As a physician, author Seth Holmes is horrified to see Triqui migrant workers’ health complaints ignored, misunderstood, or dismissed outright when they seek medical care in the United States. Based on the experiences of three men whose medical treatments he observes—Abelino, Crescencio, and Bernardo—Holmes shows that doctors and nurses consistently blame migrant workers for their own pain rather than recognizing the external factors that cause it. As a result, these doctors and nurses not only fail to treat migrant workers’ medical issues, but in many scenarios, they actually make them worse. Holmes argues that, because of modern Western medicine’s “clinical gaze”—or its narrow view of what causes disease—health practitioners are largely blind to the social, cultural, and other contextual factors that lead to health problems. And unless they build this awareness, they’re unlikely to effectively treat many of their patients—especially those from marginalized backgrounds.
Modern Western medicine’s default worldview (the “clinical gaze”) assumes that disease is an objective phenomenon rather than a subjective one, which leads medical practitioners to objectify patients and overlook the contextual factors that actually cause many diseases. Citing the influential French historian and philosopher Michel Foucault, Holmes argues that the “clinical gaze” became the norm in the late 18th century, when scientists started viewing disease as an objective problem with a specific body part, rather than a subjective problem afflicting “the whole person.” Accordingly, they started to prioritize “objective” criteria over “subjective” ones. For instance, doctors and nurses often view X-rays and official paperwork as more authoritative than actual conversations with their patients—but this leads them to overlook important elements of their patients’ conditions or personal history.
Similarly, because doctors view their own observations as “objective” and their patients’ as “subjective,” they frequently assume that patients are wrong for not conforming to their expectations—rather than seeing that their expectations sometimes do not reflect people’s real experiences. For instance, Holmes notes that doctors once sent a Triqui man to a mental asylum because he couldn’t communicate in Spanish, so they thought he was insane. In reality, the man only spoke Triqui and never learned Spanish. This shows that, because of their inflexible assumptions, doctors sometimes worsen their patients’ condition rather than improving it. Moreover, because healthcare practitioners define disease as dysfunction in an individual body, they often assume that the problem lies within the patient, even when it’s caused by social, cultural, or economic factors that patients do not control. For instance, a Mexican doctor tells Holmes that Triqui people are disproportionately sick because they don’t cook well or shower enough—while ignoring that they don’t have access to adequate food or running water in the first place. This shows that, because doctors assume that disease is caused by personal failures, they deliberately ignore the social, cultural, and economic factors that often truly cause it.
As a result of their clinical gaze, medical practitioners badly mistreat migrant workers, lose their trust, and often worsen their pain rather than healing it. Holmes illustrates this process through three case studies: Abelino’s knee pain, Crescencio’s headaches, and Bernardo’s stomachaches. Abelino has severe knee pain from working crouched down on the Tanaka Brothers Farm for many years. However, rather than talking to Abelino, the doctor gives him an X-ray, concludes that he “[does] not know how to bend over,” and says that he needs to exercise his knee by returning to work on the farm. When this worsens his pain rather than alleviating it, Abelino returns to the doctor, who decides that Abelino is unreliable and doesn’t understand his own pain. Because the doctor treats him as a set of body parts and considers his “subjective” reports less reliable than her “objective” tests, she ends up wasting Abelino’s time and covering up the real cause of his illness: overexertion from farm work.
Crescencio gets severe headaches whenever his managers at the farm scream racist insults at him. The only thing that helps these frustrating headaches is heavy drinking, and Crescencio worries that he’ll inevitably take out this frustration on his wife and children. However, when he visits a doctor to get help, the doctor immediately decides that Crescencio is an abusive husband who needs to go to therapy, fix his drinking, and take responsibility for his problems rather than blaming his bosses. Rather than actually listening to Crescencio’s individual story, the doctor simply assumes that he fits a stereotypical mold and treats the stereotype, not the person in front of her. Again, this shows how doctors are misled by their assumptions that dysfunctional bodies cause disease, and that these dysfunctions follow consistent patterns.
Finally, Bernardo has experienced severe stomach pain ever since the Mexican Army kidnapped and tortured him several years prior. When he visits a clinic, however, the doctor decides that Bernardo has “no past medical history,” tries to treat him for chest pain instead of stomach pain, and attributes his ailment to a boxing accident. They ask him to wait for several hours, but he needs to return to work, so he leaves—and the insurance company bills him $3,000 because he voluntarily left the clinic without finishing his treatment. Like Abelino and Crescencio, Bernardo primarily experiences health practitioners and institutions as distant and indifferent: they refuse to acknowledge his actual medical problems or explain their decisions, because they view him as a biological puzzle to solve rather than a human being to treat.
Based on their experiences, it's no wonder that many Triqui people believe that “doctors don’t know anything.” Doctors learn to view patients as biological objects rather than human subjects, and this often blinds them to the social factors that actually can cause disease. Of course, structural pressures often make it even more difficult for them to provide adequate care. By combining his two fields, anthropology and medicine, Holmes hopes to help other physicians see how their medicalized worldview is limiting and sometimes counterproductive. Instead, doctors must account for the social factors that contribute to illness.
Related Themes from Other Texts
Bias in Healthcare ThemeTracker
Bias in Healthcare Quotes in Fresh Fruit, Broken Bodies
Why did the Triqui people think that the physicians working with them did not know anything? What was wrong with the doctor-patient relationship? Why was it so unhelpful in its present form? Could it be changed to be more helpful for my Triqui companions? What were the economic, social, and symbolic structures impeding such change? And how might anthropology speak to clinical medicine and public health?
As an anthropologist and a physician, I am concerned both with theorizing social categories and their relationships with bodies and with the possibility that suffering might be alleviated in a more respectful, egalitarian, and effective manner. My dual training has been at once stimulating and disorienting. The lenses through which cultural anthropologists and physicians are trained to see the world are significantly different, and at times contradictory. I have found the critical social analyses of anthropology incredibly important at the same time that I have valued the grounded human concerns of clinical medicine.
Around the time of the advent of the dissection of cadavers, the conception of disease transformed from an entity affecting the whole person to an anatomically localized lesion. It was no longer considered necessary for doctors to listen to patients describe their experience of the illness—their symptoms—in order to diagnose and treat. Instead, physicians began to focus on the isolated, diseased organs, treating the patient increasingly as a body, a series of anatomical objects, and ignoring the social and personal realities of the patient, the person. In the paradigm of the clinical gaze, physicians examine and talk about the patient's diseases, while the patient remains largely silent. In many ways, this can be seen as the advent of modern positivist science in which human, social, and historical contexts are considered irrelevant.
Years later, Abelino still tells me that he has knee pain and that "doctors don't know anything" (los medicos no saben nada).
After considering in some detail the course of Abelino's interactions with health care institutions, this common statement makes more sense. Several assumptions were made along the way, from the absence of stomach problems to his first return to work being "light duty," from his ability to read English to his being paid as an hourly worker, from his incorrect picking as the cause of his injury to his faking of the pain, from the importance of "Objective" biotechnical tests to the disqualification of his words and experiences.
Crescencio's headache is a result most distally of the international economic inequalities forcing him to migrate and become a farmworker in the first place and more proximally of the racialized mistreatment he endures in the farm's ethnicity and citizenship hierarchy. These socially produced headaches lead Crescencio to become agitated and angry with his family and to drink, thus embodying the stereotype of Mexican migrants as alcoholic and potentially violent. The racialized mistreatment that produces his headaches is then justified through the embodied stereotypes that were produced in part by that mistreatment in the first place. Finally, due to powerful economic structures affecting the migrant clinic as well as limited lenses of perception in biomedicine, this justifying symbolic violence is subtly reinforced throughout Crescencio's health care experiences.
Health care professionals cannot be blamed for their acontextuality. They, too, are affected by social, economic, and political structures. Much of their blindness to social and political context is caused by the difficult, hectic, and emotionally exhausting circumstances in which they work. It is caused also by the way medical science is thought and taught in the contemporary world. Most of these individuals have chosen their positions in migrant clinics because they want to help. They have a great deal of compassion and a sense of calling to this work. Yet the lenses they have been given through which to understand their patients have been narrowly focused, individualistic, and asocial.
If health professionals responded to sickness by treating not only its current manifestations but also its social, economic, and political causes, we could create a realistically critical public health and a "liberation medicine." This latter term alludes to liberation theology, in which a reflective engagement with those who are poor and suffering leads to new ways of thinking and practicing theology in order to achieve social justice. While there is genuine need for the skills of narrowly trained, competent biomedical physicians, I am convinced this is not enough.
As shown by the health care experiences of Abelino, Crescencio, and Bernardo, medical skills practiced without recognition of the social structures causing sickness are doomed to address only the downstream, biological and behavioral inputs into disease. This leads to ineffective health care at best and complicit, injurious health care at worst.
