Critical Medical Anthropology

Merrill Singer, Hans Baer

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351845168
• Edition: 2
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The purpose of this book is to provide an introduction and overview to the critical perspective as it has evolved in medical anthropology over the last ten years. Standing as an opposition approach to conventional medical anthropology, critical medical anthropology has emphasized the importance of political and economy forces, including the exercise of power, in shaping health, disease, illness experience, and health care.

Section A:

Orientation

Introduction

As an academic discipline, mode of discourse, and domain of action, medical anthropology is both young and old. From the beginning, anthropology has had an interest in health, sickness, and healing in local context, as these are issues and concerns that encompass the most poignant of human experiences and aspirations. Consequently, these topics were on the minds of participants in some of the earliest anthropological field expeditions dating to before the First World War. However, the actual emergence of medical anthropology as a distinct and labeled sector within the larger discipline is relatively recent. In a sense, contemporary medical anthropology can be traced to a lunch meeting at the Washington Hilton on December 2, 1967. Today, the Society for Medical Anthropology, a direct product of that meeting, is one of the largest sections within the American Anthropological Association, while health-related issues have become a major area of study among anthropologists in the United Kingdom, various countries on the European continent, Latin America, and elsewhere.

Anthropology has long maintained a relationship, varying in character and depth, with that most prominent and imposing brand of healing, the health care system we have come to call scientific or biomedicine. In Firth’s evaluation, this perduring relationship has had many twists and turns, including occasional “periods of collaboration, cross fertilisation of ideas and common enthusiasms” [1, p. 237]. And this has been especially true of the branch of the discipline that claims health and healing as constituting its special domain of research, the field that has been inescapably marked by this relationship in its very title: medical anthropology.

For some, the often penetrating intimacy of the biomedicine/medical anthropology relationship is not especially problematic. Biomedicine has proven its metal in life and death issues as a science and praxis worthy of emulation, hence its social respectability, elite stature, and diffusion internationally. Indeed, anthropologists working in far flung comers of the globe report a demand for biomedical cure, even among peoples actively engaged in vital ethnomedical traditions. And even folk healers who daily enter into trance to query spirit beings, concoct all manner of magical potions, and construct curious looking protective talismans in ministering to their clients, have been quick to recognize the healing power of biomedicine and either attempt to usurp its imagery or refer patients to its practitioners for supplemental treatment. In the estimation of its advocates and admirers, scientific medicine can claim great gains in healing the sick, producing a broad decline in mortality in the Western world especially, and in eliminating infectious diseases that have caused pain and death from time immemorium. Consequently, for many anthropologists biomedicine has become “the reality through the lens of which the rest of the world’s cultural versions are seen, compared, and judged” [2, p. 4]. Moreover,

Despite the cultural relativism that is usually considered essential to anthropology, medical anthropologists generally have been reluctant to question the privileged epistemological position of scientific medicine [3 p. 115].

While some medical anthropologists continue to call for a deeper, more thoroughgoing integration with medicine, seeing it as setting the standard for relevance within the discipline, in recent years doubts have begun to surface. This apprehension has had various expressions and has been voiced by anthropologists who embrace differing perspectives. On the one hand, there has emerged a fear of the medicalization of medical anthropology, a discomfort with the expansion of medical jurisdiction over many aspects of social life and experience including social science. Kapferer laments that medical anthropology now “incorporates Western ideological medical assumptions in the routine of its practice,” and as a result, the discipline “is oriented in its very work to give a medical significance to diverse human practices” [4, p. 429]. For example, there are medical anthropologists who study folk healers so as to judge the efficacy of their practice in biomedical terms [5]. Prominent medical anthropologists, like Carol Browner, Bernard Ortiz De Montellano, and Arthur Rubel [6], in fact, have devised a methodology for the cross-cultural study of ethnomedicine using scientific medicine to provide “universalistic units of measurement” to compare and contrast healing systems. These researchers argue,

We do not idealize bioscience as the exclusive means by which understandings should be gained in the field of ethnomedicine, but we do want to demonstrate that it offers productive anchoring referents from which to launch cross-cultural comparative studies of human physiological processes and emic perceptions of them [6, p. 689, emphasis added].

Similarly, in a recent examination of folk medical illnesses, Ronald Simons and Charles Hughes commit themselves to the difficult task of fitting a host of so-called culture bound syndomes, like Latah (characterized by a vulgar and exaggerated reaction to surprise) from Malaysia and Indonesia and Koro (fear of the complete retraction of the penis into the body) from Asia, into the nosology of mental illnesses officially recognized by the American Psychiatric Association and codified in the (frequently revised) Diagnostic and Statistical Manual of Mental Disorders, [7]. In this undertaking, Latah is incorporated into the familiar realm of psychiatric discourse as a type of “Dissociative Disorder” of the “Atypical” subtype, a label used to include “individuals who appear to have a Dissociative Disorder but do not satisfy the criteria for a specific Dissociative Disorder” [quoted in 7, p. 112]. Koro, in this approach, is interpreted as a form of Conversion Disorder, although because of the tremendous fear it engenders in sufferers “it might also be appropriate to add Panic Disorder” or even Atypical Somatoform Disorder [7, p. 193].

The elevation of biomedical understanding to the status of objective reality implied in efforts of this sort has caused considerable debate in a discipline that prides itself on its cross-cultural awareness, sensitivity and relativity. One expression of discomfort in this regard is a growing concern with the medicalization of the discipline [8,910]. Often this anti-medicalism is expressed in the form of a radical phenomenology that seeks to eluciate sufferer experience independent of biomedical categorization or even diagnosis.

In addition to the anti-medicalization approach, a second critique of medical anthropology and its relationship with biomedicine has grown in recent years. Sharing aspects of the anti-medicalization perspective, and not always clearly distinguished from it by participants in and observers of the discipline, this other critique draws upon the insights of the political economy of health tradition from outside of anthropology. Unlike its radical phenomenological cousin, this approach understands biomedicine not solely as a powerful system with important social control functions in contemporary society, but more broadly in terms of its relationship with the capitalist world economic system. Since Marx and Gramsci, it has been recognized that dominant institutions and their understandings of reality tend to legitimize, rationalize, and reproduce the dominant relations of society. In adopting a supportive or subservient position vis-a-vis biomedicine, this other critique argues, medical anthropology becomes not only an instrument for the medicalization of social life and culture, but also, like biomedicine, an unintended agent of capitalist hegemony and a tag-along handmaiden of global imperialism.

The term critical medical anthropology has for several years been used by adherents of both oppositional approaches described above. These have hung together, fellow travelers with a shared passport, joined together by their common critique of medicalization, despite recognized differences and occasional sparring during anthropology conferences and in the anthropology literature. The authors of this book, coiners of the term critical medical anthropology, have been and remain strong advocates of the political economic approach within medical anthropology, although not, as the radical phenomenologists have suggested, a political economic approach that narrows the focus of its analysis to macro-systems to the neglect of micro-relationships or even sufferer experiences and struggles. Nor do we seek to construct, as some colleagues outside of critical medical anthropology sometimes suppose, a perspective that is unmindful of the complexities of biomedicine (e.g., its diverse expressions cross-culturally, its internal conflicts within a given society or across medical specialties, and its inclusion of individuals of diverse commitments and ideologies) or the non-political economic (e.g., cultural, social, ecological) mediations of health and healing.

The purpose of this book is to provide an introduction and overview of critical medical anthropology (CMA) as we see it. By this, we mean a critical medical anthropology that emphasizes the importance of political and economic forces, including the exercise of power, in shaping health, disease, illness experience, and health care. In our efforts to build a critical medical anthropology, we seek to move the subdiscipline away from its service sector subordination to biomedicine (which is not to say, away from collaboration with health care providers) toward a more holistic understanding of the causes of sickness, the classist, racist, and sexist characteristics of biomedicine as a hegemonic system, the interrelationship of medical systems with political structures, the contested character of provider patient relations, and the localization of suffer experience and action within their encompassing political-economic contexts. These aspects of the critical approach are explored here using data collected by the authors during field and applied work in various settings primarily in the United States but in England, Germany, and Haiti as well.

In light of recent reactionary efforts to “de-Vietnamize” anthropology (i.e., to shed the political conscientization that occurred as a result of the mass protests against the U.S. war in Viet Nam), it is important to note that CMA was bom within the disquitude of the post-Vietnam War period. The lead author, Merrill Singer, began college in 1968 at the height of the anti-war movement, having already entered into progressive political activisim as a high school student. Singer’s undergraduate education, at both a community college and a state university, consisted of an (at times) uneasy blend of anti-war marches, work as a sometimes full-sometimes part-time boycott organizer for the United Farm Workers Union, involvement as a co-founder of a community free clinic, cooperative living with a colorful band of fellow dissidents in both urban and rural communes, and studies initially in sociology but quickly giving way to anthropology because of its global orientation. Interest in medical anthropology began during graduate work at the University of Utah but was not consolidated until after graduation during a post-doctoral fellowship at the Center for Family Research, George Washington University Medical School. An institute of the Department of Psychiatry, at the time the Center focused on family factors in drinking and the transgenerational transmission of drinking problems. Working for a year in a medical school allowed Singer the chance to observe medical education at close range. The post-doctorate also afforded an opportunity to read extensively in the literatures of political economy of health, medical anthropology, and drinking behavior and to carry out a study of the treatment of alcohol-related problems among Christian Science practitioners. These experiences served to fix his identity as a medical anthropologist. During the next two years as a visiting assistant professor in the Department of Anthropology at American University, he taught various courses including medical anthropology a...