Pain’s Records: An Anthropological Account of Medical Documentation in South Asia

Abstract The Institute for Pain Management in Kolkata, like other modern institutions, is organised by record keeping. But the central object of its records, pain, presents a fundamental challenge to documentation. Pain is marked by a non-relational attribute that limits attempts to communicate and express it. I follow the institutional life of one patient and his struggles with health care through his documentary productions. As the paper traces clinical management of his pain, a proliferation of medical records is revealed. The forms of this documentary multiplicity, its materiality and how it enacts pain’s therapeutics are described. The challenge of pain’s communication is addressed by translating a body in pain constituted through artefacts and intersubjective relationships to a body in pain that exists almost entirely on paper. This translation proves efficacious in the eyes of doctors and patients, and is critical to the management of chronic pain in Kolkata.


Introduction
The Institute for Pain Management in Kolkata, like other modern institutions, is organised by record keeping.
But the central object of its records, pain, presents a fundamental challenge to documentation. Pain is marked by a non-relational attribute that limits attempts to communicate and express it. In her seminal work, Elaine Scarry 1 has studied the making and unmaking of human worlds by placing bodies in pain at the centre of her analysis. She has explored pain's resistance to objectification and its challenge to linguistic expression and thus, writing. Others have attempted to shift this search for an ›objecthood‹ of pain to its subjective dimensions. Scholars have demonstrated how the relationship between pain and language can be nuanced and expanded while acknowledging the challenges pain poses. A multitude of theoretical frames for understanding pain have been proposed: as an affective category, 2 affliction, 3 inscription, 4 suffering 5 , and as a phenomenological category that isolates and disrupts narrativised experience. 6 Shifting discourses away from the individual, scholars have also described the intersubjective, juridical, historical and sociocultural milieus in which pain is situated. 7 However, these writings on pain have shifted away from concerns of pain's medical researchers and practitioners, whose writings are among the discourses that Scarry analyses.
In medical discourse, pain remains a highly ambiguous condition despite being one of the most commonly reported complaints in the clinic. Pain has been at the heart of a number of medical debates such as its status as an ›object‹, 8 methods of measurement of its subjective features 9 and standardisation of its measurement units. 10

Pain and Multiplicity
Inherent in a record like the OPD slip are future acts of medical documentation. After the OPD slip, Manoj Singh is scanned at a private diagnostic centre that produces a MRI scan and report. As he visits the clinic with this new report, he meets with another pain physician -Dr. Bijoy.
This meeting results in a second OPD slip that refers him to more physiological testing. As medicine tries to record various facets of his pain experience, multiple medical documents are produced (Fig. 4).
These are recordings from different medical sites but each presents a facet of his pain. As evidentiary documents produced by multiple experts, these are translations from a body in pain to records of pain. between what is written and in expert discussions around such writings. 40 The »file-self« constitutes a patient »as an object of knowledge« and the workings of his disease are »divided up into different functions that are to be handled by specialists«. 41 We observe fragmented constitutions of the person along medical specialisations making a ›case‹ which is »thought to be coordinated by the ›team‹ approach so that the patient can be reconfigured as a ›whole person‹«. 42     After performing the procedure on January 12, Manoj Singh's pain reduced and he was discharged 4 days later on January 16. 15 Various research studies and government reports estimate the organised sector to be between 6% and 15% of the total labour force. 16 I use the term ›artefacts‹ in its scientific context as something observed in a scientific investigation or experiment that is not naturally present but occurs as a result of a preparative or investigative procedure. For example, »the curvature of the surface is an artefact of the wide angle view«. Or, at The Institute, »pain is located within a medical grid of habitats, and shifts in bodily dispositions«. Matthew Hull's »graphic artefacts« and Elaine Scarry's »artifact« are specific deployments of the word and I am not using these in the same sense though there are obvious overlaps and resonances given that one is writing about a semiotics of objects crafted through inscriptive practices in bureaucratic regimes, and the latter is discussing the central role pain plays in the making of objects and bodily substantiation that underlies production of all artefacts including scriptures (inscriptions). Both are important influences in the writing of this paper. Departing from Scarry's separation between bodies in pain and language of pain (or communicative acts of pain), Das shifts the focus to transactions between bodies in pain and language. She draws our attention to anthropological writings on the labour of mourning, most notably Nadia Seremetakis's work in which Seremetakis studies scenes of mourning and focuses on the work performed by acoustic and corporeal means in mourning by women in Inner Mani, Southern Peloponnese society. She describes it as an »iconography of the body that links ›screaming‹, coincide with such a conception of ›experience‹, Desjarlais proposed »struggling along«. He describes struggling along as proceeding »with great difficulty while trying at times to do away with or avoid constraints and hazards strewn in one's path« (Desjarlais: Shelter Blues, p. 19). It is largely a »sensorial mode of awareness which relies on forces of contingency, expediency, equilibrium and stasis« (Desjarlais: Shelter Blues, p. 22). The body does not move through a »landscape at once physical and metaphoric« and does not journey but is instead oriented to »pacing«, to an »episodic« living in which a narrative, coherence and meaning are absent, and which is marked with immediacy.

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[was] not rendered problematic [but gave] rise to new forms of medical expertise and practice« (at p. 815). By maintaining diagnostic uncertainty at PNG, chances of survival and assignment of blame in the case of death were managed. In Manoj Singh's case at the Institute, on the other hand, the uncertainty is neither about disease (chronic pain) nor afflicted bodily habitat (neck). Instead, it has come into being because of pain, a condition that affectively exceeds and is multiple. The challenge this multiplicity poses is one of choosing a therapeutic course of action. In both centres, clinicians privilege »not ›What does this patient have?‹ but ›What can we do?‹« (Street: Artefacts, p. 825). In Papua New Guinea, this leads to following all possible therapeutic courses of action for increasing patients' chances of survival while at the Institute it gives rise to more and more documentary productions and diagnostic attempts since a diagnosis is expected to reveal the pathophysiological processes underlying chronic pain. A diagnosis helps physicians plan therapeutic interventions. open wounds, and the labor task of bearing pain« in childbirth, agricultural work and in mourning (Seremetakis: The Ethics of Antiphony, p. 502). She argues that this iconography »forms a symbolic continuum« between bodies in pain, bodily gestures and sounds. Das relies on these ethnographic links between bodies in pain, their acoustic worlds and efforts at truth production to explore transactions that occur between bodies in pain and language and draws from these social constructions of pain. 37 Roma Chatterji argues for such intercorporeal engagements in her 1998 paper »An Ethnography of Dementia«. Citing Mead, she describes how the self can be understood through an intersubjective engagement which is intercorporeal and how this underlies access to another's subjectivity. She writes, »the intersubjective process of self formation is essentially cognitive -not in the sense of a recognition of a law or of a universal principle but rather as a set of bodily dispositions which constitute these anticipatory structures of meaning. Thus, intersubjectivity assumes intercorporeality. Access to the other's subjectivity as a set of stable disposition, relating to