 Retrieving
Kamala
from
the debris of epistemic violence
Dr.
Anup Dhar
A
good case!
We
have a patient of Rheumatic Heart Disease or better Rh.H.D (a good
case for final year students!!!) in Green Ward, Bed No~.530.
What(!!!)
or who we have in Green Ward, Bed No! 530, is Kamala. Kamli for
her mother.
We
have Kamli
~a poor woman-working in the fields-a bonded laborer.
~aged
20-married off at 15.
~now
living in a bustee.
~
with a daughter -one and a half years old.
~a not too tolerable husband.
~far too intolerable in-laws.
~all housed in a ten feet by ten feet room.
~suffering from Rheumatic Heart Disease.
NOT
TOO GOOD A CASE YOU SEE...........
A
Therapeutic Encounter?
Medical
Knowledge ( that is ~the text of medicine), Medical Education and
the Practice of Medicine springing out of such education, wants me
to treat Rh.HD and surely not Kamla. Kamla makes a very very brief
appearance in medical discourse. She is a acknowledged as Kamla
only once in a Clinic~ when her Ticket and turn comes~ and the
doctor announces her name. She comes forward. A THERAPEUTIC
ENCOUNTER follows!!! The Doctor's Gaze confronts a silent
body. Relevant (?) history is noted down hastily. Her symptoms
allow the disease set somewhat back~ to show through.
And
then Kamala vanishes.
Kamla
vanishes on the examination couch. The patient's bed becomes a
field of scientific exercise. A field where sickness has to be
determined and delimited.
Long
ago, Kamla was a daughter to her mother.
She
emerged as wife on her wedding night.
Next
morning she became a daughter- in -law to her husband's parents.
Much
later she acquired the 'status' of a mother.
But
today, Kamla is no more.....
What
remains of her in the 'clinic' is a tapping apex, a diastolic
thrill, a loud first heart sound, a diastolic murmur with
presystolic accentuation and an opening snap!!
What
is a 'clinic'?
A
clinic is not just symptoms ,signs and drugs.
The
clinic is the first encounter (!) between doctor and patient~ a
space for an inter personal doctor-patient
The
doctor is re-defined " as an applied scientist rather
than a healer". He is reconstructed as a specialist and as a
professional.
The
patient on the other hand is "methodically decomposed"
as a person. She (the whole/entire being~ the real being )is first
reduced to relevant(!) history~ then to a classification of
symptoms~ then to a "grammar of signs". Last to possible
possibilities.
And
from the debris of possibilities, out springs a doctor with a
loudly announced diagnosis ~ a dramatic disclosure.
The
diagnosis actually makes the doctor happy ~content!! NOT SAD!! The
diagnosis actually brightens the face of some.
For
the rest of the hovering stethoscopes, it is a defeat. They have
lost in the Christening-Competition. They wait for a re-match.
On
another pulsating chest ground.
MS!!
Whole Truth?
Kamla
is now a 'diagnosed case'. A good case for 'case hunters'!!
The
whole being is now re-interpreted as a 'system'. "In order to
know the truth of pathological fact, the doctor must(?) abstract
the patient."
She
is now no more Kamla~ Kamli or anything even remotely resembling
her past self~ her actual self. She is MS!! ( MS is the short form
for Mitral Stenosis~ a disease of one of the valves of the heart,
the mitral valve).
As
if MS and Kamla correspond!!
As
if name and object have a one to one correspondence.
As
if the very act of naming, defines the whole object.
Definition
delivers truth!! Whole Truth!!
Omnipotent~
Ubiquitous~ Universal! Homogenous Truth.
With
no breaks. No differences. No Unassimilated Contradictions. No
undecided Fragments.
And
so the doctor armed with the whole truth investigates MS.
As
if there is no reality ~other than MS. As if Kaml a was never born
in a poor family of 12 ~as if she was never a victim of
malnutrition ~as if she was never housed in a 10 ft. by 10 ft.
room~as if Kamla was never married off at well below 18~as
if she never had an alcoholic husband ~as if she never spent
unimaginable days with her in-laws~ as if.......
Social
Medicine~ the clinic's backyard ?
There
is not much space for Kamla in Modern Western Medicine. She is
silent or silenced.
The
most silent patient is the best patient.
The
best patient is the most silent patient of Post -Mortem.
Kamla
speaks only in the secluded world of "Preventive and social
medicine"~ only in the segregation of 'Para Clinics'. 'Social
Medicine' is that shelf of the modern doctor where he can dump his
conscience. Kamla's epdidemiology is carefully preserved there~
only to be forgotten ~while the clinic organises the violent
reduction of Kamala to MS ~ while the clinic" situates the
being of the disease with its cause and effects in a three
dimensional space".
Social
Medicine ~the
clinic's backyard ~is the dumping ground of our values, of the
rights of a patient, of all customary WHO declarations of the
social responsibilities of a doctor, of all healing traditions
~all of it encased in a fat para-clinical volumes, in hardbound
texts~ shelved far away from the violent operations of the clinic
~so as not to be remembered while we encounter the patient.
Social
Medicine is the Clinician's 'defense'!!
A
defense to ignore the real lives of real human beings.
And
so, the doctor investigates MS. The "Medical Gaze"
scrutinizes Mitral Valve Leaflets. It measures Pulmonary Capillary
Wedge Pressure. It sees the inside of an atrium. But it fails to
see Kamala. Because Kamala is not Kamala kamala is MS.
Kamala
is 0.9sq.cms.
That's
the size of her valve orifice.
Detached
from her life's reality, the doctor reduces her to a "Lab
Reality". She now inhabits the "lab World"~ a man
machine interface. Her valve leaflets show Rheumatic Nodules. From
a "Molar Reality" she is reduced to a "Molecular
Reality".
"Tissual
expanses form the perpetual correlative of the surface gaze that
defined the clinic".
Lab
tests provide a series of 'Readings ' for Kamala. Her suffering
can now be reduced to a structured set of 'Variables' Readings
become the 'Operational Definitions' of reality. Kamala becomes MS
with PAH in a case of Rh.HD.
She
is now a "Clinical Body" fully compartmentalized for the
doctor's therapeutic intervention. She becomes a site for
Pharmaceutical Experimentation. For diuretics and digitalis.
This is the end of Kamala~ sacrificed at the altar of a knowledge
system.
Do
I sound anti-science? Is this a crusade against western medicine?
So what if she is reduced to MS? How can the doctor treat Kamala
if he does not diagnose MS? Western medicine receives Kamala in
the emergency. May be it is a question of life and death. Where is
the time to philosophize on Kamala's biography. I know these
questions come up in the reader's mind.
I
am not anti-science. I am not pro-science either. there can
be some position,betweenor beyond the conventional for and
agaainst paradigm.
All
I want to do is to carve out a little space for Kamala in the
clinic. Kamals is usually dumped in the clinic's backyard.
We ant the clinic to be a little less confident, hence a little
less arrogant about the correctness-hence superiority- hence
greatness of its methods.
Let
the clinic wait a while for Kamala. Let it defer its too quick,
too violent reduction of Kamala to MS.I n the little extra time
and space that the clinic now accords to Kamala, her neglected
histories surface. Her epidemiology co-in-habits her symptoms and
signs. She speaks.
Our
critique of the clinic is a summoning of the clinic's limits.
Making boundaries unstable and questionable. It is not a blanket
dismissal of the clinic . It is not a negation. It does not
consist in passing from one concept to another. But in overturning
~ displacing ~ disrupting the secure confidence of conceptual
orders. If there is an element of violence in the CLINIC, then one
must contest clinic with a certain other clinic, in order to
avoid the worst violence. The critique of the CLINIC is carried
out in the name of another sort of clinic~ sort of.
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