THE CULTURAL CROSSINGS OL CARE: A call for translational medical humanities
Modern medicine is confronted with cultural crossings in various forms: The migration wave in Europe has imposed a new awareness ot the cultural dimensions ot both physical and psychological therapy (Napier et al. 2014). Religious and ideological radicalisation has raised related questions about how to draw the line between pathology and conviction, and how to deal with cultural and religious discontent, also in clinical settings (Kristeva 2016). The Lancet Commission on Culture and Health (Napier et al. 2014: 1607) provided important insights into the cultural dimensions ot health and wellbeing; most radically, it pointed out that “the distinction between the objectivity of science and the subjectivity of culture” is “itself a social fact.” When the Lancet commission aims to create awareness about the “effect of cultural systems of values on health outcomes,” however, it implicitly reinforces the ontological divide that caused the problem in the first place.
We believe that the medical humanities should play a vital role in a more radical rethinking of the divide between science and the humanities. But we also maintain that this endeavour calls for a fundamental rethinking of the medical humanities themselves. Such a rethinking should address the grounding assumptions about what the humanities are, as well as how they can interact with biomedicine in research, in the production and use ot evidence, and in the practical art of care. Drawing upon the seminal work ofjulia Kristeva (2003, 2011, 2012, 2013, 2016), we will argue that the medical humanities should fully acknowledge the pathological and healing powers ot culture, and approach the human body as a complex bio-cultural fact. Consequently, cultural dimensions should no longer be construed as mere subjective aspects of medical care, but as being constituent of, and ‘hard’ factors behind, sickness and healing. A key element in such a project is the development ot a new notion of ‘translation’ in the interdisciplinary space of the medical humanities.
Cura and the chronotopy of care
We will begin to tackle the challenges facing the medical humanities by way ot a reading of a myth attributed to the Roman mythographer Hyginus (1960). The protagonist of the myth, the goddess Cura (Care), is traditionally associated with creativity and care, but also with concern and anxiety. Our reading of the myth of Cura draws upon and expands Kristeva’s use of the tale in Hatred and Forgiveness (2012). Here, Kristeva uses the fable to reflect on the creation of man as a being belonging to different ontological domains and temporal orders. According to Hyginus’ anthropogony, Cura crosses a river and on the other side bends down to the earth to pick up a clump ot clay. From the clay she shapes a being that will become man. Jove, the celestial god of lightning and thunder, comes along, and Cura asks him to give life to the artefact she has produced. Jove complies, and gives the gift of spirit to the shape formed by Cura. But now a quarrel erupts over the name of the new creation. Should it be named after Cura who gave it form or after the male celestial god who gave it spirit? At this stage Tellus, the god of earth, intervenes and claims Cura’s creation, arguing that he provided the material from which it was formed in the first place. Saturn, the god ot time, settles the matter through an act of naming, and by dividing and temporalising the possession of the various parts that comprise man: Jove is offered man’s soul and Tellus his body, after man’s death, while Cura will possess the creation in its lifetime, since she made it. Saturn names the new being homo because it was originally shaped out ot humus. According to the myth and the Latin pun that sums up its moral, then, human life as a composite assembly of spiritual 0ove) and material (Tellus) elements is held together by Cura’s temporal care.
The myth ot Cura has been subject to various literary elaborations and philosophical elucidations, and it has also been read in the context of the medical humanities (Heidegger 1962; Reich 1995; Kleinman and Van Der Geest 2009; Svenaeus 2011). Characteristic of Kristeva’s reading, however, is her use of the myth to question the fundamental conceptual distinctions that underpin modern medicine and the medical humanities. Moreover, this reading illuminates what we here will refer to as the chronotopic organisation of care (i.e., its simultaneous temporal and spatial aspects) (Bakhtin 1981). We use this Bakhtinian coinage to draw attention to the manner in which medical research and the practical art ot care are assigned not only to separate ontological domains (nature and culture), but also to different temporal zones: The first to the universal stasis and Platonic non-time of biomedical evidence, which should apply generally, to all instances; the second to the mundane, intertextual co-creation of meaning in encounters between medical practitioners and patients, which takes place in the singular, biographical time and life-context of individuals.
In Kristeva’s rendering, Jove’s intervention and Saturn’s introduction ot the name of man separates homo as a creation (a state of being) from the continuous process of creativity (coming into being), represented by Cura, the initial forming agent and female artist behind the human species. A whole series of binary oppositions, ontological conflicts and wounds, are brought into being by this separation. In a medical context, the binary structure is reflected in a demarcation between health as a condition with illness as its deviation, and healing as an ongoing process unfolding through time.
Kristeva (2012: 154) uses what she calls the “circumscribed act” of the male gods as an allegory for the cultural distinction between health as a “definitive state,” and healing and caring as a durative “process with twists and turns in time.” Thus, the myth can be read as an allegory of how health is objectified into a condition of full being (a definitive state) outside time, while illness is conceived as the privation (steresis) of a state ot health and wellbeing considered as the origin and the norm. By the same token, cure—understood as a definitive act recreating a “definitive state” (i.e., health)—is distinguished from Cura or what Kristeva refers to as the “durative idea ot care.” Similarly, medical science concerned with cure (with nature or physis, with states of health or illness outside human time) is separated from the humanities concerned with the liminal period between birth and death. In this binary scheme, cure and care, health and healing, medical science and the medical humanities are assigned to different chronotopic zones.
On the one side of this binary structure is the transcendent and universal knowledge, the ‘gold standard’ in the terminology ot evidence-based medicine; on the other, the messy temporal space in which humans live, and where sickness and healing actually occur simultaneously.
To be sure, our intention is not to use the myth to create some kind of alternative ‘scientific model’ or as ‘evidence’ of a universal truth of the structure of human existence. Rather, our aim is to use the tale as a yardstick against which certain instituted ‘deep structures’ of modern medical epistemology and ontology can be measured. By suggesting that Man lives her life in a continuous curative passage from birth to death in which health and sickness alternate, the myth represents a challenge to the binary understanding of sickness and health inherent in modern medicine. A related challenge also becomes evident from this reading: Biomedicine is in constant need of ‘repair, ’ and it is as an instrument of repairment that the medical humanities are usually conceived. Even in its most radical versions, the medical humanities are reduced to a soft, ‘subjective’, and cultural supplement to a stable body of ‘objective’ biomedical and scientific knowledge, suturing without challenging the binary understanding ot nature and culture inherent in biomedical thinking.
As Kristeva points out, remedies for the splits between biographical and biological life, bios and zoe, soul and body, are often found in pharmaceuticals, or in the production of ideal images of‘good living’ and model narratives about ‘successful patients’ (‘the integrated disabled person,’ the ‘empowered’ or ‘health-literate’ patient, and so on) (Kristeva 2012: 157). Through these remedies, the biographical life of the patient is supposed to be reshaped in the image ot normative ideal types of biological and healthy life. The subjectivity ot the patient is re-duced—‘led back’ into static notions of‘normal’ and ‘good living.’ As a result, the psychic life of the patient is seen as healed only when it disappears, i.e., when subjectivity corresponds with the general norm of‘human life’ (Kristeva 2013: 222).
In research and theory, biomedicine also attempts to ‘bridge the gap’ between bios and гое through so-called ‘knowledge translation’ from general conditions or states of health from the laboratory, a space constructed to be, ideally, outside the cultural time of the living, and back into the singular biography and life-context ot the individual patient (Engebretsen, Sandset, and 0demark 2017). Actually, in addition to ‘knowledge translation,’ a whole range of prominent medical practices, such as ‘health literacy’ and ‘individualised care’ can be seen as ‘soft’ cultural supplements that aim at reincorporating the individual patient, biographical time, and a ‘subjective’ perspective in medicine by turning ‘cure’ into ‘care.’ All these soft supplements rest upon a distinction between nature and culture, hard and soft science. In accordance with the logic of the supplement, however, these practices also have an implicit potential for undermining the oppositions (Derrida 2016).