In “Pedagogy of the Oppressed,” Paulo Freire advocated for a teaching practice that shatters a town’s “culture of silence.” An irrepressible force against capitalism and hierarchy, Freire asked us to imagine creative modes to address this silence and then act on it, as teachers.
What about the culture of silence surrounding the local medical clinic? Along these lines, I asked a recent class of 34 students to write about their last medical experience (with identities protected). Their responses astounded me.
One student, an Iraq War veteran, went to the local Veteran’s Administration hospital to evaluate his disability claims for Post-Traumatic Stress Disorder (PTSD) only to be told he was only suffering from hearing loss and to “check the VA website” for updates.
“One doctor asked me if I had been exposed to any loud hearing noises during my time in Iraq. . . Then [another doctor] mentioned that I ‘should have been wearing hearing protection over there.’ I reminded him that it is not feasible, nor possible, to wear hearing plugs constantly over a 12 month period. So unless the insurgents would like to warn me ahead of time of an attack, loud surprises will happen.” The veteran has no hope of getting PTSD benefits and finds the VA “very dehumanizing.”
Another veteran, suffering a persistent left shoulder injury from his days as a paratrooper, was informed that his pain likely came from an earlier botched surgery by an Army doctor who was “less experienced” than other surgeons.
Then there was the father who took his three year old daughter to the ER at 2AM with a stomach ache. Over five hours she was given four x-rays, an ultrasound and an enema with no improvement (and no diagnosis) of her condition. She cried all night and was given nothing for the pain. Finally, at 7AM, after the father refused a second enema, he took her home with a prescription for MiraLAX (a laxative), gave it to her and she was quickly cured.
These stories rarely get told. In doctors’ offices around the country there exists a veritable Lock Box of stories and secrets about the sea of troubles all around us. The clinic is where — every single day — hundreds of thousands of testimonies about our afflictions go to die, never systematically broadcast to the citizenry at-large.
If my students’ reportage is any indication, then most people suffer the traumas of capital and its preferred medical approach, biomedicine, in relative silence.
This is no longer acceptable. As Foucault puts it: “The real political task in a society such as ours is to criticize the workings of institutions that appear to be both neutral and independent, to criticize and attack them in such a manner that the political violence that has always exercised itself obscurely through them will be unmasked, so that one can fight against them” (Chomsky/Foucault 2004:41).
“Medicine is a Social Science”– Rudolph Virchow, Anthropologist
Anthropologists call the dominant medical “system” biomedicine, because of its focus on biology, not the social sciences. As many social scientists will tell you, the traumas of capital amount to a biopolitics of human disposability and include things like oil wars (and their associated casualties), the fetish of technocratic rationality (over the art of medicine), the overspecialization of knowledge (to the neglect of holistic perspectives), the privileging of profits over disease prevention, the speed-up of doctors by insurers, the crisis of clinical iatrogenesis (doctor induced harm) and the relentless attacks on the social state (defunding of health, education and human welfare). On August 20, for example, the Annie E. Casey Foundation reported that the number of American children now officially in poverty has soared to 20% (14.7 million). We know that these children will, on average, die significantly earlier than their U.S. brothers and sisters who live in higher income families.
These theoretical realities manifest themselves in our everyday life at the clinic. Fifty percent (17 students) of my students complained that they were rushed or not given enough time to ask their medical questions. While many of us can identify with that experience, few readers will be prepared for the level of clinical iatrogenesis (doctor/medical harm) that appears to be present from my analysis of student reports: 35% (12 students). This included: a missed foot fracture diagnosis, advice to remain on a medication that was probably the cause of dramatically elevated liver enzymes, radiation induced scarring of the prostate, lack of a needed psychological referral, missed diagnosis of a hand fracture after a car accident, misapplied braces causing jaw pain, “shock and irritation” at a doctor’s callous treatment for chronic acid reflux disease, irregular bleeding and depression likely caused by birth control pills to control hormone levels, a physician’s diagnosis that a student’s bladder problem “could have been caused by a former practitioner who did something wrong,” and the three cases referred to in the opening paragraphs (refusal to diagnose PTSD, surgical mistakes causing shoulder pain, and a 5 hour ER visit with over-medicalization and no relief).
Remarkable also are the numbers of patients/citizens who reported that they felt that social/environmental factors may have contributed to their presenting complaint: eighteen (53%). Even more remarkable is that in every one of these eighteen cases, it was the patient, not the doctor/practitioner, who brought up the topic (13) or who thought about the topic (5). These factors included thoughts about a next door neighbor’s air conditioning causing eczema, war, medical error, work stress, home life and some of the conditions discussed above. Doctors only initiated discussion of environmentally related topics four times (e.g., drink more water to prevent cramping, allergy induced headaches, and ringworm likely caused from fellow athletes).
In short, iatrogenesis appears to be more widespread than fully appreciated by citizens. And yet no medical school yet has developed a “Department of Iatrogenic Medicine” as called for by Robert Mendelsohn, MD, in 1979.
Also, social and environmental etiologies to suffering and disease are too often ignored in clinical life. These findings confirm Howard Waitzkin’s research. He found that, for a number of reasons, social problems were not dealt with critically. Instead physicians focus their attention on physical complaints and usually fail to address patients’ underlying concerns, thus reinforcing the social problems that caused or contributed to these maladies. One reason for this phenomenon, he charged, was that “few primary-care practitioners learn to spend much time on contextual concerns in . . . their training” (Waitzkin 1991:5).
Yes, there are legions of caring physicians who bring people back to health, but even they are ensnared in a pernicious system that rigidly enforces professional conformity and public silence. Heretics are routinely punished (Carter 1992, Saputo 2009). If medical education has not already succeeded in neutralizing medical student passion, there are other means, like the stigma of being labeled different (Carter 1992, McKenna 2010, 2011).
Paulo Freire insisted that, “If the structure does not permit dialogue the structure must be changed.” Along this path, imagine if we could systematically liberate clinical complaints from their biomedical entrapment in our own towns and communities. What might we learn? How might that serve as the basis for a public pedagogy to stir citizens to political action?
Lock Box Medicine in a “Managed Democracy”
I spent three years (1998-2001) performing a holistic environmental health assessment for local government (a public health department) in Greater Lansing Michigan in an applied anthropological effort to unmask these relationships and make connections between health, medicine and the environment (McKenna 2010). Three studies (on water, air and food) revealed vast amounts of pollution from a wide array of local institutions including General Motors, Michigan State University, even local hospitals (e.g., mercury pollution). Local hospitals refused to release emergency room disease data to the local public health department, including data on the hot spots for African American asthma cases, then a crisis. They also did not release their hospital-based iatrogenic data to public health. So detailed and thorough were these three reports (produced under the guidance of a twelve member Roundtable of well-known environmentalists) that the government suppressed them and ordered me never to mention them again, even after $250,000 in expenses. I left the government and together with Roundtable member Dave Dempsey, had the reports released by Public Employees for Environmental Responsibility (PEER) to a national audience. Media response was uneven (no TV station broadcast the news), though the Lansing Sate Journal had an article which supported PEER’s version of events (McKenna 2010). But Greater Lansing doctors and medical schools said nothing. Later, in a newspaper article as a local journalist (McKenna 2003), I reflected on fifteen reasons why the reports were suppressed. Among them was reason number 9:
Attributing specific health outcomes to the environment would undermine the entire medical-industrial complex. Doing environmental health research is a very radical proposition. If a significant portion of local diseases — cancer, heart disease, asthma — could be attributed to specific environmental toxics [and toxins] at given sites, then the social order might be turned upside down as massive monies shifted to the victims of toxics (via litigation, legislation or other methods). That’s why BIO-medicine is the dominant form of medicine. It focuses on BIO-logical pathology diagnosed after the fact and pretty much ignores social, psychological and environmental etiologies to illness and disease. And if the social and psychological factors are recognized, they are seldom reimbursable (McKenna 2002).
Imagine if local oncologists left their clinics one day per week, every week, to work with citizens in public education efforts against the polluting factories. Think about the power of persuasion that ER physicians could bring to local schools, educating about bike helmets and car safety as a regular part of their job. Imagine if dermatologists protested one day a week in front of tanning salon and worked to bring sunscreen companies to justice for their false advertising.
They don’t. There is no real money in prevention.
A great deal of illness and disease can be attributed to local actors operating within larger circuits of power. These actors can be expected to be antagonistic to public health institutions and citizen activists. As Robert Lynd wrote so long ago in Middletown, “The business men who ‘run’ the average American town are very likely to oppose any expose’ for more effective public health administration (Lynd and Lynd 1929:450).” In my public health work I demonstrated how business men can often rest assured that local governmental officials will do their work for them. As hegemonic actors in larger circuits of power, local public health administrators are often willing to ignore environmental threats or to censor and suppress critical initiatives from within their bureaucracies. Doctors, by and large, are the same.
“The truth is, the real secrets of modern medicine are protected by tradition, group-think, and system constructs that punish inquiry and self-examination,” asserts Physician David H. Newman in his important text, “Hippocrates’ Shadow, Secrets from the House of Medicine (2008). “They are embedded in the presumptions and thought patters that we are taught to embrace during our indoctrination and on which we come to rely. . . .These are the secrets and lies that shape the practice of modern medicine (Newman 2008:xvi).”
Doctors are supposed to be teachers but they are indoctrinated to keep that Lock Box tightly sealed. They make their millions exploring the diseased body, not the Body Politic. By their silences, doctors serve as guardians of corruption, pacifying the local populace by refusing to convert private pains into public issues.
But it goes beyond that. In his book, “Democracy, Inc.” political theorist Sheldon Wolin argues that the United States is on the verge of becoming an “inverted totalitarian” culture (Wolin, 2008). Unlike classic totalitarianism with its strong central control and rigid citizen mobilization, our times represent the political coming of age of corporate power and the political demobilization of the citizenry. With the constant downsizing, privatization, outsourcing and the dismantling of the welfare state the resulting state of insecurity makes the public feel so helpless that it is less likely to become politically active, he argues. The biomedical system is a powerful force in this trend.
Critical social scientists, like anthropologists, are systematically excluded, as teachers, from practicing in biomedical clinics (unless they have an MD or biomedical credential). Much critical research about biomedicine (and other medical approaches) is ignored in mainstream practice. But as Freire said, “Washing one’s hands of the conflict between the powerful and the powerless means to side with the powerful, not to be neutral.” Critical medical anthropologists, following the examples of Paulo Freire and critical pedagogues like Henry Giroux, will never give up the project to transform education and create a living democracy.
We need to conduct ethnographic investigations of medical complaints in our own schools, towns and communities and then link that research to submerged (and suppressed) data about social and environmental etiologies, local and global. Then we must find creative ways to convert that emancipatory knowledge into effective pedagogical tools to civically engage the calumnies of local power.
Brian McKenna lives in Michigan. He can be reached at:firstname.lastname@example.org
A version of this article was originally published in the Society for Applied Anthropology Newsletter, Vol. 22:3, August 2011. Tim Wallace, editor. http://www.sfaa.net/newsletter/aug11nl.pdf
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