Editors' Preface: Difference and Identity in Medicine

Calls from within the field of medicine have asked nurses, doctors, and other health-care workers to become more aware of matters of difference. "[B]ias in health care must be corrected not by medical ombudsmen, or by legislation . . . but by a focus on the individual—individual patients and individual doctors," Abraham Verghese writes in the article "Showing Doctors Their Biases."¹ Mary Lebreck Kelley and Virginia Macken Fitzsimons's work teaches nurses to understand cultural diversity in clinical practice.² Medical humanities programs promote awareness of the social aspects of medicine, and the Association of American Medical Colleges has recently instituted cultural competencies for clinical interaction for the training of medical students.

These are timely and much-needed developments. Yet current efforts to impart understandings of the cultural and cross-cultural aspects of medicine suffer from an important limitation: within a medical system whose currency is diagnosis, difference is often defined through disease. Medical students learn, for instance, that African Americans are more likely to suffer from sickle-cell anemia, that women have a propensity for osteoporosis, and that schizophrenia preferentially afflicts the poor.

This special issue of Literature and Medicine focuses on difference and identity in the context of disease and disability. We explore the complex ways in which notions of disease, disability, and difference are intimately related and in which bodies marked by particular gender, racial, disability, sexuality, and ethnic identities experience disease in specific ways. Behind our investigation lies an assumption that understanding cultures and cultural ideologies is central to understanding bodies and diseases. For instance, osteoporosis is complicated by a number of factors that cannot be explained by individual pathology alone. Access to nutritional resources, cultural dietary practices, and types of labor all influence the manifestation, duration, and even the visibility of the disease. As another example, the different definitions of epilepsy between Hmong and American cultures, as described in Anne Fadiman's The Spirit Catches You and You Fall Down, arise from divergent assumptions about religion, wellness, disease, spirit, and soul. In her account, the Western medical establishment's inability to recognize these differences frustrates the well-intentioned efforts of doctors and nurses to treat a Hmong child.³

We acknowledge and build upon recent efforts of scholars in the social sciences to examine the centrality of identity to constructions of illness and health.⁴ Yet the essays in this issue take decidedly humanities-based approaches to the subject in order to emphasize an awareness of and sensitivity to difference through forms of symbolic representation such as metaphor and narrative. The authors of these essays promote exploration of cultural assumptions about values, normality, and deviance while enabling appreciation for the particular and the idiosyncratic. Taken together, this issue highlights how the humanities are particularly adept at enhancing qualities that all good clinicians must possess in abundance: imagination and the inner resources to confront the unexpected. Along the way, we hope readers will learn to negotiate what academic psychiatrists Alexander Ortega and Robert Rosenheck call the effect of matters of difference "on symptom presentation" and to realize how beliefs about difference shape their own diagnostic perceptions.⁵

One way that the essays in this volume promote new understandings of difference and identity is through the exploration of visual knowledge. Medicine would not be what it is today without a long history of its concepts and competencies being presented, regularized, and disseminated visually. From Chinese acupuncture charts, to Vesalius's anatomical illustrations, to contemporary MRI scans, medical personnel have used images to train their eyes and sharpen their diagnostic capabilities, all the while acquiring sophisticated skill at interpreting and deploying visual cues. Yet the work of making sense of an image requires more than a mere recording of facts. For example, the knowledge required for comprehending images such as a Chinese yin-yang symbol or an American ultrasound scan depends upon the intricate interplay of history, experience, cultures of representation, and many other factors that help shape modalities of seeing. Scholars such as Sue Sun, Stephen Rachman, Robert Goler, and Sander Gilman tap into this process, in which...