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Ayesha Ahmad: Silence—A Woman’s Wound

26 Sep, 14 | by Ayesha Ahmad

In a healing relationship with the wounded, we are witnesses; we are bearers of witnessing those moments when another reveals their vulnerability, and when we recognise such vulnerability then we find the unanswered voices. The foundation of any healing is when we close our eyes without losing the perception of how the other— how you— are suffering.

When we hear stories from the mouths of the women who bear the words every day of their lives about violence, there is also a profound silence of the dead— the voice of the fallen woman. The fallen woman has not disappeared, nor vanished, but she has been taken; she is a stolen breath, a stolen heart, a stolen soul, and now, now she is a stolen story.

The fallen woman, when she lived, lived between life and death. Before she fell, she lived her narrative­—she embodied every word. Her strength carried her, she became the body that was carved onto her life and shadowed by society. And, the fallen woman, she stood before she fell. She told. She told the story of her silence. This story travelled from her and her silence no longer shrouded her or protected her. Her silence fell from her, and then she too fell.

Who pushed her?

Society.

more…

Guest Essay: “A mind diseased”: Examining the evolution of madness using Shakespeare’s Macbeth by Sarah Ahmed

31 Aug, 14 | by BMJ

 

INTRODUCTION

Over the years, our understanding of what it means to be mad has evolved. Ancient civilisations held the belief that madness was as a result of spiritual possession; the Enlightenment’s concept of rationality remade madness into an external manifestation of internal grief; in the last century we have started to develop biological theories of mental health as we begin to understand more about how the brain works on a synaptic level.[1] It has even been suggested by prolific writers such as Szasz and Foucault that madness is not a disease at all but rather “a cultural construct, sustained by a grid of administrative and medico-psychiatric practices”.[1 (p.3)] It follows that as our understanding of madness has developed, so too have our readings and interpretations of madness in literature as we apply new theories of illness to fictional characters (perhaps in an attempt to empathise more strongly). Bossler said that “Shakespeare’s characters have always been a fertile field for the application of psychological principles”[2 (p.436)] and Shakespeare’s graphic descriptors of a “mind diseased”[3 (5.3.41)] have leant Macbeth to continuous reinterpretation.

In many readings of Macbeth the play has been approached using a particular literary theory or frame of reference. For example, Freud and his followers have analysed the play using the lens of psychoanalysm,[4] prion-based theories of madness have been applied to the text[5] and some have suggested that Macbeth’s madness is a result of battle fatigue.[2] Alternatively the play has been analysed using an approach more in line with New Historic theories of interpretation by considering the historical and social context of the time: the humoral theory of health[6, 7] has been applied to the play and the characters’ dramatic evolutions have been examined from a religious[8] or gendered perspective.[6] Each interpretation presents a new way of understanding old characters and each will be explored below as we examine how our understanding of madness has evolved and argue that if a frame of reference is important to our understanding of Macbeth, a deeper appreciation might be achieved by considering the notion of madness from the perspective of the Elizabethans.

 

FRAMES OF REFERENCE

By simply using a literary approach it is clear both Macbeth and Lady Macbeth undergo dramatic evolutions over the course of the play, be this into madness or something else. Macbeth, who is initially seen to cower beneath his wife’s ambition, “grows ever more frightening…as he becomes the nothing he projects”; conversely, Lady Macbeth implodes and withdraws from society.[9 (p522)]

Macbeth’s decline begins almost immediately following the couple’s decision to take the crown – the great warrior Macbeth is seen to be anxious about the proposed murder, saying “If it were done when ‘tis done, then ‘twere well/It were done quickly”.[3 (1.7.1-2)] Even before the murder his worries manifest themselves as hallucinations when he sees the now famous “dagger of the mind”,[3 (2.1.38)] which first appears clean before being doused with “gouts of blood”.[3 (2.1.46)] His deterioration progresses when he returns to the stage after murdering the King and claims auditory hallucinations, hearing “a voice cry, ‘Sleep no more:/Macbeth does murder sleep”’.[3 (2.2.38-39)] In saying this Macbeth becomes almost premonitory (like the Weird Sisters) as he does indeed suffer sleep disturbances later on, a “symptom” which is often quoted in discussions of his madness.

Lady Macbeth’s fall is more measured and gradual – whilst Macbeth is hearing noises she admonishes him as she would “shame/ To wear a heart so white”.[3 (2.2.67-68)] Here the colour white has connotations not only of innocence and purity but of cowardice; it evokes the white feathers of World War One which were given to the men refusing to enlist. Most of Lady Macbeth’s dramatic evolution occurs off-stage as is typified by the change in her mode of speech. In the banquet scene of Act3 Scene 4 Lady Macbeth’s gravitas and assurance is obvious in how she address the nobles in verse:

Think of this, good peers,

But as a thing of custom. ‘Tis no other,

Only it spoils the pleasure of the time.[3 (3.4.96-98)]

She is the very embodiment of regality. This is contrasted against Act 5 where she speaks only in prose. In Shakespeare’s plays prose was often reserved for the lower classes, or for conversations between characters who are knew each other well, such as Rosalind and Celia in As You Like It.[10] It was also used in the speech of characters who were mad or feigning insanity, as verse was apparently “too regular and orderly for expressing madness”.[10] As such Hamlet, Ophelia and King Lear all speak in prose at some point in their respective plays.

 

The (d)evolutions of Macbeth and his wife have also been subject to particular frames of reference. A psychoanalytic reading would suggest that Macbeth’s madness is due to a “psychic catastrophe”,[4 (p. 1483)] which is a direct result of his murder of the King. In this reading the King acted not only as Macbeth’s Superego, but that of the whole country, representing “the unifying power which bound the warrior’s destructiveness and directed it towards external enemies in order to preserve stability in the kingdom”.[4 (p.1488)] This goes some way to explaining why Macbeth is so affected by this particular killing as the King was not only his head of state but the means through which “Belladonna’s bridegroom”[3 (1.2.54)] could funnel his inner destructive nature. Conversely, the witches represent a “malignant regression to primitive states of mind”[4 (p.1484] and the other extreme of Macbeth’s psychic spectrum. In taking heed of their premonitions Macbeth turns towards his Id; in returning to them for help and validation Macbeth gives in to his base nature.

A Freudian reading doesn’t label Macbeth’s behaviour with a diagnosis but instead strives to understand why the Thane behaves the way he does. A Freudian would believe that Shakespeare merely described behaviour which he had observed in mankind but never had a frame of reference to explain what he saw; Freud’s theory provides this context.[4] The ease with which some of Shakespeare’s plays lend themselves to a Freudian interpretation has been used as evidence for this view with the most famous example being Hamlet and its connection to the Oedipus story. This idea that Shakespeare described human nature accurately but was missing the terminology to explain what he saw has been used repeatedly in various literary theories and evokes Lawrence Olivier’s famous proclamation that Shakespeare was, or is, “the nearest thing in incarnation to the eye of God.”

 

More recent theories of madness, which have originated as our understanding of both biology and psychology has developed, have also been applied to Macbeth. One such theory is that Macbeth suffered from Creutzfeldt-Jakob disease (CJD), or another similar prion disease.[5] The paper which proposed this theory was published in the Clinical Infectious Diseases Journal, highlighting how a person’s background can be used to form the frames of reference they use in their interpretation not only of the scientific world but of literature. It is important to note that the authors of the paper admit that Shakespeare may not have intended Macbeth’s dramatic evolution to mirror the natural history of a prion disease; similar to advocates of psychoanalysm they believe the playwright showed “an uncannily prescient understanding of prion disease transmission via exposure to neural tissues”[5 (p.299)]but lacked the context to explain it. The variety of human and animal offal present in the witches’ brew is considered the possible source of transmission.[5]

In creating their theory that Macbeth may have suffered from CJD the authors look beyond the usual symptoms of traditional madness – sleep disturbances and hallucinations – and find quotative evidence for more specific indicators of prion disease such as “neurological and cognitive deterioration”[5 (p299)] as well as “myoclonus and involuntary movements”.[5 (p.301)] However in most of the examples found it is possible to take what Shakespeare wrote and interpret it as a metaphor. For example, evidence for myoclonus is found in the following quote:

Take any shape but that, and my firm nerves

Shall never tremble. Or be alive again,

And dare me to the desert with thy sword;

If trembling I inhabit then, protest me

The baby of a girl.[3 (3.4.102-103)]

It may be that Shakespeare intended the reader to take the above literally and imagine Macbeth trembling; conversely it is just as likely that he meant it as a metaphor and Macbeth trembles in fear of the Ghost – even today we use similar expressions. After all, Shakespeare was foremost a poet. The following quote has also been attributed to myoclonus: “Then comes my fit again. I had else been perfect”.[3 (3.4.20)] It is similarly ambiguous as there is nothing in the script to suggest that Macbeth has an actual fit; it is more likely to metaphorically psychological in nature.

 

In a similar fashion, Macbeth’s dramatic evolution has been attributed to a diagnosis of battle fatigue.[2] Similar to explaining Macbeth’s madness as CJD, or even in examining it through the lens of psychoanalysm, the theory’s creator admits that although Shakespeare may not have set out to describe a case of battle fatigue, “the only thing new about [attributing a diagnosis of battle fatigue] is its name. Human nature remains the same”.[2 (p436)] Again it is interesting to note that the author of this paper is a military veteran.

The symptoms of battle fatigue are similar to those of traditional madness and CJD – “obsession of anxiety, jumpiness and inability to sleep”;[2 (p.437) however Macbeth has also been exposed to all the causes of battle fatigue.[2] The ceaseless toil of first the war and then the murder, combined with Macbeth’s powerful imagination, tips the balance of sanity towards dominant thoughts of blood and war.[2]Macbeth’s subsequent murders are explained as him returning to the place where he has known most success – the battlefield – in an attempt to cure himself of his malady; he tries to find peace by doing what he does best, except now he “enjoyed killing others too much to kill himself”.[2 (p437)]

 

IS IT ENOUGH?

In each of the above theories Macbeth is interpreted using a particular frame of thought; as was particularly prominent with the CJD and battle fatigue examples the frames of reference were drawn from the author’s life experiences. It is interesting to note that in each of the above readings it was claimed that Shakespeare merely described human nature (admittedly with some finesse and precision); what each new theory brings is context based on new interpretations of madness. Applying contemporary theories of (psychological) illness to diagnose literary characters is a phenomenon which is not just limited to Macbeth, or even to Shakespeare’s work: Winnie the Pooh’s Pooh and Piglet have been diagnosed with ADHD and General Anxiety Disorder respectively;[11] it has been suggested that Darcy may place on the Autistic Spectrum.[12] It is possible that our current biological theories will one day be disproved and appear outdated to future generations, and highly probable that as we develop new theories of madness these too will be applied to fictional characters, and we will have new ways of interpreting the actions of the Thane and his Lady.

However it is also probable that Shakespeare intentionally modelled his characters around Elizabethan notions of madness; unfortunately we can never know what Shakespeare meant when he described “a mind diseased”.[3 (5.3.41)] However by accepting that Shakespeare was an accurate portrayer of human nature we can begin to understand what Elizabethans thought about madness by examining the play in its historical and social context. Braunmuller agreed by saying that critical “claims are often false to the play’s complex relation with the social and political circumstances in which it was first written and first performed”.[3 (p.1)]Knowing more about these circumstances could be hugely useful, not only in giving readers a deeper understanding of the play but in showing us how mental illness was viewed in the 1500s/1600s. It is in this vein which we will continue.

 

HISTORICAL AND SOCIAL CONTEXT

Medicine, health and the medical professions feature heavily in Shakespeare’s plays and those of his contemporaries,[13] and “it has long been recognized that England in the period from 1580 to 1640 was fascinated with madness”.[6 (p.316)] However it has been suggested that Shakespeare’s knowledge is greater than that of a regular Elizabethan.[14] The reasons for this stretch beyond the scope of this essay but it can be assumed that Shakespeare knew about current theories of health and illness. It was during the Elizabethan era that madness started to become medicalised and was seen as humoral in nature; it was also associated with gender and religion. Each of these viewpoints have been used to interpret Shakespeare’s work.

 

Humoral theory stated that melancholy, now known as depression, was caused by an excess of black bile, the humor associated with winter and dryness. This resulted in a combination of “passivity, unsociability, fury, stupidity, paranoia, lust, anger, mania, but especially sorrow and fear”.[6 (p.319)] Most of these, in varying combinations, are seen in Macbeth and Lady Macbeth after they decide to kill the King. The use of humoral metaphors has been explored extensively in Shakespeare; in Macbeth it is especially with relation to Lady Macbeth and her ambitious nature.[7]

 

Despite more “scientific” theories it was also around this time that madness began to become gendered – although the frame of reference may have shifted from religion to reason, women were still seen as weak, second class citizens.[6] Melancholy in its purest form was associated with “the upper class, the literate, the masculine”.[6 (p. 319)] Conversely women were thought to suffer from melancholy’s sister, hysteria.[6] This idiosyncrasy can be clearly seen in Shakespeare’s Hamlet where Hamlet’s (possibly feigned) madness is always seen to be quite noble in nature – he is never anything less than the distressed Prince of Denmark – whereas Ophelia’s is seen almost to be “beautiful, sweet, lovable, pathetic”.[6 (p. 322)]

This gendered madness can also be seen in Lady Macbeth’s descent, which holds many similarities with Ophelia’s madness. Like Ophelia, Lady Macbeth speaks in riddles and without apprehension of her surroundings; both repeat key phrases in their deliriums with Lady Macbeth meditating on all the blood her and her husband have spilt; both return to the stage in their mad stage in the second half of the play after a prolonged absence; both their lives end in apparent suicides. The women of the play become “cultural scapegoats”[6 (p. 328)] as Lady Macbeth’s sex automatically acquaints her with the “so withered and so wild”[3 (1.3.38)] Weird Sisters. Conversely we sympathise with Macbeth, seeing him “not as the victim of a revengeful God, but as a victim of Macbeth himself”.[8 (p. xxii)] This is because Macbeth’s madness and feverish passion is seen as manly – at the start of the play even the strong Lady Macbeth expresses a desire to be “unsex[ed]”,[3 (1.5.39)] to possess the cruelty associated with ambition which her husband seemingly possesses.

 

The role of religion also plays an important part in the play. Although the theories of Enlightenment had started to permeate into society, religion and God still strongly influenced the way in which people interpreted their world. With this in mind it is possible to see the dramatic evolutions of Macbeth and his wife as religious punishments given due to breaches in their God-given consciences. It has been suggested that “the external phenomena associated with conscience manifest themselves more clearly in Macbeth and his wife than in any other of Shakespeare’s dramatic personages”.[8 (p. ix)] Madness aside, there are many Christian references throughout Macbeth. Lady Macbeth advises her husband to “look like th’innocent flower,/But be a serpent under’t”[3 (1.5.63-64)] in a reference to the story of Adam and Eve in the Garden of Eden. By counselling her husband to be a serpent she equates murder with its patron, the Devil. In preparation for the murder Macbeth reassures himself that Duncan’s ‘virtues/Will plead like angels”.[3 (1.7.18-19)] Lennox wishes that “a swift blessing/May soon return to this our suffering country”,[3 (4.1.48-49)] suggesting that holy salvation is needed to save Scotland from Macbeth’s unholy crimes. The fact that the Doctor advises Lady Macbeth “more needs…the divine than the physician”[3 (5.1.64)] has been used as evidence to suggest that “Shakespeare wanted us to view her condition as the result of remorse, as the outcome of her guilty conscience”.[8 (p. 15)] However this statement can be viewed in one of two ways – either the Doctor is aware that Lady Macbeth has committed unholy crimes and so needs spiritual retribution more than a medical solution; it could also suggest that the Doctor believes all cases of somnambulism to be spiritual in nature and so recommends a divine solution.

Perhaps this conflict between religion and science is indicative of Shakespeare’s own, confused beliefs. It is not impossible that he realised that “by constructing a language through which madness can be represented, the popular theatre facilitated the circulation of the discourse; by italicizing the language of madness, it encouraged its interrogation and transformation”.[6 (p. 338)] Especially true in the Elizabethan age this is particularly poignant today; theatre provides us with a way of interpreting health and disease – it allows us to be privy to people’s perceptions of illness and influences how the public view a certain disease.

 

THE EVOLUTION OF MADNESS: A CONCLUSION

As we develop new ways of understanding health and disease we have returned to old texts to apply our knowledge. This is especially true with regards to psychological illness, and Shakespeare’s work is often subjected to these new readings. You can chart the evolution of madness through critical interpretations of Macbeth; the same applies for readings of depression in Hamlet or dementia in King Lear. On one hand it is interesting to consider why we do this – scientifically speaking quotes from Shakespeare do not count very highly on the ladder of evidence based medicine. I like to think it’s a question of human nature and empathy. We can be so affected by the actions of a fictional character that we are moved to tears or laughter; characters become real to us and we want to know why they behave the way they do, both to satisfy our human curiosity and to perhaps explain why we are so emotionally affected by fiction.

It is also interesting that many of the theories we have explored use the same quotes as evidence; one line can be interpreted in many different ways. Most of the authors considered have admitted this – human nature remains constant and we simply assign different labels to it. Perhaps madness has not evolved at all, but rather as a society we have outgrown one way of thinking and are eager to make our mark on the world by creating another; where better to find reassurance that what we believe is correct but in the great fictional works that define our society?

And what did Shakespeare mean when he described “a mind diseased”? Whilst every new reading brings something profound to a seminal work perhaps it is only by considering the historical and social context that we can fully appreciate what it was that the Bard was trying to convey. As much as we – as readers, critics, health care professionals – would like to diagnose his characters we should always remember that perhaps Shakespeare was simply being a writer and creating characters who would give good performances, characters which would appeal to the public’s expectations. Madness, like beauty is in the eye of the beholder: “in the drama, as in the culture outside it, madness is diagnosed by those who observe it”.[6 (p. 321)] Ultimately, readings and contexts aside, how we view a work of art is an inherently personal experience, influenced as much by our own lives as by society; perhaps it is enough that we feel something, rather than feel nothing at all.

 

References

  1. Porter R. Madness: A Brief History. Oxford: Oxford University Press; 2002
  2. Bossler R. Was Macbeth a Victim of Battle Fatigue? College English 1947; 8 (8): 436-438
  3. Shakespeare W. Braunmuller AR, editor. Macbeth. Cambridge: Cambridge University Press; 2008
  4. Tarantelli CB. “Till destruction sicken”: The catastrophe of mind in Macbeth. Int J Psychoanal 2010; 91: 1483-1501
  5. Norton SA, Paris RM, Wonderlich KJ. “Strange things I have in head”: Evidence of Prion Disease in Shakespeare’s Macbeth. Clin Infect Dis 2006; 42: 299-302
  6. Neely CT. “Documents in Madness”: Reading Madness and Gender in Shakespeare’s Tragedies and Early Modern Culture. Shakespeare Quarterly 1991; 42 (3): 315-338
  7. Fahey CJ [Internet]. Altogether governed by humours: The four ancient temperaments in Shakespeare. Graduate Theses and Dissertations 2008. URL: http://scholarcommons.usf.edu/cgi/viewcontent.cgi?article=1229&context=etd [Accessed July 2014]
  8. Toppen WH. Conscience in Shakespeare’s Macbeth. Groningen: JB Wolters; 1962
  9. Bloom H. Shakespeare: The Invention of the Human. London: Fourth Estate; 1998
  10. Schwartz DB [Internet]. Shakespearean Verse and Prose. Last Edited 2005. URL: http://cla.calpoly.edu/~dschwart/engl339/verseprose.html [Accessed 4th June 2013]
  11. Shea SE, Gordon K, Hawkins A, Kawchuk J, Smith D. Pathology in the Hundred Acre Wood: a neurodevelopmental perspective on A.A.Milne. CMAJ 2000; 163 (12): 1557-1559
  12. Bottomer PF. So Odd a Mixture: Along the Autistic Spectrum in ‘Pride and Prejudice’. London: Jessica Kingsley Publishers; 2007
  13. Spurgeon C. Shakespeare’s Imagery and what it tell us. Cambridge: Cambridge University Press; 2005
  14. Davis FM. Shakespeare’s Medical Knowledge: How Did He Acquire It? The Oxfordian 2000; 3: 45-58

 

Other sources:

Barroll JL. Artificial Persons: The Formation of Character in the Tragedies of Shakespeare. South Carolina: University of South Carolina Press; 1974

Bradley AC. Shakespearean Tragedy: Lectures on Hamlet, Othello, King Lear, Macbeth. 3rd Edition. London: Macmillan Press; 1992

 

Sarah Ahmed is a final year medical student at the University of Birmingham, UK

A version of this article will be presented at the 7th Global Conference – Madness: Probing the Boundaries at Mansfield College, Oxford ( 5th-9th September 2014).

Correspondence to: 09saraha@gmail.com

 

Ayesha Ahmad: Book Review ‘Final Chapters: Writings about the end of life’

7 Aug, 14 | by Ayesha Ahmad

‘Final Chapters’ is the product of a creative writing competition organised through the Dying Matters Coalition, which was established in 2009 by the National Council for Palliative Care. The book invites 30 contributors to describe their reflections on dying.

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Medicine Unboxed: Students – Call for Participation

29 Jul, 14 | by Deborah Bowman

Medicine Unboxed aims to examine medicine from the perspective of the arts and humanities, and arises from the view that good medicine demands more than scientific and technical expertise, also requiring ethical judgment, empathy, and an understanding of human experience. Last year saw the first Medicine Unboxed: Students meeting at which students of the arts, health and medicine came together to share, explore and discuss drawing on the unique perspective and experience of being a student or in the early stages of a profession.

Medicine Unboxed: Students 2014 is curated by Prof. Deborah Bowman and Dr. Lucy McEllan and takes place at the Parabola Arts Centre, Cheltenham on the afternoon of Friday 21st November from 2-5 p.m. The theme for both Medicine Unboxed andMedicine Unboxed: Students is ‘Frontiers’.

We are seeking proposals for participation. Medicine Unboxed thrives on diversity and inclusivity. We are particularly keen to welcome students (undergraduate or postgraduate) from all backgrounds, including (but not limited to) art, drama, music, medicine, literary studies, philosophy and allied health subjects. You can submit a proposal, interpreting the theme ‘Frontiers’, in one of four broad categories:

1. Provocations and Debates – proposals are likely to focus on a contested aspect of health, illness and its treatment and/or to explicitly engage with multiple points of view;

2. Exhibitions and Performance – submissions in this category are likely to be creative e.g. poetry readings, monologues, excerpts from plays, creative writing, musical performances, stand-up comedy, art exhibits, short films etc.

3. Workshops and Interaction – proposals may include experiential activities such as drawing, creative writing, singing and voice activities, improvisation etc or an interactive approach to a question or concept.

4. Conversations – submissions in this category are likely to take the form of short papers or prompt material presented to, and discussed with, the audience.

Proposals may be from individuals or groups. They should be no longer than 500 words and include the i) title, ii) format, iii) names and affiliations of the people involved and iv) a summary of the contribution proposed. You should also indicate in which category you would like your proposal to be considered. Please email your proposal by 1 September 2014 to Prof. Deborah Bowman (dbowman@sgul.ac.k). All proposals will be reviewed by the advisory group for Medicine Unboxed: Students and decisions will be communicated by 15th September 2014.

If you would like to attend Medicine Unboxed: Students but prefer not to submit a proposal for participation, you will be most welcome to join us as an audience member. Tickets for Medicine Unboxed: Students cost £5 and you can register your interest by emailing Dr. Lucy McEllan (lucymclellan@nhs.net).

Follow: @medicineunboxed and @MUstudents

Explore: http://mustudents.wordpress.com/

Join: https://www.facebook.com/groups/175072369272118/?fref=ts

 

Dr Ahmed Rashid: “Diseases of the heart: Where theology meets cardiology”

6 Jul, 14 | by Ayesha Ahmad

Associations between religion and health have been debated for many years. This interest has been paralleled in the medical literature and has led to the inclusion of religious, cultural and sociological topics into medical school curricula, encouraging future clinicians to adopt a more holistic approach to understanding patients and their behaviours.

Much of the research focus has been into church-going populations in North America although the cosmopolitan nature of the modern world means that most clinicians are likely to encounter patients from any world religion. Islam is the second largest religion in the world after Christianity, but consideration about the potential impact it may have on health behaviours has rarely been considered.

He [will prosper] who brings to God a heart protected and pure.” (Quran, 26:89)

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Dr Nikesh Parekh: Film Review The Lunchbox- ‘Letters, chillies, and memories’

4 May, 14 | by Ayesha Ahmad

Set between an apartment block in suburban Mumbai and a modest office floor, The Lunchbox is a film of understated elegance exploring human emotions and connections. Ila (played by Nimrat Kaur) is a young, middle-class Indian woman who is desperately trying to rekindle a waning marriage by preparing her husband delicious lunches that are delivered by the ‘Dabbawala’ system that is widely acclaimed for its efficiency; Dabbawala is an Indian word for men who deliver vast numbers of lunchboxes hanging off the sides of their bicycle in Mumbai and some other cities in India.

more…

The Wolf of Dallas: Money, Stigma and HIV – Guest Review by Shehzad Kunwar

14 Feb, 14 | by BMJ

A Review of “Dallas Buyers Club” (USA 2013, directed by Jean-Marc Vallee). Released in the UK on Friday 7th February 2014

 

 

Say hello to Ron Woodroof, a ‘typical’ Texan. He loves the rodeo. He wears a white t-shirt, boots, a large belt buckle and, of course, a classic Stetson hat. He is a heterosexual aggressive man who loves drinking, drugs, gambling and women. Not the ‘typical’ person you envisage when you think someone with HIV/AIDS living in the 1980s. But after Ron is diagnosed with “HIV”, he becomes an “overnight champion” for human rights; in particular for the rights of those living with HIV to access unlicensed treatments. In an era where discrimination towards those living with HIV was rife, he is soon shunned by his friends and colleagues, gets evicted from his trailer and ends up in an apartment with a pre-op transsexual. His newest “enterprise” is selling FDA unapproved antiretroviral drugs to fellow end-of-lifers.

 

While acting in his new role pharmaceutical “drug dealer” Woodroof, played by Matthew McConaughey, discovers facts that elude health professionals: such as the significance of patients’ concerns and the value of achieving peace, rather than than prolonging life at all cost.

 

Based on the 1992, ‘Dallas Morning News’ article written by Bill Minutaglio, the script underwent multiple re-writes before funding was secured. With many actors competing for the role, it was McConaughey, who Woodroof’s sister said shared the same swagger and personality as her brother, who eventually secured the role.

 

Armed with a passport, and a strong sense of enterprise, Woodroof travels around the globe acquiring illegal drugs such as alpha-interferon. Ron creates his own pseudo-Big Pharma company in the form of a “Dallas Buyers Club” selling prescription-only drugs deemed illegal by the FDA

 

Moral ambiguity imbues the film, with the question of ethics as a recurrent theme. For example, in the representation of research, Woodroof and Big Pharma run clinical trials in parallel.  The numerous attempts made at shutting down Woodroof’s enterprise by the hospital and Internal Revenue Service, who he tries to bribe to keep his business going, is echoed by the pharmaceutical companies subsidizing the hospitals running the antiretroviral trials on their behalf.

 

Homophobia and ostracizing those who were ‘different’ are evident throughout the film. Director Jean-Marc Velee’s perspective of the deliberate targeting of HIV community groups, amongst the gay scene by Woodroof in selling his drugs, is paralleled by the pharmaceutical companies going straight to human trials of AZT, further exploiting and preying on the “desperate and dying”.

 

The character of Eve, played by Jennifer Garner, represents ethical medicine. She questions the pharmaceutical companies’ intentions in persevering with the clinical trials once the significant side effects of antiretroviral drugs became apparent. Her character also highlights the hierarchy that exists in medicine, then and now. As the film progresses, Eve’s voice as the younger, more empathetic doctor contrasts that of her boss Dr. Sevard. His desire to continue with the trial is directly juxtaposed with her disenfranchisement with it and continuing support for Woodroof’s work.

 

Much hype has surrounded Matthew McConaughey’s weight loss, but that is a small part of his meticulously researched performance. The subtleties and nuances of both his voice and expressions portraying a multi-dimensional figure earned him a well-deserved Oscar nomination.

 

In some aspects it seems that the film is made for the undiscerning viewer, in its stereotypes of corporate America and each characters role displayed clearly in their costume. As another variation of the classic David and Goliath story, nothing is ambiguous here and with the constant voice-overs, there is no doubting the identity of the protagonist. Velee’s perspective is that there is a direct comparison between Woodroof and Big Pharma, with Woodroof’s success in that battle epitomised in his prolonged life beyond the 30 days he was given by the medical profession.

 

This film is a timely way to revisit the HIV/AIDS crisis and continues the work of titles such as “Philadelphia” and “Angels in America”. But unlike Denzel Washington’s character, in Philadelphia, Woodroof’s personal change is guided by greed rather than compassion. Vellee, ensuring that the film’s take-home message is heard loud and clear, amplifies this journey for the mainstream viewer.

 

Dr Shehzad Kunwar (independent film maker, photographer and musician): shehzadkunwar@doctors.org.uk

To Have Been What I Always Am, So Changed From What I Was: Reflections on Altered States and Beckett

30 Jan, 14 | by Deborah Bowman

 

London is currently home to productions of four Samuel Beckett plays. A trilogy – Not I, Footfalls and Rockaby – performed by the extraordinary Lisa Dwan, is at the Royal Court Theatre in advance of a transfer to the Duchess Theatre. Across town, Juliet Stevenson takes on the role of Winnie in Happy Days at the Young Vic Theatre. Both productions are preoccupied with altered states. And, for anyone interested in the health humanities, the concept of the altered state is unavoidable and fascinating.

Not I, the first play in the Royal Court trilogy, plunges its audience into a darkness that is unremittingly absolute. Every glimmer of residual light is extinguished and the effect is devastating. There is nothing between us and ourselves. No distracting or reassuring visual clues that we have a place in the world. All that remains is the blackness. We wait until our eyes adapt – for surely they will adapt – isn’t that what eyes do? Isn’t adaptation the essence of humankind? But they don’t. We don’t. It is inescapable: our altered state.

And then, looming above us in a beam of light, is the mouth. We cannot help but focus. It commands our focus. This disembodied mouth. All that there is in the room is the darkness, the mouth and our thoughts. And so it begins. Words, sounds, glimpses of sentences tumble out of those bright red lips – a life pouring forth, demanding to be heard. At first we can’t make out the words. Some are familiar, but some a nonsense. Is it the speed? Is it the accent? We are concentrating so hard; why can’t we understand? And still the words cascade into the darkness and still we search for meaning. We revert to the comfort of clinical categorisation: this is logorrhea. But how pointless that seems – what is the value of naming but never knowing?

And still the mouth moves and the waves of sound wash over the auditorium. We sense damage. We intuit harm. We no longer need the details – we can feel it. In our altered state, all communication convention is overthrown and we discover it doesn’t matter. If we persist in attending to another, then we will make a connection.

In contrast to the claustrophobic darkness of Not I, the theatre in Happy Days is assaulted by light. It is brutal and unforgiving in its reach. Under the burning brightness, we find Winnie buried up to her breasts. As with the plays in the trilogy, we know nothing of how she came to be here. Beckett is not concerned with causality – it is enough simply to meet a person where and how they are. So, we encounter Winnie, trapped in the earth for reasons we will never understand nor need to understand.

Winnie’s altered state is physically, emotionally and metaphorically concerned with what lies beneath. The audience too, whilst looking only at the top half of her body in an unchanging set, begins to grapple with the unseen and the unexpressed. As Winnie digs deeper into the bag she treasures, her memories, hopes and identity emerge in the form of mundane, and practical objects. Her failed efforts to engage Willie – to share her altered state with another – require her to dig ever deeper into her self. The increasingly brittle humour with which she meets her predicament discomforts us – as altered states so often do.

When Act 2 opens, Winnie’s state is further altered and she is buried up to her neck. All that is visible now is her head. Her hair is disheveled and her teeth rotting. She is herself and yet, so crushingly and irrevocably altered. Her decline is physical and existential. She is in pain. She is unsure whether she is alone because she can no longer turn to see Willie. She can no longer dig deep – and what lies beneath is suffocating her.

As Willie painstakingly crawls his way across the earth, upwards towards Winnie and the gun that rests in front of her, the potential narratives flood our minds. His intentions are ambiguous to the last. But this is not a state that ends. The lights dim and the actors remain frozen on the verge of change. A change we can imagine, but cannot control. An uncertain, but unavoidable, change that mirrors the shifting and complex experiences and perceptions of those altered states that, in other contexts, we call ‘illness’.

Not I, Footfalls and Rockaby is at the Duchess Theatre from 3-15 February 2014

Happy Days is at The Young Vic Theatre until 8 March 2014

 

Guest Piece: Joseph Ting: “Medicine Now, at the Wellcome Collection London: Obesity, The Body, Malaria and Genomes”.

14 Jan, 14 | by Ayesha Ahmad

Medicine Now, a permanent exhibition at the Wellcome Collection in London, presents a range of ideas about science and medicine since Sir Henry Wellcome’s death in 1936. Designed to broaden engagement with medical science beyond the narrow confines of the laboratory or clinic, Medicine Now presents a cogent multidisciplinary view of four topics, Obesity, The Body, Malaria and Genomes. These are explored through the perspective of patients, doctors, scientists and artists.

 

Medicine Now ranges over contemporary art, the way medicine has been perceived, and has affected the human race, in the last eighty years. The intersection between art, science and medicine is made accessible to the lay audience and there are challenging displays for the specialist visitor.

 

Obesity

Dieting, weight consciousness, anxiety about body weight and shape and widespread hostilty to obesity are fundamental themes in contemporary life. There is tension between modern populations trying to control their weight amid unprecedented opportunities to let themselves go. [1]  John Isaacs’ two metre high “I can’t help the way I feel” (2003) comprise superhuman sized globules of cellulite perched on tiny legs (Fig 1).

 

This corporeal aggregate of multilobulated fat has submerged its own head, preserving its anonymity. This however has the unfair effect of diverting the viewer’s attention to the grotesquerie emanating from below the neck. A strategic overgrowth of fleshy apron over the thighs conceals the gender of the person portrayed by “I can’t help the way I feel.” Isaacs may be commenting on society’s fixation with the female form, despite obesity afflicting both sexes.

 

I can’t help the way I feel” could be considered the ugly embodiment of the obesity epidemic. The attention-grabbing dimpled thighs, soft bulges and doughy rolls of Isaacs’ sculpture reminds one of the difficulty the obese face in trying to not draw attention to themselves. The artist’s sympathetic contention that “the way in which the flesh grows, erupts and engulfs the body can be seen as a metaphor of the way in which we become incapacitated by the emotional landscape in which we live and over which we have little control” did little to temper my repulsion for “I can’t help the way I feel.” The impulse to ridicule, discriminate against, and publicly monitor the body shape of, the obese has its basis in the visible markers of fatness (wide hips, protruding belly, vast thighs) transgressing aesthetic standards and signalling pathology and disease. [1] My seeing fatness led to the negative reading of fat bodies. More than ever, judgements about our own and others’ worth is based on the morphological body as compared to the ideal.

 

The Body [Figure 1]

Anthony Gormley, a commentator for Modern Medicine, claims “the body (to be) the root of all our experience, a place where we all live and on which our consciousness depends.” The Body examines new techniques and ways of looking at our internal biological structures and function.

 

Medical imaging technologies play a crucial role in comtemporary medical care.  A century after Wilheim Rontgen discovered x rays, the human body is accessible to radiological techniques that enable doctors to peer inside the intact human body. To improve understanding of new technology, the visitor can sit on sound chairs to hear the views of a Professor of Medical Physics on CT scans and an ultrasonographer on antenatal ultrasound.

 

Anatomical objects-dissected bodies and constructed models-have aroused the interest and curiosity of lay audiences since the late fifteeth century. [2]I found the coronally-sectioned plastinated body of a standing human cadaver confronting. Michel Foucault’s vivid description of “externalising the internal” remains deeply disturbing when one imagines plastinated transparency forcing the total detachment of the body’s interior from an identifiable and skin-covered person. The sliced body brings to mind Gunther von Hagens’ Bodyworlds blockbuster that travelled the world and attracted millions of visitors. Then there was outcry protesting the moral ambiguity surrounding the display of artfully dissected human bodies for mass entertainment.  However it is hard to deny the educational value of Transparent Woman (1980), from the Stiflung Deutsches Hygiene-Museum, which allow the visitor to light up several human organs with a push button panel.

 

Moral objections are harder to pose with the Visible Human Project. Digitised anatomical bodies are developed from thin CT cross-sections of a standard adult male and female body, offering perpetual electronic cadavers that are able to be logged onto regardless of time or location, and facilitating the training of students and surgeons. Digital simulation comprise unmediated inscriptions of cadavers that have not been distorted by the pencil of the illustrator or the knife of the dissector. 2 However, unless the electronic form can be sculpted into a model by 3D bioprinting, tactile cues remain impossible.

 

The audio observations of a humanities academic seeing medical students performing anatomical dissection for the first time was most poignant as the heart was delivered into cupped hands. It brought back memories of my own tentative first encounter with our dissection group’s cadaver in the anatomy laboratory. However, The Body pays scant attention to human physiology. The finger sensor that was supposed to measure my pulse and cardiac rhythm and display this “biogram” on a touch screen failed to work. The pulse oximeter is not a new innovation, having been around for decades.

 

Malaria

The mosquitoes used by Alastair Mackie to outline the world’s coasts on a plain white board in Mosquito Coast (2002) come from the malaria research laboratory at the Division of Cell and Molecular Biology at Imperial College London (Fig 2). The fragility of thin borders formed by a delicately assembled line of single mosquitoes belies the difficulty humans have encountered since antiquity in trying to overcome malaria’s formidable defences and superb adaptation. Mosquito Coast testifies to an army of malaria-bearing mosquitos encircling land masses and islands to symbolically entrap the world.

 

At the dawn of the twenty-first century, Mackie’s map puts us on notice that the malarial mosquito loaded with its most feared pathogen still commands worldwide attention. Each year millions of people die from malaria. Over vast regions, human health continues to suffer and national economies fail. Although malaria is a potent threat only in the tropics, it remains a disease without borders, with sporadic cases occuring in returning travellers and immigrants in advanced nations. The absence of national boundaries in Mosquito Coast signify the porous permeability of malaria’s distribution. Where it had not been reported previously, de novo malaria now occurs ocassionally in northern Australia. [3]

 

Mosquito Coast  forces the recognition that malarial mosquitos remain a robust and ancient foe that continues to shape human history worldwide. Opportunities for malaria spread around the world occur with increasing international travel and trade. Mosquitoes survive transoceanic flights in aircraft cabins and baggage compartments and are brought to distant ports in shipping containers. [4]

 

Mosquito Coast stimulates thinking on the the role of global climate change, congested urbanisation and environmental degradation in expanding the habitat of malaria-armed mosquitoes. We are reminded of the disrupting effects of human activity on the ecology of pathogen carrying vectors. However it is not all bad news. Mackie’s world map reminded me of satellite-aided Geographical Information Systems that employ meterological data and malaria incidence tracking to better  deliver insecticides and antimalarial. The global reference implied in Mosquito Coast urges international research to control malaria and its mosquito vectors to be as collaborative as the tightly linked mosquitoes on show.

 

Genomes examines the scientific study of DNA as well as its social and cultural significance. The scale of the challenge faced by the Human Genome Project is mirrored in the formidable series of books containing the first printout of whole human genome, presented at reduced font to to able to accommodate 3.4 billion units of DNA code, and neatly arranged on high shelves. High tech gene sequencing is complemented by television documentaries dealing with the human suffering inflicted by a mysterious familial disease, the genetic mechanisms of which were not known then. Even when the diagnosis of a range of genetic diseases is now possible, the prospects of replacing defective genes with curative intent remains a distant dream.

 

Conclusion

 

Modern Medicine more than fulfills the Wellcome Collection’s modest aim to being a “free destination for the incurably curious.” The exhibition is capable of inciting public interest in the performance of medicine in its more recent incarnations. In exploring the connections between modern medicine, life and contemporary art, visitors can achieve intriguing insights that result from the intersections between past with present; professional and lay; science, art, and society. Obesity and Body is analogous  to “looking and being looked at [judging body weight and aesthetics], and looking through [medical imaging and anatomical models]” respectively. Genome and the (plastinated) Body displays pose difficult moral and ethical challenges.

 

Modern Medicine is cohesively curated;  the microscopic genetic imprint of life plays an influential role in determining body shape and size, and our susceptibility to diseases such as malaria. In embedding biomedicine within an rapidly evolving historical and cultural landscape, and undertaking to explore the future direction of biomedical science, the challenge Modern Medicine faces is to maintain its contemporaneity since opening in 2007.

Figure 1

 

 

Figure 2 

 

References:

1. Stearns PN. Fat history : bodies and beauty in the modern West.

New York: New York University Press: 1997.

2. van Dijck J. The transparent body : a cultural analysis of medical imaging. Seattle: University of Washington Press: 2005.

3. Hanna JN, Ritchie SA, Eisen DP et al. An outbreak of Plasmodium vivax malaria in Far North Queensland. Med J Aust 2002;180:24-28.

4. Spielman A, D’Antonio M. Mosquito : a natural history of our most persistent and deadly foe. London: Faber: 2001.

Written by Dr Joseph Ting; Adjunct Associate Professor, Faculty of Health and Social Work, Queensland University of Technology, Brisbane, and Senior Staff Specialist, Department of Emergency Medicine, Mater Health Services, Raymond Terrace, South Brisbane 4101. Email: jysting@uq.edu.au/ Joesph.Ting@mater.org.au 

Alam Anjum: Emotional Warfare: From Doctors to Patients

25 Nov, 13 | by Ayesha Ahmad

 

Whilst watching the film, “The Doctor”, released in the year 1991, I was struck by the same old question in my mind, whose answer I have been looking for several years that; to what extent does a doctor need to be attached or detached from their patients as persons?

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