A Companion to Medical Anthropology. Группа авторов
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this omission in a 1974 commentary contrasting medical anthropology and sociology. Hasan argued that, rather than focusing on the culture–society distinction, which Foster did (not uniquely: see, for example, Dingwall 1980; Paul 1963), Foster should have focused on anthropology’s holistic approach to “man” (sic). “Man” is the major focus of medicine, too, wrote Hasan; this, he argued, gives anthropology and medicine much more in common than anthropology and sociology. Hasan provided example after example of the role that biologists and “medical men” played in anthropology’s development, followed by more examples of physical/biological anthropologists at work within medicine.
It probably did not hurt Hasan’s case that physical anthropology had by this time become more biologically oriented, not only in terms of data favored but also in terms of questions asked. In any event, Foster was responsive: In revising the offending 1974 commentary for use in the first medical anthropology textbook, published in 1978 (twenty-plus years after Benjamin Paul edited the first casebook (1955)), Foster and his co-author Barbara Anderson took a more biologically informed position, even including a reference to Hasan.
Others, too, provided correctives. Take, for example, Medical Anthropology, which Gretel and Pertti (Bert) Pelto founded in 1977 (SMA was still at that time struggling to some degree with the generalist–specialist question and so only wanted a newsletter). The Peltos were committed to including a biological perspective, as reflected not only in the journal’s content but also in its editorial board (Gretel Pelto, Personal communication, December 18, 2008, and January 13, 2009). Also, a key teaching text first published in 1978 specifically highlighted biological and ecological perspectives (McElroy and Townsend 2004); and a 1980 textbook that took a biocultural approach proclaimed in its subtitle to be “expanding views of medical anthropology” (Moore et al. 1980).
Yet, despite these correctives, science itself had by the 1980s come under scrutiny. The scientific method – the paradigm that biological anthropologists most often worked within – was increasingly seen as an “establishment” tool. Worse, evolutionary biology was maligned by some because of its potential use by racists (D’Andrade 2000, p. 223).
Finding itself on the “wrong” side of the culture–biology divide thrown up and vilified by vocal and morally accusatory opponents of positivism, biological anthropology received less than its fair share of recognition. This is not to say that biological medical anthropology did not take place; indeed it did, and continues to do, in ways that have contributed greatly to advancing our biocultural understanding regarding, for example, high-altitude adaptations, lactose tolerance, breastfeeding, stress, substance use, and global disease threats as well as to building a more theory-driven epidemiology and a culturally informed epigenetics. However, such efforts were (and are) often rewarded more richly outside of medical anthropology than in it.
Keeping the Tent Big
Various answers to the cri de coeur notwithstanding, Christie Kiefer’s contribution to the definitional debate (1975) bemoaned the “irritating question” to begin with (p. 1). Kiefer worried that in trying to delimit the subfield we may cause it to wither on the vine. The quality that makes the field helpful and interesting, he said, is its very disorderliness. This only makes us “seasick” he says because “medicine thrives on orthodoxy” (p. 1); the quest to define medical anthropology reflects, he suggested, an infection with medicine’s quest for “exactitude” (p. 2). Contrasting “certainty on the one hand and meaningfulness on the other,” Kiefer argued that we should “stoutly insist” on keeping medical anthropology undefined and indeterminate.
While SMA and some of the cognate associations that emerged globally have offered various concrete definitions of the subfield’s focal concerns, and medical anthropology does have a sociocultural emphasis overall, it has matured into an inclusive arena for scholarship concerning health as a biocultural phenomenon. Furthermore, as Hsu and Potter argue, the field is “polymorph”: there are no “distinctive national styles of doing medical anthropology; diversity prevails even within a single language community [and] trans-Atlantic exchanges have always drawn on a serious engagement with research in Asia, Africa, Meso- and South America” (2012, p. 1). Likewise, Metzner and Warren position medical anthropology as a “global discipline” (2018, p. 551).
That said, many today (Metzner and Warren included) advocate increased postcolonial perspective in the discipline, particularly when working in regions that have served as research laboratories for the Global North. Mvetumbo, Oware, Yotebieng, and Syvertsen further the call for decolonization, urging colleagues working in the Global South to reduce dependency on theory generated in and for the Global North – dependency supported not just by the latter’s intellectual hegemony but by related structural factors in the Global South that make it “a challenge knowing what other researchers in our own space or country are doing” (2020).
FOUDATIONAL CONCEPTS
From Health to Sickness
Most early medical anthropologists defined health (and most still do) as a broad construct, consisting of physical, psychological, and social well-being, including role functionality. What was novel in emerging medical anthropology, however, was a distinction increasingly drawn between “disease” – biomedically measurable lesions or anatomical or physiological irregularities – and “illness” – the culturally structured, personal experience of being unwell, which entails the experience of suffering.
The effort to hash out such distinctions reflected the prioritization of a meaning-centered focus and growing use of the emic-etic framework, absorbed through linguistics. “Etic” constructs (such as the temperature represented on a thermometer) are meant to be universally applicable or culture-free. The problematic assumption of one true empirical reality notwithstanding, etic constructs are opposed to “emic” ideas: ideas (and note the implication there) that cultural insiders have about themselves and their worlds. “Disease” was an etic, universally measurable entity. “Illness” (the emic perception) was not. As such, illness could refer to a variety of conditions cross-culturally, some of which might not exist in other cultural worlds.
Thinkers of the day soon realized that, however helpful, this disease-illness dichotomy recapitulates the mind-body dichotomy that, even then, some criticized biomedicine for trafficking in. This view took fuel in part from the bourgeoning rift between positivist-minded and interpretive or hermeneutic scholars – a rift often termed the “two cultures” or science-humanities split, a la Charles Percy Snow (1993 [1959]). The problem was that while disease, as the dichotomy defined it, was bodily, illness was conversely mental: Disease was thus attributed a real, concrete, scientific factuality or objectivity that illness, as a subjective category, could be denied (see Hahn 1984).
A second criticism of the dichotomy hinged on the fact that both disease and illness were individual attributes. The term illness referred, as it still often does, to an individual’s social relations, but generally only insofar as these caused the illness (e.g., when an offended party placed a hex) or as the illness leaves the individual unable to fulfill social or role obligations. Some scholars working in the 1970s wanted to link suffering more palpably to the social order by examining how macro-social forces, processes, and events (such as capitalist trade arrangements) could culminate in public health problems and poorly functioning health systems (again, see Hahn 1984). Some recommended using the term “sickness” when highlighting larger social processes (see Frankenberg and Leeson 1976).
Medical Systems?
This definitional work occurred hand in hand with efforts to disassemble then-prevalent understandings regarding the nature of cultural systems. For instance, Arthur Kleinman’s 1978 contribution to the “What is Medical Anthropology?” conundrum accused his predecessors of reductionism. Kleinman denigrated the era of “sweeping comparative generalizations” and “ideal-type categorization,” which he painted as “superficial” and as couched at “too abstract a level to be relevant” (pp. 661–662). He argued instead for a medical anthropology that can “examine health and sickness beliefs as they are used in the usually exigent