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Robert Pearl and Jeremy core Each episode will feature one of the top leaders and innovative thinkers in health care today This shows format is simple the guests will present their roadmap for fixing American health care's biggest problems And from there, german I will scrutinize the plan and help listeners separate fixes that are the potential to succeed from simply the hype Our goal is that everyone from health care consumers to political and medical leaders will find value in the discussions on our show You may not agree with the different solutions offered, but you will never again conclude that nothing can be done We hope you will join us. Please subscribe via iTunes your favorite podcast software for more information visit our website at www.fixinghealthcarepodcast.com Welcome to new books in medicine on the new books network. I'm your host Monique de Forre I'm very excited to welcome my guest today Todd Myers When I read his book the clinic and elsewhere, I knew that I wanted to take the time to hear him talk about this Really interesting astonishing and unique book Todd is an assistant professor in the department of anthropology at Wayne State University Where he is also affiliated with the department of family medicine and public health sciences in the school of medicine He co edits the book series forums of living at Fordham University Press, and he's associate editor at Symatosphere The online social studies of science and medicine forum Todd. Thanks so much for joining us. Oh, thanks so much for the opportunity to talk about the book Fantastic. Um, Todd you are trained as an anthropologist I mean to do PhD in anthropology and you're currently In a department of anthropology at Wayne State. Could you tell us a little bit about your background and training as an anthropologist? And how and to what extent you see yourself working in that field? Yeah, so yeah, my training is in anthropology actually did this joint PhD in Anthropology and public health science at Johns Hopkins. It was a time where the Mellon Foundation had very generously Created this fellowship program for public health folks to be trained in anthropology and vice versa And so I was part of that program. So I got to spend a lot of time at the public health school at Hopkins and I still remain I guess very sympathetic to the public health project But my original training was actually not in anthropology or even in social science But I was I went to the school of the art Institute of Chicago and studied painting And so that I guess sort of began a certain sensibility towards writing towards thought And so it's that kind of I don't know interdisciplinary space That I'm trying to occupy in my work. So while I call myself a medical anthropologist, I feel like I'm sort of benefiting from moving through these different domains I've had another question about your relationship to anthropology as we'll talk about in more detail when we get to the book You characterize this book in some way as a meditation on the limits of ethnography Mm-hmm, and ethnography is such a central methodology in anthropology proper But also it's become something that many scholars across disciplines use Sometimes they're using it in ways that a trained anthropologist would kids consider to be amateurish And so I'm wondering To what extent You would consider yourself still dedicated to the practice of ethnography having written this book and thought about it in the way that you have Very dedicated but simultaneously very aware of my own limits. I mean I guess I should have Reframed that in the context of the book as a meditation on the limits of my own ability as an ethnographer You know, I mean that's in some ways. That's part of the story The kind of engagement that I was looking for was already I mean by focusing on adolescents by focusing on adolescents who are abusing opioids I you know, I'm already kind of staging this in a way that you know the closeness that one can that proximity that one can sort of establish within as a relationship is already so fraught and You know working between this clinical environment of the treatment center and then also trying to participate in some ways in the worlds in which these Kids were participating in very very kind of these varied ways outside the clinic Which of course come to bear on how they engage the clinic. I mean that as an object is already so limited and prescribed and difficult to get a handle on so I think even from the outs that I conceived of the project is one in which I was going to use ethnography as a way to Work through the problems of proximity and engagement Certainly, you know a focusing on something is also so amorphous as addiction something that you know one hand You know sort of demands some kind of resolve that it has this kind of clear set of social moral concerns And at the same time, you know how it actually unfolds in an individual's life Is so different and varied so even that figure of the addict and especially I think perhaps the the adolescent addict Is also sort of a difficult object to work with so I mean just the initial stage in the project was already putting kind of ethnography as a methodology under scrutiny And then also just kind of thinking about what a long-term engagement would be I mean this this project was the project for the book was you know with several years of Following and in the book. I talk about how even that concept of following is so difficult you know these moments of absence and Return what does it mean when someone returns and how to repair that relationship or try to figure out what happened in between? And and then also the following that happens is adolescence move between these different institutional settings All of that kind of came into this frame of ethnography So even in those moments of absence like how do you reconcile those things? You know, how does that actually come to how does that become a character of of writing? So those are things that I think I wanted to consider and in some ways were kind of The result of some previous ethnographic work that I had done So I felt like as I was moving into this project with these adolescents that I was already somehow aware of what ethnography meant and maybe even particularly in Baltimore. Mm-hmm. Yeah, we'll talk about that in a little bit So you say you followed 12 followed we'll put quotes around that word Because it's important right of you followed 12 adolescents From July of 2005 to May of 2008 and that this was part of your research for your dissertation Yeah, and this book came out of your dissertation It doesn't read at all like a dissertation. It doesn't I would never I was surprised to even hear that that it was originally one So could you tell us a little bit about how this project looked when it was your dissertation versus how it looks now as a book? Yeah, first of all when you say 2005 to 2008 sounds so long ago In fact, actually I feel like you know part of this is becoming like This is like re-education by reading the book again and kind of thinking about these problems You know as a dissertation project It was well, I guess I should probably back up a little bit and this was the second dissertation project I had really abandoned the project early on in Baltimore because it was Sort of untenable as a dissertation. I was following one family in Baltimore from 2002 to 2007 Just simply looking at the management of illness within this one family You know, how do people mobilize resources when they're faced with you know social and economic insecurities? You know, how how do individuals deal with? multiple chronic and acute medical crises and You know, so what what's the picture of care that emerges out of these relationships? And so I wanted to to look at the management of illness in this one household and and really reflect on the concept of of care and but also comorbidity, you know, all of these this kind of cosmology this configuration of illnesses that Run through relationships and really shape the kind of social course of illness within one family and as I was working with this family And I've written a few papers about this and in fact, actually This is a project that I've just recently returned to so I've just really had to consider what loss and repair and return have meant for me in relationship to this project, but just as a dissertation project, it was just an absolute disaster and in fact actually my very wise advisors all of them Independently as I was trying to split them trying to convince them all that this would be a really fantastic dissertation project all pointed to the same thing which was without an index disorder without more than one family you will never be taken seriously in terms of, you know, of selling this as a proper, you know doctoral project and also that you'll never get any NIH fellow ships or anything like this and so it was It was this kind of very difficult moment of truth within my own kind of Really it made me focus on what kinds of priorities I had in terms of my my ethnographic my anthropological research You know, I was really interested in the concept of patient hood ups really interested in how institutions multiple institutions shaped very different pictures of the patient over time and so I had to in some ways I Had to in some ways rethink How to do that project as a proper dissertation project and not just a what was described? You know by my advisors is a kind of very very detailed case study and so that brought me to the to this This drug this drug rehabilitation clinic on the on the west side of Baltimore and I sort of very reluctantly Found myself there and was kind of looking for the same project, you know with more people without a lessons And so I had to kind of read I ended up having to rethink the entire Project along the lines of addiction and and pharmacotherapy But the real motivations were still the management of illness in the day-to-day These kinds of social relationships that shape that course of illness and ultimately kind of the course of of Therapeutics the career of therapy for individuals across these different settings So the framework ended up being very much the same, but it was you know kind of the product of an abandoned read a abandoned dissertation project So I felt like even in the very beginning of my research it was it was a lot of You know recuperation And repair so so that that started the project off and then when I got to the the residential treatment center You know I had you know I had this interest in and Seeing what kind of imaginaries were being? Animated in the discussions about these adolescents lives outside of the clinic I mean the the original sort of title for the project was the clinic dreaming the social because I felt like that was Precisely what was happening when I would have discussions with these clinicians all, you know, you know very smart Very well-intended clinicians who had this picture of social life outside the clinic that was you know at worst a kind of caricature and best you know just singular and I thought you know that there has to be something at work here that That can I guess navigate navigate this sort of geographic and conceptual divide between The clinic and it's a vaginar of the social and the social itself And I mean it sounds so rudimentary even saying it out loud But that was sort of the that was sort of the motivation to begin there now of course the big surprise about the project for me was this relationship between the clinic and the social is much more porous in fact actually one of the one of the things that I try to Draw out and the book is you know How clinical reasoning finds its way into the social and actually the demands on therapy might even be more like this Kind of more literal a more sort of There might be stronger demands of a therapy outside the clinical environment than even within certainly no one in the clinic ever talked About cure in relationship to pharmacotherapy to treat opiate dependence, but in living rooms and kitchens Cure with something that was very much on the table So that's a great example now so Just and just to give us a little bit of a sense Let me well, let me tell our listeners first for those of you who have not seen the book or who haven't read it yet That it's a very slim book With a lot of white space And I love that about it by the way It's not a heavy book. It's short in in so far as it's elegant. Did your dissertation look like this? Probably not the elegant part Shortish part I was going for I mean in part the motivation for writing a book that is You know a hundred and about hundred and fifty pages even less than that Was I wanted it to be approachable for different audiences? obviously and part of that is and not just different audience in terms of disciplinary audiences, but Thinking that this would be a very useful book for undergraduates and for students of ethnography and different disciplines So that was part of the motivation. I also think that there's there's really something to be said for writing an Essay and this is a very sort of French mod. I this is kind of a French model of the book as essay and this is how I thought it This is an essay on The career of therapeutics. This is an essay on the anthropology of therapy and it uses the ethnography the parts of ethnography to give a picture including that sort of the limits of those kind of pictures that are able to be formed within ethnography But it's meant to give this picture that helps us dwell on the essay part of it the thesis part of it Which is the question of therapeutics, you know, how are success and failure? You know determined what's the limit of evidence? What does time mean in you know in relationship to this kind of therapy? What are the demands made by different social actors on Therapeutics and it's really meant to be a reflection on that and I think that The form that that has taken as a much as a very simple form in some ways, but not kind of a simple tism You know, not just a sort of not giving it Not a kind of not sort of Limiting the argument in such a way as to make it easier to take in fact actually I mean the one criticism of the book is that it you know It has it at the same time as it doesn't try to step over the kind of philosophical grammar that each of these kids Used to think about therapy It does have its own kind of philosophical grammar that it's trying to work through as well and those moments I think where where things don't quite match up are the difficult parts of the book and they are very feet They feet those are the parts that feel very theoretical problematically and the parts that don't feel very theoretical I think as you kind of mentioned earlier You know are really I mean they're they're kind of pregnant with meaning but that meaning is coming through the ethnography as opposed to being imposed by an External set of of questions or concerns, which of course I have because I'm a human being This and so I I do impose my concerns. I mean that's that's what one does They're in the best of cases, but so that's that's part of their and it's a very like you say It's a very slim volume in fact, you know and yeah Yeah, I think that that's a good time to just jump right into The book itself and you describe this book as as being something about the career of therapeutics Could you talk a little bit about what you mean by that term and how that sort of motivates the the book as a whole? Yeah, so so rather than sort of looking at I mean one of the things that's talked about so much with within addiction medicine is the the Addicts career of drug use and I thought rather than focusing in the fact actually the book even though I talk about addiction so much is not really focused on addiction as so it's not it's really focused on kind of What are the limits of understanding this particular therapeutic intervention so it's focused on this by now not very new drug? buprenorphine Really two treatment drugs the box zone and subutex which were both produced by record Ben Kaiser pharmaceuticals But this drug to ameliorate both the symptoms of withdrawal but also to treat through replacement therapy Dependents on opiates. I wanted to look at This drug in clinical trials and then follow that career of therapy past the I guess the sort of The the time frame of the clinical trial and look at the sort of afterlife or look at the career of this therapy after the questions about effectiveness of the drug and its efficacy sort of begin to transform, you know So when we move from efficacy in terms of the drug within a very narrow framework of a randomized controlled trial and into this question about clinical Effectiveness over time, you know, what does that transition actually look like and then what happens if we continue to follow that career that trajectory? even beyond the closely monitored environment of Residential treatment or even outpatient treatment. So by following the adolescents following their relationship to this therapy even in the absence of treatment that is to say they decide not to take it anymore or they you know no longer feel dependent on opiates which of you know in one of the cases with one of the kids that I followed I mean he really was so committed to getting off of heroin and oxycodone and I mean part of his motivation was to go back and to sell heroin and oxycodone, but But you know a real commitment to that idea of leaning himself off using buprenorphine and so I wanted to follow these different kinds of trajectories. So as to paint a different picture of what the What the experience of these adolescents was outside the clinic that is to say to really kind of puncture that caricature of the adolescent addict, which was not just being you know not just not just founded in the clinic, but also was really part of the the public debates about even approving the drug for addiction therapy in the late 1990s and early 2000s and so that picture of the addict this sort of this this new epidemic of you know prescription opioids within especially for for young people who don't have much of a previous career with opioids That was really that was painted as part of the reason it's a thing that that motivated social concern a thing that sort of undergirded social concern and so I kind of want to look out all of these things became rolled in to what we think therapeutics is the case of the individual Could you tell us a little bit about how the book is organized? I want there are listeners to get a sense of the kind of structure of the book as a whole because that in itself is really Part of the what's I think is so wonderful about the book How do you would you describe the organization of the book? Well the first I mean sir the first chapter is really meant to sort of dispense with a long sort of history of buprenorphine It's developed as this addiction therapy Nancy Campbell and Ann Lavelle have written this wonderful sort of history of the development that they published in the annals of the New York Academy of Sciences about the same time that the book came out so I felt like that wasn't really part of the the labor of this particular book this really was an ethnography of buprenorphine therapy and not a kind of social history mixed with ethnography So the very beginning of the book is to show how this drug this sort of this old thing this drug which you know And this is also I should probably frame this a little bit in terms of the geography of Baltimore as well And this is a drug that was tested and developed In the 70s at Bayview Hospital at Johns Hopkins on the far side and so this kind of has it's a Baltimore story at the same time But here's this drug which was kind of frankly a mediocre drug to treat moderate post-operative pain and it looked like it had some potential to to be used as a Replay as a replacement therapy something that you know as methadone mood, you know sort of moved out of favor This you know mixed agonist antagonist therapy, you know could be you know potentially used in a new way So the beginning of the book is about this sort of new uses for old things This isn't a story of pharmaceutical discovery. It's really a story of kind of reappropriation And so that's kind of the initial framework of the book to set this up is here's this opiate that's been around for ages what's the struggle to get it approved for addiction therapy and then what kinds of claims are made on this drug of which there were many in fact actually a lot of the a lot of the public discussion about the accountability or the usefulness of this drug as an addiction therapy was about treating adolescence Adolescence can be treated Kids with fairly recent Histories of opiate use could be treated with this drug, but in fact actually there were no clinical trials to demonstrate at least none the over time and so um was really interesting because Part of the the science really had to catch up with the political claims of this drug and in fact actually when the drug was approved That's when we find these large-scale clinical trials for buprenorphine one of which I followed that was that was being conducted was a multi-sided clinical trial that was being conducted at the my research site At the residential drug treatment center. So began the project by saying I want to focus on kids who are enrolled in that clinical trial And then follow them to completion of that clinical trial and then continue to follow them as they make their way in the world to really Kind of test the effectiveness of this drug. Um, that was the initial framing of the entire project but in fact actually The the kinds of demands that are made on the drug are much more complicated than just whether or not it's effective Over time, you know, what's really interesting about it is this play between success and failure And who's making those kinds of who's holding to those ideas? Um, and it's not just parents and clinicians and social workers and parole officers It's thick. It's the the kids themselves who are being treated with it So I wanted to show kind of that trajectory So that's kind of the first part of the book and then I moved directly into the Into the research setting, which is this um residential drug treatment center on the west side of um of baltimore, um, which was an old monastery and uh, an absolutely fascinating place um So loud Such a loud place I had I feel where I followed these kids and would spend time at this this drug treatment center for three years I swear I had a headache for three years It's just a cacophony And in fact actually it was this sort of sensory landscape of the old monastery these old cells Which doubled as treatment rooms and you know, these study rooms, which now are you know group therapy rooms and the stairwell Which just would echo you really could follow um You could follow the activity of the day by just simply following sound in the space Um, and in fact actually for a few of the the young people that I that I spent a lot of time with you know, it was that was profoundly comforting That there was this this kind of the sound this sort of what this incredibly loud but white noise That could be latched onto and and help order the environment for a couple of them It was just like, you know, they want they wanted nothing to do with the place but it was strange how sound worked in this monastery um, you know, so Yeah, and so that's really the second part of the book is considering this very peculiar but important geography of the monastery Um, I called the second chapter of monasticism Not just because they're in there to retrain their bodies and minds But also because it takes into account that these are that there is a spatial issue And this is also why the books called the clinic and elsewhere as well because it's you know always trying to grapple with these Um, these different geographies Um Maybe the best thing since we're kind of as you're describing Um, the the sort of the ways that you're approaching the chapters were going into some detail in the chapters So why don't we just kind of go go a little further into this chapter on monasticism? Then and so um, could you tell us a little bit about um, what you see is the significance of uh space and time to the overall argument that you're making in the book? Yeah, so I mean part of that monasticism chapter really begins part of the meditation on um, Restriction and precarity in relationship to space Um, you know, there was this large monastery where a lot of the administrative activities would happen But also group therapy sessions, etc And then there was a separate sort of residential center which was off to Not not not necessarily a new building, but it was uh, that was built. I think like late 1960s early 1970s um, which was where Um, people would stay and it was also where the cafeteria was and it was where the, um The main clinic was uh where the nurses were and that's also where kids would detox And so for all of these different kinds of spaces where I would find myself I would find myself in this sort of group therapy room I would find myself wondering around hanging out with the caseworkers trying in many ways to Manage the monotony of the everyday that the kids were also trying to manage Um, in fact, actually that's something that's so hard to represent In the ethnography, it's like, you know, how do you actually contend with this? The banality of certain moments of this of this experience for them for you Um, I found myself especially and I talked about this in the second chapter um, really strongly Hoping that something would happen during the day that would cause Some kind of conflict or gossip or would just break that they would just like punctuate that monotony And there were those moments. There were fights. There were lots of rumors stolen cigarettes Um, people not returning from day trips, you know gossiping about the caseworkers by the adolescents, you know, the adolescents You know, there ain't just like lots and lots and lots of Things that you do to fill the time and I found myself, I guess participating in that same feeling Um, but also there were these spaces like the um, these suites in the clinic where um Kids with detox for a week with buprenorphine with other drugs Um and they had medical management, etc Um, but that I never that I actually never went into and in fact, actually It's kind of that it begins this this conversation in the book about restraint And about sort of limits of it wasn't that no anyone said you're not allowed to go in the rooms where Kids are detoxing, but it was more like What's the value of spending time in there when in fact, you know, kids like the the guy called jeff in the book They're all, you know pseudonyms, but um Jeff is describing these different experiences he has of detoxing these detox three times And you know each time is different and he doesn't know what to expect and And to just describe that sort of environment of the room just felt like it was some kind of Very strange betrayal of a certain intimacy which went completely. It was it wasn't marked at all But yet it just I mean I think we use You know, there's something I guess called intuition or you know that we follow at some point When we do field work and there was just something about that space that felt restricted in some way And so it wasn't about producing some kind of objective truth about what the space of detoxification looked like but rather It was much more interested in the ways in which it didn't wasn't able to be contained within language for jeff and for others or how they struggled with it and tripped over language the language of detoxification for them was was was difficult and that shouldn't be unexpected and You know part of the project is not to add coherence where there isn't any in fact their their narratives were not coherence about these experiences and so by presenting this sort of objective picture of this space In some ways didn't really I felt that it was moving away from that kind of corporeal space or that kind of troubled Narrative space for them and so that was another way in which I guess space became so important for this It was places where I chose to go and didn't choose to go How space was described to me? How was mutually shared? You know how it was equally precarious certainly the stairwell in the middle of the monastery You did not want to get shoved down six flights of stairs Um, but you know trying to move through those geographies. It was all part of the kind of So it there was something that was being shaped in my discussions with these kids That um that had to be attended to and so it was framed within this kind of this idea monasticism. Uh-huh. Uh-huh How did how does this idea of you know, these these Centrality of space and time affect how you were beginning to understand the formulation of the concept of the patient subject. Yeah your own thinking. Yeah, that's a that's a fantastic question I mean in fact actually what it did was in part Kind of helped me to move away from thinking about the patient subject is purely sort of figured within the event that is to say You know The patient subject is is not is not formed in the clinical encounter necessarily was not formed every time You know, someone would go in for their treatment with buprenorphine or for other drugs or other kinds of medical management which they were being Participating in whether it was HIV treatment whether it was something else Um, but rather it was this patient subject was something that was formed in these different spaces in times in which you might be looking away Uh, you know, and that's kind of Now that's how I began to sort of rethink space. I mean initially a project like this would be a very Would be very simple if you if you said, okay, I'm just going to I'm going to sit in these clinical encounters Kids who come in and put this thing under their tongue let it dissolve and then they go on their merry way And this is how they're being treated with replacement therapy but in fact actually those moments were not is Didn't seem to have the same weight as trying to manage this other part of this world for them um, and Even though those sort of lessons of what it meant to be a patient Were so important and they did do some kind of self-work on them Um There was something else that was going on later in the book. I talk about this is you know a different form of patient thinking about Patienthood not as a contest between you know the formation of a patient subject and the sort of objective that is to say objectified image of the patient, you know through an ideal Scenario of therapeutics that is to say a body that can be worked on but rather thinking about this this um, you know about this figure of thought about the patient as a category of thought Um that everyone somehow participated in helping to shape. Um, I feel like I'm getting away from your initial question. Oh, no No, that's well, I think Well, I well and I think that that concern does weave through the whole book and so and it's one that evolves as the book proceeds um in the next chapter you call it appropriations of care this chapter really centers on, uh, one person, uh, laura And um, maybe to we haven't really talked a lot about the adolescents that you follow Um, so maybe we could talk a little bit about laura Um, what is her story in this chapter and what how does she her story fit with this concept of appropriations of care? Well, laura was definitely somebody who you know kind of she represented a very different figure of the adolescent addict I mean she was from a, you know, kind of lower middle class family and uh somebody who By all accounts was really not meant to be in this clinical environment Somebody who could be and you know, highly individualized outpatient treatment For opiate addiction and yet she found herself in this Clinic and she had two parents who were you know deeply concerned that she was going to be Consumed in some way by this clinical environment. These were not her people Um, and this is and this is almost a trope that I would hear in these family meetings about whether or not one saw their child Belonging there Um, and so in laura's story, I mean she found great comfort in that environment Um, the kind of attention that she received all very positive in terms of you know The friendships that she would develop in terms of her relationship to residential staff Um, it was almost kind of her lack of commonality Both socioeconomically in terms of race ethnicity a lot of different things where she lived um where her parents lived um that That sort of lack of commonality actually created an interesting space where care was made possible for her Um, and she was somebody who would continually come back to that space I mean, I think this is also In following these adolescents who would move between different clinical and non clinical institutional environments who would find themselves in different situations that were You know where things were performed under the sign of care, but it wasn't care as such. It wasn't this sort of You know, it was it was very much about managing them Um, she really saw this environment as one that was caring for her, you know much to the you know dismay of her two parents Um, so she was a very peculiar. I mean she was a peculiar kid I mean she loved being in therapy and she hated when she left and in fact actually she would relapse just to come back And then you know, and there was another young woman that I followed as well Who would do something very similar? But she in fact actually had a mother who was abusing opiates as well There were lots of kids who depended on this young woman to take care of them And she would actually relapse or use to get sent through the juvenile justice system um into residential Drug treatment Precisely to kind of escape the demands on her to be a caregiver to her younger siblings and also to her mother and other family members And so there are these kind of different pictures of care that emerge and part of the appropriation part of that is is that you know Laura's story. There's a kind of this negative aspect to what care look like from to her from the outside That is to say the values that went into Thinking about care for her be very easily be seen as this is self destructive Now she's using to be to find herself in this environment to participate in therapy and she You know really we need really need to be thinking of her in terms of turning towards, you know um Treatment without dependence and all these different things and yet for her care was valued very like Was was so that that form of care which could would be valued as like So negative for her was so positive and it was and I think that's part of the appropriation When which she took care of not just self care not in the sort of focodium sense where it's you know about self-management but also concealment Confession and thinking of one self in relationship to power, etc But for her this idea of care was something hugely individualized And and ran counter to ideas of care held by the social workers the residential staff her parents Um the clinicians there and so that's really what I'm trying to get at with that chapter that you know Here care becomes appropriated, you know, and it has this other valence and you know and it's Hugely individualized and can we and ultimately that chapter asked can we really call this care? Yes, you know, is it a form of self care? Sure, okay, but what does that really tell us about the the nature of care itself? Yeah, um or there or is there a different kind of grammar or different kind of nomenclature Which is important to deploy to describe what she's doing Um that but it's impossible to get it It's it is it's impossible to get out of that sort of question of value Yes, so that's why I was very insistent on calling it care in this case because for her it was valued very positively This seems to connect to a key set of concepts. We haven't talked about yet, but that runs through the book and that is the um relationship between the concept of cure and the concept of healing Um and as you were talking, I was think I was clearly seeing the connection to those those two ideas Could you talk a little bit about that? You know, um where that idea comes from and how that might Connect to the book as a whole sure and that's something that I mean really was drawing from I guess work that I was doing in the philosophy of medicines particular around the the writings of Shorish konkiam the french philosopher physician who Talks about this this kind of part problem with the idea of cure as cure as a return to a previous state as opposed to healing which is this this idea that One arrives at new norms of the body sort of individualized norms and is always Arriving at these different norms and and this to me seemed very much along the lines of what was the I guess the farmo the pharmacotherapeutic ideal that people would use these treatments as a way of Healing that they would arrive at new norms which whether that meant lack of you know It's sort of a resolve of the dependency to opiates or something else But rather it wasn't to cure them, but it was really to move towards um towards healing and yet those the tension between healing and cure the the idea of return and cure and the idea of A new norm in healing was something that was always on the table um in conversations about what the expectations of these drugs were Um, and this is where I think it gets into I mean the the big surprise of the book is that for those actors who were The you know physician researchers who were in charge of the clinical trial looking at you know, this buprenorphine naloxone combination drug Suboxone to treat opiate addiction we're so aware of its limits in terms of cure certainly the residential staff and the Physician assistants and social workers who are instrumental in implementing the clinical trial were very aware of its limits as a cure um You know and in any conversation after the clinical trial in straight up Treatment in the residential treatment center. There was never this idea of cure as such, but rather this long process Of healing and yet when I found myself in people's living rooms and in their kitchens You know cure was something that was really on their minds the idea we take a pill were cured You know and that was something that was so it's in some ways there is this clinical reasoning that's taken from the clinic into the social But it's it's refashioned as something else And it's no surprise to me that you know for these pharmacotherapies that there is this strong demand on cure And even management gets conflated with cure which I think is actually quite interesting here as well So part of exploring that tension in the book was not so much to See where people fell out along this spectrum of curing healing, but to see how this was always the tension In trying to understand success and failure of this of this pharmacotherapy Yeah, and how they align with as you put it earlier how they align with and reveal values around the care experience Yeah, precisely. Yeah. I just I just found that just reverberating throughout throughout the whole book Um, I want to turn to um the chapter on patienthood Yeah, and I I'm wondering because this is probably the most theoretical Chapter or the most abstract chapter and but it still has a story and it's highly readable Could you talk a little bit and explain the idea of the patient as a category of thought? Yeah, this is Yeah, this is definitely the chapter where I think so This is the chapter where I read this years a couple of years later. I think oh man The the tension that I'm trying to work within this chapter is Rather than I guess I should back up a little bit. Okay. I mean part of the idea that went into This this chapter was To see how and this was the this was kind of the original idea of the dissertation project and the original idea of the research project which was To see how people take up these these diagnostic categories and live them that is to say You know this this category of the patient attic like what does that mean to take up that diagnostic category that category which it once is Found in the DSM, but not really, you know, certainly the you know the the designation of dependency and addiction We find those things in the DSM, but there is this figure of the patient attic that is taken up in different ways And I was interested in not so much trying to understand that as I kind of Reclaiming by these adolescents or kind of refashioning of that designation by them Simply as a way to contrast the objectification of the patient in the clinic in this sort of gross you know this really kind of a very simplistic Binary of you know the the the monolith of biomedicine in the way in which it imagines it imagines patients and then patients as having Both, you know some kind of agency and simultaneously having that agency always trying to stripped away from them I wanted to see that what was what was being? Created in a different space and it's this category of thought It's this idea about the patient attic that each of these actors in different forms have some has some investment in it And so I didn't want to just simply focus on this tension between patients and doctors or you know biomedicine and I don't know the social something like this, but but rather to say what is this kind of mutual investment? What is this what what animates thought about? the patient attic that's so important here that tells us something beyond just the subjectification or the objectification of Of medical experience, you know What is this thing this container that's being carried through these different environments because it certainly was? And so that's kind of the motivation behind Writing the chapter and you could see like with this this guy this young guy jeff who I was probably closest to Just because the amount of time that I spent with him who was also probably the most Aggressively caustic at like you know, I mean he would just he would perform annoyance all the time Having to having to talk with me, which of course, you know, he didn't have to talk to me at all but um he was somebody who was really invested in Locating this concept of the patient attic and then like dissolving it in his lives. Uh-huh, you know getting away from it kind of Identifying it having certain characteristics that went into that thing and then moving so far away from it so that it couldn't you know He could no longer could come to bear on how he saw himself And using buprenorphine Strangely enough he associated with being an addict. I mean he saw that as you know A dependence on a therapy was just as bad for him as dependence on those other drugs and he wanted nothing to do with all of this and he really wanted to move back to um to selling drugs and in fact actually the reason that he Found himself in and treatment in the first place is because he no longer was able to sell drugs He actually thought it was too dangerous. I mean it was a smart smart kid Um, and you know, he eventually did get off drugs and then eventually was shot and killed Um, you know about a year and a half later In Baltimore, um because he was selling again and you know trying to re kind of reestablish himself um you know in whatever Neighborhood sort of drug market that he was participating in so you know, but he was somebody who was so invested in this idea of locating You know what it what it meant to be an addict and what it meant to be a patient how those came things came to rest on one another Um, and so that's that again That's kind of the motivation behind that chapter is really to Think beyond this sort of simple definition of what a patient is because frankly, I mean at a certain point that gets very boring Analytically, you know, is it is it are these are these kids addicts or are they patients or are they saying well? No, they're actually they're they're kind of a third category There's something else that's happening here that is being created Um, and those designations really really were powerful in the lives of these kids Well in that chapter, I think works really well where it is in the book Um, and it leads into your final chapter called disappearances And in in this chapter, you tell four very difficult stories about Four of your of the adolescents that you followed of their disappearances of and So why do you end the book with with disappearances? Well, I would say Three difficult stories and one story that is so confusing Mm-hmm, you know the story of kevin this kid who actually lived in this neighborhood that um You know, I was also working with this family that I mentioned It wouldn't be any of our conversation if I'd been following for several years and look at the management of illness He lived in the same neighborhood and so I I mean I knew this neighborhood fairly well And so when I went to his house, this is like that It's the first time I went to his mother's house. Yeah visiting somewhere else I'm looking around and driving and trying desperately To find this house and and I keep passing this sort of demolition site And I would of course I don't think anything of it and then come to find out his house had been torn down And no one knew where his mother was and his his even his parole officer Didn't have a new contact address for him or there was some confusion It was all lots of ambiguity And so kevin disappeared and this is a kid who I had known for years because he was so institutionally present You know, I mean he had he'd been arrested so many times and he'd been treatment Treatments so many times and he I mean in fact the thing that defined him was really this this sort of um This really tight lattice of institutional relationships that kind of held him. Uh-huh, you know and then to have him disappear um At least disappear for me and this is you know what I say in the book is that I mean his disappearance is He's nowhere but nowhere to me because I no longer have contact with him But what what does that mean when someone, you know, who is so institutionally visible to a fault, you know, is able to in some ways just Be gone. Um, and so what does that also say about our expectation of continuity in ethnography? Yes, I should be able to pick up the phone and you know call one of the social workers and you know find him, but no and then another young woman she really just sort of was absorbed into um Was really absorbed into these institutional environments in a way that she After I think I mentioned it a little bit before I was talking about more of it. She you know, she had so much so many obligations outside in her family life that in some ways it was kind of She allowed herself to be absorbed. Um, and really made this kind of full disappearance into the system Um, you know with with zero desire or at least Preceivable desire to want to get out. Um, and in fact, actually, that's when I lost touch with her and then You know and to see that kind of withdrawal You know, it was it was profound and it was so remarkable I mean you could Between one encounter and another you could see the point in which she's decided that she no longer wants to You know go in and out of treatment She's it's a very strange kind of turning or commitment to those institutional relationships only Um, and then the other two kids they died when one was was taken in by a group of She was very very young and a boyfriend who was you know, so sexually abusive um And was eventually taken in by a group of older women and ended up ODing um in their house um despite the fact that they were You know by all accounts really caring for her as an individual as to say that they you know were taking her out of this horrible domestic situation and Giving her a place to live and caring for her but also with that came, you know using together and You know, she just collapsed Um, and then the last Kid in that chapter was jeff and he was the one who was shot and killed and so the the last chapter of thinking about disappearance I mean it really That question of disappearance is also about presence and it's also about you know how to think about Um, the trajectory of these lives not in this constant future tense and this is what so so dominates the conversations Adolescent addiction, which is yes, you know, what does the future hold for them? Where are they going to go to college? Are they going to be are they going to remain dependent? Are they going to become worse users? And in fact actually it's these these moments in the present which are so difficult to get a handle on how can we even talk about this future tense? Yes, and I would ask this you know, I mean Stupid question every time I meet with that, you know, not every time obviously I'm not a fool But um, but this question about, you know, how do you see yourself in the future? And just to the ways in which they would represent the future when they would be willing to answer that question Um, I mean there were times where it was a future of promise and other times where that they were that future was futureless um And you know thinking about what it is about the present moment that was so important and so Difficult to even ground experience Um, that question was really aimed at that that that difficulty of presence You know how they had to endure it. They were I think that's one of the I think that might be the postscript It is Yeah, the enduring presence question and the conclusion. I mean, this is precisely the problem I mean, how is the present endured but also how does it continue to endure over time? You know a sort of series of presence, you know that have to be accounted for You know, and that's and that was also part of the writing as well just trying to not constantly place them in this future tense. Yes something Mode but rather thinking about what is it about this? What is it about the hearing now that's so important for them and Jeff's Descriptions of his detoxification are perfect example of this. You know, there was something like the uniqueness of presence for him Um in each of those scenarios and how one had no there was no correspondence between them You know, I mean, he says as much um so Yeah, that's really kind of focusing on that presence at the end almost as a kind of you know Me at my most hopeful in the writing. Uh-huh I think that's a good place to kind of turn to the conclusion because Um that idea of presence and also hope is so central to the book I'm going to take a moment. I'd love to just read a few sentences from the end of the book You write that um success and failure are dangerous claims in relation to drug dependency Cure one day cannot suffer uncure the next So why was success so important and meaningful for the individuals with whom I talked what but was defined and demonstrated so differently In each case perhaps it is too much to accept the idea that the trajectory of a treatment can vary so uncontrollably Never reaching an end. Perhaps it is because of the stakes ultimately remains so ambiguous And the terms of success are transformed so radically from one moment to the next Um when I was reading this and coming to the end of the book I was led to to thinking for a long time and i'm still thinking about this idea of what is a therapeutics of perhaps Because that's where this book really took me and i'm wondering if you might talk a little bit about that Does that make sense as a question? That makes very good sense as a question um yeah, I mean Think about how best to address this it's funny listening to those words because they can be very aware that i'm a much better writer than public speaker just in terms of clarity, but here yeah, I mean one of the I guess one of the things that um That I tried to Remedy in this writing was to move away from to To when I would talk about the sort of fragmentary nature of the ethnography when I would talk about the limits of engagement Personal relationships time disappearance and reappearance return and repair all of those things. I wanted to Demonstrate that that doesn't mean that we don't have some demands of our own on their trajectories of these young people these interlocutors these people that we come to know as ethnographers and um So that sort of the idea of perhaps you know Is it's promising and to think in terms of a therapeutics of perhaps Would cause us also to in some ways abandon these these other sort of aspirations of something like a pharmacotherapy that is to say You know Having it do work besides what it's really meant to do And that's what I think the investment for so many of the families and individuals was it was this it wasn't a therapeutics And perhaps it was a therapeutics of of unending but changed certainty You know and it's that kind of contest of certainty with the precarity of everyday life That they were always wrestling with and so in some ways as an analytical I guess as I sort of analytical posture towards therapy perhaps is perfect And yet in some ways it definitely was not the side in which they themselves were operating and so it's an interesting tension um And it's and this is almost the I think you're really speaking to the over almost the over determination of what success meant for Adolescence like jeff like tanya They're like kevin So yeah, that's a it's a fantastic question of course. I'm going to be pondering that one for one Well, I think it also is is one that that comes out of The concept of hope which is so central to the the thinking that you've been playing with in the book as well Sure. Yeah, and you know, just like I just wanted to say that yeah, I mean this this is also the you know, there's a kind of Book the book really begins with a kind of skepticism And that's the skepticism on sort of what the motivations and priorities are towards approving this drug how these trials are developed how even the public discourse in Baltimore about you know Abuse and diversion is countered with all of this promise both kind of these rhetorical strategies for and against um And but the book definitely moves. I mean, you know, re re rethinking it rereading it with some distance that to see the way in which that skepticism that skepticism begins to lighten and in fact actually in the sort of full light of The encounters with these young people over time. It isn't really skepticism so much as a kind of You know it as a kind of Our kind of regroup like a re-founding of who what we think of therapeutics to be all together Now so it begins with this question of you know, is this good or bad is this you know on the side of right? Or is this just another kind of, you know, kind of pharmaceuticalization of everyday life that we know from people like doom and others um But in fact actually there's this complete refounding of therapeutics in which they're very much participating in which is in the end So in fact it is hopeful because it is It's it's watching that refounding but even with that hope come these things Which you know have very negative consequences Um like the loss of jeff and tanya or like the disappearance of kevin and um and um and and and kisha So, um anyways, I just wanted to add that because I think that that's that's also kind of the movement of the story And I mean it it tries to attempt that movement from skepticism to a different kind of hope or re-founding in what a hundred and some pages Which is a little bit ambitious, but um But nevertheless, I mean that's the kind of maneuvers that's right because the conclusion of the book is not You know, these drugs are bad. These drugs are good In fact, actually and this is also thinking through this question of audience for the book Um, you know a lot of clinicians who have read this book and talked to me about it Are very thankful that it doesn't have that kind of first of all there's no ire for clinicians in this book Yes, and it's really demonstrating their labor and a very difficult kind of labor Um, but it's also not a story against a drug or four drug And in fact, actually it's that kind of like leaving that kind of ambiguity in the story I think is really it reflects the true ambiguity of this drug in people's lives Um over time if you know, it's by it's an opening rather a limit than a limitation But still it's that openly kind of forces us to say, you know, what do we think success and failure looks like here? Absolutely Okay, well as we get to the end you know what question i'm going to ask you right Um, how do you imagine your future Todd? Um, what what i'd like to end by asking, you know What kind of things you're working on what kind of questions sure yeah kind of engaging with now and in your own writing You talk to the beginning of our interview about returning to your project. I like to call those Lazarus projects We all have them and i'm glad to hear that you're you're having it rise up Um, so what are what are you working on now? What can we expect from you next? Yes, so the through the big ethnographic project is this return to working with this family in Baltimore Um, you know in the five years that I was gone. Um, a lot has happened um losses in the family etc And the the project is really focused on comor this idea of comorbidity or really kind of what's the work of time and symptom um, and so i'm calling it events out of sequence and um, it's kind of trying to through the writing trying to Put the Temporal because the woman who had I interviewed who was really the head of household dies in the time between And what does in but for the last several years? I've been writing In a way that would imply that she's very much alive and vital in fact actually she was somebody who had always Used to think through this kind of threshold of health and illness Um, and here, you know, she passes and so it's it's both repair in terms of relationships going back Reestablishing those relationships with her grandchildren and and her children and but also kind of Repair and recuperating those past moments of ethnography and how time begins to kind of get distorted You know, what tens are we actually talking? And so in some ways it extends a lot of the questions that I Gonna raise in the clinic and elsewhere and kind of goes back to this project that you know probably for my benefit I abandoned um You know in Baltimore and then i'm also finishing the book with Stefanos carolanos who I edit the book series at for him with we're finishing a book Which we're entitling the brittleness of the body In the sciences of the individual around world world one and it's uh more of a historical Book that looks at changes and understandings of bodily regulation In physiology as they emerge through the first world war so how ideas of homeostasis and other The concepts about bodily integration emerge So it moves between anthropology through people like wh or rivers and waltter canon in physiology But also the neurology of kirklstein and others um, so that's that's another project and then Um at the end of the year. I have a book that's coming out with um My colleague richard backstrum Um at university of edenborough that we wrote about this film this 1922 film um called hacks on the witch by vinyamin christiansen and um, it's a look at sort of the work of scientific evidence and the beginnings of nonfiction film and You know being caught by the witch and you know, it's a moving in this other domain of of writing Which is trying to understand representation and the history of anthropology. So, you know, I I'm just trying to keep myself busy out of trouble. It sounds like you're doing just Well, when any or all of these come out. I look forward to talking with you again Thanks so much for spending time with us. Um, and uh, we look forward to reading your new work. Thanks so much *Music* *Music* [BLANK_AUDIO]
Todd Meyers‘ The Clinic and Elsewhere: Addiction, Adolescents, and the Afterlife of Therapy (University of Washington Press, 2013) is many things, all of them compelling and fully realized. Most directly, the book is an ethnography of drug dependence and treatment among adolescents in Baltimore between 2005-2008. Meyers traces twelve people through their treatment in the clinic and beyond, into what he calls “the afterlife of therapy.” The group of adolescents was diverse–their economic and family circumstances, their demographics, and arc of their narratives from addiction to treatment varied widely. Yet they shared at least one important experience: “each had either been enrolled in a clinical trial or were currently being treated with a relatively new drug for opiate withdrawal and replacement therapy: buprenorphine” (4). In this way, the book is also the story of a pharmaceutical making its way and its mark in the worlds of therapeutics, law, public opinion and, especially, in the lives of its users. Meyers shows how the lives and experiences of these adolescents (as well as others in their lives) were often shaped and constrained by their roles as subjects in pharmaceutical trials evaluating the effectiveness of buprenorphine. Moreover, Meyers looks beyond the questions and answers asked and answered under the constraints of randomized controlled trials. Rather, as he puts it, “my ethnographic gaze is fixed upon the intersection of clinical medicine and social life, at the place where medical and pharmacological subjects are constituted under the sign of therapeutics” (17). As a result, The Clinic as Elsewhere locates palpable places where medicine and the social intersect in the material world and lived experience; as readers, we see the relationship between the medical and the social as much as understand it as a conceptual given. Ultimately, Meyers shows how therapeutics is not only a form of intervention, but a “sign”: under which people are constituted as subjects, and with which people “assign value, meaning, and worth assign value to pharmaceutical intervention” (116).
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