Personal pain, national character

To Arthur Kleinman, suffering lifts a veil on society.

Kleinman, the Esther and Sidney Rabb Professor of Anthropology in the Faculty of Arts and Sciences (FAS) and professor of psychiatry and of medical anthropology at Harvard Medical School, is a trained psychiatrist who studies developing nations for what their population’s travails can tell him about their societies.

Kleinman, much of whose work has centered on China, focuses on mental illness, depression, suicide, violence, and other indicators of personal crisis.

“In situations of suffering, you see elements of everyday social life that you don’t otherwise see in the everyday social domain,” Kleinman said. “Everyday social life is much more dangerous than any of us let on. Our efforts are designed to deflect attention from that danger.”

Danger springs from disease, poverty, powerlessness, political unrest, and other sources.

“How people deal with those dangers is my work,” Kleinman said. “You see revealed in the responses of people [to danger], the moral core of social life.”

Kleinman said he’s not just interested in people’s first response to a disease outbreak or a terrorist attack, for example. Secondary responses, such as the stigma that has arisen around AIDS, or some people’s transference of SARS fears from the virus to anyone Chinese, also interest him.

“You see that what’s at stake for the individual is not the same as what’s at stake for the group,” Kleinman said. “And in responding to the situation, a second threat is revealed.”

Kleinman currently has three research projects ongoing in China. One is looking at depression, a second at suicide, and a third at the changing ways the elderly are cared for at the end of their lives.

Kleinman, who holds a joint appointment in the Faculties of Medicine and of Arts and Sciences, in February will take over as chair of the FAS Anthropology Department, giving him the unusual distinction of not just serving on, but having chaired a department in two separate faculties.

From 1991 to 2000, Kleinman chaired Harvard Medical School’s Department of Social Medicine.

“I’m very excited about chairing the Anthropology Department,” Kleinman said. “I think it’ll be a challenge, but also a chance to give back to a department that has given me a great deal since I was a graduate student here in the early 1970s.”

AIDS in China

Kleinman, together with colleagues in the John F. Kennedy School of Government, is arranging a yearlong series of faculty seminars on AIDS in China, where, besides sexual and intravenous drug transmission, the epidemic has unusual roots in some rural areas. Peasants in these areas sell their blood to blood dealers, whose unsterile and dangerous procedures end up contaminating the blood of donors and recipients alike.

“There’s nothing like that elsewhere and no one knows the full impact of it,” Kleinman said.

The Chinese government reports 1 million HIV/AIDS cases, but Kleinman said he believes that number to be vastly underreported. The best-known province where AIDS is related to this blood-selling practice, Henan, probably has 1 million AIDS patients, Kleinman said.

The seminar series will culminate in early May with an international conference here at Harvard on AIDS in China, Kleinman said.

Kleinman began studying societal suffering with a study of depression in China in 1980. During the study, he looked at survivors of the Cultural Revolution and his work moved from the experience of the illness to the political violence that caused it to a broader view of societies today.

Along the way, Kleinman also examined Chinese suicide, which has a very different profile from that seen in the United States and Europe. In Western countries, suicide is more common among men than among women. In China, the opposite is true. Suicide is most common among rural women.

Discovering the reasons why opens a window on Chinese society today. While development is racing ahead in the cities, the rural areas often remain poor and lacking modern amenities. Men from the farms come to the cities looking for work, leaving women at home to care for children and elderly in-laws. Hopelessness can set in for the wives left behind, leading to suicide.

The most common methods of suicide also tell something of the two societies. In the United States, men most often kill themselves with firearms, whereas the most common mode of suicide in China is consuming strong agricultural poisons that are often kept in the house.

Differences in health care systems may also play a role in the death rates. China has roughly three times the suicide rate that the United States has, but Kleinman said that doesn’t factor in the 650,000 people each year who are brought to U.S. emergency rooms after attempting suicide, but who either made non-life-threatening attempts or were saved through medical intervention. In rural China, many people who attempt suicide as an angry impulse or a cry for help go on to die. Relatively few of them seem to be suffering from mental illness, another difference from the U.S., where 90 percent of suicides are linked to mental illness.

“This shakes up established ideas of suicide,” Kleinman said. “You can’t divorce health problems from their social roots.”

Unmasking life’s fragility

In many ways, Kleinman said, China is really two nations, the fast-modernizing coastal urban population, and the rural agricultural interior.

Looking at the final days of Chinese elders in Shanghai helps Kleinman decipher the changes going on in urban family life. Kleinman said he is studying how the elderly are increasingly spending their last days in institutions, a change from the traditional practice of having the elderly die at home.

The problem, Kleinman said, is that with more two-worker families, there’s nobody at home now to care for a sick or frail elderly parent. This trend has caused a great deal of guilt among the younger generation, which feels it is shirking an important duty.

Examining another nation’s social experience can lead to insights about one’s own. Kleinman is taking advantage of that perspective in a forthcoming book on moral experience to explore the dangers that exist and that are just as crucial in American society as in Chinese society.

China’s tumultuous recent history has left a mark on its national psyche, Kleinman said. After years of warfare against the Japanese in World War II, the Chinese Civil War, the Great Famine following the disastrous Great Leap Forward policy, and the Cultural Revolution, Chinese today view life quite differently from the average American.

“In Chinese society, especially among the older generation, there’s much more sense of the fragility of life and that endurance is a desired virtue,” Kleinman said. “I don’t think we have that sense of how dangerous life is. . . . Chinese society shows us something about the dangers of human experience that is all too easily avoided in the United States.”