Chapter Sixteen Health, Illness, Body, and Culture

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Eller Cultural Anthropology 3rd ed Chapter 16

CHAPTER SIXTEEN HEALTH, ILLNESS, BODY, AND CULTURE

Several hundred thousand people died in Liberia’s two civil wars between 1989 and 2003, leaving the survivors scarred physically and psychologically. Sharon Abramowitz tells that a post-conflict report on Liberian mental health found that forty percent of the population suffered from depression, eleven percent from suicidal thoughts, and seven percent from substance abuse (with even higher numbers among ex-combatants). Concerned not only about the damage to its citizens but about slipping back into war, the country and the world mounted a mental health intervention to aid the “traumatized nation” (Abramowitz 2014: 65), including not only individual trauma but “collective trauma” or “the disarticulation of the subjective, embodied person from the collective norms, social mores, and moral conduct that constitutes social order” (66). Some of the signs of collective trauma were fighting in the streets, sexual violence, and a general sense of fear and foreboding. Various international organizations such as Save the Children, the Center for Victims of Torture, the Lutheran World Federation/World Service, and Médecins du Monde (Doctors of the World) arrived with the task of “implementing trauma healing and psychosocial interventions, and through them, instilling post-conflict peace subjectivities” (6, emphasis in the original). In other words, the goal was not so much curing individual mental illness as managing the society and preventing a relapse into war; in fact, some organizations actually instructed their workers “to turn away anyone with a serious mental illness” (45). The patchwork of nongovernmental organizations and individual medical professionals turned the country into what Abramowitz dubs an “interventionscape,” where “flows of resources, personnel, bureaucratic protocols, administrative practices, financial mechanisms, and ethical guidelines shape the space of mental health, trauma-healing, and psychosocial intervention in the unique Liberian post-conflict landscape” (36). In the process, the Liberian people “were transformed into beneficiaries of a massive, uncoordinated, and decentralized project of humanitarian social engineering” (25)—and not only beneficiaries, since many Liberians were themselves trained as mental-health providers and as trainers of other providers, recruiting the whole society to do therapy on itself. “Trauma” became part of everyday speech, and barely-trained workers swept through the country as what Abramowitz calls “a vast, informal constabulary of care” (175), offering questionable advice, blending modern medicine with folk medicine and medicine with morality.

Illness, injury, pain, and death are universal human experiences. At first glance, health seems like a purely physical matter, just as the healthy or unhealthy body seems like a purely physical object. But the ideas and concepts, the institutions, and the practices and practitioners that societies develop to deal with illness, injury, and pain are thoroughly cultural, and even notions of a healthy human body—or a human body at all—vary across cultures.

Health is thus a perfect topic for anthropological investigation and has been a prime target of anthropological research. Health illustrates the fundamental anthropological concept of embodiment, of culture applied to, inscribed on, and enacted through the body. It opens questions of cultural knowledge (such as knowledge of medicinal plants, part of ethnobotany) and of cultural classification (such as what counts as “disease,” e,g, the American Psychiatric Association removed homosexuality from its official roster of mental illnesses in 1973). It exposes the social and cultural influences on health, from beliefs and values to lifestyle choices (like smoking) and inequalities of class, race, and gender, as well as the health influences on society, from the cost of health care to the impact of an aging population. Finally, health is a site for the practical application of anthropological concepts and methods; many anthropologists have trained as health professionals and vice versa, and there is a long productive history of collaboration between anthropologists and the medical establishment.

TOWARD A MEDICAL ANTHROPOLOGY

As previously told, anthropology was a biological and physical science before it was a cultural one, and many of its early advocates were biologists, anatomists, and physicians. (x-Ref: See Chapter 2) Among the most illustrious was W. H. R. Rivers, whose 1924 Medicine, Magic, and Religion, based on lectures given to the Royal College of Physicians of London, recognized medicine as a cultural phenomenon and as inseparably entangled with the cultural domains of magic and religion. He also wrote on psychology, as in his 1920 Instinct and the Unconscious, and in the same year he speculated on cultural and psychological (rather than biological and infectious) explanations for the depopulation of Melanesian colonial societies in his “The Dying Out of Native Races” in the medical journal The Lancet. In a second book published originally in 1926, Rivers declared:

Medicine is a social institution. It comprises a set of beliefs and practices which only become possible when held and carried out by members of an organized society, among whom a high degree of the division of labor and specialization of the social function has come into being. Any principles and methods found to be of value in the study of social institutions in general cannot be ignored by the historian of medicine.

(Rivers 1999: 61)

Other observers also remarked on the cultural dimension of health. Erwin Ackerknecht applied Ruth Benedict’s famous concept of “culture pattern” to various “primitive” medical practices, reasoning that it is “an almost hopeless task to try to understand and evaluate the medicine of one primitive tribe while disregarding its cultural background or to explain the general phenomenon of primitive medicine by purely enumerating that in the medical field primitives use spells, prayer, blood-letting, medicine men, twins, toads, human fat and spittle, etc.” (1942: 546-7). Noting that “the practice of medicine and the practice of magic have been closely associated” throughout history, the famous anthropologist Edmund Leach insisted that modern medicine retained a certain magical quality, while “people with completely mystical conceptions of the origins of illness may still handle minor ailments in a practical common sense manner” (1949: 165).

Anthropology’s relation with the medical field did not remain merely academic. According to Veena Bhasin, by the 1950s “many anthropologists were working on problems of international health; they were employed as teachers, researchers, and administrators both in universities and in hospitals” (2007: 2). One example was Cora Du Bois, who was hired by the World Health Organization in 1950. William Caudill is generally credited with devising the term “medical anthropology” (or “applied anthropology in medicine”) in 1953, and Benjamin Paul edited one of the first medical anthropology texts, Health, Culture and Community: Case Studies of Public Reactions to Health Programs, in 1955. (Margin::Key text:: Paul, Benjamin D. 1955. Health, Culture and Community: Case Studies of Public Reactions to Health Programs. New York: Russell Sage Foundation)

The advances of the anthropology of health and medicine were signaled by the founding of the forerunner of the Society for Medical Anthropology (www.medanthro.net) in 1967, and by 1971 “medical anthropology” had matured sufficiently as a discipline to merit a review article by Horacio Fabrega. Medical anthropology, according to the Society for Medical Anthropology, is the branch of anthropology investigating

those factors which influence health and well being (broadly defined), the experience and distribution of illness, the prevention and treatment of sickness, healing processes, the social relations of therapy management, and the cultural importance and utilization of pluralistic medical systems. The discipline of medical anthropology draws upon many different theoretical approaches. It is as attentive to popular health culture as bioscientific epidemiology, and the social construction of knowledge and politics as scientific discovery and hypothesis testing.

More succinctly, in a textbook intended for health professionals, Cecil Helman defines medical anthropology as the study of “how people in different cultures and social groups explain the causes of ill health, the types of treatments they believe in, and to whom they turn if they do get ill. It is also the study of how these beliefs are practices relate to biological, psychological, and social changes in the human organism, in both health and disease”; in a word, it is “the study of human suffering, and the steps that people take to explain and relieve that suffering” (2007: 1).

Comparative Health Care Systems

In the health domain as elsewhere, anthropology seeks a holistic, relativistic, and comparative or cross-cultural perspective. This can be a challenge, because many of the medical practices of modern Western societies do not seem “cultural” to Western practitioners or patients, while many of the practices of pre-modern and non-Western societies do not seem exactly “medical” (again, falling more in the category of religion and magic, if not superstition and old wives’ tales).

The most basic distinction that anthropologists and health professionals make is between biomedicine and ethnomedicine. Biomedicine is roughly synonymous with modern Western medical concepts and practices, so named because it “views disease as having a unique physical cause within the body, whether it is a microorganism causing infection, the growth of malignant cells or the failure of an organ due to repeated insults (such as alcohol consumption” (medanth.wikispaces.com/Biomedicine). It is, for most people, quite simply medicine, the “kind of legitimized, credentialed medicine practiced and recognized throughout the world by governments and licensing bodies.” As the “bio” in biomedicine indicates, “biomedical understandings of disease tend to privilege the body as the only relevant environment for the understanding of the disease causation and individuals are perceived as uniquely responsible for their health.” Biomedicine, in other words, is the world of operations, pharmaceuticals, and direct technical interventions on the individual body premised on scientific knowledge.

Ethnomedicine literally means culture-medicine or “the medical institutions and the manner in which peoples cope with illness and disease as a result of their cultural perspective” (medanth.wikispaces.com/ ethnomedicine) but in practice tends to specify other cultures’ medical systems or beliefs. Often the implication, if not the overt criticism, is that ethnomedicine is more primitive, less scientific, and ultimately less true than Western biomedicine. Also often, the assumption is that ethnomedicine is at best folk knowledge and at worst magic. Two things are true about ethnomedicine, however. First, as Leach noted, ethnomedicine also commonly focuses on the body (even if it integrates social and spiritual elements) and employs practical material means like plant remedies, massage, and such. Second, many ethnomedical traditions are quite sophisticated, like Ayurvedic (Indian) or Chinese medicine. They feature written texts and trained specialists, and some of their practices including acupuncture have been adopted by Western medicine.

Aptly, Robert Hahn and Arthur Kleinman concluded that biomedicine “is an ethnomedicine, albeit a unique one”; it is Western ethnomedicine, “the product of a dialectic between culture and nature” like every other healing tradition and therefore a biocultural thought-system like every other (1983: 306). In other influential works, Kleinman elaborated the concept of “explanatory model” to account for these different medical traditions. In an article (Kleinman 1978) and then a book he proposed the term “explanatory model” to designate “the notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process” (Kleinman 1980: 105) and thereby act as “the main vehicle for the clinical construction of reality” (110). (Margin::Key text:: 1980. Patients and Healers in the Context of Culture: An Exploration of the Borderland between Anthropology, Medicine, and Psychiatry. Berkeley and London: University of California Press) A model consists of the words, practices, roles, institutions, and instruments related to five variables in the sickness episode—etiology or cause, time and mode of onset of symptoms, pathology, course of the sickness, and treatment.

Kleinman further asserted that there were three “sectors” or “social arenas” in societies “within which sickness is experienced and reacted to,” namely the popular, the folk, and the professional (1978: 86). The popular arena “comprises principally the family context of sickness and care, but also includes social network and community activities”; not only does the vast majority of medical care happen in this sector, in non-Western and Western societies alike, but “most decisions regarding when to seek aid in the other arenas, whom to consult, and whether to comply, along with most lay evaluations of the efficacy of treatment, are made in the popular domain” (86). The professional sector or arena “consists of professional scientific (‘Western’ or ‘cosmopolitan’) medicine and professionalized indigenous healing traditions (e.g. Chinese, Ayurvedic, Yunani, and chiropractic)” (87). Note, significantly, that Kleinman’s professional sector does not equate to biomedicine. Finally, the folk sector/arena “consists of non-professional healing specialists” (86), which is an incredibly broad and unstable category, as any healing tradition may professionalize. He concluded that the three sectors/arenas “organize particular subsystems of socially legitimated beliefs, expectations, roles, relationships, transaction settings, and the like. These socially legitimated contexts of sickness and care, I shall refer to as separate clinical realities” (87), which may nevertheless overlap and interact (see below).

Healing Roles

Like every area of human endeavor, health systems feature specific healing roles. In biomedicine, the familiar roles are doctor, nurse, surgeon, pharmacist, and—according to prominent sociologist Talcott Parsons—patient. In his epic The Social System, the functionalist Parsons imagined sickness as a kind of dysfunction and the sick person as a sort of deviant social actor; more, society actually provides an “institutionalized expectation system relative to the sick role” (1951: 436), characterized by an exemption from ordinary responsibilities (e.g. the freedom to stay home from work), an obligation to want to “get well,” a notion of the patient’s inability to heal on his/her own and thus accept the dependent position of being “taken care of,” and a resultant duty to seek qualified help and to cooperate with those helpers. (Margin::Companion Website::The Anthropologist in the Sick Role: Robert Murphy’s Body Goes Silent)

We will have much to say about pre-modern and modern, ethnomedical and biomedical, healers below. For now a word about the sick person is in order. First, as we have seen elsewhere (x-Ref: See Chapter 6), people whom society might classify as sick or disabled, like the deaf, may not identify as such and may decline “treatment”; whatever society and medicine had or has to say, many homosexuals and transsexuals reject the label of illness. In some very interesting research, Rebecca Lester finds that women with eating disorders may resist medication: “They may actively restrict their intake of medications, take them and then purge them, or hoard them and ‘binge’ on them” (2014: 241). Part of the problem she attributes to the discourse of medicine as food, since food is the patients’ core issue; more profoundly, Lester reminds us that some eating-disorder patients are intentionally “depriving the body of what it needs to function optimally” and “maintaining a state of constant deprivation, of not allowing oneself to thrive” (248). At the deepest level, the disorder is “about feeling unworthy to exist and sustaining an existence as a non-entity while relentlessly punishing oneself for the unforgiveable crime of remaining alive” (249). Not quite so self-negating is what many medical professionals call the “bad patient.” As we will see in our discussion of hospitals below,