EP. 58: ANTHROPOLOGY AND MEDICINE FROM THE BOTTOM UP

WITH ERIC REINHART

Apr 18

WITH ERIC REINHART, MD

An anthropologist, writer, and psychiatry resident discusses how he applies his ethnographic work to create and implement culturally-sensitive improvements in community health.

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Episode Summary

We are joined in this episode by Dr. Eric Reinhart, an anthropologist, psychoanalyst, and psychiatry resident at Northwestern University Feinberg School of Medicine. While Dr. Reinhart is the first resident-in-training we've had on this program, his path has been far from straightforward. Prior to residency, Dr. Reinhart conducted ethnographic work in Chicago's South Side, India, South Africa, and migrant communities in Southern Europe. Through this research, he addresses the multifaceted effects of poverty and social inequities on community health. In this conversation, we discuss how he applies his anthropology training to create culturally sensitive systemic changes and how healthcare providers can play a more active role in engaging with their communities.

Eric Reinhart, MD is a political anthropologist and psychiatry resident in the Physician Scientist Training Program at Northwestern University’s department of psychiatry and behavioral sciences. He is also lead health and justice systems researcher at Data and Evidence for Justice Reform (DE JURE), the World Bank, and an advanced candidate at the Chicago Center for Psychoanalysis & Psychotherapy. His writing has appeared in The New York Times, The Wall Street Journal, Jacobin, boundary 2 online, Boston Review, Health Affairs, The New England Journal of Medicine, The British Medical Journal, and The Journal of Legal Studies.
In this episode, you will hear about:
• How having a deaf brother led Dr. Reinhart to medicine - 1:54
• Dr. Reinhart’s observations of the disconnect between the ideals he heard in medical school and the reality of how profit-driven hospitals operate - 5:59
• Why Dr. Reinhart pursued a study in anthropology to learn how to address contemporary social ills - 12:46
• How a case study of drug-resistant tuberculosis in Russian prisons informed Dr. Reinhart’s evaluation of pandemics - 19:37
• What drew Dr. Reinhart to psychoanalysis and psychiatry, and how he applies them to his field studies - 26:41
• A discussion of the power structures inherent to medico-social field work and how to properly determine what a community needs - 32:04
• Advice on how doctors and medical trainees can become empowered to help change the systems they work in - 41:21
• How Dr. Reinhart hopes to apply his experiences to improve community-based care - 48:42
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives, those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] We are joined in this episode by Dr. Eric Reinhart, an anthropologist, psychoanalyst and psychiatry resident at Northwestern University. Dr. Reinhart is, in fact, the first resident-in-training we've had on this program. But as you'll soon hear, his path has been far from straightforward. Prior to residency, Dr. Reinhart conducted ethnographic work on Chicago's South Side, India, South Africa and migrant communities in Southern Europe. Through this research, he addresses the multifaceted effects of poverty and social inequities on community health. In this conversation, we discuss how he applies his anthropology training to create culturally sensitive systemic changes in how health care providers can play a more active role in engaging with their communities. Eric, thank you for joining us and welcome to the show.
Eric Reinhart: [00:01:53] Thank you. It's a pleasure to be with you.
Tyler Johnson: [00:01:54] So, Eric, I was hoping that you could start out, you know, you are a little bit unusual in the sense that you didn't do just the straight through, you know, undergraduate, then MD, then residency path, right? You've had a little bit more of a circuitous route. So could you start by. Well, actually, before you even get to the your path, can you talk to us about what drew you into medicine and maybe that will mingle with your path, but how did you get to where you are today?
Eric Reinhart: [00:02:23] I don't know how to answer how I got into medicine without giving you maybe the answer to the first question. This more general background. So I, I grew up in a context where I didn't have a lot of professionals around me in my childhood, but one professional group that I was aware of and I did have close contact with was doctors. And then I also grew up with an older brother who's deaf. He was born deaf. Throughout childhood I was operating- We lived in a hearing environment, not a lot of deaf people around in general- and so I was operating as this interpreter all the time. And I was five years younger than him and you have this peculiar capacity as a young child to be hyper empathetic in a way that's actually quite problematic if you become an adult and you retain this. But as a child, you have this and you have a hard time distinguishing between yourself and others and some kind of way, this is part of what it is to grow up. So I experienced my relation to my brother, my brother's relation to the world in a way that was quite formative for me. And he, being a deaf young boy, was presumed to not have abilities to presume to have a certain kind of foreclosed future. There are only certain range of things that he might be able to do. There was limited imagination and he didn't share this imagination of himself, and this was a constant site of struggle throughout his childhood, throughout his adolescence.
Eric Reinhart: [00:03:34] And I was very much part of this in some way, as I often mediated between others expectations of him and his own expectations and perception of himself. And this was very, very important for me to come from a certain kind of perspective and relationship to disability, to stigma, to being presumed to be other than and not in fact to be presumed to be, but in fact to be other than the normative demands of one's environment. And so. I this structure to me, a certain kind of relationship to authority where I saw authority through this particular example with my brother, but as always, a kind of looming threat, something that would demarcate the inside and the outside of accepted systems of accepted identities and ways of being. So when I went through later to to college and ended up studying the history of science and medicine, I was particularly attracted to this because it was a disciplinary formation within the university that was particularly attentive to the way that something that was thought to be objective outside of politics or culture. But, you know, it's like physics, it's mathematics, it's biology. What do these things have to do with structures of power, etcetera? And then this whole discipline is oriented around unearthing the ways in which culture and politics and power shape what we regard as scientific knowledge.
Eric Reinhart: [00:04:49] And I was particularly drawn to the history of psychiatry and of medicine in its relationship to these kinds of normative demands. But that that kind of led me then to thinking about this one profession that I had had exposure to as a child. And it drew me further into this field, not in a traditional affirmative way, like I identified with the field, but with an appreciation for the enormous social power that this field leverages in shaping people's perceptions of themselves, their social relationships, this kind of thing. So I was always drawn to medicine for two reasons. One, because I saw this as a crucial site where knowledge, power and social life come together in this very frictive way. And then also because I didn't know how else to make money to have a career, I didn't really know what you could do. I didn't imagine that I could, for my, for example, become a professor like the teachers that I had at Harvard. That wasn't something I'd seen in my youth. I had no conception that I could do that kind of thing. So part of falling into medicine was, in part accident from pragmatic demands. I needed to figure out some way to provide for myself. And this was one of the very few ways I could imagine doing so.
Tyler Johnson: [00:05:59] And so you go to college, as you mentioned, and then coming out of college, where did you go next? And then how did that eventually bring you to actually coming to medical school?
Eric Reinhart: [00:06:12] So when I was in college, I had the good fortune of studying with a series of people who were physicians and anthropologists or historians, so people like Paul Farmer and then others who were not physicians but are very much in that world. So Alan Brandt, as a historian of science and medicine and Harvard. These people made me think that there was a possibility for engaging with the medical world, engaging with clinical care, and not being fully absorbed into the normative systems that it usually instills into its practitioners, which, you know, I'm not saying that those are all entirely bad and they serve functions, but for me personally, that was very important because of this kind of deeply seated suspicion I have of these kinds of systems so inspired in part by these people who lived within a medical world, but in a different kind of way. I ended up going to medical school at the University of Chicago, and I happened to enter there at a very what for me became very important time. University of Chicago is a like many academic medical centers in the US. It's set in a particularly dispossessed and racialized part of Chicago in the South Side of Chicago. And this was a period where there was mounting community activism around demands for a level one trauma center, the kind of trauma center that responds to people who have suffered gunshot injuries or stabbings or often car crashes, this kind of thing.
Eric Reinhart: [00:07:27] There was not one on the south side of Chicago, had not been for over 20 years. And so all of these people were being shot in the neighborhoods around the city of Chicago, put in ambulances, taken, you know, ten, 15 miles north or west to other hospitals and many times dying along the way. So the community, particularly young people, 17, 18, 19 people whose friends were being shot and killed in front of them, began to organize really around this demand that because of the emergency nature of this problem within our communities, we are owed the kind of care that this institution, which is very wealthy, is refusing to provide and has been persistently refusing to provide. So I was witness, and I maybe am ashamed to say in some kind of way, really witness I wasn't really participatory, but I was witness to these kinds of movements, which then made me yet again very keenly aware of how these sites of institutional power articulate with surrounding demands and needs that they often don't meet for various politically structured reasons. That then later shaped my anthropological work, which entailed coming back to Chicago to work on questions of violence and emergency in the South Side. And then that in turn shifted to something else which we can talk about later.
Henry Bair: [00:08:35] Well, I would like to talk about that. So I'm just reading through your Web profile here and your listed research interests are so diverse. Among others. You talk about the anthropology of law and equality and public health, aesthetic politics, medicine, policing and logics of apartheid and abolition. Most of these topics I don't know enough to begin asking the right questions to figure out what they entail. But you mentioned that you at one point found yourself in a more formalized study of anthropology. So can you tell us more about that journey and what the major questions you wanted to tackle were?
Eric Reinhart: [00:09:13] You know, in some ways I quite enjoy the university. There are certain benefits to being part of these kinds of powerful institutions, and I've benefited from those. So at the University of Chicago, which is this. Wonderful institution in many ways that also has a lot of ugly sides, like all universities in the US that have this kind of capital and are predicated upon philanthropic enterprises. Et cetera. What I was particularly attuned to there was the way that we were trained within the medical school to talk about health, justice, health equity, racial disparities, to do infinite number of studies around these. And then you go into the wards and you see how the policies of the hospital are really structured to keep. It seems like poor people out in this case, particularly poor black people. And you see how hospital administration is organized to try to attract profitable patients. A colleague of mine who was actually a medical student with me, Jen Karlin, who's at UC Davis, she wrote this this essay on financial epidemiologists that was entirely based on the University of Chicago's administrative system, which is not unique. This is repeated at hospitals all around the country. But this was the place where I was first really encountering it in an everyday kind of way. So I was struck by the contrast between our lecture halls and the ideals that we held up and what actually seemed to play out in practice and what that did to the people that I was trying to care for.
Tyler Johnson: [00:10:34] Just to be clear, can you give an example of what you're talking about when you say so? You go onto the wards and you see these structures that appeared to further marginalize people who already lacked resources or whatever? Like what's a concrete example of what you were seeing?
Eric Reinhart: [00:10:51] Well, at some institutions you'll see different kinds of staffing for different kinds of services. So you have your general medicine unit and it might now increasingly be run by Hospitalist Non-training services. They're trying to produce bare bones models to maximize revenue. And then you go to the heme ONC unit, for example, where there are different kinds of care demands and you see often a very different physical infrastructure, a very different level of staffing. Some of it's responsive to the clinical needs of patients, but a lot of it is responsive to the the marketing aims of the hospital. This is a revenue generator, whereas in many hospitals, some of your general medicine units, for example, are not revenue generators or at the University of Chicago, what was not a revenue generator was the unit that didn't exist. There was no inpatient psychiatric unit, for example. There used to be it was closed down because it didn't maximize profit opportunities. And then you also see, for example, you see this very starkly in many places with the emergency departments. Emergency departments are bottlenecks. This is how you control who gets into your hospital, because since the 1980s, there's been legislation that requires you to treat anybody who presents to the emergency department to stabilize them.
Eric Reinhart: [00:11:55] And if they require inpatient admission, you often are you administratively you have to do this and then you take in people into your hospital that as an administrator who's thinking with business logics you didn't want to take in because they are not going to bring you the revenue you're after. So what you see is a lack of investment in emergency departments to intentionally produce a bottleneck. And then across the street, the urgent care clinic where the patients who are continuously part of your hospital system and do have good insurance and do bring revenue, they go through there. They don't necessarily go through the emergency department in many instances. So you have to a two tiered system. And when you work as a medical student, you increasingly become aware of all these different mechanisms through which particular patients are selected for, not for really any clinically defensible reason, but for financial reasons that then become whitewashed in some sense through clinical rationales. So this this is the kind of thing that I'm talking about.
Tyler Johnson: [00:12:46] Okay, So I interrupted you in the stream. So you were saying that you encountered these things while you were doing part of your medical training, and then that led to...?
Eric Reinhart: [00:12:54] Well, it led me to think about so up to that point, I had really focused on historical scholarship. And I at the very end of college under the mentorship of teachers, that I was fortunate to kind of fall in under there. I got the idea that perhaps I could do what they're doing. Perhaps I could write books, perhaps I could teach. I'd really never had that idea before, but I was already in the kind of momentum of applying to medical school and going through that. So I thought, okay, I can go to medical school, but I'll do a PhD too, and that will make it some kind of pragmatic compromise between my own intellectual desires and the necessities of living and of being effective in the world. So when I was encountering all this on the wards, I was scheduled at that point to begin a PhD in history at the University of Chicago, and for a variety of reasons, but involving what I've just mentioned, I ended up withdrawing from that thinking, that historical study, as important as it was, didn't allow me to do the kind of work that I wanted to do. I wanted to be responsive to the people in front of me, to the demands in front of me, to these young people who were organizing and trying to demand structural changes at this nonprofit academic medical center.
Eric Reinhart: [00:13:59] And historical scholarship can be very useful for that. But it doesn't have the same kind of purchase on the present often that anthropological work can have. And I'd seen what Paul, for example, Paul Farmer had done at Harvard through a kind of leveraging of historical scholarship with anthropological engagement and these ethnographic vignettes and the real engaged policy work that he was able to conjoin these with. So I wasn't trying to emulate Paul exactly, but I was thinking that there's a different possibility with anthropology as a vehicle for trying to articulate with these systems. So I ended up withdrawing from the history program then and later going to Harvard for anthropology. You know, in the US, anthropology is a discipline that historically has been oriented around studying other places. You go to the Amazon, you go to, you know, North Africa or South, you know, you do something else, You don't stay here. This has been shifting over the last decade, but it was only at least it felt to me only beginning to shift at the time that I was starting. So I thought, well, I'll you know, I haven't gotten to travel much. I've lived in the US, I haven't had a lot of exposure. Maybe this is a good opportunity for me personally to go do something else and to do something that matters.
Eric Reinhart: [00:15:01] And this was something. This was during a period where thousands of people were dying in the Mediterranean Sea every day trying to cross between Africa to southern Europe. And there are migrant routes. So this and people didn't fully understand all of the dynamics that were producing this. So I spent some time in Southern Europe and North Africa trying to think about how could I, as an anthropologist, maybe relate to this, bring medical, anthropological frameworks and that kind of thing, but ultimately felt like I had to go back to Chicago, that these communities that I had witnessed organizing and demanding and being not responded to by the University of Chicago in places like this, that this is where I felt I had an ethical obligation to work. So I ended up returning to Chicago, and I was initially interested in how communities were using the framework of emergency to demand rights and the history of political theory. You can think about people like Carl Schmidt, for example. There's this idea that the state of emergency is a means by which the state suspends rights. It's a top down construction of power. Here is the bottom up communities using the framework of emergency to say you in fact, have to respond to me now and was interested in this as a kind of political concept and organizing strategy.
Eric Reinhart: [00:16:06] So I was spending my mornings at the scenes of shootings from the night before in emergency departments with families, with people who had just been shot, trying to think about how people are organizing, thinking about this. And then after a few months, actually, it didn't take very long. I felt like this is work I couldn't do, not that I personally couldn't do it, but ethically I couldn't do it. The south and west sides of Chicago for over 100 years have been studied by literally hundreds of sociologist anthropologists, if you include their students. Thousands and thousands of people who have studied these communities through frameworks of violence, so-called social pathology, through gangs, through disorder, delinquency. And even though I thought I was doing something different, I was trying to align myself with grassroots movements in these neighborhoods. Nonetheless, my point of entry was the question of violence, and I felt like I was inevitably kind of channeling the pathologizing racializing discourses of urban sociology that I was trying to get away from. And I couldn't. So I kind of had this moment of instability. I wasn't sure what it would be for me to be an ethnographer in these communities. And I fell into by accident a totally different kind of project that it's kind of the inverse in some way, which was these writing groups. There's this long tradition, particularly of black writing groups in the South and west side of Chicago from really the 30s, the 1930 during the Great Migration.
Eric Reinhart: [00:17:21] And I was interested in what did it mean after having been written so intensely by others, overridden by others for over a hundred years, for these communities to write themselves, to claim the authority, to write their own lives, to imagine their own kinds of communities, and to refuse the discourses that had been imposed on them, including medical discourses, psychiatric discourses, the language of pathology, which wasn't just about physical or psychiatric pathology, but so-called social pathology. And so I became interested in the negotiations there, where you try to write yourself in another way in a different way, in your own way, but nonetheless, the way in which you do this requires using the language that you've inherited, and that language is suffused with racializing pathologizing terms. So it's not a simple kind of resistance, a refusal. There's a process of what I think of as a form of subversion that comes out of that. You have to work within the constraints of what you've inherited, but you try to make something new out of it. And how does community form in this process of subverting your historical overdetermination? So that's the basis of my PhD work during that time was training as a psychoanalyst in Chicago that ended up becoming very closely enmeshed with the ethnographic work I was doing.
Eric Reinhart: [00:18:26] Where I spent my fieldwork was in, in these writing groups primarily, and the relationships and people's homes on street corners associated with that. But then also the people with whom I worked were taken through psychiatric units, taken through police processing centers and the jail. And so I ended up doing ethnographic work in each of these different institutional sites as the place where a kind of conflict emerges, where the psychiatrist writes you in this way, and then you write yourself in another or the police officer or the welfare office. Et cetera. So these kinds of sites of discursive conflict and defining oneself and defining one's community, and I was really throughout all of that, trying to get away from what one of my teachers, Paul Farmer, had done, which was this emphasis on structural violence, on interpreting communities through the frameworks of inequalities that constrain their lives. Like I was talking about this urban sociology tradition that writes these communities in a very particular way for 100 years, and it really corrodes the possibilities of life when you begin to absorb sociological discourse as the way that you imagine yourself. I thought of in some way Paul's work and other work in this vein within medical anthropology really focused on structural violence as potentially doing something similar.
Eric Reinhart: [00:19:34] And I think it's very important, but it has all these hazards and I wanted to do something different. I wanted to focus on on aesthetics, which is not style, but rather qualities of feeling beyond language, beyond reason. How do people, through feeling, make different kinds of communities that are a form of political subversion, of historical subversion? But then when the pandemic hit and I had done ethnographic work inside Cook County jail with people who have been arrested and processed through jails here and elsewhere, many, many, many times throughout this whole time I was teaching at Harvard with Paul Fly there. We taught some seminars together and I taught this case study with Paul that he and Salmon and others Partners in Health had had worked on in the early 2000 after the fall of the Soviet Union, increasing poverty that kind of the decimation of the welfare state. So health care, public health care, public welfare systems decline, and there's an increase in poverty that is associated with petty crime. And there's a more than 50% increase in the incarceration rate in post-Soviet Russia over the course of the 1990s. What this led to was an MDR-TB epidemic that took advantage of prisons throughout Russia to quickly multiply TB because of bad treatment regimes. And then this would this spread throughout Central Asia, Eastern Europe. It became a worldwide epidemic.
Henry Bair: [00:20:50] So sorry. Just to clarify, that's that's multidrug resistant tuberculosis. Yes.
Eric Reinhart: [00:20:54] Right.
Tyler Johnson: [00:20:54] And for for those who are maybe not initiated, it's important to know that this is an enormous problem, especially in developing nations, because tuberculosis, just normal run of the mill tuberculosis is incredibly difficult to treat and usually requires multiple different medications a day for depending on. We could talk about the data, but for six, nine, whatever, months. And then if you have MDR or XDR, so multidrug resistant or extremely drug resistant TB on top of that, then it's even more complicated and even more difficult to deliver the appropriate treatment regimens in places where it's difficult to get access to care in the first place. And then if it gets introduced into a prison system or other places where people are living in close quarters, it's a just a really, really, really tough nut to crack.
Eric Reinhart: [00:21:37] Yeah, and it multiplies really quickly when people are sleeping in bunk beds in rooms with hundreds of people, stagnant air, everybody's getting TB. And then when people are serving sentences and then leave, their treatment courses are often interrupted. And then that's an opportunity for drug resistant TB to emerge. And then this spreads not just among people who are incarcerated, but also the guards who are going in and out every day and then infect their own families without knowing it. Families that come to visit and go in and out, service providers that come in. So what you had was this epicenter of an explosive epidemic. So the Russians were increasingly aware that they had a massive problem on their hands, kind of quietly brought in Paul and Solomon to help them because Paul and Solomon had done this kind of work in the slums around Lima in Peru, where the World Health Organization had basically said, we don't know what to do with MDR-TB here. We're going to just continue with our our plan that doesn't work because it's cost effective. And Paul and Solomon and others, you know, pushed them and demonstrated that you could, in fact, effectively treat MDR-TB. In fact, you had to if you didn't, you would have a growing epidemic. It was not a viable path forward anyway. So they ended up doing this. Russia taught this many, many times when COVID broke out and the first major institutional site it reached in the US was Cook County Jail, where I had spent a fair amount of time and a lot of the people I'd worked with had spent time and I knew the physical infrastructure of the space.
Eric Reinhart: [00:22:56] I knew that within days you would have massive spread just within the processing facility alone, for example, where about 200 people every single night are standing in long lines being processed and tight spaced rooms, You know. So this marked a big shift for me, which is I had spent a decade trying to unlearn the emphasis on structural violence on in some ways political economy that I had studied for a very long time, thought it was very important, but didn't know how to do that as an ethnographer and not feel like I was reducing the communities with whom I was working, the people with whom I was working. But the pandemic forced me to do an about face of sorts and realize I needed to find a way to effectively integrate the kinds of frameworks that I had learned from Paul. I had learned from, you know, courses on on Marx and political economy and labor history. Et cetera. I needed to figure out a way to bring that into my own ethnographic work and my relationship to the world. I started with the idea of emergency in Chicago. This was for me. I internalized this sense of emergency, like, my God, within weeks we are going to have massive harm. And in fact we did. And so I started doing studies with a colleague of mine, Daniel Chen, and we showed that, you know, through the outbreak at Cook County Jail, it spread throughout the state.
Eric Reinhart: [00:24:09] We did follow up studies to shows like Spread across the country. One of the most important epidemic interventions is decarceration. In a context like the US, where you have such high rates of incarceration that this produced dramatic reductions in the spread of COVID. And then since then, I've kind of been engaged in a much more directly applied way than previously had, where I'm no longer really working on aesthetic communities, although that's in the background of everything that I do. But my work has been consumed with how do we produce the policy effects that we need right now to respond to the fact of violence and all of this emphasis on on writing, on discourse, on, you know, my psychoanalytic work. I think it's incredibly important, but it doesn't mean much if people are dead. It doesn't mean much if they cannot eat and if they cannot get housing. And I need to address with others, you know, these front end issues in order to make the ethical significance of this background, you know, to give it a chance to to blossom, to grow, for communities to form, you have to attend to the material realities that people are living first. I don't think first I think in conjunction, really. And so the part of the paradigm I'm trying to push is the idea that this isn't something I do or that we do from medical institutions or from departments of anthropology or even from legislative offices.
Eric Reinhart: [00:25:25] But this is something we have to do from the bottom up by recruiting communities into this work and giving them the resources to do it. And part of doing that. So this is an aesthetic project, making them feel the significance and the possibility of doing this. So in some way, all of my work now, I feel, has come together and coheres around a project like this where it's an aesthetic project, it's a political project, it's an epidemiological project, and it's not just about structure. Violence is determinative of everybody's life, but how do we collectively produce an effective response to it? That is also an aesthetic response. Aesthetic politics for me is this idea that you cannot have an effective politics if it's devoid of mass feeling. We see this on the right all the time in the US, really effective leveraging of mass feeling towards destructive endpoints. And we've seen persistent failure on something like the left or we don't have much of a left in the US, but like in the Democratic Party, for example, to effectively leverage irrational feeling towards constructive community building ends and think, until we do that, we will fail politically in all scales, but including in public health and community health. It's not a technological project. It's not a top down administrative task. We have to build through these kinds of relationships that have the texture of feeling that inspires people to actually buy in, to participate, to believe that something else can be possible.
Henry Bair: [00:26:41] Thank you so much for sharing all of that. It's unlike anything we've heard on this show, so I'm glad that you're able to offer your perspectives on this. Things I agree with with your point on creating social change from from a bottom up approach. Changing gears slightly and this is, I guess like a two part question. First part is you mentioned earlier that throughout all of this, you were also training to be a psychoanalyst, which I don't actually know that much about. I know what it is. I didn't know what the process was for becoming a psychoanalyst. So I guess my question is, why did you decide to go into this training? And then after this, go into psychiatry residency. But what was the thought process there?
Eric Reinhart: [00:27:22] I was drawn to psychoanalysis even before my field work, but it's really my field work that pushed me to train in it. In these writing groups that I was talking about where I'm doing my ethnographic work. The material that people bring that they want to talk about with others they want to write about is very often past traumas, these points in life that they cannot get past in some kind of way and they're trying to work through. And there's a form of community that emerges around this. But I also didn't know fully how to how to respond to it. And psychoanalytic work gave me a different kind of set of tools and perspectives with which to engage with people around this. So there's some element there. But a bigger part of it for me, I think was I'd long been interested in psychiatry, not so much for how the field of psychiatry is constituted today, but for the kinds of problems and questions that present to psychiatrists why people come to psychiatrists, the problems that both individual but at scale social problems, political problems that are distilled in the psychiatric clinic or in the psychiatric hospital emergency department. But the psychiatric apparatus and I talked about my earlier work as an undergraduate was was really in the history of US psychiatry. You know the history of psychiatry, if you know much about it at all.
Eric Reinhart: [00:28:36] You know, for example, there's this intense pathologization of non-heteronormative sexualities into the 70s and frankly, beyond even its removal from the DSM in the 80s, etcetera, and even to the present, you see transphobia that's often organized psychiatrically in some way or another, whether overtly or covertly. And that's just one of many, many different examples that don't necessarily have to do with sexuality that reflect how psychiatric epistemology, the way that we think about the human through the psychiatric framework is laden with all of these shifting normative demands, whether that has to do with sexuality, with functionality, with your relationship to work, with your relation to your family, all of these kinds of things where the goal of psychiatry historically and institutionally has been to produce functional beings, functional workers, and it has an idea of the normal of the healthy, and this is what orients the field. Psychoanalysis is a very, very different orientation. Psychoanalysis and its index not to functionality to normality or to health, but rather to desire. The question of what is your desire? Which is not an easy question to answer. And how do you know your desire? How do you separate it? Distinguish it from the desire of, say, your mother for you or of your partner, for you, of the institutions within which you work? And it begins from this.
Eric Reinhart: [00:29:55] And the orienting framework for psychoanalysis is the unique life potential of each person. And how do you maximize this? Not how do you make them normal? How do you make them healthy? And I mean, that's a very crude gloss on it in some way, but it's quite distinct from psychology or psychiatry or the normative demands of medicine. And it doesn't subscribe then to the ideas of evidence that psychiatry would have because it's not about generalizability or universalizability. It's the exact opposite. It's about singularity. And so the treatment modes are quite different and randomized controlled trials, etcetera. They are, in my mind, irrelevant to the domain of psychoanalytic work. And out of that comes for me maybe the most important general contribution, which is an ethical framework where the goal that I bring to all work that I do, including the public health work or to psychiatric work within psychiatric institutions, is to maximize somebody's freedom and possibilities, to realize their own desires, their own unique potential. And I think you can work this way psychiatrically, and I think you can design public health systems that do this. And I think if we fail to do this, certainly from a public health perspective, we ultimately fail to produce effective public health systems. What we have right now in the US are systems that are designed in a top down fashion where we have an idea of a standardized statistical outcome we're trying to produce and we're going to have biotechnological interventions. We're going to use algorithms to generate it. Et cetera. And this does not to most people, feel like an enhancement of freedom. I think in some ways it still is, in fact, but it doesn't feel like that to most people. And I think if we fail to align public health health systems in general with the empowerment of each individual to live in the way that they choose, that they desire, it will be felt to be restrictive, undesirable, to be associated with policing, with things that I think will undermine the possibility of public health to be successful. So I take that general idea, which seems quite different, different in different and distant from psychoanalysis, in large part from psychoanalytic frameworks that give me the sense of the importance of working ethically on the level of the 1 to 1 each person, not the generalizability of the algorithm or the RCT, but on this very different interpersonal, very intimate scale.
Tyler Johnson: [00:32:04] I think that Henry is certainly right, that this is a conversation that's distinct from any of those that we have had before in a way that I think is really interesting. I don't know if I'm pushing back exactly, but I hope this is sort of pushing forward because it is a tension that I think is a really interesting thing to interrogate here, which is I'm going to put down a couple of different threads and then I'm going to draw them together into the the question that I'm asking. So one common thread that I hear from both the way that you talk about your view on psychoanalysis and the way that you talk about this paradigm shift that you had in the way that you approach your engagement with marginalized communities and by extension what you were doing for your dissertation and in your teaching and everything else, which also reflects themes that I know that Paul Farmer talked about a lot. And whatever is 20, 30, 40 years ago, it was a pretty popular thing in the United States for doctors to go on quote unquote medical trips, right? So they would find a place to go. They'd drop in for two weeks, do some very kind of showy thing where they would seem to, quote unquote, fix the problem, whether it was offering surgeries or whatever, and then they would disappear. And then the people who maybe had that problem would have to wait for someone like that to come back the next time to be able to fix the problem again. Right. And I'm not a global health expert by any means, but my understanding is that a lot of the paradigm shift that Dr.
Tyler Johnson: [00:33:35] Farmer and others like him helped to introduce into the global health world was that that's that gets things exactly backwards. Right? And that what that's really doing is as much as anything in many cases, it's honoring the needs of the person who's coming in to do the work above the actual, at least sustainable needs of the people who are there on the ground. Not to say that those people never do any good, but it's just, you know, what about all the times when they're not there? Right. It's just not a sustainable model. And so then Dr. Farmer and his colleagues introduced this idea to the point of the name Partners in Health. Right. That that it has to be a partnership and that the work has to be focused on sustainable answers to the things that the people on the ground actually need, rather than sort of coming in and doing showy work for two weeks and then leaving. But what I hear you saying is that you're pushing even beyond that framework to say even the idea of coming in and and solving health problems or as you were talking about in Chicago, thinking about, quote unquote, social pathology or whatever, it's still introduces this sort of a normative element that is the person who is coming in defining what is supposed to be happening and then saying, how can I get the thing that I want to happen to happen to this group of people? Right. Whereas what I understand, you can correct me if I misunderstood, but what I understand you to be saying when you talk about the aesthetic element of this is that that aesthetic element allows the people with whom you're working to define what it is that they want to have happening, and then to use that as the starting point for whether it's going to be psychoanalysis, where you're talking about the singularity of the individual sitting in front of you, or whether it's the needs for an emergency room in the South side of Chicago or whatever.
Tyler Johnson: [00:35:16] Right. It allows the people who are doing the aesthetic work to define what it is that they're working towards. And so I get all of that. At the same time, though, sometimes when I hear people point out these kinds of distinctions, it ends up feeling to me like. I mean, you used the word gloss like however you want to frame it. And even if you use things that the people themselves are defining, but it's still in some way comes back to the same thing, because as a psychoanalyst, you're still introducing yourself as the person who has the unique tools to empower that person to embrace their own singularity, whatever, right? Or if you're doing ethnographic work or you're doing social organizing or whatever. But it feels like there's this inherent you could call it a paradox, or you could call it a contradiction in the idea that it requires this other person with special tools like that goes back to feeling a lot like what the people who were dropping in to do surgeries for two weeks were saying just with a much more complicated sort of theoretical framework behind it. But it still feels like it arrives at something of the same point. Does that make sense? Yeah, I think so.
Eric Reinhart: [00:36:25] There are a few distinctions between what you're describing, and I think what I'm after that might be useful. So in psychoanalytic work, I'm not going out and finding patients. People come to me because they have met some kind of obstacle that they feel they are incapable of moving beyond themselves. They are debilitated in some way or another. And then when they come to me as an analyst. My work is not to say, Look, I have the tools and I have the solution, I have the knowledge and I'm going to fix you. I have no idea what they need. I have no idea what it would be to fix them. I don't think in such terms. And Freud emphasizes this, like who's doing the interpretation? Who's doing the real work of analysis? It's the patient. The patient fundamentally has to do this. And this isn't just like, you know, a humble brag kind of thing or like some kind of weird epistemic humility that's just a cloak over the system of power that's operating. This is genuinely true. In order for there to be an effect, it has to be the patient, the analysand, who does the work. So the task is a little different. And I think the onus really is on the person who comes and they're the one who comes. So I don't think the savior framework. Now, you're right in some strands of psychoanalysis it does. There is, for example, the tradition of ego psychology. And I think that falls much more in line with what you're describing.
Eric Reinhart: [00:37:42] And there are lots of psychoanalysts who practice in a way that I think is very much hit by the target you've put out here. The way that I think about psychoanalysis, which is informed by Freud, by Lacan, by Bion, by others, I think is a bit different. And, you know, actually, Paul, when he first went to Haiti. So there are all sorts of criticisms of Paul, of Partners in Health that could be made. I make them myself sometimes. I hope I make them and I hope others make them with the goal of trying to produce even more constructive, even more effective systems rather than with the destructive intent. I get annoyed with academics who have no accountability to actual effects. And of course, one can criticize all day long, but what the hell are you doing that for? So I think you need to know why you're doing it. But when Paul first went to Haiti, the first thing he did was a needs assessment. It wasn't. I'm going to come show you what you need and build the clinics to give you what you need. It's like, what do you want? What do you need? And then at least in theory and I think it plays out in practice, but with limitations, the way that Partners in Health and the work in Haiti or Rwanda or elsewhere is organized is through the work of the accompanying tour, which is the community member who is employed by Partners in Health or the state in Rwanda or other agencies to work as a caregiver for their neighbor.
Eric Reinhart: [00:38:55] And accompaniment, as Paul describes it, is an epistemically humble stance. It does not say I know what's good for you. It defers to the person being accompanied and asks, What is it that you want? What is it that you need? And sometimes they can't answer and you just stay with them. It's just being there in some kind of way and being responsive to needs. Now, I think that that sounds all well and good. Sounds like a nice community health worker model in theory. Et cetera. But I think this also can be operationalized and must be operationalized as a system of knowledge production that is valued and is integrated in a systems way into informing the design of the system itself. This is what I imagine as a bottom up mode of organization where it's not just the accompagnateurs who deliver the orders or the mandates that come from above, it's that they're the ones who set the agenda and chart the path for the entire system itself. And you have to invert the power structure that you typically see so that it really is a bottom up run system. Now, is this ever going to be done completely? No. And I think there's a proper tension between the kind of top down work, some centralized work that has to be part of any effective system and this kind of bottom up element. And you have to be cognizant of that tension and keep it there, not try to resolve the tensions.
Eric Reinhart: [00:40:13] You have to work with them. And I think this is also true in analysis. So I might impose a certain kind of structure. I might produce a frame with a patient. That doesn't mean that now I have all the knowledge. We have all sorts of resistances and defenses that get in the way of doing that work. The analyst is asked to work with those and to produce a field of possibility through certain kinds of restrictions, through certain kind of pushback, through production of discomfort, of unsettling. What we think we know about ourselves is why it's not really about knowledge and so much more, much more about unknowing, about breaking links for a patient who presents with a neurotic construct as opposed to a psychotic structure where it's a different task, but about breaking links of how we put things together so as to be able to make them possible to reassemble in a different way. But don't do the reassembly. The analyst can never do the reassembly. We don't really do the breaking either, but we can apply a little pressure to assist with that process. So I don't know if that's helpful, but it's a very important question you point out, which is are we simply reproducing the same structural power dynamic and just dissimulating it, disavowing it even it operates now just in another way and think we should always be cognizant of that question and not push it away too quickly.
Tyler Johnson: [00:41:21] Let me ask you, we've been talking at very elevated heights for a minute. Let's make it practical. You know, one of the things that we have talked about with a number of guests over the past, I don't know, a couple of months, is this idea that one of the ironies of medical training, which many of our listeners are trainees, is that they go into, you know, I think most people, not all, but most at least many people go into medicine with genuinely altruistic motives. Right? They want to help. They want to make people better. They want to, you know, fix things. And yet they are then often embedded in a system that is deeply harmful, including by causing moral injury over and over and over and over and over again in some cases, in a way that I think most people are not aware of and and some people never grapple with. And those who do grapple with, it's often, you know, years after their training is done, when all of a sudden they sort of wake up and say, oh, my gosh, you know, that was not the way I was living, was not healthy or the way I am living is not healthy. Right. But I think that one thing that trainees in particular really struggle with is that if you are embedded in a system where almost by definition you have no say over anything, right? You don't even have a say over your own life.
Tyler Johnson: [00:42:38] You don't have a say over when you get to work, when you leave work, how many hours you work, when you have vacation, whether you can go to your kid's soccer game and you just don't have even when you eat or go to the bathroom. Right. In some severe cases. And then you have someone who shows up and says, well, you need to fight against the power structure or whatever. You know, it's sort of like I have hardly have time to eat my granola bar. What about you to fight after the, you know, fight against the power structure? What's that supposed to supposed to mean in any sort of concrete way that I can actually do anything about? Right. So I guess if you were talking to a group of interns are r-2s or whatever who were feeling both beleaguered and disempowered. And they were saying, We want to do something, but we have no idea what that would look like. What might you tell them?
Eric Reinhart: [00:43:29] I think part of what conditions the question prepares us to ask it is the tradition of the idea of the heroic doctor. You know, some people just have superhuman strength and after they finish on the wards in their 80 hour week or sometimes much longer, unofficially, they then go march and rallies and go to the, I don't know, the statehouse, this kind of stuff. I think this is one of our biggest enemies. The idea of the heroic doctor. It's not just that it's implausible. It's that it's ineffective. It reproduces many of the same systems that are enforcing our suffering and our patients suffering now. And it's not a vehicle for change. We have to have collective forms of organizing. What I think is extremely important from the medical perspective to recognize is that we are not going to lead the change that needs to happen. Bottom up change doesn't mean doctors who make 400,000 $500,000 a year and have an MBA or an MBA or maybe have some mid-level position in a hospice, that's not the group that's going to lead bottom up change. So what we need to do is cultivate relationships of solidarity, where we take seriously the fact that the communities that we serve know a hell of a lot of stuff that we don't. They know where we're failing in a way that we don't. They know how systems could be designed. Otherwise, if you give them the opportunity to cultivate and express that knowledge and that one of the most important things that we can do after our 80 hour weeks as trainees, as medical students and throughout those weeks, is to produce those relationships of solidarity.
Eric Reinhart: [00:45:03] And that might mean, you know, working with the neighborhood organizing group, spending your Saturdays at the Stony Island Arts Bank and trying to get to know the community, invest in it in a way that's legitimately humble and recognizes one's own limitations and then thinks about how do you leverage the institutional position and power that you have to further the goals that you see coming out of these spaces. That doesn't mean you don't have an important critical role with respect to engaging with the ideas to. I don't think that somehow disenfranchized people have magically been instilled with the solutions to all world problems. And so I think there's a space for intellectual engagement, you know, that could be critical and could give pushback at certain moments. But I think we really need to cultivate something that medical training kicks out of us, which is humility and a recognition that we are not leaders in effective movements, like we shouldn't be the leaders of effective movements. And how do we use whatever capital we have, reputational, financial, etcetera, to bring those kinds of movements that could lead bottom up, change forward and put them in positions to act. So that's a very different task than the heroic doctor finding extra energy to go, you know, confront and yell at the CEO of the hospital or something like that. I mean, might promote that, too. That's fine. But so I think that like de-centering ourselves and this fantasy of the individual hero is a key part of cultivating the kind of perspective and energy to make possible effective organization.
Tyler Johnson: [00:46:24] Yeah. You know, I just came over from Match Day and a student who I have known really well and have worked with for a long time, that student's parents were at match day. Everybody's really excited. Big smiles. And I and I told the student how proud I was and wish them the best and everything. And then sort of at the end of all of that, the student's parents looked directly at them and said, "Just remember, whatever happens, you need to remain humble." And I feel like that piece of advice is something that doctors in particular don't hear nearly enough. And I would go so far as to say that if you if you lose, the thing is that the system is primed to usher the humility out of you. Right. Because everyone looks at you differentially. Everyone wants to know what you want them to do. Everybody's looking to you for for, you know, not in all cases, but in many cases for sort of direction and whatever. And and the systems in which many people are trained are also you are the best and brightest and this and that. And so it's it's very easy to let that seep in over time and let it convince you that you are something special and apart. But I feel like maintaining that sense of genuine humility is almost unmissably vital ethical context for anything else that you want to do, right? Like if you lose grasp of the humility, even your desires to do good often get turned toward ill. If you don't have that in in the foreground to temper them.
Eric Reinhart: [00:47:58] Yeah. And I feel like I often find physicians who are very focused on personal humility but have no traction on the idea that they are channeling a very narrow, specific way of knowing the world and are foreclosing the possibilities of knowing it otherwise and engaging with people on those grounds. And I think that kind of epistemic humility is what's really important for engaging with non-medical actors and building solidarities, because it's not about a token, Oh, I really think you're important. You have a important perspective, you know, But secretly, I know the truth about diabetes. Et cetera. You have to really, truly value that knowledge. And to do that, you have to be able to understand why these other ways of being in the world and seeing the world matter, what kinds of effects they have, what kind of potential they have.
Henry Bair: [00:48:42] So, Eric, I recognize that most of our conversation so far has been about what you did prior to residency. I'd like to know now that you are a psychiatry resident, what's next for you? How do you plan to combine your anthropology interests and your experiences as a psychoanalyst to your psychiatry training?
Eric Reinhart: [00:49:03] You know, I don't fully know. I think it'll it'll shift over time. There are a bunch of different possibilities that open with this, with this combination of training backgrounds that I've had the privilege of taking a lot of time to acquire. And historically, one of the limits of psychoanalytic work is psychosis. This is a difficult terrain for psychoanalysis to effectively navigate on its own, and I think it has a lot of untapped potential, not untapped, but rarely tapped. There are certain lacanian groups, for example, that I think work very effectively with people with psychotic psychic structures. But I think the combination of psychoanalysis and psychiatry opens up new possibilities there. So I imagine that I will do some work clinically there. I think I'll continue psychoanalytic clinical work. But the most important conjunction for me is that all of these different years that I've spent have really underlined the necessity of thinking in a systems way and not just thinking in a systems way, but acting on systems. So my biggest interest right now is thinking about how we can build largely non-medical community based care systems that I think would render a lot of the medical and particularly psychiatric work we do largely obsolete because it would provide the kind of care that people actually need that they're not getting. They end up coming to medical and psychiatric institutions in pursuit of or as a consequence of not having received these other cares.
Eric Reinhart: [00:50:18] So I've been working on trying to build community health and justice worker programs that would employ particularly formerly incarcerated people, but other marginalized individuals to be empowered to produce the kind of care structures in a systematic form in communities to do this. One of the things that I've particularly been struck by in my psychiatric training is the vast majority, it seems to me, of crisis cases that present to the emergency department, for example, many of whom many of these individuals are subsequently hospitalized. Those crises did not need to come to pass. And so much of the policy response to this of the health care response is focused on the crisis itself and not prior to it was focused on non-police crisis response. For example, the mental health and policy world. Right now, why are we taking for granted that the crisis has to happen if you have just very basic housing structures, somebody who can check in on you every day or every other day or just, you know, community fabric and you can back up three weeks from when somebody gets to the emergency department. That presentation didn't need to happen. And that's not just about saving money. It's about, you know, preserving people's dignity and the fullness of their possibilities in life.
Eric Reinhart: [00:51:26] And I don't think that those changes are really going to come from within the psychiatric apparatus because it's not psychiatric care in many cases. These people need. That's not the most effective preventative care. It's not psychiatric, medical. It's community based social support that we are refusing to adequately invest. And we spend $4.3 trillion a year on health care. That's reactive. Why are we not investing in the preventative systems? And that's not work that ultimately I'm best qualified to do, but I might be able to leverage the credentials that I've acquired over these years to try to turn resources towards the kinds of communities that should be doing that work, that want to do that work, but don't have the institutional support, don't have the resources to do it. And sometimes I worry this is maybe going a bit too far, but I worry that our tendency to absorb problems within the psychiatric and medical apparatus ends up backfiring. We think it's progressive, like gun violence, for example. Well, we should think about this through the framework of epidemiology. We should think about this through through medicine and psychiatry. And in some ways that can be useful. But often what it ends up doing, I think, is absorbing these new, wider social domains into our medical apparatus, depoliticizing them, making them secondarily matters of policy.
Eric Reinhart: [00:52:34] And primarily first problems of pathology are inadequate, sufficient preventative medical care or psychiatric care. That then gives an alibi for policymakers and other officials to not invest in the kinds of basic social services and structures that people need. So where there's this increasing medicalization of policy domains, that ends up having a rather destructive effect for communities, you see this particular within psychiatry. So I'll use the term again, but a quick gloss on this is something that I think one of my projects is maybe to try to think about how do we shrink medicine and psychiatry, allocate what we have much more effectively, but shrink it so that it is not colonizing these domains that then are not attended to properly in policy and community based forms. And that's, I think, a difficult project because there are lots of vested interests in trying to continually expand this domain. So this is one of the things I think about in part because of my psychiatric training and the frustrations with how ineffective we often are in responding to the problems to present to us, because frankly, we shouldn't be the ones who are responding to it. But we're we're consuming the resources that then don't go to somebody else who could be better prepared to respond.
Henry Bair: [00:53:36] Well, with that, we want to thank you again for your time, Eric. A really thought provoking conversation and we appreciate so much your your stories and your insights.
Tyler Johnson: [00:53:44] Thank you so much, Eric. It's always nice to run into interesting people on Twitter and we appreciate that you would come and join us on the program and we wish you all the best of luck with the rest of your training.
Eric Reinhart: [00:53:53] Thank you. It's my pleasure.
Henry Bair: [00:53:56] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.thedoctorsart.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:54:15] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:54:29] I'm Henry Bair.
Tyler Johnson: [00:54:30] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.