historical summary of medical
the 1960’s to the present
Christian Alan Anderson
Department of Anthropology
University of Southern
Ph.D. Qualifying Exam: Topic/Subject
April 21, 2002
Definitions and Boundaries
Anthropology as a Subject Focus
Medical Anthropology as a Theoretical Orientation
Brief History of Medical Anthropology
Influences: Medical Anthropology of
the Non-Western ‘Other’
Emics, Etics, and Ethnomedicine
a ‘Sub-field’ and Turning the Gaze Within:
Medicine and American Culture
Anthropology Defines and Redefines Itself
Gazes and Heteroglossia: Post-1970s
1. Critical Medical Anthropology
2. Performance Perspectives
3. Narrative Perspectives
Definitions and Boundaries
Throughout this historical tour of medical
anthropology, a focus upon theory and practice with specific ethnographic
examples demonstrates the variety of approaches that have constituted medical
anthropological research over the years. Following the historical narrative,
contemporary theoretical trends and controversies are explored in more depth.
I begin with the working definition of medical
anthropology as an anthropological concern with the subject of medical and
health beliefs and practices, or simply “...the fusion of the two fields of
medicine and anthropology...” (Grolig & Haley 1976: xii). The Society for
Medical Anthropology defines its field as including
all inquiries into health,
disease, illness, and sickness in human individuals and populations that are
undertaken from the holistic and cross-cultural perspective distinctive of
anthropology as a discipline—that is, with an awareness of species'
biological, cultural, linguistic, and historical uniformity and variation. It
encompasses studies of ethnomedicine, epidemiology, maternal and child health,
population, nutrition, human development in relation to health and disease,
health-care providers and services, public health, health policy, and the
language and speech of health and health care. [Society for Medical Anthropology
web site, 2002 April, www.cudenver.edu/sma/what_is_medical_anthropology.htm]
This definition covers all the contemporary sites for medical anthropological study, and delineates the sub-field in terms of its current specialization, yet medical anthropology is a topic of study that has only recently, that is, within the last fifty years, become mature. The first half of the twentieth century, moreover, saw an anthropological concern with documenting the natural history of humanity—a preoccupation with ‘salvage ethnography,’ that is, with describing ‘primitive cultures’ in all of their aspects before they became part of an expanding global economy. Many ethnographic accounts aimed at describing a ‘whole culture,’ which entailed some discussion of health beliefs and practices, albeit as a means of elaborating on how the various aspects of the specific culture were functionally interrelated. Following the rapid expansion of a global capitalist economy, anthropologists turned their attention to specific cultural traits rather than striving to describe the ‘whole’ of any specific culture, as that would inevitably entail an ethnography of the whole world.
Widespread culture contact and rapid cultural
change was increasingly evident everywhere an anthropologist traveled. What was
once conceived as feasible, the description of a whole culture, became a fantasy
relegated to fiction (such as Aldous Huxley’s utopian novel, Island).
Ethnographers no longer aspired to write the definitive account of a culture,
but rather focused on the most subjectively interesting aspect of a culture.
Subject specialization within anthropology became important during this time.
Comparative ethnologists were always and continue to be concerned with
cross-cultural manifestations of certain institutional arrangements, economic
practices, religious practices, and so on. Since the 1970s, however, they have
had to find their data in more specialized studies that often concentrate on one
particular domain of culture. Before discussing the particular history of
medical anthropology, some definitions of the subject area from its leading
practitioners are in order.
Anthropology as a Subject Focus
One of the most notable medical anthropologists
of the late 1960’s and 1970’s was Arthur Kleinman, a psychiatrist trained in
anthropology. His research focused primarily on Taiwan, but he has also
conducted some interesting comparative work as well. Kleinman (1980) defines the
goals of medical anthropology as follows:
anthropology] must help widen and deepen the non-biomedical cultural perspective
on health, sickness, and health care. ... [Medical anthropologists] must frame
their research investigations in terms of the ethnomedical mode’s orientation
to the meaning context of illness and health care. … [B]y studying the
everyday context of health and sickness in the popular sector, anthropological
studies should do more than simply demonstrate the inadequacy of the
epistemology underlying the biomedical framework. They should focus attention on
the non-professional side of the health field and especially on its positive
adaptive features, which deserve to be better understood.
Kleinman cautions against merely
attacking the epistemology of biomedical science without understanding the
popular manifestations of the practices themselves in their cultural context of
meaning. Romanucci-Ross (1991) defines medical anthropology as concerned with
and analyses of medical systems which emerge from human attempts to survive
disease and surmount death, and are conceptualized as social responses to
illness and the sick role within the variety of world cultures. . . a study of
medical thought and problem solving, the acculturation process of the healer and
physician in diverse cultural settings, and the social and cultural context of
medicine. . . demonstrating how culture—human belief, knowledge, and
action—structures the human experience of disease, affects the ways in which
both physicians and patients perceive and define illness, and influences the
matrices of decision making in the subcultures attempting to communicate about
problems of health care. [p. ix]
This definition points to a
comparative element, and to a focus on processes of decision-making involved in
social responses to suffering.
Lindenbaum and Lock (1993) define medical anthropology simply as the “...study of the creation, representation, legitimization, and application of knowledge about the body in both health and illness” (1993: x). This definition points to a concern with the body as a cultural artifact, and as the specific subject and research site of medical anthropology. After the historical account of medical anthropology’s theoretical formulations and methodological developments, the transformation in definitions throughout the years will become clearer.
Anthropology as a Theoretical Orientation
A unified theoretical orientation has been
lacking in the field of medical anthropology, partly owing to its own diversity,
and partly as a conscious effort to respond to and construct new theoretical
formulations (Nichter 1992). The Society for Medical Anthropology, a subsection
of the American Anthropological Association, hosts gatherings of medical
anthropologists with diverse general theoretical orientations, including
biological, psychoanalytic, epidemiological, historical, and sociocultural. The
1973 conference saw an explicit call for some organized presentation of medical
anthropology theory opposed to the usual focus on particular case studies.
Medical anthropology has yet to present a unified theory, still tending to draw
on a diverse set of theoretical orientations—a sign of the diversity and
richness within, and the potential future relevance of the sub-field to
disciplines outside anthropology.
Medical anthropology draws on and contributes
to many disciplines other than anthropology, including medicine, psychiatry,
biology, sociology, epidemiology, history, psychology, political science,
ecology, and philosophy. Medical anthropology is by its nature
interdisciplinary, collaborative and eclectic in that it
us to address questions of more general interest to medical and social sciences
… [to] look specifically at the patterns of interaction between social and
medical scientists doing collaborative studies related to practical problems of
improving people’s health … [and] to look at both the sociocultural and the
bio-medical aspects of the continuing interaction between man and his complex
environment. [Kunstadter IN Kleinman, Kunstadter, Alexander, & Gate
Medical anthropology is commonly associated with ethnomedicine; biocultural and political studies of health ecology; the evaluation of health and medical related behaviors from both an emic and etic vantage point; health systems analysis and the study of health provider-client interactions; and political economic studies of health ideologies, the distribution of illness, health care resources, and the process of medicalization. [Nichter 1992: xvii]
Although they draw on a wide variety of theoretical vantage points, medical anthropologists have a common concern with the relationship between culture, health, and illness. The following history of medical anthropology will shed more light on its identity within anthropology.
A Brief History
of Medical Anthropology
The field of medical anthropology was not
defined as such until the late 1960s. Before that time various anthropologists
conducted fieldwork and comparative studies of health and medicine without
assuming the identity of a ‘medical anthropologist.’ The Society for Medical
Anthropology gained momentum only in the 1970s, and only after the mid-1970s was
there an identifiable medical anthropological community, with a specialty in
medical anthropology being offered at a few universities. I will begin this
historical narrative with a brief discussion of early influences on medical
anthropology, and then move to a discussion of the rise of medical anthropology
in the 1970s, followed by an exploration of more recent trends, including the
influence of poststructural theory in the early 1980s and into the 1990s,
relating recent extensions of earlier traditions along the way.
Influences: Medical Anthropology of
the Non-Western ‘Other’
In the context of salvage ethnography,
anthropologists went to the field to describe total cultures in terms of their
internal functional interrelationships of various behaviors, practices, and
beliefs. Following Malinowski’s notion of fieldwork wherein the ethnographer
stays in one place for an extended period of time and learns the local
language(s), ethnography as what Geertz later called ‘thick description’
became the primary focus for American anthropologists. In this context, most
ethnography included some description of the health beliefs and practices of the
particular group, usually in terms of a supposed ‘magico-religious system.’
Contemporary medical anthropologists concerned with cross-cultural comparison
draw heavily on this earlier ethnographic literature, now compiled in the Human Relations Area Files (HRAF). For instance, Arthur Kleinman’s
(1980) Patients and Healers in the Context
of Culture, while based in part on his ethnographic fieldwork in Taipei,
also draws on cross-cultural examples in order to focus on the relationship
between cultural context and healing practices more generally.
Studies on shamanism and ritual have also been
influential in medical anthropology. Balikci’s (1963) account of shamanic
practices among the Netsilik is one early example from the vast body of work on
shamanism. One of the most influential studies of ritual healing is Victor
Turner’s (1967, 1969) work among the Ndembu of Africa. Turner, often cited in
contemporary medical anthropological literature for his work on symbols and
especially his concepts of ‘liminality’ and ‘communitas’ (1969), had a
considerable influence in the development of symbolic anthropology as well.
Much recent medical anthropology work has drawn
upon these earlier ethnographic accounts concerned with the relationship between
‘magico-religious’ systems and health care. For example, in East
Asian Medicine in Urban Japan, Margaret Lock (1980) uses the heading “East
Asian medicine” in reference to contemporary practices in Japan which trace
their history to Chinese medicine. She uses the term “cosmopolitan medicine”
to refer to Western bio-medicine and the term “folk medicine” to refer to
practices influenced by Shinto traditions. Her ethnography of the popular
medical system of urban Japan is notable for its depth of historical and
ethnographic research. After tracing the history of medicine in Japan, which
includes ancient Chinese, Shinto, and Western (by way of Germany) influences,
and exploring the religious and philosophical traditions of each, she examines
Japanese socialization practices vis-à-vis medical and religious beliefs
and practices through time. Her historical perspective is especially interesting
and informative. She explores local and regional variance, and critically
discusses the potential value of the Japanese ‘holistic’ model to Western
medicine outside Japan.
Ethnoscience: Emics, Etics,
The prefix ‘ethno’ refers to the system of
knowledge and cognition typical of a given culture. The stated goal of
ethnoscience was to improve the ethnographic method by making cultural
descriptions replicable and accurate. In 1954, Kenneth L. Pike took the roots of
the linguistic concepts ‘phonemic’ and ‘phonetic’ and coined the
concepts of ‘emics’ and ‘etics,’ which were first used in the
‘ethnoscientific’ analysis of behavior. Emics are said to describe
culturally specific ways of conceptualizing, organizing, and classifying things.
Etics are understood as universal (scientific) ways of conceptualizing,
organizing, and classifying things. Etics are conceptualized as
‘culture-free’ physical and physiological features useful as a basis for
comparing emics. So the notion that “full understanding of a culture or an
aspect of a culture and particularly its full description in a foreign language
(English) require the ultimate reduction of the significant attributes of the
local [emic] classifications into culture-free [etic] terms” (Sturtevant 1964)
became accepted. The emic was understood as a local expression of etic
characteristics, or conversely, etics were built out of the comparison of
different emics. Early work in ethnoscience skirted the issue of the ultimate
inseparability of emics and etics, whereby etics also arise out of cultural
contexts, and has since been severely, and justifiably, criticized for doing so.
Cross-cultural comparison is always at least
one level removed from the ethnographic, involving the comparison of different
“emic systems” according to an “etic grid” (Sturtevant 1964). What is
‘scientific’ was taken as ‘culture-free’ (etic) and what was ‘emic’
was understood as ‘science-free.’ Ironically, while other non-western
peoples’ ways of explaining and classifying things were understood as ‘ethnoscientific,’
and therefore only comprehensible in their particular cultural contexts, those
of the ethnologists themselves, and of biomedical science more generally were
considered ‘etic’ and conceptualized as floating free of any cultural or
The prefix ‘ethno’ and the concepts of
‘emic’ and ‘etic’ had their influence upon medical anthropology in the
form of what was called ‘ethnomedicine.’ At first, ethnomedicine was simply
the application of the methods of ethnoscience to health-related beliefs and
practices. Charles O. Frake’s (1961) ethnographic study of the diagnosis of
disease among the Subanum of Mindanao is one of the most notable as well as one
of the earliest examples of ethnomedical studies. Medical anthropologists, along
with others, have leveled substantial critiques of ethnoscience methodology,
mainly regarding its assumption that diverse groups share the exact same
elicitable structure for understanding the world. Ethnoscientific approaches to
health tend to gloss over the interesting complexity of everyday life, the
dynamic context of relations between practitioners and clients, the situational
dependency of most medical treatments, and intracultural variation such as
gender, class, and ethnic differences. Contemporary medical anthropological work
approached from a biomedical or biological perspective continues to uncritically
assume the ultimate and unquestionable truth of the biomedical model in much the
same way as ethnoscientists conceptualized ‘etic grids.’
There was, however, an important insight which extended from the
tradition of ethnoscience into what is now called ‘critical
ethnomedicine’—that is, the primacy of what were then called ‘emic’
conceptualizations, but without concern for an ‘etic grid’ whatsoever.
Contemporary ethnomedicine, as we shall see below in more detail, is concerned
the full range and distribution of health related experience, discourse,
knowledge, and practice among different
strata of a population; the situated meaning the aforementioned has for
peoples at a given historical juncture; transformations in popular health
culture and medical systems concordant with social change; and the social
relations of health related ideas, behaviors, and practices. [Nichter 1992:ix,
Catherine Lutz’ (1988)
ethnography of the Ifaluk, a Micronesian islander group, attempts to describe
the conceptualizations of her subjects (like earlier ethnoscientific work)
regarding emotions and views of the person. Lutz is careful to describe and
analyze age and gender differences among the Ifaluk, while also providing a
powerful critique of what she calls “Western ethnopsychology,” locating
Western knowledge of emotions and the person also within the realm of
culture—that is, as an ‘emic’ itself. This discussion of Lutz’ work
leads into the next historical shift in focus within medical anthropology—a
focus back on the cultural ‘self,’ or the culture of the ethnographer.
Establishing a “Sub-field”
and Turning the Gaze Within: The
Medicine and American C
During the 1970’s, specific attention was
paid to the critique of the epistemological assumptions of Western medicine,
owing in part to Foucault’s (1973) The
Birth of the Clinic. Medical anthropologists, along with anthropologists in
general, turned their attention to their own societies, sometimes motivated by
the (conceptual or otherwise) disappearance of what where conventionally seen as
‘pure’ cultures, and partly out of a rising critique of anthropology’s
role in colonial exploitation. The 1970s saw a new generation of anthropologists
more concerned than ever before with the relationship of anthropology to
colonialism. Many in this new cohort of anthropologists rejected the study of
the non-Western ‘other’ because they saw anthropological knowledge being
used for European and American military agendas. Anthropologists involved in the
CIA or other governmental agencies were openly criticized for aiding in the
‘new colonialism’ (Eugene Cooper, personal communication). So, rather than
gathering information on peoples and cultural groups who potentially interested
American military intelligence, many anthropologists went to the field at home,
or else studied issues irrelevant (or so it seemed) to European and American
political concerns. Within medical anthropology, studies tended to focus on
healer/patient interactions, ethnicity, and the relationship between healing,
ritual, and religion.
Robert Edgerton’s (1967) The
Cloak of Competence, an ethnographic study of the American medical
system’s deinstitutionalization of “mentally
ill” and “retarded” patients, is an early noteworthy example of medical
anthropology on the American medical system. Emily Martin’s (1994) Flexible Bodies: Tracking
Immunity in American Culture—From the Days of Polio to the Age of AIDS, is
a more recent extension of the tradition of studying within American culture.
Anthropology Defines and Redefines Itself
Specific journals designed for medical
anthropologists to publish their research findings appeared during the same
time. Along with contributing articles to journals such as
Psychiatry, Annual Review of
Anthropology, American Anthropologist,
Current Anthropology, and Progress
in Psychotherapy, medical anthropologists started up three journals tailored
to their specific interests: Social
Science and Medicine (1966); Culture,
Medicine, and Psychiatry (1976); and the more recent Medical
Anthropology Quarterly (1986).
In 1972, the medical anthropologist Sol Tax,
called for a conference through the Society for Medical Anthropology. Professor
Tax noted that since acupuncture was beginning to diffuse to the West, a
“systematic review of other non-Western medical practices of all kinds and
from all cultures might be of interest and importance to the medical
profession” (Grollig & Haley 1976:xi). This spawned the impetus to hold a
conference on the current state of medical anthropology. One area requested for
increased focus and discussion was “the need for a presentation of a body of
organized theory for Medical Anthropology (as opposed to the proliferation of
more mere case studies of Medical Anthropology)” (Grollig & Haley
1976:xii). The conference was held in 1973. Specific geographically oriented
collections of medical anthropological work have also surfaced over the years. However,
a unified body of theory for medical anthropology is yet to be presented, and
currently seems undesirable and unnecessary.
During the 1970s an unprecedented number of
anthropologists sought jobs in non-academic or so-called ‘applied’ contexts,
as opportunities for anthropologists to become involved in health related
application of their work rose significantly. International health projects,
domestic health care programs, local primary health clinics, hospitals, and
other contexts within the health care industry actively sought out medical
anthropologists at the same time that medical anthropologists became interested
in doing more applied work. Applied
medical anthropologists rely on organizations concerned with planning, policy,
implementation, or evaluation of health services and programs, as well as
educational or training institutions for medical, nursing, public health, and
other health related personnel for employment rather than academic departments
within universities. Heggenhougen (1985) notes that it has become
‘fashionable’ to include anthropologists on the staff of both governmentally
and privately operated medical and health organizations.
Because applied medical anthropologists do not
work in the context of the academy, they publish fewer articles and books on
their own work. Usually their efforts are immediately utilized in service to the
institution for whom they are working and relegated to files within the
institution itself (Tom Ward, personal communication). Carole Hill (1985),
however, has provided an excellent introductory text regarding applied work in
and Heteroglossia: Post-1970’s
the Western philosophical traditions of symbolic interactionism (Mead 1934),
existentialism (Sartre 1956), social constructionism (Berger & Luckman
1966), early theories of performance of self (Goffman 1959), genealogical and
discourse analysis of Western knowledge (Foucault 1970,1973), and the
problematization of ‘ethnographic representation’ (Marcus & Fischer
1986; Clifford & Marcus 1986; and Clifford 1988), academic medical
anthropologists have in the 1980s and 1990s turned their attention to the role
of power and knowledge in the practice of medicine both at home and abroad. A
specific concern with ‘the body’ as a site for the inscription of cultural
power/knowledge has come to the fore in recent years (for example, Schepper-Hughes
& Lock 1987; Csordas 1994; Lindenbaum & Lock 1993; and Adams 1992).
Application of Foucault’s method of discourse analysis has proved
inspirational for critical medical anthropologists generally (Glass-Coffin 1992,
Estroff 1993), while the application of Goffman’s (1959) notion of
‘self-presentation’ has inspired a recent volume titled The
Performance of Healing (Laderman & Roseman 1996). This section explores
three current trends in medical anthropology: critical approaches, performance
approaches, and narrative approaches, especially as each deals with the issue of
1. Critical Approaches to
Mark Nichter (1992), in his introduction to a
valuable collection of recent academic studies in critical medical anthropology,
stresses the importance of avoiding ‘theoretical closure’. Two types of
theoretical closure are tempting in medical anthropology, and indeed any
ethnographic or ethnological work more generally. One kind of closure, which
Nichter calls ‘analytical involution’, is the decontextualization of healing
systems and illness as discrete domains of empirical inquiry. This leads to an
ethnocentric, disembodied (‘etic’) classification of terms whose meanings
remain nominal and reveal nothing of their pragmatic uses, polysemic qualities,
or cultural significance. This type of theoretical closure is often found in
biologically oriented approaches to medical anthropology.
The opposite extreme is the objectified reification of ‘culture’ as an unchanging and enduring static phenomenon wherein health beliefs and practices are interpreted vis-à-vis a supposedly fixed set of values, ideas, and social relations. This type of theoretical closure underestimates intracultural variability and resistance, usually associated with a distinction between ‘modern’ and ‘traditional’ health systems in terms of a static and deterministic view of culture. Ethnographies of non-Western societies by cultural medical anthropologists often conjure this form of theoretical closure. ‘Traditional’ systems are viewed as unchanging while ‘modern scientific’ systems are viewed as dynamic and responsive to change, or conversely, the ‘biomedical system’ is reified into a coherent whole which does not respond to the pragmatics of everyday life in the context of its application. Both of these extremes of reduction are stifling to analysis of health systems. The former neglects cultural factors and context altogether; the latter neglects the dynamic nature of culture and intracultural variability.
Nichter (1992) argues, bringing to mind Lutz’
(1988) view of “Western ethnopsychology,” that contemporary American
biomedicine is one of many forms of ‘ethnomedicine’ and that science in
general is motivated by a political economy. This critical view is not to be
found among biological anthropologists working in the field of medical
anthropology, where the paradigm of biomedicine is often used as a scientific
yardstick by which to measure the rest of the world’s health regardless of
sociohistorical circumstance. Lock’s (1980) work on the medical systems of
urban Japan, mentioned above, is a notable example of an even-handed historical
ethnography which takes into account a variety of overlapping and complementary
‘systems’ of health care. By focussing on the context of application and
practice in historical context she does not fall victim to ‘theoretical
closure’ in either direction.
such as Nichter’s, however, do not readily specify methods of evaluating the
efficacy of competing models (Finkler 1994). How are comparisons to be made
across cultural distances if there is no ‘etic grid’ against which one can
appeal for measurement of what’s really
going on? There is quite a bit of writing on this subject, not only within the
discipline of medical anthropology, but in social science and humanities more
generally. This is indeed one of the most vexing problems for anthropologists
Edgerton (1992), in his book Sick
Societies, has called for a re-evaluation of ethnographic contributions that
effectively sustain the ‘myth of primitive harmony,’ his own earlier work
included. Edgerton’s thesis is that ethnographers have relied too heavily on a
stance of cultural relativism, without documenting some of the more
‘maladaptive’ cultural practices. I agree with Edgerton that ethnographers
should not subscribe to a ‘myth of primitive harmony’, yet stressing only
the maladaptive aspects of cultural practices and beliefs is dangerous to the
practice of anthropology, especially in its applied settings. Pointing to the
adaptive benefits to be gained by one or many specific subcultures or elites by
employing a politics of racism, genocide, or other appalling cultural practices
or beliefs in no way makes these practices and beliefs morally right or
desirable. It merely explains why these practices may have come into being and
continue to surface in various contexts. Ideally, such analyses also point to
ways in which these practices are undermined, potentially or actually, as well.
A centered and balanced anthropology will (and does) stress both the positive and
negative consequences of certain practices and beliefs relative to specific
cultural, and especially sub-cultural, contexts. Explanations should (and do)
strive to render such practices and beliefs comprehensible (even though in some
cases detestable) to the community of anthropologists and to a wider scholarly
and general public, in all of their dimensions, both adaptive and maladaptive.
Some other responses to Nichter’s critique
(regarding the trouble of evaluating the efficacy of healing practices) draws on
the work of the social constructionist tradition of the sociology of knowledge
(extending back to Berger & Luckman 1966). One response is that one cannot know
which of several hypothetical or real methods, or systems, is best unless each
has been assessed in an actual social and historical setting with actual people
in the cultural and physical environment for which the intended remedy is aimed.
Even once a particular ‘cure’ has been applied with success (by which
measures, and from whose perspective, and to whom?) within a particular context,
still the constant flux and negotiation that is culture makes for a new context
before the possibility arises for a new application of the same ‘cure’, even
in the case that the very same individuals are in the same roles and
‘environment’ as in the first instance. There is no assurance that the
application of the same ‘cure’ will hold to the new condition because each
situation entails a new condition.
When dealing with the subject of human health
and suffering, additional complications are readily evident. How is health
measured, or suffering for that matter? Under what circumstances is an
individual healthy or sick? Considering the power relations brought to bear in
every human encounter, and especially encounters with specific health
institutions, makes possible a more complete and in-depth analysis of what is
going on in the process of treatment. Because as ethnographers we have learned
that the ‘official line’ given by informants is not always what actually
takes place in the context of action and behavior, or in the application of
knowledge, we are obliged to consider the practice
of healing, whether in a biomedical context or otherwise, as distinct yet in
relation to the tenets of an ‘emic’ theory
of health. The expressed theory
represents only one social level of a cultural reality, and necessarily comes
from socially situated individuals with political motivations, yet it should be
the basis of anthropological investigations of healing practices.
The problem of how healing works enters the field of medical anthropology under the heading of ‘efficacy.’ It is a general theoretical problem that many medical anthropologists address, and one to which my future work will remain attentive and actively engaged. The next two sections on performance and narrative take two slightly different approaches to the problem of efficacy in medical anthropology.
2. Performance Perspectives:
All the authors in The
Performance of Healing (Laderman & Roseman 1996) take a primary concern
with the dramatic and symbolic elements of ritual healing. Interpretations are
based on Arthur Kleinman’s (1980) and Byron Good’s (1977) notions of
‘culturally-constructed’ expressions of illness and health, Victor
Turner’s (1967, 1969) view of symbols as ‘multivocal’ and his notion of
‘ritual drama’, Erving Goffman’s (1974) awareness of metacommunicative
acts that ‘frame’ everyday life, developments in the ‘ethnography of
communication’ that see ‘text’ and ‘context’ as mutually constitutive
of performance domains such as have been applied in discourse analysis by
Tedlock (1983) and Rosaldo (1980), as well as contributions from aesthetic
anthropology by Steven Feld (1990) and Paul Stoller (1989) that emphasize how
paying attention to the dramatic pacing, sensation, and the ‘poetics of
form’ can bring new insights into the meaning of performances in general (Laderman
& Roseman 1996:2-5).
to performance-centered perspectives, issues of efficacy are framed in terms of
‘embodiment’, sensation, imagination, and experience. What western science
calls the ‘placebo effect’ plays a significant role in ‘etic’
constructions of efficacy cross-culturally. Somatic responses to psychological
states induced by the administration of a ‘cure’ by a healer are effected in
the performance of healing. Even if no specific substance is administered, any
sensory stimulation or deprivation can be effective in a healing performance
event. At the physiological level, endorphins can be triggered for release
having similar effects to the biochemical administration of morphine, librium,
or valium (Laderman & Roseman 1996:8). These biochemical changes in the
brain make possible trance states that are useful to effecting healing through
performance. Yet, without the accompanying ritual drama, and the guidance of the
healer, the biochemical changes may have no effect on healing the patient. In
their “Introduction” to The
Performance of Healing, Laderman and Roseman suggest that the “healing
effects of performance are, on one level, caused by the catharsis that can occur
when a patient’s unresolved emotional distress is reawakened and confronted in
a dramatic context” (1996:7), yet it is the ‘embodiment’ of healing that
is required for real effect.
essay, “Imaginal Performance and Memory in Ritual Healing,” Thomas Csordas
(1996) takes a phenomenological perspective to discuss how healing performances
work. He critiques the ‘placebo effect’ argument that relies on an
‘interpretive leap’ from trance, placebo, suggestion, or catharsis to
efficacy as insufficient. Csordas concurs that there may be such a thing as
catharsis, yet asks, “what is being catharted?” (1996:94). His innovative
approach examines “sequences of imagery not as elements in healing performance
but as performances in their own right, as a kind of performance within
performance that may not even be observable” (1996:94). What he is talking
about he calls “imaginal performances,” that is, images that appear in
patients’ and healers’ minds’ eyes and are embodied during the performance
of healing. He finds these images closely associated with memory, and thus calls
the process of Catholic Charismatic Renewal healing that he is investigating the
“healing of memories” (Csordas 1996:95). In his discussion of imagination
and memory, Csordas suggests that the experience of healing is actually
manifestation of genuine intimacy with a primordial aspect of the self—its otherness
or alterity. This otherness is the possibility of experiencing oneself
as other or alien to oneself, but it is also the possibility for recognizing the
existence of other people with whom one can have a relationship. [The otherness
of the self originates] in three features of our bodily existence: the
limitations of our physical being that leave us with a sense of inescapable
contingency, the autonomic functioning of our bodies that insistently goes on
without us but which implicates us in anything that happens to our bodies, and
the possibility of seeing ourselves as objects from the perspective of another.
This explanation of efficacy,
based on embodiment theory, is quite interesting and provocative, especially as
it allows the medical anthropologist to consider efficacy from the native’s
point of view. In Csordas’ construction, imagination and memory interact in
the patient’s mind and body, guided by the healer’s invocation of divine
authority, that is the experience of the otherness of the self as both divine
and ‘always already there.’ Csordas’ words are again worth quoting at
is thus no accident that the divine embrace is the privileged and recurrent act of
transforming traumatic autobiographical memory. Because the embrace is imaginal,
it encapsulates the pure possibility of intimacy; because the imagery is
embodied, it is convincing because it partakes of the existential ground of all
causality, force, and efficacy; and because it is enacted by a divine figure [in
this case, Jesus], its meaning and intent are beyond question. [1996:108]
I find this perspective
inspirational for understanding efficacy of healing, not only in the context of
so-called ‘faith healing’, but more generally. From this perspective,
however, the ethnographer must find out what is going on in the patient’s mind
and body, to identify what images of memory and imagination are being
‘performed’; that is, it requires ‘after the fact’ conversations with
patients and healers that invoke the performance itself as a memory in a new
situation of coeval dialogue. So, it although Csordas’ embodied explanation of
efficacy makes sense, it still leaves us with having to read our subjects’
minds in order to explain the particularities of individual cases of healing.
3. Narrative Perspectives:
Along with a focus on performance, medical
anthropologists have begun since the late 1980s to pay attention to ‘narrative
elements’ of healing practices, as both a subject of investigation and a
methodological approach. Recent innovative experiments with narrative in medical
anthropology are collected in Narrative and the Cultural Construction of Illness and Healing,
edited by Cheryl Mattingly and Linda C. Garro (2000). All of the authors
consider narrative as both emergent and situated. That is, stories have many
possible meanings and interpretations, and also come from situations of
historical, cultural, political, and social specificity. Stories of and about
illness experience become believable and efficacious based primarily on their
verisimilitude rather than their verifiability.
Narrative offers a way of bringing structure
and meaning to experience, and thus provides a powerful means of digesting the
experience of illness and healing. Stories also have beginnings, middles, and
endings, as well as dramatic elements such as plot and foreshadowing that allow
the teller to emphasize certain aspects of experience from their subjective
position. Also, stories are told to an audience, and the audience actively
participates in the telling of the story. Stories, however, have a problematic
relationship with experience. Certainly, lived experience informs the telling of
stories, yet their telling is also part of a lived experience itself, and it can
powerfully effect future experiences. There is a dialectical relationship
between experience and stories, yet in a certain sense stories themselves become
experience, as Csordas (1996) has made clear.
Narrative analysis of healing must consider
text, context, and meaning as intertwined, realize that the construction of
stories is grounded in specific cultural settings and socio-historical contexts,
and acknowledge that stories are produced as the outcome of dialogic individual
interactions between the story-teller and audience. So long as these three
tenets are kept in mind, narrative analysis can bring some very interesting and
innovative contributions to medical anthropology.
Cheryl Mattingly’s chapter, “Emergent
Narratives” (2000) combines narrative and performance approaches to examine
the construction (or ‘emergence’) of a healing narrative in a biomedical
clinical setting. Mattingly’s data come from the videotaped experience of a
9-year-old girl in an occupational therapy session in an outpatient clinic near
Boston, Massachusetts. The girl, therapist, and camera-person all participate in
constructing the ‘emergent narrative’. Before going into specific analysis,
Mattingly situates her approach in terms of narrative theory.
Mattingly notes that many narrative theorists,
herself included, take a ‘continuity view’ between ‘life as lived’ and
‘life as told’ and argue that life itself can have narrative shape (also,
Jerome Bruner 1990), while many others take a ‘discontinuity view’ that
argues since life lacks inherent plot, and since life lacks a narrator, it
therefore lacks narrative shape. We live without knowing how current and past
experiences will turn out in ‘the end’ or how their meanings may change, and
therefore our lives are always incomplete stories. Experience is indeed unruly,
and is ordered and structured through the narrative recounting of it, bringing
chaos into coherence, as James Clifford (1988) makes clear. And, in life, we are
more like characters than narrators of our own ‘story’. So, to subscribe to
a ‘life as story’ perspective assumes a naïve realism that proposes a
one-to-one relationship between experience and its narration—one that fails to
account for the socio-historical and cultural context of storytelling.
There is another critique of narrative analysis
noted by Mattingly that comes from the performance approaches discussed above.
Cultural theorists and others writing from a semiotics perspective have
suggested an ‘action-as-text’ metaphor to enable interpretation of behavior
as text. This approach tends to minimize the significance of all contextual
elements as it requires the lifting of particular actions or behaviors from
their socio-historical and cultural context of production. Some kinds of
narrative analysis, when approached from a semiotics perspective, tend to
produce this kind of a-historical treatment. Performance perspectives such as
those extolled by Csordas (1996), however, are concerned with the phenomenology
of the experience of narratives, and thus avoid the critique by paying attention
to the experience-near aspects of social phenomena.
Mattingly’s (2000) concept of ‘emergent
narratives’ avoids both of these critiques. Hers is an important contribution
to the analysis of stories as it understands narrative and action, or ‘life as
told’ and ‘life as lived’, as closely intertwined without reducing either
to a representation of the other. Mattingly looks at a specific
“improvisational and embodied” story (2000:189) in order to show the concept
of ‘emergent narratives’ in action. The story is created as lived experience
through interaction among three people: Sarah, a 9-year-old girl suffering from
vestibular problems that make balancing difficult for her; Ellen, an experienced
pediatric therapist; and a camera-person who is videotaping the session. When
Sarah suggests making a game of a routine therapeutic exercise, and Ellen
agrees, an ‘emergent narrative’ develops. Sarah’s suggestion to frame the
exercise in terms of an Olympic competition brings plot and drama, suspense and
imagination, to the activity. The question of whether Sarah will ‘win the gold
medal’ becomes central, and all participate in driving each action toward that
There are a series of improvisational elements
in the emergent narrative that help direct actions and words toward the
understood dramatic resolution of the immediate story, that is Sarah’s winning
the ‘gold medal’ in Olympic competition. Sarah keeps the event structured as
a narrative by insisting on a make-believe name for herself, and corrects Ellen
when she slips once using her real name. Ellen also keeps Sarah involved in the
dramatic plot by not validating Sarah’s apology for missing a jump, but
instead uses her improvised identity as broadcast commentator to propel Sarah
into continuing the emerging story. A ‘narrative time’ is constructed where
each action and phrase builds up to a “sense of ending” as meaning is
created in the fulfillment of dramatic movements.
There are many different emergent narrative
plots at work in this one particular moment. There is the immediate plot about
Sarah winning the gold medal, yet there is also the plot about Sarah recovering
from her vestibular problem in which the smaller story makes sense. And so,
Mattingly finds that “[m]eaning is not preordained by prior scripts or
cultural rules but in some important sense emerges… out of a social
interaction in which improvisation is prized and cultivated” (2000:197). The
competence of the occupational therapist or healer, and the efficacy of healing
require attention to and skill at reading these kinds of ‘emergent
narratives’ in practice, and modifying the healer’s own behavior to suit the
ever-changing moment of narrative emergence. In this case, it means Ellen’s
encouragement of Sarah’s success and her refusal to support Sarah’s
Furthermore, ‘emergent narratives’ are
effective because they are improvised and embodied through drama; even though
they are in one sense ‘fictional’, they are in another sense even more real
than the experience of mundane reality. Recalling Csordas’ (1996) conclusions,
Mattingly explains “[a]n emergent narrative such as this creates
‘verisimilitude’… It offers an especially authoritative vision of reality
precisely because it heightens experience by calling upon the imagination. A
sense of realness is further facilitated by the embodied character of this
storymaking” (Mattingly 2000:200). Emergent healing narratives draw on
cultural symbols and plot lines and manipulate these to construct desired
meanings, ones necessary to effect healing. Mattingly’s analysis suggests that
attention to emergent narratives can bring us closer to the experience of
healing from the patient’s point of view. “This [emergent narrative] is a
dramatic form, characterized by suspense, excitement, heightened desire, even a
kind of foreshadowing, an elusive gaze into possible futures that live far from
this small clinical encounter” (2000:206). Paying attention to emergent
narratives brings the medical anthropologist closer to understanding the
realities of healing. The concept is not only a significant contribution to the
understanding of efficacy in medical anthropology but to theoretical
understandings of human nature, what it means to be human.
Since the 1970s, medical anthropology has matured into a field of specialization, and has remained in dialogue with significant developments in anthropology more generally, as the previous sections on performance and narrative approaches demonstrate. Medical anthropologists remain primarily concerned with issues of efficacy, how healing works in cultural and socio-historical contexts. Although medical anthropologists share this common concern, there is little theoretical common ground in the field, yet there is active appropriation of all kinds of recent theoretical advances. This is a sign of the health of the field. The turn of the twenty-first century is an exciting moment for medical anthropology studies, and it remains as relevant as ever in both its applied and academic forms.
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 See also Barbara Pillsbury (1979) on international
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