Too many misfits leading to inadequate care

“The common threads in my work are body and embodiment. I studied to become a physiotherapist first, and then I completed a degree in philosophy. I then decided to also include anthropology and cultural sciences in my studies into the body and embodiment. Over the last few years, I have mainly focused my attention on the meaning of embodiment in healthcare. Western healthcare focuses on the duality of body and mind. I hypothesize that this artificial separation is the reason for the prevalence of many health issues in our society, such as obesity, inexplicable symptoms, and depression, and the fact that these issues are inadequately tackled. In my new book 'Nieuwe Lichamelijkheid', which is the conclusion to my VICI research project (Mind the Body: Rethinking embodiment in healthcare) funded by the Dutch Research Council, I delve deeper into this one-sided approach in our healthcare system.”

The book starts with a drawing of a black fetus Slatman saw. “I suddenly realized that I had only seen white people in anatomical drawings until then, and I was shocked when I became aware of this. I wanted to know how this dominance had occurred. The individual is so important in the West, more than his or her relationship with the physical and social environment. I illustrate this using the history of healthcare; the emergence of individualization in healthcare began in anatomy in the early 19th century, so before neoliberalism. By starting to view anatomy as the basis for pathology, the expectation is that diseases are caused by certain sources of disease in the body. In the search for sources of disease, medicine has become increasingly refined over the last two centuries; from organ to tissue, from cell to DNA. This search is supported by various technological developments, including the invention of the stethoscope and the ability to sequence DNA. Due to the attention for this view of the individual body, the sick person is entirely cut off from everything outside of him or herself. Due to the emergence of statistics and the term ‘normal’, the 19th century gave rise to something called the ‘normal body’ in medicine. But this so-called normal body, that in modern medicine is simply termed ‘the body’ for convenience, refers to one specific form of embodiment: the body of a white male who is not old.”

There are still standard methods that do not work as well on everyone, and that is because many interventions are only tested on ‘the body’

Which consequences does this dominance of the individual have for the treatment of people?

“The scientific racism that was present in medicine and healthcare during the 19th and 20th centuries has diminished to an extent. But there are still standard methods that do not work as well on everyone, and that is because many interventions are only tested on ‘the body’. An example is the forehead thermometer, which does not accurately measure the temperature of people with a black skin color. Medicines are mainly tested on men, even mainly on male lab animals, because of the stability of their hormone levels. The consequences are enormous, resulting in medicines and treatments that do not work for some people.

In addition, healthcare also runs into diagnostic issues for people with vague symptoms, such as backpain and chronic fatigue, for which no clear cause can be found after examination. And what happens next is interesting; medical professionals then often blame psychological causes for these symptoms. That is when a body-mind duality occurs in practice: if we cannot find a source of disease in the body, then it has to be something psychological. The answer then often comes in the form of Cognitive Behavioral Therapy (CBT), individualizing people by reducing them to their cognitive abilities.This psychologization fits in seamlessly with the current neoliberal zeitgeist: if you have a problem that cannot be explained by a physical source of disease, then you must ensure that you turn your negative thoughts about your situation into more positive thoughts.”

What should be done differently?

“Instead of focusing on the individual existence of people, it is better to look at relationships. When people are less able to do something or have limitations, then something is wrong in that relationship. In disability studies this is known as a ‘misfit’. People who are overweight, for example, are often simply told by medical professionals that they need to lose weight. In the event of severe obesity, for example, this simple solution is no longer possible due to the changes in hormone levels. Of course I advocate the prevention of severe obesity, but in my book I demonstrate that people who are already severely overweight generally receive less care and attention, both by healthcare professionals and society as a whole. These people are not protected by any anti-discrimination laws. It is considered acceptable to just call someone a fatso. It is disgraceful what happens to these people in healthcare, because when they go to the doctor they are not taken seriously at all and are not given the right care. This care is inadequate because it is based on the assumption that only the individual obese body needs changing. But if you base the care on relationships, then you may be able to deduce that taking care of overweight people also includes making adjustments to furniture, for example. These are misfits in the same way that square pegs do not fit into round holes. When there is a misfit between an obese body and a chair, then it makes a lot more sense to adjust the chair than to expect someone with severe obesity to be able to reduce his or her weight to a healthy BMI. 

By working based on ‘I can’, you can look at caring in a different way

So my book is about shifting the focus from the individual to relationships in which someone can exist. In philosophical terms I explain this as a shift from ‘I think’ to ‘I can’. By working based on ‘I can’, you can look at caring in a different way. It is a vision that looks at relationships and the existence of the body in the world. It assumes that there is a constant dialogue between the individual and the social and physical environment. I have been inspired by philosopher Maurice Merleau-Pont, who, in defining embodiment, bases his views on the clinical work of psychiatrist and neurologist Kurt Goldstein. Goldstein treated many war veterans with brain damage in the 1920s and did not exclusively look at the injury – he also looked at these people’s options. He had a holistic view of biology. You start from the whole, and for people that is a combination of the organism and its environment. An organism cannot entirely exist on its own. And yes, that idea is at odds with the idea of an anatomical view which is only interested in the individual body.”

How does the new perspective of ‘I can’ work in practice?

“Say I break my leg, and I can no longer walk. If I have a wheelchair, I can do more. But if I work in a building without elevators, then my options become limited. The presence of an elevator then reinforces my ‘I can’ again. This simple example shows how there is a constant dialogue between the body and its environment. This means the environment has a crucial role to play. Even in something as simple as a broken leg, the problem involves more than just that isolated leg. 

Another example, from our university, which considers diversity and inclusion buzzwords, often based on figures and rules. But how many blind people are there on campus? I also noticed the warning stickers on a toilet in the Cube building, showing that people should not squat on the toilet seat. Now, you need to understand that urination and defecation are culturally-taught processes. For people who have a bowel function that requires squatting, this ban leads to a daily misfit effect. If the university truly wants to be as inclusive as it declares itself to be, then it must ensure that it avoids these types of misfits as much as possible. Squat toilets could be installed. In this way your inclusiveness can actually materialize.

So back to the drawing of the black fetus; everything in anatomy is based on white people, but the majority of people are not white. How do we materialize these differences? First off, through course materials. Course books must update and diversify anatomy. This is much more effective than imposing rules.”

Date of publication: 2 November 2023