Caring across borders: The politics of belonging and transnational health
10.7340/anuac2239-625X-3624
L’offerta, la domanda e le responsabilità nell’assistenza sanitaria stanno assumendo una dimensione transnazionale. Sempre più persone si curano oltre i confini nazionali, anche se la maggior parte dei sistemi sanitari sono organizzati a livello nazionale. Sebbene la maggior parte dei lavori antropologici si siano concentrati sul fenomeno del “turismo medico”, questo articolo procede da una diversa prospettiva: considera le cure offerte e ricevute in un raggio transnazionale da parte dei migranti, analizzandole al crocevia tra spinte neoliberali e politiche di appartenenza. L’articolo esplora le traiettorie transnazionali intraprese da marocchini ed ecuadoriani che vivono in Italia per prendersi cura della salute dei figli o per la loro salute riproduttiva. Da una parte, queste pratiche di cura transnazionali sono influenzate da situazioni di appartenenza – o non appartenenza – sperimentate in Italia, incluse quelle avvenute in ambienti medici. Dall’altra, i migranti sviluppano delle tattiche per cercare di sfruttare i vantaggi offerti da uno spazio neoliberale di cura. L’articolo sottolinea la necessità di sviluppare una cornice transnazionale per regolare la crescente dimensione transnazionale dell’assistenza sanitaria con l’obiettivo di mitigare (piuttosto che aumentare) le disparità economiche e sociali tra gli stati.
application/vnd.openxmlformats-officedocument.wordprocessingml.document
2239-625X
3624
1
en
Roberta Raffaetà
Anuac
Caring across borders: The politics of belonging and transnational health
Text.Serial.Journal
https://ojs.unica.it/index.php/anuac
8
Articles
2019-07-31
2019-03-12
2019-07-31
2019-07-30
59-83
1
Roberta Raffaetà
2019/07/31
10.7340/anuac2239-625X-3624
59
Libera Università di Bolzano, Italy
2239-625X
1
en
83
Caring across borders: The politics of belonging and transnational health
https://ojs.unica.it/index.php/anuac/article/download/3624/3353
8
                                               2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83




Caring across borders
The politics of belonging and transnational health
Roberta RAFFAETÀ
Free University of Bozen-Bolzano




ABSTRACT: Health care supply, demand and responsibility are increasingly becoming
transnational. More people seek care beyond state borders, while, at the same time,
most health systems are still organized nationally. Though most socio-anthropological
literature on this topic focuses on “health tourism”, this article takes a different
perspective: it considers migrants’ health travel at the intersection between the
neoliberal framework of global health and the politics of belonging. It explores the
transnational medical trajectories of family/reproductive health among Moroccans and
Ecuadorians living in Italy. On one hand, migrant parents’ transnational practices are
influenced by contexts of belonging – or not belonging – that they experience in Italy,
including in medical encounters. On the other hand, migrants enact tactics to navigate
the neoliberal framework of care. The article highlights the need for the development of
a transnational framework to regulate the increasing transnational dimension of
healthcare in order to mitigate (rather than increase) health, economic and social gaps
between states.

KEYWORDS: HEALTH CARE, TRANSNATIONAL FAMILIES, MIGRATION, MEDICAL TRAVEL, HEALTH INSURANCE.




This work is licensed under the Creative Commons © Roberta Raffaetà
Caring across borders: The politics of belonging and transnational health
2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83.
ISSN: 2239-625X - DOI: 10.7340/anuac2239-625X-3624
60                                                                          ROBERTA RAFFAETÀ



Introduction
   Transnational travels in search of medical care are intensifying, and it has
been estimated that a large number of transnational patients are migrants
returning home for treatment (Whittaker et al. 2010 ; Ormond 2014)*.
Migrants’ health practices are often transnational composites generated
through the use of health systems and practices in both places of settlement
and of origin (Elliot, Gillie 1998; Dyck, Dossa 2007). Transnational migrants
rely on their personal networks and their knowledge about, and entitlement
to, more than one national health system (Murphy, Mahalingam 2004;
Krause 2008; Brijnath 2009; Kane 2012).
   This situation complicates the questions researchers have traditionally
asked in studies of migration and health, such as the cultural competence of
medical personnel and of how healthcare is organized at a nation-state level.
Rather, increasing attention should be paid to the complex relationships
between migrants, their place(s) of origin and their place(s) of settlement. A
focus on migrants and health in a transnational perspective also sheds new
light on the conceptual framework used to describe medical travels, usually
conceived of as “medical tourism”. The term suggests leisure and rational
choice, and therefore leaves unexplored other processes that sustain
transnational medical trajectories (Sobo 2009), which have important
ramifications for healthcare for both sending and receiving countries, at
both global and local levels. What a focus on medical tourism obscures, in
particular, is the political significance of the economic liberalization of
healthcare services across borders (Tiilikainen, Koehn 2011). Recently, Dao
and Nichter have called
      for an anthropology of health care financing in low to middle income countries
      and for ethnographies of the social and organizational life of insurance
      programs that are attentive to biopolitical issues driving insurance policy
      decisions, program implementation and their impact on health disparities, as
      well as distributive justice. […] How does current health insurance practice
      reflect fundamental ideas about citizen rights and state obligations? Asking
      this question will lead us to consider not only programs that exist, but also the
      politics of the possible (Dao, Nichter 2015: 14).

* This paper is one of the results of a Marie Curie fellowship (research project: IMPARI
(Immigration and parenting in Trentino)). It has been possible thanks to the generous
participation of the families involved, representatives from family health and social services
and associations located in Va Rendena (Trentino). I also would like to thank Lenore
Manderson for an inspiring stay during my fellowship at Monash Melbourne University,
Narelle Warren for the careful editing and Andrea Whittaker for her suggestions. I am also
indebted to Giulia Zanini, Kristine Krause and Loretta Baldassar for the enjoyable and
productive thinking together on the article topic along the years, to the three Anuac
anonymous reviewers for the very useful suggestions and the journal editors for their
editorial support.



2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
CARING ACROSS BORDERS                                                                    61


   This article does not focus on insurance programs per se, but on the
biopolitics which, transnationally, fuel the implementation of neoliberal
health care regimes. A focus on biopolitics is facilitated by the analysis of
parenting medical practices, which are considered an integral element of
“good citizenship” (Raffaetà 2015a; Umut 2011: 701). The available
literature has generally adopted a narrow domestic focus: important political
and economic issues in medical transnational travels have been overlooked
due to a narrow political focus on national settings. However, the tendency
to restrict healthcare governance to the confines of “methodological
nationalism” limits the comprehension of the actual processes in healthcare
because supply, demand and responsibility in health care are increasingly
becoming transnational. Transnational medical travels draw a “networked
topography” (Beck 2012: 362), which reconfigures space in new ways
(Raffaetà et al. 2017). This new space has been identified as “global forms”
(Knecht et al. 2012) or “medicoscapes”, which Hörbst and Wolf describe as
     […] a globally dispersed landscapes of individuals; national, transnational, and
     international organizations and institutions as well as heterogeneous practices,
     artifacts, and things, which are connected to different policies, power relations
     and regimes of medical knowledge, treatments, and healing. While
     concentrated in certain localities, medicoscapes connect locations, persons,
     and institutions via multiple and partially contradicting aims, practices, and
     policies (Hörbst, Wolf 2014: 184).

   This article examines the travels “back home” made by migrants of
Moroccan and Ecuadorian origin living in Italy in search of care for their
children, family or for their own reproductive health. By combining family
and health visits to their place of origin, parents often supplement the care
that their children and/or they received in Italy. By considering migrants’
transnational trajectories and exploring the link between the politics of
belonging and health seeking behavior, this article aims to highlight the
political dimensions of these medical landscapes and the urgent needs to be
addressed. The article calls for the development of public health regulations
within a transnational framework able to protect individual’s right to health
despite mobility beyond the neoliberal grasp. A focus on belonging is crucial
in highlighting the political implications of transnational medical trajectories
because it is a meso level which mediates between the micro level of
individual experiences and the macro level of policy and economic
inequalities between governments, rampant trade liberalism and national
politics of recognizing difference. A detailed analysis of the interstices
between these two levels, typical of anthropology, is able to illustrate both
the opportunities and challenges of the hybrid space emerging at the

                                            2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
62                                                             ROBERTA RAFFAETÀ


interface between the state and the market (Pfeiffer, Nichter 2008;
Pellecchia, Zanotelli 2010; Biehl, Petryna 2013; Maciocco, Santomauro 2014;
Raffaetà, Nichter 2015). Following this approach, the article seeks to
complement the scientific debate about global health beyond a simplifying
economic or culturalist framework.
   The first section illustrates how migrant’s families take care of their
children in Italy. Then follows a description of transnational flows of
medications and of people, analyzed in light of the politics of belonging and
an exploration of the consequences created by a free market of transnational
health services. The article illustrates an unregulated transnational medical
space and highlights the need for the development of policies governing
transnational medical flows that mitigate (rather than increase) economic
and social gaps between states.
   This study derives from ethnographic research on the experiences of
immigration and parenting conducted from 2011 to 2013 among 18
Ecuadorian and 21 Moroccan families living in Val Rendena, an Alpine valley
in Trentino, a northern region of Italy. Parents in my study migrated to
Trentino, a region which counts around 48,000 migrants, amounting to 9.2%
of the provincial population (Ambrosini, Boccagni, Piovesan 2011). The
focus on two quite different groups, Moroccan and Ecuadorian parents, was
intentional in order to think about parenting and migration beyond ethnicity
and to emphasize the findings shared by the two groups that cut across their
specificities.
   Recruitment, community liaison, advice and support, and dissemination
of findings were assisted through the establishment and meetings of
reference groups. These included representatives from local family health
and social services, Val Rendena’s multicultural association, and personal
networks. Initial participant contact was complemented by snowball
recruitment. The initial selection of the sample was based on place of
residency (Val Rendena), national origin (Moroccan or Ecuadorian) and
family status (participants had to have one or more children aged six years or
younger). The women interviewed were aged between 23 and 45 years, they
were all married except one who was divorced and a single mother, about
half of them were working (mostly from the Ecuadorian sample) and had
been living in Italy for several years.
   A three-stage methodology was devised to analyse participants’
experiences of migration and parenting. It involved in-depth interviews and
participant observation. Healthcare and parenting practices are personal and
intimate matters, especially when these happen transnationally. The
acceptance of my role as researcher was probably facilitated by the fact that I


2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
CARING ACROSS BORDERS                                                                       63


was a mother too. My 3-5 year old child would come with me to weekend
community gatherings, various parties and she mixed with the children in
the migrant community. Without participation in these activities
(substantially ignored by conventional reports of population health) I would
not have had the opportunity to grasp the often invisible, but yet very
tangible in their outcomes, transnational medical trajectories of migrants.

In Italy: the biomedicalization of parenting
   The often marginal social position of migrant families within host
societies and their distance – in time and space – from original models of
parenting made Moroccan and Ecuadorian mothers participating in the
research particularly anxious for the wellbeing of their children (Raffaetà
2013). Children’s health is a catalyst for various anxieties, hopes and feelings
in relation to the family’s migratory experience. A great symbolic
investment is made into children, who are expected to bear the fruits of
parents’ sacrifices and suffering (Carling et al. 2012; Kelley, Tseng 1992).
Children are a central axis of family migration, and an important reason why
families move across borders and sustain transnational ties (Orellana et al.
2001). Immigrant children are of great importance for receiving countries
too. Family and parenting are a crucial site of negotiation in current
democracies between the role of the individual and that of the state (Gillies
2005; Lee et al. 2010a). Children are regarded as requiring special protection,
which means that parents are especially controlled by the state. In legal
terms, parents have a “duty of care”. Processes of control in parenting
practices are increasingly at work in the global north (Faircloth et al. 2013;
Reece 2006), but immigrant parents are a special target (Grillo 2008; Walsum
2004) because children do not only belong to them but somehow also to the
state under which protection they are born. According to the legal principle
of parens patriae the state has a legitimate power to intervene into parenting
because it is legally recognized as “parent” of its citizens, children included.
As Hanan, a 33 year old Moroccan with 2 children who has been living in
Italy since 2001, notes:
     here we have responsibilities. Here we are not in Morocco, here we have more
     responsibilities towards our children, we have the opportunity to access
     healthcare. It is also a duty. Instead of using herbs, other things, it is better to
     profit of the opportunity to have proper care. Given this opportunity, why not
     exploit it?

   As Hanan observes, there is a thin line between duties and rights. The
right to access healthcare also produces more responsibilities, thus tightly
binding migrants in a medicalization circle.

                                              2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
64                                                                  ROBERTA RAFFAETÀ


   Moreover, biomedicine is not only considered credible and authoritative,
but substantially “part of the very package of improved life circumstances
that women hoped to access when they migrated in the first place” (Gálvez
2011: 12; see also Wailoo et al. 2006). Even if healthcare systems are quickly
changing towards increased privatization (Frisina Doetter, Götze 2011), in
2000 WHO ranked Italy second best in the world 1. The current national
health service (Servizio Sanitario Nazionale – SSN) was established in 1978,
with universal coverage and tax funding. Family doctors and hospitalization
is entirely covered by the SSN. Specialist visits or diagnostic tests require a
copayment when prescribed by the family doctor with the exception of
protected groups. In comparison, the Moroccan and Ecuadorian health
systems present difficulties in meeting the population’s health needs. The
Moroccan health system, reformed in 2005 in order to expand health
insurance coverage (only 16% of the population has medical coverage), does
not have a universal or compulsory health insurance system. Even though on
paper residents/citizens/local have free access to needed health care, the
quality of care these facilities provide is generally considered low and it may
depend on incentives on the supply side to require “extra charges” for
services (Prah Ruger, Kress 2007). The situation in Ecuador is different
(given its emphasis on preventive care and community health) but, like the
moroccan migrants, the Ecuadorians partecipating in the research
considered medical infrastructure at home poorly supplied and of a lower
standard than in Italy. Roberts (2013) observes that public health in Ecuador
had a role in a whitening project, aiming at transforming the poor and
indigenous population into national citizens. However, this project was
undertaken through the neglect of public medicine, encouraging people
towards private medical care: “Given that state services in the early 2000s
were generally devalued and the recourse only of poor, indigenous, or Afro-
Ecuadorians, people across class and race went into debt to afford private
medical care so they wouldnʼt be treated ‘like Indians’” (2013: 568).
   For a number of migrants, the opportunity to easily access biomedical
treatments is among the planned advantages of the decision to migrate.
Sometimes, their enthusiastic embrace of biomedicine might produce
paradoxes, as in the case of Alloui, a Moroccan woman of 34 years with two
children and one to come, who tells me she has done amniocentesis even
though she had never thought about having an abortion. As she explains, the
procedure “was prescribed by the gynecologist. And it is anyway a medical

1. WHO Health system attainment and performance in all member states, ranked by eight
measures, estimates for 1997, www.who.int/whr/2000/en/annex01_en.pdf, accessed on
25/05/2019.


2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
CARING ACROSS BORDERS                                                                   65


examination. It can be useful for the mother’s health, maybe they [the
doctors] can see something wrong, you never know, it can be useful”. At the
same time, Alloui affirms that in case the amniocentesis would prescribe an
abortion, she would not undergo it because forbidden by Islam. Hughes
Rinker (2015: 238), suggests that in the case of Morocco, adherence to
medical programs which are expression of a neoliberal development agenda
is in part due to the desire to offer their children a better life by taking
advantage “of the tools offered by the state to improve their lives and to
become finically secure”. At the same time, she notes how the neoliberal
logic of self-regulation and responsibility is not the same everywhere: in
Morocco it interweaves with Islamic beliefs.
   While some women used traditional remedies in the form of herbs, most
of the research participants discarded them, perceived as inseparable from
their legacy to poverty and to what they considered a “backwarded
mentality”. As Nadia – a Moroccan woman of 40 years, with curly and
colored blond hair, living in Italy since 2002 with two children:
     Old people treat themselves with herbs, but we do not go back, it can be
     dangerous. My father uses herbs, I don’t. My mother uses all those things [Nadia
     makes a disgusted face]. She treated us that way [she laughs]. She performed
     black and white magic. But we don’t, we do not go back. Otherwise, why would
     we be here?!

   In her argument, Nadia blends the use of herbs with magic, both
expression of outdated treatments. She underlines her determination not to
go back, and this intention is mirrored both in her migratory path and
medical treatments.
   Most of the mothers, however, found their expectations of medicalization
frustrated. Mothers often lamented the “soft” approach of Italian
pediatricians who, according to them, did not prescribe enough
medicaments and diagnostic tests. Sara, who arrived with 2 children from
Morocco in 2007, expresses clearly her dissatisfaction: “The pediatrician
examines my child only by looking, without prescribing any test. ‘Can you
prescribe me some analysis? Some X-rays to see if it is all right or not?! Tell
me why X-rays and tests exist if the eye is enough?!’” In Sara’s narrative,
technological devices have priority with regard to the “eye” and experience
of the doctor. Perceived under treatment is one of the reasons for many
families to directly go to the emergency room (ER) and sidestep the
pediatrician (Raffaetà 2013). The ER is described as a reassuring place
“because there you can find all doctors you wish, all the specialists, they are
more competent and it is a safer place. There are all the machines, all the
exams” (Ibnissam, Morocco). This attitude grounds on the comparison, here
only implicit, with the care received at home.

                                            2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
66                                                                            ROBERTA RAFFAETÀ


     Maria, 44 years, two children and lives in Italy since 2001 observes:
       Sometimes he [the Italian pediatrician] is good because he prescribes me some
       strong drugs, when it is needed. But in general, they are too hasty. The
       pediatrician, in Ecuador, explores the child from the tip of his toes until the tip
       of his hair.

   Again, the negative judgment of Italian medical professionals is made on
the backdrop of the comparison with home. The difference between the care
received at home and that received in Italy has the effect to jeopardize the
trust in Italian medical interventions. In the next sections I will illustrate the
various ways through which migrants access care transnationally and their
motivations.

Transnational flows of medicaments
   As highlighted by previous studies (Beijers, de Freitas 2008; Krause 2008;
Thomas 2010), it is common for migrants to exchange medicines and
treatments that flow back and forth between the home and the host country.
In line with these findings, research participants told how, when coming
back from home, they travelled with bags filled with essential oils, soap and
creams, used for the treatment of skin and hair problems. They also
evaluated the disparity in costs for drugs and medical interventions and
bought medicines where the prices were most reasonable. Both Moroccans
and Ecuadorians bought generic drugs (such as pain-killers or anti-
inflammatory medicines) in their home country and brought them to Italy,
or asked relatives and friends to bring such drugs when traveling to Italy. A
common explanation for justifying the transnational movement of drugs,
irrespective of their origin, is that they are identified as “more powerful”.
This explanation is provided even when the active ingredient in the
medication is exactly the same in the sending and receiving countries and
the drug differs only in name, packaging, or shape (pills, drops, powder). The
assumed difference in efficacy is often related to the national or cultural
context in which a drug is produced 2. Some research participants sent drugs
from Italy to relatives back home with the assumption that biomedicine from
Europe is more powerful than locally available drugs. The reverse was also
true, some people asking relatives and friends to send medicines from home
because these “are stronger” than the ones available in Italy. These
ambiguities and contradictions in medicaments’ perceptions reveal the

2. On the relation between assumed efficacy and meaning see Van der Geest, Whyte 1989;
Van der Geest, Whyte, Hardon 1996.


2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
CARING ACROSS BORDERS                                                                   67


tensions between the imaginary of modernity contained in Italian drugs,
based on the assumption that biomedicine from Europe is more powerful,
and the emotional attachment to medicine representing the home context,
also called “the social efficacy of traveling medicines” (Pribilsky 2008). Thus,
these contradictions are not only about modernity and tradition, but they
also reveal what is “home”, what emotions and ideas are attached to it and
how its concept is dispersed in multiple scales and times.
   Beyond social efficacy, practical considerations also matter. Jenny, an
Ecuadorian mother, explains that some drugs are available in Italy too, but
she and her Ecuadorian friends usually do not know the Italian name. Thus,
they should go to the GP (general practitioner) to have a prescription. GPs,
however, are often unwilling to cooperate. Therefore, the solution is to ask a
friend or relative to carry with him/her the drug during next trip to Italy. It is
not possible to send drugs by post from Ecuador to Italy: one needs someone
to carry drugs and show the medical prescription to customs authority at the
airport, even for drugs available over-the-counter. According to Jenny, this
is a common habit and Ecuadorian doctors are used to perform this kind of
prescriptions for expatriates. Among research participants, the readiness to
carry someone else’s drugs from or to Ecuador was an important social issue,
bonding migrants in ties of reciprocity or creating motive for conflicts in
case of denied help. This is telling of the social value assigned to
transnational drugs and the charged meanings of these exchanges.

Transnational flows of people
   Not only drugs travel, people travel too. Research participants did not
primarily travel for seeking care, but their medical encounters were part of
their visit to relatives. This is the case of Sara (whose dissatisfaction with
Italian pediatricians has already been illustrated above):
     When I go back to Morocco I take advantage of being there to have medical
     consultations, most of all for the children. In Morocco doctors make a proper
     check of all the body and then they prescribe many exams, X-rays… they make
     all, they are more precise [than in Italy]. They explain well, with calm, not as
     here [Italy] where doctors have a quick look at you and that’s all. They
     [Moroccan doctors] understand better our problems. And they are also cheap; a
     visit to a private doctor costs me around 10 Euros. And they are very
     competent, you know they have studied in France, Great Britain… they are very
     good.

  For these visits, Sara usually goes to a hospital in Casablanca, a big and
modern medical structure where, as she highlights, “Western medicine” is
practiced. Quite interestingly, the better judgment of Moroccan doctors in

                                            2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
68                                                                ROBERTA RAFFAETÀ


comparison with their Italian colleagues is granted by their European
education. This seems to instill drops of “modernity” into a comforting and
traditional background. As Sara observes, the relationship with Moroccan
pediatricians is easier, but this is not simply a matter of speaking the same
language. By saying “they understand better our problems” Sara points to
the sharing of common cultural references and knowledge of “local
biologies” (Lock 1993). This common background shapes attitudes and
expectations of both doctors and patients, facilitating the medical
encounter. For example, as most other Moroccans, Sara had her two sons
circumcised in Morocco. The Italian health system does not take into proper
account such specific medical needs, characteristic of certain groups. Given
that this practice is rather rare among Italians, migrants wishing to
circumcise their children may have to wait up to a year before being called in
for the medical procedure. As a result, many decide to circumcise their
children while visiting the home country, thereby adding the advantage of a
short waiting list to the mutual implicit understanding of gender and body
conventions that the home context brings with it.
   This is particularly important one people have to deal with parenting and
reproduction, these being issues heavily laden with political meanings. In
Ecuador, for example, giving birth to new babies is emphasized as a desirable
personal goal and social duty to be supported by all means despite the
crumbling public health care infrastructure (Lind 2012). Despite in Italy
making a family is seen favourably too, in the experience of Jenny,
Ecuadorian doctors were better at welcoming her desire to become a mother.
Jenny is 38 years and is in Italy since 2001. She and her husband were trying
unsuccessfully to have a child for 9 years. While a sperm test confirmed her
husband’s capacity to procreate, Jenny suffered from poor and sporadic
menstruation. She consulted 3-4 Italian gynecologists who performed
ultrasound; all agreed that everything was right with her. The last doctor
booked her a visit at the local centre for assisted reproduction without
explaining much. The day of the visit Jenny and her husband discovered
what assisted reproduction was. They were a bit puzzled and offended: “I do
not know what he [the gynecologist who booked the visit] understood. Probably
he still thinks I am not fertile…”. They also discovered that the first real visit
was planned 12 months later. Jenny’s husband, quite upset, said to the
doctor “within a year my daughter will be already at school!” Few months
later, during a travel to Ecuador the couple decided to consult a local
gynecologist. They showed him the exams performed in Italy and the doctor
identified an ovarian cyst, to be removed, which was preventing Jenny to


2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
CARING ACROSS BORDERS                                                             69


become pregnant. Jenny recalls that the doctor added “I assure you at 100%
that in 3 months after surgery you will be pregnant”. She had the surgery
within few days and exactly 3 months later she happily found herself to be
pregnant: “It was like a miracle, you can find this kind of stories only in fairy
tales! If I relied on Italian doctors I would be still there waiting, they
understood nothing of my condition!”.
   As a result of this almost magical experience, in Jenny’s narrative, the
competency of the Ecuadorian gynecologist goes hand in hand with the fact
that in Ecuador her desire to become a mother has been better supported in
comparison to Italy. Even if Jenny did not think to be discriminated as being
an ecuadorian migrant in Italy, still she felt that in Italy reproduction is not
taken seriously. This made her proud for her homeland, a place where one
can find good standards of biomedical care, even superior to European ones.
   Higher trust in homeland doctors may bring to the creation of
transnational “therapy networks” (Krause 2008): doctors based in various
national contexts might constitute a transnational team, as advisors and
facilitators in therapeutic decisions or in prescription made in one national
context. This is the case told by Maria, 44 years, two children, living in Italy
since 2001. When Maria’s son was 2, he had to undergo a difficult surgery for
a serious problem with his gut. She did not totally trust the Italian medical
personnel. During the time spent in hospital she called every day her aunt in
Ecuador who was working as a nurse in hospital. Maria was asking her
opinion with regard to the medical choices taken by the Italian doctors and
about the exams and the drugs prescribed. The aunt related to Maria by
consulting the Ecuadorian doctors working with her. Fortunately, the
opinions of the Ecuadorian doctors were consistent with those of the Italian
doctors, reassuring Maria and preventing medical controversies which would
have been difficult to handle.
   Other causes – at the juncture of national economies and neoliberal
processes– should be considered beyond the “cultural competency” of
doctors in sustaining transnational medical travels. Both in Morocco and
Ecuador, only the poorest access the public health system, described by
research participants as of low quality. The norm is to consult private
doctors. This is particularly true for migrants who enjoy a “status paradox”
(Nieswand 2011) when back home, by gaining a higher status through the
income they gain with low-status work in the country of emigration. This
allows them to access more easily private medical care. Laila, from Morocco,
34 years, in Italy since 1998 and with 2 children observes:



                                       2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
70                                                                         ROBERTA RAFFAETÀ

      Laila: We were in Morocco, K had fever, even if I gave him Tachipirina [Italian
      drug] the temperature did not decrease. We went to the pediatrician and he
      examined K for a long time, very differently from my [Italian] pediatrician…
      Roberta: Was he more competent?
      Laila: Mmm…same, they are both good. But pediatricians in Morocco are
      private, therefore they have to gain the visit [she laughs]…probably also this is
      the reason. And also because it was the first time that the [Moroccan]
      pediatrician saw K. In Italy I go to the pediatrician every month…

   Laila points to the fact that performing more accurate visits might be a
role played by private doctors, somehow compelled to perform a more
careful visit in order to justify their fees and to be competitive within a wide
offer of private medical care. Linked to these economic considerations, she
also alludes to organizational factors, such as the accidental access
performed by transnational patients, that might motivate a more in-depth
visit.
   Laila observations jeopardize the romantic vision many migrants
expressed about the quality of care received in their homeland. Given the
structural fallacies of the homeland health system, both in Ecuador and
Morocco, migrants might even arrange for their relatives to be cared by an
Italian doctor in person when they come for visits. Depending on the trust
between the Italian doctor and the migrant, this caring relationship can
extend through time and space. Some Italian doctors continue to provide
drug prescriptions for returned relatives that are then sent to Ecuador or
Morocco, as in the case of Carla’s mother. When Carla, originally from
Ecuador, living in Italy since 15 years and married to an Italian man with
whom she has a child, gave birth for the first time, her mother came to Italy.
Carla’s mother has had a problem with a varicose vein in her leg for many
years, but never thought to seriously take care of it. Once, while
accompanying Carla to the GP for a regular visit, the GP also had a look at
her leg. Carla’s GP prescribed a visit to a specialist for the mother, who, one
year later, had surgery on that leg in the local hospital in Italy. Even if
Carla’s mother came to visit her daughter in Italy only time to time, she
received a regular permit to stay for family reunification, thereby gaining the
right to have free access to Italian healthcare. So, the surgery did not incur
any costs to Carla’s mother, while in Ecuador it would have been an
expensive endeavour. After recovery Carla’s mother went back to Ecuador
and followed up the surgery by taking a specific kind of drug prescribed by
Carla’s GP. Carla buys it in Italy and then sends it to her mother in Ecuador.
Although this case does not deal with children’s health or reproductive
health, it reveals the crucial role of family in health-related matters and the
fact that not always migrants search care in the home country, but the flow
is sometimes reversed in light of economic considerations.


2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
CARING ACROSS BORDERS                                                                   71


   The case presented – from Sara to Carla– reveals forms of caring which
are graded according to graded forms of citizenship3. While common
understanding of gender and body (Sara) and of reproduction and parenting
(Jenny) are important in engendering trust and compliance (Maria) and
therefore addressing migrants’ preference for the care provided in the
homeland, the case of Laila and Carla point to complementary processes and
forces which somehow elusively transform migrants’ medical choices and
trajectories. These are not simple economic considerations (e.g., which
doctor cost less?) but are tactics undertaken at the juncture of national
economies and neoliberal processes. Ong (2006) argues that an interactive
mode of citizenship with alleged social rights and entitlements is emerging.
This is linked to personal affordances in a global market more than to
membership within nation-states: “Articulations between citizenship
elements, entrepreneurial traits, and global circuits fragment what we long
assumed to be a homogeneous collectivity and a unified space of
citizenship” (2006: 16).

Politics of belonging and healthcare trajetories
   A rich literature has shown how Mexicans living in the US cross the border
into Mexico to circumvent a lack of insurance and the high cost of medical
care in the US, so taking advantage of the disparity between the costs of
private health care in Mexico and the US (Chavez 1984; Seid et al. 2003;
Wallace et al. 2009). The nexus of neoliberal regimes of care and economic
disparities among states is, however, not enough to determine transnational
medical trajectories. A growing number of studies in different parts of the
world has illustrated (Horton, Cole 2011; Lee et al. 2010b; Ormond 2014)
that healthcare cost is not the main or only trigger for migrants to search
healthcare “back home”. Italy is a good case study to appreciate this because
the Italian health system includes free and unlimited access for primary,
needed and urgent care of standard. More than economic considerations,
health seeking tactics of Ecuadorian and Moroccan are influenced by the
politics of belonging (Geddes, Favell 1999; Yuval-Davis 2011) enacted in
therapeutic encounters and resulting in positive and negative experiences of
inclusion or exclusion.
   The impact of medical visits and travels to the homeland varied greatly
according to migrants’ feelings of belonging, which refers to rights and
duties, but also to the emotions that membership evokes (Hage 2003).
Belonging refers to the past (origins, heritage) but also to the future in terms

3. I thank one Anuac reviewer for having suggested this concept.

                                             2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
72                                                              ROBERTA RAFFAETÀ


of feelings of hope and imagination of what will be the future (Raffaetà
2015b). Tellingly, Carla and Laila (the first developing tactics to receive care
for her mother in Italy and the second putting the care received in Morocco
into a global perspective) were, among the women participating in the
research, the one who felt most attached to Italy. A politics of belonging is
salient in medical encounters because they concern questions of
participation and recognition. The encounter between a doctor and a patient
is not just a matter of health or a medical visit; rather, it is a political
situation in which patients are (or are not) acknowledged as citizens and
parents, through their role as patients (Gálvez 2011). Medical situations are
not only about the relationships between therapeutic professionals and
patients, but also about the interface between a person and the state, the
private and public spheres, involving both therapeutic regimes and the
politics of entitlements.
   The concept of belonging is a vital node within the recent debate
concerning the character of transnational migration (Yuval-Davis 2004).
Since the 1990s (Glick Schiller et al. 1992), transnational studies of migration
have extended the reach of traditional study of migration by exploring which
are the relationship between home and host countries and how they affect
migrants daily life. The focus has been on interconnections people between
places rather than the lives they make in one or other places. Migrants which
often travel home, or for whom home is important in any way, often feel to
belong to more than a country. A rich literature has defined this process as
the development of mixed, hybrid or multiple identities (Hall, Du Gay 1996),
deploying particular identities in specific contexts depending on which are
more strategic (Banks 1996) and occupying a “third space” (Bhabha 1990), a
space distinctive from either the home- or host-land cultures (Waters 1990).
   In Italy there is a profound absence of discourses and practices to
recognize citizenship to mixed or hyphenated identity forms, at least at an
overt level, and where legal and public discourse reinforce a
conceptualization of identities as fixed – and not even multiple (Andall
2002; Baldassar, Raffaetà 2018). In Italy immigration is a fairly new and
problematic phenomenon (Pastore 2001; Zincone 2006) and lacks a well-
developed politics of recognizing difference which entails a legitimate space
for the public discourse about the recognition and management of difference
(Grillo, Pratt 2002; Salih 2003; Riccio, Russo 2011; Ambrosini 2013).
Historically, the process of nation building demanded the marginalisation
and subordination of internal differences (north/south), and was predicated
on a denial of (local, regional and provincial) “otherness” and on the need to
remove the memory of the short Italian colonial experience, given the

2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
CARING ACROSS BORDERS                                                                       73


humiliating failure of its aspirations (Dal Lago 2009 [1997]; Mellino 2006;
Tabet,1997). These elements provide the context of incorporating the
immigrant other, both as an abstract category of otherness and as bodies
(Pizza 2012). This situation mirrors on the encountering of migrants with
institutions which address parenting practices of care (Taliani 2015).
   As a consequence of this situation, normal facts, such as a quick visit for
clear absence of alarming symptoms, appears to migrants as a deliberately
discriminatory act. As Sara, among many others, notes:
      I have the impression that here [in Italy] doctors turn a bit nasty with foreigners
      [sic, common terms to define migrants in Italy], a bit racist. I can notice this on
      the road too, the glimpses I receive because of my clothing. They are scared,
      they think I am a kamikaze [she laughs]. They always fear us. The point is not
      that the pediatrician himself is scared, but…but at the end this is the result. I
      do not think that he is so quick also with Italians…probably they are well cared
      for, they are provided with drugs and exams.

   During my fieldwork I recorded very few instances of overtly racist
behavior from the part of medical professionals. The perception to be
discriminated against, as Sara points out, does not have to do with individual
cases of racism: “The point is not that the pediatrician himself is scared
but…but at the end this is the result”. rather, this perception of being
discriminated depends from the wider social and political climate, a kind of
“structural vulnerability” (Cartwright, Manderson 2011; Quesada et al. 2011).
   For migrants in Italy the recognition of their identities as fixed impacts on
how to make sense of their multiple identities. Belonging in Italy, therefore,
is more a set of dynamic practices of belonging than identification
strategies4. Migrants’ transnational medical travels are practices and
processes of belonging which take place at the levels and the spaces where
people have the greatest capacity to act.

The neoliberalization of unregulated transnational medical space
   Migrants, by navigating among alternating feelings of belonging, make
use of the interstices created by inequalities between countries and take
advantage of gaps between different health policies and neoliberal
governance regimes. The term “transnational therapeutic opportunity
spaces” (Raffaetà et al. 2017) emphasizes the advantages of this situation. A
range of negative consequences or risky ambiguities, however, are not
excluded and are discussed in this section.

4. In this dynamic identification is not excluded though. Identification may, at times, play a
role and people can experience at times their identity as fixed, mixed and “in-between”,
even concurrently, see Raffaetà, Baldassar, Harris 2016.

                                              2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
74                                                                     ROBERTA RAFFAETÀ


   In Europe and worldwide a series of projects have been launched to build
an electronic service infrastructure for the management of cross-border
health through the development of a digital identities integrated in different
networks5. The European Commission funded (2008-2014) the project epSOS
(Smart Open Services for European Patients)6, promoted by 25 national
ministries of health (22 EU member states and 3 non-EU member states) and
a consortium of e-industry, aims to improve the quality and safety of
healthcare for citizens when travelling to another European country by
providing quick access to documentation as well as by increasing
accessibility of prescribed drugs abroad through cross-border use of
electronic prescriptions (“ePrescription” or “eMedication” systems). EpSOS
is a pilot study, further to be used for extension between EU-US. As a pilot
study, “it follows EU regulatory framework, and as such will not require
changes to national legislation governing the provision of health services.”
Even while recognizing that “epSOS focuses on electronic patient record
systems and operates within a complex policy environment”, the project
focuses on technical and clinical aspects (e.g., the development of a common
terminology for the smooth functioning of electronic data sets) and leaves
basically untouched the political and legislative void of cross-border health.
A truly political issue is so turned into a technical and technological
problem.
   The mentioned EU regulatory framework is the “Directive of the European
Parliament and of the Council on the application of patients’ rights in cross-
border healthcare”, issued on 2011, after modifications (1998) of the already
existent Regulation (EEC) No 1408/71 from 1971. The Directive states that
patients treated during their stay in another Member State should be
entitled to the same benefits as patients insured in the host Member State.
The major limit of this directive, beyond being restricted to the EU territory,
is the lack of any political effort to build a legislative transnational
framework of healthcare. As Commissioner of Health, Androulla Vassiliou,
emphasised in her presentation of the directive, it does not aim to constitute
a unified health care system, but rather to allow European patients to move
and seek treatments within EU territory by respecting the variety of national
health care systems which “remain fully responsible for organising and

5. See Szpuzsta 2009; Gemalto, Health cards and electronic healthcare solutions, www.gem-
alto.com/govt/health, accessed on 24/07/2015.
6. Cross-border health project epSOS: What has it achieved? https://ec.europa.eu/digital-
single-market/en/news/cross-border-health-project-epsos-what-has-it-achieved, accessed
on 10/06/2019.


2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
CARING ACROSS BORDERS                                                                 75


financing their home system in accordance with their traditions and their
needs”7. This statement reveals the difficulty inherent in any attempt to
transnationally regulate a sphere so dominated by national interests.
   In the interstices of this legislative and political void and within a global
context of public expenditures for health cuts and increasingly shifted
responsibility for financing health care onto individuals and the private
sector (Pfeiffer, Chapman 2010; Raffaetà, Nichter 2015) there is opportunity
for market-based initiatives to develop (Chanda 2002; Cortez 2008). This is
especially true for low and mid income countries (Janes et al. 2006; McIntyre
et al. 2008; Wu, Ramesh 2009), which are also countries of origin of many
migrants, where private medical care facilities are developing (Ormond
2014). These are especially targeted for two kinds of patients-clients: 1.
returning (even occasionally) migrants and their family; 2. the domestic elite
wishing to travel abroad for healthcare. Companies take advantage of the
structural and socio-political inequalities and the lack of regulation of the
global medical space, which cause people to shuffle between home and host
country for care. Ormond (2014: 153) reports the case of the US-based
medical travel facilitator, Planet Hospital, which launched a “medical
tourism-based” insurance called “Diaspora”. It offers accident coverage
within US and full healthcare coverage in selected medical clinics in the
country of origin for non-emergency care. Returning migrants, even if they
have citizenship rights in their country of origin, see themselves
downgraded from citizens-patients to customers. For example, Ellison
(2014) has described the development of “first-class ward” in Tanzania’s
hospital, which treat patients according to their wealth. These new kinds of
insurance products allow for further disengagement of national governments
from staffing and financing public health systems, making entitlement to
healthcare for both returning migrants and locals an increasingly hazy
horizon.

Governing transnational health: A matter of money, technology or politics?
   The article has described how transnational medical trajectories of
migrants are not just motivated by “cultural” adherence of medical concepts
or by cost but also by politics of belonging. Belonging deploys as practices of
belonging, of which migrants’ transnational medical travels are significant
examples because they take place at the levels and the spaces where people
have the greatest capacity to act. Nevertheless, in the context of neoliberal

7. Videos laud benefits of cross-border healthcare, https://expathealth.org/healthcare/-
video-cross-border-healthcare-eu/, accessed on 10/06/2019.

                                           2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
76                                                                       ROBERTA RAFFAETÀ


organization of medical care, migrants’ agency is guaranteed by the
existence of an unregulated transnational medical space. At a micro level,
this might be beneficial for singular migrants in mitigating global
inequalities but at a macro level there is a rising trend to capitalize on these
legislative and political gaps, so creating even more disparities. Migrants
exercise strategically their citizenship rights in a transnational medical
space but, at the same time, their agency is constrained by various factors as
economic inequalities and politics of belonging8. In order to address the
inequalities and ambiguities of this situation (see also Vineis 2014),
Ottonelli and Torresi (2010) propose the development of new policies: for
example, to grant returning migrants the right to use pension gains
accumulated in the host country to be entirely or partly used at home.
   The aim of this article has been twofold. First, it described the nexus
between politics of belonging and transnational health governance.
Discourse on family and children’s health enables a new focus on politics
and practices of belonging in the context of the biopolitical processes at play
in the current economic globalization process with consequent risks of
neoliberal exploitation of an unregulated transnational medical space.
Second, this article argued for the need to develop, within a transnational
framework, healthcare policy and social security laws regulating
transnational medical spaces. These, ideally, should ease national health,
economic and social disparities while, at the same time, protecting the rights
of individuals to pursue health care across national borders. As Whittaker
(2010: 409) observes, “regulation of forms of the trade requires cooperation
across sectors, state, and non-state actors [...] The challenge is to determine
both the mechanisms for regulating the trade and deciding on what basis
global regulation is undertaken”. In other words, this is first and foremost a
political decision, and it should not be left to the market or technology to
resolve it.




8. Baldassar (2014) has shown how visa regulations might be another important constraint.


2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
CARING ACROSS BORDERS                                                                77



REFERENCES
Ambrosini, Maurizio, 2013, “We are against a multi-ethnic society”. Policies of
      exclusion at the urban level in Italy, Ethnic and Racial Studies, 36, 1: 136-155.
Andall, Jacqueline, 2002, Second-generation attitude? African-Italians in Milan,
      Journal of Ethnic and Migration Studies, 28, 3: 389-407.
Baldassar, Loretta, 2014, Too sick to move: distant “crisis” care in transnational
      families, International Review of Sociology, 24, 3: 391-405.
Baldassar, Loretta, Roberta Raffaetà, 2018, It’s complicated, isn’t it. Citizenship and
      ethnic identity in a mobile world, Ethnicities, 18, 5: 735-760.
Banks, Marcus, 1996, Ethnicity: Anthropological Constructions, London, Routledge.
Beck, Stefan, 2012, Biomedical Mobilities. Transnational Lab-Benches and Other
      Space-Effects, in Reproductive Technologies as Global Form. Ethnographies of
      Knowledge, Practices and Transnational Encounters, Michi Knecht, Maren Klotz,
      Stefan Beck, eds, Frankfurt, New York, Campus: 357-374.
Beijers, Huub, Clàudia de Freitas, 2008, Cape Verdeansʼ pathways to health. Local
      problems, transnational solutions, in Transnational Archipelago. Perspectives
      on Cape Verdean migration and Dias-pora, Luís Batalha, Jørgen Carling, eds,
      Amsterdam, Amsterdam University Press: 237-254.
Bhabha, Homi, 1990, The Third Space, in Identity: community, culture, difference,
      Jonathan Rutherford, ed, London, Lawrence & Wishard Ltd: 207-221.
Biehl, João Guilherme, Adriana Petryna, 2013, When People Come First. Critical
      Studies in Global Health, Princeton, Princeton University Press.
Brijnath, Bianca, 2009, Familial bonds and boarding passes. Understanding
      caregiving in a transnational context, <ZAAQQ1, 16, 1: 83-101
Carling, Jørgen, Cecilia Menjívar, Cecilia Schmalzbauer, 2012, Central Themes in
      the Study of Transnational Parenthood, Journal of Ethnic and Migration
      Studies, 38, 2: 191-217.
Cartwright, Elizabeth, Lenore Manderson, 2011, Diagnosing the structure.
      Immigrant vulnerabilities in global perspective, Medical Anthropology. Cross-
      Cultural Studies in Health and Illness, 30, 5: 451-453.
Cartwright, Lisa, 2000, Reach Out and Heal Someone. Telemedicine and the
      Globalization of Health Care, Health, 4, 3: 347-377.
Chanda, Rupa, 2002, Trade in health services, in Trade in health services. Global,
      regional, and country perspectives, Nick Drager, Cesar Vieira, eds,Washington,
      DC, PAHO: 35-44.
Chavez, Leo Ralph, 1984, Doctors, curanderos, and brujas. Health care delivery and
      Mexican immigrants in San Diego, Medical Anthropology Quarterly, 15, 2: 31-37.
Cortez, Nino, 2008, Patients Without Borders. The Emerging Global Market for
      Patients and the Evolution of Modern Health Care, Indiana Law Journal, 83:
      71-132.
Dal Lago, Alessandro, 2009 [1997], Non-Persons.The Exclusion of Migrants in a Global
      Society, Vimodrone, IPOC.

                                          2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
78                                                                        ROBERTA RAFFAETÀ


Dao, Amy, Mark Nichter, 2016, The Social Life of Health Insurance in Low-to-
       Middle-income Countries. An Anthropological Research Agenda, Medical
       Anthropology Quarterly: 122-143.
Dyck, Isabel, Parin Dossa, 2007, Place, health and home. Gender and migration in
       the constitution of healthy space, Health & Place, 13, 3: 691-701.
Elliot, Susan J., Joan Gillie, 1998, Moving experiences. A qualitative analysis of
       health and migration, Health and Place, 4, 4: 327-339.
Ellison, James, 2014, First-Class Health. Amenity Wards, Health Insurance, and
       Normalizing Health Care Inequalities in Tanzania, Medical Anthropology
       Quarterly, 28, 2: 162-181.
Faircloth, Charlotte, Diane Hoffman, Linda L. Layne, eds, 2013, Parenting in Global
       Perspective. Negotiating ideologies of kinship, self and politics, London, Routledge.
Frisina Doetter, Lorraine, Ralf Götze, 2011, The Changing Role of the State in the
       Italian Healthcare System, TranState Working Papers No. 150, Available at
       SSRN: https://ssrn.com/abstract=1866297 or http://dx.doi.org/10.2139/ssrn- .
       1866297, accessed on 01/06/2029.
Gálvez, Alyshia, 2011, Patient citizens, immigrant mothers. New Brunswick, New
       Jersey and London, Rutgers.
Geddes, Andrew, Adrian Favell, 1999, The politics of belonging. Migrants and
       minorities in contemporary Europe, Aldershot, Ashgate.
Gillies, Val, 2005, Raising the “meritocracy”. Parenting and the individualization of
       social class, Sociology, 39, 5: 835-853.
Glick Schiller, Nina, Linda Basch, Cristina Szanton Blanc, 1992, Transnationalism: a
       new analytic framework for understanding migration, in Towards a
       Transnational Perspective on Migration. Race, Class, Ethnicity, and Nationalism
       Reconsidered, Nina Glick Schiller, ed, New York, New York Academy of
       Sciences: 1-24.
Grillo, Ralph, ed, 2008, The Familiy in Question. Immigrant and Ethnic Minorities in
       Multicultural Europe, Amsterdam, Amsterdam University Press.
Grillo, Ralph, Jeff C. Pratt, eds, 2002, The politics of recognising difference.
       Multiculturalism Italian-style, Aldershot, Ashgate.
Hage, Ghassan, 2003, Against paranoid nationalism. Searching for hope in a shrinking
       society, Annandale, NSW, Pluto Press.
Hall, Stuart, Paul Du Gay,1996, Questions of Cultural Identity, London, Sage.
Hörbst, Viola, Angelika Wolf, 2014, ARVs and ARTs. Medicoscapes and the Unequal
       Place-making for Biomedical Treatments in sub-Saharan Africa, Medical
       Anthropology Quarterly, 28, 2: 182-202.
Horton, Sarah, Stephanie Cole, 2011, Medical returns. Seeking healthcare in
       Mexico, Social Science and Medicine, 72: 1846-1852.
Hughes Rinker, Cortney, 2015, Creating Neoliberal Citizens in Morocco.
       Reproductive Health, Development Policy, and Popular Islamic Beliefs,
       Medical Anthropology, 34, 3: 226-242.


2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
CARING ACROSS BORDERS                                                               79


Janes, Craig R. et al., 2006, Poor medicine for poor people? Assessing the impact of
      neoliberal reform on health care equity in a post-socialist context, Global
      Public Health, 1, 1: 5-30.
Kane, Abdoulaye, 2012, Flows of medicine, healers, health professionals, and
      patients between home and host countries, in Medicine, Mobility, and Power in
      Global Africa. Transnational Health and Healing, Hansjörg Dilger, Abdoulaye
      Kane, Stacey Ann Langwick, eds, Bloomington, Indiana University Press.
Kelley, Michelle L., Hui-Mei Tseng, 1992, Cultural differences in child-rearing. A
      comparison of immigrant Chinese and Caucasian American mothers, Journal
      of Cross-Cultural Psychology, 23, 4: 444-455.
Knecht, Michi, Maren Klotz, Stephan Beck, eds, 2012, Reproductive Technologies as
      Global Form. Ethnographies of Knowledge, Practices, and Transnational
      Encounters, Frankfurt, New York, Campus.
Krause, Kristine, 2008, Transnational therapy networks among Ghanians in London,
      Journal of Ethnic and Migration Studies, 34, 2: 235-251.
Lee, Ellie, Jan Macvarish, Jennie Bristow, 2010a, Editorial. Risk, health and
      parenting culture. Health, Risk and Society, 12, 4: 293-300.
Lee, Jane Y., Robin A. Kearns, Wardlow Friesen, 2010b, Seeking affective health
      care. Korean immigrantsʼ use of homeland medical services, Health and Place,
      16, 1:108-115.
Lind, Amy, 2012, Contradictions that Endure. Family Norms, Social Reproduction,
      and Rafael Correaʼs Citizen Revolution in Ecuador. Politics & Gender, 8, 2:
      254-261.
Lock, Margaret, 1993, Encounters with Aging. Mythologies of Menopause in Japan and
      North America, Berkeley, University of California Press.
Maciocco, Gavino, Francesca Santomauro, 2014, La salute globale. Determinanti so-
      ciali e disuguaglianze, Roma, Carocci.
McIntyre, Diane et al., 2008, Beyond fragmentation and towards universal coverage.
      Insights from Ghana, South Africa and the United Republic of Tanzania,
      Bulletin of the World Health Organization, 86: 871-876.
Mellino, Miguel, 2006, Italy and postcolonial studies. A difficult encounter,
      Interventions, 8, 3: 461-471.
Murphy, Eleanor J., Ramaswami Mahalingam, 2004, Transnational ties and mental
      health of Caribbean immigrants, Journal of Immigrant Health, 6, 4: 167-177.
Nieswand, Boris, 2011, Theorising Transnational Migration. The Status Paradox of
      Migration, London, New York, Routledge.
Orellana, Marjorie F. et al., 2001, Nieswand of Children in Processes of Family
      Migration, Social Problems, 48, 4: 572-591.
Ormond, Meghann, 2014, Harnessing “diasporic” medical mobilities, in Migration,
      Health and Inequality, Felicity Thomas, Jasmine Gideon, eds, London, Zed
      Books: 150-163.
Ottonelli, Valeria, Tiziana Torresi, 2010, Inclusivist egalitarian liberalism and
      temporary migration. A dilemma, The Journal of Political Philosophy, 20, 2:
      202-224.

                                         2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
80                                                                     ROBERTA RAFFAETÀ


Pastore, Francesco, 2001, Nationality law and international migration. The Italian
      case, in Towards a European nationality. Citizenship, immigration and nationality
      law in the EU, Patrick Weil, ed, Basingstoke, Palgrave: 95-117.
Pellecchia, Umberto, Francesco Zanotelli, a cura di, 2010, La cura a il potere. Salute
      globale, saperi antropologici. Azioni di cooperazione sanitaria transnazionale, Fi-
      renze, Catania, Ed.it.
Pfeiffer, James, Rachel Chapman, 2010, Anthropological Perspectives on Structural
      Adjustment and Public Health, Annual Review of Anthropology, 39, 1: 149-165.
Pfeiffer, James, Mark Nichter, 2008, What Can Critical Medical Anthropology
      Contribute to Global Health? Medical Anthropology Quarterly, 22, 4: 410-415.
Pizza, Giovanni, a cura di, 2012, Fisica e politica delle migrazioni in Italia: prospet-
      tive etnografiche, Antropologia medica, 33-34.
Pribilsky, Jason, 2008, Sending energías from the Andes: the social efficacy of
      travelling medicines, Anthropology News, 49, 5: 13-14.
Quesada, James, Laurie K. Hart, Philippe Bourgois, 2011, Structural vulnerability
      and health. Latino migrant laborers in the United States, Medical
      Anthropology. Cross-Cultural Studies in Health and Illness, 30, 4: 339-362.
Raffaetà, Roberta, 2013, Famiglie immigrate e accesso ai servizi sanitari di pediatria
      nella Provincia di Trento: una ricerca antropologica in L’immigrazione in Tren-
      tino– Rapporto annuale 2012 Maurizio Ambrosini, Paolo Boccagni, Serena Pio-
      vesan, a cura di, Trento, Pubblicazioni della Provincia Autonoma di Trento:
      145-162.
Raffaetà, Roberta, 2015a, “My Parents Never Spent Time With Me!” Migrants’
      Parents in Italy and Hegemonic Ideals of Competent Parenting, Journal of
      Family Issues, 36, 9: 1192-1211.
Raffaetà, Roberta, 2015b, Hope emplaced. What happens to hope after arrival: The
      case of Ecuadorian families living in Italy, Space, Emotion and Society, 16: 116-
      122.
Raffaetà, Roberta, Mark Nichter, 2015, Negotiating care in uncertain settings and
      looking beneath the surface of health governance projects, Anthropology in
      Action. Journal for Applied Anthropology in Policy and Practice, 22, 1: 1-6.
Raffaetà, Roberta, Loretta Baldassar, Anita Harris, 2016, Chinese Immigrant Youth
      Identities and Belonging in Prato, Italy. Exploring the intersections between
      migration and youth studies, Identities. Global Studies in Culture and Power,
      23, 4: 422-437.
Raffaetà, Roberta et al., 2017, Medical Pluralism Reloaded, LʼUomo, 1: 95-124.
Reece, Helen, 2006, From parental responsibility to parenting responsibly, in Law
      and sociology, Michael Freeman, ed., Oxford, New York, Oxford University
      Press: 459-473.
Riccio, Bruno, Monica Russo, 2011, Everyday practised citizenship and the
      challenges of representation. Second generation associations in Bologna,
      Journal of Modern Italian Studies, 16, 3: 360-372.



2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
CARING ACROSS BORDERS                                                                81


Roberts, Elizabeth F. S., 2013, Assisted existence. An ethnography of being in
      Ecuador, Journal of the Royal Anthropological Institute, 19, 3: 562-580.
Salih, Ruba, 2003, Gender in Transnationalism. Home, Longing and Belonging among
      Moroccan Migrant Women, London, New York, Routledge.
Seid, Michael et al., 2003, Crossing the border for health care. Access and primary
      care characteristics for young children of Latino farm workers along the US-
      Mexico border, Ambulatory Pediatrics, 3, 3: 121-130.
Sobo, Elisa J., 2009, Medical Travel: What It Means, Why It Matters, Medical
      Anthropology. Cross-Cultural Studies in Health and Illness, 28, 4: 326-335.
Szpuszta, Mario, 2009, Federated Identity and Healthcare, The Architecture Journal,
      https://docs.microsoft.com/en-us/previous-versions/cc836394(v=msdn.10), ac-
      cessed on 13/08/2016.
Tabet, Paola, 1997, La pelle giusta, Torino, Einaudi.
Taliani, Simona, a cura di, 2015, Il rovescio della migrazione. Processi di medicaliz-
      zazione, cittadinanza e legami familiari, Antropologia Medica, 39-40.
Thomas, Felicity, 2010, Transnational health and treatment networks. Meaning,
      value and place in health seeking amongst southern African migrants in
      London, Health & Place, 16: 606-612.
Tiilikainen, Marja, Peter H. Koehn, 2011, Transforming the boundaries of health
      care. Insights from Somali migrants, Medical Anthropology. Cross-Cultural
      Studies in Health and Illness, 30, 5: 518-544.
Umut, Erel, 2011, Reframing migrant mothers as citizens, Citizenship Studies, 15, 6-
      7: 695-709.
Van Walsum, Sarah K., 2004, The Dynamics of Emancipation and Exclusion. Changing
      Family Norms and Dutch Family Migration Policies, IMIS-Beiträge, 24: 119-128.
Vineis, Paolo, 2014, Salute senza confini. Le epidemie della globalizzazione, Torino,
      Codice.
Wailoo, Keith., Julie Livingston, Peter Guarnaccia, P., 2006, Introduction.
      Chronicles of an accidental death, in A death retold. Jesica Santillan, the
      bungled transplant and paradoxes of medical citizenship, Keith Wailoo, Julie
      Livingston, Peter Guarnaccia, eds., Chapel Hill, University of North Carolina
      Press: 1-16.
Wallace, Steven P. et al., 2009, Healing south. why Mexican immigrants in
      California seek health services in Mexico, Medical Care, 47, 6: 662-669.
Waters, Mary, 1990, Ethnic Options.Choosing Identities in America, Berkeley,
      University of California Press.
Whittaker, Andrea, 2010, Challenges of medical travel to global regulation. A case
      study of reproductive travel in Asia, Global Social Policy, 10, 3: 396-415.
Whittaker, Andrea, Lenore Manderson, Elizabeth Cartwright, 2010, Patients
      without Borders. Understanding Medical Travel, Medical Anthropology. Cross-
      Cultural Studies in Health and Illness, 29, 4: 336-343.
Wu, Xun, M-, Ramesh, 2009, Health Care Reforms in Developing Asia. Propositions
      and Realities, Development and Change, 40, 3: 531-549.

                                          2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
82                                                                 ROBERTA RAFFAETÀ


Yuval-Davis, Nira, 2004, Borders, boundaries and the politics of belonging, in
     Ethnicity, nationalism and minority rights, Stephen May, Triq Modood, eds,
     Cambridge, Cambridge University Press.
Yuval-Davis, Nira, 2011, The politics of belonging. Intersectional contestations,
     London, Sage.
Zincone, Giovanna, a cura di, 2006, Familismo legale. Come (non) diventare Italiani,
     Roma, Laterza.




2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83
                                               2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83




 Roberta RAFFAETÀ has a PhD in Anthropology from the University of Lausanne and
 she has been Marie Curie (University of Trento, Monash University) and Fulbright
 (UCLA) fellow. She has extensive teaching experience in various universities and
 currently she is research associate (Assegnista di Ricerca) at the Free University of
 Bozen-Bolzano. She has conducted research on a variety of topics at the
 intersection between medical anthropology, anthropology of science and
 migration studies. She is author of more than 30 papers in international peer-
 reviewed journals and of a monograph.
 roberta.raffaeta@gmail.com




This work is licensed under the Creative Commons © Roberta Raffaetà
Caring across borders: The politics of belonging and transnational health
2019 | ANUAC. VOL. 8, N° 1, GIUGNO 2019: 59-83.
ISSN: 2239-625X - DOI: 10.7340/anuac2239-625X-3624
