This research project explores the relationship between women's literacy and reproductive health care practices1 within a specific setting, the Hout Bay Day Hospital and its environs. In this introductory chapter, I shall outline my construction of the research object. This study began as an analysis of literacy practices amongst women attending the Hout Bay Day Hospital, the manner in which these practices intersected with the dominant discourses of medicine and its attendant technologies, and how they were socially constructed and interpreted. As events slowly began to unfold I discovered that although most patients were able to read and write (a traditional construction of literacy), I seldom observed any reading and writing practices amongst patients in the day hospital, nor a direct engagement with the medical texts, symbols or artifacts which I assumed were an integral part of the regulation of the bodies and health of patients. I was puzzled by this disjuncture, finding it difficult to explain in terms of my understandings of literacy.
I was faced with a dilemma since both literate and non-literate patients appeared to have distanced themselves from the formal literacies of medicine. A number of questions needed further exploration:
· If "illiteracy" is truly the "handicap" or "social disease" that certain development and modernization discourses would have us believe, why are literate patients not visibly engaging with texts?
· Why do patients appear to become passive recipients of medical intervention once entering the medical space?
· How and why are their literacy practices being delegitimised and marginalised by the medical discourses?
The realisation that literate patients were not visibly engaging with the medical texts, and that their literacy practices were perhaps embedded in other social practices required a re-examination and reformulation of traditional conceptualisations and understandings of what it means to be literate. I thus needed to approach the field site in a different manner requiring new modes of understanding and enquiry. This required a discursive move towards understanding the human body as text as it was here that I sensed a form of disjuncture and dissonance in the manner in which patients related to medical texts and where the textual practices of the medical institution were most directly enacted and experienced.
The dilemma then was how to make the epistemological shift from literacy, as depicted by the New Literacy Studies (NLS) in which the focus is on print literacy (alphabetic literacy) as embedded in social practice, to other and differing "readings" of literacy, particularly as it relates to the body. I hoped to achieve this by exploring the manner in which social bodies entering the medical space are socially and discursively constructed, so that the body is viewed as a text to be `read' and `re- read' by the dominant medical discourse.
This section presents a summary of the theoretical influences that have been drawn on in developing a conceptual frame for this research and for providing the theoretical language for analysing the research data obtained in the field. The theoretical influences will be discussed separately, firstly literacy and then reproductive health.
In framing research questions and in deciding on methodology I was initially informed by the body of research and theory that has been called the New Literacy Studies 1, which has led to the deconstruction and subsequent reconstruction of the definitions and boundaries of literacy. The main focus of this study is literacy practices (Barton 1994; Baynham 1995; Street 1984). The conception of literacy practices, rather than literacy per se, arises out of research done within the "ideological model of literacy" (Street 1994) and within the New Literacy Studies. In this approach literacy is viewed as an ideological and socially embedded practice within particular social contexts.
I draw on the concepts of literacy practices, literacy events, narratives, voice and mediation, using the works of Street in Anthropology (1984; 1991; 1993), Brice Heath (1983) and Gee in Sociolinguistics (1990), Barton in ecology of literacy (1994), and Baynham in literacy practices and literacy mediation (1995).
The varied social and cultural meanings and contexts within which literacy is embedded and the deconstruction of the concept of literacy as the decontextualized ability to read and write has been a major influence on this research project and the bedrock upon which I placed my ensuing epistemological developments.
The NLS centres around articulating different conceptions of literacy and making them visible. These originate from research across a range of disciplines including Sociolinguistics, Anthropology, Psychology and Education.
But as Prinsloo, Morphet and Miller jointly state in their paper on University-Based Literacy Theory and Practice in South Africa:
This body of work (i.e., NLS) has not as yet had much impact on the worlds of literacy practitioners and less on policy makers in South Africa. Its impact will start to be felt, however, as it produces further tools for understanding the problems and complexities of policy and practice, as practices are brought to closer account and policy becomes concerned with the difficulties associated with success in this field. At the same time it will not be surprising if the public, as opposed to the academic, understanding of literacy will continue to make exaggerated claims on behalf of literacy's social effectivity. It is likely to carry symbolic dimensions beyond its capacity given the intractable domains it is linked to: the economy, development, progress, democracy, health and happiness (1993, 2).
It is against this setting that I lean towards Street's ideological model of literacy which is positioned against the autonomous model of literacy. Street's distinction between the autonomous and ideological models of literacy is pertinent to my research as well as his concept of literacy practices. Street's depiction of the autonomous model of literacy is relevant to the particular manner in which medical texts are often presented by the discourses of medicine:
the exponents of an autonomous model of literacy conceptualise literacy in technical terms, treating it as independent of social context, an autonomous variable whose consequences for society and cognition can be derived from its intrinsic character (1993, 5).
This model is based on the essay-text or school-based forms of literacy and generalises broadly from what is, in fact, a narrow, culture-specific literacy practice where mainstream alphabetic and numerical competency is understood as a culturally neutral technology associated with an evolutionary idea of progress. In essence literacy becomes an overburdened social signifier or to use Bourdieu's term (1973) a form of "cultural capital".
Furthermore, the ideological model of literacy rejects the notion of a great divide between oral and literate cultures as argued by Ong (1982), in favour of an oral and literate mix, dependent on social context. Street argues that he uses the term ideological because it suggests that there are always contests over the meaning and uses of literacy: "the ideological model views literacy practices as inextricably linked to cultural and power relations in society and recognises the variety of cultural practices associated with reading and writing in different contexts" (1993, 7).
Heath's classic Way with Words (1983) introduced the concept of literacy events as being:
any action sequence, involving one or more persons, in which the production and\or comprehension of print plays a role.... Literacy events have social interactional rules which regulate the type and amount of talk about what is written, and define ways in which oral language reinforces, denies, extends or sets aside the written material (Heath in Baynham 1995, 39).
Street, on the other hand, extended the concept of literacy event to literacy practices which include the cultural uses and meanings of reading and writing in social context: "Literacy practices I would take as referring not only to the event itself but to the conceptions of the reading and writing process that people hold when they're engaged in the event" (1993, 4).
Thus the concept of practices forms a bridge between literacy as a linguistic phenomenon and the social context in which it is embedded and thus enables a conceptual construction that foregrounds literacy practices as social and culturally contested practices, within particular social circumstances.
Gee, a sociolinguist, takes the notion of literacy one step further when he develops a definition of literacy which embeds it in Discourse (with a capital D). Thus he writes: "any authentic definition of literacy leads us away from reading and writing (literacy as traditionally construed) and even away from language and towards social relationships and social practices" (1990, 137).
The focus is therefore not on language or literacy, but rather on social practices within discourses. Literacy for him is closely allied with matters of language, culture, ideology, discourse, knowledge and power.
The term discourse can have a number of meanings. As it is used in linguistics it refers to the organisation of language, both the written and spoken, beyond the level of the sentence, into extended stretches, i.e., conversations, letters, lectures and medical interviews. Another meaning of discourse as in the works of Kress, deriving from the works of Foucault, refers to the systematically organised sets of statements which give expression to the meanings and values of an institution, which define and determine what can and cannot be said (Kress 1989, 7). Gee (1990), influenced by Foucault's (1972) depiction of discourse as more than just language, describes discourse as socially accepted associations or rules among ways of using language, of thinking, valuing, acting, and interacting in the right places at the right time with the right objects. These associations make visible and knowable specific cultural and subcultural identities, that is who we are and what we are doing.
Gee draws a distinction between the acquisition and learning principle. Acquisition and learning are different sources of power. Acquisition is a process of acquiring something subconsciously, by practice, without formal teaching. This process occurs in a natural non-formal atmosphere where one "learns" through trial and error and practice, a form of apprenticeship. Learning on the other hand is a process that involves conscious knowledge gained through teaching or through certain life experiences that trigger conscious reflection. This teaching or reflection involves attaining, along with the matter being taught, some degree of meta- knowledge about the matter.
Gee's founding proposition is that literacy learning always entails the simultaneous acquisition of a discourse. Reading classes are not just about learning; they are also about acquisition of values and perspectives in a discursively constituted experience of the world. He thus defines literacy as "mastery of, or fluent control over, secondary Discourses involving print" (1990, 153).
Gee's distinctions between acquisition and learning are important in terms of the experiences of people attending the day hospital. In this setting, literacy was often about acquiring certain discursive skills in order to participate in institutional or `secondary discourses'. Furthermore, they frequently did not directly relate to reading and writing skills, nor the decoding of medical texts.
The concepts of discursive domains of literacy practices which encapsulates the social literacies of everyday life offered a preferable framework. These discursive domains may exhibit discontinuous and contradictory literacy practices such as those evidenced within the discursive domain of the waiting room, where patients and staff were often observed to switch and utilise differing communicative codes depending on the context.
Foucault's perspective on discourse is an important influence in this study and on many NLS theorists. Foucault (1972) takes the concept of discourse beyond its linguistic meaning to mean unities of statements whose conditions of existence can be defined, and which make it possible for certain statements but not others to occur at particular times, places and institutional locations. Discourse analysis is not merely the analysis of a text or a piece of language but an analysis of the practices surrounding the texts. Analysis of these practices enables one (in my case) to investigate and explore the construction of the hospital experience through the texts, language, narratives and voice as well as the hidden meanings behind voice and narratives. These theoretical concepts provided me with a particular lens with which to approach fieldwork.
Street (1998) has recently elaborated on his initial concept of literacy practices to include various communicative practices. This is achieved by exploring the micro ways in which people deploy linguistic resources, including how they link communicative practices from one domain, such as literacy, with those of others such as visual images. He discusses how people employ various semiotic resources in creative and independent ways.
Breier and Sait (1996) have shown how in the Western Cape, apparently "illiterate" taxi drivers are able to get around the city by utilising a variety of semiotic devices including symbols, shapes, colours and memory. Likewise, even if one has literacy skills one might use other communicative channels in which literacy plays a minor role. Street (1998) by way of example, states that when he catches a train to London, for logistical reasons, he does not read the display board at the end of the platform, but instead identifies his train by its internal layout, colour and design. Similarly, in the day hospital and in the family planning clinic, many of the women who are literate identify the contraceptive injection by its temporal capacity and pills by its colour, shape and size.
Kapitzke (1995), working from a poststructuralist perspective, takes the position that there is no essential or "natural" way of doing reading and writing. Rather, literacy's varied meanings and forms are conceptualised as products of culture, history and discourse. She thus defines literacy as "a set of social practices using a technology of inscription" (1995, 8).
Kapitzke's conceptualisation of literacy as technology of inscription is relevant to both the research project and definition of literacy. I move away from using strictly print literacy, defined as alphabetic literacy, to literacy's many forms of inscription. The metaphors of technology and inscription are useful for this allows one to expand on the definitions of literacy as strictly social practices around print materials to other forms of inscription, such as practices or techniques of inscription on the human body. In attempting to explore and understand the varied and complex literacy practices at the day hospital, I found that the move towards body literacy enabled me to uncover hidden literacy practices, (those not strictly alphabetic) and to thereby understand dissonances that had appeared incomprehensible before.
Foucault's (1979) notions of bodily inscriptions or technologies of writing move away from viewing literacy as a natural, biological or essentialist phenomenon. He examines the way in which power is inscribed on bodies through processes and mechanisms of surveillance, supervision and self-regulation in institutions such as prisons, schools and hospitals. Lives are described and fixed in writing as part of the textualising process of the institution. The apparatus of writing constituted the individual as a describable, analysable object; a case to be judged, measured, and compared with others (Foucault 1979, 191). Thus in the day hospital the patient's body through the action of medical literacies becomes a social text capable of being read and interpreted. Through the medical "gaze" the body is read as an assemblage of symptoms and diseases. The medical gaze is in turn attached to practices of writing, recording and encoding body symptoms and signs. Medical literacy or inscription is secret or specialised knowledge particular to the medical domain. These dominant forms of literacy are themselves answered by what I refer to below as social or local literacies.
In contradistinction to standardised reading, writing and numeracy competencies of mainstream literacy, social literacy is defined as literacy practices embedded in social context. Social literacies emerge into visibility when certain modes of encoding and decoding achieve dominant political and organising power over peoples' lives and begin to colonise their everyday life spaces. What I call social literacy arises in an attempt to decode dominant alphabetic literacy; to decode the world that is reorganised or constructed by dominant literacy and mediate or resist dominant literacy in terms of pre-existing cultural values or beliefs. Thus socially embedded literacies emerge in the gap created by the discontinuities between dominant and non-dominant knowledge systems.1
I argue for a context-specific understanding of literacy. Thus while accepting Street's (1994) use of the terms "local and vernacular literacies", I broaden the concept to include social and\or local literacies as it relates to the particular social experiences and literacy practices encountered in the medical domain.
Medical literacy and technology as part of mainstream alphabetic literacy, base their legitimacy and authority on being socially decontextualised and do not take into account the everyday life practices and the existing resources of patients. Street (1994) in the context of adult literacy programmes, talks about the need to recognise local literacy practices in their complex and varied forms. However, in the context of the day hospital, I argue that it is not only a question of acknowledging different literacy variations but that these variations can be viewed as a form of resistance and contestation to dominant medical literacies or expert knowledge systems. In my research the resistance or tension that arises between local literacies and dominant medical literacies and technologies does not necessarily take the form of opposing Western medicine per se, rather it entails a complex negotiated process whereby dominant medical literacies are frequently re-appropriated and re-transcribed to suit local and personal needs. In this process, medical literacies take on meaning within the context of people's everyday life worlds. Social literacies can therefore include the manner in which patients respond to expert knowledge systems from within their own social environment and how it is recontextualised from one form of literacy to another.
To research the significance of literacy practices in terms of social meaning and location within social context required articulation of an explanatory framework that was adequate to the task of giving meaning to the diversity, heterogeneity and complexity of social practices encountered. This opened up the space for considering the existence of multiple literacies, domains and genres of literacy. Baynham (1995) and Barton (1991) have explored the notion of multiple literacies in multicultural and multilingual environments. Multiple literacies consist of a mix of dominant, non-dominant, local and community literacies as opposed to institutional or school-based literacies, vernacular as opposed to essay-text or academic literacies.
Baynham (1993) introduces the concept of literacy mediators or cultural brokers in the multilingual and multicultural setting of the Moroccan community in West London. Baynham defines mediators of literacy as people who engage with literacy tasks on behalf of others. An important aspect of literacy mediation is that it involves code-switching (between languages) and mode-switching (between oral, written, visual and other sign systems).
Fingeret (1983), in her study of "illiterate" adults in urban America, has made an important contribution towards deconstructing the deficit view of illiterate adults by exploring the intricate social networks of exchange and reciprocity between those who have the necessary literacy skills and those who do not. Fingeret's skills- orientated understanding of literacy networks tends to depict all literacy mediation as synonymous with networks of reciprocal exchange associations. Relations of power and the role of agency in literacy mediation are underplayed. Following Malan (1996), I too caution against viewing all forms of literacy mediation as constituting networks of reciprocal exchange. In certain contexts, for example institutional settings, literacy mediation can serve to underwrite subjects to the normalising gaze of institutional power and social control, whereby literacy mediators play an important socialising role between subjects and their induction into the hierarchical structures of the institution. Thus based on my understanding and experience of literacy mediation in the day hospital environment, I argue for a differentiated understanding of literacy mediation which takes into account that the agency of literacy mediators is invested with varying degrees of social power.
This review of academic literature describes the major influences towards my developing understanding of literacy. My initial understanding was not sufficiently complex to do justice to the dynamics in the field, especially if I was to take into account patients' own subjective experiences of the medical literacies. This ultimately brought me to explore the notion of body literacy.
The deconstruction of literacy which the NLS provides opens up the space to explore differing "readings" of the term literacy. This reconceptualisation of literacy as a culturally contested process involving relations of acquisition, mediation and cultural brokering was useful. Yet in spite of this, the conceptual signposting remained at the level of print literacy. In order to address the literacy practices of patients at the hospital I needed to explore other forms of literacy which went beyond the boundaries of print literacy. How were the patients bodies being read by the medical discourse and by themselves? I decided to look at the concept of body literacy as one further arena of literacy, conceptualising the body as a text. Where: "the body is viewed as a writing surface, a blank page, upon which social messages, meanings and values are inscribed" (Kapitzke 1995, 16).
The notion that the body is a text upon which cultural fictions and narratives map meanings for self and other is theoretically supported by the works of Foucault (1979) and Kapitzke (1995) and is explored further in Chapter Four.
The literature review will consist of three related areas; medical anthropology, more specifically theories around the body; the anthropology of gender, and local studies of reproductive health care.
Paralleling the manner in which the New Literacy Studies challenges political and cultural neutrality of literacy technology and development theory, medical anthropologists also question the acceptance of biological and biomedical data as an assemblage of incontestable natural facts (Lindenbaum & Lock, 1993).
In medical anthropology, medical or scientific knowledge is not necessarily the starting ground for analysis, rather there is a convergence of other discourses at play.
This perspective views all knowledge of society, sickness and the body as socially and culturally constructed and explores how medical facts are assembled and legitimized through medical discourse, care-giver/ patient dialogues and interactions, and by wider social and political institutions. Thus the medical anthropological perspective examines the social conditions under which knowledge is produced (Young 1982; Good 1994). Furthermore, medical anthropology seeks to move beyond the monological discourse of the medical establishment to examine how experiences of the body, disease, illness, sexuality and reproduction emerge at other social sites external to, but interacting with, medical institutions and practices (Martin 1989; Kaufert & O'Neil 1993, 1995;Ginsburg & Rapp 1995).These frameworks imply that gender and reproductive health cannot be treated as pre- given cultural facts but are rather subjected to ideological mediation and norms.
Haraway (1991) challenges certain taken for granted assumptions about scientific knowledge arguing that we need to recognize internal contradictions and variations within biology itself. This is particularly useful as medical anthropologists tend to in their critique of the biomedical paradigm overlook internal contradictions within these very establishments.
Martin (1989), in providing a cultural analysis of reproduction, has explored the performative and discursive construction of the female body in the medical treatment of menstruation, childbirth and menopause and demonstrates the extent to which wider metaphors of economic production current in American modernity have infiltrated medical discourse and perception.
Crucial to the study of the social formation of medical experience and understanding is the concept of cultural performance in which both the body and the treatment space are understood as theatres and rhetorical stages upon which wider social narratives such as gender norms and development agendas are materialized and made real. This framework is crucial to examining the mode of transfer of medical knowledge from care-givers to patients and in uncovering the autonomous ways in which medical norms are rescripted by patients in response to wider social forces and pressures. In turn, the performance model enables one to show how the treatment or clinic space is not isolated from wider social forces, but is penetrated by the latter and transformed into a space into which broader social conflicts are metaphorized and symbolized (Kleinman 1980; Farmer1988, 1990;Scheper-Hughes & Lock 1991).
The work of Foucault (1972; 1979) has brought the question of the discipline of the body and the rise of scientific knowledge to the centre of theories on the body and medical histories. Foucault's tenet that the language of biomedicine is produced through discourse creating its own objects of analysis, has had a profound influence on how both anthropologists and sociologists have approached the human body and biomedical categories such as disease, illness and risk (Turner 1987; Martin 1989; Lock & Scheper- Hughes 1990; Feldman 1991).
Ethnographic works, by paying close attention to the everyday lives of women and their wider familial structures, has led to a re-evaluation of anthropological theories around the body, and more specifically, for purposes of this study, around the gendered body. For medical anthropologists, the term resistance has served to bring attention to cultural forms and activities which resist the increasing medicalization of our lives and thus of the encroachment of hegemonic cultural forms(Good 1994:58).
The concept of resistance has also been used to analyze forms of illness experience and bodily dissent, more commonly studied as "possession", "hysteria" or "somatization" (Lock 1993; Good 1994). By way of illustration, Ong (1988) analyses attacks of "spirit possession" on the shop floor of multinational factories in Malaysia as part of a complex negotiation in which young women respond to violations of their gendered sense of self, difficult work conditions, and the process of modernization. Similarly Boddy(1989), in her study of Muslim women in Northern Sudan, explores the apparent contradictions between the cultural construction of women according to the male dominated Islamic derived ideology, and the cultural productions of the women themselves, manifest largely in ritual and narrative associated with the Zar cult or spirit possession. In trance, however, it is possible for women to create a reflexive, counter- hegemonic discourse that permits women to re-negotiate their sense of self. Seremetakis (1991) in her study on women in rural Greece, is similarly concerned with identifying strategies of cultural resistance that emerge and subsist on the "margins". These are expressed emotively through diverse social practices such as death laments, mourning rituals and divinatory dreaming.
The body imbued with social meaning, thus becomes not only a signifier of belonging and order but also an active forum for the expression of dissent and loss thus ascribing it individual agency (Lock 1993:141).
Linked to notions of resistance is Weiner's (1976) study on exchange in the Trobriand Islands. Challenging Malinowski's seminal works on the Trobrianders, and through foregrounding women's pivotal roles in exchange networks, kinship structures and mortuary ceremonies, she explores how women operate in differing domains of power and demonstrates how power is not necessarily located in the political sphere. Cultural power is thus often located in unexpected places.
Recent feminist scholarship1 has been attentive to the multiplicity of social relations that structure women's identities in interdependent and contradictory ways. Post- colonial feminist theorists such as Spivak (1988), Mohanty (1988) and Minh-ha (1989) have asserted that "under Western eyes, the woman -native- other category tends to homogenize Third World women". The experience of being a woman is different dependent on how one is positioned in terms of race, class, ethnicity, age and religion. Thus as a contested domain and a negotiable social process, gender is frequently fragmented, contradictory and multi-faceted.
Feminist theorists have also challenged the manner in which medical knowledge and scientific discourse encodes dominant representations of gender and of women1. Related to this, feminist theorists have attempted to demonstrate that gender is socially constructed and not a biological given. In addition, they have challenged the notions of sex, gender and sexual differences as being fixed binary categories (Moore, 1994), thus providing an important theoretical framework for reconceptualizing asymmetrical gender relations and experiences of embodiment, and the manner in which gender and sexual relations are constructed and contested in diverse social settings.
Anthropologists working in the field of reproductive health have provided important insight into the manner in which reproductive technologies and ideologies are rescripted and adapted by local communities and the manner in which social experiences of reproduction and sexuality are historically and culturally negotiated, constructed and located.
Ginsburg and Rapp's (1995) collection of studies on the anthropology of reproduction challenges traditional anthropological analyses of reproduction, by exploring the manner in which reproduction is structured across social and cultural boundaries at both local and global intersections. Using reproduction as an entry point in the study of social life, and placing it at the centre of social theory, the authors examine how cultures are produced, contested and transformed as people imagine their collective future in the creation of the next generation.
Kaufert and O'Neil (1993,1995) and Fraser (1995), explore the complex and ambiguous effects of state intervention into local, community based birthing practices. They explore how local communities both resist and embrace medicalization and efforts to impose state mandated public health care policies. This is of particular relevance to the South African context where state health care policies concerning reproductive health care practices and rights are being redefined and implemented. These studies further illustrate the need to take cognizance of local perceptions and cultural practices.
Ethnographic studies around women's reproductive practices in such diverse settings as Nigerian women's conflicting responses to the introduction of contraceptives (Olu Pearce,1995),cultural understandings as they relate to pre-natal screenings (Rapp, 1993), women's resistance to the Romanian state's banning of abortion and contraception during Ceausecu's reign (Kligman 1995), and the impact of the new reproductive technologies, such as fertility enhancement, on traditional kinship structures (Strathern 1995), offers a further means to engage in conceptualizations of power in relation to the introduction and importation of reproductive technologies and ideologies into local communities.
Similarly, Lowenhaupt Tsing (1993), in her study of the Meratus people in an isolated mountainous region of Indonesia shows how people who we assume are situated on the "margins" of society are often affected by issues of modernization and globalization and in turn challenge and reinterpret these intrusions. Thus in even the most "out -of the- way- places" heterogeneity and trans- cultural dialogue exists.
However, despite this research, a paucity of detailed ethnographic studies from within a South African perspective remains. There are various epidemiological research projects underway, however, most research remains located within biomedical and epidemiological paradigms. The need for cultural awareness has been identified locally, notably Planned Parenthood's peer education and training programmes and within my fieldsite,1 yet to date, there is virtually no medical anthropological input into these research processes and anthropologists within South Africa have given little attention to women's reproductive health care practices with the exception of Wood, Maepa & Jewkes' (1996,1997) qualitative studies on adolescent sexuality and contraceptive experiences.
I now focus on the specific research site and the context in which literacy practices are located.
Hout Bay is situated off the Atlantic coast on the Southern Cape Peninsula approximately 20 kilometers from the centre of Cape Town. The Day Hospital is an out patient clinic which is situated in the "Coloured" section of the Hout Bay Harbour area. The harbour community locally referred to as the `fishing village' is a residential Coloured area, an enclave situated within the greater Hout Bay area.1 The Day Hospital is open from Monday to Friday from 8 a.m. to 4 p.m. It is closed on Saturdays and Sundays and on public holidays.
There were a number of reasons for choosing this particular research site. One of these was my previous experience as a professional nurse. My knowledge of the daily functioning of a hospital helped me in my choice of a particular field site.
Safety as a white female researcher was another personal issue that I had to confront. Mobility into and out of the area was made easy because of the field site's particular historical and social location situated on the periphery of white suburbia. A circular tarred road provides access to the infrastructure in the area and is linked to the main access roads leading to the harbour, the city and other areas of the Cape Peninsula.
Numerous changes have occurred over the past eighteen months, this is linked to the restructuring of the health care services in South Africa, more specifically, the emphasis on public and primary health care. This has led to a more marked separation between the medical section and the family planning and mother and child health section. The medical section deals mainly with chronic medical conditions such as diabetes, asthma, epilepsy, hypertension and more recently the rising incidence of STIs and HIV \AIDS within the community. All acute medical cases are referred to the larger nearby hospitals. The mother and child care section which includes family planning services and ante and post natal care, now appears quite separate, though located within the same building. Recently TB treatment has been included in the mother and child health care section. The latter section falls under the Southern Peninsula Municipality which forms part of Community Health Services whereas the medical sections falls under the Provincial Administration of the Western Cape.
Maternity services are provided free to all women and their babies up until the age of five and has been integrated into the new restructured primary health care system. Obstetric services in SA vary widely from meeting first world standards (in many private and academic hospitals) to being almost non existent in state services (in rural and poor urban areas) (HST Update 1998:5). However, in the case of Hout Bay the situation is somewhat different.
I have detected a tension between the medical section and the family planning section, largely due to the fact that the nurses in the medical section feel that they have a greater patient load whereas the mother and baby clinic is better staffed and has fewer patients. The nurses in the latter section have also managed to establish more regular hours for consultations and visits though technically there are no longer fixed times for family planning and mother and child health care services. Since the majority of the mothers are from the harbour community language barriers do not exist, whereas many of the patients in the medical section are from Imizamo Yethu squatter camp1 and translators are frequently required. Tension has existed over which section should be treating the large number of STIs and AIDS patients. The nurses in the medical section feel that the STIs should be treated in the family planning clinic whereas the nurses in the mother and child clinic feel that many of the cases are men and not linked to family planning or maternal and child health and this could cause many patients to seek help elsewhere. In the past two months those patients diagnosed with STIs and HIV and from Imizamo Yethu squatter camp have been referred to the Main Road clinic situated adjacent to Imizamo Yethu squatter camp. The situation remains fraught with problems and will be discussed in Chapter Four.
Within the SA context, it is almost impossible to avoid experiences of race and racial classification established under apartheid. These experiences inevitably impact on the research process, affecting the manner in which the researcher is perceived by the community into which one enters. Thus my access into the fieldsite was affected by racial and gender considerations. I was repeatedly advised by the nursing staff that it was inadvisable to go out alone into the community. I was informed of the increasing crime rate and the activities of gangs in the neighbourhood. Despite this, to date, I have encountered no real problems. Perhaps because I have always been accompanied by someone from the community especially when walking the streets or going on home visits.
The research method chosen in this thesis is primarily ethnographic in nature.
Although my background as a nurse has had an important impact on the manner in which I have constructed the research object, the ethnographic approach with its intense concentration on the place itself, allowed me to distance myself from the medical discourses in which aspects of my own identity had been constructed. Self reflexivity, an integral component of ethnographic method, allowed me, despite my experience as a nurse, to distance myself from the research object as well as to consider my relationship to it.
Within the discipline of anthropology, ethnography has been defined and practiced since 1900. The main focus of ethnography is a study of people's self understanding of their life worlds, their everyday life practices and belief systems. Feldman has asserted that the primary means for conducting ethnographic research and inquiry :
is not solely observational and journalistic style description, but rather the conduct of intense, long standing dialogues between ethnographer and informants, in which the most important descriptions are those generated by actors from within the milieu being researched, and not solely by the researcher who is external to it (1994:20).
Ethnography is defined in numerous ways by various ethnographers but a common theme is the way in which the practice places researchers in the midst of what they study. In this process :
Ethnography frequently involves the abandonment of pre-conceptions and pre-field research models on the part of the investigator, who has to define his/her role in the context of profound difference (Feldman 1994:20).
Similarly, Geertz, describes ethnography as "thick description":
What the ethnographer is in fact faced with...is the multiplicity of complex conceptual structures, many of them superimposed upon or knotted into one another, which are at once strange, irregular and inexplicit and which he must contrive somehow first to grasp and then to render (1973: 10 ).
Thus the ethnographic method afforded me the possibilities of uncovering the complex and multiple layers of social reality. Ethnographic research methods are not the detailed collection of descriptions as they occur, but involve intense engagement in the field, where one is constantly shifting and reassessing one's position. In confronting the field site, I found Foucault's (1972) metaphor of "archaeology of knowledge" useful. As one discovers ideas, one uncovers precursors to them in the shifting and deeper layers and strata of an archaeological site.
The concept of self reflexivity, which I argue is integral to an ethnographic study, relates to my own experience in the field.
In anthropology, postmodernism and post-structuralism have put the "critique of objectivity and scrutiny of ethnographic authority onto the disciplinary agenda" (Bell:1993 in, Breier :1994). This has led to the emergence of reflexivity as an aspect of ethnographic method. Clifford traces the history of self reflexivity in ethnography back to the publication of Malinowski's diaries and the enormous impact that these self- revelations had on the field of anthropology.
The publication of Malinowski's Mailu and Trobriand diaries (1967) publicly upset the applecart. A subgenre of ethnographic writings emerged, the "self reflexive fieldwork account". Ranging from sophisticated and naive, confessional and analytic, these accounts provided an important forum for the discussion of a wide range of issues epistemological, existential and political (1986:14).
Reflexivity is often associated with self examination and critique, and the acknowledgment of subjective interpretations and positioning in relation to which the ethnographer provides relevant personal information. This has become increasingly important in my own research process as I have found myself moving between different positions, that of the ethnographer and that of a nurse with residual medical preconceptions and assumptions.
There has been much debate about the objective and "authorial voice" in anthropology and more specifically ethnography. Geertz, in exploring the problems associated with the construction of ethnographic texts and the manner in which the anthropologist as author is positioned within texts, provides some useful insights into the `authorial presence' or `authorial voice' :
Within anthropology it is hard to deny the fact that some individuals... set the terms of discourse in which others thereafter move. The distinction between authors and writers or in Foucault's version, founders of discursivity and producers of particular texts is not as such one of intrinsic value..... It is now hard to tell who the authors are and who will discourse in whose discursivity (Geertz 1988:19).
In traditional ethnographies, polyvocality was restrained and organized, so as to confer to one voice a pervasive authorial function and to others the role of informants or "sources" to be quoted or paraphrased. The new tendency to name and quote informants more fully and to introduce personal elements into the text is altering ethnography's discursive strategy and mode of authority.
The acknowledgment of cultural hybridity; diverse and multiple voices and genres in the field is perhaps the most challenging aspect of ethnographic fieldwork, having a causal relationship to the manner in which data is gathered, interpreted and analyzed. At times I began to lose my own discourse, and the discourse or communicative forms of my informants and had to re-evaluate the complex interplay of voices, fragments of speech and narratives that I encountered.
Feminist anthropologists have explored the role of gender in anthropology and how it impacts on ethnography and fieldwork (Callaway 1992; Bell, Caplan & Karim 1993; Moore 1994). They note that feminist or gender issues have been largely ignored by the anthropological academy. Anthropologists, more specifically male anthropologists, despite their critique of objectivity and ethnographic authority continue to ignore or marginalize women's voices. Furthermore, despite the centrality of self- reflexivity within the discipline, reflexivity has not necessarily included an awareness of gender, particularly as it relates to fieldwork experiences.
Social origins pertaining to gender, race and professional position impacted on the manner in which data was obtained. Different informants related to me differently, depending on how I was identified within their social world. Professionals related to me as professional peer and as "Sister". Patients also called me "Sister". Both are framed within medical and gendered discourse. Typified in an informant's response.
What must I call you Miss, must I call you Miss or Sister?
I found that I was often assigned a particular discursive position by staff and patients alike. The above statement reflects the multiple positions and roles assigned to me, as woman, a researcher and as a professional nurse. It was not merely a question of identifying and acknowledging these subtexts of race, gender, class or professional status, but affected the manner in which I constructed my own multiple and shifting identities within this community. Thus each of these roles offered constraints and possibilities in terms of the research process and each needed to be examined. I found it necessary to consider the manner in which the person interviewed or spoken to, (however informally), had positioned me and to take cognizance of this when collecting and interpreting my data.
I decided to accept and utilize the various discursive positions ascribed to me by professional staff and patients, feeling that it could provide further insight into the complex web of social relationships within the medical domain. On the odd occasion I did respond to medical initiatives and did "help out", offering medical expertise in situations that were appropriate, mainly on the level of medical or family planning advice. I also joined the local Hout Bay Health Forum to familiarize my self with community initiatives and health related activities.
A concern that I had anticipated at the outset of my research and in my initial research proposal was how to confront my own medical gaze. I started out by making a conscious decision to subvert my medical gaze, but soon realized that it had afforded me an entrance which might have otherwise not been possible. It was often my prior medical experience that facilitated and made the initiation process into the field site that much easier. I had been accepted into the field site by both patients and staff, not because of my position as a researcher but as a nurse.
It was through the medical gaze and their perception of my position within the medical domain, that many of the women found a safe and contained space beyond their daily hardships, and a symbolic sealing of the social contradictions of their lives beyond the clinic environment. This will be discussed further in Chapter Four.
One of the effects of undertaking ethnographic research is that the social world as experienced and lived is encountered in unpredictable and diverse ways.
I made use of informal interviews, participant observation and the recording of social narratives to develop an account of literacy and reproductive health care practices.
I found that identifying key events (see Geertz on Balinese cockfight)1 enabled me to isolate certain phenomenon and medical scenarios that I wanted to explore further and helped provide some order to the data. These consisted of observation and interviews centred around the Family Planning and Mother and Baby clinics. I chose these informants as they visited the clinic frequently and I was thus able to establish some form of continuity. I undertook these visits over a period of eighteen months, in which I interviewed patients in the waiting room, women attending the Family Planning and Mother and Baby clinic, the Nursing Sisters and doctors and in various sites beyond the clinic such as the Disabled group, Hangklip Seniors Club, women who worked at the local fishing factory, the Hout Bay Health Forum and home visits brokered by key community figures. Although the women attending the Family Planning and Baby clinic formed the core of my research, I also interviewed young mothers in their homes, schoolchildren sitting outside the hospital, ex- gangsters receiving TB treatment or attending the disabled group. I frequently moved to the area outside the hospital, where patients sat in the sun, smoked cigarettes or socialized. I sat on the steps outside and chatted to patients, holding discussions around their medications or Family Planning appointments.
The majority of the patients interviewed were from the Hout Bay harbour area, though a few were from the nearby Imizamo Yethu squatter camp My interviews were conducted in English or Afrikaans depending on which language the informant preferred. Informants often switched between English and Afrikaans, the local vernacular, interspersed with expressions and idioms particular to the vernacular of the Western Cape region. In transcribing interviews, the richness of the local vernacular is often lost as it is frequently context specific.
Some of the interviews were conducted through a Xhosa translator, a nursing assistant in the clinic. This often proved problematic as I sensed she was changing some of the contents and meanings to what she thought I would want to hear. She also often reprimanded patients for not complying with their treatment regimens.
Participant observation at times proved useful. The noise level, coupled with the continual movements of patients in and out of different spaces made interviewing difficult. It was easier to initially observe and engage in conversations at a later stage.
Frequently the only "free time" that medical staff had was during tea breaks; a ritual in which I was always included. The tea room was a place in which I often gained information about the daily happenings in the hospital.
Communication and dialogue with the doctors was limited. I had decided at the outset, due to the time constraints and the vast material to be covered, that interviews would be limited to the nursing staff as representatives of the medical domain. The decision to focus and restrict my interviews to the nursing staff centres around the primary role that they play in the functioning of the day hospital. The Community Health Services sector of the hospital is run entirely by Community Nursing Sisters. The most intense and frequent interactions are between the nursing staff and patients. As previously mentioned, my medical background further facilitated and influenced my decision to focus on the nursing staff as representatives of the medical institution.
I have changed the names of informants and staff. This is to protect and maintain patient and staff confidentiality.
This opening chapter provides an introduction to the specific research questions with which I entered the field site and the major perspectives and influences that have been drawn on. I offer my own analysis of how one might best conceptualize the relationship between literacy and reproductive health care practices and the social world of the informants in the field site. I note that the NLS has not only influenced the methodological and theoretical approach of this study but has contributed to my epistemological and consequent theoretical move from print literacy towards body literacy or the body as text. I thus extend the focus or field to include literacy as embodied in text and discourse as it intersects with the social constructions of space and the body. I also work with Street's (1993) and Baynham's (1995) concepts of literacy practices which firstly emphasize the social nature of literacy, and secondly, the multiple and often culturally contested and ideological nature of literacy practices.
In Chapter Two, I explore the relationships between texts and literacy practices in the place. I argue that texts are always located within particular social contexts and that understanding literacy involves studying both the texts and the practices surrounding the texts. I provide a narrative description of the Hout Bay Day Hospital and various texts and associated literacy practices encountered within various discursive domains of literacy.
Having provided a description of the place, the focus now moves towards an examination of literacy practices within socially constructed space. In this chapter, Chapter Three, I expand the notion of space and place as previously discussed in Chapter Two. At this juncture I provide a brief history and socio-political narrative of the area within which the day hospital is located. I work from the premise that space is not merely an objective material reality nor geographical place, but is socially constructed.
In Chapter Four I extend the `ways of seeing' literacy to include practices or techniques of inscription on the human body. The central focus of this chapter is on the women attending the Family Planning clinic, more specifically their cultural constructions around contraception and family planning.
In Chapter Five, the conclusion, I summarize the findings of the previous chapters and return to the theoretical concepts utilized in uncovering the varied ways of `seeing literacy'. I offer some suggestions for future debate and research and the possible value of this research for current health care initiatives.
