The Routledge Handbook of Medical Anthropology

Lenore Manderson, Elizabeth Cartwright, Anita Hardon, Lenore Manderson, Elizabeth Cartwright, Anita Hardon

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317743774
• Edition: 1
• Topic: Ciencias sociales
• Subtopic: Antropología

The Routledge Handbook of Medical Anthropology provides a contemporary overview of the key themes in medical anthropology. In this exciting departure from conventional handbooks, compendia and encyclopedias, the three editors have written the core chapters of the volume, and in so doing, invite the reader to reflect on the ethnographic richness and theoretical contributions of research on the clinic and the field, bioscience and medical research, infectious and non-communicable diseases, biomedicine, complementary and alternative modalities, structural violence and vulnerability, gender and ageing, reproduction and sexuality. As a way of illustrating the themes, a rich variety of case studies are included, presented by over 60 authors from around the world, reflecting the diverse cultural contexts in which people experience health, illness, and healing. Each chapter and its case studies are introduced by a photograph, reflecting medical and visual anthropological responses to inequality and vulnerability. An indispensible reference in this fastest growing area of anthropological study, The Routledge Handbook of Medical Anthropology is a unique and innovative contribution to the field.

Kuna Woman and Child, 2012. Kuna Yala, Panama.

© 2012, Mark Caicedo. Printed with permission.

About the photograph

The Kuna have achieved what very few native peoples have been able to do: adapt to change on their own terms. When I visited Kuna Yala, I saw reminders of this ability all around me: in the way tourism into their territory was regulated, in planning how to confront the effects of global climate change, and in negotiating social change between generations. By and large, young girls choose Western clothes, often wearing shorts or jeans and t-shirts, rather than traditional dress. This image of an older Kuna woman and a young girl reminds me how generational change occurs regardless of our ability to control it. Nonetheless, societies do have the cultural tools to control the rate and extent of how change occurs, and in this control, to maintain a sense of wellbeing. Panama’s Kuna are an example for other indigenous peoples adapting to a rapidly changing and modernized world.

—Mark Caicedo

1
Introduction

Sign Posts

Lenore Manderson, Elizabeth Cartwright and Anita Hardon

It is sometimes hard to explain what an anthropologist does; it is even harder to explain ‘what medical anthropologists do’ as we correct assumptions that our work centers on categorizing old bones. Now, our task is more difficult than ever, and a summary descriptor—studying people’s experience of sickness and heath, care seeking and care—is banal and inaccurate. Medical anthropology helps make sense of suffering as a social experience, but it does much more than this. It carries us into refugee camps, birthing centers, factories, boardrooms, gaols, rehabilitation centers and schools, across countries and between communities. And, as we describe below and throughout this volume, it is also a field of great privilege; medical anthropology takes us into the most intimate aspects of people’s lives, and the most intimate expressions of their joy, anxiety, grief and tenderness.

* * * *

Let us begin by explaining who we are and how we have worked, since this is central to why we have written what we have written. This was a collaborative project, and we brought to our conception of the volume and the task of its construction our experiences as students, researchers and educators in diverse settings.

Lenore was trained in Asian studies and history in Australia, and there, she held positions as a medical anthropologist in public health and medical schools until 2013; she now lives and works in South Africa and the United States, working partly on questions on public health in Africa, partly on environment and climate change. Her earliest field research projects, as an historian and anthropologist, were in Malaysia. For most of her career, she has conducted research and trained others there, elsewhere in Southeast and East Asia, and in Australia with Indigenous, immigrant and settler Australians, on questions of infectious and non-communicable diseases, gender and sexuality, diversity and inequality. Her research students have come from and conducted their research in diverse settings throughout Australia, Asia and Africa. Her work with the Special Programme for Research and Training in Tropical Diseases (TDR) over nearly 30 years has likewise contributed extensively to her understanding of medical anthropology both theoretically and in relation to its practical application in disease control programs and in enhancing people’s access to care and improved health.

Liz trained in anthropology in the United States, after initially training and working as a nurse. Her primary work has been in the United States, particularly with Spanish-speaking immigrants, and in Mexico, Central and South America, working on environmental health, immigration, and social justice—her students too are drawn from these areas. Her work among farmworkers in the US resulted in the creation of ‘The Hispanic Health Project’ that was located in southeast Idaho for over a decade. Through this work she refined her understanding of the value of high-quality data for community-based participatory research methods and community interventions. She now is employing these insights in her work with rural agricultural communities in the Peruvian Andes. Liz conceived and developed the course on Systematic Video Analysis for the Short Course on Research Methods held under the auspices of the National Science Foundation and the direction of Russell Bernard; this course is currently offered in an online format during summer sessions at the University of Florida, Gainesville. She is a trained videographer and has taught ethnographic filmmaking in the US, Mexico, Australia and Vietnam.

Anita was trained in medical anthropology in the Netherlands, after initially training in medical biology. She has conducted extensive fieldwork in the Philippines and elsewhere in Southeast Asia, with her graduate students drawn primarily Europe, Asia and Africa. With her colleagues Sjaak van der Geest and Susan Reynolds Whyte, she spearheaded the anthropological study of pharmaceuticals in the late 1980s. Since then she has been engaged in multi-level and multi-sited ethnographies on immunization, new reproductive technologies and AIDS medicines that have generated important ethnographic insights on the appropriation of these technologies in diverse social-cultural settings, their efficacy in everyday life, the role of social movements in their design, and the dynamics of care and policy making in their provision. She makes it a priority to communicate her research findings to patient advocates, policy makers, and public health researchers and practitioners, through and in collaboration with activist organizations.

This combined geographic and intellectual diversity—of where we studied, where we have taught, where we have undertaken field research, and the diverse backgrounds of our students— inspired us as we thought through the structure and potential uses of this volume, identified the case study authors, and wrote the chapters. Our shared vision, while providing a personal review of medical anthropology in the early twenty-first century, was to keep in focus the directions that contemporary medical anthropology was taking across space. These directions—no single pathway—are shaped by the intellectual traditions of our different continents, despite the travel of ideas between them. They are shaped too by inspirations from various other theoretical, epistemological and disciplinary conventions and concerns across the social sciences, and by medical and public health priorities in our different countries.

Current and emerging economic, political, social and environmental challenges, and the priorities of the people with whom we have worked, have further shaped the content and structure of this volume. The photographs that we have included stand alone, invitations to readers to engage and reflect (see About the Figures, pp. xii–xiii). The 52 case studies, from 66 authors, add polyphony to this volume, offering rich and diverse ethnographic examples of our dominant themes as they play out across geography, theoretical landscape and the political directions of contemporary medical anthropology. Around these case studies, we have woven our own texts in a shared voice.

Medical Anthropology: A Partial History

We three came to medical anthropology during a period of its vital growth, building on an earlier tradition of ethnographic enquiry into medical practices, ideas about causations of illness and symbolic healing (e.g. Polgar 1962; Rivers 1924; Rubel 1964), and emerging interest in the value of applied anthropology in contributing in practical ways to public and community health. At the time of our training and early careers, other social movements had begun to impact the focus of the discipline; from the 1970s, political, social and epidemiological factors had converged to frame an emerging, engaged medical anthropology. The last wars against colonialism and the violent inequalities that were revealed, the Vietnam War, debates about development, political ecology and environment activism, and trade union, black, Indigenous and gay rights activism, all drew our attention to the political economics of health inequalities within countries and between nations; we gained awareness too of the ways in which race, class, sex and sexuality shaped social exclusion and poor health. French philosophy offered us particular analytic tools in this context, of how knowledge shaped access to institutions, authority, power and practice (Bourdieu 1992; Foucault 1973; 1976; 1980), and of how socioeconomic inequalities are reflected in stratified bodily practices and reproduced across generations (Bourdieu 1977; 1984). Increasingly, anthropologists and others turned to document the impact of local social structures and global relations on the health status of individuals and communities, as in other aspects of social life, including income, education and employment.

Second-wave feminism and its political arms, including the women’s health movement, particularly captured our own imagination, supporting our decisions to break from sexist scripts around study and career; we were fortunate because of the number of strong women working in medical anthropology and cognate fields who had worn the path for us (Benedict 1946; Firth 1943; Geertz 1961; Mead 1928; Powdermaker 1966). In the context of health advocacy and feminist politics, many medical anthropologists turned to questions of gender and the silence around women’s experiences, and particularly began to write on reproductive health. For feminist anthropologists, this provided a way to trouble questions of nature and culture, the associations of women’s social status and biology, and the power of gender relations (e.g. Jordan and Davis-Floyd 1974; MacCormack 1982; MacCormack and Strathern 1980; Rosaldo and Lamphere 1974). It provided an avenue to bring women from the periphery to the center, and in doing so, to interrogate how biomedical regimes have changed women’s experiences in different settings and to explore the role of women healers in their reproductive and wider lives. The earliest works on reproductive health were partly inspired correctives to a view of women’s lives, bodies and domestic domains as insignificant, and in medical research, to their undisguised omission. Almost half a century later, an impressive corpus of work exists on conception and (in)fertility, contraception and abortion, pregnancy, birth and delivery, the postpartum and breastfeeding, and menstruation and menopause (see, for example, Davis-Floyd 1992; Ginsburg and Rapp 1995; Inhorn 2002; Lock 1993; Martin 1987). These works are centrally about the subjugation of women’s bodies and functions to particular discourses of gender and regimes of control. We return to some of these issues at various points in this volume—in Sebastian Mohr’s case study of sperm and its donation in Chapter 3; in a number of case studies of genetics and reproduction in Chapter 14; and in Eugenia Georges’s and Robbie Davis-Floyd’s discussion of midwifery in Chapter 15, for example.

In the late twentieth and early twenty-first centuries, a series of events in international health, involving multilateral agencies primarily, influenced how the field of medical anthropology was to develop. The Declaration of Alma Ata in 1978 (International Conference on Primary Health Care 1978) set out a vision that sought to improve the delivery of health care services, and so improve health in poor countries by redistributing authority from an urban and professional elite to local communities. Ideas about the importance of community participation, identified as critical for effective primary health care to ensure ‘health for all,’ fed directly into health policy and planning. The Declaration provided a particular role for anthropologists; in operationalizing its principles to ensure effective and sustainable health care, increasing attention was paid to the local acceptability of health programs and services, the involvement of community volunteers to build health infrastructure and extend primary care, and the mechanisms to support populations to use the medical services that were available in their localities. Medical anthropologists had experience with the communities in question.

Arthur Kleinman and his colleagues (1980; Kleinman et al. 1978), in their early work on explanatory models of illness, provided us with a tool that was clear and accessible to medical and public health professionals, enabling us to demonstrate cultural variations in the experiences, diagnosis and treatment of illness. The elegance of this model, and its appeal to health researchers, led a number of medical anthropologists to then develop manuals for rapid assessments, dating from the foundational work of Susan Scrimshaw and Elena Hurtado (1987) and parallel approaches in agriculture and community development (Chambers 1983). Despite criticisms that rapid methods produced superficial findings and that applied anthropology reinforces biomedical hegemony (Manderson and Aaby 1992), these manuals were important for anthropologists and others working in international health programs and in interdisciplinary teams, because the focused data so generated facilitated the translation of anthropology, such that interventions might take account of local understandings of illness, the circumstances that pattern risk, and the community structures that might support prevention (see, among other examples Agyepong et al. 1995; Herman and Bentley 1993; Pelto and Armar-Klemesu 2010; Pelto and Gove 1992).

It was HIV and its lethal consequence as AIDS, however, that most powerfully stimulated medical anthropology. Four years after the Alma Ata Conference, the first case was diagnosed. The subsequent HIV pandemic had singular impact on shaping medical anthropology: the only possible preventions until the successful development and roll-out of anti-retroviral therapy required detailed and nuanced knowledge especially of sexual behavior and injecting drugs—of what people did, in what contexts, and why. Anthropology, as we will demonstrate in Chapter 4, was critical to understanding the pathways of transmission and prevention, and the stigma derived from associating particular marginalized populations with the risks of infection, illness and death (Hardon and Moyer 2014).

Interplay

Over the past half-century, significant epidemiological changes have precipitated changes in health policies and programs at local and global levels, and in the work that medical anthropologists do. Today, because of early diagnosis and effective pharmaceutical interventions, increasingly infectious as well as non-communicable diseases are of long-term duration, as illustrated by HIV and as we discuss in Chapter 7. At the same time, various chronic conditions are proving to be caused by infectious agents: chronic gastritis and gastric ulcers, and possibly other ulcers, long thought to be due to diet, stress or personality, have been shown to be caused by bacteria; cervical and some other cancers are now known to be caused by human papilloma virus (HPV). However, the vaccines and drugs developed in the wake of this knowledge are not a panacea. Pathogens that cause or contribute to many diseases mutate to resist pharmaceutical interventions, often more quickly than new drugs can be developed. Anopheles mosquitos that transmit malaria rapidly develop resistance to insecticides and change their behavior in response to preventive measures, and the parasite that causes malaria has been equally efficient at developing drug resistance. In addition, as we illustrate in this volume, many people have poor access to health care, and health systems problems limit the effectiveness of interventions for both infectious diseases and chronic non-communicable diseases.

The ‘social determinants of health’ is one framework used to appreciate how social, cultural and economic environments shape health and wellbeing, disability and disadvantage. The framework, as developed by Richard Wilkinson and Michael Marmot (1999), drew on social, economic and health data from the United Kingdom. In 2005, the WHO established the Commission on the Social Determinants of Health, chaired by Michael Marmot, to examine how social inequalities and injustices compromise people’...