Thursday, July 2, 2015
Bulgakov - Baptism by Rotation, Embroidered Towel, Steel Windpipe
DOCTORS AT WIT’S ENDS
- Williams and Bulgakov: Doctors AND writers - russian literature
1. ethics of relationship with the patient & DEONTOLOGY of the medical practice - how he is recognised as “healer” - social authority
2. dramatize relationships of conflict and collaboration - doctor is cultural/social economically removed - williams and bulgakov do not share same socio-economic and cultural-linguistic background w/ their patients
3. 1920s-1930s context
BULGAKOV
- the stories we read are the first - city doctor thrown into rural village, displacement of the doctor
DOCTOR’S PERSPECTIVE - similarities & differences
- half of the 20th century: rural area in soviet and eastern united states (williams) - impoverished social context
- dramatic encounters: focus on doctor’s ability to rise to the occasion - life and death situation
- bulgakov: dramatize coming into being a young doctor into his own role as an authoritative professional - trial by fire
- williams: ongoing challenges of an experienced doctor
- bulgakov: comedian and satirical writer, williams: lyrical
THE PRACTICE
- “often after i have gone….” “this is why as a writer….” medicine nurtured as writer - healing for the doctor - meaningful experience to his own practice for story-making / brody: what he insists on
- relational ethics, attention given to patient
- “poem of life” - stylistic mark
- what he tries to extract: (125) physician enjoys a wonderful opportunity actually to witness the words being born / they say the same thing and then a new beginning starts to intervene - literature captures the surface of medicine - makes visible
- juxtaposition of role of practice medicine w/ literature - heightened, complementary relations: lyrical aspect,
“the physician, listening from day to day…”
MIND AND BODY
- relational ethics (brody)
- the patient’s story: dramatizes how patients want a name for a disease, on-going search (rambling) from the patient’s experience - page 1
- williams interjecting every now and then - sympathetic listener, occupies his role, giving reader where she’s from alternated w the patient’s story itself
- patient trusts doctor
- “oh you have read that too, she said and seemed pleased…”
- placebo effect - someone to tell troubles is what we need
- the doctor gives a physical condition for her - a relational ethics
- him becoming a professional doctor
PARALLEL STORIES
- “use of force” & “steel windpipe” : deal with cases of diphtheria
> bulgakov: vaccination didn’t exist
> williams: vaccination has been made
>> overpowering moment of the doctor
>> he confesses to having attack the child: “pleasure to attack her” “social necessity”
- “a night in june” and baptism by rotation”: stories about birth
>> a night in june: experienced doctor who knows her patient well
>> baptism: first birth this doctor is attending - life and death situation drama
>>”then i fell asleep….” medicine moving into scientific standards, minimise humanity
>> foreshadowing of avoidance of culture of pain - doctors try to minimize discomfort
>> cultural relation to pain
- attention and deference both doctors pay to the midwives of the story
- stories of doctors know best attitude - they need rationalisation, overpowering moment of the doctor
- doctors the enlightened one vs. ignorance - not knowing what to do, doctor configures himself as someone who got the patient’s back
> use of force: “disgust” - “damned little brat” (60)- social necessity that doesn’t only affect the patient but also everyone
> steel windpipe: conflict between medical institutions vs. advocates of patients -
Davis - The Wayfinders
THE EARTH AS ONE SYSTEM
Planet Earth: planet as an interconnected web of history and possibilities - culture and medicine
WHY THE WAYFINDERS?
- Asks us to consider how profoundly connected is culture/environment and health.
- Journeys of various indigenous cultures
- Fascinating: window into culture - modes of being human/consciousness for our species; adapt to various environments and develop unique ways of interacting
- Humbling: ongoing disasters of the history of arrogant and dismissal of too many indigenous cultures - last 500 years of colonial encounter, technological acceleration in Western culture
- Driven by environmental crises - we need to look at this - alarming rate we are losing Earth (cultures & language) “the ethnosphere”
- Modernity threatens to destroy the planet and our own existence.
- Davis acknowledges speciesiation: e.g. Latin language and its disappearance
> Dying of different species and languages moving in a faster rate
“Healing Journey” - Anthropological and ecological perspective
- “Constitutive relation between forms of life and the material-cultural environments that sustain or impede their thriving”
- strong interconnection between biosphere and ethnosphere
- specifics of anthropological:
> sets attention to specific set of beliefs, rituals and forms of sociality which we make sense of our experiences of illness and of wellbeing: asset to doctors of anthropological details
> impossible to think without taking account health or illness into the dynamic interactions with the social and environmental worlds through which they manifest.
> insight through anthropology.
> importance of context.
ISSUES IN WAYFINDERS
1. BIOSPHERE & ETHNOSPHERE
- Biosphere: biological web or matrix of life on our planet - “being severely eroded by the destruction of habitat and the resultant loss of plant and animal species, so too is the ethnosphere, only at a far greater rate” (2)
- Ethnosphere: social web of life - “the sum total of thought and intuitions, myths and beliefs, ideas and inspirations brought into being by the human imagination since the dawn of consciousness” (page 2)
- Language loss - increasing hegemony - “canary in the coal mine”
READING QUESTION: WHAT OTHER INDICATORS OF ERODING ETHNOSPHERE?
- Provide specific examples
2. POTENCY OF BELIEF
- Davis argues: not realness of culture against scientific testing, but the potency of belief that produces certain realities for the people/individual living.
- “the manner in which conviction plays out in the day to day lives of a people, for in a very real sense this determines the ecological footprint of a culture, the impact that any society has on its environment” (122-123)
- Reminds us that Western system of evaluation is not objective/the best, esp when it comes to environmental sustainability. (124) “a child is….” mountain to be mined
- How we see the world affects how we use it
READING QUESTION: HOW “POTENCY OF BELIEF” RESONATE WITH “THE REMEDIES”
“songs of healing”
ON METAPHOR
- Metaphor more than a literary device, it is a cognitive device
- Each culture has their own set of powerful metaphors that guide into very real ways
3. THE PROBLEM OF MODERNITY AND GLOBALIZATION
- Demystification of our notion of modernity as the pinnacle of civilisation
- Relativizes our ‘modernity’ of ethnosphere - one-sided progress for Western society - listen to other cultures towards our well-being of the planet
THE PROBLEM WITH OUR BLIND FAITH IN TECHNOLOGY
Page 193: “Modernity, whether….” “merely a constellation of beliefs, one way of doing things”
- Terrible thrive in sustainability, spiritual intuitions and generosity (195)
- “Extreme” civilisation
- Age of disintegration:
> Urbanization (201)
> lack of attention to sustained DIVERSITY - hegemony
> The brute fact of domination - colonisation and “chaotic cultural encounters” - cultures polluted: social illnesses and pollution as a result of that
CONCLUSION
- Matrixes of connectivity sustain our lives - social, environmental, familial - Indigenous health relies on this
- Individual health interconnected to the greater webs of connection, social and environmental health
Brody - Stories of Sickness / Kleinman - The Illness Experience
Wade Davis: how the Earth can be protected/sustainability - whole communities
In contrast, the readings highlight the doctor-patient relationship: nucleus of medical practice is never isolated - “social reciprocities” - web of matrix connectivities
MAJOR POINTS (BRODY)
1. Story-telling is essential to medicine as a practice: “patients come with broken stories as much as they come with broken bones” (p 16)
- Suffering as illness: “broken stories” - build/recraft this
2. Concepts of sickness in relation to narrative
- Sickness is different from suffering: sickness is profoundly social
- idea of sickness as a disruption of one’s own LIFE STORY AND SELF-RESPECT
- The sick role as literary analysis
3. Ethical role of doctor - “peer review group”
- Doctor should not impose his/her story in the patient’s
- Healing is about ENABLING the patient to tell her own BETTER story
STORYTELLING AND MEDICINE
- Medicine is a practice situated between science and art: purpose of restoring health (p 52)
- Relation between doctor and patient is required
- Doctors listen and understand the patient’s experience of suffering
- Patient’s story can and frequently does diverge from doctor’s story - full healing only comes when the stories converge and be co-authored - doctor exercises authority and power responsibly (ETHICS)
- Healing lies in the crafting of a joint story, for a better story
SICKNESS, SUFFERING AND STORY
- Articulated in social model (story)
- Suffering: “produced and alleviated by the meaning that one attaches to one’s experience”
- One can bring suffering in and out of one’s experience of sickness “PRIMARILY BY TELLING STORIES ABOUT IT.”
- Attaching a meaning to the experience
Function of story
- Stories are profoundly social
- “Serve to relate individual experience to the explanatory constructs of the society and culture and also to place the experience within the context of one’s life story” (13)
- The placebo effect: “placebo or healing by symbolic means occurs to the optimal degree when the meaning of the illness experience is altered in a positive direction” (13)
3 components in healing process via telling the story of one’s illness (13):
1. Explanation of illness experience must be acceptable and recognisable within worldview and system of belief of the patient.
2. The patient must be surrounded by caring group of individuals.
- group respect enhances self-respect
- “peer review group”
3. Patient must achieve a sense of mastery of her own life - maker of her own story than illness
READING QUESTION: DESCRIBE HOW BRODY’S 3 COMPONENTS OF STORYTELLING AS HEALING CAN APPLY TO A WHOLE COMMUNITY OF PPL
Chapter 4 in The Wayfinders - ada the 3 components
1st component:
Power of physician is in the power of naming, of giving an explanation - comfort relies on naming the complaint
- This separates the person from the disease
- Suffering includes element of person taken over by the disease - creating distance between the person and state of suffering
- Done through storytelling
KLEINMAN - ILLNESS, DISEASE AND SICKNESS
- Illness: refers to how the sick person and family or wider social network perceive, live with, and respond to symptoms and disability (3)
> Subjective experience of suffering
> Illness is always socially shaped - how to behave when sick
- Disease: illness from medical perspective (5)
> Doctors trained to extract disease from illness
> Something essential is lost in the process - deprived of value and meaningfulness
> Illness experience is stored in sickness experience
- Sickness: disorder in its generic sense across a population in relation to macro social (economic, political, environmental) …. reflection of political oppression (6) - healing not just about telling stories but could lead to cultural and political activism
HOW BRODY TALKS ABOUT SICKNESS
- Not differentiated by Brody
- Halfway between illness and sickness, Brody emphasises social dimension
- Draw attention to individually mapped experience of illness onto our “life-story”
- Conventional ways we build out life-story in Western capitalist, individual and work-oriented society
- Kleinman: illness attached and assume different meaning to various cultural universes
> more anthropology oriented
> Brody: philosophy-oriented
- Both: critical target of sickness as simple biomedical phenomena - practice of medicine is pervasive
THE BIOMEDICAL VS BIOPSYCHOSOCIAL MODEL OF SICKNESS
- Biomedical: Symptom of illness to mechanical problem of the body. - can be repaired
- Biopsychosocial: dialectic integration between physical, psychological and environmental problems (kleinman, 6)
- both are critical of narrow biomedical perspective
BIOPSYCHOSOCIAL MODEL
BRODY:
- One level of hierarchy of “natural systems” - interpreted to molecules to society
- Each level is connected to flows of information - affects hierarchies of the system
- Health - maintenance of harmony of “homeostasis” - growth and adaption
- Disease: system is disrupted either by environmental challenge or a weakness within.
- Causes and effects manifests in different levels - not from one source
- Most up-to-date, 2003
KLEINMAN:
- Integrative, dialectic and dynamic
- Doctor has to pay simultaneous attention to: natural system of hierarchies & its different lvls
> Physiological processes - e.g. hypertension - cardiovascular activity
> Psychological states e.g. panic/stress
> Social and environmental factors e.g. pollution
- Brody can’t say which one comes first, but Kleinman disagrees
READING QUESTION: COMPARE AND CONTRAST THE BIOPSYCHOSOCIAL MODELS BETWEEN BRODY AND KLEINMAN
SICKNESS AND THE SOCIAL ORDER
- Sickness is a social phenomena
- “Being sick forces us to become unpleasantly conscious of factors that previously escaped our attention” (Brody, 58)
- Disruption in our social world, we turn to normalising ideologies
- Sickness renegotiates of what normal means altogether
WHAT ARE SYMPTOMS AND ILLNESS IDIOMS?
- Symptoms: always tied to cultural beliefs and shared (learned) knowledge about the body
- to understand meanings of symptoms and illnesses, we must understand the normative conceptions - culturally relative
- Illness idioms: denote how bodily and behavioural patterns are given meaning to different cultures, and acquire different valences.
> dynamic between bodily processes and cultural categories
> indicate culturally learned ways of showing distress
THE SICK ROLE (BRODY 54-58)
- Social role we take up and are expected to play when we identify as suffering from an illness
- Important in literary analysis - records pattern of behaviour and how it could/should be managed
- Parson’s definition:
> Sickness as a form of ‘excusable’ deviant behaviour
- One you are not held accountable
- You seek social authority that will help you return to ‘normal’
- Critiques to Parson:
> We need to be approach medical authority more critically
> There is more than one sick role: ‘normality’ within cultures
> Temporal trajectory of illness is neither linear nor self-contained. Kleinman especially draws patterns of chronic illness. Illness ain’t clean cut.
Literary device used as a pattern of behaviour
Allows us to imagine sickness, experience of illness, as one that bounds to social scripts and conventions/rituals about how we are expected to behave one an illness is identified.
HOW THE SICK ROLE IS INTEGRATED IN THE LIFE-STORY/LIFE-PLAN
- Life story - comprised of a “complex network of social reciprocity”:
> consciously/unconsciously construct ourservels as significant characters within what we regards as MEANINGFUL LIFE STORIES” (Johnson, quoted in Brody, 72)
- Life-plan: ability to articulate one’s life in relation to a coherent set of expectations from oneself
> peer-review group of reference for self respect
* Sickness interrupts disrupt the self and one’s life-story and life-plan *
Critiques:
- Life-story and life-plan culturally bound: social order and expectations of our life plans
> e.g. disease associated with laziness or bad eating habits, individualisation of responsibility
> society that values work above a number of things
- Society views sickness as disorder and individuality’s responsibility as the restoration of order (Brody 57)
- In contrast, Kleinman encourages an ethnographic awareness in dealing with different “illness idioms.”
CONCLUSION
- Listening and empathy in primary care of RELATIONAL ETHICS in medicine (Brody 263)
- Doctor’s use of responsible power
- Puts patient into centerstage and the doctor’s assistance in doing so
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