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Article Highlight: Vol 40 Issue 4, Media Representations of Opioid Misuse

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The December 2016 issue of Culture, Medicine & Psychiatry is now available here. In this series of article highlights, we will explore publications included in the latest issue. This week, we present a highlight on Julie Netherland and Helena B. Hansen’s “The War on Drugs That Wasn’t: Wasted Whiteness, ‘Dirty Doctors,’ and Race in Media Coverage
of Prescription Opioid Misuse.” The article is accessible in full here.

The authors open their discussion by remarking that the media in the United States has increasingly honed in on heroin and opioid use and misuse by white individuals, particularly featuring stories like that of actor Philip Seymour Hoffman. However, throughout these articles, race is typically not mentioned in conjunction with white opioid users. At the same time, the media has historically depicted drug users as “black and brown,” and demonized these individuals as criminals whose drug use behaviors should be heavily policed.

Thus, the authors assert that there is a “narcotic apartheid” in the media, in which white drug users are insulated from the racist narratives that are attached to opioid misuse amongst non-white individuals. Coded language is typically used to delineate users by race: for instance, using “suburban” or “rural” to refer to white opioid users versus “urban” to indicate non-white users. Classist undertones also shape these narratives, as rural methamphetamine users are derided as ‘hillbillies’ who threaten the moralized order of “whiteness” as suburban and middle class. The type of drugs themselves have taken on racist and classist meanings, such that prescription drug misuse (often ascribed to wealthier, white individuals) is under-prosecuted compared to the use of methamphetamine (poorer, white individuals) and crack cocaine (people of color.)

Despite this, the authors state, it is the racist narrative that remains most prominent in media accounts. Through systematic coding and analysis, Netherland and Hansen found that middle-class white drug users are almost universally characterized in news stories as having “wasted” potential and being “victims” of a challenging climate of drug misuse. They also discovered that stories about drug misuse amongst people of color was not viewed as “newsworthy.” When it was reported, articles focused largely on arrests made or on convictions of drug-related crimes, or on the networks that linked drugs from black and Latina communities to white individuals in the suburbs. In the stories of white opioid users, the articles shifted blame away from the individuals, suggesting they did not ‘intend’ to become addicted. When discussing how to address white drug misuse, the articles most frequently turned to physicians’ prescription practices and the threat of over-prescription. Thus, the solution proposed entails greater regulation of prescription habits: again, beyond the level of the individual user.

Articles on opioid use amongst predominantly non-white, “urban” populations overwhelmingly suggested increased “criminal justice involvement” as the most appropriate response. These articles tended not to craft the stories of non-white opioid users as tragic or accidental. This centralized blame for addiction on non-white opioid users, whereas as noted before, white opioid users tended not to be blamed for their behavior. Further deepening these racist undertones was that the “dirty doctors” (those willing to prescribe opioids to predominantly white patients) reported on in the news were often themselves people of color or immigrants.

The authors conclude that characterizations of opioid news articles as “color-blind” due to the inclusion of stories on white users is misleading. While they agree that the representations of white opioid users demonstrates the impact of drug misuse across racial boundaries, there remains coded language that systematically disparages and marginalizes people of color who use these substances. Netherland and Hansen state that “in short, the problem of race and opioids cannot stop with expansion of access to treatment. Clinicians and health advocates have to address institutional racism, as reflected in media coverage of inner city heroin use versus the prescription opioid epidemic, if they want to dismantle racial exclusions in drug interventions” (page 680.)

Article Highlight: Vol 40 Issue 4, Social Withdrawal in Japan

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The December 2016 issue of Culture, Medicine & Psychiatry is now available here. In this series of article highlights, we will explore publications included in the latest issue. This week, we present a highlight on Ellen Rubinstein’s article “Emplotting Hikikomori: Japanese Parents’ Narratives of Social Withdrawal” (which you can access here.) Rubinstein observes that there has been a flurry of public attention to hikikomori, a socio-medical condition typically experienced by young people that is characterized by increasing, marked social withdrawal.

Rubinstein notes that though there is a perception of hikikomori as a condition of isolation, parents of “hikikomori children” often crafted narratives about their children’s illness that suggested it had discernible stages, signs of progress, and possibility of recovery. These narratives engaged parents in the present, facilitating connectedness between hikikomori children and their families, and thus challenging the assumption that hikikomori is a condition of perpetual or crippling isolation. For instance, some parents at a support group for hikikomori children and their families stated that their children were more mature than others, as their time away from other people encouraged them to be meditative and thoughtful.

One mother, named Kawano-san, first described her son’s hikimori as a process of productive, but not permanent, isolation in an interview with Rubinstein. Kawano-san said that her son’s withdrawal might lend him an opportunity to step away from the social world, assess his future, and prepare for college after initially failing to pass university entrance exams. She felt certain that this period would be one of reflection and reassessment, before the son eventually entered university. Kawano-san also criticized the expectation amongst many Japanese families that children should be extroverted and talkative, instead saying that her son was not pathologically isolated but simply different. Eight months after this initial interview, Kawano-san was interviewed for the second time about her son’s condition. The son had not entered college as Kawano-san expected, but the mother had readjusted her narrative such that she began to acknowledge that path might not be viable for her son. She instead noted that her son could have a disability, or that he simply needed more time to process his feelings. Kawano-san ultimately accepted that her initial expectations did not match her son’s experience, and began to try new approaches to her son’s condition: like encouraging her husband and daughter to write birthday messages to him that might make him feel more welcomed and included in their family unit.

Rubinstein examines similar cases to Kawano-san and her son, finding that many families engaged in a process of narrative emplotment and un-emplotment of their children’s hikikomori. Their narratives thereby gave order or meaning to what otherwise seemed like an ongoing and static psychological condition. Alternatively, they situated their children’s experiences in other contexts: such as expected developmental and social growth, and the efficacy of biomedical interventions or support groups for the condition. Parents of hikikomori children were not inactive bystanders, but rather active interpreters of their children’s experiences and advocates of their unique individual needs. The parents learned to read their children’s condition and support them accordingly, complicating the notion that hikikomori is solely about individual isolation or inaction.

Books for Review: Vol 40 Issue 3, Sept 2016

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In our September 2016 issue, we received these books for review at the journal. The new releases span social science methods, to two ethnographies of biomedicine and human plasticity (available here and here), and finally, two texts on organ transplantation across cultural contexts. This includes Heinemann’s Transplanting Care and Crowley-Matoka’s Domesticating Organ Transplant.

Last year, we featured a book release update on Crowley-Matoka’s work on organ transplantation in Mexico. Here, we revisit the original book release (accessible here.)

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Released this March 2016 from Duke University Press is Megan Crowley-Matoka’s Domesticating Organ Transplant: Familial Sacrifice and National Aspiration in Mexico. The text explores the familial nature of kidney transplantation in Mexico, where the organs are donated between relatives rather than received by strangers. Crowley-Matoka also examines kidney transplant in Mexico beyond the family unit, assessing national pride in transplantation procedures performed at hospitals operated by the state. Through family and government, organ transplantation thus becomes an iconic procedure in Mexican society– both within the home and across the nation– that represents the curative promise of contemporary medicine. Crowley-Matoka’s ethnography highlights the relationships between embodied experience, domestic life, national identity, and clinical practice. This text will appeal widely to scholars who study biomedicine in the Americas, the connections between medicine and the state, and familial networks of caregiving.

About the author: Megan Crowley-Matoka is Assistant Professor of Medical Humanities and Bioethics at Northwestern University. You can access more details about her upcoming book here.

Issue Highlight Vol 40 Issue 3: Asperger’s Syndrome, Subjectivity and the Senses

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This week, we will highlight an Illness Narrative from the September 2016 issue of the journal (available here). Here we feature Ellen Badone, David Nicholas, Wendy Roberts, and Peter Kien’s article “Asperger’s Syndrome, Subjectivity and the Senses.” To read the full article, click here.

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As previous blog highlights suggest, the intersections of research and illness narratives are important to an anthropological perspective on subjectivity and experience. Badone and colleagues situate their article within narrative phenomenology. They discuss how constructing an illness narrative gives patients and families hope, and frames their experiences in a positive direction. The personal narrative, then, allows individuals to express their agency in hostile structural and environmental settings. The narrative also serves as a valuable first-hand account from which medical anthropologists can learn more about the subjective experience of illness.

The authors perform a close reading of an autobiographical narrative recounted by Peter, a young man diagnosed with Asperger’s Syndrome, a type of autism spectrum disorder (ASD.) Badone and colleagues aim to describe Peter’s case to widen understandings of the lived experience of people with autism. Responding to Olga Solomon’s 2010 article “Sense and the Senses: Anthropology and the Study of Autism,” this paper calls into question key assumptions in the clinical and popular literature about ASD relating to theory of mind, empathy, capacity for metaphorical thinking, and ASD as a life-long condition.

Badone and colleagues begin with a brief history of the diagnostic label of ASD, then describe the ethnographic-autobiographical process. Peter, the pseudonym chosen by the young man whose story is told in this article, reflects on his life experiences and articulates his awareness of autism and its impact on his life. An important recognition that Peter makes is that he senses many of the places he encountered were characterized by the “opposite of accommodation.” In the context of his elementary and high school for example, Peter describes how his need for calm and respite were disregarded in the noisy, abrasive environments. But it is Peter’s mother who is his metaphorical, and social, link to the world he felt dislocated from. Peter describes how it was his mother’s love and guidance which kept him alive and motivated to improve his life.

As Peter continues to narrate his experiences, however, he begins to intentionally seek out interactions in unwelcoming social environments. To Badone, Peter’s later decisions to submerse himself in activities that he found difficult, such as unexpected social situations and interactions, was an unconscious therapeutic response. This response mirrored the principles of cognitive behavioral therapy (CBT). To Badone’s astonishment, Peter had unintentionally started a treatment regimen to gradually lessen his anxiety, decrease his “meltdowns,” and become more independent. But to do so, Peter had to alter his own connection to a social environment that initially felt closed to him.

Badone and colleagues conclude, upon analyzing Peter’s narrative, that quality of life improves when individuals with autism are allowed to flourish in a social milieu of acceptance and understanding. Through the narrative, and through phenomenological examination of moments in Peter’s life, Badone and Peter hope to foster understanding and to urge others to create inclusive communities where social interaction is supported and individuals are not made to feel unwelcome. They seek to make autism more coherent to the non-autistic world and thereby to promote the larger ethical goal of creating flexible communities open to accommodating neurodiversity.

Issue Highlight Vol 40 Issue 3: Contradictory Notions of Violence and Trauma in the Military

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This is the second post in a series of article highlights from our new September 2016 issue, available here. In this installment, we explore Tine Molendijk, Eric-Hans Kramer, and Désirée Verweij’s article “Conflicting Notions on Violence and PTSD in the Military: Institutional and Personal Narratives of Combat-Related Illness.” To read the full article, click here.

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Molendijk, Kramer, and Verweij observe that contemporary quantitative research reports that members of the military tend to underuse mental health services, most notably for PTSD. The reports note that soldiers’ beliefs about these services may be hindering utilization: however, existing studies have not specifically identified the beliefs or cultural factors that lead to under-utilization. Through a qualitative analysis of the literature, the authors argue that existing mental health interventions carry contradictory statements about violence and PTSD that may be casting particular social and moral frames onto mental illness. These interventions thus situate PTSD within a pre-figured framework, rather than presenting PTSD and trauma in a manner that individualizes and “decontextualizes” its presentation amongst members of the military: whose personal narratives also offer a distinct perspective on the experience of PTSD. The study focuses on PTSD and its treatment namely amongst the US, UK, and Dutch contexts.

To begin, the authors state that the diagnostic category of PTSD per the DSMV (and its implementation in practice) itself imposes a particular cadence on the disorder, stipulating that it emerges in response to an isolated or otherwise triggering single event, rather than to a diffuse string of violent occurrences or social disruptions. The diagnosis also pathologizes the degree of transition between military and civilian life which, to some degree, must and does occur for all soldiers. “The current mainstream PTSD-concept, with its focus on trauma exposure and individual susceptibilities,” the authors argue, “frames PTSD as the response of an individual to an event,” rather than an individual to a series of events, or many people to a range of traumas.

Beyond the diagnostic category, the “infrastructure” surrounding PTSD and its treatment in the military also impacts the way the illness is conceived and given meaning. The authors “divided the PTSD-infrastructure into five categories: pre-enlistment screening, basic training programs, counseling during deployment and pre- and post-deployment psycho-education, post-deployment screening through a survey and a meeting, and therapy.” In the earliest stages, potential military recruits are screened for existing mental illness, while those who pass screening are then subjected to psychological conditioning in their training intended to bolster soldiers’ emotional and psychological fortitude against combat scenarios. Throughout and after deployment, soldiers are also counseled and receive mental health guidance intended to ease adjustments between the “battlemind” state and the “civilian” mindset. These numerous institutional mechanisms indicate that the military infrastructure situates PTSD as a dysfunctional “deviation” from the ‘functional’ “battlemind,” rather than a natural response to trauma. Thus PTSD is cast as the failure of an individual to integrate and compartmentalize a traumatic event within the mental frameworks for coping that they have already been given, even though the military has already anticipated trauma and attempted to prepare soldiers in the event of psychological disturbance.

From the personal perspective of soldiers, however, the experience of PTSD is presented in a different but equally conflicting light. The authors note that soldiers are expected to psychologically identify and process traumatic events, but are also instructed to resist considering the emotional impact of these events: thereby cognitively preventing them from narrating, contextualizing, and giving meaning to traumatic instances. Furthermore, as violence is a routine aspect of military labor, responses to it are not necessarily “exceptional.” Entire squads may experience the same trauma, although they may not all be later diagnosed with PTSD, or share the belief that mental health care is appropriate for overcoming psychological trauma. Indeed, in military culture, many soldiers may not perceive violence as a trigger, but– as noted earlier– an expected and normal part of daily work. Additionally, acts of military violence may not be perceived as traumatic if they are viewed as necessary, just, or appropriate. Amongst soldiers themselves, PTSD therefore carries conflicting and multiple meanings. The authors summarize that “soldiers have learned that exposure to violence can harm a soldier, and that PTSD-like symptoms are not unusual. However, at the same time, they have learned that violence and stress are inherent to a soldier’s job, and that ‘good soldiers’ should be able to deal with it.” Soldiers who struggle with trauma, therefore, are given resources to address it, but may suspect that it is normal and does not (or should not) require medical intervention. Thus both the institution and the nature of the profession generate conflicting messages about the etiology and treatment of PTSD amongst soldiers.

To some degree, the authors remark, the transition from active deployment (and its related trauma or exposure to violence) to civilian life contains unavoidable contradictions, as the psychological mindset needed for combat versus the mindset for civilian life differ greatly, and the adjustments between them may be difficult. However, the contradictions within the institutional narrative of PTSD– that it is dysfunctional, yet expected, and provided with interventions–may be preventing soldiers from understanding whether or not their response to violence requires treatment, or if seeking help is a stigmatized act. Ultimately, the authors conclude, “the [existing institutional] PTSD-narrative can give soldiers the feeling that important elements of their problems are not taken into account, or that they are translated into an individual problem. If so, soldiers then hear no narrative through which they can understand and articulate their experiences and potential inner struggles about the meaning of these experiences.” The authors’ findings therefore indicate that there are significant and potentially problematic conceptual rifts in the understanding of PTSD between soldiers and institutions, and amongst soldiers acting within the military infrastructure.

 

 

Issue Highlight Vol 40 Issue 3: The Mental Health Treatment Gap Across Africa

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In the coming weeks, we will be presenting special highlights of our latest installment of the journal, released September 2016 (accessible here.) This week, we explore Sara Cooper’s article “‘How I Floated on Gentle Webs of Being’: Psychiatrists’ Stories About the Mental Health Treatment Gap in Africa.” The full article is available here.

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As Cooper notes in the outset of her article, clinicians and global health workers have identified a “gap” in available mental health services in Africa, and developed programs targeted at the resolution of lacking mental health services across the continent. Despite widespread attempts to research and resolve this gap, however, there remains concern about the problems that arise when a global, top-down approach to mental health services is applied in African contexts. Responding to this concern, Cooper sought out views on the treatment gap at the local level, specifically amongst African psychiatrists. Cooper gathered and analyzed narratives from twenty-eight psychiatrists from South Africa, Uganda, Nigeria, and Ethiopia. She found that while a biomedical, rationalistic narrative about the gap was certainly present, another, more phenomenological understanding of the “gap” emerged from the narratives of three of her participants, which urged a more sensitive approach to the implementation of mental health services in Africa.

Cooper first found that some of the psychiatrists in her study repeatedly turned to a dominant (or master) biomedical narrative to explain why the mental health treatment gap existed in their respective countries. In other words, the psychiatrists relied on a rationalistic, deductive, and material explanation that accounted for the mental health treatment landscapes across Africa. For instance, many of the psychiatrists argued that the lack of physical resources– hospitals, beds, clinicians to staff treatment centers– led patients to seek out non-biomedical interventions like prayer-based or spiritual-based care. The participants agreed that if there were enough services available, patients would not turn to complementary or religious forms of treatment. In their perspective, alternative forms of care were a substitute for biomedicine, rather than a legitimate venue for patients to seek mental health assistance in the absence of (or even alongside) biomedical resources.

Indeed, the act of seeking out these alternative treatments was viewed by the psychiatrists as a rational response: one borne out of the creativity of patients who weighed available options and selected the most appropriate, present service (rather than a complex response to a pluralism of local medical systems.) Conversely, however, the psychiatrists also argued that patients underutilized health services and lacked “mental health literacy,” or the knowledge needed to preface the choice to seek out biomedical assistance. Through these examples, and others, Cooper observes that this sub-cohort of psychiatrists tended to return to a rationalistic understanding of medical treatment that may not always have been sensitive to other means of medical decision-making or to the scope of biomedical interventions.

Yet Cooper also discovered that there were notable fractures in the biomedical “master narrative,” wherein psychiatrists’ narratives reveal concerns about the role of biomedical mental health services in addressing treatment gaps. Three psychiatrists admitted that biomedicine might not necessarily address the full scope of a patient’s mental illness or health concerns in the broader context of their lives or personal needs. For example, these three participants noted that the psychiatrist might have to explain that available treatments could potentially fail to fully resolve a patient’s complaint, or that they might have to accept that a patient’s past traumas, or troubling social circumstances, were beyond that which the psychiatrist could ameliorate through medical means. Here, the treatment “gap” is conceptual: the ideological place where a patient’s hopes, experiences, and expectations about their care may not be perfectly matched to the psychiatrist’s available treatments and medical diagnoses.

In this sub-cohort, one psychiatrist remarked that the “paternalistic” method of biomedical treatment could be unproductive, as the clinician may not be able to fully mend the patient’s health due to the social, personal, and individual complexities of the patient case. Another psychiatrist recounted a patient’s case in detail, noting that while he believed this person suffered from delusions, it was his responsibility to help the patient by trying to understand his view of reality, suffering, and personal struggle. Yet another psychiatrist recounted equally challenging cases, where they recognized that patients often were not satisfied with simply a cleanly-defined diagnosis or treatment plan, but required a more robust means of reordering and improving their lives with the psychiatrist’s guidance.

Cooper states that “for these psychiatrists, in taking people’s experiences and meanings seriously, on their own terms, one comes to appreciate that their understandings and behaviours are deeply complex and varied, affected by all sorts of social, cultural and emotional realities and rationalities.” Though the master narrative of biomedical rationality remained prominent, these alternative narratives were sensitive to the lived experiences and individual realities of the patient. They also explored the treatment gap, but viewed the “gap” as the product of complex interactions between psychiatrists and their patients. For the latter three participants, the “gap” was caused not by a lack of resources or knowledge, but by the friction between practitioners’ and patients’ expectations about the treatment of mental illness, and a mismatch between practitioners’ medical skills and the self-professed needs and understandings of patients. “According to the three psychiatrists in this [part of the] study,” Cooper concludes, “increasing the availability of services necessitates first and foremost rethinking the nature of the kinds of services that are expanded, and the associated epistemologies upon which these are based.”

Blog Archive: ALS, Quality of Life, and Feeding Tubes

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This week, we revisit an article highlight that originally debuted here in May 2016. The highlight explores Pols and Limburg’s qualitative research on the role and meaning of feeding tubes in the lives of people with ALS. The article was officially released in our latest September 2016 issue of the journal, and is accessible in full here.

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Pol and Limburg begin by suggesting that while “quality of life” has been transformed into a measurement used widely in health research, it is difficult to operationalize when considering the daily, lived experiences of patients. Rather than approaching quality of life as a measure of attainment or “outcome,” the authors instead choose to reframe it as a continual process: one that is negotiated by individual patients differently. To examine what quality of life entails in a qualitative sense, the authors interviewed a population of people with ALS in the Netherlands with feeding tubes, or ALS patients considering one.

The literature on feeding tubes, the authors note, present many perspectives on the relationships between quality of life and eating. Some sources argue that feeding tubes deprive individuals of the important social aspects of eating, while others note that feeding tubes can unburden patients for whom swallowing and the physical actions of eating are difficult, uncomfortable, or impossible.

Patients and their families interviewed by the researchers, on the other hand, demonstrate such ambiguity towards feeding tubes contextually, depending on the stage of their feeding tube transition. For many, the initial decision to have a feeding tube placed in their bodies was an upsetting signal of bodily deterioration. The procedure itself, though technically minimally invasive, was also viewed with trepidation by patients. They worried about the hospital stay, and whether or not their body would be strong enough to adapt to the tube quickly. Pols and Limburg found that for those who had undergone the procedure, “there was a remarkable consensus among patients in their evaluation of tube placement, with the main variations mentioning just how terrible it had been.” The authors later note that some patients continued to view the feeding tube negatively after it was placed, envisioning it as an unnatural, upsetting addition to their bodies. Others described it as a “necessity” that came with quality of life benefits, although it was not pleasant to have attached to their bodies.

However, for many patients who had feeding tubes already implanted at the time of the study, the response could be notably positive. These participants noted that the devices restored their health and function, and lessened distressing symptoms like choking and an inability to swallow. For one patient, the feeding tube ensured that she received the appropriate calories, such that any food she decided to eat normally could be at her discretion. Other patients who cared less about eating a range of foods appreciated that the feeding tube rid them of the need to worry about what could be easily consumed.

The authors conclude that “the feeding tube can best be understood not as an intervention that causes ‘impacts on quality of life’, but as a technology or prosthesis that may bring different qualities and appreciations that may shift over time.” They add that the feeding tube acts as an intervention that re-orders daily life for patients coping with the a ‘new normal’ of chronic illness: rather than serving to balance “good” and “bad” qualities, as outlined in the disability paradox. Lastly, they remind readers that instrumentalizing “quality of life” risks losing these facets of illness experience. This term is deeply contextual, and responsive to the needs, expectations, and hopes of each patient undergoing treatments or coping with chronic conditions.

Issue Highlight Vol 40 Issue 2: Global Health Diplomacy in Ethiopia

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Across the past few weeks, we have been spotlighting new articles from our June 2016 issue, which you can access in full here. The theme of this special issue is The Clinic in Crisis: Medicine and Politics in the Context of Social Upheaval. This week, we visit Lauren Carruth’s article “Peace in the Clinic: Rethinking ‘Global Health Diplomacy’ in the Somali Region of Ethiopia.” You can read the full article at this link.

In this article, Carruth argues that the politics of global health manifest not only at the scale of “interstate” interactions between governments, NGOs, and international assemblies, but at the local and interpersonal levels between individuals who are giving, receiving, and managing clinical care in “politically insecure” places. Through ethnographic research on two health programs in the Somali region of Ethiopia, the author argues that medical care provision can alternatively strain and strengthen political relationships between people across ethnic and social boundaries.

For instance, Somali people in Ethiopia often refused to seek medical services from the local clinic, Aysha Health Center. Somali patients complained that the Habesha (a native Ethiopian group) nurses were insensitive and uninterested in treating their health concerns. Many Somali informants offered up the same story as evidence: three mothers went to the clinic, and their three children had different ailments. Yet the Habesha nurses did not examine the children, and offered the same drugs to each of the mothers without diagnosing each patient. Somali patients also had difficulty securing a translator who could assist them in conversations with clinicians, who spoke Amharic. The Habesha clinic staff countered that the Somali patients were adverse to biomedical care, instead trusting native folk healers over the clinicians. They added that Somali patients would not adhere to the medication regimens or treatment plans that they recommended. In this case, the friction between Habesha caregivers and Somali patients intensified long-standing ethnic and political tensions at the local scale.

Carruth presents another case, however, where medical aid eases inter-ethnic relationships and ameliorate social rifts between opposing groups. She describes a mobile UNICEF clinic staffed by two Somali clinicians of the Ogaden clan operating in Ethiopia. Though these Somali clinicians were caring for fellow Somali patients, the patients descended from a less politically powerful line which did not have the dominant social standing of the Ogaden: a clan with significant regional power in Ethiopia. Though the patients were of opposing clans, such as the Issa, the two clinicians listened intently to the patients’ complaints, recalled their family lines when they returned for further treatment, and even offered resources like supplementary nutrition to ailing patients despite UNICEF limitations on what types of patients could receive these rations. The patients adored the mobile clinic staff, and the clinicians became integrated into the marginalized communities they served. This example, Carruth notes, highlights the potential for medical aid to facilitate positive and deeply personal relationships between factions in regions that have otherwise experienced significant social unrest.

Carruth concludes that in order to successfully deliver medical aid to places encountering social upheaval or unrest, it is critical to unite oppositional groups within clinical spaces themselves. Providing medical resources and building clinics alone, she notes, fails to address the need to facilitate positive relationships between individuals mired in conflict. Instead, to ease political and social tensions, Carruth posits that clinics and similar treatment centers can serve as sites of caring, communal exchange between otherwise opposed social groups.

Issue Highlight Vol 40 Issue 2: Reproductive Experiences Amongst Haredi Jewish Women

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Over the next few blog updates, we will be spotlighting new articles from our June 2016 issue, which you can access in full here. The theme of this special issue is The Clinic in Crisis: Medicine and Politics in the Context of Social Upheaval. In addition to articles that address the topics of societal unrest, political change, and human health, this installment also turns to how people navigate change and decision-making within the contexts of their own lives. Specifically, one article questions whether individual autonomy over medical decisions is a characteristic of medical care across cultural contexts. In Teman, Ivry, and Goren’s article “Obligatory Effort [Hishtadlut] as an Explanatory Model: A Critique of Reproductive Choice and Control,” we learn that the notion of reproductive choice and control does not cleanly map onto the procreative experiences of Haredi (ultra-Orthodox Jewish) women. To access this article in full, click here.

Reproductive technologies have expanded the range of procreative choices a woman and members of her family confront: should birth control be used to limit the number of children she wishes to have? Should assisted reproductive technologies (ARTs) be used to facilitate conception, or should a woman abort a fetus that has tested positive for a developmental or congenital ailment? The authors of this article suggest that in these discussions, another question has emerged. Are these decisions truly reflective of individual choice, or do individual mothers and members of their community perceive the reproductive course as one over which no person has ultimate control?

Amongst Haredi (ultra-Orthodox Jewish) women in both the United States and Israel, the authors observed another way that individuals framed their reproductive experiences. Rather than describing their procreative choices as a form of individual control over one’s life course, the Haredi women referenced hishtadlut, or obligatory effort: the notion that they were obliged to God to try to become pregnant, but not responsible for the outcome if they were unable to do so. In hishtadlut, women have “room for effort” in that they may flexibly interpret and enact what constitutes a serious attempt to become pregnant or maintain a healthy pregnancy per their religious duty to God to have children. In this explanatory framing, women recognize that they must consciously make choices that would enable God to enact a divine plan for them: however, they are not accountable for the outcome if, having invested the “effort,” God’s plan does not come to fruition or leads to the birth of a child with a developmental disability or congenital condition.

The concept of hishtadlut extended to the use of various reproductive technologies. For instance, there are many concerns about hereditary genetic illnesses like Tay-Sachs disease within the Haredi community. To ameliorate this issue, blood samples from young Haredi men and women enrolled in high school are collected and catalogued into an anonymous database. If two families are arranging a marriage between a son and a daughter, they are able to consult the database to confirm whether or not both individuals are genetic carriers of an illness. This prevents unions between two carriers who would have a greater likelihood of having a child with a genetic illness; thus a genetic carrier would be paired with a non-carrier spouse. Most women interviewed for the article agreed that this technological system facilitated the will of God, as it reduced the chance that a couple would face the difficulty of raising a disabled or an ill child. Here the technology is seen as a “blessing” from God, as it allows families and couples to avoid “heartbreak,” while bolstering a couple’s ability to have healthy children per God’s divine plan.

In other instances, technology is viewed as irrelevant out of the hishtadlut principle. For example, the Haredi women perceived genetic testing for fetal developmental or other congenital illnesses as having little purpose. In Jewish law, abortions beyond 40 days after conception are prohibited, and all fetal diagnostic testing occurs after this point in a woman’s pregnancy. Thus, the women held that the test was inconsequential, as God’s will for them and their fetus had already been ordained. If a baby was born with a disability, this was part of their fate as decided by God. Here “choice” is viewed as God’s choice for the mother and baby, rather than the mother’s own control over whether or not to give birth to a child with potential developmental or congenital conditions.

As Teman, Ivry, and Goren’s research illustrates, “choice” and “control” do not necessarily apply to the reproductive experiences of women and their families across cultures. Indeed, in a deeply religious community such as the Haredi Jews, “choice” is attributed to God while individual reproductive decision-making is cast as a means to allow God to work through individuals to enact divine will. Haredi women did not describe themselves as accountable for becoming pregnant (or having a healthy child), but they did feel obligated to use technologies and consciously make reproductive decisions or avoid certain interventions. These actions, they held, would enable God to direct their journey to motherhood and to fulfill their purpose as parents.

 

Issue Highlight Vol 40 Issue 2: Hospitals as Sites of Conflict in Pakistan

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In the coming blog posts, we will be highlighting new articles from our June 2016 issue, which you can access in full here. The theme of this special issue is The Clinic in Crisis: Medicine and Politics in the Context of Social Upheaval. This week, we will overview Emma Varley’s article “Abandonments, Solidarities and Logics of Care: Hospitals as Sites of Sectarian Conflict in Gilgit-Baltistan.” Read the full article here.

As our past blog highlights have suggested, the clinical space can both act as a site of political protest and serve to facilitate political unity. Varley’s article expands upon these themes by arguing that the clinic can also become a microcosm of inter-group tensions, wherein the hospital itself relays a picture of broader social conflict. Through her analysis of a crisis in a Pakistani hospital, Varley ethnographically demonstrates how Sunni-Shia conflicts manifest in the clinic, and how these tensions are navigated by health professionals employed there.

Varley recounts a shooting and raid which occurred at a hospital in Gilgit-Baltistan in January 2005. Shia gunmen had entered the regional hospital to hunt down Sunni male patients, aiming to retaliate after the assassination of a Shia leader killed by Sunnis. One women’s health ward, operated by nurses of the neutral Ismaili group, was left untouched after the nurses hid Sunni male patients. The nurses protected the men by insisting to the gunmen that there would be no male patients on a female ward: drawing both upon their social role as neutral Ismaili and their gendered role as caregivers of women, who were seen as uninvolved in the conflict at hand. Meanwhile, in a surgical theatre, physicians pretended as if the assassinated Shia leader on their operating table was still alive: hoping to placate the gunmen who threatened them until police or military forces could arrive to dispel the violence. Orderlies and other guards on the wards had, in some cases, fled: leaving clinical staff to defend or otherwise conceal the Sunni patients, and in other cases, fellow Sunni providers.

In reflecting on this incident, Varley notes that the hospital became an example of an “abandoned” space, one in which the necessary governmental protections and securities were not in place to ensure the safety of all patients and clinicians. The onus of protecting patients fell upon the clinicians who staffed the hospital: illustrating both the selflessness of individuals in assisting one another across oppositional group divides, and the potential for hospitals to become sites of medical and political refuge. This increased the trust between Shia providers and their Sunni colleagues in medicine. Conversely, the incident intensified professional divisions between Shia and Sunni providers, as Sunni clinicians later departed the larger regional hospital and took up employment in new Sunni health centers where they felt less at risk.

Though Varley reminds us that conflict is “corrosive” within medical professional relationships, it may also enable “renewed” feelings of trust between caregivers of opposing groups when political unrest unites them under a common aim. In sum, the hospital may serve a site of caregiving exchanges that expand beyond the bounds of medical encounters, as it becomes a sites of political action and negotiation between social groups.