Stephen D & Mary J Hallin. 21st Century Anthropology: A Reference Handbook. Editor: H James Birx. Volume 2. Thousand Oaks, CA: Sage Reference, 2010.
Medical anthropologists disagree about definitions of the terms health and illness. A complicating factor is that health and illness are not—and never have been—opposites, since both health and illness can reside within the same individual at the same time. Clearly, health, illness, and disease are related concepts. But how does illness relate to disease? All definitions of health are imbued with moral, ethical, and political implications. Perhaps the broadest definition of health is that proposed by the World Health Organization (WHO), defining health with reference to an “overall sense of well-being.” By WHO’s criteria, only a relatively small percentage of the world’s population could be classified as healthy.
Medical anthropologists find it necessary to distinguish disease from illness (Beyerstein, 1997; Eisenberg, 1977; Helman, 2001). Beyerstein argues that the term disease applies mainly to organic, physical conditions that can be traced to viruses and bacterial infections, tissue damage, cancerous growths, and so on, while illness refers to how patients perceive the physiological experience of “things not being quite right.” He narrows this distinction even further by contending that disease is primarily organic, while illness is primarily psychological. Not all medical anthropologists would accept his distinction. Beyerstein’s ideas need further refinement, because it is well established that psychological and cultural factors, such as expectations, folk explanatory models, subjective biases, and even self-delusion, may greatly shape the experience of illness (Green, 2003; Kleinman, 1997). The placebo effect (placebo is Latin for “I will please”), for example, has been noted in all medical systems (Moerman, 2001), and 21st-century medical anthropologists have become increasingly concerned with the symbolism of healing and the impact of belief (the patient’s belief and that of the healer) on the healing process itself (Buckser & Glazier, 2003; Lévi-Strauss, 1967).
Anthropologists researching health and illness have focused mainly on the relationships that cultural systems have with organizations, institutional practices, and power structures, as well as the epistemological basis of medical knowledge. In addition, they have explored the cultural dimensions of health and illness from ethnographic, comparative, theoretical, and phenomenological perspectives.
Anthropological approaches to health care differ from those of other social scientists in a number of respects. Sociologists often focus their attention on single institutions, while medical anthropologists study multiple institutions and embrace medical pluralism (Baer, Singer, & Susser, 2003). Anthropologists recognize that all societies possess numerous and sometimes conflicting ideas about illness, curing, and health, ranging from predominantly local health systems (like core-shamanism) to scientific systems (like biomedicine). As anthropologist Murray Last (1996) pointed out, there is a wide range of subcultures represented within all medical systems.
Anthropologists assert that health care specialists can be found in all societies, because sickness, pain, suffering, morbidity, and mortality exist everywhere. The wide variety of beliefs and practices associated with death and diseases; ideas about what constitutes the “good life” and “well being”; connections between morality, illness, and ethics; and the use and abuse of power and social control as mechanisms for dealing with misfortune serve to highlight the universal interconnectedness of culture, health, and illness. Indigenous ideas concerning health differ markedly from biomedicine. The !Kung San of the Kalahari Desert, for example, interpret the ability to sweat as indicative of good health, since sweat is regarded as a “life-giving” substance (R. Katz, 1982). American biomedicine does not share this interpretation of sweat.
Anthropologists are equally concerned with the hows and whys of healing. As noted, all medical systems are grounded in human frailty; that is, all humans must deal with the realities of pain, suffering, and death. But cultures deal with pain in different ways (Morris, 1998). While some societies rely almost exclusively on traditional systems of knowledge (which may seem less effective from a strictly biological point of view), other societies advocate modern, scientific biomedicine. Both traditional and biomedical systems can make claims to efficacy; for example, an estimated 25% to 50% of substances used in traditional nonbiomedical botanicals have been shown to be effective by accepted scientific measures (Singer & Baer, 2007). All societies share common concerns about the quality of life, their valuations of human life, and the alleged adequacy and/or inadequacy of their own medical practices. As a consequence, medical anthropologists have expanded their field to encompass complex social, political, economic, philosophic, religious, and ethical issues like organ transplants (Lock, 2001).
The Scope of Medical Anthropology
As noted, anthropologists look at health and illness from a broad perspective; for example, Ember and Ember’s (2004) Encyclopedia of Medical Anthropology contains 53 thematic and comparative essays as well as 52 “cultural portraits” of health and illness in specific cultures around the world. Thematic and comparative essays address topics as diverse as bioethics, medical pluralism, shamanism, homelessness, nutrition, social stratification, aging, breastfeeding, immunization, genital mutilation, alcohol use and abuse, cholera, culture-bound syndromes, stress, diabetes, diarrhea, HIV/AIDS research, malaria, mental retardation, sudden infant death syndrome (SIDS), tobacco use and abuse, and tuberculosis. The 52 cultural portraits include case studies from every continent and represent diverse cultural groups ranging from the Amish of Lancaster County, Pennsylvania, to the Hmong in Laos and the United States, to the Yoruba of Nigeria.
Another indication of the broadened scope of medical anthropology is the number of anthropologists contributing to the second edition of The Gale Encyclopedia of Alternative Medicine (2005).
Medical anthropologists examine health and illness from a human-centered perspective focusing on individuals and their well-being. Medical anthropologists are also activists. The field of medical anthropology is characterized by its applied focus and its extensive use of ethnography and participant-observation to better understand the complexities of health, illness, and health care. There is a sense of urgency in all medical anthropological research. Translation of anthropological findings is of vital concern—not only to transcend language barriers (translating research findings into local languages) but also to bringing research findings to the attention of those in a position to implement them.
From Periphery to Center
Historically, medical anthropologists have focused on marginalized groups and marginal individuals, but a number of recent studies have examined elites and elite health practices. For example, Rayna Rapp (1999) has shown how social class influences female experiences of the reproductive cycle (pregnancy, infertility, abortion, and child delivery), Myra Blueblood-Langer (1996) demonstrated how middle-class parents and siblings cope with cystic fibrosis and other chronic illnesses, and Pearl Katz (1981, 1998) has examined the interactions of senior surgeons at a Canadian hospital. Surgeons, as Katz pointed out, constitute an elite group among biomedical practitioners.
The field of medical anthropology has become highly nuanced. Few societies make either/or distinctions with respect to health. Anthropologists often focus on subjective ideas about health and illness as negotiated within the context of an increasingly sophisticated understanding of human physiology, as well as increasing disparities in global access to health care (Green, 2003). Paul Farmer (2000) has shown how social forces may alter the distribution of diseases and contribute to the advent of new microbial diseases, which often are confined to the poor. Farmer concludes by noting that in the 21st century, social forces often are—following French sociologist Pierre Bourdieu—“embodied,” or interpreted as biological events. In addition, Farmer emphasizes that many people do not have access to health care technology. A growing percentage of the world’s population is becoming medically disenfranchised.
Medical anthropologists frequently cross disciplinary boundaries and draw from the research findings of other disciplines (e.g., epidemiology, demography, paleobiology, and forensics). While anthropologists document the tremendous variation in cultural perceptions of health and illness, demographers and epidemiologists categorize these changes in terms of a worldwide health transition associated with increased life expectancy, a decline in mortality, and an overall decrease in infectious diseases due to the widespread availability of antibiotics. As noted, not all people have benefited equally from advances in biomedicine. There has been a dramatic increase in the number of chronic and degenerative diseases, as well as new epidemics like HIV/AIDS. Demographers point out that poorer nations struggle mightily with disruptions caused by rapid urbanization and—at the same time—are faced with a dramatic increase in infectious diseases like tuberculosis that have been eradicated elsewhere. As Nancy Scheper-Hughes (1992) contended, developing nations are forced to deal with all the medical problems of the developed world plus additional problems like higher rates of infant mortality, life-threatening dehydration, the lack of potable water, urban violence, and widespread hunger.
Medical anthropologists also examine ways people explain and treat diseases and ways people adapt to changing environments. McElroy and Townsend (2004) convincingly argued that environmental factors are becoming increasingly important in predicting the incidence and prevalence of diseases. Their approach—influenced greatly by the writings of Rene Dubos (1959) and Alexander Alland Jr. (1970)—looks at disease over time and space and posits that a community’s health status closely reflects its adaptations to the environment.
Negotiating Disciplinary Boundaries
Over the past 30 years, American medical anthropology has become the largest subfield of anthropology and is now the second largest unit within the American Anthropological Association. Also over the past 30 years, medical anthropologists have expanded their field to encompass everyone, any time, everywhere. They see their field as unbounded.
Some have criticized medical anthropology for its lack of boundaries, but medical anthropologists themselves celebrate the many opportunities presented by loose boundaries (Ember & Ember, 2004; Singer & Baer, 2007). Like the discipline of anthropology itself, there is consensus that medical anthropologists should not be confined to researching strictly medical topics. Medical anthropology, according to its practitioners, is the sum total of “whatever medical anthropologists do.” We have adopted this broad perspective in writing this chapter.
Some have portrayed medical anthropology as yet another subfield within anthropology, while others perceive it as a separate discipline that draws on the findings of other subfields. Some say that medical anthropology constitutes a fifth subfield within anthropology, comparable to the four standard subfields: anthropological linguistics, biological anthropology, cultural anthropology, and archaeology.
Sometimes, medical anthropologists appear inconsistent when they resist delimiting the scope of their field, especially when they argue that biomedicine should be limited in scope. Following Ember and Ember (2004), they seek to encompass topics like environmental pollution, pesticide use, alcohol and drug abuse, sexual practices, dangerous work environments, and so on within their purview (Singer & Baer, 2007) while at the same time arguing that all problems should not be seen as medical problems. Medical anthropologists frequently criticize what they see as the increasing “medicalization” of social problems like alcoholism, AIDS, and drug abuse and suggest that modern biomedicine may not provide adequate solutions to these far-ranging problems.
Toward an Anthropology of Health and Illness
Foundations of Medical Anthropology
Medical anthropology presents itself as a new discipline, although it is not all that new. It has its own intellectual traditions going back to the 19th century, and some medical anthropologists claim that their field has even earlier roots among the ancient Greeks and Romans; for example, the Roman physician Galen (Claudius Galenus) was among the first to explore comparative medical systems. Galen’s most important contribution was establishing empirical observation and scrupulous record keeping as hallmarks of medicine practice. In many respects, the 16th-century Spanish priests charged with documenting Aztec cosmology and medical practices were also pioneers in medical anthropology (Ortiz de Montellano, 1989).
In the United States, medical anthropology emerged as a specialized field of research immediately following World War II, when a number of prominent American anthropologists were brought in as consultants on health care projects in Latin America, Asia, Africa, and the Caribbean. But its origins are clearly in the 19th century. Organizationally, American medical anthropology traces its roots to the formation of the Medical Anthropology Group in 1967 under the leadership of nurse-practitioner Hazel Weidman. In 1972, the Society for Medical Anthropology was formally accepted as a section of the American Anthropological Association.
The Torres Straits Expedition (1898-1899)
Alfred C. Haddon, along with British physicians W. H. R. Rivers and C. G. Seligman, initiated the Cambridge University Torres Straits Expedition of 1898-1899. Haddon, Rivers, and Seligman are considered to be among the first to conduct systematic research in medical anthropology. Rivers (1864-1922) anticipated many of the future directions of medical anthropology. He collected valuable data on traditional healing practices among Australian aborigines (Slobodin, 1997) and reported on these practices and beliefs in Medicine, Magic, and Religion (1924/2001).
As a physician, Rivers privileged biomedical models of illness and disease, and he concluded his study of Australian aborigines by noting that while preliterate societies may appear to possess systematic and coherent beliefs concerning the causes and effects of diseases, native beliefs and practices are not equivalent to those offered by Western biomedicine. For Rivers—and the other members of the Torres Straits team—ethnomedicine and biomedicine were seen as separate and unequal domains.
From Clinic to Field (and Back)
Other 19th-century founders of medical anthropology include Rudolf Virchow, who greatly influenced Franz Boas when both were colleagues at the Berlin Ethnological Museum between 1883 and 1886; Forrest E. Clements and Erwin Ackerknecht, who published a number of seminal articles in the 1930s dealing with native understandings of illness and disease; anthropologist Cora Du Bois, who was hired by WHO in the 1950s; Edwin Wellen, who worked for the Rockefeller Foundation; and—perhaps most significant—Benjamin Paul, who was the first anthropologist to have an appointment at the Harvard School of Public Health. Funded research projects included the Navajo-Cornell Field Health Project directed by psychiatrists-anthropologists Alexander and Dorothea Leighton and a number of projects administered by Yale physician William Caudill.
Early medical anthropologists—like many medical anthropologists today—focused on infectious diseases. In many poor nations, infectious diseases were the main cause of illness and death, and in many regions of the world, 50% or more of infants died before reaching 5 years of age. Between 1945 and 1965, antibiotics transformed the treatment of infectious diseases. The use of antibiotics, immunization of children, improved sanitation, and improved nutrition became major concerns of large-scale health programs.
Western-trained physicians who directed health care projects frequently encountered resistance from locals who underutilized their clinics, ignored instructions to boil water, and otherwise refused to comply with professional advice. Project workers suggested that local cultural traditions posed insurmountable barriers to adoption of modern health practices. Anthropologists were brought in who intervened and proposed ways of incorporating native ideas to supplement allopathic health practices. Benjamin D. Paul’s Health, Culture, and Community (1955), consisting of case studies that were first presented at the Harvard School of Public Health, soon became a basic text for researchers who, encouraged by private foundations and increased availability of funding through the National Institute of Health and the National Institute of Mental Health, began new graduate programs to train medical anthropologists. Today, most anthropology departments and most medical schools regularly offer classes in medical anthropology, and medical anthropology graduate programs now exist in 34 North American universities:
- Brown University
- Case Western Reserve University
- City University of New York
- Emory University
- Harvard University
- McGill University
- Michigan State University
- Rensselaer Polytechnic University
- Southern Methodist University
- State University of New York at Binghamton
- University of Alabama
- University of Alberta
- University of Arizona
- University of Buffalo
- University of California, San Diego
- University of California, San Francisco
- University of Colorado Denver
- University of Connecticut
- University of Hawai’i
- University of Iowa
- University of Kansas
- University of Kentucky
- University of Manitoba
- University of Massachusetts
- University of Memphis
- University of Michigan
- University of Missouri
- University of North
- Carolina at Chapel Hill
- University of South Florida
- University of Toronto
- University of Washington
- Wayne State University
- Yale University
- York University
Prior to the 1960s, training of medical anthropologists varied greatly. A number of prominent 20th-century medical anthropologists had their primary training in medicine, nursing, nutrition, psychology, or psychiatry. Most notable among these are Abram Kardiner, Robert I. Levy, Jean Benoist, Gonzalo Beltrán, Arthur Kleinman, Margaret Lock, Ronald M. Wintrob, George Devereaux, and Roland Littlewood. Conversely, a number of early contributors to medical anthropology were first trained in anthropology, sociology, social work, or psychology. Examples include George M. Foster, Veena Das, Byron J. Good, Tullio Seppilli, Gilles Bibeau, Luis Mallart, Andràs Zempleni, Gilbert Lewis, Alexander Alland Jr., Ronald Frankenberg, Horacio Fabrega, Eduardo Menéndez, Gretel Pelto, Hans Baer, Ida Susser, and Merrill Singer.
In an essay published in the journal Science, physician William Caudill adumbrated what would become the main interests and concerns of 21st-century medical anthropology. Caudill reported as follows:
Social anthropologists and other social scientists have been doing unusual things of late: participating with physicians in conferences in social medicine, teaching in medical schools, working with public health services in Peru, studying the social structure of hospitals, interviewing patients about to undergo plastic surgery, and doing psychotherapy with Plains Indians. (1952, p. 3)
Caudill’s vision placed medical anthropology squarely in clinical settings. American researchers worked within the culture of medical organizations. In Europe, cooperative relationships between practitioners of anthropology and medicine are long-standing and well documented, especially in Portugal and Spain (Martinez-Hernaez, 2008). In the Americas, cooperative programs between anthropology and medicine developed in the United States, Mexico, Brazil, and Canada (Saillant & Genest, 2007).
Anthropology once occupied a prominent place in the medical sciences corresponding to those subjects commonly referred to as “preclinical.” But as medical education began to be confined to clinical settings, European medical practitioners abandoned ethnography. However, as Comelles (2000) noted, the divergence of anthropology and medicine was never complete.
Medical anthropology during the mid-1970s at the University of Connecticut Health Center in Farmington closely followed Caudill’s 1952 model for the emerging field. Lectures were given by social scientists and physicians who had appointments at the medical school. They addressed many of the topics that had been outlined by Caudill in 1952. The main textbook was Alexander Alland’s Adaptation in Cultural Evolution: An Approach to Medical Anthropology(1970). Today, medical anthropology classes at the University of Connecticut are very different. In the 21st century, UConn medical anthropology is informed by critical medical anthropology (CMA) and by the community-based perspectives of Pam Erickson, W. Penn Handwerker, Merrill Singer, Steve Schensul, and Jean Schensul.
Biomedical Approaches to Illness
As noted, medically trained researchers (Beyerstein, 1997; Eisenberg, 1977) demanded more precise definitions of illness and disease. For these researchers, the term disease is limited to organic, physical conditions, while illness refers to how patients perceive the physiological experience of “things not being quite right.” But this distinction requires further refinement, because psychological and cultural factors, such as expectations, folk explanatory models, subjective biases, and even self-delusions greatly shape the experience of illness (Kleinman, 1997; Littlewood, 2005). The term disease refers to biological causes that can be treated physically, while illness refers to the experience of symptoms. Traditional medicine is holistic, while biomedicine is predicated on mind-body dualism with the body separated from mental and social functions (Rhodes, 1996). Paul Farmer (see Kidder, 2003) advocates both a biomedical and cultural approach to illness as he seeks to bring biomedical advances to poor nations of South America, Africa, and the Caribbean.
Medical ecology looks at health implications of interactions between human groups and their physical and biological environments. It provides a useful corrective to the clinical preoccupation with disease and the anthropological focus on ethnomedicine. Following Rene Dubos (1959) and Alexander Alland Jr. (1970), medical ecology’s unit of analysis is not the individual or the society, but the total ecosystem. From the perspective of ecological anthropologists (McElroy & Townsend, 2004), health is understood with respect to individual and group adaptations. Health behaviors are behaviors that foster survival within a given environment. Health is determined by the quality of relationships within a group, with neighboring groups, and with plants and animals within the environment. Ecological anthropologists focus on beliefs and behaviors that protect individuals from diseases or injury; for example, McElroy and Townsend (2004) pointed out that use of snow goggles among Arctic dwellers protects them from Arctic glare.
Sociological (Institutional) Approaches to Illness
Still others have examined medical beliefs and practices from institutional perspectives. Medical institutions can be portrayed as monolithic or pluralistic. As Cecil G. Helman (2001) astutely observed, it is difficult to separate a society’s health care system from aspects of their religion, politics, or economics. The arbitrary division of health care sectors into popular, folk, and professional is impractical and unsatisfactory. Helman—like other social scientists— outlines a variety of help-seeking behaviors that, he suggests, will inevitably lead to what he terms healthcare pluralism. He correctly argues that while one form of health care may be elevated above all others within a given society (and that form may be upheld exclusively by the legal system), it cannot be divorced from alternative healing techniques or from other societal institutions.
Critical Medical Anthropology
Critical medical anthropology (CMA) emphasizes the structures of power and inequality in health care systems and broadens the scope of medical anthropology to include wider causes and determinants of human decision making and behaviors as they relate to health and illness (see Singer & Baer, 2007, pp. 33-34). A critical understanding of health and illness involves paying closer attention to the vertical links connecting individuals to regional, national, and global forces. The CMA perspective examines dominant cultural constructions of health and illness with respect to structures of power and inequality in health care systems and shows how these dominant systems serve to reinforce social inequalities, for example, how poverty, violence, and the fear of violence relate to disease. CMA assumes a degree of autonomy, agency, and power in making health decisions, but it also recognizes that people make these decisions in a world that is not of their own making. They have little control over factors such as the lack of health care access, the influence of the media, the lack of productive resources (e.g., land and water), and social status. Advocates of CMA consider the daunting effects of pollution, pesticides, drug laws, and street violence in the making and breaking of health and illness cross-culturally. In addition, advocates of CMA explore the roles medical practitioners play in the creation and perpetuation of illnesses. Following Ivan Illich’s Medical Nemesis (1975), CMA suggests that many illnesses are iatrogenic; that is, they are caused or exacerbated by biomedical treatment. Unlike Illich, most contemporary advocates of CMA do not blame biomedical practitioners but seek broader explanations for biomedical failures.
As noted, critical medical anthropologists seem inconsistent when defining the scope of their field. They argue that biomedicine should be limited in scope, but at the same time contend that the scope of their own discipline should not be limited. More than any other perspective, CMA emphasizes that the anthropological study of health and illness should be expanded to address global issues. But these anthropologists also protest the increasing medicalization of social problems in the United States and suggest that allopathic medicine cannot provide adequate solutions to many of these far-ranging problems.
Phenomenological Approaches to Illness
Advocates of phenomenological approaches attempt to come to terms with the subjectivity of human illness. They accomplish this by adopting traditional participant-observation methods of listening and discovering and try to provide an insider perspective; for example, Margaret Lock compared differences in women’s experiences of menopausal symptoms in Japan and the United States. Patient and healer narratives provide useful insights into cultural ideas concerning illnesses and their respective treatments (Garro & Mattingly, 2000; Good & Delvecchio Good, 2000).
As noted, Myra Blueblood-Langer researched how other family members cope when a family member is diagnosed with cystic fibrosis (CF). Siblings, Blueblood-Langer discovered, are deeply affected by the disease as are their interactions in the larger community (school, church, etc.). Like all medical anthropology, phenomenological studies also have an applied focus. Blueblood-Langer, for example, suggests concrete applications of her findings. By understanding how other family members experience CF, she was able to propose guidelines for physicians and other health care professionals dealing with the families of CF patients.
One of the most revealing phenomenological studies was provided by Columbia University anthropologist Robert Murphy, who—during the final years of his life—was afflicted with brain cancer and became paralyzed. Professor Murphy—while immobilized—described his struggle with the disease in an evocative book, The Body Silent (1987). Murphy’s book is a poignant, personal testament of what it means to be treated as disabled. He noted that as he became more and more dependent, he also began to vanish socially. Disability, Murphy contends, is experienced not just in terms of bodily affliction but as a disease that alters one’s sense of self and colors all social interactions.
A number of medical anthropologists have attempted to combine biological and symbolic or meaning-centered approaches to health and illness. Psychiatrists have been at the forefront of this movement because, as Tanya Luhrmann so astutely noted in Of Two Minds (2000), they have one foot in each camp.
Arthur Kleinman, an anthropologist and psychiatrist who has researched health and illness in Taiwan, China, and North America since 1968, is one of the most influential “bridge builders” in medical anthropology. He draws on his own multidisciplinary background to propose alternative strategies for thinking about interrelationships between medicine, society, and the modern world.
Kleinman’s Writing at the Margin (1997) explores the permeable borders between medical and social problems and examines boundaries that separate health from social change. According to Kleinman, “health” is at once an end and a means. Following French sociologist Pierre Bourdieu’s ideas about “embodiment,” Kleinman conceptualizes the body as a mediator between individual and collective experiences. He suggests that many health problems—like the trauma associated with violence and depression stemming from chronic pain—are not just individual medical problems but interpersonal experiences of suffering as well. Like Margaret Lock (2001), he emphasizes that definitions of health and illness possess wide-scale moral implications and argues for an ethnographic approach to moral practice in medicine that incorporates sociopolitical contexts of illness, responses to illnesses, social institutions relating to illness, and documents how illness is configured within medical ethics.
In the 1970s, social scientists attributed multiple medical shortcomings to the malfeasance of doctors. Medical anthropologists no longer subscribe to such negative assessments, but—like Kleinman—continue to explore tacitly held medical assumptions and epistemological concerns.
In On Knowing and Not Knowing in the Anthropology of Medicine (2005), Roland Littlewood—himself an MD and an anthropologist—argued that many medical studies have been based on the assumption that medical knowledge is uniform and consistent. Anthropologists reject the notion that cultures are discrete, bounded, rule-driven entities, but medical science has been slow to develop alternative approaches to understanding diverse, unbounded cultures of “health.” Littlewood considers the theoretical, methodological, and ethnographic implications of the disconcerting fact that most medical knowledge is dynamic, incoherent, and contradictory and that all understandings of medicine are necessarily incomplete and partial. In settings ranging from the homes of indigenous individuals to Western hospitals, it is necessary to consider issues such as how to define the boundaries of “medical” knowledge as opposed to other types of knowledge; how to understand overlapping and shifting medical discourses; how to deal with the medical profession’s need for anthropologists to produce “explanatory models”; how to address the limits of the Western scientific method and its potential for methodological pluralism; and the constraints on fieldwork, including violence and structural factors limiting access, and the subjectivity of researchers.
Religion, Magic, and Healing
Religion and healing are closely interrelated. When Forrest E. Clements (1932) first proposed a first cross-cultural classification of native causes (etiology) of disease (i.e., sorcery, breach of taboo, intrusion of a foreign object, spirit intrusion, and soul loss), four 4 of 5 native explanations were essentially religious. Erwin Ackerknecht (1971) reinforced Clements’s understanding when he suggested that all tribal medicine should be viewed as “magic medicine.” Tribal healing, Ackerknecht asserted, lacks an empirical basis. It is grounded in witchcraft and superstition.
E. Evans-Pritchard’s classic studyWitchcraft, Oracles and Magic Among the Azande(1937) concluded that the Azande interpret all illness and misfortune as a direct manifestation of witchcraft. According to Azande beliefs, there is no such thing as a natural sickness, a random accident, or a timely death. Even when a granary that is overfull and in ill repair collapses, or a 99-year-old with a history of heart trouble dies in his sleep, these events are nevertheless attributed to witchcraft.
Edward C. Green (1999) has argued that far from being the province of witchcraft, indigenous understandings of contagious diseases in Africa parallel Western concepts of diseases and are similar to “germ theory.” Green calls this indigenous contagion theory (ICT). Major components of ICT include (1) pollution and/or “mystical” contagion, (2) naturalistic infections, (3) environmental dangers, and (4) violations of taboos. Pollution beliefs, Green suggests, may be a common concern for both biomedicine and traditional healers.
There are, however, important distinctions between superstition and belief.
Traditional healers interpret and manipulate powerful cultural symbols. By introducing complex psychosocial factors, dramatic symbolic imagery, metaphor, prayers, and enactments, healers activate beliefs and expectation in patients triggering psycho-neuro-immunological responses (Cannon, 1942; Winkelman, 2000). Using theatricality and symbolism, imagery, and metaphor, healers provide a way for patients to situate and comprehend their somatic sensations (Lévi-Strauss, 1967; Romberg, 2009). Daniel Moerman (2001) convincingly postulated substantial pathways linking physiological and cognitive states. These pathways, he suggested, are the stage on which metaphorical concepts of performance may effectively influence biological processes. Just as some native ethnobotanicals have been shown to have strong efficacy, some native healing practices have been shown to have efficacy as well (Turner, 1996). Sidney M. Greenfield’s Spirits With Scalpels: The Cultural Biology of Religious Healing in Brazil (2008) addresses the symbolic aspects of psychic surgery. Greenfield neither accepts nor dismisses the bizarre practices he personally has witnessed. Instead, he seeks to reconcile religious-based healing and recent findings from neurobiology. Like Moerman, Greenfield clearly recognizes the place of symbols within the healing process and advances a theoretical model that stresses altered states of consciousness and hypnotic states and moves beyond the limitations imposed by mind/body dualism.
Navajo Healing and Aesthetics
Healing, music, and art are also closely interrelated (see Csordas, 2000). Gary Witherspoon (1977) documented the healing power of Navajo chants, while Nancy J. Parezo (1983) charted a dramatic transformation of Navajo sand paintings from the sacred to the secular. Prior to the 1920s, Navajo sand paintings were used primarily as part of a healing ritual. Sand paintings were produced to “allow the patient to absorb the powers depicted, first by sitting on them, next by application of part of the deity to corresponding parts of the patient—foot to foot, knees to knees, hands to hands, head to head” (Parezo, 1983, p. 14). Today, Navajo sand paintings are commodities. They are bought and sold as tourist art.
Shamans are the prototypical healers in tribal societies. The term shaman is derived from the Mongol-Tungusic word saman (to know). As Michael J. Harner (1980) correctly asserted, shamanism is “the most widespread and ancient system of mind-body healing” (p. 175).
Shamanic techniques are surprising universal. Joan B. Townsend (1999) has outlined some of the basic components of what has become known as the shamanic complex. These include direct communication with the supernatural, an ability to control spirits, the ability to enter into and exit altered states of consciousness, a focus on problem solving, and soul flight. In practice, shamans serve as mediums for spirits. At times, they are able to call on the spirits without entering into trance, and they sometimes remember parts of what occurs on their journeys to the spirit (supernatural) realm. (For differing interpretations see Kehoe, 2000, and Winkelman, 2000.)
Shamanic beliefs and practices have been a major topic of anthropological study since the beginnings of the discipline, but the first systematic studies of the entire repertoire of illness concepts and therapeutic practices did not begin until the 20th century, when anthropologists began to question the efficacy of shamanism (Lévi-Strauss, 1967). As noted, earlier researchers like W. H. R. Rivers had been less ambivalent about traditional healing practices and suggested that traditional healers were frauds. This changed as critics of Western medicine began to challenge the value of Western medicine, faulting it for its positivist separation of mind from body; its dehumanizing focus on body parts, malfunctions, and lesions; and its treatment of pregnancy and birthing as pathological disorders rather than normal biological processes. Shamanic techniques, critics suggested, might be superior to those of allopathic medicine. This opened the way for collaboration between biomedical practitioners and traditional healers.
Collaboration is a key concern for 21st-century anthropologists. As defined by Mattessich, Murray-Close, and Monsey (2001), collaboration is “a mutually beneficial and well-defined relationship entered into by two or more organizations to achieve common goals” (p. 4). Collaboration entails shared decision making and mutual respect (Caluccio & Maguire, 1983, as cited in Henneman, Lee, & Cohen, 1995). In all cases, a major concern is the patient’s well-being. Within medical anthropology, collaborative efforts have been focused in two directions: participatory community research and collaborative projects among health care professionals.
The primary goal of collaboration research is to foster productive relationships (both formal and informal) among all parties concerned (El Ansari & Phillips, 2001). In participatory community research, community members take an active role in the research process itself (Taylor et al., 2004). For example, Noel Chrisman (2008)—an anthropologist who teaches in a school of nursing—conducted primary research with indigenous groups like the Yakima Indians of Washington State and has worked as an evaluator for numerous community-based participatory projects sponsored by the Centers for Disease Control.
Addressing a critical shortage of biomedical personnel in Africa, WHO adopted a number of resolutions to promote collaboration between traditional and biomedical practitioners. In 1978, WHO and UNICEF passed the Declaration of Alma-Ata recommending the use of traditional healers in government-sponsored health care programs, and in 2007, the ministers of health for the WHO African Region reaffirmed their support for collaborative efforts by adopting the Declaration of Traditional Medicine.
There is considerable debate among public health professionals regarding collaboration between traditional and biomedical practitioners. Those favoring collaboration emphasize that 80% of the African population regularly use traditional medicine and point out that the ratio of traditional healers to biomedical doctors is 100:1 (Green, 2003; UNAIDS, 2000). Those against collaboration point to what they see as irreconcilable differences between the methods and goals of biomedical and traditional practitioners. Some notable examples of organizations conducting successful collaborative initiatives include Traditional and Modern Health Practitioners Together Against Aids (THETA) in Uganda, and Tanga AIDS Working Group (TAWG) in Tanzania. Much literature on collaboration has focused on ways to train, educate, and integrate traditional healers into existing biomedical systems rather than fostering collaborative relationships between them and biomedical practitioners. Initiating collaboration with traditional healers is a complicated process (Kayombo et al., 2007), and 21st-century medical anthropologists will need to examine factors that serve to promote and those that impede collaborative efforts.
Comparisons: Global and Topical
Global Comparisons: Clements, Murdock, and Fabrega
In a reassessment of Forrest E. Clements’s 1932 study, anthropologist George Peter Murdock (1980) compared medical beliefs and practices of 186 societies included in the Human Relations Area Files (Murdock, 2004). Murdock divided theories about the causation of illness into two broad categories: theories of natural causation and theories of supernatural causation. Later, Murdock attempted to correlate different types of beliefs about causality with different global regions and different levels of social organization (foragers, horticulturists, pastoral-ists, and citizens of early states). Regional differences were found to be the most significant. Africa, Murdock found, ranks high in theories stressing mystical retribution, while North America outranked all other regions in theories of sorcery. South America ranks highest in theories emphasizing spirit aggression. A major problem with Murdock’s approach—like that of Clements—is that most societies rely on multiple theories of causation. Few tribal societies (and even fewer modern societies) posit a single cause for any single illness.
Horacio Fabrega (1997) offered a more sophisticated comparison of medical systems that has greatly influenced 21st-century research. Fabrega examined behaviors that he saw as biological adaptations related to sickness and healing (SH). Chimpanzees, he posited, enact behaviors like dressing wounds with leaves or wiping their feces. Neanderthals posed an even more elaborate SH repertoire. In foraging (hunting and gathering) societies, SH behavior was provided by insightful and socially attuned individuals who possessed a keen knowledge of the biological, cultural, and social environments in which they lived. A primary focus of tribal healers is ritual intended to restore social relationships. Village-level societies are characterized by more specialized healers, more elaborate ceremonies, and a better-defined “sick role,” whereby individuals perceived as “sick” were excused from normal social and economic obligations.
As societies became more complex—as in the development of chiefdoms and early states (e. g., the Greeks and the Aztecs), medical knowledge became systematized and institutionalized to include (1) a standardized, widely accepted corpus of medical knowledge; (2) incipient medical pluralism, and (3) the presence of a wide array of competing healers—herbalists, bonesetters, and midwives who would undergo systematic training and/or apprenticeships. These trends continue.
Medical Pluralism: Looking at Health and Illness in Haiti
The Caribbean nation of Haiti ranks as the poorest country in the Americas and is one of the poorest nations on earth. Health care options range from advanced biomedicine for elites in Port au Prince to floating hospitals like Project Hope to herbalists, religious healers (Pentecostals), and Voodoo practitioners. Access at every level is restricted to those who are able to obtain referrals, contribute bribes, and/or establish political connections.
The Haitian medical system is also among the most pluralistic and convoluted on earth. It consists of five unrelated sectors: (1) the public sector (The Ministry of Public Health and Population and The Ministry of Social Affairs); (2) the private, pay-as-you-go sector (a limited number of health care providers in private practice); (3) the mixed nonprofit sector (Ministry of Health personnel who actually work in private institutions such as nongovernmental organizations [NGOs] or faith-based organizations [FBOs]); (4) the private nonprofit sector (NGOs, foundations, and associations); and (5) traditional healers. A number of overlapping bureaus supervise health programs (except treatments for AIDS and tuberculosis, which are directly under the Office of the Director General). In principle, all health-related organizations are coordinated by the Ministry of Health. In practice, the Ministry of Health has been unable to assume leadership. Allopathic medicine is available to less than 60% of the population. In 1998, there were 2.4 physicians for every 10,000 people, and in 1996, there was 1 nurse per 10,000 people and 3.1 auxiliary professionals per 10,000 people. Haiti has both public and private medical schools, but of four private Haitian medical schools, only one is accredited.
In the countryside, the most common sources of medical care are traditional healers, NGOs, FBOs (largely American-funded clinics), and aid from other Caribbean nations. In 1999, a bilateral cooperation agreement was signed with Cuba. Under the agreement, 500 Cuban health professionals began working in 62% of the municipalities for a period of five years (or until the return of 120 Haitians selected to study medicine in Cuba). This agreement has been extended.
In Haiti, as in other poor nations, religion, magic, and healing are very much interconnected. In 1987, when Brodwin (1996) began an extensive study of folk ideas concerning illness, healing, and mortality in a small (3,000+ residents) Haitian village he called “Jeanty” (a pseudonym), his primary interest was in health-related activities among villagers. Brodwin’s major concerns were as follows: (1) How does medical pluralism function in Haiti? (2) How do clients select which ethnomedical system to access from among many available options? (3) What factors influence their selections? and (4) What happens when patients and healers interact?
Brodwin observed over 50 consultations between patients and herbalists as well as consultations between patients and houngouns (Voodoo practitioners). He concluded that villagers readily consulted houngouns for pressing health problems, but—at the same time—they were ambivalent, because a houngoun has the ability to send illness as well as to cure it.
In 1987, physician and medical anthropologist Paul Farmer—along with Ophelia Dahl, JimYoung Kim, Thomas J. White, and Todd McCormack—founded the NGO Partners in Health (PIH). The first PIH clinic was established in the central plateau of Haiti. The PIH hospital in Haiti provides free treatment and dispenses drugs to treat tuberculosis and HIV/AIDS. In addition to the clinic in Haiti, PIH oversees medical clinics in Russia, Rwanda, Lesotho, Malawi, and Peru. By and large, Farmer’s clinics follow an allopathic model, with emphasis on ethnographic analysis and real-world practicality. In Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World(2003), Tracy Kidder details Farmer’s work in Haiti, Peru, and Russia, as well as Farmer’s efforts to balance clinical, humanitarian, and academic responsibilities. Kidder’s book documents the myriad difficulties Farmer faces as he attempts to secure health care for the poor.
As noted, an estimated 25% to 50% of substances used in traditional nonbiomedical ethnobotany have been demonstrated to be effective by scientific measures (Singer & Baer, 2007). This is also true of Voodoo medicines. In Passage of Darkness: The Ethnobiology of the Haitian Zombie (1988), ethnobotanist Wade Davis provided great insight into the Haitian underworld and its relationship to healing through an examination of the secret Bizango society. Equally important, Davis provided incontrovertible evidence for the existence of zombies (the living dead). Davis points out that houngouns possess extensive knowledge of plant irritants and animal poisons, such as tetrodotoxin, which is produced by puffer fish. Houngouns might administer tetrodotoxin to place their intended victims in a catatonic state (heart rate slows, breathing is imperceptible, and the victims appear dead). The victims are then buried while fully conscious. They are dug up later—often by the same houngoun who administered the tetrodotoxin, and moved to another island location where, under the influence of the botanical Datura, they become confused and disoriented. This process, according to Davis, is the process by which Haitian zombies are created.
Since its inception, medical anthropology has undergone a number of dramatic transformations. Its applied focus remains, but its methods and goals have expanded from those advocated by W. H. R. Rivers and the Torres Straits Expedition of 1899 (Slobodin, 1997). Twenty-first-century anthropologists pay greater attention to culture and symbolic healing (Moerman, 2001). There is increased reliance on ethnographic methods and a greater emphasis on collaborative research (Chrisman, 2008). Additional research is needed to identify factors that promote collaborative relationships between indigenous and biomedical practitioners.
Conceptions of health and illness are also changing (Beyerstein, 1997). There is greater attention to native ethnobotany (Davis, 1988) and to exploring the possible efficacy of traditional healing techniques (Greenfield, 2008). Epistemological and phenomenological issues have come to the forefront (Kleinman, 1997; Littlewood, 2005). Last, CMA (Singer & Baer, 2007) has had a tremendous impact on the field and has broadened the scope of medical anthropology to include wide-scale international problems like malnutrition, limited access to health care (Farmer, 2000), environmental pollution, alcoholism (Heath, 2003), sexually transmitted diseases and AIDS, smoking, violence, traffic accidents, crime, and drug abuse (Fassin, 2007; Green, 2003). Twenty-first-century medical anthropologists have become less critical of biomedicine and more concerned about worldwide access to health care.