University of Minnesota Press, 2018. 236 pages.
Asthma is thought to affect an estimated 339 million people around the globe, with a prevalence rates as high as 20% of adults in some nations (Global Asthma Network 2018). It is one of the most common chronic conditions, impacting people across all genders, ethnicities, and socio-economic classes, though it is noted as being especially prevalent in poor and minority communities. While for many sufferers, asthma has a significant impact on education, work, activity levels, and overall quality of life, the condition is generally not well understood. And, until recently, asthma has not been an especially popular topic of anthropological study.
The Asthma Files project (TAF) has made great strides in rectifying this. Spearheaded by anthropologists Kim Fortun and Mike Fortun, TAF has produced an online scholarly forum that draws together the work of scholars from around the world and a broad range of disciplines, making available information on incidence, etiology, education and health communication strategies, and caring methods (Rensselaer Polytechnic Institute 2019). Just as significantly, TAF has fostered new “experimental ethnographic” approaches to asthma, building up a novel cohort of scholars whose work now stands alongside earlier ethnographic examinations of the condition by Betsy Pohlman and Gay Becker (2006), Ian Whitmarsh (2008), David Van Sickle (2009), among others. These new endeavors reveal the wide variety of ways that respiratory distress is lived out across a range of settings, educating both lay and professional audiences and challenging assumptions about this often overlooked condition.
Alison Kenner’s book is a direct offshoot of TAF, which Kenner joined in 2009. Based on extensive fieldwork in seven American locations (with Philadelphia, New York’s Hudson Valley, and Knoxville, Tennessee receiving especially extended coverage), from 2009-2017, Kenner’s book examines asthma from a variety of outlooks, including those of sufferers (who she refers to as “breathers”) and environmental activists to health app developers and Buteyko breathing educators. The geographic specificity of Kenner’s research is important, as asthma manifests differently among different groups in different places. Indeed, one of the things Kenner does extremely well in this book is to underscore the heterogeneity of what many scientists are suggesting may not, in fact, be a single condition. As Kenner outlines, “Symptoms and triggers differ from person to person, as do disease severity and responses to medications. Age of onset varies as well, and for those who live with asthma across the life course, the disease can change over time, taking on new forms” (Kenner 2018: 9).
Public health responses to asthma also vary widely, from environmental health campaigns to, in some contexts, an almost exclusive focus on pharmaceutical solutions. Alternative healing methods, be they dietary adjustments, Buteyko or other breath retraining methods, mediation and relaxation, or water-based spa cures abound (Trnka 2017a, 2017b), as does concern and skepticism over the utility of biomedical treatments in some of the most severe and intractable cases (Kenner 2018: 87). As Kenner documents, the clinical and other healing spaces in which not only treatments but basic understandings of the dynamics of asthma come to be debated and negotiated are broad and multivariable.
Several chapters particularly stand out in this ethnography, including one that focuses on the Buteyko breathing method, which teaches suffers to elongate the pauses between breaths and can, as Kenner fascinatingly details with respect to her own experience of undergoing breath retraining, be extremely challenging to learn. But for many asthma sufferers, Buteyko breathing retraining or similar programs offer a welcomed, non-pharmaceutical approach to relief.
Similarly, Kenner’s work on asthma apps presents a novel consideration of how technologies that have been designed to help patients track their asthma can not only allow users new insights into their symptoms but, in pulling together large quantities of individuals’ data, can be used to track how changes in air quality and other environmental factors collectively impact asthma sufferers, becoming in effect “a kind of collective care for the public good” (Kenner 2018: 116).
But perhaps most compelling is Kenner’s depiction of individuals’ experiences of asthma attacks, as first-hand, deeply detailed accounts of what it actually feels like to lose one’s capacity to breathe remain surprisingly rare in the asthma-related literature. From the first pages of the book, which open with a moving account of how 34-year old Jess wakes up in the middle of the night with “air scraping against his narrowed trachea, the audible wheeze … the controlled pacing of inhale and exhale, intuitively measured by his sense of lung capacity … [and] the momentary stillness of the pause he takes at both ends of each breath” (Kenner 2018: 1), Kenner drives home the real impact of asthma and the breathlessness it can cause.
One area that might have strengthened Kenner’s analysis would have been more consideration of how her findings on asthma compare to those about other medical conditions. This book could, for example, have benefited from comparison of the experiences of asthma sufferers and those living with other chronic health conditions. How might, for example, the “asthmatic attunement” to time and place that many asthma sufferers learn to adopt (2018: 16) compare to the lived experiences of person’s with other chronic respiratory diseases or other environmentally-triggered conditions (such as chemical sensitivities)?
Given the book’s focus on asthma and climate change, a bit more could have been made of the social science literature on environmental health conditions. In particular the work of Phil Brown and the Contested Illnesses Research Group, which has studied scientific disputes over the environmental causes of breast cancer and Gulf War Illnesses, as well as asthma (e.g. Brown et al. 2012) and collaborates closely with community-based participatory research groups, seems particularly apt in terms of a fruitful comparison point for the discussion of community participation in climate change educational activism that Kenner discusses in Chapter 5.
There was also a notable gap of coverage of the role that pharmaceutical companies play in helping to determine asthma’s “carescapes” (2018: 16), particularly given historical controversies over the possible detrimental effects of pharmaceutical remedies, such as fenoterol which was widely prescribed in New Zealand, a short-acting β adrenoreceptor agonist used to mitigate asthma symptoms but was later found to be greatly exacerbating the asthma mortality rate (see Pearce 2007 for details).
Overall, however, Breathtaking presents a compelling and very readable ethnographic overview of the ways that asthma is grappled with across a variety of 21st century American contexts. This book offers an insightful and multi-faceted account of a condition that affects so many around the world.
Brown, Phil, Rachel Morello-Frosch, Stephen Zavestoski, and The Contested Illnesses Research Group, eds. 2012. Contested Illnesses: Citizens, Science, and Health Social Movements. Berkeley: University of California Press.
Global Asthma Network 2018. “The Global Asthma Report 2018.” Auckland, New Zealand. http://www.globalasthmareport.org/Global%20Asthma%20Report%202018.pdf
Pearce, Neil. 2007 Adverse Reactions: The Fenoterol Story. Auckland: Auckland University Press.
Pohlman, Betsy, and Gay Becker. 2006. “‘Stress Knocks Hard on Your Immune System’: Asthma and the Discourse on Stress.” Medical Anthropology 25(3): 265–295.
Rensselaer Polytechnic Institute. 2019. Asthma Files. https://tw.rpi.edu/web/project/TAF
Trnka, Susanna. 2017a. One Blue Child: Asthma, Responsibility and the Politics of Global Health. Palo Alto, CA: Stanford University Press.
Trnka, Susanna. 2017b. “Efficacious Holidays: The Therapeutic Dimensions of Pleasure and Discipline in Czech Respiratory Spas.” Medical Anthropology Quarterly. 32(1):42-58.
Whitmarsh, Ian. 2008. Biomedical Ambiguity: Race, Asthma, and the Contested Meaning of Genetic Research in the Caribbean. Ithaca, NY: Cornell University Press.
Van Sickle, David. 2009. “Diagnosis and Management of Asthma in the Medical Marketplace of India: Implications for Efforts to Improve Global Respiratory Health.” In Anthropology and Public Health: Bridging Differences in Culture and Society, edited by Robert A. Hahn and Marcia C. Inhorn, 65–93. Oxford, UK: Oxford University Press.
Susanna Trnka is a social and medical anthropologist at the University of Auckland. Her previous books include One Blue Child (2017) and Competing Responsibilities (2017).