Showing 1 - 10 of 401 annotations tagged with the keyword "Cross-Cultural Issues"

The Bridge in the Jungle

Traven, B.

Last Updated: May-15-2020
Annotated by:
Ratzan, Richard M.

Primary Category: Literature / Fiction

Genre: Novel

Summary:

The Bridge in the Jungle is a novel about the tragic death of Carlos, an 8 or 9 year old (no age is given) hyperactive Mexican boy, and the aftermath of his mother's overwhelming grief for him, sometime in the early 20th Century in a very poor village deep in the jungle. (The lack of specific details are intentional, as I shall discuss below.) The narrator is an American man staying in the village while looking for alligator skins and bird feathers to sell in the U.S.. He observes the little boy's brother, who works in the oil industry in Texas and has just returned for the weekend, give his little brother brand new shoes. Carlos is overjoyed to wear them since all the villagers but the pump master's wife wear threadbare rags for clothes. This is the little boy's first pair of shoes, much less shiny new American ones. While sitting outside in the village with his host, both waiting for an outdoor party, the narrator hears an ominous splash that is Carlos falling to his death off the treacherous bridge, a bridge that has no railings. The remainder of the novel depicts the grief of the young mother - a grief that reaches the suffocating proportions of Greek tragedy - and her villagers' genuine support.

Described in minute detail by the narrator, the villagers - who have turned over every stone in the woods, dived many times in the river, and ridden to nearby villages to find Carlos - turn to an old man who requests a perfectly flat piece of wood and a stout candle. He then meticulously fastens the candle to the wood and carefully launches this raft of mystical exploration and recovery on the river. Every villager watches this ceremony with rapt attention. It is truly a riveting passage, for the raft travels under its own power from the river bank against the current, meandering slowly towards the bridge where it finally stops, despite the current, under the bridge, the only place no diver has yet looked:
"The board in the meanwhile has wandered farther under the bridge, but always in a right angle to the fifth post. Now it is under the middle of the bridge. From here it sails towards the fourth post, though only for about a foot. And here it stops as if it were nailed to the water. It does not mind the current nor the light breeze that sweeps softly across the surface of the river. The manner in which the board has halted is entirely different from that in which it stopped before. Now and then it trembles slightly, as if something were breathing against it from below. But it no longer whirls. ... The board begins softly to dance as if impatient. It seems that it wants to be relieved of its torture. It wriggles, swings about itself, though it does not move as much as two inches. One might think it is trying to go down to the bottom."
(page 110-1)
A villager dives and retrieves Carlos and hands his body to his mother:
"With an indescribable nobility and solemnity, and in his eyes that pitiful sad look which only animals and primitive people possess, he steps slowly forward. And Perez, the man whose daily task it is to fell the hard trees of the jungle and convert them into charcoal, lays that little water-soaked body in the outstretched arms of the mother with a tenderness that makes one think of glass so thin and fragile that a single soft breath could break it."
(page 113)
The villagers, in a procession that is tragicomic, take Carlos' body to the graveyard where a well respected teacher, now drunk from all the mescal others have offered him, gives an eulogy that suggests Christ's Sermon on the Mount. However, with inverted symbolism, this sermon is for, not by, Jesus and is delivered by a drunken priest-figure who is so drunk he falls into the open grave. To Traven's credit he introduces this farcical moment to emphasize how none of the villagers, much less the author, and, consequently, the reader, laughs at a decent man trying his best to honor Carlos. It is truly a most moving finale to a most moving book.



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Elizabeth Siegel Watkins reports on the use of estrogen alone and in combination with progestin for women during menopause and after menopause from the 1890s until the book was published in 2007. She concentrates on the sixty years between 1942 and 2002. The event Watkins uses to mark 1942 as an important moment is the U.S. Food and Drug Administration (FDA) approval for the estrogen product Premarin as hormone replacement therapy (HRT) in women with menopause symptoms. The event she uses to mark 2002 is the release Women’s Health Initiative (WHI) findings that showed estrogen is not the “elixir of life” that many thought it was then.  

Watkins builds her story off the trajectory of estrogen use during this sixty-year period, which spanned two peaks followed by two crashes. The estrogens for HRT first crested in the early 1970s before its use dropped dramatically in 1975 on uterine cancer fears. Estrogen use began to rise in the early 1980s on regained confidence from combined use with progestin to reduce uterine cancer risk and from hopes that bone loss could be prevented and even reversed. This resurrection continued through the 1990s as estrogen use during and after menopause became “associated with reduced risk of colon cancer, prevention of tooth loss, lower incidence of osteoarthritis, increase in bone mass, reduced risk of Alzheimer’s disease, and lower rates of death from all causes” (p. 241). 
 

Based on surveys of prescribers and prescription data during this time, Watkins concludes that “physicians who saw menopausal women as patients were…enthusiastic prescribers of HRT” (p. 244). They remained enthusiastic, making Premarin the most prescribed pharmaceutical product through much of the 1990s and until 2002 when the WHI trial was stopped three years early because it showed that HRT failed to produce the expected benefits, and even worse.
Women who took the estrogen–progestin pills, as compared with those in the control group who took placebo pills, increased their risk of breast cancer by 26 percent (relative risk of 1.26), coronary heart disease by 29 percent (1.29), stroke by 41 percent (1.41), and pulmonary embolism (blood clot) by 213 percent (2.13). (p. 271)
The investigators advised clinicians based on these results, that HRT “should not be initiated or continued for the primary prevention of coronary heart disease” (p. 271). Watkins quotes an editorial from the Journal of the American Medical Association that went further in saying that the trial “provides an important health answer for generations of health postmenopausal women to come—do not use estrogen / progestin to prevent chronic disease” (p. 273). HRT prescriptions plummeted.  

These clinical inputs into the trajectory of estrogen are just the bare bones of estrogen history. Watkins fills in the story: 
The story of estrogen is woven from several strands: blind faith in the ability of science and technology to solve a broad range of health and social problems, social and cultural stigmatization of aging, shifting meanings and interpretations of femininity and female identity, and the pitfalls of medical hubris in the twentieth century. (p. 1)
Watkins weaves these strands into the story of estrogen, which she tells in a chronological fashion, often as the subjects of individual chapters. Some include: the implications of rising feminism; pharmaceutical company promotional activities; the roles of patient advocacy organizations; FDA requirements for patient information about prescription drugs; generational differences in views of menopause; evolving research methods and evidence standards; and cultural shifts and mainstream media influences. 

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State of Wonder

Patchett, Ann

Last Updated: Nov-21-2019
Annotated by:
Teagarden, J. Russell

Primary Category: Literature / Fiction

Genre: Novel

Summary:

Dr. Marina Singh, a pharmacologist and former obstetrician, is sent to a research site in the Amazonian jungle somewhere in Brazil that is operated by the company she works for, Vogel Pharmaceutical. The company chief executive officer, Mr. Fox, dispatches her there to check on the progress of the research and to get details on the reported death of her colleague, Dr. Anders Eckman, while he was there on a previous research trip. Eckman’s wife, uncertain that he was dead, asks Marina to find out what had happened to her husband. The plot centers on Marina’s dual missions at the Amazon jungle site. 

Marina’s trip reunites her with the legendary and imperious Dr. Annick Swenson, who is an obstetrician and the lead researcher at the site. Thirteen years before, Swenson was Marina’s supervisor during her obstetrics residency. A mistake Marina makes while she’s delivering a baby after disregarding Swenson’s advice drove her out of obstetrics and into pharmacology, and then eventually to Vogel. The company is supporting Swenson’s research hoping it will produce a blockbuster product. Mr. Fox is growing impatient having received only brief and vague communications from Swenson over the past five years. 
 

Decades earlier Swenson had followed her mentor to the jungle location where the Lakashi tribe lives, and after frequent visits over this time, resided there permanently to work on the research Vogel was funding. The research was based on observations Swenson and her mentor made about Lakashi women; they never go through menopause and they are fertile into their old age. Swenson’s project is to find out why, and provide the information to Vogel in order to develop a product that could give women the option to avoid menopause and to have babies much later in life. 

Swenson finds it is the bark of the (fictional) Martin trees when combined with excretions of the (fictional) Purple Martinet moth deposited in the bark Lakashi women ingest that extends their fertility after menopause. Trying it herself, Swenson becomes pregnant at age seventy–three. She also finds that the same bark protects the Lakashi women against malaria. Swenson eventually concludes that her research should not proceed to product development for fertility, but instead for prevention of malaria. Certain that no American pharmaceutical company would “foot the bill for Third World do-gooding,” Swenson decides to reallocate the fertility research funding to her malaria vaccine work without permission from the company (p. 289). A cat and mouse game ensues around the research funding, Swenson’s pregnancy ends, and the mystery of what happened to Anders Eckman is solved. Marina Singh’s life is changed, probably forever.

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Responding to a shortage of doctors in rural areas in 2013, Dr. Virji, a Muslim, moved from the urban East coast to a small town in Minnesota.  Welcomed at first, he and his family began, after Trump's election in 2016, to experience withdrawal, suspicion, and outright racism in his own and neighboring towns, despite having established solid, trusting relationships with patients.  His children were being ostracized in school.  Discouraged, he took steps to accept a job in Dubai, but changed his mind after a local pastor invited him to speak in her church to correct common misconceptions about Muslims and to engage his neighbors in deeper dialogue about their differences and commonalities.  The lecture was so successful, he took it further into other towns and parts of the country.  He has stayed in Minnesota and witnessed change because of this invitation and his candid, open-hearted response. 

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This illuminating and disturbing book explores how various forms of white supremacy became expressed in policies, laws, and elected officials, such as Donald Trump. Physician and sociologist Metzl details social changes in Missouri, Tennessee, and Kansas, where white Americans backed changes that, ironically, dramatically harmed them with gun suicides, school dropouts, worse healthcare, and shorter life spans. For Metzl, “Whiteness” refers not to skin color but to a political and economic system of white privilege.

Metzl's thesis that: “Trump supporters were willing to put their lives on the line in support of their political beliefs” was, in fact, a sort of “self-sabotage” (pp. 5-6). While a conservative political movement fostered white racial resentment, largely in lower-income communities, the mainstream GOP did its part by crafting policies against the Affordable Care Act, higher taxes, and restrictions on guns. An atmosphere of polarization and political stasis grew. Metzl writes: “Compromise, in many ways, coded as treason” (p. 11).  

Metzl focuses on the examples of Missouri, Tennessee, and Kansas to “suggest how the racial system of American fails everyone” (pp. 16, 20). He visits each state, leading focus groups, interviewing formally and informally, reading newspapers, and inductively formulating concepts that seem to explain the nonsensical behavior of rejecting helpful programs. For example, because “risk” in Missouri has become a code name for possible attacks by black people, white people buy guns, especially when restrictions are removed. Many white men feel that a gun (or many guns) restores their privilege, but suicide of white males, often low-income, goes up. Metzl’s statistics and charts show contrasts with other states with stricter laws and lower suicide rates. He calls for preventive medicine to lower such deaths.  

For Tennessee, the Affordable Care Act offered many benefits to poor or middle-income people, but Republicans (and especially Trump) attacked it as big government over-reach, socialism, exorbitant cost, a program that would help minority people, for example “welfare queens.” “Cost” became a proxy for the “we don’t like it,” even when the economics would be favorable for good healthcare for all. Blacks were generally in favor of ACA, but white blue-collar men swore by their independence and autonomy. Neighboring Kentucky accepted ACA, and ten graphs included in the book clearly chart the better outcomes for Kentucky in such areas as insurance coverage, death rates, and seeing a doctor.  

Metzl returns to Kansas, where he grew up and recalls the pride Kansans had in their state. Republican Governor Sam Brownback enacted massive tax cuts with large reductions to state services and school funding, an “experiment” in “epic defunding.” The GOP, Tea Party, Koch brothers, and “trickle down” theories all played a part in benefiting the wealthy financially, while minority and lower-income groups paid more. Infrastructure, such as roads, suffered. Untested charter schools collected wealthy white students, while public schools plunged in funding, test scores, and graduation rates (see 17 graphs). Since education is a predictor of health, there are and will be long-term costs to Kansans, especially for minority groups.  

Metzl attacks the “Castle Doctrine” (“a man’s home is…”) as a symbol of narcissism, individualism, and as a risk for all citizens when social structures are abandoned. He closes with some hopeful examples of social change for the better.

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The Farewell

Wang, Lulu

Last Updated: Aug-19-2019
Annotated by:
Jiang, Joshua

Primary Category: Performing Arts / Film, TV, Video

Genre: Film

Summary:

In The Farewell, we follow Billi, a young Asian-American woman, as she takes an unplanned trip from New York to Changchun, China, to visit her grandmother—perhaps for the last time. Billi has just found out that her grandmother (Nai Nai) has lung cancer, stage IV. The doctor gives her three months to live. As troubling as such a diagnosis already is, the situation is further complicated by the family’s choice to lie about the truth of Nai Nai’s illness to her. Now, Billi’s family gathers to see Nai Nai under the pretense of a wedding, but the festivities can barely conceal a heartfelt and heart-wrenching struggle over familial responsibility, filial piety, and whether Nai Nai deserves to know.

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Survivors

Pratt, Arthur

Last Updated: Jul-19-2019
Annotated by:
Thomas, Shawn

Primary Category: Performing Arts / Film, TV, Video

Genre: Film

Summary:

For much of the western world, the Ebola crisis came and went without much fanfare. Perhaps we were jolted by the initial news stories, taken aback by the images from affected areas, and slightly unnerved by the travel advisories as we entered security lines at the airport. But for the most part, the Ebola outbreak was an abstract crisis affecting people on the other side of the world, multiple continents away. The closest that most Americans came to Ebola was to hear in the news about the four diagnosed cases in Texas and New York City. It is safe to say that most of the world remains unaware of the depths of this crisis in the West African hotspot countries of Liberia, Sierra Leone, New Guinea, and Nigeria.  

Arthur Pratt is a Sierra Leonian pastor and filmmaker, and he witnessed firsthand the invisible enemy that threatened to destroy his country, the communities, and the families that lived there. Despite the human cost that this disease extracted from the West African people, Pratt was inspired by how the people in Sierra Leone rose up to defend their country from a viral invasion that was attacking “the fabric of what it means to be African.” He felt it necessary to tell the world the story of Sierra Leone’s unsung heroes, and so he created a documentary titled Survivors, which focused on the work done by the ambulance drivers and nurses, interwoven with personal stories of children, mothers, fathers, and communities touched by the disease. Survivors gets up close and personal to the 21-month battle against Ebola in West Africa, and shows how the common people of Sierra Leone risked everything to come together and fight back against an existential threat.

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A psychiatrist and PTSD (post-traumatic stress disorder) specialist, Dr. Shaili Jain has written a book on PTSD and its many angles, from diagnosis to treatment to a larger perspective on cultural and historic influences on the development of traumatic stress. She weaves the story of her own family’s experience with the Partition of India and Pakistan in 1947, particularly its effect on her father and grandparents, as a way to consider the effect of trauma on family, but also how those traumas become ‘unspeakable.’  

A brief but effective introduction outlines the seven parts of the book:
1. Discovering Traumatic Stress: historical perspective and the changing language to describe the effects of trauma.
2. The Brain: the physiologic and psychological underpinnings of PTSD, including effects on memory formation and retrieval.
3. The Body:  such as addiction, cardiac effects and concerns at different stages of life.
4. Quality of Life: domestic and sexual violence, socioeconomic factors.
5. Treating Traumatic Stress: programs, treatment strategies and psychopharmacology.
6. Our World on Trauma: global health, large scale tragedy, terror and war.
7. A New Era: An Ounce of Prevention: resilience, accessibility of care including early and preventative care. 

Additionally, almost 100 pages of notes, glossary, resources and an index provide an easy way to further explore, to use the book to look up specific topics, and underscore the heavily researched nature of the text.   The book is eminently readable, with numerous, well-placed stories of patient encounters and particular experiences and manifestations of PTSD.  These stories are illustrative of the concepts Jain ably explains. However, they also provide an insider’s view of what happens in the consulting room.  In the prologue, Jain describes a young Afghanistan War veteran, who has been hospitalized after a violent outbreak at a birthday party: “Josh’s PTSD was fresh, florid, and untreated…. His earlier poise caves in to reality, and his face falls to anguish.” (p. xvi) We are in the room, listening to the patient, witnessing the tears of the medical student, glimpsing the attending psychiatrist’s response, and relating to Jain, as a psychiatry chief resident, as she understands that the individual before her, even as he shows classic signs of traumatic stress, remains an individual, a person in need of care.   

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The subtitle of this collection explicitly states its purpose and implies its audience. The content includes essays on teaching, as well as a number of canonical stories taught in medical humanities courses. The first section consists of key texts that present a rationale for teaching narrative literature to medical and other health professions students. This is followed by five sections, each of which covers an aspect of that rationale, i.e. narrative exploration of  professional boundaries, empathy and respect, authority and duty, stigma, and truth-telling and communication.  

Within each section, several essays describe teaching considerations or techniques, often focusing on a specific story or novel. For example, in “A Novel Approach to Narrative Based Professionalism: The Literature Classroom in Medical Education” by Pamela Schaff and Erika Wright (p. 72), the authors describe how Pat Barker’s novel Regeneration stimulates discussion of doctor-patient antipathy, doctor-patient intimacy, and interprofessional communication. From Reading to Healing also includes the full text of many stories relevant to the essays; for example, “Toenails” (Richard Selzer),“The Most Beautiful Woman in Town” (Charles Bukowski), “The Speckled Rash” (Mikhail Bulgakov), “The Death of Ivan Ilyich” (Leo Tolstoy), “The Use of Force” (William Carlos Williams) and “The Birthmark” (Nathaniel Hawthorne). 
 

In addition to stories and novels, From Reading to Healing presents essays on teaching with film, religious literature, and even comics, cf. “Assisting Students in the Creation of a Class Oath Using Comics,” by Michael Redinger, Cheryl Dickson, and Elizabeth Lorbeer (p. 217)

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Annotated by:
Glass, Guy

Primary Category: Literature / Nonfiction

Genre: Essay

Summary:

Esmé Weijun Wang is a novelist who has been diagnosed with Schizoaffective Disorder.  The Collected Schizophrenias is a book of personal essays that was the 2016 winner of the Graywolf Press Nonfiction Prize. 

A precocious young person on a track to success, Wang experiences a manic episode at Yale that leads to her first hospitalization.  After a second hospitalization, her college washes its hands of her.  Hitting roadblocks time and time again requires her to rebuild her life over and over.  This is not a conventional chronological autobiography but rather essays that provide different approaches to the author’s experience of mental illness.  The plural “schizophrenias” of the title encompasses the whole schizophrenic spectrum of disorders.  As Wang explains, her own diagnosis is “the fucked-up offspring of manic depression and schizophrenia” (p. 10).  

In an essay entitled “High-Functioning” we learn how the author, having been a fashion editor, knows how to pass for normal: “My makeup routine is minimal and consistent.  I can dress and daub when psychotic and when not psychotic.  I do it with zeal when manic.  If I’m depressed, I skip everything but the lipstick.  If I skip the lipstick, that means I haven’t even made it to the bathroom mirror” (p.44).  

Later, in “The Choice of Children,” volunteering at a camp for bipolar children makes Wang think about what it would be like to inflict her diagnosis on her own offspring.  In “Reality, On-Screen” she attempts to convey the sensation of decompensating to psychosis.  And in “Yale Will Not Save You” she considers the failure of universities to accommodate mentally ill students. 

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