Long ago my mother, Utahna, was dying from a brain tumor. There was no way for us, her children, to prevent her death irreplaceably damaging all of our young lives. Her body and its ability to fight such an anomaly was failing; and we were powerless to stop it. Fortunately, there are those that endeavor to enter the war against such entities, illnesses, and diseases in order to save the lives of those entangled within. They practice more than just the art of medicine, but also the craft of power. “Led by medicine, the ‘human sciences,’ through their production of knowledge, developed increasingly refined ‘technologies of power’” (Davenport, pg 312). It goes without saying that in order to control the internal physiological environment doctors have to have power over it. However, such interplay is not without its social consequences. In this paper I’m going to look at some of the ways power works in and through medicine. Namely: the objectification of the body; how impoverished displaced sugar cane cutters in Alto de Cruzeiro suffer “nervosa” as a consequence to the political, social, and medical play of power; and finally, how Angel Bay medical students try to bridge the objectification and social politics in order to truly help their patients.
When my mother woke up paralyzed one morning, the emergency personnel were quick to itemize her condition into blood pressure, temperature, heart rate, what limbs she couldn’t move, where there was pain, and so on. She no longer was Utahna, a poet and mother six, but rather a puzzle that they needed to break down into smaller and smaller pieces in order to find out why her body wasn’t working. In a sense, my mother stopped being a person and became an object. This “objectifying” is when doctors, “transform them into problematic body parts rather than view them as whole human beings in fully contextualized psychological and social environments” (Davenport, pg 311). As the body is broken down into systems then subsystems, the microscopic way the doctor’s view their patients has been coined as the “medical gaze” by Michel Foucalt. The technical discourse that follows only supports the distancing of the patient from the “condition”. One might wonder why there’s a critique against this objective perspective when it seems inevitable or even professional. However, the critique is not about what it takes into account, but rather what it lacks. If the cause or the solution lies outside the physical body, will even the greatest microscope or “medical gaze” be able to find it? An example of this is sorely seen in the impoverished cane cutters of Alto de Cruzeiro.
After a quarter of a century of repressive military rule, the political climate in Alto de Cruzeiro is uneasy. Here the, “dominant exercised their power both directly through the state and indirectly through a merging with civil society… that hegemony operates as a hybrid of coercion and consensus” (Hughes, pg 171). In “Nervoso: Medicine, Sickness, and Human Needs,” Nancy Scheper Hughes indicates that it’s, “into this potentially explosive situation, doctors, nurses, pharmacists, and the first few timid psychologist to appear on the landscape are recruited in an effort to domesticate and pacify an angry-hungry population” (Hughes, pg 211). In Alto de Cruzeiro the power to address the physical ailments of its starving people lies not only on the doctor, but also on the political and social climate. With so many engaged, it raises some questions as to why their physical needs are not being met. Beyond that is why the doctors are treating their patients for “nervoso" and not hunger. “How have these people come to see themselves primarily as nervous and only secondarily as hungry?” (Hughes, pg 177) Two examples of these mortally tired cane cutters are Severino Francisco and Seu Tomas’.
Starting as an eight year old child, Severino cut the cane until he became sick. He like many others had to work the cane on empty stomachs (Hughes, pg 176). They would eat when they could and, when they couldn’t; they would try to sleep till the next day (Hughes, pg 182). Severino continued until the “illness” that spread through his legs and body got too bad for him to work in the fields. After searching for a “cure” he took up the barber profession to provide for his family. “I barely make enough to feed my wife and children. The cacula [last born] cries for milk all the time, but I have to deny her because out of the little besteira that I earn I have to put something aside every week for my medicines.” In addition, it falls to the doctors to sign his disability papers and, therefore, it is in his best interest to turn to them to for help. However, “they just kept sending me home with remedios for my heart, for my blood, for my liver, for my nerves. Believe me, so vivo de remedios [I live on medications]” (Hughes, pg 181). Seu Tomas’ was also prescribed many medications for his “illness” although, in Seu Tomas’ case, he stopped taking certain ones because they “began to offend” his empty stomach (Hughes, pg 183). When asked why they are treating his nerves and not his hunger, he laughed and said, “Who ever heard … of a treatment for hunger? Food is the only cure for that.” He goes on to say that, “It’s easier to get help with remedior. You can show up at the prefeitura with a prescription… but you can’t go to the mayor and beg for food!”(Hughes, pg 184) In both of these examples they were treated at the doctor’s for “nervoso” which is a folk term that manifests like hunger in their physical bodies as headaches, tremors, weakness, tiredness, irritability, angry weeping, among others. How are the doctors of Alto de Cruzeiro going to fight their war on illness if they cannot see their patients in their “fully contextualized psychological and social environments?” And, since they don’t, the consequences to objectifying their patients has become a population that is slowly dying of hunger, yet sees themselves as “ill” or nervous. Nancy Hughes sums up their unfortunate conclusion.
“There are power and domination to be had from defining a population as ‘sick’ or ‘nervous’ and in need of the ‘doctoring’ hands of a political administration that swathes itself in medical symbols. To acknowledge hunger, which is not a disease but a social illness, would be tantamount to political suicide for leaders whose power has come from the same plantation economy that has produced the hunger in the first place. And because the poor have come to invest drugs with such magical efficacy, it is all too easy for their faith to be subverted and used against them. If hunger cannot be satisfied, it can at least be tranquilized, so that medicine, even more than religion, comes to actualize the Marxist platitude on the drugging of the masses” (Hughes, pg 202-203).
As the cane workers are, “paralyzed within a stagnant semifeudal plantation economy that treats them as superfluous and dependent,” they are left with two choices (Hughes, pg 182). They can recognize their political, social, and physical suffering and protest; which may offer them lethal consequences. Or, they can turn to medicine to “cure” their physical crisis. In the hospital, or clinic, the doctors have two choices as well. The first is to take the pain on under the, “technical domain of medicine, where they will be transformed into a ‘disease’ to be treated with an injection, a nerve pill, a soporific” (Hughes, pg 214). While the second is to, “provide a space where new ways of addressing and responding to human misery,” is worked out (Hughes, pg 215). By practicing more than just the art of medicine and the craft of power, one way a doctor can balance the act of “gazing” is by “witnessing”. This is seen throughout the city of Angel Bay where local university medical students learn and practice in homeless clinics.
The ideology of “witnessing” is directly in opposition to how medicine constructs its patients as “objects” (Davenport, pg 316). What Beverly Ann Davenport calls “witnessing” is where the doctor consciously works to “see” the whole patient, “not simply the medical aspects of the patient’s complaint, but also his or her social and psychological environment” (Davenport, pg 318). As Beverly reports on their “quality, not quantity” motto through five micro-practices, the conflict between “gazing” and “witnessing” becomes more apparent. It starts with a gentle, thorough probing of the patient’s history. For example, when a first year student asks how long he should let the patient “ramble on” before he jumped “to the important medical stuff,” the second year student points out that allowing the patient to “ramble on” was a powerful interview technique. She asserts basically that, “what is ‘medically important’ would be revealed in the ‘witnessing’ process” (Davenport, pg 318-9). Otherwise, treatment might end up like it did for the drug user that moved to Angel Bay City from the East Coast. In that case, “the ultimate irony … is that a heroin-user is advised to quit smoking in order to take birth control pills to relieve the symptom of irregular periods, which is caused by her heroin addiction in the first place” (Davenport, pg 320).
Another aspect of “witnessing” is thinking of the patients as subjects; where the doctor sees both the disease and the person who is suffering from it. One doctor tackles this by not referring to his patient in third person singular, but rather by name. It’s not, “a 46-year-old white man who comes in with a history of …” but rather, “So I met Bill. And Bill was disheveled…” (Davenport, pg 321-2) When charting or meeting with other doctors they tend to depersonalize their patients and the discourse becomes more of “gazing” and less about the human around it. For my mother, her extreme poverty and physical beatings from her father when she was young never came into her discourse. Every time she would seek help with her headaches the doctors wrote her off a prescription or indicated that her pain was imagined and did nothing. For decades, no tests were run because they never looked beyond her body for a cause and, therefore, they never felt expensive tests were warranted. Like for my 40 year old mother, “gazing” rather than “witnessing” costs and destroys lives.
Objectification of the body may simplify medical learning, but it complicates patient care. As seen in the cane cutters of Alto de Cruzeiro, the medical removal of humanity from the people makes them political and social power tools. Unless new ways of responding to human misery are generated, and the objectification of the patient is challenged, then the loss and destruction of lives will continue. The students of Angel Bay have begun this process with the “witnessing” of their patients. Fortunately, there are those that endeavor to enter the war against illnesses, and diseases in order to save the lives of those entangled within. “Seeing” their patient may be their next great step.
Bibliography
Davenport, Beverly Ann. 2000. "ARTICLES - Witnessing and the Medical Gaze: How Medical Students Learn to See at a Clinic for the Homeless". Medical Anthropology Quarterly. 14 (3): 310.
Scheper-Hughes, Nancy. 1992. Death without weeping: the violence of everyday life in Brazil. Berkeley: University of California Press.
Tuesday, November 24, 2009
Sunday, November 8, 2009
An Aid of Meaning
Assumptions about the ailing are as common as doctors hypothesize on what’s wrong with their patients. In the work’s of John Aggergaard Larsen “Finding Meaning in First Episode Psychosis,” and Rachel R. Chapman “Endangering safe motherhood in Mozambique,” these assumptions are challenged by a broader understanding of the how and the why. Namely, by the context of the patient, and the meaning that they take in their experiences, will model how they are treated or diagnosed; the effectiveness of the treatment; and what other avenues they will take to understand their illness in order to get better.
As people go throughout their daily lives they attach meaning, symbols, and images to not only their communication, but also in their understanding of life and the world around them. In a very real aspect they are living a metaphor. These life metaphors find their voice in the narratives that often are passed over or missed entirely. When missed they present themselves in puzzles like, “why women are not going to a free maternity clinic until the end of their pregnancy, regardless of the high infant and child mortality rate?” (Chapman, 355) Or seen in the initiation of an early intervention program, OPUS, to study and understand why the mentally ill suffer as they do. (Larsen, 451) There are those that would be tempted to claim, like in the Gondola data, “high-risk women in developing countries as unmotivated and/or non-compliant victims.” (Chapman, 371) This in essence blames the women for the death of their children. Or that the mentally ill are just crazy and their ailment causes their suffering. (Larson, 451) But to accept these arguments would be to completely abandon conceptual clarity.
Conceptual clarity, or a system of explanation, emerges from many aspects. These are found in the biomedical aspect of an illness, the spiritual or religious, the financial, the cultural, and the individual narratives. In “Finding Meaning in First Episode Psychosis,” John Larson calls it Bricolage when, “they tried to connect and supplement various systems of explanation in innovative theory-building work.” (Larson, 461) That even the delusions themselves are a patients attempts, “to master a frightening and bewildering subjective state by imposing meaning or forcing an explanation upon experiences which would otherwise be meaningless or inexplicable.” (Larson, 460) In essence they are taking pieces of what makes sense and building an understanding of what they are experiencing. And for many, “they found resonance in a wider cultural repertoire, that is, the myths, traditions, and institutional bases of authority in the wider society.” (Larson, 462) It is through all the pieces or layers of understanding that the OPUS intervention program could find success.
Another parallel reference to a patients layering of treatments to find the cure is in Rachel Chapman’s “Endangering Safe Motherhood in Mozambique.” In Chapman’s chart on page 363 we see the veritable bricolage in the form of treatments the women pursue. Namely: Pharmaceutical, herbal, district health center, church, curandeiro, prophet, prayer, mission clinic, traveling “nurse”, and maternity clinic. For example, in Raquel’s story the layering of her treatment was related to finance, culture, religion, and biomedicine. After paying for first diagnosis, she was given a prescription that she could not afford. The pharmacy gave her half her treatment for the money which did not help her at all. The next month a curandeiro accepted the same amount of money for three months of an infusion of roots. This helped but did not cure the patient but gave her an understanding that it cleaned inside her for the baby. Then finally a traveling “nurse” charged three times the amount for the pills and infusion to inject Raquel and her husband over the next three weeks. She believes that the injections attacked the site where her illness was fixed. Although this overcame her symptoms, Raquel also went to her prophet who gave her a blessing and sacred water to drink and bathe in. This was to cleanse her body and to not have anymore bad luck. According to Raquel it was the multiple layers that was her cure under the umbrella of her belief that the three treatments were symbolic of the “Father, Son, and Holy Spirit.” (Chapman, 364)
With more of an Ethnographic research style that took into account attention to the Bricolage or fluidity of treatment, both authors’ uncovered important aspects in how to help and understand their patients better. This starts with understanding that the patients are very active in finding meaning in their ailment in order to help them. For example, Chapman noted that, “under conditions of frequent reproductive morbidity and loss, little access to cash, immense domestic and agricultural work burdens, and limited routes to female social and economic self-determination” the women still, “demonstrate significant initiative in mobilizing the resources they deem necessary to influence their own reproductive labor and decrease the odds of poor pregnancy outcomes.” (Chapman, 371) While Larsen argued that; “individuals take an active role when applying understandings and meanings to their situations and experiences,” that, “plural healing systems can exist within an overarching cultural tradition,” and that, “culture as a ‘tool kit’ of symbols, stories rituals, and world-views” will be used “in varying configurations to solve different kinds of problems.” (Larsen, 457) Due to these discoveries solutions could be addressed.
For the women in Mozambique, social conflict and economic tension are reproductive threats. Those, due to migration of women from large patrilocal and polygynous households into smaller nuclear residence, many women suffer under an economic vulnerability due to lack of wage paying jobs for women. (Chapman, 369) The women without cash capital cannot compete and must be directly or indirectly dependent on male cash resources. As these women compete for resources many keep their pregnancies secret as a protective measure. That once it is known they are preyed upon by mal espirito kin and midwives seeking assistant gifts. Basically, safe motherhood in Mozambique, “lies beyond the scope of medical or even public health solutions alone.” (Chapman, 372) However, some changes can be made. Merging the maternity clinic with the District Health Center will provide patient privacy and may draw more women in for early maternity care. Also, better service that lowers the wait time will draw the women who can’t be away from home or the farm long.
For those that are mentally ill, teaching them a psychoeducation, “provided highly influential concepts and theories.” Through this education many “found explanations by drawing on systems of explanation available from the cultural repertoire of the wider society.” (Larsen, 465) As meaning comes, many are relieved of their tormented feelings and to an extent their helplessness. Indeed, it is a goal as different explanations are, “rejected, accepted, appropriated, and reevaluated in a continuous process.” (Larsen, 465) By providing an institution or mental health community to provide education and various contexts, the patient can become part of the solution.
In both of these articles the Anthropologist’s looked for the narrative of those that were ailing. This required that they put aside assumptions or conclusions that they and others jumped to early on. By doing this a broader understanding of the how and why emerged in a format that could assist not only in effective treatment, but also in ways for the ailing to find meaning in their experiences. As noted above, understanding does not fix all problems. But it did offer incite into small changes that can make a difference. Perhaps, with more seeking meaning within a culture the larger socioeconomic changes can be made. In fact, I would submit that it is the only way those changes ever came to be.
Bibliography
Larsen JA. 2004. "Finding meaning in first episode psychosis: experience, agency, and the cultural repertoire". Medical Anthropology Quarterly. 18 (4): 447-71.
Chapman RR. 2003. "Endangering safe motherhood in Mozambique: prenatal care as pregnancy risk". Social Science & Medicine (1982). 57 (2): 355-74.
As people go throughout their daily lives they attach meaning, symbols, and images to not only their communication, but also in their understanding of life and the world around them. In a very real aspect they are living a metaphor. These life metaphors find their voice in the narratives that often are passed over or missed entirely. When missed they present themselves in puzzles like, “why women are not going to a free maternity clinic until the end of their pregnancy, regardless of the high infant and child mortality rate?” (Chapman, 355) Or seen in the initiation of an early intervention program, OPUS, to study and understand why the mentally ill suffer as they do. (Larsen, 451) There are those that would be tempted to claim, like in the Gondola data, “high-risk women in developing countries as unmotivated and/or non-compliant victims.” (Chapman, 371) This in essence blames the women for the death of their children. Or that the mentally ill are just crazy and their ailment causes their suffering. (Larson, 451) But to accept these arguments would be to completely abandon conceptual clarity.
Conceptual clarity, or a system of explanation, emerges from many aspects. These are found in the biomedical aspect of an illness, the spiritual or religious, the financial, the cultural, and the individual narratives. In “Finding Meaning in First Episode Psychosis,” John Larson calls it Bricolage when, “they tried to connect and supplement various systems of explanation in innovative theory-building work.” (Larson, 461) That even the delusions themselves are a patients attempts, “to master a frightening and bewildering subjective state by imposing meaning or forcing an explanation upon experiences which would otherwise be meaningless or inexplicable.” (Larson, 460) In essence they are taking pieces of what makes sense and building an understanding of what they are experiencing. And for many, “they found resonance in a wider cultural repertoire, that is, the myths, traditions, and institutional bases of authority in the wider society.” (Larson, 462) It is through all the pieces or layers of understanding that the OPUS intervention program could find success.
Another parallel reference to a patients layering of treatments to find the cure is in Rachel Chapman’s “Endangering Safe Motherhood in Mozambique.” In Chapman’s chart on page 363 we see the veritable bricolage in the form of treatments the women pursue. Namely: Pharmaceutical, herbal, district health center, church, curandeiro, prophet, prayer, mission clinic, traveling “nurse”, and maternity clinic. For example, in Raquel’s story the layering of her treatment was related to finance, culture, religion, and biomedicine. After paying for first diagnosis, she was given a prescription that she could not afford. The pharmacy gave her half her treatment for the money which did not help her at all. The next month a curandeiro accepted the same amount of money for three months of an infusion of roots. This helped but did not cure the patient but gave her an understanding that it cleaned inside her for the baby. Then finally a traveling “nurse” charged three times the amount for the pills and infusion to inject Raquel and her husband over the next three weeks. She believes that the injections attacked the site where her illness was fixed. Although this overcame her symptoms, Raquel also went to her prophet who gave her a blessing and sacred water to drink and bathe in. This was to cleanse her body and to not have anymore bad luck. According to Raquel it was the multiple layers that was her cure under the umbrella of her belief that the three treatments were symbolic of the “Father, Son, and Holy Spirit.” (Chapman, 364)
With more of an Ethnographic research style that took into account attention to the Bricolage or fluidity of treatment, both authors’ uncovered important aspects in how to help and understand their patients better. This starts with understanding that the patients are very active in finding meaning in their ailment in order to help them. For example, Chapman noted that, “under conditions of frequent reproductive morbidity and loss, little access to cash, immense domestic and agricultural work burdens, and limited routes to female social and economic self-determination” the women still, “demonstrate significant initiative in mobilizing the resources they deem necessary to influence their own reproductive labor and decrease the odds of poor pregnancy outcomes.” (Chapman, 371) While Larsen argued that; “individuals take an active role when applying understandings and meanings to their situations and experiences,” that, “plural healing systems can exist within an overarching cultural tradition,” and that, “culture as a ‘tool kit’ of symbols, stories rituals, and world-views” will be used “in varying configurations to solve different kinds of problems.” (Larsen, 457) Due to these discoveries solutions could be addressed.
For the women in Mozambique, social conflict and economic tension are reproductive threats. Those, due to migration of women from large patrilocal and polygynous households into smaller nuclear residence, many women suffer under an economic vulnerability due to lack of wage paying jobs for women. (Chapman, 369) The women without cash capital cannot compete and must be directly or indirectly dependent on male cash resources. As these women compete for resources many keep their pregnancies secret as a protective measure. That once it is known they are preyed upon by mal espirito kin and midwives seeking assistant gifts. Basically, safe motherhood in Mozambique, “lies beyond the scope of medical or even public health solutions alone.” (Chapman, 372) However, some changes can be made. Merging the maternity clinic with the District Health Center will provide patient privacy and may draw more women in for early maternity care. Also, better service that lowers the wait time will draw the women who can’t be away from home or the farm long.
For those that are mentally ill, teaching them a psychoeducation, “provided highly influential concepts and theories.” Through this education many “found explanations by drawing on systems of explanation available from the cultural repertoire of the wider society.” (Larsen, 465) As meaning comes, many are relieved of their tormented feelings and to an extent their helplessness. Indeed, it is a goal as different explanations are, “rejected, accepted, appropriated, and reevaluated in a continuous process.” (Larsen, 465) By providing an institution or mental health community to provide education and various contexts, the patient can become part of the solution.
In both of these articles the Anthropologist’s looked for the narrative of those that were ailing. This required that they put aside assumptions or conclusions that they and others jumped to early on. By doing this a broader understanding of the how and why emerged in a format that could assist not only in effective treatment, but also in ways for the ailing to find meaning in their experiences. As noted above, understanding does not fix all problems. But it did offer incite into small changes that can make a difference. Perhaps, with more seeking meaning within a culture the larger socioeconomic changes can be made. In fact, I would submit that it is the only way those changes ever came to be.
Bibliography
Larsen JA. 2004. "Finding meaning in first episode psychosis: experience, agency, and the cultural repertoire". Medical Anthropology Quarterly. 18 (4): 447-71.
Chapman RR. 2003. "Endangering safe motherhood in Mozambique: prenatal care as pregnancy risk". Social Science & Medicine (1982). 57 (2): 355-74.
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