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.
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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?
[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?]
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:
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Bourdieu, Pierre.
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Csordas, Thomas.
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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.
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Parsons, Howard.
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“Charisma and its transformation.” In: 1978 Max Weber: Economy and Society. Berkeley: University of California Press.
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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.
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Wolff, Klaus, and Johnson, Richard Allen.
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Sunday, November 23, 2008
Xkam rute' Gerardo
I am filled with remorse and shame.
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
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?
Wednesday, November 12, 2008
Epistemic ruptures
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.
Wednesday, August 13, 2008
Achike roma yiq'ax ri enter q'ij rik'in Ixin Ulew pa nujolon?
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.
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.
Thursday, July 24, 2008
I love Skype, I miss everyone
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!
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!
Friday, July 18, 2008
Getting off topic
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)
"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
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'!
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'!
Thursday, July 17, 2008
Tuesday, July 15, 2008
In Boston, thinking of Ixin Ulew
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!!!
...
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!!!
Friday, June 13, 2008
Arthur Kleinman on 'cultural competence' in medicine
I liked this.
How can I fulfill my responsibilities as a physician without thinking anthropologically, without engaging ethnographically?
How can I fulfill my responsibilities as a physician without thinking anthropologically, without engaging ethnographically?
Friday, May 30, 2008
Xkam rujite’ Vicente
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’?
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?]
Friday, May 16, 2008
Accompaniment and conversion
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?
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?
Sunday, May 11, 2008
Xkojb’a ke la Boston!
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!
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!
Wednesday, March 12, 2008
An "accident" near K'ix ya'
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.
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.
Monday, January 28, 2008
An artefact of inequality
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.
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
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.
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.
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