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The Doctor as a Humanist – a Solution to Uncertainty?

18 Jul, 17 | by amcfarlane

Jonathan McFarland, (Sechenov University), Annalisa Manca (Queen’s University, Belfast), and Irina Markovina (Sechenov University) describe their upcoming symposium, “Can the Humanities Transform 21st Century Medicine?”

In October 2017, the first “The Doctor as a Humanist” symposium will be held in Palma de Mallorca, Spain, with the following subtitle “Can the Humanities Transform 21st Century Medicine?” The symposium will bring together experts in medical humanities from around the world (UK, Spain, Russia, India, USA, Canada) along with medical students from the different participating universities (Sechenov, Moscow, Pompeu Fabra, Barcelona, Queens Belfast and the Balearic Islands University), and will be divided into sections; including Literature and Medicine, Art and Medicine, and Music and Medicine. All aim to answer the above question. One of the main goals of the symposium, which is embedded in a wider pedagogic project, is to start up an International Association, which, among other things, wishes to develop ways to introduce the humanities into the medical curriculum and practice. Siddhartha Mukherjee in a recent book comments,

I had never expected medicine to be such a lawless, uncertain world…the profusion of facts obscured a deeper and more significant problem: the reconciliation between knowledge (certain, fixed, perfect, concrete) and clinical wisdom (uncertain, fluid, imperfect, abstract). (1)

There is no doubt that life in general, and medical practice, in particular, is becoming ever more technologically oriented; we just need to watch our children plugged into their mobile phones and computer screens to see this. In the last 100 years, medicine has progressed so much, and the medical tools available to doctors has multiplied to such an extent, that previously untreatable diseases can now be cured.

This is the miracle of the twentieth century, and this is due to medical research. And yet, it has changed the practice significantly, and has even, perhaps, altered the meaning of healthcare. As Danielle Ofri said in a recent article, “thanks to a century of staggering medical progress, we now live past 80, but evolution hasn’t caught up; the cartilage in our joints still wears down in our 40s, and we are more obese and more sedentary than we used to be, which doesn’t help.” (2)

This is a long way from Osler’s three Ps: placebo, palliation and plumbing; the days when the observation of patients and noting down of their symptoms, the famous “bedside manner”, was the only solution because there was little else to be done. Osler was the father of diagnostic technique – “listen to your patient, he is telling you the diagnosis” – and, in those days, doctors were steeped in classical education. Nowadays, machinery has all but replaced the doctor’s eye and ear, and although this has brought about a democratization of medical practice, it has also transformed the doctor-patient relationship to such an extent that perhaps there is more distance between them since before the days of Rene Laennec. Modern doctors are turning away from the stethoscope and physical examination to the MRI and CT scan. Clinical judgment has been superseded by complementary tests, so, what is the answer?
On the one hand, we strongly believe that medical progress such as genomics, stem cell and tissue engineering, 3D printing and so forth, will revolutionize medical practice even further, and no one will deny that the benefits to mankind will be extraordinary. But on the other hand, what will the cost of these benefits be? More loneliness, and mental health problems in the general population, and more demotivated and burned out health professionals?

Is there a solution?

The October symposium, and the subsequent The Doctor as a Humanist Association, will attempt to use and learn from the experiences of doctors from different countries and cultures to build strategies to cope with the uncertainty inherent at the core of medical practice. Ironically, our remedy is to look to the past, when the humanities played a critical part in medical care. Indeed, this separation of the humanities from medical education is only recent, and prompts a series of questions. When did it take place? What has it meant for medical education and care? Can we bring back what has been lost? Do the humanities still have a key role in the medical care framework of the 21st century and beyond? The Doctor as a Humanist will try to answer these questions, as we truly believe they could be the key to unlocking the medical education and practice of the future.

Time present and time past
Are both perhaps present in time future
And time future contained in time past.(3)

References

1.  The Laws of Medicine: Field Notes from an Uncertain Science, Siddartha Mukherjee, Simon & Schuster/TED, 2015.
2. The Conversation Placebo, Danielle Ofri, The New York Times, 19 January 2017.
3. Four Quartets, T.S.Eliot, Harcourt, 1943.

Corresponding author: Jonathan McFarland (Sechenov University): mcfarland.jonathan@gmail.com

When Truth Speaks: Discourses of the Voice in Medicine

17 Jul, 17 | by amcfarlane

Dr Ayesha Ahmad, Global Health Humanities Correspondent, has been travelling in Afghanistan and Nepal and meeting women who’s lived experience is a conflict of chronic gender-based violence. Her initiatives are to integrate storytelling into mental health trauma interventions globally in contexts of war, oppression of women’s speech, violence towards women and girls, and writing against the backdrop of rich story-telling traditions.

Often I reflect on the stories I have listened to. At these times, I collect the way I have experienced their stories; the gazes and the silences and the image of when someone looks me in the eye and speaks. These stories come from doctors, students, patients, and from people unknown to the world because of the suffering they carry. I bring these stories together in my mind. I wonder whether practicing medicine has limits; can medicine find all of humanity? I believe medicine can, and does. I always remember some feedback I received from a lecture I once gave on conflict and health; I was told I know how to tell a story. To this day, this remains a source of strength for me. This is the humanity of medicine, of the treatment of suffering whether from the clinic or the academy; the telling of and listening of stories.

I am one of countless individuals indebted to Professor Rita Charon who is working in some context of the clinic and feels at home with the concept of narrative as foundational for medical practice. My work focuses on the written narratives in mental health trauma related to gender based violence. Alongside, Charon’s pioneering research, during my PhD I saturated myself with Jacques Derrida’s notions of discourse and the signs and symbols of how we interpret and understand our experiences. To write the phrase ‘medical practice’ begs reflection; what does practicing medicine mean? Medicine places the unknown existentialisms of our human condition into a sphere of turning narratives; we find structures among these, creating universalities of being human wherever the world tilts; our births, living, suffering, dying, and death, and then the spirit, where medical practice halts and understands that spirits cannot be treated, and are only for healing. Spirits, then, are an equaliser; whilst medical practice is the handling of humanity, a spirit solidifies the existence of the story.

In my field of global health, I bear witness to the narratives of healing from the depths of all languages; the narratives of different authenticities that speak from a truth that I have perceived in the eyes of people who I am recollecting now, one by one. As Charon describes, I am honouring their stories. Their truths are speaking.

In all the stories that I have received, though, I have held disclosures yet at the same time I face distances of darkness, spaces of unfilled voices and visibilities that remain silent and unseen. This is the tragedy I am writing about. The truths that are unspoken, yet lived.

I question my role as an academic researching, lecturing, discussing ethics consultations, writing, presenting in international conferences, collaborating with non-governmental organizations, providing medical education for students and trainee doctors, and trying to find ways to free the tightly-rolled narratives of the marginalized. Medical practice provides a mode of examination for the way our stories make us ill; the somatised symptoms of a suffering that our societies suppress; because we fear bearing witness to suffering, and the telling of a story requires justice. But when the perpetrators are our protectors then what is the role of medicine? Can medicine practice justice?

I have heard the truths of doctors who witness other doctors committing abuse and violence towards patients in countries that are born from structural poverty, colonialization and chronic humanitarian crises; I have held in my hands the transcripts of traumas from the land as well as the body from asylum seekers and refugees; I have seen the pains that languages cannot speak. In all of these the truth has spoken; these are the discourses of medicine; the signs and symbols of our suffering of humanity and the patients for the practice of medicine.

Some of our greatest contemporary writers, Elif Shafak and Adiche, warn against the reduction of our identity into a single narrative. Truth also follows a similar path; symptoms of suffering are not reducible to a single narrative, not of the body, not of the mind, not of the spirit. The narratives of a narrative-based medicine are embodied, encompassing, and excite the diversity of different discourses.

We do not need to speak every language or interpret every sign or symbol to practice medicine; rather, to honour humanity, we need to have space for the truth to speak—that is, for our voice and our visibility to be present, that is the practice of medicine.

“Congenital Glaucoma”: Commentary

12 Jul, 17 | by amcfarlane

Dr Richard Ratzan gives us a commentary on his poem “Congenital Glaucoma, published in BMJ Medical Humanities, and explains why he decided to write about this case using the sonnet form.

This little girl – she was probably about 13 or 14; I don’t remember since it was about 10 years ago – was from Mexico, almost certainly illegally but I do not remember that for certain either. She was with 2 or 3 boys her same age. What struck me about the case – and prompted me to write about it – were the following: first, how animatedly happy they all were. In retrospect, given how devastated I was that she was not only blind but preventably so, I was impressed that this misfortune was not precluding their youthful joy. (Whether she was so joyful when the ophthalmologist gave her the official bad news in his office – as he did since I called him about her two days later – I do not know.) Secondly, as someone who makes it a practice to look in at least 3 to 4 sets of fundi a shift – I find it useful and I do not want to lose this skill, as I would were I to use it, as my residents do, only when I “need to”, e.g., for severe headaches or visual problems – I was astounded, as I have not been that many times in my professional life, by the sight of her fundi: each cup was a bottomless pit of featureless whiteness, with vessels falling off into them from the edge of her retina as though falling off the edge of the universe. (I was also acutely aware then, as I write “sight” now in the preceding sentence, of the irony that it was only my good vision that could diagnose her lack of it.) Thirdly, I was struck by how blasé about it my resident, a good PGY3, was. Yet again I marveled at young physicians’ lack of ability to marvel. Is it their lack of experience, the paucity of fundoscopic examinations (not that they do that many these days or ever will accrue a database with which to compare) against which to measure medical horror when they see it? Or is it simply a different attitude they bring to work, an unwillingness or youthful inability to see the wonder of clinical medicine when it rears up in front of you? It is not callousness, at least in this young resident’s case. And fourthly and lastly, I grieved at the tragedy of her being born in Mexico without the resources we in the U.S. take for granted. If her parents here had noticed her trouble seeing as a younger girl – as I am sure hers in Mexico had – she would have gone to an ophthalmologist and – case closed – gotten preventive therapy. No blindness. Which is why, as someone who knew little girls like this when I used to spend a lot of time in Mexico, I referred to it as a sacrifice – a sacrifice of Mexico’s poverty and inadequate health care. A sacrifice I tried to make more historical and poetic with references to pre-Columbian mythology.

Why a poem, and why and how a sonnet? I have been interested in telling medical stories, vignettes, case histories, in verse for years since there is an economy to verse and a freedom “to tell all the truth, but tell it slant” [ref 1], a quotation (the title of the poem, actually) from Emily Dickinson that my late physician-poet friend, John Stone – and a far greater poet than I – liked to invoke whenever he was asked the same question – why poetry? But why a sonnet and not a villanelle [ref 2] or a sestina [ref 3]? It is the liberating mode of poetry and the simultaneous discipline, the challenge, of packing everything into a tightly defined package of a sonnet’s 14 lines. First I must squeeze the facts of the case into the octet, the first 8 lines, and then the exposition of the ideas, which exposition will only work if I have been successful in the first 8 lines, into the terminal sestet, the final 6 lines. Although Shakespeare usually uses the last two lines as the “volta” (Italian for “turn”, the axis point at which the poet gets to the crux of the poem) of the sonnet, I almost always follow the Petrarchan model using a sestet to “wrap up” the case. What I find most challenging is the tension between being too economical – writing solipsistically cryptic references only I understand – and prosaically literal. The former borders on the opaque (Wallace Stevens can pull it off; I can not). The latter is the case history we have all learned to use when dealing with other medical listeners. In between is poetry. As my second son said with amazement some years ago, upon hearing that I had attended a standing-room-only poetry reading by Mary Oliver at Smith College, wondering what the big deal was about poetry, “Poetry is incomplete prose. There are words missing.” (I didn’t have the heart to tell him that his definition of poetry was a veritable haiku. I did not want to ruin his day.)

References

1. Dickinson, Emily. “Tell all the truth but tell it slant”. Poetry Foundation. Accessed May 5, 2017.
2. Williams CK. “Villanelle of the Suicide’s Mother”. Reviewed by Ratzan RM. Accessed May 5, 2017.
3. Hadas, PW. “To Make a Dragon Move: From the Diary of an Anorexic. Reviewed by Donley C. Accessed May 5, 2017.

Book Review: Understanding Health Inequalities and Justice

11 Jul, 17 | by amcfarlane

Understanding Health Inequalities and Justice: New Conversations Across the Disciplines by M Buchbinder, M Rivkin-Fish and RL Walker (eds). Chapel Hill, NC: University of North Carolina Press, 2016, 320 pages, £37.50.

Reviewed by Professor John Harrington, Cardiff University

Inequality has returned to the political agenda in Europe and North America in the aftermath of the financial collapse of 2008 and the austerity programmes which followed it. The paradoxical success in failure of Bernie Sanders and Jeremy Corbyn in US and British elections respectively marks this shift. The long decades of neo-liberal hegemony, which privileged supply-side ethics and economics over the redistribution of resources, have come to an end. Instructed by scholars such as Thomas Piketty and challenged by the Occupy movement, parties of the right and the so-called centre left now accept that a direct concern with remedying inequality is essential to sustaining the legitimacy of the capitalist order. Contemporary health policy and politics are no exception. Persistent inequality in access to care and in health outcomes, exacerbated it is claimed by austerity regimes, track patterns of social exclusion and historic disadvantage associated with gender, race, geographic location and citizenship-status. While policymaking and research on health inequalities and injustice is of longstanding, they have gained urgency in the present conjuncture.

This collection is timely therefore, containing engaging and fresh interventions on the connections between health inequality and justice from scholars working in ethics, anthropology, history of science and health policy studies. Its aim is not only to provoke reflection on how we define and address health inequalities and inequities, but also to contribute at the level of methodology, highlighting the analytical strengths, but also the blindspots of the different disciplines in their engagement with these questions. But it does much more than simply line up perspectives one alongside the other. Lively interdisciplinary dialogues are ‘staged’ within individual chapters themselves. Paul Brodwin’s essay on mental health, for example, showcases the possibility for a productive interaction between the first-person testimony of survivors and abstract work on the ethics of recognition. In a respectful reading he shows how each approach can complement the other. Personal accounts indicate the dynamic nature of the quest for respect and intersubjective recognition by former patients, while theory can clarify the values which are often simply assumed by personal accounts. His hopeful conjugation of two different genres stands in contrast to the hermeneutics of suspicion which suffuses the encounter between disciplines evident in other chapters. Thus, Eva Feder Kittay uses ethnographic accounts to challenge the assumption in law and policy that all patients exercise their autonomy to the same extent and in the same way. Her use of personal narrative here allows the reader to go deep and wide: identifying the influence of historic discrimination and location within networks of support on the ability of different individuals to behave ‘autonomously’ in accessing and benefitting from health care.

It is a notable strength of the book that the interdisciplinary conversation signalled in its subtitle is also carried on across chapters, as well as within them. Thus, Kittay’s review is augmented by the theoretical platform developed by Janet Shim and colleagues in their own critique of the ‘Patient-Centred Care’ model which has underpinned recent US health reforms. Building on the work of Pierre Bourdieu, they argue that clinical encounters are shaped by the specific ‘cultural health capital’ available to each party. This repertoire of communication skills, educational attainment, deportment and etiquette is itself unequally distributed among patients, leading to correspondingly varied attitudes and interventions on the part of their doctors.

The salience of such pre-conscious attributes (or ‘habitus’) is taken up in relation to the oral health of Mexican migrants to the US by Sarah Horton and Judith C. Barker. Drawing on extensive ethnographic work they show the enduring influence of limited access to dental work on the health and broader social prospects of the children of undocumented workers. Detailed stories of women prevented from breastfeeding by their employment conditions and the efforts made by children and young adults to hide or remedy defects make vivid the insight which several contributors borrow from Nancy Krieger, writing elsewhere, that inequality is embodied. The critique of formal autonomy is extended by Janet De Bruin and colleagues in their chapter on conceptions of risk in pregnancy, which shows how legal measures and media discourses about maternal responsibility, claimed to be based on neutral empirical studies, are in fact deeply shaped by culture and prejudice. This provides empirical substance for a critical ethical review of policy with reference to the six essential heads of well-being set out by Madison Powers and Ruth Faden in their theory of social justice and health.

The chapters discussed are animated by faith in the capacity of interdisciplinary approaches to produce new perspectives on the nature and ethical significance of health inequalities, even if their conclusions are often pessimistic in substance. Nicholas King is a notable exception to this, warning of the perils of ‘cross-disciplinary’ cherry picking which lead to easy but not wholly justifiable policy recommendations. His immediate target is the widely held view that reducing social inequalities will lead to improvements in health. That position, he argues, confuses the undeniable association of poverty and ill health, with the existence of a causal relationship between them, which has not by and large been proven. He suspects philosophers and social scientists of wilfully or carelessly paying insufficient attention to the limits of epidemiological findings and assuming their objective and value-free character in order to strengthen their own normative position. This argumentative sleight of hand will be found out, he suspects. Better to be honest and stake a direct claim for combatting social injustice, regardless of its (unproven) effect on health. This is a wise counsel, though King might have augmented it by adopting the contextualizing methods on display elsewhere in the book. A more historically-informed reading would suggest that the desire to ground interventions in ostensibly neutral studies concerning health effects is consonant with the dominance of evidence-based policymaking, and the more insidious compulsion to defer open debates on distribution and equality both typical of neo-liberalism.

The problem of causation also troubles Paula Braveman in her opening contribution to the book. She accepts that the term ‘health inequities’ gains its specific rhetorical force from the attendant notion that such disparities can be traced to unfair social structures. Like King, she accepts that this causal flow is hard to prove. Like him she wishes to avoid pinning the case for active intervention to meet health needs to this element, arguing instead that bare health inequalities are themselves of ethical significance in so far as they compound pre-existing unfairness. State responsibility to act in such cases can be based on the normative repertoire of international human rights law, and in particular its strong injunction against discrimination and its focus on remediating the position of disadvantaged groups. This is indeed a plausible reading of human rights law, though one wonders at the extent of its likely political traction in the US, which has not of course ratified the International Covenant on Economic, Social and Cultural Rights, central in this context.

State obligations are a key focus of Jennifer Prah Ruger’s chapter, which is the only one to engage directly with questions of global health justice. Based on a careful blending of governance studies and theories of justice she sees an important role for the nation state, which had previously been somewhat overlooked in the global health literature. The state is conceived of here as an indispensable lever for addressing health inequalities as between populations in different parts of the world. This is a wholly instrumental characterization. The state’s contribution is defined only in categorical and functional terms, circumscribed by universally binding standards of justice themselves based on the rights and responsibilities of individuals. No attention is paid to the historical specificity of different states, and particularly those in the global south which are the focus of most global health efforts in practice. As medical anthropologists and historians of science have shown, the work of independent states in health as in other social sectors was oriented by the aspiration for development and emancipation from the effects of colonialism widely shared among their citizens. Of course, in many cases this aspiration was bitterly disappointed. But states remain nonetheless the objects of desires and concerns which exceed the merely instrumental.

Ruger also demonstrates the power of the capabilities approach in orienting studies of health justice domestically and globally. Its emphasis on the protection and promotion of agency is a theme taken up implicitly and explicitly by many other contributors from different disciplines. Indeed, the detailed ethnographic studies and closely-read patient testimonies, as well as the critical engagement with popular discourses around pregnancy and migrant health rights, offer us wide ranging evidence of the ceaseless struggle to secure patient autonomy and health justice. Structural determinants, arising out of economic and legal constraints, as well as conscious bias and inherited disadvantage mean that health agency is almost always realized in ‘tight corners’. This crisply edited, well-constructed collection deserves our praise for directing our attention ‘up’ to the level of critical ethics, and ‘down’ to the messy world of practice and in forcing us to reflect on the often problematic, but sometimes enriching and productive relationship between the two.

CFP: Pain and its Paradoxes

11 Jul, 17 | by amcfarlane

BMJ Medical Humanities will host a special issue on PAIN in June 2018! We want you to be part of it!

Title: Pain and its Paradoxes
Abstract Deadline: August 1, 2017
Final Submission Deadline: October 1, 2017 (publication date June 2018)

Pain is almost certainly the most common illness experience on the planet. Yet, it is frequently treated poorly, and those who experience pain often endure skepticism, doubt, and stigma for their condition. In most places around the world, pain closely tracks social power structures, which means that marginalized groups are both more likely to experience pain, and are more likely to have it regarded dubiously and treated inadequately.

Moreover, while pain is a near-universal part of the human condition, it remains difficult to define and conceptualize. As Emily Dickinson famously noted, pain has an element of blank. And while pain and suffering are often experienced together, they remain distinct phenomena: some people in pain do not suffer, and some people who suffer state that they are not in pain. Pain is an essential pathway to redemption for many, and for others it exists only as a devastating, hollowing experience that defies meaning. In short, the paradoxes of pain are multiple, varied, and slippery. While pain has not escaped scholarly attention in the medical and health humanities over the last decade, current and inequitable burdens of global pain alone justify sustained focus and analysis. Accordingly, the Special Issue of Medical Humanities on “Pain and its Paradoxes” aims to integrate critical and rigorous scholarship (peer reviewed) addressing the lived experiences of pain, past, present, and future. Specifically, we invite manuscripts on subjects including but not limited to

  • The nature and concept of pain;
  • The history of pain;
  • The phenomenology of pain;
  • Narratives of pain;
  • The relationship between pain and suffering;
  • Pain as an emotional experience (including the history of pain as emotional experience);
  • Pain and anxiety;
  • Pain and sympathy;
  • Pain and grief;
  • Pain and inequalities (race, gender, class, age, disability status, etc.);
  • Pain and disability;
  • Pain and stigma;
  • Pain and pharmaceuticals, including but not limited to opioids

The editors are especially interested in manuscripts considering pain from non-Western contexts.

Interested contributors should send an abstract to EIC Brandy Schillace (bls10@case.edu) and Guest Editor Daniel Goldberg (daniel.goldberg@ucdenver.edu) no later than August 1, 2017. Final submissions should be submitted to the BMJ Medical Humanities online ScholarOne system, choosing the category Special Issue: Pain and it’s Paradoxes by October 1, 2017. All contributions will be subject to rigorous peer review.

Storytelling, Suffering, and Silence: The Landscape of Trauma in Afghanistan and Nepal

4 Jul, 17 | by amcfarlane

Dr Ayesha Ahmad, Global Health Humanities Editor, has been travelling in Afghanistan and Nepal and meeting women who’s lived experience is a conflict of chronic gender-based violence. Her initiatives are to integrate storytelling into mental health trauma interventions globally in contexts of war, oppression of women’s speech, violence towards women and girls, and writing against the backdrop of rich story-telling traditions.

As I write from the heights of Nepal, my vision is engulfed by a globe of surrounding mountains. They stand majestic and solemn into the sky. Carved deep into the mountain hearts are the trails and tracks of their wanderers’ journeys and within them are the graves of the stories that they told. At dawn, the story rose, and at dusk, the story faded.

Peacefulness betrays the legacies that we could find. The stories in the mountains are resting. This is a beautiful silence. There is a freedom in their untouched and unheard voices. Because they lay with the mystery of the mountain’s strength and existence; there is a landscape of stories and a landscape of mountains.

I came here to hold the stories that cannot rest, the stories that are suspended in a silenced captivity in hidden spaces of suffering.

The tragedy of a story is when the storyteller is no longer writing the story that she is living with within her.

The stories I was graciously given were from a women’s safe house, a vast juxtaposition to the wide and open world that her ancestors believed in. Now on her horizon there is no distance to seek, no land to explore, no story being told.

One month ago, I was writing beneath a different mountain in the heart of Afghanistan, but the stories echo, timeless and boundary-less.

It is a strange role to be receiving the telling of a story. I feel an extreme privilege to be surrounded by a story that has not been opened before. When a person gifts their story, it is a journey of exploration. Finding the story of the self creates a landscape, and to bear witness is to discover an unexplored territory, a place within a person’s world that has not been seen before.

The stories that were being shared with me were secrets, secrets in the mountains just like the mountains themselves contained secrets, journeys that no longer held paths to their destination, spaces of pure untouched land.

The tragedy of the story, though, is in its silencing. The stories were like bodies that fell from hidden mass graves, their sufferings and the deaths that buried them deep in silence were marked by injustice, brutality, violence, and isolation.

Even in the speaking of the story, the words that were falling heavy into the air were betrayed by a wounded silence. The story-teller must bear their self to tell their story, but in the diminishing of their identity as a human being, I could feel their burdens, the weight of a wish to be held as a person in their worlds. Underneath these moments where the women became their own storytellers, they were story-sufferers, suffocated by a silenced self and voice.

During the telling of their story, time felt different. Time did not pass by. There was a suspension of the time that had been lost from their lives because of violence; those moments that placed them in the grave whilst still alive and stole their breath away.

Their story became our journey. They travelled with me, we became wanderers through a language that was not ours. We wanted to speak of beauty, of dreams, of hope, but the narrative that had been sewn into their skin told a more sombre tale. Still, we continued, we took each step together through this tough terrain and we found a path through as she held her words like a fence that guided us to a space where she could kneel and touch the ground, and find her land of freedom.

I will carry their words, such precious cargo, from these mountains, cradles and graves, from the women, the silenced storytellers of Afghanistan and Nepal to the front-lines for justice.

There is silence in the mountains. Yet, silence comes from somewhere, from the winds and the valleys across their distance. Silence sounds beautiful when the silence is part of freedom, but being silenced means solitude and stagnancy. A story that cannot travel is a mountain that does not reach the sun.

The suffering of the silenced mountain story-tellers continues; there is silence, but not the absence of a voice or words, there are shadows but not the absence of self, and there are the graves of untold stories, but the mountain and her story-tellers exist together and the stories will wait their time to be told.

Film Activism: Science, Art and Social Reform

30 Jun, 17 | by amcfarlane

Our Screening Room editor, Khalid Ali (Khalid.ali@bsuh.nhs.uk), interviews film director and producer James Redford.

Activism is defined as ‘efforts to promote or direct social, political, economic and/or environmental reform to make improvements in society’. James Redford, documentary filmmaker, producer, and humanitarian uses documentary filmmaking to truly earn the title of a ‘film activist’. I met him in London in May 2017 where he was promoting his latest documentary Resilience: The Biology of Stress and the Science of Hope.

Reflecting on his inspirations for the film, James explains: ‘Resilience contains disturbing information about the adverse health effects of difficult childhood experiences. If I had not encountered something we can do to offset those experiences, I would not have made that film. I would be only displaying the medical basis for bad news. We must understand the biological risks for children exposed to emotional, physical and sexual abuse, neglect, violence or mental illness in their homes.  However, if you provide that child with even one caring, responsible, consistent adult who shows them what it means to be in a loyal, stable relationship with an adult – such as a religious leader, an extended family member, an educator, a social worker, a volunteer, or a police officer with the right training – you can minimize the toxic effects of a bad environment. And that applies globally; qualities of love, compassion, care and connectivity are universal.  In the fall of 2016, I visited The Navaho Nation, an indigenous Native American nation within the USA; I observed how their religious and cultural values reduce the risk of ill health attributed to centuries of oppression and genocide.  In their religion there is an appreciation of healing through family and community gatherings and rituals that supports the mental health of the individual. Chanting religious traditions can have the same healing effect as someone with training in care and compassion. I also showed the film in Columbia, Kazakhstan, New Zealand and now in the UK, and every time I am amazed by the overwhelmingly positive reception due to its universal message’.

When I asked Mr Redford about the conception of Resilience, he stated: ‘The story began in 2012 when I made another film, The Big Picture: Rethinking Dyslexia, in collaboration with Karen Pritzker, a notable philanthropist in the USA who supports many social causes.

Karen was working with educationalists on how to support children with dyslexia but had also known about the little-known Adverse Childhood Experiences (ACES) Theory. The science was there for 15 years, but not widely known. I read the study after she sent it to me, and along with her daughter, producer Dana Schwartz, decided to make the film. The first film we made addressing the ACEs study was Paper Tigers.

It was based on the true story of a high school principal in Walla Walla Washington who employs creative methods in supporting troubled children using the principles of ACES. A year spent at the school with the at-risk teens reveals just how far patience and compassion can go in setting kids on a healthier course.’

James Redford’s interest in using film to explore important medical issues has a personal dimension. After a childhood autoimmune illness caused liver failure, James received two liver transplants in 1993. That experience led him to making The Kindness of Strangers, an interwoven story of real-life organ donors and transplant recipients. James (who prefers to be called Jamie) reflects on his self-discovery journey in hospital wards: ‘I had to go through a lot of mental and psychological tests before the transplant operation. I came to know that having the support of close family relationships was shown to reduce failure rates in transplants. That was my first realization that there is a link between what was happening in someone’s immediate family environment and its effect on someone’s physical health. In America, in the 90s, there was a myth that transplantation medicine was a mysterious world where dark things happen, people were kidnapped, and organs were taken without their consent. I acknowledge that there are black markets for organ donation, but at the same time there is also altruism in its purest form: families who, at the time of losing a loved one, find it in themselves to consent to donate the organs of that deceased loved one. I believe that human beings have it in themselves to do beautiful, charitable things. I am alive because of it. The Kindness of Strangers was embraced by doctors, health care professionals, social workers and recognized organizations. Surviving that personal journey of illness, and recovery was the inception of the James Redford Institute for Transplant Awareness.’

The Big Picture: Rethinking Dyslexia film was another story anchored in James’ personal experience. ‘My son Dylan, who is now a successful artist at 25, was diagnosed with dyslexia at a young age – he was struggling at school as his handwriting and reading did not reflect his intellect or intelligence, so he was often labelled as lazy. Luckily my wife, a life-long educator, knew how to secure the right help for him. Karen Pritzker’s daughter, Allison Schwart, is also dyslexic, and both she and Dylan agreed to discuss on camera how and where to get support and which techniques are most helpful. Assistive technology such as dragon speech, speech recognition software, and autocorrect are terrific and now widely available. Dyslexia is not a moral or character flaw- science proves that underlying anatomical brain differences are the reason for the symptoms of dyslexia. It is important to disseminate these films and show them widely in schools.’

James’ work also reveals a passion for environmental issues. ‘I grew up in a home with parents who were active environmentalists. My father, actor/director/producer Robert Redford, has been a passionate advocate for environmental protection for over five decades. After the box-office success of Butch Cassidy and the Sundance Kid my parents bought a small family resort in the Rocky Mountains of Utah to protect the land from being developed into condominium units. At the time the land had been overgrazed by sheep and the native predators – wolf, coyote, and mountain lion – had been poisoned off the land. Under the protection of my parents, the natural landscape recovered to its original glory. I produced HBO’s Mann V. Ford, a documentary that chronicles a Native American community that was poisoned by the paint waste from the Ford Motor Company. I also directed HBO’s Toxic Hot Seat, a film that looks at the efforts of the United States chemical industry to hide the health risk of chemical flame retardants.’

In order to honor my father’s environmental legacy and to pursue my own, the two of us founded The Redford Centre, a non-profit environmental media company that has been active for 10 years now in accelerating better and healthier environments for all.

In partnership with the Redford Center, I am now completing HBO’s Happening: a Clean Energy Revolution. President Trump’s decision to break our nation’s promise to support the Paris Climate Accord in no way reflects what is happening in America with clean energy. The clean energy economy is booming at the same rate of growth we saw with radio, TV, and the Internet, and I’m hoping that the film will do its part to accelerate that growth even further. With climate change, every second counts.’

Jamie summarizes his mission eloquently: ‘My films and stories discuss problems as well as offer solutions. Through my company KPJR films and The Redford Center, I have the privilege of offering hope and solutions to some of our most vexing social, environmental, and health challenges. Through film we can bring about change, we can fix things – or at least try to do them better.’

Book Review: No Apparent Distress

27 Jun, 17 | by amcfarlane

No Apparent Distress: A Doctor’s Coming-of-Age on the Front Lines of American Medicine by Rachel Pearson, New York: W.W. Norton, 2017, 272 pages, £21.99.

Reviewed by John Coulehan, Stony Brook University, NY

Was there a time before memoirs of medical training became a popular genre of nonfiction?  It’s difficult now to imagine a time before aspiring young physician-writers frequently turned their attention to the slings and arrows of outrageous—but also often sublime—medical education. Intern by Doctor X, one of the earliest first-hand accounts of  hospital training, appeared in 1965. Its lurid description of life in a teaching hospital forced the author to remain anonymous, but the book was eagerly consumed by the public, whose appetite for these stories has grown and multiplied over the ensuing decades. Soon additional memoirs began to appear, and a new genre, the medical bildungsroman, was born. Today Amazon and Barnes & Noble offer dozens of books featuring the personal stories of young physicians. Some of these, like Danielle Ofri’s Singular Intimacies or Atul Gawande’s Complications, are first rate literature; others are merely workmanlike. Some focus mostly on the writer’s internal struggle or character formation; others are explicit in their critique of depersonalization, overuse of technology, or injustice in American medical care.

The plots of medical bildungsromans are pretty standard: an idealistic student enters the maelstrom of medical school or residency training, overcomes obstacles, gains practical wisdom and survives, determined to become an altruistic and humane physician, despite external constraints, like deficiencies in the health care system. Some physician-writers are able to combine these generic ingredients into compelling and provocative stories. To do so requires freshness of insight, a talent for vivid storytelling, and a distinctive voice.

Rachel Pearson’s No Apparent Distress displays all of these qualities in good measure. Dr. Pearson graduated from the University of Texas at Galveston in a combined MD-PhD program, with her PhD in Medical Humanities . The book’s title is an ironic reflection on the traditional medical shorthand, “The patient is in no apparent distress,” or shorter still, the chart entry, “NAD.” As Dr. Pearson makes apparent, there is in fact a great deal of distress among students, physicians, patients, and in the American health care system as a whole.

Aside from the author herself, the book’s  most significant character is St. Vincent House, the site of a student-run free clinic for indigent and uninsured patients. Over 25% of Texans were uninsured in 2008. For those in Galveston, St. Vincent’s (with the motto, “All Are Welcome Here”) was virtually the only available safety net. Rachel began working in the clinic  from her first days in Galveston and continued throughout medical school, eventually serving as a student director. Thus, much of No Apparent Distress is devoted to her education at St. Vincent, which included in-depth learning about the social and cultural context of medicine, and the glaring inequities in American health care. The publisher’s flyer describes No Apparent Distress as “a searing indictment of America’s health care system.” I would not call the book “searing.” Yet, it’s compassionate and hopeful stories of struggling patients teach the reader much more about injustice than searing rhetoric could.

Take the example of Mrs. Klein, who appeared at St. Vincent’s with a large abdominal mass that had been growing for three years.  Dr. Pearson recounts her difficult, but successful, attempt to enlist faculty volunteers to biopsy the mass, interpret the slides, and eventually obtain coverage for Mrs. Klein in Galveston’s indigent care program, allowing her to undergo surgery. Although this entire process required eight months, it was doubly successful because the mass turned out to be benign. Meanwhile, the author describes her experience with the “luxury medicine” that took place nearby, a month long rotation with Doctor Houston whose internal medicine practice featured cosmetic Botox injections, laser hair removal, and “electrode” treatment for diabetic foot pain. This contrast between uninsured and luxury medicine highlights the irony of “no apparent distress.”

Another major theme of the book is uncertainty and error as experienced by a physician-in-training. Like many physicians, Dr. Pearson vividly  remembers her first significant medical error. When evaluating a St. Vincent’s patient, she forgot to report abnormal urinalysis findings to her preceptor. This, in turn, led to an incorrect diagnosis. Several months later the patient was found to be suffering from terminal kidney cancer. The author agonizes over her personal responsibility for the delay in his diagnosis (as I think most conscientious students and physicians would), even though it’s difficult to see how a single urinalysis result would have made a difference to the outcome.

Dr. Pearson relates a number of other instances of hesitation, error, awkwardness, and confusion as she progresses through medical school. As I noted earlier, these are all standard student responses, as are the array of hostile, difficult, engaging, and grateful patients. What makes No Apparent Distress stand out is the author’s ability to bring her feelings and these characters to life. She also has a distinctive voice, an attractive mixture of naiveté, passion, sharpness, and common sense that hooks the reader and makes him keep turning pages. Finally, this memoir is unusual in its focus on efforts to care for the uninsured patient as an integral part of medical education.

No Apparent Distress carries the subtitle, “A Doctor’s Coming-of-Age on the Front Lines of American Medicine.”  This is unfortunate because it evokes the hackneyed war metaphor that the author strongly condemns as contributing to the inhumanity of contemporary American health care. Fighting, battles, front lines—we need less of this violence and more of the caring that Dr. Pearson actually prescribes. So forget the subtitle, but read the book, which is a notable contribution to the medical bildungsroman.

Book Review: Balint Matters

20 Jun, 17 | by amcfarlane

Balint Matters: Psychosomatics and the Art of Assessment by Jonathan Sklar, London: Karnac, 2017, 254 pages, £27.99.

Reviewed by Dr Neil Vickers.

Michael Balint is mentioned in medical humanities circles as a revered ancestor, much as one might talk about William Empson as a significant figure in the history of English literary criticism. Everyone knows they’re important but surprisingly few people read either writer today or even know why they should. (An important exception is Josie Billington’s superb Is Literature Healthy? – reviewed here – which devotes a chapter to Balint.) Empson did theory before Theory, and Balint did narrative medicine before Narrative Medicine. Both men were at least as interesting as what came after them and yet both have become unduly sepia-tinted with the passage of time. Part of the reason for this fading in Balint’s case has to do with the fact that his clinical examples are firmly rooted in the sociological reality of the 1940s and 50s. The world Balint describes is hidebound by class. As a psychoanalytically-minded medical humanist, I occasionally press a copy of Balint’s classic, The Doctor, the Patient and the Illness (1957) on M.Sc students, but always with the caveat about his antiquated case material. ‘Someone should update it,’ I whisper, as they saunter out of the room.

Now someone has updated it. In his new book, Balint Matters, Jonathan Sklar, psychiatrist, psychoanalyst and leader of Balint groups (as well as a leading scholar of Ferenczi’s thinking) has produced a masterly summary of the Balint technique, along with a history of Michael Balint’s contribution to the theory of the doctor-patient relationship in collaboration with his wife, Enid. The second half of the book, entitled ‘Assessment’, which I won’t discuss here could be published as a volume in its own right. Assessing a patient for psychodynamic treatment is a topic on which surprisingly little has been written.

Michael Balint was born Mihály Bergsmann in Budapest in 1896. His parents were descendants of German-Jewish families who had been in Hungary for only two or three generations. (This German-Jewish world of Leopoldstadt is described in a wonderful series of autobiographical interviews that Georg Lukacs gave towards the end of his life, published as Gelebtes Denken). In 1916, young Mihály took the momentous decision to abandon Judaism in the hope of eluding the anti-Semitism that was still rife in Austro-Hungary and changed his name to Bálint (which means ‘Valentine’ in Magyar). He first came into contact with psychoanalytic ideas while a medical student in Budapest. His fellow-medical student and first wife, Alice Szekely-Kovacs, was one of Sándor Ferenczi’s analytic patients. Balint himself held off from having analysis with Ferenczi at first, and following the overthrow of the Hungarian Soviet Republic (which had bestowed a public professorship of psychoanalysis on Ferenczi, a world first) Michael and Alice fled to Berlin in 1919 to train as analysts at the Berlin Psychoanalytic Institute, where both had analysis with Hans Sachs, and where Michael did a PhD in chemistry and physics. The couple went back to Budapest in 1924 and became patients, colleagues and friends of Ferenczi. Balint became Ferenczi’s literary executor and the chief exponent of his thinking in the international psychoanalytic movement for decades. If the rediscovery of Ferenczi has reinforced the air of ‘always the bridesmaid, never the bride’ hanging over Balint, so has the explosion of interest in Winnicott, with whom he has so much in common.

Balint’s main contributions lie in two areas: psychosomatics, understood holistically as the study of the relationship between mental and physical disturbances; and the uses of therapeutic regression, which he explored in his other great book, The Basic Fault (1967). Sklar’s concern is with the first and specifically with the work Balint developed at the Tavistock Clinic in the 1940s and 50s with his third wife, Enid (Alice having died shortly after they arrived in England, to escape the Anschluss). Balint focused his attention on how the doctor’s attitudes and approach affected the course of an illness, and suggested that ‘the most frequently used drug in general practice was the doctor himself, i.e. it was not only the bottle of medicine or the box of pills that mattered, but the way the doctor gave them to his patient—in fact, the whole atmosphere in which the drug was given and taken.’

Sklar offers a number of clinical vignettes from Balint groups he has facilitated, describing how this works in practice. These case histories for me formed the heart of the book. I won’t spoil the reader’s pleasure by describing too many of them but among those that stood out for me was the case of a 70-year-old woman who was addicted to dihydrocodeine, a strong opioid analgesic. The woman had complained of a pain in the hip but a scan revealed only minor osteoarthritis. Her condition never seemed to improve. She made occasional visits to a cousin who lived far away and would ask her doctor for a bumper supply of painkillers to get her through. Then, much against the patient’s will, her daughter visited the GP and told her that her mother never went to see a cousin, and that the story was just a ruse to get more prescription opioids. The GP was appalled to realise that in the course of the previous year she had prescribed more than 3,000 dihydrocodeine tablets to this woman. In discussion with the group, the GP realised she knew nothing about her patient’s history. With a bit of help from Sklar, the group discussion included the following ideas: 1) the patient had an addictive relationship to the doctor; 2) the doctor felt depressed on behalf of the patient; 3) the doctor was unconsciously acting as a container for aspects of her patient’s mind, perhaps playing the part of a distant depressed mother, who gave her daughter ‘the wrong medicine.’ Feeling, noticing and understanding these projections didn’t cure the patient but they did give her doctor more freedom in the way she related to her. Addiction could now be seen as a way of representing early childhood deprivation.

Balint groups have also been used with psychiatrists. Sklar is fascinating on the attempts by some trainees to use Balint groups as a covert form of personal analysis. This arises not least because of the peculiar pressures of working with severely disturbed patients. The kinds of problems many of the trainee psychiatrists brought had to do with the ways in which they were made to carry aspects of their patients’ mental disturbances. Again, to pull out just one example, Sklar describes the case of a young psychiatrist, Dr L, overwhelmed by the suicide of a male patient who had been admitted at his mother’s request, shortly after the latter’s recent remarriage. Dr L bitterly regretted not administering ECT. Perhaps it would have saved him? She was also worried about the effect of the suicide on the other patients on the ward where the man was being treated. The nurses had suggested that a community ward meeting should be convened to break the news. The group listened to Dr L’s anxieties and asked for information about the patient’s history. It turned out that his biological father had killed himself by electrocution. Sklar asked how the ward meeting had gone. It had been fine for the most part though a psychotic woman had to be removed. This woman had told the meeting she was the angel of death and that there would be more deaths. Somewhat to the group’s surprise, Sklar observed that the psychotic woman had voiced what was in effect Dr L’s own worst fear about herself. Here was an instance of the need to listen to the very mad, as barometers of the most split-off emotions in the room. The psychotic woman had been excluded because she was voicing the emotions that were most unacceptable to the group. Dr L then remembered that her patient had killed himself on his mother’s birthday and that her recent marriage was to an electrician. These snippets, combined with the knowledge of the patient’s father’s suicide, shed new light on the hopes she had placed in ECT. They amounted to a re-enactment of the patient’s deep upset over his father’s suicide and at the same time offered a means to shut out and ignore the meaning of the mother’s marriage to an electrician. As a result of this meeting, Dr L softened down her until-then vigorously-asserted opinions about psychiatry’s exclusively organic basis.

For me, the most moving chapter in the book describes Sklar’s work in the early 2000s at a hospital in an unnamed city in South Africa. In 2007, it was estimated that nearly 6 million South Africans had HIV or AIDS, or 12 per cent of the population. This was overwhelming to the medical professions attempting to offer treatment at a time when antiretrovirals were beyond most people’s reach. Thabo Mbeki’s refusal to believe that HIV had anything to do with AIDS licensed widespread denial of the natural history of the disease and its behavioural causes. Of course, the doctors knew how AIDS was commonly transmitted but the overwhelming nature of the incidence of the disease and the need to shield families from stigma meant that patients were often treated as if they were just medically irrelevant dying people. The doctors for whom Sklar acted as a Balint facilitator told him of their anger at the way AIDS patients were treated as undeserving and subhuman. But they also described the primitive fears the disease evoked in the workplace. The whole practice of medicine was at risk of becoming warped by the cultural phantasies surrounding it.

Sklar’s book deserves to be read by anyone who wants to know how to listen to patients with an analytic ear, how to understand the dilemmas of clinical practice analytically, or why psychoanalysis still has so much to offer physical medicine. As his title makes clear, Balint matters, particularly in an environment where doctors and patients are urged to forget about the whole person and focus instead on gross symptoms and quick fixes. As a result of his endeavours, it should be easy for most readers to imagine a Balintian response to many clinical dilemmas. It is even possible that this brilliant exposition of Balint’s thought will initiate a new phase in the reception of this underrated and very fertile thinker, and bring about further extensions of the Balint model of the kind Sklar himself has achieved here.

Book Review: Eros and Illness

13 Jun, 17 | by amcfarlane

Eros and Illness by David B. Morris, Cambridge: Harvard University Press, 2017, 368 pages, £31.95.

Review by George Derk, PhD (gtd2gu@virginia.edu)

With the provocative pairing in the title of his new book, David Morris sets himself the task of dramatically altering the perceived relation between these two terms. As he contends, there exists less of an opposition and more of an affinity between them than we are usually willing to admit. At times, they even seem like bedfellows rather than rivals: “eros and illness both usually send us under the bedcovers” (27). Professor Emeritus of English at the University of Virginia, Morris began his academic career focusing on eighteenth-century literature before turning his attention to the medical humanities. In some ways this new book is a follow-up to and an elaboration of a couple of his previous ones, including The Culture of Pain (1991) and Illness and Culture in the Postmodern Age (1998), but at least one significant difference sets this recent work apart from the rest. Morris draws from his personal experience as caregiver for his wife, Ruth, after she was diagnosed with early-onset Alzheimer’s. It is this model of care, where provider and patient are the most intimate of partners, that allows Morris to explore the neglected dimension of eros in illness.

Morris begins by developing a capacious interpretation of eros, one that cannot be reduced to sexual activity nor to the Roman equivalent of Cupid. He instead derives his understanding of the concept from both the French philosopher Georges Bataille and the Canadian poet Anne Carson, and while he carefully stipulates that eros resists any easy definition, the word that comes closest to naming it is desire. He proceeds with a thorough examination of desire in the context of health care—or what he calls “medical eros”—mostly through illness narratives and doctors’ memoirs. He occasionally supplements these primary texts with analysis of literature and the other arts, as when he discusses the waiting involved in caregiving as akin to the waiting depicted in Samuel Beckett’s most famous play, or as when he finds an affirmation of eros in a series of nude portraits that Amedeo Modigliani painted while suffering from a terminal illness in wartime Paris. What he eventually uncovers amounts to an alternative medical genealogy, a recovery of the ancient figure of Asklepios as the embodiment of the obscured tradition of eros in Western health care. For Morris, the dominant stature of the other ancient healer, Hippocrates, and what he represents—biomedicine, or what Morris terms “medical logos”—has resulted in a reduction of the pluralism of healing practices, inhibiting the effectiveness of treatment for chronic illness.

From a certain angle, the book falls into a recognizable pattern of decrying how science-based, data-driven medicine has lost sight of its core humanistic principles, which I suspect would prompt many health care professionals to respond that the realities and demands of the job only allow for so much empathy and compassion. However familiar Morris’s argument may sound, the frequency with which medical logos runs up against its own limits warrants reiteration. If medical eros seems like some New-Agey solution to the problems of modern health care, it does a lot more good than some of the other reactions, such as over-treatment, that occur when doctors confront uncertainty or a lack of options. Perhaps the more insightful and original contribution of this book, though, is less its appeal to humanize medicine and more its belief that anyone can learn how to care for those who fall ill. Indeed, as Morris suggests with his own transformation from English professor to fulltime caregiver, the innate capacity to provide humane care stems from the eros that one already bestows onto his or her loved ones. The relative absence of Ruth’s story further underscores that this book chronicles the experience of illness not from the perspective of the patient but from that of the caregiver, although at times the boundary blurs. Morris himself becomes a patient after suffering a heart attack, which he attributes to the stress of providing care and which he takes as an example of a “supradyadic effect,” or how one’s health is interdependent on the health of those in one’s social network.

The book, overall, reads like part Bildungsroman of a caregiver and part philosophical treatise on the nature of caregiving. Morris strives to preserve the desire that drew him to Ruth in the first place and sustained them through three decades of marriage. In the face of regret at not recognizing Ruth’s symptoms earlier, guilt for his irritability towards Ruth’s increasing debility, and, most of all, anguish at the terrible inverse logic of dementia (“she was fading emotionally, just when I felt in greatest need of her ordinarily loving expressiveness”), Morris maintains that eros doesn’t necessarily have to evaporate altogether and may actually serve as the greatest resource when medical logos has no answers (39). Along with the personal experiences that he relates, the case for eros is strongest when grounded in specific instances wherein biomedicine finds itself ill-equipped. Morris’s inclusion of the writings from people with non-normative identities—such as the African-American, lesbian poet Audre Lorde who claims in The Cancer Journals (1980) that the “love of women healed me”—proves particularly effective in this regard. Dwelling on the accounts from those at the margins testifies to the potential of medical eros to help remedy the imbalance of treatment for underserved communities. In addition to the benefits made available by eros, the cost of not acknowledging its contributions equates to an egregious oversight. Morris cites an estimate by the American Association of Retired Persons that within the U.S. 36-38 million family caregivers provide $350 billion (approximately £270 billion) in unpaid labor annually.

Yet counterexamples exist to raise questions about this book’s insistence, in its more unrestrained moments, on championing eros as a possible panacea. The anti-psychiatry movement, which Morris overlooks, would seem to embody many of the characteristics of medical eros. For all the necessary reforms that it has lead to, it has arguably been too successful in undermining biomedical treatments for psychiatric ailments. While the dismantling of mental health care results more directly from draconian cuts to funding than from this particular movement, the U.S. continues to live with the legacy of an impaired system of psychiatric care. That said, Morris anticipates an objection such as this by advocating for a balance between eros and logos. His goal, as he states it, is for biomedicine “to recognize eros and to deal with it—the good and the ill—mindfully” (13).

The principal testament to eros that Morris offers may ultimately be the fact that he managed to write this book. While caring for Ruth, Morris admits to feeling drained of his normal passion for writing: “I could write, but writing lacked all pleasure, joy, and desire” (251). As the examples curated by Morris attest to again and again, illness throws eros into disarray. One of the more telling instances in the book involves the poet Jane Kenyon, suffering from end-stage leukemia, who is reminded by her husband that the bed she lies on is the same site of their countless sessions of lovemaking over the years. This is the type of recognition that Morris prescribes, an awareness of how a bed, as object and symbol, stands for the underlying bridge between eros and illness. The challenge of the latter consists of finding new ways to realize the former. The strength of Eros and Illness resides in how Morris models the counteracting of illness by eros through his writing, eloquently giving voice to Ruth, who lost hers, and rediscovering his own in turn.

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