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Book Forum: History and Policy   |    
Social Suffering
RENATO D. ALARCҎ, M.D., M.P.H.
Am J Psychiatry 2000;157:1027-1028. doi:10.1176/appi.ajp.157.6.1027
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Edited by Arthur Kleinman, Veena Das, and Margaret Lock. Berkeley, University of California Press, 1997, 381 pp., $48.00; $17.95 (paper).

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Much more than a book on social suffering, this volume attempts to be a powerful scholarly statement about the value of a return to basics in cultural anthropology and, hence, the need to go beyond the point where any subject can be examined as "a single theme or a uniform experience." The reading is fascinating as, from the perspectives of anthropology, social history, literary criticism, religious studies, and social medicine, the authors proclaim that "the forms of human suffering can be at the same time collective and individual…the modes of experience in pain and trauma can be both local and global." Yet, what is fascinating is also complex, and what is complex cannot easily be integrated or reduced to a cosmetic simplicity—nor should it be. Thus, the main risk for the reader is that of wandering into a maze of dazzling rhetoric, convoluted hermeneutics, and brilliant insights. Reading this book can be a delight or an exhausting journey, and its content can be an inspiring tale or a painful realization of inevitabilities.

The first article, by Arthur and Joan Kleinman, sets the stage for the critical approach to the "cultural appropriations of suffering in our times," such as the distortions conveyed by the subtle crafting of the media, the gross manipulations of politicians in power, or the sophisticated coldness of World Bank statistics. In the next chapter, David Morris’ study of the contributions of literature brings into sharp relief the conflicting dimensions and the absence of borders between words and images in the description and understanding of suffering. The notion that "whatever its wider resonance, suffering is ultimately an individual matter" sounds like a subtle rejoinder to the previous chapter. Illustrative of the complexities of the subject, however, it seems that even Morris contradicts himself: at one point, he emphasizes the detachment created by the literary images of suffering, and, at another, he comments empathetically on the open crying of readers of Uncle Tom’s Cabin.

Lawrence Langer takes a more militant position in his chapter. He claims that "we need a new kind of discourse to disturb our collective consciousness and stir it into practical action that moves beyond mere pity." He insists on the difficulties in describing and believing in the suffering of others and indirectly blames national reconciliation efforts (without naming South Africa among his examples) because they defuse alarm by deflecting atrocities and create, in that sense, "a fragile peace." The myth of "civilized beings," all but destroyed by the testimony of victims, has mankind swinging indeed between hope and despair.

Veena Das examines the position of women in the scenery of suffering. She denounces the traditions that diminish women and permit the perpetration of subtle everyday violence against them. Describing the plight of Indian women, she mentions silence as an imposed response that thwarts the transactions aimed at an accurate construction of pain. In his chapter commenting on Das’ essay, Stanley Cavell deepens the search for "words and tones of words" that will allow sufferers to break their silence, itself a reinforcer of the social silences perpetuating the suffering. A similar purpose colors Mamphela Ramphele’s chapter, "Political Widowhood in South Africa: The Embodiment of Ambiguity," which deals with the personification of "social memories for the benefit of society."

The notion of ambiguity is taken up by Vera Schwarcz, who writes about the public uses of personal grief in modern China. Political language covers up grief, translating "individual suffering into a public commodity," making suffering a "didactic value in communal life." At the opposite end, the sufferer’s voicing of his or her own sorrow opens a pane of truthful attentiveness. Intellectual figures, muted and humiliated by the Cultural Revolution but resilient enough to create their own suffering-transcending testimonies, give sorrow a unique meaning of dignity and power.

Maoism as a source of social suffering in China is also the subject of Tu Wei-Ming’s essay. He narrates vividly the process that in a few decades "destroyed the intelligentsia" and created a massive, collective conspiracy of silence, a docile multitude of workers, and the covering up of indescribable violence. Political leadership, ideological legitimacy, and moral authority were manipulated by Mao to foster an aggressive anthropocentrism, the myth of the general will, and a romantic utopianism that numbed the country and caused a "moral inversion on the social level."

Another look at the distortions of human suffering comes through Ann Harrington’s examination of Nazi medicine. Trading on historical contradictions and dialectic maneuvering, the Nazi regime created a medicine that was at once "objective" and "holistic," each tendency demanding to be recognized as the "official truth." The extreme example of scientism (science as ideology) should make us reflect on the current obsessiveness with reified "facts" on the one hand versus the ascendance of "prevention and education" full of vagaries and vagueness on the other.

Far away from the miseries and suffering of war and torture, Margaret Lock’s chapter on the reconstruction of death in North America and Japan is a powerful, novel approach to "the havoc and misery that technology can create." Although technology is an integral part of the history of human aspirations, Lock insists that it is by no means autonomous and points out that "the characterization of suffering, being culturally constructed, has a profound influence on [technology’s] development, associated discourse, and application." For instance, the implementation of transplantation technology requires a "redefinition of death," about which North American and Japanese views differ significantly. Modern Western thought is seen as having "capitulated to the view that death is essentially a biological event." This "fetishization" of the American population and the "flow of organs from the poor to the rich, from the Third World to the First World" eloquently reflect the motto of "progress as tragedy." Lock calls this the "slippery slope of personhood" or moral integrity.

Allan Young comments on the "new rhetoric of suffering, grounded in the authority of science, and predicated on the mechanism called psychogenic trauma." He writes about the historical genealogy of traumatic memories, concluding that "fear, like pain, was transmuted into an evolutionary gift, enabling the organism to anticipate threats and to avoid its destruction." In the next chapter, Paul Farmer discusses "mechanisms through which large-scale social forces crystallize into the sharp, hard surfaces of individual suffering." Farmer ascertains that structural violence runs through the axes of gender and ethnicity and is aggravated by cultural differences. Furthermore, the World Health Organization (WHO) now acknowledges that poverty is the world’s greatest killer, and the poor are not only more likely to suffer but also more likely to have their suffering silenced.

Paradoxically enough, Talal Asad finds that the rules enshrined in the WHO Universal Declaration of Human Rights "cover a wide range of qualitatively different kinds of behavior" that go from the definition of what is truly human to moral and legal judgments about pain and suffering, and to the always colliding nature of individual and social interests. In examining torture, Asad finds it inseparable from a "disciplinary society," a practice that unfortunately seems to be as current now as it was many centuries ago. Although some attribute torture to "primitive urges," others think that it is "a practical logic integral to the maintenance of the nation states’ sovereignty."

E. Valentine Daniel examines the plight of refugees, using the example of the three immigration waves of Sri Lankan Tamils into Britain, each of them dealing differently with "the unavailableness of a nation." The worst thing about suffering of this kind is a true "disaggregation of identity." The pace of time and the passing of history caught three generations of people from the same land carrying three different images and one common alienation. In spite of these "bleeding realities," Daniel also sees an opportunity to reach "authenticity of being," caring for themselves and others, and for the pursuit of individual and collective potentials. Solidarity may very well be the common name for these endeavors.

The final chapter, "Religions, Society, and Suffering," is by J.W. Bowker. He comments on Weber’s discernment of the different ways in which religions have constructed social meaning out of the experience of social suffering. In this view, religions are systems organized for the protection and transmission of the achieved discoveries of human competence, discoveries that have been truly prodigious; however, religions are also a complex group of interpretations of texts, beliefs, documents, books, and doctrines. The spectacular advances in medical knowledge and interventions have led to the increasing isolation of religion as a human activity, a situation that becomes even more abstruse when economic factors start playing a role. Religions look to the wider context of society in their attempts to account for illness. This came initially from ignorance, but the "other side of the coin of ignorance bears the imprint of concern" and consolation.

This book is a tribute to the commitment of social science and the intellectual community to examine collective suffering with a multidimensional richness that rescues lessons critical for the work of health professionals in general and psychiatrists in particular. It cleverly points out the boundaries of modern and postmodern dilemmas: science and society, technology and humanism, social and clinical phenomena, human misery and human greatness. It denounces while describing; it instills hope while condemning. It digs into history and covers vast geographies—although there is nothing about Latin America—and vindicates the individual’s search for meaning in an ocean of social forces. After all, that is the substantive mission of the healer in the classic and eternal sense. The authors of the essays and the editors of this book have successfully conveyed, without concessions to simplicity, an elemental but profound and essential message.

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