Chronic Conditions, Fluid States: Chronicity and the Anthropology of Illness
Lenore Manderson & Carolyn Smith-Morris, eds. Rutgers University Press, 2010. 320 pp., paperback.
Review by Matthew Wolf-Meyer (UC Santa Cruz)
The use and experience of time is a perennial, albeit minor, interest in anthropology generally, and medical anthropology in particular. This has everything to do with the processes of degeneration, production and reproduction that anthropologists of medicine have focused on — including but not limited to cancer, HIV/AIDS, diabetes, pregnancy and surrogacy, addiction, depression and schizophrenia. In each case, what marks the experience of individuals struggling with these medical and social disorders is a differential sense of time, both as individuals and as they are governed or controlled by society. These experiences become marked as “chronic” to designate this difference of time from the temporal experience of the normal. But, increasingly, the category of the healthy, of the normal, has become colonized by that of the chronic — and vice versa: chronic illnesses are now lifetime struggles, conditions that individuals, families and societies confront on an everyday basis. Despite this — or maybe because of it — to date, there has been very little sustained interest on the part of medical anthropologists in what makes chronic time different from everyday life, nor any broad reworking of the anthropological understandings of time from the position of the chronic. And this is where Lenore Manderson and Carolyn Smith-Morris’ edited collection, Chronic Conditions, Fluid States, offers its intervention. In this review essay, rather than tackle all of the essays included in the collection, I choose to focus on two generative chapters and raise a number of questions about the place — and conception — of time in anthropology, and especially medical anthropology. Other readers will no doubt find chapters that resonate with them and their interests; my own interests in sleep and daily rhythms of American everyday life drew me towards the contributions of Steve Ferzacca and Carolyn Smith-Morris. But, before I turn to their individual contributions to the volume, Manderson and Smith-Morris’ introduction bears discussion as it serves as an intervention in its own right.
Manderson and Smith-Morris’ stated intention is “to draw on the idea of chronicity to heighten sensitivity to the structural factors that create, maintain, and produce fluidity and flux in these [chronic] disease patterns, their management, and outcomes” (1). At the heart of their concern is the shifting ground on which the old chronic-acute dichotomy now finds itself: what was once treated as acute and life-threatening has been tamed into a chronic illness (diabetes, HIV/AIDS, some experiences of cancer). As a result, what is now a lifelong experience of disorder is punctuated with acute moments — symptoms flare up and recede, tumors grow and remit. At least this is the case for those in wealthy countries or those with robust social health care programs. For others, the acute-chronic dichotomy still holds, and the challenge is then twofold: staging interventions that transmute the acute into the chronic, and, secondarily, installing therapeutic regimes that sustain individuals and communities with their now chronic conditions. Manderson and Smith-Morris go on to suggest that “Our task has been to challenge a single, hegemonic conceptualization [of chronic illness], to illustrate its role in supporting existing power structures behind global health paradigms, and to reaffirm the habitus of illness as segregated, individual, and stigma-producing event” (ibid.). I’ll return to this below, but for now I want to raise a rhetorical question: Might we be missing the forest for the trees in focusing on the individual experience of chronic illnesses? Might our anthropological tools be failing us by attending too closely on the person and not enough on the social? In the age of ever-widening experiences of the chronic, it may be time to open up the scales of our analysis and their techniques.
Along these lines, Manderson and Smith-Morris argue that “Our work must encourage counterhegemonic discourses and pragmatic health solutions that address a life span, and lifelong characteristics of susceptibility, identity and constitution, rather than temporally liminal illness events” (11). What they hope to achieve in the collection is a movement away from conceptions of illness as temporally bounded — as if they have no lingering effects, somatically or socially — and towards a conception of individuals as continuing to confront the ramifications of their “chronic” and “acute” disorders. The effort of many of the contributors, following this, is to focus on conditions considered chronic and to expose how — through ethnographic attention — they are punctuated with periods of “acute” intensity: diabetes, schizophrenia, infertility, cancer, lupus, HIV/AIDS, cystic fibrosis, pediatric clubfeet and Down syndrome all receive attention. Manderson and Smith-Morris mention in their introduction the inverse, namely acute conditions that turn into chronic ones, as in the case of Dengue fever — and one might also include malaria here, as well as many other “acute” disorders that affect individuals’ lives in chronic ways. And if the intervention of Chronic Conditions is to be carried further, it requires thinking outside of those conditions that have been designated by physicians and scientists as “chronic” and “acute” and towards all of the disorders of everyday life that have become increasingly medicalized (menstruation, sleep, excretion, etc.). What the contributions to Chronic Conditions index is that modern, especially American and Western European, everyday life is now based on conceptualizing self and society through the lens of chronic, constant medical intervention — the self-surveillance integral to what David Armstrong refers to as “surveillance medicine” (Armstrong 2002). In turn, the medicalization of normal human variation leads to new spatiotemporalities and ways for individuals to conceive of themselves, their social relationships and their worlds. Whereas “acute” understandings of self and society once ruled, now “susceptibility, identity and constitution” lay the basis for subjectivity. As Manderson and Smith-Morris lay out, this necessitates critical intervention into the medical categories that constitute this foundation.
Manderson and Smith-Morris suggest that “New models are needed — based perhaps on a continuum or notion of continuity “(18), and it is here that anthropology might make its most sustained intervention into these categories of “chronic” and “acute,” drawing upon ethnologic studies of temporality and society. One of the challenges that Chronic Conditions makes clear is that anthropology needs to move beyond descriptions of alternative experiences of time, and towards developing theories of temporality that accord with the worlds of individuals and societies. This requires confronting extra-anthropological studies of time, as well as casting a wide net within anthropology for support in this reconceptualizing project. For many of the authors in Chronic Conditions, the work of Gay Becker (1998) looms large (the book is the result of a conference panel in Becker’s honor), but there is less rigorous engagement with other anthropologists of time — Carol Greenhouse (1996), Nancy Munn (1996), Johannes Fabian (1983), Alfred Gell (2001), and Janet Hoskins (1997). Further afield, but still necessary for a rethinking of hegemonic conceptions of time, the historical and sociological work of Evitar Zerubavel (1985 ), Henri Lefebvre (2002 ), Mark J. Smith (1997) and Dorothy Smith (1987) may prove useful in this effort. And it is also worth thinking more ontologically about time, and considering the work of philosophers Michel Serres (1995 ), Henri Bergson (1991 ), Elizabeth Grosz (2004), Bernard Stiegler (1994) and Gilles Deleuze (1994 ); other ontologies will necessarily require new ethnographic modalities, and may be the most profound way to overturn contemporary models of “chronic” and “acute” disorder.
The contributions by Carolyn Smith-Morris and Steve Ferzacca help point to possible routes that a rigorous critique of medicalized time might follow. Drawing on her fieldwork among the Pima community in Arizona that focuses on experiences of diabetes, Smith-Morris concludes her chapter by suggesting that “Defragmenting our own ethnographic language [of temporality] will help defragment our Cartesian view of the body, destabilize the dichotomies that reify biomedical strategies and treatments, and ultimately alter the targets for intervention and our definitions of success” (35). She goes on to argue that “Anthropological discourse that defragments will privilege continuity of illness and health together in lived experience, especially as these inform the identity of persons with chronic diagnosable conditions” (ibid.). Smith-Morris suggests, following Becker, that continuity is what weaves an individual’s understanding of his or her life together, and that this lays the basis for articulating a conception of self against biomedical models that place emphasis on disconnected, “acute” events. This emphasis on continuity echoes Lefebvrian interests in the seriality and rhythm of the everyday (Lefebvre 1987), and might provide a way to consider both the lives of individuals and communities — how is continuity something that is constructed and always under construction (Messinger 2010)? Who values continuity, and under what circumstances? It may be that it is especially in the case of individuals dealing with chronic, recurrent symptoms that continuity becomes salient, while, for many, one day needn’t follow from the day before. It may be the case, following Lefebvre, that this emphasis on continuity in the lives of individuals is especially “modern” — and, if so, one might reasonably wonder if it is the flipside of what Emily Martin described as a contemporary interest in personal “flexibility,” the ability to adjust to adversity rather than being overcome by it (Martin 1994). But these questions are for future research; Smith-Morris helps to show how the very idea of chronicity may be indebted to the “biotechnological ability to treat or manage a condition” (37) and that our ethnographic burden is in exposing how medical institutions obscure that technological conceit in favor of pathologizing individuals and their behavior.
Steve Ferzacca’s contribution to Chronic Conditions offers some tools for thinking about the circumstances under which continuity becomes a feature of everyday life. Drawing on his fieldwork in Java and in Canada on diabetes, Ferzacca coins two terms to help conceptualize experiences of medically-mediated time, “vital time” and “circumstantial time” (159). Vital time “combines event history and mechanically derived time cycles to organize diagnosis and therapy” (ibid.); it leads to “self-management” strategies, as individuals monitor themselves and their symptoms against expertly determined markers. Circumstantial time, in contrast, posits “diabetes [and other disorders, presumably] within the time frame of social and cultural progress linked to economic development” and epidemiological data (ibid.). For Indonesians, self-management is not as salient as it is for Canadians, who measure themselves against normative models of disease progression; instead, for Indonesians, diabetes becomes a marker of modernity, its presence placing Java at a historical threshold embodied in its citizens. Ferzacca goes on to suggest that the measurement of vital markers is “meant to establish therapeutic rhythms, which as embodied mnemonic devices, acknowledge the chronicity in the everyday lives of sufferers” (162). This chronicity is the basis for the continuity Smith-Morris discusses, but it is only possible because of the medical frame of vital time. In contrast, Ferzacca’s Javanese respondents evidence how diabetes (and other “diseases of modernity”) come to mark discontinuity in their lives: one’s life before being diagnoses stands in stark contrast to post-diagnosis — a traditional/modern rupture. Medical therapy becomes less about producing everyday continuity and more focused on the possibility of the continuity of one’s life, where being “modern” can often produce social frictions and estrangements. Rather than accept narratives of continuity as necessarily counterpoised to hegemonic discourses of time in medicine, thinking through other models of time opens up possibilities for research and critique.
In closing, I want to raise two concerns for future studies of time in medical anthropology, one already hinted at above, the other regarding the necessity for also considering space. One of the fruitful aspects of Ferzacca’s vital and circumstantial times are that they combine scales — they allow analysis to move between individuals and societies. Anthropological critique needs to find ways to move beyond the lives of solitary individuals or small groups to conceptualize how whole societies formulate particular experiences as meaningful and necessary. That the lives of individual Javanese are changing against the experiences of their “traditional” peers and that these changes are both somatic and temporal leads to the inevitable conclusion that there are national times, ways that whole populations become synchronized, coordinated, and subject to particular rhythms (cf. Lefebvre 2004; Schivelbusch 1986 ). And this leads me to my second concern, regarding space. Time and space are immanent qualities, and are inseparable (Massey 2005). From the changing patterns of self-management that Ferzacca outlines to the times of nations, the emergent spatiotemporal rhythms of everyday life are increasingly “chronic” and mediated by medical conceptions of order and disorder. Taking time seriously necessitates that we also attend to how time shapes space — and how, inevitably, bodies mediate and are mediated by these chronic spatiotemporalities. This opens up the possibility of seeing the globe as marked by particular intensities of rhythm and order, and how diverse places are connected through spatiotemporal techniques (Braun 2007); it also provides a means to think about the disorder of individuals and societies and how they have become subject to medicine as a means of restoring order. Chronic Conditions brings our attention to a nexus of necessary concerns — bodies, disorder, time — and lays the basis for another generation of medical anthropology in pursuit of conceptualizing and critiquing the spatiotemporalities of everyday life and its medicalization.
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