Translating Medicine: Interview with Harris Solomon, author of Metabolic Living

Roanne Kantor //

Q: What does medicine mean to you? How does it relate to your projects (past or current), and the academic position you hold?

A: For me, medicine is most meaningful on a several fronts  right now, in light of my current ethnographic research in and around casualty (emergency) and trauma wards at public hospitals in Mumbai.

The first is how medicine works as a differential of narrative. Besides being a different medical science than I was used to in earlier research (more on that in bit), trauma medicine is also different in terms of story.  Usually the patient cannot speak, or doesn’t speak much. The intensive care unit in trauma adds another layer of complexity; many patients are intubated. The very idea of “illness narratives” is out the window. This has been both refreshing and unnerving to me, given that the whole idea of a semi-coherent narrative of illness experience is one of the foundations of medical anthropology that I was trained in. Ethically, and sensibly, I did not focus on patient stories when they were in dire straits. This has shifted how I write about everyday violence and efforts to treat it, in a context where the object of violence — the person who is injured — is no longer a readily available resource of story.

But there are stories, still. Thinking from this place is where I might begin to address to your question about translation. One of the things I pay attention to is how patient kin create accounts of the accident and the hospital’s care (or lack of it, if they deem things neglectful). I am just as interested in how doctors and nurses and technicians and janitors do the same thing. This is often an issue of creating a conversation about the patient, around the person, right by their bed, sometimes while they inhale and exhale in synch with a ventilator. You, the anthropologist, hear about a person, sometimes as if she is not there, but in fact she is right there in front of you. One does not so much give an account of oneself, so much as others speak in one’s stead. It is a space of translation in this way. Translation may be supportive, but it can also be dismissive or directed in unexpected directions: in the anxiety around an event (not necessarily the event itself), and at odd angles to the subject of injury (not necessarily parallel). This ultimately gets called “care” and “neglect” but perhaps more attention to translation might show how these are some but not all of medicine’s poles.

The second thing medicine means for me at the moment has to do with medicine as a differential of expertise, by which I mean that “medicine” is in practice a complex family tree of expert knowledges. Surgery governs most of what I see in my current project. I had a bit of experience with fieldwork around surgery in my previous book project about metabolic disease, but most of that project’s  clinical fieldwork involved time in outpatient diabetes clinics. There, the most common way of doing and knowing and thinking medicine involved figuring out ways to tilt someone’s physiology in a different direction, over a protracted timeframe. You, the doctor, are up against hormone concentrations (dwindling, unless you add more insulin), and downstream impairments involving vision, blood circulation, and touch sensations,  These things take time to figure out. Often you change an insulin dose, and hope to get the person to come back a few weeks later, and hope that it works. Or you counsel someone on their lunchbox choices, and get them to try something different, and hope that it works. This, then this, and if not, you try something else. It is intimate, and tends to pull physicians into eddies of a patient’s apparent willpower, domestic dynamics, and the expression of some sort of truth at the doctor’s desk. But it is often a medicine of “try this, then that if the first thing doesn’t take” and it is a medicine with a protracted temporality. People don’t (usually) have diabetic situations that are immanently deadly.

By contrast, in the trauma ward, general surgeons are in charge, and work most closely with anesthetists. Orthopedic surgeons and neurosurgeons make occasional appearances.  It is about getting someone stable as soon as possible. Trauma holds the potential to kill someone soon, sometimes in hours or even minutes. So you, the surgeon, stop bleeding, raise blood pressure, suture wounds, get imaging for potential surgery if the person is stable, take them to surgery maybe. It can be fast-paced but not in the “ER” television show sort of way. Its melodrama is often more protracted, and unfolds through relations between a patient’s family and the ward staff. The bureaucracy is intensive. And it can take quite some time for someone to die, even in the most injurious of circumstances. There is a lot of waiting. Medicine in this ward is also an expertise cultivated through pedagogy. The hospital is a teaching hospital, meaning that many of the doctors are residents. The are constantly seeking out consults, guidance, and are sometimes performing procedures for the first time. So medical expertise is not something given; it is crafted.

The third thing that medicine means to me at the moment is an encounter with authority. Because the hospital I work in is a municipal public hospital, it is a key site of state power in a setting of deep health inequalities. As scholars such as Rama Baru, Lawrence Cohen, Veena Das, Sarah Pinto, Kaushik Sunder Rajan, Mohan Rao, and many others have demonstrated, the lived realities of “health access” stretch far beyond yes/no matters in much of India.  I have been struck by the number of cases in the trauma ward that arrive as “transfer” cases from private hospitals. These are often situations where a family’s resources run out, or the sticker price on keeping someone alive is beyond reach, and so people turn to the public hospital. Like public hospitals in cities perhaps elsewhere (certainly in the US, in my view), the hospital is a hazy window onto the world outside its walls. Its story is a story of the city, and how the poor approach the state’s promise of public health in the form of a hospital. But it is sometimes less a window than a message, often a tense promise that can all too easily break.

This is especially fraught in moments of a patient’s death, which are moments that unfortunately punctuate nearly every day in this trauma ward, given the high caseload and high mortality rates. I have spent quite some time paying attention to the specific words and phrases that doctors use to inform a patient’s relatives of his death. Some are poetic. There was one doctor whose love of Urdu couplets seemed to inflect even his most even-handed deliveries of a patient’s instabilities (his patients were often “nazuk,” meaning brittle, the kind of brittleness you see in a flaky sweet that shatters upon touch).  But most often, one must speak death, often by communicating that a patient is no more, or, just as often, one doesn’t say anything at all, just a head down, an apology perhaps. The more experienced doctors invest a lot of time “readying” kin for this news. “Call your people from the village,” they tell them. Make plans. So that you know when the time comes that the person may not sudden rebound, like in a film.  It’s not so much that language sets up clinical reality as the thing that punctures clinical fantasy. It’s more that language gets wrapped up into the reshuffling of a world amidst injury’s aftermath. Telling someone they are going to die, and telling their family that they’re dead, is crushing. But it may not be the most crushing center of things, *for them*. Tying back to your question, medicine is a message here. For me, part of ethnography involves listening to how the message might connect to the reshuffling.

Q: Your projects have to do with the intersection between medicine at the individual level (your fieldwork with people living with diabetes and surviving traffic accidents) but also with environmental health. Indeed, as I understand it, you’re particularly interested in the messiness of defining exactly where one field ends and the other begins (recursive body-city relations). Still, these fields don’t always talk to each other. Do you ever find yourself “translating” for colleagues on either side of this divide? You are also trained in a number of fields: linguistics, public health, and anthropology. Especially in your current appointment (in part in the Global Health Institute), do you ever find yourself “translating” between disciplines? What kinds of misunderstandings arise?

A: I encounter a lot of translation work in this regard. One way to look at it is methodologically, such that ethnography can more strongly address certain types of research inquiries, and more quantitative public health methodologies can more strongly address others. I am very lucky to work with amazing public health researchers in India, and we take this approach when writing or researching together. We translate methodology for each other, and that’s how we collaborate.  I have also been lucky to work with students in both the US and India who aren’t yet fixated on a certain method, and this flexibility means that student research can be capacious and multimodal. For instance, some of my students at Duke put together a complex project on cyclist deaths in Durham. They created a podcast that situated survivor stories amidst the changing politics of traffic and of the city’s rapid gentrification more generally.  They also built digital maps based on computational models of the city’s most crash-heavy intersections.  They took a key question — how does death through car-bicycle collisions unfold? — and ran with it. I’d call that translation work of environmental health.

I do think that some of the translation work between anthropology and public health can be understood as different demands on what counts as the grounds of the political. For instance, one sees a pivot from local to global to now planetary health. That is the trend I see, in documents, in conversations, and on Power Point slides. Attending to politics is attending to scale, here. The balloon inflates: it’s not just people, not just institutions, but, well, more and more. Thus the gesture to “planetary,” which even for all of its conceptual perils, attempts to reckon shifts in temperatures, pollutants, or wheezes (to name just a few sentinels), because “global” might be too flat a frame in a world of ever-increasing inequities. But can one hold onto the expansive promise of a “planetary” rubric, even as the perils of environmental degradation register locally? I’m not keen to see another face-off between local and global, where certain bodies are made to bear the load of intelligibility while experts toggle scale. And there is lots to think through here on the different scalar imaginaries of medicine and public health. Perhaps translation’s work lies in these indeterminate zones, around contested objects and framings of medicine’s politics of “where” as much as its politics of “who” and “what.”

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