I have since had extensive opportunity to reconsider. I first started to appreciate some of the misrepresentations incorporated in my '80s nightmare-of-urban-decay conception of the drug when a friend lent me a riveting ethnography of Harlem crack dealers by the anthropologist Phillipe Bourgeois called In Search of Respect. Bourgeois' book is based on an absurdly long period of clearly gruelling fieldwork living with crack dealers, and I highly recommend it to anybody who is at all interested in the relationship between domestic drug policy and social class.
I really started to realize just how incommensurate with reality our unexamined cultural narrative about crack is when I started working in a county hospital, and immediately became acquainted with an enormous number of casual crack users.
I should probably take a moment here to say explicitly that I am absolutely not for crack cocaine in any conceivable sense. This is not a call for legalization, nor do I wish to downplay the consequences of using crack for one's cardiovascular health regardless of whether one is addicted to it or not. I have seen my share, and probably yours, of crack-induced medical problems in every conceivable setting - I'm just suggesting that the reality of crack cocaine, in the population I work with, is very different from what I was lead to believe by Nancy Reagan, and we can probably learn more about it from well-informed anthropologists than we did from her.
Among a certain subset of my patients, (mainly the American-born working poor,) casual crack use is surprisingly common. When I say "casual," what I mean to convey is that there are a lot of people out there who use crack like most middle-class white Americans use alcohol - occasionally, functionally, and without any overt social consequences. And I'm not just talking about wild young men who also drink Steel Reserve and smoke heroic amounts of marijuana. I have at least one respectable grandmother in my primary care clinic who admits to taking the occasional hit and is not, by any stretch of the imagination, some kind of antisocial monster. Quite the contrary. In fact, I think I could say without doing violence to the facts that crack use the American metropolis can be loosely analogous to, say, the way that other cultures use betel nuts or coca leaves. Again, I stress that this comparison has nothing to do with physiology; drinking a bottle of Smoking Loon (or, for that matter, Carlo Rossi) a few times a month is better for you by several orders of magnitude than smoking crack with the same frequency. This is a point about cultural significance and the reality (or unreality) of pathological addiction, not the incidence of cardiovascular disease.
The reason that I think this is important is that all of my colleagues come from cultural milieus like my own which, although they are highly diverse (Germany, India, Iran, Mexico, Argentina, etc.) definitely do not involve casual crack use, and are also similar to mine in that their primary access to what crack is really like is via highly mediated and agenda-driven cultural artifacts like Robocop. This has profound significance for the way that we relate to patients as diagnostic and therapeutic agents; we (the doctors) have a variety of highly charged notions about crack use, which aren't particularly commensurate with those of the users and, (more importantly if you belong to the standard school of medical epistemology) don't cohere particularly well with the ethnographic reality.
An interesting consequence of this is that crack is authorized as an etiological agent in a variety of contexts precisely by these thoroughly cultural attitudes towards it, rather than by that increasingly valorized commodity, "evidence." The menagerie of conditions I have seen attributed to cocaine continues to expand monthly. Many of these attributions are just - cocaine does, in fact, cause hypertension, stroke, myocardial infarction, cardiomyopathy, renal failure, thrombotic microangiopathy, etc. - but a significant number of them are, if one takes a few steps back, bizarre. For instance, I admitted a woman a few weeks ago who was incidentally found to have astronomically elevated liver function tests. No obvious etiology was apparent, although salient historical features included the fact that she had taken cocaine during the previous week, and that she had a new sexual partner. When I presented the case to my supervisor in the morning, I duely mentioned that she had used cocaine four or five days prior to her presentation and gave my conjecture, which I expected to be borne out by pending serology, that she had an acute, sexually transmitted viral hepatitis. He gave me an mercifully avuncular smile and said, "There's nothing mysterious about this - it's cocaine-induced hepatitis. We see it all the time."
Cocaine-induced hepatitis is (I checked,) not widely reported in the literature, and she did, in fact, turn out to have acute hepatitis B. The point here is not to tout my diagnostic acumen; the doctor in question is definitely more knowledgeable and very probably just plain cleverer than I am. The point is that cross-cultural perceptions influence diagnosis. Casual crack use represents a cultural littoral between the physicians at my institution and their patients, and as such it lends itself to overdetermination.
The significance of this fact was impressed upon me when an emergency medicine attending told me that of all the urine toxicology screens which are sent at my hospital (and the ED sends them on just about everyone) something like sixty percent are positive for cocaine. This indicates both the incredible prevalence of casual cocaine usage in the general population, and the fact that whenever you're stumped for a diagnosis, roughly sixty percent of the time you have the option of blaming it on cocaine. And what I have come to appreciate is that this option is vastly over-used, and that this amounts (in cases where the diagnosis is not clearly referrable to cocaine) to blaming medical problems on cultural differences.
This means, fundamentally, that we have a propensity to explain things we understand (e.g., that Mr. A. is suffering from a hypertensive emergency because he just smoked a bunch of crack and given that cocaine is an indirectly acting sympathomimetic amine it can be expected to facilitate the release of noradrenaline from presynaptic sympathetic axon terminals, causing peripheral vasoconstriction and a corresponding acute elevation in blood pressure,) in a completely different way from things we don't understand, (e.g., Ms. B has an elevated white blood cell count in conjunction with an accelerated erythrocyte sedimentation rate and a diffuse pustular rash for which no explanation is apparent, and she smoked cocaine this weekend, so presumably this is an atypical adverse cocaine reaction.) The historian of science Stephen Schaffer makes the same claim (and I am indepted to him for this formulation) about the way we tend to think about science: we are accustomed to attribute scientific developments to social context only when they are wrong, and to attribute what is currently construed as correctly reflecting the actual nature of things to the pure and untainted light of reason; but this is pretty much the same (this is his example,) as saying that Newton thought that a principle of mutual attraction is active between the center of any given massive body and all other massive bodies which acts instantaneously across empty space because it actually does, and Leibniz disagreed because he was German.
This is a really problematic observation, because in medicine we tend to assume that the correlation of two phenomena for which robust evidence of association is lacking is the basis of a publishable case report, not evidence of a lack of anthropological sophistication and reflexive discipline on the part of the clinician. As a mentor of mine recently said, "There's this thing called Occam's Razor, which says that when two rare things happen at the same time they're probably connected."
What I'm suggesting is that actually we have to be much more careful. To take the example at hand, correlation of patchy pulmonary infiltrates on chest X-ray with recent cocaine use might indicate a case of "Crack-Lung" which could be written up as a case report; but, on the other hand, it might indicate a diagnosis of coccidoidomycosis for the patient and a diagnosis of conflation-of-cultural-difference-with-biological-determinism for the physician.
And this isn't, by any means, limited to the attribution of otherwise inexplicable disorders to cocaine (or, put another way, to the synonymous use of the terms "cocaine-induced" and "idiopathic"): let me tell you a story which was presented at a recent joint emergency-medicine internal-medicine conference. An African-American woman in early middle age with a long history of crack use, whose urine had tested positive for cocaine every time anybody cared to test it, presented to our emergency department repeatedly with emergently elevated blood pressure. Looking back over the case files, (which span months) the story does not add up; she did not respond in the way one would have expected to the standard interventions for cocaine-induced hypertension or essential hypertension, yet she was routinely discharged from both the emergency room and the hospital ward with incongruously high blood pressures, (albeit lower than those she presented with) without anybody batting an eye. Eventually somebody did notice that, for some reason, the drugs weren't working, and she got a full-body CT scan in the ED which disclosed a near-total renal artery stenosis. This is a classic cause of refractory hypertension, as any third-year medical student could tell you. Had she been a middle-class white woman without a history of cocaine use, she would have fit a classic diagnostic profile and this would have been discovered much earlier, possibly at her initial presentation; but because she fit a certain classic cultural profile, several doctors (all of whom are, I am not being sarcastic, brilliant diagnosticians and deeply empathic individuals who work at the county hospital because they want to serve the disenfranchised) bent the circumstances they actually saw to fit a culturally motivated conception which they expected to cohere with reality. And I probably would have done the same thing. In fact, it is more than likely that I already have.
So what's the point? It certainly isn't that we shouldn't, like, you know, pass judgment on people, just because they smoke crack, or that racism is a common facilitator of hypertension. It's that anthropology offers as much discriminant information, under many circumstances, as does biomedicine (narrowly construed). You can learn as much information of important diagnostic utility about people by attempting to understand their cultural milieu or, (actually more importantly,) by reflecting in a disciplined manner on your own and its implications for your apprehension of theirs, as you can from their Chem7 or their complete blood count.
Much of the basic science that has created the immensely powerful apparatus of modern biomedicine was (at least allegedly) founded on the distinction between primary properties (like mass or velocity, which can be demonstrated by universally reproducible means in any cultural context,) and secondary properties, (like color, taste, or justice, which only exist for specific observers under specific circumstances). The point is that this distinction, at least in clinical medicine, is going to have to break down, and we are going to have to start taking seriously the prospect of doing anthropology at the bedside.
Posts
