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.