Bookreviews

01 Mar 2012

Boudewijn Chabot & Stella Braam, Uitweg: Een waardig levenseinde in eigen hand [way out: A dignified end of life in one’s own hands].

Amsterdam: Nijgh & van Ditmar, 5th edition, 2012. 304 pp. € 25.95. ISBN 978 90 338 9496 6.

Several Dutch ‘right to die’ groups advocate changes in Dutch euthanasia law or look for alternative solutions for those who want to end their lives in a humane and dignified way. Uitweg – translated into English as ‘way out’ – presents a strong practical statement in this on-going debate. written by Boudewijn Chabot and Stella Braam, it is a detailed guidebook for those who want to end their lives.

The Netherlands is one of the few countries in the world in which it is possible for doctors to legally grant a voluntary and well-considered euthanasia request of a patient who suffers unbearably and without prospect of improvement. Although euthanasia remains a criminal offense, performing euthanasia is allowed for doctors who follow the six requirements of due-care laid out in the Dutch Euthanasia Act. The law was enacted in 2002, after nearly forty years of national debate wherein the right to die was one of the pivotal and controversial issues. However, the Euthanasia Act did not grant the right to euthanasia for everyone with a wish to die. Since doctors are never obliged to grant a euthanasia request, patients are dependent of the willingness of a doctor to cooperate. This is a key reason why the Euthanasia Act did not end the Dutch right to die debate. Several organised groups in the Netherlands (NVVE, Stichting De Einder, uit Vrije wil) oppose the fact that euthanasia remains hardly available to, for example, psychiatric patients or people suffering from the early stages of Alzheimer disease. They also disagree that the law does not permit euthanasia to older people who regard their lives as ‘completed’.

Trained as a psychiatrist, Boudewijn Chabot has been involved in the euthanasia debate for years. In the 1990s he was prosecuted for performing euthanasia on a woman whose suffering was not related to a somatic disease. The Dutch Supreme court ruled in this case that non-somatic psychological suffering may also constitute unbearable suffering, the main legal criterion for euthanasia. In 2007 Chabot obtained his PhD in sociology, with a dissertation on a practice that thus far was barely examined in the Netherlands. using qualitative and quantitative methods, chabot studied why, how and how often people in the Netherlands try to end their lives in a humane and dignified way without the help of a medical doctor. Uitweg can be seen as an extension of his dissertation, except that chabot and co-author and journalist Stella Braam shake off the perspective of the ‘neutral observer’ who tries to unravel and understand a practice. Uitweg is not a sociological study, but a detailed instructionguide for people who want to end their lives “in a humane and dignified way,” as the authors put it. It is, as Chabot himself ambitiously calls it, a “guidebook for a new generation.”

The authors wanted to write a book showing people with a well-considered wish to die an alternative to, on the one hand, impulsive and possibly mutilating suicide methods, and on the other hand, euthanasia with the help of a medical doctor. The first edition of the guidebook (published in 2010) described two methods for what the authors coin ‘self-euthanasia’ – collecting lethal drugs obtainable through internet pharmacies, and stopping with eating and drinking under palliative care. The fifth revised version of the book (published in 2012), added a third method: the helium method. The method describes how legally accessible helium gas can be used to die quickly and painlessly in your own bed. The method is complemented by a dvd, which can be ordered on the internet (http://www.heliumthuissterven.nl/english-dvd/dyingat-home-with-helium). Besides detailed technical instructions, the book also provides important (Dutch) juridical do’s and don’ts for friends, family members and others escorting a person’s final steps. The book and its instructions remain within the limits set by Dutch criminal law. The instructional chapters are combined with detailed narratives of people who went through one of the described methods.

The authors address the book to those who want to die as well as to family members and professional health-care workers confronted with someone with a continuous and well-considered death wish. Yet it is also interesting from sociological perspective. The guidebook received a lot of media attention in the Netherlands and raised new discussion and controversy. It is easily available in Dutch bookstores as well as on the internet, and as such has the potential to influence the way people die in the Netherlands. So for sociologists interested in the on-going Dutch debate concerning end of life issues as well as in the Dutch culture of death and dying, it is a book that should not be missed. There is, however, one big obstacle to wider circulation: it is only available in Dutch.

Donald van Tol

Lecturer, Dept. of Medical Ethics, university of Groningen Medical centre

Janice Graham & Peter Stephenson (eds.), Contesting aging and loss.

Toronto: University of Toronto Press, 2011. 209 pp. € 31.99. ISBN 978 1 44260 100 0.

‘Contesting Aging and Loss’ by Graham and Stephenson brings a fresh perspective to the question of ageing. Rather than seeing ageing as a period of decline, isolation and despair, the editors approach loss from the social determinants of healthy ageing, thereby questioning the automatic connection between ageing and the paradigm of loss. The volume has an activist aim: to give voice to the many ways loss is contested in the various social worlds in which older people age, and to open up debate around the way ageing is routinely framed in public discourse and policy.

The introductory chapter by Graham and Stephenson sets the stage, connecting the various contributions to the concept of loss. Stephenson’s chapter in the first part, ‘Paradigms and perspectives’, provides the theoretical framing: he argues that the connection between ageing and loss can be traced to a linear conceptualization of time, which produces a notion of ‘novelty-seeking’ as the essence of living. This structures what is considered ‘normal’ in ageing and what is seen as loss.

The second part, ‘Local understanding and knowledge about aging – how seniors see it’, argues that it is the adjustments that older people make to changes in their lives that define their experiences of ageing. The three chapters that constitute this part describe ageing from the perspective of everyday life in a variety of settings. Von Faber and Van der Geest provide a well-elaborated and subtle critique on the way successful ageing is measured in terms of autonomy and health. Participants in their study, who were over 85, define successful ageing as ‘making adjustments in good spirits’. This notion of adapting to the ups and downs of life is mirrored in chapter four. Exploring ageing and well-being among Italian canadians, Migliore and Dorazio-Migliore argue that conflating loss with old age overlooks the fact that loss can occur at any moment in life, and appeal for a more individual view of ageing that looks at the variety of meanings that individuals attribute to good or bad old age. The chapter by Oakley feels somewhat out of place as it describes how older people in a vastly different setting, rural South Africa, manage to overcome loss associated with new knowledge and a new economy, but fits in the sense that it is also about contesting the assumption that ageing only is about marginalization and loss.

In the third section, experiences of illness, indignity and stigmatization are situated in the more structural disadvantages that come with declining socioeconomic means and status. Drawing on a case study in Sydney, Australia, Russell highlights a group often ignored in policy and research – older marginalized men – and shows how discussions of ageing should take into account the local histories of work and politics that disadvantage certain groups. Holmes and Stephenson take us into the hospital and show how older people often find it difficult to discuss the structural problems that complicate their health. The chapter offers a compelling argument for taking power relations seriously.

The fourth section, ‘Embodiment and disembodiment’, discusses an extreme form of ageing-related loss: the assumed loss of personhood that accompanies cognitive decline. kontos’ touching chapter on embodied selfhood in a care facility for people with Alzheimer’s disease brings to life persons who are often considered to have ‘departed’ already. She shows how the self is enacted in gestures, expressions of class and skills and makes a powerful plea for what she calls “humanizing dementia.” Graham echoes kontos’ plea by voicing a strong, almost angry, statement against the way pharmaceutical companies frame drug efficacy, thereby ignoring the important role of care networks and social life. The volume concludes with a section entitled ‘Policies and practice’ that is comprised of a chapter by Graham. Graham argues that ageing should be framed in terms of social networks, broader definitions of personhood and self, and the many ways in which older people adapt to change.

All but one of the articles are based on research in developed countries – The Netherlands, Australia and canada – where institutional care, medical technologies and social security schemes interplay with experiences of ageing. It would have been interesting to also explore the adaptive capacities of older people in settings where these social institutions are absent, or where, as a result of societal trauma, older people’s frame of reference has been dramatically altered. Overall, however, this volume is an important contribution to the field of ageing studies. It is especially important for students of geriatrics and gerontology, staff working in care institutions and policy makers, as it contains vivid examples and clear directions as to how care for older people can be improved. In that sense, the book fully accomplishes its aim.

Josien de Klerk post-doctoral researcher, University of Amsterdam

Kristien Hemmerechts, Haar bloed [Her blood].

Breda: De Geus, 2012. 253 pp. € 18.95. ISBN 978 90 445 1828 3.

For three years the hospital of the Free University of Amsterdam has been inviting literary writers to spend some months on one of its wards to gather inspiration for a book. The idea behind this initiative is the expectation that these writers will be able to transform their observations and experiences into a true-to-life description of what happens in a hospital and present this to a wide public. One could call it literary hospital ethnography.

The Belgian novelist Kristien Hemmerechts was the third invited writer; she spent one month on the Haematology ward. Haar bloed is the result of her observations. Her novel has, however, little to do with life in the hospital. It appears that she has used her stay with the haematologists mainly to learn the medical language of blood and blood diseases. She uses this professional language in a tale about friendship, love and kinship (in Dutch bloedverwantschap, consanguinity). The somewhat clichéd metaphors of blood are lavishly employed throughout the story of a medical student, Titus, who is fascinated by blood, and his friend and enemy Pieter. Their common girlfriend Roos is diagnosed with leukaemia and undergoes a series of complicated operations, which keep her alive though seriously disabled.

I doubt that Haar bloed is what the hospital had expected from the author. The reader learns little about doctors, nurses or patients on the Haematology ward. Furthermore, the hospital’s experiment with literary writers seems to have come to an end for a quite different reason, however. The fourth ‘writer in residence’ only spent three weeks in the hospital. Then public outcry over a TV documentary series that showed patients at the hospital without due respect for their privacy led to an immediate stop to both the filming of and the writing about hospital life. One wonders if from now on anthropologists will also be banned from the hospital’s wards.

Sjaak van der Geest

Medical anthropologist, University of Amsterdam

Maya Unnithan-Kumar & Soraya Tremayne (eds.), Fatness and the maternal body: Women’s experiences of corporeality and the shaping of social policy.

Oxford: Berghahn, 231 pp. £45. ISBN 978-0-85745-122-4.

Fatness and the Maternal Body is a timely addition to the growing canon of obesity scholarship within anthropology. The volume, which emerged from a workshop held by the university of Oxford Fertility and Reproduction Studies Group, aims to show the complexity that surrounds various understandings of body weight, with a particular focus on how different cultural perspectives on fatness intersect with the gendered expectations of reproduction and motherhood. Unnithan-Kumar and Tremayne have brought together original research from seven areas – the UK, Ireland, North Africa, Tanzania, Ghana, Australia, and India – that illustrates “the everyday context in which fat maternal bodies are made meaningful” (p. 18). While any anthropological examination of body weight is likely to incorporate the themes of sex/gender and kinship, tackling these issues head-on makes this collection especially valuable.

The volume takes the cultural construction of obesity as a starting point, but the chapters also center upon ‘biological’ matters of nutrition, including epigenetics, intra-uterine development, body weight and fecundity, and worldwide epidemiological transitions. This interest in the body’s biological materiality allows several of the contributing authors to demonstrate how depictions of biology/physiology interconnect with those of reproduction (in both cultural and maternal forms). By juxtaposing “subjective accounts of fatness” with the “objectification of fatness” in health policy literature, the fat maternal flesh that is the volume’s focus is shown to be at once biological and constructed (p. 3). Moreover, as several of the chapters make clear, the bodies under consideration are “doubly grounded in biology,” being both biologically reproductive and biologically fat (p. 5).

The editors make an important intervention at the outset by separating obesity from fatness – the former referring to the biomedical label for having too much weight, and the latter entailing cultural interpretations of body size, which are not necessarily negative. Doing so allows them to take seriously concerns of health and fitness, without assuming that fatness is necessarily unhealthy or undesirable. This, in turn, introduces nuance to the staid public health oriented discussions of obesity, creating space for the existence of complex situations in which girth is both desirable and metabolic illness feared. It also helps illuminate situations in which not all fat is the same: there are good fats and healthy fats alongside fats that are unwanted or seen as dangerous.

The various chapters cohere around four themes: 1) Culturally framed notions of nature – a theme that extends a feminist insistence that ‘nature’ is a cultural category by showing how views of body fat are contingent rather than universal; 2) Gender and sexual inequalities, a theme in which fatness exists alongside gender, race and class as a means through which subjectivities are produced; 3) Maternal fatness – a theme that shows how understandings of food and nutrition connect to reproductive health, in addition to bodily health more generally; and 4) Global notions of risk and modernity – a theme that illustrates how the expansion of a biomedical view of body weight results in bodies that must be disciplined and controlled. by surveying diverse geographic and cultural regions, and by drawing on an array of different social science methods, the book does not advance a single argument about the meanings of the fat, fertile, female form. Instead, whether examining how fatness becomes desirable for breastfeeding mothers in malnourished regions of Tanzania, or exploring the relationship between maternal and childhood obesity in the uk, the overarching message of the book is that no single social policy can address “the problem” of maternal obesity. Indeed, ‘the problem’ is variegated and multiple, appearing as different problems in the different sites where it comes into focus.

If there is a shortcoming in the text it lies in the discontinuities found across some of the chapters. For example, while warin et al. avoid presuming that they know what ‘obesity’ or ‘fatness’ mean, instead drawing their ideas about these terms from the Austrian women they interviewed, Guntupalli’s study of the nutrition transition in India begins with the premise that “overweight and obesity are prevalent, not only in developed but also in developing countries” (p. 188). And whereas walentowitz draws out the complexity of the fattening and feeding process for Taureg women, thereby illuminating the difficulty of making broad moral assessments about body weight, many of the chapters open with warnings about the spread of obesity and present the condition as clearly negative and with dire consequences for population health. There are benefits to incorporating a variety of methods in a study of maternal fatness, but this also, at times, weakens the coherence of the text as a whole. And while several of the chapters independently address ‘the shaping of social policy’, a concluding chapter that pulls together the themes of policy and the diverse ‘experiences of corporality’ outlined in the book would have been helpful.

Still, this book is an impressive collection of different perspectives on, and stories about, obesity and fatness. Given the growing prevalence of discussions about the ill-effects of too much weight in diverse regions throughout the world, research that destabilizes the taken-for-granted narratives that emerge in public health and policy circles is increasingly necessary. That Unnithan-Kumar and Tremayne do this while also providing a cogent analysis of how these narratives interplay with the female reproductive form makes this a valuable contribution to the field of obesity science.

Emily Yates-Doerr

Post-doctoral fellow, University of Amsterdam

Ton van der Lee, Kinderen van Afrika: Het succes van particuliere hulpprojecten.

Amsterdam: Uitgeverij Balans, 2011. 245 pp. € 17.95. ISBN 978 94 600 3346 9.

‘Kinderen van Afrika: Het succes van particuliere hulpprojecten’ (Children of Africa: The success of private initiatives in development aid) is a publication written by someone who lost his heart to the red dust and friendly people of the continent. His somewhat romantic picture of the communal spirit of village life contrasts with life in ‘the west’ where people do not even know their neighbours. However, it is also an enjoyable read and an informative and practical handbook that can guide anyone who wants to set up his own development project.

Author Ton van der Lee lived in different African countries for twelve years and published and produced several books and documentaries about his experiences on the continent. In this particular book he describes his journey in setting up a unique development project (Stichting Sanouna) in a small village on the edge of the river bani in Mali. Grounding the book within the western political climate where less and less money is made available for international development and the public has become increasingly critical of the effects of aid for developing countries, the author writes honestly about personal motivations and moments of discouragement, challenges, successes and achievements in setting up and running an aid project.

Through the stories of his encounters with the villagers of Sanouna, the author takes the reader into the sometimes beautiful and at other times harsh and challenging realities of their world. These personalized accounts provide the reader with plenty of useful practical information on numerous aspects of project management (particularly for Dutch development practitioners). The author offers tips for and discusses pitfalls involving topics such as fund raising, establishing development trusts, proposal writing, important development approaches (empowerment, capacity building and ownership), website building, and recruitment of volunteers. Van der Lee encourages ‘project managers’ to understand the local cultural, economic and political context before starting a development project. A project that does not take into account what people themselves want and need is doomed to fail. According to Van der Lee, local ownership, a ‘food for work’ approach to avoid dependency on aid, sustainability, partnerships with local organizations and existing community structures, and proper monitoring and evaluation should form the key ingredients. Written in a style between ethnography and a non-fiction novel, the author reflects on his position as a relatively rich, white Westerner while introducing the reader to the people of Sanouna. we meet the friendly and conservative Abba, the village head, and the young and modern ‘Michael Jackson,’ an excellent dancer who is fascinated by western culture, fast motorbikes and the girls in the village. There is Oumou, the village beauty who refuses to become the second wife of a man who does not treat her well, and who is frowned upon by other women because she runs away from this undesirable future. We get to know the strong, active women of the village who prepare daily healthy meals for their malnourished children with Stichting Sanouna’s money. The children who receive food in turn attend English classes in the school built by the project. we meet Salifu and his wife Fatou, who want to have a baby and seek assistance from both a marabout (spiritual leader/healer) and a biomedical doctor. By writing about his observations of and experiences with the people of Sanouna, Van der Lee shows how issues such as gender inequality, uneven distribution of wealth and power, poverty, corruption, the capitalist international market economy, perceptions of the west, and traditional and spiritual healing are felt and experienced in their daily lives.

Throughout the book Van der Lee passionately argues that the future of development aid lies in small-scale projects initiated by individuals and not in large-scale, generalized development aid. Although introducing this overarching theme through personalized stories is an effective way of engaging the reader and of presenting challenges for people in this African country, the author does not connect these localized stories with international development dynamics or theories of development. For readers who expect to be challenged to think critically about the usefulness and effectiveness of development aid in general, the book might therefore be somewhat disappointing.

In conclusion, Van der Lee’s book is an engaging, vivid and beautifully written story of life in a community in rural Mali. Although the author at times romanticizes this reality by using simplified descriptions of people’s challenges, values and lifestyles, the book’s objective of providing a practical handbook for people who want to set up a development project is surely met.

Anna Lisa Albers

Medical anthropologist, Botswana

Arko Oderwald, Koos Neuvel & Willem van Tilburg (red.), Ontspoorde cellen. Kanker in fictie.

Utrecht: De Tijdstroom, 2011. 374 pp. € 25.00. ISBN 978 90 5898 199 8.

Hoe een boek met teksten over kanker te recenseren in een wetenschappelijk tijdschrift dat het sociale domein van ziekte en gezondheidszorg tot haar domein rekent? Het lijkt op het eerste gezicht een boek met vooral literaire impressies. wat kan een sociaal-wetenschappelijke onderzoeker ermee? Ik denk het boek te bezien op de mogelijkheid er vraagstellingen voor wetenschappelijk onderzoek aan te ontlenen. Het boek bevat gecompliceerde verhalen, gelardeerd met beschouwingen, vaak alsof de schrijvers nabij waren, alsof ze nabij konden zijn.

Al lezende drong zich steeds meer de indruk op dat kanker en dood zo verwarrend en bedreigend zijn dat omstanders en nabestaanden en verslaggevers daarvan bijna niet anders kunnen dan aankleden wat ze (hebben ge)zien, het ruwe ervan vertalen, er filosofische beschouwingen op los laten, kanker en dood vergelijken met politieke ontwikkelingen, of er poëtische gedachten aan verbinden, en – iets dat opvallend vaak gebeurt in het boek – kanker en dood romantiseren met behulp van (hogere) literatuur.

Soms kleden de schrijvers kanker en sterven aan als iets dat zich als grauw voordoet, als het grijze gevoel van uitzichtloosheid zich opdringt en mensen parachuteert in een wereld van onwetendheid en schemer, van alleen met zichzelf zijn en soms ook van allenige beslissingen die hopelijk tot de dood leiden. Sommigen spreken van een ‘ondefinieerbare situatie’, van ‘afbraak van menszijn’, van een ‘op tilt geslagen brein’ als het bericht komt, van ‘bitter intiem’, van ‘verraden en verwoest’, van een ‘familie die meesterft’ en iemand schrijft – in navolging van Susan Sontag – over een ‘obscene ziekte, noodlottig, afzichtelijk en weerzinwekkend’, een ziekte die ‘trauma en drama’ brengt, en nog weer anderen karakteriseren kanker als ‘snel en sluw’ en als een ‘messcherpe, gekartelde en verwoestende indringer’, als een ‘verrader’, als een ‘duivelse persiflage op het menselijk leven’ en zelfs als ‘blinde machtsovername’.

Anderen echter verbinden er poëtische gedachten en filosofische beschouwingen aan. De bittere realiteit van kanker en dood lijkt zo dragelijk te worden gemaakt, plaatsbaar, onthoudbaar, niet te vreemd, niet te rauw en niet te angstaanjagend, om de harde realiteit uit het bewustzijn te bannen. zulke schrijvers produceren teksten vanuit een romantiserend vertoog. Dat heeft veel ‘Anklang’ bij degenen die zich schriftelijk over hun doodservaringen (van anderen) uitlaten. Dat is op zich niet zo verwonderlijk. wie de overlijdensadvertenties naspeurt en begrafenissen en crematies bijwoont, wordt ook daar vaak geconfronteerd met poëzie en verhalende literatuur en met muziek die sterk contrasteert met de alledaagse muziek van radio en TV. Het kermen, het bloed, het krijsen en de radeloze blik komen in het boek niet voor. Er verschijnen eerder geromantiseerde verslagen van kanker en dood. De lezer stoot dan op een titel als ‘De dramatische kracht van kanker’. Die kracht blijkt niet in de kanker te schuilen, maar in de auteurs die de term gebruiken. Een ander schrijft: ‘Hoop’ is zo ongeveer de eerste ideologie die we op kanker loslaten. Iets verderop lezen we een essay met als titel ‘Toekomst na het doodvonnis’. zoiets definitiefs als de dood onder ogen zien gaat blijkbaar moeilijk af. Er moet ideologisch een toekomst aan verbonden worden. Soms steekt wel iets van verzet de kop op tegen deze ideologisering. Er is sprake van ‘worstelen’ met het einde en in het essay over Sagan is sprake van het ‘noodzakelijke lot’, maar onmiddellijk daarop volgen alweer teksten over ‘op weg naar het einde, maar wel met goede muziek’ en van de ‘verzoening met het onverzoenlijke’ en ‘kanker als een goede dood’. En iemand die twee boeken over kanker bespreekt, concludeert dat beide “niet zozeer over kanker gaan, maar over wat het leven waardevol maakt.” In een andere tekst is zelfs sprake van ‘metaforen die helpen’ en de therapeutische kracht van een poëzieproject. Iemand anders merkt op dat het stervensproces met zo’n begeleiding ‘verbazingwekkend soepel’ verloopt: doodsangst is “goed te bestrijden met gesprekken en medicatie.” “Het aansturen op actieve copingmechanismen geeft de patiënt zo veel mogelijk controle over zijn doodsangst,” concludeert weer een ander. Dan volgt een tekst waarin ‘woede’ wordt aangeraden in plaats van ‘wanhoop’. Achterblijven wordt tot een ‘goedaardige kunst’. En zelfs als in een tekst het ‘noodlot’ wordt onderkend, wijst de auteur ons nog op de mogelijkheid van ‘vlucht’ en verschaft ons een survival-gids: ‘alles om te overleven’. Deze teksten laten ons zien hoe deze mensen ziekte en dood aankleden en tot draagbare fenomenen maken die zich zonder veel trammelant in ons geheugen kunnen vestigen. zo maken zij familiehistories, of reisbeschrijvingen en fotoboeken waar men later nog met enig genoegen in kan bladeren. Wie deze constateringen interessant vindt, kan het boek gebruiken als een dataverzameling voor een eerste verkenning hoe kanker en sterven figureren in onze menselijke levens en hoe ideologieën kanker en sterven maken tot wat zij sociaal zijn. Dat lijkt mij de waarde van het boek voor sociale wetenschappers te zijn: de ideologisering van kanker en de dood in verschillende vertakkingen te laten zien. Het kan onderzoekers tot ideologieonderzoek van ziekte en dood aanzetten.

Gerhard Nijhof

Emeritus hoogleraar Medische Sociologie, Universiteit van Amsterdam

Pharos, Migratie en gezondheid – Feiten en cijfers – 2011.

Utrecht: Stichting Pharos, 2011. 94 pp. € 15. 00. ISBN 978-90-75955-74-3.

In deze publicatie van de Stichting Pharos bieden verschillende auteurs een overzicht van de actuele stand van zaken betreffende de overeenkomsten en verschillen in gezondheid, zorggebruik en kwaliteit van de zorg tussen migranten en niet-migranten in Nederland. Onder ‘migranten’ wordt in dit boek ook asielzoekers, vluchtelingen en ongedocumenteerden verstaan. De aandacht is in deze publicatie gegaan naar drie sectoren in de gezondheidszorg: de publieke gezondheidszorg, de gezondheid van migrantenjeugd en de eerstelijnszorg. Het is de eerste uitgave in een reeks die Pharos in de komende jaren wil publiceren. In de volgende uitgaven komen andere sectoren van de gezondheidszorg aan de orde. wat bij het lezen van de publicatie vooral opvalt, is dat de verschillen in gezondheidssituatie tussen – vooral tweede generatie – migranten en niet-migranten kleiner worden. Soms is dat gunstig, maar soms ook niet. Uit het hoofdstuk publieke gezondheidszorg, geschreven door Hosper, blijkt bijvoorbeeld dat Turkse vrouwen van de tweede generatie vaker roken dan de eerste generatie Turkse vrouwen. Bij Turkse mannen is dat andersom. Verder komt er veel meer obesitas voor bij migrantenvrouwen dan bij vrouwen van Nederlandse afkomst, maar bij de tweede generatie vrouwen is dat verschil al veel kleiner. Deze convergentie wordt deels verklaard door het hogere opleidingsniveau van de tweede generatie, maar deels ook door het hebben van een ander schoonheidsideaal en ander beweeggedrag. Turkse vrouwen die in Nederland zijn geboren bewegen bijna net zoveel als vrouwen van Nederlandse afkomst. De voedingsgewoonten van eerste generatie migranten zijn over het algemeen gezonder dan die van oorspronkelijke Nederlanders, maar tweede generatie migranten blijkt het Nederlands eetpatroon, van snacks, frisdrank en fastfood, over te nemen. Vooral schaamte en onbekendheid met preventief onderzoek zouden de redenen zijn dat eerste generatie Turkse en Marokkaanse vrouwen relatief weinig deelnemen aan bevolkingsonderzoeken. De incidentie van kanker ligt bij migrantenvrouwen overigens lager dan bij vrouwen van Nederlandse afkomst. De cijfers over deelname aan bevolkingsonderzoeken én sterfte aan kanker convergeren met elke volgende generatie echter ook.

In het hoofdstuk over migrantenjeugd, geschreven door Van wieringen en Tuk, vallen vooral de verschillen in perinatale en zuigelingensterfte op. bij de eerste generatie is de perinatale sterfte 40 % en bij de tweede generatie migranten 10 % hoger dan bij Westerse moeders. De zuigelingensterfte laat vergelijkbare verschillen zien. Opvallend is ook dat Antilliaanse en Arubaanse ouders veel vaker opvoeding-ondersteuning zoeken dan bijvoorbeeld Marokkaanse ouders. Ook maken jongeren van Turkse en Marokkaanse afkomst minder gebruik van de jeugd GGZ dan jongeren van Nederlandse afkomst, maar zijn zij oververtegenwoordigd in de forensische GGZ.

Het hoofdstuk over de eerstelijnszorg, geschreven door Hosper, Van den Muijsenbergh en Schoevers, besteedt vooral aandacht aan de toegankelijkheid en kwaliteit van de huisartsenzorg voor migranten. Migranten consulteren de huisarts vaker dan niet-migranten, maar het aanbod van de huisartsenzorg sluit veelal niet aan bij het perspectief van de migrant. Als redenen daarvoor worden onder meer communicatieproblemen, andere opvattingen over ziekte en gezondheid en lagere gezondheidsvaardigheden genoemd. Migrantenvrouwen maken minder gebruik van verloskundige zorg dan vrouwen van Nederlandse afkomst en er komt dan ook veel vaker moedersterfte onder hen voor. Ook maken migrantenvrouwen minder vaak gebruik van kraamzorg, door bijvoorbeeld de relatief hoge kosten en gebrek aan informatie over de wijze waarop dit is aan te vragen. Het is daarentegen positief dat migranten de tandarts vaker bezoeken dan oorspronkelijke Nederlanders, terwijl Turkse en Marokkaanse migranten minder vaak cariës hebben.

De gegevens over de verschillen en overeenkomsten tussen de verschillende groepen in Nederland maken duidelijk dat er veel gezondheidswinst te behalen is met gerichte gezondheid bevorderende activiteiten en preventieve maatregelen voor (groepen) migranten en niet-migranten. De publicatie zou om die reden vooral gelezen moeten worden door beleidsmakers in de zorg en zorgverzekeraars. Daar echter in elk hoofdstuk ook aanbevelingen worden gedaan over specifieke interventies en (na)scholingsmogelijkheden is de publicatie voor een ieder die betrokken is bij de publieke en eerstelijnszorg lezenswaardig. Het is een compact boekje met heldere grafieken en mooie illustraties.

Loes van Willigen

Consultant Gezondheidszorg en Mensenrechten

C. Jason Throop, Suffering and sentiment: Exploring the vicissitudes of pain and experience in Yap.

Berkeley: University of California Press, 2010. 353 pp. US$ 24.95 (paperback). ISBN 978-0-520-26057-3.

Throop’s ‘Suffering and Sentiment’, located on the Micronesian island Yap, is without doubt a masterpiece of ethnographic sensitivity and depth. The author sets out to achieve mainly two things. In his own words: “… to provide an ethnographic description of pain’s significance in the context of local understanding of subjectivity, social action, and morality… and to address a number of long-standing debates in both philosophy and anthropology over the concepts of ‘experience’” (p. 2). My conclusion after reading his book is that the greatest achievement of his study may be not so much the completion of these two objectives but his observations and comments on the way to these objectives: his careful analyses of local morality, personhood and sociality. But let us first briefly summarize the overall study.

Throop starts with a theoretical introduction presenting the various debates about ‘experience’ and ‘pain’ in anthropology, philosophy and psychology, which advocate a phenomenological approach. For those who long for the every-day concreteness of anthropological description this may be a somewhat daunting beginning. They are immersed in discussions that may only truly make sense after they have completed the book. But for the growing number of colleagues who favour a high level of theorization in anthropology, this ‘daunting’ introduction may rather have a welcoming effect.

I will return to the thrust of this introduction when I reach the book’s conclusion.

The first chapter deals with the pre-colonial, colonial and recent history of Yap, an island in the Pacific Ocean, north of Papua New Guinea. The second introduces the reader to the main topic of the study: pain and suffering in the context of the ethnographic research. Throop, with his strong focus on language, presents a number of key concepts that stand for models of moral thought and action in Yap society (among others: ‘suffering’, ‘exhaustion’, ‘endurance’, and ‘compassion’). Chapter three opens up the author’s lucid perspective on the moral dimension of nearly everything in Yap society, including land, work, food, relatedness, house building, ritual, hierarchy, respect, hunger, and suffering. The chapter also contains a refreshing examination of idioms of purity and order. chapter four discusses local understandings of subjectivity in the configuration of body, mind and emotion. Throop argues that ‘reflective mental life’ is valued over ‘impulsive somatic life’, which leads to the cultivation of self-mastery as a core value.

This mind-over-body value is beautifully illustrated in chapter five on ‘Privacy, secrecy and agency’. Throop describes how mature and civilized living is characterized by self-restraint, which shows itself particularly well in how people communicate knowledge and information. The capacity to keep information concealed proves someone’s virtue. That control extends to the non-expression of emotion, personal interest, desire and passion. I found this the most exciting part of the study; Throop describes seven strategies to resist total openness and uphold ambiguity, superb observations of how opacity of knowledge is practised and how this contributes to moral status.

The art of self-restraint leads to the four final chapters that deal with the experience and management of pain and suffering. Chapter six is an exposé of local philosophy and ethics theory about suffering, which can be either destructive and meaningless or meaningful and socially constructive. Throop speaks of ‘mere-suffering’ and ‘suffering-for’. Suffering, he writes, “… may thus present an opportunity for sufferers to highlight their abilities of self-governance. … an occasion to demonstrate to others their strength of mind and their ability to discipline their bodies” (p. 192).

Chapter seven contains eight narratives of people who reflect on the pain they suffer(ed) in their lives. The purpose is “… to demonstrate the extent to which a temporal orientation to past experiences of pain often provides a means for suffering to be configured in terms of more coherent varieties of experience” (p. 196). Most of the narrators “… cast their experiences of pain within moral frameworks that are shaped according to a constellation of virtues associated with hard work, effort, and endurance” (p. 195). Throop thus demonstrates how temporality moves suffering from disjunctive to conjunctive or, to use calvin Schrag’s terminology, from ‘granular’ to ‘coherent’. Chapter eight is entirely devoted to one case of a young girl with a complicated fracture who undergoes several painful healing sessions at a local bonesetter’s.

In her case, too, the move from disjunction to conjunction is explicated.

In the conclusion, Throop lifts his ethnographic observations to the level of phenomenology and ethics. Building upon work of Husserl, Lévinas, Csordas, Leder, Kirmayer and others he argues for an understanding of morality and experience that goes beyond “… the often simplistic and partial renderings of human existence traditionally offered in the context of granular and coherence theories of experience” (p. 16). What can we conclude about his ambition to push forward the cultural understanding of morality and the experience of pain and suffering by bringing Lévinas to Yap and uncovering the moral potential of suffering in Yapese daily life?

As I mentioned before, I am not sure that the main achievement of this study lies in the fulfilment of the two objectives quoted before. The experience of pain and suffering remains somewhat distant in spite of his experience-near research. The eight narratives that are presented and analysed speak about chronic pain, which has allowed these people the time to settle with its presence and make it part of their daily lives. The stories tell us mainly how they reworked their pain over the years (perhaps recounted with some degree of performance towards the ethnographer). They provide striking examples of the work of memory in the framing of suffering in the moral world of Yap culture, but the acuteness of the pain sensation itself remains elusive. The only direct observation of pain reported in the study is that of the young girl during several bonesetting treatments. Here again, the language produced around the pain experience is ‘distant’. The child is too young to articulate the experience; others (the father, the healer and the ethnographer) speak on her behalf. They ‘translate’ the pain into moral language and transform it into ‘suffering-for’. But this ‘suffering-for’ is a filtered leftover that has travelled from the moment of acute pain to the later reflection, or from the person in pain to the bystanders. Of course, the moral reworking of pain over time is inescapably tied to the experience of pain and suffering itself, but it is also a ‘departure’ of that pain. The rich moral and meaning-making language for suffering falls still at the moment of infliction.

Interestingly, the first page of the book pictures the opposite of what the entire book sets out to argue. Moral eloquence disappears in the face of suffering and pain; no words suffice. Throop describes how one evening he is conversing with a man about his pain: “The pain, he said, had been unbearable. It was like nothing he had ever felt before; he could not find words to describe it. It was a pain so intense, so insufferable, that it was all that he knew. He could not feel his body, only pain. It was, he said, a pain for which ‘it would have been good had I died’” (p. 1).

In conclusion, this ethnography is not so much about the ‘vicissitudes of experience and pain’ as the title promises but about the moral reworking of pain over time.

And it does so extremely well.

Sjaak van der Geest

Medical anthropology, University of Amsterdam