Ambiguity/Struggle

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

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

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

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

Rune'y Lola

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

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

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

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

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

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

Zizek on excremental ideology

Zizek.

Me.

Zizek is much, much funnier.

Pain, addiction and The War on Drugs

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

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

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

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

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

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

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

The experience of exception

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

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

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

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

the fetishization of regulation, and the secret thereof

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

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

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

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

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

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

Action, context, revolution.

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