In the first chapter of her book, Diedrich examines two case studies of illness narratives of tuberculosis in the early twentieth century US: those of Betty MacDonald in her book The Plague and I, a white woman who received treatment for her illness at a top-notch institution called the Firland Sanatorium (the Pines Clinic and Sanatorium in the book), and Madonna Swan, a Lakota woman who narrated her experience of being kept in the Souix Sanatorium near Rapid City to St. Pierre, a pastor in her community. She illustrates the ways in which these two narratives are examples of ". . . the anatomo-clinical method and the two modes of biopower: the disciplining of bodies and the regularization of populations," (1). She also presents these two illness narratives as examples in which the hegemonic structure and categories of the medical industrial complex and US genocide/eugenics are both upheld and challenged through the stories of both women.
Diedrich first launches into an explanation of her approach to the two case studies, using the theories of biopower and subjugated knowledges as posited by Foucault. She is interested in exploring the subversive/productive potential of these two illness narratives as subjugated knowledges (as apposed to hegemonic ones) that position "the patient" in other ways besides the passive body upon which medical practice and theory is inscribed (though this indeed still occurs). She writes:
"For Foucault, the investigation into subjugated knowledges in the past opens up a space for thinking, being, and doing otherwise in the present and future. . . Subjugated knowledges always threaten to disrupt the power/knowledge nexus; they are something of a Freudian "return of the repressed" in terms of socio-cultural rather than individual histories," (2).
She refers this to the "overturning moment" in postmodernity as expressed by historian Michel de Certeau, in which the general, or popular knowledge of the "ordinary" man situates itself within and outside institutional, specialized, and authoritative knowledges. She also writes that Arthur W. Frank says, in his book The Wounded Storyteller, that the "proliferation of illness narratives from the patient's perspective is a necessary counternarrative to the narratives of doctors and other medical professionals. . . he [Frank] identifies the figure of the "wounded storyteller" as having emerged in postmodern times, because in postmodernity, "the capacity for telling one's own story is reclaimed" (7)," (2). Continuing with Frank, Diedrich writes how he explains that the modern experience of the patient is much different from the postmodern experience of the patient. The modern patient, Frank tells us, assumed the "sick role" characterized by absolute passivity and surrender to medical practices and technologies. The modern focus on acute illness meant that patients generally recovered or died. The postmodern patient, in contrast, is characterized by chronic illness, someone who negotiates the space between health and illness. Frank calls this a "remission society." Here Diedrich writes, "In a "remission society" the boundaries between health and illness are permanently disrupted, thereby challenging the dichotomous formulation of health as the norm and illness as that which deviates from the norm," (3). She writes that Frank argues that contrary to the postmodern proliferation of the illness narrative signaling an evacuation of ethics and a move towards a relativization of the experience of illness, it rather signals a "radical democratization of medicine."
Diedrich moves to an explanation of the mechanisms of the anatomo-clinical method and its relation to biopower through a discussion of the terms Foucault opens his book The Birth of the Clinic with: space, language, and death. Foucault's description of space is both an internal and external space: the space of the body as internal, and that of the clinic which is external. These spaces form the venue for the unequal meeting of doctor and patient, in which the "pathological fact" is located in the patient by the doctor, thus individualizing the patient as a body only, rather than as a subject of the experience of their illness. Foucault's second term, language, is explained through the way the doctor moves from examination to interrogation, and "makes the body speak," as it were, its pathology. Here, though the patient may speak of their illness, it is not their voice that matters, for nothing but the doctor and, supposedly, the body, speaks in the true, initiates-only language of modern medicine. Thus, the doctor resembles a "speaking eye" that interprets the objects of the patient's body and words into a pathological fact. Foucault's third term, death, becomes clear from the point that what matters is not the words of the patient but the doctor's interpretation of the patient's abstracted body. However, the uncertainty of the pathological fact present in a living patient can only truly dissipate upon the patient's death, at which point the corpse could be made to tell all of the body's internal workings. Foucault marks these medical developments within a larger philosophical development, in which the individual could now "be both subject and object of his own knowledge" (197)," (6).
Diedrich then moves to the next subheading in the chapter: Tuberculosis as Experience and Event. Here she summons the work of Anne Hunsaker Hawkins, who coins the term "pathography" to describe illness narratives. Hawkins defines the term "pathography" as, "our modern detective story," where we are transported out of the everyday, familiar world of health into the unknown, uncharted world of illness (1)," (6). She says that Hawkins draws a parallel between illness narratives and older narratives of religious conversion, ". . . what she identifies as the "myth of rebirth;" that is, that the experiences of religious conversion and of illness afford "a process of transformation so profound as to constitute a kind of death of the 'old self' and rebirth to a new and very different self" (33)," (7). Diedrich wants to illustrate how tuberculosis is both an experience of those afflicted with it and in what ways it is an illness event that differs dramatically based on the context in which it takes place. She also situates the telling of both women's stories as two separate events. Whereas MacDonald's story was published shortly after her discharge from the sanatorium, Swan's story was published much later, and she did not write it, but told it to St. Pierre, who therefore had a definitive and ultimate role in how the story was told. "Tuberculosis as experience and event comes into being through the various spaces, objects, and people associated with its diagnosis and treatments," (11).
Diedrich draws out the parallels between Foucault's anatomo-clinical method and the experience of MacDonald at The Pines. While The Pines itself is quietly sequestered from the general population, the clinic in which MacDonald is first diagnosed with TB is part of the same complex of buildings that houses a jail, police station, emergency hospital, and venereal clinic, ". . . the link between criminality and disease is designed into the architecture of the building itself," (10-11), showing the spacialization of criminality and disease in this illness event. At the Pines itself the doctors are illusive at best, engaging in little if any direct dialogue with MacDonald about her treatment and progress. Indeed her discharge from the sanatorium was unexpected - her doctors did not update her on her progress. The privileged position of being a patient at The Pines required adherence to a strict "new regime of living" that required absolute, rest, absolute inert docility of the patient, which MacDonald notes extended well beyond the time one actually spent at the sanatorium. This "technology of the self" required first and foremost a disciplining of the mind before that of the body. Diedrich writes, "The ability to monitor oneself effectively indicates one's desire fore health and, and one's desire for health indicates one's fitness for citizenship in a normalizing society," (13). Here we see not only the external space of the clinic in connection with deviance, but also the internal space of body, disciplined into an almost death-like posture, enabling the professionalized eye of the doctor to speak of the immobilized body, and thus also to make the body speak through compliance to a "regime of living." Diedrich also cites MacDonald's acknowledgement of the inevitable failure of TB patients to completely adhere to the tuberculosis routine as a possible proto-ethics of failure. MacDonald's experience is certainly illustrative of the disciplining of bodies described in Foucault's biopower.
Madonna Swan's experience and illness even, in her initial diagnosis and the time she spent in the Souix San, in contrast to MacDonald's experience and illness event, was characterized by the widespread death of other Lakota in a place to which they were sent to die. MacDonald describes this as being parallel to Foucault's assertion that the nineteenth century saw a shift from the "right of sovereignty to "take life or let live" to a new state right to "make live and let die" (241)," (17), though I would contend that "take life" is probably still appropriate in this instance. She describes TB as being a disease "endemic," in the Foucaultian sense, to indigenous populations, as death which, rather than being an event, becomes part of the backdrop of everyday life - it gnaws and saps at the general community. The eugenic intent of this massing of TB positive indigenous people together in a virtual hospice is the regularization of populations of Foucault's biopower. While Swan does survive her stay at Souix Sans, it is only when she is accepted into a white sanatorium that she begins to recover.
COMMENTS AND QUESTIONS. . . .
-Diedrich wants to challenge the binary between health/illness. How does she accomplish this/fall short? What nuances of this binary does she draw out here?
-Diedrich cites the tuberculosis routine describes by MacDonald as an ethical technology of the self. What might she mean here? Can we connect this to Foucault's virtue ethics?
-How does ethics and ethical practices of self making encompass both life and death in these case studies?