the coming of age of critical medical anthropology

Sm. Sci. Med. Vol. 28, No. 11, pp. 1193-1203, 1989 Printed in Great Britain. All rights reserved

0277-9536/89 S3.00 + 0.00 Copyright 0 1989 Pergamon Press plc

THE COMING OF AGE OF CRITICAL MEDICAL ANTHROPOLOGY

MERRILL SINGER

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

Abstract-This paper reviews the development over the last 15 years of a broadening critical trend in the field of medical anthropology by: (1) examining shortcomings of conventional medical anthropology that led to interest in critical alternatives; (2) examining historical and occupational factors that tend to conservatize the subdiscipline; (3) reviewing the body of literature produced thus far by its adherents; and (4) suggesting directions for future work.

Key wor&-medical anthropology, critical analysis, political-economy

“We seem to have taken a wrong turn in understanding at some critical point in the past, a false choice that bedevils our thinking in the present.”

ERIC R. WOLF

The wrong turn in anthropological thinking to which Wolf calls our attention was the ideographic shift ushered in by Boas, Malinowski and other ethnog- raphers of their era. Argues Wolf,

Fieldwork-direct communication with people and partici- pant observation of their ongoing activities in siru-became the hallmark of the anthropological method. . . Yet the very success of the method lulled its users into a false confidence. It became easy for them to convert merely heuristic considerations of method into theoretical postu- lates about society and culture [l, p. 131.

Yet, while ethnography provided the fuel, the motor driving the turn towards conceptualizing human groupings as autonomous, self-created, and self- maintaining cultural systems was not, as Wolf (21 well recognizes, a mere fortuitous feature of method. As the offspring of colonialism (a parentage captured in Leeson’s [3] depiction of the discipline as ‘colonialism’s social science’), anthropology played a historic role in extending the very political-economic processes that transcend, weld together, and even bring into being (as well as destroy) reputedly separate and autochthonous societies and cultures. According to Magubane and Fat-is:

The most specific contribution of anthropology to the colonial enterprize is ethnography. . . The micro-investigation of cultural entities to emphasize their uniqueness provided a vital basis for the policies of divide and rule [4, p. 991.

Awareness of the skeletons in the anthropological closet led to calls for the decolonialization of the discipline (or even for its deconstruction). For Wolf and others, this means a critical turn toward political- economy and to Marx. These offer theories and methods for understanding the present world holisti- cally in terms of the growth of the world-system, the penetrating effects of capitalism, and the determinant role of class, sex, and race on social behavior. In some areas, progress is evident. Anthropology now has its Leacocks, Asads, Magubanes, Goughs, Nashs, Friedmans, Godeliers, Roseberrys, Blochs,

and O’Laughlins among others [5]. But the discipline is no longer unified, it is fragmented into a host of specialty areas. In some subfields the appear- ance of a critical trend has been slower going than others. It is with the ongoing process of correcting the effects of anthropology’s wrong turn in thinking within medical anthropology that I am concerned with here.

MEDICAL ANTHROPOLOGY IN QUJLSTION

In the mid-1960s there were no journals, textbooks, or scholarly organizations specific to medical anthropology [6]. The subject of its inquiry was not well defined, its practitioners lacked a coherent professional identity, and the writings of incipient medical anthropologists were scattered throughout the anthropological, medical, and public health litera- tures. Much has changed in 20 years. Today, there are at least 4 journals, a growing number not only of textbooks, but edited collections, book-length mono- graphs, and book series, and the Society for Medical Anthropology is one of the largest units of the American Anthropological Association. Still, a growing sense exists among some, perhaps many, medical anthropologists that there are significant limitations in the perspectives, approaches, models, and theories of the subdiscipline.

This malaise has had various expressions. In 1977, Kiefer, then the editor of the now defunct Medical Anthropology Newsletter, raised the questions: “Is medical anthropology part of the solution to Mankind’s problems? Is it one of the problems?’ [7, p. 11. Some researchers began to wonder aloud if the first of these queries would have to be answered in the negative and the second in the affirmative. Several Third World anthropologists, in particular, developed incisive critiques (8-121. Shortcomings of conventional medical anthropology that contributed to the rise of the critical trend include the following: microlevel circumscription, neglect of social relations, medicalization, and ecological reductionism.

First, medical anthropology is criticized for restricting its focus and analysis to the microlevel, as if the groups and communities it studies are

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independent actors responsible for unilaterally build- ing, owning, and operating the self-contained theaters of their social dramas. The obfuscation of restricted microlevel focus is seen in the emphasis given to “the ritual and symbolic realm in culture, [while] the political and economic issues which affect the health and health behavior of populations [are] not.. . widely considered” [13, p. 5611. As a result, medical anthropology to a large degree became an examination of the cultural determinants of illness, curing, and resistance to biomedicine with little consideration of “the importance of the social formations in which ‘cultural factors’ occur” [14, p. 481. This failure to locate microlevel behaviors, beliefs, and meaning systems within encompassing and determinant social structures, relations, and processes is termed “socioculturalism” by Onage [9]. Ignored in socioculturalist writings is Janzen’s [15, p. 1291 reminder that “[no] anthropological generalization is worth more than its understanding of political process”. As Aidoo [1 I], O’Neal [16], and Chavez [17] emphasize, for the Third World, Fourth World, and labor migrant peoples that have drawn the lion’s share of anthropological attention, understanding health-related issues necessitates an often over- looked examination of colonial and neocolonial experiences.

Second, conventional medical anthropology is scored for its handling of the concept of social relations, which it understands not as the structuring configuration of power alignments that pervades every arena of social life and is embodied in all institutions in society, but rather as the character of interpersonal bonds between particular individuals or small groups. The doctor-patient relationship, for example, as Schoepf (18, p. 1121 indicates, is not, as it has sometimes been treated, “an internally balanced and self-maintained dyadic social system”. Rather, the character of doctor-patient interaction is structured by a wider field of class and other relations embedded within, but not always directly visible from, the clinical setting. Failure to locate personal relations, face-to-face interactions, social networks, social support systems, and other ties of a similar order within the encompassing and determinant set of social relations has been a significant weakness of mainstream medical anthropology.

Third, is the problem of the medicalization of medical anthropology. Indeed, there is a growing sense that Ptlanz’s criticism of medical sociology on this score applies as well to medical anthropology. “Overwhelmed by the complex of values upheld by medicine” [19, p. 5681, medical anthropologists have taken professional roles and developed analytic concepts that reinforce the medical monopoly over human suffering. Witness the oft applauded disease/ illness dichotomy. Taussig [20], in a landmark critique of both medicine and conventional medical anthropology, laid bare the act of reification central to diagnosis. Disease, seen only as a malfunction- ing in biological or psychological processes [21], possesses a phantom-objectivity. Through our denials of “the human relations embodied in symptoms, signs, and therapy, we not only mystify them but we also reproduce a political ideology in the guise of a science of (apparently) ‘real things’-biological and

physical thinghood” [20, p. 31. Lost in the political act of transforming names into things is the capacity for critical awareness. Lost in the embrace of medical reification and a clinically reproduced commoditized reality is the capacity for a critique of medicine.

What results. . is the desocialization of sickness and medicine. The primacy of the individual is emphasized while social determinants are reduced, fragmented, or distorted [22, p. 1361.

One expression of medicalization, recent calls for anthropologists to engage in a “mandate for clinical relevance” [21]-by providing physicians with both a window on the patient’s construction of illness and a culturally sensitive bedside manner, also is criticized. Warns Taussig, “there lurks the danger that the experts will avail themselves of that knowledge only to make the science of human management all the more powerful and coercive” [20, p. 121. Such calls reveal also the extent to which medical anthropology takes biomedicine at face value ignoring its political- economic functions, including: (1) profit-making; (2) physical reproduction of the working class; (3) social control; (4) social reproduction of class and other power relations; and (5) cultural hegemony [23]. That analyses which present this critique of biomedicine have been met by red-baiting [24] suggests that the political-economic role of doctoring is not wholly outside the consciousness of its practitioners.

Last, the medical ecology perspective, which has achieved ‘a broad tacit consensus’ in medical anthropology [25, p. 1871 is found wanting [26]. Typically, writings that adopt this perspective abstain from analysis of critical relational factors, such as owner- ship of the means of production, export of capital, extraction of profit, and racial and sexual oppression, that underlie and ultimately determine human response to the physical environment. Rather, a politically and economically (and hence socially) constructed environment is treated as natural and diseases with a social origin are interpreted as “measures of the effectiveness with which human groups . . . adapt” to nature (27, p. lo]. Given the source of many of the dominant environment- shaping processes in the contemporary world, the reading of disease rates as measures of environmental fitness takes on the political function of victim- blaming; enfeebling, thereby, medical anthropological insight.

CONSERVATIZING FEATURES OF MEDICAL ANTHROPOLOGY

Considering the concern elsewhere in anthropology with developing a critical perspective [28], a concern that achieved its zenith during the very period that medical anthropology was consolidating, why did medical anthropology remain isolated so long from critical thinking? Some general reasons have been identified by Gruenbaum, who notes that:

anthropologists get lost in the fascinating minutiae of experiences in the field; the fragmentation of social science is often simply accepted by respecting the ‘territory’ of economists, historians and political scientists whenever we step outside the confines of exotic cultures; and it has been our professional tradition to leave policy decisions [to others] [14, pp. 47481.

The coming of age of critical medical anthropology 1195

More specific to medical anthropology, although stemming from a general characteristic of the discipline, failure to develop a critical perspective is traceable to the inattention given to institutional actors with major parts in the health field inter- nationally, such as manufacturers of medical commodities, government health and development agencies, international lending institutions, professional medical associations, and private health foundations [29]. Medical anthropologists have been disinclined to answer Nader’s [30] admonishment to ‘study up’. As a consequence, “the existing power structures have remained untouched” [ 19, p. 5731.

Finally, there are the ways that perspectives within medical anthropology have been shaped by the origin, institutional place, and composition of the subdiscipline. While ethnomedical interest within anthropology is of considerable age, medical anthropology as a distinct and organized phenomenon

is predominantly a result of the influence of the international public health movement and clinical medical activities on ethnomedical research in cultural anthropology. . . Ethno- medicine’s identification with organized medicine and public health. . caused it to splinter from anthropology. . . . Like medical sociology, the integrity of medical anthropology is challenged by increased involvement in health policy research and clinical program development and evaluation (31, p. 12981.

Batalla [8] argues that applied work within and for medical and other bureaucracies tends to have significant conservatizing effects. Applied work seeks to avoid rapid social change and consequent potential for social and cultural disruption,

Sometimes it looks as if those who work along the road of slow evolution intend to achieve only minimal changes, so that the situation continues to be substantially the same; this is, in other words, IO change what is necessary so rhar rhings remain the same. Those who act according to such a point of view may honestly believe that their work is useful and transforming; however, they have in fact aligned themselves with the conservative elements who oppose. . . structural transformations [8, p. 921.

Trapped in a restricted role as the translator of cultural knowledge to health care providers [32], appointed the task of discovering “how to get patients and healthy laymen to do things that medical practitioners consider good for them” (33, p. 651, selected “to provide apologia for sponsors’ mis- takes” (31, p. 13011, and given responsibility to depoliticize issues in health politics [34], medical anthropologists in applied employment may tend to overlook the social production of illness, political factors underlying the medical construction of disease, the medicalization of social problems, the social control functions of medicine, the blame-the- victim components of medical ideology, structural inequities in health care provision, the reproduction within medical professions of power structures outside of medicine, and the role of medicine in the reproduction of exploitive class, gender, and race relations [29].

Indeed, medical anthropologists often are seduced by the magic spell of medicine [35], a spell consisting of (questionable but usually unquestioned) claims

of efficacy, comparatively high social status, political legitimacy, and considerable (though delegated) power within society. The stature of medicine is such that for many anthropologists biomedicine serves as “the reality through the lens of which the rest of the world’s cultural versions are seen, compared, and judged” [36, p. 41. Given Hunter’s reminder that clinicians have dominated medical anthropology since its inception [31], especially its theoretical perspectives, this is not so surprising. In addi- tion, medical anthropologists increasingly have traded the discipline’s traditional holism for a reductionistic replication of medicine’s fine-grained division of knowledge and labor. The consequence of the ongoing medicine-like specialization within anthropology (the logical extension of which would be an interest group within the Society for Medical Anthropology for every ‘disease’) is, as Baer indicates, “even further erosion in medical anthropology of the limited critical perspective of biomedicine and [the] larger world economic system. . .” [37, P. 64.

In sum, the microscopic focus and all but over- powering ideographic slant of anthropology’s colonial past on the one hand, and the often co-opting nature of applied employment on the other, act as powerful barriers to the emergence of critical perspectives within medical anthropology. Still, over the last several years, scattered attempts to plant the seeds of critical thinking in medical anthropology have blos- somed into an emergent critical trend with mounting visibility in the field.

CRITICAL MEDICAL ANTHROPOLOGY IN REVIEW

Troubled by the issues discussed above and growing increasingly aware that medical anthropology was developing in seeming ignorance of the burgeoning literature on the political economy of health, some medical anthropologists began to wonder about the misdirection of their field and to posit the creation of a new medical anthropology that corrects the defects of the socioculturalist and adaptationist approaches with the insights of what Elling terms the progressive-holistic perspective.

Work from . . . [this] perspective understands societies as involving class conflict and sees the state apparatus and medical-health systems as mediating this conflict in favor of the ruling class in capitalist societies. The historical develop- ments and political-economic conditions are viewed as primary, with value orientations and beliefs flowing from these fundamental conditions 138, p. 2361.

The initial effort to forge a critical redirection for medical anthropology can be traced to the sym- posium ‘Topias and Utopias in Health’ at the 1973 IXth International Congress for Anthropological and Ethnological Sciences, which ultimately developed into a volume with the same title. In his review of the political-economy of health literature, written a decade after the International Congress, Baer [39, p. 161 notes that “Topias . . . remains the only major book in the medical anthropological literature that includes political economic interpretations”.

An explicit turn toward the political-economy of health tradition within medical anthropology awaited

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Morsy’s ‘The Missing Link in Medical Anthro- pology: The Political Economy of Health’ published in 1979 (401. In this and a number of subsequent papers, Morsy [41, p. 1591 advocated adoption of “a political economy perspective which undermines the idealist, reductionist and dualist approaches” characteristic of much medical anthropology. Morsy’s work helped to inspire Baer’s [39] review, noted above, which not only offered a handy (if problematic) definition of political-economy of health (“a critical endeavor which attempts to understand health-related issues within the context of the class and imperialist relations inherent in the capitalist world-system”), but helped to intro- duce many medical anthropologists to the political- economy of health literature. Over the next several years the number of medical anthropologists concerned with critical alternatives began to grow, as did their impact on medical anthropology symposia and literature. By the 1987 American Anthropolog- ical Association Annual Meeting, a shared sense had emerged that critical medical anthropology had come of age as an important perspective within the discipline.

Beyond its critique of the limitations of conventional anthropology and its advocacy of broader frames of reference, what has this new approach achieved thus far or failed to achieve; what are its major themes and key concepts; what differences have emerged among its adherents? While answers to some of these questions have been alluded to already, this section will concern itself with developing fuller responses.

Among the major contributions of critical medical anthropology are the following: (1) examination of the social origins of disease and ill health in light of the world economic system; (2) analysis of health policy, health resource allocation, and the role of the State in Third World nations; (3) re-thinking of the contemporary understanding of medical pluralism; (4) development of a critique of biomedical ideology, practice, and structure; (5) attending to the role of struggle in health and health care; (6) re-examination of the microlevel of the individual, including illness behavior and illness experience, within the context of macrolevel structures, processes, and relations; and (7) investigation of health and health programs in socialist-oriented countries. Each of these will be discussed in turn.

Study of the social origins of illness has a con- voluted history in the health and social sciences. It is a field, Waitzkin concludes, that began with Engels but has “been largely forgotten and then rediscovered with each succeeding generation” [41, p. 771. Within medical anthropology, it is a subject that attracted negligible attention until the emergence of the critical trend. In the last several years, critical medical anthropologists attempted to correct this short- coming through studies of malnutrition [43-45], environmental and occupational health problems [ 13,46-48], substance abuse [49, 501, infant mortality [51], and emotional conflicts and disorders [52-551 in terms of the structural contradictions of capitalist production and the for-profit character of capitalist distribution. Consider the issue of malnutrition. In an article deemed sufficiently enlightening to be

reproduced in one of the most widely read collections of medical anthropology papers, Newman [56] argues the following about its causes:

On a gross world basis the American Geographical Society (1953) maps show that the areas of undernutrition and malnutrition closely coincide with the tropical and warmer temperate regions of backward food producing techno- logies. To a considerable extent the nutritional deficiency diseases are distributed by climate zones, are often worse at certain seasons, and are sometimes related to specific food crops. When these deficiency diseases reach epidemic pro- portions, they appear to represent the worst lags in man’s adaptation to his nutritional environment.

By contrast, in his study of Cauca Valley in the tropical country of Columbia, where 50% of the children are malnourished, Taussig [43] found it necessary to consider the effects of a burgeoning agribusiness sector, the World Bank, U.S. multinational corporations, USAID, the Rockefeller Foundation, U.S.-based private consulting firms, U.S. and Columbian university staff and the like. Except by examining the role of powerful national and international forces with vested interests in the production or protection of profit, Taussig found it impossible to understand malnutrition in a fertile region that exports cash crops to the U.S. Similarly, Davison [44] argues that efforts to account for hunger in Haiti, the tropical breadbasket of the French empire in the 18th century, only in terms of ecological or cultural factors, eliminate from consideration the effects of several hundred years of colonial and neocolonial extraction from the island. Critical medical anthropology studies such as these demonstrate the necessity of situating the examination of ill health within the “wider field of force” [l], i.e. the global social relations (often implemented by multinational corporations, facilitated by international lending institutions, and supported by ‘development’ agencies) that determine what is produced, how it is produced, and who benefits (or suffers) from production. As Scheper-Hughes shows in her work in yet another tropical setting, Northeast Brazil, conventional perspectives that

interpret the extremely high rates of death and disease. in the developing world as the almost inevitable consequences of largely impersonal ecological, climactic or demographic conditions. obscure.. the role of economic relations in the social production of morbidity and mortality . . [5 I, p. 5351.

The need to reinsert societal cases back into the world economic system for understanding also can be seen in critical medical anthropology studies of the relationship between the State, health policy, and resource allocation. For many of the cases of traditional interest to anthropology, this means an examination of contemporary health policy and practice in relation to the legacy of colonialism and the development of underdevelopment on the one hand and the emergence of neocolonialism and the functioning of a comprador elite on the other.

Several critical medical anthropologists have examined the health policies of colonial regimes [3, 11, 14, 571. These accounts parallel Lasker’s description of the role of health services in the Ivory Coast.


Study of the Ivory Coast reveals the many ways in which French colonizers, clearly the dominant group until independence, relied on the Western health system to further their economic and political aims. As the goals of colonial rule changed over time, so did the nature of medical care organizations. The result has been a highly unequal allocation of services, benefiting primarily the French and those Africans who were considered important for the maintenance of a productive economy and of political stability. Although many individuals who worked in the health services in the colonies were motivated by humanitarian concerns and many positive results were achieved in improv- ing health, it should nevertheless be. . . clear. . that the health system was developed primarily to promote French interests [58, p. 2781.

With independence, colonialism commonly gave way to a pseudo-independence in which the class structure created by the colonial regime served as a foundation for maintaining the metropolis-satellite relationship, and in which the health care sector remained shackled to the colonial past and the neocolonial present. As Whiteford [59] reveals in her research in the Dominican Republic, under pressure or persuasion from without, Third World countries adopt health care policies and programs designed to maintain ties with the capitalist core rather than improve the health of their populations. Features of the medical sector identified by critical medical anthropologists in dependent capitalist countries include: (1) provision of a costly and centralized biomedicine to the national bourgeoisie (and the military) that is woefully ill-suited to the health care needs of an underdeveloped country; (2) maintenance of a highly centralized and rigidly organized health system with decision-making power concentrated at the top; (3) production of medical specialists that rapidly are drained into the lower echelons of the health systems of developed countries; (4) creation of a market for imported pharmaceuticals and other medical commodities; and (5) emergence (or continu- ation in ever changing form) of a lower tier of health workers and folk healers who treat the rural as well as urban masses.

On the whole, as McDermott [60, p. 1981 shows in her study of health policy in Hong Kong, State intervention “has done little more than further im- plant and solidify biomedicine”. A more general conclusion of critical medical anthropology is illustrated by Stebbins [60. p. 1391 in his work on Mexican health policy, namely that State intervention in health care without a significant reallocation of resources “addresses symptoms rather than causes of disease and is not likely to significantly improve the health status of the people who are most in need of such assistance”. State intervention, in fact, most commonly serves not to challenge but to reproduce inegalitarian social relations. The process also has been described in a First World case by S. Morgen [62] in her analysis of State cooptation of a feminist health clinic.

The above list of features of the medical sector suggests that the medical pluralism described in numerous conventional medical anthropology reports does not float in the ratified air of symbolic meanings and explanatory models, but, as Franken- berg [63, p. 1981 insists, is anchored to class divisions. This point is illustrated in a study of hypoglycemia by

Singer and his co-workers. Relative to the diverse explanatory models (EMS) associated with this condition, they note the following.

Medical pluralism is . . a product of a larger social dynamic. The EMS involved in the hypoglycemia contro- versy represent alternative, yet intertwined, mystifications of social etiology, produced and defended by different strata within the medical system and within society generally [64].

An important issue in the study of medical pluralism is the role of the State. In the Third World, State support for folk medicine appeals to popular anti- imperialist sentiment but is often shallow; “Members of the ruling class whose ailments require deeper penetration look to injections, drugs or surgical intervention from the West” [63, p. 1981. Even in situations where explicit financial or legal support for traditional medicine is lacking, governments “like to keep traditional medicine alive, because it is recognized that traditional physicians take some of the strain off Western doctors in dealing with self- limiting disease” [89, p. 1351. More broadly, it has been argued that traditional medicine is allowed and even fostered by the State as a means of handling the potentially disruptive ‘human fallout’ associated with capitalist development (including market penetration, proletarianization, urban migration, and poverty) that is not easily fitted to the diagnostic categories and treatment modalities of biomedicine. Thus, folk medicine has been described as being “compensatory and accommodative rather than cor- rective” [66, p. 1661. In sum, the success of folk and heterodox healing systems in capitalist countries is contingent upon gaining “acceptance from strategic elites who are seeking solutions to the contradictions of capitalist-intensive medicine and/or by patients who demand forms of treatment neglected by ortho- dox medicine” [67, p. 31, as Baer found in his studies of chiropractic and osteopathy in the U.S. and Britain.

Additionally, argues Taussig [68], much folk healing in the contemporary world, or what he calls “shamanism in its colonized form”, cannot be understood in isolation from the history of social relations and the restructuring of social life produced by capitalism. For example, there is the source of the folk healer’s magic. The power of the indigenous healer, he asserts, lies in his/her ability to manipulate an imagery created in the colonial encounter: an imagery of wild men and savages, of threatening disorder at the margins of proper society, of bloody terror and uncompromising brutality (projected on to natives by colonial masters of such arts), of recal- citrant paganism in need of Christian discipline. In appealing to the spirits, to African Gods and Amerindian culture heroes, to devil figures of all kinds (as these spirit beings were rendered in Chris- tian understanding), to rhe very entities that are said to cause sickness and misfortune, the folk healer seeks to tap the power of disorder attributed by the colo- nialist to pagan religion and culture. Thereby, the “political events of conquest and colonization . . . become objectified in the contemporary shamanic repertoire as magically empowered imagery capable of causing as well as relieving misfortune” [68, p. 367. And, not unrelatedly, it is the magic power

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of capitalist society-a power demonstrated daily in technology, in science, in the flood of commodities- that the Third World patient hopes to tap in seeking biomedical treatment. Writing of Columbia and of plantation workers who cannot earn enough to keep starvation at bay, Taussig [68, p. 278) describes in some detail the inappropriateness of biomedical ‘cures’.

Yet amazingly awful and absurd as they are, [biomedical] services supplied by the official medical system and its university-trained doctors, backed by the multinational corporations of ‘science’, agribusiness, and pharmaceuticals, are sought by many. This optimistically desperate search is testimony to a magical attraction, in this case to officialdom and to ‘science,’ no less and probably a good deal greater than that involved in the magic of so-called magical medicine.

The attention accorded folk medicine by conventional medical anthropology is another issue of concern to critical medical anthropologists. While some have interpreted this as further expression of anthropology’s preoccupation with anything pur- portedly traditional to the neglect of everything transformed, Harrison contends a more explicitly political function.

Traditional healers became fashionable for anthropologists and other social sciences because [such research] gave former colonial nations access to the local population’s thought patterns and medicines. . . . As a result, colonial powers.. . are able to maintain a presence in these countries . . . under the guise of helping them develop new local level low cost health care delivery systems [69, p. 131.

The nature of biomedicine, the dominant medical system in both developed countries and the Third World, also has been a topic of interest to critical medical anthropology, as it has been increasingly for medical anthropology generally. Recent work by conventional medical anthropologists focuses on the analysis of biomedicine as a cultural system, the problematics of medical roles, the dynamics of medical discourse, and the thought-worlds of physicians in clinic contexts. By contrast:

A critical medical anthropology must address questions of. : (1) Who has power over the agencies of biomedicine? (2) How and in what form is this power delegated? (3) How is power expressed in the social relations within the health care delivery system? (4) What are the economic, socio- political and ideological ends and consequences of the power relations that characterize biomedicine? and (5) What are the principal contradictions of biomedicine and arenas of struggle in the medical system? [70, pp. 95-961.

Answers to these types of questions, it is contended, provide the macrolevel context for considering other issues on the agenda of medical anthropology. For example, in addressing the last of these questions in a study of prenatal care in a public clinic, Lazarus [71] identifies three major contradictions of biomedicine: (1) the asymmetrical relationship between doctors and patients (a relationship that replicates class, racial, and sexual hierarchies in society generally [72]); (2) emphasis on the training of resident physicians rather than the provision of care to patients; and (3) a division of labor within the clinic that divides the patient into a poorly coordinated series of clinical functions bureaucratically delegated to

an array of specialists (e.g. nurses, clerks, aides, physicians).

The differences in the analytic approach to biomedicine taken by conventional and critical medical anthropologists can be illustrated with an example. Efforts by mainstream medical anthropologists to analyze clinical discourse began with the assumption that it entails a set of “transactions across diverse explanatory models or conceptual systems” [73, p. 1941. Negotiations between doctors and patients are examined in terms of the differing models of reality possessed by each party to the interaction. Critical theorists, like Young [74], however, argue that the starting point for the examination of such discourse lies in an appreciation of the social relations underlying and determining discourse production. Consequently, it is insufficient to simply assert that medical discourse is socially constructed, it is necessary to recognize that it is “constructed in ways which produce only conventional meanings, i.e. ones resonant with the dominant ideology” in society [74, p. 1341, a fact demonstrated by Waitzkin in his studies of the micropolitics of the doctor-patient encounter [75]. Others, like Susser, add that it is misleading to assume a priori that non-medical groups embrace folk explanatory models. This assumption “tends to underestimate the impact of modem work experiences, income, political power, and class relations on social perceptions of health and illness” [13, p. 5621. While it is a strength of anthropology to never expect uniformity across populations (or even within populations), this strength becomes a weakness if it produces inattention to the unifying effects of phenomena like proletarianization, com- modification, and mass advertising.

Generally, the critical approach to biomedicine is concerned with locating “the clinical relationship and the whole medical complex within its encompassing political-economic framework so as to remind us that physicians and patients alike are but two layers in a larger social dynamic characterized by inequality, dominance, and.. . struggle” [76]. While it is recognized that physicians have the upper hand in the doctor-patient relationship and that this position of power is utilized for self-interested and system- maintaining non-medical goals, the medical arena (or any other social field) cannot be thought of as comprised solely of dominating actors and dominated objects. Rather, the clinical encounter is a “combat zone of disputes over power and over definitions” [20, p. 91. In a case study of an HMO obstetric patient, Singer argues that the prevailing liberal view of

an active, aggressive male physician in control of health care, and a female patient that is a passive victim, mani- pulated and dominated is faulty. Instead, we have accounts of the aatherina of intelliaence. the mobilizing of allies, the formulating of-strategies,-and the pressing of demands; in short, a narrative of struggle and combat in the very heart of physician-controlled territory.

The lesson is clear: until we fully realize that social process in the medical arena is shaped not by the unrestrained will and might of potent oppressors but by an ongoing clash between those best served and those least served by existing medical institutions,


and between those most in control of and those least in control of medical knowledge, procedures, and technology, we will misunderstand . . . [clinical process] [76]. Such examples express a fundamental understanding of critical medical anthropology, namely that it is problematic to assume that, because power is concentrated in macrolevel structures, the microlevel is mechanically determined from above. Lost in a mechanistic understanding of the construction of daily life is appreciation of the role played by conflict and struggle in all social relationships in and out of health care.

conditioned by the prevailing structure of social relations.

This discussion underlines the importance of a critical focus on the microlevel, including the level of individual experience and behavior. In addressing this realm, Scheper-Hughes and Lock stress that critical medical anthropology must part company with the political-economy of health tradition over the latter’s tendency to “depersonalize the subject matter. . . by focusing on the analysis of social systems and things, and. . . neglecting the particular, the existential, the subjective content of illness, suffering, and healing as lived events and experiences” [77, p. 1371. In their view, critical medical anthropology must bridge the macro-Marxist/micro- phenomenologic divide so as give voice “to the submerged, fragmented, and muted subcultures of the sick and disabled” [77, p. 1371.

The process of embodying experience of material conditions and social relations in illness has been referred to as somatization [771. As Kleinman indicates [80, p. 561, under capitalism, somatization is “frequently an emblem of worker dissatisfaction, demoralization, and alienation”. More generally, he asserts, “persons who are at greatest risk for power- lessness and blocked access to local resources are most likely to somatize” [80, p. 1741, regardless of the political-economic context. Sensitivity to this phenomenon avoids entrapment in both the medical conception of illness as individual and the narrow commonsense interpretation that the inner life of feelings and experiences is unique, particular, and personal. When, as is the case under capitalism, even human feelings are transformed into commodities produced under alienating conditions for sale on the market, the individual and his/her illness can only be understood in relation to macrolevel relations and processes [81].

Others, following Mills, maintain that the starting point for comprehending individual ‘troubles’ must be a careful analysis of “the structural transformations that usually lie behind them” [78, p. 11. Con- cretely, this insight takes several forms. For Taussig [201], it means analyzing not just the suffering but also the social relations mapped into disease. Sufferer experience is understood thereby as process constructed and reconstructed in the behavioral arena between socially constituted categories of meaning encoded in symptoms on the one side and the political economic forces that shape the context and content of daily life and relationship on the other. For example, in a study of Haitian folk nosology, Davison and co-workers trace the relationship between two illnesses: jibromm (a spoiled ball of blood in the womb believed to threaten the life of a developing fetus) and pedisyon (a condition in which a fetus remains in the womb indefinitely in an underdeveloped state). They argue:

Finally, critical medical anthropology looks beyond the confines of the capitalist core or periphery to health and health care in countries struggling to break free of the capitalist economic system. Issues of concern in this regard include: (1) what Elling [38, p. 2071 has termed the “close intertwining of health systems with their political-economic contexts at national and world-system levels”; (2) the nature and differences between socialist-oriented and capitalist social formations and their respective understandings of health and approaches to health care; (3) the similarities and differences in the health sectors of the array of socialist-oriented societies; (4) the relative effect of political-economic change on the organization, operation, and efficacy of the health care system; and (5) factors beyond political-economy that influence health and health care following social transformation.

Thus far, only a small number of critical medical anthropologists have worked in socialist-oriented societies, and only one, Donahue [82], has completed a book-length account. In his various writings on the health sector in Nicaragua, one of the poorest, least developed, and most threatened of socialist-oriented societies, Donahue concludes that the

We see in thejbromm concept what appears to be a creative reconstruction of Haitian reproductive illness beliefs under changed social circumstances, Just as pedisyon emerged among rural Haitians as a route to action.under conditions of French cultural hegemony, fibromm has developed among urban migrants under conditions of a new, biomedical hegemony. Doctors, who are known to be powerful healers and are even said to be God’s representatives, are not interested in pedisyon, which they dismiss as super- stition. A woman complaining of fibroma is another matter. The transformation of pedisyon into fibromm, an alchemy that transpires within the realm of folk culture, changes an illness that can only be treated by folk healers into one that can only be treated by doctors [79, p. lo].

health care system is moving toward a model of primary health care which is decentralized and oriented to local needs, especially in the rural areas. Yet, within the [health] Ministry itself there are interests which could direct the health care system more to urban and professional demands. . . . An analysis of the process of change within Nicaragua suggests that the revolution in health, even in an optimal ‘decentralized-concerted political environment. . is being negotiated.. .The strides made in health care since 1979 are abundant evidence of the political will to improve the health and well-being of the Nicaraguan people. Yet, the ultimate success of the revolution in health will depend on how the actors are able to confront the internal pressures to professionalize the process and the external pressures to destabilize it [83, p. 1561.

At the heart of this interpretation is the under- Central to Donahue’s analysis is recognition that standing that individual experience is fitted to popu- socialist transformation tends to be accompanied by lar conception of legitimate illness expression and (1) a far reaching re-organization of the health care that both experience and popular conception are system; (2) an increase in popular involvement in

SS” **!I,--H

1200 MERRILL SINGER

health policy decision-making and implementation; and (3) improved health. However, seizure of the State apparatus does not immediately nor auto- matically eliminate class divisions within society, disparities in access to health care knowledge, and self-serving behaviors by health care professionals.

Cuba, which has had a longer period to consolidate its revolutionary transformation in health care and in society generally, has been examined by Guttmacher. She notes a marked improvement in health but adds that while “socioeconomic status no longer objec- tively determines one’s access to health services as it does in market-centered societies . . . traditions and modes of behavior shaped by previous inequalities still may limit people’s actual use of services” [84, p. 5171. Beyond the health care sector, Guttmacher [85] reports the continued existence of occupational and environmental health and safety risks, despite a sincere movement toward preventive medicine in socialist-oriented societies.

Broader comparisons of health and health care in socialist-oriented and capitalist countries have been assembled recently by several critical medical anthropologists [86-881. While it is recognized that much work in this area remains to be done, there is agreement that a significant difference exists

between socialist health and capitalist health. This difference, reflected in the health improvements following the establishment of a socialist-oriented state, appears to be an outgrowth of the social investment of national resources. This investment takes several forms, including more equi- table distribution of income, commitment to improved literacy and public education, special attention to the problems of the most subordinated sectors of the population (e.g. the working class, minorities and women) and . . changes in the health care system [8i’J

Debate exists, however, concerning: (1) the necessity of socialist transformation for broad improvements in health care in Third World countries [89]; (2) the extent of popular involvement in the health care systems of socialist-oriented societies [88]; (3) the source of health problems in these societies [80,85]; and (4) the specific similarities and differences between health care and health in socialist-oriented and capitalist societies [87].

CONCLUSION

Having established the need for medical anthropology studies to be situated in the wider sphere of social relations, contributors to the next phase in the development of critical medical anthropology must begin to address a number of issues. Included among these are the following.

First, critical medical anthropologists must determine the relationship of their project to the political- economy of health. Needed is a rigorous critique of the political-economy of health literature (an endeavor begun by L. Morgan [90]) and a clarification of the distinctive contribution of anthropology to the critical study of health and healing. Already a debate is emerging between those critical medical anthropologists for whom it seems completely appropriate that a portion of their work involve macro- analysis focused on entities like cross-national systems and large scale institutions and those who

maintain that critical microanalysis should be our special domain of activity.

Second, the means of appropriately analyzing micro-macro relations must be addressed. While ethnographic research provides us with rich data from the microlevel, there is a tendency in the critical medical anthropology literature to assert rather than to specifically demonstrate detenninance by structural factors outside the local setting. As Pelto and DeWalt indicate, “postulated relationships among levels need some clearer delinations, in terms of empirical, observable social units” [91, p. 1871. Criti- cal medical anthropologists must enhance the corpus of research and analytic methods suited to this task, including, perhaps, the development of research approaches designed to simultaneously investigate linkages between several levels of health and social systems.

Third, in investigating connections among levels, we must cast our gaze in both directions. To reiterate Frankenberg’s [63, p. 2061 call, we must demonstrate clearly “what effects are produced at the local level by national and international social processes; and what is coming from the local level in return” (emphasis added). Recognizing that the course of social life inside and outside the health arena involves contention between individuals and groups with conflicting social interests and unequal abilities to mobilize power, we must sharpen our attention to the issue of implicit and explicit struggle as it is mani- fested in illness expression, clinical interaction, relations among health care systems and providers, and health-related movements and organizing efforts by patients, workers, and oppressed populations.

Fourth, the exact meaning of the term critical medical anthropology will eventually need to be considered. Currently, several different orientations are fellow travelers with a common passport. While it is not necessary that the range of critical approaches be narrowed to some allegedly ‘correct’ perspective, it is appropriate to begin clarifying the critical content of critical medical anthropology. In part, this will involve a clarification of the relationship of critical medical anthropology to the contributions of Marx and Engels among others.

Fifth, the importance of biomedicine in the world and its strategic location as “a primary interface between the capitalist class and the working class” [92, p. 6031 demands that it receive increased attention. While a start has been made in this area, there is much work to be done in clarifying and accounting for its expressions cross-culturally, its political-economy functions, the nature of the relations it fosters, the character of its co-existence with a range of alternative healing systems, and the world views it generates.

Sixth, the specific relations between biomedicine and capitalism require further study. Brown’s [93] pioneering study provides an approach similar to that employed in ethnohistorical studies in anthropology and thus offers a method for further work in this area. Also important is McLean’s [94] analysis of therapy as a form of production that reflects the larger production process in capitalist society.

Seventh, where possible, further on-the-ground studies of socialist health care would help address


many of the unanswered questions about the relationship between political-economy and health care organization, social transformation and improvements in health, and the specific functioning of health care institutions in a socialist context.

Finally, there is the issue of praxis. How can critical medical anthropology serve counterhegemonic ends in both the short and long run? While the ways health care workers [75] and international health agencies [95] can move in this direction have been offered, what specific role might anthropology and its practitioners play in the creation of a new medical system and what might that new system be? In attending to the development of a critical praxis, the following remarks of Conrad and Schneider [96, p. 771 deserve our close consideration:

the fundamental issue is who controls what model and what are the consequences. To merely substitute a social model of health and a new set of social health experts without altering the existing medical dominance is surely problematic; its likely result is the extension and reproduction of prevailing power relations. If the social model of health were grafted onto the existing medical system, it might truly encourage the medical control of everything.

Acknowledgements-Special thanks are extended to Hans Baer, Fuat Yalin, Lani Davison, Ronald Frankenberg, Vicente Navarro, and Nancy Scheper-Hughes for reading and providing comments on all or parts of earlier versions of this paper.

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the coming of age of critical medical anthropology

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