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.

SPA 2017 Biennial Meeting: Breakfast Lecture with Richard Shweder and Byron Good

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This week we’re featuring a summary of The 2017 Biennial Meeting of The Society for Psychological Anthropology Breakfast Lecture. This year, the Breakfast Lecture presented a conversation with the 2016 Lifetime Achievement Awardee, Richard Shweder, and the 2017 Lifetime Achievement Awardee, Byron Good. In this event, Dr. Shweder and Dr. Good reflect on morality and “the mental” in both Cultural Psychology and Psychological Anthropology, discussing how profoundly different worlds still share some moralities and orientations. They also discuss some critical challenges and opportunities for psychological anthropology. By interviewing each other, a foundational technique in anthropology itself, Dr. Shweder and Dr. Good explore their past works, theoretical orientations, and their anticipation of where anthropological explorations of psychological processes are heading.

2016 SPA Lifetime Achievement Awardee Richard Shweder

The conversation begins with Dr. Good asking Dr. Shweder to “tell us about your history.” Dr. Shweder delves into his upbringing in Great Neck on the north shore of Long Island, at the time an emerging suburb with a very progressive, left-wing population. He discusses the first time he heard the word anthropology in his 11^th grade English class when “Mr. Beal” said, “for any of you who don’t know what to do in life, there’s this thing called anthropology.” After graduation Dr. Shweder went to the University of Pittsburgh where Dr. Arthur Tuden, an Africanist and Cultural Anthropologist, taught his Introduction to Anthropology class, bringing in the study of culture with current events and ultimately solidifying Dr. Shweder’s path in Anthropology. From Pittsburgh, Dr. Shweder progressed to Harvard, where he states several figures had an impact on his intellectual growth, including Cora DuBois and John Whiting. After finishing his Ph.D. at Harvard, Dr. Shweder taught at the University of Nairobi in Kenya before finally landing at the University of Chicago.

Dr. Shweder then, discussing approaches and schools of thought in Cultural Psychology, defines Cultural Psychology as “the study of differences in mentalities across human populations.” Psychological Anthropology, for Dr. Shweder, has been more interested in taking universal psychological schemes and applying them to particular cultures to see whether or not different practices or beliefs were essentially manifestations of a broader psychological concept, such as a variation on an Oedipus complex. There is not a denial of universals in Cultural Psychology, however, since, to Dr. Shweder, there is not a way of studying differences without also studying universals. Dr. Shweder describes his way of defining the Cultural Psychology of Morality as “investigating the fates of moral absolutes in history and to show the way they get transformed, take on different content, and lead to different judgments.” To Dr. Shweder, behind a culture or individual is a set of moral absolutes, or rules of moral reason. Yet these moral absolutes and rules are abstract concepts which do not present determinations of actual cases, histories, or cultural contexts. Cultural Psychology is not about looking for likenesses, but looking for the differentiations and local adaptations that have taken place. For Dr. Shweder, the psychological means looking at differences in “the mental.” “The mental” refers to what people know, think, feel, want, and value as good and bad. Dr. Shweder states, “Anywhere you look in the world you’re going to find that people know, think, feel, want, and value things as good and bad. In some sense, that’s what it means to be a person.”

Dr. Shweder follows up with a discussion that anthropologists are supposed to fairly represent the groups they study; to try to portray their way of life in a way that the people the anthropologist is writing for might see them not as “exotic aliens,” but as morally sensitive persons who do things for recognizable reasons. Dr. Shweder proposes the conspicuous use of the notion of “oppression,” or seeing the social order as oppressive, combined with the now popular term “agency,” suggests that to have agency was to be opposed to culture. Thus, for Dr. Shweder, the concept that there might be people whose agency was used to carry forward a cultural tradition which was in a framework where they felt they could be fulfilled, was gone. “When I went to India I was in a world where if I approached it as ‘a good liberal,’ assuming everything is free choice and the world is there to satisfy my preferences, I would have seen it as an oppressive order. Yet the people who live there, for the most part, feel quite at home with rich, meaningful lives,” Dr. Shweder states.

Building off the discussion of morality, Dr. Good then engages with concepts of morality and oppression. Dr. Good states that for him, the experience of morality is often an experience of oppression. He expresses that many people spend at least parts of their lives resisting or fighting against morality, feeling that the moral system around them is actually an oppressive system causing them to live their lives “wrongly” within it. It seems to Dr. Good that reading ethics with a grand “they” or a grand “we” misses, ethnographically, another side of the story. Dr. Shweder responds that there is a multiplicity of the moral world. The moral world has many goods and desires that are in conflict with each other, and one cannot have them all. This sets up the dynamic of resistance since the system of conflict and prioritization pushes alternatives to the side. Dr. Shweder states that within any society there is the orthodox and the heterodox, that which is center stage and that which is done covertly. The mistake is to privilege one ethic over another, to act as if that privileging itself is not a choice or commitment, or to label the ethic of autonomy as the “natural way” in which anyone who is fully enlightened will ultimately go. Dr. Shweder cautions against the view of “liberalism as destiny,” where there are stages of moral development, the height of moral development being an autonomous, individualized person or society.

2017 SPA Lifetime Achievement Awardee Byron Good

Dr. Good then discusses his personal and academic history. He starts by commenting that his childhood and upbringing couldn’t have been more different than Dr. Shweder’s, growing up on a Mennonite farm in the Republican mid-west. Dr. Good spent much of his life feeling that religion and divinity grounded and oriented aspects of his academic life. “I don’t romanticize ethical norms if they, over time, have become more and more interested in controlling our lives in ways that we have very little direct knowledge of,” Dr. Good states. “I don’t romanticize suffering.” While at Goshen College in Goshen, Indiana, Dr. Good started studying mathematics before spending a year at the University of Nigeria. Dr. Good expressed this time as having a powerful impact which changed his life. “My worldview became profoundly different,” he states. Coming back from Africa convinced that there had to be something more than mathematics, Dr. Good decided to go to Harvard Divinity School. It was there that he began taking courses in anthropology and religion. Attending the University of Chicago for his Ph.D., Dr. Good states his first year at Chicago was Clifford Geertz’s last year. Yet even after Geertz left, Dr. Good still considered him a mentor and inspiration. This was also a very political moment for universities and the country in general. Dr. Good describes how he came of age in anthropology in a time of the Vietnam War, in a time of activism, and in the time of the Civil Rights Movement. These were all very powerful influences on how Dr. Good conceptualized the importance of anthropology.

Discussing his research, Dr. Good describes the time he spent in a genuinely post-colonial conflict setting of Aceh, Indonesia. He became very aware of colonialism and its colonial history and how it had impacted political life along with a diverse set of religious and cultural influences. It was a setting that had a history of tremendous violence. “It was my first experience of working in areas of really intensive conflict,” Dr. Good states, “and I have to say that I went home from that experience very affected by listening to stories of violence.” Terms like “post-colonialism” and “post-colonial subjectivity,” and even terms like “haunting” and “hauntology” became central to his vision of what Psychological Anthropology can be today. Dr. Good poses the question of how one does Psychological Anthropology in settings of violence. “My thinking about hauntology started off with being in Aceh, and thinking about what Aceh was like post-tsunami and post-conflict,” Dr. Good remarks. Aceh was a place where ghosts and spirits of the dead were everywhere, alongside the ghosts of the recent violence and the emergence of political gorillas who had been previously hidden away. “Suddenly Aceh was no longer in the midst of a war and people who had been fighting were coming back and appearing in everyday life,” Dr. Good explains, “and I began thinking about post-authoritarian Indonesia and why it is that there are certain moments in a society that ghosts begin to appear in a very powerful way, and ghosts that are related to historical violence.” Dr. Good became fascinated with the relationship between historical memory, histories of violence, how they make themselves present, and how they reintroduce themselves in psychological experience.

To wrap up the Breakfast Lecture, Dr. Shweder discusses how the issue of nationalism is front and center in a very powerful way at the moment. He suggests that anthropologists should be qualified to talk about the ethno-national impulses people are facing and examine why it is that some people feel like their way of life, or their control over their life, is being threatened by globalization, for example. He calls on anthropologists to give a native point of view instead of simply reacting with fear and mainstream ideology. “This is anthropology. There are in-groups and there are out-groups. People have ways of life and traditions; they want to exercise control over their way of life. This has to be examined,” Dr. Shweder states. He further discusses that one of the things that’s exceptional to the United States is that we are a nation in which constitutional patriotism is the binding feature. In principle, that means there is space for cultural diversity. “The ways in which tyranny can be built up and balanced through distribution of power are all rich topics right now. Immigration. Making sure we represent minority views in a way that majority groups understand them and why the way they live is both meaningful and justifiable.” Dr. Shweder finishes by stating that there are also threats to anthropology from within. He warns against a “liberal tyranny” which can be compared to a “white-man’s-burden-style” of thinking with regard to cultural differences. Dr. Shweder sees this as using the notion of oppression or exploitation as an excuse for interventions into other people’s ways of life rather than starting by seeing whether or not one can understand other practices and social organizations in a morally-motivated way. Dr. Good closes the conversation session by encouraging anthropologists to be engaged in both theoretical debates within the discipline as well as policy and implementation projects and practices which can benefit the people in the communities we study.

Richard Shweder is the Harold H. Swift Distinguished Service Professor of Human Development in the Department of Comparative Human Development at the University of Chicago. He is the author of Thinking Through Cultures: Expeditions in Cultural Psychology (1991) and Why Do Men Barbecue? Recipes for Cultural Psychology (2003), both published by Harvard University Press. Dr. Shweder is also an editor or co-editor of many books in the areas of cultural psychology, psychological anthropology, and comparative human development. For more information on Dr. Shweder, visit his page at the University of Chicago here, as well as the Society for Psychological Anthropology 2017 Biennial Conference Breakfast Lecture website, available here.

Byron Good is a Professor of Medical Anthropology at, and former Chair (2000-2006) of, the Department of Social Medicine, Harvard Medical School, and Professor in the Department of Anthropology, Harvard University. Dr. Good is director of the International Mental Health Training Program, funded by the Fogarty International Center to train psychiatrists from China in mental health services research. Dr. Good’s broader interests focus on the theorization of subjectivity in contemporary societies, focusing on the relation of political, cultural, and psychological renderings of the subject and experience, with a special interest in Indonesia. He is the editor or co-editor of many significant volumes, books, and is a former editor-in-chief of our Culture, Medicine, and Psychiatry journal (1986-2004). For more information on Dr. Good, visit the Harvard Medical School Department of Global Health and Social Medicine website here, as well as the Society for Psychological Anthropology 2017 Biennial Conference Breakfast Lecture website, available here.

Guest Blog: “Telemedicine in Ghana”

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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.

Interview: Jonathan Sadowsky and “Electroconvulsive Therapy in America”

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This week on the blog we’re highlighting an interview with Dr. Jonathan Sadowsky about his new book Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy, released November 2016 by Routledge. The book (available here) follows the American history of one of the most controversial procedures in medicine, electroconvulsive therapy (ECT), and seeks to provide an explanation of why it has been so controversial, juxtaposing evidence from clinical science, personal memoir, and popular culture. ECT is widely demonized or idealized. Some detractors consider its very use to be a human rights violation, while some promoters depict it as a miracle, as the “penicillin of psychiatry.” Sadowsky contextualizes the controversies about ECT, instead of simply engaging in them, making the history of ECT more richly revealing of wider changes in culture and medicine. He shows that the application of electricity to the brain to treat illness is not only a physiological event, but also one embedded in culturally patterned beliefs about the human body, the meaning of sickness, and medical authority.

Dr. Sadowsky is the Theodore J. Castele Professor of Medical History at Case Western Reserve University in Cleveland, OH, the Associate Director of Medical Humanities and Social Medicine, the Medical Humanities and Social Medicine Initiative co-founder, the Associate Director of Medicine, Society, and Culture in the Bioethics department of the Case Western Reserve University School of Medicine, and on the Editorial Board here at Culture, Medicine, and Psychiatry. Sadowsky’s research concentrates largely on the history of medicine and psychiatry in Africa and the United States. His previous publications include Imperial Bedlam: Institutions of Madness in Colonial Southwest Nigeria (1999), available here from the University of California Press.

From all of us at CMP, we hope you enjoy our new interview category!

For someone who is thinking about reading your book or about to start, is there anything you would like them to know beforehand?

I would urge everyone to understand that not everybody’s experience of a medical therapy is the same. People should be careful not to generalize from experiences they’ve had, or that loved ones have had, and assume everyone has had the same experience. People who’ve had bad experiences with ECT have criticized me for to wanting to pay attention to the voices of people who’ve had good experiences, and people who’ve have good experiences have wanted to say “oh sure that might have been true in the 1950s but everything’s fine now.” ECT has a complicated story. I have met people who have told me that this treatment saved their lives and that it did so with either none or only the most mild of adverse effects. Those people are very concerned to make sure that the therapy gets represented in positive light because there are so many negative depictions. At the same time I’ve heard from and spoken to people who say they’ve lost 20 points off their IQ after having this treatment, or who had huge gaps in memory, or that they know somebody who had killed themselves after an ECT treatment. And what I find a little bit puzzling still after all these years of working on this book, is the way people are so unwilling to see that other people might have had a different experience than their own. But it’s my feeling as a social and cultural historian that it’s my responsibility to take into account all voices. So that’s the main thing that I want people to know and think about, that experiences of this treatment do vary and people shouldn’t be too quick to generalize from their own experience.

How did you become interested in ECT?

I was already several years into my career as a historian of medicine, and in particular psychiatry, and had no knowledge of the treatment other than the images that many of us have from movies like One Flew Over the Cuckoo’s Nest. Images that it was a highly frightening and abusive treatment. I was a well-trained student of medicine and psychiatry and I didn’t know anything more than that. And then I began to hear stories, both from patients and from clinicians, about it being a valuable treatment and that was just so intriguing to me. So I began to look at some of the clinical literature and it was represented in almost completely the opposite way, as this safe, effective, humane treatment that’s been unfairly stigmatized. I felt like these were two completely distinct realities. It wasn’t so much that I wanted to reconcile them, but I just wanted to understand how views of this treatment became so bifurcated. And that became the central goal of the project: to understand why it became a controversy and have such strongly held opinions on either side.

What did you find most exciting to research and write about?

I worked on this project for a long time and one of the things that sustained me was that there are so many different angles to it. I was interested in learning about how it was used to treat homosexuals in 1950s, to see what the reaction of the psychoanalytic community was, and how it figured as a symbol for all that was worst in psychiatry in the antipsychiatry moment. And then there were all the debates going back to the inception of the treatment, ongoing continual debates about the extent of memory loss. Is it a serious problem? Is it a rare problem? These debates are still raging. All of this I found so intriguing. The history of ECT is also replete with ironies. Such as the irony that it was developed initially as a treatment for schizophrenia based on a hypothesis that schizophrenia has an inverse relationship with epilepsy. That hypothesis is no longer even believed in, and schizophrenia is not the main indication anymore, and yet it’s effective. That’s so weird and so seemly random! Another irony is that this treatment which become an icon for frightening medical treatment, and became almost like people’s haunting nightmare of how medicine could abuse you if you came into its clutches, was initially developed as a way to try to create a safer, less frightening treatment than chemical convulsive therapy. So it’s these layers of irony that I just found so interesting and kept me intrigued in the book.

Did you come across anything unexpected?

Yes, I did come across things that were unexpected. I found the gender politics to be very elusive. I found very little evidence for the idea that women were given ECT for simply protesting against their social role as housewives, which was promoted in another book on ECT. But it does appear likely that over the course of the treatment’s history more women have gotten it than men, and there is likely a gender politics to this. Minimally it may mean simply that more women are getting diagnosed with depression, and that’s the main indication. And we know that. The diagnosis of depression has predominated among women. There is a darker possibility, which is that women’s cognitive abilities haven’t been as valued, and so doctors have been more willing to use a treatment that might damage cognitive abilities on women than they were on men. I didn’t see any proof for that. But I think there were suggestive circumstances that might indicate that that played a role. In many realms of medicine, and this has been really well documented by historians, anthropologists, and sociologists of medicine, women’s complaints about medical treatments are more quickly dismissed than men’s complaints. So it’s quite possible that some of the complaints about memory loss, which have persisted throughout the history of this treatment, have been taken less seriously because they were so often voiced by women. I’m not arguing that women had more memory loss than men, but if they predominated in the treatment, and there were complaints about memory loss, it is plausible to suggest that perhaps there has been too much dismissal. I didn’t have evidence such as clearly sexist language in clinical reports that would strengthen a speculation like that, but one thing I do argue in the book is that the history of ECT is filled with doctors dismissing patient complaints of adverse effects. There are a number of ECT providers now, however, who are trying to be very sensitive to these complaints about memory and cognitive deficits following the treatment, but there still exists in clinical manuals the claim that serious memory problems are extremely rare, and that rarity really hasn’t been proven. So it remains a problem. The history of ECT treatment has shown a tendency to dismiss patient complaints about adverse effects, and this has not served anyone well. If anything, the tendency to dismiss complaints has worsened the stigma attached to the treatment. It’s understandable that some clinicians might feel some defensiveness for a treatment they feel is helpful and safe, but the dismissal of complaints of adverse effects has led to embittered patients and worsened the stigma. In a recent piece in The Conversation (available here), I argued that if we wanted to spell the stigma attached to ECT, it’s going to take more than attesting to its therapeutic efficacy. It’s going to mean we have to reconcile with its full costs.

Why was it important for you to try and remain neutral and not argue for or against ECT?

I’m not trying to presume objectivity. Everyone has a point of view. But I thought I could tell a more interesting story by taking a step back and making the controversy itself my study rather than becoming a disputant in the controversy. There’s some precedent for this. Didier Fassin, an anthropologist, did a book on AIDS in South Africa, When Bodies Remember (available here), in which he did the same thing; he tried to look at the structure of the controversy. He was trying to understand the medical controversy over HIV as an anthropologist, even though he did actually side more with one than the other. But I do argue in the book there are good reasons to attest to efficacy of ECT and it is a valuable part of psychiatry’s repertoire, that it has a place in medicine. But I also argue that there were good grounds for people to contest it and have fear of the treatment. I really try to resist the view, which is very common in clinical literature on ECT, that opposition to ECT is irrational. There are rational reasons for the resistance rooted in some of its historical uses, some of which were abusive, and rooted in the experiences of adverse effects. At the end of the book I lay it all out and I say exactly what I think about ECT after trying to look at it from a step back. I think it’s an invaluable part of psychiatry and could be very useful for many people. But I don’t think it should be used as a first or second resort; other things should be tried first because there are risks. I’m glad it’s there if I should ever need it, but I hope I never need it.

Would ECT be perceived differently if it didn’t treat the brain but some other organ?

Probably. In our society now, more than any other organ your brain is you. It is the seed of the self in our self-conception. I would go beyond that. The side effects do occur, without making any kind of representation about how common these problems are, but at least some people do experience permanent memory losses. I used a lot of patient memoirs in the chapter on memory as my source material. And as one of the memoirists wrote: We are our pasts. You lose your memory it’s like you lose a part of yourself. I think in some ways people feel they lose a part of themselves if they lose their memories more than even if they were to lose a limb. Losing a limb is very traumatic, I don’t mean to minimize that. But in a way, you lose your leg and you say “I lost my leg.” It’s something that belongs to you, but it isn’t you in the same way that maybe you feel your memories are you. Memories are not just something that you have, they’re something that you are.

I think ECT is a treatment for the very ill and as a society we do generally accept that treatments for the very ill sometimes involve radical interventions. Chemotherapy for cancers for example. Most of us are glad we have it, and there isn’t a large anti-chemotherapy movement. My leading theory for why ECT treatment occasions this kind of resistance is because of depression’s uncertain status as illness. No one disagrees that cancer is an illness. When you have cancer you accept that you need surgery or radiation or chemotherapy. These are things that you normally wouldn’t do to your body if you were healthy and you didn’t need them. Cancer is clearly different from normal. But depression has this ambiguous status for two reasons. It is an ambiguous word in the English language because it refers both to an illness which can be extremely severe, yet it also refers to a mood that’s normal and that everybody at some point in their lives gets a little bit depressed. We might have disagreements about how long it has to go on and how severe it has to be to be considered an illness. But it becomes something different when we call it an illness. Secondly why I think depression’s status is a bit uncertain, is that there continue to be people who reject medical models for what we call mental illness altogether. Some might believe what people need is talk therapy and they shouldn’t have drugs or shock therapies or anything like that. Some might believe that they don’t need any treatment at all; they might want to de-medicalize the entire thing. For example, for something to qualify as disease, there has to be some kind of lesion, or something physical that can be identified. Since we don’t have the means to do that with depression, it should be removed from the medical realm. I argue against this view. The idea that there has to be some kind of visual marker is arbitrary. I do think what we consider an illness is a social decision. But if you look at it historically and anthropologically, the idea that things we call madness are medical problems is pretty widespread. And in some ways having to have something be visually identifiable is buying into a lot of biomedical hegemony. I just don’t see why that should be the criteria for illness. Ultimately it’s a philosophical question. Most people in our society do accept that severe depression actually constitutes an illness category, but I think these kinds of ambiguities leave people unsure whether this is something worthy of very strong medicine. ECT is strong medicine. It’s a big decision to undergo ECT and it’s the right decision for some people. It’s a decision that shouldn’t be made lightly and shouldn’t be treated like a trip to the dentist.

Is there anything else you want to add?

I was really gratified by the number of anthropologists who read and used my first book on insanity in Nigeria, Imperial Bedlam (available here), and I would be thrilled if anthropologists gave this book the same attention. And I’d also like to add that Routledge says there will probably be a paperback within the next year and a half.

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

Posted by jknopes

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.”

Issue Highlight: Vol 39 Issue 3, Suicide in Rural Kenya

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When a new issue of Culture, Medicine & Psychiatry is released, we feature a series of blog posts that highlight these latest publications in our journal. The current September issue includes articles that address psychiatric conditions and the experiences of people with mental illness across cultures. Readers may access the full issue at Springer here: http://link.springer.com/journal/11013/39/3/page/1. In this issue highlight, we will discuss an article on ethnographic analyses of suicide and distress amongst three communities in northern Kenya.

Suicide in Three East African Pastoralist Communities and the Role of Researcher Outsiders for Positive Transformation: A Case Study

Bilinda Straight, Ivy Pike, Charles Hilton, and Matthias Oesterle – Pages 557-578

http://link.springer.com/article/10.1007/s11013-014-9417-4

The authors of this article strive to establish a nuanced and ethnographically rich understanding of suicide and mental distress in an under-studied population of three distinct, yet interacting, pastoral communities in northern central Kenya. These three groups– the Pokot, Samburu, and Turkana– are engaged in intercommunity conflicts over territory and land use agreements, despite the communities’ shared and entangled oral histories. Such tensions are only exacerbated by mutual fear of raids by other groups, dearths in food available for forage, and the theft of livestock from individuals who sell the animals to finance political campaigns. Poverty is likewise aggravated by these patterns of loss and violence.

This turbulent social environment creates widespread mental distress amongst the three communities, yet individuals from each group stressed to the research team that they felt obligated to persevere despite these pressures, making admitting psychological suffering (and especially confessing thoughts about suicide) deeply taboo. Therefore, any mental health intervention would have to be responsive to the extent to which Pokot, Samburu, and Turkana culture disallow individuals from discussing or even thinking about suicide: an act which could create even more social strain on the family of the person who committed it. The researchers confirmed this inability to discuss suicide by the high rates of non-response on a survey question which asked participants whether or not they had experienced suicidal thoughts.

Suicide thus proves to be a unique case for anthropological analysis because it is both driven by the social conditions of those who take their own lives, as well as disruptive to the communities in which these people lived. Its treatment by global health workers must in turn be sensitive to cultural beliefs that forbid conversation about suicide, especially in communities where the death of an individual may contribute to already extraordinary social distress.

From the Archive: Global Health, Biomedical Difference, and Medical Training

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In our “From the Archive” series, we revisit articles from past issues of the journal. In this installment, we review Betsey Brada’s article “‘Not Here’: Making the Spaces and Subjects of ‘Global Health’ in Botswana,” from the June 2011 special issue on the theme of “Anthropologies of Clinical Training in the 21st Century.”

What do we mean when we employ the term “global health,” particularly about the nature of caregiving in other cultural contexts? In her ethnographic research at a training hospital in Botswana, Betsey Brada posits one theory of the term as engaged with by medical and pre-medical students, missionary doctors, resident medical staff, and other key clinicians at the field site. Brada finds that while global health is often narrowly defined as biomedicine performed in “resource poor” or “resource limited” regions, this definition in fact relies intensely on a complex, comparative understanding of place, technology, and biomedical skill.

For example, Brada describes one case where a German man on vacation in Botswana broke his leg and required surgery. Upon returning to his home country for a follow-up examination of his healing leg, the man’s physicians were surprised at the skill of the procedure, remarking that it was commendable given that it was performed abroad. The German physicians had therefore assumed that care in a “resource limited” context was correspondingly of a lower quality than biomedical care delivered in a developed country, even though clinicians often tout the “universality” of biomedicine as a cultural boundary-crossing (if not hegemonic) mode of scientific healing. The medical staff in Botswana remarked that many physicians in developed countries believed biomedicine in the developing world to be crude, simplistic, and backwards: even though staff members at the Botswana hospital had been trained at advanced facilities across the world, many of them in developed countries.

Students studying and volunteering at the hospital were also repeatedly instructed in lectures to understand the differences between pharmaceutical use in the United States versus medications available in Botswana. American physicians described an extensive list of common medication available in the hospital’s pharmacy in terms of how it was no longer used in the United States, but had to suffice “here.” This example, too, underscores the tangled relationships between space, technology, and an understanding of global biomedicine primarily in terms of nations offering cutting-edge care versus those countries that had, in their perspectives, fallen behind.

Brada also argues that medical anthropology and linguistic anthropology have much to contribute to one another, although the disciplines are not often engaged in scholarly conversation. She notes that the careful analysis of language used to distinguish “here” (Botswana) from the developed world, including the United States and Europe, demonstrates the division between spaces that is central to definitions of global health as given in biomedicine. Brada asserts that an understanding of “global health” only emerges whenever we attend to the terminology that physicians, staff, and students use to separate medicine in the developed world, from medical standards implemented on the global scale by the WHO, to the terms used to describe medical care in local, foreign contexts.

The June 2011 special issue features other fascinating articles that address the cultural situatedness of biomedical knowledge, and how medical concepts are translated to future clinical practitioners. To learn more about this issue, see the links below.

To find the article and abstract on our Spring site, click here: http://link.springer.com/article/10.1007/s11013-011-9209-z

For the full special issue, including links to other articles in the June 2011 installment, click here: http://link.springer.com/journal/11013/35/2/page/1

Book Release: Paul Stoller’s “Yaya’s Story: The Quest for Well-Being in the World”

Posted by jknopes

Image from UC Press website

Out this month from the University of Chicago Press is Paul Stoller’s book Yaya’s Story: The Quest for Well-Being in the World. The text traces the author’s friendship with a Songhay trader from Niger named Yaya Harouna: a man who moved to the United States as Stoller, an anthropologist, had likewise made a journey from the USA to Africa as a Peace Corps volunteer. Their story begins whenever Stoller meets Yaya selling artwork in an African market in New York City’s Harlem neighborhood, where Stoller carried out research.

Although the men’s histories are markedly different, they become close after the two are each diagnosed with cancer: this serves as the heart of Yaya’s Story, and the experience upon which the two men’s culturally divergent, yet not entirely dissimilar, narratives cross paths. With extensive publications in the genres of both ethnography and memoir, Stoller is certain to blend keen anthropological insight with deeply personal accounts of human suffering, endurance, and resilience in the face of illness across cultures in his latest book.

Stoller, Professor of Anthropology at West Chester University, is a 1994 winner of a Guggenheim Fellowship and the 2013 recipient of the prestigious Anders Retzius Gold Medal in Anthropology from the King of Sweden.

You can find out more about the book here, at the UC Press website:

http://www.press.uchicago.edu/ucp/books/book/chicago/Y/bo18882897.html

Current Issue: Preview of Books Received, Part Two

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In this special feature on the blog, we’re highlighting recent book publications that have been submitted for review to Culture, Medicine, and Psychiatry. This week, we are pleased to present a short overview of Making and Unmaking Public Health in Africa: Ethnographic and Historical Perspectives, a volume of works edited by Ruth J. Prince and Rebecca Marsland. This book addresses the experience of African public health initiatives from numerous vantage points. Published by the Ohio University Press, a paperback version was released in December 2013. You can learn more about the book here: http://www.ohioswallow.com/book/Making+and+Unmaking+Public+Health+in+Africa.

Book cover image via the Ohio University Press website.

Prince and Marsland’s edited collection was the result of a 2008 workshop at the University of Cambridge hosted by the Centre of African Studies and the Department of Social Anthropology. Africa has long served as an “arena” for discussions about global health, human rights, and humanitarian aid, but the notion of health-for-all is complicated against a backdrop of African state formation, international interventions, and transnational policies.

This text explores what public health means for clinical professionals, patients, government officials, and citizens throughout Africa. Instead of generalizing what the meaning of public health to these groups might be, this book aims to establish a rich, complex anthropology of African public health that weighs the importance of politics, culture, and local understanding to the definition and delivery of public health initiatives. The volume covers topics in numerous countries including Uganda, Nigeria, Kenya, and Tanzania, and takes a blended historical-anthropological approach to studying public health.

These brief summaries are intended to give our readers a glimpse into the newest academic publications that we’re excited to discuss in our journal and with our followers on social media. For a full list of books that have been submitted for review at CMP, click this link: http://link.springer.com/article/10.1007/s11013-014-9383-x. This page also has information regarding the submissions process for authors who’d like their academic releases reviewed in the journal, as well as information for those interested in composing a review. For more information on this process, please contact managing editor Brandy Schillace.