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Essay: The Health Resource Center Ethnography – Views of Marx and Foucault

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The Health Resource Center Ethnography – Views of Marx and Foucault

The Saint Louis University Health Resource Center is located on 1408 N Kingshighway Blvd, St. Louis, MO 63113 in the Victor Roberts Building. The Health Resource Center is a free clinic operated by medical students at Saint Louis University School of Medicine under the guidance of doctors. The clinic relies on volunteers from undergraduates, to physical therapy students, to optometry students, to medical students, and so on. The Health Resource Center, though, is a resource for not only the surrounding patient population, but also for the students, who receive practical experience in the clinic, gain skills on how to care for patients, and practice patient interactions. The Health Resource Center provides many different clinics, with some specialty clinics only occurring once a month. I attended the Saturday morning general clinic for my observations. I have volunteered in academic hospitals but have never experienced an academic outpatient clinic setting. Because of this, I was interested in learning about the dynamics of being a teaching facility, while being a clinic without much resources. The dual modality of being an academic and free health care clinic seemed like a structure that was not beneficial on either or both ends of the scenario.  In analyzing Marx’s perspective of medical care having a focus on power and economic dominance in capitalism, I hope to evaluate a free health clinic in comparison to traditional medical institutions. The comparison between the two medical institutions will aim to evaluate political representation, class relations, and property rights as well as greater themes of the impact of the economy on personhood. Regarding Foucault, the manufacturing of the individual, the soul of a person, the medical gaze, and techniques of the body will be explored in the context of a free health clinic in order to understand the mechanism of power in this society. The free health care clinic attempts to function as a contrast to the mode of capitalism but is inevitably shaped by the overarching structure; the clinic also holds a power as a structure over those who participate or are affected by it.  

In the Economic and Philosophical Manuscripts of 1844, Karl Marx describes how private ownership divides society into two different classes: the property owners and the workers without property (CITATION). The result of this divide has an impact on the lives of workers, leading them to be impoverished and alienated from the surrounding world (Manuscripts of 1844, ###). The working class do not own their products, since capitalism has sanctioned it to be the property of the owner (Manuscripts of 1844, ###). There is an estrangement of the worker from his product, leading to an alienation that causes a degradation. Also, from the process of creating the product itself, the working class no longer has the ability to make a choice about production (Manuscripts of 1844, ###). The performance no longer is the action of an individual but rather an action done in order to survive in the economic system (Manuscripts of 1844, ###). This adds to the loss of identity of the individual worker. In that sense, the worker then feels an antagonism towards the greater power structure of private property ownership and capitalism (Manuscripts of 1844, ###). Economic and Philosophical Manuscripts of 1844 notes the role of capitalism as a socioeconomic system with political representation, class relations, and property rights. The use of capitalism as the driving force behind the degradation of the working class can lead to further explanations on how the economic system lead to the troubles of the workers. This can, in extent, be used to explain the degradation physically and socially of the individuals that rely on a free health care clinic.

In The Manifesto of the Communist Party, Marx and his co-author Friedrich Engels argue that “history of all hitherto existing societies is the history of class struggle” (CITATION). They emphasize the role of the collective struggle on groups of similar economic situations (The Manifesto, ###). The changes that shape society are lead by these shared struggles when facing material and economic interest (The Manifesto, ###). The struggles are between those with economic dominance and those without (The Manifesto, ###). History has been shaped by the dominant classes preventing the economic interest of the lower classes (The Manifesto, ###). These economically dominant classes continue to shift society towards their own interest, by political institutions and society as a whole (The Manifesto, ###). The powerful have shaped the economic system of the world, moving towards capitalism (The Manifesto, ###). The Manifesto of the Communist Party can help to explain the organization of the social world in a capitalist society. Class struggle in society is represented in the health system, from those who participate actively within it as a career to those who rely on the system as a whole for treatment and care. The health care system is intrinsically a part of the capitalist economy, continuing to maintain power and dominance and retain class differences.

In Capital, Marx defines capitalism as an economy based on the accumulation of commodities, which are objects of human need or desire (CITATION). The value of a product depends on how useful the product is, such as how much does it fulfill the needs or desires of individuals (Capital, ###). Marx defines the usefulness of a commodity as its use-value, which is an intrinsic property (Capital, ###). But, not only do objects have a use-value, but they also obtain an exchange-value, which determines the value of a commodity in relation to other commodities (Capital, ###). Exchange-value is dependant on the commodity the product is being compared to, in order to determine relative value. Because of this inconsistency, complex markets measure the value of products by money (Capital, ###). Money allows commodities of different use values to be compared since the value corresponds to the amount of labor that was required for the commodity to be produced (Capital, ###). Marx uses the labor theory of value that implies a social dimension to commodities since the exchange value of the product results from economic interdependence and divisions of labor (Capital, ###). The social aspects of economy are often overlooked in capitalist society, since money is the dominant mode for assessing value (Capital, ###). Marx argues this leads to ignorance of products being formed from exploitation of wage labor (Capital, ###). Capital provides context on capitalism, value, labor theory of value, and money as means to understand the role these play in the context of a free health care setting.

In The Birth of the Clinic: An Archaeology of Medical Perception, Foucault uses the term of “medical gaze” in order to describe the separation of the person’s body from the person themselves (CITATION). The “medical gaze” is one that is dehumanizing to the individual, since there is a greater focus on the disease state rather than the sick individual (Birth of the Clinic, ###). When starting to analyze the body, intellectual structures that were invested in power interests shifted the human body to entering the field of power itself (Birth of the Clinic, ###). The human body thus became a possible target for manipulation by power (Birth of the Clinic, ###). Another shift was from the French and American revolutions that yielded the medical doctors as individuals that would solve the problems of humanity and abolish sickness (Birth of the Clinic, ###). From this, since the human body was believed to be the sum of an individual, the medical doctor obtained an unforeseen power (Birth of the Clinic, ###). The medical gaze of the physician was able to deduce symptoms, illness, and disease, understanding the patient by discovering hidden truths (Birth of the Clinic, ###). Foucault viewed the shift to modern medicine as a change in the structure of knowledge (Birth of the Clinic, ###). It joined is a greater structure so that medicine was a discipline that depended on accepted practices that were already in place (Birth of the Clinic, ###). The Birth of the Clinic: An Archaeology of Medical Perception focuses on the techniques that were formed in order to produce individuality, from the clinical examination to anatomy. The focus turned to notion of an individual, since the knowledge obtained was embodied in one person. The individual housed the localization of a disease, and the ill state lead to the person being treated. It explains methods to treat the body as an object. Also, Foucault claims the physical body may not be a true reality but is for the current medical perception; this makes modern medicine something that can be understood and shaped, since it came from origins that are exploratory. In that sense, the human body can be used to understand medical practice, individuality, the medical gaze, and manipulation of power.

In Discipline and Punish: The Birth of a Prison, Foucault analyzes the change in punishment from times past to the current system. The sentences prisoners obtain for their crimes are aimed at the individual correcting behaviors and improving outlooks (CITATION). Because of this shift, punishment also centers around the sense of shame prisoners obtain for the crime they commit (Discipline and Punish, ###). The punishment of the prison system was no longer a physical one, but rather something beyond (Discipline and Punish, ###). The physical punishments that remain still reminisce to something greater, such as the soul (Discipline and Punish, ###). The soul was now responsible for the actions of the body and was being punished (Discipline and Punish, ###). The judgment of crimes now evaluates the greater motives, beliefs, and instincts of the individual themselves (Discipline and Punish, ###). From this, the individual could be directed to not make the same choices again; it is necessary to know the motive to be able to dress the individual person (Discipline and Punish, ###). Not only was the crime of the individual being judged, but also the soul of the criminal (Discipline and Punish, ###). The hierarchical structure of power breaks down to many different individuals, so not only one person judges the actions of the criminal (Discipline and Punish, ###). Foucault is concerned about punishment as a complex social function, a political tactic, its relation to science, and how its changed the use of the body as means to power (Discipline and Punish, ###). Punishment is located in the systems of production and political economy (Discipline and Punish, ###). Power is used as a strategy and is present in human relations throughout society (Discipline and Punish, ###). Foucault emphasizes the relationship between knowledge and power. He is also concerned about the creation of the modern soul, relating to psyche, personality, and consciousness in a scientific sense (Discipline and Punish, ###). In this sense, he notes that the soul is the prison of the body (Discipline and Punish, ###). Discipline and Punish: The Birth of a Prison also describes the treatment of the human body as an object, through series of techniques that arose in different institutional structures, such as prisons, hospitals, and schools. Also, though, the notion of power is written about, since the localization of power is not necessarily clear and is often spread across a greater network. Foucault implores that power creates the individual and the knowledge that exists about the individual. The notion of power, individuals, and techniques can be applied to the question of free health care clinics.

The time was eight o’clock in the morning. The security guard, dressed in a pair of light-wash denim jeans, a dark blue long-sleeved button down, and a royal blue Saint Louis University baseball cap, asked the two individuals at the front desk if he could open the clinic door. The two individuals behind the front desk, a male and female dressed in business casual clothing, with black slacks and white long-sleeved button downs, made sure they had everything in place before agreeing. The male and female were undergraduates attending Saint Louis University and were volunteers at the Health Resource Center. They had a role called patient liaisons and were tasked with working at the front desk of the clinic. The security guard opened the door into the clinic waiting room. Patients filed into the room and sat in the chairs placed in the waiting room. He handed the patient liaisons a clipboard that contained the patients’ names and time of arrival.

The waiting room was silent, nothing was said between patients. The only sounds were the two patient liaisons at the front desk speaking in hushed tones. Suddenly, the female patient liaison stood up and called a name from the clipboard. A female patient stood up from her seat and went up to the front receptionist desk. The patient liaison asked her for a proof of identification. After a few moments of just hearing the keys tapping on her keyboard, the patient liaison returned the proof of identification and asked if the patient was new or returning. Then, she asked for the reason why the patient was visiting the clinic. The patient liaison took note of the response of the patient, by typing on the computer. She got a clipboard and pen and proceeded to explain the documents to the patient. The forms that they required to be filled out included a patient intake form, a consent to treat, and a notice of privacy practices. She explained each document briefly. The optional documents included one form that meant to determine the behavioral health status of the patient, and another form was if the patient needed help signing up with health insurance. The patient then took the clipboard and pen and proceeded back to her seat and start on her paperwork. During this interaction, the male patient liaison was just observing. Then, he called the name of the next patient. The same procedure continued throughout the clinic, though they were working simultaneously in checking in patients after the first patient.

After the initial wave of patients entered the clinic as soon as the door opened, there were no other patients that came into the clinic. As the check in procedure was commencing, patients were becoming more relaxed and were not silent. The patients as a whole were evenly distributed in gender as well as in age, though there were no individuals that seemed to be over mid-sixties. The patients were mostly African American individuals. There were only two white patients out of the twenty-seven patients that were seated in the waiting room. The patients were dressed casually, though some dressed in more expensive clothing than others. There was a sign posted behind the receptionist desk that read no sunglasses, hats, or sagging pants were allowed. The security guard asked patients to abide by the rule if he noticed that any patients were not following the procedure.

Some patients that were in the waiting room were still waiting to be checked in when some of the earlier patients finished filling out the paperwork. The patients returned the clipboards with the paperwork, and the patient liaisons organized the different forms, placing some forms in a organizer hanging from the wall. The patient liaison handed the forms to someone on the other side of the wall, who was a third patient liaison who was adding the patient information on the computer. The same procedure continued for much of the first hour of the clinic.

At nine o’clock in the morning, the other entrance door to the clinic was propped open, and the medical staff started to enter the clinic. I noticed that there were many medical students that were entering the clinic and going to the back room of the clinic, where they would hold their morning meetings. The physician walked into the clinic from the same route and went to the back room of the clinic to hold the meeting. There was a discrepancy between the time of the arrival of the patients to the time of the medical providers to the time of the volunteers. The medical staff was younger from mid-twenties to mid-thirties, dressed in business casual or scrubs, evenly distributed in gender, and from varied racial backgrounds.

This discrepancy was not unnoticed. Many patients went to the front desk to speak to the patient liaisons to ask why it was taking so long. Some were agitated by the amount of time that it was taking for the appointment, since some individuals were not there for extensive testing. The patient liaisons had to explain that the physicians and medical staff did not arrive until after the clinic opened, so that was why there was a delay. A few patients had to leave before having their appointment, telling the patient liaisons that they were going to be late for work or had to pick up their kids.

It was around nine-thirty when the medical students opened the door to the waiting room and called out patient names. Some patients were confused as to why people who were after them in line got called to see the physician first, but the patient liaisons explained that there were different wait times for different services. It was also at this time that new patients started entering the clinic and beginning the check in procedure. At this time, some patients who were checking in asked for hepatitis A shots. The patient liaison had to explain that the clinic had reached the maximum capacity for shots they can provide but gave a list of other clinics that offered the same resource. They also explained how some patients wait hours before the clinic opens in order to be the first five people in line, so they can receive the shot. Some potential patients were shocked by this, whereas others knew about this or expected it.

Not much longer into the clinic, at around ten o’clock, potential patients who were entering the clinic were being turned away, since they had also reached the maximum capacity that the medical students would be able to treat. They can only guarantee that twelve patients can be seen. Some patients were understanding, while others were in disbelief, since the clinic was open until twelve o’clock. Patients were being taken back in a second entrance door to the clinic, in order to answer questions about the behavioral health information and the process of signing up for health insurance.

Throughout the course of the clinic, as patients went to the back to be treated, the clinic quieted down. As patients left the clinic, some thanked the patient liaisons, some greeted, and others did not interact with the patient liaisons at all.

The observations understood in the context of Marx begin at the evaluation of the base and superstructure present in society. The base entails the means and relations of production whereas the superstructure represents everything that does not directly relate to production. The base shapes the superstructure, which in turn maintains the base. The structure of the free health clinic itself is of interest but also introduces the question as to why the structure was formed and maintained in the first place.

In the context of American society, the base to understand the structure is the capitalist society that it functions in. Aspects of the capitalist society include private property, which Marx regards as having a role in the breakdown of social relationships (CITATION). The alternative that arose from the breakdown of social relationships was the exploitation of human labor (CITATION). Since the economic system of private ownership, clear divides can be marked between those who obtain property and those who do not (CITATION). The capitalist society continues to mark the divide from the past with a deeper line in modern times. The socially constructed aspects of capitalism magnify the divide between the elite individuals of society and the working class.

The system of conflicting social relations of capitalism shapes the structures of the society that participate in it. The patients that attend the clinic represent the working class that cannot provide for themselves enough to afford their needs. Private ownership leads to an impoverished working class that puts other aspects of livelihood at risk. The manipulation of pay and constant competition for jobs leads individuals to a state of despair. To the extent that they reach out for outside sources of help in order to maintain a livelihood. The patients that attend the clinic may be impoverished from the role of capitalism. At the clinic, though, there is a sense of alienation. The clinic was silent, without patients speaking to each other or interacting with one another. The same for patient interactions between volunteers and medical staff. The formalities and lack of warmth from the workers could lead to a greater feeling of alienation for the patients. The antagonism that exists between different classes impacts the interactions that occur within the clinic. In the moments where patients were told about being unable to be seen by the physician, an unconscious sense of antagonism may have been felt by the patient that was denied care. The subconscious of the all individuals  is shaped by the effects of capitalism and divisions within society. The resulting impoverishment, alienation, and antagonism lead to a loss of the identity by patients. Not being able to pay for care needed, being dependant, can affect the patients as well, outside of the walls of the clinic. A disconnection of the individual from the rest of the world, by not being able to participate in society or normal functions of exchange, can lead to other outcomes.

The health system reflects the class structure that is prevalent in society. The hierarchy exists in many dimensions in the context of the clinic. Class structure exists within the providers, with the physician having the highest class. The hierarchy exists also within the medical students, with experience working in the clinic. Also, the many positions have a hierarchy of directors and leads. The volunteers also have a structure of hierarchy among those who have titled positions and vast amounts of experience ranking higher. More importantly, though is the class differences between the medical staff and the patients. The medical staff come and work in the clinic voluntarily, and they decide to spend their time on Saturday mornings to work in the clinic. For the patients, though, attending the clinic is much less of a choice, but rather a necessity. The class struggle shows that some groups have the leisure to sign up to work for free and only gain from an academic experience. The patients, though, often have to miss hours at work in order to attend the clinic and are losing money the time they spend at the clinic. But, in consideration of receiving medical care at no cost, many patients do not seem to complain about the situation. In a sense, though, there is still a collective between those in similar economic situations.

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