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Chapter 4
Themes
Key
LitCharts assigns a color and icon to each theme in Fresh Fruit, Broken Bodies, which you can use to track the themes throughout the work.
Social Hierarchy and Violence
Global Pressures and Individual Choices
Labor and Immigration Policy
Bias in Healthcare
Anthropology and Activism
Summary
Analysis
When Holmes first arrived in San Miguel, local officials invited him to help out in the town’s small medical clinic. They complained that the doctor working there doesn’t speak Triqui and “doesn’t know anything.” In fact, Triqui workers repeatedly told Holmes that both Mexican and U.S. doctors “don’t know anything.” In this chapter, Holmes wants to explain why they feel this way by showing how doctors treated Abelino, Crescencio, and Bernardo.
To Holmes, Triqui people’s suspicion of doctors reflects a deep clash between the two group’s worldviews. When Triqui people say that doctors “don’t know anything,” this suggests that they don’t see, understand, or benefit from doctors’ expertise. As both an anthropologist and a physician, Holmes is particularly suited to understanding how this divide came to be.
Themes
The Clinical Gaze. Holmes explains that his two fields, medicine and anthropology, view the world in very different ways. But by combining them, scholars have examined how patients tell stories about illness and how structural violence causes it. Holmes wants to show how both these things also apply to healthcare professionals: social structures affect the way they do their jobs and the way they tell stories and understand illness shapes whether they effectively treat patients.
Medicine is biological and focuses on individual humans’ bodies and minds, while anthropology is qualitative and focuses on groups of people (communities and societies). This is why their fundamental worldview often clashes, but also why they can complement one another in such fruitful ways. Analyses of how patients narrate illness use anthropological tools to improve medicine. Meanwhile, social analyses of how structural violence causes illness—like the one that Holmes provided in his previous chapter—examine health and illness through an anthropological lens. Holmes combines both these approaches and takes them one step further by examining medical practitioners’ side of the story, too.
Themes
The influential philosopher and historian Michel Foucault argued that, at the end of the 18th century, doctors switched from viewing disease as a problem with “the whole person” to seeing it as located in a specific body part. As a result of this new “medical gaze,” they stopped paying attention to patients’ perceptions and stories. Today, many doctors try to work against this norm. But the “medical gaze” still leads most practitioners to objectify patients, viewing them as collections of body parts and diseases rather than individuals. This often prevents doctors from forming genuine relationships with their patients.
Foucault’s theory of the “medical gaze” allows Holmes to explain why doctors systematically ignore the social factors that make Triqui migrant workers sick. Namely, it’s about their perspective and assumptions—doctors are specifically trained to assume that illnesses are biological, not social. This is similar to how white Americans frequently think that Triqui people are lazy and stupid, when they’re really impoverished, forced to work in terrible conditions, and unable to communicate across a language barrier. Holmes describes this as a form of symbolic violence, which suggests that the medical gaze is, too: by assuming that all medical suffering is biological, doctors cover up, justify, and exacerbate social suffering.
Themes
Abelino’s Knee: Structure and Gaze in Migrant Health Care. Holmes explains what happens when Abelino seeks medical care. The doctor X-rays his knee, tells him to stop working in the fields, and sends him to physical therapy instead of giving him an injection that Abelino knows will alleviate his pain. Later, a different doctor tells Abelino to do lighter farm work, but Samantha, the administrative assistant, refuses to change his schedule. Abelino visits a traditional Triqui healer and his pain slightly improves, but not enough for him to return to work.
Abelino’s experience shows how doctors’ medical gaze leads them to give Triqui people ineffective medical treatment in the United States. Namely, because Abelino’s doctor assumes that his severe pain is merely biological, he ignores the way Abelino’s job forces him to overwork his knees. The doctor also ignores Abelino’s personal knowledge of his condition, as he assumes that his medical expertise makes his own analysis more accurate. As a result, he denies Abelino the treatment he already knows to work. Meanwhile, the traditional healer does help Abelino because he shares Abelino’s cultural context and is more likely to understand Abelino’s story. This shows that the personal aspect of medicine can often be as important as the biological aspect in treating people’s pain.
Themes
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Abelino tries to file for worker’s compensation. But the state asks him to work “lite duty” (which doesn’t exist on the farm), and the farm understates his pay and hours, so he gets little compensation. His knee doesn’t improve after weeks of physical therapy, so he goes to a rehabilitation clinic, where the doctor again sends him back to work. The doctor also decides that he bends over improperly and is an unreliable source, even though she never directly talks to him.
The state agency also offers Abelino ineffective solutions and inadequate compensation because it uses a one-size-fits-all approach and does not take his specific work circumstances into account. In other words, the system is not set up for migrant workers like Abelino, and as a result, it perpetuates structural violence on them by denying them the benefits it is supposed to provide. The rehabilitation doctor also assumes that medical practitioners always know best and thereby discounts Abelino’s understanding of his own experience. Ultimately, Abelino effectively gets denied medical treatment by a system that deliberately excludes him.
Themes
During a meeting about Abelino’s compensation, Samantha complains about having to go outside in the freezing winter temperatures to feed her horses. Holmes points out that the workers have neither heating nor insulation in their shacks, but through her complaints, Samantha diverts attention from this greater suffering. In the meeting, Abelino learns that he’ll lose his worker’s compensation when he leaves Washington to spend the winter in California. The government representative also tells him he can continue to do light work on the farm—which he later learns means picking strawberries.
Samantha’s story is a clear example of what Holmes calls symbolic violence: by focusing on her own limited suffering, she distracts from Abelino and the other migrant workers’ far greater suffering sleeping outside in freezing temperatures. Holmes suggests that she’s really doing this for herself, so that she can avoid thinking about her responsibility for the workers’ pain and suffering. Then, the state essentially repeats the same process: based on a technicality, it rejects Abelino’s call for help and mixes up the cause of his illness with the cure.
Themes
Abelino finally gets the injections he’s been asking for, and his pain significantly improves. His physical therapist notes that the doctors prioritized their “Objective” scans over his “Subjective” reports of pain, and Holmes concludes that this led them to mix up cause and effect, prescribing Abelino more work for a work-related injury. While the government reports that Abelino has healed, his doctor claims that Abelino is lying, and the injections aren’t actually helping. When Abelino returns to Washington the next year, his knee pain comes back, too. However, based on an MRI scan, the government declares that he’s healed and denies him compensation.
Like Holmes, Abelino’s physical therapist understands how the medical gaze—or the preference for “Objective” measures of illness over “Subjective” ones—prevents doctors from adequately treating their patients’ illnesses. But Abelino’s doctor would rather assume that Abelino is lying than admit that her “Objective” treatments were ineffective, while the treatment he asked for actually worked. Similarly, the state decides whether Abelino is in pain by looking at a scan, rather than listening to his report of how he feels. This shows how deeply doctors and the medical establishment have internalized the medical gaze: they seem incapable of recognizing a medical problem that they can’t measure through their “Objective” methods. Of course, these methods only seem “Objective” because they focus on people’s biology, not their experiences.
Themes
It makes sense that Abelino thinks “doctors don’t know anything”—the medical system totally failed him. Holmes draws three conclusions about Abelino’s experience. First, Abelino’s doctors only trusted their own observations, while ignoring Abelino’s personal history, needs, and reported symptoms. Second, doctors blamed Abelino for his pain rather than seeing the structural factors behind it. Finally, because of the market forces in the U.S.’s for-profit healthcare industry, doctors have to make important decisions very quickly, with very little information or support. This shows that structural violence also affects healthcare professionals and compromises their work.
Holmes’s conclusions about Abelino’s treatment make it clear that the medical gaze often limits doctors as much as it helps them. However, much like farm executives implement exploitative working conditions because of economic pressures, doctors operate under the medical gaze because of certain practical pressures and limits on their profession. For instance, they didn’t have the time or energy to truly listen to Abelino and treat him as an individual (rather than as a body, interchangeable with anyone else). Similarly, they blame Abelino for his illness in part because they can’t do anything to change the social conditions that really caused it—the most they can do is advise him how to change his behavior as an individual.
Themes
The Field of Migrant Health. Holmes summarizes the health services his Triqui companions can access. In the Skagit Valley, a local clinic treats migrant workers and other local poor people one night a week for a $15 copay. A similar clinic in the Central Valley charges $30. In San Miguel, one nurse and one doctor alternate days at the government clinic, but they don’t speak Triqui. While nearby mestizo cities have better healthcare, the Oaxaca state government prevents other Triqui towns from getting clinics. Triqui people also visit traditional healers in both Oaxaca and the U.S.
While Triqui people have some access to medical care in both the U.S. and Mexico, they receive the worst care available in each respective country’s healthcare system. Similar to migrants’ health problems, migrant health clinics’ problems aren’t technical or scientific, but rather structural and distributional. Namely, migrant clinics need more staff and money. The fact that they don’t have enough suggests that the U.S. and Mexican governments do not consider Triqui people’s health a priority.
Themes
Structural Factors Affecting Migrant Health Clinicians. Holmes explains that migrant health clinics generally lack the necessary funding, equipment, and staff to provide a reasonable standard of care. One doctor tells Holmes how young migrants work themselves to the point of irreversible injury. Because the workers lack health insurance, the clinics can’t cover their costs and must spend valuable time cutting their budgets, seeking donations, and doing paperwork. Workers frequently miss appointments, move towns, and face language barriers—qualified translators are seldom available, especially for Triqui. In short, while migrant health clinicians sincerely care about their patients, the medical system is failing them.
Just as the global agriculture industry imposes structural violence on farm workers and managers by forcing them to minimize costs by any means necessary, the for-profit U.S. healthcare industry forces medical practitioners to prioritize cost over quality. This means that those unable to pay—like the Triqui migrants—end up with substandard care and nowhere to turn. Ultimately, clinics pass the structural violence they face from their economic conditions onto their patients, much like farm owners do to their workers. This multiplies the issues that doctors’ clinical gaze and prejudice create for patients.
Themes
Crescencio’s Headache: Structure and Gaze in Migrant Health Care. Rather than prescribing him medication, the doctor sends Crescencio to talk therapy, which he obviously can’t afford. Holmes later visits this doctor, who doesn’t remember Crescencio, but then looks at his file and explains that he has to take responsibility for his anger issues and stop beating his wife (which he isn’t doing). She never mentions the constant racist abuse that’s really causing his headaches, and she thinks he should stop drinking—even though the drinking alleviates his headaches. Ultimately, she assumes that Crescencio conforms to the racist stereotype of a violent, alcoholic Mexican domestic abuser. This reinforces the structural and symbolic violence that caused his headaches in the first place.
Crescencio’s doctor doesn’t even remember his case, which shows that she treats him more as a stereotype than as a patient. This fits with the idea of the medical gaze: she assumes that all men who present the same symptoms (drinking and anger towards their families) have the same basic problem (domestic abuse). However, in viewing Crescencio as interchangeable with her mental stereotype, she ends up ignoring his specific story, treating him inadequately, and compounding his sense of racial injury. This again shows how the medical gaze creates structural violence (by harming people at the bottom of social hierarchies, like Crescencio) and symbolic violence (by covering up those hierarchies and their effects).
Themes
The Gaze of Migrant Health Clinicians: Washington and California. Holmes argues that the way medical professionals perceive migrant workers strongly affects the way they treat them. Some doctors praise farmworkers for their bravery, perseverance, and respectfulness, while others complain that they don’t understand Western medicine and still visit traditional healers. These are really just deep cultural misunderstandings. Some are more severe than others: for instance, some doctors and nurses believe Mexicans have different kinds of bones or are predisposed to domestic violence, depression, and alcoholism. Other medical professionals point out that they almost never see these problems among migrant men.
Holmes emphasizes the diversity in medical professionals’ perspectives on migrant workers. Nevertheless, these varying perspectives are often based on strong stereotypes and unfounded assumptions. This leads doctors to treat migrants as interchangeable, rather than paying attention to their individual stories and needs. Holmes certainly hopes doctors can shed their empirically false negative beliefs about migrant workers and their bodies, but he also wants them to rethink their understanding of cultural sensitivity. This should mean understanding the way culture affects individuals, not assuming that everyone who belongs to a certain racial, ethnic, or cultural group has exactly the same beliefs.
Themes
Americans’ varying assumptions about migrants often have drastic consequences. For instance, Triqui people traditionally marry in their teens and usually do not register their marriages, so 17-year-old Triqui men often get imprisoned for years for having children with their 16-year-old wives. Doctors and social workers believe that migrant workers take advantage of social services like welfare and free healthcare—but the Triqui migrants didn’t mention using social services to Holmes even once. Similarly, one doctor complains that Mexican workers visit multiple doctors in the U.S., but another points out that this is because they face a severe language barrier and physicians who assume they’re lying. In short, public and medical attitudes toward migrants are varied and contradictory.
These deep cultural misunderstandings contribute to Triqui people’s marginalization in the U.S. As on the Tanaka Brothers Farm, structural and symbolic violence work together in the examples Holmes gives here. For instance, doctors’ cultural insensitivity forces Triqui people to visit multiple doctors in order to get adequate care (which is a form of structural violence because it prolongs and worsens their suffering). But these multiple visits lead insensitive doctors to assume that Triqui people are taking advantage of the system (which is a form of symbolic violence) and treat them even worse (which intensifies structural violence). This cycle of misunderstandings is similar to the way the structural violence of labor exploitation and the symbolic violence of racism work together on the Tanaka Brothers Farm and in U.S. immigration policy.
Themes
Bernardo’s Stomachache: Structure and Gaze in Migrant Health Care. Bernardo only speaks Triqui, so his Spanish-speaking daughter-in-law struggles to translate his broken Spanish into English for the English-speaking doctor. The doctor concludes that Bernardo has “no past medical history” and describes him as “an old boxer” with severe chest pain. (He really has stomach pain because the police tortured him.) Bernardo asks for the medicine he usually takes for his pain, but the doctors ignore him, so Bernardo leaves and returns to work. He later gets a $3,000 bill. In short, because he was overworked and lacked a translator, the doctor ignores Bernardo’s real complaint and blames him for his own injury.
Holmes shows that the doctor fails to treat Bernardo’s symptoms because of a severe language barrier. However, the doctor is either unaware of how this barrier distorts the information he receives, or is uninterested in overcoming the barrier and accurately understanding Bernardo’s condition. As with Abelino and Crescencio’s doctors, this shows how the medical gaze leads doctors to ignore social factors and amplify their patients’ suffering as a result. While financial and organizational pressures are also partially responsible for the inadequate treatment Bernardo receives, the consequences of the doctor’s medical gaze and these organizational failures ultimately fall on Bernardo’s shoulders. His $3,000 bill for a useless doctor’s visit shows how structural violence gets passed down social hierarchies, leaving people at the bottom to suffer the worst of it.
Themes
Holmes also interviews Bernardo’s doctor in Oaxaca, who blames Bernardo’s pain on Triqui people’s poor eating habits. Rather than seeing the specific political and economic causes behind Bernardo’s pain, this doctor attributes it to his belief that Indigenous people are behaviorally and culturally inferior.
Healthcare perpetuates structural and symbolic violence similarly in different places: mestizo doctors in Mexico look down on Triqui patients much like white English-speaking doctors in the U.S.
Themes
The Gaze of Migrant Health Clinicians: San Miguel, Oaxaca. Holmes describes San Miguel’s small, government-funded health clinic. Poor local women supply water to the clinic, which is usually closed, even during its official hours. Its mestizo staff misunderstands and looks down on the local Triqui people’s culture. For instance, they criticize Triqui people’s resistance to family planning but don’t care about the town’s widespread illiteracy. They blame local health problems on the community’s “custom[s]”—like living three families to a house, burning their trash, and using toilets inconsistently. Of course, these are the result of poverty and poor infrastructure, not Triqui culture.
Although the health clinic is supposed to serve the town community, in reality, the town ends up serving the health clinic (for instance, by providing its staff with water and changing community norms in order to meet the clinic’s expectations). Like the U.S. doctors who mistreated Abelino, Crescencio, and Bernardo, the staff at the San Miguel health clinic blames the victims and reverses cause and effect. Specifically, they wrongly assume that people choose living conditions that are really the product of poverty. This is also similar to the way the U.S. public and politicians frequently blame immigrants for choosing to cross the border illegally, instead of understanding the real social, political, and economic factors that drive them to migrate.
Themes
The local nurse blames mothers for feeding their children poorly, but she doesn’t understand that the mothers can’t afford to buy nutritious food. In fact, this nurse classifies Triqui children as malnourished based on an index developed for mestizo children in Mexico City. She openly tells Holmes that she wants to leave San Miguel, where she feels the locals don’t recognize or appreciate her efforts. She talks down to her patients, gives them the wrong medicine, and closes the clinic early, but she justifies this by claiming that Triqui people “are lazy, dirty, ignorant, mean gossipers” unworthy of her time and energy. In fact, they are often dirty, but only becuase they don’t have running water and it’s very difficult for them to bathe. (In San Miguel, Holmes can only bathe once a week.) Eventually, this nurse gets fired and replaced.
More than any of the other health professionals Holmes has interviewed in this chapter, the mestizo nurse in San Miguel openly shares her insensitivity and prejudice towards the people she’s supposed to treat. Her attitudes clearly illustrate how health workers can easily miss relevant context about their patients’ lives. This can lead them to blame people for health problems that are really the result of structural violence. In fact, as Holmes explains in the next chapter, blaming the victim is one of the most common and pervasive forms of symbolic violence.
Themes
The new nurse in San Miguel also views Triquis as inferior: she thinks they’re overindulgent, lawless, and primitive, which is why they cross the border. In fact, she even blames Triqui people for the clinic’s own failures: when a mother loses her baby after the clinic doctor refuses to treat its infection, the nurse claims that it was the woman’s fault for not seeking proper medical attention in town. Ultimately, San Miguel’s medical staff lack resources, are forced to work hours away from home by the government, and don’t understand Triqui people’s culture, history, or social context. As a result, just like the doctors Triqui migrants visit in the U.S., these mestizo doctors blame patients for their illnesses, perpetuate racist stereotypes, and provide inadequate and sometimes outright harmful treatment.
The new nurse mostly agrees with the old nurse’s beliefs about Triqui people, which signals that their prejudices are not uncommon. Holmes strongly implies that Triqui people probably don’t readily seek medical care or trust doctors because of their past interactions with the clinic. In turn, this might give new nurses and doctors the impression that Triqui people don’t understand or believe in Western medicine. Regardless, the pattern of distrust and misunderstanding leads doctors and nurses to abdicate their duty to help and Triqui people to conclude, like Abelino, that “doctors don’t know anything.” The infant’s death shows how this can have tragic consequences.
Themes
Acontextual Medicine and Apolitical Cultural Competency. Holmes concludes that doctors almost never examine how their patients’ social and economic contexts contribute to illness. In fact, clinicians fail to understand these contexts because of social, political, and economic forces like their busy schedules, their lack of resources, and the “medical gaze” they’re trained to adopt. This leads them to prioritize data over people’s experiences and blame disease on malfunctioning bodies, not social, cultural, or political factors. In turn, they blame patients for their own suffering.
Ultimately, Holmes’s central problem with the medical gaze is that it’s “acontextual.” This means that doctors view people’s bodies in isolation: they try to understand and fix the body’s problems without trying to understand what created those problems. Of course, fixing these problems often requires social and political change, not just biological interventions, which means that medicine is not always enough to solve them. Nevertheless, Holmes thinks that doctors can heal suffering more effectively if they acknowledge these limits than if they pretend they don’t exist.
Themes
Many doctors try to address this problem through cultural competency training, which often reinforces stereotypes and teaches doctors to view patients’ cultural beliefs as a barrier to effective treatment. But Holmes’s research shows that healthcare’s culture is the real problem. He proposes “structural competency” instead. When they don’t understand structural violence, doctors tend to reinforce it. They also often justify the hierarchies that cause it through symbolic violence. However, the U.S. also needs to restructure its healthcare system to make it more accessible and equitable.
As Holmes shows, doctors often conflate cultural competency with harmful stereotypes. This prevents them from treating their patients adequately. For instance, Abelino’s doctor insisted that he was an unreliable source, incapable of really understanding his own body because he did not think like her, in terms of the medical gaze. In other words, the doctor viewed cultural competency as meaning that some people think about their bodies incorrectly because of their culture. However, Holmes’s structural competency means doctors learning how to put their own incorrect assumptions about the body aside, so that they can treat patients as individuals with complete lives, rather than collections of body parts.
Themes
