Culture

AAA 2016 Session Highlights: Part 1, Evidence

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Image via AAA Website

This is the first in a two-part series spotlighting sessions in medical anthropology at the upcoming 2016 Annual Meeting of the American Anthropological Association (AAA) in Minneapolis, Minnesota. Though not intended to be exhaustive in scope, this series will highlight a selection of sessions at the AAA that may interest our readers and conference attendees. The sessions spotlighted here centered around two themes: evidence (Part 1) and discoveries (Part 2.) These two subjects are also the core themes of this year’s annual meeting. For more information, find details about this year’s conference at this link.

Sessions on “Evidence”: Paper Sessions on the Themes of Knowledges, Certainties, Uncertainties, Evaluation, and Medical Data in Practice

HEGEMONY OF EVIDENCE: THE SHAPING OF KNOWLEDGE AND UNCERTAINTY

Wednesday, November 16th / 4:00 PM – 5:45 PM

Chair: Shannon Satterwhite (University of California, San Francisco)

This session will include papers on biopolitics, medical documentation, certainty and diagnosis, maternal health data collection, and nursing and primary care practices.

AMBIGUITIES OF CERTAINTY: NEGOTIATING KNOWLEDGE AND NAVIGATING THE BOUNDARIES OF EVIDENCE

Thursday, November 17th 8:00 AM – 9:45 AM

Chair: Anna Zogas (University of Washington)

Papers in this session will address health rationalities and socialities, the nature of uncertainty and medical evidence, and the boundaries of medical knowledges.

EVIDENCE? ACCIDENT? DISCOVERY? PSYCHOSIS, MORAL SUBJECTIVITY AND CARE 

Thursday, November 17th 10:15 AM – 12:00 PM

Organizer(s): Neely Myers (Southern Methodist University) and Michael D’Arcy (University of California, Berkeley)

Chair: Lauren Cubellis (Washington University, St Louis)

Discussant: Elizabeth Bromley (University of California, Los Angeles)

In this session, the presenters will explore numerous connections between psychological experiences, illnesses, and clinical evidence.

EVIDENCE AND THE ENDS OF AIDS: SCIENCE, DISCOURSE, AND POLITICS AT THE END OF THE TREATMENT SCALE-UP ERA

Thursday, November 17th 4:00 PM – 5:45 PM

Organizer(s): Nora Kenworthy (University of Washington, Bothell) and  Matthew Thomann (Columbia University)

Chair: Richard Parker (Columbia University)

Discussant: Vinh-Kim Nguyen (Graduate Institute of International and Development Studies Geneva, Switzerland)

Papers in this session will explore global AIDS/HIV landscapes, including the reframing of risk, data, and treatments. They will also consider the ties between science and politics in HIV/AIDS research and global health initiatives.

CLINICAL IMPRESSIONS: REGIMES OF INTERPRETATION AND EVALUATION IN HEALTHCARE

Friday, November 18th 10:15 AM – 12:00 PM

Organizer(s): Adam Baim (University of Chicago), Colin Halverson (University of Chicago)

Chair(s): Talia Weiner (University of Chicago), Miao Hua (University of Chicago)

Discussant: Barry Saunders (University of North Carolina, Chapel Hill)

This session will explore how biomedical systems are evaluated, how biomedical practitioners evaluate illness, and how medical evidence and interpretation align in numerous settings.

From the Archive: Patients-as-Syndromes in Internal Medicine

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In our “From the Archive” series, we highlight an article from a past issue of the journal. In this installment, we explore Robert A. Hahn’s piece “‘Treat the patient, not the lab’: Internal medicine and the concept of ‘Person,'” available in full here. This article was featured in Volume 6, Issue 3 (September 1982.)

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Throughout the history of the journal, our authors have turned the same anthropological gaze equally onto both biomedicine and other medical systems. As Hahn introduces this article, he states that the healer in all cultural contexts fashions medical and social truths together, such that the patient and patient body are reinterpreted (and potentially reordered) through medical treatment by the healer. Biomedicine, he states, also recasts illness in ways that alter the medical position of the patient. To understand how physicians of biomedicine engage with patients conceptually in this way, Hahn conducted an ethnographic study of four internists. As internal medicine is often characterized as highly rationalistic and thus emblematic of biomedical practice, Hahn argues, he states that understanding the internists’ perspectives may shed light more broadly on biomedicine as a particular method of envisioning illness and its relationship to the patient.

Hahn begins by positing that the nature of internal medicine as a profession itself is a form of interpretation of what constitutes the patient and body over which it has medical purview. Internal medicine does not focus on mental health (psychiatry) or on the internal visceral body (surgery.) Thus, the “body” it treats exists in relative isolation from the mind, yet is not a physical or functional body such as the one manipulated directly through surgery. The conditions internists treat exist apart from the person and, to a degree, from the patient’s body: instead, the internist focuses on internal diseases and pathologies that become entities of treatment divorced from the individual receiving care. These illnesses– forged into concrete ontological “things”– are countered with similarly material antidotes. Hahn adds that the prestigious status of the internist in the culture of clinical practice, both currently and historically, lends this physiologically-based view of the body and its treatment significant legitimacy in the biomedical landscape.

To demonstrate these concepts, Hahn presents the case of internist Dr. Barry Siegler. “Barry,” as he comes to be called, repeatedly instructs his residents and other clinicians to be wary of individual metrics and lab results, as these single numbers and tests cannot be incrementally fixed: rather, he contends, they must be examined and addressed in concert such that the whole patient is successfully treated. Hahn describes this as relational knowledge of pathology, rather than “singly” reading and responding to individual metrics. However, Barry does not mean to champion holistic, person-centered care: instead, he posits that the entire patient should serve as the point of focus such that no aspect of the patient’s pathology is excluded from diagnosis and subsequent treatment. For example, Barry argues that the patient interview is a tool for the extraction of cues that would lead the clinician to better understand the etiology and symptomatology at hand.

Thus the patient’s “syndrome” comes to exist as a materially and ontologically “real” entity that is distinct from the social, personal, and existential contexts of the patient’s life. This perspective is crystallized in Barry’s tendency to refer to patients as their diseases, such as “a conversion reaction.” He also refers to patients he believes to have mental illness in the same manner, such as the “neurotic,” although he admits that psychiatric pathologies are a “Pandora’s box” beyond the limits of his professional power to address. Again, the patient as a person (and even as a subject or individual mind) fades as the disease pathologies that characterize their illness are reified and made the central objects of the internist’s medical gaze. Due to the close alignment between physiology and organic sciences (chemistry and biology), Hahn notes that the internist’s ontological transformation of the patient into their pathologies– and the pathologies into discrete objects of attention– are deemed especially real, true, and justifiable. Likewise, the body itself is interpreted as a closed, contained system that becomes the object of internal medicine: the ‘whole patient’ is instead the ‘whole pathophysiology.’

Hahn concludes that this vision of the body is decidedly Western: it individualizes the body, and makes a Cartesian division between the body (physical) and the mind (psychological, social) such that it is made treatable and conceptually readable by internists who isolate it from other contexts and who distinguish diseases as concrete, material things. The article ultimately suggests that certain biomedical visions of the body and appropriate patterns for treatment may not align with the perspectives of patients, who understand their illness within the social, spiritual, cultural, and other frameworks that structure their daily lives.

 

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.

Medical Humanities as an Intersection: Fostering Cross-Disciplinary Intellectual Spaces, A Commentary

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This week, we are featuring a commentary on the medical humanities, which first appeared this week here on The Daily Dose blog. This piece explores the nature of interdisciplinary research on the social, cultural, and experiential dimensions of medicine. It also spotlights the new Medicine, Society & Culture initiatives at Case Western Reserve University.

 

When I set out to write this commentary, I first intended on penning a blog piece about my own definition of the medical humanities as someone trained in both the humanities and the social sciences. Having come to medical anthropology from a past life in literary studies, my work has straddled the fissure between humanities and qualitative social sciences. I have presented work both on the history and theatrical presence of anatomical learning in the English Renaissance, and on my ethnographic research with medical students in the gross anatomy lab today. Sometimes, my work is focused solely on the present; in other instances, I turn to the historical past to inform my work as a scholar of contemporary medical training. My vision of the medical humanities is one that arrives from both within and beyond traditional disciplinary boundaries.

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My approach, however, is but one. I recognize that the medical humanities do not offer a single or unified outlook on human health, illness, and medical practice. In fact, the medical humanities are populated by historians and artists, poets and literary scholars, philosophers and social scientists. Our individual professional identities may be firm—I identify now as an ethnographer and anthropologist, not a literary scholar—but the social, cultural, historical, experiential, and existential study of medicine is simply too complex to be dominated by a single field. The medical humanities (and its ally, social medicine), welcomes perspectives on the humanistic study of medicine informed by our varied native disciplines. More than a single field, the medical humanities often serve as a crossroads: an intellectual intersection (physical, virtual, or social) at which scholars across fields gather in dialogue, whether they identify with a single specialty or as interdisciplinary scholars. For this reason, and regardless of disciplinary allegiances, we can all benefit from the medical humanities as a site of discussion that welcomes myriad voices. Diverse perspectives encourage us to analyze human health and medical problems from numerous angles. As we all carry with us our own analytical methods and theories to this junction, so too do we leave these dialogues having ourselves learned and gained the critical perspectives of our peers. This sharpens our focus anew on social, cultural, and medical problems for which one discipline lacks all answers.

The value of the medical humanities is that they enable all of us to see medical and social problems through multiple lenses. If we cannot fully grasp a complex medical problem through ethnography alone, we turn to historical approaches to complete our understanding of the issue at hand. If individual illness narratives beg to be woven together through other data, we look to sociology and economics to conceptualize the underlying health inequities faced by diverse populations, amongst other socio-medical problems. And, further, when we strive to understand how medical science is confronting illness and suffering today, we turn to nurses, social workers, therapists, physicians, and other health professionals whose day-to-day interaction with patients is deeply informative for our own research. Indeed, clinicians also benefit from our work: the humanities have been widely integrated into coursework for physicians in the United Kingdom[1] and the United States[2]. While obstacles remain in the creation and implementation of medical humanities curricula for future medical practitioners[3], this coursework has widened the intellectual space in which medical humanists exchange ideas with multiple audiences.

Whether medical humanities programs are physically housed within humanities departments, or whether they are exported into numerous health education venues, they remain a space for invaluable cross-disciplinary conversation. I have been fortunate to serve as the administrative coordinator of a medical humanities and social medicine collaborative that has overcome departmental boundaries in creating a new space for scholarly dialogue. This new university-wide initiative in medical humanities and social medicine (MHSM) is anchored by a Bioethics MA degree track entitled Medicine, Society and Culture at Case Western Reserve University. Though the degree program is housed in the School of Medicine, our MHSM (Medical Humanities and Social Medicine) advisory committee (which oversees university-wide activities in medical humanities[4]) includes historians, philosophers, literary scholars, social scientists, rhetoricians, and many others. Across the university, we facilitate lectures, administer competitive conference and research grants for students, and support faculty scholarship and teaching innovation. In the region, we collaborate with neighboring institutions to spearhead events that bring together scholars in all disciplines to discuss common themes in the social and contextual study of medicine, illness, and human health. In addition, we look forward to welcoming our first entering class of graduate students in the Medicine, Society, and Culture track in the Bioethics graduate program this Fall 2016. These students will complete clinical rotations, bioethics coursework, and multidisciplinary training in medical humanities and social medicine.

In sum, the Medicine, Society and Culture initiative has become another significant intersection at which scholars—both practicing academics and new graduate students alike—are able to trade theories, exchange methods, and discuss contemporary intellectual issues with fellow medical humanists and social scientists. Thus, our program seeks to both produce new scholars who approach illness and medicine as inherently multi-faceted human experiences, and to facilitate dialogues with current scholars within various departments who strive to complicate their own understandings of health and the human condition.

Beyond university programming, however, there are many ways that all medical humanities scholars strive—and should continue—to reach across departments and disciplines to share our methods, theories, approaches, and reflections on medicine with one another. This blog is one such space that beautifully forges virtual connections across academic audiences with a shared interest in health, illness, and medical practice. My own field, medical anthropology, by its nature requires researchers to inform their claims through many kinds of data that necessitate several forms of analysis: all which dovetail approaches in other fields. So too did my previous training in literary studies require me to be conversant in historical methods, in close reading techniques, and in the same inductive reasoning skills that I now apply to my ethnographic work. No discipline is an intellectual island: and if there is a universal value of the medical humanities, it is that it has made junctures out of disparate disciplines. It is at once clinical, scientific, and humanistic.

 

About the Author: Julia Knopes is a PhD candidate in anthropology at Case Western Reserve University, and serves as the administrative coordinator for the newly-launched MA Track in Medicine, Society & Culture in the CWRU Department of Bioethics. Julia’s research examines the socio-material basis of professional role development amongst American medical students. She holds an MA in Humanities from the University of Chicago and a BA in English from Washington & Jefferson College. You can learn more about Julia’s work and current research here.

References

[1] Macnaughton, Jane. (2000). “The humanities in medical education: context, outcomes and structures.” Journal of Medical Ethics: Medical Humanities 26: 23-30.

[2] Hunter, KM; Charon, Rita; Coulehan, Jack. (1995). “The study of literature in medical education.” Academic Medicine 70(9): 787-794.

[3] Shapiro, Johanna; Coulehan, Jack; Wear, Delese; Montello, Martha. (2009). “Medical Humanities and Their Discontents: Definitions, Critiques, and Implications.” Academic Medicine 84(2): 192-198.

[4] Information on members of the CWRU MHSM advisory committee can be found here: http://case.edu/medicine/msc/about/advisory-committee/

Fall 2016: Blog Update

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The Culture, Medicine & Psychiatry blog will return to regular, once-weekly updates next week on Wednesday, following our reduced summer upload schedule. In the meantime, our readers can access articles and illness narratives from our new September 2016 issue here.

In the coming weeks, check back on the blog for special article highlights from the new issue, as well as “From the Archive” features, news posts, book release updates, commentaries, and other entries at the blog. As always, we continue to welcome submissions of guest commentaries on the cultural, social, and humanistic study of health and medicine. Please contact our social media editor, Julia Knopes (jcb193@case.edu) for more information.

Best wishes from the CMP Editorial Team!

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Book Release: Eigen’s “Mad-Doctors in the Dock”

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To be published this November 2016 from Johns Hopkins University Press is Joel Peter Eigen’s Mad-Doctors in the Dock: Defending the Diagnosis, 1760-1913. This medical history examines the foundations and early development of the criminal insanity defense in England. Drawing on testimony and documents from almost 1,000 trials, this text examines how physicians, surgeons, and other health care providers connected diagnosis with legal culpability.  The text promises to carefully assess the dynamic relationships between criminal justice, mental health, medicine, and the emergent disciplines of forensic psychology and psychiatry. This book will be of equal interest to anthropologists of medicine and law, as well as psychological anthropologists, historians and sociologists of medicine, and cross-disciplinary scholars in the medical humanities.

To learn more about this upcoming release, click here.

About the Author: Joel Peter Eigen serves as the Charles A. Dana Professor of Sociology at Franklin and Marshall College as well as Principal Fellow (Honorary) at the University of Melbourne. This text is the third in a series that Eigen has published on the history of the insanity defense. The first book, Witnessing Insanity: Madness and Mad-Doctors in the English Court, was released in 1995 by Yale University Press and is available here. The second book, Unconscious Crime: Mental Absence and Criminal Responsibility in Victorian London, was published in 2003 by Johns Hopkins University Press. It can be purchased here.

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.