Over the 20th century, Malians relied on local reproductive specialists: excisers (who oversaw initiation and circumcision ceremonies), nuptial counselors (who provided sexual education at marriage), and midwives. These older women’s work remained vital to social conceptions of proper reproduction, even as the biomedical maternal health system expanded, and Malians adjusted to new forms of religiosity and new ideas of status. Reproductive Labors: Women’s Expertise and Biomedical Authority in Mali 1935-1999 traces how, as biomedical care expanded over the 20th century, women and their families, feminist activists, medical professionals, and non-profit workers began to debate the importance of local reproductive practices. Part 1 explores the role of specialist labor in socializing sexuality and gender norms. In Chapter 1, I argue that following the end of slavery in the early 20th century, Malian families used nuptial counseling to instill concepts of honorable sexuality and demonstrate status at marriage (1935-1958). After independence, public outcry over unwed mothers revealed different visions of extra/marital sexuality and adolescence for nuptial counselors and state-affiliated women activists (1959-1986). In Part 2, I turn to reproductive health interventions. Chapter 3 reveals how the colonial maternal health system relied on external actors, from benevolent associations to Malian midwives, all of whom defined women’s bodies as childbearing bodies (1935-1958). Successive post-colonial governments sought to develop policies to ensure rural health access, toggling between training medical professionals to work in rural places and training local specialists, such as midwives, in biomedical techniques (1957-1976). The integration of midwives into biomedical clinics created substantial overlap between various therapeutic interventions, as I show in Chapter 5. Finally, Chapter 6 demonstrates how Malian participation in anti-excision activism owed as much to previous debates over marriage, unwed mothers, and rural maternity care as to transnational feminist movements and developmentalist interventions (1984-1999). Reproductive Labors is based on interdisciplinary research in Mali, Senegal, France and the US, including archival research, oral histories, and ethnographic work. In addition to working in national archives, the project engages with the floatsam of project reports now safe-guarded in people’s homes, bureaucratic documents from institutional archives like Mali’s National Health Directorate, and student theses. However, women’s specialist labor is less visible in archival material. In response to this elision of gendered knowledge, the project integrates ethnographic observation and French and Bamanakan oral history interviews with women specialists, as well as medical personnel and gender-rights activists. Reproductive Labors demonstrates how Malians were socialized into heterosexuality not simply through family or media, but through specific specialist interventions which linked heterosexuality to biological reproduction and gendered identities, deepening key themes in gender and sexuality studies. Reproductive specialists’ expertise was defined by their gender, skill, age, and social status, as most were older women of endogamous social group descent. Conversely, the activists who campaigned against them were usually highly-educated young women with close ties to international feminist institutions, although these linkages were structured by the colonial afterlives of educational and financial networks. Over the 20th century, questions about which group should have authority over young women’s reproductive experiences led to numerous debates for women and their families. Secondly, this project demonstrates that the continued value of local specialists for Malians, alongside the medical system’s reliance on external actors and instability in rural areas, created a specific form of Malian biomedicine driven as much by local therapeutic practices and social hierarchies as by international norms, enriching recent scholarship on the local specificities of biomedicine. Finally, this dissertation deepens scholarship on state-making in Africa. It demonstrates that reproductive health was not simply a subfield of the post-colonial Malian health system but that it became a key site for innovation in governance. As the first academic history of reproductive health in Mali, which has one of the world’s highest rates of maternal and child mortality, this dissertation seeks to understand the history of reproductive practices as a step towards reproductive justice.

Innovative primary care models that deliver comprehensive primary care to address medical and social needs are an established means of improving health outcomes and reducing healthcare costs among persons living with chronic disease. Care management is one such approach that requires providers to monitor their respective patient panels and intervene on patients requiring care. Health information technology (IT) has been established as a critical component of care management and similar care models. While there exist a plethora of health IT systems for facilitating primary care, there is limited research on their ability to support care management and its emphasis on monitoring panels of patients with complex needs. In this dissertation, I advance the understanding of how computational methods can better support clinicians delivering care management, and use the management of human immunodeficiency virus (HIV) as an example scenario of use. The research described herein is segmented into 3 aims; the first was to understand the processes and barriers associated with care management and assess whether existing IT can support clinicians in this domain. The second and third aim focused on informing potential solutions to the technological shortcomings identified in the first aim. In the studies of the first aim, I conducted interviews and observations in two HIV primary care programs and analyzed the data generated to create a conceptual framework of population monitoring and identify challenges faced by clinicians in delivering care management. In the studies of the second aim, I used computational methods to advance the science of extracting from the patient record social and behavioral determinants of health (SBDH), which are not easily accessible to clinicians and represent an important barrier to care management. In the third aim, I conducted a controlled experimental evaluation to assess whether data visualization can improve clinician’s ability to maintain awareness of their patient panels.

Humans’ social relationships determine to a large degree their trajectories in life. Despite strong evidence for the impact of interpersonal relations on wellbeing, the causal links between the two are not yet fully understood. This dissertation offers a new perspective on the mechanisms through which social ties influence negative (excessive drinking) and positive (participation in recreational activities) health behaviors. In three studies employing a unique combination of social network, fMRI, and experience-sampling methods, we propose that health decisions are the result of complex computations involving prior social experiences, perceived social norms, social comparison processes, and current feelings of connections. Each chapter of this dissertation discusses one of these three studies. Chapter 1 provides evidence that past social experiences shape valuations of new information by showing that pairs of students that drink often together tend to have more similar neural responses to novel alcohol cues in regions associated with affective self-generated thought. In addition, this Chapter suggests that researchers must consider the intricate interplay between individuals’ personal goals and their communities’ norms to understand the influence of social environments on neural representations. The degree to which students aligned their neural response patterns to alcohol with those of their peers depended on interactions between their individual motives for drinking and their group’s approval of this behavior. Chapter 2 presents novel findings that people spontaneously represent social information from multiple networks (e.g., popularity and leadership) at a neural level in social cognition (right TPJ, dmPFC) and valuation (vmPFC) regions. Importantly, individuals who display higher neural sensitivity to status differences are also more likely to align their drinking behavior with their group norms in daily life. Together, our results provide insight into the neural mechanisms through which social comparison processes shape conformity and suggest social cognition and valuation regions as important hubs orchestrating this process. While Chapter 1 and Chapter 2 focus on the influence of social ties on drinking, Chapter 3 discusses the protective role of close relations during difficult times. We provide evidence that close college friendships, even if afar, helped young adults cope with the stress of the COVID-19 pandemic. Follow-up between- and within-individual analyses reveal that this buffering effect could be explained by differences in the quality of online interactions (e.g., via phone, text messaging), instances of personal disclosure, and participation in enjoyable activities. All in all, this dissertation advances our understanding of why measures of social wellbeing are the best predictor of health trajectories in life, by highlighting the important role social ties play in shaping valuation of new information, guiding behavior to meet social goals, and protecting against stress by allowing people to engage in recreational activities.