First of all, congratulations to Daniel Lende and Greg Downey whose excellent Neuroanthropology blog has just made the move to a new science blogging platform: PLoS Blogs. This new venture, under the auspices of the Public Library of Science -- which has been in the forefront of developing open-access journals in science and medicine -- includes a number of great-looking blogs, including science journalist Steve Silberman's NeuroTribes, The Gleaming Retort by John Rennie--who was editor in chief of Scientific American from 1994 to 2009, and pharmacologist David Kroll's Take as Directed, among several others. Given that anthropological perspectives are often given short shrift in science-and-medicine-oriented venues, it is particularly gratifying to see Neuroanthropology included among the PLoS Blogs.
Also, the blog of the Foundation for Psychocultural Research is starting to become more active. They have just posted the first of several summaries of their conference on Cultural and Biological Contexts of Psychiatric Disorder, which Emily Ng reported on for Somatosphere in February.
Thursday, September 2, 2010
News from the blogs we read...
Monday, August 30, 2010
Towards an era of bureaucratically controlled medical compliance?
Applbaum and Oldani emphasize in their introduction that while patient compliance and non-compliance has long been studied in epidemiology and health services research, it has increasingly become the object of intense interest in the pharmaceutical industry:
“Worldwide pharmaceuticals sales in 2010 are projected at US $825 billion, representing a compound annual growth rate of roughly 10% per year from 1999 onwards. Pharmaceuticals account for 18% of healthcare expenditures worldwide, a percentage that has grown in double digits in recent years. Through much of the 2000s the industry was the world's most profitable. Amid the relative poverty of breakthrough drug discoveries, corporate strategists have turned to treatment non/compliance as a recovery site, a slag heap for lost profits,” (Applbaum and Oldani 2010).And as Joe Dumit adds in his afterword:
“Compliance's usefulness as a measure of prescribed treatment adherence by a patient has been its ability to index treatment success, and therefore help in ensuring and governing health. What these anthropologists have discovered, however, is that because of its function as an index, compliance has been itself instrumentalized and made to serve goals sometimes quite far from health. Most fascinating is that it is not only pharmaceutical and insurance companies - the standard bugbears of capitalized medicine - that are engaging in this instrumentalization of compliance, but it is happening across the board, by the severely mentally ill, TB treaters, doctors and nurses.As you’ll see in the abstracts reproduced below, there are a number of great ethnographically-rich papers here:
…
Where compliance may have been at times a research question of efficacy or an index correlating with health, throughout these ethnographies compliance has become the operative definition of risk prevention. At the experiential level, we might call this process 'interpillation'. With a tragic nod to Althusser's own struggles with mental illness, interpillation is the process of calling into being biomedical subjects as having been always-already in need of treatment. Individuals, especially those with mental illness, are increasingly left with no other subject position,” (Dumit 2010).
Kalman Applbaum; Michael Oldani, Towards an era of bureaucratically controlled medical compliance?
Paul Brodwin, The assemblage of compliance in psychiatric case management
In the post-asylum era, case managers perform much of the face-to-face work of pharmaceutical compliance for people with severe and persistent mental illness. Their work demands careful orchestration of the assemblage of compliance, including the actual medications, the ideology of biopsychiatry, the division of professional labor, and certain mundane tools. Ethnographic vignettes from an Assertive Community Treatment (ACT) team show how case managers use this assemblage in their everyday routines, but also how it undercuts key elements of the original ACT mission. Reflecting its roots in the deinstitutionalization movement, the ACT model gives case managers limitless responsibilities for clients' lives, but then narrowly defines their role as the prosthetic extension of psychiatric authority. To produce compliance, case managers depend on the medication cassette, analyzed here as a human/non-human hybrid woven into their ordinary work. The medication cassette has pre-scripted uses that enlist clinicians in biopsychiatric thinking and also silently impose compliant behavior on clients. The elements in the assemblage of compliance depend on each other, but they do not form a seamless whole, as evidenced by the dilemmas and micropolitics of the clinical front-line. Theoretical notions of assemblages and technologies of compliance, drawn from science and technology studies, illuminate a core conundrum of practice in psychiatric case management.
Annette Leibing, Inverting compliance, increasing concerns: aging, mental health, and caring for a trustful patient
Why, after 40 years of intensive research, is adherence to treatment still an issue? This paper suggests a possible solution to an apparently unsolvable problem: reconceptualizing adherence. To understand how adherence can affect key personnel in any western health system, this study focuses on community nurses working with older mental health patients in Quebec. When they spoke about adherence, nurses presented an idealized image of the nurse-patient relationship, namely, the caring nurse and the trustful patient. However, this idealization cannot be reduced only to questions of power and paternalism. By reconceptualizing adherence as a 'matter of concern', health professionals and researchers alike might come to understand individual care situations within a broader notion of conflicts in patient care.
Jeffrey Longhofer; Jerry Floersch, Desire and disappointment: adolescent psychotropic treatment and adherence
This paper situates medication adherence among adolescents in current cultural and political-economic debates about compliance/adherence and the formation of biomedical subjectivities. Building on prior work of the authors, this paper explores the role of desire in adherence to show how subjectivities are shaped by concordant, instrumental, or conditional forms of desire. Data is used to show how parents and adolescents compare the medicated self before and after, resulting in the formation of desire. It is argued that adherence is an outcome of desire: no desire, no adherence, or varying types of desire. Moreover, adherence is not a steady state. It is produced moment to moment as adolescents confront the desires of others. The study uses interview data to construct a case study of concordant desire, which is a form most likely to produce adherence. With concordant desire the medicated come to expect a future life on medication and a life where symptoms are stripped of their social and psychological meaning and significance.
Kelly A. McKinney; Brian G. Greenfield, Self-compliance at ‘Prozac campus’
This paper focuses on psychiatric medication experiences among a sample of North American university students to explore a new cultural and social landscape of medication 'compliance.' In this landscape, patients assume significant personal decision-making power in terms of dosages, when to discontinue use and even what medications to take. Patients carefully monitor and regulate their moods, and actively gather and circulate newly legitimated blends of expert and experiential knowledge about psychiatric medications among peers, family members and their physicians. The medications too, take a vital role in shaping this landscape, and help to create the spaces for meaning-making and interpretation described and explored in this article. In concluding the article, the authors claim that two popular academic discourses in medical anthropology, one of patient empowerment and shared decision-making and the other of technologies of self and governmentality, may fail to account for other orders of reality that this paper describes - orders shaped and influenced by unconscious, unexpressed and symbolic motivations.
Carolyn Rouse, Patient and practitioner noncompliance: rationing, therapeutic uncertainty, and the missing conversation
Currently, the life expectancy of black Americans is about five years shorter than that of white Americans when factoring for gender. Poor patient compliance is often used as an explanation for why black people have worse health outcomes. The proof, however, is anecdotal and relies primarily on discourses about black people's general dysfunction. Black patients often respond in kind to problems they experience with health care access. They often conclude that the medical professionals they work with are racist. In most cases, neither of these explanations is correct. This paper argues that behavioral explanations for health care disparities shift attention away from structural issues, namely health care rationing and the limits of therapeutic medicine. The lack of an open discussion about the structural issues is part of the reason the goal initiated by the Clinton administration to end racial disparities by 2010, Healthy People 2010, largely failed.
Ian Harper, Extreme condition, extreme measures? Compliance, drug resistance, and the control of tuberculosis
This paper explores the issue of compliance by focusing on the control of tuberculosis. In the last ten years, patient compliance in tuberculosis control has discursively shifted from 'direct observation' of therapy to more patient-centred focus and support drawing on rights-based approaches in dealing with health care provision. At the same time, there has been an increased international concern with the rise of drug resistant forms of tuberculosis, and how to manage this. This paper looks at these issues and the tensions between them, by discussing the shift in discourses around the two and how they relate. Drawing on experience from work in Nepal, and its successful tuberculosis control programme, it looks at debates around this and how these two arenas have been addressed. The rise of increasingly drug resistant forms of tuberculosis has stimulated the development of new WHO and other guidelines addressing how to deal with this problem. The links between public health, ethics and legal mandate are presented, and the implications of this for controlling transmission of drug resistant disease, on the one hand, and the drive for greater patient support mechanisms on the other. Looking forwards to uncertain ethical and public health futures, these issues will be mediated by emergent WHO and international frameworks.
Michael J. Oldani, Assessing the ‘relative value’ of diabetic patients treated through an incentivized, corporate compliance model
Primary Care clinics in the United States continue to incentivize doctors to adhere to clinical guidelines regarding record keeping and managing specific patient disorders. This paper offers a case study of a US physician working in a system of total compliance. This narrative will illustrate how a specific system has emerged that pays doctors an end-of-year bonus for achieving compliance in four specific areas: record keeping, service hours, customer satisfaction surveys, and maintaining tight control of diabetic patients. In particular, special attention is paid to the emphasis on 'the numbers' within the corporate compliance model, and specifically, the relative value units (RVUs) used for structuring billing, labeling patients, and organizing the day-to-day activities of doctors. Although incentivized models of compliance have proved effective in managing both doctors and patients, especially in the UK, 'gaming' the system can occur. This paper identifies one example of how patients assume a hidden risk within this model by potentially being labeled noncompliant by having the wrong numbers, even when receiving good clinical care and acting medically compliant.
Douglas Glick; Kalman Applbaum, Dangerous noncompliance: a narrative analysis of a CNN special investigation of mental illness
Prevention of illness has become a central theme in debates over strategies to reduce healthcare costs. Severe mental illness poses a special challenge to the paradigm of rational prevention, the principal strategy of which is adherence to pharmacological therapies. With the contraction in the US of in-patient psychiatric care from the 1960s onwards, the mentally ill have become more visible among the homeless and among those caught up in the penal system. Their characteristic visibility contributes to their image as threatening. The perceived dangerousness and the combined societal and economic costs associated with the illness have generated a heightened, and in some venues even a sensationalized rhetoric surrounding the questions of responsibility and control, which we consider in terms of compliance. Using the linguistic method of discourse analysis, we analyze one high profile instance - an episode of CNN's 'Special Investigations Unit', which aired several times in the summer of 2007 - to demonstrate a narrative linking of the high social costs and failures associated with noncompliance and, therefore, the imperative of enforcing it for the safety of society. Through the semiotic reduction of a 'poetic parallelism', the episode reflects and reinforces existing cultural models for mental illness, including its status as straightforward biological disease amenable to pharmacological therapy but which remains uncontrolled due to widespread noncompliance.
Joseph Dumit, Inter-pill-ation and the instrumentalization of compliance
More syllabus mania! (figuratively speaking)
We should have some more posts in our series on syllabi and reflections on teaching, but in the meantime, you might want to check out similar efforts underway at other blogs. The brilliant h-madness is also running a series of posts of syllabi and comments on the experience of teaching the course. The series focuses on courses in the history of psychiatry, and the first installment -- “Madness, Science, and Society in the Modern West” by Paul Lerner of the University of Southern California -- is now available. Upcoming posts will feature syllabi by Elizabeth Lunbeck, Mark Micale, and other leading historians of psychiatry.
Also, over at Neuroanthropology, Daniel Lende (now at the University of South Florida) is sharing his excellent syllabus for "Biocultural Medical Anthropology." The course is impressive in that it includes both topics like diet and nutrition and those such as biopower/biopolitics -- steering clear of the kind of bio vs. cultural opposition and encampment which unfortunately befalls a lot of anthropology.
Again, if you teach a medical anthropology course (or anything else that fits under the umbrella of topics we cover at Somatopshere) and would like to share your syllabus and thoughts on teaching the course, please contact us at admin@somatosphere.net.
Monday, August 23, 2010
Teaching Critique of Humanitarianism: A Syllabus for Comparative Study
Garces Comparative Humanitarianism
Thursday, August 12, 2010
PsychoDoctor and internet suicide: mental health and psychiatry in Japan
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| Cover of the DVD for PsychoDoctor. |
In "Widening the Psychiatric Gaze: Reflections on PsychoDoctor, Depression, and Recent Transitions in Japanese Mental Health Car," Ken Vickery examines Japan's status as something of an outlier among post-industrial states in terms of mental health services (long-term hospitalization continues to be a common mode of care for patients with schizophrenia), and looks at the efforts made to transform representations of psychiatry by PsychoDoctor, a recent television series (right). His abstract:
"Japan has one of the world’s highest rates of psychiatric institutionalization, and popular images of mental health care and public attitudes toward mental illness there have been stigmatized for decades. However, there are transitions underway that are reshaping the mental health care landscape as well as affecting public representations of mental illness. Those transitions include attempts to promote community-based care, move away from long-term hospitalization, reduce stigma, increase utilization of services, and bring clinical psychological services under the national health insurance umbrella. This article discusses one cultural representation in which those transitions are brought into relief: a 2002 television series entitled PsychoDoctor that portrayed the clinical practice of a psychiatrist. The article analyzes the messages inherent in the series about the nature of mental illness, the everyday-ness of sufferers, and the expanded repertoire of treatments now available. In so doing, the article suggests that the efforts of progressive clinicians, pharmaceutical companies, and mental health activists to put forth new images of mental illness and mental health care are now having a degree of success in the arena of popular culture," (Vickery 2010).
"Existing models for understanding suicide fail to account for the distinctiveness of Internet group suicide, a recent phenomenon in Japan. Drawing from an ethnography of Internet suicide websites, two social commentaries in Japanese popular culture, and the work of developmental psychologist Philippe Rochat, I argue that participation in Internet suicide forums and even the act of Internet group suicide result from both a need for social connectedness and the fear of social rejection and isolation that this need engenders. These needs and fears are especially strong in the case of Japan, where the dominant cultural rhetoric ties selfhood closely to the social self that is the object of perception and experience by others. I show how such an understanding of Internet group suicide helps us to understand some of its basic characteristics, which are otherwise difficult to explain and which have puzzled the Japanese media and popular accounts: the “ordinariness” or casual nature of Internet group suicide, the wish for an easy or comfortable death, the wish to die with others, and the wish to “vanish.” Internet group suicide sheds light on questions of Japanese selfhood in modernity and expands our understanding of suicide in Japan in general," (
Monday, August 9, 2010
Janelle Taylor on teaching "Perspectives in Medical Anthropology"
This post was contributed by Janelle Taylor (University of Washington).
ANTH 475 Syllabus 2009
In Tristes Tropiques, Claude Lévi-Strauss explained that it was his dread of teaching the same course over and over again that impelled him to travel to Brazil and pursue anthropology:
“After spending a happy year at the Mont de Marsan lycée, teaching and preparing my course of lessons as I went along, I was dismayed to discover at the beginning of the next school year… that I would have to repeat the same course for the rest of my life…” (p. 53)
For my part, I have taught the same upper-level undergraduate medical anthropology class (ANTH 475, “Perspectives in Medical Anthropology”) every year since I came to the University of Washington more than a decade ago now.
How is it that repeating the same course leaves me feeling not “dismayed,” but actually pretty jazzed? I can’t help thinking that perhaps if Lévi-Strauss had stuck with his lycée job a bit longer, he might have been able to discover through teaching some version of the same insight he arrived at in the Amazon: that a really good structure contains within itself endless creative possibilities. I think that the reason my “Perspectives in Medical Anthropology” class works well, and remains interesting and fun to teach over and over again, is because it has a robust and flexible structure.
The big idea for this course is that it is possible to create understanding about health, illness, and medicine not by looking inside the individual body, but by using ethnographic research to situate individual lives within broader contexts. (This is a very new idea to many of my students, the majority of whom are upper-level undergraduates hoping to pursue careers in medicine, nursing, public health, pharmacy, and other health-related professions). Since the world obviously does not present itself in pre-packaged chunks of context, ethnographers must make choices – at once theoretical and methodological -- about what and whom to include, what and whom to leave out, and why. Following from this, the course is structured in a manner intended to highlight conceptual differences among ethnographic studies, such that students may get a sense of how it matters whether, for example, one begins with questions about meaning, or questions about power, or questions about technology, etc.
The course thus does not “cover” any set list of specific illness conditions, nor any particular world area. Topic headings for each day and for each week are meant to help students situate specific ethnographic studies assigned for the day, as examples of how particular theoretical & methodological approaches may be applied. The specific articles assigned often change from one year to the next; the weekly topics also shift and change a bit over the years, reflecting developments in the field. I select articles that I want to read, and ones I love -- because they are written clearly and well, and exemplify the best potential of ethnographic research, to yield surprising and challenging insights.
Key to the success of this structure are the writing assignments, especially the “reflection paper.” This is something I dreamed up the first year I taught the course, that has proven to work wonderfully well. On the first day of class I tell students that for the next class meeting they must write a short (2-3 page) account of an episode of illness and healing that they know about at first hand. An open-ended assignment such as this, at the very start of the quarter, inevitably creates some anxiety, and they always want to know more specifically what I am looking for; I tell them, “Just write an honest account.” (I reassure them that these will not be graded; I also advise them to bear that in mind when deciding what to write about, that that these will be read and commented on by their classmates as well as by me.)
On the second day of class, I ask the students to tell me about some of the choices they found themselves making when they wrote their accounts, and I list these on the board. Referring to this list, I talk about how the choices that each of them had to make are similar to some of the choices faced by ethnographers, and segue from there into a discussion of what ethnographic research is.
At the end of the quarter, after exploring many different approaches and topics, reading some very compelling articles, watching documentary film clips, and writing two analytical papers, the students are asked to look back at their firsthand account, and write a paper that reflects on it in light of what they have learned. I leave this very open-ended, and encourage them to draw connections with whatever articles seem most relevant and helpful. I advise them that they can treat their firsthand account as “data” and reflect on how they told that story (what they left out, what voice they chose to adopt, etc), or they can consider the specific health problem about which they wrote in light of what they may have learned about it through the class readings, or they can write about what sort of research they might want to pursue on the topic about which they wrote, if they were to go on to become an ethnographer.
For the final class session, small groups of students are assigned to read each other’s firsthand accounts and reflection papers, and discuss them. The course is thus structured to end by positioning the students as authors who create new understanding, informed by scholarly research, about matters they know at first hand, and also colleagues who respond respectfully and thoughtfully to the work of others. And when that is what one repeats, teaching the same course every year can be not a grind, but a positive joy.
Janelle S. Taylor is Associate Professor of Anthropology at the University of Washington, and author, most recently, of The Public Life of the Fetal Sonogram: Technology, Consumption, and the Politics of Reproduction (Rutgers University Press, 2008).
Syllabi and reflections on teaching - a call for contributions
For those of us preparing to teach in the fall, August is not only a month of mosquito bites and leisurely naps on the beach, but also the time for writing or reworking our syllabi and course plans. So in the spirit of the month, we are presenting a small series of posts about teaching medical anthropology and related topics. There are a number of sites where topic-specific syllabi have been gathered -- the Society for Medical Anthropology has a page, as does the Society for the Social Study of Science. However, in addition to the syllabi, we'd like to include some reflections on the process of teaching the course itself -- what the guiding ideas behind it were, how it was designed, what aspects of it have worked particularly well, and so on. I wrote a similar post last year about an "Anthropology of the Body" course I had taught, and since then I've noticed that there is considerable interest in this kind of account.
The first of our posts is written by Janelle S. Taylor, Associate Professor of Anthropology at the University of Washington, and author, most recently, of The Public Life of the Fetal Sonogram: Technology, Consumption, and the Politics of Reproduction (Rutgers University Press, 2008).
Also, we'd like to invite Somatosphere readers to submit their syllabi and some thoughts on the process of teaching. If you have a course that you think is particularly worth sharing -- or an idea of someone who teaches such a course (we'd be happy to solicit the post from them) -- get in touch with us at admin@somatosphere.net.
Thursday, August 5, 2010
Michael Oldani on Pharmaceutical Industry Sales Practices
At the website for Dalhousie University's Novel Tech Ethics team -- headed by bioethicist Françoise Baylis -- you can watch a lecture by Somatosphere contributor Michael Oldani titled "Tales from the Script: Insider/Outsider Perspectives on Pharmaceutical Industry Sales Practices." Oldani was a pharmaceutical sales representative for Pfizer before becoming a medical anthropologist (he and I constituted two-thirds of our cohort in Princeton's doctoral program in anthropology). In previous work he examined the practices of pharma sales reps during the 1990s, drawing on the anthropological literature on gift and commodity exchange. See for example "Thick Prescriptions: Toward an Interpretation of Pharmaceutical Sales Practices," MAQ 18(3), 325-356, 2004.
In the lecture you can watch online Oldani looks at what has become of these practices since industry groups have enacted regulations on the activities of sales reps in the wake of public debates regarding the pharma industry and its undue influence on both research and clinical domains.
Watch: "Tales from the Script: Insider/Outsider Perspectives on Pharmaceutical Industry Sales Practices."
Friday, July 30, 2010
Plenary talks from the 2010 SCA conference
Videos of several of the plenary talks from this year's Society for Cultural Anthropology conference on Natureculture -- which Stephanie Lloyd recently reported on for Somatosphere -- are now available for viewing and listening on the Cultural Anthropology journal website and on a Vimeo site.
I am embedding videos of the talks by Judith Farquhar and Donna Haraway below, and on the CA site you can also view Sarah Whatmore's talk, "Affective Environments: Thinking Through Flooding" and Stefan Helmreich's "Nature/Culture/Seawater."
Judith Farquhar (University of Chicago), "Plural Ontologies, Medical Agency: How Chinese Medicine Argues About Being"
Monday, July 26, 2010
An archive of interviews with anthropologists
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| Alan Macfarlane interviews Clifford Geertz in 2004. |
The interviews are accessible both through Macfarlane's own website and through DSpace at Cambridge, (there are also clips available for viewing on YouTube, but these are rather short). Most of the interviews can be either viewed in their entirety online or downloaded -- and they can be browsed by name or subject-matter. A list of all the interviews is also available here.
This is really an invaluable collection. It is a readily-available historical archive, an excellent resource for teaching and, of course, a great tool for professionally-justified procrastination.
Monday, July 19, 2010
Ethnography and the somber realities of "intervention"
In this weekend's LA Times Angela Garcia reflects on the ubiquity of addiction and its attendant crisis in New Mexico's Espanola Valley, where she conducted fieldwork for her recently released book The Pastoral Clinic: Addiction and Dispossession along the Rio Grande (University of California Press, 2010). Garcia, a medical anthropologist at UC Irvine, notes that the Espanola Valley "has the highest per-capita rate of heroin-related deaths in the United States," a situation which many residents view as linked to the region's "history of land loss, which reaches back to the colonial era and continues today," (Garcia 2010).
Through the deeply tragic story of Dion, a two-year-old who died of a drug overdose (he had, apparently, "come down with the flu and... his parents may have "treated" him with the drugs they knew best," (2010)) Garcia questions the easy narrative of addiction and therapy offered by A&E's popular reality show "Intervention":
[The show] closes each episode with a gathering of family, friends and a professional "interventionist" confronting the featured addict. Accept the "gift" of in-patient treatment, they are told, or be cut off from the circle of people who have heretofore loved and "enabled" you. Overwhelmingly, the addicts featured on "Intervention" agree to treatment.
In the world of television, this means they get meds to stabilize them and are then chauffeured to a state-of-the-art inpatient program, usually by the sea. Like other "makeover" shows, the lavishness of the solution is so grossly disproportionate to what would be available in real life that it all seems like a Frank Capra movie. To be fair, "Intervention" does report relapses in that little text box at the end of the show.
For most addicts, "rehabilitation" isn't so glamorous. It usually comes through some form of incarceration by the state, often ordered by the courts after an arrest. As part of their plea agreement, Dion's parents will be treated at the clinic where I once worked. I hope they succeed, but I also know that today, the service the clinic provides is even more limited than it was in my time.
On Monday night, I will again watch "Intervention." Much as I resist it, there will be moments when I am moved by the story line. But when it's over, I will be angry — angry at how easy it all looks, at how accessible treatment appears to be, at how great the distance is between this representation and the reality for most addicts. Then, on Thursday morning, I will again read the online edition of the Sun and learn the latest news about overdoses in the Espanola Valley. And I will wonder how much longer it's going to take for a more profound intervention to take place," (Garcia 2010).
See: Angela Garcia, "Dion's Short, Tragic Life," Los Angeles Times, July 17, 2020.
For a previous post on Garcia's Cultural Anthropology article, "The Elegaic Addict," look here and check out her book, The Pastoral Clinic: Addiction and Dispossession along the Rio Grande (University of California Press, 2010).
Tuesday, July 13, 2010
Roberto Abadie investigates the world of 'professional guinea pigs'
Anthropologyworks alerts us to an article in the Chronicle of Higher Education about medical anthropologist Roberto Abadie and his new ethnography on professional research subjects in clinical trials. As the article explains, "Since 1980, when Phase 1 drug tests on prisoners were banned in the United States, university medical schools and pharmaceutical companies have depended on volunteers... to test the safety of new drugs," (Glenn 2010). While bioethicists have debated whether paying volunteers constitutes "'undue inducement' that might tempt them to take risks against their better judgment," (Glenn 2010) little empirical work has been conducted on the people actually taking these risks. However:
"But now an anthropologist has produced a study of several dozen medical volunteers.... Roberto L. Abadie, a visiting scholar in the health-sciences program at the Graduate Center of the City University of New York, spent a year living in youth hostels and group houses in Philadelphia, trying to get a sense of why volunteers do what they do and how they understand their risks.
He offers his findings in The Professional Guinea Pig: Big Pharma and the Risky World of Human Subjects (Duke University Press, August). The book's primary purpose is to offer a detailed description of medical volunteering and its contexts, not to weigh in on the ethics of clinical trials. But after his year in the field, Mr. Abadie does have opinions about policy: Volunteers underestimate their long-term risks, he says, and universities should do more to protect them....
...
Mr. Abadie spent time with anarchist activists who are attracted to guinea-pigging because of the flexibility it offers. Between 1996 and 2002, that milieu was documented in Guinea Pig Zero, a Philadelphia zine published by and for activist medical volunteers.
But Mr. Abadie's book also examines two other types of medical volunteer. First, he describes transient, economically struggling people who travel from place to place in search of lucrative trials. These volunteers are often less educated and more socially isolated than the anarchists.
Second, Mr. Abadie spent months at an HIV clinic where patients were participating in long-term trials to determine the effectiveness of new drug combinations. That environment is very different from the Phase 1 trials described elsewhere in the book. At the clinic, the HIV patients knew they had a personal stake in the development of new drugs, and the financial compensation they received was much smaller. Even though they were taking risks by participating in the drug studies, Mr. Abadie says, those volunteers seemed to reap psychological gains," (Glenn 2010).Carl Elliott's 2008 New Yorker article "Guinea-Pigging" is an excellent introduction to these issues. It is available here, courtesy of Guinea Pig Zero.
David Glenn, 2010. "Inside the Risky World of Drug Trial 'Guinea Pigs.'" The Chronicle of Higher Education.
Roberto Abadie, 2010. The Professional Guinea Pig: Big Pharma and the Risky World of Human Subjects (Duke University Press).
Tuesday, July 6, 2010
Smile or Die: Barbara Ehrenreich on positive thinking (the cartoon version)
At Savage Minds Matt has linked to an excellent animated version of a talk by David Harvey on the recent global economic crisis. The animation is one of a series put together by the Royal Society for the encouragement of Arts, Manufactures and Commerce (RSA), all of them based on longer lectures given at the Society. Aside from the content -- many of the talks are very good -- the animations represent a very interesting way of communicating relatively complex ideas in a visual mode. They're a bit like animated versions of the old "Introducing..." series (Introducing Marx, Introducing Freud, etc).
A number of these talks address issues we deal with regularly here at Somatosphere, including a talk by Philip Zimbardo (of Stanford prison experiment fame) on "The Secret Powers of Time" and Matthew Taylor on the ways that policy debates are increasingly drawing upon psychology and neuroscience research.
Perhaps the most interesting one is Barbara Ehrenreich's critique of positive psychology -- "Smile or Die." The animation is based on this more extended talk, also viewable as a video on the RSA website, and draws on her recent book, Bright Sided: How the Relentless Promotion of Positive Thinking has Undermined America. The argument (essentially that "positive thinking" as promoted in the US amounts to an ideology of social control) certainly isn't strikingly original, but it is important and the animation alone makes watching it worthwhile.
Thursday, July 1, 2010
Olga Solomon on Anthropology and the Study of Autism
More of the articles in the 2010 issue of the Annual Review of Anthropology are now available online (unfortunately only to those with subscriptions or institutional access). One of the most interesting reviews is an article by Olga Solomon called "Sense and the Senses: Anthropology and the Study of Autism." Solomon is a linguist in the Department of Occupational Science and Occupational Therapy at the University of Southern California, who has written extensively on autism, language and sociality. She was a co-editor of a recent special issue of Ethos on autism, which I wrote about here several months ago.
As Solomon writes, this review "considers the production of knowledge about autism as a clinically relevant category at the intersection of sense as culturally organized competence in meaning making and the senses as a culturally normative and institutionally ratified sensory and perceptual endowment," (2010: 243). This focus on the production of knowledge is particularly important given the broad significance that autism has taken on in the sciences of the mind and brain over recent years. Solomon explains: "As currently defined in psychiatry and cognitive psychology... autism reaches in contradictory and unexpected ways to the very core of what it means to be human: Autism is used as a counterexample to empathy and intersubjectivity but also as evidence of the limitless potential and neurodiversity of the human mind," (Solomon 2010: 242).
The abstract:
"As a clinical category and a sociocultural phenomenon, autism occupies a prominent albeit ambiguous place in ongoing social science and humanities debates about empathy, intersubjectivity, intentionality, epistemological certainty, and moral agency. Autism is used as a counterexample to feeling empathy and understanding other people’s feelings, beliefs, and intentions. Alternatively, it is given as evidence of the limitless potential and neurodiversity of the human mind. This review offers an examination of the field of autism research relevant to anthropology of the senses. It considers the production of knowledge about autism as a clinically relevant category at the intersection of sense as culturally organized competence in meaning making and the senses as a culturally normative and institutionally ratified sensory and perceptual endowment. In such a distinction, both sense and the senses are paths toward and an object of the empirical understanding of autism," (Solomon 2010).
Direct link to: Olga Solomon, 2010. "Sense and the Senses: Anthropology and the Study of Autism." Annual Review of Anthropology, Vol 39.
Wednesday, June 30, 2010
From Nature/Culture to Culturally-Dominated Nature: A Spring Conference Overview
A particularly packed spring conference season recently wound up for me, having attended four conferences over the course of about a month and a half. Two of these stood out for the contrast of the approaches to the human, personhood and the self and the questions they raised for the study of each. What was most interesting, was the relative absence of the human in these social science meetings (one anthropology, the other a multi-disciplinary crowd of sociologists, historians and anthropologists, among others), either ignored or present only in its most generic form. The two conferences in question were the biennial meeting of the Society for Cultural Anthropology (SCA) and the annual meeting of the Association Francophone Pour le Savoir (ACFAS). I will start with a discussion of the second, but focus on the first.
I participated on a day and a half long panel at ACFAS (10-14 May, Montreal) entitled “Des ‘affections nerveuses’ au XIXe siècle aux anxio-dépressions contemporaines: continuités et ruptures” (From ‘nervous disorders’ of the 19th century to contemporary anxieties and depressions: continuities and ruptures). During Danilo Martucelli’s (e.g. Dominations ordinaires: explorations de la condition moderne [2001]; Les sociologies de l’individu [with François de Singly, 2009]) introductory presentation at our session a a big, round bumble bee flew in through one of the open windows. It buzzed lazily around the large room, circling the heads of attendees including Martucelli’s, moving in and out of the attention of the audience and presenter depending on their proximity to the buzzing. The bee, at least for me, provided some moments of levity –observing Martucelli’s eyes very nearly cross as he watched the bee move in to circle his head yet again – in a presentation that earnestly set about debunking theories concerning the causes of an apparent rise in mental illness. The explanations he found lacking included: an actual increase in rates of psychological disorderedness; increased demands for autonomy and individualistic personalities leading people consider themselves psychologically disordered if they fail to meet this contemporary behavioural and personality standard; social constructionist arguments about the increasing inclusiveness of mental illness categories; and institutional changes that encourage individuals to explain suffering using psychiatric languages.
In place of these explanations, Martucelli asked us to be persuaded by his thesis that there has been a “singularization” of the modern individual in the way daily life is experienced (e.g. weakening of the social bond) and the way that personal disordered states are treated (e.g. with a pill rather than psychosocial interventions). He further argued that this is an increasingly ‘normal’ way of living with the ‘pathological’ in which personal challenges are seen through the interiorizing lens of mental illness rather than in relation to socio-economic or political circumstances. Martucelli’s presentation provided an interesting overview of the differences he perceived between largely macro sociological explanations of shifts in individualism provided by French theorists. Though I – among other attendees, judging from their questions – remained uncertain of the theoretical distinctiveness that Martucelli that claimed existed between his argument and those theories he interpreted and criticized, which included arguments about individualism and autonomy put forward by Alain Ehrenberg (e.g. La fatigue d’être soi [1998] recently translated as The Weariness of the Self [2009]) as well as Marcel Gauchet’s arguments about individualism and the social bond (e.g. La démocratie contre elle-même [2002]) and even work on the language of suffering (though the topical and methodological differences between Martucelli and Didier Fassin are the most vast and obvious), his generalized discussion of theories of the role of psychiatric disorder and modern individuals succeeded in raising questions and debates. However, little insight was shed on the individual he discusses, who is not identified according to chronology (though it is a ‘contemporary’ individual), geography (though we might assume France), economic, political or gender traits, revealing the limits his sweeping, distanced analysis.
Somewhere mid-way through Martucelli’s 45 minute presentation, there was a “THWAP!!” followed by “Bang! Bang! Bang!”. The big, fuzzy-looking bee was no more, having been ‘taken care of’ by a young French sociologist. Culture had just obliterated nature and no one appeared bothered by it. This event brought me out of the stream of Martucelli’s talk and it was at this moment that it struck me – and continued to strike me through the rest of Martucelli’s presentation – that I wasn’t in Santa Fe anymore.
I had returned the previous Sunday from the biennial SCA meeting based this year in Santa Fe, NM (May 7-8, 2010). The theme of this year’s conference was Nature/Culture. It was the flattening of the bee that brought into stark contrast the vast differences –too numerous to detail here though I will attempt to outline a few – between the conferences. Looking back at the SCA meeting, it seemed unthinkable that any harm could come to a creature such as a bee, at a conference where non-human animals and non-human actors (e.g. dingoes, dogs, chickens, floods, fish, tubing, monsters) took a more central place than humans in many participants’ presentations. These animals, objects and creatures took on different roles in attendees’ papers: at times drawing attention to the fabricated discontinuity between animals and humans, the relationship between the way we live and the effects on our natural environment, specialist versus non-specialist claims to knowledge about ‘nature’, and at other times creatures were evoked to refer to what was otherwise unspeakable in human relations. But what the flattened bee reminded me of was the opening up of particular moral concerns for the non-human at the SCA meeting and ways in which this has raised questions about the practice of social science and constructions of humanness and personhood.
Deborah Bird Rose’s May 8th presentation (entitled “Double Death: In the Shadow of Extinction” in the programme, though changed to “Ethnographies of Extinctions in Multi-Species Communities” if my notes serve me well) – which was part of the morning plenary session alongside Judith Farquhar and chaired by Danilyn Rutherford – about the extermination of pit bulls as a moral enterprise made this moral argument most clear to me. In her paper, Rose drew attention to how the study of non-humans is central to understanding how we construct knowledge about the world around us and the essential beliefs that guide our actions and ethics whether in regards to non-humans (e.g. animals, natural resources) or humans (e.g. animalized humans). Rose described her interest in what renders something or someone killable – this is the word I have scribbled in my notes though I remember that “killable” was not the word she used. She criss-crossed her analysis about the “knots of connectivity in the extinction process”, focusing on dingoes in Australia, pit bulls in the United States and an analysis of Emmanuel Levinas’ writings about a dog named Bobby who visited him and his fellow Jewish detainees in Nazi Germany. Rose evoked Levinas’ story of Bobby in order to raise questions about a type of humanism (influence by Levinas) she wants to question in contemporary anthropology, particularly one in which responsibility is felt toward other humans – the encounter with the face of the other – compared with the indifference we give to our fellow species such as animals. What Rose focused on was the role that non-humans play in the emergence of defining humans as animals who (normally) cannot be treated with impunity versus the non-humans who can.
Rose’s description of the extermination of dogs and dingoes appeared to be a call for a different model of humanity involving the ‘humanization’ of animals (also raised in exchanges between John Law and Donna Haraway in the May 7th evening plenary session) and it seemed she might almost be implying parity between treating animals and animalized humans (e.g. in Nazi labour camps) with impunity. Part of Rose’s support for her position comes from her Australian aboriginal informants, one of whom she quotes as saying “nothing is nothing” (i.e. we have to question reigning humanism and cannot treat animals as nothing). Rose’s paper highlighted the strength of a particular moral position in anthropology represented at this conference and a shift toward studies of companion species (and other objects) in which the humans they are companions to become less and less visible.
While non-humans were highlighted in many sessions, this position toward humanism was not necessarily the reason for their presence. At the sessions I attended, humans had a higher profile than in others perhaps, even if they were often distinguished by being dead, magic or monsters. Their ‘other’ human nature was often evoked to raise questions of personhood and the self more commonly represented in anthropology. One of these was “SuperNature” whose participants focused on the role of magic, spirituality, ghosts and belief among the people anthropologists study and anthropologists themselves. Presenters examined the history, uses and changing meaning of magic tricks such as the “spirit cabinet” (Graham Jones) as well as the role of economic and class disgruntledness in modern day spiritual specialists alongside the gendered distinctions between (feminine) mediums and (masculine) technologically-armed ghost hunters who use their tools to ‘make visible’ the ghosts among us (Misty Bastian).
In another panel entitled “Architectures of the Future: Human Potentials and Hypothetical Monsters”, monsters appeared as incipient terrorists (Mona Bhan), symbols of political and affective spaces (Courtney Nickerson) and really bad bosses (Noelle Mole). They were also discussed in terms of efforts to find the material signature of evil in the brain (Mark Robinson). Discussant David Valentine questioned the role of monsters in panelists’ presentations, asking what it is that makes a monster, and if it is just a metaphor for something more monstrous, do we need to talk about the monsters themselves? In the papers presented, he continued, was it not the state, global capital and science as the real monsters? While there appeared to be general agreement on this issue, he and the panelists noted that the interesting quality of monsters was in their temporal transformations: how they change, how they might now be understood to straddle nature/culture in new ways and what that might tell us about the ‘real monsters’ within or surrounding us.
I presented on the panel organized by Matthew Wolf-Meyer “Tarrying with Neurodiversity: Moving Beyond Pharmaco-natures” that was one of the few panels to focus on humans, even if our focus was on their neurotransmitters. Each panellist tackled the concept of neurodiversity from a different angle, including as a means of reimagining pathology as normal variation (Matthew Wolf-Meyer, introductory comments on autism and further discussion of the medicalization of diverse sleep patterns), to the politics of recognizing biological difference among human groups (Stephanie Lloyd), to discourses about the need to medicate neurodiversity and its relationship with pre-existing social expectations (Michael Oldani), and they way in which people recovering from mental illness use neurological explanations to imagine a future as a ‘different’ person rather than someone simply in life-long recovery (John Marlovits).
These two conferences, ACFAS and SCA, offered radically different ways of approaching some of the core issues in medical anthropology, STS and bioethics. Methodologically, they push us to look for answers to questions about humans and human suffering in different places and from different sources and each approach has its strengths and weaknesses. Some yield big answers, such as Martucelli’s thesis concerning the singularization of society and the effects on the individual. However, when asked about when this transition in thoughts about the self took place, Martucelli’s response was an untroubled, “Je n’en sais rien” (I have no idea). His responses were similar to other empirical questions. He was, it seemed, talking about a highly generic human, found presumably everywhere but nowhere and defining this person was not of interest to him. Rose’s approach urged a much more minute consideration of the species surrounding humans to understand where a definition of humanness originates, leading us to a range of ethical considerations using a very specific lens. Social scientists studying monsters, ghosts and debates about neurotransmitters use these stand-ins to examine how it is that humans depict, to a certain sense, themselves to themselves.
The variety of ways that humans were present and absent in these two conferences – and the compatibility and incompatibility of these approaches – provides fodder to analyse the use and limits of each of the perspectives (for example, Danilyn Rutherford asked how Levinas’ ethics could apply to people with autism, which is a question that could equally apply to a range of humans considered emotionally or cognitively compromised), for how they encourage us to reconsider traditional anthropological terms such as the self and personhood and for scholars of many different disciplines to ask themselves what they want a study of humans and the life sciences to be about.
Friday, June 25, 2010
Book Review: The Madness within Us: Schizophrenia as a Neuronal Process by Robert Freedman
The Madness within Us: Schizophrenia as a Neuronal Process
by Robert Freedman
Oxford University Press, 2009. 198 pages. $35.00 (hardcover)
A perusal of The Madness within Us: Schizophrenia as a Neuronal Process is well worth the time of anyone interested in schizophrenia research. Author Robert Freedman is a clinician and scholar who also has a family history of schizophrenia. Inspired by Harry Stack Sullivan's classic work, Schizophrenia as a Human Process, Freedman writes poignantly of the experiences of his patients and the struggles of their families, providing us with a very human sense of what it means to experience and bear witness to psychosis. In addition, Freedman provides a highly accessible and rich overview of the latest schizophrenia research from neurobiology, animal modeling, developmental and genetic studies.
Colonial Psychiatry Hub: a new blog
Colonial Psychiatry Hub is a recently launched blog written by a DPhil student at the Wellcome Unit for the History of Medicine, University of Oxford, whose research "concerns the practice of psychiatry in Church Missionary Society hospitals in Uganda, 1897-1944." While it has only been up for a number of months, the site has great potential to fulfill on its aim of "bring[ing] together resources for the study of colonial psychiatry." In addition to posts on topics such as "Sleeping sickness and lunacy" and "Fear, witchcraft and 'superstition' in East Africa", the author has posted a bibliography of scholarly texts on colonial psychiatry. Let's hope for the addition of more similar resources.
Wednesday, June 16, 2010
Podcast: Interviews with Renée Fox
Friday, June 11, 2010
Call for papers: Culture-nature revisited (June 8-11, 2011, Grenå, Denmark)
The following announcement has been circulated by Mette Bech Risør:
The 7th Conference in Nordic Anthropology of Health and Medicine will be held June 8-11, 2011 in Grenå, Denmark, under the auspices of the University of Copenhagen and University of Aarhus. The conference is organized by: Department of Anthropology and Ethnography, Aarhus University; Department of Anthropology, Copenhagen University and VIA University College.
The opposition or dichotomy between culture and nature has been central through much of the history of anthropology, especially in defining what anthropology is about and defining cultural versus natural phenomena in specific cultures, not to speak of the interaction between the two. With Latour in mind it is now, however difficult to maintain a distinction that may belong only to an outdated vision of modernity that we have never reached.
As with many other fields in anthropology, the culture-nature distinction has now entered a more complex state where it is worth a closer inspection. This is especially the case for medical anthropology where new research fields in medicine, biochemistry, biotechnology, genetics, etc. with the use of e.g. animal spare parts in human bodies or the invention of cyborg-technology, makes it obvious that the borderlines between nature and culture are apt to rethinking in anthropological terms. Another development going on is an expanding physiologization of processes until now thought of as primarily or exclusively social, cultural or psychological. These developments are very visible e.g. within the field of psychiatry where the brain and neuro-chemical processes are given priority to the psyche and psychological mal-adaptation. In these research fields, as well as in others, the distinction is constantly challenged, directly or indirectly, and the possible changes, socially and culturally, contain a huge potential for critical thinking and analysis by medical anthropology. Some rethinking already takes place – the concept of ‘local biology’ has for instance been suggested by Margaret Lock to encompass the biological body, social reality and cultural discourse to overcome both the arbitrariness of the material, biological body and the cultural body. But also concepts such as cyborgs, bio-sociality etc. point in new directions for the relationship between nature and culture.
With the conference we call for an exploration of both new lines of thought along the distinction, still holding it alive, and lines of thought that dissolve it or critizise it. We wish to invite for discussions that address the topic both philosophically and theoretically as well as pointing to the impact of changes an analysis of culture versus nature may show to have on everyday social processes, illness perceptions, health management, dialogues on illness and health, health strategies and citizenship in general. Exploring the cultural and societal dimensions of these new configurations of the culture-nature relationship is not only relevant from a scientific, anthropological point of view, but is also important in a broader societal perspective. With the following sub-themes we hope to cover the most important fields where medical anthropology plays a part:
Borderlines
Animals and humans share phenotypic as well as genotypic features. In the health sciences this similarity has increasingly made animals stand in as “models” for human disease states. Another aspect of this interconnection between animals and people is about combining human and animal biology. Transplantation of animal tissue to humans has taken place since the early 20th century. Recently, human DNA has been transferred to animals resulting in for instance the famous Danish transgenic “Alzheimer’s pigs” that with an added human gene is hoped to develop symptoms similar to Alzheimer’s patients. Simultaneously with biological similarity, animal experiments (as well as agricultural breeding in general) assume that humans differ fundamentally from animals in moral terms. These recent developments within the health sciences probe anthropological questions about boundary demarcation and relationships. How do relations and demarcations between humans and animals unfold in specific empirical fields? In what ways are movement and boundary demarcation mutually reinforcing? How are health, humanness and species configured in research practices that seek to enhance public health? How does care for animals coexist with practices that instrumentalize them (as part of nature) to serve human needs?
Technology
It is well known that technology has great impact on both health care professionals and lay people’s perceptions of what constitute disease and treatment. The issue of technologization of health care also opens the question of where it leaves more old fashioned virtues of medicine: care, clinical knowledge, clinical diagnosing of patients etc. How is the ‘culture’ of medicine being changed, as the medical technology of scientists is gaining importance at the expense of more experience-near knowledge of clinicians?
The expanding biomedical technology furthermore raises more fundamental questions concerning what constitute a human being, how much can be changed before humanity is called into question, how adaptive is the human body and the human mind, what is treatment and what is improvement, how are we to understand medical technology that aim at improve the performances of the human body and human mind – and below these questions – what is human normality?
Environmental and climate change
The last couple of years, climate changes and its consequences for human life have become a growing topic in all kinds of research fields because of its major impact on everyday life. Climate changes affect living in ultimately basic ways and require for example insight into the understanding of new disease patterns, changed food consumption and agriculture and new social life processes in general. Most of this research today takes place in relation to populations dependent on direct natural resources, that is indigenous people in many countries, especially visible in the Arctic, the Pacific Islands, on the borders of large desserts etc. But also in other areas we are to expect changes – e.g. the re-introduction of malaria in Northern Europe.
Basically one could ask: how is culture changed by nature? What kind of society or culture will be a result of global climate changes? However, to go a little further, climate change also specifically invokes our understanding of the concept of culture and nature - this could be addressed critically. Cultures and societies adapt or do they? To what? The question of adaptation makes it pertinent to challenge the roles of culture and nature in this process. Finally the pre-understanding of the concepts that may guide our research as well as the research of other disciplines may be scrutinized.
Bio-sociality
In some areas of life, biology seems to play an increasing important part in our perception of who we are and what we are. As mentioned above, the brain and neurochemistry is gaining importance at the expense of the mind and psychology. As we gain access to the brain and its internal processes through different kind of scanners our perception of neurological and cognitive processes changes and presumably also of the concept of what a person/human being is and what an illness is.
As a growing body of literature has pointed out our social identities are to an increasing degree defined through biology. Bio-sociality, bio-citizenship and bio-nationality are central terms in the social science of the 21st century.
But also in an old fashion field such as gender, biology seems to expand its territory. When boys in school can not behave, it is not any longer due to a bad upbringing; it is due to the testosterone level in their brains, that their brains are developing slower than girls etc. Not to mention the increasing number of especially boys being diagnosed with ADHD and medicated accordingly.
For this conference we call for papers from the medical anthropological field exploring the culture nature relationship from one of the four fields described above. The papers can be either theoretical or empirical but should be based on research and aim at expanding the anthropological understanding of where the culture-nature distinction stands at the beginning of the 21st century.
Key note speaker(s) will be announced later.
Abstracts:
Abstracts, no more than 300 words in length, should be submitted to line.jorgensen@anthro.ku.dk Deadline for submission of abstracts is October 1st 2010
Registration
Full details regarding registration and costs will be available to participants at time of announcement of accepted abstracts. Registration costs will cover accommodation - as the conference place is also a hotel - as well as breakfast, lunches, coffee breaks, opening reception and banquet. The final price will depend on final funding but will not exceed 500 EURO in total and probably be less.
Venue
Kystvejens Hotel and Conference Centre, Grenå, Denmark.
Brief history of the network
The Network of Nordic Medical Anthropologists was established in September 1997 in Gothenburg. The workshop was a kind of inventory of anthropologists working within the subfield of medical anthropology in Sweden, Denmark, Finland, Norway and Iceland. The second meeting was held in Denmark in February 2000. It had three main themes: 1) Body, senses, and experience, 2) Health systems, medicines, and technology, and 3) Handicap, rehabilitation, and competence. The third conference, under the heading Expressions of suffering was held in February 2002 in Finland. The fourth conference was held in Norway, August 2004 with a title Health and Identity in Risky Times. The fifth conference was held in June 2007 in Iceland, with a title Medical Anthropology in the 21st Century. The sixth conference was held in Sweden in June 2009, with the title Ethics and Medical Anthropology: Probing Moral Universes and Pinpointing Moral Dilemmas.
