thesis. I

acknowledge contributions gleaned from their work, and point out some differences in the

approach I evolved. These comments are located within a framework putting epistemological and

methodological alternation before allegiance to fixed notions of self, theory or method.

11.2 Strangeness and the Author’s Vision

In my selective application of grounded theory methodology, the in vivo codes (Strauss 1987:33-

34) of research subjects received attention as being remarkable to the researcher, a gringa

sociologist who was granted access to Bolivian hospitals and medical schools over a period of two

years. The dimensions of abortion talk addressed in each chapter emerged from my interrogation of

data, as I explicitly or implicitly contrasted what I found with what could or should have been there

(Atkinson 1990:162).6 In this sense, the authorial narrative of knowledge-construction is

inseparable from the actors, actants and issues represented. Foregrounding of the author’s vision,

rather than of the topics and contexts named by those studied (Schegloff 1997), is characteristic of

auto/biographical method (Stanley 1992; 1996), critical autobiography (Jackson 1990; Church

1995), and some cultural studies of health and illness (Stacey 1997).

Unlike the last four authors referenced, I carried out fieldwork as ethnic as well as professional

outsider to my research settings. My strangeness was noted by others in research encounters,7 and I

also drew attention to strangeness encountered from my perspective (Atkinson 1984:169-172). I

fed these impressions back to doctors studied, and to wider audiences of health sector

professionals. Why did hospital doctors discriminate between abortions ‘done’ by women, and

pregnancy interruptions (anonymously) performed for therapeutic reasons? How did the white coat

5‘The aim of the Adversary Method (...) is to show that the other party is wrong. (...) The Adversary Paradigm prevents us from seeing that systems of ideas that are not directed to an adversary may be worth studying and developing, and that adversarial reasoning may be incorrect for nonadversarial contexts.’ (Moulton 1989:12,17, italics in the original) 6 ‘A great many ethnographic, “interpretative” accounts (…) trade on contrasts between what “everyone” (including the ethnographer, in many instances) regards as “normal”, and the supposedly unusual features of a given setting. Likewise, they may be organized in terms of a contrast between actual states of affairs, and what is portrayed as “reasonable” under similar circumstances.’ (Atkinson 1990:162) 7 See 4.1.1, ‘Profession and ethnicity’, in Chapter 4, White on White, and 7.3.1, ‘Partner, couple or pair?’ in Chapter 7, Changing Voices.


28

acquire significance as a metonym for the doctors’ protest march? How was my attempt to request

informed consent for observation interpreted by a woman consulting in a gynaecology outpatients

clinic? On what basis did medical teams on ward rounds come to present cases around beds that

were empty? Who ended up washing Manual Vacuum Aspiration (MVA) instruments, and how

was the ward rule ‘The one that uses it, cleans it’ established and broken? How could a

gynaecologist refute a woman’s account of pain in an MVA procedure? Why would specialists

reject multiple evidence of a therapeutic pregnancy interruption in a teaching hospital?

Recalling doctors’ responses to such interrogations, I cite an observation made by Dr. Salinas (Dr.

S), Insurance Hospital gynaecology ward chief, in the discussion following my ‘Changing Voices’

presentation to his staff:

Dr. S: Er: [.] to me the only thing that called my atte:ntion, [.] is tha::t [1] in all [.] the:- [.]

in all the interpreta:tion of the wo:rk, in the conclusions and recommendations, [2]

as if there were [.] a: [.] mm: [.] an idea [.] of fo:rcing [.] and saying, ‘Well, why do

you not accept abortion? [.] In an open form, all: of you.’ [.] But [.] unfortunately:,

[.] we have: [1] no:rms:, we have regula:tions. [2]8

Dr. Salinas adequately captured the spirit of my intervention in medical territory. In presenting

purportedly descriptive analyses of doctors’ talk, I implicitly demanded a transformation in their

approach to abortion. Dr. Salinas named his individual reading of my counter-discourse (Billig et

al. 1988:19-24), and argued against it in normative terms on behalf of an institutional collective.

My response through this thesis is to acknowledge my transformative agenda, to challenge the

italicised statement ‘we have: [1] no:rms:’, and to deconstruct the medical ‘we’ and the normative

voice as contingent and negotiable.

11.3 A Hybrid Methodology

The particular contribution of this thesis to the sociology of medicine lies in its deconstruction

(Derrida 1972 cited in Kamuf 1991:108; Cameron 1985:140; Elam 1994:5)9 of topic, method, and

8 See 7.4, ‘Doctors’ Reactions: A Perfect Fit’, in Chapter 7, Changing Voices, and Appendix 7 for the full bilingual transcript of the discussion. 9 See the Introduction for complementary definitions of deconstruction.


29

authorial voice (Atkinson 1990). While I often appealed implicitly to modernist metanarratives,10 I

set out not to know a priori what the context was (Schegloff 1997:171), not to predetermine the

dimensions of my topic, and not to bring a pre-given critical framework down on my data (van Dijk

1993).

In my Introduction, I mapped a discourse graphic with arrows pointing inwards towards a question-

mark incognito (Fig. 1). I focused chapters on discourse-arrows named by medical research

subjects, and by myself as author: not-doing, field, white coat, gringa, bed, syringe, pain, living

being, pareja, and ‘just one language’ - a gynaecological criterion - as valid to define a hospital

event. All these and more were ‘abortion’ in particular Bolivian medical settings and encounters.

None encapsulated the topic, and each spoke of ‘it’ in different terms. My question in the

Introduction – ‘Researching… What?’ - was provisionally answered by eleven chapter-vignettes, a

pattern of story-crystals displayed on the plane of a field mapped from within (Marcus 1994:567).

The arrow-dimensions of my topic, presented in successive chapters, were identified by mixing

ingredients from ethnography, ethnomethodology, discourse and narrative analysis. This produced

a methodological salad, a metaphor I appropriate in an affirmative rather than a derogatory sense

(Díaz Martínez 2002a:35).11 I initially applied methodological hybridity as demonstrated in Talk,

Work and Institutional Order: Discourse in Medical, Mediation and Management Settings (Sarangi

and Roberts [eds.] 1999), using a combination of ethnography and discourse analysis to generate

and triangulate data.12 The editors of this volume recommend using ‘feedback from medical

counterparts’ to supplement their analyses (Cicourel 1999). Hybridity and triangulation are

proposed as ways for researchers to obtain ‘extended data sets’ (Atkinson 1999) and ‘insider

medical knowledge’ to enrich their own interpretations (Sarangi and Roberts [eds.] 1999:70).

My application of methodological hybridity became broader and more exploratory than the modes

alluded to in the previous paragraph, and I came to use indefinite triangulation for dialogic rather

than purely cognitive ends (Cicourel 1974:195-204).13 I made changes in my methodological

approach in response to particular research situations and audience-readings. I found that

interpretative strategies that furthered my understanding or political agenda were differently 10 See 1.4, ‘Doing “Abortion In Bolivia”’, in Chapter 1, Doing Abortion: ‘[W]hat were absolutes or universalities under modernism become particular positions under postmodernism; shorn of their automatic authority but still active’ (Jordan 1997:496). 11 ‘The incorporation of methods and findings originating in different perspectives does not imply making “methodological salads”. It is possible to respect the original identity of each perspective and at the same time, to maintain a critical, integrated vision of the social order of the clinical institutions that allow one to see and understand how the doctor-patient relationship functions (Miller, 1997).’ (Díaz Martínez 2002a:35) 12 Contributors to Section 1, ‘Medical practices and health care delivery’, are Atkinson, Erickson, Cook-Gumperz and Messerman, and Cicourel. Contributors to Section 3, ‘Methodological debates’, are Silverman, Hak, Gumperz, and Roberts and Sarangi. (Sarangi and Roberts [eds.] 1999: 61-224, 389-503) 13 See 2.4, ‘Data Analysis and Triangulation’, in Chapter 2, Mapping the Field.


30

received by audiences that were critical, and those that were defensive of the medical profession.

My relations with doctors became less instrumentally focused, and more open to negotiated

interaction in medical territory (Rance 2000b).14 I moved from sharing transcripts with research

collaborators, to discussing preliminary findings, and organising discussion exercises (Rance

1999a; 1999b). The final object of my inquiry was not a truth ‘out there’ to access, but the process

and effects of mutually constitutive, trans-disciplinary performances.

I gradually moved from an empiricist discourse approach towards a literary critical perspective

focusing on the rhetorical production of sociological accounts, starting with my own (Atkinson

1990:10-34). The exercise of transposing transcript notations in translation involved a detailed re-

reading of selected data from this critically reflexive perspective. This led me to analyse my

interventions in the early interviews as influenced by the poststructuralist paradigm that shaped my

initial thesis proposal. Despite my declared intention to frame interview questions with reference to

research subjects’ language as registered in observation, I often introduced my own theoretical

categories which were then appropriated by interview subjects in their replies. There were conflicts

and ruptures between my ‘ethical’ pursuit of dialogue and transparency about my interests and

goals, the effort to produce objective analysis of medical discourse, and my action-research agenda

of provoking doctors’ reflexive criticism of their own language and practice.15

What did I gain from combining – eclectically, partially, subjectively – elements of different

paradigms in my research? First, a respect for the principle of symmetry (Potter and Wetherell

1987), the base line of methodological relativism (Collins 1983), that allows talk to be heard and

mapped, at least initially, without regard for truth or falsity. Grounded theory, ethnomethodology

and conversation analysis intensified my practice of registering and citing detail, not just for

‘witness category entitlement’ (Potter 1996:165-166), but also to substantiate the construction of

meaning in situated encounters. I learned to take others’ talk seriously as argumentation (Billig

1999), and not to reify my own discourse, in similarly understanding it as persuasive rhetoric

(Atkinson 1990:83).

A principle I gleaned from postmodernism was the validity of superficiality: mapping, navigation,

horizontal browsing, attention to relations and effects, the sufficiency of the flat planes of page,

screen, text. I spread my research thin, mapping a wide field without digging thoroughly into any

point on the surface. This lateral mode of exploration can be contrasted with excavating endeavours

14 In October 2000, in a Buenos Aires seminar on ‘Complementation of Medical and Social Sciences’, I presented a paper whose title translates as ‘Improving the quality of postabortion care: Strategies for sociological intervention in medical territory’(Rance 2002). 15 See the transcript in Appendix 3 for examples of such conflicts in a recorded interview with Dr. Dávila.


31

that mistrust outward appearances and delve into the depths behind language, under the skull, in the

heart, underlying forces, unconscious motivations, profound feelings. Nevertheless, while

attempting to put the romantic rhetoric of emotional sociology on hold, I often naturalised inner

experience ‘to get the reader or the audience to “feel the passion” of the circumstance under

consideration’ (Gubrium and Holstein 1997:58-59).16

Drawing reflexive criticism into the thesis narrative (Woolgar 1988; Potter 1996:231), I struggled

with the search for an authorial voice. Like the doctors I studied, I used the ‘Changing Voices’ of

my thesis title to pursue effects with particular audiences, present or projected. I forged17 shifting

selves in the words and deeds of the moment, taking up the voice of an essentialised subject at

some points, and at others letting my personae float in imagined spaces between body and name.

In writing, I alternated between soft, emotionally expressive narratives, and hard, distancing

accounts using detailed citations and references to bolster facticity (Potter 1996:117). Through this

division, I reproduced ‘Gender and Science’ associations between empathy, subjectivity and

femininity on the one hand, and detachment, objectivity and masculinity on the other (Keller 1985).

I found that the rhetoric of discourse analysis achieved greater acceptance with medical

professionals, while that of ethnography appealed more to undergraduate medical students and

feminists. Some peer reviewers in the field of medical sociology found the auto/biographical thread

in my accounts superfluous, and distracting from my discourse analytic arguments. Without

declaring fixed loyalty to any one rhetorical mode, I took voice to be an artifact, forged in

interaction.

11.4 Ironic Use of Deadpan Understatement

Within an overarching bid for subjectivity, I sought to de-naturalise my narrative through the use of

reflexive criticism, a method that is ‘corrosive to all authoritative accounts, including that of the

current analyst and writer’ (Potter 1996:231-232). Such textual practices have been qualified as

insane (Craib 1997:10), ideologically irresponsible (Eagleton 1991:198), and dangerous from

different critical perspectives:

16 See for example 6.4, ‘Outing the Researcher’, in Chapter 6, Sociology of a Syringe, and 8.1, ‘Epiphany’, in Chapter 8, Managing Pain. 17 Forging carries associated meanings of fabrication, counterfeit, invention, and beating into shape (OED).


32

The danger of this approach, emphasized by some social analysts (for example, Parker,

1992), is that criticism may be blunted by the concern for a fully symmetrical management

of factual versions or by the turn to reflexivity. The rich and powerful will carry on

exploiting the poor and powerless while researchers, bewitched by reflexivity, explore their

textual navels (cf. Edwards et al., 1995). The reflexive worker’s response to this is that

one’s textual navel is an excellent start point for considering the constitution and

mystification of power. (Potter 1996:232)

While agreeing with Potter’s response, I suggest an alternative argument to counter warnings about

blunted criticism and complicity with exploitative systems. Sociologists of medicine – including

those committed to descriptive approaches - rarely abstain altogether from inferring criticism of

doctors’ discourse and practice, although their strategies are often oblique rather than direct.

Sudnow sets out to show the relevance of a sociological perspective in his classic study of the

social organisation of dying. He defines the sociological perspective as an objective one - an

ethnomethodological stance of impassive scrutiny - that does not specifically aim to perform

‘transformations on the object’ (Sudnow 1967:v, 9). Despite his claim to distanced appraisal,

Sudnow does make suggestions for addressing ‘prominent problems of interaction between

bereaved and nonbereaved persons’ in US society (Sudnow 1967:11).

In his narrative, Sudnow signals the problems he observed without resorting to evaluative

comment, or to an ethnographic rhetoric of strangeness (Atkinson 1990:113).18 His naming of

phenomena as ‘sociologically interesting’, ‘instructive’, ‘striking’, ‘significant’, ‘useful to

consider’, or ‘relevant to note’ (Sudnow 1967:35-53) often serves to convey a stoically controlled

reaction of bemused horror. One particularly grotesque incident is qualified by Sudnow as ‘a rather

unfortunate circumstance’: a nurse’s unwittingly callous act in exposing the corpse of an extremely

malformed, stillborn infant to the shocked ‘grandmother’ of the dead ‘baby’ (Sudnow 1967:84,

scare quotes in the original).

The rhetoric of deadpan understatement,19 used by Sudnow and other descriptive analysts, is a

pseudo-literal strategy carrying ironic, critical effect. My naming of this discourse contains its own

negation (Billig et al. 1988:19-24): to signal a facial or verbal expression as deadpan summons a

contrary rhetoric of engaged emotion as an appropriate mode for conveying something shocking or 18 Atkinson notes the achievement of ironic effect through the apparently detached ethnographic narrative of When Prophecy Fails (Festinger et al.1964): ‘There is no textual marking of the events as bizarre, incredible or out of the way. The narrator is only minimally present: a few phrases and terms are placed in quotation marks, and there is sparing use of evaluative comment’ (Atkinson 1990:113). 19 ‘Deadpan a., n., adv., & v. A. adj. Expressionless, impassive, unemotional, detached, impersonal. E20.’ (OED)


33

hilarious.20 Through the juxtaposition of negatively charged citations of data and dry authorial turns

of phrase, authors can implicitly appeal to readers’ assumed empathy with the medically

(mis)treated. In displaying the ‘bare facts’ of a clinical encounter, bolstered by titles and subtitles

drawn from in vivo codes, medical sociologists can achieve underhand ridicule of professional

behaviour, together with inference of the epistemic privilege of lay accounts.

11.4.1 ‘It’s all negative’

To illustrate use of this device, I reproduce the last of four vignettes incorporating data from a 1995

study that I presented to an international meeting on expanding postabortion care services (Rance

2000): 21

Figure 11.1

Ethnographic Vignette Illustrating Ironic Use of Deadpan Understatement

20 I noted my own use of this strategy in the first paragraph of 5.2.1, ‘Rectangular planes as sites of knowing’ (Chapter 5, The Empty Bed). I initially made a ‘deadpan’ citation from first-year student Ignacio’s account putting cadavers before teachers as elements that made him happy with the Medical School. I later qualified his phrase as a ‘delightful blooper’, to explicitly convey the hilarity it provoked in me, rather than ironically inferring ridicule of it (Freres Alvarez 1998). 21 Parras and Rance 1997 cited in Rance 2000a. Presentation to the AVSC/Ipas International Workshop: ‘Taking Postabortion Services to Scale’, Mombasa, 15-18 May 2000.

‘That’s our guarantee’

Mrs. Suxo (Mrs. SS), aged 29, is consulting with general practitioner Dr. Tapia (Dr. TT) in a peri-urban State health centre. The reason given for consulting is that she has had no period since an abortion two years previously. At that time, Mrs. Suxo had requested an IUD from this same provider. Dr. Tapia had told her to come back when her menstruation returned.

Dialogue during the 35-minute consultation:

Dr. TT: No menstruation?

Mrs. SS: No. But I had some bleeding after being hit.

Dr. TT: Anti-tetanus vaccine? Pap? [Does gynaecological examination].

You knew your belly was growing. Don’t wear a tight girdle, that’s why your

baby does not grow well. You’re 6 months pregnant. After that we’ll give

you an IUD.

Mrs. SS: Yes yes yes! That’s what I wanted. You told me to come back when I had

my period.

Dr. TT: That’s our guarantee. Otherwise, the baby comes out with the Copper T in its

hand.

Mrs. SS: It’s your fault. If I do not get my period, how am I supposed to know?


34

From its very title, ‘That’s our guarantee’, this vignette invited the audience to focus critically on

Dr. Tapia’s justification of his delay in inserting the IUD requested two years earlier by Mrs. Suxo

after an abortion, a medical act that led to another unwanted pregnancy. The opening notes on

context situated Mrs. Suxo as active instigator of two consultations with Dr. Tapia. The doctor’s

strategy of continuing with a chain of closed, clinical queries, taking no account of Mrs. Suxo’s

allusion to violence (with its agent deleted), proved disturbing to gender-aware health professionals

in the audience. Dr. Tapia’s warning about the baby coming out clutching an IUD22 invited ridicule

of a doctors’ appropriation of a ‘lay’ myth to justify withholding a contraceptive method . Mrs.

Suxo’s direct attribution of blame to Dr. Tapia for causing her already advanced pregnancy, in a

singularly assertive patient-to-doctor challenge,23 achieved resonance in this international meeting

on postabortion care services. Later in my presentation, I pointed to contrasts between international

protocols for postabortion care, and the treatment dispensed by Dr. Tapia.24 However, the act of

showing the vignette, in itself, elicited audience reactions of dismay, amusement, indignation, and

technically informed criticism.

Such indirect moves to provoke criticism may be well received in ‘anti-medicine’ circles (Osborne

1994), but they tend to raise the hackles of doctors and others defending the health systems alluded

to. The Bolivian delegation at the Mombasa meeting included representatives of Ipas (my former

employers), DFID (funders of the Ipas project), another US reproductive health agency, the

Ministry of Health, the Bolivian Society of Obstetrics and Gynaecology, and a national network of

health sector non-governmental organisations (NGOs). With the exception of the DFID

representative, who subsequently named me external evaluator of the Ipas project, my colleagues

on the country delegation were critical of my presentation in the session on Women’s Rights and

Needs. On the account of one NGO delegate, they saw it as letting down the side and giving

Bolivian postabortion care services a bad name.

22 In other versions of this much-cited myth, the baby is born with the IUD incrusted in its head. 23 In the Spanish original, Mrs. Suxo’s challenge to Dr. Tapia was still more forceful, since she used the second person singular, ‘tú’ mode of address, which slid from informality to rudeness: ‘Es tu culpa’ (It’s your fault). 24 ‘In each of these consultations, the provider had the opportunity to go on from diagnosing a pathology, to understanding aspects of the woman’s social situation, to offering appropriate support, and ultimately to preventing further damage to her health and wellbeing. This ideal situation did not occur in any of the four consultations. National policies on postabortion care, reflecting the spirit of the Cairo and Beijing consensus documents, were not carried into these medical encounters. (…) In Mrs. Suxo’s case, “family planning services (...) to avoid repeat abortions” had not been offered in her last consultation with the same provider when she explicitly requested them. Dr. Tapia had not complied with her request for an IUD, offered alternative contraception, or informed her about the risk of conception before her menstruation returned. This negligence led directly to another unwanted pregnancy. Dr. Tapia made no comment on Mrs. Suxo’s allusion to her partner’s violence. She was offered no further support.’ (Rance 2000:5-6)


35

This negative response echoed the reported comments of some doctors to a research presentation I

gave in the Medical School, incorporating ethnographic vignettes. To my query about her

colleagues’ reactions, Dra. Tania Tamayo, a public health specialist, replied:

They said, ‘It’s all negative’. You get to feel wounded! They think they’re the kings of

medicine... They feel they’re being alluded to! They don’t like other people getting in there

to say anything. They don’t accept other people. They expect everyone to say their career is

the greatest. There’s no-one above a doctor. It’s hard, if you don’t reach that moment of

self-criticism, to the point of saying: ‘What am I doing!’.25

Ethnographic vignettes achieve critical effect by appealing to audiences’ assumed values. They

serve to confirm prior notions of the already convinced, but prove inflammatory to sceptics or

members of professions alluded to in the texts. Whenever I presented such extracts of field data,

doctors demanded more contextual information, and objected to the selection of fragments of

conversation. They accused me of stereotyping their profession, and of not showing ‘nice provider’

examples to balance the ‘bad provider’ ones. They reacted defensively to the inference that one

encounter could represent an entire system: ‘So you’re saying that our whole quality of care

programme is a disaster!’.26 Taking these arguments into account, I conceded that the use of

‘exemplars’, while purporting to show what was possible within a health system at a given

moment, slid into inferences of representativity and generality that could not be sustained

(Atkinson 1990:84-92).

Trans-disciplinary dialogue is hampered by the scepticism that sociology transmits, an attitude that

‘can readily harden into a doctrinaire cynicism’ (Strong 1979:201). ‘There is an almost invariable

tendency to link analysis with devaluation and to take discovery as if it were always disclosure...

the grey mood and the unflattering anticipation are occupational afflictions of the searching

sociological mind’ (Strong 1979:201 citing Halmos 1973:293). Irony, a hallmark of the

sociological approach,27 makes deadpan understatement - criticism in the guise of ‘mere’

description - a far from innocent rhetoric. Notwithstanding my claim to research and write

25 Notes written at the time of a telephone conversation with Dra. Tania Tamayo, Field Notebook 16, 25/2/99. 26 Comment received from a male doctor following a presentation to an audience of health sector professionals (Rance 2001). 27 ‘Within sociology, irony is not confined to the ethnographic genre. Indeed, it has been argued that it is especially characteristic of sociology in general.’ (Atkinson 1990:158)


36

primarily for doctors, and my attempt to minimise the use of irony, I have appealed to this textual

convention at several points in my thesis.28

11.5 Alternation: from Epistemology to Strategy

I pointed above to doctors’ adverse reactions to the presentation of ethnographic vignettes that

through deadpan understatement, inferred ironic critique of medical practice. While effective for

preaching to the converted, this method proved inappropriate for promoting dialogue between

sociology and medicine.

In the course of my research, I experimented with two other forms of data analysis and

presentation: interpretative repertoires (‘Changing Voices’) and a story dossier (‘One Woman, Five

Voices’). In this section, rather than defending one of these methods as more valid than the other, I

shall suggest their alternating use as a form of sociological intervention in medical territory (Rance

2002). I now conceptualise alternation not only as an inevitable element in knowledge-

construction, as discussed in my first chapter (Collins and Yearley 1992:302),29 but also as a

methodological strategy for trans-disciplinary dialogue. To substantiate this proposal, I compare

doctors’ responses to my presentations of ‘Changing Voices’ and ‘One Woman, Five Stories’. I

draw some conclusions concerning different applications and effects of deconstruction, understood

as a practice that keeps ‘the act of naming and defining as a site of contestation’ (Elam 1994:5).

11.5.1 Deconstruction and reconstruction

From a sociological perspective, interpretative repertoires can be said to deconstruct medical

discourse on two levels. Firstly, they draw on fragments of text extracted from different

interactions. Secondly, they undo the notion of a unitary professional position and separate it into

three voices (technical, normative and pragmatic).

However, when I presented doctors with a descriptive analysis of their changing voices, they took

the three repertoires as reinforcing and reconstructing their discourse, hence their favourable

responses to the method. This analytic framework validated their discursive variations, and their

28 See for example 3.4.2, ‘Insight Into Medicine’, in Chapter 3, March of the White Coats, and 5.2, ‘Patients as Audio-Visual Aids’, in Chapter 5, The Empty Bed. 29 See 1.4.1, ‘Epistemological pluralism’, in Chapter 1, Doing Abortion.


37

capacity to adopt appropriate repertoires at different moments. It also provided them with a

defensive instrument to counter accusations of hypocrisy and ‘double morality’,30 frequently made

against doctors in Bolivia with reference to their contradictory statements about abortion. In this

sense, the use of repertoires promoted a notion of medical integrity, which I parody as ‘One

Doctor, Three Voices’.

In contrast, the story dossier sociologically reconstructs a critical event from different narratives.31

It incorporates extracts that crystallise the discourse of each actor, and juxtaposes them on one page

to map out a picture of the event. Nevertheless, analysing doctors’ negative reactions to this

artifice, I attribute their rejection to the effective deconstruction of their professional authority. The

dossier ignored the hegemonic status of medical knowledge and ‘cut it down to size’ – just as I set

out to do at the start of my research32 - placing the gynaecologist’s account on the same plane as

that of other, ‘less qualified’ actors. It had the offensive effect (Potter 1996:106-108) of relativising

and challenging medical knowledge.33 Moreover, the selection of one textual extract to typify the

discourse of each actor shrank and froze it into a unitary position. The gynaecologist was implicitly

stereotyped as (appropriately) technical, and the resident as (inappropriately) sentimental. The

dossier text-as-actant provoked doctors to assert binary difference between correct and incorrect

performances of professionality.

Weighing up the relative advantages and disadvantages of the two methods from the perspective of

my transformative agenda, I note that interpretative repertoires had the undesirable effect of

magnifying and validating medical knowledge. For this very reason, ‘Changing Voices’ was

enthusiastically appropriated by doctors. I conclude that this method can be used to promote

consensus with doctors regarding the variable and contingent nature of their declarations on

particular issues, including abortion.

The story dossier approach, on the other hand, achieved my desired goal of cutting medicine down

to size. In doing so, ‘One Woman, Five Voices’ needled doctors to annoyed reaction, because it

radically undermined their authority as experts. I conclude that this method can be productively

used to generate conflict with and within the medical profession, regarding contrasting versions of

critical events.

30 See 7.1, ‘Origins of an Interpretative Application’, in Chapter 7, Changing Voices. 31 I am indebted to Brian Torode’s observation of the deconstruction of medical discourse in interpretative repertoires, and the reconstruction of lifeworld discourse in the story dossier. Personal communication, 25/11/97. 32 See ‘Cutting Medicine Down To Size’ in the Introduction. 33 See Potter 1996:106-108 for a discussion of offensive and defensive rhetoric in fact construction.


38

Thus, rather than opting for one method or the other, I propose alternating between the two as a

transformative strategy. As a topical case in the Bolivian context, I take the example of therapeutic

abortion as an issue meriting further discussion with doctors. Obstetricians participating in dossier

exercises rejected textual evidence of its practice in teaching hospitals. At the time, I surmised that

the dossier method was not appropriate at the highest professional level. What strategy could I use

to counter their resistance?

Building on doctors’ appropriation of interpretative repertoires, a preliminary intervention would

be to fracture the assumed unity of medical discourse on abortion, through a new set of ‘Changing

Voices’ drawn from my data on therapeutic pregnancy interruption. Hospital practice of therapeutic

abortion would figure as a technical and pragmatic possibility. The normative voice – ‘[W]e DO

NOT [.] DO [.] ABORTION’34 and ‘We base ourselves on norms that are already written’35 –

would be removed from a position of unique validity.

Interpretative repertoires would thus be used as an explanatory formula to achieve some degree of

consensus on discursive variation, before turning to the potentially conflictive story dossier format.

Space could be opened to acknowledge the different voices of gynaecologist Dr. Gonzáles and

resident Dr. Losada, in a further discussion of the dossier on Mrs. Mayta’s therapeutic pregnancy

interruption. I propose this alternating method as a sociological contribution to trans-disciplinary

dialogue in a range of fields – medicine, nursing, social work, and many others - concerning

medical, paramedical and ‘lay’ discourse, and the relations between them.

11.6 Performing Consensus and Conflict

Writing about the Bolivian delegation in Mombasa (in 11.3, above) brought me memory flashes of

scenes linking me with these institutional actors and others, through fifteen years of involvement in

the field of reproductive health. As Gringa Boliviana – a nickname announcing the paradox of my

original and adopted nationalities36 - I have been afforded space and support to intervene in

groundbreaking areas of rights advocacy.

34 See transcript excerpt introducing Chapter 1, Doing Abortion. 35 Notes made in Field Notebook 13 at the time of a dossier discussion with Maternity Hospital obstetricians, 18/8/98. See Appendix 10 for the bilingual transcript of my notes. 36 See 4.1.2, ‘A joke on the gringuita’, in Chapter 4, White on White. I am indebted to my friend and mentor René Pereira Morató, former head of Bolivia’s National Population Council (CONAPO) where I worked from 1998 to 1991, for giving me my Gringa nickname, for providing me with my first opportunity to work with the Bolivian government, and for critically supporting my activities over the years.


39

11.6.1 The Gringa Boliviana story

Since my teenage years, I have ‘activated’37 with a number of organisations and networks

promoting rights-related causes. Soon after arriving in Bolivia in 1980, I joined a group producing

underground bulletins denouncing abuses of successive military dictatorships. In 1981 I joined the

feminist cell (Frente de Mujeres) of a left-wing party opposing those regimes. In 1988, as social

communicator with the National Population Council (CONAPO), a technical unit within the

Ministry of Planning, I organised debates on the then taboo issue of family planning.

In 1991 I was a co-founder of the National Committee for the Defence of Reproductive Rights. In

1993, I was a governmental delegate at preparatory events for the International Conference on

Population and Development (ICPD). In 1994 I set up the first of four regional Working Groups on

unwanted pregnancy and abortion. In that same year, I was a non-governmental delegate at the

Cairo ICPD.

In 1997 I participated in the organisation of the first national meeting on Masculinities. In 2000, I

joined national and international networks opposing the US Congress ‘Gag Rule’ which prohibited

recipients of USAID population funds from carrying out abortion-related activities. Later that year,

with a Bolivian advocacy collective, I took up sexual rights issues, supporting the cause of

transvestite citizenship in political and cultural events.

Throughout this process, I have developed a profile as researcher, university teacher, project

coordinator, and technical evaluator of postabortion care services. Although my critical

interventions have left some burnt bridges and spoiled relations, I maintain a niche as gringa

activist whose professional contributions are sought and acknowledged in various sectors.

I originally intended to keep this curriculum vitae out of the thesis, justifying my reticence on

several counts. First, I wanted my research to stand on its own merits, without summoning extra-

academic credentials to bolster the significance of my interventions. Secondly, I now read much of

my ostensibly transgressive reproductive rights activism in Foulcauldian terms, as collusive with

bio-power: population control with a female gendered face, the individual rights paradigm of the

Cairo Programme of Action (Hawkins 2002:70).38 Thirdly, in terms of empirical relevance, my

37 In Bolivia and other Hispanic contexts, activar, traditionally used as a transitive verb, has also been appropriated intransitively by activists to signify a mode of acting-up with transformative goals. 38 ‘A dominant perception is that the ICPD POA represents a radical break from neo-Malthusian population policy, in its assertion that programmes that are demographically driven and intended to act directly on fertility are inherently coercive and abusive of a woman’s right to choose the number and spacing of her


40

performances as activist rarely figured among features of topic and context named by participants

in the interactions I analysed. Nevertheless, I balanced these reservations about scene-setting39

against my supervisor’s suggestion that I tell the Gringa Boliviana story, to continue with the

torturous process of slow auto/biographical disclosure (Sharff 1982:119).40 I leave the preceding

paragraphs - a dynastic script (Hankiss 1981:205)41 in imagined inverted commas - as a prelude to

a discussion of conflict and consensus in research relations.

11.6.2 Conflict and transformative action

My story involves Ipas, the US-based NGO for which I did successive consultancies between 1993

and 1998, and whose Bolivian project I have evaluated since 2000 for DFID, the UK government

funder. In the period of my contract research, my status as Gringa Boliviana was a card dealt by all

players involved with varying effects. It often proved advantageous for Ipas, and for the Bolivian

government as project partner, to work with a consultant who had long-standing relations with a

range of institutional networks. At some moments, however, I used these relations to lever support

for interventions that conflicted with Ipas or governmental policy. As freewheeling gringa,42 I

alternately asserted my institutional affiliation, and promoted radical rights agendas with other

activists. This performance of autonomy provoked dilemmas confronting ethics and politics:

Ethics has to do with application of a system of moral principles to prevent harming or

wronging others, to promote the good, to be respectful and to be fair. Politics has to do with

the methods and strategies used to gain a position of power and control. Ethics and politics

are intertwined in sensitive research, especially that performed in community settings.

(Sieber 1993:14, my italics)

children (McIntosh and Finkle 1985:227). The International Women’s Health Coalition (IWHC) took the lead in formulating this feminist position in the lead up to ICPD. However, far from being anti-Malthusian, the policy position which seeks to provide a common ground for “multiple women’s voices”, effortlessly melds a quasi liberal-radical feminist agenda with the neo-Malthusian population orthodoxy.’ (Hawkins 2002:70) 39 See 6.2, ‘Scene-Setting: Too Much, Too Little?’, in Chapter 6, Sociology of a Syringe. 40 ‘“[S]low disclosure” – reminiscent of “slow torture”! Sets you up as having the whole story to disclose to your audience.’ (Barbara Bradby, comments on Chapter 6, 8/7/02) 41 ‘This account too can be analysed as the script of a ‘dynastic’ strategy in which my present, ‘good’ situation is a linear consequence of positive traditions.’ (1.2, ‘A Personal Abortion Story’, in Chapter 1, Doing Abortion) 42 Former allies turned critics of my freewheeling gringa performances have openly and covertly labelled me ‘maverick’, ‘Quixote’, ‘ruinous’, and ‘spoiled’.


41

In sensitive research (Renzetti and Lee [eds.] 1993) – indeed, in any kind of research - ethics and

politics may be messily tangled rather than harmoniously intertwined. In naming ‘community

settings’, Sieber refers somewhat euphemistically to locations marked by social inequality where

researchers have some advantages. In such contexts, by taking an ethical approach, researchers can

moderate their power-seeking urges in order to avoid harming research subjects, construed as

vulnerable (Salinas Mulder et al. 2000; Rance and Salinas 2001b:14-15). However, when

negotiating with sponsors, funders or gatekeepers who temporarily have the upper hand,

researchers may adopt a political stance, seeking to gain power and control. In these situations,

researchers’ strategic interests may conflict with sponsors’ notions of good, respect and fairness.

While relations with Ipas were generally smooth in the early years, I have alluded to some tensions

and arduous negotiations that developed with my former employers.43 Areas of conflict included

topics I chose to include in my 1997 research presentation and report; the change in methodology

adopted during that year; the obligation to predetermine numbers of interviews and levels of groups

addressed in my 1998 action-research in the Medical School; authorisation to present a dossier of

‘real stories’ on a polemical theme to students and teachers in that setting; and adverse reactions by

the Bolivia delegation to my presentation at the Ipas co-sponsored Mombasa meeting.

In political terms, I found it understandable that Ipas representatives should defend their

institutional interests. Using the same logic, as activist, consultant and researcher, I did not cede to

‘moral recriminations’ about promoting particular agendas. While recognising that ‘money does

not come free’ (Wenger 1987:5), I did not consider that s/he who paid the piper necessarily called

the tune. Ipas contracted me, but their project partners – the Ministry of Health and DFID –

supported my methods and disclosure of my findings.

Official restrictions on MVA use, and institutional barriers to studying the technology, were

removed sixteen months after I presented my 1997 research report. In January 1999, the Ministry

of Health approved MVA trials in two regional hospitals. In a February 1999 memorandum to Ipas,

I reiterated recommendations from my 1997 report concerning MVA, pain management and

anaesthesia, which were relevant to their new project. The Gender Vice-Ministry published my

1998 Medical School research report, incorporating the ‘One Woman, Five Stories’ story dossier,

and included it among books launched at an International Women’s Day event (Rance 1999a). A

1999 DFID evaluation qualified my Medical School research as one of the main unexpected

43 See 7.3, ‘Discussable and Taboo Topics’, in Chapter 7, Changing Voices; 10.1, ‘The Problematic Relationship’, in Chapter 10, Audiencing Hospital Stories; and 11.4, ‘Ironic Use of Deadpan Understatement’ (above) in this chapter.


42

successes of the Ipas project. In 2000, DFID contracted me as external evaluator of the project in

which I had formerly participated.

I cite these outcomes – this time using an ‘antithetical’ script of triumph over adversity (Hankiss

1981:205) - to indicate the potential for transformative action, weaving an uneasy path between

institutional politics and rights advocacy. In the next section, I continue with the theme of

consensus and conflict, and draw some conclusions about the tangled relations between personal

and professional agendas in the field of medicine.

11.6.3 ‘Why are people so nice?’44

One member of the Bolivian delegation in Mombasa (11.3, above) was Dr. Dávila, the

gynaecologist who had been my main research collaborator in the State Hospital three years earlier.

I contrast the account of conflict with fellow-delegates concerning my Mombasa presentation with

a harmonious portrayal of my relations with Dr. Dávila, taken from notes made during my 1997

fieldwork:

Dr. Dávila himself spoke Aymara and I had previously heard him expressing positions

defending indigenous culture and identity and condemning imperialist violations of

Bolivian women’s reproductive rights. In other observations I had seen him take an active

interest in references to Andean traditional medicine made by women consulting. His

approach to me as gringa researcher was simultaneously friendly and challenging,

supportive and critical. I felt comfortably equal with him, knowing he set me certain limits

but quickly opened spaces for my fieldwork wherever he could. We had a regular exchange

of literature, ideas and invitations to events of mutual interest.45

At other points in my fieldnotes, I alluded to the relative ease of my relations with Dr. Dávila and

with Dr. Gonzáles, his counterpart in the Insurance Hospital. I attributed this not just to

interpersonal affinity, but also to my careful negotiation of access, attention to research ethics, and

information sharing throughout fieldwork. I drew attention to certain incidents as testifying to

cordial and productive research relations: when Dr. Dávila summoned me to his students’

44 I borrow this subtitle from Payne’s analysis of sociologists’ representations of harmony in field settings (Payne 1995:30). 45 Excerpt from draft of Chapter 4, White on White, 2001.


43

presentation on abortion,46 when Dr. Gonzáles introduced me to residents visiting the Insurance

Hospital as ‘our sociologist companion’ (nuestra compañera socióloga),47 and when my friendship

with Bertha Bastos survived a heated discussion about medical versus ‘lay’ truths.48

Reflexive criticism (Potter 1996:231) leads me to look beyond this self-congratulatory rhetoric and

re-examine my constructions of people in the field as nice (Payne 1995:30). I return to my positive

scene-setting for the observation in Dr. Dávila’s outpatients clinic, cited in the penultimate

paragraph. Attributing such representations to ‘the incomer’s need to seek social support’, Payne

asks: ‘is it really credible that sociologists have this ability to get on with everybody?’ He invites

researchers to look sceptically at (self-)flattering portrayals of the ease with which they gained

access, people’s niceness towards them (and each other), and insiders’ acceptance of the outsider’s

presence (Payne 1995:30).

My construction of relations with Dr. Dávila as ‘comfortably equal’ lends itself to closer scrutiny. I

interrupt this ‘nice’ story with notes on his handling of another consultation at the end of the

morning surgery:

When I switched off the cassette recorder before leaving, he took on an authoritarian, even

aggressive tone with the next patient, a woman de pollera49 of over 50 who had come for a

cancer check and was lying on the gynaecological examination table. He threw questions at

her in a brusque manner and expressed prejudice and suppositions about her sexual and

reproductive life.50

Here, I am exploring something other than the notion of ‘real’ and ‘contrived’ selves as contingent

upon performance in social situations (Goffman 1959:254-255; 1997:l). I am looking instead at the

tendency for authors to produce favourable portrayals of research collaborators and their relations

with them, and at the discomfort that can ensue on both sides when idealised representations break

down. I take issue with authors whose complicity with the medical profession seems overly marked

(Bosk 1979), and also question the unremitting ‘doctor-bashing’ stance evidenced in some critical

exposés (Millman 1976). Nevertheless, at different moments I have adopted these positions and

other intermediate ones, within the gamut of possible relations – contrariwise and otherwise -

between sociology and medicine.

46 See the introductory section of Chapter 2, Mapping the Field. 47 Notes written at the time in Field Notebook 3, 16/4/97. 48 See Appendix 11 for transcript of notes on this conversation. 49 See 4.1.1, ‘Profession and ethnicity’, in Chapter 4, White on White. 50 Notes made at the time in Field Notebook 1, 10/12/96.


44

My pursuit of harmonious relations with Bolivian doctors collapsed dramatically four years after

my fieldwork ended. In 2001, I supported a 19-year-old niece’s complaint about medical

negligence surrounding her baby’s death during labour in a public hospital. The ensuing medical

audit implicated a former research collaborator, who was by then the hospital’s director.51 This

critical event jolted me back out of relativism and into anger and pursuit of justice. Between these

two stances wandered the limpho ghost52 of reciprocal loyalty to the doctor who for months had

allowed me to ‘track’ him through his daily rounds. Reverting to notions of misplaced trust

(Parsons 1951:435-453),53 I felt ‘betrayed’ at the hospital director’s failure to ensure that my niece

received some medical explanation about her baby’s death before leaving the hospital. I infer this

doctor’s own sense of betrayal from the words of another gynaecologist, who told me that

professional colleagues had commented: ‘If Susanna says she doesn´t want to do harm, why is she

distributing those letters of complaint like pamphlets?’. By that point, my former research

collaborator and I, no longer performing ‘niceness’, had located ourselves on opposite sides of the

provider/user fence.

At the epiphanic moment of the baby’s death and throughout the year that followed, the ‘partial

connections’ (Strathern 1991) among my roles collided, generating conflict with former allies. As

researcher, I continued to give presentations to medical audiences. As relative of a health service

user, I became embroiled in a lengthy audit process, taking the case with my niece to health

authorities, independent committees, pressure groups, and finally to the Ombudswoman (Defensora

51 ‘My (19 year old) niece L's baby died shortly before birth on Monday. She and her partner/classmate E had got pregnant in their last year of school, and despite all the problems, very much wanted the baby. L had gone for antenatal checks and had scans and all seemed well right up to a couple of days before the birth (9 months). Then on Friday she had a fall (slipped over at home) and went to the hospital (quite nice new adolescents' centre at the Women’s Hospital). Her woman doctor she liked a lot wasn't there and she didn't feel confident about seeing another doctor (having had negative experiences in the General Hospital and another State health centre). She went home and decided to go back on Monday. She went into labour at 3-4 a.m. Monday, was in the hospital by 7, the doctor who admitted her said he heard the baby's heartbeat, but an hour later it couldn't be heard. There was an excessive delay in getting her attended and a scan done and eventually she gave birth at 3 p.m. but the baby had been dead some hours (not clearly determined how many) before that. She is still in hospital, had two blood transfusions and is very upset and wants OUT because she can't stand hearing women in labour and seeing babies all around. I got the director of the hospital (one of whose projects I'm evaluating, and he is Dr. X, one of my main research collaborators…) to get in there right from the start - when J, L's mum, first phoned me on Monday at 11 a.m. and I went in - and to follow up what was happening. E and I went to see him yesterday but we haven't had a satisfactory explanation yet. They are not (being) clear about whether the baby was still alive when she entered hospital on Monday. The doctors wanted to do an autopsy but we said no. I am insisting on responsibility of the specialist doctor who was on duty, since the one who said he heard the heartbeat was in training and the director says he may have got it wrong. So... L may be out of hospital today, we will collect the baby from refrigeration, do a wake in the house, and soon after have the burial.’ (E-mail message from SR to Barbara Bradby, 22/2/01) 52 Limpho: unbaptised soul of an aborted foetus that inhabits a member of the aborting woman’s household. See footnote on the penultimate page of 9.2, ‘A Dossier of Life and Death’, in Chapter 9, One Woman, Five Stories. 53 See 7.6, ‘Interpreting Individual Contradictions’, in Chapter 7, Changing Voices.


45

del Pueblo). As consultant for DFID, I continued to evaluate postabortion care services, including

those in the hospital being audited.

In this episode and others, I found performances of consensus and conflict to be contingent, with no

fixed attitude on my part or on that of doctors. Divisions between sociology in, of and with

medicine seemed less and less clear. Many researchers are too heavily implicated in the use of

medical services to claim a clean distance from the profession. As individuals, they and their

families need doctors at certain moments. As health service users, they are apt to evaluate and

judge medical professionals. As sociologists, they aim to study them, and also influence their

discourse and practice (Strong 1979:203, 213). 54 These roles can cross and combine in messy

ways:

[A]lthough professional scepticism may account for a good deal of the distortion that

creeps into our analysis, there are other factors which are surely also present. One of these

is the fact that sociologists, as well as being students of medicine, are not infrequently its

patients as well. Given the natural importance to them of their own health and the

somewhat bureaucratic and impersonal nature of those medical services which are, these

days, available to the professional middle-class, may harbour distinctly personal grudges

against medicine. Such feelings are likely to be amplified where particular sociologists are

members of subordinate groups within our society or have chosen to act as their

representative. (Strong 1979:201)

11.7 Abortion: The Vanishing Topic

In acknowledging the partiality of my approach, what can I offer audiences seeking new

knowledge about abortion talk in Bolivian medical settings? In the course of my research, my focus

shifted from abortion per se to trans-disciplinary relations between sociology and medicine. The

theme of study became those relations, and the methods used to explore them. Just as Button

signalled the ‘vanishing technology’ as an effect of Actor Network Theory (Button 1993:23-24),55

to a certain extent I vanished abortion and exited at a point of radical indeterminacy.

54 ‘The collection by Davis A. and Horobin G. of personal accounts of their illnesses by medical sociologists (Medical Encounters. Croom Helm, London, 1977) is a fascinating mixture of analysis and animosity.’ (Strong 1979:213) 55 See 6.5, ‘Actors and Actants’, in Chapter 6, Sociology of a Syringe.


46

Death and Furniture arguments (Edwards et al. 1995)56 may be summoned to claim that my thesis

should not fail to engage with the hard fact that one woman dies each day in Bolivia from abortion

complications, and that it cannot deny the solidity of metal curettage instruments and plastic

aspiration syringes. From certain public health and feminist perspectives, Saving Women can be

construed as a vital necessity and a moral imperative, not a discourse to be questioned.57 In the heat

of ‘violent, bloody, and lethal’ events, I also alternate into materialist critiques of semiotic analysis,

as enunciated by Foucault in an interview on ‘Truth and Power’:

Neither the dialectic, as logic of contradictions, nor semiotics, as the structure of

communication, can account for the intrinsic intelligibility of conflicts. ‘Dialectic’ is a way

of evading the always open and hazardous reality of conflict by reducing it to a Hegelian

skeleton, and ‘semiology’ is a way of avoiding its violent, bloody, and lethal character by

reducing it to the calm Platonic form of language and dialogue. (Foucault cited in Fontana

and Pasquino 1977:56-57, my italics)

I grappled with precisely this dilemma in the pain dossier. The epiphanic (Denzin 1989:15-18)

encounter with contradictory accounts of Mrs. Gong’s treatment with MVA led me to abandon

interpretative repertoires (Gilbert and Mulkay 1984) and map a battle among discourses (Foucault

1975) concerning this critical hospital event. However, the concept of agent-displacement (Sykes

1985) took me beyond an oppositional analysis of the four narratives, to an understanding of

speakers’ collaborative protection of the gynaecologist’s interests.58 Discourse analysis generated

an effective mode of argumentation, and a credible alternative to the affirmation of Mrs. Gong’s

experience as undeniably real.

The adversary method (Moulton 1989) can be subverted by identifying points of dialectic

referentiality between apparently opposed arguments. Commonality is paradoxically enabled by

difference, as I noted in an earlier abortion study where health service providers and users made

contradictory declarations within the same interview (Rance 1995:112-114). I commenced my

research aware of threads of discourse common to parties ‘on both sides’ of the abortion debate

(Ginsburg 1989:222) - or rather, on all sides. If speakers change what they say about a topic

56 See 8.2, ‘Pain, Death and Furniture’, in Chapter 8, Managing Pain. 57 For a discussion of the Saving Woman Device (SWOD), see 7.2, ‘Doctors’ Interpretative Dilemmas’, in Chapter 7, Changing Voices. The discourse of Saving Women from injury or death from unsafe abortion is current in the publications of the Centre for Reproductive Law and Policy (CRLP), a major feminist advocacy organisation; and in press releases and coverage of the Women on Waves Foundation’s floating abortion clinic, that docked off Ireland at the start of its voyage. (See Guardian and New York Times Webpages from August 2001, for example: (http://www.nytimes.com/2001/08/26/magazine/26ABORTION.html). 58 See 8.4, ‘A dossier of pain’, in Chapter 8, Managing Pain.


47

according to context, conflicting positions may converge at certain moments. This possibility was

indicated by Vincente, a first-year medical student participating in a group dossier discussion: ‘Er...

look, with regard to this specific theme of this lady and everything that happened to her? I think

that the most feasible thing was... that this abortion should have been done, regrettably. I am

religious, I’m against abortion, but in this case...’. 59

My experience mirrored Ginsburg’s in Contested Lives: The Abortion Debate in an American

Community, as I too encountered the hostility that can be provoked by chipping away at the smooth

walls of assumed oppositions. Like Ginsburg, I met with suspicion from colleagues and fellow

activists, and wondered with them if I had gone native among the doctors and pro-lifers (Ginsburg

1989:222-223).60 Mapping the field in virtual and real terrains,61 I found that tenets that had long

sustained my pro-choice activism were dissolving into uncertainty. I could no longer situate myself

in a truth-wielding stance vis-à-vis a homogenised adversary. A hard core of anti-abortion militants

were indeed ready to shoot doctors in the back to defend foetal rights, but there were many people

addressing issues of fertility and infertility, pregnancy, miscarriage, foetal death and childbirth,

with whom I found affinities linking our research and politics.

11.8 Semiotic Action-Research

Actor Network Theory (Law 1992; Latour 1992) led me away from a rigidly oppositional mode,

and towards a conceptualisation of consensus and conflict concerning abortion as mutually

59 Translated excerpt of Transcript GP1.1:2-3, recorded group discussion, 5 female and 6 male first-year medical students,19/5/98. 60‘After I returned from the field and began to present my work in public, the reactions of colleagues raised new problems for me. It is one thing, I learned quickly, for an anthropologist to offer the natives’ point of view when the subjects are hidden in the highlands of New Guinea and have little impact on the lives of the assembled audience. It is quite another to describe the world view of people from the same culture whom some people in my audiences considered to be “the enemy”. I tried to think of the mission of Boas and Mead to break down cultural stereotypes when I found myself fielding occasionally hostile responses from colleagues. Some explained to me their concern that I had “gone native” and become a right-to-life advocate. One skeptic suggested that my data were simply not true. I started wondering if I had been overly optimistic, reading too much into the words of my interpreters, hoping that the commonalities I was seeing were evident to them in ways more significant than the tentative demonstrations and confessions of recognition that I had witnessed.’ (Ginsburg 1989:222-223) 61 One virtual exchange was my 1997-1998 e-mail correspondence with US art student Jessica Moore, who posted flyers in Dublin with photos of women’s faces, their mouths blanked out with a quote from Bishop Joseph Cassidy: ‘The most dangerous place to be at the moment is in the mother’s womb’. A ‘real’ encounter disarming my prior notion of pro- versus anti-choice actors was my 1999 visit to the ‘Clínica Pre-Vida’ (Pre-Life Clinic) in the Bolivian city of Santa Cruz de la Sierra. The clinic’s director turned out to be Dr. Osvaldo (Chato) Peredo, former member of Che Guevara’s guerrilla movement, now practising past lives regression and other alternative therapies with the Asociación de Medicinas Convergentes (Association of Convergent Medicines).


48

constitutive. The quirkiness of ANT, its mad humour and fantastic virtuality, inspired flying leaps

in my conceptualisation of the links between doctors and abortion. Following applications of ANT

to asthma (Prout 1996), atherosclerosis (Mol 1999b) and anaemia (Mol and Berg 1994; Mol

1999b),62 my chapter-arrows point to performances of abortion linking human and non-human

actants: doctors, coats, nurses, beds, women treated, syringes, and foetuses.

Actor Network Theory does not engage with pre-given notions of social structure and relations:

‘Social relations do not necessarily precede medicine. They also follow from it – and they can be

found inside it. Whoever wants to study society may go, too, to the sites we studied, for there it is –

in all its ambiguity, ambivalence, shifts and balances, efforts at coordination, conflicts, and

compromises’ (Mol and Berg 1999:11).

ANT’s semiotically derived perspective makes ‘no assumption that specific links or nodes in the

network are guaranteed, as it were by a form of semantic cohesion given in the order of things;

instead both links [and] nodes have to be uncovered by the analyst. They could be otherwise’ (Law

1995:3, my italics). There may not be an overall pattern in a network,

[f]or by now we know that these stories do not necessarily add up. Do not necessarily come

to a point. That we may need to give up single narratives in favour of many small stories.

(…) Perhaps there is no single and coherent pattern. Perhaps there is nothing except

practices. Stories performing themselves and seeking to make connections. Practical and

local connections. Specific links. (Law 1995:12-13, underlining in the original)

The mutually referential vision of ANT ‘does not easily fit our traditional notions of politics.

Which means that new conceptions of politics need to be crafted’ (Mol 1999a:85). Ontological

politics pursue temporary alliances and destabilising moves rather than radical change. They

generate more questions than answers, and ‘it is also possible that these questions will evaporate

and we’ll enact and undergo, yet again, a shift in our theoretical repertoire, finding other ways of

diagnosing the present’ (Mol 1999a:87).

The performance of this thesis effectively led me to craft a new conception of abortion politics. My

62 ‘Studying the performances of anaemia reveals their multiplicity. But this multiplicity does not come in the form of pluralism. It is not as if there were separate entities each standing apart in a homogeneous field. So anaemia is multiple, but it is not plural. The various anaemias that are performed in medicine have many relations between them. They are not simply opposed to, or outside, one another. One may follow the other, stand in for the other, and, the most surprising image, one may include the other. (…) Alternative realities don’t simply coexist side by side, but are also found inside one another.’ (Mol 1999a:85)


49

first destabilising move was to disarm the textual unity and solidity of abortion. I then pursued

temporary alliances with doctors, and involved medical students and teachers in deconstructive

exercises which generated more questions than answers. Inspired by Mol’s (1999a) ‘Ontological

Politics’ and Cussins’ (1999) ‘Ontological Choreography’, I coin my own term: Semiotic Action-

Research. This refers to collaborative work on language for transformative ends, drawing on

method rather than substance, relational strategising rather than the antagonistic assertion of facts,

rights and wrongs.

As a form of ‘radical semiotics’, Actor Network Theory has been criticised for its symmetrical

treatment of human and non-human actors as indeterminate and unpredictable, and for its

conceptual obscurity (Abercrombie, Hill and Turner 2000:4-5). Recovering the principle of

epistemological alternation applied throughout my thesis, I take my own difficulty in grasping the

complexity of ANT’s relational materiality as an indication of the insufficiency of paradigmatic

coherence as a framework for understanding. I embrace the inter-linking of rigour and imagination

in qualitative research, and sacrifice some clarity in the cause of creative exploration. In a

rhetorical bid for alternation into semiotic ‘out-there-ness’ (Potter 1996:150-151), I conclude by

jumping from Derrida’s ‘destabilizing jetty’ to a ‘simply stating jetty’ (Derrida 1990:84),

brandishing his assertion:

Deconstruction is neither a theory nor a philosophy. It is neither a school nor a method. It is

not even a discourse, nor an act, nor a practice. It is what happens, what is happening today

in what they call society, politics, diplomacy, economics, historical reality, and so on and

so forth. Deconstruction is the case. (Derrida 1990:85)63

63 I am indebted to Geraldine Cullihy for bringing this text to my attention. Personal communication, Dublin, 17/7/02.

Changing Voices References

50

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Changing Voices Appendices

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APPENDICES

Changing Voices Appendix 1

81

Appendix 1

Contextualisation of transcript excerpt introducing Chapter 1, Doing Abortion

Excerpt of transcript of recorded interview with the following characteristics:

Participants: Dr. Antunes (Dr. A), director of State Hospital

SR as researcher

Date and time of interaction: 6/12/96, 11.55 a.m. – 12.05 p.m.

Place: Dr. Antunes’ office in the State Hospital

Source of notes on context: Field Notebook 1, notes summarised 9/12/96, edited 10/7/02

Number and date of transcript: 2.1, 9/12/96 to 11/12/96

Context:

The transcript excerpt which follows is from a recorded interview which I (SR) requested with Dr. Antunes

(Dr. A), while I was waiting to meet with two gynaecologists suggested by him as potential research

collaborators in the hospital.

Dr. Antunes was very busy and had a series of visits and interruptions in the course of the morning. His

office was being renovated and a worker was painting the outside of the door which was ajar. A group of

male doctors and administrative personnel were grouped around a table at the far end of the office. Female

receptionists, secretaries and nurses entered and left the office periodically, some of them staying in the

anteroom just outside.

Despite the lack of privacy and the rather agitated atmosphere, Dr. Antunes agreed to give the ‘five-minute’

interview I requested, which actually lasted a total of 8 minutes. He first suggested postponing it until after

the weekend but I insisted and he accepted.

When I started to record, he took the cassette recorder from my hands and held it before him in both hands

throughout the interview, switching it off and on again on the occasion of one interruption by a male medical

colleague. In this way he effectively demonstrated his decision to give the recorded interview.

The excerpt here selected and translated is of 1.5 minutes of transcript, starting 5.5 minutes into the

interview.


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SR: And what do you think about the question of the Mother-Child Insurance [.] of inclu:ding or not including treatment of complications of abortion within the Insurance Scheme. [3] Dr. A: [[in a very low tone, like a whisper]] But it would be a great marvel for it to be- [.] if that were to enter. But that gives way to a lot of susceptibility. [‘] [.] [[in a very low tone]] I believe that that: [.] gives way to a lot of susceptibility because if it includes: [2] er:: [1] practising the abortion [1] listen to me well [3] if it includes [.] practising the abortion [1] they would be thinking that [‘] the Maternity Insurance were [.] were [[in a low voice]] paying for or legalising abortion. [.] [[in an increasingly loud tone]] And with that we [.] do NOT [.] agree, [.] with legalising abortion. [‘] [.] We are AGAINST the legalisation of abo:rtion. NO. [.] [[in a lower tone]] [.] What we are doing is struggling AGA::INST abortion [.] doing family planning on that level. [‘] [.] So- [‘] I believe that it ought to be thought about [.] it is being made to enter within the Maternity Insurance, PERfect because that way [.] the- the- the- the- mother [‘] [.] but [.] of abortion [.] in process [.] not an induced abortion. [.] We know that an abortion [.] is a crime. SR: Mh-hm. [‘] But [.] let’s say [.] when the woman enters [.] sometimes there’s a lot of diff::iculty [.] in kno:wing [.] if it’s an abortion that’s sponta::neous or indu:ced. [4] Dr. A: That’s [the] problem. [.] I’m telling you. [.] This [.] has to be taken with great [.] care. [.] And- and- that’s a problem [‘] [.] that:: [3] [[in a very low tone]] the government has to see to.

SR: Y qué opina Uste:d de la cuestión del Seguro de Maternidad y Niñe:z [.] que se inclu:ya o no se inclu:ya la atención a complicaciones del aborto dentro del Seguro. [3] Dr. A: [[en tono muy bajo, como susurro]] Pero sería una gran maravilla que se- [.] que ingrese esto. [‘] [.] Pero esto da para mucha susceptibilidad. [‘] [.] [[en tono muy bajo]] Yo creo que esto: [.] da para mucha susceptibilidad porque si se incluye: [2] eh:: [1] realizar el aborto [1] escúcheme bien [3] si se incluye [.] realizar el aborto [1] estarían pensando de que [‘] el Seguro de Maternidad estaría [.] -aría [[en tono bajo]] pagando o legalizando el aborto. [.] [[en tono cada vez más fuerte]] Y en eso NO [.] estamos [.] de acuerdo [.] en [.] legalizar el aborto. [‘] [.] Nosotros estamos en CO:NTRA de la legalizació:n del abo:rto. NO. [.] [[en tono más bajo]] [‘] Lo que sí estamos luchando CO::NTRA el aborto [.] haciendo la planificación familiar a ese nivel. [‘] [.] -tons- [‘] [.] yo creo que se debe pensar [.] se está haciendo [1] que entra dentro del Seguro de Maternidad perFECTO porque así [.] la- la- la- la madre [‘] [.] pero [.] del aborto [.] en curso [.] no un aborto provocado. [.] Sabemos que un aborto [.] es un crimen. SR: Mh-hm. [‘] Pero: [.] digamos [.] cuando ingresa la mujer [.] a veces hay mucha dificulta::d [.] para sabe:r [.] si es un aborto espontá::neo o induci:do. [4] Dr. A: Ese es [el] problema. [.] Yo te digo. [.] Esto [.] hay que tomar [.] con muchas [.] pinzas. [.] Y- y- ese es un problema [‘] [.] que:: [3] [[en tono muy bajo]] el gobierno tiene que ver.


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SR: Right: Dr. A: [[in a low tone]] Here [on] this level we are operative, [.] [‘] [1] if they accept it within the Maternity Insurance [.] welcome. [1] Because we [[in a loud tone]] DO NOT [.] DO [.] ABORTION [.] [‘] W- [.] we are AGA::INST the- [.] legalisation of abortion, once again I repeat it because about this I want [‘] you to be VERY clear [.] we are [1] AGA:NST legalising abortion. SR: Mm. [1]

SR: Ya: Dr. A: [[en tono bajo]] Aquí [a] este nivel nosotros somos operativos, [.] [‘] [1] si es que lo aceptan [.] dentro del Seguro de Maternidad [.] bienvenido. [1] Porque nosotros [[en tono fuerte]] NO [.] HACEMOS [.] EL ABORTO [.] [‘] E- [.] estamos EN CO::NTRA DE la [.] de [.] legalizar el aborto, nuevamente lo repito porque eso yo quiero [‘] que sea Usted BIEN claro [.] estamos EN [1] CO:NTRA de legalizar el aborto. SR: Mm. [1]


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Appendix 2

Contextualisation of transcript excerpt introducing Chapter 2, Mapping the Field

Excerpt of transcript of interaction observed and recorded by SR with the following characteristics:

Participants: Dr. Dávila (Dr. D), staff gynaecologist and academic coordinator of

residents’ training, principal research collaborator in State Hospital.

Group of five fifth-year medical students, four men and one woman, Elba (E)

who presented the case history.

SR as researcher.

Date and time of interaction: Friday 14/2/97, 10:07 - 12:11 a.m.

Place: Dr. D’s gynaecology outpatients clinic, State Hospital


Number & date of transcript: 3.7, 17/2/97 - 11/2/97

Context:

This transcript is of a participant observation that I (SR) did with Dr. Dávila (Dr. D) and a group of fifth-year

undergraduate medical students, during consultations combined with a teaching session prepared on Dr. Dávila’s

initiative, in the third of four months’ fieldwork in the State Hospital. This session focused on the treatment of

incomplete abortion and a discussion on abortion with the interns, one of whom, Elba (E), presented a case

history.

I had telephoned Dr. Dávila early that morning with the intention of postponing my observation session for

another day, because I was exhausted from the week’s activities. However, Dr. Dávila immediately said that he

was expecting me, and that his students had prepared for the session on abortion with my presence in mind. I

went to the gynaecology outpatients clinic, without taking my white coat because I had anticipated another kind

of dynamic – more of a classroom nature – for the teaching session.

Dr. D immediately had me shown into the consulting room. He was demonstrating the insertion of an IUD with

a woman who was lying on the gynaecological examination couch. For the next two hours, I alternated periods

of recording and moments at which I made fieldnotes. The excerpt transcribed below corresponds to the first

five minutes of a total of 46 minutes recorded during the two-hour session.

Reflecting on this event, I was struck by Dr. D’s demonstration of will to collaborate with my research. I was

also alarmed by the invasive nature of the consultations combined with a teaching session. I imagined the impact

for the women consulting of being examined in the presence of a group of students. I felt that this situation

would have made requests for these women’s consent for my presence something of an absurd formality.


85

Start of Transcript 3.7 [[Before the recording, there are 13 minutes of consultation combined with teaching activities. In the first 14 seconds of the recording, laughs and jokes can be heard from SR, Dr. D and the students, generated by my request to those present to record the session. My request gives rise to jokes from Dr. D about my intent to spy ‘for the CIA’ and the ‘subversive’ activity of a Peruvian student. Then a serious atmosphere is restored and Dr. D situates us within the pre-established theme for the teaching session.]] Dr. D: Well. [2] -so we’re going to:: deal with the: the theme of: [1] of abortion, from: [2] any point of view, [.] I, what I would like, for you to analyse it after reading the history, [1] for you to tell me what you think of those: [1] of what we have found, right, in reality. [1] It’s a patient [??] how is it? [1] we´ll [commence]. What- what patient is it? [1] E: It’s a pa{tient} Dr. D: {Well} summarised, now. [2] E: It’s a patient of nineteen years, [[for 8 seconds, all that can be heard is the occasional sound of papers being rustled]] Dr. D: Well who did the- who did the clinical history? {[???] know.} {[[The sound of papers being rustled continues.]]} E: [[reads from clinical history]] Nineteen ye:ars, [.] tra:der, concubine, [1]

Inicio de la Transcripción 3.7 [[Antes de la grabación, transcurren 13 minutos de consulta combinada con actividades de docencia. En los primeros 14 segundos de la grabación se escuchan risas y bromas de SR, Dr. D y los estudiantes, generadas por mi solicitud a los presentes para grabar la sesión. Mi pedido da lugar a chistes por parte del Dr. D sobre mis fines de espionaje ‘para la CIA’ y la actividad ‘subversiva’ de un estudiante peruano. Luego se vuelve a reestablecer un ambiente de seriedad y Dr. D nos ubica en la temática preestablecida para la sesión docente.]] Dr. D: Bueno. [2] -tonces vamos a:: tocar el: el tema del: [1] del aborto, desde: [2] cualquier [1] punto de vista, [.] Yo lo que quisiera que lo analicen después de leer la historia, [1] que me digan qué piensan ustedes de esos: [1] de lo que hemos constatado, no, en la realidad. [1] Se trata de una paciente [??] cómo es? [1] [comenz]aremos. Qué- qué paciente es? [1] E: Es una pacien{te} Dr. D: {Bien} resumido nomás. [2] E: Es una paciente de diecinueve años, [[durante 8 segundos sólo se escucha el ruido ocasional de papeles que se hojean.]] Dr. D: Quién ha hecho pues la- quién ha hecho la historia clinica? {[???] saber.} {[[Sigue ruido de papeles que se hojean.]]} Es1: [[lee de historia clínica]] Diecinueve a:ños, [.] comercia:nte, concubina, [1]


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born in Umapampa, [1] lives in Altamira, in Zone C.i [2] And [??] motive of consultation, for genital haemorrhage and pain in the lower abdomen. [2] Um: regarding the history, she recounts that [2] the clinical condition begins on one fourth of February approximately [.] [‘] at one in the morning, after a wardrobe fell down on her [2] and [.] subsequently [.] a pain begins of colic type, of great intensity [1] localised in the hypoga:stric region with irradiation to the: dorsal lumbar region. [1] Which was not modified by posture. [1] This pain is accompanied by genital haemorrhage in great quantity, [.] with coagulation [.] and a bad odour. [1] When this condition did not abate the patient approached Altamira Hospital from where she was referred to this hospital centre. [1] And after being assessed [.] [[rustles papers]] er: her admission is decided. [2] Regarding the family precedents, [3] er [.] she mentions that the companion with whom: she finds herself [.] er living// Dr. D: //She’s a concubine? E: She’s a concu{bine.} Dr. D: {She’s a concu}bine. E: Yes. [1] Companion healthy, [1] she has three children, [1] of five, {four and a year and a half}. Dr. D: {[[Gives inaudible instructions about instruments to male students practising internal examination on woman lying on the gynaecological couch.]]} [2]

nacida en Umapampa, [1] vive en Altamira, en la Zona C. [2] Y [??] motivo de consulta, por hemorragia genital y dolor en abdomen inferior. [2] Em: respecto a la historia, ella relata que [2] el cuadro clínico se inicia un día cuatro de febrero aproximadamente [.] [‘] a la una de la mañana, luego que se le cayó un ropero encima [2] y [.] posterior a eso empieza [.] un dolor tipo cólico de gran intensidad [1] localizado en región hipogá:strica con irradiación a la: región dorso lumbar. [1] Que no se modificaba con las posturas. [1] Ese dolor es acompañado de hemorragia genital en gran cantidad, [.] con coágulos [.] y maloliente. [1] Al no remitir el cuadro la paciente acudió al Hospital Altamira de donde es remitida a este centro hospitalario. [1] Y después de ser valorada [.] [[hojea papeles]] eh: se decide su internación. [2] En cuanto a los antecedentes familiares, [3] eh [.] menciona que el compañero con el: que se encuentra [.] eh viviendo// Dr. D: // Es concubina? E: Es concu{bina.} Dr. D: {Es concu}bina. E: Sí. [1] Compañero sano, [1] tiene tres hijos, [1] de cinco, {cuatro y un año y medio}. Dr. D: {[[Da indicaciones inaudibles sobre instrumentos, a estudiantes ♂ practicando examen interno a mujer echada en la mesa ginecológica.]]} [2]


87

E: On her mother [1] on her mother three caesarians were practised [??] [[inaudible due to the sound of papers being rustled]] [dys]tocial. [.] The father is living, apparently healthy, she has ten siblings, apparently healthy. [2] In the personal precedents, non pathological, [.] er the patient [.] followed schooling to the grade of fourth year primary, [.] she is Catholic [.] her dwelling is rented and consists of adobe rooms [[For four seconds, papers being rustled can be heard, and the distant voice of Dr. D giving instructions to the students who continue practising the gynaecological examination.]] E: with plastered walls, it has drinking water, electricity [.] but no drainage. {[2]} {[[The distant voice of Dr. D can be heard talking with the students who are practising the examination.]]} E: Diet is predomi- with a predominance of carbohydrates. [2] Personal pathological precedents, [1] imm:unisations comple:te, [.] no traumatisms, [1] [??]. [1] Mentions processes of [??]ism, repeated [tonsi]llitis [.] when she was a girl. [2] [[in a loud tone, calling Dr. D who continues to supervise the students in the practice of the gynaecological examination]] Shall I continue, Doctor? [[For three seconds, the distant voice of Dr. D can be heard.]] E: Gyneco-obstetric precedents. [.] Menarche at twelve years, [.] current menstrual rhythm [1] five in thirty, [1] gestation four for three, caesarians zero, abortions [1] one, spontaneous. [1] LMPii [.] first [.] of: {[2]}

E: A su madre [1] a su madre se le practicaron tres cesareas [??] [[inaudible por ruido de papeles que se hojean]] [dis]tócicos. [.] El padre vivo, aparentemente sano, tiene diez hermanos aparentemente sanos. [2] En los antecedentes personales no patológicos, [.] eh la paciente [.] cursó el grado de escolaridad hasta primero básico, [.] es católica [.] su vivienda rentada y consta de cuartos de adobe [[Durante 4 segundos, se escucha papeles que se hojean y la voz lejana de Dr. D dando indicaciones a los estudiantes que siguen practicando el examen ginecológico.]] E: con paredes revocadas, tiene agua potable, luz [.] pero no alcantarillado. {[2]} {[[Se escucha voz lejana de Dr. D hablando con los estudiantes quienes practican el examen.]]} E: La alimentación es predomi- a predominio de carbohidratos. [2] Antecedentes personales patológicos, [1] in:munizaciones comple:tas, [.] sin traumatismos, [1] [??]. [1] Menciona procesos de [??]ismo, [amigda]litis a repetición [.] cuando era niñ[a]. [2] [[en tono alto, llamando a Dr. D quien sigue asesorando a los estudiantes en la práctica del examen ginecológico]] Sigo Doctor? [[Durante 3 segundos, se escucha voz lejana de Dr. D.]] E: Antecedentes ginecobstétricos. [.] Menarca a los doce años, [.] ritmo menstrual actual [1] cinco por treinta, [1] gesta cuatro para tres, cesareas cero, abortos [1] uno, espontáneo. [1] FUM [.] uno [.] de: {[2]}


88

{[[distant voices of Dr. D and students can be heard]]} E: [[hesitating]] Octo:-ber [.] October ninety six [1] and [.] date of last birth twelfth of [1] August ninety five. {[3]} {[[distant voices of students and Dr. D can be heard]]} E: Does not report use of: [1] contraceptive methods. [2] The start of- [.] of her sexual relations was at twelve years, in a voluntary manner. [.] Never had a PAP done [.] and neither did she ever [.] do mammary checks. [.] Does not know about family planning. [2] On physical examination, presents moderate general state oriented in the three spheres [1] with pale hydrated skin and mucous membranes. [1] [??], arterial pressure one hundred/sixty, cardiac frequency eighty- [.] eighty six per minute, respiratory frequency twenty [.] per minute, [1] temperature thirty seven point eight degrees. [2] Head normocephalous, {[3]} {[[distant voice of Dr. D can be heard calling to E]]} Dr. D: Let’s stop for a little while. E: Right. [4] Dr. D: [[to one of the men students who is practising the examination]] Let’s see. Now you’re surely looking for [??]. [[For 18 seconds, the distant voices of Dr. D and the men students can be heard.]] Dr. D: [[to men students]] Umm: [.] Where is the: [[For 7 seconds, distant voice of Dr. D talking with the men students]]

{[[se escuchan voces lejanas de Dr. D y estudiantes]]} E: [[hesitando]] octu:-bre [.] octubre del noventa y seis [1] y [.] fecha del último parto doce de [1] agosto del noventa y cinco. {[3]} {[[se escuchan voces lejanas de estudiantes y Dr. D]]} E: No refiere uso de: [1] métodos anticonceptivos. [2] El inicio de- [.] de sus relaciones sexuales fue a los doce años, de manera voluntaria. [.] Nunca se realizó un PAP [.] y tampoco nunca [.] hizo control mamario. [.] No sabe sobre planificación familiar. [2] Al examen físico, presenta regular estado general orientada en las tres esferas [1] con piel y mucosas pálidas hidratadas. [1] [??], presión arterial cien/sesenta, frecuencia cardíaca ochenta- [.] ochenta y seis por minuto, frecuencia respiratoria veinte, [.] por minuto, [1] temperatura treinta y siete puntocho grados. [2] Cabeza normocéfala, {[3]} {[[se escucha voz lejana de Dr. D llamando a E]]} Dr. D: Un ratito pararemos. E: Ya. [4] Dr. D: [[a uno de los estudiantes hombres que practica el examen]] A ver. Ahora seguramente está buscando [??]. [[Durante 18 segundos, se escuchan voces lejanas de Dr. D y los estudiantes .]] Dr. D: [[a estudiantes ]] Este: [.] Dónde está la: [[Durante 7 segundos, voz lejana de Dr. D hablando con los estudiantes ]]


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Dr. D: [[to students grouped around his table for the case presentation]] You already know that this is a pa:tient [2] E: Nineteen years of age Dr. D: Of nineteen years of age [1] who commenced her sexual activity very precociously at twelve years, [.] and who at this stage of life already has three children:, [.] and who was pregnant with a: fourth [.] and who suddenly presents: the same old story, [1] that she got fallen on: [.] by the wardrobe, that she fell, {[3]} {[[sound of papers being rustled for three seconds and distant voice of male student]]} Dr. D: and [2] who [.] comes with a threat- [.] with a [.] diagnosis of [1] abortion [.] [[coughs]]. [.] We don’t know why they:: they sent her from: from Altamira Hospital. E: Because it says they didn’t ha:ve instruments. 1st male student (St♂1): Yes, they didn’t have instruments. [1] Dr. D: Ay. [3] Right. [1] -so they didn’t have instruments. [.] But when she comes here, [.] she comes already with a bit of a fever, [2] She comes with fever, isn´t that right? St♂2: Yes Dr. D: Umm::: and it’s done to her [.] what must be done! Or aren’t- or are you: [.] in disagreement [.] with: [.] the treatment [???.] [3]

Dr. D: [[a estudiantes agrupados alrededor de su mesa para la presentación del caso]] Ustedes ya saben que se trata de una pacien:te [2] E: Diecinueve años de edad Dr. D: De diecinueve años de edad [1] que ha comenzado su actividad sexual muy precozmente a los doce años, [.] y que a estas alturas de la vida ya tiene tres hijos:, [.] y que estaba embarazada de un: cuarto [‘] y que de pronto presenta: la historia de siempre, [1] que le ha caído: [.] el ropero, que ella se ha caído, {[3]} {[[ruido de papeles que se hojean y voz lejana de estudiante hombre ]]} Dr. D: y [2] que [.] viene con ame- [.] con un [.] diagnóstico de [1] aborto [.] [[tose]] [.] No sabemos por qué le:: la remitieron de: del Hospital Altamira. E: Porque dice que no tení:an instrumen{tal}. St♂1: {Sí,} no tenían instrumental. [1] Dr. D: Ay. [3] Ya. [1] -tonces no tenían instrumental. [.] Pero cuando viene acá, [.] viene ya con un poco de fiebre, [2] Viene con fiebre, no es cierto? St♂2: Sí Dr. D: Este::: y se le hace [.] lo que se debe hacer! [.] O no- o están: [.] en desacuerdo [.] con: [.] el tratamiento [???]. [3]


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St♂3: No, it’s the: [2] That treatment [.] er: [.] that was [.] that was proposed [for] the patient, [.] is the: [1] is the habitual: treatment [.] that [.] that generally [??] in incom- incomplete abortions. [2] Dr. D: Mm in all of them? [.] St♂3: No. Not all [.] Dr. D: But? St♂3: Not in all of them. Dr. D: Mm:. (4)

St♂3: No, es el: [1] [‘] Ese tratamiento [.] eh: [.] que se ha [.] que se planteaba [para] la paciente, [.] es el: [1] es el tratamiento habitual: [.] que [.] que en general [??] en los abortos incom- incompletos. [2] Dr. D: Mm en todos:? [.] St♂3: No. [.] No todos [.] Dr. D: Sino? St♂3: No en todos. Dr. D: Mm:. [4]

i Pseudonyms for place names. ii ‘LMP’, Last Menstrual Period, in Spanish FUM, Fecha de Ultima Menstruación.


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Appendix 3

Contextualisation of transcript excerpts cited in sections 3.2.3 and 3.2.5 of

Chapter 3, March of the White Coats

Excerpt of transcript of recorded interview with the following characteristics:


residents’ training, principal research collaborator in State Hospital

SR as researcher.

Date and time of interaction: Friday 31/1/97, 3.15 – 4.45 p.m.

Place: Dr. Dávila’s private surgery on the ground floor of his house.

Source of notes on context: Field Notebook 2, notes translated and summarised 31/1/97, edited

18/7/02

Number & date of transcript: 3.6, 31/1/97 - 5/2/97

Context:

This transcript is of an interview that I (SR) requested with Dr. Dávila to talk about some aspects noted in

previous observation sessions. This was our first re-encounter after the end of year holidays, and Dr. Dávila

was still on leave. First we discussed matters concerning the Working Group on unwanted pregnancy and

abortion. My questions in the interview were guided by points I had identified in fieldnotes and transcripts.

During the interview, Dr. Dávila’s wife passed twice through the adjoining room. When his young son came

into the surgery, I momentarily suspended the recording. I lost some of the recording by not noticing when

the first side of the cassette had finished. The excerpt here selected and translated corresponds to 7 minutes of

recording, starting 40 minutes into the 55-minute recorded interview, which was part of an encounter lasting

an hour and a half.

After the interview, we talked for twenty minutes about opportunities for me to observe teaching sessions.

Dr. Dávila suggested organising a session on the topic of abortion, to be filmed on video, with ‘pre-intern’

students commencing their 5th year of medical studies. I expressed reticence about the use of video but was

won over by Dr. Dávila’s enthusiasm for the technology.

We talked about taking advantage of spaces in undergraduate and postgraduate teaching to influence the

transformation of aspects of biomedical culture (such as the impersonal management of the ward round),

which we both constructed as having a negative effect on doctor-patient relations. We confirmed our

appointment in the State Hospital for February 2nd, so that Dr. Dávila could introduce me to the residents on

duty in the emergency service where I wanted to do an observation session.


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[6] SR: [‘] We:ll. [1] And to finish, [.] is there anything that:: [.] you would like to a:sk, li:ke, about: what I- I’m do:ing, the re:search: and: [.] [‘] the observation and things like that? [7] Dr. D: One time what thing would I like to ask, [.] [‘] [[smiling]] now it’s my turn! {[[laughs loudly]]} SR: {[[laughs]]} Dr. D: [[laughs]] Mm:: [4] What is the fundamental objective? [.] SR: [‘] To impro:v:e [.] the access and qua:lity [.] of postabortion services. [1] Right:? [.] It’s:- it’s: [.] [‘] a bit, the slo:gan of the project of IPAS:. [.] Right? [.] Er [.] MY rese:arch is within that. [.] Within the framework of the IPAS project, [2] which is to: [.] bro:aden [.] er: [.] the access and coverage [.] of [.] postABO:RTION services. [.] [‘] So: to me what’s of interest is seeing [.] what factors can have in:fluence [.] [‘] so that people can [.] or can’t [.] use the ser:vices: [.] and have [.] a: [.] a care which is adequate [.] for their needs, right? [1] [‘] And I, THAT is what I am addressing [1] er [1] but NOT [.] NOT SO: MUCH [.] concentrating myself [.] on the aspect of interviews with the women, with the patients, with the users [.] [‘] [.] BUT [.] with people [.] who provide the services:. [.] To see: [.] how [.] you [.] conceive of your work, [.] how you manage it, how you talk, how: [1] [‘] you communicate with peopl:e [.] and how you see [.] the view of your own work, right? [.] [‘]

[6] SR: [‘] Bue:no. [1] Y para terminar, [.] hay alguna cosa que:: [.] tú quisieras pregunta:r, así:, sobre: lo que yo- yo estoy hacie:ndo, la investigació:n: y: [.] [‘] la observación y estas cosas? [7] Dr. D: Una vez qué cosa quisiera preguntar, [.] [‘] [[sonriendo]] ahora me toca a mí! {[[ríe fuerte]]} SR: {[[risas]]} Dr. D: [[risas]] Mm:: [4] Cuál es el objetivo fundamental? [.] SR: [‘] Mejora:r: [.] el acceso y la calida:d [.] de servicios postaborto. [1] No:? [.] Es:- es: [.] [‘] un poco el le:ma del proyecto de IPAS:. [.] No? [.] Eh [.] MI investigació:n está dentro de eso. [.] Dentro del marco del proyecto de IPAS, [2] que es para: [.] amplia:r [.] ah: [.] el acceso y la cobertura [.] de [.] servicios postABO:RTO. [.] [‘] Entonces: a mí me interesa ver [.] qué factores pueden influi:r [.] [‘] para que la gente pueda [.] o no pueda [.] usar los servi:cios: [.] y tener [.] un: [.] una atención adecuada [.] a sus necesidades, no? [1] [‘] Y yo ESO lo estoy abordando YO [1] eh [1] pero NO [.] NO TA:NTO: [.] concentrándome [.] en el aspecto de entrevistas con las mujeres, con las pacientes, con las usuarias [.] [‘] [.] SINO [.] con gente [.] que provee los servicios:. [.] Para ve:r [.] cómo [.] ustedes [.] conciben su trabajo, [.] cómo manejan, cómo hablan, cómo: [1] [‘] se comunica con la gente: [.] y cómo ven [.] la óptica de su propio trabajo, no? [.] [‘]


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For me it’s very important. [.] [‘] Because YOU have the side of power. [1] [‘] Right? You ha:v:e [.] after all [.] erm [.] you have had more access to educa:tion, to forma:tion, [.] [‘] to professional status, [1] to the link with profess:ional [.] organisations:, [.] [‘] contacts with the power of the sta:t:e, [.] ri:ght? [.] You: [.] can have influence [.] a lot, [.] I think, [.] also as teachers, [.] [‘] on the ru:nning of the exercise of medicine here. [1] Right? You have power. [1] And that’s why it interests me li:ke [.] mm [.]di:aloguing and understa:nding that a bit! [??,] [.] [‘] precisely to see those po:ssible spaces for change, right? For transformation. [1] That’s what interests me. [.] [‘] Because for me, [1] when there is an: [.] excellent service, people will go. They will approach. [.] They will want to go. [1] [‘] Right? So for me, there’s mu:ch more weight [.] on the offer than on the demand. [2] Much more it interests me [.] that: [.] the [.] offer should improve, [1] so that there is an increase in the demand. I don’t say that people HAVE to go and use the services just because they have to! Right? [.] Because they have other o:ptions in [.] [‘] traditional health, in A:ndean health, Andean medicine, right? [.] [‘] And it will depend on each person if they use or not [.] [‘] the biomedical services. [2] -so for me, [.] the biomedical services have to improve [.] to constitute themselves [.] [‘] as a more interesting alternative for people. [1] That’s what interests me. [.] It’s broadening the o:ffer a bit. [3]

Para mí es muy importante. [.] [‘] Porque USTEDES tienen el lado del poder. [1] [‘] No? Ustedes tie:nen: [.] nomás [.] ahm [.] han tenido más acceso a la educació:n, a la formació:n, [.] [‘] al estatus profesional, [1] al vínculo con organismos: [.] profesiona:les, [.] [‘] contactos con el poder estata:l:, [.] no:? [.] Ustedes: [.] pueden influir [.] mucho, [.] yo pienso, [.] también como docentes:, [.] [‘] en la ma:rcha del ejercicio de la medicina aquí. [1] No? Tienen poder. [1] Y por eso a mí me interesa como: [.] mm [.] dialoga:r y entende:r un poco eso! [??], [.] [‘] justamente para ver esos espacios posi:bles de cambio, no? De transformación. [1] Es lo que a mí me interesa. [.] [‘] Porque para mí, [1] cuando hay un: [.] excelente servicio, la gente va a ir. Va a acudir. [.] Va a querer ir. [1] [‘] No? -tonces para mí, hay m:ucho más peso [.] en la oferta que en la demanda. [2] Mucho más me interesa [.] que: [.] la [.] oferta mejore, [1] para que haya un incremento en la demanda. Yo no digo que la gente TIENE que ir a usar los servicios porque sí! No? [.] Porque tiene otras opcio:nes en [.] [‘] en salud tradiciona::l:, en salud andi:na, medicina andina, no? [.] [‘] Y dependerá de cada persona si usa o no [.] [‘] los servicios biomédicos. [2] -tonces para mí, [.] los servicios biomédicos se tienen que mejorar [.] para constituirse [.] [‘] en una alternativa más interesante para la gente. [1] Eso es lo que a mí me interesa. [.] Es ampliar un poco la ofe:rta. [3]


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Dr. D: Improving it. [1] SR: Yes! [1] Dr. D: Yes, improving it, right? SR: Yes! Dr. D: To improve it we have to find [.] [‘] our errors:. [.] SR: Mm:: Dr. D: Like, see them. [.] Know them. SR: Mm [.] Dr. D: Mm. [1] SR: And not only errors but [.] as I see it, cultural differences. [2] And not only of ethnic culture but of [[laughing]] medical culture! [‘] [.] Right? [.] Culture of health. [1] That: [.] just as you:, as you show when you relate to people, you recognise too that they come from another system too [.] [‘] of health. [.] [‘] And: that they also know things about traditional medicine, isn´t that right? [1] Dr. D: Yes, that’s how it is. SR: And that that option [.] of going [.] to you:r [.] consultation [1] is not [.] the only form of looking after their health. [1] There are others! [1] -so if they go [.] it’s for something, isn’t that right? [6] Dr. D: Also, it would have to be seen: [1] the rela:tion [1] analyse it a bit mor:e [1] from a social point of view [1]

Dr. D: Mejorarla. [1] SR: Sí:! [1] Dr. D: Sí, mejorarla, no? SR: Sí! Dr. D: Para mejorarla tenemos que encontrar [.] [‘] nuestros errores:. [.] SR: Mm:: Dr. D: Así, verlos:. [.] Conocerlos:. SR: Mm [.] Dr. D: Mm. [1] SR: Y no solamente errores sino [.] como yo veo, diferencias culturales. [2] Y no sólo de cultura étnica sino de cultura [[riendo]] médica! [‘] [.] No? [.] Cultura de salud. [1] Que: [.] como tú:, como demuestras cuando tratas con la gente, tú reconoces también que viene de otro sistema también [.] [‘] de salud. [.] [‘] Y: que conoce también cosas de la medicina tradicional, no es cierto? [1] Dr. D: Sí, así es. SR: Y que esa opción [.] de ir [.] a tu: [.] consulta [1] no es [.] la única forma de atender su salud. [1] Hay otras! [1] -tonces si va [.] es por algo, no es cierto? [6] Dr. D: Además, habría que ver: la relació:n [1] analizar un poco más: [1] desde un punto de vista social [1]


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like [.] what [.] what is signified by the relation [1] doctor-pat:ient. [3] Tha::t:: [.] if there’s a [.] if if:: [.] the fact [1] that [.] a person [.] asks another about something that [.] is [.] bothering them, [2] that’s to say, [1] any person, right? [1] Already they are already acting [.] with power. SR: Tha:t’s it. [3] Dr. D: Already they’re with {power.} SR: {Aha:} [.] SR: {They’re giving you power.} Dr. D: {A lot, because the} other [.] the other [.] [‘] is: [.] is: needy. [.] SR: [[sighing]] Right. Dr. D: Yes. [2] So: [2] um: [.] we have to try to be [2] like priests! [2] Bu::t [2] well that’s the ideal! [.] SR: Mh. [1] Dr. D: [[taking in a long breath]] But it would have to be seen too, how a:r:e [.] how a:r:e the providers of health! [1] Maybe the providers of health also are si:ck. [2] They’re sick: because [1] because:: [.] they: have [.] [‘] they have to work in a load of pla::ces because the mo::ney doe:sn’t go far enough for them [.] [‘] or because:: [[laughing]] the boss [?] [[laughs]] pressures them a lo:t, [.] [‘] in the end [1] that aspect too would have to be analysed. [1] If they’re well pai:d, or they’re not [.] because the health sector is converting itself [.] [‘] into a

cómo [.] qué [.] qué significa la relació:n [1] médico-pacien:te. [3] E::se:: [.] si hay un [.] si si:: [.] el hecho [1] de que [.] una persona [.] pregunta a otra de algo que [.] le está [.] molestando, [2] o sea, [1] cualquier persona, no? [1] Ya está actuando [.] con poder. SR: E:so. [3] Dr. D: Ya está con {poder.} SR: {Aja:} [.] SR: {Te está dando poder.} Dr. D: {Mucho, porque el} otro [.] el otro [.] [‘] está: [.] está: necesitando. [.] SR: [[suspirando]] Ya. Dr. D: Sí. [2] Entonces: [2] este: [.] nosotros tenemos que tratar de ser [2] cómo sacerdotes! [2] Pero:: [2] eso es pues el ideal! [.] SR: Mh. [1] Dr. D: [[aspira largamente]] Pero habrá que ver también cómo está:n: [.] cómo está:n: los prestatarios de salud! [1] De repente los prestatarios de salud también están enfe:rmos. [2] Están enfer:mos porque:: [1] porque:: [.] tienen: [.] [‘] tienen que trabajar en montón de pa::rtes porque no: les alcanza el dine::ro [.] [‘] o porque:: [[riendo]] su jefe los [?] [.] [[risas]] ajusta mu:cho, [.] [‘] en fin [1] ese aspecto también habría que analizar. [1] Si están bien paga:dos, no están [.] porque el sector salud se está convirtiendo [.] [‘] en un


96

sector: [.] that is mi:litant, combative:, [.] in search of improvements in salaries:. [1] Because [1] private medicine [1] private medicine, er of- lucrative, [1] has been reduced a lot. [1] And me:dicine:: [.] has become mor:e [.] it’s not a doctor, more it’s a salaried worker. [1] It’s a salaried worker [??]. [.] And every salaried worker [.] that’s to say, at a: given moment [.] can:: [1] maybe they get to care little. [2] The sam:e they earn [.] if they attend one patient [1] or if they attend ten. [1] O:r [.] or what do they do? [2] -so [.] those aspects: have to:: [.] [‘] have to::: um: be improved. [1] They have to [.] consciousness has to [?] be raised [1] and there just must be a search for some me:thod. [1] Because if:: [.] if the providers of health [1] are not satisfied, [2] well: er:: the matter gets: [.] a little difficult. [2] SR: [‘] And thi:s latest medical: stri:ke, the demonstra:tion: and all: [.] has been [.] exceptional, right? [.] In history here. [2] Dr. D: Yes:. [1] Yes. [2] Unfortunately there is::: is involvement [1] in some organisations: [1] of political aspects:. [2] That should not be done. [1] That’s to say:, [.] and political in the sense of:: um [.] [‘] of::: [1] If you are in power [.] now, [1] I’m going to ruin you. [1] And if: I’m going to be there tomorrow, [1] I’m also going to ruin you, that’s to say revengefulness. SR: Mm. [.] Mm.

sector: [.] combati:vo, peleador:, [.] en busca de mejoras salariales:. [1] Porque: [1] la medicina privada [1] la medicina privada: eh: de- lucrativa, [1] se ha reducido muchí:simo. [1] Y la: la medici:na:: [.] se ha hecho más: [.] no es un médico, más es un asalariado. [1] Es un asalariado [??]. [.] Y cada asalariado [.] o sea en un: momento dado [.] puede:: [1] de repente le importa poco. [2] Igual: gana [.] si atiende un paciente [1] o si atiende diez. [1] O: [.] o qué hace? [2] -tonces: [.] esos aspectos: tienen que:: [.] [‘] tienen que::: este: mejorarse. [1] Tienen que:: [.] se tiene que [?] hacer tomar conciencia [1] y debe nomás buscar algú:n mé:todo. [1] Porque si:: [.] si los prestatarios de salud [1] no están satisfechos, [2] pues: eh:: el asunto se pone: [.] un poquito difícil. [2] SR: [‘] Y esta: última: hue:lga médica:, la manifestació:n: y todo: [.] ha sido [.] excepcional, no? [.] En la historia aquí. [2] Dr. D: Sí:. [1] Sí. [2] Infelizmente se::: se involucran [1] en algunas organizaciones: [1] aspectos políticos:. [2] Que no deberían hacerse. [1] O sea:, [.] y políticos en el sentido de:: este [.] [‘] de::: [1] Si tú estás en el poder [.] ahora, [1] te voy a arruinar. [1] Y si: yo voy a estar mañana, [1] yo también te voy a arruinar, o sea el revanchismo. SR: Mm. [.] Mm.


97

Dr. D: And without seeing [.] the damage that’s being done. [.] SR: Mhm. [.] Dr. D: It wou:ld be:: [.] well, [.] to try to:: [2] well do a unionism:: umm:: that’s real! [2] Pure! [1] Right? [2] That- that tha:t implies well um: [1] [[with a long sigh]] a series of [.] [‘] of other: activities, right? [1] A series of activities. [[The interview is interrupted for one minute (15 seconds recorded, the rest unrecorded) when Dr. D’s son enters, Dr. D introduces us, they talk briefly and his son leaves the surgery.]]

Dr. D: Y sin ver [.] el daño que se está haciendo. [.] SR: Mjm. [.] Dr. D: Serí:a:: [.] bueno, [.] tratar de:: [2] hacer pues un sindicalismo:: este:: real! [2] Puro! [1] No? [2] Eso- eso e:so implica pues este: [1] [[suspirando largamente]] una serie de [.] [‘] de otras: actividades, no? [1] Una serie de actividades. [[Se interrumpe la entrevista durante un minuto (15 segundos grabados, el resto sin grabar) cuando entre el hijo de Dr. D, Dr. D nos presenta, ambos conversan brevemente y su hijo sale del consultorio.]]


98

Appendix 4

Contextualisation of transcript excerpt introducing Chapter 4, White On White

Excerpt of transcript of recorded interaction with the following characteristics:


residents’ training, principal research collaborator in State Hospital.

Mrs. Nina, woman consulting in gynaecology outpatients clinic.

SR as researcher.

Date and time of interaction: Tuesday 10/12/96, 11.00 – 11.30 a.m.

Place: Dr. Dávila’s gynaecology outpatients clinic, State Hospital


Number & date of transcript: 3.4, 27/1/97

Context:

This transcript is of the first part of a recorded participant observation session that I (SR) carried out during

Dr. Dávila’s gynaecology outpatients clinic. The time and place of the session had been suggested four days

earlier by Dr. Dávila in our first conversation in his private surgery. On arriving at the clinic I found queues

of women, some standing and awaiting numbered tickets for consultations, and others sitting on benches

outside the surgery doors. The women were called to the consultations by their last names: ‘Mrs. N’. Dr.

Dávila had me shown in. He asked almost immediately, ‘And your white coat?’, a condition for observation

that had also been set by doctors in a previous study (Parras and Rance 1997).

Dr. Dávila had accepted my proposal that I should request consent for observation and recording from each

woman consulting and from other people entering the clinic, although he commented that this seemed

unnecessary. From the start of the session, Dr. Dávila involved me in the consultations, asking me to pass

him slides and forms for PAP smears, and to go to the door and call the women in. He laughed when I

‘escaped’, as he said, from one consultation with a man he was about to examine (the partner of a woman he

had attended in a previous clinic) who had penile herpes.

By the time I left, Dr. Dávila had seen a total of six patients during the clinic that morning. He said this was

few in relation to the twelve he normally attended. This allowed him to dedicate considerable time to each

one. When I switched off the cassette recorder before leaving, he assumed an authoritarian, quite aggressive

tone with the last patient who was lying on the gynaecological examination couch, a woman de pollera of

over 50 who had come for a cancer check and was lying on the gynaecological examination table. He threw

questions at her brusquely and expressed prejudice and suppositions about her sexual and reproductive life.

Transcript 3.4, from which this excerpt is taken, is of the recorded interaction between Dr. Dávila (Dr. D),

myself (SR), and the fifth woman he attended, Mrs. Nina (Mrs. N), a woman de pollera aged 30. The

translated excerpt that follows if of the first half of her 31-minute consultation.


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Start of Transcript 3.4

Dr. D: [[leafing through papers, in a low tone

as if talking to himself, reads the first and last

names of the next patient]] SN.

[2]

SR: [[to Dr. D]] [??]?

Dr. D: [[continues as if talking to himself]] SN.

[[to SR]] Yes!

[[For five seconds, footsteps can be heard of

Dr. D as he goes to the surgery door,

opens it and calls the first and last names of

the patient.]]

Dr. D: SN?

[[For 12 seconds, sounds can be heard

from the doorway, footsteps, and a brief,

inaudible exchange between Dr. D and Mrs. N.

Both enter and approach the table of the

consulting room.]]

SR: [[to Mrs. N]] Excuse me Madam, I’m

called Susanna Rance, I’m doing a study with

the hospital [.] to support the service.

Mrs. N: [[sighing]] Right.

SR: And I’m obse:rving and recording some

consultations.

Inicio de la transcripción 3.4

Dr. D: [[hojeando papeles, en voz baja

como hablando solo, lee el primer nombre y el

apellido de la próxima paciente]] SN.

[2]

SR: [[al Dr. D]] ¿[??]?

Dr. D: [[sigue como hablando solo]] SN.

[[a SR]] ¡Sí!

[[Durante 5 segundos, se escuchan los pasos de

Dr. D quien va a la puerta del consultorio,

la abre y llama el nombre y el apellido de

la paciente.]]

Dr. D: ¿SN?

[[Durante 12 segundos, se escuchan ruidos

desde la puerta, pasos, y un breve

intercambio inaudible entre Dr. D y Sra. N.

Ambos entran y se acercan a la mesa del

consultorio.]]

SR: [[a Sra. N]] Disculpe Señora, me llamo

Susanna Rance, estoy haciendo un estudio con

el hospital [.] para apoyar el servicio.

Sra. N: [[suspirando]] Ya.

SR: Y estoy observa:ndo y grabando algunas

consultas.

1 All place names in transcripts are pseudonyms.


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Mrs. N: Right.

SR: You haven’t got a problem, I can

sta:y? [.] And reco:rd?

Mrs. N: Ahh:

SR: If: if you don’t like it, I can go out too.

Mrs. N: Right. [.] Ah [.] I have a problem with:

{[?]}

SR: {If you want:}

Mrs. N: a bit, with: health.

SR: [[in a louder and more emphatic tone]] Er

[.] no [.] I’m reco:rding [.] the consultations of

all the people who come to talk with the

doctor, [.] [‘] right?

Mrs. N: Ahh: right

SR: and it’s:: [.] a study to support the

se::rvice, so there can always be [1] attention

to:: the patients, right? [‘]

Mrs. N: Ri:ght.

SR: and to know [.] what things concer:n them

[.] and: [.] all that, right? And [.] so if you

have any doubt I can go out. [.] There’s

no problem too.

Mrs. N: R::ight. [‘] [.] Er: [.] I have a problem

with [1] health, right, that’s to say:: with::

Sra. N: Ya.

SR: Usted no tiene problema, ¿me puedo

queda:r? [.] ¿Y graba:r?

Sra. N: Ahh:

SR: Si: si no le gusta, puedo salir también.

Sra. N: Ya. [.] Ah [.] yo tengo problema de:

{[?]}

SR: {Si quiere:}

Sra. N: un poquito de: salud.

SR: [[en tono más fuerte y enfático]] Eh

[.] no [.] estoy graba:ndo [.] las consultas de

todas las personas que vienen a conversar con el

doctor, [.] [‘] ¿no?

Sra. N: Ahh: ya

SR: y es:: [.] un estudio para apoyar el

servi::cio, para que haya siempre [1] la atención

a:: las pacientes, ¿no? [‘]

Sra. N: Y:a.

SR: y saber [.] qué cosas les preocu:pa

[.] y: [.] todo eso, ¿no? Y [.] entonces si Usted

tiene cualquier duda yo puedo salir. [.] No hay

ningún problema también.

Sra. N: Y::a. [‘] [.] Este: [.] yo tengo problema

de [1] salud, no, o sea:: de::


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SR: Yes.

Mrs. N: my wo:mb, {all that,}

SR: {Yes:, well}

Mrs. N: right now for example I have::

[[she sighs, touching her neck]] I don’t know,

yesterday the wi:n:d blew on me, I don’t know,

{[?]}//

SR: //[[in loud and emphatic tone]] {That}

you’ll be telling to the doctor. Only

I’m as:king you, [‘] if you agree that

I should stay here [1] during the consulta:tion.

[.]

Mrs. N: Ahh: right.

SR: If I can sta:y, [.] or you prefer

that I [.] that I go out.

[1]

Mrs. N: Also you can go out, er, I haven’t:: [.]

you know, about ano- problems of another: , of

[.] that’s to say: [.] I mean to sa:y [.] problems

of:: [.] personal! [.] That, you want: to know?

SR: No no! [‘] If you are bothered that I

should be here?

[.]

Mrs. N: N:o.

SR: in the consultation?

SR: Sí.

Sra. N: mi matrí:z, {todo,}

SR: {Sí:, pues}

Sra. N: ahorita por ejemplo tengo::

[[suspira, tocando su cuello]] no sé,

ayer me sopló el vie:n:to, no sé,

{[?]}//

SR: //[[en tono alto y enfático]] {Eso}

le va estar contando al doctor. Solamente

le pregun:to, [‘] si Usted está de acuerdo en que

me quede aquí [1] durante la consu:lta.

[.]

Sra. N: Ahh: ya.

SR: Si me puedo queda:r, [.] o Usted prefiere

que me [.] que me salga.

[1]

Sra. N: También puede salir, este, no tengo:: [.]

sabe, de o- problema de otro:, de

[.] o sea: [.] quiero deci:r [.] problemas

de:: [.] ¡personal! [.] ¿Eso quiere: saber Usted?

SR: ¡No no! [‘] ¿Si a Usted le molesta que yo

esté aquí?

[.]

Sra. N: N:o.

SR: ¿en la consulta?


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Mrs. N: No.

SR: Because if you like I can go out.

[.]

Mrs. N: N:o.

SR: And if you agree I stay:[.] and

I can record.

Mrs. N: Stay: here, just.

SR: [[in relieved tone]] Thank you.

Mrs. N: All right.

[[For seven seconds, the sound can be heard of

papers that Dr. D is leafing through.]]

Dr. D: [[prolonged laughter]]

Mrs. N: [[joins in with laughs]]

SR: [[laughing]] He’s laughing, the Doctor is!

Mrs. N: {[[laughs increasingly loudly]]}

SR: {[[laughs increasingly loudly]]}

{[[laughing]] {How can I go out, right?!}

Mrs. N: {[????]} the lady [??] [[continues

laughing]]

Dr. D: {[[joins in with laughs]]}

Sra. N: No.

SR: Porque si quiere Usted yo puedo salir.

[.]

Sra. N: N:o.

SR: Y si está de acuerdo me quedo: [.] y

puedo grabar.

Sra. N: Qué:dese nomás aquí.

SR: [[en tono aliviado]] Gracias.

Sra. N: Ya.

[[Durante 7 segundos, se escucha ruido de

papeles que hojea Dr. D.]]

Dr. D: [[risas prolongadas]]

Sra. N: [[se suma a las risas]]

SR: [[riendo]] Se ríe el Doctor!

Sra. N: {[[se ríe cada vez más fuerte]]}

SR: {[[se ríe cada vez más fuerte]]}

{[[riendo]] ¿Cómo puedo salir, ¿no?!}

Sra. N: {[????]} la Señora [??] [[sigue

riendo]]

Dr. D: {[[se suma con risas]]}


103

SR: {[[joins in with laughs]]} [[laughing]] It’s

that I didn’t explain myself well, right?

Mrs. N: {[[laughs]]}

Dr. D: {[[laughs]]} Yes.

SR: [[to Mrs. N]] What do you say?

Mrs. N: [[laughs]]

Dr. D: [[in a low tone, to SR]] [you] need [to

explain] [??]

SR: [[in a loud tone, laughing]] Ri::ght?


Dr. D: {[[laughs]]}

SR: {[[laughs]]} [[to Mrs. N]] You have to

teach me. [.] Let’s see, [[laughing]] how does

one ask for permission?

Mrs. N: {[[laughs and sighs]]}

SR: {[[laughs and sighs]]}

[1]

Dr. D: [[laughing]] ‘I have [.] problems!’!

[[laughs]]

SR: [[laughing]] He just lau:ghs,

the Doctor does! [[laughs and sighs]]

SR: {[[se suma con risas]]} [[riendo]] Es

que no me he explicado bien, ¿no?

Sra. N: {[[risas]]}

Dr. D: {[[risas]]} Sí.

SR: [[a Sra. N]] ¿Qué dice?

Sra. N: [[risas]]

Dr. D: [[en tono bajo, a SR]] [te] falta

[explicar] [??]

SR: [[en tono alto, riendo]] ¿No::?

Sra. N: {[[risas]]}

Dr. D: {[[risas]]}

SR: {[[risas]]} [[a Sra. N]] Me tiene que

enseñar. [.] A ver, [[riendo]] ¿cómo se

pide permiso?

Sra. N: {[[risas y suspiros]]}

SR: {[[risas y suspiros]]}

[1]

Dr. D: [[riendo]] ‘¡Tengo [.] problemas’!

[[se ríe]]

SR: [[riendo]] Se rí:e nomás

el Doctor! [[risas y suspiros]]


104

Mrs. N: [[laughs and sighs]] Ay: [??] I don’t

know, well, what it is you’re asking so-//

SR: [[in a loud tone]] //No, {I [???] no:thing. [.]

You just: [.] are going to talk and}

Mrs. N: {[???]}

Dr. D: {[?????]}

SR: and I [.] only [.] want [.] to be here,

right?

[1]

Dr. D: {[[laughs]]}


SR: But I didn’t expla//

Dr. D: [[to Mrs. N]] //Or you make her

frightened, [.] the gringuita!

[.]

[[laughs from SR and Mrs. N]]

Dr. D: Well!

Mrs. N: [[laughing and sighing, in a low tone]]

the gringuita [[laughs and sighs]]

SR: {[[laughs]]}


[1]

Sra. N: [[risas y suspiros]] Ay: [??] no

sé pues qué es lo que está preguntando entons-//

SR: [[en tono alto]] //No, {yo [???] na:da. [.]

Ustedes nomás: [.] van a conversar y}

Sra. N: {[???]}

Dr. D: {[?????]}

SR: y yo [.] solamente [.] quiero [.] estar aquí,

¿no?

[1]

Dr. D: {[[risas]]}

Sra. N: {[[risas]]}

SR: Pero no me he expli//

Dr. D: [[a Sra. N]] //¡O le hace

asustar a [.] la gringuita!

[.]

[[risas de SR y Sra. N]]

Dr. D: ¡Bien!

Sra. N: [[riendo y suspirando, en tono bajo]]

la gringuita [[risas y suspiros]]

SR: {[[risas]]}

Sra. N: {[[risas]]}

[1]


105

Dr. D: [[smiling]] How many years old

are you, Mrs. N?

Mrs. N: Ah I’m [1] thirty.

[7]

Dr. D: Where do you live?

[.]

Mrs. N: By the Truck Stop I’ve

been living just for [.] a short time but

I haven’t got an address. [[in a very low tone

that becomes a whisper, with a nervous laugh]]

Yes::, just an empty plot of land it is.

Dr. D: Mm. [2] Do you work?

[1]

Mrs. N: M [.] Yes [.] as a maid I work [.]

{like}

Dr. D: {Maid?}

Mrs. N: [.] also sometimes I wash clo:thes an:d

[2]

Dr. D: all right:. [.] Single, married,

{concubine}

Mrs. N: {I h- in:} concubine. [.] I have two

children.

[1]

Dr. D: Where was the place of birth?

[.]

Dr. D: [[sonriendo]] ¿Cuántos años

tiene, Sra. N?

Sra. N: Ah yo tengo [1] treinta.

[7]

Dr. D: ¿Dónde vive?

[.]

Sra. N: En la Parada de Camiones estoy

viviendo recién hace [.] poco tiempo pero

no tengo dirección. [[en tono muy bajo que se

vuelve susurro, con una risa nerviosa]]

Sí:: lote vacío nomás es.

Dr. D: Mm. [2] ¿Trabaja?

[1]

Sra. N: M [.] Sí [.] de empleada trabajo [.]

{así}

Dr. D: {¿Empleada?}

Sra. N: [.] también hay veces lavo ro:pas y:

[2]

Dr. D: -ta bien:. [.] ¿Soltera, casada,

{concubina}

Sra. N: {T- en:} concubino. [.] Tengo dos

hijos.

[1]

Dr. D: ¿Dónde ha nacido?

[.]


106

Mrs. N: U:mm: [.] Munaypampa.1

Dr. D: NO, YOU you you you

Mrs. N: Me:, in the countryside I was born.

Dr. D: Whe:re?

Mrs. N: Juárez Province:: [.] Calapata.

[.]

Dr. D: How’s that?

Mrs. N: Calapata.

Dr. D: Calapata?

Mrs. N: Yes. [.] We belong to Canton Cristóbal

Márquez.

[2]

Dr. D: I don’t know it. Whereabouts is that?

Mrs. N: It’s over on that side. [‘] Er: [.] facing

Mount Inti.

[1]

Dr. D: Ah. [.] What’s it called?

Mrs. N: Er:: [.] Juárez Province XM an::d

Dr. D: Yes. Canton.

Mrs. N: Canton Cristóbal Márquez. But

{it has}

Dr. D: {Cristóbal Márquez}?

Sra. N: E:mm: [.] Munaypampa.

Dr. D: NO, USTED Usted Usted Usted

Sra. N: Yo: en el campo he nacido.

Dr. D: ¿Dó:nde?

Sra. N: Provincia Juárez: [.] Calapata.

[.]

Dr. D: ¿Cómo?

Sra. N: Calapata.

Dr. D: ¿Calapata?

Sra. N: Sí. [.] Pertenecemos a Cantón Cristóbal

Márquez.

[2]

Dr. D: No conozco. ¿Por dónde es eso?

Sra. N: Es aquel lado. [‘] Ehh: [.] frente al

Cerro Inti.

[1]

Dr. D: Ah. [.] ¿Cómo se llama?

Sra. N: Eh:: [.] Provincia Juárez y::

Dr. D: Sí. Cantón.

Sra. N: Cantón Cristóbal Márquez. Pero

{tiene}

Dr. D: ¿{Cristóbal Márquez}?


107

Mrs. N: Yes.

[For six seconds, Dr. D writes.]

Dr. D: [[in an almost inaudible tone, talking to

himself]] Right. [[in direct, emphatic tone]]

Why have you come?

[1]

Mrs. N: Mm: [.] I’ve come to consult about

my wo:mb, there are times I feel [‘] [.]

that’s to say they hurt, my ki:dneys [1] or-

I don’t know what part it’s called, this pa:rt:: [.]

that part [.]

First I had myself put in um: [2]

a copper T but:: [.] it was there about two

months: [.] a bit more it was there. [.] Mh. [.]

A::nd I had that taken out of me up over the::re

[.] mm [.] what’s it called that: surgery

over the::re [1] in the:: [.] what’s it called that:?

[.] mm [.] Villa Asunción. [.] That’s it.

[.]

Dr. D: Right.

Mrs. N: I don’t know. [.] In there I had it

taken ou:t of me and:

Dr. D: [??]

Mrs. N: Right. [.] So: [.] I had it taken ou:t

an:d after tha::t [.] a short while ago: [.] [[in a

low tone]] I got some descharge [.] a lot [??].

Sra. N: Sí.

[Durante 6 segundos, Dr. D escribe.]

Dr. D: [[en voz casi inaudible, hablando solo]]

Ya. [[en tono directo y enfático]]

¿Por qué viene?

[1]

Sra. N: Mm: [.] yo vengo a consultar de

matrí:z:, hay ratos me siento: [‘] [.]

o sea me duele los riño:nes [1] o-

no sé qué parte se llama esta pa:rte:: [.]

esa parte [.]

Primero me he hecho colocar ahm: [2]

T de cobre pero:: [.] estaba como dos

meses: [.] un poco más estaba. [.] Mh. [.]

Y:: me he hecho sacar eso allá arri:ba::

[.] mm [.] ¿cómo se llama ese: consultorio

allá:: [1] en el:: [.] ¿qué se llama ese:?

[.] mm [.] Villa Asunción. [.] Así.

[.]

Dr. D: Ya.

Sra. N: No sé. [.] En ahí me he hecho

saca:r y:

Dr. D: [??]

Sra. N: Ya. [.] Entonces: [.] Me he hecho saca:r

y: de ahí:: [.] hace poco: [.] [[en tono bajo]] m:e

ha venido unos flojos [.] fuerte [??].


108

Dr. D: Mh.

Mrs. N: And it gives me itchiness.

Dr. D: Because it’s that.

Mrs. N: And [.] first here it hurt me.

That’s to say: [‘] er- after my period like a:

blow that it gave me there

Dr. D: Mh

Mrs. N: So- after that [1] er: [.] like that

I made it pa:ss me, pa:ss [.] then: [1]

that came on me. [1] And ever so often. [.]

Th:other day I came. [.] It was on strike [.]

Dr. D: Mh.

Mrs. N: No-one was there. [‘]. [1]

[[in a very low tone]] That’s it. Now [‘] I’ve

come. [.] To consult oneself, what it is that

I’ve got. [1] [??] those things.

[.]

Dr. D: Right. But what- [.] [[enunciating very

clearly]] what [.] wha:t [[uses the familiar ‘tú’

form for the first time, pronouncing very

clearly]] are you principally coming for, why?

[‘] Because you have di:scharge, or because

it hu:rts you, or- [.] why.

Mrs. N: Because mm:- it hu:rts mme:,

that’s to say first the ki::dneys:

Dr. D: Mh.

Sra. N: Y me hace escosión.

Dr. D: Porque es eso.

Sra. N: Y [.] premero aquí me ha dolido.

O sea: [‘] ah- después de mi período como un:

golpe que me ha dado ahí

Dr. D: Mh

Sra. N: Entons- de eso [1] eh: [.] así

he hecho pasa:rme, pasa:r [.] después: [1]

me ha venido eso. [1] Y seguidamente. [.]

Lo:otro día he venido. [.] Estaba en paro [.]

Dr. D: Mh.

Sra. N: Nadie había. [‘]. [1]

[[en tono muy bajo]] Eso es. Ahora: [‘] he

venido. [.] A consultarse, qué es lo que

tengo. [1] [??] esas cosas.

[.]

Dr. D: Ya. Pero qué- [.] [[enunciando muy

nítidamente]] ¿por qué [.] p:or qué [[recurre al

tuteo por primera vez, enunciando muy

nítidamente]] vienes principalmente, por qué?

[‘] ¿Porque tienes flu:jo, o porque

te due:le, o- [.] por qué.

Sra. N: Porque mm:- mm:i duele,

o sea a principio los riño::nes:


109

Dr. D: Wh:- where does it hurt you, show me

[[in a low tone]] where does it hurt you

Mrs. N: [[firmly]] Here.

[1]

Dr. D: The tummy.

Mrs. N: Yes. [‘] And [.] do:wn there in the

vagina: it makes me itchiness.

Dr. D: It itches you.

Mrs. N: Yes.

[1]

Dr. D: And that is:: [.] what most worries you.

Mrs. N: Tha:t: most wor{ries me}

Dr. D: {Yes?}

Mrs. N: an::d [.] what’s it called [.] [‘] and

no way, I don’t know, I fee::l pain in my bo:nes

[.] like [.] cold that comes in:to me [1] like.

[5]

Mrs. N: And also I have headaches

so:::metimes, li:ke [.] as though [.] doped I go

round.

[6]

Dr. D: Since more or less a month:? [.] That.

[.] Two months.

[1]

Dr. D: Dó:- ¿dónde te duele, mostráme

[[en tono bajo]] dónde te duele

Sra. N: [[en tono firme]] Aquí.

[1]

Dr. D: La barriga.

Sra. N: Sí. [‘] Y [.] abajo: a la

vagina: me hace escosión.

Dr. D: Te escuece.

Sra. N: Sí.

[1]

Dr. D: Y eso es:: [.] lo que más te preocupa.

Sra. N: E:se: más me preo{cupa}

Dr. D: {¿Sí?}

Sra. N: y:: [.] qué se llama [.] [‘] y

ni hacer, no sé me s::iento dolor de hue:so

[.] así [.] frío que me e:ntra [1] así.

[5]

Sra. N: Y también tengo dolor de cabeza

hay ra:::tos así: [.] como que [.] atuntada

andu.

[6]

Dr. D: ¿Hace más o menos un mes:? [.] Esto.

[.] Dos meses.

[1]


110

Mrs. N: Yes, one month after my period

ca- period came to me on the fourtee:nth [1]

mm:: after my period- my period [3]

pa:ssin:g abou:t eight day:s like. [1]

It came to me.

[3]

Dr. D: Right. [4] [[in loud and direct tone]]

HOW are you urinating?

[2]

Mrs. N: Er:m: [.] tha:t [.] my urine is strong [1]

the [.] odour is really strong, that’s to say

there are times it unchanges, [‘] it’s the colour

of pineapple, at times it’s the colour of te:a, [‘]

at times it seems purple too [‘] like.

Dr. D: P:[??] these two last days

[1]

Mrs. N: Yes, {well}

Dr. D: {There} it is. O{dour?}

Mrs. N: {Like that} it is.

Dr. D: How have you urinated? Aren’t you

urinating at every moment?

Mrs. N: I’m no::t uri{nating}

Dr. D: {Don’t you} get the call to urinate at

every moment? Doesn’t it bu::r:n: you when

you urinate?

[1]

Sra. N: Sí un mes después de mi período

me ha- período me ha venío cato:rce [1]

mm:: después de mi período- mi período [3]

pasa:n:do un:os ocho dí:as así. [1]

Me ha venido.

[3]

Dr. D: Ya. [4] [[en tono fuerte y directo]]

¿COMO estás orinando?

[2]

Sra. N: Eh:m: [.] e:se [.] mi orín es fuerte [1]

el [.] olor es bien fuerte, o sea

hay ratos desvaría, [‘] es color de

piña, hay ratos es color de té:, [‘]

a veces parece morada también [‘] así.

Dr. D: P:[??] estos dos últimos días

[1]

Sra. N: Sí, {pues}

Dr. D: {Ahí} es. ¿O{lor?}

Sra. N: {Así} es.

Dr. D: ¿Cómo has orinado? ¿No estás

orinando a cada rato?

Sra. N: N::o estoy ori{nando}

Dr. D: ¿{No te} llama a orinar a

cada rato? No te a::r:de: cuando

orinas?

[1]


111

Mrs. N: [[sighing]] It does:n´t burn me.

[1]

Dr. D: No? {No}

Mrs. N: {No.}

Dr. D: does it hurt you?

[.]

Mrs. N: [‘] Befo:re, before {???}

Dr. D: {NO NO NO, NOW} well.

{Now.}

Mrs. N: {Now}

Dr. D: Befo:re, [[in a low tone, as if talking

to himself]] already is no:t of much interest.

[[in a regular tone]] Now.

[.]

Mrs. N: Now it doesn’t, it doesn’t bu:rn me but

rather:: [1] Before my period: [.] that’s to say [.]

before my period came it::: hurt me,

that’s to say [.]

in- [.] since I work, I do, [‘] in my work

they don’t e:ven: give me to s- [.] not even to t-

like [.] pass water, my:: [.] lady [.] [‘]

that’s to say ‘What have you don::e?’

she’ll be saying to me then, so- I ha:v:e

to bear it, so- for that reason [.]

[‘] that’s to say, li:ke [.] it’s like I:: [‘] [.] like

as if [.] a:ir is in my- inside my my

Sra. N: [[suspirando]] N:o me arde.

[1]

Dr. D: ¿No? {No}

Sra. N: {No.}

Dr. D: te duele?

[.]

Sra. N: [‘] A:ntes, antes {???}

Dr. D: {NO NO NO, AHORA} pues.

{Ahora.}

Sra. N: {Ahora}

Dr. D: A:ntes, [[en voz baja, como hablando

solo]] ya: no: interesa mucho.

[[en tono regular]] Ahora.

[.]

Sra. N: Ahora no, no me a:rde sino

que:: [1] Antes de mi período: [.] o sea [.]

antes que me bajaba mi período mi::: dolía,

o sea [.]

en- [.] como trabajo yo, [‘] en mi trabajo

no me da n:i: para s:- [.] ni para t-

así [.] desaguar, mi:: [.] señora [.] [‘]

o sea ‘Qué has hecho::?’

me dicerá ps entons- me to:ca:

aguantar entons- de ese motivo [.]

[‘] o sea como: [.] como qui mi:: [‘] [.] como

que [.] a:ire está en mi- dentro de mi mi


112

stomach here so- from the umbilicus it rose up

to me here. [.] Here I felt bad. [.]

[‘] After: [.] that: [1] er I::um [.] I took

herbal te::as [.] like. [‘] So that:: [.] that a:ir

wouldn’t make me make me swell up. Af:ter [1]

um [.] ALREADY I WAS ALL RIGHT: [.]

after that, [.] that: [.] thing cam:e to me.

[3] That’s to say more before i:t used to swell

me up here [.] where the womb is [.] there [.]

like as if: like I’m blown up. [2] So

[.] er I

Here the second side of cassette 3.1 ends

(up to here, there have been 7 minutes of

recording 3.4).

[[The recording is cut for a few seconds

while SR changes the cassette.]]

Start of the first side of cassette 3.3

[16]

Dr. D: [[in an emphatic and direct tone]]

When did the period come?

[1]

Mrs. N: Er: fourteenth of::: m::

[.]

Dr. D: November.

Mrs. N: November.

estómago aquí entons- del ombligo me subía

aquí. [.] Aquí me sentía mal. [.]

[‘] Después: [.] eso: [1] eh me::m [.] he tomado

mate::s [.] así. [‘] Para que:: [.] ese a:ire

que no me se me hinchar. Después: [1]

ehm [.] YA ESTABA BIEN: [.]

después de eso, [.] es:a [.] cosa me ha: venido.

[3] O sea más antes mi: hinchaba

aquí [.] donde el matríz [.] ahí [.]

así como: como que estoy enflado. [2]

Entonces [.] eh yo he

Termina el segundo lado del cassette 3.1

(hasta aquí, van 7 minutos de la

grabación 3.4).

[[Se corta la grabación durante unos segundos

mientras SR cambia el cassette.]]

Se inicia el primer lado del cassette 3.3

[16]

Dr. D: [[en tono enfático y directo]]

¿Cuándo ha bajado la menstruación?

[1]

Sra. N: Eh: catorce de:::m::

[.]

Dr. D: Noviembre.

Sra. N: Noviembre.


113

Dr. D: That’s to say, it’s just about to come

now, right?

Mrs. N: Yes, it’s just//

Dr. D: //Every month it comes?

Mrs. N: Every month. One {day: it does:, [??]}

Dr. D: {How- How many da}ys does it last?

How many days does it last?

[.]

Mrs. N: Er: [.] four days.

Dr. D: [[repeats in almost inaudible tone,

talking to himself while he notes down]] Four

days. [2] [[in emphatic tone]] When did it come

down to you for the FIRST TIME? [.] How

many years old were you?

Mrs. N: I was: ele:ven years old.

Dr. D: Eleven. Early you got it!

Mrs. N: [[in a low tone, sighing]] Yes::

Dr. D: And how many kids have you had?

Mrs. N: Er:: [.] I’ve had two:.

Dr. D: TWO?

Mrs. N: [[in a very low tone]] Mm:

{[?] after:}

Dr. D: O sea, ya va a bajar

ahora, ¿no?

Sra. N: Sí, ya va//

Dr. D: //¿Cada mes baja?

Sra. N: Cada mes. Un {dí:a sí:, [??]}

Dr. D: {¿Cuánt- Cuántos dí}as dura?

¿Cuántos días dura?

[.]

Sra. N: Ehh: [.] cuatro días.

Dr. D: [[repite en voz casi inaudible,

hablando solo mientras anota]] Cuatro

días. [2] [[en tono enfático]] ¿Cuándo

te ha bajado la PRIMERA VEZ? [.] ¿Cuántos

años tenías?

Sra. N: Yo tiní:a o:nce años.

Dr. D: Once. ¡Temprano te ha bajado!

Sra. N: [[en voz baja, suspirando]] Sí::

Dr. D: ¿Y cuántas wawas has tenido?

Sra. N: Eh:: [.] he tenido dos:.

Dr. D: ¿DOS?

Sra. N: [[en voz muy baja]] Mm:

{[?] después:}


114

Dr. D: {[??]} Af{ter?}

Mrs. N: [[in a very low tone]] {I’ve had} two

abortions:.

Dr. D: Two abortions!

Mrs. N: [[in almost inaudible tone]] Yes.

Dr. D: Yes? [1] And did you have it

taken out of you, or all by itself did it come out?

[1]

Mrs. N: Mm: [.] no. [1] Or:{:[.]}

Dr. D: {[??]}

Mrs. N: I had it taken out of me.

[.]

Dr. D: The two {times?}

Mrs. N: {[?]} Yes. [[in a very low tone that

becomes almost inaudible]] The two times.

Because I didn’t hav:e [.] [in]su:ran:ce: [.] my

little daughter was only three months:,

Dr. D: Yes

Mrs. N: And after three months that: I: had it

taken out of me again I got pregnant [[in

almost inaudible tone, sighing]] and again I had

it taken out of me. [1] My daughter was going

to su:ffer.

[.]

Dr. D: {[??]} ¿Des{pués ?}

Sra. N: [[en tono muy bajo]] {He tenido} dos

abortos:.

Dr. D: ¡Dos abortos!

Sra. N: [[en voz casi inaudible]] Sí.

Dr. D: ¿Sí? [1] Y vos te has hecho

sacar, o solito se ha salido?

[1]

Sra. N: Mm: [.] no. [1] O:{:[.]}

Dr. D: {[??]}

Sra. N: yo me he hecho sacar.

[.]

Dr. D: ¿Las dos {veces?}

Sra. N: {[?]} Sí. [[en voz muy baja que

se vuelve casi inaudible]] Los dos veces.

Porque no tení:a [.] [se]gu:ro:s: [.] mi

hijita tenía apenas tres meses:,

Dr. D: Sí

Sra. N: Y después de tres meses que: me he

hecho sacar de vuelta me he embarazado [[en

voz casi inaudible, suspirando]] y de vuelta me

he hecho sacar. [1] Mi hija iba

a sufri:r.

[.]


115

Dr. D: Ri:ght. [2] That’s to say [.] four times

you’ve got pregnant, you’ve had two kids [1]

two abortions. THE LA:ST, [.] the la:st, what

was it? [.] That fail- that abortion, or [.] birth.

[1]

Mrs. N: Mm: [.] it was:n’t [.] a birth, but it

{was [?]}

Dr. D: {Abortion.}

Mrs. N: Abortion.

Dr. D: Whe:n: was that?

Mrs. N: [‘] That’s to say, just like that it appe-

that’s how that was. [.] Mm [.] when

she was three months my daughter, at: four

months already I was: pregnant, I was.

Dr. D: Right. And?

Mrs. N: After [.] that I had it taken out of me,

[.] like at: two months I had it taken out of me.

Dr. D: Right. When was that?

[.]

Mrs. N: That was: like: [.] My daughter is four

years old.

[1]

Dr. D: Right. Four years ago?

Mrs. N: Yes:.

Dr. D: Y:a. [2] O sea [.] cuatro veces

te has embarazado, has tenido dos wawas [1]

dos abortos. LO U:LTIMO, [.] lo ú:ltimo, ¿qué

ha sido? [.] ¿Ese frac- ese aborto, o [.] parto.

[1]

Sra. N: Mm: [.] n:o era: [.] parto, sino

que {ha [?]}

Dr. D: {Aborto.}

Sra. N: Aborto.

Dr. D: ¿Cuá:n:do ha sido eso?

Sra. N: [‘] O sea, así ha apare-

así ha sido eso. [.] Mm [.] cuando

estaba de tres meses mi hija, a los: cuatro

meses ya estaba: embarazada yo.

Dr. D: Ya. ¿Y?

Sra. N: Después de [.] eso me he hecho sacar,

[.] como de: dos meses me he hecho sacar.

Dr. D: Ya. ¿Cuándo ha sido eso?

[.]

Sra. N: Eso ha sido: así: [.] Mi hija tiene cuatro

años.

[1]

Dr. D: Ya. ¿Hace cuatro años?

Sra. N: Sí:.


116

Dr. D: Or after, another one did you have?

[.]

Mrs. N: N:o. I haven’t had//

Dr. D: //It’s- since that time, again you haven’t

got preg{nant?}

Mrs. N: {An:d [.] right.} [‘] I had it

put in me for that, so as not to have one,

Dr. D: {Yes}

Mrs. N: {I di}d:- [.] a copper T, in

Grover Hospital they put it in me.

Dr. D: And:?

Mrs. N: An:d after: with:: Doctorita María [.]

López I had it put in me. [2] After I: [.]

{she [??]}

Dr. D: [[almost shouting]] {HOW LONG}

DID YOU USE IT?

Mrs. N: Ah: [.] two ye:ar: [.] and a bit more

than- [.] like {five mo:n-}

Dr. D: {Two years.}

Mrs. N: No.

Dr. D: Right. {Up until}

Mrs. N: {Four months.}

Dr. D: O después, ¿otro más has tenido?

[.]

Sra. N: N:o. No he tenido//

Dr. D: //Es- desde esa vez ¿ya no te has

em{barazado?}

Sra. N: {Y: [.] ya.} [[suspira]] Me he hecho

colocar por eso para no tener,

Dr. D: {Sí}

Sra. N: {he he}cho:- [.] T de cobre en el

Hospital Grover me han colocado.

Dr. D: ¿Y:?

Sra. N: Y: después: a:: la Doctorita María [.]

López me he hecho colocar. [2] Después me: [.]

{ella [??]}

Dr. D: [[casi gritando]] {CUANTO TIEMPO}

HAS USADO?

Sra. N: Ah: [.] dos a:ño: [.] y un poco más

de- [.] co{mo cinco me:-}

Dr. D: {Dos años.}

Sra. N: No.

Dr. D: Ya. {¿Hasta hace}

Sra. N: {Cuatro meses.}


117

Dr. D: whe:n [.] until- up- until whe:n?

[2] Until when? When did you have it

taken out of you?

Mrs. N: I had it taken out of me in October.

Dr. D: Up until October of this: [.] now

already- now do you want to get pregnant?

[1]

Mrs. N: N::o! I’m taking care of myself like

that, {just.}

Dr. D: {How} are you taking care of yourself?

Mrs. N: Like that counting the days.

Dr. D: Yes? [[in a low tone]] How do you

count the days?

Mrs. N: That’s to say, fifteen day:s [.] I count,

at times twelve day:s, like that.

Dr. D: And?

Mrs. N: But:: [.] {I’m}

Dr. D: {And what happens?}

Mrs. N: That’s to say: [.] I’m not: [.] either I’m

not taking any pill, all this.

Dr. D: Let’s see. Now [.] now [.] for when

do you expect your menstruation?

[.]

Dr. D: cuá:ndo [.] hasta- hace- hasta cuá:ndo?

[2] ¿Hasta cuándo? ¿Cuándo te has hecho

sacar?

Sra. N: Me he hecho sacar en octubre.

Dr. D: Hasta octubre de este: [.] ahora

ya- ahora ¿quieres embarazarte?

[1]

Sra. N: ¡N::o! Me estoy cuidando

así {nomás.}

Dr. D: {¿Cómo} te estás cuidando?

Sra. N: Así contando los días.

Dr. D: ¿Sí? [[en tono bajo]] ¿Cómo

cuentas los días?

Sra. N: O sea, quince dí:as [.] cuento,

hay ratos doce dí:as, así.

Dr. D: ¿Y?

Sra. N: Pero:: [.] {estoy}

Dr. D: {¿Y qué pasa?}

Sra. N: O sea: [.] no: [.] tampoco estoy

tomando ningún pastilla, todo esto.

Dr. D: A ver. Ahora [.] ahora [.] ¿para cuándo

esperas tu menstruación?

[.]


118

Mrs. N: Er [.] I expect it for [1] fif:teenth,

fourteenth, around then.

Dr. D: Now can you have relations, or not?

[1]

Mrs. N: N::

[1]

Dr. D: [[in a low tone]] Right now if your

husband [1] er: [.] says to you [1] ‘let’s have

relations.’ [2] Can you have it [.] so as not

to get yourself preg:nant, [.] to

get yourself preg:nant, how [??]?

Mrs. N: Mm: [1] Yes, but: [.] as I’m not:: [.] t-

when it is:: [.] p:assing, the period, [1] [‘] the

Doctorita told me, you’re going to take care of

yourself, she {told me.}

Dr. D: {When} it’s passing?

[.]

Mrs. N: ‘When your period is passing you take

care of yourself,’ she told me.

Dr. D: That’s to say when you are- [.]

menstruating, [1] you’re not going to [.] have

relations?

[1]

Mrs. N: When I am menstruating I can have

relations, but when alre:ady it’s passed me,

[.] I can’t have relations, because:

Sra. N: Eh [.] espero para [1] qui:nce,

catorce, por ahí.

Dr. D: Ahora ¿puedes tener relaciones, o no?

[1]

Sra. N: N::

[1]

Dr. D: [[en tono bajo]] Ahorita si tu

marido [1] e:ste [.] te dice [1] "tenemos

relaciones". [2] ¿Puedes tenerlo [.] para no

embaraza:rte, [.] para

embaraza:rte, ¿cómo [??]?

Sra. N: Mm: [1] Sí, pero: [.] como no:: [.] t-

cuando está:: [.] p:asando el período, [1] [‘] l:a

Doctorita me ha dicho, te vas a cuidar,

me ha {dicho.}

Dr. D: {¿Cuando} está pasando?

[.]

Sra. N: ‘Cuando está pasando tu período te vas

a cuidar,’ me ha dicho.

Dr. D: O sea cuando está- [.]

menstruando, [1] ¿no vas a [.] tener

relaciones?

[1]

Sra. N: Cuando estoy menstruando puedo tener

relaciones, pero cuando ya se me ha:ya pasado,

[.] no puedo tener relaciones, porque:


119

Dr. D: That’s to say, five [.] day:s only [1] [‘]

It lasts you four days, your menstruation?

Mrs. N: Yes.

[1]

Dr. D: And those four days only you can

hav:e [1] relations, then [1] all the {month,}

Mrs. N: {[?]}

Dr. D: NOTHING?

[1]

Mrs. N: [‘] N::o! That’s to say, twelve days: [.]

to m:e she told that, well, up to fifteen

maximum you’re going to take care of yourself,

she told me. [2] Because:: [1] you can’t be-

[.] maybe//

Dr. D: //AND AFTER THE FIFTEENTH?

[2]

Mrs. N: One can have rela{tions.}

Dr. D: {That’s to say,} now you can

have them?

Mrs. N: [[in an almost inaudible tone]] Yes:.

[1]

Dr. D: Like that you take care of yourself.

[1]

Mrs. N: Yes.

Dr. D: O sea, cinco [.] dí:as nomás [1] [‘]

Te dura cuatro días tu menstruación?

Sra. N: Sí.

[1]

Dr. D: ¿Y esos cuatro días nomás puedes

tener: [1] relaciones, después [1] todo el {mes,}

Sra. N: {[?]}

Dr. D: NADA?

[1]

Sra. N: [‘] ¡N::o! O sea, doce días: [.]

m:e ha dicho ella pues, hasta quince

máximo te vas a cuidar,

me ha dicho. [2] Porque:: [1] n:o puedes estar-

[.] por ahí//

Dr. D: // Y DESPUES DEL QUINCE?

[2]

Sra. N: Se puede tener rela{ciones.}

Dr. D: {O sea,} ¿ahora puedes

tener?

Sra. N: [[en voz casi inaudible]] Sí:.

[1]

Dr. D: Así te cuidas.

[1]

Sra. N: Sí:.


120

Dr. D: [[in an almost inaudible tone, as if

talking to himself]] Right. [3] So [.] you are

using the method of rhy:thm, right? That

would be it [.] [[while noting down what he is

saying]] me:thod of rhy::thm.

[1]

Mrs. N: Yes. [sighs] After I had it

taken out of me [??] but, she gave me like a

little pill, [.] she prescribed it to me ‘so

you don’t-‘ [‘] er- [.] because: they say that

quickly one gets pregnant when

the copper T is taken out.

[1]

Dr. D: And?

Mrs. N: An:d [.] I took it, but::

Dr. D: What little pill?

Mrs. N: Tha:t was: m::- I don’t know what it

was called that little pill to::- [.] little tiny ones.

[2]

Dr. D: Which?

Mrs. N: [??] a little ta:bl:et:

[.]

Dr. D: Yes. [.] Each day?

[1]

Mrs. N: Yes, ‘Each night you’re to take it’//

Dr. D: [[en voz casi inaudible, como

hablando solo]] Ya. [3] Entonces [.] estás

usando el método del r:itmo, ¿no? Eso

sería, [.] [[a tiempo de anotar lo enunciado]]

m:étodo del r::itmo.

[1]

Sra. N: Sí. [[suspira]] Después que me he

hecho sacar [??] pero, me ha dao así una

pastillita, [.] me ha recetado ‘para que

no te-’ [‘] eh- [.] porque: dice que

rápido se embaraza cuando

se saca el T de cobre.

[1]

Dr. D: ¿Y?

Sra. N: Y: [.] he tomado, pero::

Dr. D: ¿Qué pastillita?

Sra. N: E:sa era: m::- no sé qué se

llamaba esa pastillita para::- [.] chiquititos.

[2]

Dr. D: ¿Cuál?

Sra. N: [??] una ta:ble:ta:

[.]

Dr. D: Sí. [.] ¿Cada día?

[1]

Sra. N: Sí, ‘Cada noche vas a tomar’//


121

Dr. D: //Each- [.]Did you take it? All the

{month?}

Mrs. N: {I} took it. All- [.] all the month I

took that, after [1] [‘] that’s to say, it gave me

lik::- [.] dizziness it gave me, then

I left that.

[.]

Dr. D: Mhm:

Mrs. N: ‘You’re to come back’, she told me

[??]. [.] That’s to say in the: [.] clinic: [.] what’s

it called that hospital, what’s it called that

hospital, [.] [‘] ‘There I’ll give it to you’,

she told me.

But: [.] I haven’t gone back again because: [1]

it gave me like di:zziness: [.] it was bad for me

[???] it was bad for me.

[.]

Dr. D: Mm

Mrs. N: That’s why I left it. [1] But- [1] [‘’’]

and

[1]

Dr. D: Ve:ry well. [1] So now: you’re

taking care of yourself with the method of

rhythm, right?

Mrs. N: Yes.

[1]

Dr. D: //Cada- [.] ¿Has tomado? ¿Todo el

{mes?}

Sra. N: {He} tomado. Tod- [.] todo el mes he

tomado eso, después [1] [‘] o sea, me ha dado

com::- [.] maríos me ha dao, después

lo he dejado eso.

[.]

Dr. D: Mjm:

Sra. N: ‘Vas a volver’, me ha dicho

[??]. [.] O sea en el: [.] clínica: [.] qué

se llama ese hospital, qué se llama ese

hospital, [.] [‘] ‘Ahí te voy a dar’,

me ha dicho.

Pero: [.] ya no he vuelto porque: [1]

me ha dado como m:areos: [.] me hacía mal

[???] me hacía mal.

[.]

Dr. D: Mm

Sra. N: Por eso he dejado. [1] Pero- [1] [‘’’]

y

[1]

Dr. D: Mu:y bien. [1] Entonces ahora: te estás

cuidando con el método del

ritmo, ¿no?

Sra. N: Sí.

[1]


122

Appendix 5

Contextualisation of transcript excerpt introducing Chapter 5, The Empty Bed

Excerpt of SR’s transcribed field notes on interactions with the following characteristics:

Participants: Dr. Gonzáles (Dr. G), staff gynaecologist and academic

coordinator of residents’ training, principal research collaborator

in Insurance Hospital.

Mrs. Mayta (Mrs. M), awaiting oncological surgery following a

therapeutic interruption of pregnancy in the hospital.

Mrs. Quiroga (Mrs. Q), awaiting gynaecological surgery.

Three other women visited in their beds on the ward round.

Nurse, medical resident, and intern Rayda (R), all women.

SR as researcher.

Date and time of observation: Monday 31/3/97, 8.10 – 8.30 a.m.

Place: Gynaecology ward, Insurance Hospital

Source of notes on context: Field Notebook 3, notes summarised 21/4/97, edited 22/7/02.

Number & date of transcript: A.X9.1, 21/4/97

Context:

This transcript is of fieldnotes written at the time of the gynaecology ward round which I accompanied on the

invitation of Dr. Gonzáles, my principal collaborator in the Insurance Hospital.

Just before the ward round, on the initiative of Head Nurse Elena Elías, for the first time I attended the daily

change of medical shifts (cambio de turno) in the gynaecology ward classroom. This session was led by Dr.

Salinas, the ward chief. When it ended, Dr. Salinas introduced me to the group of doctors and residents,

saying: ‘She’s going to accompany us’. He asked me to give a talk two days later to all the ward staff, to

present some of my research findings.

I left the classroom with Dr. Gonzáles, a nurse, and two women whom I took to be residents, to accompany

them on the ward round. This transcript is of notes I took at the time of the ward round and just afterwards, in

view of those present. Before leaving with Dr. Gonzáles for the operating theatre, I spoke to Rayda, who

turned out to be an intern.


123

Start of Transcript A.X9.1, notes from

Field Notebook 3:

Dr. G starts the medical visit with ♀ nurse and

2 ♀ residents.i

Dr. G: (1st bed visited) 16 weeks of

pregnancy. Tumour. Dermoid.

(to SR:) Medical Council. Interruption of

pregnancy. Pregnancy of high risk. It’s in the

pages of the daily report... → Oncology.

_____

Dr. G: (to Mrs. M) How are you

A little bleeding

You know

Transfer to Oncology –

You’re not to get pregnant

Reproductive Health

She mustn’t have another unwanted pregnancy,

→ another abortion.

Dangerous.

_____

Mrs. M: All right doctor

________

Dr. G: Her risk card

(NOTE: check)

_____

✰ We include her as incomplete abortion.

____

♀ Nurse: She is Doctor on Methergin

_ _

Dr. G: Dermoid tumour.

Inicio de la transcripción A.X9.1, apuntes del

Cuaderno de Campo 3:

Dr. G empieza la visita médica con enfermera

♀ y 2 residentes ♀.

Dr. G: (1ra cama visitada) 16 semanas de

embarazo. Tumor. Dermoide.

(a SR:) Junta médica. Interrupción de

embarazo. Embarazo de alto riesgo. Está en las

hojas del informe diario... → Oncología.

_____

Dr. G: (a Sra. M) Cómo está

Sangradito

Tú sabes

Transferencia a Oncología -

No hay que embarazarse

Salud Reproductiva

Que no tenga otro embarazo no deseado,

→ otro aborto.

Peligroso .

_____

Sra. M: Ya doctor

_____

Dr. G: Su carnet de riesgo

(NOTA: chequear)

_____

✰ Le incluimos como aborto incompleto.

_____

Enfermera ♀: Ella está Doctor con Methergin

- -

Dr. G: Tumor dermoide.


124

Mrs. M x Pregnant ♀ resident

Dr. G

Nurse

♀ resident SR Dr. G: (to Mrs. M) You’ve got up?

A little bleeding?

Little?

Right.

_____

A little more orientation.

____________________

(Next bed)

Dr. G: (to pregnant woman resident)

35 years.

Bleeding.

Pelvic tumour

Biopsy

_____

Nurse: Metronidazol.

_____

Dr. G: (to ♀) A little bit of patience.

Metronidazol in pessaries.

_____

Dr. G: (to ♀) Have someone come and give

blood – in case we decide on the intervention.

_____

Dr. G: (examines same ♀ in the bed)

A little bleeding ...

Seventh day

Mrs. M x Embarazada RM Dr. G

Enfermera ♀RM SR Dr. G: (to Mrs. M) Te has levantado?

Sangradito?

Poco?

Ya.

_____

Un poco más orientación.

________________________

(Próxima cama)

Dr. G: (a Residente Médica embarazada)

35 años.

Sangrado.

Tumor pélvico

Biopsia

_____

Enfermera: Metronidazol.

_____

Dr. G: (to ♀) Un poquito de paciencia.

Metronidazol en óvulos.

_____

Dr. G: (a ♀) Alguien que venga a dar

sangre - por si decidimos la intervención.

_____

Dr. G: (examina a misma ♀ en la cama)

Sangrecita ...

Séptimo día


125

Operatedii

♀: All right Doctor.

♀: - - go to the bathroom

Cramp in my leg

It doesn’t pass in me

Dr. G: Ferrous sulphate

Dizziness?

♀: A little...

Dr. G: We’ll see the haemoglobin, how it is.

Bland diet.

Take out little stitches.

Keep resting –

Today is the 31st.

_____

♀: Doctor?

_____

Dr. G: ...

_____

♀: I want...

_____

Dr. G: (speaks very rapidly) Ask for

an appointment for check-up.

(8.14)

♀: All right Doctor.

This Friday.

(Rapid exchange)

♀: (complains as Dr. G takes out stitches)

Dr. G: Loosen up now.

Operadita -

♀: Ya Doctor.

♀-- ir al baño

Calambre en la pierna

No se me pasa

Dr. G: Sulfato ferroso

¿Mareos ?

♀ Un poco...

Dr. G: Veremos la hemoglobina como está.

Dieta blanda.

Sacar puntitos.

Mantener reposo -

Hoy día es 31.

_____

♀: Doctor?

_____

Dr. G: ...

________

♀: Yo quiero...

_______

Dr. G: (habla muy rápido). Pide

una cita para control.

(8.14)

♀: Ya Doctor.

Este viernes.

(Intercambio rápido).

♀: (se queja cuando Dr. G saca puntos)

Dr. G: Sueltita nomás.


126

Analgesic.

(SR and ♀ in previous bed exchange

gestures of empathy with ♀ who is

complaining).

(Bed # –)

Dr. G: (to SR) She’s from another service,

from surgery...

_____

(Bed # -)

Dr. G: She has done to herself...

(a ♀) Where do you work?

(rural worker)

_____

♀: Doctor, am I going to have - -

days?

_____

Dr. G: - - yet.

You have to be tranquil.iii

Do you work Saturdays?

♀: No. Monday to Friday.

_____

Dr. G: You’re going to wrap yourself up well.

You’re going to take care of yourself.

_____

(Bed # – Dr. G greets and leaves.

____________________

(→ Ward 9)

(# – empty bed – they stand at the foot of the

bed.)

Dr. G: (to SR) They are patients who are going

to be operated downstairs...

Calmante.

(SR y ♀en cama anterior intercambian

gestos de empatía con ♀ que

se queja.)

(Cama # -)

Dr. G: (a SR) Es de otro servicio,

de cirugía...

_____

(Cama # -)

Dr. G: Ella se ha hecho ..

(a ♀) Dónde trabajas ?

(campesina)

_____

♀: Doctor, voy a tener - -

días?.

_____

Dr. G: - - todavía.

Tiene que estar tranquilita.

Sábado trabaja?

No. Lunes a viernes.

_____

Dr. G: Se va a abrigar bien.

Se va a cuidar.

_____

(Cama # - Dr. G saluda y sale.

____________________

(→ Sala 9)

# - cama vacía - se paran al pie de la

cama.)

Dr. G: (a SR) Son pacientes que se van

a operar abajo...


127

_________

Dr. G: (to SR) Do you want to enter the

operating theatre?

SR: I do too, if you allow me to.

Dr. G: - - pupils who are going to arrive

from the interior of the country... but I don’t

see them –

_____

(Dr. G writes at foot of empty bed.

Puts papers on bed.)

______________

(Patient enters in a hurry.)

Mrs. Q: Here I am! Here I am!

Sorry –

(to Dr. G:) I’ve got my period.

Nothing to do with it?

Dr. G: No – it’s programmed.

(To R who is leaving:) See you Rayda.

(SR asks Rayda if she is a resident.)

R: Intern –

SR: Of what year?

R: Final year.

___________

We go down → operating theatre...

SR: (to Rayda) Does the visit really end there?

R: The Doctor only passes it in his ward.

_________

Dr. G: (a SR) ¿Quiere entrar a

quirófano ?

SR: También, si me permiten.

Dr. G: - - alumnos que van a llegar

del interior del país... pero no

los veo -

_____

(Dr. G escribe a pie de cama vacía.

Pone papeles en cama.

__________

(Paciente entra apurada.)

Sra. Q: Aquí estoy! Aquí estoy!

Perdón -

(a Dr. G:) Estoy con mi período.

Nada que ver?

Dr. G: No - está programada.

(A R, saliendo:) Nos vemos Rayda.

(SR pregunta a Rayda si es residente.)

R: Interna -

SR: De qué año?

R: Ultimo año.

_________

Bajamos → quirófano...

SR: (a Rayda) Acaso la visita se termina allí?

R: El Doctor sólo pasa de su sala.


128

SR: His ward?

R: It’s passed by 3 doctors at once – on

Wednesdays - grand round, there is.

______________________________

End of Transcript A. X9.1

SR: Su sala ?

R: Pasan 3 doctores a la vez – el

miércoles - visita general hay.

_____________________________

Fin de la transcripción A.X9.1

Notes i I initially supposed that both women were residents, but at the end of the round I found that one of them, Rayda, was an intern. ii Diminutive form, operadita, used in Spanish original. iii Diminutive form, tranquilita, used in Spanish original.


129

Appendix 6

Contextualisation of transcript excerpt cited in section 6.6 of

Chapter 6, Sociology of a Syringe

Excerpt of transcript of interview recorded by SR with the following characteristics:

Participants: Nurse Elena Elías (Nurse EE),i Head Nurse of Insurance Hospital

gynaecology ward;

SR as researcher.

Date and time of interview: Wednesday 4/6/97, 10.15 – 11.23 a.m.

Place: Nurses’ station, gynaecology ward, Insurance Hospital


Number & date of transcript: 14.1, 12-13/6/97

Context:

This was the first interview I (SR) requested with Nurse Elena Elías (Nurse EE), on the day I returned to the

hospital for the final stage of fieldwork. This followed almost a month of my absence from the hospital

because of illness (paratyphus). It fell three days after the general elections won by ADN (Acción

Democrática Nacionalista), the party of former military dictator General Hugo Banzer.

My wish to interview Nurse Elías (Doña Elena) was generated by a recorded interview that I had done earlier

that morning with staff gynaecologist Dr. Walters. He had mentioned that a barrier to the wider use of

Manual Vacuum Aspiration (MVA) was nurses’ resistance to the technology because of the extra work it

meant for them, disinfecting the instruments and cleaning up blood spattered in the treatment rooms.

I requested the interview with Doña Elena and waited for an hour in the nurses’ station until she had time for

me. She was especially busy because she was due to go on holiday leave two days later.

We did the interview with the sporadic presence of various other paramedical workers, and visitors. I tried to

complete it in the shortest possible time because Doña Elena was very busy and there were frequent

interruptions and a lot of noise.

The transcript below corresponds to the totality of the 11-minute recorded interview with Nurse Elías.


130


SR: Right! [‘] so [.] mm: [.] I wanted

to ask you [.] about: the use of MVA, of

manual aspiration

Nurse EE: Ah, right

SR: in the Hospital. [‘] And:: what it signifies

for the personnel, especially in Nursing,

[‘] the use [.] or non-use of this me{thod}

Nurse EE: {Ah, right}

SR: especially for the treatment of

incomplete abortion.

[.]

Nurse EE: Mostly they do:n’t [.] they don’t

do it in incomplete abortions. [1]

The majority of times they do it [.] [‘] on:

patients who have for example:

anembryonic diseases: or:

trophoblasticii diseases. [.] In those

{cases}

SR: {Mm}

Nurse EE: they do it [.] to se:nd um: [.] all

that’s: [.] obtained [.] to Pathology it’s sent [.]

for bio:- o:r to do a biopsy.

SR: Right

Nurse EE: To determine [.] from what cause

Inicio de la Transcripción 14.1

SR: Ya! [‘] -tonces [.] mm: [.] yo quería

preguntarle [.] sobre: el uso del AMEU, de la

aspiración manual

Lic. EE: Ah, ya

SR: en el Hospital. [‘] Y:: qué significa

para el personal, especialmente de Enfermería,

[‘] el uso [.] o no uso de este mé{todo}

Lic. EE: {Ah, ya}

SR: especialmente para el tratamiento del

aborto incompleto.

[.]

Lic. EE: Mayormente no: [.] no

hacen en abortos incompletos. [1]

La mayoría de las veces hacen [.] [‘] en:

pacientes que tienen por ejemplo

las: enfermedades anembrionadas: o:

l:as enfermedades trofoblásticas. [.] En esos

{casos}

SR: {Mm}

Lic. EE: hacen [.] para envia:r ahm: [.] todo

lo: [.] obtenido [.] a Patología se envía [.]

para: bio:- o: para hacer una biopsia.

SR: Ya

Lic. EE: Para determinar [.] de qué causa


131

is: the:

SR: Right

Nurse EE: the: [.] well the: [.] the

degeneration, like of the tissue, right?

SR: Aha

Nurse EE: of that degenerated pregnancy, it’s

a degenerated pregnancy, it would be

SR: Right

Nurse EE: It is not: a normal pregnancy.

SR: Mm

Nurse EE: Uh- in those cases they do it. [‘]

And [.]

also they do it when there’s a lot of bleeding,

like haemostasisiii, in an emergency,

so as: not to wait for the patient [‘] uh:

to bleed herself away until she goes to

the operating theatre,

because in theatre they don’t do it to them

immediately, they rarely accept them from us

when they’re emergency cases. [‘] Because

always they’re busy, the theatres. [.] {In}

SR: {Mhm}

Nurse EE: those cases, yes, here also

es: el:

SR: Ya

Lic. EE: el: [.] pues el: [.] la

degeneración, eso del tejido, ¿no?

SR: Ajá

Lic. EE: del embarazo ese degenerado, es

un embarazo degenerado, sería

SR: Ya

Lic. EE: No es: un embarazo normal.

SR: Mm

Lic. EE: Ah- en esos casos hacen. [‘]

Y [.]

también hacen cuando hay mucho sangrado,

como hemostasia, de urgencia,

para: no esperar a que la paciente [‘] eh:

se desangre mientras vaya a

quirófano,

porque en quirófano no les hacen

inmediatamente, rara vez nos aceptan

cuando son casos de urgencia. [‘] Porque

siempre están ocupados los quirófanos. [.] {En}

SR: {Mjm}

Lic. EE: esos casos sí, aquí también


132

they use: MVA

SR: Right

Nurse EE: for those cases.

[.]

SR: And why would it be that

they’re no longer using it so much for::

incomplete abortion?

[.]

Nurse EE: No, they do:n’t use it, not at all.

SR: Aha

Nurse EE: Mhm

SR: Because it’s: {[??]}

Nurse EE: {ON RARE OCCA:SIONS}

they used it [.] on rare occasions they used it.

SR: Yes

Nurse EE: [‘] It seems tha::t [1] they have the

idea: that if it were to be used, if they learn,

some other doctors, that, [.]

er:: [‘] they would do it even in their surgeries:

[.] if they had that, that’s why it seems that it’s:

like restricted, [‘]

only for those cases of:: [.] haemorrhages: in

cases of: pregnancies like [1] anembrio:nic,

mo:lar,iv

emplean el: AMEU

SR: Ya

Lic. EE: para esos casos.

[.]

SR: Y ¿por qué será que

ya no están utilizando tanto para::

aborto incompleto?

[.]

Lic. EE: No, no: usan, nada.

SR: Ajá

Lic. EE: Mjm

SR: Porque es: {[??]}

Lic. EE: {RARA VE:Z:}

usaban [.] rara vez usaban.

SR: Sí

Lic. EE: [‘] Parece que:: [1] tienen la

idea: de que si es que se usara, si aprenden

algunos otros médicos eso, [.]

eh:: [‘] harían hasta en su consultorios:

[.] teniendo eso, por eso parece que es:

así restringido, [‘]

sólo para estos casos de:: [.] hemorragias: en

casos de: embarazos así [1] anembriona:dos,

en mo:la,


133

SR: Mm:

Nurse EE: like degenerated, right, a

degenerated pregnancy.

SR: Right

Nurse EE: That’s it. [.] Because always

they first do MVA on them here [.] [‘] and

afterwards only in the afternoon they go to:

theatre for their curettage,v {fo:r}

SR: {Ah:}

Nurse EE: further clea:ning, in: theatre.

SR: Ah, right

Nurse EE: First of all, always here the

MVA, with MVA they resolve: it

SR: Ah, right

Nurse EE: the anembryonic ones.

[.]

SR: Right. [1] Right. But from the point of

view of the nurses, let’s say, [1]

which of the methods has more

advantages? [.] From the point of view of

you: all.

Nurse EE: Mm:: curettage in theatre, n:-

because this MVA is a little bit

traumatic here, [‘]

SR: Mm:

Lic. EE: así degenerados, no, un

embarazo degenerado.

SR: Ya

Lic. EE: Eso. [.] Porque siempre

les hacen primero AMEU aquí [.] [‘] y

después recién en la tarde van al:

quirófano para su legrado, pa{ra:}

SR: {Ah:}

Lic. EE: limpie:za posterior, en: quirófano.

SR: Ah, ya

Lic. EE: Primeramente siempre aquí el

AMEU, con AMEU resuelven:

SR: Ah, ya

Lic. EE: los anembrionados.

[.]

SR: Ya. [1] Ya. Pero desde el punto de

vista de las enfermeras, digamos, [1]

¿cuáles de los métodos tiene mayores

ventajas? [.] Según el punto de vista de

ustedes:.

Lic. EE: Mm:: el legrado en quirófano, n:-

porque esto del AMEU es un poquito

traumático aquí, [‘]


134

the patients: [.] a:re without anaesthesia:,

directly they do it to them [‘]

with local: anaesthesia in the ne:ck of the womb

sometimes:, some little pricks and nothing

more, directly! [‘] But that is not an

anaesthesia: nor of- complete relaxation! [.] [‘]

So they feel mu:ch pain [2] much pain.

Mu:ch they complain, the patients.

SR: M:hm: [.] And as regards the hygiene of

the i:nstruments:

Nurse EE: That is d- it’s s- it’s sterilised here,

for half an hour with: [.] with: bleach, it’s [??]

with::: [deter]gent [??] [.] sodium hypochlorite!

[.] At two per cent it’s used, [‘] for half

an hour they’re sterilised [.] the {ca}

SR: {Right}

Nurse EE: nnulae. The syringe, not. [‘]

It’s not sterilised, the syringe is not sterilised,

{right?}

SR: {Aha}

Nurse EE: The ca:nnulae, [‘] and:: [.] the::: [.]

the cannulae! in themselves.

SR: Right:

[.]

Nurse EE: And their adaptors too {are}

las pacientes: [.] está:n: sin anestesia:,

directamente les hacen [‘]

con anestesia local: en cue:llo

a veces:, unos pinchacitos y nada

más, ¡directo! [‘] Pero eso no es un

anestesia: ¡ni de- relajamiento completo! [.] [‘]

Así que siente mu:cho dolor [2] mucho dolor.

Mu:cho se quejan las pacientes.

SR: M:jm: [.] Y en cuanto a la higiene de

los instrume:ntos:

Lic. EE: Eso se de:- se e:-se esteriliza aquí,

por media hora con: [.] con: lavandina se [??]

con::: [deter]gente [??] [.] hipoclorito de sodio!

[.] Al dos por ciento se usa, [‘] por media

hora se esterilizan [.] las {cá}

SR: {Ya}

Lic. EE: nulas. La jeringa, no. [‘]

No se la esteriliza, la jeringa no se esteriliza,

{ ¿no?}

SR: {Ajá}

Lic. EE: Las cá:nulas, [‘] y:: [.] el::: [.]

¡las cánulas! en sí.

SR: Ya:

[.]

Lic. EE: Y sus adaptadores más {se}


135

SR: {Yes:}

Nurse EE: sterilised in: that

{sodium hypochlorite.}

SR: {Ri:ght.} [.] [‘] But [.] does that mean

more work for Nursing? That type of:

{sterilisation?}

Nurse EE: {Er: n:o:t} mu:ch. Only that

they wait, it’s- here the:- the one who

takes charge: directly is the one doing cubicles.

The one who is in charge of [?]. So she is

the one who already knows,

SR: Mhm

Nurse EE: [‘] she sterilises [.] for ha:lf

an hour, half an hour she ca:lls: them, they do

the MVA, [‘]

and: the doctor who u:ses [.] all the instruments,

he in person has to wa:sh, [‘] dry: and

[[smiling]] return everything clea:n,

well lubricated the syringe, all that, [‘] in

person, [[laughing]] right, to Nursing!

SR: Yes!

Nurse EE: We: [.] the nurse does not

occupy herself with the cleaning after use.

SR: Ah:, {right}

Nurse EE: {The} doctor in person [.] does the

clea{ning.}

SR: {Sí:}

Lic. EE: esteriliza en: ese

{hipoclorito de sodio.}

SR: {Ya:.} [.] [‘] Pero [.] ¿eso significa

más trabajo para Enfermería? ¿Este tipo de:

{esterilización?}

Lic. EE: {Eh: n:o:} mu:cho. Sólo que

esperan, es- aquí la:- la que se

encarga: directamente es la de cubículos.

La que está a cargo de [?]. Entonces ella es

la que ya sabe,

SR: Mjm

Lic. EE: [‘] esteriliza: [.] m:edia

hora, media hora les lla:ma:, hacen

el AMEU, [‘]

y: el médico que utili:za [.] todo el instrumental,

él en persona tiene que lava:r, [‘] seca:r y

[[sonriendo]] devolver todo li:mpio,

bien lubricada la jeringa, todo eso, [‘] en

persona, [[riendo]] no, ¡a Enfermería!

SR: Sí:!

Lic. EE: Nosotros: [.] la enfermera no

se ocupa del aseo después del uso.

SR: Ah:, {ya}

Lic. EE: {El} médico en persona [.] hace el

a{seo.}


136

SR: {And:} why

was that determination made?

Nurse EE: Because they have to clean

we::ll, since they are with gloves, directly

they come here and they clean it and they

lubricate it,

-so they know how to lubricate and how

to handle the syringe, we don’t know very

well how to handle the syringe, bec-

they [.] [‘] un- adjust its bu::ttons, some things

they have nh [.] behind that, [‘] and they in

person

SR: Right

Nurse EE: Like that.

SR: Ah{a:}

Nurse EE: {Sin}ce the beginning

it was: implanted that method of:

SR: Ah:, right

Nurse EE: the one who uses it, [.] does! [.] the

cleaning. [.] For the cleanliness {of the

instruments}

SR: {Right, right}

Nurse EE: they use, like.

SR: Right. [.] [‘] And:: Doña Elena, when

SR: {Y:} ¿por qué

se ha tomado esta determinación?

Lic. EE: Porque ellos tienen que limpiar

bie::n, como están con guantes, directamente

ellos vienen aquí y lo asean y ellos

lo lubrican,

-tonces saben cómo lubricar y cómo

manejar la jeringa, nosotros no sabemos muy

bien manejar la jeringa, por-

ellos [.] [‘] de- ajustan sus boto::nes, unas cosas

tienen ellas nj [.] detrás de eso, [‘] y ellos en

persona

SR: Ya

Lic. EE: Así.

SR: Aj{á:}

Lic. EE: {Des}de un principio

se ha: implantado ese método de:

SR: Ah:, ya

Lic. EE: el que usa, [.] hace! [.] el

aseo. [.] Por la limpieza {del

instrumental}

SR: {Ya, ya}

Lic. EE: que usa, así.

SR: Ya. [.] [‘] Y:: Doña Elena, cuando


137

some times it’s used for example, Cytotec [1]

Right:?

Nurse EE: Right

SR: To reso:lve some interru::ption

in the {se}

Nurse EE: {Right}

SR: cond trimester

Nurse EE: THEY WAIT! They wai:t unti::l

it’s produced er: the birth or the abortion,

then they g- go down to theatre. [1] Those

patients always in theatre are done.

SR: Ah:, right

Nurse EE: In theatre always.

SR: Right:

Nurse EE: Because they need rel:-

relaxation more: [1] so the patient

tranquil[???] and they can do the cleaning

com{plete, right?}

SR: {Ah:, right} [.] But what has it signified

for you, as nurses, the introduction

of: this:- this medication?

[1]

Nurse EE: It’s to help to dilate in:

big pregnancies, so!

alguna vez se utiliza por ejemplo Cytotec [1]

¿No:?

Lic. EE: Ya

SR: Para resolve:r alguna interrupció::n

de {se}

Lic. EE: {Ya}

SR: gundo trimestre

Lic. EE: ¡ESPERAN! Espe:ran a que::

se produzca eh: el alumbramiento o el aborto,

después ba- bajan a quirófano. [1] Esos

pacientes siempre en quirófano hace.

SR: Ah:, ya

Lic. EE: En quirófano siempre.

SR: Ya:

Lic. EE: Porque necesita relajam:-

relajamiento más: [1] para que la paciente

tranquil[???] y puedan hacer la limpieza

comple{ta, ¿no?}

SR: {Ah:, ya} [.] Pero ¿qué ha significado

para ustedes, como enfermeras, la introducción

de: esta:- este medicamento?

[1]

Lic. EE: Es para ayudar a dilatar en:

embarazos grandes, ¡pues!


138

SR: Mm

Nurse EE: To help that. It he:lps. [.] [‘]

Because sometimes with: induction only, it

does no:t give a result. It does not

SR: {Mm:}

Nurse EE: {give} a result. But

putting in that: me- that medication, it does. [.]

We help more the dilatation of the

neck of the womb, so that it can give [1]

eliminate the product, right? that’s already bad.

[.] Or is dead. [.] Dead product. [‘]

Mostly they do it in: dead, retained foetuses

and which are already: [‘] um::: of:: several

months of:: [.] pregnancy, right?

SR: Mm

Nurse EE: Of some age. [.] [??]

[.]

SR: Right

Nurse EE: That’s it.

SR: [‘] Although at some moment:: er:: given

the: resolution of the Medical Council it-

also it’s used: to interrupt a

pregnancy, {isn’t that right?}

Nurse EE: {Ah yes.}

SR: Mm

Lic. EE: Para ayudar eso. Ayu:da. [.] [‘]

Porque a veces con: inducción nomás,

no: da resultado. No

SR: {Mm:}

Lic. EE: {da} resultado. Pero

colocando esa: me- ese medicamento, sí. [.]

Ayudamos más a la dilatación del

cuello, para que pueda dar [1]

eliminar el producto, ¿no? que ya está mal. [.]

O está muerto. [.] Producto muerto. [‘]

Mayormente hacen en: fetos muertos retenidos

y que son ya: [‘] ahm::: de:: varios

meses ya de:: [.] embarazo, ¿no?

SR: Mm

Lic. EE: De edad. [.] [??]

[.]

SR: Ya

Lic. EE: Eso.

SR: [‘] Aunque en algún momento:: eh:: previa

la: resolución de la Junta Médica sa-

también se utiliza: para interrumpir un

embarazo, {¿no es cierto?}

Lic. EE: {Ah sí.}


139

SR: [??.]

Nurse EE: But on rare occasions that is

SR: Almost not [.] Mhm:

Nurse EE: Mostly they come already with

their dead [2] retained eggs,vi with abortions

already incomple:te, [.] [‘]

in those cases where already they are

quite advanced pregnancies it is put into them

the [.] [‘] induction [.]

and Cytotec so that [‘] it can eliminate

complete, because if they were to take that

directly to theatre, [.] [‘] it comes out piece

by piece and: {that is}

SR: {Ah:, right}

Nurse EE: so: traumatic, so terrible that

they should take out a: little foetus like that,

piece by piece, n:: [.]

SR: Right

Nurse EE: It’s: for that that they do it to them

[‘] They have generally- they have to eliminate

so that afterwards they take her to: theatre.

SR: Right:

Nurse EE: [They start.]

SR: Mhm: [2] Let’s say when you say

that [.] uhm [.] traumatic:, [.] does that mean

SR: [??.]

Lic. EE: Pero rara vez es eso

SR: Casi no [.] Mjm:

Lic. EE: Mayormente vienen ya con

sus huevos muertos [2] reteni:dos, con abortos

ya incomple:tos, [.] [‘]

en esos casos cuando ya son

embarazos ya avanzaditos se les coloca

el [.] [‘] la inducción [.]

y el Cytotec para que [‘] pueda eliminar

completo, porque si llevaran eso

directamente a quirófano, [.] [‘] sale pedazo

por pedazo y: {eso es}

SR: {Ah:, ya}

Lic. EE: tan: traumático, tan terrible que

saquen a un: fetito así,

pedazo por pedazo, n:: [.]

SR: Ya:

Lic. EE: Es: por eso que les hacen

[‘] Tiene generalmente- tiene que eliminar

para que luego le lleven a: quirófano.

SR: Ya:

Lic. EE: [Empiezan.]

SR: Mjm: [2] Digamos cuando Usted dice

que [.] ahm [.] traumático:, [.] significa


140

let’s say for the patient, {for the nur:}

Nurse EE: {for the pa:tient},

SR: se herself

Nurse EE: That’s it- [[laughing]] the ones who

see [??] piece by piece, [the head:] [.]

No!

SR: Right:

Nurse EE: When they’re big, like that it is.

[.]

SR: So for you all it has been like: [.]

a benefit [.] the introduction of this

medi{cation?}

Nurse EE: {Right} [.] Ah yes, yes. So they

can {he}

SR: {Yes:}

Nurse EE: lp to eliminate.

SR: Right. [‘] And s- since how many years

is it being used, the Cytotec?

Nurse EE: This year only recently [?]

SR: ONLY RECENTLY!

Nurse EE: Yes, only recently.

SR: Yes:!

digamos para la paciente, {para la misma enfer}

Lic. EE: {para la pacie:nte},

SR: me:ra:

Lic. EE: Así es- [[riendo]] las que

vemos [??] pedazo por pedazo, [la cabeza:] [.]

¡No!

SR: Ya:

Lic. EE: Cuando son grandes, así es.

[.]

SR: Entonces para ustedes ha sido como: [.]

un: beneficio [.] ¿la introducción de este

medica{mento?}

Lic. EE: {Ya} [.] Ah sí, sí. Para que

puedan {ayu}

SR: {Sí:}

Lic. EE: dar a eliminar.

SR: Ya. [‘] ¿Y ha- ¿hace cuántos años

que se está utilizando el Cytotec?

Lic. EE: Este año recién [?]

SR: ¡RECIEN!

Lic. EE: Sí, recién.

SR: ¡ Sí:!


141

Nurse EE: Only recently, yes yes. [‘] It

was used:, the laminaria.vii [.] Some:

little {sticks.}

SR: {Ah::}

Nurse EE: Tha:t was what was {used}

SR: {Tha:t’s it}

Nurse EE: But since this year recently it is

being used, that [???]

SR: Yes:. Ri::ght

Nurse EE: Yes. [.] Because it is not- the

laminaria always-

and now already it can’t be found the laminaria,

it’s for that it seems that they have: introduced

this Cyto{tec.}

SR: {No more,} it can’t be found, {the the}

Nurse EE: {No more!}

SR: mina{ria?}

Nurse EE: {They loo:k:,} but all

over the place, the relatives have to go and buy

SR: Yes?

Nurse EE: [They say that] no,

they don’t find it.

Lic. EE: Recién, sí sí. [‘] Se

usaba: la laminaria. [.] Unos:

tronqui{tos.}

SR: {Ah::}

Lic. EE: E:so era lo que se usa{ba}

SR: {E:so}

Lic. EE: Pero ¿desde este año recién sí está

empleándose eso [???]

SR: Sí:. Ya::

Lic. EE: Sí. [.] Porque no- la

laminaria siempre-

y ahora ya no se encuentra la laminaria,

es por eso parece que han: introducido

este Cyto{tec.}

SR: { ¿Ya no} se encuentra {la la}

Lic. EE: { ¡Ya no!}

SR: mina{ria?}

Lic. EE: {Bu:sca:n} pero por todo

lado, los familiares tienen que ir a comprar

SR: ¿Sí?

Lic. EE: [Dicen que] no,

no encuentran.


142

SR: Be{fo:re though it was not}

Nurse EE: {[???]}

SR: so difficult!

Nurse EE: Yes, { right now no.}

SR: {In the phar}macies they sold it!

Nurse EE: Already there is not any [[laughs]]

SR: Already there is not any?

Nurse EE: They search a lot to be able to

find it.

SR: And why would that be?

[1]

Nurse EE: We don’t know!

[1]

SR: Or {would it be that they are trafficking}

Nurse EE: {There is no explanation}

SR: with that, that they’re spe:culating, {or:}

Nurse EE: {May}be! Right? [.] But already

there is no laminaria, already they {cannot}

SR: {Right!}

Nurse EE: get hold of it. [‘] For that they have

introduced Cytotec.

SR: A:n{tes pero no era}

Lic. EE: {[???]}

SR: ¡tan difícil!

Lic. EE: Sí, {ahorita no.}

SR: {¡ En las far}macias vendían!

Lic. EE: Ya no hay [[ríe]]

SR: ¿Ya no hay?

Lic. EE: Buscan mucho para poder

hallar.

SR: ¿Y por qué será eso?

[1]

Lic. EE: ¡ No sabemos!

[1]

SR: O {será que están traficando}

Lic. EE: {No hay ninguna explicación}

SR: con eso, que están especula:ndo, {o:}

Lic. EE: { ¡Tal} vez! ¿No? [.] Pero ya

no hay la laminaria, ya no {pueden}

SR: { ¡Ya!}

Lic. EE: conseguir. [‘] Por eso han

introducido el Cytotec.


143

SR: Because

Nurse EE: [[to a man, Mr. X,viii who

is calling her from the open door]]

SORRY! [.]

[[to SR]] S- sorry, just a moment

SR: Yes yes

Nurse EE: [[calling the male doctor, Dr. X]]

B- but do we g- give permission to the

gentleman? Because [‘]

Dr. X: Tell him that:: {[?]}

Nurse EE: [[calling Mr. X]] {The} doctor

is the one who has to note it in

the case evolution form, we canno- we can not

give

Mr. X: [[to Dr. X]] Thank you very much!

[[For 9 seconds,

sounds and simultaneous voices can be heard,

only partially audible]]

SR: [[to Nurse EE]] Because it seems that

it was a really practical method, right?

Nurse EE: Yes

SR: the laminaria?

Nurse EE: It was, it was

SR: Porque

Lic. EE: [[a un hombre, Sr. X, que

le está llamando desde la puerta abierta]]

¡PERDON! [.]

[[a SR]] Per- perdón un momentito

SR: Sí sí

Lic. EE: [[llamando al médico, Dr. X]]

Pe- pero ¿le da- damos permiso al

señor? Porque [‘]

Dr. X: Le dice que:: {[?]}

Lic. EE: [[llamando al Sr. X]] {El} médico

es el que tiene que anotar en

hoja de evolución, no- no podemos

dar

Sr. X: [[al Dr. X]] ¡Muchas gracias!

[[Durante 9 segundos,

se escuchan ruidos y voces simultáneas,

sólo parcialmente audibles]]

SR: [[a Lic. EE]] Porque parece que

era un método bastante práctico, ¿no:?

Lic. EE: Sí

SR: ¿la laminaria?

Lic. EE: Era, era


144

SR: And also it’s something: from na:ture,

isn’t that {right?}

Nurse EE: {Yes:}

SR: It’s something::- from where

would they bring that, eh?

Nurse EE: Ay I don’t know, it was a

little stick like that: [.] a little stick.

SR: Yes:. [.] That swells itself, right?

Nurse EE: Yes:, yes yes

SR: Yes

Nurse EE: With the moisture in:: the::

neck: of the womb it starts to: [.] increase in

volume and that makes it dilate,

the neck of the {uterus,}

SR: {Ah: right:}

Nurse EE: [???]

SR: Yes. So: [.] it has disappeared, this has,

and they have started to use the Cytotec. [.] [‘]

But when the patients [.] or the- the

relatives go to buy Cytotec,

do they find it just, easily?

[.]

Nurse EE: Yes! Because they bring it.

They bring it to: [???] They indicate it to them,

the doctors [??] that it’s to: [????]

SR: Y además es algo: de la naturale:za,

¿no es cier{to?}

Lic. EE: {Sí:}

SR: Es algo:: ¿de dónde

traerán, no?

Lic. EE: Ay no sé, era un

tronquito así: [.] un tronquito.

SR: Sí:. [.] Que se hincha, ¿no?

Lic. EE: Sí:, sí sí

SR: Sí

Lic. EE: Con la humedad de::l::

cuello: empieza a: [.] aumentar de

volumen y eso hace que se dilate

el cuello del {útero,}

SR: {Ah: ya:}

Lic. EE: [???]

SR: Sí. Así que: [.] ha desaparecido esto,

y han empezado a usar el Cytotec. [.] [‘]

Pero cuando las pacientes [.] o las- los

familiares van a ir a comprar Cytotec,

¿encuentran nomás fácilmente?

[.]

Lic. EE: ¡Sí! Porque traen.

Traen para: [???] Les indican

los médicos [??] que es para: [????]


145

SR: Right, right. [.] Right [.] Right!

Anything more that you want to express about

the question of the: treatment of

incomple:te abortion, all this? Any

sugge:stion, recommenda:tion?

[2]

Nurse EE: Well [.] the: [.] it seems that

it’s failing, something: in the [.] the pla:nning,

the methods that they’re using, or: [.]

there are a lot of people who are not co:ming

[1] to do the:- [.] family planning,

they’re not, it may be that they’re instru:cted,

that it’s explai:ned to them, [‘] they do not::

accept it sometimes! [.] {They do not}

SR: {Mm:}

[.]

Nurse EE: have themselves put i:n not even an

intrauterine device, [??], back they- [.] come

with an: abortion.

SR: Mhm:

Nurse EE: That’s it. [.] That would be it.

[.]

SR: Right. [.] And that: what would they have

to do with it for example the husbands? [.]

Of: the ladies?

Nurse EE: Let’s see, the- the husband is

the one who refuses, does not wa:nt to accept

SR: Ya, ya. [.] Ya [.] ¡Ya!

¿Alguna cosa más que quiere expresar sobre

la cuestión del: tratamiento del

aborto incomple:to, todo esto¿Alguna

sugere:ncia, recomendació:n?

[2]

Lic. EE: Pues [.] el: [.] parece que

está fallando algo: de la [.] la planificació:n,

los métodos que estan usando, o: [.]

hay mucha gente que no está vinie:ndo

[1] a realizar el:- [.] la planificación familiar,

no, puede ser que les instru:ye,

se les expli:ca, [‘] no::

aceptan a veces! [.] {No se}

SR: {Mm:}

[.]

Lic. EE: hace coloca:r ni siquiera un

dispositivo, [??], vuelven a- [.] venir

con un: aborto.

SR: Mjm:

Lic. EE: Eso. [.] Eso sería.

[.]

SR: Ya. [.] Y eso: ¿qué tendrán

que ver por ejemplo los esposos? [.]

¿De: las señoras?

Lic. EE: A ver, el- el esposo es

el que se niega, no quie:re aceptar


146

that into her they put:- that she uses pills or: that

they put into her a [.] device!

[.]

SR: Mm

[2]

Nurse EE: It depends too on the culture of

each: [.] husband.

SR: Mm

Nurse EE: Some men out of ignorance

say that the- the woman is there to have

children! And:

SR: Mm

Nurse EE: [???{????]}

SR: {[‘] And do you see it as necessa}ry

always that: they speak with the husband so that

the lady can {use a: method?}

Nurse EE: {Yes: Because afterwards}

they have problems.

SR: What type of problems?

[.]

Nurse EE: It’s said that they complain, [.]

as it stays, the little threads, it seems that there

is- [.] [[laughing]] the pro:blem! [2] I do no:t

know.

SR: In what sense? That he {no:tices, or

a que le pongan:- a que use tabletas o: que

le coloquen ¡un [.] dispositivo!

[.]

SR: Mm

[2]

Lic. EE: Depende también de la cultura de

cada: [.] esposo.

SR: Mm

Lic. EE: Algunos hombres por ignorancia

dicen que la- la mujer ¡es para tener

hijos! Y:

SR: Mm

Lic. EE: [???{????]}

SR: {[‘] ¿Y Usted ve necesa}rio

siempre que: hablen con el esposo para que

la señora pueda {usar un: método?}

Lic. EE: {Sí: Porque después}

tienen problemas.

SR: ¿Qué tipo de problemas?

[.]

Lic. EE: Dice que se quejan, [.]

como queda los hilitos, parece que ahí

es- [.] [[riendo]] ¡el proble:ma! [2] N:o

sé.

SR: ¿En qué sentido? ¿De que se {fi:ja, o


147

that it bo:thers him, or what?}

Nurse EE: {[????] in: having relations well

it sticks into you!

SR: That they notice? Or: {that

they get annoyed?}

Nurse EE: {N:: n::} That it bothers him, the

{man! [??] the man, yes!}

SR: {Ah, it bothers him, they say?}

Nurse EE: Yes, I think so! But I’m not- [‘]

I am no:t so su:re, right, but {the ladies}

SR: {Ahá:}

Nurse EE: sometimes do not wa:nt to have it

put into them while [the men ??].

SR: Ah:, right.

Nurse EE: [??]

SR: Right, right. [3] Right.

[2]

Nurse EE: And sometimes always we call the

husband, that: [.]

the doctor for example says ‘Have her call the

husband too to consult if: we’re going to use or

not the:’

SR: Right:.

le mole:sta, o qué?}

Lic. EE: {[????] al: tener relaciones pues

¡se te mete!

SR: ¿De que se fije? O: {¿que

se moleste?}

Lic. EE: {N:: n::} ¡Que le moleste al hom{bre!

[??] al hombre, ¡sí!}

SR: {Ah, le molesta, ¿dicen?}

Lic. EE: Sí, ¡yo pienso que sí! Pero no- [‘] no:

estoy tan segu:ra, no, pero {las señoras}

SR: {Ajá:}

Lic. EE: a veces no quie:ren hacerse

colocar mientras [los hombres ??].

SR: Ah:, ya.

Lic. EE: [??]

SR: Ya, ya. [3] Ya.

[2]

Lic. EE: Y a veces siempre llamamos al

esposo, que: [.]

el médico por ejemplo dice ‘Que llame al

esposo más para consultar si: vamos a usar o

no el:’

SR: Ya:.


148

[[For 11 seconds, sounds of the telephone and

others, simultaneous voices including that of

Nurse EE, which are only partially audible.]]

SR: Right. So, Doña Elena. Any thing more

that you want to comment? Or-

Nurse EE: [[laughing]] That only!

SR: Very good! [.] Right, thank you!

Nurse EE: Not at all

SR: Thank you

End of Transcript 14.1

[[Durante 11 segundos, ruidos del teléfono y

otros, voces simultáneas incluyendo la de

Lic. EE, sólo parcialmente audibles.]]

SR: Ya. Así Doña Elena. ¿Alguna cosa más

que quiere comentar? O-

Lic. EE: [[riendo]] ¡ Eso nomás!

SR: ¡Muy bien! [.] Listo, ¡gracias!

Lic. EE: De nada

SR: Gracias

Fin de la Transcripción 14.1

i As her colleagues on the ward did, I addressed Head Nurse Elena Elías as Doña Elena. In Hispanic contexts, Nurse is a respectful title used to preface a woman’s first name. It is more formal than Señora which can preface first or last names. ii ‘trophoblastic a. (Embryol. & Med.) relating to or consisting of trophoblast L19. trophoblast n. (Embryol & Med.) a layer of cells or a membrane surrounding an embryo, which supplies it with nourishment and later forms most of the placenta L19.’ (OED) iii ‘haemostasis n. M19. Med. Stoppage of bleeding; stoppage or esp. prevention of the flow of blood.’ (OED) iv ‘molar adj. Med. Of the nature of a mola or false conception. rare. E19.’ (OED) v Legrado is translated as curettage. Common medical terminology in English is D&C, dilation and curettage. vi Medical terminology for this in English is a missed abortion. vii ‘laminaria n. M19 Any brown seaweed of the genus Laminaria, with long thin flat fronds; collect. seaweed of this genus. Also called oarweed, kelp.’ (OED) In Bolivia and other Andean countries, a processed form of this seaweed is sold in pharmacies, in short, smooth, round sticks. When inserted in the cervix, these absorb bodily fluid, expand, and provoke dilation. viii X (Mr. X, Dr. X, etc.) is used to identify different people who intervene momentarily in transcribed interactions, or who are anonymous in the thesis narrative.


149

Appendix 7

Contextualisation of transcript excerpts cited in sections 7.3, 7.3.1 and 7.4 of

Chapter 7, Changing Voices

Transcript of recorded discussion with the following characteristics:

Participants: Dr. Losada (Dr. L), third-year medical resident;

Dr. Salinas (Dr. S), head of gynaecology ward, Insurance Hospital;

Three women medical residents: RM♀1, RM♀2, and Dra. Helga Haber

(Dra. HH), European friend of SR;

Licenciada Irma Illanes (Lic. II), social worker;

Karen, colleague on project visit from USA;

SR as researcher.

Date and time of discussion: Friday 11/7/97, 12.50– 13.00 p.m.

Place: Gynaecology Ward Classroom, Insurance Hospital


Number & date of transcript: 12.3, 17, 20 and 21/7/97

Context:

This transcript is of a recorded discussion following SR’s presentation of preliminary research findings to

Insurance Hospital gynaecology ward staff. After the presentation, I requested and received the consent of

those present to record their comments and questions, as input to validation of the research data and

methodology.

Those present were Dr. Salinas (Dr. S), the ward chief; three male residents including Dr. Losada (Dr. L);

four women residents including Dra. Helga Haber (Dra. HH), a friend of European origin; social worker

Licenciada Irma Illanes (Lic. II); Karen (a colleague on a project visit from the USA) and another woman

representative of IPAS; and myself (SR) as researcher. No nurses were present, despite repeated invitations

made by SR and the social worker Lic. Illanes.


150


[[During the first eight seconds of the

recording, what is heard are

only partially audible interventions by SR,

a ♀ medical resident and a

♂ resident, Dr. Losada (Dr. L). Dr. L continues

with the first comment on

SR’s presentation:]]

Dr. L: [?] it’s that:: if it:: [.] was a matter of

finding out if it was induced or no:t, each- ['] it

was as part of a study! [.] To justify

as well what it was::- uh: Reproductive Health

And so, as a: [1] result of that study,

[1] i:t was arrived at that [1] the women were

in fact using [.] abortion as a: method of

family planning! [.] [‘]

So it was no- it was not [2] th- the like there it

says, ‘To know, for what?’, a:pparently without

sense, [1] because the treatment is the same,

[.] but [2] a- well to de:monstrate tha:t [.] it was

being done, abortion! [.]

[‘] And it is being u:sed: [.] and so- there had to

be alternatives offered in all this, right? [‘] It

WAS NOT [.] er:- [.] knowing to say

then, ‘We discri:minate her, we do not

attend her.’

[‘] That’s to say [.] it seems to me that a

little bit the ide:a when that is proposed, [1] er-

[.] it might seem without sense, truly,

‘For what are finding out [.] [‘] if it’s:


[[ Durante los primeros ocho segundos de la

grabación, se escuchan

intervenciones sólo parcialmente audibles

de SR, una residente médica ♀ y un

residente ♂, Dr. Losada (Dr. L). Dr. L prosigue

con el primer comentario sobre

la presentación de SR:]]

Dr. L: [?] es que:: si se:: [.] trataba de

averiguar si era inducido o no: cada- [.]

¡era como parte de un estudio! [.] Para justificar

también lo que era::- ah_ Salud Reproductiva.

Y entonces, como: [1] resultado de ese estudio,

[1] se: llegó de que [.] las mujeres estaban

nomás utilizando [.] el aborto como: método de

planificación! [.] [‘]

Entonces no e- no era: [2] el- el como allá

dice ‘Conocer, ¿para qué?’, a:parentemente sin

sentido, [1] porque el tratamiento es el mismo,

[.] sino [2] a- pues para demostra:r que: [.] ¡sí se

estaba haciendo el aborto! [.]

[‘] Y se está utiliza:ndo: [.] y entons- se debía

ofrecer alternativas en todo esto, no? [‘]

NO ERA [.] eh:- [.] conocer para decir

entonces, ‘La discrimina:mos, no

la atendemos’.

[‘] O sea [.] me parece que un

poquito la ide:a cuando se plantea eso, [1] eh-

[.] pareciera [??] sin sentido, verdad,

‘¡Para qué estamos averiguando [.] [‘] si es:


151

provoked or induced!

[.] The: objective at that time in finding o:ut,

was precisely to say, [1] ‘It is

being used as a method of planning and

so- there must be done some:thing, it has to be

used, plan- [‘] already like to- ju:stify [.]

after what came with:

Reproductive Health and all this, right?

That’s to say [1] er- when one sees like co:ldly,

a bit like:- it seems [2] without sense the thing,

bu:t I believe that the idea was another one. [.]

{Nothing more [?]}.

SR: {Very well.} Excellent. Thank you. [‘] Uh

I am going to give you afterwards copies [.] of

all these overheads [.] so that:[.]

you can read them with more time, [.] and

[????] you can make them. [.] Because: I need

this kind of input//

Dr. S: //Evidently. [[He turns and addresses the

staff members present to

stimulate their participation. Copies of the

overheads are handed out to all those present.]]

[???] [4] We offer the wo:rd, [2] to:

co:mment [3] er: [2] to make questions, [2] in

relation [1] to these conclu:sions [.] of

Susanna’s. [3]

[[Turning round to address the staff]] If

anyone has- [4] Well. I am going to sta:rt [1]

Well. First I want:: [3] to congra:tulate [.]

provocado o inducido!

[.] E:l objetivo de ese entonces al averigua:r,

era justamente para decir, [1] “Se está

utilizando como método de planificación y

entons- se tiene que hacer a:lgo, se tiene que

usar el plan- [‘] ya como pa- justifica:r [.]

después lo que ha venido con:

Salud Reproductiva y todo esto, ¿no?

O sea [1] eh- cuando uno ve así friame:nte,

medio que:- parece [2] sin sentido la cosa,

pero: creo que la idea era otra. [.]

{Nada más [?]}

SR: {Muy bien.} Excelente. Gracias. [‘] Ah [.]

yo les voy a dar después copias [.] de

todas estas transparencias, [.] para que: [.]

las puedan leer con más tiempo, [.] y

[????] los pueden hacer. [.] Porque: yo necesito

este tipo de insumo//

Dr. S: // Evidentemente. [[Se voltea y se dirige

a los miembros del personal presentes para

estimular su participación. Se reparten copias

de las transparencias a todos/as los/las

presentes.]]

[???] [4] Ofrecemos la pala:bra, [2] para:

comenta:r [3] eh: [2] para hacer pregu:ntas, [2]

en relación [1] a estas conclusio:nes [.] de

Susanna. [3]

[[Volteándose para dirigirse al personal]] Si

alguien tiene- [4] Bueno. Yo voy a empeza:r [1]

Bueno. Primero quiero:: [3] felicita:r [.]


152

Susanna [2] this::- this work that you have done

[1] reflects [2] er: [.] the truth [2]

with reference to the management [.] of

incomplete abortion. [2]

Er: it reflects [2] an interpretation: of yours, [.]

per:sonal, [.] very clear [2] with regard to these

approaches: [.] humane, [1] related [1] er: [.]

with: [1] er: [.] the a::spect [.] of me:dicine, [1]

the aspect of nursing, [2] of Social Service, [1]

and the humane aspect. [2] We believe that it is:

[.] the: faithful reflection [2] of everything: tha:t

happens [.] in this service. [2]

Er: [.] to me the only thing that called my

atte:ntion, [.] is tha::t [1] in all [.] the:- [.] in

all the interpreta:tion of the wo:rk, in the

conclusions and recommendations, [2] as

if there were [.] a: [.] mm: [.] an idea [.] of

fo:rcing [.] and saying, ‘Well, why do you not

accept abortion? [.] In an open form, all: of

you.’ [.] But [.] unfortunately:, [.] we

have: [1] no:rms:, we have regula:tions [2].

Another thing that calls my attention [.] is that:

[2] uh: [.] the decision of the woman. [.] I

believe that you are right, [.] you know, [.] it’s

another cu:lture, [.] unfortunately, [.] in our

environment still [.] predominates machis:mo,

[2] that the woman always depends on the:- on

her partner, [1] and [.] of course on a decision.

[.] The ideal would be that: [.] our women

should have a level: [1] of culture, [1] so that

they alone should decide. [.] That should be. [.]

It should be a norm. [2]

Susanna [2] esta::- este trabajo que has hecho

[1] refleja [2] eh: [.] la verdad [2]

en cuanto se refiere al manejo [.] del

aborto incompleto. [2]

Eh: refleja [2] una interpretación: tuya, [.]

person:al, [.] bien clara [2] en cuanto a estos

enfoques: [.] humanos, [1] relacionados [1] eh:

[.] con: [1] eh: [.] el aspecto:: [.] mé:dico, [1]

el aspecto de enfermería, [2] de Servicio Social,

[1] y el aspecto humano. [2] Creemos que es:

[.] el: fiel reflejo [2] de todo: l:o que

sucede [.] en este servicio. [2]

Eh: [.] a mí lo único que me ha llamado la

atenció:n, [.] es que:: [1] en todo [.] el:- [.] en

toda la interpretació:n del trabajo:, en las

conclusiones y las recomendaciones, [2] como

si hubiera [.] una: [.] mm: [.] una idea [.] de

forza:r [.] y decir, ‘Bueno, por qué no

aceptan el aborto? [.] En forma abierta, todos:.’

[.] Pero [.] lamentablemente:, [.] nosotros

tenemos: [1] no:rmas, tenemos reglame:ntos [2]

Otra cosa que me llama la atención [.] es que:

[2] eh: [.] la decisión de la mujer. [.]

Creo que tienes razón, [.] tú sabes, [.] es

otra cultu:ra, [.] lamentablemente, [.] en nuestro

medio todavía [.] prevalece el machis:mo, [2]

que la mujer siempre depende del:- de

su pareja, [1] y [.] por supuesto de una decisión.

[.] Lo ideal sería que: [.] nuestras mujeres

tengan un nivel: [1] de cultura, [1] para que

ellas solas decidan. [.] Eso debería ser. [.]

Debería ser una norma. [2]


153

Simply that omment, [1] and to congra:tulate [.]

that a:ll [.] that you have said [.] is true.

[2]

SR: Thank you.

[4]

Dr. S: [[addressing the staff]] Anyone

more [.] asks: [.] [[to Dr. Losada]] Doctor?

[3]

Dr. S: Well!

[2]

SR: I beg you really, I’m- I’m:

very interested in that you can [????],

comment, di:ffer, right? [.] I need that tr-

truly really as input for my final report. I don´t

want: [.] for me to stay all alone: [.] with the

analysis [??]. As he says, the Doctor, it’s

something subjective that’s mine, [.] I [.] am a

person outside the area of medicine, [1] I need

the criteria of you all [.] really, to

enrich the work, [???] to the women [???].

[4]

RM♀1: [[First ♀ medical resident]] Eh:: [.] I

would like [??] [.] the majority of the abortions

that come: [.] are: as incomplete abortion [.]

and it’s difficult to deter- uh- to arrive

at a diagnosis or to identify if it’s spontaneous

or provoked:, [1] the way of treating is the same

to all the women. [1]

The problem occurs [.] when the patient

co:mes, [.] and already on entry she says that

Simplemente ese comentario, [1] y felicita:r [.]

que to:do [.] lo que has dicho [.] es cierto.

[2]

SR: Gracias.

[4]

Dr. S: [[dirigiéndose al personal]] Alguien

más [.] pide: [.] [[al Dr. Losada]] Doctor?

[3]

Dr. S: Bueno!

[2]

SR: Les ruego realmente, me- me:

interesa muchísimo todo lo que puedan [??]ar,

comentar, discrepa:r, no? [.] Necesito eso de-

de veras como insumo para mi informe final.

No quiero: [.] quedarme yo solita: [.] con el

análisis [??]. Como dice el Doctor, es

algo subjetivo mío, [.] yo [.] soy una

persona fuera del área médica, [1] yo necesito

los criterios de ustedes [.] realmente, para

enriquecer el trabajo, [???] a las mujeres [???].

[4]

RM♀1: [[Primera ♀ residente médica]] Eh:: [.]

quisiera [??] [.] la mayoría de los abortos

que vienen: [.] son: como aborto incompleto [.]

y es difícil deter- ah- de llegar

a diagnosticar o de identificar si es espontáneo

o provocado:, [1] el trato es igual

a todas las mujeres. [1]

El problema ocurre [.] cuando la paciente

vie:ne, [.] y ya de entrada ella dice que


154

it has been an abortion: [.] provoked. [.] [‘] The

discrimination is not on our part. [1] The

way of treating the patients is the same. ['] The

discrimination is from Nu:rsing, [1] and::

the Coverage Rights Office. [.]

['] Certainly, in- what is do:ne is [.]

to inform the patient [.] that they are in an

extra-ordinary risk:, [.] and the co:st that

would be implied by a curettage here in the

Hospital. [2] And the:- obviously the patient es

the one who decides if she is: capable to- [.] pay

[.] or not pay the cost, which is much more high

[.] that in any other place, right? [.]

The way of treating is the same, obviously,

treatment of medicine, personnel, and all that: is

the same! [2] Bu:t uh:- th- the: problem exists

in the Coverage Rights Office.

[8]

[[Inaudible comments from Dr. Salinas and Dr.

Losada.]]

SR: We:ll.

[1]

Lic. II: [[Social Worker Lic. Irma Illanes]]

Clarifying that of: [?] the risks [???]ary!

[3]

SR: Irma [.] Can you again explain this:-?

[.] I didn´t understand very well.

Lic. II: That the discrimination is [.] not [.]

so:: much from Nursing as from

ha sido un aborto: [.] provocado. [.] ['] La

discriminación no es por nuestra parte. [1] El

trato a las pacientes es el mismo. ['] La

discriminación es desde Enfermerí:a, [1] y::

Vigencia de Derechos. [.]

['] Ciertamente, en- lo que se ha:ce: es [.]

informarle a la paciente [.] que está en un

riesgo extraordinario:, [.] y el co:sto que

implicaría un legrado aquí en el

Hospital. [2] Y l:- obviamente la paciente es

la que decide si está: capacitada para- [.] pagar

[.] o no pagar el costo, que es mucho más alto

[.] que en cualquier otro lado, no? [.]

El trato es el mismo, obviamente,

trato médico, personal, y todo eso: es

el mismo! [2] Pe:ro eh:- e- el: problema existe

en Vigencia de Derechos.

[8]

[[Comentarios inaudibles de Dr. Salinas y Dr.

Losada.]]

SR: Bie:n.

[1]

Lic. II: [[Trabajadora Social Lic. Irma Illanes]]

Aclarando lo de: [?] los riesgos [???]arios!

[3]

SR: Irma [.] Puedes volver a explicar esto:-?

[.] No he entendido muy bien.

Lic. II: Que la discriminación no [.] es [.]

ta:nto de Enfermería como de


155

the Coverage Rights Office, what

the Docto:ra said, [‘] but rather [.] on the

pa:rt of the- of the Code of Social Security [1]

in which it is mentioned in one clause [.] the

problem of the risks that are extra-ordinary!

[5]

Dra. HH [[European medical resident, friend

of SR]] Uh I wanted in reality to make the

same: [.] comment, I am new in the

service, but: [.] this point that:- about

incomplete abortion and the normative point, ['']

it seems to me that it is rather the: [.] pragmatic.

[.] ['] That’s to say as pragmatic, all of us say

here, ‘We:ll, we attend them all equal.’ [']

But that is pragmatic.

The normative is that the National Insurance

Scheme does no::t ['] co:ver [1] the: uh:

let’s say, what’s it called the treatment [''] of an

abortion [.] uh: induced in another place. [1]

Right? And that we have to just [.] uh [.]

ex:pose it here en normative, that [.] that is the

nor:m. ['] Now that it pleases us or does not

please us, that is another point. That is the

subjective point, right? But [''] that- th:- the

norm remains in curren- uh:: [[laughing]] in

current coverage, and not only Coverage

Rights! {But in cov:erage}

RM♂?: {[[laughs]]}

Dra. HH: [''] and [.] uh it- it- even

we practise it, because in the- in the: little time

that I have been in the service, we: have seen

cases [''] that::: well: uh::- that’s to say,

Vigencia de Derechos, lo que

ha dicho la Docto:ra, ['] sino más bien [.] de

pa:rte de- del Código de Seguro Social [1]

en el que está mencionado en un acápite [.] el

problema de los riesgos extraordinarios!

[5]

Dra. HH: [[residente médica europea, amiga

de SR]] Eh quería en realidad hacer el

mismo: [.] comentario, yo soy nueva en el

servicio, pero: [.] este punto que:- sobre

el aborto incompleto y el punto normativo, ['']

me parece que es más bien el: [.] pragmático.

[.] ['] O sea como pragmáticos, todos

decimos aquí, ‘Bue:no, les atendemos a igual.’

['] Pero eso es pragmático.

Lo normativo es que la Caja Nacional de Salud

no:: ['] cu:bre [1] los: eh:

digamos, qué se llama el tratamiento [''] de un

aborto [.] eh: inducido en otro lado. [1]

No? Y eso tenemos que nomás [.] eh [.]

ex:ponerlo aquí en normativo, que [.] eso es la

nor:ma. ['] Ahora que nos guste o no nos guste,

eso es otro punto. Ese es el

punto subjetivo, no? Pero [''] eso- l:- la

norma sigue vigent- eh:: [[riendo]] en

vigencia, y no solamente Vigencia de

Derechos! {Sino en vigen:cia}

RM♂?: {[[se ríe]]}

Dra. HH: [''] y [.] eh se- se- hasta la

practicamos, porque en las- en el: poco tiempo

que he estado en el servicio, he:mos visto

casos [''] que::: bueno: eh::- o sea,


156

there has not been discrimina:tion in

a personal sense to th- these persons, but

there has been n- [''] it has been explained

to them that that is the norm and they have gone

away: to another place, so [.] that is the norm

and [.] ['] [[leafing through papers]] it remains

in current coverage.

['] That would be [.] to add to that. [[in

a lower tone, searching for the point on sheets

distributed to participants with copies of

overheads.]] And there was another thing that-

what little thing more that I wanted to say

[[for 4 seconds, he searches among the sheets

distributed.]] No. I cannot remember! [[laughs]]

[[??!]]

[[10]]

Dr. S: [[to Dr. Losada]] You wanted to speak?

[2]

Dr. L: No. [.] It’s all right.

Dr. S: No?

[1]

[[laughs from participants]]

SR: [[to Dr. Losada]] Doctor Losada, any

observation: [.] that-

RM♀♀?: [[inaudible comments from

women medical residents]]

Dr. L: [[to SR]] No, it’s all right [.]

it has been, it seems to me a:- good impre:ssion,

no se ha discrimina:do en

sentido personal a l- estas personas, pero sí se

ha n- [''] se les ha explicado que eso es

la norma y se han ido: a otro lado,

entonces [.] eso es la norma

y [.] ['] [[hojeando papeles]] sigue

en vigencia.

['] Eso sería [.] para añadir a eso. [[en

voz más baja, buscando punto en hojas

repartidas a asistentes con copias de

transparencias]] Y había otra cosa que-

qué cosita más que quería decir

[[durante 4 segundos, busca entre hojas

repartidas]] No. No me recuerdo! [[ríe]]

[[??!]]

[[10]]

Dr. S: [[a Dr. Losada]] Querías hablar?

[2]

Dr. L: No. [.] Está bien.

Dr. S: No?

[1]

[[risas de participantes]]

SR: [[to Dr. Losada]] Doctor Losada, alguna

observación: [.] que-

RM♀♀?: [[comentarios inaudibles de

Residentes Médicas]]

Dr. L: [[a SR]] No, está bien [.]

ha sido, me parece un:- buena impresió:n,


157

and it’s:- the- [.] what you have seen in the

service, right?

[2]

SR: And that concurs more or less with your

vision, or do you have any discre:pancies,

things that: you think that I am not reflecting

[??]?

Dr. L: No, it’s all right! [.] It’s all right.

[4]

Dra. HH: [??]

[[laughs from women present]]

Dra. HH: [[smiling]] [[to SR]] In your

[[telephone rings and RM♀? answers]]

Dra. HH: recommendations concerning [.] the:

active promotion without: [.] requesting the::

the:: [.] consent of the husband, precisely what

he said, the Doctor, ['''] [.] uhm: [3]

I am n::ot so much in agreement that that stays

alo:ne. [.]

That’s to say, I am in agree:ment that it should

not be an obstacle, right? If the woman says, ‘I

already do not want to have children. I want a:-

a method’ [''] [.] and neither does anyone do it,

right, that they dema:nd that he comes, the

hu:sband, that’s to say:- it’s:- the other- [.]

pragmatic, precisely, that’s to say ['] uh:

[she] gets lost. ['] But I believe that [.] as a

recommenda:tion [.] ['] and as a

y es:- la- [.] lo que Usted ha visto dentro del

servicio, no?

[2]

SR: Y eso concuerda más o menos con su

visión, o tiene algunas discrepa:ncias,

cosas que: piensa que no estoy reflejando

[??]?

Dr. L: No, está bien! [.] Está bien.

[4]

Dra. HH: [??]

[[risas de mujeres presentes]]

Dra. HH: [[sonriendo]] [[a SR]] En tus

[[suena teléfono y contesta RM♀?]]

Dra. HH: recomendaciones en cuanto [.] a la:

promoción activa sin: [.] pedir el::

el:: [.] consentimiento del esposo, justamente

lo que dijo el Doctor, ['''] [.] ehm: [3]

N::o estoy tan de acuerdo que eso se queda

so:lo. [.]

O sea, estoy de acue:rdo que no debería ser un

obstáculo, no? Si la mujer dice, ‘Yo

ya no quiero tener hijos. Quiero un:-

un método’ [''] [.] y tampoco nadie lo hace,

no, que exi:ja que venga el

mari:do, o sea:- es:- el otro- [.]

pragmático, justamente, o sea ['] eh:

se pierda. ['] Pero yo creo que [.] como

recomendació:n [.] ['] y como


158

programmatic approach, we have to just uh::

involve the men in contraception!

['] [.] If we close our eyes as women,

I believe that we cut ourselves in our own flesh.

['] [.] That’s to say if the ma:n does not

participate: in the:- in what concerns conception

and contraception and having kids, [''] uh: th-

we are going to keep them back another:

five hundred centuries more! ['] So no: [.] for

me that would not be the policy. The policy

would be rather [.] to gi:ve counselling to the

me:n! Involve the men. [']

Not, that’s to say:- no::t [.] no:t to say, ‘Well,

it’s a matter for the woman and only the woman

decides, and the man well let him do what

pleases him!’ [´´]

No:: no it does not seem to me that that is the

approach that- that’s to say, in the long run,

right? I’m talking already of [[laughs]] of ideals

further beyond, right? So I believe that this is a

little: [.] it would have to be used, that, if:: [2]

all th{at:}

SR: {Yes}

Dra. HH: point of vi{ew}

Dr. L: {Yes,} I believe that it is not:- it is not

the decision of the woman, right? It is said that:

family planning is the decision of the

couple, [1] it is: [.] written like that, that is up to

the couple to know and decide [.] ho:w many

and whe:n to have the family. [.]

enfoque programático, tenemos que nomás eh::

involucrar a los hombres en la anticoncepción!

['] [.] Si nos cerramos los ojos como mujeres,

creo que nos cortamos en la propia carne.

['] [.] O sea si el ho:mbre no

participa: en el:- en lo que es

concepción y anticoncepción y tener wawas,

[''] eh: va- los vamos a atrasar otros:

quinientos siglos más! ['] Entonces no: [.] para

mí no sería la política. La política

sería más bien [.] da:r consejería a los

ho:mbres! Involucrar a los hombres. [']

No, sea:- no:: [.] no: decir, ‘Bueno,

es asunto de la mujer y solamente la mujer

decide, y el hombre bueno que haga lo que

le guste!" ['']

No:: no no me parece que ese es el

enfoque que- o sea, a lo largo,

no? Estoy hablando ya de [[ríe]] de ideales

más allá, no? Entonces creo que esto es un

poco: [.] habría que emplear eso, sí:: [2]

todo e{se:}

SR: {Sí}

Dra. HH: punto de vi{sta}

Dr. L: {Sí,} creo que no es:- no es decisión de

la mujer, no? Se dice que:

planificación familiar es la decisión de la

pareja, [1] está: [.] escrito así, que es de

la pareja de saber y decidir [.] cuá:ntos

y cuá:ndo tener la familia. [.]


159

That’s to say, it is not at any moment that I

know of:, only related to the woman, but

it’s a treatment of the couple.. ['] That’s why

within the methods it goes so: much for the

woman, so much for the male. [.] Right? [.]

There is not only [?] of the woman. [']

[.]

Dra. HH: Yes, but: here it is in the:- [.] uh:

I am referring to the recommendations of: of

Susanna, [''] o:bviously we hav- that’s to say,

there have been seen cases, right, of ladies that

do not have for example a partner who

participates. [1] That’s to say, uh they say:- yes,

at times they come. So just the same

she is given a method. [.] We are not going

to say, ‘We::ll, so she is not eligible.’

But:: ideal it would be [.] to involve the man.

[1] In: in the process. [2] [??]

SR: Well.

[3]

Dr. S: Very well! [1] Uh so: er: [.] I believe

that there are no more comments, [1]

we thank you: [2] and::: [2] with Karen already

we have spoken [2] [''] the- [.] for the future of

MVA, right? [2] So we hope: [.]

we’ll be commu:nicating [.] sending you the

information, [2] and:: [.] well! Continuing with

this method.

[5]

[[end of Transcript 12.3]]

O sea, no es en ningún momento que yo

sepa:, solamente relacionado a la mujer, sino

es tratamiento de pareja. ['] Por eso

dentro de los métodos va ta:nto para la

mujer, tanto para el varón. [.] No? [.]

No hay sólo [?] de la mujer. [']

[.]

Dra. HH: Sí, pero: aquí está en las:- [.] ah: me

estoy refiriendo a las recomendaciones de: de

Susanna, [''] o:bviamente hemo- o sea, se ha

visto casos, no, de señoras que

no tienen por ejemplo una pareja que

participa. [1] O sea, ah dicen:- sí,

a veces vienen. Entonces igual

se le da un método. [.] No vamos

a decir, ‘Bue::no, entonces no es eligible".

Pero:: ideal sería [.] que se involucre al hombre.

[1] En: en el proceso. [2] [??]

SR: Well.

[3]

Dr. S: Muy bien! [1] Ah entonces: eh: [.] creo

que no hay más comentarios, [1]

le agradecemos: [2] y::: [2] con Karen ya

hemos hablado [2] [''] el- [.] por el futuro de

AMEU, no? [2] Así que esperamos: [.]

comunica:rnos [.] enviarle la

información, [2] y:: [.] bueno! Continuar con

este método.

[5]

[[fin de la Transcripción 12.3]]


160

Appendix 8

Contextualisation of transcript excerpts cited in sections 8.2 and 8.4 of

Chapter 8, Managing Pain

Transcript of interview recorded by SR with the following characteristics:

Participants: Dr. Walters (Dr. W), staff gynaecologist, Insurance Hospital;

SR as researcher.

Date and time of interview: Friday 25/7/97, 9.29 – 9.40 a.m.

Place: Gynaecology ward classroom, Insurance Hospital


Number & date of transcript: 13.2, 1/8/97

Context:

I requested this recorded interview with Dr. Walters (Dr. W) on the day I went to the hospital to ask Dr.

Gonzáles for a final interview, and to give the staff invitations to a meeting of the Working Group on

unwanted pregnancy and abortion.

I had had a conversation with Dr. Walters an hour earlier, on entering the gynaecology ward classroom to

observe the morning change of duty shift. At that moment, he had spoken in very positive terms about the

more frequent use of Manual Vacuum Aspiration (MVA) on the ward since our last encounter. After this

conversation, I spoke to my medical resident friend Dra. Helga Haber (Dra. HH) and did a recorded interview

with her. I remained worried about her accounts of pain management and other aspects of MVA use.

A short while afterwards, I looked for Dr. Walters to ask him for an interview about the matter. He accepted

immediately and we went to the ward classroom for a recorded interview which lasted 11 minutes, here

transcribed in its totality. Just before I commenced recording, Dr. Walters had mentioned the presentation I

had given to ward staff two weeks earlier. He had been absent on that day, but I had given him copies of my

overheads, on which he started to comment.


161


SR: What thing do you want to comment to me

first, what you have thought a bit about what

you have seen of my preliminary results?

[2]

Dr. W: Uh: [.] it seemed very interesting to

me, un th- contribution [.] ['] that you have

made, [.] ['] and:: the truth is that: [.] that gives

an impulse [1] and an:: [1] an incentive so that:

the others:- the medical staff of the service [.]

['] uh:: should think first [.] about this method,

[1] that is [.] really of: a lot of goodness and:

less: [.] less risk, right? [2]

From that:: it has been possible to observe that

in this latest season the i:ncidence of:

MVA [1] ['] has- has: increased. [1] W-

we are doing it, already they are more

conscious, [.] ['] I see that it’s been encouraged

at the level of the residents, [2] [''] uh: to do it,

and they among themselves are: [1] fighting to

do it! [2]

And:: [.] with the supervision of us:, it’s:-

it’s being done with very good results.

Patients that ['] are:: going away on the same

da:y, [.] are admitted by Emergencies, [.]

they do not need hospitalisation, except in some

or another case, right? ['] We had a case of

a: hydiatiform [.] mola, [.] ['] that:: [2] almost

by routine should be done by curettage [1] an:

uterine instrumental curettage [.] ['] following

the MVA.


SR: Qué cosa quiere comentarme

primero, lo que ha pensado un poco de lo que

ha visto de mis resultados preliminares?

[2]

Dr. W: Eh: [.] me ha parecido muy interesante,

ah l: aporte [.] ['] que Usted ha hecho, [.]

['] y:: la verdad es que: [.] eso da un

impulso [1] y un:: [1] un aliciente para que: los

otros:- los: médicos de planta del servicio [.] [']

eh:: pensemos primero [.] en este método, [1]

que es [.] realmente de: mucha bondad y:

menos: [.] menos riesgo, no? [2]

De ahí que:: se ha podido observar que

en esta última temporada la incide:ncia del:

AMEU [1] ['] ha- ha: incrementado. [1] E-

estamos haciendo, ya están más

conscientes, [.] ['] veo que se ha incentivado

a nivel de los residentes, [2] [''] eh: para hacer,

y ellos se andan: [1] peleando por

hacer! [2]

Y:: [.] por la supervisión nuestra:, está:-

se está haciendo con muy buenos resultados.

Pacientes que ['] se están:: yendo en el mismo

dí:a, [.] son internadas por Emergencia, [.]

no necesitan hospitalización, salvo en alguno

que otro caso, no? ['] Hemos tenido un caso de

una: mola [.] hidiatiforme, [.] ['] que:: [2] casi

de rutina se debe hacer un legrado [1] un::

legrado uterino instrumental [.] ['] posterior al

AMEU.


162

But: [.] since: we’re on [.] on: [1] on stri:ke

[.] with the: nurses, it was not possible to do it.

['] We are giving her dis:charge, at any rate,

to this patient. [.] [''] And:: we are going to be

observing her, how:: she develops afterwards.

[.] There is not at this moment any bleeding,

[2] ['] so- I believe it [.] is going to be:

advisable that we check

more later, the problem of her

trophoblastici disease, right?

[.]

SR: Mm: [.] ['] And with regard: to MVA with:

incomplete abortion, how

has it gone for you all?

Dr. W: We have done:: uh:: [.] uh three cases.

[2] Very well. [1] That’s to say ['] [.]

it is done the intervention, [.] ve:ry little pain,

['] it is not used, the paracervical block, because

the neck of the womb is half open, [2] and:: and

you see, they go away happy:! [.] They go away

content:! You see? And we too. [''] Uh::

we are more content, right? from that we fr::-

[''] uh:: [.] free up a bit the part of

programming of the operating theatre.

[.]

SR: Mhm:

Dr. W: Right?

SR: Mhm [.] ['] Right. And: how

is that being managed a bit of the

ve:rbal anaesthesia, the acco:mpaniment, the

con{trol of pain}

Pero: [.] como: estamos en [.] en: [1] en pa:ro

[.] con las: enfermeras, no se ha podido hacer.

['] La estamos dando de al:ta, de todas maneras

a esta paciente. [.] [''] Y:: la vamos a ir

observando como:: luego evoluciona.

[.] No hay en este momento ningún sangrado,

[2] ['] -tons- creo que [.] va a ser:

conveniente que la controlemos

posteriormente más el problema de su

enfermedad trofoblástica, no?

[.]

SR: Mm: [.] ['] Y en cuanto: al AMEU con:

el aborto incompleto, cómo

les ha ido?

Dr. W: Hemos hecho:: eh:: [.] eh tres casos.

[2] Mu:y bien. [1] O sea ['] [.]

se hace la intervención, [.] m:uy poco dolor,

['] no se utiliza el bloqueo paracervical porque

el cuello está entreabierto, [2] y:: y

ve, se van felices:! [.] Se van

contentas:! Ve? Y nosotros también. [''] Eh::

estamos más contentos, no:? de así des::-

[''] eh:: [.] desocupamos un poco la parte de

programación de quirófano.

[.]

SR: Mjm:

Dr. W: No?

SR: Mjm [.] ['] Ya. Y: cómo

se está manejando eso un poco del

anestesia verba:l, el acompañamie:nto, el

con{trol del dolo:r}


163

Dr. W: {But [.] uh::} [1] I in particular

to them: [.] to them I am explai:ning to the

patients about what it involves, the intervention.

[.] ['] That it is a me:thod that a:lways

has been done without anaesthesia! Because it’s

the method [1] that was:::- that was invented:,

or it was:: [.] done the study of it for this. [.] [']

But: m: [.] there are some patients who

understand and others who do not. [.] [']

The ones who do not, sur:ely [.] because since

there are so many people that are around the

patient, [.] [''] that’s to say people who are

obse:rving, ['] that are in teaching, ['] [.]

it ca:n cause that- that nervous tension, and:

to them:- it seems that it would hurt them more.

[.] [']

But: [.] I have been able to observe myself:,

on a level: private for example, [.] ['] that:: [.]

well explained, the patient absolutely does not::

[1] does not have: any problem! [1]

She submits herself to the intervention without

risk and without [''] without major

nervous problem!

Because we are [.] ['] doctor-patient! [.]

Maybe the husband. [1] Or the nurse [.] right?

['] But here, [.] we- we are about, some- some

ten: persons around the p:atients, all of us

want to collaborate, [2] and: and that itself

gives her a little bit of [.] overprotection to the

patient and she does not tolerate it very well, in

many cases. [2]

That’s what ['] we could comment with regard

Dr. W: {Pero [.] eh::} [1] Yo particularmente

les: [.] les estoy explica:ndo a las

pacientes de qué se tra:ta la intervención.

[.] ['] Que es un mé:todo que sie:mpre

se ha hecho sin anestesia! Porque es

el método [1] que se:::- que se ha inventado:

o se ha:: [.] hecho el estudio para esto. [.] [']

Pero: m: [.] hay algunas pacientes que

comprenden y otras que no. [.] [']

Las que no, seguramen:te [.] porque como

hay tanta gente que está alrededor de la

paciente, [.] [''] o sea la gente que está

observa:ndo, ['] que está en enseñanza, ['] [.]

pue:de ocasionar ese- esa tensión nerviosa, y:

les:- parece que les doldría más.

[.] [']

Pero: [.] he podido observar yo:

a nivel: privado por ejemplo, [.] ['] que:: [.]

bien explicadas, la paciente absolutamente no::

[1] no tiene: ningún problema! [1]

Se somete a la intervención sin

riesgo y sin [''] sin mayor

problema nervioso!

Porque estamos [.] ['] médico paciente! [.]

Tal vez el esposo. [1] O la enfermera [.] no?

['] Pero aquí, [.] ha- habemos como unos- unas

diez: personas alrededor de las p:acientes, todos

queremos colaborar, [2] y: y eso mismo

le da un poquito de [.] sobreprotección a la

paciente y no tolera muy bien, en

muchos casos. [2]

Es lo que ['] podríamos comentar al respecto


164

to the:- to the paracervical anaes{thesia.}

SR: {Right:.} Now [1] perhaps it might be that

some of these people [1] ['] were to give

constant accompaniment to the patient

during the procedure. Let’s say that they were

at her si:de, that to her they were ta:lking,

explai:ning, {making her brea:the,}

Dr. W: {Yes. That is what is being} done.

SR: ['] That, right?

Dr. W: Mm

SR: Having so many peo:ple there, some:{one

would have to be there, isn’t that right?}

Dr. W: {So:meone has to be there. [.]

Of cou:rse.} That’s it. Well I have been doing

that, when they do: the:: clea:ning or the

aspira:tion, the: residents. [2] I explai:n to them,

I treat them with ki:ndness:, giving affection,

more co:nfidence, ['] [.] and: it’s worked! It’s

worked.

SR: Mm:

Dr. W: ['] But in others, for example yesterday

in an: incom:plete abortion that screamed

tremendously, ['''] [1] m: until:: well, the

people that were there outside

c- cleared out, right? But: it is not like that!

It is: n:ot [.] worth so: much. Because the

neck of the womb was open! [.]

de la:- del anestesia paracervi{cal.}

SR: {Ya:.} Ahora [1] quizás sería de que

algunas de estas personas [1] ['] dé

acompañamiento constante a la paciente

durante el procedimiento. Digamos que esté

a su la:do, que le esté charla:ndo,

explica:ndo, {haciéndole respira:r,}

Dr. W: {Sí. Eso es lo que se está} haciendo.

SR: ['] Eso, no?

Dr. W: Mm

SR: Habiendo tanta ge:nte, al:{guien

tendría que estar, no es cierto?}

Dr. W: {A:lguien tiene que estar. [.]

Cla:ro.} Eso. Bueno yo he estado haciendo

eso, cuando ha:cen la:: limpie:za o la

aspiració:n los: residentes. [2] Yo les expli:co,

las trato con cari:ño:, haciendo afecto,

más confia:nza, ['] [.] y: ha resultado! Ha

resultado.

SR: Mm:

Dr. W: ['] Pero en otras, por ejemplo ayer

en un: aborto incom:pleto que gritó

tremendamente, ['''] [1] m: hasta que:: bueno, la

gente que estaba ahí afuera

s- se ha [des]ocupado, no? Pero: no es así!

N:o es: [.] para tan:to. Porque el

cuello estaba abierto! [.]


165

SR: Mm:

Dr. W: It entered, a cannula size ten!ii [2]

That’s to say, what- what pain could she have?

SR: Mm

Dr. W: Right? ['] But she’s very sensitive, the-

the patient.

SR: Mhm:

Dr. W: Even though I spo:ke to her, if

everyone was there:, [.] ['] the husband

was outsi:de, the husband was walking around

chewing his nai:ls, [.] [''] He says ‘What have

you done to my wi:fe! Why did she scream

[[laughing]] so: much!’

SR: Right:

Dr. W: Right? [.] But:: it was achieved and

already:- and today she is leaving,

we kept her in for: [.] preventively! [.]

Right?

SR: Right [1] Right, right

[2]

Dr. W: The method continues to be good, [.]

['] the: problem is that:: [.] that there is t- one:-

one: only: [2] only one ca:nnula for example of

size six:, or only one cannula of [''] of

four, [.] of four millimetres there’s one only, ['']

-so we have to [1] fi:nish and wait

twenty minutes for it to be sterilised, so th:-

SR: Mm:

Dr. W: Entró una cánula de diez:! [2]

O sea que- qué dolor podía tener?

SR: Mm

Dr. W: No? ['] Pero es muy sensible la-

la paciente.

SR: Mjm:

Dr. W: Pese a que le he habla:do, si

todo el mundo estaba ahí:, [.] ['] el esposo

estaba afue:ra, el esposo andaba

mascándose las u:ñas, [.] [''] Dice ‘Qué le han

hecho a mi espo:sa! Por qué ha gritado

[[riendo]] ta:nto!’

SR: Ya:

Dr. W: No? [.] Pero:: se logró y

ya:- y hoy día se está yendo,

la hemos mantenido por: [.] por prevención! [.]

No?

SR: Ya: [1] Ya, ya

[2]

Dr. W: El método sigue siendo bueno, [.]

['] el: problema es que:: [.] que hay t- una:-

un: solo:: [2] una sola cá:nula por ejemplo del

número seis:, o una sola cánula del [''] del

cuatro, [.] de cuatro milímetros hay uno solo, ['']

-tonces tenemos que [1] termina:r y esperar

veinte minutos a que se esterilice, entonces e:-


166

that is the problem, what we would like

is to have [''] more cannulae! [1] Right?

[.]

SR: {Mm}

Dr. W: {More} cannulae.

SR: Mm:

[.]

Dr. W: And well, and:: and not to wait

for them to be ste:rilised! Right? [2]

SR: Mhm:

Dr. W: To open it and right away to u:se it and

to do [your job!] [.] That will be talked about

with IPAS surely, they are going to:-

they are going to see: the work that is being

done here, right?

[2]

SR: And::: as you unfortunately

were not there the day that: I gave my

presentation of res{ults}

Dr. W: {Yes::}

SR: prelimina{ry,}

Dr. W: {That’s it}

SR: but I don’t know what: you heard

a:fterwards:, any co:mmentary:,

[.]

ese es el problema, lo que nosotros quisiéramos

es tener [''] más cánulas! [1] No?

[.]

SR: {Mm}

Dr. W: {Más} cánulas.

SR: Mm:

[.]

Dr. W: Y bueno, y:: y no esperar

que se esterili:cen! No::? [2]

SR: Mjm:

Dr. W: Abrir y:: de una vez utiliza:r y

hacer [tu labor]! [.] Eso se hablará

con IPAS seguramente, ellos van a:-

van a ver: el trabajo que se está

haciendo acá, no?

[2]

SR: Y::: como Usted lamentablemente

no estaba el día que: yo he dado mi

presentación de resul{tados}

Dr. W: {Sí::}

SR: prelimina{res,}

Dr. W: {Así es}

SR: pero no sé qué: ha escuchado

despué:s:, algún comenta:rio:,

[.]


167

Dr. W: No no, absolutely not, no: I have not

heard [??]. But I have- read:: your [1] summary,

it was very i:nteresting, [2] like I tell you it’s an

i:mpulse so that we continue wo:rking,

SR: Mm

[.]

Dr. W: and we take into account the: defects

that {we}

SR: {Mm:}

Dr. W: have as well! In the form of

expressing ourselves, right?

SR: Mhm:

Dr. W: with the patients themselves.

SR: Right:

[1]

Dr. W: I think that: [.] to u:s it serves a lot,

that.

[2]

SR: And is there: any thing that you remember,

from those little sheets, like in particular, that

surpri:sed you, had an i:mpact on you, any

thing that you remember especially?

[.]

Dr. W: At this moment, [1] the

recommendations! Right?

Dr. W: No no, en absoluto, no, no: he

escuchado [??]. Pero lo he- leí:: su [1] resumen,

estaba muy interesa:nte, [2] como le digo es un

impu:lso para que sigamos trabaja:ndo,

SR: Mm

[.]

Dr. W: y nos demos cuenta de los: defectos

que tenemos {noso}

SR: {Mm:}

Dr. W: tros también! En la forma de

expresarnos, no?

SR: Mjm:

Dr. W: con las mismas pacientes.

SR: Ya:

[1]

Dr. W: Creo que: [.] n:os sirve mucho a

nosotros eso.

[2]

SR: Y hay: alguna cosa que recuerda,

de estas hojitas, así en particular, que

le ha sorprendi:do, le ha impacta:do, alguna

cosa que recuerda en especial?

[.]

Dr. W: En este momento, [1] las

recomendaciones! No?


168

SR: Mhm:

Dr. W: That they should have [.] well, that-

that they should:: [.] that all the staff [.] without

exception [1] we should:: be [.] tr- trained,

[1] as well as receiving: more: uh

information, right? And it’s what is happening,

there doesn´t exist information.

SR: Mhm:

[.]

Dr. W: It’s a ne:w method that:: even though

it’s sim:ple, but:: since:- since it creates more

work, [2] well they don’t take it into account.

It’s better to send it in the afternoon, right?

[.]

SR: Mm

[.]

Dr. W: But:: [.] already they are

becoming aware! Like I tell you, look, there are

six MVAs that were done yesterday!

SR: Mm::

[2]

Dr. W: Today there is::- there is going

to be done another one more now.

SR: Right:

[2]

Dr. W: Even though we have the strike, but: [.]

it is- [.] it is being done, {right?}

SR: Mjm:

Dr. W: Que deben tener [.] bueno, que-

que debe:: [.] que todo el personal [.] sin

excepción [1] debemos:: ser [.] en- entrenados,

[1] por otro lado recibir: mayor: eh

información, no? Y es lo que está sucediendo,

no existe información.

SR: Mjm:

[.]

Dr. W: Es un método nue:vo que:: si bien

es sen:cillo, pero:: como:- como crea mayor

trabajo, [2] pues no lo toman en cuenta.

Es mejor enviarlo en la tarde, no?

[.]

SR: Mm

[.]

Dr. W: Pero:: [.] ya se están conscientizando!

Como le digo, mire, son

seis AMEUs que se han hecho ayer!

SR: Mm::

[2]

Dr. W: Hoy día se está::- se va

a hacer otro más ahora.

SR: Ya:

[2]

Dr. W: Pese a que tenemos el paro, pero: [.]

se está- [.] se está haciendo, { no?}


169

SR: {Right}

Dr. W: And they are being mobilised, the

beds!

SR: Right:

[.]

Dr. W: ['] After the:: informa:tion [.] what

other thing was I commenting:? [.] I do not

remember: [2] Th:- the form of treatment! that::

they should: have, the patients, right? [1] It’s

very important. [2] And: in some way I

would like it to be don- that they should have

privacy, as well! Because it cannot be done

[.] ['] in a way that is so open. You have seen

the cubicles we have, they are o{pen!}

SR: {Yes:, well} [.] Yes

[.]

Dr. W: Right? [1] So it seemed to me that

he who enters an interve:ntion [2] so-

surrounded by:- by by [.] by fi:ve or seven

persons, ['] feels bad! Right? That

there should be a li:ttle bit of [1] of privacy

for the patient. And for the selfsame party, [.]

for him who is doing it as well!

SR: Mm:

[1]

Dr. W: Because he feels [.] pressured, ['] and

there is no lack of someone who says ‘Doctor,

I want you to sign this for me’, when one is [.]

doing the intervention, ['] that’s to say, ['] [.]

SR: {Ya}

Dr. W: Y se está movilizando

las camas!

SR: Ya:

[.]

Dr. W: ['] Después de la:: informació:n [.] qué

otra cosa comentaba:? [.] No

me acuerdo: [2] E:- el: trato! que::

deben: tener las pacientes, no? [1] Es

muy importa:nte. [2] Y: de alguna manera a mí

me gustaría que se hag- que tengan

privacidad, también! Porque no se puede hacer

[.] ['] en forma tan abie:rta. Ha visto los

cubículos que tenemos, son a{biertos!}

SR: {Sí:, pues} [.] Sí

[.]

Dr. W: No? [1] Entonces me ha parecido que

el que entra a una intervenció:n [2] entons-

rodeada de:- de de [.] de ci:nco o siete

personas, ['] se siente mal! No? Que

debe haber un poqui:to de [1] de privacidad

para la paciente. Y para el mismo parte, [.]

para el que está haciendo también!

SR: Mm:

[1]

Dr. W: Porque se siente [.] presionado, ['] y

no falta alguien que dice ‘Doctor,

quiero que me lo firme esto’, cuando uno está

[.] haciendo la intervención, ['] o sea, ['] [.]


170

there’s n:o [.] idea of what is being done, right?

SR: Right

[2]

Dr. W: -so uhm::: we need a little bit

of:: of instruction, information, [.] and study in

this, fo:r the personne:l [.] that is paramedical,

[[someone knocks on the classroom door]]

Dr. W: residents and: interns, [2] so that

we can uh: polish it! in a form [.]

that’s a:dequate, this method, right?

[.]

SR: Mhm

Dr. W: And that it comes out for us [.]

a hundred per cent!

SR: Mm

Dr. W: Right?

SR: Right

Dr. W: That’s what I could [.] comment to you

SR: Right

Dr. W: And from here on to some time ahead

we’ll see: statistics!

SR: That’s it!

n:o hay [.] idea de lo que se está haciendo, no?

SR: Ya

[2]

Dr. W: -tonces: ehm::: necesitamos un poquito

de:: de instrucción, información, [.] y estudio en

esto, a:l persona:l [.] paramédico,

[[tocan la puerta del aula]]

Dr. W: residentes y: internos, [2] para que

podamos eh: pulir! en forma [.]

adecua:da este método, no?

[.]

SR: Mjm

Dr. W: Y que nos salga [.]

cien puntos!

SR: Mm

Dr. W: No?

SR: Ya

Dr. W: Es lo que yo podría [.] comentarle

SR: Ya

Dr. W: Y de aquí a un tiempo más

veremos: estadísticas!

SR: Eso!


171

Dr. W: [[smiling]] Right?

SR: That’s it!

Dr. W: If they’re noting it down, so [??] in the

clinical {his}

SR: Mhm

Dr. W: tories, ['] we don’t have the computer

that before they gave us [.] to note down these

cases, ['] but I believe that it’s::- it’s going:: [.]

it’s going to be possible to do a study of these

cases.

SR: Mhm

Dr. W: Right?

[2]

SR: Very well.

Dr. W: Very well [1] [?] I congratulate you

and I thank you a lot for your interest [1] in

supporting us!

SR: Right [[laughing]] {Thank you!}

Dr. W: {Right?}

End of Transcript 13.2

Dr. W: [[sonriendo]] No?

SR: Eso!

Dr. W: Si están anotando, entonces [??] en las

historias {clíni}

SR: Mjm

Dr. W: cas, ['] no tenemos la computadora

que antes nos daban [.] para anotar estos

casos, ['] pero creo que se::- se va:: [.]

se va a poder hacer un estudio de estos

casos.

SR: Mjm

Dr. W: No?

[2]

SR: Muy bien.

Dr. W: Muy bien [1] [?] la felicito

y le agradezco mucho por su interés [1] de

apoyarnos!

SR: Ya: [[riendo]] { Gracias!}

Dr. W: { Ya?}

Termina la Transcripción 13.2

Notes i ‘trophoblastic a. (Embryol. & Med.) relating to or consisting of trophoblast L19. trophoblast n. (Embryol & Med.) a layer of cells or a membrane surrounding an embryo, which supplies it with nourishment and later forms most of the placenta L19.’ (OED) ii Canula de diez, a ten-millimetre diameter cannula.


172

Appendix 9

Contextualisation of transcript excerpts cited in sections 9.1 and 9.2 of

Chapter 9, One Woman, Five Stories

Transcript of fieldnotes made by SR on interactions with the following characteristics:

Participants referred to in notes: Mrs. Mayta (Mrs. M), woman who had undergone a therapeutic

abortion in the Insurance Hospital.

SR as researcher.

Dr. Losada (Dr. L), third-year medical resident.

Dr. Gonzáles, principal research collaborator in the Insurance

Hospital.

Date and time of interactions: Wednesday 2/4/97, 9.15 – 10.05 a.m.

Place: Gynaecology ward and hallway just outside it, Insurance

Hospital.


Number & date of transcript: A.XPZ.02, 13/5/97

Context:

I made these fieldnotes on Wednesday April 2nd 1997 between 9.25 and 10.08 a.m., sitting near the windows

in the hallway outside the gynaecology ward of the Insurance Hospital. They were written at two different

moments, just after conversations with Mrs. Mayta (Mrs. M).

I had met Mrs. Mayta for the first time two days previously on the ward round. After the round I requested

and received her permission to consult her medical history folder, which I did that same morning.

Earlier on the day I made the fieldnotes transcribed below, I had requested a recorded interview with medical

resident Dr. Losada (Dr. L) who was in charge of Mrs. Mayta’s treatment. After interviewing him, I

approached Mrs. Mayta to ask her about her experience of the treatment. We had two conversations, and

immediately after each one, I wrote the notes which follow.


173

(9.25 - 9.35, notes afterwards, on 6th floor.)

Mrs. M: (to SR)

- I thought they were going to take out

just the tumour from one side

- No, I was in agreement

- I had sorrow for the baby

- The Doctor knows --- interrupt

- like a birth...

- My husband took it to the Cemetery,

we buried it, they baptised it

- The Lord can get angry

- I never have done those things

- Dr. Losada sacrificed himself for me

- He ran around

- We who wear the pollerai know how

to bear it

- My births, just like that they used to be,

of one hour

____________

(9.25 - 9.35, apuntes después, en el piso 6.)

Sra. M: (a SR)

- Yo pensé que iban a sacar

el tumor nomás de un lado

- No, yo estaba de acuerdo

- Tenía pena por el bebé

- El Doctor sabe --- interrumpir

- como parto...

- Mi esposo lo ha llevado al Cementerio,

lo hemos enterrado, le han bautizado

- El Señor se puede enojar

- Yo nunca he hecho esas cosas

- El Dr. Losada se ha sacrificado por mí

- Ha correteado

- Nosotros de pollera sabemos

aguantar

- Mi parto así nomás sabe ser,

de una hora

____________


174

(Conversation with Mrs. Mayta, patient of

Bed #, she continued on the ward ...

She came in walking and sat on the bed.

I approached to ask her how she had got on

with her treatment.

She didn’t look at me until the end.)

_________

(While we were talking,

Dr. Gonzáles called me from the corridor.

He was going downstairs with some

forms about attention in reproductive health,

with numbers of abortions, IUDs, etc..

He wanted to show me –

He said that I should wait for him –

that he would be back in 5 minutes.)

__________

(She keeps calling me Doctoritaii – although

I tell her my name.

__________

(10.04: For the past 10 minutes

I’ve been talking with Mrs. Mayta –

on the 6th floor, near the window –

We talk about her treatment and recovery.

I speak to her: ‘You have to take care of

yourself now so as not to get pregnant quickly.’

She has heard of a thing that

is inserted inside so as not to get pregnant.

Before – a little nuniii told her –

15 days after menstruation,

(Conversación con Sra. Mayta, paciente de

la Cama #, seguía en la sala...

Entró caminando y se sentó en la cama.

Me acerqué para preguntarle cómo le había ido

con su tratamiento.

No me miró hasta el final.)

_________

(Cuando estuvimos hablando,

me llamó el Dr. Gonzáles desde el pasillo.

Estaba bajando las gradas con unos

formularios de atención a salud reproductiva,

con número de abortos, DIUs, etc..

Me quiso mostrar –

Me dijo que le esperara –

que volvería en 5 minutos.)

__________

(Me sigue llamando Doctorita – aunque

le digo mi nombre).

__________

(10.04: Desde hace 10 minutos

converso con Sra. Mayta –

en el 6to piso, cerca de la ventana –

Hablamos de su tratamiento y recuperación.

Le hablo: ‘Tiene que cuidarse

ahora para no embarazarse rápido.’

Ella ha escuchado hablar de una cosa que

se coloca adentro para no embarazarse.

Antes - una monjita le dijo –

15 días después de la menstruación,


175

you are not to have relations –

Then, 15 days you can sleep.

But her husband did not take any notice

She didn’t do that.)

______

She says that some say that [the IUD] does

harm

I say to her – to some women

it does not give them any problem –

To others, it does.

That we are different... that if it causes her

problems she can have it taken out again –

‘like a poultice’iv – it’s not for life.)

End of Transcript A.XPZ.02

no hay que tener relaciones –

Después, 15 días puede dormir.

Pero su esposo no hacía caso

Ella no ha hecho eso.)

______

(Ella dice que algunas dicen que [el DIU] hace

daño

Yo le digo - a algunas mujeres

no les hace ningún problema –

A otras, sí.

Que somos diferentes... que si le causa

problemas lo puede hacer sacar otra vez –

‘como un parche’ – no es para toda la vida.)

Fin de la Transcripción A.XPZ.02

i Pollera: Wide, layered skirts traditionally worn by Andean indigenous women. ii Doctorita: A diminutive that can be variously interpreted as inferring familiarity, affection, or the innocuous nature of the woman doctor referred to. iii Monjita: A diminutive that can be variously interpreted as inferring familiarity, affection, or the innocuous nature of the nun referred to.. iv Parche: Poultice impregnated with a curative animal or vegetable substance, used in Andean traditional medicine. I used this simile to simplistically convey the possibility of having an IUD inserted and having it removed again.


176

Appendix 10

Contextualisation of transcript excerpts cited in section 10.3 of

Chapter 10, Audiencing Hospital Stories

Transcript of field jottings made by SR on interaction with the following characteristics:

Participants referred to in jottings: Dr. Maidana (Dr. MM), senior staff obstetrician in Maternity

Hospital affiliated to National Insurance Scheme.

Dr. Navia (Dr. NN), junior staff obstetrician in Maternity

Hospital affiliated to National Insurance Scheme.

SR as researcher.

Date and time of interaction: Tuesday 18/8/98, 14.15 – 14.35 p.m.

Place: Paediatrics ward waiting room, Maternity Hospital.

Source of notes on context: Field Notebook 13, notes summarised 13/5/97, edited 29/7/02.

Number & date of transcript: A.XPZ.02, 13/5/97

Context:

I made these field jottings at the time of an encounter with Dr. Maidana (Dr. MM) and Dr. Navia (Dr. NN) in

the waiting room of the Maternity Hospital paediatrics ward. A week earlier, I had given a ‘Changing

Voices’ research presentation to medical, paramedical and administrative staff on the invitation of the

director Dr. Harb, my main research collaborator in that hospital. After the presentation, I requested Dr.

Harb’s help to locate some hospital doctors with whom I could carry out story dossier discussion exercises.

He introduced me to Dr. Maidana, whom I had seen several times on previous visits to the hospital. He

offered to do the session the following week with another obstetrician who would be on duty then.

I arrived at 13h on the agreed day and looked for Dr. Maidana, who was having lunch. Several staff members

recognised me from the presentation and greeted me. The head nurse went to tell Dr. Maidana that I was

waiting for him. He came out and we went to look for Dr. Navia, who immediately agreed to accompany us.

On my suggestion, we went to the paediatrics ward waiting room. I explained about the exercise and left

them the story dossier sheets to read. I estimated that it would take them ten minutes to read and discuss it,

and they agreed that that time would be sufficient. The jottings transcribed below were made when I returned

to the waiting room after ten minutes.

At the end of the session, I asked Dr. Maidana and Dr. Navia if they would participate in a further exercise,

writing an auto/biographical account: ‘A critical event in my medical formation’. Dr.Maidana’s final

intervention concerned an incident he had just remembered that was relevant to the proposed exercise.


177

(14.15, notes made at the time.)

Dr. MM:

- The five stories make it seem as if they

were of five different patients.

- The point of view of the gynaecologist and

the diagnosis – is very directed towards

induced abortion. The indication of a

dermoid tumour is not very strong.

I do not find why the pregnancy comes to

be interrupted.

- It does not seem... to hold the

Medical Council in a hospital... they are

more firm – in defence of life.

- In a hospital, this type of decision is not

taken in the Reproductive Health

programme – above all for a cyst –

that does not have so much importance.

Dr. NN:

- What the social worker says is very

directed. There is not an explanation to the

patient – alternatives are not given. It is

directed towards an abortion.

- The woman says – ‘I thought that

they were going to take out the tumour just

from one side. I had sorrow for the baby.’

But the social worker says another thing.

It’s contradictory.

- She says ‘We who wear the pollera know

how to bear it.’ The woman – because of

the social condition – for that maybe

it was not explained...

(14.15, apuntes tomados en el momento.)

Dr. MM:

- Los cinco relatos hacen parecer que

fueran de otros cinco pacientes.

- El punto de vista del ginecólogo y el

diagnóstico – está muy dirigido al

aborto inducido. La indicación de un

tumor dermoide no es muy fuerte.

No hallo por qué se llega a interrumpir el

embarazo.

- No parece... hacer la

Junta Médica en un hospital... son

más firmes – en defensa de la vida.

- En un hospital, no se toma este tipo de

decisiones en el programa de Salud

Reproductiva – sobre todo para un quiste –

que no tiene tanta importancia.

Dr. NN:

- Lo que dice la trabajadora social está muy

dirigido. No se explica a la paciente – no

se da alternativas. Está dirigido a un

aborto.

- La mujer dice – ‘Pensé que

me iban a sacar el tumor nomás

de un lado. Tenía pena por el bebé.’

Pero la trabajadora social dice otra cosa.

Se contradice.

- Dice ‘Nosotros de pollera sabemos

aguantar.’ La mujer – por

la condición social – por eso quizás

no se ha explicado...


178

Dr. MM:

- The resident does not give an explanation

of a scientific type – not even

gynaecological – it seems more an

interview that is very sentimental – more

from the moral and religious point of view

– not scientific.

- (The interview) It does not seem

as if it were done in a hospital –

- By chance – in any place.

- A resident in the third year... has the

capacity to be able to give correct

explanations in a scientific form –

he talks rather in a religious form.

- It’s a counter-position - in Medicine,

we do not take much into account - -

religious aspects... It has to be of a

scientific nature.

- The report of the nurse – is not in

agreement with the norms – that (she

should know, a) registered nurse – she

changes the concepts – says ‘obitus’ –

knowing that it does not occur at

16 semanas.

- An obitus – (has to be) above 20

weeks.

- It says ‘curettage’... to extract the placenta

- Normally it is done to take out the

placental remains - -

- They do not explain for what cause she has

to go down urgently to theatre -

Dr. NN:

- It seems a ‘dermoid tumour with little feet’

(they both laugh)

Dr. MM:

- El residente no da una explicación

de tipo científico – ni siquiera

ginecológico – parece más una

entrevista muy sentimental – más

desde el punto de vista moral y religioso

– no científico.

- (La entrevista) No parece

que fuera realizado en un hospital –

- Al azar – en cualquier lugar.

- Un residente de tercer año... tiene la

capacidad de poder dar

explicaciones correctas en forma científica

– él habla más bien en forma religiosa.

- Es una contraposición – en Medicina,

no tomamos muy en cuenta - -

aspectos religiosos... Tiene que ser de

carácter científico.

- El informe de la enfermera – no está de

acuerdo a las normas – que (debe conocer

una) Licenciada en Enfermería –

cambia los conceptos – dice ‘óbito’ –

sabiendo que no sucede a

las 16 semanas.

- Un óbito – (tiene que ser) encima de 20

semanas.

- Dice ‘legrado’... para extraer la placenta

- Normalmente se hace para sacar los

restos placentarios - -

- No explican por qué causa tiene que bajar

urgente a quirófano –

Dr. NN:

- Parece un ‘tumor dermoide con patitas’

(ambos se ríen)


179

Dr. MM:

- ¿Is it a hospital?

- It does not seem to me that a hospital

would accept the interruption of a

pregnancy –

- More still – with a Medical Council –

- In all the hospitals of Bolivia...

(it should be) protected, human life –

- It is the first time that I hear that it has to be

interruption (.....?)

SR:

- ¿Has it any utility, the exercise?

Dr. MM:

- This hospital does not have norms for

attention, conduct – each service does

what it can

- It does not adhere to an

internal regulation of a hospital.

- The patient should be attended with one

norm alone – the gynaecologist – the social

worker – to lead

the patient in only one direction.

Dr. NN:

- To speak only one language.

Dr. MM:

- That the resident should adhere to the

norms – of the hospital –

- That he should learn correctly

- (Giving) various points of view - - instead

of helping the patient – confuses her

- That they should have programmes of

teaching – that take into account all the

Dr. MM:

- ¿Es un hospital?

- No me parece que un hospital

acepte la interrupción de un

embarazo –

- Más – con Junta Médica –

- En todos los hospitales de Bolivia...

(se debe) precautelar la vida humana –

- Es la primera vez que escucho que hay que

interrupción (.....?)

SR:

- ¿Tiene alguna utilidad el ejercicio?

Dr. MM:

- Este hospital no tiene normas de

atención, conducta – cada servicio hace

lo que puede

- No se rige a un

reglamento interno de un hospital.

- A la paciente se la debe atender con una

sola norma – el ginecólogo – la

trabajadora social – encaminar

a un solo lado a la paciente.

Dr. NN:

- Hablar un solo idioma.

Dr. MM:

- Que el residente se rija a las

normas – del hospital –

- Que aprenda correctamente

- (Dar) varios enfoques - - en lugar de

ayudar a la paciente – la confunde

- Que tengan programas de

enseñanza – que tomen en cuenta todos los


180

aspects

- scientific

- psychic

- moral –

- for the integral formation of the resident.

- It has to be modified, the system of

teaching that is not in accordance with

reality.

- The resident is the man – who already is a

specialist – he must have concepts that are

more clear – more based on

professional ethics.

- The doctor – has to leave to one side his

religious beliefs – first, the profession

SR:

(¿Have you not both seen situations like that, in

which they have been handled,

different approaches?)

Dr. NN:

- ¡There are! But more in small things

Dr. MM:

- In treatment. Not in conducts like that,

aggressive – this type of aggressions.

- Before it was worse.

Dr. NN:

- We base ourselves on norms

that are already written

Dr. MM:

- In a hospital

- always we go protecting

human life

aspectos

- científico

- psíquico

- moral –

- para la formación integral del residente.

- Hay que modificar el sistema de

enseñanza que no está de acuerdo con

la realidad.

- El residente es el hombre – que ya es

especialista – debe tener conceptos

más claros – más basados en la ética

profesional.

- El médico – tiene que dejar de lado sus

creencias religiosas – primero la profesión

SR:

(¿No han visto situaciones así, en

que se han manejado

diferentes enfoques?)

Dr. NN:

- ¡Hay! Pero más en cosas pequeñas

Dr. MM:

- En el tratamiento. No es conductas así

agresivas – este tipo de agresiones.

- Antes era peor.

Dr. NN:

- Nos basamos en normas

ya escritas

Dr. MM:

- En un hospital

- siempre vamos precautelando

la vida humana


181

Dr. NN:

- Including – when there are foetuses

that are deformed –

- in Medical Councils – it is difficult

to decide.

Dr. MM:

- (They are seen, the) possibilities to live.

- (It is tried, to) correct the defects –

- a measure that is aggressive –

- because of another tumour –

- pathology - - life of the baby - -

Dr. NN:

- All the tumours are compatible with the life

of the baby - -

Dr. MM:

- Even cancer is compatible with

pregnancy.

(I give forms for the stories → collect

Friday 14h from director’s office)

Dr. MM:

- Right now I have just remembered an

incident

- from when I was in first year!

End of the transcript of notes A.GPD.2

Dr. NN:

- Incluso – cuando hay fetos

malformados –

- en Juntas Médicas – es difícil

decidir.

Dr. MM:

- (Se ven las) posibilidades de vivir.

- (Se trata de) corregir los defectos –

- una medida agresiva –

- por otro tumor –

- patología - - vida del bebé - -

Dr. NN:

- Todos los tumores son compatibles con la

vida del bebé - -

Dr. MM:

- Inclusive el cáncer es compatible con

el embarazo.

(Doy formularios para relatos → recoger

viernes 14h de Dirección)

Dr. MM:

- Justo ahora me acabo de acordar de un

incidente

- ¡de cuando estaba en primer año!

Fin de la transcripción de apuntes A.GPD.2


182

Appendix 11 Contextualisation of transcript excerpt introducing Chapter 11, Contrariwise and Otherwise Excerpt of transcript of field notes on interactions registered by SR with the following characteristics: Participants: Bertha Bastos (B), intern friend and research collaborator

SR as researcher and friend

SR’s 12-year-old son Amaru Villanueva

Date and time of interaction: Friday 15th May 1998, 10.30 – 11.30 p.m.

Place: Walking on the street, urban residential zone

Source of notes on context: Field Notebook 11, notes made 15-16/5/98, edited 30/7/02

Number & date of transcript: S.1, 22/6/99

Context: These fieldnotes were written half an hour and then five hours after a conversation in the street with Bertha

Bastos (B), an intern friend I had got to know through fieldwork in the Medical School, with whom I had

ongoing discussions about relations between sociology and medicine.

That evening we had gone bowling and to eat hamburgers together with my twelve-year-old son, Amaru. The

three of us were walking back along the main avenue of a residential street in the southern zone of the city.

Bertha was smoking a cigarette and we walked and talked together before getting our respective taxis home.

Bertha initiated the conversation transcribed below, bringing up the topic of a legal medicine lecture that I

had observed with her class in the Medical School that morning, on Bertha’s suggestion and invitation.

I wrote the notes here transcribed and translated on returning home at 11.45 p.m. that night, and on waking at

5.10 a.m. the following morning.

Parts of my notes were in English, and I present these in the left-hand column with no parallel translation.

The text originally in Spanish is presented in the right-hand column, with an English translation running

parallel.


183

Start of Transcript S.1

(11.45 p.m. Just got back from bowling and

McDonald’s with Bertha and Amaru. The last

hour was a rather disturbing and surprising

conversation between me and Bertha, with

which Amaru appeared to be bored stiff at the

time, but afterwards reacted with amazement at

how ‘square’i she seemed to him, and great

surprise when I said she was actually one of the

more open students I’d met. I’ll try to

remember parts of the conversation which

struck me:)

B: It seems that you did not like the class this

morning.

SR: It’s not a question of whether I liked it or

not – it interested me, as a form of expressing

the medical model.

B: What do you mean by that?

SR: Well, for example…

professional protectionii against litigation,

lawsuits for medical negligence... and the

informed consent form which

has more the function of safeguarding the

interests of the doctor, than the rights of the

patient.

B: But this form is much better than

others that I have seen, which as he said, are

like registrations in a hotel.

SR: But all the same, the language is not

B: Parece que no te gustó la clase de esta

mañana.

SR: No es cuestión de que me haya gustado o

no – me interesó, como forma de expresar

el modelo médico.

B: ¿Qué quieres decir con esto?

SR: Bueno, por ejemplo…

la protección gremial en contra del litigio,

los juicios por negligencia médica... y el

formulario de consentimiento informado que

tiene más la función de precautelar los

intereses del médico, que los derechos del

paciente.

B: Pero este formulario es mucho mejor que

otros que yo he visto, que como dijo él, son

como registros en un hotel.

SR: Pero de igual manera, el lenguaje no es


184

understandable for many people who are users

of the services. Still less for those who do not

know how to read and write.

B: So what would you do? The doctor

would have to give a class to each one…

SR: Put it in language which is more simple

and clear. And put a note saying that if the

person doesn’t know how to read and write –

that there’s an obligation to explain everything

and to verify the comprehension and the

informed consent of the person.

I have seen that in the Insurance Hospital, in a

case of therapeutic abortion, in which the

woman and her partner had a lot of doubts

about the procedure.

And the resident, seeing that, made them sign

an informed consent form –

not so much to ensure their comprehension and

agreement, but rather to protect himself

against a possible lawsuit.

Other things I noted in the class today were: the

use of slides without any attempt to

protect the identity of people by covering

their eyes; the repeated projection of images of

medical pornography, the child with an

immense tumour in his face – showing it

unnecessarily several times, as if to

impress and frighten; and also the references

to the ‘subjective’ nature of what

the patient reports, versus the ‘objective’ nature

of the medical diagnosis.

entendible para muchas personas usuarias

de los servicios. Menos aún para los que no

saben leer y escribir.

B: Entonces, ¿cómo harías tú? El médico

tendría que dar una clase a cada uno…

SR: Ponerlo en un lenguaje más sencillo

y claro. Y poner una nota diciendo que si la

persona no sabe leer y escribir –

que se debe explicar todo

y verificar la comprensión y el

consentimiento informado de la persona.

Yo he visto eso en el Hospital del Seguro, en un

caso de aborto terapéutico, en que la

mujer y su pareja tenían muchas dudas

sobre el procedimiento.

Y el residente, viendo eso, les hizo firmar

un formulario de consentimiento informado –

no tanto para asegurar su comprensión y

acuerdo, sino más bien para protegerse

en contra de un posible juicio.

Otras cosas que noté en la clase hoy, fueron: el

uso de diapositivas sin ningún intento de

proteger la identidad de las personas, tapando

sus ojos; la proyección repetida de imágenes de

pornografía médica, el niño con un

tumor inmenso en la cara – mostrándolo

innecesariamente varias veces, como para

impresionar y asustar; y también las referencias

a lo ‘subjetivo’ de lo que

refiere el paciente, versus lo ‘objetivo’

del diagnóstico médico.


185

B: But it can’t be any other way!

We know that the great majority of patients

either enlarge or diminish what they have.

Doctors divide into symptoms and signs – the

symptoms are what the patient reports. And the

signs are what the doctor really observes,

objectively.

SR: From sociology, it’s considered that the

doctor also observes from his subjectivity.

And that there is not a hierarchy of knowledge

– that the constructions of the patient and the

doctor have the same value and validity.

B: That can’t be. For example, a patient

with a problem of the gall bladder, who

exaggerates his pain – whilst the doctor

evaluates and knows that such pain cannot exist

– because it’s known – studies have been done.

SR: But the patient will have his reasons for

representing his pain in this way.

B: But what can we do?

We have to programme surgery –

giving priority to the most urgent cases. You,

what would you do?

SR: As a sociologist, it’s not up to me to

programme surgery. I would be more interested

in knowing how that person constructs their

pain and what they seek with that

representation.

B: And what would you do, with a patient who

consults for a problem of vision who says

B: ¡Pero no puede ser de otra manera!

Sabemos que la gran mayoría de los pacientes,

o agranda o achica lo que tiene.

Los médicos dividen en síntomas y signos – los

síntomas son lo que el paciente refiere. Y los

signos son los que realmente observa el médico,

objetivamente.

SR: Desde la sociología, se considera que el

médico también observa desde su subjetividad.

Y que no hay una jerarquía de conocimientos

– que las construcciones del paciente y del

médico tienen igual valor y validez.

B: Eso no puede ser. Por ejemplo, un paciente

con un problema de vesícula, que

exagera su dolor - mientras que el médico

valora y sabe que tal dolor no puede existir

– porque se conoce – se ha hecho estudios.

SR: Pero el paciente tendrá sus razones por

representar su dolor de esa manera.

B: ¿Pero qué podemos hacer nosotros?

Tenemos que programar cirugías – priorizando

a los casos más urgentes. Tú,

¿qué harías?

SR: A mí como socióloga, no me compete

programar cirugías. Me interesaría más

saber cómo esta persona construye su

dolor y qué busca con esta

representación.

B: Y qué harías, con un paciente que

consulta por un problema de la vista que dice


186

that he sees the small letters and not the

big ones? What would you say?

SR: I would not have to fix his problem with

vision, or know if what he says is true or not.

I would be more interested in talking to him to

know how he constructs his reality, his eyes, the

fact of seeing well or badly; if he wants to wear

glasses or not; if there are people who are

pressuring him to wear them; if he thinks that

he is not going to look good with glasses;

etcetera. It is not my problem to resolve

his problem with vision.

B: But what do you want us to do?

To talk to him about that?

SR: No – you do what you have to

do, within your medical model. But I

as a sociologist see things in another manner

and my work is different.

B: But you are attacking our way of

doing things!

SR: I don’t say that it’s good or bad. Only that

it’s a particular model, a special way of

constructing and treating the human body – and

that it’s very different from the

sociological model.

B: But you’re not understanding what the

doctor wanted to say this morning! That’s how

signs and symptoms are registered, as

‘subjective’ y ‘objective’. In what other way

can it be done?

que ve las letras chicas y no las

grandes? ¿Qué dirías?

SR: Yo no tendría que arreglar su problema de

la vista, ni saber si lo que dice es cierto o no.

Me interesaría más charlar con él para

saber cómo construye su realidad, sus ojos, el

hecho de ver bien o mal; si quiere usar

lentes o no; si hay gente que le está

presionando para que los use; si piensa que

no se va a ver bien con lentes;

etcétera. No es mi problema, solucionar su

problema de la vista.

B: ¿Pero qué quieres que hagamos nosotros?

¿Qué le conversemos sobre esto?

SR: No – ustedes hacen lo que tienen que

hacer, dentro de su modelo médico. Pero yo

como socióloga veo las cosas de otra manera

y mi trabajo es diferente.

B: ¡Pero tú estás atacando nuestra forma de

hacer las cosas!

SR: No digo que está bien ni mal. Sólo que

es un modelo particular, una forma especial de

construir y tratar el cuerpo humano – y

que es muy diferente del

modelo sociológico.

B: ¡Pero no estás entendiendo lo que

quería decir el Doctor esta mañana! Así

se registran los signos y síntomas, como

“subjetivo” y “objetivo”. De qué otra manera

se puede hacer?


187

SR: I’m telling you that there are other ways

of constructing reality. Just as you cannot

think like a sociologist, nor can I

think like a doctor.

B: Yes, but it cannot be denied that... (I think

that here she tried to assert the superiority of

the medical vision).

SR: It’s that there are different ways of

constructing and seeing reality! I’m not saying

that one is better or worse than the other – but

that both occur.

(16-5-98. 5.10 a.m. on waking)

B: But I am trying to explain to you

why the Doctor explained it that way –

it seems that you do not understand!

SR: I understand that this forms part of his

model. But you in medicine learn a

type of language, a terminology, and to say

‘that’s how it is’. In sociology, we learn to

question the terms and to say: Why

would it be called like that? How could it be

called otherwise?

It’s not a destructive thing – but of curiosity,

of examining how reality is constructed in

different ways.

B: But you are researching among us,

among the doctors! And you’re learning how

we explain things.

SR: Yo te estoy diciendo que hay otras formas

de construir la realidad. Tal como tú no puedes

pensar como socióloga, yo tampoco puedo

pensar como médico.

B: Si, pero no se puede negar que .. (pienso

que aquí trataba de aseverar la superioridad de

la visión médica).

SR: ¡Es que hay diferentes maneras de

construir y ver la realidad! No estoy diciendo

que una es mejor o peor que la otra – sino

que ambas se dan.

B: Pero yo te estoy tratando de explicar,

por qué el Doctor lo explicó de esa manera -

¡parece que no entiendes!

SR: Entiendo que esto forma parte de su

modelo. Pero ustedes en medicina, aprenden un

tipo de lenguaje, una terminología, y a decir

‘así es’. En sociología, nosotros aprendemos a

cuestionar los términos y a decir: ‘¿Por qué

se llamaría así? ¿Cómo se podría

llamar de otra manera?’

No es una cosa destructiva – sino de curiosidad,

de examinar cómo se construye la realidad de

diferentes maneras.

B: Pero tú estás investigando entre nosotros,

¡entre los médicos! Y estás aprendiendo cómo

nosotros explicamos las cosas.


188

SR: Yes, but I’m more interested in the

negotiation between you and other people –

like the users of the services (I don’t say

‘patients’ because that emphasises submission,

dependency and a lesser hierarchy faced with

medical power) – try to validate their version

of reality – in the interaction – what happens

and who succeeds in validating their version of

the facts.

I could do this same work in a

fishery, a beauty salon or a restaurant –

what interests me is human interaction and the

management of power relations between

people of different social groups.

B: But you have to see that the patients almost

always enlarge or diminish the condition

they have. They do not tell you the truth.

SR: That supposes that there is a ‘condition’

out there that is objectively demonstrable.

That any person can recognise as

true.

In sociology we do not give greater hierarchy to

that medical version of the facts.

We consider the knowledge of the user

as equal to that of the doctor, in status.

B: --- ?

SR: (saying goodbye) – I hope you do not get

totally disgusted with sociology!

____________

SR: Si, pero más me interesa la

negociación entre ustedes y otras personas –

como las usuarias de los servicios (no digo

‘pacientes’ porque esto enfatiza la sumisión,

la dependencia y una jerarquía menor frente al

poder médico) – tratan de hacer valer su versión

de la realidad – in la interacción – qué pasa

y quién logra hacer valer su versión de

los hechos.

Yo podría hacer este mismo trabajo en una

pesquería, un salón de belleza o un restaurant -

lo que me interesa es la interacción humana y el

manejo de las relaciones de poder entre

personas de diferentes grupos sociales.

B: Pero tienes que ver que los pacientes casi

siempre agrandan o achican el cuadro que

tienen. No te dicen la verdad.

SR: Esto supone que hay un ‘cuadro’

ahí fuera que es objetivamente demostrable.

Que cualquier persona puede reconocer como

cierto.

En sociología no damos mayor jerarquía a

esa versión médica de los hechos.

Consideramos los conocimientos del usuario

como iguales a los del médico, en status.

B: --- ?

SR: (despidiéndose) - ¡Espero que no te

disgustes del todo con la sociología!

____________


189

Amaru reacted strongly to Bertha’s attitude as

rigid, arrogant, and unable to see other

constructions of reality outside – or alternative

to – the medical model. He said ‘I believe in

science’, but ‘there are other ways of describing

realities and phenomena, including illnesses’.

I was struck by Bertha’s sense of being

attacked, on having a critical vision of medical

discourse presented. How she clung to a notion

of medical superiority and patients’

unreliability. I hope this doesn’t ruin our

friendship! I felt the end of the conversation and

the farewell were a bit abrupt. I’ll see her on

Wednesday in the legal medicine video and ask

how she felt about the conversation.

________

All this makes me think that showing the

dossiers – while the exercise can serve to

highlight the relativity of medical discourse –

could also serve to emphasise the falsity,

distortion and lack of knowledge of other

participants, from a medical point of view. It’s a

pity I can’t use the pain dossier – for me, that’s

the one that most brings the point home –

picking up what Bertha said about the

‘impossibility’ of a certain kind of pain –

backed up by studies done on nerve paths, etc..

I think this conversation showed up a major

facet of medical education: the teaching of a

positivistic model, faith in the superiority of

medical knowledge, and warnings of patients’

unreliability and manipulative behaviour used

to get ahead on the operating lists.


190

______

This makes me think especially of the part in

the medical history where it says: ‘Fuente de

información: paciente confiable’iii (I take this to

mean, for purposes of the medical version of

events).

End of Transcript S.1

i ‘Cuadrada’ in Spanish, literally and figuratively ‘square’. ii ‘Professional’ does not adequately express the associations of ‘gremial’ in the original. This adjective comes from the noun ‘gremio’, often used by doctors in Bolivia to refer to their profession as a craft or union-like fraternity: ‘el gremio médico’. ‘gremio, m. lap; body, society, company, guild, corporation; fraternity; trade-union’ (Cuyás xxx). iii ‘Fuente de información’, source of information. ‘Paciente confiable’, patient trustworthy.


191

APPENDIX 12

Translated excerpts from Bolivian Ministry of Health 1999 policy document, National Programme for

Sexual and Reproductive Health

Ministerio de Salud y Previsión Social. Coordinación del Programa Nacional de Salud Sexual y

Reproductiva. Unidad de Atención a las Personas. Programa Nacional de Salud Sexual y

Reproductiva 1999 – 2002. La Paz, 1999

A12.1 Excerpt on maternal mortality from Section III. ‘Demographic, economic, political, social, cultural,

educational context’, pp. 33 – 34;

A12.2 Excerpt on abortion from Section III, ibid., pp. 35 – 36;

A12.3 Excerpt on problems affecting sexual and reproductive health and services from Section VI.

‘Priority Problems’, p. 40;

A12.4 Excerpt on basic principles and approaches from Section IX. ‘Principles, Vision, Mission,

Objective, Results and Indicators of the Programme’, p. 48.

A12.1 Excerpt on maternal mortality from Section III. ‘Demographic, economic, political, social,

cultural, educational context’, pp. 33 – 34:

‘4. Maternal mortality

‘According to a direct estimate made by the DHS 94 study, the rate of maternal mortality for the period 1989

– 1994 was 390 deaths per 100,000 live births. In urban areas the mortality rate reached 262, while in rural

areas it was 563 deaths per 100,000 live births. By region, in the high plateau it reached 591 (346 urban and

929 rural), 286 in the valleys and in the plains, 166 deaths per 100,000 live births. On observing the type of

mortality, it was ascertained that 61.7% occurred during pregnancy, 22.8% in childbirth and 15.5%

postpartum.

‘Three quarters of these deaths are produced in pregnancy, with greater frequency than in childbirth and

postpartum (haemorrhage, abortion, hypertension, etc.). It is evident that pregnant women younger than 19

and older than 34, like women who have very short intervals between pregnancies (less than 24 months),

increase the risk of dying. The majority of maternal deaths are produced at home. Unpublished data from the

then National Health Secretariat estimated that in 1995 abortion was responsible for between 27 and 35% of

maternal mortality.’


192

A12.2 Excerpt on abortion from Section III, ibid., pp. 35 – 36:

‘6. Abortion

‘As in many countries of the world, abortion constitutes a serious public health problem in Bolivia. The Penal

Code considers abortion as a crime against life and bodily integrity, establishing penalties depriving liberty

and other greater ones when abortion is followed by lesions or death. Abortion is permitted when the life or

health of the woman are endangered if the pregnancy continues or if the pregnancy is the result of rape,

abduction not followed by marriage, abuse or incest (The Population Council 1995). The penalisation which

the legislation establishes for practitioners and for the woman who requested it, together with the absence of

comprehensive studies, prevents more precise knowledge regarding the national dimensions and

repercussions of this problem for the rights, health and life of Bolivian women, and for this same reason,

makes it difficult to link actions addressing it on its different levels.

‘Data on Bolivia estimate that approximately 115 abortions are produced daily and between 40,000 and

50,000 annually. The principal factor underlying the decision to abort is unwanted pregnancy. Given the

illegal nature of abortion in the country, the majority of abortions are clandestine and practised by

unqualified persons, which gives rise to conditions of risk for health.

‘The complications derived from induced abortion vary, depending on whether the woman resides in the rural

or urban area, on her educational status and socio-economic level, as has been demonstrated by studies in

other countries (The Alan Guttmacher Institute, 1994).

‘It is calculated that of all pregnancies produced worldwide, some 20 to 30% terminate in induced abortions.

In 1986 the number of abortions practised in Bolivia was estimated at 42,000. Rates have been found of 600

deaths per 10,000 abortions practised in the country (compared with 0.5 per 100,000 in the United States,

according to a study from the same year). This would give us an approximate figure of 252 women who die

yearly in the country due to the complications of these interventions.’

A12.3 Excerpts on problems affecting sexual and reproductive health and services from Section VI.

‘Priority Problems’, p. 40:

‘1. Relating to the sexual and reproductive health of the population:

• Maternal morbidity and mortality associated with complications of the reproductive cycle (pregnancy,

childbirth and postpartum).

• Morbidity and mortality of women associated with gynaecological cancers (cervico-uterine and

mammary).


193

• Morbidity and mortality of women associated with complications of unwanted pregnancy (induced

abortion).

• Morbidity in adolescents, adult women and men, associated with risk behaviours (sexually transmitted

diseases, HIV and AIDS).

• Mistrust of the services offered by the network of establishments.

• Unsatisfied demand for family planning.

• Lack of knowledge about sexual and reproductive rights.

‘2. Relating to the supply of sexual and reproductive health services:

• Insufficient and weak situation of management systems at different levels: central departmental, district

and local; expressed in:

Weakness in the development of systems for leadership and management of the programme at

different levels (weak sectoral leadership).

Insufficiency in the development and application of programmatic orientation, technical and

administrative norms and protocols for care.

Limited integration of general services with those pertaining to sexual and reproductive health

(including the availability of checks for STDs and HIV/AIDS.

Influence of biomedical and assistential approaches in the management of services.

Weakness in gender, ethnic (limited capacity for intercultural dialogue) and generational

perspectives.

Insufficiency in the application of specific plans within the network of public services.

Insufficiency in the provision of human resources, equipment and materials for management tasks.’

A12.4 Excerpt on basic principles and approaches from Section IX. ‘Principles, Vision, Mission,

Objective, Results and Indicators of the Programme’, p. 48.

‘1. Basic principles and approaches

In recognition of the just aspirations of the Bolivian population to levels of sexual and reproductive health

which are compatible with human, sexual and reproductive rights, expressed in numerous political and legal

instruments and honouring the commitments made in important international and national forums, through

this Programme the following principles and basic approaches are taken up and appropriated:


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• ‘The recognition of reproductive health as “a general state of physical, mental and social well-being in

all aspects relating to the reproductive system, its functions and processes”.1 In consequence,

reproductive health involves the capacity to enjoy a satisfactory and risk-free sex life, as well as the

capacity to procreate and the freedom of decision about whether or not to do so, when and with what

frequency. This state “implicitly entails the right of men and women to obtain information and have

access to family planning methods of their choice which are safe, efficient, acceptable and economically

attainable, as well as other methods of their choice for the regulation of their fertility, which are not

legally prohibited, and the right of women to have access to health care services which promote risk-free

pregnancies and births.

• ‘Recognition that reproductive health care includes sexual health, whose objective is the development of

life and personal relations and not merely advice and care concerning reproduction and sexually

transmitted diseases.

• ‘Recognition of sexual and reproductive rights, which embrace certain internationally recognised human

rights, which refer to the “right of couples and individuals to freely and responsibly decide the number of

their children, the spacing and timing of births, to have access to the necessary information and means to

do so, and the right to achieve the highest level of sexual and reproductive health”. “The right of each

person to adopt decisions relating to reproduction without suffering discrimination, coercion or

violence.”

• ‘The importance of giving full attention to promoting relations of mutual respect between men and

women and particularly, to the satisfaction of additional needs and services for adolescents so that they

can assume their sexuality in a positive and responsible manner.

• ‘The provision of quality services, which implies the opportune and sufficient offer of information and

orientation, the development of environments and mechanisms favouring free choice, the delivery of

services by trained and motivated providers, respect for privacy and confidentiality, an integrated

approach to care.

• ‘Promotion of individual responsibility, citizens’ participation, shared responsibility and management,

which seeks to involve individuals in making decisions which are relevant to aspects connected with

their health and with the care of the population’s health.

• ‘Respect for culture and diversity, which demands differentiated attention in recognition of the

population’s cultural models and values for social life and organisation.’

1 Author’s note: Here and elsewhere, this national policy document directly cites excerpts from the United Nations ICPD 1994 Programme Of Action.


195

APPENDIX 13

United Nations Population Fund 1996. Programme of Action adopted at the International Conference on

Population and Development, Cairo, 5 – 13 September 1994. Paragraph 8.25 (pp. 70-71):

‘8.25. In no case should abortion be promoted as a method of family planning. All Governments and relevant

intergovernmental organizations are urged to strengthen their commitment to women’s health, to deal with

the health impact of unsafe abortion1 as a major public health concern and to reduce the recourse to abortion

through expanded and improved family-planning services. Prevention of unwanted pregnancies must always

be given the highest priority and every attempt should be made to eliminate the need for abortion. Women

who have unwanted pregnancies should have ready access to reliable information and compassionate

counselling. Any measures or changes related to abortion within the health system can only be determined at

the national or local level according to the national legislative process. In circumstances where abortion is not

against the law, such abortion should be safe. In all cases, women should have access to quality services for

the management of complications arising from abortion. Post-abortion counselling, education and family-

planning services should be offered promptly, which will also help to avoid repeat abortions.’

1 Unsafe abortion is defined as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both (based on World Health Organization, The Prevention and Management of Unsafe Abortion, Report of a Technical Working Group, Geneva, April 1992 [WHO/MSM/92.5]).


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APPENDIX 14

Translated excerpt from the Bolivian Penal Code, Title VIII, Crimes against Life and Bodily

Integrity, Chapter II, Articles 263–269 on abortion (Bolivia. Código Penal, pp. 92 - 93):

CHAPTER II

ABORTION

‘Article 263.- (ABORTION).- He who should cause the death of a foetus in the maternal womb or

should provoke its premature expulsion, shall be sanctioned:

1) With deprivation of liberty from two to six years, if the abortion should have been practised

without the consent of the woman or if she were less than sixteen years old.

2) With deprivation of liberty from one to three years, if it should have been practised with the

consent of the woman.

3) With confinement from one to three years of the woman who gave her consent.

The attempt on the part of the woman is not punishable.

‘Article 264.- (ABORTION FOLLOWED BY LESION OR DEATH).- If the abortion with the

woman’s consent should have been followed by lesion, the penalty shall be deprivation of liberty from one to

four years; and if death should ensue, the penalty shall be augmented by half.

If abortion without consent should result in lesion, a penalty shall be imposed on the author of deprivation

of liberty from one to seven years; if death should occur, deprivation of liberty shall be applied from two to

nine years.

‘Article 265.- (ABORTO HONORIS CAUSA).- If the crime should have been committed to save the

honour of the woman, either by herself or by third parties, with her consent, confinement shall be imposed

from six months to two years, with the penalty aggravated by a third if death should ensue.

‘Article 266.- (NON-PUNISHABLE ABORTION).- If the abortion should have been the consequence

of an offence of rape, abduction not followed by marriage, abuse or incest, no sanction will be applied,

provided that the penal lawsuit has been commenced.


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Neither will it be punishable if the abortion should have been practised with the purpose of avoiding

a danger for the life or health of the mother and if this risk could not be avoided by other means.

In both cases, the abortion must be practised by a physician, with the consent of the woman and

judicial authorisation where corresponding.

‘Article 267.- (UNINTENTIONAL ABORTION).- He who through violence should have given rise to

abortion without intending to cause it, but with the pregnancy being in evidence or with knowledge of it,

shall be penalised with confinement from three months to three years.

‘Article 268.- (BLAMEFUL ABORTION).- He who should blamefully have caused an abortion will be

liable to provide labour for up to one year.

‘Article 269.- (HABITUAL PRACTICE OF ABORTION). He who should habitually dedicate himself

to the practice of abortion shall be liable to deprivation of liberty from one to six years.’


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APPENDIX 15

Translated excerpt from the Bolivian Political Constitution, Article 3 on State and religion

(Bolivia 1985. Constitución Política del Estado, p. 6):

‘ARTICLE 3. – The State recognises and sustains the Apostolic Roman Catholic religion. It

guarantees the public exercise of all other cults. Relations with the Catholic Church will be governed by

covenants and agreements between the Bolivian State and the Holy See.’


199

APPENDIX 16 Translated excerpt from the Bolivian Medical College’s Code of Ethics, Article 15 on therapeutic abortion (Colegio Médico de Bolivia 1993. ‘Código de Etica Médica’ in Estatutos y Reglamentos 1993 p. 111): ‘Art. 15 The interruption of a pregnancy will only proceed by therapeutic indication agreed by a

medical council and with due authorisation from the patient or her direct relatives.’


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APPENDIX 17

Register of Materials Used For Analysis

17.1 Register of Appendices A - H submitted in spiral-bound volumes with preliminary contract

research report, February 1997. Translations of contents follow: all materials are in Spanish.

Speakers are identified with lettered and numerical codes in these Appendices. This register

incorporates pseudonyms used in the thesis when applicable.

Appendix A

Tables charting variations in 40 contextualised discursive constructions of therapeutic abortion,

corresponding to five medical research subjects in the State Hospital, December 1996 – January 1997:

Dr. Dávila, staff gynaecologist and head of residents’ training:

Graph: Variations in 20 discursive constructions of therapeutic abortion over the two-month

period;

Comparison of 20 contextualised discursive constructions of therapeutic abortion.

Dr. Antunes, hospital director: 10 discursive constructions

Dra. Campos, first-year medical resident: 4 discursive constructions

Dr. X, first-year medical resident: 2 discursive constructions

Dr. Justiniano gynaecology ward chief: 4 discursive constructions

Appendix B

Tables showing contextualisation of the 40 discursive constructions of therapeutic abortion registered in

Appendix A.

Appendix C

Two clippings from national newspapers referring to therapeutic abortion, 22nd January and 6th February

1997.

Appendix D

Scheme for the analysis of 20 contextualised discursive constructions of therapeutic abortion, by diverse

research subjects in the State Hospital, registered in field notes made on unrecorded observations and

interactions.


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Appendix E

Scheme for the analysis of 103 contextualised discursive constructions of abortion, by four research subjects

in the State Hospital, from transcripts of recorded interactions:

Dr. Dávila, staff gynaecologist and head of residents’ training: 32 discursive constructions in 5

interactions.

Dr. Antunes, hospital director: 31 discursive constructions in 1 interaction

Dra. Campos, first-year medical resident: 10 discursive constructions in 1 interaction

Ms Ulloa, secretary, hospitalised in gynaecology ward: 30 discursive constructions in 1 interaction

Appendix F

Selected fieldnotes referring to therapeutic abortion, transcribed from 10 entries in Field Notebook 1 between

December 6th and 17th 1996

Appendix G

Two selected excerpts referring to therapeutic abortion from an e-mail message sent on December 6th 1996

from SR to Ipas, transcribed on 15th February 1997.

Appendix H

11 transcripts of recorded observations and interactions, 6th December 1996 to February 14th 1997, with the

following research subjects:

Dr. Dávila, staff gynaecologist and head of residents’ training, State Hospital: 7 transcripts (3.1-3.7)

Dr. Antunes, director of State Hospital: 1 transcript (2.1)

Dra. Campos, first-year medical resident, State Hospital: 1 transcript (4.1)

Ms Ulloa, secretary, hospitalised in gynaecology ward, State Hospital: 1 transcript (5.1)

Mrs. X, sociologist: 1 transcript (6.1)

17.2 Register of appendices I - L submitted in spiral-bound volumes with first year contract research

report, September 1997

Appendix I

13 transcripts of recorded observations and interactions with staff and women hospitalised in the Insurance

Hospital gynaecology ward between April 2nd and July 25th 1997, with the following research subjects:

Dr. Losada, third-year medical resident: 2 transcripts (10.1, 10.2)

Licenciada Irma Illanes, social worker: 2 transcripts (11.1, 11.2)

Dr. Salinas, gynaecology ward chief: 3 transcripts (12.1 – 12.3)

Dr. Walters, staff gynaecologist: 2 transcripts (13.1, 13.2)

Head Nurse Elena Elías: 1 transcript (14.1)

Dra. Helga Haber, first-year medical resident: 1 transcript (15.1)

Mrs. Gong, women hospitalised in gynaecology unit: 1 transcript (XPM.1)

Mrs. X, woman hospitalised in gynaecology unit: 1 transcript (XPC.1)


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Appendix J

16 transcripts of selected fieldnotes from Field Notebooks 2 – 5, from entries made between 25th March and

30th July 1997, on observations and interactions in the Insurance Hospital with the following research

subjects:

Dr. Gonzáles, staff gynaecologist and head of residents’ training: 7 entries transcribed (A.X9.00 –

A.X9.5)

Licenciada Irma Illanes, social worker: 1 entry transcribed (A.X11.1)

Dr. Salinas, gynaecology ward chief: 1 entry transcribed (A.X12.1)

Dr. Walters, staff gynaecologist: 1 entry transcribed (A.X13.1)

Dra. Helga Haber, first-year medical resident: 1 entry transcribed (X.15.1)

Mrs. Mayta, women hospitalised: 2 entries transcribed (A.XPG.02, A.XPG.03)

General observations: 2 entries transcribed (A.OBS.1, A.OBS.2)

Appendix K

Copies of overhead transparencies with preliminary results of research in State Hospital, presented at

Population Council meeting on quality and accessibility of abortion services, New York, March 1997.

Copies of overhead transparencies with preliminary results of research in Insurance Hospital, presented to

staff of gynaecology ward, Insurance Hospital, July 1997.

Appendix L

Selection of clippings from national newspapers referring to abortion, the medical profession, health workers

and medical education, 13th September 1996 to 3rd August 1997.

17.3 Register of appendices M - Q submitted in spiral-bound volumes with second year contract

research report, September 1998:

Appendix M

12 transcripts of recorded interviews with students in the Medical School of La Paz State University (UMSA)

between 17th March and 19th May 1998:

X, woman student repeating first year: 1 transcript (EY.1)

Ignacio, first-year student: 5 transcripts (ES.1-3, ES-SR.1-2)

X, male first-year student: 1 transcript (EN.1)

XX, male first-year student: 1 transcript (EH.1)

XX, female first-year student: 1 transcript (EE.1)

XXX, female first-year student: 1 transcript (ET.1)

X, male fifth year student: 1 transcript (ER.1)

Group of first-year students, 5 women, 6 men: 1 transcript (GP1.1)


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Appendix N

Reduced selection (for contract research sponsors’ use) of clippings from national newspapers referring to the

medical profession, health sector reform, higher education and medical education, 25th July 1996 to 2nd

August 1998

Appendix O

Fuller selection (for researcher’s use) of clippings from national newspapers referring to the medical

profession, health sector reform, higher education and medical education, 25th July 1996 to 2nd August 1998

Appendix P

19 transcripts of recorded interactions, and fieldnotes on discussions with interns, residents and teachers in

the Medical School, State university (UMSA), La Paz and three associated teaching hospitals, between 5th

May and 18th August 1998:

X, male intern: recorded interview, 21/7/98 (INhV.1)

X1, male intern: recorded interview, 21/7/98 (INhY.1)

X2, male intern: recorded interview, 21/7/98 (InhH.1)

X, female intern: recorded interview, 23/7/98 (INmG.1)

Dra. Juárez, medical resident: recorded interview, 19/6/98 (R1mV.1)

Dr. X1, medical resident: recorded interview, 19/6/98 (R1hE.1)

Dr. X2, medical resident: recorded interview, 19/6/98 (R1hF.1)

Dra. X1, medical resident: recorded interview, 21/7/98 (R1mF.1)

Dra. X2, medical resident: recorded interview, 23/6/98 (R3mL.1)

Dr. X3, resident: recorded interview, 23/7/98 (R1hJ.1)

Dr. XX, teacher: recorded interview, 5/5/98 (DO.1)

Dra. XX, anatomy teacher, research collaborator: recorded interview, 12/5/98 (D1mA.1)

Dr. Harb, director of Maternity Hospital: recorded interview, 17/7/98 (D2hB.1)

Group of interns, 3 men, 1 woman: recorded group discussion, 3/8/98(GPIN.1)

Group of interns, 3 women, 2 men: recorded group discussion, 13/8/98 (GPIN.2)

Group of medical residents, 3 women, 1 man: recorded group discussion, 26/6/98 (GPR.1)

Pair of medical residents, 1 man, 1 woman: recorded discussion, 4/8/98 (GPR.2)

First pair of obstetricians, notes on discussion, 5/8/98 (AGD.1)

Second pair of obstetricians, notes on discussion, 18/8/98 (AGD.1)

Appendix Q

33 first person narratives: "A Critical Event In My Medical Formation", written by first year students,

interns, residents and teachers of the medical school, State University (UMSA), La Paz and associated

teaching hospitals between 12th June and 25th August 1998:


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Female 1st year student, 28 years, 12/6/98



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












Female intern, 25 years, 7/8/98

Male intern, 25 years, 7/8/98






Female resident, 29 years, 29/6/98



Male resident, 25 years, 29/6/98



Male teacher, 56 years, 18/8/98






17.4 17 Field Notebooks, 23rd August 1996 – 28th August 1999 (notes summarised in typed, spiral-bound

volume):

1. 23/8/96 – 19/1/97 10. 30/3/98 – 5/5/98

2. 21/1/97 – 27/3/97 11. 5/5/98 – 25/6/98

3. 28/3/97 – 16/4/97 12. 26/6/98 – 8/8/98

4. 16/4/97 – 9/6/97 13. 10/8/98 – 28/10/98

5. 15/6/97 – 19/9/97 14. 29/10/98 – 27/11/98

6. 22/9/97 – 21/11/97 15. 29/11/98 – 2/2/99

7. 24/11/97 – 19/12/97 16. 5/2/99 – 22/5/99

8. 27/12/97 – 8/3/98 17. 24/5/99 – 28/8/99

9. 9/3/98 – 29/3/98


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APPENDIX 18

Texts reproduced from Hord, CE 1999. ICPD Paragraph 8.25: A Global Review of Progress.

Chapel Hill, NC: Ipas

A.18.1 Ipas Mission Statement (unnumbered page preceding Acknowledgements)

A.18.2 Excerpt from Chapter One, ‘Adapting Policies’, p.3

A18.3 Excerpt from Chapter Three, ‘Researching Best Approaches’, p.8

A18.1

‘Ipas Mission Statement

‘Ipas works globally to improve women’s lives through a focus on reproductive health. Our work is based on

the principle that every woman has a right to the highest attainable standard of health, to safe reproductive

choices, and to high quality health care. We concentrate on preventing unsafe abortion, improving treatment

of its complications, and reducing its consequences. We strive to empower women by increasing access to

services that enhance their reproductive and sexual health.

‘Ipas technologies, training, research and technical assistance:

support the development of women-centred reproductive health policies;

improve the quality and sustainability of services;

ensure the long-term availability of reproductive health technologies; and

promote women’s active involvement in improving health care.’

A18.2

Excerpt from Chapter One: ‘Adapting Policies’ (box, p. 3)

‘Bolivia is a striking example of policy change. In the 1960s, Bolivia had the highest maternal mortality rate

in Latin America, yet contraception was taboo. Family planning grew in acceptance during the 1980s and, as

a result of nationwide advocacy leading up to and following Cairo, Bolivia’s reproductive health policy is

now one of the most progressive in the region.1 As of early 1999, the government plans to cover the cost of

emergency treatment for first trimester hemorrhage, including incomplete abortion, in the national health

insurance plan.’

1 Camacho, Alma Virginia; Rance, Susanna; Abernathy, Marian; Escóbar, Alexia. ‘From “The Blood of the Condor” to Cairo: Abortion and Reproductive Health Policy in Bolivia’. Paper presented at the American Public Health Association meeting, November 1 1995.


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A.18.3

Excerpt from Chapter Three: ‘Researching Best Approaches’ (p. 8)

‘Studies on Postabortion Care

....

‘ In Bolivia, where government policy has changed in favour of reproductive health since

ICPD, very little data exist on the extent and quality of postabortion care in public sector hospitals,

though the costs of treating abortion complications are estimated to be 30-40% of total hospital ob-

gyn costs. An opinion survey conducted among public sector health professionals in 1998 indicated

that they identify incomplete abortion as a frequent cause of maternal mortality for women locally,

and that an overwhelming number support the introduction of MVA in public sector hospitals to

improve the quality and efficiency of postabortion care services.2 Based on this study and

information about the success of a similar approach in Peru, the Ministry of Health (MOH) has

decided to introduce MVA for postabortion care in tertiary level hospitals throughout the country.3

2 Friedman, Alison; de la Quintana, Claudia; Jové, Gretzel; King, Tim D.N. Diagnóstico de los Servicios de Atención Postaborto (APA) en el Sistema Boliviano de Salud Pública. Informe de los Resultados de Investigación al Ministerio de Salud y Previsión Social (MSPS). Carrboro, NC: Ipas, 1999. 3 Personal communication with Dr. Guillermo Cuentas, Bolivia, February 1999.


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APPENDIX 19 Dra. Bertha Bastos’ auto/biographical account of medical students’ hospital training

Editorial note:

In the final month before submitting my thesis, I wrote to my friend Bertha Bastos, whom I had met in 1998

when she was an intern in her sixth year of undergraduate medical studies. I asked her to write me an account

of medical students’ education and hospital training, and to clarify my doubts about divisions between years,

and the categories ‘Intern’ and ‘Pre-Intern’. I also asked her about some abbreviations she had mentioned as

being in current use among hospital staff.

By this time, Bertha – Dra. Bastos, already a qualified doctor, in her late thirties – had emigrated to North

America in search of personal and professional opportunities. We corresponded by e-mail in an informal

vein. In a message sent on July 20th 2002, Bertha responded with this narrative, which I transcribe below in a

translated version, with her informed consent.

In editing the account on July 29th 2002, I made some changes in punctuation to aid readability. In the edited

text, inverted commas (‘’ “”), dots (…), and round brackets (()) correspond to punctuation in the original,

while italics and phrases in square brackets ([]) are my additions:

About your enquiries: the ‘Pre-Internship’ is really the fifth year of Medicine and the Internship is

the sixth year. However, in the pensum it figures like this: Medicine, five years and one of

Internship. And a curious thing… when you are in the fifth year, no-one calls it Pre-Internship, and

when you are in the Internship… no-one calls it sixth year. Only when you are in Internship they say

to you, ‘When you were in “Pre-Internship” you should have learned all the things that now “I” have

to teach you’… That’s when you realise that the fifth year was Pre-Internship…

About the stages in formation, I’ll give you the whole Study Plan (valid since 1984). The period is

annual, it has always been so since I was studying. I think that before it was by semesters (but I’m

not sure). This Plan was approved by Resolution HCU No. 155/85, October 3rd 1985:

Undergraduate Study Plan for Students of Medicine, Bolivia, since 1985

FIRST COURSE Weekly hours of Theory Weekly hours of Practice Histology 3 3 Embryology 2 3 Anatomy 2 12

Total 7 18 SECOND COURSE Physiology-Biophysics 5 6 Microbiology 2 2 Biochemistry 5 3 Public Health I 2 2 Parasitology 2 2

Total 16 15


208

THIRD COURSE Weekly hours of Theory Weekly hours of Practice Pharmacology 3 3 Pathological Anatomy 4 4 Physiopathology 3 3 Medical Psychology 1 1 Medicine I 5 5 Surgery I 2 1

Total 18 17 FOURTH COURSE Medicine II 4 5 Surgery II 3 3 Neurology-Neurosurgery 2 2 Psychopathology-Psychiatry 2 3 Traumatology-Orthopaedics 2 3 Public Health II 2 2

Total 15 18 FIFTH COURSE Medicine III 3 3 Surgery III 5 3 Legal Medicine 1 1 Gynaecology 2 3 Obstetrics 1 3 Paediatrics 2 3 Public Health III 2 -

Total 15 16

Rotating Internship One calendar year according to the Rotating Internship Regulation

Undergraduate Degree in Medicine (Licenciatura en Medicina)

COURSE CONTENTS Public Health I Biostatistics-Demography Medicine I Semiology, Laboratory, General Radiology Surgery I Surgical Technique Medicine II Cardiology, Pneumology, Rheumatology, Infectology,

Immunology, Tropical Medicine. Surgery II General Surgical Pathology. Surgery of face and neck. Surgery of

thorax. Cardiovascular surgery. Public Health II Epidemiology, Environmental Health, Sanitary Administration. Medicine III Nephrology, Haematology, Endocrynology, Gastroenterology. Surgery III Abdominal Surgery and Urological Proctology, Ear, Nose and

Throat (Otorrinolaringología), Ophtalmology, Anaesthesiology.

The fifth year is very hard, but nothing compares with Internship (you already know, I think you’re

tired of hearing me say that…). From the third year you already have experience in the hospital,

that’s to say with the patients (now clients of health), and obviously with the doctors and their

respective personalities, principally and effectively with the latter.

Nevertheless, you can do nothing (with the patients), only learning to do the ‘clinical history’, that

you finish learning to do in Internship, unfortunately. It’s not that it’s difficult, however I don´t

know why the doctors, above all those in the General and Insurance Hospitals, have an ‘issue’ with


209

that. You have to do it to the taste of each one of them, and in each speciality it always varies in

some aspect, they ‘hassle’ you a lot… but really a lot with the spelling and grammar.

So well, as I was telling you, in third year you already have contact with the ‘action’, I’m referring

to the fact that by then you don´t have classes only in the Medical School, but you already go to the

hospitals. In the fourth year, they already give you patients, that’s to say that they designate one to

you… they don´t give them to you… but it’s already your responsibility. But always concerning the

Clinical History (CH), that’s to say if the patient for example has a heart condition, your teacher

isn’t interested in your knowing how to prescribe for them or how to help them in relation to their

pathology. What interests them is that the CH should be well done, with good spelling, on good

paper, and for example if they have a ‘scar’ on their back and you didn´t put it in the CH, you’re

lost, get it? What they (the teachers) do is get you to do the greatest observation concerning the body

of the patient.

In the fifth year you already do some shifts in the hospital, for example in Emergencies, and you

already do surgery on dogs, of course that last thing is not very frequent, I luckily had to do it only

once.

I was forgetting to tell you that in the third year you already practise with your actual classmates, for

example in Surgery I, they inject you and you have to do injections, and there’s a practice where you

put the injection yourself in your own calf (that is really impressive, I can tell you, I still remember it

now).

Also in fifth year you go into births, although it’s more theory they give you, than the practice which

they make you see.

The subject I liked best was Legal Medicine, we had a teacher who was very good in his field and in

others too, he was a very cultured and well-prepared man. Nevertheless, it was in that course that I

saw the videos I told you about, do you remember? Documentaries, short films and videos that were

somewhat ‘morbid’ to say the least. We saw, for example, a man in the electric chair, in all the

process of his death, really morbid. You also get to see rapes, even a murder by a Satanic sect,

cruelty to animals, accidents on big highways, all in all, many things that maybe take years to forget.

About all that you have to do a piece of work to present, only that I don´t remember the treatment

given to that work because I never did it, I think you had to give your points of view about it.

About the abbreviations, I don´t understand very well what you want. I imagine that it’s what I

commented to you on some occasions: a HY [HI] is a hysteria [histeria], for example a woman

comes in who’s fainted or with nervous attacks, without stimulus or organic pathology, and we say

among ourselves, ‘She’s got a HY’, meaning that she is hysterical. A ‘little rat’ [ratita] is the person


210

who takes rat poison supposedly to commit suicide, those are the patients that interns most flee

from, since it is really gross.

From any year in Medicine they say Doctor or Doctora, but only the patients, and it’s enough for

you to be wearing an overall [mandil]. Some doctors, very few, call you Doctora in the Internship,

and when you already graduate, well you ‘have earned that right’… That about the patients, they use

it to gain your attention (in their logic), it’s like saying ‘Colonel’ to an ‘officer’ [cabo] when they

want to take you to the Transport Police for some demeanour…

I think that is what I have to tell you, I hope to have helped you with what you wanted, if not, please

let me know, OK?

Bertha.

Documents

Tesis Susanna Rance Aborto en Bolivia Copy