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Anthropology of Healing:

 

An historical summary of medical anthropology

from the 1960’s to the present

Christian Alan Anderson

Department of Anthropology

University of Southern California

 

Ph.D. Qualifying Exam:  Topic/Subject

April 21, 2002

 

 

CONTENTS:

Introduction:  Definitions and Boundaries                                 

Medical Anthropology as a Subject Focus                                  

Medical Anthropology as a Theoretical Orientation                   

Allied Disciplines                                                            

A Brief History of Medical Anthropology                                     

Early Influences:  Medical Anthropology of the Non-Western ‘Other’

1.  Salvage Ethnography:  Magico-Religious Systems             

2.  Ethnoscience:  Emics, Etics, and Ethnomedicine                       

Establishing a ‘Sub-field’ and Turning the Gaze Within:  The 1970s  

1.  Western Medicine and American Culture                            

2.  Medical Anthropology Defines and Redefines Itself            

3.  Applied Medical Anthropology                                    

Multiple Gazes and Heteroglossia:  Post-1970s Postmodernism         

1. Critical Medical Anthropology                                      

2. Performance Perspectives                                             

3. Narrative Perspectives                                          

References Cited                                                            

Annotated Bibliography                                                 

Introduction:  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.

 

Medical 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:

... [Medical 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.  [p. 384-85]

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 the

descriptions 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.

Medical 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.

Allied Disciplines

        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

...allows 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 1978:393]

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.

 

Early Influences:  Medical Anthropology of the Non-Western ‘Other’

1.  Salvage Ethnography:  Magico-Religious Systems

        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.

2.  Ethnoscience:  Emics, Etics, and Ethnomedicine

        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 contextual grounding.[1]

        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 with the

study of 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, my emphasis]

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 1970s

1.  Western Medicine and American C ulture

        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.

2.  Medical 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.[2]  However, a unified body of theory for medical anthropology is yet to be presented, and currently seems undesirable and unnecessary.

3. Applied Medical Anthropology

        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.[3] 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 medical anthropology.[4]

 

Multiple Gazes and Heteroglossia:  Post-1970’s Postmodernism

Drawing on 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 efficacy.

        1. Critical Approaches to Medical Anthropology:

        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.

Critiques 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 today.

Robert 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).

According 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.

In his 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

a 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. [1996:104]

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 length:

It 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 question.

        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 anxieties.

        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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[1] Catherine Lutz (1988) provides a well-written and well-argued critique of biomedical ‘etics’ in the introduction of her work Unnatural Emotions.

[2] See, for example, Caudill & Lin (1969), Kleinman et al. (1978), and Leslie (1976) for collections relating to South and East Asia; and Parsons (1985) regarding the South Pacific.

[3] USC’s department of occupational therapy currently relies on the anthropology department for training its students in cultural aspects relevant to social work.

[4] See also Barbara Pillsbury (1979) on international aid evaluation in the context of women’s health.