Tension between advocacy and research is something I suspect every social scientist experiences to different degrees. For those of us in health services research, awareness of this conflict proves frequent, since we routinely find ourselves trying to reconcile different implicit assumptions about our jobs: health workers have a mission to help their patients, while health researchers have a mission to understand the systemic and individual factors that shape patient experience. While my own training associates investigation of this conflict most closely with the work of medical anthropologist Nancy Scheper-Hughes, there are many voices within the social sciences that ask us to be more attentive to this internal dialogue that shapes both our desired outcomes and our methods along the way. What do we owe to those who are the subjects of our research as well as the principal subjects of their own lives? Assuming we do wish to serve our subjects in some sense, will we accomplish this best by advocating for what they say they want and need, assembling objective evidence to support those positions, or by cultivating an “outsider’s” gaze laying claim to a more generalized and independent assessment of the situation?
One thing that struck me when I started working at a Veteran’s Affairs Medical Center was the way our common language made constant, casual use of the concept of service. There is the obvious formal explanation that the VA provides care to former military service members, but this underlies a whole way of talking and thinking that goes beyond the technical. At the VA, although we sometimes see “patients,” we usually see “Veterans,” and we never see “customers.” Our shared organizational shorthand for the patient-subject is neither biomedical nor economic, but sociological. A discourse of service is evidenced by variations on the slogan, “you served your country, now we will serve you,” seen so often on the walls of our hospital. This explicit rationale of reciprocity and interdependence, rather than a market-based transactional one, is relatively rare within US society. This arguably militarizes the concept of citizenship, since military service is understood to generate a particularly valued type of citizen. In the United States today, healthcare reform notwithstanding, we admit no right to healthcare except for our elders and our warriors, effectively transforming a (universal) right into a (limited) privilege. But this logic also simultaneously elevates those partners who reciprocate with their service – in this case, VA caregivers.
In my current research investigating the functioning of primary care clinics during a period of organizational transformation, unprompted utterances in interviews and focus groups with employees of all kinds confirm the widespread presence of this logic. Employees speak of the “privilege” of working with their patients and the satisfaction derived from their own identity in service to others, especially those who have “earned” their care through service. Humanistic motivations are common throughout healthcare and not unique to the VA; what is unique is the emphasis on the specific obligation in place towards these specific (Veteran) humans.
I dwell on this theme of service and how it shapes both patient and employee expectations and relationships, both because it fascinates me in terms of its possible implications for how a health system operates, and because I recognize a parallel dynamic in the relationship between me and the participants in my research. Having given me access to their lives, participants have also, in different ways, gained access to mine. Whether it becomes the main focus of our interaction or wavers in the background, the question of “who is the research for?” is always there, and dialogue has a way of encouraging us to try to negotiate a purpose that serves both (all) of us. Universal claims of respect for other humans’ dignity are at work, but the lived expectations of the reciprocal social relationship exert a stronger influence on daily actions: we are talking to each other, after all. Additionally, since much of my research is with VA employees, the terms of my relation to them invariably are colored by the norms and expectations of the culture of service that frame their relation to their patients.
Given that much of my own methodological approach is grounded in participatory research methods, which strive always (more or less successfully) for the full participation of all involved parties in the co-production of knowledge, I am comfortable with the idea that I am unavoidably engaged in a reciprocal process with people who are part of the work I do. What has surprised me is the fit, in practice, between these participatory approaches and the idea of the public servant. There is not space here to discuss the gradual acceptance of more participatory approaches within even the more clinical and expert-driven research paradigms. My point is simply that working within an organization that reminds one constantly of one’s role as servant – whether nurse or statistician, anthropologist, or dietician – can encourage methodological choices, such as greater research subject participation in the design of studies and the analysis of results that usually are justified only by particular theoretical orientations.
I am happy about this coincidence, though I’m aware it only comments on, but does not answer, the questions I introduced at the start of this column. I believe that the voice of a researcher should be a critical as well as an empathic one. There is no predetermined right way to ensure that both those goals are met (though some approaches and tools that are more likely to succeed than others). Most researchers highly value their independence, but most social scientists also know that we can value something that we know to be a (partial) fiction. Not only that, we can generate consequential action out of such not-entirely-true realities for ourselves and our communities. Given that, the concept of service might sometimes mediate the advocacy/research knowledge dichotomy by offering itself as a legitimate goal and creating space for discussing how we might achieve it without compromise of our critical rigor or our human interdependence.
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
Anais Tuepker is an Investigator with the Portland (Oregon) VA Medical Center’s Health Services Research and Development Program and an Assistant Research Professor, Department of Internal Medicine at Oregon Health & Science University. She received her doctorate in sociology from the University of New South Wales, Australia. She subsequently completed a Master of Public Health degree from Oregon State University, with a focus on international health and displacement. She has worked in health program planning and evaluation in both the United States and internationally.
Sarah Ono, Heather Schacht Reisinger, and Samantha L. Solimeo are contributing editors of Anthropology in the Public Sector.