By Caty Brown
Black mother of five Mrs. Flowers presents to her primary care provider with complaints of “pressure.” She tells her doctor about headaches, trouble sleeping, and concern for her sons’ drug problems. She thinks the swelling in her feet is from her long hours at the restaurant, working to support her family and ailing mother whom she fears is going senile. She denies shortness of breath and chest pain and tries to emphasize that her trouble sleeping is because of dreams about her recently deceased lover. She says these things make her pressure worse: “There’s too much pressure and it’s making my pressure bad” (Kleinman, The Illness Narratives 134). The note written by her doctor is as follows:
39 year old Black female with hypertension on hydrochlorothiazide 100 mgs. daily and aldomet 2 grams daily. Blood pressure now 160/105, has been 170-80/110-120 for several months, alternating with 150/95 when taking meds regularly. Has evidence of mild congestive heart failure. No other problems. (Kleinman, The Illness Narratives 134).
What happens to the story of Melissa Flowers, a sick woman experiencing a great deal of social pressure, when translated into the medical record? How do the quantitative aspects of her disease overshadow her lived experience of suffering? Here, we see that “the voice of medicine drowns out the voice of the life world, often in ways that seem disrespectful, even intolerant, of the patient’s perspective” (Kleinman, The Illness Narratives 129). Mrs. Flowers becomes a noncompliant woman with hypertension, rather than the mother and caregiver with a richly textured life full of familial stresses. This “voice of medicine” Kleinman discusses is the voice of biomedicine, a system of medicine that uses a “language of structural flaws and mechanisms as the rationale for therapeutic efficacy” and feels “discomfort with dialectical modes of thought” (Kleinman, Writing at the Margin 29). Patients’ illness narratives and experiences of suffering are not privileged enough to be written into the medical record, while blood pressure readings and medications are fully addressed. Biomedicine in many ways is a product of biopower, which “brought life and its mechanisms into the realm of explicit calculations and made knowledge-power an agent of transformation of human life” (Foucault 143). Biomedicine and biopower both address the body mechanistically, as an object that can be taken apart and put back together again to increase its functionality or address its faults.
Under this framework, medical practitioners become the exclusive knowers, who act as intermediaries between an objectified patient and the “ultimate truth” that exists within their biological bodies. Some of this effect results from biomedicine’s obsession with the scopic, with what can be seen and therefore known, which acts to distance the “knowing subject” from the objectified patient “in the interests of unfettered power” (Haraway 581). Biomedicine sees disease as an internal failure, a fault in the biological machinery that can be “made visible as the ultimate basis of reality” and “can be viewed, under the microscope if need be, as a more basic substance than complaints or narratives of sickness with their psychological and social entailments” (Kleinman, Writing at the Margin 36). Instead of acting as marked bodies with their own situated subjectivities, doctors act as all-powerful seers, with a “conquering gaze from nowhere” that lends validity to their diagnoses while distancing and delegitimizing patient perspectives (Haraway 581). The language of biomedicine, rich in results from MRIs, CTs, labs and other technocratic diagnosis methods, is “enforced as the standard” and dominates the sphere of medicine far beyond the patient’s account (Haraway 580). In Mrs. Flowers’ medical record, her blood pressure results took center stage, given much more importance than her complaints of family disruption and loss of loved ones. Though her complaints of “pressure” obviously refer to both her blood pressure and the pressures of living in poverty and losing a loved one, her doctor only cared for the symptoms that corresponded to an underlying mechanistic problem. Quantifiable diagnostic results that can be visually compared against normalized charts are seen as important under biomedicine, regardless of what might make the most impact on a patient’s health.
The privileging of a doctor’s knowledge over a patient’s through the use of scopic and technocratic biomedicine manifests itself across a variety of specialties, but none quite so salient as with women’s healthcare and obstetrics/gynecology. The “Father of Gynecology,” J. Marion Sims, perhaps helped to set the tone for the burgeoning field, in treating his “patients” as objects to advance the discipline. He worked on several enslaved Black women, whom he experimented upon in the efforts to surgically solve vesicovaginal fistulas (Snorton 21). His mission was to become seeing and knowing, through surgery that would open the women’s bodies and right the internal wrongs. In this endeavor, the speculum (derived from the Latin “tool for looking”) was invented. A tool for topographizing the flesh, the speculum made women’s bodies capable of “expansion and inspection” (Snorton 31). Sims operated on some of the women upwards of 30 times, likely without anesthesia. Following the “success” of his surgical procedure, Sims sent the women back to their enslavers (Snorton 30). The women’s health was secondary to Sims’ own notion of discovery and medical advancement, as evidenced by his use of their bodies for torturous experimentation and his returning of the women to their enslavers. The field of gynecology began by privileging the doctor’s scopic perspective as the grounds for truth and knowledge, while forming patients as inert objects who play no agentive role in their own health.
This precedent set the tone for a field of obstetrics that operates with a “doctor-up, mother-down” hierarchy, where doctors are more privileged knowledge-havers than mothers and are allowed a physically higher vantage point during supine births (Cheyney 531). Though women have been delivering babies since the beginning of humanity, biomedicine has made birth something in need of constant medical management. Women “are told that something is wrong with us at every turn… We need thousands of dollars’ worth of technology to get our babies out alive. Our breast milk is a burden, so we’re offered a substitute… The myth of the totally dysfunctional female body is big business!” (Cheyney 519). Biomedicine constructs women’s reproductive bodies as inherently faulty, in need of technocratic and scopic solutions —so much so that home delivery with a midwife in some US states is an act of civil disobedience (Cheyney 523).
Even long before birth, expectant mothers are subjected to a process of “strange-making,” where their bodies are made to seem unfamiliar and unknowable to them. Their physicians, over dozens of pre-birth check-ups, use medical terminology to judge the natural embodied experiences of pregnancy (such as “’false labor,’ ‘irritable’ uterus, or ‘incompetent’ cervix’”), and withhold or neglect to explain information about the birthing process and the outcome of complex technocratic procedures (Cheyney 526). In doing so, doctors become “powerful ritual elders and elite knowledge bearers who will take responsibility for monitoring and eventually delivering the baby” (Cheyney 526). Mothers begin to feel as if they have “little or nothing to add” to the process, and their medical providers have total authority over the happenings of their birthing bodies (Cheyney 526). Much of this effect is a direct result of biomedicine, where physicians are trained to view health as something borne directly of internal biological mechanisms, and to view themselves as seers able to bring forth biological truths out of the body in order to diagnose and treat.
Labor itself is an incredible act of medical management, where women are put flat on their back and tethered to the trappings of a medically managed birth, including IVs, electronic fetal monitors, catheters, and more that prevent movement. This position serves to make the mother ultimately viewable, where the birth canal is easily visible for the physician, and monitors report each change to the medical personnel in the room. Women often feel as if the focus has been transferred from mothers to machines: “During my hospital birth, I was so over the focus on that damned monitor. Everyone kept staring at it saying, ‘here comes another contraction’ and I was like, ‘no shit!’ Sometimes you wonder if anyone remembers there’s a real, live person connected to the strip of paper they’re so obsessed with” (Cheyney 529). Not only do these scopic and technocratic approaches decenter the role mothers play in birthing their children, they also negatively impact health outcomes for both infant and mother.
Throughout history, women have given birth by moving between various positions that utilize gravity to help the infant out of the birth canal; no benefits of the reclined supine position have been scientifically found for the mother or infant. Yet the supine position is favored in countries that use biomedical approaches, likely due to the increased scopic availability and ease of monitoring (DiFranco & Curl) Additionally, directed pushing (such as with a ten-count breath cycle) is also favored, where medical personnel direct the mother to push, rather than allow her to direct her efforts according to her body’s natural urging. Directed pushing has been shown to “stress the maternal cardiovascular system, reduce circulating oxygen, and trigger changes in the fetal heart rate” (DiFranco & Curl). Despite evidence showing that tethering mothers to monitors, placing them on their backs, and directing them to push via an outside metric is directly harmful, these practices are favored, proving that prioritizing the scopic and technocratic approaches to medicine can be directly detrimental to patient outcomes—and yet remain the standard of care.
It is perhaps no surprise that so many of biomedicine’s violences are felt by birthing mothers, as biopower exercises itself at “the juncture of the ‘body,’ and the ‘population,’” where sex is a “critical target of a power organized around the management of life rather than the menace of death” (Foucault 147). Mothers, and more generally, all patients treated under biomedicine might feel there is “hardly any place for [their] experience of suffering” (Kleinman, Writing at the Margin 31). To turn biomedical healthcare back towards health and care, it is imperative to shift priorities to give the patient at least equal import to the quantitative, technocratic, scopic methods used to diagnose them. For mothers, biomedicine must “overturn mechanistic views of the faulty female body in need of medical management, replacing them with the language of connection, celebration, power, transformation” (Cheyney 537). Rather than refusing the use of technocratic tools—which can give important information about the internal state of the body—moving towards a medicine that places patient and doctor on equal footing, as knowers of different but equally useful information, will serve patient health. Mothers deserve to “hav[e] knowledge, hav[e] a sense of control, and hav[e] a choice during pregnancy and labor,” rather than be subjected to the medical interventions dictated by an all-knowing, distant medical professional (MacDonald 556). Instead of crafting patients as medicalized, inert objects, patients should be seen as people with lives, instincts, urges, and more that should be welcomed in their diagnosis and treatment—and reflected in their doctor’s note.
Cheyney, Melissa. “Reinscribing the Birthing Body: Homebirth as Ritual Performance.” Medical Anthropology Quarterly, vol. 25, no. 4, 2011, pp. 519–542., https://doi.org/10.1111/j.1548-1387.2011.01183.x.
DiFranco, Joyce T., and Marilyn Curl. “Healthy Birth Practice #5: Avoid Giving Birth on Your Back and Follow Your Body’s Urge to Push.” The Journal of Perinatal Education, vol. 23, no. 4, 2014, pp. 207–210., https://doi.org/10.1891/1058-1243.23.4.207.
Foucault, Michel. “Right of Death and Power over Life.” The History of Sexuality, Penguin Books, 2020, pp. 135–159.
Haraway, Donna. “Situated Knowledges: The Science Question in Feminism and the Privilege of Partial Perspective.” Feminist Studies, vol. 14, no. 3, 1988, pp. 575–599., https://doi.org/10.2307/3178066.
Kleinman, Arthur. “Conflicting Explanatory Models in the Care of the Chronically Ill.” The Illness Narratives: Suffering, Healing, and the Human Condition, Basic Books, New York, New York, 1988, pp. 121–136.
---. “What Is Specific to Biomedicine.” Writing at the Margin: Discourse between Anthropology and Medicine, Univ. of California Press, Berkeley, California, 1997, pp. 21–40.
MacDonald, Margaret. “Natural Birth at the Turn of the Twenty-First Century: Implications for Gender.” Gender in Cross-Cultural Perspective, Pearson, Boston, Massachusetts, 2013, pp. 547–557.
Snorton, C. Riley. “Anatomically Speaking: Ungendered Flesh and The Science of Sex.” Black on Both Sides: A Racial History of Trans Identity, University of Minnesota Press, Minneapolis, Minnesota, 2017, pp. 17–219.