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Unformatted text preview: 689 1 Medical Anthropology: An Introduction to the Fields Peter]. Brown, Ronald L. Barrett, Mark B. Padilla WHAT IS MEDICAL ANTHROPOLOGY? To define medical anthropology, we must first intro- duce its parent discipline and some of its key concepts. Introductory anthropology courses usually begin with some variation of the short and classic definition, ”Anthropology is the study of humankind.” Although vague, this definition underscores that anthropol~ ogy is a holistic and interdisciplinary enterprise that uses many different approaches to important human issues. In the broadest sense, these approaches are usually categorized into four major fields: cultural anthropology, physical or biological anthropology, archaeology, and linguistics. Today, however, introductory courses are often the first and last place where anyone gives much thought to the relationships between the four fields of anthropology. In recent decades, anthropology has gone the way of many academic disciplines. Its fields and subfields have become increasingly specialized, each with its own lexicon and theoretical orientation. As a result of these increasingly specialized differ- ences, the academic discussions between the fields of anthropology have diminished considerably, espe- cially between many areas of biological and cultural anthropology. Such trends are unfortunate because the compartmentalization of anthropology often under- mines the discipline’s greatest strengths: its holistic approach and interdisciplinary nature. Despite their specialized perspectives, cultural and biological anthropologists have a great deal in com— mon. For example, one useful definition of culture is learned patterns of thought and behavior shared by a social group. (Anthropologists have many different def— initions of culture, and the lack of complete agreement about this term might be considered evidence of the concept’s centrality within the discipline.) Cultural patterns might be considered to have three basic, inter- connected domains: (1) infrastructure—the domain of material and economic culture; (2) structure—the do- main of social organization, power, and interpersonal 10 relations; and (3) the belief system or superstructure— the domain of symbols, cognitive models, and ideol- ogy. For example, in the traditional culture of a north Indian village, all three levels of the cultural system are important—in agriculture and the economy of the vil— lage, in the social organization of the caste system, and in the religious beliefs and rituals of Hinduism. The three domains are closely related, and they all satisfy human needs. Many anthropologists argue that the three domains of culture are influenced by the biologi- cal aspects of human experience as a social species liv- ing within an ecological setting. The human organism is an open system, highly permeated by cultural in- fluences, many of which can have a profound impact on growth and development. Human biology and culture are intimately related, and it is important to have a holistic perspective on these interrelationships when studying human issues pertaining to health and sickness. Medical anthropology is a relatively new area of specialization within anthropology. Medical an~ thropology is not really a subfield (like biological an- thropology, archaeology, cultural anthropology, or anthropological linguistics), partly because these sub— fields generally have a central theoretical paradigm. Medical anthropologists use a wide variety of theo— retical perspectives, and they do not agree on which ones are best. Therefore, medical anthropology is sim— ply the application of anthropological theories and methods to questions of health, illness, medicine, and healing. As such, it may be more correct to refer to a variety of medical anthropologies. Medical anthropologists engage in basic research on issues of health and healing systems as well as ap— plied research aimed at improving therapeutic care in clinical settings or public health programs in commu— nity settings. The purpose of basic research is to ex— pand knowledge; the purpose of applied research is to help solve specific human problems. There is a great deal that we do not know about the causes of sickness and the processes of healing, and anthropologists may contribute to the growth of human knowledge in these important areas. The health problems facing people in all parts of the world are overwhelming and complex, and there is good evidence that anthropologists can contribute to the design and implementation of pro— grams to alleviate these problems. In regard to the four traditional fields of American anthropology, the most common type of anthropol- ogist is a cultural anthropologist. Most practicing medical anthropologists were trained in cultural an- thropology. On the other hand, as you will see by the selections in this book. biological anthropologists, ar- chaeologists, and even anthropological linguists may be interested in and may contribute to studies in mecb iJcal anthropology. Medical anthropology includes any of these subfields as they apply to issues of human health, sickness, and healing. A3 is the concept of culture, the notion of health is difficult to define. According to the charter of the World Health Organization, health refers not merely to the absence of disease but to a state of physical, social, and psychological well-being [Dubos 1959). What constitutes well-being in one society, however, may be quite different in another. The ideal lean- flgured body may signal health in the West but may indicate sickness and malnutrition in sub-Saharan fifrica (Brown 1991]. In the fishing villages that line Lake Victoria, the parasitic disease schistosomiasis is so prevalent that the bloody urine of young males is considered a healthy sign of approaching manhood (Desowite. 1981}. In the United States, the ”elegant pallot" and ”hectic flush" of consumption (tuber- culosis) were often mimicked at the turn of the cen- tury because of their association with famous writers and artists [Sontag 1978]. Any conceptualization of health must therefore depend on an understanding of how so—called normal states of well-being are con- structed within particular social, cultural, and historir cal contexts Sickness is an inclusive term that includes all un— wanted variations in the physical, social, and psycho- logical dimensions of health. Robert Hahn defines sickness as ”unwanted (:Onditions of self, or substan- tial threats of unwanted conditions of self" [Hahn 1995222). These conditions may include "states of any part of a person—~body, mind, experience, or relation- ships“ {Hahn 199522). More specifically, the criteria that people use when they assign the term sickness to a given state is based on complex interactions between human biology and culture. Sickness can be further divided into two basic categories: illness and disease. Disease refers to the outward, clinical manifestations of altered physical function or infectiOn. It is a clinical phenomenon, dec fined by the pathophysiology of certain tissues within Introduction to the Fields of Medical Anthropology 11 the human organism. illness. on the other hand, en~ compasses the human experience and perceptions of alterations in health as informed by their broader so- cial and cultural meanings. The distinction between disease and illness is useful because it helps to explain the phenomenon of patients who seek medical atten- tion in the absence of clinically identifiable symptoms (illness without disease) and those who do not seek medical attention even though they exhibit signs of pathophysiology [disease without illness). This distinction also explains differences in the quality of communication and therapeutic exchange between patients and healers. For example, a physi- cian using a disease model may see the patient's symptoms as the expression of clinical pathology, a mechanical alteration in bodily processes that can be "fixed" by a prescribed biomedical treatment. From the patient’s perspective, however, an illness expe- rience may include social as well as physiological processes. The patient's problem may just as easily be caused by an evil spirit, a germ, or both. The physi- cian’s diagnosis may not make sense in terms of the patient's theory of illness, and the "cure" may not take into consideration the patient's family dynamics the potential for social stigma in the community, or the lack of resources for follow-up visits or hang and ex- pensive therapies. Healing systems often cut across categories of reli~ gion, medicine, and social organization. Therapeutic modalities may range from cardiac bypass surgery to amulets to protect against the evil eye to conflict reso- lution between kin groups. Shaman, priests. univer— sity-trained physicians, and family members may assume a healing role at any given time. In recent decades, medical anthropologists have distinguished between biomedical systems of heating based 0n Western scientific notions of medicine and ethnomecl- ical systems of healing based on all other notions of healing. As we shall see, this distinction may be more a convenience than a reality. BASIC APPROACHES TO MEDICAL ANTHROPOLOGY Although the scope of anthropological inquiry into is- sues of human health, sickness, and healing is very di- verse, and the subfields engaged in these inquiries often overlap with one another, we can nevertheless identify five basic approaches to medical anthropol- ogy: {1] biological, (2] ecological, [3] ethnomedical, {4} critical, and [5} applied. The first two of these ap- proaches focus on the interaction of humans and their 12 Understanding Medical Anthropology environment from a biosocial perspective, that is, with a focus on the interaction betWeen biological and health questions and socioEConomic and demographic factors. The other three approaches emphasize the in- fluence of culture (the patterns of thought and behav- i0r characteristic of a group). All five approaches in medical anthropology share four essential premises: first, that illness and heating are basic human experiences that are best understood holistically in the complex and Varied interactions be tween human biology and culture; second, that dis- ease is an aspect of human environments influenced by culturally specific behaviors and sociopolitical cir- cumstances; third, that the human body and symp- toms are interpreted through cultural filters of beliefs and epistemological assumptions; and fourth, that cul- tural aspects of healing systems have important prag- matic consequences for the acceptability, efficacy, and improvement of health care in human Societies. Biological Approaches Much of the research in biological anthropology con- cerns important is3ues of human health and illness and therefore often intersects with the domains of medical anthropology. Many contributions of biologi— cal anthropologists help to explain the relationships betWeen evolutionary processes, human genetic varia- tion, and the different ways that humans are some- times susceptible, and other times resistant, to disease and other environmental streSSDrs. The evolution of disease in ancient human populations helps us to bet- ter understand current health trends. For example, the recent global trend of emerging and reemerging infec— tious diseases, such as tuberculosis and AIDS, is inflw enced by forces of natural and cultural selection that have been present throughout modern human evolu- tion. During the time of the Paleolithic, early human populations lived in small bands as nomadic hunters and gatherers. The low population densities during this period would not have supported the acute in- fectious diseases found today [Hart 1983); instead, chronic parasitic and arthropod-borne diseases Were more prevalent (Klilrs 1983; Lambrecht 1964). The shift toward sedentary living patterns and subsistence based on plant and animal domestication, sometimes called the Neolithic Revolution, had a pro— found effect on human health. Skeletal evidence from populations undergoing this transition indicates an overall deterioration in health consistent with the known relationship between infectious disease and malnutrition (Pelletier et al. 1993). These emerging in- fections have been attributed to increasing population density, SOCial stratification, decreased nutritional va— riety, water and sanitation problems, and close contact- with domesticated animals (Cockburn 197]; Feuneej 1970). These changes had a disproportionate impact. on women, young children, the elderly, and the" emerging underclass, who were most susceptible to: infections in socially stratified societies (Cohen and Armelagos 1984). A more recent threat to human health has come from chronic degenerative conditions. These so—called diseases of civilization—such as heart disease, dire betes, and cancer—wire the leading causes of adult mon- tality throughout the world today. Many of these diSeases share common etiological factors related to human adaptation over the last 100,000 years. For ex- ample, obesity and high cousumption of refined carbo- hydrates and fats are related to increased incidence of heart disease and diabetes. Human Susceptibility to ex- cessive amounts of these substances can be explained by the evolution of human metabolism throughout millions of years of seasonal food shortages and diets low in fat (Eaton, Shostak, and Konner 1988). A related theory of "thrifty genes" has been pro posed to explain relatively shorter term evolutionary changes that account for genetic Variation in the sus— ceptibility to chronic diseases among different content- porary populations (Neel 1982). For example, certain Native American and other recently acculturated pop- ulations have significantly higher prevalences of adult- onset diabetes and hypertension in comparison to populations that have been subsisting on high calorie and fatty diets for many generations. The thrifty gene hypothesis proposes that the difference in susceptibil- ity to chronic diseases in these populations is related to the degree of genetic adaptiveness to changes in diet and activity that have occurred in recent human his- tory [see selection 5 by Ritenbaugh and Goodby]. In other Words, during feast or famine times in the past, genes affecting insulin physiology were selected for, which allowed people to adapt to irregular food sup ply,- some populations may have been forced through an evolutionary bottleneck of natural selection result« ing in higher gene frequencies of this particular adap— tation. In the context of modern diets, however, these genes add to the burden of chronic disease. As with infectious disease, variation in human susceptibility to chronic diseases cannot be accounted for by genes atone. Environmental and SOCiOCultural factors play a major role as well. Here, human phys— iological measurements have demonstrated the im- pact of sociocultural conditions on human health. For example, a recent anthropological study of African Americans suggests that the psychological stress related to racial discrimination may contribute to higher prevalences of hypertension in these popula- tions (Dressler 1993). Some biological contributions to medical anthro- pology actually critique the misapplication of biologi- ml concepts. During the late nineteenth century, measurements of cranial size were taken of Jewish and southern European immigrants to the United States and compared with Anglo-American residents. The difference in cranial size between these populations Was used to support a theory of racial hierarchy based on hereditary differences in brain size. By careful com- parisons between first- and second-generation groups from these immigrant populations, Franz Boas was able to demonstrate that these differences were attrib- utable to environmental influences on body size (Boas 1940). Subsequent analyses have discredited previous studies relating measurements of intelligence to those of cranial capacity (Gould 1981), and categories of human races have been shown to have little validity in the study of human variation. In 1980, an economist put forward a hypothesis that children suffering from mild to moderate malnu- trition (MMM) were positively adapted to their cir- cumstances by conserving growth in order to maintain an equilibrium of body functioning. These children Were not considered impaired aside from diminished growth and were therefore ”small but healthy." This same paper recommended that aid programs restrict food distribution to children who were actually starv- ing (Seckler 1982). However, anthropological studies have shown that MMM children are not healthy at all. They suffer from increased infections, decreased cog— nitive development, and decreased fertility later in life (Martorell 1989). This information is very important as it can influence health policy affecting the lives of mil- lions of children. Finally, biological anthropologists provide impor- tant information regarding the ethnopharmacological aspects of traditional medical systems. Nina Etkin de- fines ethnopharmacology as “the study of indigenous medicines that connects the ethnography of health and healing to the physical composition of medicines and their physiologic actions” (Etkin 1996:151). Es— chewing biological reductionism, she asserts that ethnopharmacologists consider not only the physio- logical properties of plant substances but also issues related to their selection, preparation, and intended uses within particular social settings and broader bio- cultural frameworks. Ecological Approaches Ecology refers to the relationships between organisms and their total environment. Within medical anthro- pology, the ecological perspective has three major premises. First, the interdependent interactions of Introduction to the Fields of Medical Anthropology 13 plants, animals, and natural resources comprise an “ecosystem” with characteristics that transcend its component parts. Second, the common goal of the species within an ecosystem is homeostasis: a balance between environmental degradation and the survival of living populations. In this homeostatic system, in- fectious disease agents (pathogens) and their human hosts are understood to exist in a dynamic adaptive tension that strives toward a relatively stable balance between pathogens and human responses. Third, modern human adaptations include cultural and tech- nological innovations that can dramatically alter the homeostatic relationship between host and disease, occasionally creating severe ecological imbalances. In some cases, these imbalances may benefit humans in the short term, decreasing the prevalence of a particu- lar disease in a population and improving human health. In other cases, homeostatic imbalances favor disease agents, providing an opportunity for diseases to reach epidemic proportions and dramatically in- crease human morbidity and mortality. Thus, an ecological approach to medical anthro- pology emphasizes that the total environment of the human species includes the products of large-scale human activity as well as ”natural” phenomena and that health is affected by all aspects of human ecology. The term medical ecology has been used to describe this approach as the intersection of culture, disease ecol- ogy, and medicine in the study of medical issues (McElroy and Townsend 1996). This approach can be further distinguished by two levels of analysis. At the microleve], cultural ecology examines how cultural beliefs and practices shape human behavior, such as sexuality and residence patterns, which in turn alter the ecological relationship between host and pathogen. At the macrolevel, political ecology examines the historical interactions of human groups and the ef- fects of political conflicts, migration, and global re- source inequality on disease ecology...
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