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

Posted by jknopes

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

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

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

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

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

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

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.

In the News: Telemedicine in the United States

Posted by jknopes

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The intersections between technology, medicine, and health are a frequent site of discussion at Culture, Medicine & Psychiatry. In our last issue of 2015, for instance, Yael Hashiloni-Dolev[1] examined the role of new medical technologies that enable posthumous reproduction, while Petersen and Traulsen[2] shed light on the nuanced social uses of psychoactive medications amongst university students. These articles underscore the centrality of technology in everyday human health behaviors, and on the cultural meaning of these new tools in local medical landscapes.

Another technological innovation altering the social world of medicine—one making headlines in recent months—is telemedicine. In the Journal of the American Medical Association[3] (JAMA), telemedicine has been described as “the use of telecommunications technologies to provide medical information and services,” often a shorthand “for remote electronic clinical consultation” via phones and internet applications.

In the December 2015 AARP Bulletin, author Charlotte Huff[4] remarked that over 1 million patients will use telemedicine services this year, and remote access to physicians by phone, video chat, and email is more and more commonly covered by American employers’ health insurance packages. A Reuters article[5] adds that in Texas, a telemedicine company is working to block a state law that would require physicians to see a patient in-person before consulting with them via phone, email, or other means. And in the New York Times[6], a physician observed that telemedicine may prove a useful tool for children and adolescents: many of whom have grown up in a digital culture of “oversharing” and would not balk at texting their physicians images of strange rashes or lesions on their bodies. As this new tool of health care delivery is negotiated in different societal arenas, so too are its implications increasingly worthy of anthropological attention.

Telemedicine is altering the social fabric of medicine in a number of significant ways. Here, we will outline two potential outcomes of telemedicine on medical exchanges facilitated by technology. First, telemedicine extends the professional reach of biomedical clinicians. Areas where biomedical care is inaccessible, or where only indigenous medical systems exist, may now fall under the electronic eye of a faraway practitioner. This has extraordinary consequences for the ubiquity of biomedicine and the consolidation of biomedical power. Second, and rather conversely, telemedicine empowers the patient in the clinical encounter. Because the physician or clinician is not physically present to examine the patient’s body, the patient themself is the one who touches a swollen throat, or flexes a stiff joint, and relays their response through phone or web camera. In sum, the patient gains greater control over bodily (and verbal) narratives that, unlike an in-person exam, the clinician does not have total access to.

The rise of telemedicine speaks to medical anthropologists, certainly, but it also presents a fascinating case more broadly for science and technology theorists and scholars in health communication. As the topic of telemedicine continues to capture the interest of medicine and the media, so too will it fall under the consideration of researchers piecing together the networks that bring patients and their caregivers together in novel ways.

[1] http://link.springer.com/article/10.1007/s11013-015-9447-6

[2] http://link.springer.com/article/10.1007/s11013-015-9457-4

[3] http://jama.jamanetwork.com/article.aspx?articleid=386892

[4] http://www.aarp.org/health/conditions-treatments/info-2015/telemedicine-health-symptoms-diagnosis.html#slide1

[5] http://www.reuters.com/article/health-case-to-watch-teladoc-idUSL1N14H0CT20151228

[6] http://well.blogs.nytimes.com/2016/01/18/using-phones-to-connect-children-to-health-care/?ref=health

Issue Highlight: Vol 39 Issue 4, Incarceration & Medical Anthropology

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This blog post is the second installment of our three-part issue highlight on the new December 2015 issue of Culture, Medicine & Psychiatry (the full issue is accessible here.) In this week’s blog, we examine Carolyn Sufrin’s article on the shared roles of clinicians and anthropologists working with incarcerated women in the United States.

Clinician-anthropologists are in a unique position to lend voice to their participants and to care for their medical needs. For Carolyn Sufrin, who served both as a physician and an ethnographic researcher for incarcerated women in the United States, the clinical and anthropological roles intersected in deeply meaningful ways. Sufrin notes that in these dual roles, she observed with female prisoners and analyzed their experiences, and provided reproductive health care and delivering the same women’s babies in a county hospital, where imprisoned women gave birth. The women were alternately enrolled in Sufrin’s study upon ceasing to officially be her patients, or were individuals that Sufrin cared for during her tenure as their OB/GYN.

Sufrin uses her case as an example of how to interpret the ethical consequences of working as a clinician-anthropologist. Part of the challenge she faced as both a physician and anthropologist to the women was that IRB and HIPAA regulations divided the types of data she could use in her anthropological research. Though some details of her participants’ lives, such as past trauma or childhood abuse, were essential to their experiences as mothers and as incarcerated women, she could not use this data inasmuch as it had been shared with her in the context of a patient-practitioner interaction: in other words, it was considered classified personal health information that could not be subsequently utilized in her ethnographic research. These methodological hurdles, Sufrin explains, shed light on the complexities of what constitutes “sacrosanct” data. It also suggests how the safeguarding of medical data does not necessarily translate to the “protective” collection of ethnographic data which is not isolated to the case of individual patients, and which relies on knowledge of participants and their connections to other people (in this instance, to individuals in the participant’s life who had caused past psychological harm.)

Likewise, as stated earlier, relationships between the participant/patient and the clinician/anthropologist are another form of interpersonal connection which must be reconfigured depending on the nature of the exchange taking place. In Sufrin’s case, this meant being clear with her participants that– upon entry into her anthropological study– she was no longer their physician, and that the nature of their exchanges and their professional relationship would take a new form. She could share their information (albeit de-identified), unlike information drawn solely from their medical records or from an examination.

Yet here, Sufrin notes that the anthropologist– like the clinician– is still engaged in an ethic of care. For example, one of Sufrin’s former patients in the prison was charged with child endangerment after giving birth in an alley and handing her child to a stranger, unable to afford treatment at a hospital following her release from prison. The story made news headlines, and as public knowledge, was within the realm of information that Sufrin employed in her ethnographic analysis of reproductive health in the American prison system. However, Sufrin knew an added piece of information that was not already publicized from her interaction with the woman in prison: a clinical detail that she understood as a physician, but was shared during her time as an ethnographic researcher. This detail would have enhanced her analysis of the situation, but she chose to omit it out of concern that to publicize the detail would be to betray the woman’s trust in her as a researcher and as someone who served in the prison as a physician.

In other instances that Sufrin discusses, her role as both an anthropologist and clinician led the women she worked with in each capacity to feel as if she was especially attentive and caring. Rather than always relying on her medical authority, Sufrin underscores her decision to remain non-judgmental and supportive even when the women in her study had made potentially harmful choices; for example, she chose not to openly admonish a woman who was continuing to use crack upon release from jail, despite being thirty-two weeks pregnant. Sufrin notes that her silence hid her own frustration with this choice, but it strengthened the woman’s trust in her as an anthropologist and “as a doctor.”

In sum, these dual roles ultimately bolstered her relationships to the incarcerated and formerly incarcerated women that she served. Thus, the author argues that both anthropologists and clinicians share an “ethic of care” in their relationships with research subjects or patients. This ethic involves a careful fostering of the professional, interpersonal connections that ethnographers make with research participants, or that physicians make with their patients. This care entails the protection of private information and the researcher/clinician’s conscious attendance to interpersonal exchanges that bolster the patient/participant’s trust in the clinician/anthropologist. Likewise, an analysis of the clinician role alongside the anthropological one demonstrates both the delineations between multiple forms of care and social connection, as well as the shared commitment in medicine and anthropology to the sensitive attendance to patient and participant experiences.