Papers by Audrey Bochaton
Mobilities, 2019
This Special Issue expandsmobilities research through the idea of therapeutic mobilities, which c... more This Special Issue expandsmobilities research through the idea of therapeutic mobilities, which consist of multiple movements of health-related things and beings, including, though not limited to, nurses, doctors, patients, narratives, information, gifts and pharmaceuticals. The therapeutic emerges from the encounters of mobile human and non-human, animate and inanimate subjects with places and environments and the individual components they are made of.We argue that an interaction of mobilities and health research offers essential benefits: First, it contributes to knowledge production in a field of tremendous social relevance, i.e. transnational health care. Second, it encourages researchers to think about and through functionally limited, ill, injured, mentally disturbed, unwell and hurting bodies. Third, it engages with
the transformative character of mobilities at various scales. And fourth, it brings together different kinds of mobilities. The papers in this Special Issue contribute to three themes key for the therapeutic in mobilities: a) transformations (and stabilizations) of selves, bodies and positionalities, b) uneven im/mobilities and therapeutic inequalities and c) multiple and contingent im/mobilities. Therapeutic mobilities comprise practices and processes that are multi-layered and mutable; sometimes bizarre, sometimes ironic, often drastically uneven; sometimes brutal, sometimes beautiful – and sometimes all of this at the same time.
This article revisits the conceptualisation of pharmaceutical regulation. While States and multil... more This article revisits the conceptualisation of pharmaceutical regulation. While States and multilateral organisations play a central part in devising rules, regulation as a social practice extends beyond their role. Domestic and international interests, geopolitics and spatial configurations, commercial and health considerations, governmental policies and individual behaviours and legal and illegal transactions all contribute to regulating the pharmaceutical milieu. This consideration expands the epistemological range of pharmaceutical regulation, which then appears as the assemblage of heterogeneous laws, rules and codes of conducts. The way in which these layers are connected forms what regulation actually is in practice. Regulation multiple thus appears as the product of tensions between harmonisation efforts and persistent diversity, as well as the result of interactions and overlaps between official regulation and unofficial regulatory practices. This article explores these tensions in the Southeast Asian pharmaceutical market along three themes: circuits and logistic regimes; control and attention to quality; bridges and harmonisations.
We investigate the notion of therapeutic mobilities through the case study of transnational healt... more We investigate the notion of therapeutic mobilities through the case study of transnational health care practices and medicinal flows within the Hmong diaspora between Laos and the U.S. Drawing upon narratives of traditional healers, pickers, and plant sellers, as well as a collection of postal registers, we highlight how therapeutic mobilities follow the routes of migration and organize the practices of healing among Hmong in receiving countries, particularly in the U.S. Through the different and multidirectional aspects of therapeutic mobilities, we illustrate how transnational healing touches upon questions of cultural identity within the Hmong diaspora. Therapeutic mobilities not only involve border-crossing, they also strengthen existing bonds within the Hmong diaspora. Similarly, herbal treatments not only achieve a therapeutic function, they also represent a range of meanings and values for patients. We explore the fabric of therapeutic mobilities through the prism of translocality and medical pluralism.
Keywords: Therapeutic mobilities, medicinal plants, translocality, medical pluralism, migration, diaspora, Hmong, Laos, United States
Les Tribunes de la santé, 2014
This special report of the RFST journal is linked to a one-day seminar held in January 2014 in Pa... more This special report of the RFST journal is linked to a one-day seminar held in January 2014 in Paris by the College international des sciences du territoire (CIST), area of work “health and territorial inclusion of populations”. Through a multidisciplinary approach, the aim of the seminar was to better understand the relationship between gender, territory and health.
In geography and sociology, inequalities between men and women has been widely documented in terms of occupation, ownership or avoidance of space (private or public) or in terms of access to knowledge, power and resources. A lot of studies in the field of public health also show significant differences between men and women in terms of life expectancy, mortality, morbidity but also representation of health, and more generally health behaviors. But despite these observations, considerations on relationship between gender, territory and health still remain innovative.
The contributions of this special report bring original insights by their disciplinary anchor and their own field research, and lead to two central questions: how differences between men and women in spatial practices reflect on their health and their health behaviors? And, what is the role of gender, among other determinants, in the health care pathways and the health of the population?
The special reports of the RFST remain open permanently. It means that new texts will be added in the future and will provide answers to these questions and probably will submit new questions.
The feminization of the physician workforce is a growing phenomenon, increasingly studied by hist... more The feminization of the physician workforce is a growing phenomenon, increasingly studied by historians, sociologists and physicians who examine the consequences of this shift on the medical profession in a context of increasing health inequalities. While inequality in health worker distribution is also increasing in France, geographers have little studied the relation between feminization and the territorial organization of healthcare provision.
Many official reports and scientific studies show that disparities in the distribution of physicians increase over France and at different spatial levels (Maurey, 2013). Considering the workforces of physicians in relation to the French population, the situation of France is quite good but their distribution reveals clear spatial inequalities. Major disparities can be observed between administrative areas, for example “les régions”. As shown in the map below, medical coverage is significantly higher in the French southern regions (particularly Provence-Alpes-Côte-d’Azur with one doctor for 244.77 inhabitants) and also the capital region called Ile-de-France (which one doctor for 252.22 inhabitants). On the contrary, the region called Picardie displays the lowest medical service (one doctor for 388.13 inhabitants) followed by the region Centre (one doctor for 375.43 inhabitants). Inequalities are even stronger within regions at a local level. Medical doctors concentrate mainly in urban areas and therefore neglect rural areas which appear and are described as “medical deserts”. In 2012, 20% of general physicians work in rural areas whereas 27% of French people live there.
map 1 denoyel.gif
The objective of this article is to explore the factors commonly discussed and perceived to explain this phenomenon. Among these, the feminization of the medical profession is often designated as a central determinant of the ongoing developments of the medical sector and the increasing spatial disparities among the French territory. We wanted to test the idea that medical deserts exist because of the feminization of the medical profession with local data, collected across the Burgundy region.
In Burgundy, the under-representation of female doctors in rural areas is real but the differences observed between the physical locations of male and female doctors are relatively moderate and not significantly different. However, some discourses from the medical sector, political sphere and media tend to associate closely the current increase of the spatial inequalities of medical care and the feminization of medical profession. The tweet from Senator Mayet “medical deserts, the fault of the women?” of 27 July 2015 can certainly appear anecdotal but it still shows an overview of current thinking that can circulate on the effects of the feminization of the medical workforce.
To understand the rationales behind medical deserts, it appeared that we should go beyond gendered explanations in order to address the broader social and economic determinants which contribute to this phenomenon. Some recent studies show that young medical practitioners, both women and men, wish to preserve time for family or for social activities leading them to reconsider their relationships to work (Deriaz et al. 2010). In 2003, Robert Herin already stated about the liberal healthcare provision in Normandy that the new generations of physicians (regardless of gender) were seriously concerned by living environment, educating children, the range of jobs for spouses, the qualities of cultural and social environment, etc. All these determinants tend therefore to lead young doctors towards urban environments more than rural areas. As a consequence, we must consider the spatial disparities observed among the medical physicians in France more as a generational issue than a simple gendered issue.
Espace Politique, Jan 2015
Nous proposons d’explorer la recomposition actuelle de l’espace frontalier lao-thaïlandais à
tra... more Nous proposons d’explorer la recomposition actuelle de l’espace frontalier lao-thaïlandais à
travers les comportements thérapeutiques des individus, et plus particulièrement le recours
aux soins des Laotiens dans les hôpitaux thaïlandais limitrophes, appelés par commodité les
recours transfrontaliers. Cette pratique d’une partie de la population vivant dans les bordures
frontalières accompagne l’ouverture récente du Laos et souligne l’écart de développement
existant entre les deux pays.
Les recours aux soins transfrontaliers sont des indicateurs pertinents pour décrire et expliquer
les processus socio-territoriaux actuellement à l’oeuvre au sein de l’espace lao-thaïlandais.
L’approche par les soins présente l’intérêt d’aborder la frontière sous tous ses aspects :
politique, économique, sociale, culturelle et sanitaire. La maladie ne concerne en effet
pas seulement l’individu affecté dans son corps biologique, mais également sa famille, sa
communauté, les thérapeutes, les institutions publiques de santé ainsi que les institutions
administratives et politiques. L’approche sanitaire privilégiée dans cette contribution donne
ainsi la possibilité de renouveler la réflexion sur la frontière.
Entre l’effacement progressif de la frontière dans les pratiques des patients et son maintien
réaffirmé par certaines déclarations des dirigeants politiques et des responsables hospitaliers,
l’espace lao-thaïlandais s’avère complexe ; les fonctions, tant de coupure que de couture, de
la frontière sont tour à tour invoquées voire instrumentalisées suivant les intérêts propres à
chacun.
Health migration and new challenges around the Lao-Thai border
In this paper, we are exploring the current reorganisation of the Lao-Thai border area through
the study of the therapeutic behaviours of individuals. We are focusing on the mobility
of Laotian patients towards the neighbouring Thai hospitals. This practice of some border
inhabitants can occur with the recent opening of Laos and it also emphasizes the development
gap between the two countries.
These patients’ flows are relevant indicators to describe and explain the socio-territorial
processes currently at work within the Lao-Thai area. This approach using health determinants
allows studying the various characteristics of a border: political, economic, social, cultural
and medical. A disease does not only affect an individual in his biological body but it also
has an impact on his family, his community, therapists, public health institutions as well as
administrative and political institutions. Therefore, this approach offers us to embark in a new
debate on the border.
The Lao-Thai border area is complex; on the one hand, we observe the gradual weakening of
the border though the practices of patients; and, on the other hand, its continuation is reaffirmed
by statements of some political leaders and hospital officials on both sides.
Social Science and Medicine, Jan 2015
Drawing upon research conducted on cross-border patients living in Laos and seeking care in Thail... more Drawing upon research conducted on cross-border patients living in Laos and seeking care in Thailand, this paper examines the important role played by social networks in patients’ decision-making and on the itineraries they choose to seek treatment on the Thai side of the border. Due to the vastly contrasting situations between the two countries in terms of healthcare supply, and considering Laotians’ increasing demand for high quality health care, a number of them have managed to satisfy their needs by combining cross-border treatment with the use of the healthcare facilities provided by their own country. This study consisted first of household surveys conducted in five border areas (2006-2007) in Laos in order to quantify and map out cross-border healthcare-related travel patterns. Afterwards, interviews were conducted with cross-border patients (55), Laotian and Thai medical doctors (6), Thai social workers (5), and officials working in public institutions (12). While socioeconomic and spatial factors partly explain cross-border mobility, patients’ social networks significantly influence treatment itineraries throughout the decision-making process, including logistical and financial considerations. The social networks existing at different geographical levels (neighbourhood, regional and global) are therefore a powerful analytical tool not only for understanding the emergence of these cross-border movements but also for justifying them in an authoritarian political environment such as Lao PDR’s.
European Journal of Transnational Studies (EJOTS), May 2013
In today’s world, people move more, move further, and move for increasingly varied reasons such a... more In today’s world, people move more, move further, and move for increasingly varied reasons such as work, studies or leisure. Seeking health care away from one’s home is a part of this trend and many patients do not hesitate to cross national borders to consult a physician or get a surgical intervention. This article examines this form of mobility towards Thailand from both global and regional perspectives. This situation involves long-distance patients travelling from highly industrialized countries and closeby neighbors, such as Laotians, who may just cross the border to get treated a few kilometers away from home. Constrasting these senarios complicates the findings by studies on “medical travel” as it brings in heterogeneity and variability. There are significant differences in patients’ motives, in the social implications of their cross-border health-seeking behaviours, and in the responses by health infrastructures and authorities in both the host country (marketing, regulation or even quality of care) and the patients’ lands of origin (policies, intermediaries, and emerging specialized agencies). This paper takes this situation as a case study to describe and explain the rise of a new transnational healthcare paradigm.
Espace, Population Sociétés, 2011
In today’s global world, open borders, trade development and increased movements lead to a growin... more In today’s global world, open borders, trade development and increased movements lead to a growing interconnection of the countries all over of the globe and produce changes within national territories and their periphery.
The impacts of the frontier on borderlands are often analyzed through an economic approach to market exchanges, capital flows or movements of migrant workers. We propose here to study the reshaping of the Lao-Thai border area through an original indicator: the medical practices and particularly the use of Thai health facilities by Laotian patients.
A significant part of the population is involved in this practice, which is directly connected to the recent political and cultural opening of Laos. This phenomenon highlights the development gap between Laos and Thailand, specifically the healthcare disparities between the two countries. These movements are also facilitated by the proximity and the historical links between the people living along the Mekong.
Through the study of cross-border healthcare seeking behavior, we aim to study the socio-territorial dynamics of the Lao-Thai border area. We also intend to show how this study of health indicators can both renew and re-inform the concept of border.
Emerging Themes in Epidemiology, 2007
Geographical objectives and probabilistic methods are difficult to reconcile in a unique health s... more Geographical objectives and probabilistic methods are difficult to reconcile in a unique health survey. Probabilistic methods focus on individuals to provide estimates of a variable's prevalence with a certain precision, while geographical approaches emphasise the selection of specific areas to study interactions between spatial characteristics and health outcomes. A sample selected from a small number of specific areas creates statistical challenges: the observations are not independent at the local level, and this results in poor statistical validity at the global level. Therefore, it is difficult to construct a sample that is appropriate for both geographical and probability methods.
We used a two-stage selection procedure with a first non-random stage of selection of clusters. Instead of randomly selecting clusters, we deliberately chose a group of clusters, which as a whole would contain all the variation in health measures in the population. As there was no health information available before the survey, we selected a priori determinants that can influence the spatial homogeneity of the health characteristics. This method yields a distribution of variables in the sample that closely resembles that in the overall population, something that cannot be guaranteed with randomly-selected clusters, especially if the number of selected clusters is small. In this way, we were able to survey specific areas while minimising design effects and maximising statistical precision.
We applied this strategy in a health survey carried out in Vientiane, Lao People's Democratic Republic. We selected well-known health determinants with unequal spatial distribution within the city: nationality and literacy. We deliberately selected a combination of clusters whose distribution of nationality and literacy is similar to the distribution in the general population.
This paper describes the conceptual reasoning behind the construction of the survey sample and shows that it can be advantageous to choose clusters using reasoned hypotheses, based on both probability and geographical approaches, in contrast to a conventional, random cluster selection strategy.
Emerging Themes in Epidemiology, 2007
Book chapters by Audrey Bochaton
Zoé Vaillant, Stéphane Rican, Audrey Bochaton, Marianne Viot, Hélène Charreire, Aude Salamon, Lau... more Zoé Vaillant, Stéphane Rican, Audrey Bochaton, Marianne Viot, Hélène Charreire, Aude Salamon, Laurent El Ghozi, Philippe Basse, Jean-Marie Chali, Candy Jangal
The Elgar Handbook on Medical Tourism and Patient Mobility, Jun 26, 2015
in Frontières, politique de santé et réseaux de soins, F. Moullé, S. Duhamel (dir.), Paris, L’Harmattan, coll. Géographie et Culture, 286 p., 2010
20 Décembre 2006. Le second pont international sur le Mékong reliant Savannakhet (Laos) et Mukdah... more 20 Décembre 2006. Le second pont international sur le Mékong reliant Savannakhet (Laos) et Mukdahan (Thaïlande) est inauguré officiellement par les dirigeants des deux pays. Cette nouvelle infrastructure transfrontalière illustre la logique de rapprochement et de coopération initiée par les deux états voisins depuis le début des années 90. Quelques jours plus tard, la presse laotienne [Le Rénovateur, 10.01.2007, p.7] ripostait de manière virulente à un article paru le 25 décembre 2006 dans le Bangkok Post, dans lequel l’auteur thaïlandais affirmait que le nouveau pont représentait un grand espoir pour les prostituées laotiennes qui pourraient ainsi vendre leur service à un plus grand nombre de visiteurs. La mise en service du pont ouvre en outre le débat sur les problèmes de la diffusion des maladies sexuellement transmissibles et de l’augmentation des délits [Bangkok Post, 19.12.06, np ; 27.12.06, np ; Vientiane Times, 08.01.07, p.8]
Ces anecdotes éclairent bien l’ambiguïté des relations entretenues entre le Laos et la Thaïlande, entre une ouverture promue et la persistance de questions épineuses entre pays
voisins. Les démêlés diplomatico-politiques entre les deux Etats ne sont pas récents et la politique de coopération, si elle tend à les réduire, ne les a pas complètement effacés. Du côté des populations vivant de part et d’autre de la frontière, l’ouverture favorise des traversées multiples, particulièrement les mobilités orientées du Laos vers la Thaïlande. Les deux pays ont en effet des niveaux de développement différents à la faveur de la Thaïlande, pôle dynamique d’Asie du Sud-Est d’un point de vue économique, culturel et sanitaire. Les Laotiens sont ainsi de plus en plus nombreux à traverser la frontière le week-end afin de faire
des achats dans des centres commerciaux encore inexistants au Laos. De la même façon, la Thaïlande accueille de plus en plus de patients laotiens, non satisfaits de leur système de santé national.
La dynamique transfrontalière procède ainsi tout autant des projets de coopération initiés par les politiques bilatérales que des pratiques de la population. Quand ces deux logiques coïncident, les effets sont cumulés et la dynamique transfrontalière aboutie. Mais lorsque les états n’ont pas de politique de coopération bien définie alors que des besoins existent – comme dans le domaine des soins – nous verrons comment les pratiques locales viennent
pallier le vide institutionnel et organiser le territoire transfrontalier par le jeu de réseaux informels.
Nous partons du postulat que le réseau social d’un patient constitue un capital déterminant dans la mise en oeuvre des recours transfrontaliers vers la Thaïlande. Outil de solidarité et
vecteur de diffusion des pratiques, les réseaux sociaux sollicités par les patients en route vers des structures de soins thaïlandaises sont à l’origine d’un territoire transfrontalier réticulé.
in 'Fieldwork in Tourism: Methods, Issues and Reflections', Michael Hall (ed.), London, Routledge, 324 p., 2010
"From culture, to cookery, to eco - tourism, the holiday experience is becoming more and more div... more "From culture, to cookery, to eco - tourism, the holiday experience is becoming more and more diverse. Since the Asian financial crisis of 1997, medical tourism has increasingly contributed to this trend, particularly in Thailand and India. The main motivation of our project is to engage a research study on medical tourism which has been almost exclusively approached from the point of view of the media today. Medical tourism has been indeed widely commented by the press, which presents the ‘sea, sun, sand and surgery’ (Connell, 2005) phenomenon as ‘the’ answer for patients living in developed countries and having to deal with long consultation waiting lists, and high medical costs. Until now, few articles are putting medical tourism in perspective and therefore we wanted to go a little further than the headline story that the media and the medical tourism stakeholders keep selling. Through a comparison between India and Thailand, our objective was to better assess medical tourism, its development, its impacts. Medical tourism takes place in different parts of the world today and emphasises well the globalization in the field of health care. In this context, we thought that the mirroring effect between the two countries would be very effective to deepen our understanding of the phenomenon, and to bring out the main elements constituting this trend.
During our research project we had to conduct many interviews with medical professionals, marketing and operation managers of corporate hospitals, and key members of different ministers or professional organisations in India and Thailand. Following Herod (1999: 313) in his effort to define foreign elite, we can identify our interviewees as “foreign nationals who hold positions of power within organizations such as corporations, governments”. In India and Thailand, the corporate hospitals, the professional organisations (e.g. the Confederation of Indian Industry) and the ministry of health and the ministry of tourism are instrumental in the growth of medical tourism. There is a growing literature about the specificity of elite interview (e.g. Sabot, 1999; Desmond, 2004; Herod, 1999; Smith, 2006; Welch et al, 2002). Though not exclusive, interviewing elites raises various methodological issues like the access to the informers, the unbalanced power relations during the interview, the reliability of information. Herod (1999) even considers that conducting research on foreign elites bring very specific issues of cultural positionality that do not exist in the case of study on non-foreign elites.
The objective of this article is to address the methodological issues we faced as French PhD students interviewing foreign elite. How did we interact with the main actors of medical tourism both in India and Thailand? How did we deal with interviewees who are mastering the art of communication and marketing? What strategies were adopted to get the right information during the interview?"
in Asia on Tour: Exploring the rise of Asian tourism, Tim Winter, Peggy Teo, T.C. Chang, London, Routledge : 97-108., 2008
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the transformative character of mobilities at various scales. And fourth, it brings together different kinds of mobilities. The papers in this Special Issue contribute to three themes key for the therapeutic in mobilities: a) transformations (and stabilizations) of selves, bodies and positionalities, b) uneven im/mobilities and therapeutic inequalities and c) multiple and contingent im/mobilities. Therapeutic mobilities comprise practices and processes that are multi-layered and mutable; sometimes bizarre, sometimes ironic, often drastically uneven; sometimes brutal, sometimes beautiful – and sometimes all of this at the same time.
Keywords: Therapeutic mobilities, medicinal plants, translocality, medical pluralism, migration, diaspora, Hmong, Laos, United States
In geography and sociology, inequalities between men and women has been widely documented in terms of occupation, ownership or avoidance of space (private or public) or in terms of access to knowledge, power and resources. A lot of studies in the field of public health also show significant differences between men and women in terms of life expectancy, mortality, morbidity but also representation of health, and more generally health behaviors. But despite these observations, considerations on relationship between gender, territory and health still remain innovative.
The contributions of this special report bring original insights by their disciplinary anchor and their own field research, and lead to two central questions: how differences between men and women in spatial practices reflect on their health and their health behaviors? And, what is the role of gender, among other determinants, in the health care pathways and the health of the population?
The special reports of the RFST remain open permanently. It means that new texts will be added in the future and will provide answers to these questions and probably will submit new questions.
Many official reports and scientific studies show that disparities in the distribution of physicians increase over France and at different spatial levels (Maurey, 2013). Considering the workforces of physicians in relation to the French population, the situation of France is quite good but their distribution reveals clear spatial inequalities. Major disparities can be observed between administrative areas, for example “les régions”. As shown in the map below, medical coverage is significantly higher in the French southern regions (particularly Provence-Alpes-Côte-d’Azur with one doctor for 244.77 inhabitants) and also the capital region called Ile-de-France (which one doctor for 252.22 inhabitants). On the contrary, the region called Picardie displays the lowest medical service (one doctor for 388.13 inhabitants) followed by the region Centre (one doctor for 375.43 inhabitants). Inequalities are even stronger within regions at a local level. Medical doctors concentrate mainly in urban areas and therefore neglect rural areas which appear and are described as “medical deserts”. In 2012, 20% of general physicians work in rural areas whereas 27% of French people live there.
map 1 denoyel.gif
The objective of this article is to explore the factors commonly discussed and perceived to explain this phenomenon. Among these, the feminization of the medical profession is often designated as a central determinant of the ongoing developments of the medical sector and the increasing spatial disparities among the French territory. We wanted to test the idea that medical deserts exist because of the feminization of the medical profession with local data, collected across the Burgundy region.
In Burgundy, the under-representation of female doctors in rural areas is real but the differences observed between the physical locations of male and female doctors are relatively moderate and not significantly different. However, some discourses from the medical sector, political sphere and media tend to associate closely the current increase of the spatial inequalities of medical care and the feminization of medical profession. The tweet from Senator Mayet “medical deserts, the fault of the women?” of 27 July 2015 can certainly appear anecdotal but it still shows an overview of current thinking that can circulate on the effects of the feminization of the medical workforce.
To understand the rationales behind medical deserts, it appeared that we should go beyond gendered explanations in order to address the broader social and economic determinants which contribute to this phenomenon. Some recent studies show that young medical practitioners, both women and men, wish to preserve time for family or for social activities leading them to reconsider their relationships to work (Deriaz et al. 2010). In 2003, Robert Herin already stated about the liberal healthcare provision in Normandy that the new generations of physicians (regardless of gender) were seriously concerned by living environment, educating children, the range of jobs for spouses, the qualities of cultural and social environment, etc. All these determinants tend therefore to lead young doctors towards urban environments more than rural areas. As a consequence, we must consider the spatial disparities observed among the medical physicians in France more as a generational issue than a simple gendered issue.
travers les comportements thérapeutiques des individus, et plus particulièrement le recours
aux soins des Laotiens dans les hôpitaux thaïlandais limitrophes, appelés par commodité les
recours transfrontaliers. Cette pratique d’une partie de la population vivant dans les bordures
frontalières accompagne l’ouverture récente du Laos et souligne l’écart de développement
existant entre les deux pays.
Les recours aux soins transfrontaliers sont des indicateurs pertinents pour décrire et expliquer
les processus socio-territoriaux actuellement à l’oeuvre au sein de l’espace lao-thaïlandais.
L’approche par les soins présente l’intérêt d’aborder la frontière sous tous ses aspects :
politique, économique, sociale, culturelle et sanitaire. La maladie ne concerne en effet
pas seulement l’individu affecté dans son corps biologique, mais également sa famille, sa
communauté, les thérapeutes, les institutions publiques de santé ainsi que les institutions
administratives et politiques. L’approche sanitaire privilégiée dans cette contribution donne
ainsi la possibilité de renouveler la réflexion sur la frontière.
Entre l’effacement progressif de la frontière dans les pratiques des patients et son maintien
réaffirmé par certaines déclarations des dirigeants politiques et des responsables hospitaliers,
l’espace lao-thaïlandais s’avère complexe ; les fonctions, tant de coupure que de couture, de
la frontière sont tour à tour invoquées voire instrumentalisées suivant les intérêts propres à
chacun.
Health migration and new challenges around the Lao-Thai border
In this paper, we are exploring the current reorganisation of the Lao-Thai border area through
the study of the therapeutic behaviours of individuals. We are focusing on the mobility
of Laotian patients towards the neighbouring Thai hospitals. This practice of some border
inhabitants can occur with the recent opening of Laos and it also emphasizes the development
gap between the two countries.
These patients’ flows are relevant indicators to describe and explain the socio-territorial
processes currently at work within the Lao-Thai area. This approach using health determinants
allows studying the various characteristics of a border: political, economic, social, cultural
and medical. A disease does not only affect an individual in his biological body but it also
has an impact on his family, his community, therapists, public health institutions as well as
administrative and political institutions. Therefore, this approach offers us to embark in a new
debate on the border.
The Lao-Thai border area is complex; on the one hand, we observe the gradual weakening of
the border though the practices of patients; and, on the other hand, its continuation is reaffirmed
by statements of some political leaders and hospital officials on both sides.
The impacts of the frontier on borderlands are often analyzed through an economic approach to market exchanges, capital flows or movements of migrant workers. We propose here to study the reshaping of the Lao-Thai border area through an original indicator: the medical practices and particularly the use of Thai health facilities by Laotian patients.
A significant part of the population is involved in this practice, which is directly connected to the recent political and cultural opening of Laos. This phenomenon highlights the development gap between Laos and Thailand, specifically the healthcare disparities between the two countries. These movements are also facilitated by the proximity and the historical links between the people living along the Mekong.
Through the study of cross-border healthcare seeking behavior, we aim to study the socio-territorial dynamics of the Lao-Thai border area. We also intend to show how this study of health indicators can both renew and re-inform the concept of border.
We used a two-stage selection procedure with a first non-random stage of selection of clusters. Instead of randomly selecting clusters, we deliberately chose a group of clusters, which as a whole would contain all the variation in health measures in the population. As there was no health information available before the survey, we selected a priori determinants that can influence the spatial homogeneity of the health characteristics. This method yields a distribution of variables in the sample that closely resembles that in the overall population, something that cannot be guaranteed with randomly-selected clusters, especially if the number of selected clusters is small. In this way, we were able to survey specific areas while minimising design effects and maximising statistical precision.
We applied this strategy in a health survey carried out in Vientiane, Lao People's Democratic Republic. We selected well-known health determinants with unequal spatial distribution within the city: nationality and literacy. We deliberately selected a combination of clusters whose distribution of nationality and literacy is similar to the distribution in the general population.
This paper describes the conceptual reasoning behind the construction of the survey sample and shows that it can be advantageous to choose clusters using reasoned hypotheses, based on both probability and geographical approaches, in contrast to a conventional, random cluster selection strategy.
Book chapters by Audrey Bochaton
Ces anecdotes éclairent bien l’ambiguïté des relations entretenues entre le Laos et la Thaïlande, entre une ouverture promue et la persistance de questions épineuses entre pays
voisins. Les démêlés diplomatico-politiques entre les deux Etats ne sont pas récents et la politique de coopération, si elle tend à les réduire, ne les a pas complètement effacés. Du côté des populations vivant de part et d’autre de la frontière, l’ouverture favorise des traversées multiples, particulièrement les mobilités orientées du Laos vers la Thaïlande. Les deux pays ont en effet des niveaux de développement différents à la faveur de la Thaïlande, pôle dynamique d’Asie du Sud-Est d’un point de vue économique, culturel et sanitaire. Les Laotiens sont ainsi de plus en plus nombreux à traverser la frontière le week-end afin de faire
des achats dans des centres commerciaux encore inexistants au Laos. De la même façon, la Thaïlande accueille de plus en plus de patients laotiens, non satisfaits de leur système de santé national.
La dynamique transfrontalière procède ainsi tout autant des projets de coopération initiés par les politiques bilatérales que des pratiques de la population. Quand ces deux logiques coïncident, les effets sont cumulés et la dynamique transfrontalière aboutie. Mais lorsque les états n’ont pas de politique de coopération bien définie alors que des besoins existent – comme dans le domaine des soins – nous verrons comment les pratiques locales viennent
pallier le vide institutionnel et organiser le territoire transfrontalier par le jeu de réseaux informels.
Nous partons du postulat que le réseau social d’un patient constitue un capital déterminant dans la mise en oeuvre des recours transfrontaliers vers la Thaïlande. Outil de solidarité et
vecteur de diffusion des pratiques, les réseaux sociaux sollicités par les patients en route vers des structures de soins thaïlandaises sont à l’origine d’un territoire transfrontalier réticulé.
During our research project we had to conduct many interviews with medical professionals, marketing and operation managers of corporate hospitals, and key members of different ministers or professional organisations in India and Thailand. Following Herod (1999: 313) in his effort to define foreign elite, we can identify our interviewees as “foreign nationals who hold positions of power within organizations such as corporations, governments”. In India and Thailand, the corporate hospitals, the professional organisations (e.g. the Confederation of Indian Industry) and the ministry of health and the ministry of tourism are instrumental in the growth of medical tourism. There is a growing literature about the specificity of elite interview (e.g. Sabot, 1999; Desmond, 2004; Herod, 1999; Smith, 2006; Welch et al, 2002). Though not exclusive, interviewing elites raises various methodological issues like the access to the informers, the unbalanced power relations during the interview, the reliability of information. Herod (1999) even considers that conducting research on foreign elites bring very specific issues of cultural positionality that do not exist in the case of study on non-foreign elites.
The objective of this article is to address the methodological issues we faced as French PhD students interviewing foreign elite. How did we interact with the main actors of medical tourism both in India and Thailand? How did we deal with interviewees who are mastering the art of communication and marketing? What strategies were adopted to get the right information during the interview?"
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the transformative character of mobilities at various scales. And fourth, it brings together different kinds of mobilities. The papers in this Special Issue contribute to three themes key for the therapeutic in mobilities: a) transformations (and stabilizations) of selves, bodies and positionalities, b) uneven im/mobilities and therapeutic inequalities and c) multiple and contingent im/mobilities. Therapeutic mobilities comprise practices and processes that are multi-layered and mutable; sometimes bizarre, sometimes ironic, often drastically uneven; sometimes brutal, sometimes beautiful – and sometimes all of this at the same time.
Keywords: Therapeutic mobilities, medicinal plants, translocality, medical pluralism, migration, diaspora, Hmong, Laos, United States
In geography and sociology, inequalities between men and women has been widely documented in terms of occupation, ownership or avoidance of space (private or public) or in terms of access to knowledge, power and resources. A lot of studies in the field of public health also show significant differences between men and women in terms of life expectancy, mortality, morbidity but also representation of health, and more generally health behaviors. But despite these observations, considerations on relationship between gender, territory and health still remain innovative.
The contributions of this special report bring original insights by their disciplinary anchor and their own field research, and lead to two central questions: how differences between men and women in spatial practices reflect on their health and their health behaviors? And, what is the role of gender, among other determinants, in the health care pathways and the health of the population?
The special reports of the RFST remain open permanently. It means that new texts will be added in the future and will provide answers to these questions and probably will submit new questions.
Many official reports and scientific studies show that disparities in the distribution of physicians increase over France and at different spatial levels (Maurey, 2013). Considering the workforces of physicians in relation to the French population, the situation of France is quite good but their distribution reveals clear spatial inequalities. Major disparities can be observed between administrative areas, for example “les régions”. As shown in the map below, medical coverage is significantly higher in the French southern regions (particularly Provence-Alpes-Côte-d’Azur with one doctor for 244.77 inhabitants) and also the capital region called Ile-de-France (which one doctor for 252.22 inhabitants). On the contrary, the region called Picardie displays the lowest medical service (one doctor for 388.13 inhabitants) followed by the region Centre (one doctor for 375.43 inhabitants). Inequalities are even stronger within regions at a local level. Medical doctors concentrate mainly in urban areas and therefore neglect rural areas which appear and are described as “medical deserts”. In 2012, 20% of general physicians work in rural areas whereas 27% of French people live there.
map 1 denoyel.gif
The objective of this article is to explore the factors commonly discussed and perceived to explain this phenomenon. Among these, the feminization of the medical profession is often designated as a central determinant of the ongoing developments of the medical sector and the increasing spatial disparities among the French territory. We wanted to test the idea that medical deserts exist because of the feminization of the medical profession with local data, collected across the Burgundy region.
In Burgundy, the under-representation of female doctors in rural areas is real but the differences observed between the physical locations of male and female doctors are relatively moderate and not significantly different. However, some discourses from the medical sector, political sphere and media tend to associate closely the current increase of the spatial inequalities of medical care and the feminization of medical profession. The tweet from Senator Mayet “medical deserts, the fault of the women?” of 27 July 2015 can certainly appear anecdotal but it still shows an overview of current thinking that can circulate on the effects of the feminization of the medical workforce.
To understand the rationales behind medical deserts, it appeared that we should go beyond gendered explanations in order to address the broader social and economic determinants which contribute to this phenomenon. Some recent studies show that young medical practitioners, both women and men, wish to preserve time for family or for social activities leading them to reconsider their relationships to work (Deriaz et al. 2010). In 2003, Robert Herin already stated about the liberal healthcare provision in Normandy that the new generations of physicians (regardless of gender) were seriously concerned by living environment, educating children, the range of jobs for spouses, the qualities of cultural and social environment, etc. All these determinants tend therefore to lead young doctors towards urban environments more than rural areas. As a consequence, we must consider the spatial disparities observed among the medical physicians in France more as a generational issue than a simple gendered issue.
travers les comportements thérapeutiques des individus, et plus particulièrement le recours
aux soins des Laotiens dans les hôpitaux thaïlandais limitrophes, appelés par commodité les
recours transfrontaliers. Cette pratique d’une partie de la population vivant dans les bordures
frontalières accompagne l’ouverture récente du Laos et souligne l’écart de développement
existant entre les deux pays.
Les recours aux soins transfrontaliers sont des indicateurs pertinents pour décrire et expliquer
les processus socio-territoriaux actuellement à l’oeuvre au sein de l’espace lao-thaïlandais.
L’approche par les soins présente l’intérêt d’aborder la frontière sous tous ses aspects :
politique, économique, sociale, culturelle et sanitaire. La maladie ne concerne en effet
pas seulement l’individu affecté dans son corps biologique, mais également sa famille, sa
communauté, les thérapeutes, les institutions publiques de santé ainsi que les institutions
administratives et politiques. L’approche sanitaire privilégiée dans cette contribution donne
ainsi la possibilité de renouveler la réflexion sur la frontière.
Entre l’effacement progressif de la frontière dans les pratiques des patients et son maintien
réaffirmé par certaines déclarations des dirigeants politiques et des responsables hospitaliers,
l’espace lao-thaïlandais s’avère complexe ; les fonctions, tant de coupure que de couture, de
la frontière sont tour à tour invoquées voire instrumentalisées suivant les intérêts propres à
chacun.
Health migration and new challenges around the Lao-Thai border
In this paper, we are exploring the current reorganisation of the Lao-Thai border area through
the study of the therapeutic behaviours of individuals. We are focusing on the mobility
of Laotian patients towards the neighbouring Thai hospitals. This practice of some border
inhabitants can occur with the recent opening of Laos and it also emphasizes the development
gap between the two countries.
These patients’ flows are relevant indicators to describe and explain the socio-territorial
processes currently at work within the Lao-Thai area. This approach using health determinants
allows studying the various characteristics of a border: political, economic, social, cultural
and medical. A disease does not only affect an individual in his biological body but it also
has an impact on his family, his community, therapists, public health institutions as well as
administrative and political institutions. Therefore, this approach offers us to embark in a new
debate on the border.
The Lao-Thai border area is complex; on the one hand, we observe the gradual weakening of
the border though the practices of patients; and, on the other hand, its continuation is reaffirmed
by statements of some political leaders and hospital officials on both sides.
The impacts of the frontier on borderlands are often analyzed through an economic approach to market exchanges, capital flows or movements of migrant workers. We propose here to study the reshaping of the Lao-Thai border area through an original indicator: the medical practices and particularly the use of Thai health facilities by Laotian patients.
A significant part of the population is involved in this practice, which is directly connected to the recent political and cultural opening of Laos. This phenomenon highlights the development gap between Laos and Thailand, specifically the healthcare disparities between the two countries. These movements are also facilitated by the proximity and the historical links between the people living along the Mekong.
Through the study of cross-border healthcare seeking behavior, we aim to study the socio-territorial dynamics of the Lao-Thai border area. We also intend to show how this study of health indicators can both renew and re-inform the concept of border.
We used a two-stage selection procedure with a first non-random stage of selection of clusters. Instead of randomly selecting clusters, we deliberately chose a group of clusters, which as a whole would contain all the variation in health measures in the population. As there was no health information available before the survey, we selected a priori determinants that can influence the spatial homogeneity of the health characteristics. This method yields a distribution of variables in the sample that closely resembles that in the overall population, something that cannot be guaranteed with randomly-selected clusters, especially if the number of selected clusters is small. In this way, we were able to survey specific areas while minimising design effects and maximising statistical precision.
We applied this strategy in a health survey carried out in Vientiane, Lao People's Democratic Republic. We selected well-known health determinants with unequal spatial distribution within the city: nationality and literacy. We deliberately selected a combination of clusters whose distribution of nationality and literacy is similar to the distribution in the general population.
This paper describes the conceptual reasoning behind the construction of the survey sample and shows that it can be advantageous to choose clusters using reasoned hypotheses, based on both probability and geographical approaches, in contrast to a conventional, random cluster selection strategy.
Ces anecdotes éclairent bien l’ambiguïté des relations entretenues entre le Laos et la Thaïlande, entre une ouverture promue et la persistance de questions épineuses entre pays
voisins. Les démêlés diplomatico-politiques entre les deux Etats ne sont pas récents et la politique de coopération, si elle tend à les réduire, ne les a pas complètement effacés. Du côté des populations vivant de part et d’autre de la frontière, l’ouverture favorise des traversées multiples, particulièrement les mobilités orientées du Laos vers la Thaïlande. Les deux pays ont en effet des niveaux de développement différents à la faveur de la Thaïlande, pôle dynamique d’Asie du Sud-Est d’un point de vue économique, culturel et sanitaire. Les Laotiens sont ainsi de plus en plus nombreux à traverser la frontière le week-end afin de faire
des achats dans des centres commerciaux encore inexistants au Laos. De la même façon, la Thaïlande accueille de plus en plus de patients laotiens, non satisfaits de leur système de santé national.
La dynamique transfrontalière procède ainsi tout autant des projets de coopération initiés par les politiques bilatérales que des pratiques de la population. Quand ces deux logiques coïncident, les effets sont cumulés et la dynamique transfrontalière aboutie. Mais lorsque les états n’ont pas de politique de coopération bien définie alors que des besoins existent – comme dans le domaine des soins – nous verrons comment les pratiques locales viennent
pallier le vide institutionnel et organiser le territoire transfrontalier par le jeu de réseaux informels.
Nous partons du postulat que le réseau social d’un patient constitue un capital déterminant dans la mise en oeuvre des recours transfrontaliers vers la Thaïlande. Outil de solidarité et
vecteur de diffusion des pratiques, les réseaux sociaux sollicités par les patients en route vers des structures de soins thaïlandaises sont à l’origine d’un territoire transfrontalier réticulé.
During our research project we had to conduct many interviews with medical professionals, marketing and operation managers of corporate hospitals, and key members of different ministers or professional organisations in India and Thailand. Following Herod (1999: 313) in his effort to define foreign elite, we can identify our interviewees as “foreign nationals who hold positions of power within organizations such as corporations, governments”. In India and Thailand, the corporate hospitals, the professional organisations (e.g. the Confederation of Indian Industry) and the ministry of health and the ministry of tourism are instrumental in the growth of medical tourism. There is a growing literature about the specificity of elite interview (e.g. Sabot, 1999; Desmond, 2004; Herod, 1999; Smith, 2006; Welch et al, 2002). Though not exclusive, interviewing elites raises various methodological issues like the access to the informers, the unbalanced power relations during the interview, the reliability of information. Herod (1999) even considers that conducting research on foreign elites bring very specific issues of cultural positionality that do not exist in the case of study on non-foreign elites.
The objective of this article is to address the methodological issues we faced as French PhD students interviewing foreign elite. How did we interact with the main actors of medical tourism both in India and Thailand? How did we deal with interviewees who are mastering the art of communication and marketing? What strategies were adopted to get the right information during the interview?"