Lectures

Medical anthropology applied to education in socio-health professions: From the enchantment of technology to the enchantment of the encounter

“If you want to understand what a science is, you should look for the first instance not at its theories and its findings, and certainly not at what its apologists say about it, you should look  at what the practitioners of it do,” wrote Clifford Geertz (1973, p.311). To contribute to the continuous redefinition of medical anthropology, we will present the theoretical framework of our teaching practices. As anthropologists and lecturers of human sciences in the faculty of physiotherapy at the Campus LU.de.S of Lugano, in Switzerland, we propose to our students some central themes of medical anthropology, including the notions of body, health and disease, by accompanying frontal teaching with experimental laboratory activities aimed to placing the physician’s lived body at the core of the training and knowledge acquisition process. 

We will describe the process of a laboratory where, through poetic expression activities, the physician’s body is progressively revealed with its own agency and its own poetics: a canoe prow-board (Gell in Coote 1992, p.44) prepared for a new type of encounter, beyond the therapeutic. As art in Gell, we conceive the physician’s body, as magical, endowed with technical knowledge that heals and arouses enchantment but is also capable of creating therapeutic alliance, starting from the poetic encounter with the other – patient.   

Despite the profound differences that exist between different paradigms, clinical or critical, there are some continuities in the intentions and practices of those involved in medical anthropology, including the articulation of the relationship between human sciences and bio-medical sciences, the study of this connection and the application in the training of doctors. Merril Singer outlined how it was precisely in the objectives of a new phase of critical medical anthropology “to move beyond the academy” (Singer 2005, p.81), crossing over into its applied dimension, that sees the effort to change as one of its fundamentals (Singer 1990, pp. 548-549).

With this article, in this historical time, when the attention to education is focused to pass to virtual space – for the recent spread of the Sars-COV-2 –, another step in the Western process of concealing the body, we propose in a stubborn and contrary way, to draw attention on one hand to the body like a place of  experience  knowledge and reflection, and on the other, to creative process as a way of performing the body of future doctors.

In the first part, through an ethnography of the experience in the classroom, we will try to make to emerge the phenomenology of what we have defined a process of formation of a body territory made up of subjectivities “squeezed out” (Turner 1982, p. 36)  within the group, in a dynamic relationship of lived experience and artistic expression.

In the second part we will present, as a historical precedent of anthropology applied to teaching, the history and the work of the CEAM, Centro de Estudios de Antropologia Mèdica in Santiago de Chile, at the beginning of the 1960s (Hoffmann 1961), designed to complete the training of medical students, focusing in particular on the objective linked to the vocation of the doctor through the integration of the human sciences and forms of artistic expression in the training of doctors.

The learning convivial ritual emerging from a shared poetic practice, creates a context that emphasizes the experience of the intersubjective space, where students develop the appetite of the other’s appetite (Borutti 2015), co-creating each other in a dynamic reciprocity.

Underlying this educational path is the consideration of disease as a place of resistance and the territory of treatment as a space of creation in which the healer co-inhabits and co-creates it together with the patient, dwelling together. A territory that brings new possibilities for the construction of subjects (singular healers and patients), unhinging the hierarchical logic of the spatialization of the disease that tend to conceal the patient (Foucault 1998, pp.24-28).

Our educational intervention is not so much concerned with the content of poetic productions and their analysis, but with the process through which poetic language becomes a tool for dissolving conceptual armors, for the fact of living the experience of the desire for reciprocity. Such a desire generates attention rather than intention. Attention to possible correspondences with the other – the patient, in which both mutually transform themselves through the relationship (Ingold 2016). In this sense, educational action becomes political because it carries with it the idea of ​​the encounter as the elementary structure of care. Without aprioristic ideological content, it foresees that structures arise from the encounters themselves: the doctor and patient can negotiate a treatment path together starting from their singular encounter.

The care process becomes a Derriddean margin, where the disease is only a part of it, an interstitial place where the relations between illness, sickness and disease (Kleinman 1978; Good 1977) are confronted with the archaeologies of the patient and of the doctor inscribed in their poetic body. Transforming this place of double absence (Sayad 1999) into a place of construction of presence is, at the beginning, the task of those who take care, activating the process of a shared anthropopoiesis (Remotti 2013). Healing is therefore not just taking care of the other but at the same time taking care of this act of making the human, where this “margin” becomes “central” (Malighetti 2012), worthy of being cultivated and inhabited.

Here the physician’s body becomes magical, endowed with technical knowledge that heals and arouses enchantment (Gell 1992), and a body that is also capable of creating therapeutic alliance, starting from the poetic encounter with the other – patient. A therapeutic alliance arises not from functionality but from “[t]aking others seriously and opening up to imaginations enriched by their experience ” (Ingold 2020, p.16). That experience meets the doctor’s, giving life to a sort of co-agency from which emerges the intuition that things are in life and not life in things.

The doctor must be prepared and his body must be trained to be poetic, to try to immerse himself in the sea of the reign of reality its liquid richness (Bastide 1945), that is to make poetic intuition a way of living the social experience.

In this sense, a performing artistic laboratory was proposed, leading the group to experience the performance as a form of social meta – comment represented by “a story that a group tells to itself and about itself” (Turner  1982 ) producing a ” performative reflexivity” in the individuals who are part of it (Singer  1959). 

The exercise analyzed here is a shared poetic production, borrowed from the letters workshop conducted by the Brazilian artist Maíra Paiva in the Arthur Bispo do Rosario Cohabitation Center[1], in Belo Horizonte – Brazil, and adapted to a class, composed of about 20 students, of Health and Society 2 of the year 2019-2020 in the faculty physiotherapy of the LU.de.S Campus of Lugano.

The class was divided into groups of about 8-10 people. After an hour of warm-up we sat in a circle and the exercise (because this is what we are talking about) was to write on topics that were gradually proposed. The first theme was “the body.” Each pupil was given the time they needed, and the rules of writing, calligraphy and spelling were suspended.

After some hesitation (expressed in glances, mutual smiles and gossip), the students gathered in the silence in which the creative presence is enough in itself (Le Breton 1997). A writing that is not speaking. Being silent and screaming without noise (Duras 1994, p. 21). An event that transcends the lived experience and creates the present.

As the pupils finished, they were invited to put down their pens and wait for their colleagues.

The second part of the exercise was to present one’s work by transforming the exploration of experience from individual to collective (Minelli, 2017), relocating into the group.

The eyes lowered back to their paper but this time not to create but to escape.

Finally Elca stood up (each poet has designated himself with a nickname), he warned the group that his work was not beautiful, sheltering himself while awaiting judgment.

My body moves, it speaks for me; the body is the face, is instinct, sensation, something that comes before thought or word. My body is light and flies when I am happy and it is heavy in moments of sadness; no matter how many physical efforts I have made before, the body moves according to the mood, according to the sensations.

White was the second:

Dry, too dry,

white, too white,

oh my body,

I can’t like you.

If the clinical gaze, identified by Foucault (1998), was based on the botanical conception of disease and on the enumeration of “what is discovered as analogous or equal on statistically significant evidence” (Auersperg 2016), the poetizing, according to the psychiatrist Alfred Auersperg[2], on the other hand, is able to open spaces to the singularity of each one, to his own subjective perception and to the courage to express it. This perceived subjectivity is reconstructed in sharing, in a new space formed by the encounter, which does not exclude but includes the mode of objective corporeality to which anatomy and physiology refer: it is precisely in the “horizon of the encountering” (Auersperg 2016, p. 9), that the possibility of manifestation of the symptoms arise.

White’s whiteness, far from meaning other than itself, a color considered dominant for instance, is the manifestation of a feeling of one’s body perhaps as vulnerable, not beautiful enough, but it is also a representation of a pale body, which perhaps wishes to be read. The poetic gesture reveals precisely bas-reliefs that otherwise would remain hidden from the reductive lens of nosology.

Elca decided on the second theme, “The space”. X spoke up:

                Space is a burden

               It chains us to the ground

               I look at you lying there

               But with the thought I fly

And in turn they decided on the third theme, the fourth and so on until the end. As the themes proceed, the “fhysiopoets” were transformed into a spontaneous communitas as it was well described by Turner in which being “squeezed out” was stimulated by the other’s appetite (Borutti 2015), which replaced the fear of the judgment of the other .         

The bodies of the students came out of the starting scheme of the round table and J got up in his chair:

        We are infinite

           you and me are evrything that never ends like these

              wor ds, bro  k   en, wron but full of meaning.

The objective of this exercise was to stimulate the capacity to generate a new relational territory, in which the poetic body of a “person” has no borders in its subjectivity, on the contrary is permeated by the flow of the other’s subjectivity. Poetic language becomes the vehicle through which being is given, is eventifyed (Heidegger 1968).

Thus, in the space of care we intend to introduce the notion of existential territory constituted through the expressive appropriation of material and affective elements that produce spaces for possible coexistence (Reinhemer 2009), spaces for the construction of the human, transforming care into a place that is not just to dwell but a territory to build together, proposing in its construction, lines of flight and de-territorialization (Deleuze and Guattari 1997).

In this place lives a doctor-poet, a seismograph of reality, (Von Hofmannstadt in Gabrielli 2015) a “meaning operator”, able to stand on the margin without authority by opening to the enchantment of the encounter.

The Centro de Estudios de Antropología Médica CEAM: a historical precedent

In the attempt to structure an educational practice of the doctor, in our specific case of the physiotherapist, which accords the body the centrality that medical anthropology has attributed to it mainly since the 1980s, we have focused on a similar experience conducted in the early sixties in Santiago de Chile.

In 1960, Francisco Hoffman, an esteemed professor of physiology at the School of Medicine in Santiago de Chile, founded the CEAM, Centro de Estudios de Antropologia Médica, to train medical students. After a meeting with Carl G. Jung, Hoffmann orientated his research interests to the areas of sociology and anthropology.[3] He found collaboration, in the pioneering enterprise, in his wife Elena Jacoby (known as Lola Hoffmann), physiologist and psychiatrist; in Claudio Naranjo, medical psychiatrist; in Rolando Toro, professor of psychology of expression, and in the artist Ludwig Zeller. The research center, led by this small group of pioneers, dissolved after a few years, in 1965, but it represented “a significant step in Chilean medical culture in the process of humanization of medicine.”[4]

Hoffman and his collaborators aimed to putting into practice the basic principles of an integral medicine, an idea shared at the time also by the illustrious Spanish doctor Rof Carballo, with his idea of dialogical medicine (Bombaci 2015). The aim of this integral medicine was mainly to identify problems related to the disintegration of knowledge in specialisms and the capitulation of science to technical studies. They wanted to integrate more human and humanistic aspects in the medical field, within the larger project of humanizing medicine. The doctor’s training had to include the deepening of the notion of human being, getting out of the dichotomies of the notions of health derived from the positivist biological paradigm of the late nineteenth century, by integrating new aspects of the human, starting in particular from the human sciences, but not only. For the development of the personality of the members of the group some activities were proposed, meetings in small groups with the participation of each one in setting the problems and in their discussion, theoretical seminars, discussion groups of a more personal nature and the combination of the various activities.

The themes were chosen by the teachers who defined a series of points of medical interest to be explored, for example the different notions of the body and the comparative ideas of health coming from cultural anthropology. From this and activities of human studies applied to medicine, Hoffmann approached, a definition of medical anthropology, which would arise from a shared practice and embedded knowledge:

In the course of these studies one could properly arrive at what could be defined as a medical anthropology, as a synthesis of humanities, sciences and arts, which contributes to the conceptual expansion of medicine, in its individual, social, somatic, psychological, preventive and curative” (Hoffman 1960 , p.150 ). 

This medical anthropology derived from the practical application of it, particularly in the fields of training and education of doctors. In order to perform their profession, in a more complete way, they would have to be completed in the growth as human beings through a series of cognitive and practical experiences that could show them how the experiences of suffering, pain, disease and vulnerability were inherent in their human wholeness. Experiencing this completeness in oneself and then corresponding and relating to one’s patients, not reducing them in their illness but considering them in their most complete humanity. This approach would have strengthened the “professional vocation”, the individual and social ethical values, bringing to the fore the notion of the human being as a subject with agency and affective not only as an object of technical-scientific study and therapeutic treatment.

The term vocation, “the call”, a topos of the narratives on medicine, appeals to “the dialogical reality of the human being, revealed in the encounter or in the dialogue, highlights that in the innermost depths of his existence, even in his physical structure, man is constituted in an essential way by his neighbor”. (Carballo 1961, p.34). In this sense, the preparation of the doctor must include preparation of the body for the encounter. The disposition to the other cannot be constituted only through the study of the patients’ suffering. The study of the narrative approaches of illness, for example, is necessary but not sufficient for the formation of the desire of the other, an appetite for otherness that generates productive encounters of meaning, change and healing.

These are instead possible results of a correspondence (Ingold 2016) that happens between the doctor and the patient, an alliance that arises spontaneously in an encounter based on reciprocity and “tenderness” (Carballo 1961). The Chilean experience was oriented by a vision of an “integral man” (Hoffmann 1961), an “eternal man” (Auersperg 2016), by the sharing of an anthropological aesthetics on the basis of which to found care practices that respond to the affective dimension of the human being. The doctor is “a man capable of taking charge of reality” (Javier Zubiri in Carballo 1961) with “silences full of attention, caresses, kisses”. We believe that through a body-oriented education to attention described by Ingold as the very etymological definition of education, “a ‘leading out’ of the person along a line of movement ” (Ingold 2013 and 2020 ), it is possible to evoke the reality of the vocation to medical practice: the vocation to the encounter.  


Viviana Luz Toro Matuk, Ph.D, is a social anthropologist, Adjunct Professor of Applied Ethics and Philosophy of Health at L.U.de.S Lugano Campus in Switzerland and co-founder of LIB, Laboratorio de Investigación Biocentrica, in the International Biocentric Popular University Scuolatoro in Italy. She did research in Pernambuco in Brazil and in Gabù in Guinea-Bissau on freedom, ethics and values in post-colonial and post-slavery societies. She is now interested in historical issues of Medical Anthropology and its applied forms in education.

Stefano Fontana is Adjunct Professor of Health and Society at L.U.de.S Lugano Campus in Switzerland and conducts art workshops in psychiatric communities in Italy. He is a PhD candidate at the University of Milan – Bicocca in co-tutorship with the Federal Rural University of Rio de Janeiro, with a research on the construction of citizenship though art process in the public network of mental health in Belo Horizonte, Brazil.


Notes

[1] Cohabitation centres are artistic devices of the public mental health network in Belo Horizonte (Brazil) where art is used not like therapy but like an instrument to create a new kind of citizenship.

[2] Prince Alfred Auersperg worked at the surgical clinic of Vasconcelos, Brazil, with research on the psychophysiology of visceral and transmitted pain. 1949 he was offered by the Dean of the Faculty of Medicine of Concepción (Chile) to open a clinic and the chair of psychiatry. From 1949 to 1968 he was professor and director of the psychiatric clinic at the Universidad de Concepción. In 1956 and 1957 he researched at the Child Study Center of Yale University, where he worked with the child psychologist Käthe Wolf, who emigrated from Austria. Since 1953, Auersperg stayed in Europe several times, especially in Heidelberg in contact with Viktor von Weizsäcker, Walter Ritter von Baeyer, Herbert Plügge and Frederik Buytendijk. Since 1965 there have been several conversations between Auersperg and Martin Heidegger on questions of perception, as well as with Ludwig von Bertalanffy, the founder of systems theory. With a strong personality and great originality of thought Auersperg was also the inspiration of the researchers who founded the Center of Medical Anthropology in Chile.

[3] In Günther, B., Cori, O., Croxato, H., “Figuras seneras del ciencia chilena”, Editorial Universitaria, 1981, Santiago, Chile.

[4] Private conversation with Rolando Toro on the history of CEAM, of which he was part as a researcher, in November 2009, a few months before his departure. After this experience, Hoffmann fell ill and retired. Lola went from being a physiologist to be an important figure in Chilean psychiatry. Naranjo was Fritz Perls’ successor in Esalen and researched ethno-pharmacology and psychoactive substances. Toro became known for creating a system of human development, based on dance and the encounter, first called Psicodanza and later Biodanza (Toro 2016). Zeller is a recognized artist, particularly in Mexico.

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