© 2013 E.I. Kirilenko
2013 – № 1 (5)
Key words: research in humanities, narrative medicine, medical and anthropological discourse, interdisciplinary research, cultural and historical approach
Abstract: In the framework of the review of the collection of scientific papers “Obshestvo remissii: na puti k narrativnoy medicine” (“The society of remission: on the way to narrative medicine”), the author highlights 3 main topics: development of narrative medicine, analysis and development of modern medical and anthropological discourse framework, elaboration of theoretical instruments and concepts of medical and anthropological research. Among all the works, presented in the collection, the author favours the most the articles by V.Lekhtzier, D.Mikhel and B.Ivkov, analyzing their content in detail.
The interest of humanitarian research to medicine is very great nowadays (it may be comparable only with the interest to law topics. Compare: M. Foucault – a medicine theorist and a prison history researcher).
The collection under review is a significant phenomenon in Russian human sciences since it helps to reveal some quality changes in the attitude of humanitarian knowledge towards medicine. Let us address three points: detailed description of one of the strategies of modern medical treatment – narrative medicine – is given in the collection. The framework of concepts of medical and anthropological discourse is being developed in the context of discussion of humanitarian problems of medicine, which, therefore, contributes to formulation of methodological basis, possible institutionalization of medical anthropology as a trend of modern interdisciplinary research.
Multicultural reality forms a diversified image of medicine. V. Konovalov distinguished five leading strategies of medical treatment in the modern world using primarily cultural and historical approach as a basis: scientific (western), eastern, folk medicine (ethnomedicine), homeopathy, healer medicine (Konovalov, 1996). The latest trends in medicine are diverse as well: narrative, behavioral, “medicine and culture”, evidence-based, personalized medicine, biomedicine, etc. The latter three rest upon the complex of natural-science and mathematic approaches, the first ones consolidate mainly around humanitarian axis.
The division here goes along the line where a major problem of modern medicine is defined: intensive development of scientific approaches, technical support of medicine and discrepancy between these opportunities and patients’ expectations, mismatch of scientific, scientific and technical and humanitarian components, inability of doctors to “see” and “hear” their patient, split between medical expectations of the modern society and those functions that are at the foreground in modern scientific medical support (I. Illich talks about clinical, social and cultural destructions (“iatrogenesis”) caused by modern medicine, as well as involvement of the patient in the sphere of political relationships (Mikhel’, 2011, p. 258)).
One of the indications of ill-being in this sphere is complete separation that gains on doctors and patients, the sick and the healthy, a gap that appears inside a medical community (Lekhtsier, 2012, p. 110).
A possible response to this situation is the development of narrative medicine. This is the first important subject matter of the book. For the first time in Russian literature the exhaustive presentation of this strategy is made: the theory and practices of “talking” (Gotlib, A.S.) medicine are laid out, the reasons, origins and peculiarities of this trend are investigated, doctors’ and patients’ narratives are analyzed, the possibility of using narrative practices from the perspective of patients and doctors is revealed. The experience of North American medicine is complemented by the research of the experience of cooperation between doctors and patients in Russia.
The requirement to introduce patient’s narrative into medical practice is one of the ways to control the disease (Lekhtsier, 2012, p. 278). Attention to the situation of illness, recognition of a chronic patient as a central figure of modern medicine put forward the concept of “the remission society”. And this is another important theme of the book – analysis and development of modern medical and anthropological discourse concept framework. Saturation of daily medical experience with multiple mythological constructs (the myths of saturation, nutrition, hydration, purgation, etc.), intensification of medical thematization in cultural consciousness, establishment of the concept of disease including chronic disease as a priority one in modern cultural discourse, an attempt to present the history of culture as a “history of pain” – all these topics make it possible to put forward the concept of “the remission society” in a row of comparable analogs in determining modern society identity.
A corresponding terminological set is being developed in this research aspect: medicalization of the society, disease as a nosological entity and as experience (D. Mikhel’ suggests distinguishing illness and disease (Mikhel’, 2011, p. 40)), disease and pain as social and cultural phenomena as opposed to objectivistic model of disease; chronic patient as a central figure of the modern medicine; the remission society, disease as a biographic situation, biographic break and biographic adjustment to disease, etc.
The efforts to develop theoretic tools, notions and concepts influence the situation of consolidation of heterogeneous and multidirectional medical and anthropological studies – and this is the third theme of the book under review. The task of coupling medicine and humanities knowledge running like a golden thread through the contemporary history and epigrammatized by M. Foucault – the place of medicine is paramount in the “architecture of human sciences” – finds its expression in Russian practice in the tendency towards integration of medical and humanitarian studies in a strategy that forms in a particular way.
The conception of the book is formulated in the introduction: the remission society (the subject mater of the first chapter) puts forward the figure of a chronic patient, and his experience is not only a routine element of a traditional medical history but it becomes an important condition of humanization of medicine and increase of its therapeutic effectiveness. The phenomenon of narrative medicine is the subject matter of the second chapter of the book. The cultural aspect of the analysis (disease as a phenomenon of a cultural narrative) is the subject matter of the third chapter.
Authentic texts on theory and practice of narrative medicine are presented in the fourth chapter of the book.
We would like to specially dwell on four articles out of fifteen diverse and original articles presented in the book.
This is, first of all, the text by V. Lekhtsier. We are not talking about his main article with a comprehensive analysis of the narrative medicine based on the most interesting source – the works of R. Charon, an American doctor. We are referring to his introduction to the book named “Byt’ uslyshannym…” (“Get a hearing…”). One should agree with the author that the concept of the remission society is the important experience in the search of self-identity which helps the modern society understand something important about itself. This concept is absolutely natural and convincing, it corresponds to multiple intuitions in modern culture. If it “suddenly” became clear to V. Veresaev, a sophomore who was just learning medicine, that there are no healthy people, everybody is ill: “a normal man is an ill man”, then it seems logical that a new medical motto is getting established in public consciousness of the medicalized society: there are no healthy people, only under-examined ones . This intuition of a nonclassical culture (Freud talked about total neurotization of the modern society) is documented in the contingence of the situation of health and illness (according to Selye, stress can cause an unhealthy condition but at the same time it is “appetite for and fragrance of life”). It appeared in attempts to search for a positive sense of disease. As it is pointed out by V. Filatov, a contemporary researcher, “in the XX century scientific interpretation of the phenomenon of disease implies denying of a strict opposition “health – disease” and the traditional definition of these notions as different in essence” (Filatov, 2002, p. 6). Probably only contemporary experience could prompt such a metaphor of a disease to a poet: “Flue in October is all-seeing like the God. / Like angels with the wings of dragonflies, / Rhinitises fly off the skies before the winter season / And bewitch our bodies” (by Bella Akhmadulina). These intuitions correspond with the formula of Arthur Frank, an American researcher: a modern world is the remission society. Additional justification of this concept appears as a result of its inclusion in the stylistics of postmodern consciousness which is oriented towards erasing of differences, oppositions and contradictions – and this is also original argumentation of V. Lekhtsier.
However, recalling K. Popper’s logic of reasoning, the boundaries of applicability of this concept should be defined. There is a liberal counterargument: one third of all ill people who do not belong to chronic ones turn out to be non-legitimate in the remission society. There is a cross-cultural counterargument: can it be presupposed that acquisition of the concept of remission society as a successful identity formation of a modern civilization corresponds to deep national archetypes with their melancholic orientation (K. Bogdanov recalls M. Gorky’s words that “Russian literature is the most pessimistic literature in Europe” (Bogdanov, 2005))? There is a historical and cultural argument: the issues of disease prevention, healthy lifestyle are actively present in modern cultural consciousness – this is the developed and differentiated practice which is determined by the conception of healthy society and is inherited from the past. One can remember that early Greeks, for example, knew phylaxis (the art of health maintenance) besides prophylaxis (the art of preventing diseases) (Levin, 1887, p. 873).
We would like to point out innovatory (for Russian literature) way of interpretation of the idea of top-priority role of chronic diseases in the disease structure of the modern society. It drastically changes the perspective of disease analysis applying additional explanatory scheme. Besides linear representation (disease as an incidental occasional phenomenon on the life path, infectious diseases giving way to diseases of civilizations) a wave scheme of diseased conditions (chronic-remission) is being established.
The notion that chronic but not acute case is the dominant idea in doctor’s system of reference allows to correct the beliefs about the peculiarities and tasks of modern scientific medicine. “The medicine of acute conditions” probably should give up its place to “maternalistic1” (V. Lekhtsier) medicine with its main purpose: care for the patient through his whole life.
The article by D. Mikhel’ is the introduction to the history of formation of medical anthropology, the trend which includes a wide range of medical and humanitarian studies and is actively developed abroad and in modern Russia. Noting that only some elements of medical and anthropological studies are found in the Soviet literature (to be fair one can refer to rather active and effective practice of humanitarian study of medicine in Russia at the end of the 19th – first third of the 20th centuries (Rossiiskii, 1923; Vinogradov, 1923) ), the author actually does the most important work gleaning a holistic picture of medical anthropology as the most important trend in current interdisciplinary research. The author offers historiography of medical and anthropological research, defines terminology and key concepts. D. Mikhel’ noticed that the notions of experience of pain and disease are an organic result of anthropologists’ interest in the phenomena of disease and health. Rich empirical data is given in the article, cultural side of disease experience is underlined. The most important thematization of medical and anthropological studies is experience of the body. The author draws attention to its possible modifications (the individual, the social and the political body, gender aspects of corporality). As a contribution to the development of perceptions of organization of medical experience one could suggest its structuring based on the analysis of a linguistic situation and allowing to point out six main elements: these are experience of the body, attitude to the doctor, notion of the patient’s figure, notion of disease and health, medicinal practice.
Ivkov offers methodology of biographical analysis of a disease experience based on a wide range of studies including the approaches of Alfred Schütz, an Austrian philosopher, and a biographical method of Fritz Schütze, a contemporary German sociologist (probably it is worth pointing out the figure of Fritz Schütze – see the work under review, p. 77). Conceptual tools, which allow for analysis of the “narrative of a chronic patient as a pathway of pain”, distinctions appearing here, structural and dynamic features of this experience, are studied in detail in the article.
Revelation of structures of biographic processes reflecting inclusion of a disease in the life experience can obtain substantive development and significant didactic sense if we approach the layer of cultural history disclosing clinical aspects of the biography of its cultural heroes. This genre of study of the “diseases of great people”, which is all-liked by medical men for the opportunity to hone one’s professional skills, includes humanitarian and scientific and medical components and gives a perfect opportunity to see disease in a biography as an important part of it using appropriate tools. Thus, A. Blok’s biomedical pathway of disease (subacute bacterial endocarditis) is combined with acute worldview and existential crisis: “there is not enough air”. This approach does not solve immediate therapeutic problems but it cultivates an individualized view on a disease, forms the skill of seeing the development of pathology as a fact of biography beyond the scope of biomedical pathway of a disease, assimilating the experience of living with disease accumulated in culture, “cultivating the skills of compassion and emotional response” in medical students (A.S. Gotlib) and in such a way trying to go away from one-dimensional figure of a doctor-technologist.
The works by K. Bogdanov are well known to Russian readers: the researcher restored and enriched the line of correlation of literature and medicine that was developed yet by A.P. Chekhov who studied “medical practice in Russia” on the material of folk tradition, historical texts.
Obviously this tradition has historic and literary value, but not only. Russian literature of the 19th century, overcoming, according to I. Kondakov, the borders of art, was a kind of a tool for socio-cultural research. This experience of “mirroring” medical plots in cultural consciousness, existing in literature, allowed to study the peculiarities and laws of development of medical discourse in the context of culture, on the one hand, and to reveal cultural semantics of medical artifacts on the other hand. The suggested plot is the great study guide for current dentist students allowing to reveal cultural connotations in the sphere of their professional activities, and at the same time to observe the laws of “dentistry” establishing in Russia.
In conclusion it should be noted that the book under review is an innovative and ingenious phenomenon in Russian literature.
These are the needs of life that dictate the search for new approaches in medical and humanitarian studies. It is not once that the opposition between “highways” and “paths” in Russian medicine was observed. Declarations and experience of scientific and technic and technological development of modern scientific medicine (biomedicine, high tech medicine) contrast to real situation in Russian healthcare services, which gives rise to a logical question: whom does this feast of intellectual and technical thoughts address if only 3 % of the people interviewed in 2011 said that the situation in the Russian healthcare services was good, and 58 % of them said that it was bad2; if, according to 2012 poll, healthcare services rank third among underdeveloped sectors after agricultural industry and forestry3; if people “avoid going to clinics”4.
- Compare: in the novel “Rakovyi Korpus (Cancer ward)” by Solzhenitsyn medical staff called Lydmila Afanasyevna Dontsova, a chief of the department, “mother”.
- Bogdanov, K.A. (2005), Doctors, patients, readers : patographic texts of the Russian culture of XVIII-XIX centuries, OGI, Moscow.
- Filatov, F.R. (2002), “The phenomenon of a disease in different knowledge systems: a conflict of interpretations”, Moskovskiy Psikhoterapevticheskiy Zhurnal, №2, p. 6.
- Konovalov, V.V. (1996), “The crisis of medicine at the turn of XXI century and the ways of recovery from it”, Chelovek, №1, pp. 106-119.
- Lekhtsier, V.L. (2012), “Narrative medicine: the bright utopia of Rita Charon?”, The society of remission: on the way to narrative medicine, p. 110.
- Levin, A.M. (1887), “Aretaeus of Cappadocia (A sketch from the history of Greek medicine)”, Vrach, №45. p. 873.
- Mikhel’, D.V. (2011), “Medicalization as a social phenomenon”, Vestnik SGTU, №4(60), 2nd ed, p. 258.
- Rossiiskii, D.M. (1923), The history of general and Russian medicine and healthcare service). Bibliography (996-1954), Moscow.
- Vinogradov, G.S. (1923), Studying folk medicine from Russian population of Siberia, GubVPO Press, Irkutsk.