RUPA MARYA AND RAJ PATEL
Rupa Marya is associate professor of medicine at the University of California, San Francisco and co-founder of the Do No Harm Coalition, a collective committed to addressing disease through structural change. Raj Patel is an award-winning writer, filmmaker and academic, author of Stuffed and Starved (2007) and The Value of Nothing (2009), and co-director of the documentary The Ants and the Grasshopper (2021). Their new book Inflamed: Deep Medicine and the Anatomy of Injustice, a joint project that exposes the often-unseen relationships between health, social inequality and the climate catastrophe, is out this year. TANK spoke to Marya and Patel about dismantling hierarchies of power, their vision for deep medicine, and moving towards cultures of care.
Interview by Matthew JanneyPortraits by Jennifer Graham (Marya) and Sheila Menezes (Patel)
Matthew Janney In Inflamed, you write that, “Every diagnosis, according to conventional Western medicine, is a story pulled apart, a narrative told out of joint.” What’s wrong with these current diagnostic practises?
Raj Patel Every civilisation that has medicine, and that is to say, every civilisation, tells stories. And so, the way that you know that you’re giving medicine is because of the story that precedes it. The story that precedes a great deal of Western medicine is about individual insults to individual organs in your body. In general, medicine under the Western capitalist colonialist cosmology is very individualised; in that cosmology, there’s little room for the knowledge and wisdom of other kinds of civilisation.
Rupa Marya The stories that we’ve been telling ourselves through Western medicine are inadequate at addressing the problems that humanity is facing. Maybe it has helped people predominantly in the Global North, people who are predominately white and male, people of property. But it doesn’t help the poor, the people on the margins, people who have been colonised and people who are struggling against systems of oppression. If you talk to any Indigenous person in the United States, they’ll tell you very clearly why they suffer from inflammatory diseases at the highest rates of anyone in the United States. And it won’t just be an analysis of the structural determinants of health; it’ll be an analysis of 600 years of history and how critical knowledge systems and critical relationships that maintained health were disrupted, interrupted and severed. What we’ve done in this book is offer a wider perspective, a longer narrative drawing from history and the analysis of lines of power to show how these things are impacting individual bodies, but also bodies as a whole, our communities and also the relationships we have. As physicians or healthcare providers, this work challenges us to really think more holistically about what health is and what it is not. It is much easier when you’re trained in the pharmaceutical approach to medicine just to think of one individual, one defective protein, one defective gene, one missing hormone, replete it, and then think that you’ve done your job. What we’re saying is that the work at hand right now is much greater than that. It has to involve dismantling those structures of oppression that are causing these diseases, which are the same things that are causing climate catastrophe.
MJ Are you starting to see changes to lines of communication between different industries? Are medics talking to social workers, for example?
RP The bifurcation remains. Let’s talk about the gut microbiome, because people seem to be into that. One way of thinking about the fact that in the Global North, particularly in cities, we have very denuded and not very diverse gut microbiomes compared to Indigenous people is to think, well, the way to fix that is through supplements. And what we need to do is go to the Yanomami tribe in Brazil and find their poop and turn it into a pill and swallow that. All of a sudden their very diverse microbiome will become part of ours. And what we need is essentially an Elon Musk of poop who can launch himself into our inner space and repopulate it with the kinds of missing microbiome and the missing sort of fauna that we need in order to be able to be healthy. Now, that approach sounds ridiculous, but it is nonetheless a frontier of research and pharmaceuticals. On the other hand, another way of understanding that the reason that our gut microbiomes are denuded, lies in ecological factors. The way to follow through with that idea is instead to be thinking about widespread social change. That second part is still in its early stages. It’s very interesting that while the evidence accumulates that colonialist capitalism is destroying the planet, the response from within capitalism is no less to try and monetise what the solution is.
RM There have been people who have been practising what we’re calling deep medicine for the last 600 years. It is about never separating the systems of knowledge, understanding that you cannot have medicine without having history, ecology, social science. Look at what’s happening right now with Covid-19 in California; it’s a perfect example. Doctors are telling us: “We have 70% vaccination rates.” But in fact, did the 70% count all the undocumented people who are the backbone of the entire food system in California? They have more vaccine hesitancy. They have more barriers to access, including a police force that will deport them when they show up to get medical care. Once they enter a system, they become very vulnerable to their families being separated, which is one of the long-lasting hallmarks of colonial culture, separating Brown and Black families. It just shows the incompetence of Western ways to address the magnitudes of problems that we’re seeing. And that will lead to unnecessary death. That failure is a failure of really understanding what 70% does and doesn’t mean.
MJ As you speak I have this image of a hospital as this top-down, centre of knowledge. Surely the architecture, the actual infrastructure of medicine needs to be adapted for these more pluralistic conversations to take place. Right now, it’s very hierarchical.
RM I’m on a panel over the next two months with Deanna Van Buren. She’s an architect out of Oakland who is designing spaces for justice. She’s a Black woman and is doing a pop-up village for Black pregnant women at my hospital at UCSF. She is what you’re invoking. The coherence of the spaces that we’re in limits our sense of possibility or our sense of healing. I’m involved with the Lakota Dakota community in Standing Rock, helping to form a clinic to decolonise medicine. We have been meeting for a couple of years now to talk about what this space should look like and feel like, because traditional health services centres are colonial structures: there’s not enough room for a family in the clinical exam room; they want circular spaces; they want spaces for elders; they want spaces for children; they want a kitchen. So their considerations are completely different from what you think of when you think of a Western medicine hospital. Would I want to die in a Western medicine hospital? No. Would I feel healed in a Western medicine hospital? Not really. I would feel like an emergency is perhaps averted. But really, what is healing? What gives us a sense of being human and connected? That is so much bigger than the colonial architecture of a hospital and everything that it implies could ever do.
RP In the book we write about how Frantz Fanon, one of the earliest decolonising medics, butted up against precisely this kind of problem. What does he do when he’s in an Algerian hospital and trying to decolonise psychiatry? Well, he works with two groups. There’s a group of white women and a group of Algerian men. With the white women he tries to help them by setting up a film club, tries to turn wards into cinemas and installs a printing press. For the men, the clinic moves into a football field. In both cases, the hospital is not configured to be a cinema and a printing press and a sports stadium, so at some point, the physical limitations of the hospital exceeded what Fanon needed to do. In the end, he recognises that the physician is also caught up in these structures of capitalism and leaves the hospital entirely as part of his decolonising practise because it’s not possible within the context of a colonial French outpost to engage in decolonising medicine.
MJ How seriously is epigenetics taken in the medical world?
RM I don’t think we give it the weight that it’s due, personally, because I think that we still focus on cancer as an individual thing. We don’t know yet enough in medicine and science to be able to attribute a certain cancer to a certain epigenetic imprint or phenomenon. That’s why it hasn’t really found its way into clinical application. There is enough science there to start being more strident about regulating the corporations poisoning the Earth. Most doctors don’t ask, what do your parents do? They don’t say, OK, here’s a Latina woman, where did you grow up? When did her parents emigrate? How did they emigrate? What work do they do? People aren’t asking those questions. And if they did, they’d start to notice a trend.
RP What’s important is that the discussion about epigenetics is nudging at this much bigger discussion around everything from endocrine disruptors to the damage that racist and sexist narratives are causing our bodies and the traumas that are inflicted by a society that is oppressive. Those are ongoing stresses that will inflame our bodies. And the stories that we tell in Inflamed are precisely about these chronic conditions.
RM As Raj just encapsulated, you realise that this capitalist structure is a form of biological warfare against the working class around the world, against the peasants, against the Indigenous and people at the margins, that it’s not simply just unfair, but it’s actually killing people and it’s killing people in this very clear way. We have enough data and evidence now to see the impact of these social structures on our bodies, so it’s imperative to start moving these structures into other systems of organisation.
MJ Care, particularly the Insta-friendly, and individualised, version of “self-care” is a term thrown about a lot these days. How do we move towards the culture of care that you’re talking about, one that is lasting, pluralistic and community based?
RP Covid-19 has been a catastrophe for so many reasons, but one of the things that has come out of it is precisely this kind of organised care. For example, peasants in rural Brazil send things to the favelas, send food to communities that are going hungry, that need care in a very physical way. Those kinds of interactions between people across spaces are not done for the “gram”. This is not a performative version of care; this is a kind of mutualism that has been demanded and made possible by relationships between country and city. You see these kinds of caring relationships circulate in the shack communities in South Africa. You see them circulated in protests, for example. The good news is the practices are already there, and this is not a kind of paradise built in hell, a kind of short-term vision of care, but it’s actually fairly durable. That’s one of the ideas that we’re very excited to see: despite the state, there are ways for certain kinds of democratic socialism and anarchist mutualism to flourish despite it all. ◉