Book Review: “A Surgeon in the Village”

Posted by sonya.petrakovitz

This week we are highlighting a book review written by Veronica Tomasic originally published in MedHum Daily Dose, a blog for the intersections of medicine and humanities, available here. The book is entitled A Surgeon in the Village: An American Doctor Teaches Brain Surgery in Africa (2017) by Tony Bartelme, published by Beacon Press.

A Surgeon in the Village: An American Doctor Teaches Brain Surgery in Africa (Beacon Press, 2017) is the story of American neurosurgeon Dr. Dilan Ellegala’s efforts to provide medical aid in Tanzania. It was written by Tony Bartelme, an American reporter for Charleston, South Carolina’s Post and Courier; Bartelme is a three time Pulitzer prize finalist, including for the series that formed the basis for this book. The Post and Courier’s executive editor relayed a story to Bartelme about a “crazy brain surgeon who opened a guy’s head with a wire saw in Africa”; Bartelme’s interest was piqued and thus began the story that he narrates here (269).

A Surgeon in the Village is a bildungsroman of sorts. It describes the beginning of Ellegala’s career as a neurosurgeon and his personal journey toward finding meaning in his work. It is also about his ideas for how foreign medical aid should be delivered, and the growth of an organization, Madaktari Africa (Madaktari means doctors in Swahili), that he formed as a result of his ideas.

We first meet Ellegala when he has just completed his neurosurgery training in the US. He is burned out after years of grueling residency and fellowship programs. He travels to Tanzania for six months, volunteering to perform brain surgery at a small, remote hospital. Ellegala is determined to spend as much time as possible vacationing while there. But his plan changes after he starts to attend daily morning meetings where the visiting foreign students and MDs, and local medical personnel gather to discuss their cases. Ellegala observes that the foreign students sit in a privileged position at the front of the room, while the local personnel — such as assistant medical officers (or “AMOs,” who have paramedic plus a few years’ level of training) — stand at the back of the room. This disturbs his sense of propriety — in the US, medical students typically stand or sit behind attendings and residents. He insists that the students and local personnel trade places, a shift that becomes a central organizing metaphor for the book. The change symbolizes the degree of responsibility Ellegala believes the local staff should have for the care they provide, and the respect he feels they should be shown by foreign visitors.

Galvanized, Ellegala starts to rethink traditional models for providing aid in Tanzania, a country with limited resources to train and keep its own MDs. Rather than encourage foreign MDs to travel to a hospital, perform surgeries for a brief period of time and then leave, Ellegala realizes that it makes more sense to train local AMOs to perform neurosurgical procedures. If they can take over, he reasons, a hospital will transition from being dependent on outside help to being self-sustaining. Ellegala notices an AMO who has a surgeon’s confidence about him, Emmanuel Mayyega, and he trains him to diagnose and perform operations for a number of conditions, such as intracranial tumors, head trauma, and hydrocephalus. Eventually, Mayyega trains others. And thus began the “train forward” movement in Tanzania.

Bartelme weaves through his account the challenges Ellegala faces in his career as he devotes time, money, and considerable energy to Madaktari Africa. He also describes some of the ethical issues that are raised by the “train forward” practice. For example, should we accept that people will die in countries where there are not enough traditionally-trained MD surgeons to perform surgeries? Or should surgeries in these countries be performed by people with limited training and supervision because they can save lives? And what about the liability exposure for people trained under such circumstances? One area where the book could have been strengthened would have been to devote a chapter to the history of aid organizations and their varied philosophies. While mention of organizations such as Smile Train, or Paul Farmer’s Partners in Health, among others, are interspersed throughout the book, it was never clear to me whether Ellegala was the first person to conceptualize “train forward,” or whether such a practice had already been established in other countries.

Altogether, A Surgeon in the Village is a warmly engaging account of one doctor’s efforts to make a difference in a part of the world that has limited medical resources, and the personal rewards his efforts afforded him. It would be useful for medical providers and students to read, as well as anyone interested in how best to provide aid to other countries.

Veronica Tomasic (PhD, JD) practices community law in the New Haven, CT, area. She is a scholar of literature, painting, psychoanalytic theory, and end-of-life issues.

For more information about the book, visit the Beacon Press website, here.

Article Highlight: Vol. 41, Issue 2, “Engaging with Dementia: Moral Experiments in Art and Friendship”

Posted by sonya.petrakovitz

This week, we are featuring an Article Highlight written by Monica Windholtz, an Integrated Graduate Studies student in the Anthropology and Bioethics departments at Case Western Reserve University. Monica highlights Janelle S. Taylor’s article from the latest edition of Culture, Medicine, and Psychiatry (Vol. 41, Iss. 2), entitled Engaging with Dementia: Moral Experiments in Art and Friendship. The article examines activities and social circumstances used to involve people with dementia in the world. Taylor depicts the steps involved in creating ‘moral experiments’ that plant patients with dementia in life. Through interviews with caregivers of people with dementia, Taylor explores the role of art and community in engaging those with dementia.

In this article, Taylor analyzes the experiences of individuals with dementia as relayed through the narratives of their caregivers. The article begins with the concept of media portrayals of dementia. Dementia is typically not represented well in the media, with stories devoid of “either subtlety or compassion” (285). In 2014, Julianne Moore received critical acclaim and an Academy Award for her role as the titular character in the film Still Alice, based on a book. The book and movie both chronicle the decline of Alice Howland, a brilliant scientist, as she suffers from early-onset Alzheimer’s Disease. While her husband and two oldest children are unable to confront the changes in Alice and focus only on treatment, her daughter Lydia attempts to understand her mother and engage with Alice’s new world. The article highlights Lydia’s artistic interactions with her mother to introduce the concept of the positive impacts of art and relationships to those with dementia.

While there is currently no effective cure for dementia, caregivers attempt to guide those with dementia to live full lives. The arts have especially served as a way to engage people with dementia, using programs in “storytelling, poetry, painting, dance, theater, [and songwriting]” (287). These programs engage and enrich the lives of individuals suffering with dementia. Artistic forms of expression help to imbue the lives of dementia patients with meaning. In Seattle, such programs to connect with dementia patients have been increasing.

Taylor labels these programs as “moral experiments,” following the work of Cheryl Mattingly where experiments are created by people trying to do the right thing (289). By attempting to enrich the lives of those with dementia, artistic programs are exploring new ways to bring meaning to their daily experiences.

Through an analysis of her interviews, Taylor recounts the experiences of those who have served as caregivers for family members or friends with dementia. In one case, a woman named Janet offered to help engage her friend’s husband, who was suffering with dementia. Their interactions formed a strong friendship between Janet and the husband, enabling him to still feel a sense of community, even as a patient with dementia.

Taylor found that caregivers and friends of those with dementia often see themselves as modeling or teaching proper behaviors to the rest of society, which may exhibit apprehension or discomfort when engaging with dementia patients. Since these anxious attitudes are common, caregivers may have interventions with their social groups or instruct others in how to interact with the individual with dementia. According to Taylor, people should attempt to interact with dementia patients, as they still understand the social environment, even if the context is not clear. Thus it is important for communities and social groups to still recognize the person with dementia in social settings.

Another striking example of people coming together was with the caregivers of Jacqueline, an immigrant woman in Seattle. Jacqueline had relied on the care and help of her mother in the home for many years, but soon after her mother’s death Jacqueline developed dementia. Those that knew Jacqueline were drawn into greater involvement in her life because of her dementia, and helped with the tasks her mother had otherwise taken care of. The group even created a calendar to organize their efforts to aid her.

The Still Alice novel uses the motif of a butterfly to reflect the theme of transformation while still being the same being. As discussed by Taylor, one caregiver of a dementia patient referred to the group that sought to improve the patient’s life as their ‘cocoon.’ The article reflects on the prominent transformations that patients with dementia undergo, and how cocoons and butterflies can both serve as symbols for the moral communities that protect and engage the patients.

In conclusion, Taylor reflects how Still Alice shows that it is not only science and medicine that can improve the lives of those with dementia. Engaging dementia patients through art and the community can help to improve their lives. Finally, there is further room for anthropologists and other researchers to understand and document these other forms of support and improvement.

Guest Blog: “Telemedicine in Ghana”

Posted by sonya.petrakovitz

This week on the blog we are hosting a guest post by Heather Baily, a Doctoral student in Anthropology at Case Western Reserve University. Here, she presents some of her research on telemedicine in Ghana.

In November 2015, Tanja Ahlin and Mark Nichter issued a “Take a Stand” statement in the Critical Anthropology for Global Health interest group (available here), calling for more anthropologists to study telemedicine. Telemedicine is the use of telecommunication tools, namely cell phones and computers, to exchange information regarding patient health. A recent report from the World Health Organization (2016) states that universal health coverage cannot be achieved without this form of e-health. Universal health coverage, as well as comprehensive primary health care, has been an overarching goal of the international health and global health community since the Alma Ata conference in 1978, but these goals are very difficult to achieve. Telemedicine is poised to help achieve greater health coverage and access, yet the field is still very new, particularly in resource-poor settings, and is evolving rapidly alongside cell phone technology.

In June of last year, I traveled to Ghana to investigate the ways in which telemedicine is being used there. Ghana is in the midst of scaling up a successful telemedicine pilot project into a national telemedicine program through Ghana Health Services. Public health administrators in the pilot project districts, as well as doctors and nurses who worked with the program, all spoke favorably of the new technology. Each clinic and hospital has a designated smartphone to be used for various medical communication purposes, including receiving calls from patients, over-the-phone consultation from doctors at the regional hospital call center, and direct contact with the other clinics and district health offices through encrypted instant messaging apps, such as WhatsApp.

Practitioners reported decreased maternal mortality since the implementation of this program, as well as an increase in utilization of local clinics and trust in the staff. In Ghana, once someone has completed medical training of any kind, such as a community health nurse or a registered midwife, they must complete their “national service,” a two-year contract in an assigned village. Typically, community health nurses are younger and not from the village in which they are assigned to work. A “small girl/boy” is a common term used in Ghana for a young person, indicating not only their age, but their social status and lack of social legitimacy. Thus, being able to access and connect a patient to a doctor at a hospital over the phone has helped the nurses achieve more legitimacy and overcome their “small girl/boy” status.

I draw from several areas of anthropological theory when examining the impacts of telemedicine in Ghana, specifically the anthropology of reproduction since my dissertation research focuses on obstetric care. The concept of authoritative knowledge is particularly useful in this case. Authoritative knowledge is knowledge that is given more weight than other types of knowledge, or ways of knowing, by collective assessment in a local setting and is displayed in everyday practices (Jordan, 1990; Davis-Floyd & Sargent, 1997; Ivry, 2010). This concept relates to legitimacy in the health care setting as authoritative knowledge shapes interactions between patients and caregivers, access to knowledge, and health care decision-making. Access to physicians may alter the hierarchy of who has authoritative knowledge, adjust healthcare seeking patterns, or disrupt local power structures and “knowing” about birth.

Science and Technology Studies provides a foundation from which to examine the historical contexts and meanings of technologies and how people interact with them. The introduction of a communication technology which links rural areas to clinicians at a regional hospital complicates questions of the way people interact with technology, especially as it regards obstetric care. Rayna Rapp (1999) examined technologies used in assisting reproduction, which she calls “technologies of knowing.” In this study, she examined the production of knowledge as a result of new technology. Following this tradition, it is important to examine the intersections of technology, reproduction, and knowledge by investigating ways in which the introduction of a new technology changes how a patient might acquire and use knowledge.

Studying telemedicine from an anthropological perspective builds on our understanding of how people interact with technology, particularly when seeking healthcare treatments, and how technology can influence a universal human experience, such as pregnancy and childbirth. As telemedicine is widely regarded as the much-needed direction medical care is heading around the world, it is crucial to examine ways it can shape an individual’s interaction with a technology and with the community at large.

About Heather:

Heather Baily is a dual degree Ph.D./MPH student in Anthropology at Case Western Reserve University. She has a MA in Anthropology from CWRU and a BA in Anthropology and Sociology from Colorado State University. Her research investigates the intersections of new telecommunication technologies used in healthcare and local structures of reproductive knowledge and authority in Ghana.

References Cited:

Davis-Floyd, R., & Sargent, C. F. (1997). Childbirth and authoritative knowledge: Cross-cultural perspectives. Berkeley: University of California Press.

Ivry, T. (2010). Embodying culture: Pregnancy in Japan and Israel. New Brunswick, NJ: Rutgers University Press.

Jordan, B. (1990). Technology and the social distribution of knowledge: Issues for primary health care in developing countries. In J. Coreil and J. D. Mull, (Eds.), Anthropology and Primary Health Care pp. 98–120).

Rapp, R. (1999). Testing women, testing the fetus: The social impact of amniocentesis in America. New York: Routledge.

World Health Organization. (2016). Global diffusion of eHealth: making universal health coverage achievable. Report of the third global survey on eHealth. Geneva.

In the News: Health Disparities and Water Quality in the 2016 Rio Summer Olympics

Posted by sonya.petrakovitz

August 2016 – The 2016 Summer Olympic games in Rio de Janeiro, Brazil has dominated news headlines in recent weeks. The athletics event, taking place from August 5 to August 21, featured 207 countries in the Parade of Nations as well as the first ever Refugee Olympic Team. It is the first time the games have been held in South America. But besides highlights on the events and spotlights on athletes’ training regimens and backgrounds, there is another stream of news stories surrounding the Olympic Games. These stories have focused on two key public health issues related to this year’s Games: health disparities and water quality issues.

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Rio’s Olympic beach volleyball venue is on Copacabana Beach. Photo from Marcio Jose Sanchez for AP.

Only two years ago the FIFA World Cup was making similar headlines in Brazil. As reported in 2014, and highlighted in this blog^{^[1]}, there have been past concerns about access to quality healthcare despite the surge of funds for the World Cup event. These reports unmasked a problematic system of health disparities to a global audience. The Daily Californian^{^[2]} stated that many Brazilians were “unhappy that their government [was] funding stadium renovations instead of spending on more instrumental matters like improved health care and emergency services.” Reports relating to the current Olympics have painted a similar picture for the present health scene. As Reuters^{^[3]} reported in December 2015, the governor of Rio de Janeiro declared a state of emergency “as hospitals, emergency rooms and health clinics cut services or closed units throughout the state as money ran out for equipment, supplies and salaries.” According to CNN^{^[4]}, the financial crisis has been causing difficulties in the “provision of essential public services and can even cause a total breakdown in public security, health, education, mobility and environmental management.”. While the state of emergency declaration provides a critical 45 million reais ($25.3 million) in federal aid and may facilitate the transfer of future funds, estimates state that Rio de Janeiro owes approximately $355 million to employees and suppliers in the healthcare sector alone, and the state needs over $100 million to reopen the closed hospital units and clinics.^{^[5]} While the city of Rio spent approximately $7.1 billion on improving toll roads, ports and other infrastructure projects, the Brazil Ministry of Health devoted only $5.7 million to address health concerns^{^[6]}.

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The Christ the Redeemer statue is visible above the Santa Marta favela in Rio de Janeiro. Photo from Joao Velozo for NPR.

In addition to these issues (and the high-profile Zika virus, which is causing health concerns in multiple countries^{^[7]}), concerns surrounding water quality and cleanliness in Brazil has garnered considerable attention. A recent scene involving the diving and water polo pools turning a swamp-green color because of an algae bloom left some athletes complaining of itchy eyes.^{^[8]} While the Olympic Games have brought international attention to the impact of water quality on the athletes and visitors, the residents of Rio have been dealing with theses concerns on a daily basis for much longer. With almost 13 million people living in and around Rio, the current sewage system is struggling to cope. One news report^{^[9]} notes that “about 50 percent of what Brazilians flush down the toilet ends up in the country’s waterways. Diseases related to contaminated water are the second leading cause of death for children under five in Brazil.” Tests performed in a variety of areas, including the sailing venue of Guanabara Bay, over the course of a year found high levels of “superbugs of the sort found in hospitals on the shores of the bay.” The possibility of hospital sewage entering the municipal sewage system remains a concern.^{^[10]}

An economic recession, compounded by water concerns, political unrest, and a presently faltering healthcare system all leave many Cariocas— citizens of Rio– who rely on the public health system in a challenging and hazardous situation across the social, medical, and political spheres. With hopes of local profits from the Olympic Games ranging in the billions of dollars, much is at stake for both residents and investors.^{^[11]} Despite the risks and tribulations, many residents welcome the international event and attention, and credit the Olympics for cultivating “several underutilized, often abandoned spaces have been transformed to ones that appeal and cater to local residents”. Many “beautification” projects leave residents hoping the installation of new art and the newly constructed spaces will leave a lasting impression on its residents and visitors long after the games end.^{^[12]} Despite this optimism, the citizens of Rio are not impacted equally by the Games.^{^[13]} The improved infrastructures will likely benefit those who already have access to services. Tourism, and tourism cash, has been weak in the favelas, or shantytowns, which house at least 25% of the population in Rio. The infrastructure inequities have even bypassed some neighborhoods entirely, leaving those residents out of the celebrations.^{^[14]}

Overall, these Olympic Games promise once again to bring the world’s cultures together in competition and camaraderie, yet they do not do so without controversy. This global spectacle illuminates athletics and sportsmanship, as well as the intersections between cultural events, politics and nationalism, power and profit, and community health. These larger issues lead to questions about what will happen to the residents of Rio after the Games have drawn to a close.

^{^[1]} https://culturemedicinepsychiatry.com/2014/07/11/news-the-2014-world-cup-and-healthcare-in-brazil/

^{^[2]} http://www.dailycal.org/2014/07/08/uc-berkeley-faculty-graduate-students-look-world-cup-different-light/

^{^[3]} http://www.reuters.com/article/us-brazil-health-emergency-idUSKBN0U716Q20151224

^{^[4]} http://www.cnn.com/2016/06/18/americas/brazil-rio-state-emergency-funding-olympics/

^{^[5]}http://www.reuters.com/article/us-brazil-health-emergency-idUSKBN0U716Q20151224

^{^[6]} http://wuwm.com/post/let-s-do-numbers-money-spent-rio-olympics#stream/0

^{^[7]} http://www.nytimes.com/2016/01/29/world/americas/brazil-zika-rio-olympics.html?_r=0

^{^[8]} http://uk.reuters.com/article/uk-olympics-rio-diving-pool-idUKKCN10O0UW?feedType=RSS&feedName=sportsNews

^{^[9]} http://wuwm.com/post/rios-water-problems-go-far-beyond-olympics#stream/0

^{^[10]} http://edition.cnn.com/2016/08/02/sport/rio-2016-olympic-games-water-quality-sailing-rowing/index.html

^{^[11]} http://www.newsweek.com/rio-2016-who-stands-benefit-successful-olympics-453094

^{^[12]} http://www.kvia.com/news/rio-olympics-bring-beautification-projects/40884340

^{^[13]} http://www.npr.org/sections/thetorch/2016/08/11/487769536/in-rios-favelas-hoped-for-benefits-from-olympics-have-yet-to-materialize

^{^[14]} http://www.reuters.com/video/2016/08/14/olympic-infrastructure-causes-suffering?videoId=369565427

Guest Blog: ‘In-Betweenness’: Liminality, Legality, and Migrant Health in Siracusa, Italy

Posted by jknopes

This week on the blog, we are hosting a guest post by Adam Kersch, an MA Candidate who will begin his PhD in anthropology at the University of California – Davis this fall. Here, he presents findings from his ethnographic research on the health and wellbeing of migrants entangled in the legal webs of relocation in southern Italy.

In January to July 2015, I conducted ethnographic research at a reception center for migrants in Siracusa, Italy, focusing on the struggles they faced upon arrival. Although the legal difficulties and hurdles that migrants faced were readily apparent, the toll that these policies took on the health and well-being of these migrants became increasingly visible during my research. Migrants coming to Italy and to Europe have often endured traumatic events resulting from war, violence, and poverty. Once migrants come to Europe, this crucial period of psychological and physical recovery is marked by ongoing anxiety and hardship as they navigate a complex web of legal processes as they seek asylum. That is, procedures and policies that compose the migration reception apparatus commonly have direct and deleterious effects on migrants’ health.

Abraham was one such migrant whose mental well-being was harmed by slow moving legislative mechanisms. Abraham, a 25 year-old Pakistani man, had been waiting in Umberto I, a primary reception center for migrants in Siracusa, Italy, for nearly six weeks and had heard nothing regarding the status of his asylum request. The poorly-supplied center was only designed to hold migrants for 72 hours, and no legal information was provided to its residents, leaving the migrants waiting in Umberto I without a clue as to their futures in Italy. Abraham left Pakistan fleeing sectarian violence and lack of economic opportunity. After some travel, he found himself in Libya, seeking passage to Europe. Like many other migrants, he was tortured and robbed by militias while in Libya as he worked to pay for his passage to Europe. Reeling from torture, the stress of his liminal status in Italy became unbearable. The center had given him no idea as to when he would be transferred, why he was there, or what his future might be like. Like many others before him, one day Abraham had enough of the waiting and clandestinely left the reception center. He contacted me a few days after leaving, begging for help. He was in Northern Italy, trying to cross the border into France to meet with a friend in Spain, but he kept getting caught and sent back to Italy. “I want to die,” he confessed, “I am a failure. I cannot support myself, I cannot support my family. No money, no work.” Having come to Europe for safety and to help support his family back in Pakistan, the painfully lethargic process of legal recognition prevented Abraham from being able to achieve his goals. His lack of documents prevented him from legally seeking work, but the longer he waited for these documents, the longer his family in Pakistan went hungry, unable to support themselves. Trying to seek asylum elsewhere seemed to him the only logical choice.

During my fieldwork in 2015, I found that migrants waiting to hear about their legal status in Italy had little to no access to legal information, and that this state of liminality facilitated social, psychological, and somatic trauma. Centers like Umberto I function as a part of the migrant reception apparatus in Italy that treats migrants with spotty assistance at best, and absolute negligence at worst. This lack of legal knowledge contributes to an environment of anxiety and leads to the physical and mental suffering of the hundreds of thousands of migrants who have come to Italy in recent years. This dearth of information violates United Nations and European Union (EU) policies on migrant reception, both of which stress that migrants should have access to any legal personnel willing to provide services. In this way, these policies suspend migrants in an ambiguous, unresolved legal status that both directly and indirectly impacts the psychological and somatic health of the migrants and their families.

Lamin, a 20-year-old migrant from Gambia, was another temporary resident of Umberto I. He, like Abraham, experienced deteriorating health as a result of the migrant reception policies and procedures in Siracusa. He had unknowingly agreed to serve as a legal witness for the state against the captain of the boat that brought him across the Mediterranean, who was being charged with human trafficking. The police had effectively coerced Lamin to sign the papers, which were in Italian. They assured him the papers were for his own benefit as they would secure him legal protection. However, since signing them, he had no updates about the court proceedings or about his own legal status. Lamin languished in Umberto I for the moment that he might be transferred or summoned, all the while ignoring the severe pain he was experiencing as a result of holes that had been drilled into his teeth when he was tortured in Libya. He refused to seek medical help, fearing that he may miss his chance to leave Umberto I and finally move forward while getting his teeth fixed. It was only after significant encouraging that he finally sought care from Emergency, a local medical NGO. Thankfully, Lamin successfully recovered and was finally transferred a few weeks later.

In cases such as Lamin’s, legal liminality takes priority over physical suffering. As a result, the slow and onerous migrant reception apparatus exacerbates and prolongs the wounds of migration, whether they are psychological, physical, or social. Those in Umberto I are far from the only sufferers of legal liminality. Cutiyo and her daughter, both refugees from Somalia, came into the legal office late one night in Siracusa. Cutiyo had regularly been coming to speak with Giulia, a local legal activist, to help file a family reunification to bring her husband living in Somalia to Italy. She often saw Giulia simply to ask about the progress of her husband’s case, wondering when she might finally see him again and when he would finally be safe from the violence in Somalia. Cutiyo spoke softly and left quietly after speaking to Giulia. Giulia turned to me, on the verge of tears, and explained that Cutiyo’s husband had been shot in the head five times by militants the night before in Somalia. This happened only a day or two before Cutiyo’s husband was finally to be brought to Italy to be with his wife and daughter. If the sluggish process had been streamlined, perhaps the family could have been reunited. Instead, Cutiyo was now alone in Italy with her daughter, faced with both an uncertain legal status and the social distress and strain caused by the death of her husband. The slow-moving Italian legal system had produced another casualty.

These moments of “in-betweenness” that migrants experience are crucial periods of temporal and social displacement that exacerbate the traumas from which many migrants are attempting to recover. As migrants wait to receive documentation or for their families to be reunited, the physical and psychological risks inherent to seeking a new future in Europe are placed in migrants’ peripheries as they seek legal recognition. As observed by anthropologists Cristiana Giordano (2014) and Miriam Ticktin (2011), granting asylum is often a process of recognizing and validating the suffering migrants experience before arriving in Europe. In circumstances such as these, suffering can become a migrant’s path to legal protection, functioning as a perverse currency that promises security and safety. But during the period in Europe preceding asylum decisions, migrants’ pains are perhaps ironically exacerbated by obtuse and labyrinthine legal processes in the very countries they have come to for protection. Whether it be by anxiety that defers attention to health issues, an uncertain future prompting a rejection of the reception apparatus, or documentation that arrives too late, migrant legislation and reception procedures in Siracusa, Italy have severe consequences for the well-being of people seeking a new future in Europe.

Sources Cited

Giordano, Cristiana. (2014). Migrants in Translation: Caring and the Logics of Difference in Contemporary Italy. Berkeley: University of California Press.

Ticktin, Miriam. (2011). Casualties of Care: Immigration and the Politics of Humanitarianism in France. Berkeley: University of California Press.

About the Author: Adam Kersch is currently a MA Candidate at the University of Central Florida and in September 2016 will begin his first year of PhD studies in Sociocultural Anthropology at the University of California, Davis as a Mellon Institute Comparative Border Studies Fellow. His research is focused on provision of health and legal services to migrants in Italy. He is particularly interested in human rights, imaginaries of Europe, and the politics of care in the context of austerity.

Blog Archive: Neuropsychiatry and Culture

Posted by jknopes

This week on the blog, we revisit a guest commentary piece written last year by M. Ariel Cascio, PhD (originally posted here.) Dr. Cascio is an anthropologist specializing in the cultural study of science and biomedicine, psychological anthropology, and the anthropology of youth. Her research explores the biopolitical dimensions of autism and autism-related services in northern Italy. She can be reached at ariel.cascio@case.edu.

In the 21st century, anthropologists and allied scholars talk frequently of the biologization, cerebralization or neurologization of psychiatry. Many make reference to the 1990s, the “Decade of the Brain” that closed out the last century. They talk about “brain diseases” as a dominant discourse in discussions of mental illness. The 2014 Annual Meeting of the American Anthropological Association hosted a panel on “reflections on mind and body in the era of the ‘cerebral subject.’” In these and other ways, scholars write and talk about increasing dominance of brain discourses in discussion of psychological and psychiatric topics. This dominance has historical roots, for example in German (Kraepelinian) psychiatry, and authors in Culture, Medicine & Psychiatry and elsewhere have written about the historical context and local manifestations of this dominance of the neurological in the psy- sciences.

In this blog post I explore a situation in which neurology and psychiatry have long co-existed: the Italian field of neuropsychiatry. While the field “neuropsychiatry” is not unknown in the United States, and similar terms are used in other countries as well, I offer some comments specifically on the Italian context. The example of Italian neuropsychiatry provides one case of a particular historical relationship between neurology, psychiatry, and psychology that would be of interest to any historical or anthropological scholars of psychiatry.

The Italian medical system distinguishes between neuropsychiatry and psychiatry, neuropsichiatria infantile and psichiatria. Neuropsichiatria infantile (child neuropsychiatry), abbreviated NPI but sometimes referred to simply as neuropsichiatria (neuropsychiatry), addresses neurological, psychiatric, and developmental problems in children under age 18. Psichiatria (psychiatry) treats adults starting at age 18. As such, it is tempting to simply distinguish child and adult psychiatry. However, neuropsychiatry and psychiatry actually have distinct origins and practices. As the names imply, neuropsychiatry links neurology and psychiatry. Adult psychiatry, however, does not.

While Italian psychiatry has its roots in early 19th century organicist and biological approaches, in the 1960s a younger generation of psychiatrists, most prominently Franco Basaglia, aligned themselves with phenomenology and existential psychiatry. These psychiatrists crystallized their ideas into the ideology of Psichiatra Democratica (Democratic Psychiatry) and the initiative of “Basaglia’s Law,” the 1978 Law 180 which began Italy’s process of deinstitutionalization, generally considered to be very successful (Donnelly 1992). While childhood neuropsychiatry is indeed the counterpart to adult psychiatry, more than just the age group served differentiates these fields. If Italian psychiatry has its roots in Basaglia and the ideology of democratic psychiatry, neuropsychiatry has its roots at the turn of the 20th century, in the works of psychiatrist Sante de Sanctis, psychopedagogue Giuseppe F. Montesano, and pedagogue Maria Montessori.

In this way, neuropsychiatry’s origins bridged psychiatry and pedagogy (Bracci 2003; Migone 2014). Giovanni Bollea has been called the father of neuropsychiatry for his role in establishing the professional after World War II (Fiorani 2011; Migone 2014). Fiorani (2011) traces the use of the term neuropsychiatry (as opposed to simply child psychiatry, for example) to Bollea’s desire to honor the distinctly Italian tradition and legacy following Sante de Sanctis.

Several features distinguish psychiatry and neuropsychiatry. Migone (2014) argues that child neuropsychiatry has taken more influence from French psychoanalytic schools, whereas adult psychiatry has taken more influence from first German and then Anglo-Saxon psychiatries. Migone further explains:

Child and adolescent psychiatry in Italy is therefore characterized by a reduced use of medications (if compared to the United States), and by a diffuse use of dynamic psychotherapy, both individual and family therapy (from the mid-1970s systemic therapy spread). The attention to the family and the social environment is extremely important for understand the clinical case during the developmental years. [My translation]

Moreover, neuropsychiatry is known for being multidisciplinary and working in equipe, teams of psychiatrists, psychologists, social workers and so on. It incorporates psychoanalysis, psychotherapy, dynamic psychology, psychological testing, social interventions, and more (Fiorani 2011).

This extremely brief overview outlines key characteristics of Italian neuropsychiatry and the ways it is distinguished from Italian psychiatry, as well as from U.S. psychiatry. Italian neuropsychiatry provides one example of a long-standing relationship between neurology, psychiatry, psychology, philosophy, and pedagogy. By drawing attention to this medical specialty and the complexities of the different fields it addresses, I hope to have piqued the interest of historical and anthropological scholars. I include English and Italian language sources for further reading below.

References and Further Reading – English

Donnelly, Michael. 1992. The Politics of Mental Health in Italy. London ; New York: Routledge.

Feinstein, Adam. 2010. A History of Autism: Conversations with the Pioneers. Malden, MA: Wiley-Blackwell.

Levi, Gabriel, and Paola Bernabei. 1997. Italy. In Handbook of Autism and Pervasive Developmental Disorders. 2nd edition. Donald J. Cohen and Fred R. Volkmar, eds. New York, NY: John Wiley & Sons.

Nardocci, Franco. 2009. The Birth of Child and Adolescent Neuropsychiatry: From Rehabilitation and Social Inclusion of the Mentally Handicapped, to the Care of Mental Health during Development. Ann Ist Super Sanità 45: 33–38.

References and Further Reading – Italian

Bracci, Silvia. 2003. Sviluppo della neuropsichiatria in Italia ed Europa. Storia delle istituzioni psichiatriche per l’infanzia. In L’Ospedale psichiatrico di Roma. Dal Manicomio Provinciale alla Chiusura. Antonio Iaria, Tommaso Losavio, and Pompeo Martelli, eds. Pp. 145–161. Bari: Dedalo.

Fiorani, Matteo. 2011. Giovanni Bollea, 1913-2011: Per Una Storia Della Neuropsichiatria Infantile in Italia. Medicina & Storia 11(21/22): 251–276.

Migone, Paolo. 2014. Storia Della Neuropsichiatria Infantile (prima Parte). Il Ruolo Terapeutico 125: 55–70.

Russo, Concetta, Michele Capararo, and Enrico Valtellina. 2014. A sé e agli altri. Storia della manicomializzazione dell’autismo e delle altre disabilità relazionali nelle cartelle cliniche di S. Servolo. 1. edizione. Milano etc.: Mimesis.

Guest Blog: The Autism Spectrum, Anorexia, and Gender

Posted by jknopes

This week on the blog, we are hosting a guest post by Carolyn Smith, MA, a third-year PhD student in medical anthropology at Case Western Reserve University. Carolyn studies the intersections of mental health, eating, and the body, blending biological and cultural approaches. This blog post complements our July 2015 issue on autism, which you can read more about in the links provided at the end of the guest post.

In Autism spectrum disorders: Toward a gendered embodiment model, Cheslack-Postava and Jordan-Young[1] argue the importance of gender theory in understanding the preponderance of male cases with autism spectrum disorders (ASD) in the United States. In addition to evidence of autism as sex-linked, the authors argue that there is evidence as well for biases in diagnosing autism, and that social environment likely plays a role in male susceptibility. The literature on anorexia nervosa offers a parallel argument: anorexia nervosa, like autism, is often described in terms of biological risk factors[2] yet it remains a socially charged, deeply gendered diagnosis. In the USA and other societies with thin female beauty ideals, for instance, anorexia nervosa is most widely attributed to women.[3]

Both anorexia nervosa and ASD are recognized by the American Psychological Association (APA) and have specific criteria. While these categorizations are justifiably scrutinized by medical anthropologists, here I use the APA criteria as a cultural document that reflect what conditions that biomedical practitioners in the United States are cataloguing when they demarcate mental conditions. Anorexia nervosa is an eating disorder characterized as one of the most fatal mental illnesses in the United States.[4] Diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) includes restrictive eating and an intense fear of gaining weight/persistent behaviors to prevent weight gain. [5] One key criterion for anorexia is being of low body weight with the absence of any other pathology. The inclusion criteria have changed over the years, as have social ideas about the disorder and who suffers from it. Meanwhile, autism is classified as a neurodevelopmental disorder with social deficits and rigid behaviors.[6] The understandings of autism, like anorexia nervosa, have also changed over time in the United States.

Yet gendered categories for these conditions persist. In the realm of psychiatric health, autism is assumed to be a male disorder, and anorexia nervosa, a woman’s diagnosis. This simple categorization overlooks the extent to which anorexia and autism are demonstrably comorbid in studies carried out in the USA and the UK.[7] [8] [9] One study from the UK, in fact, found that anorexics, restrictive-type were five times more likely than the general population to score as high on the Autism Questionnaire as someone with an ASD. ⁹ This finding offers no simple cause-and-effect explanation for how the two disorders are linked. However, this new data suggests that the body, the mind, gender roles, and dieting behaviors may be entwined in ways that resonate with cultural beliefs and categories.

There are competing theories about the etiologies of anorexia as well as autism, each with gendered overtones that do not reflect the findings of associations between the two psychiatric conditions. One theory of autism is that it is linked to a “hypermasculinized” brain.[10] Meanwhile, in a 2012 article for Psychology Today, Maestripieri argues that anorexia may be due to a “hyperfeminine” brain. The two conditions, it seems, appear to be “oppositional.”[11] However, these theories do not capture the wide diversity of cultural perspectives within the USA or UK, meaning there may be unique gendered understandings of psychiatric disorders between social groups that are not accounted for in existing research. In either case, what is clear is that cultural categories of psychiatric conditions in the US and UK may be missing how patients (of any gender, from numerous cultural backgrounds) live and seek care with either condition.

These gendered categories become even more complex for individuals diagnosed as both autistic and anorexic. The comorbidity of ASD and anorexia is complicated by the fact that restrictive dieting in anorexia may lead to cognitive impairment, which subsequently causes behaviors that might be confused with cognitive patterns on the autism spectrum. However, people with anorexia do report having autistic traits prior to the onset of their eating disorder, and people recovering from anorexia appear more often than non-anorexics to fall along the autism spectrum. ^6,7 Thus, the two illnesses co-produce one another in ways that cross traditional gender lines (autism as male, anorexia as female) while also making it difficult, if not impossible, to isolate each condition from the other. Here medical anthropologists can offer valuable perspectives from the view of patients, who may describe their eating patterns and body image in terms that span and challenge existing diagnostic divisions.

Though there may be no empirical means to measure the extent to which ASD and anorexia overlap, existing theories about socialization may shed some light on how these two illnesses co-occur. There are numerous common traits between anorexia nervosa and ASD, including perfectionism, social withdrawal, and obsessive thinking.⁶Girls and women with anorexia appear to have other similar traits to boys and men with autism: systematizing, a fascination with details, and resistance to change. Anorexic individuals with these autistic traits, Baron-Cohen hypothesizes, could become fixated on the systemic relationships behind body weight, shape, and food intake.[12]Of course, this would depend on whether or not the person with autism was brought up in a cultural environment where food intake and body shape are viewed as something that can and should be regulated at all. Here is where socialization may play a crucial role in the development of anorexia nervosa out of behavioral patterns attributed most often to autism.

The comorbidity of ASD and anorexia nervosa presents an anthropologically complex case where discrete classifications of mental illness may not reflect the connectedness of the two conditions. Likewise, the gendering of each illness as dualistic male-autistic and female-anorexic overlooks the extent to which the conditions share behaviors, tendencies, and thought patterns. Though national clinical studies in the USA and the UK suggest a connection between autism and anorexia, cultural readings of gender, eating, and self-regulation amongst patients with comorbid cases might better illuminate how these conditions manifest on the local scale, and between cultural groups.

Additional Reading

Publications:

Jaffa, T., Davies, S., Auyeung, B., Allison, C., & Wheelwright, S. (2013). Do girls with anorexia nervosa have elevated autistic traits. Mol Autism, 4(1), 24.

Nilsson, E. W., Gillberg, C., Gillberg, I. C., & Raastam, M. (1999). Ten-year follow-up of adolescent-onset anorexia nervosa: personality disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 38(11), 1389-1395.

Oldershaw, A., Treasure, J., Hambrook, D., Tchanturia, K., & Schmidt, U. (2011). Is anorexia nervosa a version of autism spectrum disorders?. European Eating Disorders Review, 19(6), 462-474.

Websites:

ASD and Autism

https://www.psychologytoday.com/blog/games-primates-play/201208/the-extreme-female-brain

http://www.medicalnewstoday.com/articles/264666.php

https://books.google.com/books?hl=en&lr=&id=iPGFAgAAQBAJ&oi=fnd&pg=PR10&dq=malson+the+thin+woman&ots=sQPGnzOFN1&sig=ZSv8OMyuNAFQ3UgBOWZTEX5lHAg#v=onepage&q=malson%20the%20thin%20woman&f=false

CMP Special Issue Features: July 2015 Issue on Autism

https://culturemedicinepsychiatry.com/2015/07/08/special-issue-highlight-the-anthropology-of-autism-part-1/

https://culturemedicinepsychiatry.com/2015/07/22/special-issue-highlight-the-anthropology-of-autism-part-2/

https://culturemedicinepsychiatry.com/2015/08/05/autism-in-brazil-and-italy-two-cases-from-the-june-2015-special-issue/

References Cited

[1] Cheslack-Postava, K., & Jordan-Young, R. M. (2012). Autism spectrum disorders: toward a gendered embodiment model. Social science & medicine, 74(11), 1667-1674. “Our argument is fully biosocial, and our main points in advancing it are to articulate a model for autism, specifically for explaining the male-female disparities in prevalence, that does not exclude social environmental variables, and is therefore more biologically satisfying; and to demonstrate concrete mechanisms whereby autism may become more prevalent in males as a result of social structures and processes related to gender (p. 1673).”

[2] Bulik, C. M., Slof-Op’t Landt, M. C., van Furth, E. F., & Sullivan, P. F. (2007). The genetics of anorexia nervosa. Annu. Rev. Nutr., 27, 263-275.

[3] Malson, H. (2003). The thin woman: Feminism, post-structuralism and the social psychology of anorexia nervosa. Routledge.

[4] Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders: A Meta-analysis of 36 Studies. Arch Gen Psychiatry. 2011;68(7):724-731.

[5] IBD

[6] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.).

[7] Zucker, N. L., Losh, M., Bulik, C. M., LaBar, K. S., Piven, J., & Pelphrey, K. A. (2007). Anorexia nervosa and autism spectrum disorders: guided investigation of social cognitive endophenotypes. Psychological bulletin, 133(6), 976.

[8] Nilsson, E. W., Gillberg, C., Gillberg, I. C., & Raastam, M. (1999). Ten-year follow-up of adolescent-onset anorexia nervosa: personality disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 38(11), 1389-1395.

[9] Baron-Cohen., Jaffa, T., Davies, S., Auyeung, B., Allison, C., & Wheelwright, S. (2013). Do girls with anorexia nervosa have elevated autistic traits. Mol Autism, 4(1), 24.

[10] Baron-Cohen, S. (2002). The extreme male brain theory of autism. Trends in cognitive sciences, 6(6), 248-254.

[11] Maestripieri, D. (2012 August 23). The Extreme Female Brain: Where eating disorders really come from. Psychology Today. Retrieved from https://www.psychologytoday.com “Therefore, just like Autism Spectrum Disorders may be the product of the combination of the extremely high systemizing and low empathizing tendencies that characterize the extreme male brain, eating disorders may be a manifestation of high negative evaluation anxiety that originates from the combination of the extremely high empathizing and low systemizing characteristics of the extreme female brain.”

[12] (2013 August 10). Anorexia and autism – are they related? Medical News Today. Retrieved from http://www.medicalnewstoday.com

Guest Blog: Culture, Medicine, and Neuropsychiatry

Posted by jknopes

This week, we are featuring a special guest blog post by M. Ariel Cascio, PhD. Here, she discusses neuropsychiatry in the Italian context and within the United States.

References and Further Reading – English

Donnelly, Michael. 1992. The Politics of Mental Health in Italy. London ; New York: Routledge.

Feinstein, Adam. 2010. A History of Autism: Conversations with the Pioneers. Malden, MA: Wiley-Blackwell.

Levi, Gabriel, and Paola Bernabei. 1997. Italy. In Handbook of Autism and Pervasive Developmental Disorders. 2nd edition. Donald J. Cohen and Fred R. Volkmar, eds. New York, NY: John Wiley & Sons.

References and Further Reading – Italian

Fiorani, Matteo. 2011. Giovanni Bollea, 1913-2011: Per Una Storia Della Neuropsichiatria Infantile in Italia. Medicina & Storia 11(21/22): 251–276.

Migone, Paolo. 2014. Storia Della Neuropsichiatria Infantile (prima Parte). Il Ruolo Terapeutico 125: 55–70.

ABOUT THE AUTHOR

M. Ariel Cascio is an anthropologist specializing in the cultural study of science and biomedicine, psychological anthropology, and the anthropology of youth. She recently successfully defended her dissertation on autism in Italy at Case Western Reserve University. She can be reached at ariel.cascio@case.edu. Her blog, written in Italian and English, can be viewed here: https://arielcascio.wordpress.com/.

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.