Medical Humanities Blog

Dissertations in the Medical Humanities

The most recent doctoral dissertations in the medical humanities are up at the University of Pittsburgh's general collation.  Lots of interesting titles over there.

(h/t H-SCI-MED-TECH listserv) 

Note: While there are many titles and apparent approaches relevant both to the MH and to health policy at the web site, IMO none of the titles I reviewed are primarily about the medical humanities.  What I mean is that the MH are, IMO, not merely the sum of its disciplinary parts.  MH is not just history of medicine + cultural studies + literature & medicine + ethics in medicine,etc.  The MH are, like most true interdisciplinary fields, emergent; they arise out of work in disciplines without being reducible to them.

While I'm certainly not contending there is an essence of the MH, I do think it's important to note that the MH are not simply the sum of "humanities" work as applied to medicine.  The humanities, understood historically and contextually, do supply a way of conceiving of the world and (wo)man's place in it, and the best source for this is by examining the medieval and Renaissance humanists themselves.  What did they believe? What were their motivations? Why did they eschew Scholasticism? Are the answers to these questions instructive for contemporary social and cultural critics of medical and scientific practice? (If the answer to this is 'no,' I'm in a lot of trouble!) How so?

I look forward to having the opportunity to discuss these and other ideas at the conference next week marking the 25-year-anniversary of the graduate program in the medical humanities at UTMB (my current program).  Those who are attending; please feel free to say hello.

CDC Reports: Systematic Reviews & Early Stress Across the Lifespan

CDC released two reports this week that may be of interest to a medical humanities audience.

The first Report is a collaboration between CDC and the Milbank Memorial Fund entitled "Improving Population Health: The Uses of Systematic Reviews," by Melissa Sweet and Ray Moynihan.  Those uninterested in methodology will nevertheless find much of use in the report, as the Executive Summary presents a nicely complicated account of public health policy discourse.  It can be downloaded free of charge, thanks to the Memorial Fund, here (PDF).

The second report is a CDC report on the effects of early stress across the lifespan.  We've touched here at MH Blog -- just last week, actually -- on the increasing importance of stress, early childhood, and the neuroendocrine pathway as a significant, if not superior, account of the molecular mechanisms by which social and economic conditions produce health and illness.  (Note, of course, this is a medical humanities blog, so please do not think that I deem the social and ethical importance of stress and early childhood to be a function of its possible effects on the neuroendocrine system.  Indeed, such objectivizing is a trope I will be critiquing in my research on pain).

In any case, this second report, which I have only skimmed, seems to touch on a similar cluster of concepts, and therefore looks to be worth reading, at least.

(h/ts to LL and SDOH Listserv) 

The Science & Epidemiology of Racism

On February 29, 2008, the 29th Annual Minority Health Conference begins at UNC-Chapel Hill.  The Keynote Lecture, entitled "The Science and Epidemiology of Racism in the United States: an Ecosocial Perspective," will be delivered by Nancy Krieger, M.S., Ph.D.  Krieger is a social epidemologist with a background in biochemistry who does important work explaining how socioeconomic conditions produce health and illness.

You can download a 09.28.2007 lecture delivered by Krieger here (fourth from the top, entitled "The Elephants in the Room: Social Justice, Public Health, and Health Inequalities").  The Webcast for the 2.29 lecture runs from 2:00 PM to 3:30 PM EDT, and will be available in archival format for those poor saps who, like me, will be unable to watch it live.

Health Wonk Review

The latest Health Wonk Review is up at Merrill Goozner's GoozNews.  We made the Review, and as always, there are many posts worth reading.

On Brain Imaging & Poverty

In an elegant confluence of two of my central interests -- neuroimaging and the social determinants of health, the Chronicle of Higher Education reports on some fascinating research forthcoming in the journal Developmenmtal Science.

The PI is Martha Farah, who is a cognitive neuroscientist at Penn and is doing important work in neuroethics.  (In fact, Farah is on the Executive Committee of the Neuroethics Society, and she has a fascinating paper in the new journal Neuroethics, edited by Neil Levy).

According to the article, the question Farah et al. set out to investigate is the extent of low socioeconomic status on neural structure. 

She and her colleagues have investigated the issue by trying to tease out which aspects of poverty alter specific cognitive skills, such as memory, language, and the ability to delay gratification. The researchers studied a group of African-American children of low socioeconomic status, who had been tracked from birth through high-school graduation by Hallam Hurt, a pediatrician at Penn.

Over the years, Dr. Hurt's team had assessed the home environments of the children, monitoring how nurturing parents were, and how intellectually stimulating the homes were—for example, whether the children had access to books and visited museums.

Farah et al. reportedly found that cognitive skills were linked with particular features of the environment, such as how "intellectually stimulating" the home environment was. 

To test why, the researchers did MRI scans of the children. They found that students raised in nurturing homes generally had bigger hippocampi, the portion of the brain associated with forming and retrieving memories. The discovery dovetails with previous research in rodents, which showed that rats raised in a stressful environment develop smaller hippocampi.

The article goes on to note that while prevailing opinion at the "annual meeting . . . of the American Association for the Advancement of Science" (where Farah et al. presented the finding) supported the notion that social conditions is a prime determinant in neural development, some cautioned that the extent of the correlation is unclear.

There is more in the article, including some interesting work on stress in children related to low socioeconomic status.  As they say, go read the whole thing.

Work on early childhood development, including neural development, is important in SDOH research.  The best evidence suggests that social and economic factors may act as a kind of trigger -- not a prime cause, but a trigger -- for a cascade of subsequent stimuli that correlate strongly with poor health outcomes (and poor education, as well, which is even more strongly correlated with poor health outcomes).  The causal relationship here is both extremely complicated and quite murky, as it is not the case that deleterious social conditions in early childhood inevitably cause poor health in a linear sense.  Nevertheless, the epidemiologic evidence seems to link such conditions in early childhood -- as far back as prenatal periods -- to just such a "cascade."

While it seems prudent to avoid commenting further on the significance of the observations regarding the size of the children's hippocampi until the study is available for review, the notion that early childhood development seems to be of great significance in protracted health measures is evidence-based.  Such an evidence base may support greater allocation of resources to early childhood development programs as a means of enhancing population health.  Indeed, some SDOH scholars urge just such investment as a public health policy.

Two further points.  First, though this likely crosses the barely perceptible line I (vainly?) try to maintain between my professional life and this blog, I would like to again suggest that those interested in this issue should hasten to review the report prepared by my colleague, Dr. Winifred Hamilton, who heads the environmental health group at Baylor College of Medicine's Chronic Disease Prevention & Control Research Center, where I work.  The report meticulously documents a staggering lead problem in Galveston, TX (where I attend graduate school).  The report may be downloaded here.

Second, the possibility that chronic stress can exert strong influences on neural development is consonant with work (see Brunner & Marmot 2006) suggesting that stress may activate the neuroendocrine pathway in ways that seem to produce illness and poor health.  Indeed, such a pathway is one of the most promising explanatory models for grounding how social and economic conditions may cause molecular changes.

In any case, it was exciting to see a convergence of two of my own central research interests, and I look forward to reading the study when it is published (I will post a follow-up with the link once it becomes available).

(h/t SDOH Listserv)

Conference on Psychiatry and Freedom

The International Network of Philosophy and Psychiatry is hosting the 11th International Conference for Philosophy & Mental Health, Oct. 6-8 2008, in Dallas, TX.

Conference Description
This international conference will combine invited and submitted papers and structured discussions on a range of themes concerning the relation of psychiatry and human freedom. The intended audience is the public, mental health professionals, philosophers, social scientists, ethicists, humanities academics, and policymakers. A range of topical “sections” have been organized, which explore the domain of Psychiatry & Freedom. The conference organizers welcome suggestions and submissions for novel “sections.” Sections may include invited and submitted papers, “paper sessions” and “symposia”(see “Three Ways to Submit Abstracts” below). A Conference objective is the development of conference sections or presentations into chapters for one or more topical books to be published in a book series under the “Psychiatry and Freedom” rubric. The official conference language is English.

Conference Objectives
The conference intends to assess the status of psychiatry's impact on, or contribution to, human freedoms; assess ideological, political, sociocultural, methodological, and epistemic influences on psychiatry as a humanitarian discipline; and propose constructive ideas for public and professional policy concerning mental health care and its place in society. The conference is intended to stimulate scholarly interest in the issues of psychiatry and freedom, and organize an international community of scholars around this theme.

The deadline for Abstract submissions is March 1, 2008.  Further details can be found here.

(h/t Neuroethics Society)

Literature & Medicine Podcasts

Giskin Day over at the (UK) Medical Humanities Blog provides a link to several talks stemming from a conference sponsored by the journal Literature & Medicine on "Caring for the Caregiver."

Podcasts available for download include, inter alia, lectures by Rita Charon and Rafael Campo.

On Nurse Practitioners & Physician Assistants

Howard Spiro, editor of the Yale Journal of Humanities in Medicine, has kindly granted permission to MH Blog to reprint in full an essay he authored that pushes, in his own words, some "heterodox opinions" on the proper role of nurse practitioners and physician assistants.  The essay, which is not copyrighted -- we here at MH Blog are staunch supporters of open access -- is reprinted below the fold, followed by some commentary.

Cancer and Our Environment: Essential Reading

In the latest issue (well, the latest issue to arrive by post) of the Times Literary Supplement (Feb. 1, 2008) there is a wonderful (one of my favorite adjectives, so no doubt I overuse it) review by Sandra Steingraber of two books concerning the question of the relationship between possible and probable environmental causes of cancer and the citizens who by dint of circumstance are now "environmental detectives in their own communities: "Dead and Dyeing" (no, that's not a typo, you'll have to read the full piece to learn why).

The first book is by Devra Davis: The Secret History of the War on Cancer (New York: Basic Books, 2007). Davis earlier authored When Smoke Ran Like Water: Tales of Environmental Deception and the Battle Against Pollution (2004) and has been called "one of the world's leading epidemiologists and researchers on environmentally linked illness." Steingraber cites her impeccable credentials: directs the Center for Environmental Oncology at the University of Pittsburgh Cancer Institute, is a former adviser to the World Health Organization, served as a public-health scientist in both the Carter and Clinton Administrations, and is the founding director of the Board on Environmental Studies and Toxicology in the National Academy of Sciences.

The "basic thesis of this book," writes Steingraber, "is that 1.5 million lives have been lost, because Americans failed to act on existing knowledge about the environmental causes of cancer." Here are some of the factors as described in the review that "both acting together and independently of each other," led to this failure: a) "the cowardice of research scientists, who publish thoroughly referenced reports but pull their punches at the end, by claiming that more research needs to be done before action can be taken. Statements like these are then exploited by those who profit from the status quo;" b) "regulatory agencies have become unresponsive to new scientific evidence;" c) and perhaps one reason for the previous factor, namely, the well-known phenomenon of regulatory capture: "government agencies and charities whose mission it is to eradicate cancer...have had meaningful work on cancer prevention compromised by corporate interests;" d) for epidemiologists requiring access to industry (owing to the necessary focus on workers 'who are exposed to the highest amounts of suspected carcinogens') "the price for access, too often, is the promise of secrecy." "Having struck a Faustian bargain, occupational epidemiologists can have--and have had--their funds withdrawn if they go public with their results;" e) "various kinds of scientific evidence--such as animal research--have been gradually declared inadmissible in legal cases," the legal bar having been set rather high: "'Basically,' says Davis, 'before you can collect damages, you must get cancer or some other awful disease, show that someone else already got it from the same things you did, prove that you had specific exposure to a particular agent, find the firm that caused your harm and can now pay for it, and prove that they knew the exposure was harmful'" (I suspect the last is often an insuperable obstacle); and f) "outright harassment of researchers, including Davis herself...."

Our second title is Phil Brown's Toxic Exposures: Contested Illnesses and the Environmental Health Movement (New York: Columbia University Press, 2007). From the review:

"Brown, a medical sociologist at Brown University, has been a researcher in the field of environmental health for several decades, beginning with his groundbreaking work on the Woburn cancer cluster, made famous in the Hollywood movie A Civil Action. [....] As he demonstrates, almost all cases of cancer clusters, from Love Canal onwards, have been discovered by citizen activists--not by scientists, nor by government agencies [think Erin Brockovich]. This is because no governmental agency or scientific body engages in routine surveillance that would uncover sentinel health events [of course the government is adept at routine surveillance of another sort!]. It is also because cancer registries, which could function as early-warning systems, publish their results in obscure almanacs and do not actively investigate communities where cancer rates are elevated. Often, as Brown notes, these communities are never even informed that their cancer rates are statistically excessive. But, in the cases where citizens have engaged in their own lay epidemiology and have become environmental detectives in their own communities, new avenues of scientific research have been made possible, which, in turn, have spurred on better environmental decisions. When sympathetic scientists work hand in hand with these activists, new forms of knowledge are created that challenge the lifestyle and hereditary foci of conventional epidemiology."

As Daniel would say: Recommended

Patrick S. O'Donnell

Petri Dishes in the Bedroom for Culturing Addiction

I learned of the following article by Tara Parker-Pope in the New York Times at Professor Malloy's HealthLawProf Blog: http://lawprofessors.typepad.com/healthlawprof_blog/

Parker-Pope discusses a recent study concerning the subject matter or references found in the songs teenagers are listening to via (largely) their MP3 or compact disc players. She explains:

"One in three popular songs contains explicit references to drug or alcohol use, according to a new report in The Archives of Pediatrics and Adolescent Medicine. That means kids are receiving about 35 references to substance abuse for every hour of music they listen to, the authors determined. While songs about drugs and excess are nothing new, the issue is getting more attention because so many children now have regular access to music out of the earshot of parents. Nearly 9 out of 10 adolescents and teens have an MP3 player or a compact disc player in their bedrooms."

So why might we be concerned about this?

"Studies have long shown that media messages have a pronounced impact on childhood risk behaviors. Exposure to images of smoking in movies influences a child's risk for picking up the habit. Alcohol use in movies and promotions is also linked to actual alcohol use. Researchers from the University of Pittsburgh School of Medicine studied the 279 most popular songs from 2005, based on reports from Billboard magazine, which tracks popular music. Whether a song contained a reference to drugs or alcohol varied by genre. Only 9 percent of pop songs had lyrics relating to drugs or alcohol. The number jumped to 14 percent for rock songs, 20 percent for R&B and hip-hop songs, 36 percent for country songs and 77 percent for rap songs."

"The study authors noted that music represents a pervasive source of exposure to positive images of substance use. The average adolescent is exposed to approximately 84 references to explicit substance use per day and 591 references per week, or 30,732 references per year. The average adolescent listening only to pop would be exposed to 5 references per day."

"Whether any of this matters remains an open question. While the impact of exposure to images of smoking and alcohol in film has been well documented, less is know about the effect of music on childhood risk behaviors."

I happen to think it does matter, and very much at that, if only because, as the conclusion to the article states, "'Music is well-known to connect deeply with adolescents and to influence identity development, perhaps more than any other entertainment medium,' said the study authors."

Let's look beyond contemporary social science and back to ancient philosophy for another take on why we might have reason for concern about the music young people listen to. Classical Chinese worldviews (in particular Confucianism) and the classical Greek conception of paideia alike accorded an important role, to put it rather feebly, to the arts in moral education and education generally, with music (or poetry, which was chanted or sung, as the Confucian Odes) and dance playing an especially prominent part. This was so if only because the Chinese and Greeks understood, in the words of the late philosopher Iris Murdoch, that "we see and love beauty more readily than we love good, it is a spiritual thing to which we are most immediately and instinctively attracted." This explains why for both Plato (in the Laws) and Confucius (in the Analects), training in the arts (wen in Confucianism) is absolutely indispensable for moral development and spiritual growth as well as the corresponding increase in self-knowledge. Indeed, it is because the arts naturally have such a powerful effect on young hearts and minds (and bodies!) that they are (or should be) the principal form of early moral education, and (should) continue to play a prominent role in ethical and spiritual development throughout our lifetimes. By whatever means we come to know "the Good" in Plato or what is termed jen by Confucius, this knowledge, however dim or partial in the beginning, allows us to discriminate the good from what is substantially less-than-the-good or even "the bad" in art, for not all art is equally conducive to awakening in us a love of the good, a disposition to virtuous behavior, a fondness for something greater than an egoistically oriented awareness.

Intriguingly, Steven J. Lonsdale writes in his Dance and Ritual Play in Greek Religion (1993) that "the word nomos (law, custom; it is similar to the notion of li in the Analects, but Confucius clearly distinguished custom, social norms and etiquette, that is, forms of li when practiced with the requisite reverential bearing by those--like the junzi or the Sage--possessed of jen, from law proper, owing to the latter's ultimate reliance on external sanctions that require physical coercion and punishment) in the Greek title [of Plato's Laws] also has a musical meaning (melody), and Plato puns on the legal and musical senses of the word on several occasions in reference to the so-called kitharodic nomos, a genre associated early on with Terpander and Dorian Sparta, whose conservative musical traditions served as models for Plato's own polis."

In her remarkable book, The Five "Confucian" Classics (2001), Michael Nylan discusses the use of the (book of) Odes as "tools for learning" in Chinese traditions, its "vital importance as a cultural repository of eminent utility and a teaching tool for the social graces." The Odes were fundamental to the cultivation of the social graces which are thought to be indissolubly connected to habituation to virtue:

"As a textbook of style and the language of diplomacy (in both senses of the word), the Odes could hardly be outdone. A storehouse of elegant language and refined formulae, preferably intoned with special pronunciation in set keys, it served as a kind of early thesaurus and book of etiquette rolled into one, whose limited format was of limitless applicability. The social graces in turn were what made for an impressive character: the 'sound of virtue' capable of influencing others for the good. Good students of the Odes, according to tradition, could 'incite [others'] emotions, observe their feelings carefully, keep company with others, or express grievances, either in the service of their fathers at home or their princes abroad.' [....] Adherents and opponents of Confucius alike had the followers of the Sage continually 'reciting the three hundred odes, playing them on strings, singing them, and dancing to them.'"

As Nylan notes, the Analects help us see the important role that the Odes played in ethical training and Confucian self-cultivation:

"Confucius taught three important lessons: that mastery of the polite arts is valuable only to the extent that it is predicated on an acute moral sense [keeping in mind that li performance and training in wen are what awaken a moral sense in children], whose ultimate worth is greater than conventional beauties of form; that the Odes' literary figures nonetheless supply apt metaphors for the process of moral cultivation; and that the cultivation of one's humanity would have undeniable attractions for those who witnessed it."

I recall the snickering and snide comments in Left and Liberal circles (and from some well-known musicians as well) when Tipper (Mary Elizabeth Acheson) Gore co-founded the Parents Music Resource Center (PMRC) with Susan Baker (wife of then U.S. Sec'y of the Treasury James Baker), because Tipper heard her then 11-year old daughter playing "Darling Nikki" by Prince. Gore sought warning labels for some of the records marketed to children, although she was carelessly and inaccurately accused of advocating or being on a slippery slope toward censorship, despite her avowals to the contrary, including public proclamations of her commitment to the First Amendment. Now whatever we may think of her means and methods, Tipper Gore seems to have been expressing, however awkwardly or inchoately, a Confucian- or Platonic-like perspective on the power, for good and (in this case) ill, of the arts:

"Plato's insistence on music and dance in moral education in the Laws is one of the ways in which his views differ most strikingly from Socrates in the early dialogues, for whom knowledge of the good was sufficient to attain virtue. But Plato, who was acutely aware of the effect of music and dance on the irrational, believed that gymnastic and musical training, as well as philosophical investigations, contributed to civic virtue 'because rhythm and harmony penetrate most easily into the soul and influence it most strongly, bringing with it decorum and making those who are correctly trained well-behaved.'"

While I remain a recalcitrant Marxist in many respects, I confess to being a Confucian or Platonic conservative in the above matters, one reason I find the Times story so troubling.

Patrick S. O'Donnell