The biotechnical embrace.

This essay discusses three interpretive concepts that link bioscience and biotechnology to society: the medical imaginary, the biotechnical embrace, and the clinical narrative. Drawing on research carried out in the United States and internationally on the culture and political economy of biomedicine, the essay examines these interpretive concepts through examples from studies of patients, clinicians, scientists, and venture capitalists engaged in the worlds of oncology and high technology medicine. These interpretive concepts contribute to an understanding of how the affective dimensions of the experience of patients, clinicians and scientists invested in high technology medicine are fundamental to bioscience and biomedicine, and to the political economy and culture of hope.

Physicians' discourses on malpractice and the meaning of medical malpractice.

Recent analyses of the professions have considered the question of the changing nature of professional power. This study is an interpretive analysis of the meaning of physicians' discourse in the face of a perceived challenge to the traditional boundaries of clinical practice from malpractice suits. The data for this analysis were drawn from interviews with physicians from three specialties and from documents produced by the AMA/Specialty Society. Four modes of discourse were observed: (1) affective lament; (2) rejection of tort law; (3) complaints about a deterioration in the culture of clinical practice; and (4) a call for active campaigning. Analysis of the modes of discourse highlights both the ways in which professional power is subjected to challenge and the forms of political, financial, and cultural struggle that professional organizations and individuals engage in to resist such challenges.

Cultural studies of biomedicine: an agenda for research.

This paper outlines a 'cultural studies' approach to investigations of the transnational world of contemporary biomedicine. Although biomedicine is fostered by an international political economy and global community of medical educators and bioscientists, it is taught, practiced, organized and consumed in local contexts. This essay argues that cultural studies of contemporary biomedicine should focus on the dynamic relationship between local and international worlds of knowledge, technology and practice. Three issues illustrate this approach: (1) an exploration of the tensions inherent in the local and cosmopolitan shaping of 'clinical narratives', with examples drawn from comparative studies of oncology; (2) an exploration of the influence of biomedical research findings and international clinical trials on the production of clinical narratives, with examples drawn from current research on breast cancer; and (3) an exploration of the local or national and 'international' or 'transnational' dimensions of the production of biotechnologies and pharmaceutical therapeutics. The essay concludes with a discussion of the limits that privilege either universal or local perspectives and claims to knowledge and the ethical challenges that become apparent from this perspective.

In the subjunctive mode: epilepsy narratives in Turkey.

Careful analysis of transcripts of interviews we conducted with a sample of persons identified as suffering epilepsy or seizure disorders in an epidemiological study in Turkey revealed not only that life stories of illness have an overall narrative structure but that the interviews were composed as a corpus of shorter stories. Analytic concepts from reader response theory bring attention to aspects of both the overall life story and the stories told about illness. In particular, we identify 'subjunctivizing tactics' present in the narrative representation of illness that allow sufferers and their families to justify continued care-seeking and to maintain hope for positive, even 'miraculous,' outcomes. In particular, these narratives maintain multiple perspectives and the potential for multiple readings, suggesting alternative plots about source and outcome of illness, and they represent potency and the possibilities for healing through stories of encounters with the mysterious.

Oncology and narrative time.

Oncologists encounter the uncertainty of time horizons in their patients' lives. Although American oncologists are given a cultural mandate to instill hope in the therapeutic narratives they create with patients, uncertainty leads them to expressions of time without horizons or of time with highly foreshortened horizons as they seek to create for patients an experience of immediacy rather than of chronology. The distinctiveness of the American pattern is highlighted through comparison with Japanese exemplar cases and stories of therapeutic practices in oncology. Concepts drawn from narrative analysis of temporality and the construction of the therapeutic plot are employed.

Women, poverty and AIDS: an introduction.

PIP: By the mid-1990s, global human immunodeficiency virus (HIV) infections among women are expected to equal those among men. This trend reflects economic, political, and cultural factors that limit women's ability to protect themselves from HIV transmission. Studies in developing countries have indicated that HIV-infected women (other than sex workers) do not average significantly more sex partners than uninfected controls; the chief risk factors are poverty, migration to urban centers for employment as domestics, and sexual contact with soldiers or truck drivers. Social marketing projects aimed at increasing condom availability overlook the fact that, in many cultures, fidelity is confirmed by having sex without a condom. The same social forces that place poor women at greater risk of HIV infection are responsible for the inadequate allocation of resources to assist women with HIV and those who serve as caretakers of infected family members. The articles in this monograph illustrate the interaction of acquired immunodeficiency syndrome (AIDS), gender, and poverty in North America and on a global level.^ieng

Local knowledge: research capacity building in international health.

Processes of building research capacity in international health projects and their implications for anthropology are addressed using examples from the Applied Diarrheal Disease Research project funded by the United States Agency for International Development. Two aspects of training are examined: the way interdisciplinary methods--qualitative and quantitative approaches--are presented to researchers, given the context of international health research culture; and how researchers' local knowledge and local concerns in pursuing health research relevant to policy led them to become interested in anthropology. The consequences for anthropology's place and product in future capacity building efforts in international health research are discussed.

Mothers' fear of child death due to acute diarrhoea: a study in urban and rural communities in northern Punjab, Pakistan.

The investigation of cultural models of diarrhoeal illness which are employed by mothers and their emotional responses to children's illnesses is presented in a study of 595 households in urban and rural communities in Punjab, Pakistan. The household survey of mothers of children 0-36 months was complemented with in-depth interviews of a subsample of 70 mothers. Findings indicate that diarrhoea must be regarded not only as a disease but as a symptom belonging to several popular illness categories. Mothers' emotional responses to symptoms are in part shaped by the illness categories to which they assign a child's diarrhoea episode, and maternal fears that symptoms of diarrhoea may be life threatening are associated with previous experiences with death of children, with treatment choices and help-seeking. A significantly higher proportion of mothers who fear diarrhoea to be life threatening to their children than mothers with other concerns choose to use NIMKOL, the Pakistan ORS. The necessity of recognizing the complexity of interpretive and emotional processes which shape the care of children and the home treatment of childhood disease is emphasized.

Localization and quantification of epidermal growth factor receptors on single cells by confocal laser scanning microscopy.

We have established a method for quantifying binding of fluorescence-labeled growth factors to their receptors on single cells in situ with the confocal laser scanning microscope (CLSM). Biotinylated epidermal growth factor (EGF) coupled to phycoerythrin-labeled anti-biotin was used to compare the levels of fluorescence on three different cell types for which the number of EGF factors was known from Scatchard analysis of [125I]-EGF binding. The results showed that as few as 10,000 receptors/cell were detectable above back-ground. This method will provide a rapid and quantifiable alternative to autoradiography for ligand binding to single cells in situ.

Organization of non-muscle myosin during early murine embryonic differentiation.

A monoclonal antibody (3D10) recognizing myosin heavy chain was isolated following immunization with a synthetic peptide sequence of eight amino acids. The antibody reacted with purified rabbit skeletal myosin and light mero-myosin in enzyme-linked immunosorbent assays and Western immunoblotting. A band of approximately 200 kDa was detected in cell extracts of an embryonal carcinoma (EC) cell line (P19EC) and one of its cloned differentiated derivatives, suggesting reactivity against non-muscle myosin. By indirect immunofluorescence, typical myosin banding patterns were observed in cryostat sections of human skeletal and cardiac muscle tissue. In undifferentiated P19EC cells, speckled immunofluorescent staining was observed in the cytoplasm that became organized in cortical rings where the cells made direct contact with each other. These rings consisted of circular bundles of F-actin decorated by myosin. Undifferentiated embryonic stem (ES) cells derived directly from mouse embryos shared the same features, although the pattern was less pronounced. Human testicular primary germ cell tumours showed cortical staining in the embryonal carcinoma component reminiscent of the staining of EC cells in vitro while cytoplasmic staining was observed in tumour cells with a differentiated morphology. In preimplantation embryos, the immunofluorescent staining was observed at cell apices of blastomeres of morula stage embryos. In blastocysts, staining of inner cell mass cells was not detectable. By contrast, various differentiated derivatives of P19EC contained extensive F-actin microfilament bundles throughout the cytoplasm decorated with myosin. Thick stress fibers in filopodious extensions of cells were particularly highly decorated by myosin. Over the nucleus, linear arrays of myosin containing speckled patterns of immunofluorescence were observed that were not associated with F-actin. The same pattern of staining could be observed in trophectoderm cells of the blastocyst. We conclude that embryonic non-muscle myosin is organized in specific patterns depending on the state of differentiation. As the myosin is primarily associated with F-actin we suspect that it forms part of a contractile apparatus that may have significance during embryonic development.

Patients' preferences for learning the results of mammographic examinations.

The communication of diagnostic test results is an important aspect of the interaction between doctors and patients. Communication of mammogram results is of particular interest because the test is used to detect a common and potentially dangerous malignancy and because patients in the United States are able in some locations to obtain mammography at their own request, rather than being referred by a physician. We conducted a survey to learn about the preferences of a group of women at a traditional mammography center for learning the results of this commonly performed test. We asked women undergoing mammography to respond to questionnaires designed to learn: 1) How they felt about different methods of telling patients the results of mammograms; 2) How they were informed of the results of previous mammograms; 3) How they were told the results of the current mammograms. Patients indicated that if no abnormality is detected, they prefer to have their doctor call with the result, but if the study is 'abnormal' they wish to be told by their own physician in the office. Failing to notify the patient if the study is normal was the least preferred outcome. This group of patients did not express an interest in the most immediate form of notification (i.e. learning the result from the radiologist performing the test). Analysis of how patients felt about ways in which they were previously informed of the results of mammograms suggests that their reactions are influenced to a large extent by their clinical status. Patients undergoing mammography for diagnostic purposes, for example, were less pleased by a 'preferred' method (i.e. being told by their physician) than were those undergoing screening mammography. While patients have opinions about how they would prefer to be told their mammogram results, they are accepting a variety of methods of telling, if they are receiving good news. If abnormalities are found, patients prefer to be told in person by their own physician. Interpretations of surveys of patient satisfaction should be tempered by the finding that the clinical status of the patient alters their perceptions of satisfaction with this aspect of their physician's behavior. Patient preferences may change if increasing numbers of women are told their results by the radiologist.

Feeding practices for young Pakistani children: usual diet and diet during diarrhoea.

Diarrhoea is among the foremost disorders responsible for high mortality and morbidity in children of third world countries. In addition, improper feeding during diarrhoea leads to a vicious cycle of frequent episodes of diarrhoea and malnutrition in these children. In this study 595 households (200 urban and 395 rural) with 741 children who met the age criteria of 36 months or less were randomly selected for assessing the feeding practices during diarrhoea. Out of these, 276 (37%) were infants and 465 (63%) were toddlers. The majority of both breastfed and non breastfed children were also receiving solids and liquid foods. Animal milk was used by 89% of non-breastfed children. Forty six percent of breastfed and 78% of non-breastfed children were given "Khitchri" (rice cooked with lentils) as a solid diet. During diarrhoeal episodes, most mothers (70%) continued breast feeding their children. Whereas, 53% children also received solid and semi-solid diet which was either "Khitchri" or banana as mentioned by more than half of the respondents. The majority of mothers (97%) considered breast-feeding to be a good practice during childhood diarrhoea.

Oncologists vary in their willingness to undertake anti-cancer therapies.

Previous studies have shown that groups of cancer sub-specialists differ in their stated willingness to undergo treatment for diseases lying within their area of expertise. In order to learn whether oncologists feel similarly about other forms of cancer, medical, radiation, and surgical oncologists were asked to fill out a questionnaire indicating whether they would be willing to undergo either chemotherapy or radiation therapy for a variety of common malignancies, or recommend them to a spouse or sibling. Subjects were also asked whether they would undertake an experimental therapy (interleukin-2) for any of three malignancies, or recommend such treatment to a spouse or relative. Fifty-one oncologists (14 radiation oncologists, 14 surgical oncologists, and 23 medical oncologists) were recruited from the staff of four university teaching hospitals. Although they agreed about accepting or declining therapy for some examples, there was considerable heterogeneity in their responses. In only 37% of the 30 cases involving standard therapies did greater than or equal to 85% of the oncologists agree that they would accept or refuse therapy. Only some of the variation of the responses could be attributed to the sub-specialty orientation of the oncologists. Physicians were as willing to recommend standard therapies for themselves as a spouse or sibling. Physicians were also divided in their opinion about whether they would accept a particular experimental therapy if diagnosed with one of three neoplasms. They were significantly more likely, however, to recommend it for a spouse or sibling than to accept it for themselves. Variation in the proportion of patients who receive anti-cancer therapies may relate, in part, to differences in opinion concerning the worth of such therapies among oncologists or primary physicians. This study shows that oncologists are quite heterogeneous with regard to their personal preferences for anti-cancer treatments for a variety of malignancies. Further studies are required to learn if such attitudes (among oncologists or primary physicians) directly affect the administration of such therapies.

Filipin-sterol complexes in molluscan gill ciliated epithelial cell membranes: intercalation into ciliary necklaces and induction of gap junctional particle arrays.

Freeze-fracture electron microscopy has been used in conjunction with the antibiotic filipin to investigate possible differences in the distribution of sterols in ciliary and somatic cell membranes of scallop and mussel gill epithelial cells. Contrary to previous reports, we find that filipin-sterol lesions can occur among the strands of the ciliary necklace but they are partially excluded from the smooth neck region above the necklace where the membrane is tightly apposed to the axonemal microtubules. No obvious differences in filipin-sterol lesions occur in the membranes of mussel gill cilia of varying mechanical sensitivity. Although abundant in the apical plasma membrane, filipin-sterol complexes are rare within the membranes of microvilli. Filipin-sterol lesions form outside the loosely parallel particle strands of septate junctions, sometimes increasing their relative orderliness. At sufficiently high density, filipin-sterol protrusions within the plasma membrane result in mass aggregation of gap junctions, possibly through recruitment of unorganized connexons.

American oncology and the discourse on hope.

From the perspective of medical anthropology and comparative research, American oncology appears as a unique variant of international biomedical culture, particularly when contrasted with oncological practice in societies such as Japan and Italy. Based on interviews with 51 oncologists in Harvard teaching hospitals, this paper argues that American oncological practice draws on distinctive cultural meanings associated with "hope" and is infused with popular notions about the relationship between psyche and soma, the progressive efficacy of biotechnical interventions, truth-telling, and the nature of the physician-patient relationship.

Mechanical sensitivity and cell coupling in the ciliated epithelial cells of Mytilus edulis gill. An ultrastructural and developmental analysis.

Transmission electron microscopy has not provided strong evidence for gap junctions in Mytilus edulis gill tissue, in spite of extensive physiological evidence for coupled ciliary arrest in lateral cells and coupled activation in abfrontal cells. To investigate the kinds and relative distribution of cell junctions and also to determine whether ciliary membrane particle differences exist in these two types of oppositely mechanically sensitive cells, we analyzed the structure of these and two other ciliated cell types (frontal and laterofrontal) by freeze-fracture replication. Gap junctions occur in all four ciliated cell types, but they are relatively small and of variable morphology, often consisting of elongate, winding complexes of membrane particles. Statistically, such structures rarely would be recognized as gap junctions in thin sections. Gap junctions appear to be most abundant between the highly coupled abfrontal cells, minimal between laterofrontal cells, and not evident in the epithelial cells that separate coupled ciliated cell types. The ciliary necklaces of the mechanically activated abfrontal cilia are typically 4- or 5-stranded while those of the remaining three cell types are mainly 3-stranded. In developing gill tips, ciliated cells have abundant gap junctions and newly formed cilia have a full complement of necklace particles. Nascent lateral cilia are not mechanically sensitive, indicating that the acquisition of mechanosensitivity does not correlate with the presence of ciliary necklace or other membrane particles. Lateral and laterofrontal cells become sensitive to neurotransmitters soon after the appearance of the latter during development, but mechanosensitivity of both lateral and abfrontal cells arises substantially later.

Telling the diagnosis of cancer.

Although a concensus has emerged in this country that patients should be told when cancer is discovered, no data is available to indicate how and where patients are currently told that they have cancer. Fifty-five patients undergoing anticancer therapy were therefore interviewed to learn how this process occurs. The majority of patients were told by surgeons (74%) and only a minority by primary care physicians (11%). Most were told in a traditional medical setting (42% in the doctor's office, 17% in a hospital room), but 23% were told over the telephone and 19% in the recovery room. Two indicators of patient satisfaction with the telling process suggested that different sites of telling were not equivalent. Patients told over the telephone or in the recovery room were more likely to describe the telling in negative terms and less likely to describe their doctors as being helpful in understanding their illness than those told in a doctor's office or in their hospital bed. This pilot study indicates considerable variation in this aspect of patient care and suggests directions for future research. To determine whether interviews that explore these issues with cancer patients are unpleasant or stressful, patients' reactions to being subjects in this study were sought. Patients asked directly at the completion of the interview or surveyed 2 to 4 months later said the interview had been helpful and/or a positive experience. None expressed negative feelings about participating. Concerns about the psychological harm resulting from such study of this patient group do not appear to be warranted and should not impede future research.

Disabling practitioners: hazards of learning to be a doctor in American medical education.

Ongoing work with first and second-year medical students suggests that American medical culture is characterized by a juxtaposition of notions of "competence" and "caring," and that the training of students to be competent physicians requires a reconstruction of "common sense" views of the patient, of sickness, and of the personal boundaries of the medical student. Contradictions that arise from efforts to maintain qualities of caring while undergoing these changes are highlighted.

Ritual, the state, and the transformation of emotional discourse in Iranian society.

This paper explores the social and cultural organization of Iranian emotional discourse and its transformation in post-revolutionary Iran. First, the Moharram dramas we participated in during field research are described, indicating how these performances organized a 'prototypical' view of the social order, the self, and the passions. Using Kapferer's distinction between "transcendental" and "transformative" rituals, we argue that these dramas were traditionally organized as "transcendental" rites. Second, data on grieving rituals and depressive illness among Iranians is introduced, focusing on the "transformative" qualities of mourning rites and suggesting an interpretation of depression as a failure of the "work of culture." Third, the appropriation of these symbolic forms of society, self, and the emotions by the current Iranian Islamic state and the role of the state in defining the meaning and legitimacy of emotions and their expression is analyzed.