My musings...

Development in Guatemala: history, political economy, ethnography

2011-12-06T11:53:00.000-08:00

The abstract is available here. The paper as a whole is worth reading if you have access, if I do say so myself.

Do not be afraid...

2011-10-12T11:30:00.000-07:00

...to really want what you desire.

I pledge to really want: pneumococcal conjugate vaccine for the indigenous and poor in rural Guatemala.

Description of the problem:
In rural Guatemala, Maya children are theoretically at increased risk of invasive infection with encapsulated organisms, not only for socioeconomic reasons, but also via possible genetic or hereditary mechanisms. This theoretical risk is based on data from populations served by US Indian Health Service (primarily Apache, Alaskan native and Navajo nation) and Canadian Inuit and First Nations populations.

Evidence for multiple etiologies for this elevated risk has been presented (increased nasal carriage, inadequate vaccine coverage, dysfunctional maternal-to-infant transmission of passive immunity to encapsulated organisms, increased host and community susceptibility, i.e. genetic polymorphisms that decrease immunogenic response to encapsulated pathogens and/or vaccine components vs. underlying malnutrition vs. poor living conditions and crowding vs. inaccessibility of healthcare services), and the importance of timely and universal immunization against lethal encapsulated organisms of among indigenous populations in North America is well established, and some have even advocated "enhanced" vaccines and vaccination schedules for this at-risk population. (See: Lancet 1996;347(9000):517-20; Pediatrics 1999,104(3 Pt 1):564-7; Lancet 1996 Feb 24;347(9000):517-20; Am J Dis Child 1986, 140(9):943-6.)

Unfortunately, because of limited health services in rural areas of Guatemala and the long-standing marginalization of Maya communities, little to no research has been done on the elevated risk that encapsulated organisms may pose to indigenous Guatemalans. The single epidemiologic research study from Guatemala (Pubmed search terms, July 8, 2010: ("Haemophilus influenzae"[Mesh] OR "Streptococcus pneumoniae"[Mesh]) AND ("Guatemala"[Mesh] OR "Indians, Central American"[Mesh])) is based on cases presenting to large biomedical centers in Guatemala City--centers that are accessible to few impoverished, rural Maya communities; these studies, thus, suffer from distortions due to selection and severity biases (Int J Infect Dis. 2008 May;12(3):289-97). Moreover, besides one study on shifting antimicrobial sensitivity of nasopharyngeal S. pneumo isolates in Guatemalan children (Int J Infect Dis 2008, 12(3):289-97), and another on passive immunity via breastfeeding (Adv Exp Med Biol 1991;310:1-15), the only published study on prevention of invasive infection with encapsulated organisms in Guatemalan children is based on 103 Guatemala-to-US adoptees from Guatemalan orphanages and foster homes between 1988-2004 (Pediatrics 2005; 115(6):e710-7).

The latter data showed that 46% of the 103 adoptees had any (i.e., adequate and inadequate) documented vaccination against Hib, and only 26% of the 103 adoptees had adequate, documented vaccination against Hib. That is, about one-quarter of this cohort of Guatemalan children met the recommended standards for immunoprophylaxis against Hib. Of course, this data also suffers from selection bias, as protection and healthcare in orphanages and foster homes, most of which will be in larger urban centers, may be quite dissimilar from the experience of the general population of rural Maya children. This cohort of children should not be taken as a representative sample of pediatric preventative care in Guatemala, as they were being actively optimized, from legal, biomedical and moral standpoints, for adoption by concerned and sympathetic families in the US. Moreover, while the sample size (n = 103) lends an added measure of biostatistical robustness to the analysis, the cohort was accumulated over the course of sixteen tumultuous years in recent Guatemalan history. Even from a limited biomedical perspective, this cohort is neither homogeneous, spanning the years when Hib vaccination would have been introduced in Guatemala (late 1980's to early 1990's), nor representative, polysaccharide pneumococcal vaccination having been introduced briefly in the mid-2000's (indeed, no mention is made of pneumococcal vaccination status in this paper). More broadly, in sociological and historical terms, the years between 1988-2004--to say nothing of the years since--saw huge upheavals in the organization of the Guatemalan government and health systems (e.g., the transition to democracy in the 1990's, and the neoliberalization of rural healthcare in the 2000's).

In short, there is insufficient data on the risk of and rates of vaccination against invasive pneumococcal and H. influenzae, type B disease in Guatemalan children, particularly in rural areas where majority Maya communities may have both a higher incidence and severity of infection due to encapsulated organisms. According to official sources, national coverage with 3 doses of Hib is 92%, thanks in large part to a combined Hep B/Hib/DTaP (i.e. Pediarix) that was introduced in 2005. No similar data is available, however, for pneumococcal vaccination. Children do not routinely receive this vaccine, even though many government-issue vaccination cards actually include a blank space for PCV7 (and, on some newer cards, even PCV13). The Guatemalan Association of Infectious Diseases, the Guatemalan Pediatric Association and the Guatemalan Internal Medicine Association justify the absence of PCV7 in governmental community outreach programs in rural areas by citing WHO guidelines that "countries should consider implementing pneumococcal vaccination, especially countries with under-5 mortality > 50/1000 live births"--the official national rate in Guatemala being 35/1000, which hides the same regional and ethnic disparities that I have alluded to above--"and countries with total under-5 deaths >50,000"--the official national rate being 15,000. This line of argumentation assumes that we cannot truly want what is only humane to desire: it assumes that it is impossible to make morally and statistically significant improvements on the rate of infant and child mortality.

My task, then, is to have the courage to really want a world where indigenous Guatemalan children are protected against unnecessary death due to invasive pneumococcal disease. In pragmatic terms, it will be necessary to mount direct assaults on intellectual property rights by establishing strategic alliances that re-establish and protect the domain of the biomedical commons.

---

Citations:
Clin Infect Dis 2000, 31(1):34-41; Clin Infect Dis 2010, 50(9):1238-46; Pediatr Infect Dis 2009, 28(8):711-6; Clin Infect Dis 2008, 47(4):476-84; J Infect Dis 2007 Oct 15;196(8):1211-20; J Infect Dis 2007 Jul 1;196(1):104-14; JAMA 2007, 297(16):1784-92; Clin Infect Dis 2007, 44(9):1173-9; Vaccine 2007, 25(19):3816-26; Am J Epidemiol 2004,160(3):270-8; Lancet 2003,362(9381):355-61; J Infect Dis 2003 Jul 1;188(1):81-9; Pediatrics 1999,104(3 Pt 1):564-7; J Infect Dis 1994, 170(2):461-4; J Infect Dis 1994,170(2):368-76; J Infect Dis 1994, 170(2):368-76; Arch Intern Med 1992, 152(8):1641-5; J Infect Dis 1974,130(1):67-9; Am Rev Respir Dis 1974;109(5):577-8.

Protocolos de los promotores de salud de San Lucas T. - Enfermedades Crónicas

2011-07-24T09:22:00.000-07:00

Protocolos – Promotores de Salud del Área Rural de San Lucas Tolimán

Asma
Menores de 8 años:
Etapa 1: Diagnostico nuevo
-Albuterol/salbutamol tomado

Etapa 2: si usa albuterol/salbutamol o tiene síntomas de asma más de dos días a la semana, o si tiene tos nocturna más de dos veces al mes
-Seguir albuterol/salbutamol cuando hay muchos síntomas
-Empezar una medicina de control: montelukast (4mg al día para los niños entre 6 meses y 5 años; 5mg al día para los niños entre 5 años y 14 años, 10mg al día para los mayores de 15 años)

Etapa 3: si a pesar de usar la montelukast, todavía sigue con síntomas o usa albuterol/salbutamol más de dos días a la semana, o si tiene tos nocturna más de dos veces al mes
-seguir albuterol/salbutamol, y montelukast
-medir fiebre, escuchar los pulmones y respiraciones para descartar una neumonía
-si no hay neumonía, es precisa una referencia antes de buscar otros tratamientos

Mayores de 8 años y adultos
Etapa 1: Diagnostico nuevo
-Albuterol/salbutamol tomado

Etapa 2: si usa albuterol/salbutamol o tiene síntomas de asma más de dos días a la semana, o si tiene tos nocturna más de dos veces al mes
-Seguir albuterol/salbutamol cuando hay muchos síntomas
-Empezar una medicina de control: montelukast (5mg al día para los niños entre 5-14 años; 10mg al día para los mayores de 15 años)

Etapa 3: si a pesar de usar la montelukast, todavía sigue con síntomas o usa albuterol/salbutamol más de dos días a la semana, o si tiene tos nocturna más de dos veces al mes
-seguir albuterol/salbutamol, y montelukast
-medir fiebre, escuchar los pulmones y respiraciones para descartar una neumonía
-si no hay neumonía, empezar segunda medicina de control: esteroide inhalado (por ejemplo, beclometasona, mometasona, budesonide)

Para ataques de asma:
-pensar en una referencia para sacar al paciente
-usar esteroide tomado o inyectado
-prednisona 1 mg/kg dos veces al día x 7 días (60mg dosis máxima en un día)
-prednisolona 1mg/kg dos veces al día x 5-7 días (80mg dosis máxima en un día)
-dexametasona 4mg inyectada para niños o 8mg inyectada para adultos x 2 días
-usar albuterol/salbutamol cada 4-6 horas todos los días por 5-7 días

Para cualquier paciente con asma, evaluar por reflujo gástrico y rinitis alérgica:
-para reflujo gástrico, si tiene dolor de la boca del estómago, considerar un tratamiento por H. pylori
-amoxicilina, metronidazole, omeprazole/lansoprazole, peptobismol (2 semanas)
-amoxicilina, claritromicina, omeprazole/lansoprazole (2 semanas)
-metronidazole, tetraciclina, peptobismol, ranitidina/famotidina (2 semanas, después del tratamiento, seguir ranitidina/famotidina por 2 semanas más)
-para reflujo gástrico sin dolor de la boca del estómago, se puede tratar con ranitidina, famotidina, o en casos más graves de reflujo gástrico, omeprazole, lansoprazole
-para rinitis alérgica, se puede tratar con loratidina (5mg para los niños entre 2-5 años, 10mg para los mayores de 6 años)

...

Enfisema

Sospechar enfisema en los adultos ancianos (mayores de 55 años) que se han quedado expuestos a mucho humo durante el transcurso de su vida, o que han fumado puros/cigarros, o que han tenido muchas infecciones respiratorias (neumonías).

Los síntomas de enfisema son lo siguiente:
-tos por más de 3 meses
-tos crónica con flemas
-dificultad de respirar

Los signos de enfisema son lo siguiente:
-chispas y sibilancias en los pulmones
-muy lenta la expiración comparada con la inhalación
-deformidad de los dos lados en forma de un barril
-saturación baja de oxígeno de forma crónica (menos de 94%)

OJO 1: si hay fiebre con los síntomas y signos mencionados, o pérdida de peso, o escupen sangre, se tiene que sospechar la tuberculosis.

OJO 2: los pacientes con enfisema, por ser mayores de edad, se tienen que hacer exámenes generales porque muchas veces hay otra enfermedad común también, por ejemplo: anemia, diabetes, presión alta, infecciones urinarias, dislipidemia, ataques cardiacos, fallos cardiacos etc.

Para enfisema, los tratamientos principales son:
-esteroide inhalado dos veces al día
-tiotropium inhalado dos veces al día
-formoterol inhalado dos veces al día
-albuterol/salbutamol inhalado cuando hay más síntomas
-omeprazole/lansoprazole a diario, aunque no hay síntomas de reflujos gástricos ni de gastritis (esto baja la incidencia de infecciones respiratorias, según un estudio reciente)
-para los casos muy graves (saturación de oxígenos menos de 89%), se puede buscar oxígeno inhalado para la casa
-evitar el humo (por ejemplo, a traves de un poyo mejorado con chimenea)
-también si fuera posible, ponerles sus vacunas de PPSV23 cada 5 años, y de Influenza viral trivalente cada año
-si al paciente con enfisema se pone el flema muy blanco (color de papel), se puede probar un tratamiento de antibiotico: doxiciclina (200mg por 7 días) o azitromicina (500mg por el primer día, después 250mg por 4 días)

...

Epilepsia

-para todos los casos de epilepsia, se deben de sacar los siguientes estudios en algún momento: resonancia magnética, electroencefalograma, electrolitos, urea, creatinina, bilirubinas, ALT y AST, fosfatasa alcalina, albumina, amonio

-para los niños, se debe evitar el uso de fenitoina y de fenobarbital; en cambio unas medicinas con menos efectos secundarios son carbamazepine y ácido valproico (depakene)

-cualquier mujer con epilepsia que toma una medicina para epilepsia debe tomar su suplemento de ácido fólico y seguir su tratamiento durante el embarazo bajo observación médica. Si una mujer embarazada está tomando fenitoina durante el embarazo, durante los últimos meses, debe recibir inyecciones de vitamina K.

-cualquier mujer con epilepsia que está mamando a un niño debe evitar la fenobarbital y la fenitoina. Es más seguro tomar la carbamazepine, y ácido valproico, pero siempre bajo observación médica.

Dosis de las drogas anti-epilepticas:

Carbamazepine:
Para adultos, empezar 200mg dos veces al día.

Para niños, empezar 10mg/kg dos veces al día.

Antes de empezar carbamazepine, los pacientes deben sacar una hematología completa, bilirubinas, ALT y AST, fosfatasa alcalina, albumina. Si el paciente ha tenido cualquier problema de la sangre o del hígado en el pasado, no debe tomar carbamazepine.

Ácido valproico:
Para adultos y niños, empezar 5mg/kg dos veces al día.

Antes de empezar el ácido valproico, los pacientes deben sacar bilirubinas, ALT y AST, fosfatasa alcalina, albumina, amonio. No usar ácido valproico en los niños menores de 2 años, sin receta médica.

Fenitoina:
Para adultos, empezar 100mg dos veces al día.

Para niños menores de 10 años, empezar 4mg/kg, dos veces al día.

Para niños de 10 a 16 años, empezar 3mg/kg, dos veces al día.

Fenobarbital:
Para adultos, empezar 50mg, tres veces al día.

Para niños, empezar 5-6 mg/kg, una vez al día.

OJO: fenobarbital tiene muchos efectos secundarios, y sólo se debe usar en los casos que no se han podido controlar con otras medicinas. Desde nuestras observaciones, es muy común encontrarnos con pacientes con epilepsia que han tomado fenobarbital durante mucho tiempo, pero esto se da porque fenobarbital es una medicina muy barata, y no es por ser la mejor medicina para convulsiones.

...

Hipertensión (presión alta)

-Más de 140/90 es hipertensión (presión alta).
-Más de 160/100 es hipertensión avanzada.
-Más de 200/120 es una crisis hipertensiva.
-Pero, más de 120/80 es pre-hipertensión.
-En un caso de un embarazo, siempre referir cualquier mujer con presión alta.

-Para diagnosticar la hipertensión, tiene que haber dos veces que la presión sale alta.

-Para pre-hipertensión, se aconseja no echarle sal a la comida, salir a caminar una hora todos los días.

-Si se le diagnostica la hipertensión en un paciente de menos de 20-25 años, puede haber otra causa de la presión alta, por ejemplo chequear: glucosa, orina, electrolitos, urea, creatinina, TSH (tiroidea), electrocardiograma.

-En las embarazadas, referir de una vez para tratamiento bajo observación médica. Hay dos razones por hacer esto: primero, las medicinas para presión alta pueden provocar problemas al feto, así que se tienen que buscar medicinas diferentes; segundo, la presión alta durante el embarazo puede ser parte de la toxemia o preeclampsia, la cual provoca convulsiones y muerte tanto a la embarazada como a la criatura.

-Para la hipertensión, si no es un caso avanzado, empezar aconsejandole al paciente que no eche sal a la comida, y que salga a caminar una hora todos los días.
-En estos casos, si sigue alta la presión después de dos meses, empezar con un tratamiento: hidroclorotiazida (HCTZ) 25mg al día.
-Después de dos meses, si todavía sigue alta la presión, agregar otra medicina: para empezar, enalapril 5mg, una vez al día, o captopril 25mg, tres veces al día.
-Si el paciente empieza a sufrir una tos seca y necia, o si se le hinchan los labios al paciente, es un efecto secundario del enalapril, y se debe de cambiar enalapril a otra medicina: atenolol 25-50mg, una vez al día. OJO: el parar atenolol de un día al otro, puede provocar un ataque cardiaco.

-Para la hipertensión avanzada, primero sacar las mismas pruebas de arriba: glucosa, orina, electrolitos, urea, creatinina, TSH (tiroidea), electrocardiograma. Si todos los resultados salen normales, entonces empezar el tratamiento de una vez.
-En estos casos, empezar de una vez un tratamiento con dos medicinas: 1. hidroclorotiazida 25mg al día y, 2. enalapril 5mg una vez al día o captopril 25mg tres veces al día.

-Para una crisis hipertensiva, referir de una vez porque el paciente corre riesgo de un ataque cardiaco, derrame cerebral, o fallo renal muy pronto.

...

Diabetes

Es una enfermedad silenciosa por problemas de la pancreas que va directamente el azucar en la sangre y provoca varios problemas en el cuerpo.

SINTOMAS:
Mucha sed, perdido de peso, visión borrosa, dolor de cabeza, y orina frecuentamente.

Pacientes chequeo de azucar en ayunas mas de 126 mg/dL a mas es hiper-glucosa , si es menos de normal es hipoglucemia o depende del caso y los sintomas que presentan.

También se puede diagnosticar la diabetes después de haber comido (no en ayunas) si sale la glucosa más de 200 mg/dL en dos ocasiones.

También la “pre-diabetes” se puede diagnosticar en ayunas si la glucosa sale más de 100 mg/dL, y después de haber comido (no en ayunas) si sale la glucosa más de 140 mg/dL.

Estos pacientes necesitan exámenes de presión arterial, orina, y, si tienen mucha tos, pruevas de B.K. (baciloscopia) y radiografía.

Si el paciente de diabetes tiene su presión aterial más de 130/80, ya es presión alta. En estos pacientes, se debe empezar con captopril o enalapril de una vez para la presión alta.

TRATAMIENTO:
Empezar con metformina de 500mg 2.veces al dia dosis maximas es de 2,000 mg 2 veces al dia.
Plan educacional sobre su dieta

Si la paciente tiene los niveles de azucar alto despues del tratamiento de la dosis maxima de metformina entonces se puede agregar la glibenclamida 5mg al dia. A tres dias se puede aumentar la dosis a 5mg dos veces al dia si sigue alta la glucosa, de allía cada tres días se puede subir la dosis según la glucosa en ayunas. La dosis maxima es 8 tabletas de 5mg de glibenclamida (es decir, 40mg) al dia. Y si la paciente todavia tiene los niveles de azucar alto entonces referirla a la clinica paroquial porque puede ser necesario recetarle inyecciones de insulina.

Electrolitos, urea,y creatinina tres examenes hacerlo a un mes despues del tx de metformina

En caso de embarazo referir para cuidado médico. Durante el embarazo la única medicina para diabetes que se debe utilizar es la insulina, es decir no se debe de seguir la metformina, la glibenclamida, etc.

Ojo. Con los diabeticos, chequeos de los pies , hemoglobina, presión arterial, hacer electrocardiagrama.

Observacion: todos lo hombres con mas de 50 anos y mujeres mas de 60 anos deben tomar aspirina 325 todos los dias siempre y cuando que no tiene síntomas de gastritis ni sangre oculta en los heces. También a todos los pacientes con diabetes darle un diente de ajo todo los dias; nuestros compañeros de Wuqu’ Kawoq prefieren esta última estrategia a la aspirina, ya que es menos riesgoso.

Subjectivation of Bare Life in the Post-Peace Concentration Camp

2011-07-18T16:23:00.000-07:00

"Nearly half of preschoolers in Guatemala are malnourished. Malnutrition can hamper a child's performance in school, making them more likely to drop out, and children who are malnourished early in life can suffer long-term consequences in both mind and body. In order to combat this problem, MF has established six Preschool Nutritional Centers in different communities in the region, which provide 3-5 year-old children at risk of malnutrition with a healthy meal and a nutritious snack daily, as well as lessons on basic hygiene, and multivitamin supplements. The children, many of whom have not learned to speak Spanish at home, also get a head-start on learning Guatemala's official language before beginning school."

"Normal" malnutrition = statistical normalization of structural violence

2011-05-21T16:29:00.000-07:00

"Due to the high incidence of stunting among Guatemalan children, weight-for-age was deemed to be a more appropriate measure of malnutrition than standard height-for-weight ratios. Children with weight-for-age ratios at 90% or above the mean of the reference population were assigned a level of ‘normal’ malnutrition while those between 75% and 89.9% were assigned a level of ‘mild’ malnutrition, 60% to 74.9% were categorized as moderately malnourished, and those at 59.9% or below."

Cook D, et al. J Health Popul Nutr 2009;27(1):31-40.

Narco-state

2011-05-18T21:40:00.000-07:00

Is Guatemala a...?

http://www.as-coa.org/articles/3338/A_Plan_of_Action_for_Guatemala/

Beyond Development: Building Collaborative Networks in Guatemala

2011-04-06T23:15:00.000-07:00

Check out Futuros Colectivos/Más Que Desarrollo II: Construyendo Redes Colaborativas en Guatemala.

Ambiguity/Struggle

2010-04-26T22:01:00.000-07:00

"Hay hombres que luchan un día y son buenos. Hay hombres que luchan un año y son mejores. Hay hombres que luchan muchos años y son muy buenos. Pero hay los que luchan toda la vida. Esos son los imprescindibles." ~Bertolt Brecht

I find comfort in mutual exhortations to "continue to struggle," to "keep fighting." Uttered by colleagues and friends, these words affirm the profound, often unspeakable yet always shared experiences that emerge in the crucibles of solidarity.

The ambiguity of Brecht's words, however, evokes the mystery of inspiration. What, or whom, are we struggling against? What is it about the outcome--or is it the process--of such struggles that make them "indispensable?"

Brecht reminds me that the unspoken may be unspeakable. What if, after all, our most formidable enemies are not external to us, but rather reside in our midst? What if the impulses to resist and revolt are traced to their origins? Do we dare admit our mundane familiarity, and even intimacy, with the spectral and grotesque horrors we have declared ostensibly to be our enemies?

Rune'y Lola

2010-04-09T07:45:00.000-07:00

Lola was 9 months pregnant on Tuesday. Per her husband, who is a public health nurse and a community health worker, an ultrasound two weeks previously demonstrated a breech position, and they were advised by the physician that she would most likely require an operative delivery. The local Centro de Salud recently opened a maternity ward to much fanfare; nonetheless, despite a staff of 3 physicians and 6 nurse-midwives, they do not offer C-sections.

On Wednesday, Lola began to have contractions. They immediately contacted the Centro de Salud. Two hours later, in the back of a speeding ambulance on its way to the regional referral center at Hospital Nacional de Sololá, Lola gave birth to a little girl. Likely suffering from intrapartum asphyxiation, and because the "ambulance" was not fitted for any of the emergent diagnostic and therapeutic maneuvers that are required in such cases, the baby was dead at birth.

On Thursday, following an overnight vigil and baptism by one of the community's catechists, the little girl was buried alongside her deceased grandmother, in a small community cemetery on a neighboring plantation. Lola, thankfully, is recovering and has not suffered further physical complications from this harrowing experience.

I spoke to Lola's husband on Friday morning, the day after the funeral. He said:

"All of this is an experience for us; we are trying to start over.

"Despite the whole team of personnel, so many doctors and nurses, they work like midwives, nothing more. And we have no other alternative. This is an experience for us, and it motivates one to continue fighting to improve our healthcare system."

Zizek on excremental ideology

2010-04-06T13:31:00.000-07:00

Zizek.

Me.

Zizek is much, much funnier.

Pain, addiction and The War on Drugs

2010-03-24T17:13:00.000-07:00

Pain and addiction are two complex phenomena whose presentation and management in the acute setting are further complicated by synergies between symptoms and biological dependence, as well as by comorbid psychiatric and organic pathologies. Such interactions and the concomitant pitfalls that plague physicians are abundantly described in the medical literature and discussed in clinical situations. In particular, it is the highly subjective specificity of these interrelated forms of suffering that have resulted in quite a bit of attention on the part of outpatient clinicians and psychiatrists--both of whom are afforded substantial time and space, relatively speaking, to explore the affective and moral contexts of individual patients' lives. If there is any credence to the "humanistic" notion that the depth and quality of interpersonal engagement can be as or more important than frequency, the emergency physician's relative lack of familiarity with the anthropological specificities of context could be seen to hamper acute management. A salutary corrective to this potential disadvantage, I think, would be to approach patients in acute pain and addiction/withdrawal from a perspective informed by historical and social context.

When an attending bluntly opines that, "I don't give these people [alcoholics] anything because they just go out and overdose on Ativan, go on another binge and the whole thing starts again," wouldn't it be appropriate to critically examine the alternatives faced by alcoholics and other drug users once they leave the ER? If, as the same attending admitted, "people tend to hate Haymarket," doesn't the abandonment by the public sector of our addicted and withdrawing patients---who, after all, are usually in the ER because their money (or luck?) ran out---place a burden of responsibility on us? If I were homeless, unemployed and physiologically addicted, I'm not sure that being denied the means to pharmacologically manage my symptoms on the street would improve my chances of recovery.

But, mere empathy aside, there are broader considerations that might humanize the approach to acute care for "pain-seekers"---and reveal the violent contradictions of such epithets. As demonstrated by Ethan Nadelmann, JD PhD of the Drug Policy Alliance, histories of xenophobia, racism and classism have driven the contradictions and vacillations in anti-drug policy, from the outlawing of opiates with the influx of immigrant Chinese to the west coast, the illegalization of marijuana in response to fears of migrant Mexicans in the midwest, and the crackdowns on alcohol production and "public drunkenness" due to the "less White"--that is, poor, non-Protestant--communities of Eastern European and Irish refugees that took hold in American cities throughout the 19th and 20th centuries. Of even more contemporary relevance is the pernicious effects of the War on Drugs. Since its inception, this "War" has been highly racialized, with its differential repression and litigation of crack vs. cocaine, for example. It has also been made manifest in ways that are profoundly classist--again, as exemplified by differential treatment of "possession" (for personal consumption) vs. "intention to deliver" (for economic gain), as well as by the unconstitutional levels of police surveillance and resultant risks of incarceration in neighborhoods inhabited by a preponderance of young people of Color. The "War," as Nadelmann explains, has been central to the criminalization of drugs, transferring responsibility and power from the positive social institutions of public health and medicine, to the negative formations of courts and prisons.

It is a little known fact that William S. Halsted, the famed surgeon who was appointed Chief at Johns Hopkins in 1890, who developed the inguinal hernia repair and radical mastectomy, and who published 180+ scholarly articles during his career, was chronically dependent on cocaine--which his friend and colleague, William Osler, treated and managed through a chronic regimen of morphine injections. It is important to consider such precedents and contexts to avoid adding to the stigmatization and marginalization of our desperate--and often sick, poor and "pain-suffering"--patients who present acutely in the ER.

My notes: Michael Hardt, "On love [as political practice]"

2010-03-23T22:55:00.000-07:00

The ways that love has been destroyed as a potentially powerful political concept:

1. The reduction of love to the space of the heterosexual family, that is, love as a closed social phenomenon, rather than an open, plural mode of pro-social being-in-the-world.
2.The identitarian ideas of love as love for the Same, or the creation of the Same through love: true love can be felt only for those who are essentially like us, or, alternatively, love as a hegemonizing force that transforms the object of love into the Same-as-Self. Rather than love being a kind of experiment with deep, lasting commitment to Other(s) without the presumptuous dissolution of difference and singularities.
3.The binarist division of eros/cupiditas vs. agape/caritas, or, what amounts to the same, the demotion of one pole vis-à-vis the other. That is, either caritas (charitable love for the holiness of the poor) is a side-product of libido; or, eros-libido must be "tamed" by the impulses of caritas.
4. The reduction of love to “charity,” specifically to the poor, which takes the Other as object, and not as subject. That is, a love whose terms and distribution are determined by those who are NOT poor, as opposed to a love defined and directed by the poor themselves, of which they are subject-agents, not passive thing-objects.
5. The trivialization of love as an involuntary passion or a sensation, not as a productive and incremental practice.

The experience of exception

2010-03-11T09:04:00.000-08:00

I am struggling with what to make of personhood and subjectivity in contexts of extreme deprivation and concomitant suffering. When political-economic phenomena conspire with overt interpersonal violence in the lives of the sick and poor, what does it mean to try to describe the structure of experience? What does it mean, for example, to elaborate ethnographically (i.e. in person, and in text) on the experience of "social death"?

Much anthropological work on trauma and violence has dealt with the sequelae of such situations, but how might we approach an ethnography of ongoing violence? It seems too ethically and epistemologically simple to rely on the hackneyed and normalizing conception of current violence as just "another layer of complexity," as if the shedding of blood were a fresh coat of multivariegated paint. Such a metaphor, even in its more nuanced, less reified forms, implies the stability of an edifice (i.e., the structure of experience) that, on close inspection, does not provide shelter, at the very least, or worse still, that may not even be there, having been annihilated long since. When--and, more importantly, how--can we begin to admit that the rubble of culture is becoming an evanescent dust, so pulverized by violence that recognizably "human experience" itself seems to evaporate into thin air? If we acknowledge the profundity of the indignities implied by descriptions of "social death," and by the extreme physical suffering of the indigent sick (e.g., deadly "syndemics" of chronic starvation and gang-related physical violence), doesn't a sense of solidarity and concomitant honesty obligate us to repudiate facile formulas like "weapons of the weak?"

Put another way, this is my dilemma: Giorgio Agamben's descriptions of "bare life," at times, seems to me to describe with disturbing accuracy the contemporary lives of the indigent sick. In engaging with and attempting to represent the situations faced by many of my very poor patients in rural Guatemala, however, Agamben's "homo sacer" seems to recapitulate neo-colonial ideologies about "savage Indians" as nearly bestial "clean slates" where "civilization" must be inscribed. But when people are stripped violently bare of what even they themselves would "identify" as universal prerequisites of human dignity, and when, moreover, they are denied the materials necessary for mere survival by everyday structures of violence, what do we risk in describing and publicizing such a "state of exception that is the rule?" The dangers of such an interpretation seem to be magnified when dealing with contemporary "states of exception" that are structured by seemingly self-perpetuating processes of neoliberalism and extractive global capitalism--as opposed to the historically or spatially remote examples of mid-20th century fascist dictatorships that serve as primary material for Agamben's reflections.

Does the ethnography of "bare life"--in all its dehumanizing, exploited nudity--verge on a grotesque "pornography of suffering?"

the fetishization of regulation, and the secret thereof

2010-02-05T02:30:00.000-08:00

Of the colorful characters who populate open-air markets and equally crowded public buses in rural Guatemala, one quickly identifies the ersatz physician by his charismatic, albeit illogical, sales pitch and his mound of medicines: "This little tablet, ladies and gentlemen," and a quick chortle for effect, "this tiny little tablet, will provide the 100 % cure for pain -- headaches, liver pain, kidney pain..."

Once, curious, I asked to look at the miraculous plastic blister pack that would cure multi-system organ failure: tetraciclina. "Holy shit," a responsible and self-respecting healthcare professional might say, and he'd be right, but not because he seems to have discovered the cause of novel antimicrobial resistance profiles in Central America, which he has not. Rather, his expression of dismay--"holy shit"--contains a metaphorical truth, insomuch as it recapitulates the fallacy of misrecognizing as transcendent and powerful something that is anything but. The obsession with Big (Bad) Pharma, just like our reflexive condemnation of ersatz physicians handing out low-dose antibiotics willy nilly in rural Guatemala, leads us to an upside down diagnosis of the causes of these predicaments.

Shall we turn things on their heads, right side up?

Amidst vociferous calls for increased scrutiny and regulation of pharmaceutical marketing and distribution strategies to curb the corrupting effects of competition, a paradox emerges: the Central American Free Trade Agreement (CAFTA-DR) was accompanied by "TRIPs-plus" laws, which, strangely, impose unprecedented restrictions on market competition in the name of intellectual property, by severely constraining National Drug Regulatory Authorities' (NRDAs') ability to acquire non-originator, or "generic," bioequivalent formulations to important new drugs (Health Affairs 28(5):w957). For example, as a result, Guatemala's national HIV/AIDS treatment program was obligated to begin purchasing two second-line antiretroviral medications from the originator, multiplying the total cost of one of them 15-fold. Life-prolonging medicines became impossibly unaffordable from one year to the next; put another way, a year's supply of Kaletra--and Abbott's intellectual property--was deemed of higher value than the relatively expendable life of an impoverished HIV+ Guatemalan.

We should be cautious, then, as the fetishization of regulation can lead to very divergent outcomes--either the assumption or disavowal of social responsibility. The fetish of "Pharm-Free," deposits and fixes responsibility for moral failures on individual actors--physicians, CEOs, biotech companies and salespeople--thereby magnifying their sins to the point of demonization. Banal, everyday objects are transformed by the activist fetish into the creeping manifestation of something evil, nearly supernatural--like sacred excrement.

In fact, these fetishes merely distract our attention, keeping secret another more abject one--the fetishization of commodities. The regulation of markets, as a solution, assumes the ontological inescapability of those markets. Indeed, the immoral strategies identified by "Pharm-Free" fetishists are merely distal expressions of the originary immoral presumption that Capital and caregiving are fungible.

Action, context, revolution.

2010-01-30T18:21:00.000-08:00

"The same gesture, performed at a wrong moment (too early or too late), is no longer an act...what makes an act 'unconditional' is its very contingency: if the act were necessary, this would mean that it is fully determined by its conditions, that it can be deduced from them (as the optimal version arrived at through strategic reasoning or rational-choice theory). [...] The link between the situation and the act is thus clear: far from being determined by the situation (or from intervening in it from a mysterious outside), acts are possible on account of the ontological non-closure, inconsistency, gaps, in a situation." ~Slavoj Zizek ( 2008 In Defense of Lost Causes)

On "health reform"

2009-12-21T13:11:00.000-08:00

A quick slippage can be traced from the 2008 US Presidential Election campaigns to now in the discourse on the allopathic healthcare system. At some point, any mention of the need for an "overhaul" became replaced by monotonous details of "reform." The metaphor of "revolution," on the other hand, barely got any play.

Soon after Obama's election, Gallup and other polls demonstrated that people were beginning to feel more comfortable about their ability to afford healthcare. The sense of corporal insecurity and dread of being abandoned in their senility was diminished by the simple fact that politicians were "finally taking healthcare reform seriously," meaning little more than that they were finally talking about it.

For some reason, interviewers and acquaintances think that I should have something particularly enlightening to say on the current debate. The people who are closest to me know that I am too intellectually pessimistic to respond with anything more than grumbles. Moreover, the people who are closest to me know that what is being touted as "reform," or even as "the public option," will do little to make easier our "bloody" struggles to ameliorate the gruesome realities faced by the indigent sick.

But my grumbling is just another shade of gray in the monochromatic swirl that is the debate on healthcare "reform."

A different, more radical pessimism is required, and for that purpose I will borrow from a friend:
"It's preposterous to think that someone should get paid to provide medical care -- 'Wait, you saved my life so you want me to pay you money???'"

Yeah, seriously: fuck you!

Perplexing insistence...

2009-11-23T19:20:00.000-08:00

Please take a moment to look at the newest issue, "Killer Apps," page 30-32: The Atrium.

The 5 Laws of Infectious Disease

2009-10-20T17:56:00.000-07:00

As per Dr. William Muller, Children's Memorial Hospital, Chicago, IL:

1. The average of two standards of care is not a third standard of care.
2. Vaccines are not a religion.
3. Always ask: where and how?
4. Antibiotics are not anti-pyretics.
5. Never pull out the big guns without an exit strategy.

A terrible commerce: Bourdieu, capital accumulation, and growth failure among indigenous children in rural Guatemala

2009-10-03T08:35:00.000-07:00

Presented September 2009 at Society for Medical Anthropology annual conference, Yale University.

This paper was one of 5 in a panel organized by Bridget Hanna and me: "Global Health and Social Theory: Practice, Pedagogy and Unintended Consequences ." Arthur Kleinman agreed to serve as the discussant! The ensuing conversation was also enriched by the contributions of Peter J. Brown, whose idea of "macroparasites" (Cultural Anthropology 2(1):155-71) was the original inspiration for my expansion of Bourdieu's typology.

...

Since I began collaborating in community health interventions in Guatemala in 2007, I have felt so utterly demoralized at times that I think I’ve hit rock bottom. Struggling against the baleful synergies between disease and structural violence, as a medical student and wannabe anthropologist among the indigenous, rural poor in the Kaqchikel highlands, I have been faced with the abominable tasks of explaining and making sense of the unnecessary suffering and irredeemable deaths of patients, friends, and colleagues. If, as Paul Farmer writes, engagement with the indigent sick makes for a “vital practice,” shaping my imagined life-work in exciting ways, it has been in learning to write ethnography and think with social theory that I have found some solace. Even if we failed to identify any pragmatic contribution to be made by social theory to the clinical practice of social medicine, for me, at least, the practices of reading and writing—hobbies or not--have become central to my sense of who I am. Experiences, memories and vignettes about people and places compel me to go back to the communities I have grown to care about, but compulsions like this can be ignored until they become cold. It is in the application of social theory, implicit but nonetheless palpable in the vignette I will present shortly, that I have found new spaces to imagine solutions and renewed the desire to make meaning, permitting to keep going as often as I can.

I have found Pierre Bourdieu’s (1990) typology of capital to be very productive for making meaning and explanations, and for acting in my lifeworlds, and in the following vignette I have attempted to highlight the transactions and forceful deployments of social capital (that is, the force of relationships), cultural capital (that is, the force of privileged epistemology and habitus), and economic capital. In the case of child malnutrition in Guatemala—as in many other cases—I think we must consider bodily and biological capital in the flows that comprise this abhorrent commerce. Bourdieu’s typology of capital can be augmented by more economistic and biological
considerations, and global health practice can become more sophisticated and effective by deploying Bourdieu’s analytic method. The consequences of child malnutrition are pervasive and debilitating. An analysis of epidemiologic studies suggested a significant association between child malnutrition and mortality that could not be attributed merely to confounding by socioeconomic factors or intercurrent illness; extensive reviews of published empirical data subsequently concluded that malnutrition is indeed an underlying cause of childhood mortality from diarrhea, acute respiratory illness, and malaria. (Pelletier, 1994; Rice, 2000; Caulfield, et al, 2006; WHO, 1995) Poor infant and childhood nutrition in the first two years of life is associated with impaired neurodevelopmental attainment, manifested as poor school performance, fewer years of schooling and, ultimately, deficits in productivity and inequalities in health in adulthood. (Lissauer, 2001; Caulfield, et al, 2006) By paying attention to the transactions—and to the quality and quantity of capital we bring as clinical or ethnographic practitioners—I think we begin to have a methodology for devising social strategies in solidarity
with the sick and poor.

…

There is an abandoned stable on a defunct German plantation in the central coffee-growing piedmont of Guatemala, where, this past Tuesday, two “health promoters,” arrived from their nearby communities, also former coffee plantations, and began setting up to weigh the children who are being raised there. The “health promoters,” Vicente and Dominga, are trained as nurses
and are able to provide some basic but quite competent primary care during these visits. They have some medicines—amebicides, antibiotics, anti-helminthics, even equine-dose ivermectin—a rare commodity where onchocerciasis is endemic and human-dose formulations of ivermectin are strictly rationed. Therapeutic decisions for the children who present with acute cases, or just as often, acute exacerbations, of diarrhea, are made on the basis of very crude symptom-based algorithms. Despite Vicente’s eagerness to have me teach them to do stool microscopy for ova and parasites, the only microscopes that were donated to us were unrepairably broken.

Finally, when it seemed that we might be able to obtain a functional microscope from an itinerant parasitologist and physician, our efforts in this respect were convincingly discouraged by those who were concerned that the health promoters’ free stool studies would create
unwelcome competition for local labs, which in turn would undermine their valuable support for Vicente and Dominga’s existing efforts--and the support of these labs and associated clinical facilities has, in fact, been quite valuable. In any case, the aforementioned medicines, as well as stethoscopes, otoscopes and other supplies, are provided by a local Catholic mission. Vicente and
Dominga also receive some support from a pediatrician at Stanford, Paul Wise, who applies and holds pressure as necessary to maintain their stock of medicines, as well as a steady supply of Incaparina, a cornmeal-based therapeutic food. (To me, the irony of providing a cornmeal-based therapeutic food to children whose ancestors were responsible for domesticating maize, is quite grotesque.)

But after a few hours here in “Nueva Providencia”--New Providence--it becomes clear that much more is needed. This slow trickle of pharmaceuticals and calories—which can feel like quite a bit on the backs of those carrying it across the stream and up the hill to the abandoned stable--is overwhelmingly inadequate. The national prevalence of stunting, or deficits in height for age,
among children under-5 y/o in Guatemala is ~40 %, which is already the worst rate in the hemisphere. In this particular community, according to data collected by Vicente and Dominga, it is closer to 70%. Incidentally, the space and time necessary to collect that data were made available to the health promoters through the intervention of Paul Wise. Again, as a pediatrician at Stanford who is engaged in community health interventions and biosocial research, in Guatemala and elsewhere, Paul has access to funding—capital—that can help Vicente and Dominga set aside enough time to collect anthropometric data to guide and evaluate their interventions in the communities they serve.

When presented with Vicente and Dominga’s independently collected data, the functionaries at the local statesponsored healthcare NGO refused to make any changes to their reports to municipal and departmental authorities that rates of malnutrition have stabilized at around 30%--better, that is, than national indicators. One health promoter, Rogelio, who works closely with Vicente and Dominga, expressed his anger at the government functionaries’ rude dismissal of their concerns. “We are not malnourished,” he was told by the administrator, “we are ‘chapines’—Guatemalans—that’s just the way we are.” The government functionary—a man with a relatively comfortable salary and a home in the center of town—could afford to dismiss the concerns of a “muchacho de la finca”—“a boy from the plantation.” A medical and public health student at Stanford, nonetheless, is working with Vicente, Dominga and others to publish their independent data.

In the face of what is now being referred to grandiosely as “the financial crisis,” the state-sponsored NGO announced in November 2008 that due to central government budget cuts, they would discontinue community health and primary care services until further notice. Curiously,
the services to be discontinued did not include growth monitoring nor other data collection activities. Rising unemployment and the 2nd consecutive coffee crop failure exacerbated the effects of the acute-on-chronic crisis for poor families in Nueva Providencia. The water pump in Nueva Providencia broke last year, leaving half the households in the community without any water source, which is to say nothing about its potability. In fact, even before the water pump broke, Vicente and Dominga, again with donated supplies, had conducted their own tests and detected heavy coliform contamination of the water in Nueva Providencia.

…

There are many ways to begin to approach the difficulties of the situation I’ve described. Paul Wise, for example, is concerned about the synergies between unequal pediatric health outcomes and what he calls “failed governance,” for example, the relationship between infant mortality (120 per 1,000 live-births in some communities, three times the national average) and a concomitant neoliberal neglect of public services and burgeoning of an unregulated, uncoordinated and inexpert Third Sector to fill the gaps--which, incidentally, I am a part of, as a medical student who is forced by necessity and scarcity to provide clinical services beyond his level of official training and without basic resources. Vicente, also, can be disarming and
eloquent when he engages with this sort of biosocial analysis. But his more immediate concerns are of a different sort, as expressed in a recent email: “nos miraremos de repente si es posible para unos c.d. regrabables para informes anuales y un cargador de baterías se lo agredece mucho cuidese mucho saludos de Vicente y José Eduardo” [“we’ll see each other by chance if it is possible for some re-writable CD’s for annual reports and a battery charger, you are much thanked, take care, greetings from Vicente and José Eduardo [Vicente’s 3-y/o son]”].

Vicente has learned from experience that it will be a few months, yet, till I graduate from medical school and before he will be able to convince me to bring antibiotics and amebicides when I travel from Chicago or Boston to Guatemala. Until then, besides my continuing accompaniment and support as their “doctorcito, ri tijoxel chin aq’omanel, mo’s, qa-visitante, ntzijon pa qachab’al” [“little doctor,” “the foreigner, our visitor who speaks our language”), what are the most important things he wants from me?

Re-writable CD’s and a battery charger, the latter for his digital camera! He is meticulous in documenting the problems facing their patients, as well as their efforts to alleviate their suffering.

…

This is, of course, one of the recurrent and compelling apologias for an anthropology of suffering as witnessing. I personally do not know if I am entirely convinced by the moral force of such cultural capital, and I certainly do not believe in a mechanistic interaction between economic
capital and social and cultural capital—otherwise, I would be much more successful than I have been in getting my friends and loved ones with means, and grantmakers and foundations, to give cash and in-kind donations.

Ultimately, tracing the movements of capital makes me hopeful because I see points where I can intervene. While anthropology is personally, intellectually and clinically important to me, then, I must admit that very utilitarian stakes are in play for me as I continue this hobby of medical anthropology. Ultimately, medical anthropology’s place at the margins of clinical medicine seems to be the most effective space for clinicians who hope to marshall capital in various forms towards the alleviation of suffering in places like Nueva Providencia.

Matyox chiwe.

2009-09-09T18:21:00.000-07:00

Thank you:

http://www.globalgiving.com/projects/diabetesmaya/

Many Maya patients and families struggling against poverty, racism and diabetes have found solace through Wuqu' Kawoq's ongoing solidarity.

Much thanks to those who have already given!

These are uncertain times for everyone. Please help, as you are able, to ameliorate the insecurities that plague Wuqu' Kawoq's patients.

~Shom

where is the financial crisis now

2009-08-27T20:31:00.000-07:00

here?

Tib'ana achike yixtikir. Do what you can.

2009-08-23T14:20:00.000-07:00

Please see link.

At the risk of ethnocentrism...

2009-08-10T19:44:00.000-07:00

It is a horrible experience to talk to your friend in Kaqchikel about his mother's fatal stroke and recognize his description as decorticate, then decerebrate, posturing.

I know this speaks more to my linguistic incapability and to some latent Orientalism in me. But still, it really was horrible.

My familiar friend, speaking in familiar words--and suddenly, I see the pathophysiology of a herniating brain.

I did not explain to him what had happened to his mother's brain.

I suppose it did not matter, either way.

WWKD (What Would Karl Do?) - stamina, starts and fits

2009-08-08T08:29:00.000-07:00

From The Eighteenth Brumaire of Louis Bonaparte:

"Bourgeois revolutions, like those of the eighteenth century, storm more swiftly from success to success; their dramatic effects outdo each other; men and things seem set in sparkling brilliants; ecstasy is the everyday spirit: but they are short lived; soon they have attained their zenith, and a long depression lays hold of society before it learns soberly to assimilate the results of its storm and stress period. Proletarian revolutions, on the other hand, like those of the nineteenth century, criticise themselves constantly, interrupt themselves continually in their own course, come back to the apparently accomplished in order to begin it afresh, deride with unmerciful thoroughness the inadequacies, weaknesses and paltrinesses of their first attempts, seem to throw down their adversary only in order that he may draw new strength from the earth and rise again more gigantic before them, recoil ever and anon from the indefinite prodigiousness of their own aims, until the situation has been created which makes all turning back impossible, and the conditions themselves cry out:

Hic Rhodus, hic salta!
Hier ist die Rose, hier tanze!
[Here is Rhodes, leap here!
Here the rose, dance here!]

Never talk politics and religion...

2009-07-10T17:00:00.000-07:00

Fourth year medical students are warned at my school to avoid the topics of politics and religion when applying for residency programs. We are taught in the preceding years that this applies to clinical encounters with patients and to professionalism in medicine.

The fundamentally flawed assumption in all this is that the practice and discourse of medicine are scientific and therefore fundamentally non-political.

This is, of course, entirely untrue. The provision of allopathic medical care at wealthy academic medical centers is absolutely political, based on access to the accruing benefits of power and violence that permit capital accumulation.

I wish I could say, however, that the political practices of biomedicine are limited to such insidious phenomena. In that case, one could say that at least physicians, nurses and everyone else is just doing their best. Any instances of collusion in regnant economies of inequality and harvests of violence are unfortunate and unintended. If politics is implicated in medicine, it must be working behind the backs of those teams of sleep-deprived people in white coats who congregate every morning before most other people are awake.

Fine. If that is so, then why is it acceptable on the in-patient wards to complain about Medicare physician payment cuts, and about Obama's "socialist" healthcare plan?

If it is so damn hard to pay taxes out of a six-digit physician's salary, then why not complain about the "hard-earned tax dollars" that go to the military budget every year without fail? That is, ~$500 billion per year, depending on how you do the math. Comparing this figure to Obama's stimulus package CBO and to the healthcare budget, we are faced with the gut-wrenching realization that people (who happen to be physicians) can be bitterly opposed to "government-sponsored" healthcare while having little problem with government-perpetrated violence.

Physicians can be as self-serving and reactionary as anyone else who benefits from the way things are. Unfortunately, the contemporary industries of medical education and healthcare provision reward these qualities.

Lest this sound like an angry rant, I should say that I am deeply, deeply saddened by all of this. I have had the luxury of persisting, albeit in little ways, in those brands of radical idealism that call for lived and pragmatic solidarity with the poorest and most marginalized.

And it is horribly, devastatingly disappointing to witness such countervailing ideologies and ways of being-in-the-world in people with whom I share something so presumably sacrosanct as the mandate to alleviate suffering.

So now I tried to bring it up...

2009-07-09T14:19:00.000-07:00

During moments of downtime, I introduced the topic of high neonatal and infant mortality in communities in Guatemala where I have friends and patients.

The most I've gotten as a response? "Yeah, that makes sense. I mean its not like some places in Africa..."

What?

In the Neurosurgical Intensive Care Unit

2009-07-08T17:53:00.000-07:00

the anthropologist in me (or is it just the same old suspicious world-systemist in me?) is making comparisons between the energy that is quite readily and appropriately expended on prolonging the life of critically ill and injured in chicago (electricity and materials for manufacturing and operating the mechanical ventilators) vs. the energy that is so violently taken away from indigenous children in rural guatemala (food scarcity, absence of government-run sewage treatment+disposal --> diarrhea, all of which manifests as chronic malnutrition).

here, suffering patients warrant fancy machines.

in socorro, suffering children get contaminated wells, juan's 5-foot-deep holes on the footpaths (for sanitation...eventually...labor paid in kCal's by adult male beneficiaries...); energy sapped by malnutrition enteropathy and bellies pregnant with worms; jun ti way rik'in jub'a ri atzan; fewer and smaller red blood cells and inches off children's linear growth potential.

i imagine accusations, eg from critical care docs, that this comparison amounts to a rationalization of euthanasia. but that is a provocatively empty, reflex reaction. i'm trying to be provocative, sure, but simply to call for even more care for more sick people.

...

sadly, it feels dicey when i broach this topic with my teammates in the ICU. if only they knew: i'd be overjoyed if they did what they do everyday in the ICU for a patient in guatemala.

Dilemmas in a polytherapeutic context

2009-06-16T06:53:00.000-07:00

Is it worth it to try improving (or preventing) the provision of care by providers whose competence is questionable? How harmful does an intervention need to be before you step in and try to stop it?

Doesn't the fact that people are going to those other providers mean that your services are not fulfilling the full range of a community's needs?

Fight crisis with crisis

2009-05-12T02:17:00.000-07:00

Some help on a recent post from Walter Benjamin:

"The tradition of the oppressed teaches us that the 'state of emergency' in which we live is not the exception but the rule. We must attain to a conception of history that is in keeping with this insight. Then we shall clearly recognize that it is our task to bring about a real state of emergency, and this will improve our position in the struggle against Fascism. One reason why Fascism has a chance is that in the name of progress its opponents treat it as a historical norm." ~quoted in Taussig, "Terror as usual" (1989)

Horse Ivermectin

2009-05-10T19:04:00.001-07:00

"If you don't speak the language, you're just practicing veterinary medicine." ~ Arthur Kleinman

What if you speak the language while calculating the appropriate does of equine-strength Ivermectin for all the members of the family?

On activism

2009-04-29T19:20:00.000-07:00

Prompt: Activism, applied research and theory have had an interesting and in no way similar relationship to each other in the scholars we have looked at in this semester. There is no consensus on what activism or applied research might be, nor even what counts as theory or explanation. Consider these questions in the work of the following scholars: Moore, Scott and Das. How have they resolved these pulls or pressures, if they have? If you anticipate similar pressures in your own career, what if anything have learned from them?

...

“Why does one engage in doing something that in reality never comes, and never can come, to an end? … in order to be able to orient our practical activities to the expectations that scientific experiences places at our disposal.” ~Max Weber, “On Science as Vocation”

In his exposition on science as vocation, Max Weber insisted on a practical segregation between the commitment to rigorous sociological critique and what he considered an equally compelling obligation—active participation in political process. Nonetheless, as evidenced by the quotation above, Weber’s exploration of the relationship between his “scientific” and “practical” (that is, “political”) activities acknowledges and affirms many contemporary anthropologists’ sense of indeterminacy as they navigate between the falsely dichotomized realms of “applied anthropology” and “theory.” The lives and work of Sally Falk Moore, Joan Scott and Veena Das are unique examples of how academics have struggled and, in some sense, made peace with this tension. Before delving into their particular decisions, however, I found it helpful to briefly consider two essays to help orient myself to to broader disciplinary conversations on this issue: Scheper-Hughes’ call for “a militant anthropology,” and Rylko-Bauer et al’s more recent attempt to “reclaim applied anthropology.”

Scheper-Hughes’ 1995 strident essay, “The Primacy of the Ethical: Propositions for a Militant Anthropology,” decried anthropology’s secular soteriology of the anthropologist as “fearless spectator,” that is, “a passive act which positions the anthropologist above and outside human events as ‘neutral’ and ‘objective’ (i.e., uncommitted) seeing I/eye.” (419) Drawing on the Levinasian notion of the primacy of the ethical, a pre-epistemological, pre-linguistic encountering of the Other, and on Carol Gilligan’s ethics of care, Scheper-Hughes calls instead for anthropology as “witnessing…in the active voice,” positioning the anthropologist “inside human events as a responsive, reflexive, and morally committed being, one who will ‘take sides’ and make judgments.” (419) Scheper-Hughes claims that anthropology’s “theoretical abstractions and rhetorical figures of speech” are an example of humans’ “uncanny ability to hold terror and misery at arm’s length.” (417) Scheper-Hughes imagines the next generation of “barefoot anthropologists” who position themselves as “negative workers,” that is, who work persistently against the grain of hegemony, however that is to be defined. (420) In contrast, Rylko-Bauer et al (2008) adopt a much less polemical tone, tracing a history of what they define as “applied anthropology.” Pointing to historical examples like Sol Tax’s “action anthropology” and Cornell’s Vicos, Peru project, they insist on the possibility of pursuing “the ‘mutually instrumental’ goals of advancing knowledge and of being politically and ethically effective.” (185)

Of note, Rylko-Bauer et al, as does Scheper-Hughes in a later reflection on the aforementioned essay, indicate the work of Paul Farmer as exemplary of the agenda they hope to advance. Interestingly, Rylko-Bauer et al, in their “history of the present” in contemporary anthropology, arrive at Farmer’s work as the culmination of an “applied” current that diverged from a more theoretically driven current in the early 1940s-50s. (181-182) This genealogy ignores Farmer’s claim that his dissertation and resultant ethnography, AIDS and Accusation (1993), was in fact an attempt to respond to George Marcus and Michael Fischer (1986), who called for increased attention to history and political economy within interpretive or symbolic analyses. While improving on Scheper-Hughes’ haphazard and inconsistent gestures to more rigorous reflection (e.g., referring to anthropology’s subjects as, “hungry populations of the Third World that generously provide us with our livelihoods”), Rylko-Bauer’s history and subsequent proposal, thus, contain unsubtle blindspots, including a trivialization of the “handmaiden era,” which Feuchtwang (1973) identifed as the “colonial formation of British social anthropology”; not to mention the erasure of the origins and trajectory of the Manchester School, whose members were quite attentive to global political-economic processes; and of the simultaneously occurring work of Boas and Dubois—much of which was unequivocally “applied,” insomuch as its explicit objective was to disturb and change unjust discourses, practices and policies, but also in that both Boas (Boas 1974, 1940; Stocking 1968) and Dubois (Baker, 1998: 108-126) flexibly modified the methods, theories and sites of their investigations and interventions according to the contingencies of the historical moment. Both Scheper-Hughes and the exponents of “applied anthropology” considered here, on the other hand, have a pre-determined vision of the proper priorities and imperatives of anthropology, which causes them each to elaborate a simulacrum of process and indeterminacy (through personal experience of fieldwork, and disciplinary history, respectively) within teleological arguments, essentially closing off the possibility of interrogating the ongoing processes of working out their own positions in worlds that, upon close inspection, continue to be as indeterminate as ever. I find that Sally Falk Moore, Joan Scott and Veena Das, like Weber, more fully acknowledge indeterminacy in the relationship between their scholarly existences in academic worlds and their social existences in political worlds—and the un-givenness of each, independently, as well—and we have much to learn from them as we strive to struggle along and work through these tensions ourselves.

In her memoir, “Part of the Story,” Moore describes the contingency of her decision to go into anthropology in the first place. Indeed, trained first as a lawyer, it was an ethical response to her involvement in the Nuremberg trial that resulted in her decision to study anthropology at all. Furthermore, she refers to heated debates between visiting African students while she was at USC, and the heterogeneity of post-colonial African societies that it signified, as the inciting experience that led to her notion of the “semi-autonomous social field,” which she mobilized with supporting ethnographic evidence (1973, 1992) in a powerful critique of the ignorance in post-colonial African states’ statutory law of the fields of “customary law” that governed many communities.

In “Certainties Undone” (1999), Moore makes quite explicit her approval of ethnographic work that does “depart from an earlier, narrower anthropology” to mount indictments of the global political economy. Interestingly, in our class discussion with her, Moore’s criticism of Bornemann’s book took on a much more strident tone than the aforementioned published review. She railed against the weak linkages in Bornemann’s argumentation, paying particular attention to the absence of “evidence” for his broadest claims. Coombe, on the other hand, had compiled essays from contributors who were more explicit in acknowledging the limits of their “competence” as anthropologists, foregoing grand and potentially unsubstantiated claims, in favor of gesturing towards the larger processes in which the ethnographically described cases were embedded.
Her exhortation to our class to think about “the concrete,” resonates with her trenchant attack of the Comaroffs’ sweepingly lyrical piece on post-colonial violence in South Africa (1999). While I suspect much of this difference of opinion derives from their distinct modes of writing, and while her rejoinder reflects a shared attitude of concern with the Comaroffs regarding the people and societies they describe, we must recall that Moore used her training as both a lawyer and anthropologist during significant periods of her career to correcting the work of aid and development entities. It would behoove us to note her substantial experience in effecting change through observation and critique. Regardless of how we feel personally about her Manchester school-inspired prose and about the potentially ethnocentric, universalizing notion of “the concrete,” her exhortations serve as a warning to anthropologists who wish their knowledge-production to enable and assist the poor and otherwise marginalized: we must consider the criteria that define evidence and the modes of argumentation that are acceptable to powerful entities and individuals whose action(s)—or inaction(s)—can have dire consequences in the lives of our interlocutors in the field.

Like Moore, Joan Scott acknowledges the contingency of her engagement with history. In “Finding Critical History,” Scott does not describe her academic work as a natural evolution out of her committment to political engagement and activism: “Becoming a historian was not a consolation for politics, but a companion to it. Though not an inevitable one” (3). Nonetheless, as she explains viz. her engagement with social history as a young historian, her knowledge-production was intimately intertwined with her political engagements: simultaneous with her participation in the vibrant campus activist movements of the time, she and her peers “were rewriting some of the meanings of politics in these studies, with an eye to legitimating the movements of social protest that were taking shape around us.” (11)

At the same time, with her deconstructivist turn in her academic work, a similar turn seems to have occurred in her understanding of herself as historian, academic and social actor. In fact, here she might object that the notion of, “herself,” and the multiple aspects of “herself” that I identify, are mere discursive constructs: “I was not the origin of the gender concept, even among historians, but my paper was a site where several lines of thought converged. ‘Joan Scott’ is not, from this perspective, a person, but a place holder, a representative for a collective endeavor of which I (Joan Scott) was only a part.” (2) Nonetheless, despite the sincerity and modesty of her words, her distinction between the discursive “Joan Scott” who wrote “Gender: a useful category of historical analysis,” and the I (Joan Scott) reflecting on a career, does not somehow evacuate Joan Scott—without quotation marks—of a sense of political and intellectual agency. She may have been only “a part” of a collective endeavor, but she was a part of it, nonetheless, and an active part, at that.

Moreover, as reflected in the very effort to trace her intellectual trajectory, deconstructionism does not result in a refusal to describe her existence as that of a coherent, continuous subject through time. She does, of course, apply her Foucauldian scalpel to the notions of race (2007) and experience, but, while Scheper-Hughes, Rylko-Bauer (2008) and others might want to push Scott over the edge of “the postmodern chasm,” they (and we) would be remiss in not recognizing the imaginative thought—and thoughtful strategy—that her approach enables. In the conclusion to Scott’s interrogation of “experience” (1991), we could easily substitute “anthropology” for “history,” and “anthropologist” for “historian,” when she writes: “Experience is, in this approach, not the origin of our explanation, but that which we want to explain. This kind of approach does not undercut politics by denying the existence of subjects; it instead interrogates the processes of their creation and, in so doing, refigures history and the role of the historian and opens new ways for thinking about change.” (797) Indeed, it was the turn from social history to deconstructionism that opened up the space for productive experimentation with ideas—a theoretical opportunism of sorts—that has permitted Scott’s versatile movement between political-economic, post-structural and, most recently, psychoanalytic frameworks according to the exigencies of her work at the given moment.

Again, “militant,” “applied” and even “processualist” anthropologists might counter that academia’s theorizing into existence of “new ways for thinking about change” does not necessarily translate into solidary intervention that makes concrete changes in situations marked by material poverty and physical violence. In responding to the criticism that academics engage in purposeful purposelessness, Scott replies: “Critique is not criticism, nor the proposal of alternatives. … The point of critique is to make visible those blind spots in order to open a system to change. Not to replace what is with a fully formulated, ideal plan, but to open the possibility for thinking, and so acting, differently.” Scheper-Hughes’ problem with “post-modernism,” which Scott finds so productive, is uncertainty. Scott is not threatened by uncertainty; rather, she accepts it and chooses to see contingency and indeterminacy as the conditions of change. Indeed, this is precisely what Parité and The Politics of the Veil are about—the productive use of destabilization of categories to attempt to make change.

Nonetheless, the vehemence of Scheper-Hughes’ attack on “post-modernism” and Scott’s defensiveness—evidenced in the last quotation by her reliance on a somewhat Kantian subject who can change actions according to changing thought—make me suspect that something more personal is at stake. Scheper-Hughes, horrified by the deconstruction of race and ethnicity in South African university classrooms while those same categories mark who dies and who lives in the bantustans, relegates academic discourse, at least in South Africa, to an almost violent irrelevance (417); Scott, on the other hand, sees teaching (in a classroom, no doubt) as a form of activism: “the transmission of knowledge for a purpose beyond itself, a purpose animated by caring relationships and politics (shaping the way kids thought about the world in order to make it a better place) (2). Indeed, just as Scott was able to do at various points in her career, teaching students, shaping their thinking and helping them to form charismatic communities of resistance is social action, and, at universities where today’s undergraduates will be tomorrow’s deciders, a particularly effective one at that.

We can extend Scott’s line of thinking by taking a cue from her own theoretical orientations: to what do “application,” “activism” and “theory” refer, anyway? “Application” describes even the most self-contemplating “anthropology”—the anthropologist observes and writes, or otherwise produces, maintains and applies knowledge, if not in order to fulfill some very deep and individual yearning, then to pay the bills and get funding for the next adventure. Scott has already shown us, above, that “activism” is discursively deployed and can be discursively reinterpreted. What is left of “theory,” then, if anything? Can “theory,” “explanation,” and “knowledge,” do things?

Here, I find useful the idea of “nextness” that Das (2007; 78) extrapolates from Cavell in describing another dichotomy, the relation between norm-setting legislation and transgression. Noting that Foucault reverses but nonetheless maintains that basic dichotomy in Discipline and Punish, Das proposes in its stead a “nextness”:
Thus, instead of imprisoning metaphors to capture the relations between outward criteria and inner states, one may think of these as lining each other, of having a relation in which they are next to each other but joined in the way in which legislation and transgression are joined. (78)

Cast in terms of “nextness,” the relationship between theory and application or activism takes on new meaning. Indeed, this nextness is similar to the notion Das describes of “abstract questions,” or theory, as a shadow: “concrete relations that we establish in living with others are like shadows of the more abstract questions—that is, we learn about the nature of the world in the process of such living.” (4) What if relation of theory, explanation, the act of writing, to application and activism is not a simple dichotomy? What if, in the case of anthropology, the practices of reading and writing, and the application of knowledge towards social action, are thought of rather as lining each other, next to each other but joined? In a sense, Das is suggesting that when the limits of either action or writing are transgressed, we must resort to the other.

When Das describes “witnessing” as exemplified by her interlocutors’ folding in of poisonous knowledge in the descent in the everyday, made manifest in reinhabiting the world through a gesture of mourning (78), she is also describing her own anthropological practices of “witnessing.” Indeed, Das parallels the gesture of mourning with Wittgenstein’s gesture of waiting when his spade, as indicative of a pen, is turned: “For me the love of anthropology has turned out to be an affair in which when I reach bedrock I do not break thorugh the resistance of the other, but in this gesture of waiting I allow the knowledge of the other to mark me.” (17) Writing, and theory, are the anthropologist’s descent into the everyday, the way that Das folds in the poisonous knowledge of others’ pain and suffering into her everyday lifeworld.

The metaphor of the eye, also, is a useful corrective to Scheper-Hughes’ simplistic reduction of the anthropologist to the observing I/eye. If, as interpreters of Wittgenstein posit, “the relation of the subject to the world is like that of the eye to the visual field—the eye is not itself in the visual field that it defines,” Das writes: “…the experience of being a subject is the experience of a limit. … It is Wittgenstein’s thought that the subject is the condition of experience.” (4) Simply because the observing I/eye does not behave according to Scheper-Hughes’ particular brand of anthropological militancy, the anthropologist is not reduced to a disembodied, impassionate camera. Das asks us if there might be an alternative, that is: “to not simply articulate loss through a dramatic gesture of defiance but to inhabit the world, or inhabit it again, in a gesture of mourning? It is in this context that one may identify the eye not as the organ that sees but the organ that weeps.” (62) The observing I/eye is the same I/eye that weeps. Incidentally, the I/eye is also the one that reads—just as the myth of the dispassionate observer is over-turned, the possibility that reading theory and ethnography can expand empathic vision means that the production of written texts is hardly without positive social impact.

Thus, in distinguishing her mode of anthropology from Scheper-Hughes’, Das poses an alternative “public role for anthropology” that integrates theory and practice. She writes: “To hold these [disparate] types of words together and to sense the connection of these lives has been my anthopological kind of devotion to the world.” (221) This anthropological devotion is intertwined with her social action and activism—indeed, her way of doing anthropology responds to the exigencies of her activism in a way that “militant anthropology” denies.

Anthropological practice is reading and writing, but also being-in-the-world and engaging in social action. In concluding this essay by thinking with Das, I hope to have shown that this dichotomy is a false one. Alongside what I have learnt from the works considered here and others about the relationship between theory, activism and application, I have, as Das puts it, found myself holding their words together with the wisdom—however mere, as all eleven might protest, or not—that I have been privy to in accompanying the members of “my” cohort through this year. And it is from these experiences of reading, writing, and being together that I have learned that anthropology, for many of us, is little more than an anti-heroic attempt to exist, think and act more meaningfully, more socially, and more fully, whatever form this takes in each individuated life-work.

Citations:

Baker, Lee. From Savage to Negro.
Boas, Franz. Race, Language and Culture.
Boas, Franz. "On alternating sounds."

Comaroff, J and J Comaroff. "Occult economies and the violence of abstraction."

Das, Veena. Life and Words.
Farmer, Paul. AIDS and Accusation.

Marcus, George and Michael Fischer. Anthropology as Cultural Critique.

Moore, Sally Falk. As noted in text.
Rylko-Bauer, et al. "Reclaiming applied anthropology."

Scheper-Hughes, Nancy. As noted in text.
Scott, Joan Wallach. The Politics of the Veil. Parité. And otherwise as noted in text.

Stocking, George. "Franz Boas and the culture concept in historical perspective." In: Race, Culture and Evolution.

Weber, Max. From Max Weber.

"financial crisis"

2009-04-24T21:31:00.000-07:00

the current "financial crisis" can only be understood as such from a particular positionality.

from other positions, financial crises happen every few coffee seasons, every few births.

the current situation, then, represents but an acute exacerbation of a financial system based on everyday crises.

naysay

2009-04-11T15:53:00.000-07:00

too many people, too often respond to a sense of urgency with words of false comfort and feigned wisdom.

even if i am young, that's not the only reason to feel impatient about unnecessary suffering.

even if i am idealistic, that's not the only reason to aim for the highest standards of care for the indigent sick.

The Problem

2009-03-31T00:36:00.000-07:00

“Solito.” “Alone,” in Spanish diminutive. Speaking from his perspective as a father, health promoter and rural peasant from an indigenous hamlet in Guatemala, a friend describes a pathetic, oppressive feeling of abandonment.

He’s just recounted the entirely preventable death of a neighbor’s malnourished child during a rotavirus outbreak. Child malnutrition is rampant among impoverished Guatemalan indigenes. The national prevalence of chronic malnutrition is the highest in the hemisphere. In the poorest communities where I work, chronic malnutrition under 5-years-old exceeds 60%; infant mortality estimates reach 120 per 1,000 births, about 4 times the already appalling national rate.

The terrible irony is that my colleague’s community of 300-500 households serves as the target of no less than 6 “development” entities that address healthcare, poverty and food security. We foreigners are a common sight here, towering over everyone else. Thus, the persistence of hunger and needless deaths begs the question: how does “development” affect the “target population”?

In part, we hope to help by providing access to Pierre Bourdieu’s, “cultural capital,” which in turn can mobilize economic Capital for “development” and “autonomy.” But can knowledge be turned to power, if childhood malnutrition influences academic attainment and physical labor capacity? Extrapolating on Bourdieu, of what use is cultural capital to people who are sapped of biological capital through illness and death? What do “individual liberties” and “community autonomy” mean here? Does blatantly unnecessary suffering affect “development” discourse and practice?

Regarding the suffering of others also might affect us in a more personal sense. For example, how deeply and durably is the “development” worker (and medical student) affected by the experience of examining a jaundiced, tachypneic newborn and telling the parents—who are friends and collaborators—that their baby is septic and could die?

Thus, two challenges emerge. First, what interventions would make children survive and grow? I believe that profound structural change is required: titles to arable land, potable water systems, food security and a full range of medical interventions commensurate to the severity, prevalence and distribution of disease. To achieve these things, those with more power must be convinced to mobilize it. Here, the second challenge becomes rate-limiting: is it possible to affect the ethical response of “development” workers to such situations?

Here, Sally Falk Moore’s methodological focus on articulating social fields permits a salutary, albeit ambitious, parsimony. The challenges presented above reflect two interpenetrating social fields, inhabited by “us” (“development” workers) and “them” (“the community,” “the poor,” or “the Maya”). Our two challenges fuse into one: faced with the disheartening and enraging stubborness of the material world, how might we muster an equal and opposite stubborness in struggling to embody and implement hopeful imaginaries of humane social realities? Can we operationalize and institutionalize the radical forms of pragmatic solidarity that seem eminently appropriate? By using our understanding of these social fields and their points of articulation, we can release the potential energy in the intersubjective spaces inhabited by development workers and community members, thereby engendering collaborative and transformative social movements.

A challenge for us

2009-03-10T20:57:00.000-07:00

A baby died in Quixayá three days ago.

V thought it was rota, as there is an outbreak right now. Diarrhea and vomiting for 2-3 days, so he said they needed to go to the clinic ASAP.

But the mother is a patoja and doesn't have a esposo, she doesn't have any support. She said, thank you for your advice, but I don't have pasaje. So V out of sincerity of his heart gave her pasaje from his own wallet.

The patoja took the baby right away, but it was too late.

Rute' Gerardo - Patricia Cuj Xet'

2009-02-10T07:00:00.000-08:00

Ruchaq' Gerardo rub'i Erick, xutaq chwe jun rutzil chi nuwach iwir chaq'a roma kite' ri ka'i. Kite' la yawa', la ixoq xkam pa noviembre kan, roma ri k'atan chi rij, xtzoqpin, xtzoqpin sib'elaj ronojel q'ij, xkikot, xkikot enter ruchakul ronojel aq'a.

Erick xa xura'ij xuya' jun rutzil chi nuwach richin ri Q'ij Kichin ri Taq Achib'ila' (Día de la Amistad). Xutaq jun rufoto chwe. Pan enero xiq'ax akuchi k'o wi ke la Campo Santo pa San Lucas chin xinya' wutzil chire, chin xinya' kan jun k'otzij richin. Wakamin ninna yirutz'u', man wetaman ta aj akuchi wi, pero ke ri ninna.

Y ninb'ij chwe chi nutz'u nuwach, ntze'en oku' najin nub'an chwach qa xel el pa Ruwach Ulew, taq najin yiq'ax rik'in, jantape nkanaj pa jay, nuxlan pa ch'at. Yojtzijon b'a chik pa ruwi' ruk'aslem, y najin ninb'ij chire chi k'o chi nwa b'a chik, y niqatz'u jub'ey chik rik'in Gerardo ri taq raq'om, achike aq'om najin nuqum wakamin, achike aq'om utz chi ruwach, achike aq'om man kan ta utz wakamin, achike man k'atzinel ta, yojtzijon chik.

Ninna chi yirutz'u y retaman chi itzel xinna roma rukamik, roma man xqato' ta chanin b'a chik, retaman chi sib'elaj sib'elaj yib'ison, yirutz'u y retaman. Man wetaman ta achike roma, pero ninna chi nutz'u ri ya pa nuwach, nuk'oxaj chi najin yinoq' wakamin. Ninya' jujun tzij chire, yitzijon b'a pa chab'al, nink'utuj chi nuku' numak, y ninmatyoxij chin xutaq la wuj chwe.

Y ninb'ij chwe chi ntze'en chik, jeb'el ntze'en, junam oku' xtze'en ojer. Ninb'ij chi man nrajo ta chi tan itzel ninna, pero kowin ninb'ij ke ri? Man wetaman ta, pero ninb'ij chi man nrajo ta xa yib'ison roma ri xb'a el pa Ruwach Ulew. Man wetaman ta akuchi k'o wi wakamin, pero ninna rutzil wichin.

Matyox chawe, nana. Ninmey awach sib'elaj. Ninyab'ej chi utz ab'anon, ki' ak'u'x, utz nanna achakul, awanim, mas tranquilo yawar ri taq aq'a wakamin. Utz kib'anon konojel awach'alal, ri Neitan xuchop jujun taq tzij pa chab'al yan, ri ka'i ne'y ixtani jeb'el, jeb'el xintz'u.

Yiq'ax awik'in jub'ey chik chanin. Tachajij awi', nan.

Matyox chawe, matyox, matyox. Ke ri k'a.

Jun nimaläj ixöq, nimaläj iyom.

2009-02-02T23:02:00.000-08:00

Tatz'u.

My first term paper in anthropology...

2008-12-19T11:25:00.000-08:00

Theoreticians aside, the section, "Exposition: The carbuncles and the coat," will prove least stupor-inducing. Unfortunately, I ran out of time with the exposition and hope to develop this further in the future. In particular, I did not get a chance to discuss in greater depth: Marx's relationship with his ever-more depressed and anxious wife, his relationship to the things out of which he constructed himself (i.e., his coat), the influence of charismatic authority in the intellectual-financial Marx-Engels dialectic, his epistolary near-falling-out with Engels, his embodied experience of the death of eight-year-old son, his embodied experience of financial instability, and his volatile relationships with contemporaneous leftist interlocutors. I also would have liked to address some of the more common psychoanalytic connections between Marx's childhood and university experiences and relationships to his moral experience as an adult in London.

Karl’s Coat and Carbuncles
Shom Dasgupta

"You correctly observed from my last letter that the state of my health has improved although it fluctuates up and down from one day to another… Unfortunately I am continuously interrupted by social troubles and lose a lot of time…even my stock of paper will have run out by Saturday."
London, 7 August 1866, letter from Karl Marx to Friederich Engels (Raddatz 1980)

Introduction: Theory sans thought; citations sans suffering
Just as in clinical medicine, I have noticed a tendency in myself and in my fellow social scientists in training to hack at immense, often overwhelming, volumes of information with reductionist scalpels: just as “jaundice” prompts me to reflexively scan a medical text’s table of contents for “hematology” and “hepatology,” I have found myself cataloguing salient social theoretical concepts according to author, book title and school of thought. Perhaps this is not problematic in and of itself and, indeed, represents a necessary step towards deeper engagement and understanding. The fact remains, however, that these “buzz words” are referenced and deployed in abstraction from their social context. Whatever the reason for this frugality of thought (at best, convenience, more probably, laziness), the concepts and their expositors become reified, metonymic pellets of language. This is not uniformly the case, of course, and at times we are attentive to the impact of contemporaneous interlocutors or the political-economic context on a particular thinker. Even in these cases, however, the charge of alienation holds fast, I think, as we rarely investigate the local moral experiences and the material, phenomenological worlds that were constructed, inhabited and transited by the person who wrote the text under consideration.

Peter Stallybrass (1998), in his essay, “Marx’s coat,” reflects on this alienation of concepts from the human thought, intellectual labor and material resources required to communicate them, recounting Hans Christian Andersen’s story, “The Shirt Collar.” In the story, the reader learns of an unhappy shirt collar who, after several proposals to fellow garments and appliances at the laundry, decides to foresake dreams of vestuary marriage, submitting himself at the papermill to become the very page on which the story is printed. As Stallybrass notes, this twist restores “the literal matter of the book” to what is increasingly an “‘invisible’ medium joining the immaterial ideas of the writer to the immaterial mind of the reader.” (Stallybrass 1998)

This lesson is particularly striking in the case of Karl Marx, whose legacy to contemporary social science, as we learn in the social anthropology Proseminar, is a thoroughgoing materialist approach to understanding society and history. I, for one, have discovered that I am guilty of reifying the printed record of his philosophy: I assumed an expansive tome like Das Kapital could not have been researched and written without a great deal of financial security. As evidenced by the citation that introduced this essay, however, Marx’s household was often on the brink of bankruptcy, and, in fact, Marx expressed concern that he would soon be out of writing paper during the very months in 1866 during which he was finalizing the manuscript of the first volume of Das Kapital. (Raddatz 1980) How do we ignore the fact, as noted wryly by both Marx and his mother, that these intense reflections on money were written by a man who regularly ran out of it?

In any case, my objective here is not to demonstrate that Marx’s philosophy was ideological superstructure erected on the basis of his experience of financial instability. Often, it seems that such investigations have the unsympathetic objective of mobilizing social construvist arguments to make a political point about the mutability of Marxian political-economic critiques. For me, it is primarily admiration for his intellectual legacy that has drawn my attention to Marx’s lived experience. Not only am I interested in what I stand to learn from Marx’s life about “muddling through” my own moral experience (Kleinman 2006; Kleinman 1988), but I was also astonished to learn of the chronic poverty and suffering that seem to have characterized the Marxes’ life as refugees in London. My investigation, then, represents a very personal endeavor, as Lévinas exhorted, to “acknowledge and affirm” (Kleinman 2006) the Other in the form of a thinker whose ideas I find useful and engaging.

However, lest the primacy of the ethical proscribe any epistemological production whatsoever, and lest acknowledgment and affirmation devolve into shallow sympathy or voyeurism, it behooves us to establish a theoretical framework for understanding moral experience and local moral worlds before contemplating the details of Karl Marx’s lived experience of financial hardship, illness and suffering.

Theory:Grotesque ideas more wonderful than “table-turning”
The misfortune, instability and suffering that permeate accounts of Marx’s adult life exemplify Kleinman’s (2006) position “that dangers and uncertainties are an inescapable dimension of life.” Moreover, it is in the face of danger and uncertainty that meaning is produced and experienced, and that moral lives are made. Situations that threaten what really matters to an individual or a community pose difficult questions about how to life a moral life. Such threatening situations are a routine occurrence in most people’s moral experience but can become particularly acute or critical in certain instances.

Immediate threats can take on unparalleled acuity when they become manifest at the intimate level of the body. (Kleinman 2006) The experience of illness, both acute and chronic, demonstrates poignantly the intimate inseparability of corporal and moral experience. We discover and monitor both our bodies and inner worlds, not through given or a priori mechanisms, but via social constructs based on previous empirical experiences. Illness and other bodily phenomena are interpreted and imbued with meanings that respond to both strong emotions and interests. Indeed, the experience of chronic illness comes to be so intimately intertwined with the patient’s life that her illness narrative becomes a means of narrating her life history. (Kleinman 1988)

Through multiple exacerbations of chronic illness, the patient begins to lose her unexpressed trust in the continuity and resiliency of her body. This feeling of vulnerability, of diminishment, is only intensified by the incredible time, energy and financial resources that are absorbed by medical tests and interventions, the maintenance of remission, and intermittent illness episodes. The sufferer of chronic illness becomes hypervigilant, continuously reading the signals of her body and environment in order to prevent or prepare for an exacerbation. (Kleinman 1988) The daily struggle to cope with chronic illness can be described as “anti-heroic.” (Kleinman 2006)

The understandable exhaustion and frustration that result can lead to resigned pessimism about the possibility of controlling the illness. On the other hand, the patient may turn to moral, religious or medicalized perspectives and/or embody ritual behaviors supplied by her culture in order to make sense of the new situation. Often, patients will experience their illness in dichotomous ways: as illness experience qua experience or as the experience of an observing self, in which the body-self is alienated, or becomes a vehicle for transcendence or a source of embarrassment and grief. These two modes of illness experience generate a secondary, unresolved and dynamic tension between immense self-knowledge, and myth-making via cultural mechanisms, the latter of which serve to fill the void of alienation between the observing self and body-self. Ritual behaviors and culturally informed myth-making integrate feeling, thought and bodily process. (Kleinman 1988)

The aforementioned integration of “subjective” (feeling, thought) and “objective” (bodily process) aspects of illness experience supersedes what has been termed the “representationalist flaw” in past understandings of the body. According to Descartes’ duality, the mind is subject and the body is relegated to the status of object: ontologically, the body is a thing upon which worldly phenomena can be inscribed; anthropologically, it is a thing to observe and represent. (Csordas 1994) While Foucault’s conception of bio-power proves useful in capturing the immanent and generative modes of modern ordering and discipling of bodies, it fails to concede agency and subjectivity to the body. (Turner 1994) Taylor, Ricouer and Jackson all reinvest the body with agency. Csordas suggests the phenomenological term “being-in-the-world” to describe the existential, conditional immediacy that distinguishes a methodological focus on “lived experience” as opposed to representation. (Csordas 1994) Lyon and Barbalet have suggested another, perhaps more directive methodology of concentrating on emotion as both social and embodied phenomenon: affect is conceived as the interpersonal, public manifestation of emotion; and the body is conceived of as “haptic,” engaging in active sentience of the world by integrating voluntary movement and touch-temperature-pain-proprioception. (1994)

In addition to illness, another instance that can force a particularly acute and critical reevaluation in the individual’s moral life occurs when she becomes aware of something ethically wrong in the moral environment. A sense of responsibility for broad social-historical trajectories raises the stakes in the already opaque struggle to live a moral life. (Kleinman 2006)
Ultimately, the inherent danger and uncertainty of the world make for an unequal struggle that can be “fierce and desperate.” Nonetheless, the individual can create or imagine mechanisms to avoid fatalism, and these mechanisms become particularly salient in the careful negotiation of “gray zones” where the difference between sustaining and jeopardizing a moral life becomes exceedingly thin. The creativity and imagination of the individual in gray zones are crucial to legitimating new, “anti-heroic” ways of living in the world, regardless of whether large-scale social change results. (Kleinman 2006)

Thus, living a moral life entails a passionate anxiety arising from the aspiration to remake oneself and one’s moral world in response to convictions about what should really matter. Kleinman posits that the requisite interrogation of one’s moral life can provide a kind of “quiet liberation.” (2006) It is also worth noting, however, that this self-induced interrogation of one’s moral experience and moral environment is circumscribed at some point to ensure self-preservation and to avoid the paralysis of nihilism or excessive relativism. (Kleinman 2006)

Implicit in the foregoing outline of the moral experience is a degree of individual agency, however constrained by regnant social structures. This in turn implies a relative social constructivism according to which a dialectical relationship obtains between social structure and individual agency. Bourdieu’s concepts of social space and symbolic power illuminate this dialectic further: structures are somewhat arbitrary and historically contingent, and individuals have some capacity for shaping structures. Nonetheless, “this in no way means that one can construct anything anyhow, either in theory or in practice.” (Bourdieu 1989)

This last point has some important implications. The social space maps to geographic space, and symbolic capital, when acknowledged, corresponds to cultural or economic capital. That is, although there exists a plurality of possible structures, there is an elective affinity between permutations of symbolic hierarchies and material reality. Furthermore, the particular structure obtaining in a particular society at a particular moment is presented as “commonsense” and can come to powerfully shape an individual’s schemes of perception and appreciation. The individual’s habitus, including her cognitive structures, is essentially the internalization of structures from the world. (Bourdieu 1989) Put slightly differently, perception, the basic mode of gathering data for living a moral life, is “apperception.” (Boas 1889) The official currency of particular symbolic structures renders language into discourse, categorization (kathegorein: to accuse publicly) into symbolic violence. (Bourdieu 1989)

The appearance of an official, static “commonsense,” is, however, just an appearance. The potential for symbolic violence should not obscure “the objective element of uncertainty,” or the semantic, temporal elasticity and interchangeability of the characteristics of official “commonsense.” Symbolic struggle, then, can occur, and does so via either the reappropriation and deployment of components of “commonsense” (“the objective side”) or the direct contestation of those components (“the subjective side,” which amounts, in Bourdieu’s phrasing, to “a struggle over the legitimate exercise of…the ‘theory effect’). The symbolic effectiveness of any attempt at “world-making” through symbolic struggle is mediated by the “power of constitution” (which depends on access to symbolic capital) and the “power of consecration/revelation” (which depends on the homology between symbolic and material reality). (Bourdieu 1989)

Bourdieu’s contribution to Kleinman’s conception of moral experience and moral worlds assumes relative stability and continuity in a society’s structures. As previously described, in this framework, symbolic struggle can attack regnant components of commonsense but will depend on symbolic capital and/or symbolic-material homology. A less conservative alternative to Bourdieu’s conceptualization of the “theory effect” is suggested by Weber’s notion of “charisma.” Charisma emerges in extraordinary situations to meet extraordinary needs. Its scope and longevity are self-determined (in that it is entirely dependent on the enactor of charismatic authority and does not harden into an iron cage), and its effectiveness is attributed to “the virtue of the mission.” (Roth 1978)

As with Bourdieu’s description of the process by which symbolic capital is accumulated (and symbolic power thereby deployable), charismatic authority requires both that the charismatic leader prove himself to his followers and that the followers recognize the leader’s charismatic authority. The accumulation of symbolic capital, however, is described as a relatively long process of gradual institutionalization of authority; this more closely resembles Weber’s bureaucratic authority. Charismatic authority is, by definition, extra-institutional and arises spontaneously. It exists in the material world but is decidedly not of it; that is, it is inherently anti-economic, and, indeed, its continued appearance of authenticity and vitality depends on genuinely communist, non-individualist relations to material resources. It is naturally unstable and revolutionary: it can dissipate as quickly as it emerged, and its radical restructuring of society occurs not from without (e.g., as with rational bureaucratic organization) but from within individuals (e.g., via “central ‘metanoia’ of the followers’ attitudes”). Charismatic authority can become more stable and permanent through institutionalization; the flexibility and fluidity of charismatic authority facilitates the blending into an amalgam of extant institutions of traditional authority. The instability of charismatic authority means that it often co-exists, or potentially co-exists, with a more stable patriarchy or bureaucracy that carries out ordinary functions of society. (Roth 1978)

Exposition: The carbuncles and the coat
In the post-revolutionary years as a semi-permanent refugee in London, Marx’s experiences of illness, financial hardship, political research and writing, and domestic tension were all embedded in rich, interconnecting webs of significance.

Of the several illnesses that plagued him intermittently at this time, the one that most severely interfered with his normal daily functioning was what he and his physicians referred to as, “boils, furuncles, and carbuncles.” These lesions erupted continuously, distributed in the axillae, inguinal, genital, perianal and suprapubic areas, with at least one particularly severe, acute episode per year. The eruptions formed into painful inflammatory nodules and suppurative sinus tracts. This illness persisted for at least twelve years, beginning as early as 1862 and continuing through his most intense period of research for Das Kapital. (Shuster 2007) He received treatment from a number of physicians and underwent therapy at spas, as well. He was most commonly treated with oral arsenic preparations, topical compresses and surgery as needed. Concurrent with these carbuncles, Marx began to experience an inflammatory condition of the eyes that at times forced him to curtail his reading and writing. (Raddatz 1980)

Marx’s illness would leave him bedridden, as he would lament to Engels in letters written from a supine position because he found it to painful to sit up. (Raddatz 1980) He himself noted an impact both on his output and the quality of his writing, and Engels noted a stylistic sharpness when he was in the midst of a relapse. (Shuster 2007) Although these repeated episodes were debilitating, and although its relentless progression was accompanied by a growing disillusionment with himself and the world (for its failure to fulfill his revolutionary predictions), he struggled through pain and even avoided his arsenic preparations, which he felt made him temporarily dull, in order to complete his book. (Siegel 1978)

The progressive nature of the disease certainly caused Marx to wonder, “Why me?” His explanation was that his proletarian life in a proletarian country debilitated him through physical fatigue, malnutrition and inadequate sanitation. Both his mistrust in his evidently incompetent physicians and his inability to turn to religion required a moral explanatory perspective on his illness. This was a “proletarian disease,” and the only way to cure and prevent it would be to end his “night work,” so crucial to his endeavor to finish his book. Indeed, he, his family members and other interlocutors all understood his persistence as a sacrifice of his body for a greater cause. (Siegel 2007) His illness experience, then, became one with the narrative of his life history.

It appears that Marx did experience his illness dichotomously. Above, we saw that his experience of the carbuncles qua experience was one of sacrifice requiring moral fortitude. Nonetheless, in a letter addressed to Engels, he wrote:

"…I picked up a sharp razor, a memento from our dear Lupus, and cute the swine with my own hand…The rotten blood flowed, or rather squirted up high, and I now regard this carbuncle as buried even though it still wants some nursing." (Raddatz 1980)

The comparison of the carbuncle, still a part of his body, to an animal is evidence of a sense of alienation of the observing self from the body-self. His self-adjudicated sacrificial persistence despite his illness, at other times, becomes a corporal performance of his sense of self, an immanent “being-in-the-world.” (Csordas 1994)

Jerrold Siegel, in his psychohistory of Marx, draws suggestive parallels between his subject’s emotional state and his bouts of carbuncles. He posits that this disease was a somatic manifestation of self-directed hatred and anxiety over what Marx perceived as a failed enterprise, Das Kapital, and over the failure of his predictions about the future course of social change. (1978)

While many of Siegel’s analyses are insightful and responsive to Marx’s local moral world, this particular explanation, with which Siegel concludes his final chapter as a kind of victorious flourish, seems more like the product of literary fantasy, at best, and tendentious, unsympathetic and dishonest posturing, at worst. Indeed, a recent investigation by dermatologists revealed that, on the basis of a historical reconstruction of Marx’s clinical scenario from his correspondence with friends and family, he most likely suffered from hidradenitis suppurativa. (Shuster 2007) This debilitating condition is exceedingly difficult to treat, requiring a number of interventions that were not yet available in the mid-19th century, and is recognized for causing self-loathing, low self-esteem and depressed mood. (Shuster 2007; Klaus and Johnson 2005)

In any case, besides slowing his progress on Das Kapital, Marx’s chronic illness was also directly related to his family’s financial hardship. On several occasions, he spent several weeks sleeping at the homes of close friends to avoid his physicians when they would visit his family’s flat in Soho to collect a debt. (McLellan 1973) Ironically, despite numerous spies’ reports of his family’s quarters as “proletarian” or “subproletarian”, Marx and his wife Jenny accumulated annual gifts, loans and donations of cash from friends, family and supporters that should have been enough to provide them with a very comfortable lower middle class lifestyle. (Stallybrass 1998; McLellan 1973) Engels, for one, responded promptly to Marx’s constant requests—and even demands—for financial support, which were usually expressed in the urgent tones of a man hiding from bill collectors. In fact, when Engels sold his share in his cotton mill, he apportioned £350 from his pension as an annual stipend to Marx, continuing to supplement this generous amount upon request. (Raddatz 1980)

Nonetheless, the Marxes habitually fell into debt, and not entirely without consequences. Jenny Marx, in letters to a friend, told of an occasion when her husband was arrested for suspicion of theft upon trying to pawn her heirloom silver, emblazoned with the noble Argyll family crest. On another occasion, she describes, clearly mortified, the entire family’s unceremonious eviction from the flat they had been renting. (McLellan 1973) In letters following the death of their newborn daughter, Jenny lamented that had they not been utterly penniless at the time, they might have been able to afford either the physician’s fees or the therapeutic holiday to the seaside that would have saved the child. (Siegel 1978)

Of particular importance to Marx, too, their financial instability required him to put his coat in and out of pawn frequently; without his coat, however, he would not be granted access to the reading room at the British National Museum, where he conducted his daily researches for Das Kapital. In fact, on at least two occasions, he wrote to Engels that he was forced to pawn his coat in order to purchase writing paper for his articles for the New York Daily Tribune, the remuneration from which he would use to begin to pay debts, such as a cumulative doctor’s bill of £26, the equivalent of several months’ rent in their flat at the time. (Raddatz 1980; Stallybrass 1998; McLellan 1973)

An insidious flow of coats, carbuncles and cash seemed to whirl around Marx and his family during these chaotic years. Beyond the simplistic explanation of poor budgeting, what was behind this perpetual, indeed extremely harmful, overspending and indebtedness? What, exactly, was at stake? And moreover, why did Engels continue to rescue Marx from his family’s financial misadventures, even after Marx proved himself unable to respond compassionately (or draft a convincing apology, for that matter) to his “greatest friend” after the death of his partner of many years, Mary Burns? (Raddatz 1980)

With respect to the Marxes’ motivations, a number of possibilities have been suggested. In order to appear trustworthy and receive sufficient credit with the butcher, the baker, the cheesemonger, the grocer, and others, a certain level of outward bourgeois appearances and accoutrements were required. (McLellan 1973) That is, the family adopted or performed, through clothing and objects, a habitus identifiable as bourgeois, thereby conferring upon themselves a level of symbolic capital consonant with the credit they needed to maintain a bourgeois lifestyle. This line of argumentation is not as tautological as it appears: a diachronic shift in the family’s standard of living, coincident with a string of small inheritances, can be identified between their residence in Soho and North London. So the Marxes used temporary injections of money to permanently raise their average monthly expenditures. (McLellan 1973) According to Marx, his family life had him “up to the crown” in “this bourgeois crap,” and he often complained to Engels that his wife was not as resistant as he, and that she frequently became bedridden for “social” or “bourgeois” reasons. (Raddatz 1980) Marx’s complaints notwithstanding, the family moved shortly after each death of a child, and their extravagant spending may have represented an attempt to achieve progressively more salutary standards of living. (McLellan 1973)

Siegel provides a much more intriguing explanation. The maintenance of outward appearances was absolutely necessary to mask internal strife. While Jenny commented on occasion that she enjoyed the relative anonymity of London, her family was prominent among the French and German émigres/refugees, and her husband’s ascension as a polemical political figure made them an object of the scrutiny of spies, reporters, politicians and others. Marx was publicly attacked by enemies on the left and the right, in England, Germany, France and the United States. (Siegel 1978) But why would the Marxes go to such lengths in their dissimilation? Siegel proposes, albeit without extremely compelling evidence, that the maintenance of appearances became especially pressing in the context of public rumors—and Jenny’s discovery—that the newborn child of Helene Demuth, the Marxes’ servant, was the son of Karl Marx.

Putting aside the conspiratorial nature of Siegel’s hypothesis, and recognizing the fact that this possibility fits well into his broader project of demonstrating Marx’s irrationality and corruptibility, this consideration does bring up an interesting point. In the close quarters that they sometimes inhabited in London, how did Marx feel when it became evident that his wife had discovered his illicit relationship with Helene, who lived in their flat and had worked as a younger woman in the von Westphalen’s house before Jenny’s betrothal? Given the evidence, it is clear that Engels, Marx and his daughters made great efforts to suppress this embarrassing secret; for example, the collection of Marx and Engels’ correspondence to one another contains no letters dated between two weeks before and two weeks after Helene Demuth gave birth to her son. (Siegel 1978) To what degree can we understand Jenny’s overspending as an effort to sublimate her disappointment with the life she had been forced to leave by the man she fell in love with as a young woman? And might we understand Marx’s increasingly neurotic and strangely unproductive obsession with his research and writing as an attempted escape from a historical reality and moral environment so at odds with the ineluctable world whose evolution he had so confidently predicted only a few years before? To what extent was his “bookworming” (Wheen 2000) a return to the safer, rarefied philosophizing with which he had begun his career as a scholar? Did Marx see in his book the potential to redeem himself and regain some of symbolic and economic capital he had squandered since 1848?

With respect to Engels’ motivations for continuing to rescue Marx from bankruptcy, it is noteworthy that although the former, heir to a wealthy mercantile family, may have identified an opportunity to accumulate symbolic capital among the international left through his friendship and collaboration with the latter, Engels nonetheless distanced himself repeatedly from Marx’s publications. He commented that he considered it silly to keep his name on The Holy Family, which Marx had singlehandedly exploded Engel’s brief treatise of twenty pages into a monstrosity; similarly, Engels was very reluctant to write reviews to advertise Marx’s essays and books. Nonetheless, he obsequiously supported Marx, tolerating his at times personally offensive behavior.

To understand the Marx-Engels dialectic, it is helpful to recall the stunning presence that Marx supposedly had about him. Indeed, members of the Young Hegelian’s Doctor’s Club expressed relief when Marx began his rebellion against Hegelian philosophical spiritualism: they felt that they could think for themselves again, no longer overwhelmed by that “ox’s head” that was the domineering genius of Marx. Engels wrote superbly, true, but he originated the detailed historical-materialist analysis that would cause future generations to invoke Marx’s name and not his own. How did Marx, having produced only a few minimally circulated pieces of writing and having isolated himself in later years from many on the international left, become such a singularly infamous and feared figure?

Marx’s power over others—whether inspiring awed admiration or fear or anger—was, I believe, Weber’s charisma. Indeed, Marx and Engels represented opposite, complementary poles of authority: the former charismatic, revolutionary and incapable of establishing any stability in his life; the latter bureaucratic, succeeding within the regnant economic system and maintaining enough order to permit Marx’s boistorous creativity to flourish. Ultimately, it is noteworthy that Marx’s intensity and presence were characteristics noted by his family members from very early in his life. Perhaps, despite the long and established traditions of semiotic and phenomenological approaches in sociocultural anthropology, fine-grained attempts to achieve a deep knowledge of another person must rely on the biological and ontogenetic insights of fields whose methods and objectives that we have been to hasty to regard with scorn.

Bibliography:

Boas, Franz.
1889 "On Alternating Sounds." American Anthropologist 2:47-53.

Bourdieu, Pierre.
1989 “Social space and symbolic power.” Sociological Theory 7(1):14-25.

Csordas, Thomas.
“Introduction: the body as representation and being- in-the-world.” In: 1994 Embodiment and Experience: The Existential Ground of Culture and Self. Cambridge, UK: Cambridge University Press.

Kleinman, Arthur.
1988 Illness Narratives. USA: Basic Books.
2006 What Really Matters. Oxford: OUP.

Lyon, M.L. and Barbalet, J.M.
“Society’s body: emotion and the ‘somatization’ of social theory.” In: 1994 Embodiment and Experience: The Existential Ground of Culture and Self. Cambridge, UK: Cambridge University Press.

McLellan, David.
1973 Karl Marx: His Life and Thought. NY: Harper & Row.

Parsons, Howard.
1964 “The prohetic mission of Marx.” The Journal of Religion 44(52):52-72.

Raddatz, Fritz.
1980 Karl Marx and Friedrich Engels: Selected Letters: The Personal Correspondence, 1844-1877. Boston: Little, Brown and Company.

Roth, Guenther, ed.
“Charisma and its transformation.” In: 1978 Max Weber: Economy and Society. Berkeley: University of California Press.

Seigel, Jerrold.
1978 Marx’s Fate. Princeton, NJ: Princeton University Press.

Shuster, Sam.
2007 “The nature and consequence of Karl Marx’s skin disease.” British Journal of Dermatology 158(1):1-3.

Stallybrass, Peter.
“Marx’s coat.” In: 1998 Border Fetishisms. NY: Routledge.

Turner, Terrence.
“Bodies and anti-bodies: flesh and fetish in contemporary social theory.” In: 1994 Embodiment and Experience: The Existential Ground of Culture and Self. Cambridge, UK: Cambridge University Press.

Wheen, Francis.
2000 Karl Marx: A Life. NY: W.W. Norton.

Wolff, Klaus, and Johnson, Richard Allen.
2005 Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology: Fifth Edition. NY: McGraw Hill.

Xkam rute' Gerardo

2008-11-23T16:30:00.000-08:00

I am filled with remorse and shame.

Rosalina, always taking the pulse of her community, called a few minutes ago to inform me that Gerardo's mother passed away this morning. I gasp. How can this be? My disbelief, refracted through my idiotic training, transmutes into an eruption of questions: What did she die of? When? Did they call the doctor? Did she suffer a lot? How is Gerardo's father?

Rosa seems overwhelmed by my response but tries to answer my questions. She died of her disease. What disease? The disease she had. What disease??? She had a stroke a week ago. I am searching for the proximal cause of death, but I give up. It doesn't matter. She had a stroke a week ago, and now she is gone. She died very early this morning; they did call the doctor; the whole family is crying.

I thank Rosa for calling and tell her I will call again in a couple of days. I close my eyes and put down the phone. Suddenly, shame sweeps over me, and I cover my mouth, as Catholics often do when they enter the sanctuary and kneel in prayer. Elena asks me who died and how it happened. I become angry--not at Elena, but at myself as I realize my impotence, exclaiming, "I have no fucking idea!"

How disingenuous of me.

She was treated for P. vivax in June when we left and got better. According to Gerardo, she began having fevers again in July or August, and they got progressively worse and more frequent. She became weak and anorexic again after a few weeks of increased energy and appetite. She was offered another course of treatment for P. vivax. A thick and thin smear was not repeated prior to this second course of treatment with the same medication. A week ago, she suddenly became unable to use one of her legs and to speak. Rosa explained that she passed away because she did not want to have a cholecystectomy, recommended by a physician in Pan Ajachel who detected incidental gall bladder polyps on ultrasound, which was ordered when she visited complaining of cyclical fevers and anorexia (with no belly pain, mind you). Her CBC was unremarkable except for her ESR, elevated to 150, but no other labs were ever drawn to follow up on the ESR.

I sit down and prepare myself to call Gerardo. No answer. I find that I am incapable of expressing myself in Kaqchikel, fumbling through a sincere but incoherent message expressing my condolences.

I cover my mouth again with my hand and begin to acknowledge my complicity in her death. I, a fucking medical student, tried to help her family navigate their care decisions. They did ask for my input, and I feel quite sincerely that the doctor in Pan Ajachel was trying to take advantage of them. And if I had been there when she was unsuccessfully retreated for malaria and given no more follow-up, I would have told them this was fucking bullshit. I told Gerardo in June and again a few months ago that I thought she needed to see a rheumatologist, that I thought there was something funky going on and it didn't feel good. But the fact is that I wasn't there when the fevers returned, and I can't help but feel ashamed that I did not do more. I did not do everything I could. I did not try hard enough. I did not make sure she was worked up for immunologic markers. And now she is gone.

I call again and get Erick, Gerardo's brother, on the line. Again, I fumble and become silent. He thanks me for my call and for my prayers. I mean to ask how his father is doing, and I mean to give him my condolences. My Kaqchikel fails me, however, and I realize that I have asked him if his father is well, and I have asked him to forgive me. How callous I must sound. I fumble on.

I am struck by Erick's lament--"we prayed for a miracle, but it did not come; we prayed to God, but she had to go." A similarly untrue teleology is indicated by Rosa's answers to what she must have thought were morbid questions. "She died of her disease; the disease that she had." Explaining indigenous peoples' resistance to family planning and apparent acceptance of child malnutrition and mortality, a quite racist ladino physician once told me that among populations with high infant and child mortality, the death of a child is met with muted pain and sorrow in comparison to more healthy populations.

Of course these lies expose themselves for what they are in moments like this--they melt into thin air, as it were, and become transparent. But I cannot avert my gaze, and I am obligated to contemplate the imperious immediacy of unnecessary suffering and premature death. The simple truth is that something should have been done to get to the bottom of what was making her sick, and the absurdity of the care she received is revoltingly grotesque. I return to my initial response: How can this be? How can this have happened?

Lest we fall into the trap of mystified resignation, however, I feel moved to continue searching for an answer. Per Levinas, the ethical should reign supreme when we regard the pain of others; that is, epistemology is a load of fucking crap. Nonetheless, I wonder: how useful is my "acknowledgment and affirmation" of her and her family's illness experience now? And given the abject failure of my praxis, doesn't my rhetorical question ("how can this be?") simply rationalize my succumbing to the moral paralysis induced by cultural relativism?

Our failure to provide a diagnosis and effective treatment (or even palliation) arose from very simple and terrible causes. To anyone who would deny those causes or throw their hands up in the air ("what is to be done?"), I retort with one last rhetorical question: aren't you ashamed of yourself?

I am enraged and ashamed by her death. I am ashamed that I had to write this entry, and I am ashamed that I feel compelled to share it with you, and that I have done so in this format and in this language. Indeed, I am ashamed that I am able to share it with you at all, and that I am able to reconstruct the story without the direct input of Gerardo, Erick, their mother, Rosa, or anyone else living in Pa Poqolaj. And I am ashamed that I do not have a picture of Gerardo's mother, and I am ashamed at my selfish sadness that I will not have another opportunity to sit at the edge of her bed, listening as she tells me how she is feeling.

Lover of men

2008-11-23T08:41:00.000-08:00

Philanthrope - lover of men.

Philos - love.

Anthropos - man.

The common usage of this word should be unsettling. After all, who does not consider himself a lover of men?

Epistemic ruptures

2008-11-12T14:25:00.000-08:00

Last week, in my section for the global health course, we were deconstructing commonly used algorithms for pharmacotherapy in major depressive disorder and DSM IV's diagnostic criteria for PTSD, and I described how I had been taught by psychiatry residents to use mnemonic checklists to diagnose pathology (e.g., D-I-G-F-A-S-T for manic episodes, S-I-G-E-C-A-P-S for depressive episodes), and one of my incredibly wise premed students asked, "How do we avoid becoming like that?" She meant, I think, "How, in the many years we ultimately spend immersed in the hierarchical world of medical education, do we avoid becoming socialized and unreflexively adopting biomedicine's elitist, egotistical, and technocratic view of humans and communities?"

I didn't have a good answer. Initially, I thought about how this particular exercise would not be particularly forthcoming in a medical school class, requiring the application of discourse analysis to psychiatry. So I said, "interdisciplinarity." That was an unsatisfying answer, though. After all, in my own experience, I didn't simply decide to care about political economy and take time away from studying medicine and public health because I thought anthropology would prevent me from falling into the trap of cynicism. Of course, I've taken to Arthur Kleinman's notion of "the interior intellectual life," and I believe anthropology will provide a regenerative balm that will help me to live a moral life in a world of danger and uncertainty.

Nonetheless, I realized, even in my own life, that it is my lived experience of being present with others that has--albeit gradually--made me discern and acknowledge the imperative for analysis and praxis founded on justice and solidarity. At times, the more momentous experiences are accompanied by sudden, intensely embodied awareness (e.g., out-of-body transcendence in mapping political-economic history onto landscapes; deep gut-wrenching sadness as I am penetrated by a mother's lament). At other times, these experiences seem unremarkable but remain with us nonetheless, shaping us in powerful ways that defy reason. Reading La Prensa, for instance, before tearing it into strips to use as toilet paper in our outhouse in Pampojilá, I realized that this "respectable" publication contained little of relevance to the lives of the functionally illiterate women who were our neighbors and patients, providing little more than colorful advertisements for commodities worth a month's wages and Ladinos' analyses of national Ladino politics. Indeed, those pages were not worth anything more than to wipe my ass with. Whatever it is that triggers us to feel the presence of the numinous, and whatever it is that causes toilet truths to be indelibly imprinted in our minds, it has been in trying to understand such experiences--and elaborate plans for praxis based on them--that I have realized that, to develop accurate, honest analyses of health and illness that are in solidarity with the poor and marginalized, I must engage the methods and modes of analysis of anthropology, which were my first vehicle into the study of inequality and resultant suffering.

In Mountains Beyond Mountains, Tracy Kidder asks Paul how he came to the perspective he has on Haiti and on the world. Paul explains that it was a sort of gradual process in which he witnessed a lot of things and learned a lot of things about history and liberation theology, and that he eventually just came to see the world the way he does. Then, he second-guesses himself, saying, well, there was this one time... and he describes the story from very early on in his engagement in Haiti of a pregnant woman with severe malaria who needed a blood transfusion to survive. Paul didn't have enough money on him, so he ran around trying to collect money for the unit of blood, but ended up getting just enough too late. The woman died, and her sister, who had accompanied her to the clinic, began wailing,"Tout moun se moun! ("Every man is a man!") This caused what Kidder calls an "epiphany," and which I think it'd be better to call an "epistemic break." That is, we walk around and have a certain understanding and established knowledge of the world and our place in it, and sometimes things don't turn out as they're supposed to but overall things are pretty stable and normal. Then come moments that suddenly turn our whole epistemology on its head--or, perhaps, back onto its feet--because we can find nothing in our previous understanding or experience that explains away the moment. Living and working among the poor does often cause a slow epistemic shift, as Paul initially describes, but the centrality of epistemic breaks in the narratives of those we seek to emulate is important to note, because we stand to learn a great deal on how to approach our own personal struggles to live moral lives. If nothing else, we might come away understanding the importance of alertness or receptivity to "epistemic breaks" in all their potentially mundane and extraordinary manifestations.

Achike roma yiq'ax ri enter q'ij rik'in Ixin Ulew pa nujolon?

2008-08-13T07:16:00.000-07:00

Achike roma yiq'ax ri enter q'ij rik'in Ixin Ulew pa nujolon? Achike xq'ax chwe? Achike modo xq'ax ya ri?

Jub'a k'ayew ri apo. Qitzij, rin ninxb'ij wi' b'a roma ri sachnaq nucontrol pa ruwi nuk'aslem. Pero chuqa' npe jun k'a k'a libertad roma ri decentralizacion pa nuk'aslem.

Pero de todos modos b'a ninxb'ij wi'.

Xseqer, nan; xseqer, tat.

2008-08-13T06:01:00.000-07:00

Rin ninmey qachb'il ke la Ixin Ulew. Ninmey ri k'aslemal kikojol ri winaqi' ke la.

Wawe pa ri nimatinamit rub'i Boston ri taq nimaq'a ri winaqi' man nkitz'u ta kiwach, man nkiq'ejela ta ki. Chi rij ri xk'is ri wa'in, ri rikil, wawe majun winaq ta nub'ij, "Matyox."

K'a wakami Elena chuqa' rin nqab'ij chiqe, "matyox." Yalan jeb'el ri k'aslemal xqatamaj ruwach ri juna' qa.

I love Skype, I miss everyone

2008-07-24T08:03:00.001-07:00

Yesterday, Elena talked to Angel. He recognized her voice right away! Surprise, surprise. She's everyone's favorite. (Is that bitterness you sense? No...)

I also got in touch with Rosalina! Rija' xk'oje rik'in Odilia iwir aq'a, xub'ij chwe chi rija' xq'ax rik'in Dr. Tun y wakami maq'a npe Dr. Pablo richin nutz'et ruwach, to xkikot nuk'u'x.

Odilia is the woman with RA and severe, recurrent asthma (plus what I think may be ILD related to the RA). It is possible that Odilia's management will continue to be sub-optimal for now, but with Paul on board, I hope that at some point we will be able to get her on DMARDs. In any case, Rosa and Odilia seemed happy about the care she is receiving at the clinic. For once, she has had a chest film and some blood work done. (It sounds like they are awaiting a uric acid--doh! Hopefully there was a RF drawn. Can you imagine: a 21-year-old woman who lays in bed all day crying from joint pain and swelling, and she's never had a work-up? Damn it, as my mother says, "That really pisses me!") Pablo Benedicto has been working his magic, and Odilia has not had to "collaborate" (what the !*%# does that mean, anyway?) for any of her tests or medicines!

Getting off topic

2008-07-18T09:36:00.000-07:00

I'm afraid that I will start to get off-topic (at least as far as this blog's web address goes), especially as I delve into some theoretical realms to which I have yet to be exposed. I might have to create another blog. In the meantime, here is something off-topic, but hilarious!

"All those Theories in Philosophy which are expressed only in metaphorical Termes, are not real Truths, but the meer products of Imagination, dress'd up (like Childrens babies) in a few spangled empty words... Thus their wanton and luxuriant fancies climbing up into the Bed of Reason, do not only defile it by unchaste and illegitimate Embraces, but instead of real conceptions and notices of Things, impregnate the mind with nothing but Ayerie and Subventaneous Phantasmes. [Free and Impartial Censure of the Platonick Philosophy (1666)]"
~Quoted in Metaphors We Live By (Lakoff and Johnson, 1980)

Xitzijon rik'in Gerardo pa ruwi k'iy q'ij

2008-07-18T08:46:00.000-07:00

Iwir xitzijon rik'in Gerardo, nutijonel richin chab'al. Xikikot sib'elaj richin xitzijon rik'in rija', roma ri pa k'iy q'ij qa xojtzijon. Yalan utz runa'oj Gerardo.

Rija' xub'ij chwe chi xkamisax jun k'amol b'ey pa ri gobierno pa ka'i q'ij qa, roma ri jun asunto politico. Xeb'anataj cosas ke ri q'ij q'ij pan Ixin Ulew. Pa ri k'a k'a Indice de Paz, Ixin Ulew xel 103 kojol 140 chik paises.

Jun chik k'ayewal wakami, ri meb'a'i man yekowin ta yewa', roma ri jotol rajal renojel. Roj wawe pan Estados nqab'an preocupar pa ruwi ri pwaq roma ri jotol rajal ri gasolina, pero tab'ana pensar pa ruwi ri winaqi' ke la aj Nueva Providencia--rije' man yewa' ta utz taq e k'o taq condiciones economicas favorables, y achike nab'ij chi rije' nkib'an wakami? K'a e k'o winaqi' pa Colonia Pampojila', akuchi roj xojkanaj wi ri juna' qa, rije' man yekowin ta nkiloq' rik'il richin ri wuqq'ij, y roj xqatz'u' chi la tinamit la mas utz kikaslem, k'o mas kipwaq! Y achike nab'ij chi xtib'anataj roma ri yalan meb'a ri winaqi', achike k'o chi nkib'an richin nkil/nkiwil ri wa'in?

Konojel ri taq k'ayewal yepe roma ri gobierno man nkiya' ta ri taq servicios publicos, o mas utz ninb'ij, rije' man utz ta nkiya' ri taq servicios. Nkiya' jujun, pero man utz ta rub'eyal.

Gerardo xuk'utuj chwe si najin ninkanoj jujun Kaqchikela' winaqi', pero majani ninkanoj. Jun wachb'il xintamaj ruwach ke la Chile xub'ij chwe chi rija' nutamaj kiwach k'iy winaqi' aj Ixin Ulew que e k'o wawe pa Boston, y rija' xub'ij chwe si ninwajo' rija' nub'an presentar chike. Y ninwajo'!

PEPFAR2

2008-07-17T17:43:00.000-07:00

PEPFAR2 passed the Senate. There are some problems with the legislation (from an evidence-based perspective) , and there will likely be some effort to make minor changes, but this is still an important victory!

In Boston, thinking of Ixin Ulew

2008-07-15T18:19:00.000-07:00

We've been in Boston a little over two weeks now, and it has been good. I spent a week with Peter (Rohloff), and his friend Andrea, at his new place in Jamaica Plain. He recently began his intern year in IM/Peds at BWH. It was a good week for me, mainly bumming around and spending time with Andrea (and Peter, when he was home). We went to Vermont over the weekend, which was really nice--we got to spend some time with Peter's parents and see the beautiful place he calls home. It reminded me a lot of Ixin Ulew.

...

I am auditing a class on global health delivery, which is a "new" science (it only seems somewhat new to me, honestly; the innovation in it is really more in the integrated application of existing ideas and technologies to particular settings/populations) being developed my Jim Kim. It is very interesting to me because it provides a forum for thinking through, in an intensive case-based way, a lot of obstacles and issues similar to the ones we faced last year (or rather, continue to face) in our work with the health promoters.

...

My job is also good. I am working with a few different people to develop a course that will be taught by Paul Farmer, Jim Kim and Arthur Kleinman. It is entitled, "Case Studies in Global Health." It is going to provide a very theoretically deep perspective on the history of and contemporary issues in global health. Very cool. I am learning a lot!

...

The health promoters are having problems, similar to the ones they often face. I talked to Vicente and Dominga this morning, and ever so briefly I felt like I was sitting in the centro comunitario in K'ix Ya', speaking Kaqchikel to Dominga and Spanish to Vicente, thinking through things with them and expressing my support and sympathy for their difficulties.

I miss Ixin Ulew!!!

Arthur Kleinman on 'cultural competence' in medicine

2008-06-13T14:01:00.000-07:00

I liked this.

How can I fulfill my responsibilities as a physician without thinking anthropologically, without engaging ethnographically?

Xkam rujite’ Vicente

2008-05-30T15:03:00.000-07:00

Öj tz’uyül chwäch ri kaxa. Najin ye’ok, najin ye’el ri winaqi’ pa jay.

Nuwäch nojnäq rik’in sib’, nutz’am nojnäq rik’in ruxla’ pom. K’o b’ey ninna jun itzel uxla’, kojol ruxla’ pom.

Nqayab’ej.

Rachajil ri kaminäq ndok richin yojruq’ejela’. Man ndoq’ ta chik wakami. Yan q’axnäq oxi’ ik’, oxi’ ik’ tzaqät pa ruxikin ruch’at, tz’uyül warnäq ri 90 q’ij qa. Rija’ nukw’aj rukiy pa ruk’u’x, najin nuchajij ri kaminäq chuqa’ taq rume’al wakami.

Nqayab’ej chik. Tew ri ya’, b’uyül ri kaxlawey. Ral ri kaminäq ndok, nuq’etej Katy. Najin ndoq’, ndoq’ chik rija’. “Gracias, doctora,” ncha, ndel ël.

Nqayab’ej chik.

Nqak’oxaj jun oq’ej. (Ay Dios, rute’ rujite’ Vicente! Majani ri’j ta ri kaminäq.)

“¿Por qué esto le pasó a mi hija? ¿Por qué se murió? ¿Por qué nos dejó? ¡Se ha ido de su casa! ¡Yo no sabía que le iba a pasar algo así a mi hija! La matan…Ayyyyy! ¡Mi hija! ¿Por qué? Señor, ¿por qué?”

Qitzij. Atyux roma?

Npe raxtew chuwij. Npe ya’ pa nuwäch. Man roma ta ri tew ya’, man roma ta ri sib’.

Atyux roma? Man wetaman ta. Rik’in jub’a junan ri kitzolintzij ri taq k’utunïk chik:

Atyux roma xb’anatäj ri k’ayewal pa b’ey pa ox’i ik’ qa? Atyux roma ri aq’omanela’ man xkiq’alajirisaj ta ri situación k’a xapon ri doctora Katy rik’in rupalaj mo’s? Atyux roma xkiya’ jun aq’om chupam betametasona kichin rusokotajik roma ri ch’at? Atyux roma Vicente xojroyoj taq xek’oje pa b’ey, xetzolin pe, richin xuk’utuj achike xekowin xkib’an richin ri itzel uxla’, roma ri man xkiya’ ta formaldehida ke la Roosevelt? Atyux roma man xqatamaj ta si xojek’ulun pa jay, roma ri majun gasolina pa ruch’ich’ Lencho roma ri jotol rajal ronojel wakami?

Röj yojb’a ël ri lunes petenäq. Pero ri k’aslem xtub’an seguir wawe. Röj yojb’a ël, pero ri kamïk manaq.

Kan ke ri, ri kaslem? Pa jaru q’ij xtiq’ax ri uxla’?

...

[Us, seated before the casket. People are entering and exiting the house.

My eyes are filled with smoke, my nostrils are filled with the scent of incense. Sometimes I smell an ugly smell, between wafts of incense.

We wait.

The widower enters to greet us. He is not crying anymore. He’s already spent three months, three months to the day, by her bed, sleeping sitting up for the past 90 days. He carries his pain in his heart, now he is caring for his late wife and for his daughters.

We wait a bit more. The soda is cold, the bread is soft. The daughter enters and hugs Kate. She is crying. She cries more. “Thank you, doctora” she says and steps out.

We wait a bit more.

We hear weeping. (Oh God, it is Vicente’s late mother-in-law’s mother! She was young, yet.)

“Why did this happen to my daughter? Why did she die? Why did she leave us? She has left her house! I did not know that something like this would happen to my daughter! They kill her…Ohhhhh! My dauther! Why? Lord, why?”

True. Why?

A chill comes over me. Water comes to my eyes. Not because of the cold soda, not because of the smoke.

Why? I don’t know. Perhaps these questions have similar answers:

Why did the accident on the highway three months ago happen? Why did the doctors not clear up the situation until doctora Katy arrived with her cara de gringa? Why did they apply an ointment containing betamethasone for her bedsores? Why did Vicente call us when they were on the highway, coming back with the body, to ask what they could do for the smell, because they had not embalmed her with formaldehyde at Roosevelt? Why did we not know whether we would make it home, because the tank in Lencho’s car was empty because everything is expensive nowadays?

We are leaving this coming Monday. But life will go on here. We will leave, but death will not.

Is that just the way life is? In how many days will the smell pass?]

Accompaniment and conversion

2008-05-16T16:42:00.000-07:00

We are scheduled to fly to Atlanta on June 3, and the proximity of our departure date has provoked a good deal of reflection on the 9 months we have spent here with the health promoters.

When we arrived in San Lucas, I had expected to spend the year investigating etiologies of child malnutrition in the health promoters’ catchment area. It became clear very quickly that this would be difficult, if not impossible. The parish expected us, as foreign visitors, to do nothing more than “accompany” the people we met—that is, observe their work and their lives and ask a few questions, learning about another people mainly for our own edification. Attempting anything more would mean we were trying to “become indigenous” (a preposterous but perplexingly real concern of the parish; I never got up the courage to point out to the gringo priest and co-administrators that, as a Bengali, I am, in fact, indigenous); or that we were “interfering” (I learned not to ask, “with what?”) or “generating dependency” (similarly, “how, and on what?”). Ultimately, I agree that my research plan was naïve, over-ambitious and, if actually executed, would have been potentially disruptive of a locally driven program whose broader objectives I did not fully understand.

Moreover, it seemed that my attempts to fulfill the most basic requirements of critically engaged, quality ethnographic research—learning the preferred language of the communities, living in an indigenous aldea, and responding responsibly and justly to the petitions and opinions of my indigenous colleagues—engendered passive-aggressive and patronizing skepticism towards me and, more importantly, towards Vicente and his team of health promoters. The treatment we received, and the overflow to Vicente, was confusing and painful for all of us, and I decided that insistence on my part could endanger the program.

Despite the apparent failure that this “research year” has been—my mother has been asking all year when I will start my study, which was supposed to be the basis of my MPH thesis—I think that we have done something infinitely more valuable than a limited, qualitative study on child malnutrition. In light of the parish administration’s hostile perception of our activities, it is ironic that the best way I have of describing what we have done here is precisely what they told us to do—“accompany” Vicente, Dominga, Rosa, Abelino, and the rest of our friends and colleagues living and working in the aldeas around San Lucas.

The “accompaniment” prescribed to us by the parish co-administrators is inspired by the philosophy guiding organizations like Peace Brigades, International. Such organizations focus on situations (such as exhumations of mass graves) where marginalized actors are predisposed to acute, severe human rights violations. The role played by international “observers” in such instances is a very crucial one; even if the “accompaniment” required amounts to little more than physical presence, the transfer of our symbolic power confers protection to otherwise vulnerable individuals.

Nonetheless, the “nonpartisanship” and “objectivity” that are a part of this sort of accompaniment cannot be applied beyond the limited involvement of short-term accompaniers. In forging substantive relationships with the people we are accompanying, and in coming to a fuller understanding of the milieu in which we are working, we would have to suspend our intellects and/or our hearts to continue a shallow and ultimately inconsequential form of “bearing witness.” And in our particular situation, we are faced with morally clear decisions when our new friends ask us to contribute our relevant skills and resources to support their work.

It is hard to define neatly the kind of accompaniment we have been engaged in here. For me, it has involved learning to communicate in Kaqchikel, and living, working, eating and recreating with our indigenous colleagues and friends on a daily basis. It has meant talking with Vicente in the small anteroom of his house, discussing his dreams, both for the community health program and for his life. It has meant sitting with Rosa working on her backstrap loom on a cloudy day, listening as she weaves personal concerns into conversation about her community and family. It has meant being woken up in the middle of the night to attend to neighbors’ medical emergencies. It has meant frustration and anger at the care that our friends are forced to beg or become indebted for at health centers and hospitals. It has meant being acutely aware of my deficiencies—in speaking Kaqchikel, in speaking Spanish, in providing healthcare, in learning from and teaching others. It has meant becoming acutely aware of how distracted I am by mundane and selfish concerns.

In short, our “accompaniment,” while profoundly fulfilling, has been quite nebulous, variegated, and difficult. It is difficult because there is no endpoint. We cannot exit the friendships we have made and experiences we have had—we could try to suppress the memory of them, only to suffer pain when they resurface. It is difficult because we have, in some way, begun to see our lives as dictated by the experience of communion with our neighbor. How can my life remain unchanged by the encounters we have had? It becomes increasingly more difficult to consider a life that is dedicated to something other than the people whose lives have become so tangible to us. This, I think, is the beginning of the “conversion to the neighbor” described in Gustavo Gutiérrez’s spirituality of liberation. How much can I really rejoice about studying medical anthropology (a strange area of study to most of our friends here) next year at Harvard University (which, similarly, none of our friends here have ever heard of), when that year of study means that I will not be here to continue helping and will be simultaneously postponing the completion of training that will allow me to provide effective, pragmatic services to the poor?

Xkojb’a ke la Boston!

2008-05-11T14:28:00.000-07:00

During our time here in Guatemala, I have been forced to reflect quite a bit on how to respond to our experiences here. When we arrived, I had thought that all I needed to do was apply my existing skills in medicine and public health and my linguistic capacity in Spanish, and I would be able to do good work.

In encountering the limits of my abilities in medicine and public health, my perspective on my remaining training has changed significantly. Before, I thought of the years of training before me as a series of prerequisites; now, I have become aware of the clinical opportunities I need to seek out if I am to become a competent physician to impoverished populations in complex healthcare landscapes like the one we have encountered here. Honestly, in light of our experiences, I feel that 3 years of residency training is not enough—I need to gain an internist’s knowledge of medicine, a pediatrician’s knowledge of children’s health, a psychologist’s aptitude for psychiatric elements of illness, and an obstetrician’s experience and surgical dexterity. This makes the prospect of choosing a specialty for residency more complicated. In any case, this past year will make me a more deliberate learner as I continue in my clinical training.

Another unexpected realization of this year is the narrow scope of the training and education I have pursued thus far. Issues of cultural and socioeconomic justice have only been touched upon in passing in my medical and public health education. While I have a natural predilection to trying to contextualize my experiences in broader perspectives of political economy and history, I have neglected this as a focal practice in my life, partly because I have been overwhelmed by the pace of medical school and partly because this is not something that is emphasized as important for medical students, at least not in my experience at my school. I have experienced a growing awareness of the necessity of anthropologic perspectives and ethnographic practice through my engagement here in Guatemala. I have had inklings of this awareness over the past three years, and I somehow knew that at some point I would probably pursue studies in medical anthropology—to the point that when I started thinking concretely about applying to programs this past fall, I already knew where to look and which schools to consider. In December and January, with the encouragement of Elena, friends and mentors, I submitted applications to a number of schools that offer Master’s programs in anthropology for healthcare professionals.

Of the programs to which I was accepted, I decided that Harvard University’s MA in Social Anthropology with a focus in Medical Anthropology was best suited to my needs. The program offers a broad introduction to anthropological theory and the opportunity for in-depth study of a variety of topics of utmost importance to a student of the health and lives of the global poor. In addition, the institutional partners participating in the Program in Medical Anthropology at Harvard (e.g. Partners in Health and the Dept of Social Medicine and Health Inequalities) are exciting to me as a physician-in-training who hopes to couple critically engaged scholarship and social justice work to clinical medicine.

So I am taking another leave of absence from the MD/MPH program at Northwestern, and Elena and I are making preparations to move to the Boston area this summer. We are looking forward to this next step in our journey, and Elena has already begun to look for jobs in Boston’s non-profit sector. Once we have an apartment, we would love visitors!

An "accident" near K'ix ya'

2008-03-12T15:15:00.000-07:00

There was a pickup accident outside San Lucas last Sunday. The pickup truck belongs to somebody in Sololá, and the driver was doing a favor for the owner by taking the car out. Apparently it was the first time this driver had ever taken people in a pickup, plus it was a different type of pickup—a little higher than most. The car came down to Quixayá, and on its way back up towards San Lucas, it started to swerve, and the people started grabbing hold of each other and screaming. There was an oncoming car, and the driver swerved away and smashed into a rockface. The vehicle didn’t turn over, but people were thrown out of the pickup. The pickup was full. 18 of the passengers were so badly injured that the parish clinic referred them out to the larger hospitals in Sololá (14) and Escuintla (4).

Another pickup on its way from San Lucas towards Cocales slowed down at Quixayá to inform people that there had been a crash, “y que parece que son su gente” (“it looks like they are your people”). Vicente and his wife Gloria were at home and got news that their family members had been in the pickup that crashed. They went up to the scene of the accident. Gloria’s mom hurt her head—a flap of skin on her forehead and scalp was avulsed away, and she was bleeding a lot, as you might expect. They took her to Sololá immediately, but they couldn’t do the right studies there (head trauma), so they then referred her to Roosevelt, the government hospital in the capital. Her first CT wasn’t read until the next day, but thankfully it was negative, at least for an acute bleed. As of today, she has not spoken yet, and she is currently unconscious, but it seems that she was more conscious before (looking around, moving a little bit), so she may be medically sedated for some reason. Vicente said that Dr. Tun (the parish clinic doctor) said he was worried that she had broken her neck. Gloria’s sister’s 8-month-old girl was also in the crash, and she was sent immediately from SLT to the IGSS hospital in the capital, but this may have more to do with the fact that they have IGSS coverage than with the actual severity of her injuries (IGSS stands for Instituto Guatemalteco de Seguridad Social, and is basically a government-administrated, employer-funded health insurance system). Apparently one whole side of the baby’s face got swollen, especially her eye. Today Vicente said that they got news that there is a fracture in her skull, but it is unclear to me where. Either way, this sounds serious.

Paul Farmer talks about how the shitty roads and crappy tap-taps in rural Haiti cause lots of accidents that ruin lives, and how these risks (the risk of being in an accident, and of not being able to navigate or adjust well to the sequelae thereof) is disproportionately high amongst the rural poor. I have been trying to figure out if this most recent accident is similar. Can what happened on Sunday be interpreted in a critical anthropological perspective; can the impact on peoples’ lives be placed in the context of poverty and marginalization?

The difficulty I have been having with contextualizing the accident is that it was so random that Vicente’s family members happened to be on that particular pickup. There are many people who travel on pickups and camionetas (chicken buses), many of which pass by Quixayá every day. It just seemed like what happened to Vicente’s family was out of horrible chance. I suppose that because Vicente and all the people who live in the rural areas here, including me and Elena now, have this same baseline risk, it seems random that some people get hurt and others do not. But the fact is that Vicente and his family would not have the same baseline risk if they were commuting in Chicago—I do not fear for my life every time I am faced with the prospect of taking the CTA trains and buses in Chicago. But Vicente is definitely afraid of camionetas, to the point of insisting that we not take them. When I asked Rosa, a health promoter from Pampojila (the community where we live), if there were less deaths in the colonia after the highway was paved (thinking that she would say yes, because more people could get to the San Lucas hospital on time now), she said no, there are more deaths because the cars crash and sometimes even run over people. The risks related to automobile accidents here are so widespread that they become normalized for me, someone who is living here and thereby taking on, to some small degree, the risks that are a daily part of life for people here. There is a reason that “traumotología” is such a popularly claimed medical specialty here—the majority of the population in this country is not riding around in their own car with a valid license, and that is why there is so much automobile accident-related trauma (and why it is lucrative to be a traumatologist).

A long, integrated process of poverty and marginalization have made it normal to ride around the Guatemalan highlands standing up in the back of a small pickup truck that struggles to move uphill under the weight of the other 20 people standing with you; the same process has created inadequate numbers of corrupt traffic police and allowed many people, including many drivers of public transportation, to drive without a license. And these same processes have made emergency and rehabilitative medical care relatively or absolutely inaccessible to most people in our communities here. So for instance, Vicente’s mother-in-law needed a head CT immediately, and she probably didn’t get it for another 4-5 hours; when she finally got it, her husband had to pay 400 Quetzales (two weeks’ salary for a campesino around here) for it. Nobody should ever have to pay to see a doctor or get diagnostic tests or medicine. But this is only the last part of a long sequence of problems.

An artefact of inequality

2008-01-28T13:18:00.001-08:00

There is an old (ancient) centrifuge in Quixayá, donated to the health promoter program. It works. But I don’t know what they would use it for in Quixayá. Vicente seemed to think it was to be used to run bacterial cultures. The lab at the parish clinic doesn’t even run cultures. Vicente said that we could lift the lid and use it as a fan, as the air in the community center in Quixayá tends to get hot and stagnant in the summer. We all had a good laugh.

But seriously…places like Guatemala get our garbage. They get people who are confused and lost, or idealistic and energetic but without any applicable skills. They get our junk—whether or not they want it, need it, or know what to do with it other than put it away and out of sight. So while no diabetic in Quixayá is on metformin (first-line treatment in the States), an old centrifuge collects dust, hidden under a large (and largely unused) examination table in the community center.

Vitamin B King Kong

2008-01-28T13:17:00.000-08:00

Doña Candelaria was told by a local NGO that Rosbin is malnourished. Later, when Lesvia asked Rosbin to hand her a basket that was high on a shelf, he said he could not: “I can’t help you because I am malnourished!” Again, we all had a good laugh.

What is Doña C supposed to do with the information that Rosbin is malnourished, now that he is 7-years-old? Especially when the advice given to her was to take a Vitamin B-complex supplement and “pay attention to how he is eating”?

At least Rosbin can use his malnourishment as an excuse to avoid helping around the house. And this morning at breakfast he was running around the kitchen saying that the vitamin supplement will turn him into King Kong, similar to the effect of spinach on Popeye.

Joia Mukherjee on sustainability

2007-11-03T15:00:00.000-07:00

"One criticism often lobbed at PIH is that its projects are not 'sustainable,' said Mukherjee, as the traditional view of a successful development projects is to have it be self-sustaining after the development organization leaves. '[But] we’re global citizens and we’re not leaving. We’re in this together. You don’t exit from humanity,' countered Dr. Mukherjee. 'You don’t have an exit strategy.' The only thing that is truly self-sustaining is entropy, she added.

'If you teach people to fish, then they can fish for a lifetime,' she said, quoting a common sentiment of sustainable development. 'But in fact, if the rivers are dry, and there are no fish, and you have no fishing pole, you can’t learn to fish,' she said."

(PIH E-Bulletin, October 2007)

A response to the new parish co-administrators' ideology of volunteerism

2007-10-17T14:55:00.000-07:00

When I’ve asked the health promoters to respond to the questions, “What do you want, what do you need to do your work well,” the answers I hear are as follows: “We need more medicines. We need more trainings. We need more autonomy and more material resources. We need to receive compensation for our work.”

It may seem to some that these are grand demands. And of course providing all these requests at once and in full might prove unsafe for patients and be detrimental to the credibility of the health promoter program, were resources or medicines to be used inappropriately. Nonetheless, as grand as these demands might seem, they are also quite simple, and quite logical. The felt needs of people who are trying to help their communities have been expressed quite clearly to me—as a person who has been accompanying them daily in their work and collaborating closely with them to support and expand their existing activities. These needs are echoed, in one form or another, regardless of whom you ask among the senior and graduated health promoters. On the other hand, even the most superior health promoters are afraid to ask or demand what they know very well is their due—they feel unfree to express themselves to the people with the most authority in the local system of symbolic power and political economy, that is, administrators and other caciques in the parish hierarchy.

So, I am at times upset by immodest, cultural relativist claims that stress cultural difference, when the real differences seen in the communities here are those of poverty—poverty of financial resources, poverty of opportunities, poverty of education, and so on. These claims—much accepted in traditional development thought because they make the work easier, lowering the standard of care and justifying sometimes horrifying outcomes—are all the more irksome when one realizes who is stressing these “cultural” differences. These explanations erase and suppress—sometimes after obligatory acknowledgment—the fact that these “cultural” differences are more a product of generations of “unfree, desperate, and short” lives and ways of being. The people laying these “ideological landmines” (“Things are just slow down here,” “it has to come from them, not from us,” “that’s not sustainable,” “you are not here to do anything, your job is only to learn”) would have us believe, in some degree, that impoverished Maya communities in rural Guatemala are inhabiting a different political and economic universe than us U.S. Americans. We thereby run the risk of forgetting that our lives of luxury and endless opportunity are based on hundreds of years of oppression and violence against indigenous peoples.

To make development, social justice, and socioeconomic rights-building efforts work, we certainly must work in concert with people and communities. If we insist “radically” that all efforts for community development must come from the oppressed and marginalized with no intervention or assistance from us, I think we are making a huge mistake. Doing so would be to waste the symbolic and financial capital that we enjoy as powerful people in a deeply stratified world—and the health promoters, like other impoverished and marginalized people elsewhere, are very aware of our power and of the wastage of that power: Vicente recently said to me, “You will buy these things for the training session, because you have money”; the graduated health promoters’ response to Elena’s presentation of the topic of family planning amounted to, “We want family planning methods, and women in our communities want it, but until you help put these methods within our reach, it is pointless to talk about this issue.” If we choose not to listen to oppressed and marginalized peoples’ opinions and protestations that those of us who have power and money should consider it an obligation to use these resources to help them struggle for their rights and for more just lives, then we run the risk of taking a comfortable seat in our liberal leather armchairs, munching on popcorn as we watch the lives of the poor unfold and pat ourselves on the back for “witnessing” and doing development “work.” We run the risk of being so keen on listening and learning that we become deaf and impotent, recapitulating the theme of foreign invaders taking more than they are giving in return.

If anything, the health promoters insist that we NOT remain seated, that we get up and walk with them towards more just realities. The graduated health promoters exude hope and love when they speak of past volunteers who have "fought" (“luchó mucho por nosotros y por nuestras comunidades”) for their cause. The health promoters are credible, inspiring people who speak on behalf of their communities, and they have reproached us for not doing everything in our power (and we do have a lot of power) to get them the means to get what they need to take care of their neighbors. I cannot say in good faith that I am upholding the pillar of subsidiarity if I do not heed their rather clearly expressed, felt needs.

A case we saw in San Andrés

2007-10-01T14:15:00.000-07:00

N.S., a 30-month-old boy, is seen during a follow-up house visit for failure to thrive. At this visit, he weighs 18 lbs, 12 oz. He was first seen 6 weeks previously, when he was just recovering from a 1-week bout of diarrhea, and his weight at that time was 16 lbs, 8 oz. His mother relates that N.S. began standing up and taking a few steps about 3 months ago; now, he is able to walk unassisted but cannot yet run. He says "mama," but no other words. The heart, lung, thyroid and abdominal exams are unremarkable. The boy's 8-month-old sister weighs 16 lbs. These are the household's only children. Both N.S.'s mother and father are present during the visit. When asked why she thinks N.S. is not growing well, his mother replies, "Last month he had diarrhea. Now he does not have diarrhea, but I give him food and he does not like to eat. He only eats one or two tortillas with salt. He likes Incaparina, but I only give it to him sometimes." The family lives in a resettlement community--families were moved from a plantation to this new location following landslides that destroyed all of their houses; the new land was purchased by the Catholic parish in San Lucas Tolimán. The community recently had unpurified, running water installed in all of the houses. In this community, there is a government-sponsored daycare for children 5+ years that provides two meals daily; there are mixed reports from community members and daycare caretakers regarding rate of attendance and family's usage of these free meals. There are biannual deworming treatments in the community.

-What are the possible ("social" or "environmental") etiologies of failure to thrive in N.S.? How do we figure out how likely these etiologies are, and how big an impact they are having on the growth of N.S.?

-What would be some strategies to tackling the possible etiologies of failure to thrive in this case?

-What should we be doing with respect to N.S.'s sister and protecting her growth and development?

Subsidiarity

2007-09-28T13:10:00.000-07:00

Subsidiarity is one of the four pillars of Catholic social teaching that calls us "to respond to the expressed needs" of the poor and marginalized. Over the past few weeks, Vicente has asked the health promoters to put their heads together to generate a list of ideas that they would like to develop further, and needs that they would like to see fulfilled. Here is a sampling.

Rehabilitate 90% of the cases of child malnutrition through talks, visits, awareness, follow-up, trainings and searching for appropriate technologies for the purpose of treating malnutrition.

Family planning.

Medicines for chronic diseases: epilepsy, asthma, anemia, fecal exams, prenatal visits, general medical consultations.

House visits for 'special children.'

Pap smear clinics.

...and, lastly, my personal favorite:

Visits to people with incurable diseases or people with scarce economic resources; through house visits, people feel happier; and also, monthly clinics because there are patients who have indeed been helped a lot and are recovering from their illness.

Quite a bit of work to do, eh?

The vitality of practice, the importance of language

2007-08-13T15:06:00.001-07:00

I’m glad to be out of Antigua. Witnessing (and contributing to) contemporary phenomena of colonization in the former imperial capital of Central America was an instructive but grating experience for me. I was anxious to get to San Lucas Tolimán—where the real work would be and where I needed to go to begin the process of accessing poor, rural indigenous communities. And sitting in the central park practicing glottal sounds and memorizing vocabulary while trying to ignore loud tourists (all seeming to be expounding on volcano excursions, local restaurants or iPods in annoying West Coast vernacular or nearly incomprehensible Southern drawls) was helping only somewhat with learning Kaqchikel. Now that we are in San Lucas, I feel less anxious (and less like a waste of space), and, as anticipated, things are slow in getting started here, so I am glad we came here a week earlier than we had planned.

So far we’ve been here 4 days and have spent them mainly introducing ourselves to individuals involved in the preventive health program. At the moment, I have more to reflect on from last weekend, when we accompanied Peter on his patient visits in Santiago Sacatepéquez.

...

Two house calls in particular stand out in my mind. The first was to the home of an elderly diabetic woman, whom, after walking down a path of cracked cement and (in my case, anyway) nearly tumbling down a short dirt incline, we found sitting in a dark back room with a piece of blue cloth wrapped lightly around one foot. As we entered and took the seats that were invariably offered us by our gracious hosts during house calls, I noted an oddly pungent odor that, when the blue cloth was gently removed by the patient’s daughter, turned out to be the smell of rotting flesh. Her great toe was almost entirely detached from her foot by black gangrene, and her other toes appeared similarly infected, swollen or dying; particularly concerning was the redness and swelling in her foot and ankle, suggestive of soft tissue involvement and evolving osteomyelitis. The second was to the home of an elderly couple—the day before, Peter had been telling me about the woman, who has Parkinson’s, but ultimately it was the case of the man that captured my attention. He watched us from bed, his gaunt frame and features appearing at least 10 years older than his stated age of 63. He told Peter that he had been experiencing up to 15 bright red, bloody bowel movements a day for several months now and described dizziness and fatigue, both symptoms of anemia which indicated the severity of his bleeding. Bright red blood per rectum, as it is known in U.S. emergency departments and hospital wards, has a fairly extensive differential, but the subacute onset, progressive symptoms and accompanying anorexia and weight loss in this elderly patient made colon cancer the leading diagnosis. In both of these cases, the patient had endured fairly concerning symptoms for astonishing periods of time, and, despite Peter’s insistence that there was little that he could do, both patients resisted the idea of going to one of the regional public hospitals.

These examples spurred a cascade of thoughts about structural violence and the multiple manifestations of resultant marginalities in the lives of these two people. The first was an older woman with diabetes that, due to the lack of access to medical care generated by socioeconomic and cultural marginalization, remained undiagnosed until Peter recently began taking random finger-stick blood glucose measurements in the community. I am almost certain that the metabolic derangements associated with the disease had already wreaked havoc in the form of end-organ damage prior to this most recent, and more evident, complication. Similarly, this same socioeconomic and cultural marginalization generated a well-founded reluctance to go to a hospital where doctors would communicate in a difficult language (that is, if they communicated at all) and explain little about unfamiliar and thus frightening therapeutic options (that is, if they did indeed present them as options, or if they presented any possible therapies at all, for that matter). Moreover, if the patient did ultimately make it to the hospital, the inaccessibility of the antibiotics that would be the standard of care in the United States (either due to absolute absence or relative lack of access due to cost) would necessitate a more extensive surgical debridement (and subsequently increased disability) to effect a lasting cure. Moreover, the significance of disability in this context—a context that itself is generated and conditioned by poverty—was apparent in my own difficulty getting to her room. Similarly, the second patient was a 63-year-old man who, not having received a single screening colonoscopy, flexible sigmoidoscopy, or even a simple rectal exam and fecal occult blood test (strongly recommended by the US Preventive Services Taskforce for anyone 50-years-old and above), now had what was probably flagrantly symptomatic colorectal cancer that had, given the severity of his bleeding, likely metastasized already and become virtually untreatable. Moreover, because he had never had a cardiovascular work-up or even a lipid panel (cholesterol, etc.), for that matter, and because he had never been on lipid-lowering or other cardioprotective therapy (other than the antioxidants that Peter gives many of his patients), it was possible that he had underlying coronary artery disease that put him at high risk of a heart attack given the degree of his symptoms of anemia. If he did overcome his understandable resistance to going to the hospital, he would be treated by surgeons and medical doctors who definitely lack the proper resources and who probably also lack adequate training to be treating him. When people here say they are afraid to go to the hospital because that is where one goes to die, that assessment may be very accurate indeed.

My medical and public health education takes on new meaning here. Ironically, the importance of what I have learned thus far becomes vividly apparent in a context where much of it cannot (yet) be put into practice. The insights from my meager personal study of social theory and anthropology take on a special vitality here. It is sometimes difficult, even for someone who strives to think and act in terms of social justice, to make sense of perspectives like that presented in the essays in Pathologies of Power if one is sitting at a desk in downtown Chicago, blocks away from a world-class hospital; this difference, I think, is what Paul Farmer refers to as “the vitality of practice.”

...

Wicha is the Kaqchikel woman from Santiago Sacatepéquez who has taken it upon herself to organize, facilitate and otherwise assist Peter’s clinics and house calls there. She is an interesting person, and I hope to say more when I have spent more time around her—and when I speak enough Kaqchikel to understand her better.

This last point is an interesting one. When I had originally emailed Peter, I had introduced myself as a medical and public health student interested in learning a bit of Kaqchikel—he replied with what he describes as an “unforgiving” email that I absolutely had to learn the language before pretending to do any good, lasting work. I have argued similarly at Northwestern about the importance of health care practitioners in the U.S. learning Spanish, so I could understand where he was coming from, even if I did not understand the details of the situation that informed his perspective. The two days in Santiago Sacatepéquez and our interactions with Wicha made evident—even though I was a bit reluctant to admit it at first—the fact that I need to learn Kaqchikel.

When we had walked around on Saturday making house calls, there were numerous occasions when we were walking up a hill and Wicha would break the relative silence in Kaqchikel. Peter would smile and say something in response, and a brief conversation would ensue. Only on occasion did we speak in Spanish—and when we did, it was really just me asking Peter questions in a language that Wicha would understand; she would walk a few steps ahead, listening but saying little. On Sunday, when we were sitting in the cofradía, Elena leaned over and asked Wicha a question in Spanish. Elena’s Spanish is not yet perfect, but, nonetheless, on the basis of my experience with gringos and shoddy translations in other contexts, I found the question to be entirely intelligible, both in terms of grammatical structure and pronunciation. Wicha listened to the question twice, and turned to me, asking, “¿Qué dice?” (“What did she say?”) Similarly, on our last house call for the weekend on Sunday, Peter had Wicha and me go down to the square to buy gauze at a pharmacy—Peter first asked Wicha, who hesitantly pointed at me to ask if I could go with her. On our long walk down the hill to the pharmacy, our conversation was notably absent—I asked a question or two and Wicha responded with yes or no answers, and I got the sense that my Spanish was difficult for her and that it would have been much easier in Kaqchikel. On our bus ride home that afternoon, Peter noted that Wicha hates speaking Spanish. I understand now what Peter means when he says the dynamic and perspective rendered in Kaqchikel are completely different. I have quite a bit of work to do if I hope to do meaningful and useful work here.

More thoughts from "the field"

2007-08-13T14:59:00.000-07:00

The major causes of morbidity in Central America and the Caribbean are maternal and neonatal problems, depression and violence. This fact, as Peter explained to me while we were awaiting a bus back to Antigua from his clinic in Santiago Sacatepéquez, calls into question the imposition of the appellation, “tropical medicine,” in his words, “wherever it is warm and there are mosquitoes.” Peter’s assessment, that “tropical medicine” is a mythical creation and a relic of imperialism, shed some light on my confusion about the eligibility requirements for the American Society of Tropical Medicine and Hygiene’s certification in tropical medicine: one must work in an impoverished country for at least two months before sitting for the certification exam; this is puzzling because it is implied that the “tropics” are an epidemiologically homogenous zone—somehow, working south of the U.S.-Mexican border is supposed to prepare certificate recipients to manage malaria, even if this work is conducted in the Guatemalan central highlands, where mosquito-borne diseases, as far as I am aware, are essentially nonexistent. This use of the word, “tropics,” reminds me of the equally perplexing use of the word “field” by a certain human rights professor at Northwestern in reference to what amounts to any and all non-First World settings. Such terminology obscures the diversity of different impoverished locales and their inhabitants and, perhaps more importantly, creates the potential for objectifying marginalized peoples and conceiving of their world as laboratories where very real and actively generated death, destruction and disability are rendered “facts of life” that fail to implicate the comforts enjoyed by us who descend from our universities and institutions to work in “the field.”

…

On Saturday, I followed Peter and Wicha, a Kaqchikel woman from Santiago who organizes and supports his activities there, on several house calls. Needless to say, the opportunity to enter the intimate sphere of people’s homes and to watch Peter work was unlike anything I had experienced previously, in Guatemala or elsewhere. Despite the relatively slow pace of the work—which is partly due to what Peter calls “the hospitality mechanism”—the relationship-building and patient-centered health education that is made possible through these house calls has allowed the gradual deconstruction of well-founded negative conceptions and assumptions about Western allopathic medicine and its providers. The perspective that comes from this mode of practice, in conjunction with critical analysis, is markedly absent when a physician blames an impoverished HIV-positive patient’s antagonistic posture towards healthcare providers completely on denial (failing to see that physicians are often representatives of oppressive power structures) and when medical students fail to recognize how heavily the Tuskegee syphilis experiments influence some African Americans’ contemporary mistrust of physicians.

...

I had asked Peter when we were in the market buying medicines if he and his colleagues had been collecting any quantitative data to demonstrate positive outcomes achieved through their treatment methods. Of course, the collection of such data requires a great deal of time and money, both of which are in short supply for any incipient NGO. Ample anecdotal data, however, directs his work. Again, the limited resources available require definitions of “treatment success” that differ from what would be considered the “standard of care” in resource-rich settings. Peter talks about using what he can to bring a patient’s random blood glucose from 300-400s down to high 100s/low 200s, and, while he admits that this is not “perfect” management and that there are other important treatments and outcome measures to be considered in diabetics, he points to the change in quality of life that he has observed in many of his patients. If the best available care is the ultimate lofty goal, and if the needs of many individuals must be at least temporarily balanced with the needs of a few, then helping a patient progress from a bedridden existence to planting his first maize crop in 3 years can be considered an exciting and unequivocal success—even if his fasting glucose is above 126 mg/dL.

...

Today, Monday, I began instruction in Kaqchikel! I learned letters and sounds and some rudimentary conversations (“Good morning. How are you? I am fine, thanks. Where are you from? I am from Chicago.”). Learning a new language is difficult, but it is also a lot of fun. There is nothing more fulfilling than the way one’s head throbs after spending a few hours in the kind of transcendental levels of concentration required by the effort to internalize a completely new vocabulary and grammar. The arrangements for lessons are still a little up in the air, and I’m taking things on a day-to-day basis in terms of teachers and times of day that they are available. The majority of the teachers at the language school are working with a summer class from the United States until the end of this week, which means that things may be a bit disjointed and disorganized this week. In any case, I got a new textbook that Peter suggested and that is a more extensive version than the English language one I got in the United States—this is quite exciting for a Bengali with a book fetish! I also learned from the teacher that I worked with today that the fair rate for personal tutoring with a teacher who lives closer to where we will be spending the rest of the year (that is, on Lake Atitlán) is relatively compatible with our small budget. So, good things, so far—now all I have to do is put in tons of hours and much effort. Ack!

On Mayan medicine

2007-08-13T14:56:00.000-07:00

A quick disclaimer: of course what is written here is the result of just 2 days in Guatemala, and some of the perspectives and information are liable to modification over time (and rightfully so, I think) as we gain experience and knowledge. So the following entry is really just a representation of where I am and what I’m thinking about right now on this journey. Thanks for your patience. Without further ado…

On Saturday morning I woke up early to make sure I had time to stop by an Internet café to print a copy of my proposal before meeting Peter, who is serving as an advisor on my project in San Lucas Tolimán, in Antigua’s central park. I arrived a bit early, so I sat and reread my proposal briefly. I spotted him after a few minutes, walking quickly to catch up with him and calling out to get his attention. We shook hands and headed to the market—we had spoken the evening before, and he had told me that he needed to stop by the market to purchase some medicines.

I followed closely behind him so that I could hear what he was saying and so that I wouldn’t lose him in the maze of shop stalls. Finally, he stopped in front of a large corner stall full of fresh produce, which he looked at and said, “This is the woman I usually buy stuff from.” I looked more closely at the stall’s wares, searching for strips of pills and bottles of ointment, but saw none; I looked around me at the other stalls, searching for a small stash of allopathic medications or medical supplies, but all I could see was more fresh produce. Peter got the attention of the woman who runs the store and, speaking to her in Kaqchikel, began asking her for things.

The only word I understood was “manzanilla”—chamomile—and I quickly realized that, given Peter’s avid interest in ethnomedicine, when he said he needed some “medicines,” I should have understood that he meant medicinal herbs. He proceeded to collect a sizeable bunch of different herbs and vegetables, and in between speaking in Kaqchikel to the storeowner and her assistant, he explained to me in English the rationale and principles for using alternative medicine. Medicinal herbs are cheaper and, for a physician who has not yet received what will be a nominal license to practice, more easily accessible than allopathic medications. The usual issue of cost and accessibility is compounded by the fact that generics are, according to Peter, virtually impossible to come by in Guatemala. I do not know the reasons for sure, and nor did Peter, but I have a bad feeling that this is the result of predatory, “neoliberal” policies akin to the stipulation that the sums of money recently promised by the United States for the purveyance of anti-retrovirals in sub-Saharan Africa be used to purchase only non-generic medications, converting what could have been a huge humanitarian gesture into a kick-back to First World pharmaceutical companies. (I use quotes around “neoliberal” because I think that cheap drugs should be the outcome of a neoliberalism that fosters and is based upon truly equal competition.)

Reasons other than cost (and Peter’s current student’s-stipend-budget) drive the use of herbs. First, the structural violence that has and continues to characterize relations between indigenous and non-indigenous peoples is manifest between practitioners of Western allopathic medicine and indigenous patients, and the use of medicines that are a part of indigenous Mayan medicine fosters trust and adherence to treatment regimens. On our walks between patients’ houses, Peter explained several examples of patients who quietly refuse to take allopathic medications but whose diseases have nonetheless been brought under relatively good control with only herbal medicines. Second, the use of Mayan medicines, in conjunction with activities such as Peter's financial sponsorship of Mayan religious ceremonies, serves the ostensive mission of Peter’s newly founded NGO, Wuqu’ Kawoq (see sidebar for Internet link), “strengthening Mayan culture and medicine”: the study and use of medicinal herbs contributes to the effort to preserve and revitalize Mayan knowledge and culture. In any case, after this interesting introduction, and after two days of continuing to learn from Peter about medicinal herbs, I am convinced that they should be appropriately incorporated as first-line treatments.

Peter also explained that at this point he is using about 20 or so such remedies, and that an important criterion for use of a specific medicine is scientific literature verifying its benefit—of course, not all of this evidence is from head-to-head randomized controlled trials comparing herbs to allopathic medicines, and Peter also noted wryly that it is a little imperialistic to make decisions based on Western allopathic standards, but that it is an easily rationalized way of selecting from the hundreds of herbal therapies for various ailments.

That's all for now. Thanks for reading! I'll post more soon.