Polycystic ovary syndrome (PCOS), an endocrine disorder with no known cure that compromises fertility, is a lifestyle disease affecting a growing number of urban Indian women. Media accounts and medical practitioners have noted a recent rise in PCOS cases in urban India and attribute it to "Westernization," modernization, stress, and lifestyle changes following on the heels of economic liberalization in 1991, which opened up the country to processes of globalization. Discourse about PCOS has thus opened up a space for commentary indexing anxieties about larger social and political economic shifts in the country, and women with PCOS are individualized embodiments of the biosocial stresses caused by these shifts. Against the backdrop of a rapidly changing sociocultural landscape with potential for new opportunities for women, the syndrome also poses a challenge to women's traditional roles as wives and mothers, as its symptoms negatively affect reproduction and physical appearance. In this dissertation, I investigate aspects of public discourses about PCOS and lived realities of the syndrome in India as a lens into the interaction of processes of globalization with the local socioculturally embedded body.

In the United States, a growing proportion of the population is aged 65 and older. Associated with this demographic transition is a rise in the number of people who are aging with chronic disease. While there is a cultural ideal for older adults to remain in the community and out of institutional settings ("aging in place"), there is little recognition of the work and experience of trying to accomplish this. In the following papers, I draw on 12 months of ethnographic research in the Southwest US to describe the work of "aging in place." As a starting point, I use Medicare-funded home health care (HHC), which stands at the crossroads of acute-based institutional care and custodial, long-term care. In the first paper, using definitions of place from cultural geography, I explore the work of aging from the perspective of chronically ill older adult HHC users. I illustrate how bodies, practices, and places shift as processes of disease and medicalization inscribe them with risk, and the ways in which people accept, resist, and negotiate these changes. The second paper extends the work on audit culture to describe how Medicare's audit system has structured the organization and practice of HHC, and how this has reinforced the commodification of patients. I note how HHC nurses can draw on personal and professional logics in their documentation practices as a means of resisting rationalizing forces and opening up eligibility for care. The third paper uses case studies to push the literature on family caregiver burden to include the fraught, yet highly meaning-filled experience of caregiving. The cases show the difficulties and ambivalence in providing care to a chronically ill family member. Throughout these articles, underlying the tensions, uncertainties, and gaps I explore questions about what type of care is needed, who is worthy of care, and how responsibilities are distributed. I focus on how people's worlds and work are structured by larger scale social, cultural, and economic forces, and attend to the ways in which they reproduce, contend, and negotiate these forces from their unique positions, in effort to protect what they value.

With its oil wealth and an environment of abundant rivers, lakes, and the largest coastline in the United States, Alaska is one of the last places one would expect to find water insecurity. Yet approximately one third of households in remote Alaska Native villages lack in-home piped water and suffer the health consequences of poor sanitation and inadequate treated water. This problem has become particularly acute in the wake of surging energy prices and a concomitant shift in policies that increasingly require demonstrated economic sustainability before funding will be allocated for village water and sanitation projects. In response to increasing costs of living and the failure of development projects to foster the conditions under which they would be able to provide for their needs, many Iñupiat assert the importance of traditional values, practices and values that from their view constitute a path out of insecurity and into self-sufficiency. These Iñupiat point to modern technology as the source of what they call the spoiling of their communities. In this dissertation, I explore the disjuncture between how the state and the Iñupiat signify historical and contemporary issues and solutions around water, energy, and development. I suggest that the unintended consequences of decades of interventions to improve Iñupiaq health and well-being have been manufactured insecurity that is exacerbated by weakened social networks of reciprocity (the Iñupiaq traditional value of sharing), and rendered invisible by sustainability policies. I argue that these multifaceted processes of domination and suffering are all part of what many Iñupiat describe spoiling. In other words, when the Iñupiat talk about being spoiled by technology, they are talking about the historical domination by the state over their social reproduction in ways that produce and exacerbate the insecurities characterizing daily life in these remote villages.

In this dissertation, I look to contemporary menopause management in the Southwest, United States, as an ideal case study of the 'real world' negotiation of a widespread contemporary conundrum--characterized by discourses of risk, proliferation of information and choice, chronic doubt, and personal responsibility for decision-making. While there have been previous studies of menopause in the US, this circumstantial ethnography seeks to understand contemporary menopause management in an era characterized by a massive shift in the biomedical risk discourses about menopause, the explosion of therapeutic choice in a burgeoning pluralistic health care environment, and the broad expansion of women's identities, body projects, and life priorities over the last several decades.I report on fourteen months of ethnographic fieldwork conducted in 2007 and 2008 with menopausal women and health care providers in the southwestern US. Research components included ethnographic interviews (N=60) and focus groups (6 groups with 27 participants) with midlife women, interviews with health care providers across a range of therapeutic modalities (N=20), and observation of emerging discourses of menopause in science, media and marketing.This dissertation illustrates that contemporary menopause management is a recursive process characterized by the ongoing re-evaluation of the impact menopause is having on one's life--in context. Participants described the unfolding of the lived-experience of menopause over time--even years beyond the end of menstruation. Risk discourses are not embodied en masse but reflect the concerns most salient in women's lives. While women access various expert and lay resources, they favor personal experts--sources deemed professionally sound and personally relevant--and their own embodied knowledge. For their part, health care providers described themselves as "normalizing" menopause and practicing patient-centered care aimed at empowering women to make their own decisions about how to manage menopause. Lacking an ideal choice, women make provisional treatment decisions that resonate with their current menopausal subjectivity. Despite abundant options, menopause management is increasingly stratified, with some able to access more information resources and afford more extensive decision-support. Among women with severe symptoms, bioidentical hormone therapy--productively positioned between biomedicine and complementary/alternative medicine--has emerged as a popular harm reduction strategy.

The democratic decentralization of government administration in Indonesia from 1999 represents the most dramatic shift in governance in that country for decades. In this dissertation I explore how health managers in one kabupaten (regency) are responding to the new political environment. Kabupaten health managers experience decentralization as incomplete, pointing to the tendency of central government to retain control of certain health programs and budgets. At the same time they face competing demands for autonomy from puskesmas (health center) heads. Building on Scott's (1985) idea of a "moral economy" I delve beneath the political tensions of competing autonomies to describe a moral landscape of underlying beliefs about how government ought to behave in the health sector. Through this analysis certain failures and contradictions in the decentralization process emerge, complicating the literature that presents decentralization as a move in the direction of "good governance" (Mitchell and Bossert 2010, Rondinelli and Cheema 2007, Manor 1999). Decentralization brings to the fore the internal divisions within government, yet health workers present a united front in their engagements with the public. Under increasing pressure to achieve global public health goals such as the Millennium Development Goals, health managers engage in multiple translations in converting global health discourses into national and local health policies and in framing these policies in ways that are comprehensible and compelling to the general public. Using the lens of a "cultural theory of state" (Corrigan and Sayer 1985) I describe how health professionals and volunteers draw on local cultural forms in order to render global frameworks compatible with local moralities. I introduce the term "moral pluralism" to describe how individual health workers interrelate several moral frameworks in their health promotion work, including Islam, evidence based medicine and right to health. My conclusion is that kabupaten health managers are engaging in two balancing acts. The first is between decentralization and (re)centralization and deals with the proper way to manage health programming. The second is between global health discourses and local cultural forms and concerns the most effective way to convey public health messages in order to bring about behavior change in line with national and global public health goals. This is the first anthropological study of how government officials at different levels negotiate the process of health decentralization in the face of increasing international pressure to achieve global public health goals.

In the context of increasing nursing labor shortages around the world, the Philippines has become a major producer and exporter of nurses, with 85 percent of employed Filipino nurses working outside of the Philippines. Based on 12 months of ethnographic research in a provincial center for nursing education and healthcare in Northern Luzon, Philippines, I utilize a global nurse care chain (Yeates 2004a, 2009a) framework to explore transnational nurse migration out of the Philippines through the experiences of nurses, nursing students, their families and other stakeholders in nurse production and migration. As a more local GNCC analysis, the present study traces the production and provision of nursing care labor through the family and local and transnational household, to formal training and nursing experiences in educational and health institutions, and through other encounters with state, private, and international agencies that facilitate and shape the experiences and subjectivities of migrant nurses. Chapter 2 traces the relationship between the production and migration industries and between these industries and the state, exploring the ways that both the healthcare landscape and experiences of new nursing graduates (as consumers and laborers) has been shaped by migration booms and busts. Chapters 3 and 4 examine the household as a site of nurse production and the role of the household's moral economy and structures of feeling (Williams 1977). In Chapter 3, I examine nursing students' narratives of choice in the decision to study nursing and argue that obligation to family and reciprocal financial and emotional relationships underlie nurse production. In Chapter 4, I explore the ways that nurses and students imagine their future lives and identities as migrant nurses, illustrating how subjectivities are shaped by a legacy of transnational migration, imagination, and family moral economy. In Chapter 5, I use the narrative of a returned migrant nurse to illustrate the long-term impacts of past and temporary migration, and the ways that returned migrants may construct their identities through remembering. The final chapter explores the nurse migration industry through recruitment agents and nurses navigating this privatized industry as they pursue migration opportunities. Beyond an ethnography of nursing students', nurses' and their families' experiences of nurse training and migration processes, this dissertation focuses the roles of the state, private industry, and family in the mobilization of gendered and filial subjectivities to stimulate nurse production and migration, and explores the complex effects of unregulated nurse migration industries on students, nurses, and families as consumers and laborers.