Guest Blog: Reflections on Antibiotic Use in American Hospitals

Posted by jknopes

This week, we are featuring a special guest blog written by Katharina Rynkiewich from Washington University in St. Louis. Today, she tells us about her experiences researching antibiotic use among infectious disease practitioners in Chicago, Illinois. If you would like to submit a guest blog entry on your research, please send a 500-700 word piece to social media editor Julia Balacko at jcb193@case.edu.

In the spring of 2013, I conducted research on hospital-based infectious disease specialists in Chicago. Although my participants had a lot to say about antibiotic resistance, I was most surprised at how they characterized and criticized fellow clinicians’ use of antibiotics in relation to resistant disease strains. In hospitals, they suggested, the regulation of antibiotics has changed drastically in the past half century. Some of the older infectious disease specialists I interviewed remembered a time when antibiotic overuse was rampant within the hospital setting. “Anyone could prescribe antibiotics,” my participants complained when describing that era. Clinicians and hospital officials at that time had little reason to expect that antibiotic resistance would become the expensive, lethal, and complicated problem that it is today.

In health care settings now, there is more regulation concerning the use of antibiotics. Clinicians are experiencing a lull in the production of antibiotics for infectious diseases, and practitioners must make do with the limited antibiotic supplies they have. Today, there are systematic hospital reviews of antibiotic use to monitor how often the drugs are used. However, most practitioners can still prescribe antibiotics with little oversight. Procedurally, the review of antibiotics in the hospital setting is an enormous task, and an adjustment of patient treatment plans may not occur until after the first few doses of an antibiotic have been given. There is room, therefore, for antibiotic-resistant diseases to generate as misuse and overuse of antibiotics still occurs.

One way to mitigate overuse employed was the notion of antibiotic stewardship: an idea that the infectious disease specialists I interviewed frequently emphasized. “Stewardship” here refers to the responsibility of certain clinicians to manage antibiotic prescription and usage. The infectious disease specialists expressed a desire to have more control over the distribution of antibiotics in hospital settings, leaving surgery to the surgeon and cancer to the oncologist. The infectious disease staff wished for this level of control over antibiotic use despite the fact that both surgeons and oncologists can prescribe antibiotics independently, meaning antibiotics are not managed by one clinical care specialty. When asked whether, in general, practitioners today realize the importance of antibiotic stewardship in light of the dangers of antibiotic resistant infections, one infectious disease practitioner joked, “Which doctors?” My data show that many infectious disease specialists note that their management of antibiotic resistance is quite a challenge because most other physicians within and outside of hospitals may readily prescribe them.

This issue is especially pressing because illnesses themselves are rarely treated with one biomedical intervention, or by one clinician. Few patients can be treated for one disease with one corresponding treatment, meaning that patients’ cases are managed with a variety of therapies and by a number of doctors. Patients can also have multiple conditions, again meaning that multiple types of practitioners can prescribe antibiotics for these patients at different points in their hospital stay. In these complex networks of caregiving, who gets the power to give antibiotics might not always be clear, or there might be tension when deciding who gets to limit the drug’s use. Indeed, when an infectious disease specialist is added to a patient’s chart, they are often added as a consult, meaning their advice may not be adhered to by the primary physician.

Certainly, we can expect that infectious disease specialists want professional autonomy over the management of antibiotic drugs, which means limiting and surveying the drug’s accessibility to other clinicians. But to do so, this would mean that other practitioners would have to agree to the control of part of their treatment plans by an outside party. This relationship of competing interests and access to antibiotics leads to disagreements and struggles of bureaucratic power in the hospital. As it stands, the future of antibiotic resistance rests in the hands of all practitioners who must negotiate who gets to prescribe, and who gets to control, the use of antibiotics.

About the Author: Katharina Rynkiewich

I am a PhD student in Anthropology at Washington University in St. Louis. My current research involves studies of infectious disease practitioners and treatment of infectious disease in hospital settings, and will focus on hospital policy regarding infection and epistemic differences among specialty groups of physicians. In 2013, I completed a masters program (MAPSS) at the University of Chicago, and research for this post was done in partial fulfillment of this masters.

From the Archive: Biotechnology and the Culture of Medicine

Posted by jknopes

In the “From the Archive” series, we highlight articles published throughout the journal’s history. We look forward to sharing with our readers these samples of the innovative research that CMP has published on the cultural life of medicine across the globe.

In this installment of From the Archive, we turn to Mary-Jo Delvecchio Good’s article The Biotechnical Embrace (Vol 25 Issue 4, December 2001.) In this piece, Delvecchio Good frames three concepts in the cultural study of biomedicine: medical imaginaries, biotechnical embraces, and clinical narratives. Here, we will briefly outline these notions.

The medical imaginary, we learn, is the envisioned potential of the new technologies and treatments that medicine could produce in the future. The power of possibility in this sense impacts both clinicians, who are always working to stay ahead of new scientific knowledge, and patients: often those afflicted with diseases for which no current remedy exists. The medical imaginary situates medical progress in a position of hope and opportunity. Stories of medical failure, malpractice, or dearths of medical knowledge, although evidence contrary to establishing an “optimistic” view of the field, are framed in an overarching positive narrative of scientific progress.

Delvecchio Good next describes the biotechnical embrace: the embracing of, and the “being embraced” by technical innovations. This refers to the public “enthusiasm” for biotechnical therapies, as well as the engagement of biotechnologies with the patient’s body. Like the medical imaginary, the biotechnical embrace concept recalls a biomedical commitment to scientific progress and possibility. Even whenever a treatment is highly experimental, not yet approved as effective, or so new that its pitfalls are not fully known, patients will ’embrace’ and request it– and the public will hastily invest in it.

Lastly, we parse the concept of the clinical narrative, or ethnographic frame. This qualitative data is what evidences popular and clinical enthusiasm for bioscientific innovation and the use of the latest technological treatments.

Put simply, narratives can demonstrate that patients and clinicians alike are able to frame care in terms of the gap between what is presently the case, and what might be. For instance, a cancer patient might note the gaps between their condition, current treatments they have used, future therapeutic options, and subsequent clinical outcomes for his or her illness. Clinical narratives remind us that patients (and caregivers) do not view medicine as a static database of information, but instead a dynamic and progressive body of knowledge that exists in relation to illness experiences.

Click here for a link to the abstract and further details about the paper: http://link.springer.com/article/10.1023/A%3A1013097002487

Preview of Books Received: Vol. 38 Issue 4, Dec 2014

Posted by jknopes

The following are previews of two books received for review at Culture, Medicine, and Psychiatry. These previews provide a snapshot of recent publications in medical anthropology, cultural studies, and the history of medicine. For a full list of books received in December 2014, click here: http://link.springer.com/article/10.1007/s11013-014-9395-6

Image via Berghahn Books

Culture, Suicide, and the Human Condition

Edited by Marja-Liisa Honkasalo and Miira Tuominen / Afterword by Arthur Kleinman

This collection of research on suicide argues that suicide is not “a separate realm of pathological behavior,” but instead a human action contextualized by a suicidal person’s cultural, historical, and ethnic roots. However, “the context never completely determines the decision,” allowing the authors to focus on suicide as both cultural and psychological phenomena. The authors emphasize individual action and choice regarding the decision to commit suicide. Similarly, the collection presents a complicated puzzle: suicidal narratives make sense of self-killing to a community, and depict suicide as a “solution to common human problems.”

Culture, Suicide, and the Human Condition was released in March 2014 by Berghahn Books. More details on the book here: https://www.berghahnbooks.com/extras/docs/flyer/HonkasaloCulture_9781782382348.html

Image via MIT Press

A Metaphysics of Psychopathology

Peter Zachar

Zachar’s book asks what constitutes the “real” in psychopathology. He states that in psychiatry, pathologies are assumed to be “real,” while in psychology, the “realness” of a pathology is debated in terms of its roots in personality, superego, or in “general intelligence.” Neither discipline, however, aims to pin down what “real” entails for mental illness and conditions. Some pathologies move from being cast off as imaginary to being embraced as legitimate, such as PTSD, and others, like multiple personality disorder, are classified as real only to be later considered imaginary. Zachar takes a philosophical approach to considering what “real” means in terms of psychiatric and psychological classification, proposing a new classificatory system that the summary asserts “avoids both relativism and essentialism.” He then uses this model to interpret recent “controversies” in the inclusion of certain mental disorders within existing classificatory systems.

A Metaphysics of Psychopathology was released in March 2014 by MIT Press: http://mitpress.mit.edu/books/metaphysics-psychopathology

AAA 2014: Perspectives on the Bruno Latour Distinguished Lecture

Posted by jknopes

This year at the American Anthropological Association 2014 Meeting, Bruno Latour was invited to deliver the distinguished lecture. Entitled “Anthropology at the Time of the Anthropocene,” Latour discusses the rise in the term anthropocene to describe our current stage of natural history. Although the term makes reference to how “human” (anthro) our current age may be, Latour jests that this term was introduced by geologists, not social scientists. In the anthropocene, it is humans that play the defining role in our geological historical moment.

The assumption, Latour notes, is that human agency is the prime source of action that shapes the physical world. Humans are responsible for climate change, for pollution, for altering the literal, natural fabric of our world. Yet we know that not all humans have the same impact on our environment. As Latour quips, there is not “One Human” who is responsible for the changes we see in our climate or environment. We are simultaneously assessing human power as a plural, collective entity, as well as using this concept to suggest that the blame for global change does not fall evenly across all humans. As anthropologists and cultural theorists, we know how fragile human agency can be when we divide it amongst many contending social and cultural groups.

Our blog editor at the Latour Distinguished Lecture

Is there another way to think about human action that does not problematically configure humans as both collective and individual, acting but not universally accountable for all human actions? Latour posits that rather than focusing solely on agency, with a strong emphasis on human intention and purpose when committing action, we could think instead about animation, or what forces–human and non-human– are in motion in a given social space. To do so, we can no longer assume that the human agent is a colloquial be-all-end-all.

How does this assertion speak to medical anthropology, social medicine, and medical humanities? At first, we might raise our brows at the discussions of geography, environment, and most of all the suspicion surrounding the primacy of human agency. Decentralizing the human agent, we might say, is perhaps the least humanistic approach to the study of human experience. Indeed, medicine is the care of humans by humans!

However, our human ability to question our own power and position in the universe, amidst other natural and non-human forces, is a mark of our species. Whether through philosophy, religion, or social science, humans have a proclivity for ruminating about our place in the material, corporal world. We crave knowledge about what sets us apart from non-human things, and how we are sometimes reliant on them. For scholars of medicine, such inquiries about our relationships with the physical universe is key. We consider the place of non-human agents in disease and care. We ask: why do physicians rely on certain tools? Why do patients see stethoscopes, thermometers, and scalpels as making a clinician legitimate in his or her practice? How are medical traditions made unique by their tools and pharmaceutical formulas? Could the layout of a hospital or clinic itself alter the way care is given?

In an age where technology permeates developed and developing societies, Latour’s suggestion to destabilize human agency is productive when considering medicine as a cultural object. We must think not only of ourselves, but the physical environments we live in and the material objects and devices we cannot seem to live without.

Many scholars understandably resist Latour’s idea that non-humans could have some primitive agency. Yet even if we do not assign agency to non-human tools, things, and environments, thinking seriously about their role in sociocultural systems is informative. Medicine is a lively site of exchange between patients and physicians, as well as practitioners and devices, patients and new medical innovations, and the built environments which house them. As Latour invites us to do, we should pause to consider humans within the midst of a rich material world around us that– like humanity itself– is constantly in motion.

Julia Balacko is a second-year PhD student in medical anthropology at Case Western Reserve University. She holds an MA in Humanities from the University of Chicago. Her research focuses on the culture of human anatomy and dissection in Western medical traditions, as well as public access to anatomical and pathological specimens.

Note on the presenter:

Bruno Latour is professor at the Sciences Po Paris in Paris, France. A central theorist in STS (science and technology studies), he is the author of We Have Never Been Modern (1991), Science in Action (1987) and Laboratory Life (1979).

You can read the full text of Latour’s lecture here: http://www.bruno-latour.fr/sites/default/files/139-AAA-Washington.pdf

Current Issue Highlight: Vol. 38 Issue 4, December 2014

Posted by jknopes

In our “Current Issue Highlight” series, we provide brief synopses of some of the original articles and commentaries published in our latest issue of Culture, Medicine, and Psychiatry. We hope these glimpses into our recent publications serve as a taste of the research we publish, as well as offer fresh insights on the intersections of culture, disease, health, and healing.

“The Ethics of Ambivalence and the Practice of Constraint in US Psychiatry”

Paul Brodwin

“This article,” the abstract begins, “investigates the ambivalence of front-line mental health clinicians toward their power to impose treatment against people’s will.” Ambivalence is itself a psychological construct that describes the tensions between love and hate, or multiple perspectives, within both individual subjects as well as the collective social group: here, psychiatric health workers. Central to this article is the friction generated between the clinicians’ self-concept as caregivers and their professional drive to control patients. Such ambivalence about clinical work in psychiatry is evident in the ethnographic research presented here.

Brodwin’s piece reminds us that anthropology is perfectly situated to draw meaning from these problematic and conflicted perspectives within a social group. Rather than reconciling the participants’ feelings and drawing one universal message from them, Brodwin presents us with an authentic picture of the complicated world of clinical psychiatric practice. He concludes, “To understand the paradox, fieldwork should focus especially on the moments when people’s sense of unease erupts into collective life.”

Link to article: http://link.springer.com/article/10.1007/s11013-014-9401-z

“A Village Possessed by ‘Witches’: A Mixed-Methods Case–Control Study of Possession and Common Mental Disorders in Rural Nepal”

Ram P. Sapkota, et al.

In this article, the authors probe an important question: if we consider spirit possession and psychopathology as separate categories, rather than assume possession as a form of mental illness, how might we describe mental illness within a population who has experienced spirit possession? For societies in which spirit encounters are frequent and socially normative, reading mental illness as distinct from possession is particularly critical when exploring local psychic events.

Nepal provided fertile intellectual grounds for exploring this question because spiritual possession occurs regularly. When the researchers delivered educational sessions on psychosomatic and psychosocial illnesses, suggesting that spirit possession might be a type of mental distress, villagers in the study resisted this notion. They argued that possession was rooted in cosmological and supernatural disturbances, making them altogether different psychological phenomena.

Instead of casting possession as a brand of psychiatric illness, the authors suggest that we might view possession as a coping mechanism against other mental duress. In another way, we could conceive of possession as a cultural idiom of distress: reframing illness in terms of a socially acceptable category of experience that is widely shared.

Link to article: http://link.springer.com/article/10.1007/s11013-014-9393-8

“Confinement and Psychiatric Care: A Comparison Between High-Security Units for Prisoners and for Difficult Patients in France”

Livia Velpry & Benoît Eyraud

Focusing on French mental health care, this article explores the evolving use of confinement as part of the treatment of mentally ill individuals who exhibit violent behavior. The authors parallel the nature of confinement in French psychiatric wards to the security practices of high-security prison units.

In their research, Velpry and Eyraud discovered that the public appeal to heightened security in psychiatric institutions, as well as executive action from the president, led to a “turn” towards new confinement measures. Second, psychiatrists used this new narrative of control to justify control techniques that they argued gave patients “psychic structure.” Rather than standing as its own therapeutic measure, physicians employed confinement as a means of managing “difficult” patients.

As an object of inquiry, this recent trend in French psychiatry recalls the complementary trajectories of care and justice, power and control, as well as reflects on the changing landscape of what we define as therapy.

Link to article: http://link.springer.com/article/10.1007/s11013-014-9400-0

“Psychiatry with Teeth: Notes on Coercion and Control in France and the United States”

Anne M. Lovell & Lorna A. Rhodes

This commentary piece on the articles published in the current issue highlights the “rough edge” of the use of constraint and coercion to subdue “difficult” psychiatric patients. Lovell and Rhodes note that many of the articles demonstrate how these forms of discipline and control are enacted at the local scale, and remind us that the exchange between psychiatric patient and the care institution is the site of the strongest conflict when we look at systems of control. What is the border between “care and custody,” the issue asks? How do we as anthropologists contribute to the knowledge about these complex social interactions?

Furthermore, the authors observe that the geographic emphasis on psychiatric care in France and the United States is hardly accidental. Although care practices for the mentally ill differ widely between the two countries, the focus on constraint and control is similarly present in the scholarly literature produced on psychiatry in each place. Likewise, in French and American research, there is a mutual tendency to study mental health care in terms of autonomy, freedom, humanism, and democracy.

Link to commentary: http://link.springer.com/article/10.1007/s11013-014-9420-9

Want to see a preview and abstracts of all the articles in the current issue? Find details on the full issue here: http://link.springer.com/journal/11013/38/4/page/1

Book Release: Sharon R. Kaufman’s “Ordinary Medicine”

Posted by jknopes

Via the Duke UP website

In May 2015, Sharon R. Kaufman’s book Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line is set to be released by Duke University Press. The text will address the contested division between what is a life-saving therapy and what proves to be over-treatment of older patients. This divide, Kaufman states, is frequently negotiated by pharmaceutical, biomedical, and insurance industries. Treatments that might seem aggressive or unnecessary to address late-life health concerns have become common procedures.

Drawing on ethnographic accounts from older patients, their families, and their physicians, Kaufman demonstrates how patients and their caregivers decide how much medical intervention is enough, or when it has gone too far. Kaufman considers what this new, medicalized meaning of the “end-of-life” means for patients and for the social world of medicine, while inviting us to consider how we might refresh the goals of medicine when caring for older patients.

Kaufman has previously published on a related topic in her book And a Time to Die: How American Hospitals Shape the End of Life. She is the Chair of the Department of Anthropology, History and Social Medicine at the University of California, San Francisco.

See more about the book from the publisher’s website here:

https://www.dukeupress.edu/Ordinary-Medicine/index.html

A Few Words from the AAA 2014 Meeting

Posted by jknopes

This week, many of our readers (and staff members here in the office of Culture, Medicine, and Psychiatry) are attending the American Anthropological Association’s annual meeting in Washington, DC. For those of you presenting, we wish you the best of luck in delivering thoughtful and productive presentations. To all attendees, we hope you have pleasant travels to the nation’s capital, and return from the conference with new knowledge and fresh ideas.

via Wikimedia Commons

Much like conferences in our field, CMP social media is a common space for intellectual inquiry about contemporary issues in anthropology. In the spirit of building this communal space electronically, we now invite our followers to submit approximately 500-word blog entries– ranging from brief commentaries on a research project, recent presentation, or reflections on topics in medical anthropology, medical humanities, and social medicine– to be considered for our blog.

We ask that submissions to the blog be widely accessible to readers across anthropology and the humanities: from advanced undergraduate students, graduate students, professors, as well as applied practitioners and interdisciplinary researchers. Accepted pieces will be posted here and shared via our Twitter account. This is an opportunity to showcase your work to new audiences and to gain valuable insight into producing widely accessible, digital scholarship. Please direct your submissions to Julia Balacko at jcb193@case.edu.

Thank you for following CMP social media. We look forward to receiving your guest blog submissions and hearing more from you about exciting new research from the AAA Annual Meeting.

Best Wishes,

The CMP Editorial Staff

AAA 2014: Sessions on Biotechnology and Medical Practice

Posted by jknopes

For our readers attending the American Anthropological Association annual meeting this year, we’ve put together a second selected list of sessions on anthropological approaches to biotechnology and forms of medical practice. The following selection of sessions was drawn from this year’s AAA online presentation schedule for the 2014 annual meeting, to be held this year in Washington, DC from December 3-7th (for more information, click here: http://www.aaanet.org/meetings).

Wednesday, December 3rd

Reproductive Potentialities: Assisted Reproductive Technologies and the Imagination of Possible Futures

8:00pm-9:45pm

https://aaa.confex.com/aaa/2014/webprogram/Session11643.html

Thursday, December 4th

Techniques and Technologies of Global Health

9:00am-10:15am

https://aaa.confex.com/aaa/2014/webprogram/Session11699.html

What Constitutes Medical Knowledge?: Part 2 of a Discussion of Affliction by Veena Das

11:00am-12:45pm

https://aaa.confex.com/aaa/2014/webprogram/Session10870.html

Saturday, December 6th

Producing Intercultural Discourse in the Clinical Encounter, Part 2

2:30pm-4:15pm

https://aaa.confex.com/aaa/2014/webprogram/Session12505.html

Revisiting Midwifery: New Approaches to an Old Profession

6:30pm-8:15pm

https://aaa.confex.com/aaa/2014/webprogram/Session11410.html

Ordering, Morality, and Triage: Producing Medical Anthropology Beyond the Suffering Subject – Part 1: Biomedical Interventions and Failings

6:30pm-8:15pm

https://aaa.confex.com/aaa/2014/webprogram/Session11357.html

Sunday, December 7th

Doctors: Influencing and Being Influenced by Their Work and Subject

10:00am-11:45am

https://aaa.confex.com/aaa/2014/webprogram/Session12929.html

From the Archive: Caregiving and Dementia in Urban India

Posted by jknopes

In the “From the Archive” series, we will highlight articles published throughout the journal’s history. We look forward to sharing with our readers these samples of the innovative research that CMP has published on the cultural life of medicine across the globe.

Recently, one of our readers on the Culture, Medicine, and Psychiatry Twitter account requested that our next “From the Archive” post address an aspect of aging and community. In the spirit of the reader’s suggestion, this week we are featuring a 2008 article by Bianca Brijnath and Lenore Manderson entitled “Discipline in Chaos: Foucault, Dementia and Aging in India.” (you can find out more about the article here: http://link.springer.com/article/10.1007/s11013-008-9111-5.)

The authors posit that caregivers for those with dementia are important providers of structure: they are responsible for the patient’s hygiene, diet, and medical needs, as well as accountable for the actions of people who, experiencing symptoms of dementia, sometimes act out in ways which are not consistent with public cultural norms. Typically in India, such care falls into the hands of younger relatives. Domestic caregiving by these family members “prevents the demented body from threatening the stability of the social body.” There are tremendous “social anxieties,” the authors write, surrounding the potential for someone with dementia to resist normative behaviors per the local codes of social life.

The Foucauldian stream of thought here is quite present: the caregiver must “discipline” the body of the dementia patient to reinforce the cultural codes of the society in which both actors live. Although there exists the notion of seva, or the submission of younger relatives to the direction and advice of older relatives, this idea of the respected and powerful elder is complicated in the face of dementia where the power to attend to another person is rather reversed. Instead of being disciplined by the familial patriarchs or matriarchs, younger relatives must both discipline the elder who is unable to provide the social structure for themselves, as well as their own bodies by taking on new routines and practices to accommodate their family member with the illness.

Power, however, is still bi-directional: those with dementia have extraordinary power in altering the routines of their familial caregivers, and even act out violently: the authors note they may “kick, hit, punch, bite, and threaten with a weapon” when they are upset, and are not necessarily expected to limit these actions on their own due to their condition. The transactions of power, agency, and authority in these relationships are resonant with similar social exchanges as explored via the Foucauldian lens in other Western settings.

Brijnath and Manderson’s piece highlights important features in the care of dementia patients, and demonstrates that community-based models of caregiving for the elderly are not as simple as the removal of power from the elderly individual and the installation of authority in the caregiver. The caregiver, too, is both self-disciplined and disciplined by the acting out of their ward.

AAA 2014: Sessions on Psychiatry, Mental Illness, and Drugs

Posted by jknopes

For our readers attending the American Anthropological Association annual meeting this year, we’re featuring a list of sessions sure to pique your interest in various aspects of mental illness, health, drugs, and psychiatric care. The following selection of sessions was drawn from this year’s AAA online presentation schedule for the 2014 annual meeting, to be held this year in Washington, DC from December 3-7th (for more information, click here: http://www.aaanet.org/meetings). Sessions in the list are organized by chronological date and time.

If you would like your session to be added to this list, please email a link to the session description on the AAA website to: jcb193@case.edu.

Global Mental Healthcare: Challenges, Controversies and Innovations

Wednesday, December 3rd 2pm-3:45pm

http://aaa.confex.com/aaa/2014/webprogram/Session12926.html

“Global” Knowledge, “Local” Care, and Subjectivity: Producing an Anthropology of Psychosis

Wednesday, December 3rd 2pm-3:45pm

http://aaa.confex.com/aaa/2014/webprogram/Session11392.html

Psyche and the Brain in the 21st Century

Wednesday, December 3rd 4pm-5:45pm

http://aaa.confex.com/aaa/2014/webprogram/Session11636.html

Transcendance and the Everyday in Responses to Trauma

Thursday, December 4th 2:30-4:15pm