Indeed, we get at different understandings of disease and different conceptions of health based on where we start our study. Decentering, moving between clinic, homes and neighbors is really important. I am thinking here of Bourgois and Schonberg’s study of heroin addicts (Righteous Dopefiend). If they had started in the local emergency room rather than in their everyday travails to get the next fix, they would have never seen how they make a community; how their intricate moral economy is organized in part around avoiding the pain of withdrawal and structural abjections of all kinds. In this context, what are “addicted subjects” and what ideas of compliance are available to them?
Michael A. Whyte
The temporality of the domestic fascinates me. There is an interesting chronicity here. Work in refugee studies can usefully draw contrasts between “refugee time” and “administrative time.” Those following the juridical pattern, for example, those engaged in filing claims and counterclaims, see time very differently than those waiting for a relative to return. For them, it is an order of documents and processes, rather than a biological order. We have to attend to how these different orders of time speak or don’t speak to each other.
You also challenged us to reflect on what we do when we do fieldwork and suggested that the interview can create the subject we are looking for, “obscuring the webs of relations that create subjectivity.” Why is it assumed that anyone can just “observe”?
There seems to be openness about diagnosis and treatment of depression in the Chilean primary health care centers. In India, the case is different. I saw so many times that the disease is medicated, but doctors simply do not tell their patients. This leads to a different dynamic in how the drugs are used and understood. Another problem is that general practitioners that prescribe these drugs rampantly often presume that poverty and economic insecurity leads to depression. Yet it has never been easy to live in India. Why would the last ten years have seen such a massive rise in depression? I am very suspicious of any doctor using these socioeconomic stress arguments to justify their prescriptions.
In Brazil, the discourse is the similar, general practitioners diagnosing antidepressants and invoking economic stress as the justification.
I want to rescue the clinic as starting point. I am thinking of Rayna Rapps’s work (Testing Women, Testing the Fetus). Starting with the neighborhood does do something different than starting with a clinic, but it’s not necessarily better. It is still possible to transcend the received wisdom of how biomedicine works from within the clinic. The notion of the “everyday” is also an abstraction. It’s a workable notion, but it’s not reality; you’re still making claims.
I guess I want to rescue the clinic as a starting point. I am thinking of Rayna Rapps’s work (Testing Women, Testing the Fetus). Starting with the neighborhood does do something different than starting with a clinic, as you argue. But I wouldn’t say it’s necessarily better. Instead we can see that each starting point can throw the other into doubt. It is still possible to transgress the received wisdom of how biomedicine works from within the clinic. In this same vein, the notion of the “everyday” is itself an abstraction, like the space of the clinic. It’s a workable notion, but it’s not reality; you’re still making claims.
You remind us of anthropology’s disruptive capacity. We are in some ways the anti-global enterprise. I love your insight that there is no such thing as the common medical problem, and that the only way to get at that is through participant-observation. What would it mean to do what you do in mental health for global health? Michel Foucault made the point that modernity includes a shift from the disease in the life of the patient to the patient in the life of the disease. But disease is never really one thing as we see here and in the other papers. If we really took this seriously, I wonder what it would look like as a theoretical shift.
The alternative that you propose between the clinical space and the domestic space is stated in a way that makes the word “health” a problem. In the domestic space perhaps we should think in terms of “life” and not necessarily in terms of “health”. Yesterday Michael was saying there is a problem with the “global” in global health, and that global health needs to be problematized in terms of everyday life. But health itself should be problematized.
It is interesting how the understanding of depression has changed and these changes have important implications. In the 1970s and 80s, there was a hardening of depression: phenomenology in the place of psychology on the one hand, and pharmacology on the other. In the end, depression was diagnosed through the “test” of the drug. It became that which could be treated with drugs. Now we have a second generation of drugs that a GP can give that makes people even less uncomfortable when they take it. As a result, both the market and the definition of depression expand. I think one of the key questions we have been asking is about the materiality of things. The role of drugs is especially important—their materiality, especially with regard to mental health, and in their role in the market and in the definition of depression expanding.
Susan Reynolds Whyte
I appreciate your focus on methodology because we often skate over it quickly to get to analytical issues. I think it is important to appreciate that these same ethnographic methods are also very useful in looking at clinical spaces. We aren’t just focused on the drugs or the treatment of a disease, but on the concerns of people in this space. There is a specificity to diseases as well as to treatments. Do you think that certain kinds of diseases lend themselves to particular methods? For example, chronic diseases seem suited to narrative approaches.
What does this do to our imagining of a next form of community psychiatry?
Michael M. J. Fischer
How to consider the juridical space with respect to health citizenship. I am thinking of ethnographies of health care workers and how they might help their patients/ clients to think about rights to health. Raising questions about these issues in the course of participant observation could also serve as a mode of consciousness-raising and critical thinking.