When Biomedicine Meets Cultural Anthropology
A system ‘alone’ is unable to produce an explanation of itself, is incomplete and it needs the ‘other’ systems to gain a sufficient level of intelligibility” (1)
Since caregivers are often faced with the suffering of others, especially early in their careers, they may wonder whether enough is being done, and whether they are really taking care of the person in front of them. Inexperience, as well as the fear of failure may lead them to focus more on the disease than on the person.
What can I do to better understand my patients’ suffering?
This is the main question I would like to ask this young anthropologist. Herein are her answers to this and other questions I asked her in an attempt to explore and explain the boundaries where biomedical science and humanistic disciplines meet.
What is cultural anthropology?
Cultural anthropology is a discipline whose origins conventionally date back to the late eighteenth century (when Société des Observateurs de l’homme was founded in Paris) and that, with the publication of the first works by Malinowski and Radcliffe-Brown in the Twenties, saw the blossoming of its “classics”. Its aims are to study the dimensions of human sociality, and especially the variety and the diversity of cultures drawn from communities in different times and places.
What does “culture” mean?
The concept of “culture” is clearly central to this subject: “culture”, which has recently undergone continuous, critical re-elaboration, is described as being very close to the definition of cultural anthropology itself. Currently, we may define culture as “a fluid and shifting boundary set of manifestations and symbolic creative practices, related to social institutions and to interactive relationships that form the social fabric of a given human community”(2).
Can you explain it in other words? How can the society in which a subject lives influence his/her way of looking at the world, especially with regards to suffering?
Since the beginnings of cultural anthropology, its interest turned to how (practically and symbolically) members of human societies organise and confront life experiences, which then led anthropologists to study how different populations, especially those once considered “primitive”, manage the phenomena of disorder and suffering. The study by Evans-Pritchard among the Azande is emblematic, and the resulting publication dated 1937 is now considered the first text in medical anthropology (3).
From cultural to medical anthropology: what do these classifications mean? And what happened when anthropology met bioscience?
Medical anthropology (a particular area of cultural anthropology) initially involved heterogeneous phenomena ranging from the indigenous interpretations of the disorder to the links between culture and psyche, rituals and therapeutic healing; however, the encounter with biomedicine represented a turning point. Until then, in fact, allopathic medicine was not seen as comparable to other medical systems. On the contrary, it was considered a type of knowledge that could provide an empirical description of objective reality and, as such, it seemed to be a useful tool for the interpretation and evaluation of other models. Soon, however, this position was questioned. Kleinman, among others, noted that biomedicine, as well as systems developed elsewhere, provide an interpretation of reality (4).
What is the key point of the different way of looking at this issue?
Biomedical interpretation – as well as interpretations pertaining to other medical systems – is characterised by a particular way of looking at the world and at experiential phenomena, and it is the result of a peculiar historical process. It also uses certain patterns, cuts out certain perspectives and proposes specific value systems by excluding other possible representations of the phenomena that are being investigated.
Pain, suffering, sorrow: how can we enclose them in this model?
The biomedical model provides a specific interpretation of suffering (though hardly exhaustive of the many possibilities of interpretation), and therefore it sometimes contrasts with other models. This different way of seeing life can create communicative and relational barriers, thus leading to situations of non-compliance and to the lack of therapeutic efficacy.
How can I incorporate your message into my daily routine? How can I put it into practice?
This takes on great significance in clinical practice. Indeed, when a person is suffering he/she tries to weave a complex web of different cultural perspectives in an attempt to make sense of his/her suffering. In part, the subject appropriates him/herself of a biomedical prospective, but at the same time, popular representations, familiar conceptions and social experiences will superimpose, thus creating a particular horizon of meaning. The person then orients his practices in relation to this meaning, and either accepts – or does not accept – the solutions proposed by the therapists. This is why an analysis that takes into account the diverse cultural perspectives (among other things, in a social space traversed daily by multicultural trajectories) – will prove to be very useful.
In other words, from your point of view, anyone could live and interpret their disease in their own way by drawing from a web of social and culturally shared representations, is that right?
Yes, by simplifying the concept, we can say so. Consequently, understanding how the sick persons experience their own illness and how they represent it becomes crucial: which etiologies do they attribute the onset of symptoms to? How do they read them, and how do they live them? In other words, in which way are they able to render them intelligible when called to make sense of them?
Try to explain this to me. Why would it be so important?
An analysis of this kind is essential if we consider that symbolic representations are always intrinsically related to the practices enabled by individuals: depending on how a person interprets a phenomenon, we expect that he/she will act in a certain way and not in another. This is of great importance in case of a disorder because the interpretation a person gives to a phenomenon will influence the care that is provided, the health professionals themselves, and the solutions they propose. Therefore, the evolution of the disease itself will also prove to be very different, even compared with apparently similar physiological conditions.
Taking care of the socio-cultural dimension could therefore be very important: one might expect to detect any possible correlations between the clinical condition of the patients, some of the interpretative models they propose, and the ability to share such interpretations with the health care professionals. Mutual exchange of biomedical and non biomedical models – each willing to corrupt their own integrity – could also lead to the co-construction of a shared (and therefore more effective) therapy. Still, for the benefit of the patient, bringing the signs carried in the body into their own personal world view in order to acknowledge them as being more understandable, and therefore acceptable, may be a key point.
How can we collocate the signs (or the symptoms) within this model?
With regards to this concept, the theories regarding embodiment that were proposed in the late eighties in medical anthropology (5) emphasised that the symptoms (or their perpetuation despite treatment) express, through “body language”, a problematic relationship of the subject with the external environment. An environment in which (necessarily) other human beings live, in which they have their own way of relating and interacting i.e., the socio-cultural environment. In order to cure (or to take care of) a disorder, the social relations inscribed in it cannot be ignored: indeed, they might prove to be one of the causes supporting the affliction itself.
It is perhaps worth recalling a precious gift of anthropology, namely the recognition of the inherent “biological incompleteness of the human being” (6): by his own “nature”, man must make use of cultural and symbolic practices, as well as of a network of social relations in order to survive. His instinctual apparatus is not sufficiently defined, he is a “naturally” open entity – just an incomplete one – that society structures. The individual bases his existence on these social frames, and through them he is able to respond to adversity, including disorders and afflictions. The same health apparatus is a socio-cultural construction in itself. A crisis within a similar apparatus, the non-sharing of its operation, immediately makes the effectiveness of such practices problematic.
In conclusion, what is the take home message that an anthropologist may leave a young doctor?
The modeling approach to multifactorial disorders (models created to analyse how the social frame and cultural dynamics interact with the biological and biomedical practices, since they do influence each other) could be extremely useful for proposing a broader understanding of the disease processes and for extending the potential of care within clinical practice.
Savino Sciascia is a medical intern and a TLS Regional Advisor. Ilaria Lesmo is a second year anthropology post-graduate student. They both attend CMID, Interregional Centre of Coordination of Rare Diseases of Piedmont and Aosta Valley, Giovanni Bosco Hospital in Turin, Italy.
sciascia.savino(at)gmail.com
References
1. Remotti F, 2005 “Sull’incompletezza” in Affergan F., Borutti S., Calame C., Fabietti U., Kilani M., Remotti F., 2005, Figure dell’umano. Le rappresentazioni dell’antropologia, Roma, Meltemi Editore (ed.orig. 2003, Figures de l’humain. Le représentations de l’anthropologie. Editions de la Maison des Sciences de l’Homme, Paris).
2. Affergan F., Borutti S., Calame C., Fabietti U., Kilani M., Remotti F., 2005, Figure dell’umano. Le rappresentazioni dell’antropologia, Roma, Meltemi Editore (ed.orig. 2003, Figures de l’humain. Le représentations de l’anthropologie . Editions de la Maison des Sciences de l’Homme, Paris).
3. Evans-Pritchard E., 1937, Witchcraft, Oracles and Magic Among the Azande, Oxford, Oxford University Press.
4. Kleinman A., 1878, “Concepts and a model for the comparison of medical systems as cultural systems” in Social Science and Medicine, vol.12, 85-93.
5. Scheper-Hughes N. and Lock M. 1987, “The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology” in Medical Anthropology Quarterly (1): 6-41.
6. Geertz C., 1973, The Interpretation of Cultures, New York, Basic Books.