How medicine and anthropology merge in caretaking | Interview with Dr. Arthur Kleinman

00:18How it all started

Jed Macosko: Hi, I’m Dr. Jed Macosko at AcademicInfluence.com and Wake Forrest University, and today we have another wonderful guest, Professor Arthur Kleinman who’s gonna tell us a little bit about how he found his career when he was a younger person.

So, Professor Kleinman, can you tell us a little bit about that?

Arthur Kleinman: Sure. First of all, let me say, it’s a pleasure to be here and to be speaking to high school students who I think are where the action is.

So, well, I came from a business family and no one really in my family had a strong academic interest, but when I went to school, I did. I had a strong intellectual interest and that intellectual interest in part was because I had two names. I had, until I was 12 years of age, in school, I was Arthur Schtier, or Stier really, it is the way it was pronounced and at home and then outside in the world, I was Arthur Kleinman.

And that’s because my mother divorced when I was young and it wasn’t until I was 12 years of age that I even learned about or knew about the fact that I came from some other family, and that my step father wasn’t my biological father.

And that was in the era in the 1940s, when people were very loathed to talk about divorce or about complex family situations, so I found they’re all mystery and not surprisingly, I got very involved in trying to interpret things, interpret the world around me, my family, who I was, and I had these strong intellectual urges.

I was interested in ideas, I was an incredibly a developed reader, I was intense in my concern for figuring out the world and bringing meaning to my life. And all of that cohered, not in high school so much, but when I got to university and I want to Stanford University, and when I was at Stanford, I developed a strong historical and anthropological sense of the world around way and I was particularly interested in understanding how other people besides me figured out their worlds, figured out who they were, what their families were, what their backgrounds were, where they were headed and this conspired over time.

So that when I was at Stanford Medical School, I became much more interested in the personal and social aspects of illness and of caregiving than I did with the mechanical details of say surgery or biotechnology, et cetera. And that placed me in the realm of people who end up going into psychiatry and that’s what I went into, but I comfortably…

Jed: That’s what I was gonna ask, you must have been really perfect for psychiatry.

Arthur: Yeah, I was perfect for psychiatry, but I felt that psychiatry was not perfect for me because it seemed to focus only on the inner workings of a person, and I had come to realize that every person is responding to their social world, what I call their local worlds.

And so, I needed something beyond psychiatry that could enrich psychiatry and also bring something new, and that was anthropology. And since I was interested in kinda trying to…

Jed: Yeah, how did you even know about… Yeah, sorry to interrupt, but how did you even know about this field? Had you taken some classes in it when you were in undergraduate at Stanford or did you hear about it from friends or what was the connection?

Arthur: No, it actually was a kind of a counter to that. Like when I was at Stanford, as an undergraduate, I’d taken no anthropology, but I had taken and majored in history, and so even though I was a pre-med student, I majored in history, that’s an easy thing to do.

Today you can major in humanities, social sciences, whatever, and at that time it was a little unusual, so I had a historical sense of the background of where things came from, of the need to re-socialize problems, that is to see problems not as just natural or biological or physical, but to see them in their social concepts.

So for example, today, when we think of COVID and the COVID epidemic, all the social worlds of people come to mind. African-Americans and people of Latino background who are having a rougher time in the COVID than white Americans.

Well, that’s part of social suffering. Structural violence, racism, etcetera, all that was interesting to me at the time, but very few people were knowledgeable about it or interested in it.

And when I went to medical school, my second year in medical school, I was really tired of the biology and the chemistry, and the labs and I went to hear a lecture by the new head of psychiatry at Stanford at that time, and he became my mentor, his name was David Hamburg, and after the lecture I was so excited about what he talked about, which was the way the social world came into the body and affected who you were.

I said, “Oh God, I wanna do exactly what you’re doing. This is what I wanna do.” And David became a career-long mentor of mine. And when I was in medical school, I was also deeply impressed by the social problems that people brought to medicine and also by the potential for social solutions. This happened in many ways.

So for example, when I was a young medical student on a surgical service or a burn service, I was with a seven-year-old girl who had been terribly burned in much of her body, and every day she had to undergo the horrible ritual of being placed in a bath of water in which the burned tissue was tweezer-ed away from her by a surgeon and a nurse and I was there simply as the young medical student to observe and hold her hand.

Jed: Ah! And this is…

Arthur: And after a couple of days, I literally couldn’t take it any more because she was screaming and yelling. And so I turned to her and I said, “How do you endure this? How do you get through this?”

And I was amazed that she stopped crying, she stopped shouting, she squeezed my hand hard and she told me and I realized from that and from number of other encounters that you could talk to patients and actually ask them what they were feeling, what they were going through, and that you could intervene because just by asking that question, being at with them and ask, “How do you go through this?”

It changed entirely her response to the daily bath and the tweezing of the dead tissue. She looked at me and talked to me and allowed me to sort of enter her world and help her. And I realized, probably you can do some amazing things just by talking to people.

08:51China and depression

Arthur: I did many things in my life and one of the things that I’ve done, because I have worked in China, lived in China for a long time, is I was the first person to introduce the modern idea of depression into China.

In 1978, when I first went to China, the Chinese did not use the idea of depression. Almost no patients were ever diagnosed with that, and yet that was the commonest diagnosis in the rest of the world for psychiatry. So I just couldn’t understand it.

And then I slowly learned that it was at that time, it’s changed radically now, China but at that time, it was really socially impermissible to talk about your deep feelings in public or with others who you didn’t know but what you could talk about was your bodily complaints, and so these bodily complaints often were metaphors for what you have experienced and what others have experienced.

And so I studied clearly these complaints and how they related to depression. There were very common symptoms, they were pain usually pain in the head or in the back, they were exhaustion or fatigue and dizziness. They were the commonest complaints that people, I was studying gave.

And I slowly worked out with them and with those people around them that this was really a way of talking indirectly about the social world. So they had just come out of a miserable, awful time that went from 1966 to ’76 in China that was called the Great Proletarian Cultural Revolution and during the Cultural Revolution, these people I studied had had terrible experiences.

They had been sent to remote villages in the countryside and treated terribly. They had been fired from their jobs, they had their possessions destroyed, they had been terrorized, etcetera.

And these three complaints conveyed that indirect, the pain, where they were talking of the pain in their head or the pain in their back, it was really the only way in which they can talk about the pain that came out of this horrible time.

The dizziness related to the chaos of that period and the sheer up and down, one day someone was up, next day they were down, the uncertainty chaos, the confusion of the time was that these dizziness. People were dizzied by the various political movements, etcetera.

And then the third complaint, the exhaustion and the fatigue was that they had had enough, they had put so much energy into this, they had been so hurt, they have been so defended, that they had expended their vitality, and they were just so totally exhausted and all these symptoms, by the away, are fairly common symptoms associated with depression.

In America, we think of depression as a psychological problem, but really it also has physical dimensions to it and those include fatigue and being unable to concentrate, feeling maybe that you don’t have the energy to do things and also being agitated at times and having a variety of physical complaints, including pain.

So I introduced the modern idea of depression into China at that time and I trained the first group of Chinese psychiatrists who became the new academics. The older academics refused to accept the kind of research I did.

But all their students were animated by it and enthusiastic, and so the current leaders of psychiatry in China were those young psychiatrists who followed my work. And so that’s an important part of what I do. And to show the end result of that and how it leads to what I wanna talk about next, which is the importance of care in all of this.

I just wanna say that in doing that research, almost 40 years ago, I used to listen to people who had no one else to talk to. I speak Chinese, and I was listening to them, and I was paying attention and I was really interested. And I was letting them say things and legitimating them for ’em. And they told me these terrible sorrows one after another.

I got a letter a few years ago from one of the research subjects in that study, who said to me, “You know, it’s a long time ago, but I wanna tell you that that active listening was the most important thing that happened to me at that time. You let me for the first time, express what I felt and what I was going through, and it was impossible to do that in other circumstances. I couldn’t speak to my family, I couldn’t speak outside of the family,” and I realized that there’s a way of doing research, especially social and psychological research that has care built into.

And that intense witnessing, that listening to someone, and showing you’re really interested, that responsiveness to that, that sense you’d give them that you’re affirming who they are, you’re acknowledging their problems. Those are both psychologically important and morally important, and so with that as kind of background, my bigger theme became care and caregiving.

And that’s what my recent book which I hope some of you will read, which is called The Soul of Care: The Moral Education of A Husband and A Doctor. It’s about my moral education.

Is the story of why care is so central to our society. Why it is the hidden glue that holds our society together. If you’re attentive at this moment, in COVID endemic, to all the women who have been talking with anger and rage about the difficulties that they’re having caring for the family, caring for themselves, caring for elderly parents. Caring for young children in the midst of a chaotic epidemic in which it’s unclear what they should be doing. What is the right answer is unclear. It doesn’t seem to be clear guidelines or the forces to support them.

They work outside the family, but they don’t have care to take care of their children, the small children or they’re uncertain whether they can let their children go back to school because of the dangers of COVID.

So this situation that women are in is really telling because in most societies all over the world, including ours, for the longest period of time, it’s women who have done most of the care. And that care has been uncompensated. Unpaid. Free care. And has given women no status, no money. And even in some sense, put them down as something that had less status in working in their jobs outside the family.

And as women have entered the workforce in high levels have jobs outside of the family and men, there’s people like me and those of you in the audience that are men have not picked up the caring activities to the extent that they should, women have had double burden. They’ve had to work outside the family and continue to do most of the care. Uncompensated without support. And so this is a story about how we understand care in society.

And today I think is a wonderful time to understand the importance of care in society, that this is not just care for physical problems or even for mental health problems, it’s care for social problems.

Our concern with racial justice today, our concern with economic justice, all of that is a caring approach. And we are at the point now where politically we’re asking questions we never asked before. Why doesn’t the government feature care as a central part of its activities? So it’s just as important as security or criminal justice, or economic growth. Why isn’t care as central and what would happen if we made care that central? Not just care by physicians, and not just care by nurses, but care that women, principally do in the family. The care delivered to the elderly and to children, the care provided by educators. Mentoring is a form of care. All of these areas.

So could we have a kind of society in which care was featured more, and not just internally to have a better society, in which we took care of social problems and emphasized our concern with others and helping others, doing good in the world, but outside even our policies for other countries or could have a care element built into them. So that’s where I am right now.

Jed: That is amazing. Well, thank you so much for sharing about that interesting trajectory, your book sounds fascinating, and I noticed the byline of your book is about you being a husband and a doctor.

Arthur: Yes.

19:35Doctor to anthropologist

Jed: Now you are in the Harvard’s Department of Anthropology, and you mentioned along the way that you got interested in anthropology by way of being a doctor and a psychiatrist…

can you tell us your career path just so we know how a person who was going to China as a psychiatrist teaching students of psychiatry, so you were really a Professor of Psychiatry, how did you end up working then as an anthropologist? Where did this switch happen from the ’70s till now?

Arthur: Yeah, exactly. So I’m actually, I’ve held many roles at Harvard. I’ve been Professor of Psychiatry, I’ve been Professor of Anthropology and I’ve been Professor of Global Health and Social Medicine, so I’m split between Harvard Medical School and Harvard’s Faculty of Arts and Sciences. And I also, because of my China interest for eight years, headed Harvard’s Asia Center.

Jed: Wow!

Arthur: ’Cause that’s where a lot of my research has been.

Jed: Wow, so you’ve really worn at least four hats.

Arthur: But how did I get there, how did I get there?

Jed: Yeah, tell us when you came to it?

Arthur: Okay, so I said I was an undergraduate pre-med with a history major. So I went to Stanford and I became a physician at Stanford Medical School and then I went to do my internship at the Yale New Haven Hospital, Yale and New Haven, and then it was the middle of the Vietnam War, it was 1968, and I… ’67, ’68, and I was, I ended up as a US Public Health Service fellow at the NIH, the National Institute of Health. I actually, I entered the National Institute of Allergy and Infectious Diseases at the NIH, I believe, the same year as Tony Fauci. [chuckle] Only I didn’t know it’s him.

Jed: Okay.

Arthur: I didn’t know. And I was sent by National Institute of Allergy and Infectious Diseases that he now heads, I was sent to Taiwan at that time, because we didn’t have relations with China at that time, not until 1970s, did we have such relationships with China.

And so I went to Taiwan where I learned my Chinese. My wife was a China scholar, she helped me along the way with that and that’s where I decided during that period of time that I just couldn’t do medicine alone, I had to do some kind of social science that let me deal with the local society, and so, that’s when I became interested in anthropology. I went to Harvard, became an anthropologist.

Jed: Wait, wait, wait.

Arthur: And while I was an anthropologist…

22:40Harvard or the University of Washington?

Jed: Hold on one second.

So did you go as a professor to Harvard and became an anthropologist?

Arthur: No, I came as a graduate student.

Jed: Oh wow, so you went back to get a PhD in anthropology?

Arthur: Yeah, I went back to school and got my anthropology, and during my… At the time of doing anthropology, I realized that which branch of medicine would I be most comfortable and I decided that was going to be working with people with mental illness and with the, my particular interest or special interest was in depression, anxiety and how they complicate chronic medical illnesses, like diabetes, heart disease, cancer. So I went to, I did my psychiatry at the Massachusetts General Hospital, a great hospital in Boston…

Jed: Oh wonderful!

Arthur: Associated with Harvard Medical School and when I came out of that experience, I had two job offers. So this is a different time. I don’t wanna make students feel pessimistic, because this is a different age, hard to get jobs now.

In that time, in the 1970s, it was easy to get jobs, especially in academic jobs, and I had two offers. One was to stay at Harvard and run a department at Harvard School of Public Health, called Health and Social Behaviour, but at an untenured level.

And the other job was from the University of Washington in Seattle, and that university offered me a tenured professorship in psychiatry, but also in anthropology. And, actually it was my wife when just a couple of minutes when she heard the choices, she said, “Oh, we’re going for the tenure.” [chuckle] And so, because tenure means that they can’t fire you, okay?

Jed: That’s beautiful.

Arthur: So, and we had never been to Seattle. We were in north, from the northeast, I was New Yorker and we had been in Cal, and she, my wife was Californian, but we had never been to the state of Washington or Seattle, and when we went there we went there with some concerns, like you always do when you have something new and you go to a new place, and it was the most wonderful place to be because I could build all my programs there and receive credit for them.

Whereas at Harvard, I worked with a group of people, many of them senior to me, and to sort of appear in that setting, you had to find space that was your space. And so at Seattle, there was no one else in my space, and I built what was known as cultural psychiatry, psychiatry working across cultures, we now call it global mental health.

And I also built a field called Medical Anthropology. That is anthropology applied to medicine. And I signed at the University of Washington and had a wonderful set of six years there, and at the end of my six years, Harvard made an offer to me that I could not turn down. And so the family returned to Cambridge, Boston area.

Jed: And how big was your family at that point? Was it just still you and your wife?

Arthur: I was, my wife and two children.

Jed: Okay. Were they young?

Arthur: And the two children did not wanna come to the East Coast. They loved the North West.

Jed: Oh, yeah I can imagine.

Arthur: And the Pacific Northwest. But they came back. My son went to a school called Andover in Massachusetts, my daughter went to a school called Milton in Massachusetts. And my wife and I found the house in Cambridge, Massachusetts that we live… I live in to this day.

In fact, I’m speaking to you from that house, that same house that I came back to in 1982 at Harvard. That was 38 years that I’ve been a full professor at Harvard and 46 years, if you count when I first started at Harvard, that I’ve been here all together.

Jed: Wow, wow.

Arthur: So this is really… Has become my…

Jed: Home.

Arthur: My home. There are three messages I’d like to give the students.

Jed: Okay.

One, is not to be afraid of change and of doing something different and new. And so, as I said, when we went to Seattle, we knew nobody. In fact, nobody in Boston who we knew, knew anything about Seattle.

And at that time, people thought we were going to some foreign place where maybe they didn’t even have electricity or something. [chuckle] So provincial and stupid were the ideas locally here in Boston.

And when we got there, we found it was just one of the greatest places in the world, so we had a great lifestyle there. That’s one lesson: Be open to new possibilities, and when you see something that looks like a good shot, take it.

The second thing is, you’re not gonna have the same job environment that I had, where I could literally call my tune, what I wanted to do. But central to getting your good job and doing the kind of work you want to do, is to find in yourself what is it that you’re good at and to work hard at it. And so I discovered in myself that I had only really one virtue on the research side: I was a very good interviewer, [chuckle] very good interviewer. And I found that I had a virtue on the clinical side, which was I was a damn good doctor.

And the two came together for me. So interviewing became my basic research methodology, although I hated other kinds of things. But interviewing was the basic research methodology, and I feel like I can interview at the highest level, in terms of being effective.

And secondly, I found that I had an opportunity to write. And I’m sure many of you have interests in writing or the arts, and for me, writing became very important and academic life gave me the opportunity to write. And so I’ve written seven books myself, and four books I’ve co-authored, and I’ve co-edited 29 books, so all together 40 volumes.

Excuse me, my phone just… Turn that off.

And 40 volumes all together. And during that period of time, I discovered that though I was emphasizing research and writing… And so I’ve written 350 articles. I really like teaching, but at the beginning, in order to prosper in academia, in order to do well, you’ve gotta get publications out.

So my life was taken up with writing. But over time, I realized that I was equally as interested in seeing patients and taking care of them, and in teaching as I was in doing the research and writing it up, and I kept those three things going.

And now, that’s my third and last point, which is people are gonna tell you, “Well, you can either do this or you can do that.” Don’t believe them. You can do as many things as you feel you need to do.

I felt I needed to do three things every day: Write or do the research, that was the base of writing, take care of patients and teach. And for teaching, I was interested not just in teaching medical students but in teaching anthropology graduate students, and particularly, undergraduates.

I feel like undergraduates in university are the most exciting people to teach because you have the chance to affect what choices they make in life, what directions they go in.

So I’ve had the privilege of teaching thousands of undergraduates at Harvard over the decades. That’s been just a wonderful experience. But the point that I’m making to you is, I didn’t have to give anything up to there.

And I had a wonderful wife and kids who helped me to proceed along that path. And now as I approach retirement, I’m a few years away from retiring, I begin to realize that I’ve gotten pleasure and satisfaction and been successful in each of those domains, and that I’ve received different things from each domain.

Writing has given me a chance to express myself and let all the music in me come out, whatever it was. The teaching had this wonderful quality of being able to mentor and help people find a direction.

And the patient care had this great experience of entering into the world of other people and helping them. And all of these things, I believe, are captured in that term I told you earlier, care.

And at the end, the soul of care… That is all these things I’m talking to you about, becomes the care of the soul. And you end up, through all these things, having built yourself and cared for yourself.

And this is an unfinished project because life is incomplete, unfinishable, but we get a direction. We get a sense of who we are. We get a comfort in living within our bodies, living within our minds. We find a meaning and we find happiness.

Find happiness even amongst all the suffering that people have to endure. And so now that’s what I wish for each of you, to find that kind of balance, that fullness of being.

Well, I have a term for this, I call it “presence”. It’s your liveliness, your vitality, your fullness and your comfort with that. It’s not put on, not a show, not inauthentic. This is authentically finding that you find yourself through working with and caring for others. And along the line of the… I’ve had some difficult experiences, not just successes.

So one of the most difficult experiences was that for 10 years, from 2000-2010, or really 11 years, 2011, I had to take care of my late wife, Joan Kleinman, who was my intellectual collaborator and research collaborator. We had a wonderful marriage, but she developed early onset Alzheimer’s disease.

And for 10 years, I took care of her, ’cause she had taken care of me for 36 years. So the 10 years was hardly payback in terms of what she deserved. But taking care of her taught me an enormous amount. And that’s in the book, and it made me a different person.

I was a very driven, hard-nose kind of person, and my students, my patients, my family made me a different person. They transformed me into who I am today, which is a much more caring, a much more careful, much less careless, much more satisfying and comforted and comfortable in my own self-person. That’s what I wish for each of you.

35:39Sign off

Jed: That is so good, thank you so much, Professor Kleinman. We really appreciate you taking the time with us today.

Arthur: My pleasure. Thank you.