ANTH 227 (1-2) Illness & Sickness PDF

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Department of Anthropology McGill University Fall 2019 Introduction to Medical Anthropology ANTH 227 Stewart Medical Building, Room S1-4 Professor Sandra Teresa Hyde, [email protected] Leacock Building, Room 818, 855 Rue Sherbrooke Ouest Wednesday, 14h00 – 16h00 I.Medical Anthropology: History & Scope 10.09 Session 3: Illness & Sickness (1) Gordon, Deborah R. 1988 “Tenacious Assumptions of Western Medicine” in Lock and Gordon, (eds), Biomedicine Examined (pp. 19-56) MC "While biomedicine has successfully created and hoarded a body of technical knowledge to call its own, its knowledge and practices draw upon a background of tacit understandings that extend far beyond medical boundaries." • "The biological reductionism by which modem medicine is frequently characterized is more theoretical than actual; in its effects, biomedicine speaks beyond its explicit reductionist reference through the implicit ways it teaches us to interpret ourselves, our world, and the relationships between humans, nature, self, and society. It draws upon and projects cosmology (ways of ordering the world), ontology (assumptions about reality and being), epistemology (assumptions about knowledge and truth), understandings of personhood, society, morality, and religion (what is sacred and profane). Although biomedicine both constitutes and is constituted by society, this interdependency is nevertheless denied by biomedical theory and ideology which claim neutrality and universality." • Mirroring this ideology, social and historical studies traditionally tend to illustrate western medicine as the universal constant from which all other healthcare systems are established in fundamental principles. But as scientific discoveries break apart absolute truths of biomedicine, so does western medicine in increasingly being understood as one of many medicines. • "A growing body of literature demonstrates how biomedical knowledge and practices are eminently and irreducibly social and cultural." • "These studies reveal more and more how biomedicine evolves through social choices rather than natural inevitability." • "For despite many significant recent changes -- such as greater attention to patients' experiences, the whole life cycle, uncertainty and probability theory, a multi-causal view of disease, and greater partnership with patients -- many important approaches remain the same [in the practices of biomedicine]." • "Clearly the tenacity of biomedical assumptions and practices derives from numerous sources - the efficacy of much of medical practice, the extensive web of institutions, the political, economic and personal investments in the current model and the successful response of many physicians to criticism." This text aims to consider "the background of biomedicine primarily in terms of two major western traditions - "naturalism" (usually referred to in the literature as "science") and "individualism" a complex of values and assumptions asserting the primacy of the individual and of individual freedom." I.The 'Autonomy of Nature'

"Naturalism is founded on a number of important distinctions that assert the autonomy of "nature" from the "supernatural," from human consciousness, from "culture," "society," "morality," "psychology," and particular time and space." (i) Nature is Distinctive from the 'Supernatural': Matter is Opposed to Spirit. "In contrast to the somewhat capricious supernatural world, nature is considered to be orderly, lawful, and therefore predictable." • "Medicine repeats this claim of autonomy from religion, regarding illness as distinct from "misfortune" or divine punishment and disease not as sin but as mechanism." (ii) Nature is Autonomous from Human Consciousness "Similarly medicine distinguishes between "signs," objective indications in the patient's body, and "symptoms," the patient's complaints. Medical social scientists distinguish between "disease," biological abnormality, and "illness," the patient's experience. Health or illness is defined more through objective data offered by the body than the experience of the patient. They are defined as separate from the individual." • "Human meaning is subjective in the naturalist understanding." (iii) Atomism: The Part is Independent of and Primordial to the Whole "Atomism of many sorts prevails in medicine: diseases are considered to have an identity separate from their specific hosts and are located and treated in the "atom" of society." • Naturalism is characterized by a unitary ontology. (iv) Nature is Separate from Culture "The cultural dimensions in medicine are usually seen to be restricted to the superficial, to apply to patients' behavior and understandings, to exist primarily in "others" beliefs." (vi) Nature is Autonomous From Society "What is regarded as the truth (knowledge) is considered to be autonomous, separate from power." ; beyond the sphere of influence. (vii) Nature and Truth is Universal, Autonomous from Time or Space "Nature is a reality that is omnipresent, universal, eternal, and absolute." (2) Arthur Kleinman, 1973 (reprint 2010). “Medicine’s Symbolic Reality: On a Central Problem in the Philosophy of Medicine,” MAR Pp. 86-90. "medicine deals with two kinds of reality, 'scientific' and 'ordinary'; or put differently, it is both a biophysical and a human science." -Concerning itself with the study of disease, its biological substratum, and its determinants, effects, and control. • "Often the biophysical root for a general critique of the whole of medicine [, the precise definition of abstractions such as health and illness, make for] a largely unprofitable endeavour which has characterized much of what could be called the philosophy of medicine. Only recently has there been more than superficial and somewhat embarrassed attention given to medicine as a socio-cultural system, as a practice and a human reality. Obviously, it is this archaic root of medicine which [makes for] crucial, social and individual aspects of language." • Presenting a challenge ahead of modern theoretical structures of biomedical science - a structure based largely upon knowledge limited to medicine's biophysical reality. "Recently (..) entrenched medical empiricism for medicine as a human science [has been] stretched and forced to fit an elusive medical subject." The socio-cultural approach to medicine has redefined our understanding of medicine, and "we find the traditional dichotomy in scientific medicine undergoing marked change." Language is a mediating reality.

"These historical, anthropological, sociological, psychiatric, and medical field studies have begun to unify their interests around a common theme, the comparative study of medical systems: that is, appreciation for the structure and significance of medicine as a health care system in different cultural settings and historical contexts." "No matter what the perspective — diachronic or synchronic — medicine is always found to constitute a system. The medical system is an ordered, coherent body of ideas, values, and practices embedded in a given cultural context from which it derives its signification." • "The medical system forms an indissoluble and hierarchical whole in which healing acts are closely linked with ideas about disease causation and models for classifying disease. (..) Healing is not the outcome of diagnostic act, but the healing function is active from the outset in the way illness is perceived and the experience of illness organized." "Disease occurs as a natural process. It works upon biophysical reality and/or psychological processes (..) but the experience of illness is a cultural or symbolic reality. The experience of illness involves feelings, ideas, values, language and non-verbal communication, symbolic behaviour, and the like. What is perceived as illness in one culture may not be perceived in another. (..) Psychosomatic pathology has been well described, but we are just learning about socio-somatic pathology." "Classification of disease is, in fact, the first therapeutic act. Classificatory schemes are intended to domesticate and make known a 'wild' and unknown phenomenon, which threatens the very idea of social order and personal stability, and transform it into something known, named, and thus manageable. In this sense, ideas of witchcraft as a random and highly malignant explanatory model are not at all badly matched with diseases such as endemic malaria and the pneumonia-diarrheal complex of disorders of infants, which are random and highly malignant. Some diagnostic systems are entirely symbolic, relating specific illnesses to specific therapies." "The healing dialectic has been considered effective when the bonds between the sick individual and the group, weakened by disease, are strengthened, social values re-affirmed, and the notion of social order no longer threatened by illness or death; or when the experience of illness has been made meaningful, personal suffering shared, and the individual leaves the marginal situation of sickness and has been reincorporated in health or even death back into the social body. Healing is the endpoint of the medical system, the successful reordering and organizing of the disease experience and, where possible, its control." "Within the form of symbolic reality structured by the system of medical care, healing has a position situated at the strategic interface between the cultural systems, the system of social relation, and the individual. Healing occurs along a symbolic pathway of words, feelings, values, expectations, beliefs, and the like which connect cultural events and forms with affective and physiological processes. Psychosomatic and socio-somatic correlates are implicit in all medical healing relationships. (..) We reiterate that this symbolic structure is present not only in therapy, where it plays a patent role of mediation, but also in the social construction and cognitive mapping of illness," "What are the real health needs of individuals, communities, or populations? What are the purposes of clinical care? What is the nature of clinical interpretation and knowledge? What is medical healing? How are medical ideologies constructed and how do they relate to political ideologies and social phenomena? How are social sources of power tapped for explanation and therapy? These questions are of particular significance for developing countries, where health structures are being remade." "Our general medical model confronts the tremendous distortion and abridgement of technical purposes in contemporary technological medicine: technical control has been accompanied by the separation of efficacy from meaning, progressive dehumanization of the healing function, (..)

ironically, medicine, one of the first human sciences and in some ways a paradigmatic one, is in the tragic process of emancipating itself, via technicalization of all of its problems, from this vital source." Tuesday, September 10 Lecture 3: The Philosophical Assumptions of Biomedicine I.Review of Brown's six sub-disciplines of Medical Anthropology. The definition of medical anthropology according to the Society for Medical Anthropology (2017): •

Medical anthropology is a subfield of anthropology that draws upon social, cultural, biological and linguistic anthropology to better understand those factors which influence health and well-being (broadly defined), the experience and the distribution of illness, the prevention and treatment of sickness, healing processes, the social relations of therapy management, and the cultural importance and utilization of pluralistic medical systems. It draws on many different theoretical approaches.

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Medical anthropology is as attentive to popular health culture as to bioscientific epidemiology, the social construction of knowledge and politics of science as scientific discovery and hypothesis testing.

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Medical anthropologists examine how the health of individuals, larger social formations, and the environment are affected by interrelationships between humans and other species; cultural norms and social institutions; micro and macro politics; and forces of globalization as each of these affects local worlds.

Emic: inside.; Etic: outside. Medicine as ideology Western medicine is just as much a part of the ideological apparatus of our social order. -Georg Lukacs. • Anthropologist Michael Taussig argues that scientific explanatory models, their practices and ceremonies are legitimized to achieve an ideological effect by reifying signs as dissocialized facts of nature. • E.g. ETOH consumption mirrors the cultural values of inebriation. i.Two early orientations in the field of Medical Anthropology a. Biological (biomedicine) and the Anthropology of disease (biological anthropology). b. Sociocultural (empiricist orientations) and the Non-empiricist (illness narratives). i. Empiricist orientations : • Medical sociology: get facts right, then figure out the puzzle • Non-empiricist: the facts and the anthropologist's ideas themselves are also subject to particular historical and social norms. • Integrative medicine i. •

Non-empiricist epistemologies : Traditional anthropology - study sickness, healing, health, illness as in studying beliefs and practices of exotic peoples.

Anthropology of Illness

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Understanding illness in order to improve disease outcomes; - Learning people's explanatory models in order to cure them, e.g. Intravenous drips in China. - In other words, it has a clinical outcome, e.g. Physicians have attempted to reorient their understandings of fatigue. Sickness is a process for socializing disease and illness : (1) Plural medical systems - who gets what illness depends on the diagnostician, the matter of belief in pseudosciences determines whether the course of treatment will take on aggressive operation or the manipulations of a chiropractor or of a traditional Chinese medicine practitioner. (2) Physicians have a right to diagnose, to translate signs and symptoms into illness. Biomedicine's Epistemology : Biomedicine draws on (1) cosmology, a way of ordering the world; (2) ontology, assumptions about reality and being; (3) Epistemology, assumptions of knowledge and truth making; and (4) definitions of culture, personhood, society, morality and religion. Two ways of thinking about biomedicine :

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According to medical anthropologist Deborah Gordon (1988), biomedicine does two interesting things: (1) It absorbs folk traditions and vise versa, e.g. the use of leaches in medicine; (2) It has very simplistic key assumptions, e.g. gender dimorphism. Biomedical knowledge Similar to Evans-Pritchard's study of the Azande, biomedicine has its own rational system, that it is culturally and historically specific. E.g. it is gendered. In biomedicine, the patient is our gaze - here, we turn out gaze back on biomedicine just as Dr. Lock suggests in her article, 'Seeing like an Anthropologist'. I.Introduction to philosophical foundations and assumptions in biomedicine.

In 'Biomedicine Examined', Deborah Gordon (1988) writes that biomedicine draws on key philosophical concepts divided into two grand assumptions. (1) The Autonomy of Nature - 7 assumptions.; (2) The Autonomy of the Individual - 3 assumptions. Assumptions made about the autonomy of nature : i.Naturalism; Autonomy of nature over the supernatural and separation of ontology (reality) and of epistemology (knowledge). Nature as something visible, measurable. ii.Nature is autonomous from human consciousness; Reality exists and is observable, distinct from the observer. E.g. Unlike Cree notions of health, ‘being alive well’; if the land is healthy, the people can be healthy – not indicated by blood sugar, etc. Distinction of signs (objective indicators of the patient's disease) and of symptoms (bodily complaints, feelings about one's illness). iii.Atomism; The part is independent of the whole, disease have separate entities from their host. Viruses have nothing to do with the individual body, this is in opposition to the Azande illness

epistemologies. Treat autonomous units of the body separately - the lungs, heart, genitals, throat for different medical specialists. iv.Nature is separate from culture; Nature is characterized by a unitary ontology. It is not only separate from culture, but prior to it. In biology as in medicine, culture is approached as a code, similarly to DNA. a. E.g. a unitary reality and interpretation, ethnolinguistic minority group assumptions and prejudice relating back to sex work v.Natural separate from morality; Nature or naturalism is indifferent to moral good. Disease processes are indifferent to the value of the patient who experiences the illness. a. E.g. In traditional Chinese medicine, it is the patient who is crucial to the diagnosis, for considerations of socioeconomic origins. vi.Nature is autonomous from society; Unlike philosopher Michel Foucault, truth is considered separate from power. The natural is beyond the sphere of social influence. a. E.g. gender differences not learned, but natural. Disease outcomes for different social classes seen as individual problems, not as collective responsibilities. vii.Nature & truth is universal and separate from time and space; Western science believes that time does not enter the equation. The doctor tells the truth about the disease, as if there was only one truth. a. E.g. challenged in “Tenacious Assumptions of Western Medicine”; Cheryl Chase activist (intersex children); stepping into the realm of medicine Assumptions made on the philosophy of possessive individualism : i.Autonomy of naturalist rationality; Naturalist truth is not supernatural or spiritual, but a matter of truth. Separation between nature and culture. Rationality is separate from morality. Division of subjectivity and objectivity. ii.Autonomy of the human being; Sovereign individual. The human being is treated as a single unit, as we define, for example, the fetus as separate from the womb or its carrying mother in comparison to Indian or Chinese understanding that they are one. Individual is prior to society and culture. Each individual possesses their own body and space. iii.Autonomy of morality; Defend the sovereign of the individual body. E.g. Bioethics - advance directives in hospitals, protects the individual from the wishes of the family and of the medical practitioner. Naturalism as the bedrock of morality, to call something natural is not as appreciated as calling something rational. Deborah Gordon argues, when we study biomedicine, to be weary of the blame of biomedicine on its short comings, to do so is to reproduce its ideology, that it is autonomous from society including from its medical practitioners. If we choose to call certain practices of biomedicine dehumanizing, we must examine what we define as being humane in Western societies. What might have changed since the publication of Gordon's philosophical assumptions on the autonomy of nature and of the individual in 1988, and what defies the chronological theory of time in its assumptions of biomedicine?...