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Misrecognition and Critical Consciousness The NEW ENGLAND JOURNAL of MEDICINE Perspective June 20, 2019 Case Studies in Social Medicine Misrecognition and Critical Consciousness — An 18-Month-Old Boy with Pneumonia and Chronic Malnutrition Héctor Carrasco, M.D., M.P.H., Luke Messac, M.D., Ph.D., and Seth M. Holmes, M.D., Ph.D. Misrecognition and Critical Consciousness Shortly after midnight in the moun- The next afternoon, Dr. R. re- tainous town of La Soledad, home ceived a message that the boy’s to an indigenous community in condition had worsened, but he the poorest state of Chiapas, had not yet been taken to the hos- Mexico, a mother woke Dr. R. to pital. Dr. R. immediately left the see her 18-month-old son. The clinic and went to the patient’s patient was well known to the home, where he found the toddler clinic staff as one of many local lethargic and cyanotic. With the children with chronic malnutri- help of community members — tion. On this night, he presented one person offered a car, another with dyspnea that he’d had for paid for gasoline, a third took 6 hours. care of the family’s other children In the “SOAP” note, Dr. R. — the mother accompanied the wrote, “Subjective: 1.5 y/o chroni- patient to the nearest hospital, cally malnourished boy. Parents 1 hour away. There, he was intu- state poor appetite, cough, and bated and given intravenous levo- felt warm. Objective: Fever, tachy- floxacin. cardia, dyspnea, and crackles left Antibiotic treatment cured the upper anterior lobe. Assessment: pneumonia, but Dr. R. remained Community-acquired pneumonia, concerned. Such cases were far likely Strep. pneumoniae. Plan: too common in La Soledad. Rec- First dose ceftriaxone now and re- ognizing that his patient had been ferral to nearest hospital.” predisposed to pneumonia by mal- n engl j med 380;25 nejm.org June 20, 2019 2385 PERSPECTIVE Misrecognition and Critical Consciousness enroll all mothers of malnour- ished children. Over the course of 2 months of workshops on the food groups and balanced diets, however, attendance fell from 50 women to 5. An elderly woman explained to Dr. R.: “Doctorcito, the problem isn’t lack of educa- tion; the problem is lack of food.” Appreciating this wisdom, the team tried new tactics. A commu- nity health worker created an egg- incubation project. But the eggs didn’t hatch, probably because the heat lamps shut off during the re- gion’s frequent power outages. Next, the collective created a dem- onstration home garden, but after 3 months of tending the poor soil, it produced only four carrots and one lettuce plant. The team then ob- tained support from Heifer Inter- national for an animal husbandry program. After much deliberation, the families decided they wanted chickens rather than the pigs or rabbits that Heifer had proposed. nutrition, Dr. R. began conversa- than 80% of families in Chiapas Dr. R. felt gratified as he wrote tions with community members suffered from food insecurity. prescriptions for “15 hens and a seeking ways to improve the nu- Motivated to address the dire rooster” for each of the 68 fami- tritional status of the region’s situation in La Soledad, Dr. R. lies with at least one child with children. As a newly minted phy- convened a team of like-minded chronic malnutrition. Unfortu- sician from a middle-class family community members and other nately, 30% of the hens died in the who had been educated at an elite health professionals to start a nu- first week from an unknown ill- medical school, Dr. R. had no trition education program. Led by ness, and the new hens intro- training in social medicine. But a nutritionist and a nurse from the duced a virus that killed off 20% he had become aware that more community, the program aimed to of the local chicken population. Social Analysis Concepts: Misrecognition and Critical Consciousness Dr. R. initially thought that mal- “Misrecognition” refers to the of characterizing others by their nutrition could be solved with process by which political, eco- place in a social hierarchy appear medicine, education, and dona- nomic, and social-structural causes inevitable. Inequity has thus be- tions. He was trained to treat of health problems are interpreted come as unquestioned as the air pneumonia with antibiotics. When instead in biologic, behavioral, we breathe. Bourdieu often point- he recognized that curing the in- and technological terms (see box).1 ed to the widespread acceptance fection was insufficient, he worked As sociologist Pierre Bourdieu has of pervasive sexism as one exam- with a collective to go beyond the elaborated, the culturally con- ple of misrecognition: though the most proximal cause of disease. structed categories we use to de- result of historical, social, and cul- But their attempts to address root scribe the social order, our im- tural processes, gender inequality causes began with behavioral and plicit assumptions about social is often understood as natural be- technological interventions. roles, and our unconscious habit cause we see gender as primarily 2386 n engl j med 380;25 nejm.org June 20, 2019 PERSPECTIVE Misrecognition and Critical Consciousness change education,” to the charac- sequences. In this case, the eggs ter of charitable interventions, could not be incubated because “Misrecognition,” a social theory assumed that his pneumonia re- of power outages, the garden term from Bourdieu, refers to an inac- sulted from a biologic or behav- would not grow in poor soil with- curate or incomplete appraisal of the ioral deficiency in him or his out fertilizer, and the donated causes of a social problem because of community. hens spread disease. assumptions learned through every- The choices that community Eventually, shared reflection day social interactions. Misrecogni- members and Dr. R. made in at- on these flawed interventions led tion often causes us to see aspects of tempting to address malnutrition the team toward what education the social world as natural or normal demonstrate the unintended con- theorist Paulo Freire called “criti- sequences of misrecognition. cal consciousness” (see box)2 — and to take them for granted.1 Though Dr. R. knew that acute a collective process of question- “Critical consciousness,” a con- episodes of childhood infectious ing the historical and sociologic cept from Freire, refers to a capacity disease would recur until chronic bases of social inequity and act- that can be developed by community malnutrition was addressed, his ing to change them. Bringing this members, including those who are first response involved health consciousness to bear on up- marginalized, to perceive, analyze, education, a common approach stream factors, the group recog- and respond to the social forces af- that focuses on patients’ choices nized that the root causes of fecting their day-to-day lives.2 as the primary cause of illness. malnutrition in La Soledad lay in Community members corrected a history of exploitation in which Dr. R.’s assumptions, clarifying native people were forced to work that their main problem was a lack for wealthy landowners and were biologic and are accustomed to not of knowledge, but of food. denied access to arable land of gender differences in familial and The collective attempted to their own. When land reforms social roles, labor positions, and solve malnutrition by incubating swept across Mexico during the even physical mannerisms. eggs and gardening. Though such early 20th century, landowners In the case of the boy in La technological or skill-based ap- used violence to maintain politi- Soledad, much of the initial analy- proaches often have salutary ef- cal power in Chiapas. sis and intervention, from the fects, they rarely address funda- This history of discrimination structure of the clinical note, to mental causes of illness and and dispossession was an impor- the ideas underlying “behavior- frequently have unintended con- tant fundamental cause of chron- ic childhood malnutrition in Chi- apas, which, according to the 2012 National Health and Nutri- tion Examination Survey, affected 44% of children in rural areas — four times the national average. The history became more rele- vant to the collective over time, as they realized that teaching mothers about nutrition would accomplish little. Without arable land and fertilizer, they could not grow viable crops. Without power, they could not incubate eggs. Without savings to fall back on, unanticipated problems like the spread of a disease among hens could spell disaster. These experiences and related discus- sions led to consideration of more creative and critical alternatives. n engl j med 380;25 nejm.org June 20, 2019 2387 PERSPECTIVE Misrecognition and Critical Consciousness Clinical Implications Physicians inevitably encounter deeper causes of illness and ing the roots of health problems. In complex health problems, which death? teaching literacy to workers in we are taught to interpret in bio- 1. Health professionals can become Latin America, Paulo Freire sought logic or behavioral terms. Yet more vigilant regarding potential mis- to impart both the ability to read these problems are often inter- recognition. Acknowledging mis- and the capacity to challenge twined with and significantly in- recognition forces us to question deeply ingrained social catego- fluenced by historical, social, po- how the lenses through which ries and assumptions. He used a litical, and economic forces.3 In we perceive the world might lead collaborative process dependent medicine and public health, prac- us to recommend ineffective inter- on the knowledge, experiences, titioners are trained to implement ventions.3 The well-intentioned and participation of community biologic, behavioral, or technical actions of Dr. R. and his team members in order to inculcate interventions, which have led to did not address the fundamen- the confidence that they could some remarkable population-level tal causes of malnutrition in La effect change, and to translate successes; vaccines and antibiot- Soledad.
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