Magali Bouchon • Socio-anthropologue, Médecins du Monde
The seminar, “Socio-anthropological research at Médecins du Monde: What use is it to act?” was held on 14 December 2018. This day was the opportunity to look back on the ten years of Médecins du Monde’s (MdM) socio-anthropological approach, and provide – with the input of researchers and academics – perspectives for fruitful collaboration between the world of research and that of humanitarian action.
Research in epidemiology and socio-anthropology at Médecins du Monde (MdM) has become a vital component in designing innovative projects aimed at accurately identifying and developing practical and reliable models of intervention. As part of the association’s social mission, this research was reorganised into the newly created Research and Learning Department in 2017.
In this article, we will examine how research has become a decision-making tool in its capacity to enhance knowledge and improve the capacity-building of MdM’s teams through its approach of encouraging community participation. Such an approach allows different forms of knowledge, both technical and experiential, to be more complementary and more consistent. We will also see how research, in conjunction with MdM’s advocacy, serves as a guide for those who help shape the social determinants of health. As a medical NGO, MdM’s mission does not limit itself to providing just essential health care. From a policy point of view, it also sets out to overcome the barriers to health and advocate the full right to healthcare for all. Research, carried out in line with MdM’s principles of action founded on a community-based approach to healthcare, and extending beyond its mission of expressing moral indignation, promotes the acquisition of expertise and supports advocacy-based actions applicable to real-life situations.
Emerging needs in socio-anthropology
In 2007(1)Marie-Laure Deneffe and Marie-Ange Vincent, « Appréhender la différence culturelle : une préoccupation permanente », in the dossier « Anthropologues et ONG : des liaisons fructueuses ? », Humanitaire, special edition, n°4, autumn/winter 2007., MdM’s teams voiced concern that their interventions were suffering from a repeated lack of effectiveness and poor quality due to an imperfect knowledge of the social dynamics relating to healthcare. Their feedback indicated that better implementation and support was needed to understand the complex therapeutic procedures affecting the communities involved in a project. In fact, health-oriented undertakings are also social and cultural undertakings. An unintended pregnancy, for example, represents a social choice. That is a reflection of the extent to which family planning does or does not conform to social norms that govern fertility, to decision-making systems within families, and to power structures(2)Refer to Yannick Jaffré, « Corps biologiques, corps désirants, corps politiques. Les interfaces sociales et techniques des programmes de “santé de la reproduction” en Afrique de l’Ouest », in Gilles Boëtsch, Lamine Gueye, Enguerran. Macia, Yannick Jaffré (dir.), Santé et société en Afrique de l’Ouest, CNRS éditions, 2005.. It should also be noted that humanitarian programmes essentially presuppose that various conflicting, sometimes incompatible representations of sexual and reproductive health, have arisen.
Structurally, any intervention confronts dissimilar rationales and representations head on, since it is based on an activist-oriented, political, normative, and technical vision. This raises the question of cognitive frameworks; starting from what fundamental analysis and from what type of worldview is the thought-process behind an intervention conceived?
Anthropology can contribute to professionals taking account of what people say and what they express in terms of their needs, all while gaining a better awareness of the beliefs and practices of popular cultures. Fundamental analyses can help resolve contradictions and develop effective programmes in line with local social and cultural standards. They can also clarify the true socio-cultural context of programmes from a less partial and less biased point of view.
At MdM, these concerns have given rise to the “Sociocultural Determinants of Access to Care” project, aimed at systematising technical expertise and socio-anthropological surveys around various key points. This project’s development reflected the dual policy of seeking to improve the quality of its programmes through a better understanding of the issues, and helping the humanitarian vision evolve, shift its outlook, and consider things from different angles. In the last ten years, the need for socio-anthropological expertise has become firmly entrenched in MdM’s practices, as evidenced by the broader scope of its studies and its partnerships.
Today, how does socio-anthropological research, from the data it generates, contribute to improving the quality of programmes? How can it, through the acquisition of greater knowledge and the involvement of its field operatives and the communities being studied, make a straightforward, logically thought-out project become a more mobile, less asymmetrical process? In other words, how can research support the dynamics of social transformation? How does it sustain the interactions between endogenous processes of change and the outside interventions that aim to steer these changes? In essence, these were the questions raised during the seminar on 14 December 2018.
The production of knowledge through socio-anthropological research: a decision-making tool
The contribution of knowledge provides a sociologising vision to a programme and encourages “thinking outside the box”.
As Yannick Jaffré(3)Yannick Jaffré is an Anthropologist and Director of Research at CNRS. emphasised during the seminar, it is a matter of “grasping the complexity of what is real”. Programmes must be built around actions that take full measure of the whole social environment in which they are set and actions capable of exposing conflicts and contradictions between individuals and communities. In addition, anthropological surveys at MdM are often undertaken during a diagnostic phase that investigates how the environment exposes people to health-threatening risks.
Thus, a socio-anthropological research project carried out on unintended pregnancies in Ivory Coast was set up to understand why Ivorian high school students were unwilling to follow the prevention guidelines distributed in schools. This research project, which examined the maturation process of adolescent sexuality, revealed that prevention guidelines, when applied, clashed with the private sphere of individuals. Adolescent girls are subject to assorted kinds of pressure (peer pressure and the influence of the media) that encourage precocious sexuality and relationships with multiple partners, yet they face many socio-cultural barriers to contraception. Even though they are aware of the risks of being sexually active, they have very few means of preventing an unintended pregnancy. Young girls therefore find themselves caught between the risks of being sexually active and the risks of being exposed to precarity, danger and gender-based violence, as can occur when they refuse to have sex or ask that a condom be worn. Programmes using an individual approach to empower young people do not take sufficient account of their weak capacity to act.
This type of study helps field personnel to perceive things from a different angle during a prevention campaign. It also gives them a better understanding of the obstacles and determining factors that shape the real-life situations of young people and make them reluctant to take part in prevention programmes. By describing situations and exploring the conflicts, contradictions, and constraints that are difficult for individuals to overcome, this research project has provided professionals with “social knowledge”. Knowledge that is essential for a better understanding of the rationale for certain behaviours can therefore be acquired and shared.
Yannick Jaffré believes that these actions must take into account each person’s individual rationale: “If people have no reason for doing what they do, they won’t do it for any reason.” Social sciences insist on the constancy of people’s actions and explain how people react differently depending on the situation. By keeping records of these various situations, we can arrive at a general understanding of people’s behaviour and open the channels for discussion, rather than imposing certain programmes that may be too far removed from people’s real-life experiences.
Participative approaches in research: innovation among field operatives and communities
Another contribution of social science research to humanitarian practices lies in the survey methodology. As mentioned by Marie Jauffret-Roustide during the seminar, participatory research has grown considerably in recent years in areas related to social inequalities and health. Getting beneficiaries involved with the humanitarian teams makes beneficiaries more willing to define their needs, strengthen their own capacities, and increase their autonomy – which is also called empowerment. This type of research can lead practitioners to take an inward look at their own professional practices and enjoy the benefit of acquiring detailed real-world knowledge and the practices of the communities concerned. By involving operating personnel in research, a process of social transformation and alteration of their self-image takes place.
This process can be illustrated by a research project in Myanmar that was carried out with the participation of field operatives, members of the partner association, and local residents. Its purpose was to examine the social aspect of actions taken to decrease potential security threats in one basically prohibitionist, socio-cultural, political, and religious model: Kachin province. The project was also meant to help set up a community strategy devised to improve the way neighbourhood residents live together. Furthermore, it sought to minimise the ostracism of drug addicts by providing specific factual information on the conflicting approaches to managing addictions. At the same time, it was an attempt to improve the effectiveness of actions taken to reduce security threats. Asking seldom-asked questions of neighbourhood residents who were not the direct beneficiaries of the projects was an indication to them that greater credence was being given to what they had to say. This made it possible to transform the problems perceived by field operatives and community members into an opportunity for dialogue. The interviewees, who were unfamiliar with the measures set up to reduce security threats, began to express an interest, and this eventually made them feel more relaxed with their interviewers. This survey, involving field operatives, the partner association, and neighbourhood residents, led to a mutual learning process on this one topic where each party was placed on the same level of knowledge and understanding of the context as the others.
Pragmatically speaking, getting some residents to participate in the data gathering team also had the positive effect of opening up opportunities that had formerly been inaccessible. The data gathering team was able to acquire access to, in the words dear to Jean-Pierre Olivier de Sardan, “strategic arenas”, in so far as these residents were already involved in various social or religious groups. This was the case with the observations made in treatment centres for addiction run by Baptist groups, previously closed to MdM personnel.
This participatory research project consisting of interviews by MdM’s field operatives, brought into play their accumulated empirical knowledge without having to rely on any analysis. Their findings were significantly more relevant, since they were based on practical knowledge.
The researcher’s role was less about providing expertise on a specific topic or situation, but rather to structure the interviews, apply the knowledge acquired, and facilitate the collective thought process. This was all the more important because research can only be productive in terms of changing practices if the field operatives know how to make practical use of their findings, that is to say, how to link the results of their study with day-to-day professional practices.
Participatory research exposes the challenge of constructing a shared vision of a situation; it is only from such a shared vision that we can find the levers for action. This means that language and know-how must find common ground, leading to the acceptance that routine practices must be re-examined in order to make them evolve.
By helping people committed to action learn from their practices and change their ways of thinking and acting on society, social science research has the dual role of opening up new channels and providing guidance. It therefore helps to acquire a clearer vision of what can be used in the struggle to change things. Such research exposes social relationships and forms of dominant behaviour. As these findings become available, they let individuals put their real-life contexts into words, so that they can better understand their position and the challenges they face, and thus acquire greater autonomy.
Giving a voice to communities unnoticed on the political scene: narrative democracy
By giving people their say, research demonstrates that it values knowledge founded on experience. Research also provides greater visibility in the public debate, and in doing so, gives people greater power to react when exposed to vulnerable situations, in so far as they can speak their mind using their own words. Giving individuals their say means recognising the existence of those who have been left unheard.
This issue is all the more important for advocacy, because knowledge does not necessarily have a direct impact on moral policies, as was described in Hélène Le Bail’s work on prostitution(4)Hélène Le Bail et Calogero Giametta, « Que pensent les travailleur.se.s du sexe de la loi prostitution ? Enquête sur l’impact de la loi du 13 avril 2016 contre le “système prostitutionnel” », Médecins du Monde, 2018, https://www.medecinsdumonde.org/sites/default/files/Rapport-prostitution-BD.PDF. The findings of the social sciences exert an influence only to the extent that they are disseminated and are taken up by society, where they supplant other ways of viewing social considerations, and give communities the levers for reflecting on their situation and legitimising their claims. It can be argued that scientific knowledge serves in the struggle for a cause, because it helps to get a grip on reality and pinpoint problems.
It always pays to acquire an understanding of what we seek to change or improve. An in-depth knowledge of socio-cultural determinants repositioned in a global context of constraints is essential for effective action. The value of research also lies in its capacity to support field operatives so that their knowledge becomes more meaningful and can be converted into action. This, in turn, helps to reduce the gap between the underlying social needs and expectations of a community and the resulting responses. This contributes to social change.
In addition, it is important for field operatives to be reminded that the value of anthropology also lies in its capacity to clarify what is complex, to unsettle what is thought to be certain, and to rattle the knowledge of certain experts, all with an ethical concern for community-centred projects.
Translated from the French by Alan Johnson
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|￪1||Marie-Laure Deneffe and Marie-Ange Vincent, « Appréhender la différence culturelle : une préoccupation permanente », in the dossier « Anthropologues et ONG : des liaisons fructueuses ? », Humanitaire, special edition, n°4, autumn/winter 2007.|
|￪2||Refer to Yannick Jaffré, « Corps biologiques, corps désirants, corps politiques. Les interfaces sociales et techniques des programmes de “santé de la reproduction” en Afrique de l’Ouest », in Gilles Boëtsch, Lamine Gueye, Enguerran. Macia, Yannick Jaffré (dir.), Santé et société en Afrique de l’Ouest, CNRS éditions, 2005.|
|￪3||Yannick Jaffré is an Anthropologist and Director of Research at CNRS.|
|￪4||Hélène Le Bail et Calogero Giametta, « Que pensent les travailleur.se.s du sexe de la loi prostitution ? Enquête sur l’impact de la loi du 13 avril 2016 contre le “système prostitutionnel” », Médecins du Monde, 2018, https://www.medecinsdumonde.org/sites/default/files/Rapport-prostitution-BD.PDF|