A Companion to Medical Anthropology (Hardcover)

Chapter One

Elisa J. Sobo

Introduction

As Scotch noted back in 1963, "Medical scholars have literally for centuries been aware of the social dimensions of health and illness and have, in their research, focused on a variety of social and cultural variables, while anthropology has only lately indulged in similar research" (p.30). Many working outside of anthropology advocated early on for socio-culturally informed approaches, and called for changes in social structure, occupational expectations, and urban environments to defeat certain epidemics (e.g., Bernadine Ramazzini, Benjamin McCrady, Lous-René Villermé, Emil Chadwick, Lemuel Shattuck, Rudolph Virchow, Henry E. Sigerist, and Erwin H. Ackerknecht (Scotch 1963:30–31). If we consider the work of these forebears as well as varied anatomists, physiologists, geographers, etc., who shared early anthropologist's scholarly interest in the human condition, it becomes clear that medical anthropology exists as the outcome of many lines of intertwined inquiry into humankind, some of which emerged in different fields independently – and some of which provoked further interest in health in anthropology proper.

A crucial example of this came with the end of World War II, when medical anthropology received impetus and support from foundation- and government-funded applied work in the arena of international and public health. Data collected by anthropologists in earlier times for simple descriptive purposes proved invaluable; anthropologists helped ensure that social and cultural aspects of health and healing were taken into account in ways that promoted program success. As Foster puts it, this marked a turnaround in which the increased value of ethnological data was driven not by changes on the inside of anthropology but rather by outside interests – those of the international and public health markets (Foster 1974). Anthropology or, more specifically, ethnology, now had direct "technical" (Scotch 1963) relevance.

Indeed, the first review of the field emphasized its practical utility. It was titled, "Applied Anthropology in Medicine" (Caudill 1953). In 1959, an article by James Roney carried the shorter phrase, "Medical Anthropology," in its title (Roney 1959; see also Weidman 1986:116). But what did this label describe? What tensions did it encompass?

Building on previous historical reviews (including Browner 1997; Claudill 1953; Colson and Selby 1974; Fabrega 1971; Foster 1974; Foster and Anderson 1978; Good 1994; Hasan 1975; Lock and Nichter 2002; McElroy 1986; Polgar 1962; Scotch 1963; Sobo 2004; Todd and Ruffini 1979; Weidman 1986), this chapter examines the historical context of the struggle to define the field. In the 1960s and 1970s, debate centered on then-prominent applied-theoretical and generalist-specialist divides. The contrast between physical (later, biological) and cultural perspectives also made its mark. Later developments related to the evolving definition of culture, the influence of critical (and later synthetic) thinking on the subdiscipline, and the role of extra-disciplinary interaction.

Medical Anthropology Takes Shape

Application or theory?

Good refers to medical anthropology in the 1960s as a "practice discipline" (1994:4), dedicated to the service of improving public health of societies in economically poor nations. Indeed, initial efforts at organizing a medical anthropology interest group – diligently fostered by Hazel Weidman – resulted in an invitation from the Society for Applied Anthropology or SfAA to affiliate in 1968. A full account of this and subsequent developments is offered in Weidman's important historical review (Weidman 1986).

Although the invitation was accepted by the fledgling medical anthropology community (then called the Group for Medical Anthropology or GMA) as a practical solution to the challenges of maintaining cohesion, the endorsement of and by applied anthropology was "something of an embarrassment" to many (Good 1994:4). Even George Foster, a key founding figure, had to work through ambivalences here. "We were trained to despise applied anthropology," he once said; recalling that he did not join the SfAA until 1950; until then "I would have nothing of it" (Foster 2000, quoted in Kemper 2006).

As Scotch reported in 1963, there were those who felt that because of its practical bent, "the quality of literature in this area is not always impressive ... It is superficial, impressionistic, and nontheoretical" (Scotch 1963:32). Some felt that those who elected to engage in medical anthropology were "less rigorous than their more traditional-minded contemporaries" (p.33); they were denigrated as mere "technicians" (p.42).

Generalists or specialists? Apprehension also ran high over whether formally organizing as medical anthropologists would reinforce an "artificial area of study"; in support of this claim some pointed to "the lack of systematic growth and the failure to produce a body of theory" (Scotch 1963). Some feared that formal organizing might "prove detrimental to the development of theory in anthropology" as it would force the fragmentation of the field (Browner 1997:62).

The American Anthropological Association (AAA) was at that time experiencing growing pains. Its Committee on Organization described "financial and organizational disarray" in 1968 (Anthropology Newsletter 9(7)) and noted that while anthropologists in general desired to "retain an integrated professional identity" the profession also faced strong "fissiparous tendencies" (as cited in Weidman 1986:116). Some medical anthropologists felt, accordingly, that focusing on developing the group's then-nascent newsletter (Medical Anthropology Newsletter, or MAN) would be better than assembling as if a faction. This might be termed the "function but no structure" constituency (Weidman 1986:119).

It is helpful here to recall that the AAA did not, at the time, have "sections" as we know them today. Many members believed that research should contribute to anthropology in general, not just some special subgroup. Arthur Rubel, for instance, until his death "would not be pigeonholed as a medical anthropologist ... for he always saw health/medical phenomena as human behavior to be understood as anthropologists understood other forms of human behavior" (Cancian et al. 2001).

An uneasy resolution

Partially due to the fear that affiliating with the SfAA, which was independent of the AAA, might distance medical anthropologists from the parent discipline unduly, and because to incorporate independently in another form would be financially costly (Browner 1997), the GMA continued to push the AAA to create a mechanism for organizing as an AAA subgroup. Eventually, largely due to the GMA's own organizing efforts, this came to pass (see Weidman 1986:121,124) and the SMA received formal status as an AAA affiliate in 1972 (Society for Medical Anthropology 1975).

This move firmly anchored the group within academic anthropology. It also allowed the AAA some control over the shape that medical anthropology took, due to imposed bureaucratic imperatives. However, in part because those not interested in direct involvement in the application of their work tended purposefully not to identify with the group (cf. Good 1994:4), the influence of applied perspectives remained strong.

Many members retained an affiliation with the SfAA and Human Organization (the SfAA's journal) was a popular publication outlet for medical anthropology. So was Social Science and Medicine, founded in 1967. Many SMA members were employed in schools of medicine, nursing, or public health. Others worked directly in the international and public health fields. From the viewpoint of those seeking practical solutions to specific health problems, theory seemed abstract, obstructive, and sometimes even irrelevant. The authority of biomedical clinical culture, where curative work and saving lives takes precedence, was manifest (Singer 1992a).

What's in a name? There are still those anthropologists who prefer to self-identify as anthropologists interested in health rather than as "medical" anthropologists. In some cases they cling to the old-fashioned academic belief that applied work is infra dig. In others, their concern relates to the desire, noted above, to advance the larger discipline or, to paraphrase George Stocking, to guard the sacred bundle (1988). A statement issued by the SMA in 1981 defining medical anthropology addressed this, asserting unambiguously: "Medical anthropology is not a discipline separate from anthropology" (p.8).

But this did not offset objections related to the narrow technical or Western definition of the term medical, noted for instance at the GMA's 1968 organizational meeting. Madeline Leininger suggested the alternate "health anthropology" (which some prefer today as well); "lively discussion followed" (Weidman 1986:119). It is not just that medical leaves out nurses and members of the allied health professions. Narrowly defined, it refers only to biomedicine. The appellation "medical anthropology" thus has been seen by some as suggesting a biomedical gold standard against which to measure all other healing or curing practices. Other concerns have been the implied focus on pathology and the implicit devaluation of interpretive ethnographic methods and of studies of non-"medical" healing.

Nonetheless, many self-identified medical anthropologists' work has nothing to do with "medicine" as it is technically defined. For them, and even for many anthropologists working in biomedical settings, the term medicine is generic. It is understood to refer to any system of curing or healing, no matter what specific techniques are involved.

Cultural Interests Assume the Lead

For better or worse, the subfield moved forward as "medical anthropology." The SMA's incorporation in the early 1970s seemed to spur a number of "What is Medical Anthropology?" essays. As Howard Stein noted in 1980, "I have heard the cri du coeur, `What is medical anthropology?' (MA) as a recurrent, quasi-ritualized annual event" (p.18). While in its initial phase, generalist-specialist and applied-theoretical tensions had prominence, in this phase the tension between cultural and biological priorities took precedence.

A felt need

Despite physical (now `biological') anthropology's contribution to the subfield's growth, beginning with studies of hominid paleontology, anthropometry, and the geographic distribution of certain traits, and later with studies of a more ecological and adaptationist perspective, medical anthropology's official emergence was largely fostered by culturally oriented scholars, mobilized by their new-found role in international and public health (see Paul 1963; Polgar 1962). This included those affiliated with the "culture and personality" school (e.g., Caudill, who wrote the aforementioned 1953 review). Thus, Colson and Selby's (Colson and Selby 1974) "annual review" of the field's progress (1974) gives much space over to work on "social pathologies" (p.253), such as drug and alcohol use or addiction, and issues relevant to "ethnopsychiatry" (p.248). A similar pattern infused the earlier review by Fabrega (Fabrega 1971), who noted "the affinity that `medical anthropology' has always had with psychiatry" (p.186). Even Scotch's 1963 review, organized around the theoryapplication question, reveals the psychological influence, for instance discussing work relating "modal personality" to certain forms of mental illness (p.43). This distinct focus on "nurture" over "nature" reflects the strength of cultural determinism in early 20th century US anthropology.

The strong presence of cultural anthropologists had a sizeable impact on early efforts to organize the medical subfield. For one thing, while the seven goals drafted by the initial steering committee of the emerging medical anthropology network did refer to "social and cultural aspects of health, illness, and systems of medical care" (Weidman 1986:118), biological aspects received no mention. Further, all of the goals stressed communication (Browner 1997). While physical anthropologists had been working and publishing in and with medicine since anthropology's inception, cultural anthropologists as a whole were still at that time rather new to it and seemed uncomfortable in that milieu. In comparison to their physical/biological counterparts, they generally lacked easy access to it anyhow and could claim little authority within it. Cultural scholars' desire for increased intellectual discourse provided great organizing momentum.

Biological voices In a 1975 "What is Medical Anthropology" commentary published in the SMA's newsletter, MAN, Khwaja A. Hasan, who (along with several others) actually used the phrase "medical anthropology" in print prior to those generally credited for inventing it, took the emerging subfield in general and, more specifically, George Foster himself, to task for neglecting the biological side of the anthropological equation (Hasan 1975). Foster made this omission in a 1974 commentary (also published in MAN) contrasting medical anthropology and sociology (Foster 1974).

Hasan argued that, rather than focusing on the culture–society distinction, which Foster did (as others have: e.g., Paul 1963), Foster should have depicted anthropology as the study of "man" (sic). "Man" is the major focus of medicine, too, wrote Hasan; this, he said, gives anthropology and medicine much more in common than anthropology and sociology. Example after example of the role that biologists and "medical men" played in anthropology's development are 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 types accessed but also in terms of questions asked. In any event, Foster was quite responsive to Hasan's argument: When Foster revised the offending 1974 commentary for use in the first medical anthropology textbook, published in 1978, he and his co-author Barbara Anderson took a more biologically informed position. They included also a reference to Hasan (Foster and Anderson 1978).

Others, too, provided correctives. A key teaching text also first published in 1978 specifically highlighted biological and ecological perspectives (McElroy and Townsend 2004); a 1980 textbook that took a biocultural approach proclaimed in its subtitle to be "expanding views of medical anthropology" (Moore et al. 1980).

Concurrently, while both the introductory undergraduate and graduate "model courses" prepared by Arthur Rubel and published in the newsletter MAN in 1977 and again as part of a "model course" collection (Todd and Ruffini 1979) to aid curricular development for the subfield were short on biology, it did gain representation in Model Course VIII, "Biomedical Anthropology." This course, prepared by Frederick Dunn, also laments the "limited attention" paid to biological concerns (p.95). Model Course IV, "Nutritional Anthropology" (by Cheryl Ritenbaugh) is quite biological. Having said that, nutritionally oriented anthropologists, who had a very active SMA special interest group from the start, did break away to establish their own AAA section in 1974.

Medical anthropology's initial culturalism was not so much, then, a prejudice against biological anthropology as it was a simple artifact of the professional activities of many of medical anthropology's organizationally active founders. And yet, despite the corrective directions taken in the mid-to-late 1970s, science itself had by that time come under scrutiny. The scientific method – the paradigm that biological anthropologists most often worked within – was increasingly seen by those who dominated the field not only as an "establishment" tool. Worse, evolutionary biology was maligned by some because of its potential use by racists (D'Andrade 2000:223).

Finding itself on the "wrong" side of the culture–biology divide that had been thrown up, and upstaged by vocal and morally accusatory opponents of positivism, biological anthropology received less than its fair share of recognition from some corners. 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, and HIV/AIDS as well as to building a more theory-driven epidemiology. However, such efforts were often rewarded more richly outside of medical anthropology than in it.

(Continues...)

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