sot. .sci. MrJ Vol. 30. No. 2. pp. V-VIII. 1990 Printed in Great Bntam. All rights reserved

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INTRODUCTION

CRITICAL MEDICAL ANTHROPOLOGY IN QUESTION

MERRILL SINGER, HANS A. BAER and ELLEN LAZARUS

Hispanic Health Council, 98 Cedar St., Hartford, CT 06106. U.S.A.

In 1986, a special issue of this journal was published under the title Toward a Critical Medical Anthropol- ogy [I]. Along with another collection of shorter papers in the now defunct newsletter of the Society for Medical ,4nthropologv [2], the 1986 special issue of Social Science and Medkne helped to launch a new perspective in the literature of medical anthropology. In the intervening years, various symposia have been held at anthropology conferences and a growing number of papers have appeared reflecting and devel- oping this paradigm. The present collection repre- sents another step in the evolution of critical medical anthropology. As expressed in the introduction to the 1986 collection, this work developed in response to a “growing recognition that medical anthropology needs a critical analysis of the socio-medical context in which it has emerged” [3, p. 951. This context is a particular moment within the capitalist world eco- nomic and medical system. An effect of this context is that conventional medical anthropology:

incorporates Western ideological medical assumptions in the routine of its practice. Hegemony is facilitated insofar as these assumptions have embedded within them ideological principles intrinsic both to structures of domination within Western contexts and to the controlling articulation of the West with non-Western peoples. Such a process is expanded through a kind of Western medical imperialism that is mediated by medical anthropological practice [4, p. 4291.

As would be expected of an approach that calls into question previous work, critical medical anthro- pology (CMA) has assembled its share of antagonists. While much criticism has been uttered sotto coce in the hallways of anthropology meetings, recently crit- ics were provided an opportunity to comment on a set of papers edited by Ronald Frankenberg published under the rubric of CMA [5]. Because the present collection unsettles much of the ground on which several of the commentaries were launched, it seems appropriate to respond to critiques of CMA by way of introduction to the papers that follow [6].

Broadly, the commentaries can be divided into those which are sympathetic but suggest CMA may be going about things in the wrong way [7], and those which are not convinced about the merits of our approach. To the former, we issue an invitation to join the process of creating an alternative critical view in medical anthropology. To the latter, we have more to say.

Two general problems pointed out by the commen- tators concern the theoretical unity of CMA and its ability to generate empirical research. Unable to find

sufficient bonds connecting the papers in the collec- tion of essays edited by Frankenberg, Stephen Kunitz argued, “there may be less to critical medical anthro- pology than meets the eye” (8, p. 4341. If the real reason for the appearance of a school of critical anthropology lies outside the realm of theory build- ing, he speculated, it must have been invented to meet its creators’ desire for professional recognition. The problem here is not with CMA per se. or the questionable motives of its adherents, since most academic writers publish for pretty much the same reasons whatever their perspective. Rather, the prob- lem resides with the collection of articles brought together for commentary. To our knowledge the authors of only one of the papers explicitly consider themselves to be critical medical anthropologists [9].

The present collection, by contrast, while demon- strating the breadth of interests of critical medical anthropologists, is united by the distinctive, vital. and still evolving paradigm of CMA. The nature of this paradigm, its key constructs and critique of conven- tional medical anthropology, as well as areas of internal disagreement and debate, are presented here through two groups of papers; the first present CMA theory while the second employ this theory in the analysis of anthropological data. Singer’s paper, in particular, is concerned with developing a definitional overview of CMA, including its differences with alternative research strategies in medical anthropol- ogy, the scope of its concerns, the nature of its core concepts and research agenda, and its potential for guiding praxis. Points raised in the paper might serve as CMA’s “blueprint.. . for the construction process that would take us toward a broader view of the system(s) in which the healing of people’s bodily and psychic ills takes place” [lo, p. 4371 or are caused to begin with. Along with others in this collection. it offers response to those like Stephen Kunitz who question the existence of shared premises within CMA.

Relative to the second of the alleged problems of CMA, Pertti Pelto questioned its ability to “lead to new data quests, which in turn throw light on ‘how the system works-where the changes are occurring, and what structures offer models for remodeling the models”’ [IO, p. 437). The case study papers in this coliection, however, demonstrate that CMA does foster empirical research. These and related papers address a range of issues, including the capitalist world system [ll], the corporate and state sectors [ 121, plural medical systems [ 131, medical institutional structure, policy and decision-making [14], health

V

VI Introduction

personnel interactions [I 51, provider patient relations [16], suffer experience and behavior [ 171, and human psychobiology [ 181.

A pivotal problem with the critics we are discussing is that apparently they are not familiar with the broad political economy of health literature. For example, Thomas Csordas claimed that ‘*critical medical anthropoligists . . . often favor the term ‘biomedical hegemony’ as if biomedicine itself constituted the ruling class” [19, p. 4171. In the present collection of papers, Baer’s examination of the Kerr-McKee company and Kenyon Stebbin’s analysis of trans- national tobacco companies demonstrate that they do not misunderstand what Csordas [ 19, p.4201 accu- rately calls “the real ruling class”, and that it “is the locus of hegemony, including hegemony over health and illness” [20]. Moreover, these papers illustrate the health implications of the fact that “There is nothing more jealously guarded by the capitalist sector than control over the means and processes of production” (21, p. 770). Corporate attitudes about access to and control of profitable markets also have grave health consequences. For these reasons corporations should be primary targets of medical anthropology analysis

PI. The history of biomedicine’s relationship with the

ruling class is described in part in Brown [23]. As he makes clear, and as several papers by critical medical anthropologists have underscored [24], during the twentieth century

Capitalists and corporate managers [came to believe] that scientific medicine would improve the health of

society’s work force and thereby increase productivity. They also embraced scientific medicine as an ideological weapon in their struggle to formulate a new culture appropriate to and supportive of industrial capitalism. They were drawn to the profession’s formulation of medical theory and practice that exonerated capitalism’s vast inequities and its reckless practices that shortened the lives of members of the working class [23, pp. 10-I I].

By promoting the status and authority of bio- medicine, the ruling class was serving its own inter- ests, as were biomedical professionals who accepted recognition, funds, and legitimacy from the ruling class. But while physicians became agents of the ruling class, this alliance hardly made them members of that elite sector (although medicine certainly did attract some of the sons and daughters of ruling class families). As a group, physicians conform to Gramsci’s notion of “intellectuals of the urban type” [25, p. 141, in that they serve to articulate the relation- ship between the ruling and subordinate classes. Indeed, as Howard Waitzkin argues, “profession- als-especially doctors-are a primary interface be- tween the capitalist class and the working class” [26, p. 6031. As such, biomedicine is contradictory and an arena of conflict. And some of that conflict is between the ruling class and biomedical profession- als, who can have opposed as well as shared interests

1241. Yet, as Mary Ann Bates’ paper in this collection

shows, none of this denies the degree of power, within the realm of treatment, exercised by physicians. Writing in a tradition pioneered by Howard Waitz- kin, she elucidates the nature and rapid diffusion of a particular surgical procedure. Building on Haber-

mas’ critique of science as a value-free enterprise, Bates reveals the appropriateness of relabeling bio- medicine “bourgeois medicine”. Her point is not that the medical profession is the ruling class, but that ruling class ideology and motivation rules medicine. Significantly, unlike Habermas, Bates, as well as the other contributors to this collection, seeks to expand rather than to abandon empirical class analysis [27].

Other ways in which the ruling class serves its own interests within the health arena are seen in Lyn Morgan’s and Linda Whiteford’s analyses of primary health care in Costa Rica and the Dominican Repub- lic. These papers illustrate the core contradiction of PHC identified by Zaidi:

Primary health care may indeed be ‘revolutionary’ in its approach-at least on paper-but too many vested interests will prevent it from being truly revolutionary in practice [28, p. 1261.

By examining national health care efforts in the bright light of international power relations and national class relations, these papers offer fresh in- sight for medical anthropology about ‘how the sys- tem works’.

A final issue raised by our critics concerns the uniqueness of the CMA perspective. In Pertti Pelto’s assessment [ 1 I, p. 4351, our papers “do not depart in any notable way from much recent w-ork in medical anthropology,” while Sue Estroff wrote. “who took power, production, and resources out of the analysis of culture-meaning-symbols” [29, p. 423]? However, as Bruce Kapferer [4, p. 4271 contends. the brand of “fairly conventional anthropological humanizing and relativizing” characteristic of much medical anthro- pology is far less radical or challenging than its authors assume. By contrast, what CMA offers is a critical frame of reference and broad context for issues of anthropological concern. The broad context is that of political economy, which to date has not been the common frame for medical anthropology. While lip service is given to the importance of exam- ining variables such as power and mode of produc- tion, others like class interest, exploitation, social control, subordination, hegemony, and the world capitalist system remain neglected concepts in the subdiscipline. Indeed, to mention capitalism may seem subversive to some anthropologists who thus disguise it as modernization, industrialization, civi- lization, urbanization, and development in sentences that talk of ‘diseases of.. .‘. As the articles in this collection indicate, the departure CMA makes from much work in anthropology is to use critical concep- tions for the cross-cultural elucidation of health and health-related behavior. For some, like Richters, these notions have a “bluntly crude” edge [30, ~4421, unwieldy for the precise dissection of the interwoven complexities of contemporary social life. Still, we claim, they offer needed weapons with which “to fight the peists of capitalistic culture” (30, p. 4441 in and out of medicine and medical anthropology. As Richters herself suggests “there is no hope in our fights against totalitarianism if we do not acknowledge the dictatorship of our conscience” [31, p. 361.

Introduction VII

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REFERENCES

Baer H.. Singer M. and Johnsen J. (Eds) Toward a critical medical anthropology. Sot. Sci. Med. 23, No. 2. 1986. Singer M.. Baer H. and Elling R. (Eds) Symposion: critical approaches to health and healing in sociology and anthropology. Sot. Med. Anrhrop. 17, 1986. Baer H.. Singer M. and Johnsen J. Introduction: toward a critical medical anthropology. Sot. Sci. Med. 23, 95-98, 1986. Kapferer B. Gramsci’s body and a critical medical anthropology. Med. Anrhrop. Q. 2, 42&432, 1988. The development of critical medical anthropology is analyzed in Singer M. The coming of age of critical medical anthropology. Sot. Sci. .Ued. 28, 1193-1203, 1989. Frankenberg R. (Ed.) Gramsci. Marxism, and phe- nomenology: assays for the development of critical medical anthropology. Med. Anrhrop. Q. 2, 1988. Most of the papers in this present collection were finished prior to publication of the Med. Anfhrop. Q. Special Issue. Bibeau G. A step toward thick thinking: from Webs of significance to connections across dimensions. Med. Anfhrop. Q. 2, 402-416, 1988, which. innocent of the multi-dimensional model that ushered in CMA, contends that the idea of a multi-layered reality constitutes the as yet untaken first step in the develop- ment of CMA. See CMA model in [3]; see Singer M. Developing a critical perspective in medical anthro- pology. Sot. Med. Anrhrop. 17. 128-129, 1986 on CMA recognition of the importance of local context factors. Kunitz S. Comment. Med. Anrhrop. Q. 2, 43343, 1988. Another, Soheir Morsy. has participated in CMA sym- posia but has her own set of criticisms as well as defenses of CMA; See Morsey S. Drop the label: an ‘emit’ view of critical medical anthropology. Anfhrop. Newsl. 30, 13, 16, 1989. Pelto B. A note on critical medical anthropology. Med. Anrhrop. Q. 2, 435437. 1988. References include Stebbins in this issue; also see Singer M. Toward a political-economy of alcoholism: the missing link in the anthropology of drinking. Sot. Sci. Med. 23, 113-130, 1986. References include papers by Baer, Morgan and Whiteford in this issue. Ong A. The production of possession: spirits and the multinational corporation in Malaysia. Am. Elhnol. 15, 28-42. 1988; Hopper K. More- than passing strange: homelessness and mental illness in New York Citv. Am. Erhnol. 15. 155-167.

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1988: and papers in Ref.111. References include Morsy S. Islamic clinics in Egypt: the cultural elaboration of biomedical hegemony. Med. 27. Anrhrop. Q. 2, 355-369, 1988; Maclean A. Family therapy workshops in the United States: potential abuses in the production of therapy in an advanced capitalist society. Sot. Sci. Med. 23, 179-191, 1986; Baer H. The American dominative medical system as a reflection of social relations in the larger society. Sot. Sci. Med. 28, 1103-I 112, 1989. References include Bates in this issue; also see Morgan 28. S. The dynamics of cooptation in a feminist health clinic. Sot. Sci. Med. 23, 191-200. 1986; Chavez L. 29. Mexican immigration and health care: a political economic perspective. Hum. Org. 45, 344-352, 1986; Stebbins K. Does access to health services guarantee improved health status? The case of a new rural health clinic in Oaxaca. Mexico. In Encounters wirh Biomedicine (Edited by Baer H.). pp. 3-28. Gordan & Breach, New York. 1987; O’Neil J. The politics of

health in the Fourth World: a northern Canadian example. Hum. Org. 45, 119-128, 1986. References include Padgett and Johnson in this issue; also see Lazarus E. I’m just a clerk: medical workers and prenatal care, presented at the American Anthropology Association, Phoenix, Ariz., 1988. See Pappas G. in this issue; Also Lazarus E. Theoretical considerations for the study of the doctor-patient relationship: implications for a perinatal study. Med. Anthrop. Q. 2, 34-38, 1988; Singer M. Cure, care and control: an ectopic encounter with biomedical obstet- rics. In Case Studies in Medical Anthrooolopv (Edited by Baer H.). Gordon & Breach, New York,-i987. _ References include Singer M.. Arnold C., Fitzgerald M., Madden L. and von Legat C. Hypoglycemia: a contro- versial illness in U.S. society. Med. Anfhrop. 8, l-35, 1984; Singer M.. Davison L. and Gerdes G. Culture, critical theory, and reproductive illness behavior in Haiti. Med. Anthrop. Q. 2, 370-385, 1988. References include, Scheder J. A sickly-sweet harvest: farmworkers diabetes and social equality. Med. Anrhrop. Q. 2, 251-277, 1988. Csordas T. The conceptual status of hegemony and critique in medical anthropology. Med. Anrhrop. Q. 2, 416-421. 1988. We happily concur with Csordas’ view of the ruling class. If then, our only disagreement is about the exact role of the medical profession within capitalist hegemony, there is common ground on which critical and interpretive medical anthropologists can talk to rather than passed each other. Elling R. Worker’s health and safety (whs) in cross- national perspective. Am. J. publ. Hlrh 78, 769-771, 1988. As they have been for critical anthropologists like I. Susser, J. Nash, A. Ong and A. Ferguson. Brown E. R. Rockefeil& Medicine Men. University of California Press. Berkeiev. Calif.. 1979. On the ideo- logical aspects of this relationship. see Woolhandler S. and Himmelstein D. Ideology in medical science: class in the clinic. Sot. Sci. Med. 28, 1205-1209. 1989. Baer H. The organizational rejuvenation of osteopathy: a reflection of the decline of professional dominance in medicine. Sot. Sci. Med. ISA, 710, 1981. Gramsci A. Selections from the Prison Norebooks. Inter- national Publishers, New York, 1971. Waitzkin H. Medicine superstructure and micropolitics. Sot. Sci. Med. 13a, 601-609, 1979; a cogent analysis of the mediating role of physicians and medicine within the context of a particulkar ‘disease’ entity is provided by Figlio K. Chlorosis and chronic disease in !9th-century Britain: the social constitution of somatic illness in a capitalist society. In Women and Healrh: The Polirics of Sex in Medicine (Edited by Fee E.), pp. 213-241. Baywood, Farmingdale, N.Y:, 1983. See Foley H. Does the working class have a culture in the anthropological sense. Culr. Anthrop. 4, 137-162, 1989. The current discussion in anthropology generally concerning the relationship of class to culture resonates with similar developments in critical medical anthropol- ogy. For a fuller treatment of this issue see LiPuma E. and Meltzoff S. Toward a theory of culture and class: an Iberian example. Am. Ethnol. 16, 313-334, 1989. Zaidi A. Poverty and disease: need for structural change. Sot. Sci. Med. 27, 119-127, 1988. Estroff S. Whose hegemony?: a critical commentary on critical medical anthropology. Med. Anthrop. Q. 2, 241-246, 1988. Interestingly, a concise statement of hegemony appears in Estroffs book Making it Crazy, p. 122. University of California Press, Berkeley, Calif., 1981. It appears in the form of a wall poster in the office of one of her nurse informants that reads: “The Golden Rule: He who has the gold makes the rules.”

VIII Introduction

30. Mullings L. Minority women, work and health. In 32. Richters A. Fighting the piests of our times: medical Double Exposure: Women’s Health Hazards on the Job anthropology and cultural hegemony. .Ved. .kthrop. Q. and at Home (Edited by Chavkin W.), pp. 121-138. 2, 438-447, 1988. Monthly Review Press, New York. 1984. 33. Richters A. Medical anthropology: from applied to

31. Winter B. Health care: the problem is profits. In Social critical science. Presented at the Utrner Reimers >Lfeet- Problems (Edited by Williamson J., Evans L. and ing, Bad Homburg, 1987. Munley A.), pp. 436-444. Little Brown. Boston, Mass., 1981.