Anthropology and clinical Practice TORIO Cecil Helman Anthropology Today, Vol. 1, No 4.(Aug, 1985), pp. 7-10 Stable uri http://links.jstor.org/sici?sici=0268-540x%28198508%291%3a4%03c7%3aaacp%3e2.0.co%03b2-w Anthropology Today is currently published by Royal Anthropological Institute of Great Britain and Ireland Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at http://wwwjstor.org/about/terms.htmlJstOrsTermsandConditionsofUseprovidesinpartthatunlessyou have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and you may use content in the JStOR archive only for your personal, non-commercial use Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or inted JStOR is an independent not- for-profit organization dedicated to creating and preserving a digital archive of scholarly journals. For more information regarding JSTOR, please contact support @jstor. org Wed oct 1821:12:512006
For further reading of some of the methods of infertility alleviation were nineteenth century, London New York: Methuen, 1984 Fox, R. Kinship and Thus, Lord Denning: We shall have a man whose se 5. G.D. Mitchell &R Snowden, The social implications of riage, C UP,new be used to procreate children long after he himself is d artificial insemination by donor, Report to ESRC on Grant edition, 1983. may procreate dozens and dozens of children by 00/23/0031,1982. and a women. There could be dozens of children walking about the 6. The Committee tends to use this principle when it app Good. Research Practices streets with the same fair features as the father but no one will of a particular practice, but not when it does not in the study of kinship. know who is the father(House of lords Weekly Hansard, Vol. 7. It should also be remembered that state agencies regularly Academic press, 1984 456, No 1265, col 544 ) In the House of Commons, Mrs Jill take children into care for their best interests. Knight said 'It seems such a calculating business to flush 8. Perhaps this needs a little further explanation. Take the of the ingredients in a test tube before shoving it into the deep whom is widely known about and the other no-one knows about freeze. It is a bit like a housewife buying a packet -mix from The husband will be the pater of the child, and the first lover supermarket store, cooking it all up and then popping it in may be publicly regarded as the genitor whereas, in fact, it the freezer to save time at the weekend(House of Commons the second lover who is actually responsible for the pregnancy Weekly Hansard, vol 68, No. 1326, col. 566) and is thus the genetic father 3. A much-quoted MORI poll commissioned by the Inter- 9. In fact, there are four possible roles here, because just denominational Order of Christian Unity published in with men the genitor and the genetic father may be a different September 1984 showed that 57%o of those polled were against person so the genetrix may be different from the geneticmother. human embryos. The results of a survey carried out by doctors occur and the wrong egg to be fertilia ble for a mix-up to surrogate motherhood and 51%o against experimentation in Edinburgh and reported in The Times(1 May, 1985)indicated 10. Ghost-marriage is the marriage of a woman to a dead that of the 1,000 women interviewed nearly three-quarters man, so that her offspring, regardless of whom the genitor against laws being passed to forbid all embryo research re those of the deceased. The levirate is the marriage of a oman to her deceased husband's brother but any children she 4. See Angus McLaren, Reproductive rituals: the percep may bear to him are regarded as belonging to the dead man of fertility in England from the sixteenth century to the 11. Oxford: Clarendon Press, 1982. Anthropology and clinical Practice CECIL HELMAN Cecil Helman is a lecturer This article arises from my own dual perspective- as crises of relevance. within the medical world, the last both medical doctor and anthropologist. It covers some 50 years have seen a gradual shift in its centre of gravity Middlesex Hospital of the areas where the concepts, skills, and research from the isolated family physician embedded in a Medical School, and is a ndings of social anthropology have been useful to those community(and in its local culture) towards the new Research Fellow in ivolved in clinical or preventive medicine. My own view, temples of medical science- the hospital, the medical University College London. clinically applied anthropology will be one of the few in the types of data that medicine considers valid: from He is also the founder of branches of anthropology that will expand in the next the subjective interpretation of symptoms and signs the british medical Anthropology societ decade or so towards the notionally objective'(and quantifiable) 1976 indings of diagnostic technology. But the growth of higl Medicine and social anthropology technology medicine has been paralleled by a growing dissatisfaction with medical care, and with its neglect Anthropology and clinical medicine have had a long of the social and psychological dimensions of ill-health association over the years, but one marked- until quite This backlash against'scientific' medicine has led to an cently. by mutual incomprehension. Doctors have increase in litigation, to the growth of alternative long seen anthropologists as merely the collectors of therapies, and to a new interest (now offically approved medical exotica from the non-Western world -of by WHO) in the role of traditional healers in the Third ' primitive' practices and beliefs, which can be World. It has also allowed anthropology to play a larger comfortably juxtaposed against the triumphs of the role in understanding those socio-cultural aspects of brave new world of medical science. A more thoughtful, illness and health ignored by modern medicine, and thus but less common approach, has been to scour the help design more appropriate forms of health care in indigenous pharmacopoeias that anthropologists have the future. For example, anthropology can contribute brought back from the field, searching for drugs that to the understanding of how cultural metaphors that are could be useful in a Western setting(a project now linked to certain serious diseases(such as AIDS), may supported by the world health Organization). In this adversely affect their detection, spread, or even way, studies of ethnobotany have brought to light curare treatment rom South America, anti-malarial plants from the Hausa of Northern Nigeria, and ammi visnaga from Preventive medicine traditional Egyptian medicine- found to be useful for treating whooping cough, angina pectoris, and other In a growing number of studies, anthropology has conditions.A third, even less common approach, has been an important part of multi-disciplinary research cen the use of ethnographies to understand how certain into the origin and spread of certain types of ill-health diseases can be related to the ways a particular human especially those where cultural factors are important group has adapted to its own environmental niche. In some cases, anthropologists have worked on projects In the past few years, for different reasons, both together with clinicians, epidemiologists, nutritionists medicine and anthropology have suffered their own and geneticists. One famous example, from the
mid-1950, s, was the solution to the problem of kuru -a in some cases, be harmful to the woman's health. On disease confined to the women and children of the South a more general level, cultural beliefs about what Fore people of New Guinea. It was found to be due to constitutes beauty(in most cases, conceptions of ideal a 'slow virus'(one which lies dormant in the body female beauty associated with appeal to males)can also months or years, before causing the disease)-in the result in a variety of disabilities- as any glance through victims brain, and to be transmitted by ritual the history of female costume will reveal cannibalism practised only by female kin of the decease One strand of anthropological research into the origin and their children. Anthropologists found that the of disease seems to indicate how cultural expectations disease first made its appearance at roughly the same can be pathogenic to certain individuals. In these people, time that the South Fore women borrowed the practice attempts to meet cultural norms of prestige, of ritual cannibalism from nearby tribes ccomplishment and social behaviour as measured by More recent studies on kinship and marital p he size of their car, or the size of their yams- may well especially among groups that practise endogamy -have prove dangerous to their health. This is case in the so- hed light on the transmission of recessive, inherited called"Type A personality, common in Western societ diseases- such as thalassaemia, haemophilia, or Tay. and first described by two cardiologists, Friedman and Sachs disease. Similarly, studies of migrations, of residential patterns, and of mass public rituals and competitive, preoccupied with deadlines, chronically pilgrimages, have all helped researchers understand how impatient, and in a constant struggle to achieve an fectious diseases, and the vectors of parasitic diseases, unlimited number of goals in as short a time as possible. an spread throughout a population. The large body of Epidemiological studies indicate that those with this work on nutritional anthropology has also contributed form of behaviour are much more likely to get coronary to understanding why-in the presence of adequate sources of nutrition in the environment.there may be Western industrial, urban society rewards this pathogenic ver-or under-nutrition in certain groups of people In behaviour, and"Type a personalities'are common particular, studies of cultural definitions of what among captains of industry, top managers, and leading constitutes'food(as opposed to 'non-food), of specific academics and professionals Can one, therefore, regard food taboos, and of the various humoural orhot-cold this type of behaviour as a Western culture-bound systems of food classification- all reveal that people disorder created and reinforced by the values of our often choose what, how, and when to eat on grounds society? Some of the evidence for this view is briefly that are not nutritional but cultural. Many of these summarized in my book, Culture, Health and lness nutritional studies reveal the multi-causal origin of many One further example of the pathogeniceffect of cultural rms of malnutrition. For example, the high incidence beliefs(also called the nocebo effect"), is the well- of rickets and osteomalacia among Asian women living described"voodoo death'or'magical death, reported in Britain has been blamed on a number of factors. from many parts of the world. Further studies of this cluding: a deficiency of Vitamin D in their vegetarian phenomenon will probably also shed light on a wider diet, the phytic acid content of chapattis which range of conditions with a strong social component apparently prevents absorption of calcium, certain the large number of psychosomatic disorders, for genetic factors, and a lack of ultra-violet light on the skin- due to types of female dress that cover large areas of the body surface, the seclusion of Asian at Anthropology and primary care home for much of the day, and poor, inner city housing (due in turn to poverty, discrimination, and The consultation between doctor and patient in primary care, is an area well searched by psychologists and sociologists. Most have Anthropological research has also shed light on seen it as the main interface between lay and medical on the cluster of meanings associated with articularly, perspectives on ill-health in our culture. The pure medical ohol abuse and smoking behaviour their use in perspective has been to see the consultation as a particular culture, and their relationship to gender roles problematic, due to 'miscommunication' and non and expectations. Some work has also been done on how compliance with medical instructions-to see it,in cultures differentiate between ' normal, socially other words, as a clash between medical truth and" lay sanctioned drinking(such as that at wakes, weddings health beliefs In most cases, these studies view the private, isolated event, usual behaviour. More recently, there has been considerable only two or three individuals. Medical anthropologists, research on the subcultures of urban drug addicts, and however brought a more complex perspective to their stereotyped world-view which divides those around the study of the consultation. They have pointed out them into'hustlers'and'squares'. For those working in for example, that this interaction is embedded in a wider ne area of alcohol or drug abuse, some of this research value system and in a particular social context. In rovides a useful starting point for the design of different ddition, both parties carry with them a unique'internal types of rehabilitation programmes. contextof prior experience education, beliefs, social The considerable literature on cultural conceptions and cultural background. Both 'innerand outer' of body image- particularly the perception of the body, contexts of the consultation help determine what is said and its changes, through socially-derived categories ow it is said, and how it is heard and interpreted.It is of key value to clinicians. It helps explain how people has also been pointed out that medical consultations interpret(and describe)subjective physical symptoms, a Western form of divination and treatment ritual their attitudes to surgical operations and certain medical which the chaos of subjective symptoms is organized treatments, as well as attitudes to pregnancy, birth and into the diagnostic categories of modern medicine, and menstruation. In the case of pregnancy, studies of a which is replete with the multi- vocal symbols of healing group,'s ethnoanatomy and ethnophysiology can reveal power and legitimacy the white coat, the stethoscope, he origin of customs or beliefs that may be dangerous the examination couch, the diplomas on the wall. In this to the pregnant woman, or to her unborn child. Attitudes setting, the prescription becomes a gift'(a la Marcel to menstruation, and taboos associated with it, may also, Mauss), cementing the relationship between healer and
patient, and confirming the patient in a sick role. there are still few ethnographies done in the U. K though nthropological studies have also provided a useful this gap is gradually being filled. Much of the data corrective to those doctors who still believe that primary available now comes from sociologists, but care is what the phrase implies. They have shown that, anthropologists have contributed studies of ethnic in Britain and America, only a minority of abnormal minorities, of concepts of illness among working class ymptoms(about one-quarter to one-third) are dealt with women in Aberdeen, Glasgow and Cardiff, of menstru by the official medical system. In both countries, the beliefs in South Wales, of folk models of 'fevers,'colds' real site of primary health care is within the family, with and 'chills'in a London suburb, and of health beliefs mothers and grandmothers being the main health care in an East End community. Littlewood and lipsedge providers. Other sources of health advice are doctors' in their Aliens and alienists, have also examined the receptionists, pharmacists, womens magazines, radio relationship of British psychiatry to ethnic minority rogrammes, as well as local folk healers(both sacred patients, and the problems of cross-cultural labelling of nd secular) such as astrologers, psychic healers, Tarot mental illness. Other studies in this area are under way card readers, and herbalists. Self-help groups (some and should illustrate further the value of looking at ill equivalent to what Turner calls communities of health in the community from an emic perspective suffering )also provide much of the health care, especially of stigmatized conditions or lifestyles. Medicine as a professional subculture Traditional healers from among ethnic minorities such Recently, following the advice of their colleagues to as Hindu vaids, Muslim hakims, Chinese herbalists and study up,' in the social scale, anthropologists have turned acupuncturists, and Caribbea their attention to studies of the medical profession in part of the spectrum of healers available outside the different Western countries. They have pointed out the medical profession. Kleinman, in his Patients and culture-bound nature of Western medicine, and the Healers in the Context of Culture, suggests that healers variations in the content and distribution of certain in each culture be subdivided into three overlapping diagnostic categories(such as schizophrenia), the type "sectors of health care the professional, or legitimated of treatments used (such as the rate of certain surgical representatives of Western medicine, the folk, both sacred operations ) and the number and types of drugs and secular folk healers, and the popular sector of lay self-diagnosis and treatment. In non-Western societies, attempts have been made to relate these variations to health care, and this takes place within familiar social certain core cultural values of each society. A recent and cultural contexts book, Physicians of Western Medicine, edited by two anthropologists, included thirteen ethnographies of Several medical anthropologists have pointed out American, Canadian and English doctors. It covers, for intrinsic differences between medical and lay perspectives example, the world-views of American internists and on ill-health, and this has formed the basis for their psychiatrists, surgical decision-making, medical models critique of Western medicine. The medical or disease of the menopause, and the complex interrelationships perspective employs a reductionist world-view, between patient and practitioner explanatory models in emphasizing physiological data as being intrinsically an English suburb. Other studies, published elsewhere, more'realthan social or psychological factors. It is also have described the rituals of purity and pollution in characterized by a mind-body dualism, and by a view surgical operating theatres, and the use of folk concepts f disease as an abstract, recurrent'thing, which has and language by general practitioners. It is instructive the same content whenever it appears, irrespective of to compare these studies, with the more common studies local cultural conditions. By contrast, the illness or lay of both Western and non-Western folk healers perspective is a broader concept, including the subjective illustrate how these different systems of healing cover response of the patient to being unwell; how he, and those different, though overlapping, parts of the spectrum of around him, view the origin and significance of this misfortune. Other medical ethnographies have been event; how it affects his behaviour or relationships with useful in understanding the role of the medical subculture others(Frankenberg uses the term sickness to apply to in exercising social control, or in'medicalizing'dissent this social aspect); and the steps he takes to remedy the non-conformity, or the normal phases of the female life- situation. It includes not only his experience of ill-health, cycle. Similarly, they help one to understand the spread but also the meanings he gives to that experience. Illness, of medical metaphors into everyday life (an epidemic herefore, is clearly patterned by culture, and learning of muggings, the virus of soccer hooliganism), about it should be an important part of all health care. especially where they are associated with dangerous In linking a group,s culture to that of the individual diseases of uncertain origin- such as cancer or AlDS. patient, Kleinman suggests that clinicians discover their patients' explanatory models.notions about the Anthropologists in clinical settings origin, timing, physiology, severity, and appropriate In Britain, anthropologists working in me treatment of their condition Part of these models ften find themselves in marginal, ill-defi emic perspectives on the causation of ill-health, and often they are viewed as outsiders, other misfortunes. A large number of ethnographic consultants brought in to find a specific studies have been done on beliefs about the origin of specific clinical problem. Why do one category of ill-health in the individual's behaviour, or in his natural, patients refuse vaccination, while another welcome social, or supernatural environments. Many famous them? Why do patients in one ethnic group classify onographs in this area are reprinted in Landy's comprehensive book Culture, Disease, and healing. penicillin as symbolically 'hot, and therefore refuse to cept it for fevers? Why do some patients cling to food To make such medical ethnographies meaningful to taboos, even in the presence of obvious malnutrition? health professionals, it has become increasingly Why do about 90 of patients use self-treatment, or important to move away from purely non-Western lay health advice, before arriving at the GP's surgery naterial. Studies of shamanism in Siberia, or To many anthropologists, used to a more open-ended ethnomedicine in Zaire, have not been met with a brief, this applied aspect of their work may bring with receptive ear by most Western doctors. Unfortunately, it the danger of a new reductionism- the clinical
imperative. Other anthropologists, critical of the medical Whether as clinicians, outside consultants,or world view, find themselves in the uncomfortable therapists, there are numerous situations where medical position of being asked to find out why the natives are anthropologists can contribute to clinical or preventive restless, and what can be done to improve their medicine. Obviously, for this to be possible, their contribution must be recognized by both government Nevertheless, despite these problems, it will become and health authorities, as well as by those responsible mportant in the future for medical anthropologists to for undergraduate medical education be perceived as having a specific, though independent ea of expertise, which is relevant to health care and 1. For "Type a personality see also Freedman, M.& preventive medicine. Above all, doctors will have to be Rosenman, ociation of specific overt behaviour onvinced of the usefulness of having anthropologists pattern wit avascular findings. Journal of the permanently on the faculties of medical schools and American blood an cadio ion, vol. 169. 10 hospitals- and of their value in designing systems of health care which are humane, culturally appropriate, Further Reading Note: There is now a considerable literature on clinically applied and cost-effective. In the United States by contrast, medical anthropology. The following list of publications is onl applied medical anthropology is well established. Many a partial one, but it covers some of the main works on the subject major medical schools have one or more medical published in the last eight years anthropologists on their staff; in many of these, they are integrated with departments of family or community Chrisman, Noel J. and Maretzki, Thomas W(eds)198 medicine, psychiatry, or schools of nursing. In these Clinically applied anthropology: Anthropologists departments, they are not only involved in teaching and science settings D Reidel Publishing Company research, but also provide a 'consultation-liaison service Foster, George M and Anderson, Barbara G. 1978. Medical providing expertise in cases where the socio-cultural anthropology, John Wiley and Sons background of the patient is relevant to diagnosis or Physicians of western medicine, DReidel Publishing Company. anthropologists working in clinical settings in the USA Harwood, Alan(ed) 1981. Ethnicity and medical care, (as well as strategies to increase their input into medical Helman, Cecil G. 1984. Culture, Health and llness: An care)are included in Chrisman and Maretzki's Clinically introduction for health professionals, John Wright and Sons Applied Anthropology, and in a recent issue of Kleinman, Arthur. 1980. Patients and healers in the context Medical Anthropology quarterly. Overall, it is among of culture, University of California Pi psychiatrists, family physicians, community physicians, Landy, David. (ed) 1977. Culture, disease, and healing nurses, midwives, and health educators that medical Macmillan anthropology has been most welcome in the USA-and the situation is similar in Britain alienists: ethnic minorities and psychiatry, Pe Anthropologists are in a unique position if they ar Marsella, Anthony J and White, Geoffrey M.(eds )1982 also trained as doctors or nurses. With this ' double vision they are hopefully able to bring an extra Medical Anthropology Quarterly, 1985, Vol. 16, No 3, dimension to their daily medical work- and a more pp59-7 ethnographic, qualitative, and comparative approach to Romanucci-Ross, Lola an, Daniel E and Tancredi, their research. It is also easier for them to be invisible Laurence R(eds)1983. The anthropology of medicine, Bergin field-workers, viewing the medical profession from and Garvey within its high walls. But it also raises the usual questions World Health Organization. 1978 The promotion and of applied anthropology: to what extent can one development of traditional medicine, WHO Technical Report successfully be both participant and observer, especially Series. No 622. in a clinical setting? How long can one remain an academic voyeur, in the presence of suffering or death? evertheless, the number of those in this po●●●●●●●●●●●●●● many more in the USA where MD-PhD and MD-MA programmes in medical anthropology are producing Research in Social Anth more graduates each year. It remains to be seen whethe 1975-1980 his will lead to a new generation of more humane Editor: Jonathan Webber clinicians or whether their new attitudes will be Register of Theses in Social frustrated by the medical systems in which they work Anthropology accepted for Psychotherapists are another group likely to find Higher Degrees at British anthropology of clinical value. In particular, the area Universities 1975-80. It was of family therapy is a promising one for anthropologists commissioned by the Social to work in, especially since the growth of the systems Anthropology Committee of the approach. This views the family as a complex system SSRC (now Economic and Social of relationships, which aims to maintain homoeostasis, Research Council. Abstracts of even at the cost of scapegoating one of its members nearly all the theses are included, Although one can recognize a dubious functionalism and they are indexed by author; by underlying this approach, I think it is possible- at least university; by country; by peopl in some contexts- to see the family as a partially cultures; and by subject. solated small-scale society. Some of the work of victor xliii, 425 pp. Hardback Turner on the symbolic resolution of social conflict ma ￡14/USs22, paperback￡8/USs13 well be relevant here, and should be explored further (25o discount for Fellows of the Anthropological concepts are beginning to enter famil RAi, post paid from RAI therapy, but often in the distorted form of ethnic Distribution Centre. Blackhorse tereotypes -the Italian family, 'the Irish familyand Rd, Letchworth SG6 1HN, Herts
