Health and Disease: III. Anthropological Perspectives

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III. ANTHROPOLOGICAL PERSPECTIVES

Medical anthropologists focus on people's life worlds (the subjective experience or phenomenology of sickness and healing), their cultural systems of meaning (e.g., ideas about what causes disease and how it is diagnosed), and the material conditions in which experiences and beliefs are situated (e.g., local disease ecology). Medical anthropologists attempt to understand and describe the medical beliefs and practices of people whose cultures and life worlds are often very different from their own. They routinely are confronted with the problem of translating unfamiliar meanings and experiences into familiar (Western) terms and concepts without taking them out of context or subordinating them to Western assumptions about sickness, health, efficacy, autonomy, and the like (Lock and Gordon; Kleinman, 1988; Gaines).

The anthropological perspective makes it possible to examine and clarify bioethical issues from multiple cultural points of view. The current debate over the bioethics of organ harvesting—the surgical removal of transplantable body parts such as the heart, liver, and kidneys—illustrates why it is important to have a clear understanding of cultural points of view. For transplantation to succeed, organs must be removed either (1) from a living donor in cases in which the organ is not vital to the donor's survival (e.g., a single kidney) or (2) immediately after a donor's death, before the organs have begun to decompose.

In most Western societies the line between life and death in the context of organ harvesting is identified with brain death, the irreversible loss of higher brain functions. The decision to identify death with brain death is consistent with Western cultural notions: Selfhood is identified with the mind, and the mind is by convention situated in the brain. This arrangement has the practical advantage of leaving a working heart in a harvestable body, facilitating the collection of transplantable organs. Japanese culture, in contrast, recognizes a different relationship between selfhood and the body: The self is not identified with a single body region. From this perspective a brain-dead body with a functioning heart has not crossed the line from life to death and is not yet a harvestable resource (Lock, 2002). Clearly, cultural definitions of selfhood and personhood have a profound impact on people's responses to bioethical issues.

Orientations to the Body

The history of medical anthropology is to a large extent a history of scrutinizing and challenging Western assumptions about sickness, beginning with the distinction between biomedicine and traditional medicine. (Most medical anthropologists prefer the term biomedicine to the alternative terminology: scientific, modern, and Western medicine. For an explanation see Leslie.) At first glance the distinction appears to be a commonsense way to classify different kinds of medical systems; in practice it rests on a set of problematic assumptions.

First, it implies that traditional medical systems have something fundamental in common, whereas in reality socalled traditional systems are highly diverse in both their medical theories and their practices and share little as a category other than being different from biomedicine (Leslie and Young). Second, juxtaposing traditional medical systems with biomedicine implies that biomedicine is a monolithic system, beyond the reach of culture. However, social scientists have demonstrated significant variation in biomedical notions, technologies, and clinical practices both within communities and across cultures (Brodwin, 2000; Hahn and Gaines; Lindenbaum and Lock; Lock, 1993; Lock, Young, and Cambrosio). Third, comparing biomedicine to other medical systems also sets biomedicine as the standard of medical care because it is based on scientific principles; this conveys the idea that other medical systems are not as real or therapeutically effective.

A more useful way to compare medical systems across cultures is to start with the question, How do the beliefs and practices of a medical system orient healers and patients to their bodies? An answer from the Western perspective might be that because the body is the site of the pain and suffering associated with sickness, the body must be the focus of attention for patients and healers everywhere. In reality, medical systems are not equally interested in the body. Rather, those systems and their perspectives are distributed along a continuum that includes the biomedical perspective among many others.

At one end of the continuum are systems whose orientation to the body can be called externalizing in that their diagnostic and therapeutic ideas and techniques direct people's attention away from the sufferer's body. In those systems the medical gaze looks outward, scanning networks of people and beings (e.g., ancestral spirits, possession spirits, demons) for morally significant encounters and events involving the sick person or that person's close relatives. The diagnostic goal is to construct a useful etiology, that is, a string of circumstances and events that lead to the onset of suffering and distress and identify the ultimate source of the sickness. The therapist's goal in those systems is to insert himself or herself into the patient's sickness narrative and, once there, persuade or coerce the pathogenic agents to stop afflicting the patient. The classic account of diagnosis and treatment in an externalizing system is E. E. Evans-Pritchard's Witchcraft, Oracles, and Magic among the Azande (1937).

A sick person's body is a site of discomfort and distress, and in this sense sickness is the same all along the continuum. At the externalizing end, however, the patient's bodily experiences and transformations are mute. Typically, the body is a black box in that although people may have names for certain body parts and organs, they can posit no functions or systemic connections for them. Pain, suffering, and the visible transformations that accompany sickness and disease signify only themselves; they reveal nothing about processes and events that biomedicine recognizes are taking place inside. Although practitioners may give patients medicaments to take, those medicines are characteristically anodynes or substances that are intended to make the patient more comfortable while the actual cure is being pursued elsewhere. In short, in externalizing systems medical meanings and experiences are created and connected by discrete socio-logics rather than by a universal bio-logic (Lock and Gordon).

Anthropologists describe three broad types of therapeutic strategies that operate in externalizing medical belief systems: agonistic strategies, in which the goal is to eliminate or neutralize pathogenic agents; initiatory strategies, in which the goal is to bring the patient and the pathogenic agent into a permanent and manageable relationship (Boddy); and strategies of persuasion, in which the goal is to persuade the pathogenic agent through offerings or appeals to cease afflicting the patient (Lewis). Beyond these generalizations, externalizing systems are highly heterogeneous.

Biomedicine is at the opposite end of the continuum, among the internalizing systems, in which diagnosis and therapy orient patients and healers toward the body. Here sickness coincides with the limits of the body, and the goal of diagnosis and therapy is to get inside the body, to take control of its internal parts and processes. Circumstances and events outside the body are interesting only to the degree to which they lead to inferences about pathological processes taking place inside. It is in these systems that one finds theories of pathophysiology, the grammars that enable people to read bodily changes symptomatically.

Medical Efficacy

Common sense inclines people to suppose that because internalizing systems are able to read embodied symptoms, they are more empirical and realistic than externalizing systems are. Ethnographic research, however, indicates that all medical systems, externalizing as well as internalizing, are generally empirical and realistic. That is, they are capable of routinely producing self-vindicating outcomes, evidence that demonstrates their efficacy.

Medical efficacy can be demonstrated by two different kinds of results. First, efficacy is sometimes a capacity for producing hoped-for results, such as the amelioration of pain or the remission of symptoms. In practice it is not difficult for externalizing and internalizing systems to produce hoped-for results in light of the fact that the majority of medical problems consist of either (1) transient or recurrent symptoms that are perceived as being discrete disorders or (2) self-limiting diseases, episodes that end in either spontaneous remissions or death. In these circumstances medical practices acquire a reputation for hoped-for efficacy when three conditions are met: An intervention routine occurs between onset and outcome, remissions predominate over deaths and other unwanted outcomes, and superior alternative interventions are absent or inaccessible.

Second, efficacy can take the form of producing expected results. This occurs when practices and procedures are able to produce evidence that affirms the line of reasoning and the underlying assumptions that persuade patients and practitioners to select particular interventions. Expected results can be produced without also producing hoped-for results. Thus there is the grim joke that the operation succeeded but the patient died: The patient's body, once opened up, reveals a pathology that affirms the correctness of the assumptions and choices that have led from diagnosis to surgery, but the intervention is unsuccessful because of circumstances beyond the clinician's control. All medical systems, whether internalizing or externalizing, appear capable of distinguishing between hoped-for results and expected results.

In addition, serious sickness is a source of distressing feelings that are only incidentally connected to the pain and suffering of a sick person. Medical practices may have the effect of reducing such distress by connecting sickness events to local systems of moral and cosmological meaning. This power to give meaning to and impose moral order on chaotic and threatening events may be sufficient to perpetuate certain medical practices even when those practices have no great reputation for producing cures. Those practices sometimes are called healing rituals by anthropologists.

The Mind-Body Problem

One of the current debates in biomedicine surrounds the mind-body problem, which has arisen from the observation that sickness is simultaneously an objective phenomenon and a subjective phenomenon. In the language of the social sciences the objective (or bodily) component is called disease, and refers to abnormalities and dysfunctions in organs and organ systems. The subjective component is called illness, and refers to the patient's unique and holistic experience of either disease-related distress or certain other socially disvalued states, such as psychogenic mental disorders, that conventionally are bracketed together with diseases. Disease can occur in the absence of illness, as in the case of undiagnosed and asymptomatic hypertension, and illness can occur without disease, as in adjustment disorder and somatization disorder.

Anthropologists have critiqued the mind-body distinction in two ways. The first critique calls for a reconceptualization of the relationship between mind and body. The argument is that people need to free themselves from the objective-subjective comparison and take account of the continuous interaction between mind and body: the capacity of the mind to affect bodily states positively and negatively, the mind's predilection for using bodily states as idioms of distress, and so on (see Csordas).

The second and more radical critique refers back to anthropology's task of translating unfamiliar meanings and experiences into intelligible concepts without subordinating them to Western assumptions about sickness, healing, and agency. Both Western culture and biomedicine assume the existence of a mind situated in the brain. In practice, the mind is one of the Western ways of talking about the self: the body's seat of consciousness, the subject of its experiences, the initiator of the body's purposeful actions, the repository of its memories, and the locus of moral agency. To anthropologists the Western mind/self is a cultural artifact; it exists because people have practices that make it exist in the same way that possession spirits exist in the Sudanese zar cult. Indeed, there are many cultures and systems of medicine that are mindless in the sense that they have no corresponding network of mental and moral meanings, and they constitute people and experiences in fundamentally different ways. Thus, the mind-body distinction has been criticized not because there is a need for more effective concepts for connecting psyche (mind) to soma (body) but because the notion of mind itself and the practices through which that notion emerges subordinate non-Western cultures and realities to a distinctively Western ontology (Good and Kleinman; Kleinman, 1988).

Patterns of Resort

The idea that in any community an individual's medical behavior is congruent with a unitary set of meanings concerning sickness and its causes, diagnosis, and treatment is an obstacle to translating medical realities between cultures. Anthropologists make a series of distinctions between medical traditions, sectors, and systems so that they compare cultural norms of medical behavior:

A medical tradition is a set of practices and technologies organized around historically situated ideas about etiology, symptomatology, and treatment. Biomedicine, Ayurvedic medicine, and the zar cult are examples of medical traditions. Traditions are simultaneously vocabularies for interpreting the world and plans of action and technologies for producing facts that confirm their interpretations of the world.
The actual forms a tradition takes in a specific community make up its medical sector. A particular medical tradition can be put into action in various ways. It can be used to justify a range of practices, technologies, and routines, and it can be adapted to a variety of institutional settings. For example, in many less developed countries the biomedical tradition is practiced in four sectors: licensed professionals (physicians, nurses, etc.), fee-for-service injectionists (who inject clients with substances from the biomedical pharmacopeia), pharmacists (who can diagnose symptoms as well as prescribe treatments), and domestic settings (where the biomedical tradition is employed mainly to diagnose problems). Although the four sectors share a single tradition, they include different sets of options. In the first sector clinicians monopolize diagnosis and treatment choices and decide which etiologies will be tested and confirmed and which sets of cultural meanings and socioeconomic implications will be realized through these practices. Injectionists and pharmacists represent patron-dominated sectors of biomedicine in the sense that patients or members of their families make their diagnoses before consulting the practitioner. Practitioners may be asked for alternative diagnoses, but the ultimate decision is the patient's.
A medical system is equivalent to the collection of traditions and sectors that are available to the people in a particular community. Medical beliefs and practices are useful to patients and their families because those people know how to incorporate them into patterns of resort. These are the paths that people create in the course of actual sickness episodes as they navigate their way from one medical sector to another, picking and choosing from among their options.

The ethnographic literature suggests two main patterns of resort. In the first the patient or a surrogate simultaneously consults alternative traditions. People have various motives for following this strategy. In some cases patients believe that the effects of multiple interventions are cumulative; in other cases they are unsure which, if any, of the available traditions will provide an effective cure. In some communities, notably in southern Asia, the simultaneous pattern of resort reflects a therapeutic division of labor. Biomedicine is prized for its quick effects against causal agents such as microbes and its ability to treat symptoms such as high fevers. The Ayurvedic tradition is valued for its ability to counter the perceived side effects of biomedicines, especially antibiotics, and its ability to restore an equilibrium among the body's organs and humors, that is, the state synonymous with health. The alternative strategy consists of a sequential pattern of resort in which the individual exhausts the resources of a tradition or sector before moving on to an alternative tradition in the medical system (Young, 1983).

The paths that individuals follow through their medical systems are determined by a variety of factors. For example, patients who want to avoid stigmatizing etiologies (ones that would contaminate or spoil an individual's social identity) or diagnoses with a poor prognosis are likely to compare the range of diagnoses and etiologies that belong to the various traditions in their medical system and then start off with the tradition that offers the most favorable outcomes. The choice may be influenced by cost-benefit calculations. That is, a practitioner's or sector's economic and geographic accessibility are weighed against the perceived seriousness of the patient's sickness and the value of the patient to his or her family (Nichter).

Implications for Bioethics

Why is it important for bioethics to understand that health, illness, and disease are socially shaped, culturally constructed, and historically situated? Basically, those ethnomedical beliefs and values inform people's health-related behavior. More specifically, culture shapes the ways in which people make decisions in the context of morally charged healthcare situations. Culture also shapes the kinds of ethical situations that can arise in a particular healthcare or healing setting and the frameworks for understanding and models for responding to those ethical dilemmas. Anthropology's cross-cultural or comparative perspective, combined with ethnographic methodological approaches, helps people (1) recognize that moral norms vary cross-culturally and (2) challenge tacitly held cultural assumptions in biomedicine and bioethics about what counts as human, self and other, normal and abnormal, life and death, right and wrong, and other key moral concepts (Marshall and Koenig, 1996, 2001; Haimes).

Anthropological investigation into contemporary debates about bioethics raises new questions, provides insights into the ways in which people experience ethical issues, and broadens the scope of inquiry. Anthropological research on genetics, for example, shows that women's decisions to undergo prenatal genetic testing are informed by cultural definitions of risk, perceived acceptable forms of disability, and social dynamics between women and genetics counselors (Browner et al.; Rapp). These factors may come as a surprise to bioethicists, who may expect attitudes toward abortion to take a primary role in women's prenatal decisions. With regard to examining the genetic basis of medical conditions such as Alzheimer's disease and sickle-cell anemia among African Americans, anthropologists have been at the forefront in pointing out the problems with using the term race. For instance, using that term risks perpetuating essentialism about clinical phenomena. They also have identified how notions of heredity hinge on cultural ideas of kinship and the implications of genetics research for defining claims to group identity (Koenig and Silverberg; Brodwin, 2002; Gordon; Wailoo, 1997).

The ability to explicitly recognize the cultural basis of bioethical constructs, such as the concept of autonomy, can help bioethics scholars rethink the premises of moral arguments. Furthermore, by recognizing that medical systems maintain their own logic, bioethicists and biomedical practitioners are more likely to attempt to understand patients rather than label them as irrational or incompetent. Patients' perceived levels of competency—from both legal and ethical perspectives—can affect their involvement in medical decision making.

As an example one might consider the case in which a Mien mother from Laos brings her daughter to a pediatrician for her four-month immunizations (Crigger). The pediatrician observes a number of burns on the child's stomach and considers whether to call the Department of Child and Family Services, thinking that the mother has abused her child. The burns actually were the result of a healing ritual designed to ameliorate the child's symptoms that were identified as meaningful to Mien culture. Understanding that the burns are a result of a therapeutic regimen can help the pediatrician realize that the mother was not abusive or neglectful; instead, she was attentive to improving the health of her child (Brown and Jameton). In contrast, one might consider the physician's attempt to pierce skin with a needle as unnecessarily harmful even though it is intended to improve health. Different cultures have different conceptions of what therapeutic interventions constitute acceptable harms or risks and benefits. This case illuminates how culturally shaped ethical notions of risk and benefit are. With a cultural perspective in mind bioethicists can reconstruct arguments regarding risk-benefit ratios. Biomedical healthcare practitioners who recognize these cultural dynamics can better provide not just culturally competent care but also high-quality care.

Conclusion

A community's medical beliefs do not correspond to a homogeneous set of meanings. Both in complex societies and in traditional and tribal societies individuals are drawn by sickness into multiple and often contradictory systems of meanings and action. The appearance of unity and homogeneity within a specificcommunity is not accidental, however. Usually it is an expression of power, of the capacity of one segment of the community—its medical experts, political leaders, moral authorities, and others—to define and control which of the alternative sets of medical meanings will be carried over into public discourse. In this sense power is the ability to convince people that the socially dominant meanings of sickness are also the authentic meanings (Young, 1982).

allan young (1995)

revised by elisa j. gordon

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Encyclopedia of Bioethics