ROWMAN & LITTLEFIELD

Lanham • Boulder • New York • London

Introducing Medical Anthropology

A Discipline in Action

Third Edition

Merrill Singer University of Connecticut

Hans A. Baer University of Melbourne

Debbi Long RMIT University

Alex Pavlotski Aukland University

Executive Editor: Nancy Roberts Editorial Assistant: Megan Manzano Executive Channel Manager—Higher Education: Amy Whitaker Interior Designer: Ilze Lemesis

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Names: Singer, Merrill, author. Title: Introducing medical anthropology : a discipline in action / Merrill Singer, University of

Connecticut, Hans A. Baer, University of Melbourne, Debbi Long, RMIT University, Alex Pavlotski, Aukland University.

Description: Third Edition. | Lanham : ROWMAN & LITTLEFIELD, [2019] | “Second edition 2012”—T.p. verso. | Includes bibliographical references and index. |

Identifiers: LCCN 2018048811 (print) | LCCN 2018051819 (ebook) | ISBN 9781538106471 (electronic) | ISBN 9781538106457 (cloth : alk. paper) | ISBN 9781538106464 (paper : alk. paper)

Subjects: LCSH: Medical anthropology. Classification: LCC GN296 (ebook) | LCC GN296 .S57 2019 (print) | DDC 306.4/61—dc23 LC record available at https://lccn.loc.gov/2018048811

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Preface ix

About the Authors xi

1 Introduction to the Anthropology of Health 1

Introduction and Overview 1

Encountering Health Anthropology 1

Three Case Studies in Applied Health Anthropology 2 Coping with Cystic Fibrosis 2 The Bone Crusher 3 Pesticide Poisoning 5

Practical and Theoretical Contributions of Health Anthropology 8 Clarifying the Culture of Health and Illness 8 Health Inequality 9

Defining Health Anthropology 10 Culture and Biology 10

History of Health Anthropology 12 The Straits Expedition 12 W. H. R. Rivers and Beyond 14 Rudolf Virchow 15 Erwin Ackerknecht and William Caudill 15 The Postwar Period 15 Health Anthropology and National Development 16 The Discipline Is Born 16

The Relationship of Health Anthropology to Anthropology and to Other Health-Related Disciplines 17

Health Research and the Subfields of Anthropology 17 Health Anthropology and Epidemiology 20 Illness and Help-Seeking Behavior 24 Health Anthropology and Public Health 24 Health Anthropology and Bioethics 31

Health Anthropology Theories 32 Medical Ecology 32 Meaning-Centered Health Anthropology 33 Critical Health Anthropology 34

2 What Health Anthropologists Do 37

Introduction and Overview 37

Contents

iii

iv Contents

Three Settings, Three Case Studies, Three Health Anthropologists 37 Life and Death in Tanala 37 Studying Surgeons 39 Folk Illness in Haiti 41

A Case Study 43 Having Impact 43

What Health Anthropologists Study 44 A Diverse Discipline 44 Studying the Life Course 46

Conducting Research: A Peculiarly Anthropological Approach 49 Holistic, Field-Based Understanding 49 Ethnography 49 Complex Sociocultural Tapestries 52

Research Methods 54 Multimethod Research 54 Examining Lives 55 Focus Group Interviews 56 Considering Consensus 57 Doing Diaries 57 Quantitative Methods 58 Broader Collaboration 59

Health Anthropology in Use 59 Mobilizing Research Findings 59

The Health Anthropology Crystal Ball 61

3 Understanding Health, Illness, and Disease 65

Introduction and Overview 65

Conceptions of Health and Illness 65 Defining Terms 65 Differentiating Disease and Illness 66 Reconceptualizing Disease and Illness 69 Understanding Cure 69 Folk Understandings 70 Understandings of Disease Causation 71 Humanizing Biomedicine 73

Sufferer Experience 73 Experience and Cultural Symbols 73 Cultural Emotions 74 Social Suffering 76 Beyond Social Suffering 77 Disability and Chronic Illness 78 The Patient in the Body 78 The Cultural Construction of Disability 79

Contents v

Stigmatization 82 Human Rights and Health 83

Illness Narratives 85 The Social Uses of Narration 86 Analyzing Narrative 86

Embodied Health Experience 88 Why Bodies? 88 Body Theory 89 Bodies in the Age of Immunology 90 Cyborg Bodies 91 Mindful Bodies 92 Engendered Bodies 95 Understanding Medicalization 95

Healer versus Sufferer Conception of Disease 96 The Two Sides of Compliance 96 Insider and Outsider Assessments of Health Status 98 One Word, Two Meanings 98 Diseased but Not Ill 99 Mismessaging 99 Analyzing Health Discourse 100

4 Health Disparity, Health Inequality 102

Introduction and Overview 102

What Is Health Disparity? 102

Health Disparity in the United States 103

Gasping for Breath 104

Causes of Health Disparity: Lifestyle versus Social Inequality 106 Living Right 106 Structural Explanation 106

Biology of Poverty 108

Insuring Disease 109

Culturally Competent Care 110

Health and Social Disparities Cross-Culturally 113 Child and Maternal Health Disparities 116

Addressing Health Disparities 121 Addressing Health Disparities in the Community 121 Upstream Analyses of Health Disparities 122 Gender and Global Health 124 Focusing on Disparity in Diseases 125 Multidisciplinary Approaches 126 Studying Local Mediation of Global Health 126

vi Contents

Pushing Back on Health Disparities 128

“Race” and Health Disparity 128 Race and Racism 129

5 Health and the Environment: Toward a Healthier World 131

Introduction and Overview 131

Medical Ecology and Critical Health Anthropology on the Environment 132

Health and the Environment in the Past 134

Health and the Environment Today 136 Depletion of Natural Resources and Environmental Degradation 137 Capitalism and Climate Change 139 Infectious Diseases in a Globalizing World 140 The Impact of Climate Change on Health 141 Other Environmental Impacts on Health 145 Water and Globalization 146

The Political Ecology of Cancer 148 Cancer in the Community 149 Cancer and Industry 150 China’s Cancer Villages 151 Anthropological Examinations of Cancer Treatment 152 Nuclear Reactors and Health 152 Unconventional Natural Gas Extraction and Health 153

The Impact of Private Motor Vehicles on Health 154

The Political Ecology of AIDS: Assessing a Contemporary Syndemic 155

6 Ethnomedicine: The Worlds of Treatment and Healing 159

Introduction and Overview 159

Approaching Ethnomedicine 159

Indigenous and Folk Medicine Systems 162 Ways of Healing 162 Typologies of Healing Systems 163

An Evolutionary Model of Disease Theories and Healing Systems 165 Health, Illness, and Medicine in Family-Level Foraging Societies 166 Health, Illness, and Medicine in Village-Level Societies 169 Health, Illness, and Medicine in Pastoralist Societies 170 Health, Illness, and Medicine in Chiefdom Societies 171

Contents vii

Folk Healers in Modern Societies 171

Case Study: Are the Therapeutic Aspects of Religion Something That Partially Address Refugee Health Problems? 173

Biomedicine as the Predominant Ethnomedicine in Modern Societies 175

Hospitals 176 Health Anthropology and the Pharmaceutical Industry 178

7 Plural Medical Systems: Complexity, Complementarity, and Conflict 182

Introduction and Overview 182

A Case Study of Medical Pluralism in a Rural Area in a Developing Society: The Altiplano of Bolivia 183

Themes 183 Medical Subsystems 184 Status of Health Care in Bolivia in the Pre-Revolutionary Era 184 Social and Health Conditions in Bolivia after the Election of Indigenous President Evo Morales 185

A Case Study of Medical Pluralism in an Urban Setting of a Developing Society: A View from Central Java 188

Medical Subsystems 188

A Case Study of Medical Pluralism in a Developed Society: The Australian Dominative Medical System 190

Medical Subsystems 190

Typologies of Plural Medical Systems 195 Healing and History 196 Patients of CAM 199 CAM and Class 201

New Directions in the Study of Medical Pluralism 207 Medical Syncretism 208 Medical Diversity 209 Medicoscapes 210 The Globalization of Traditional Medicine and CAM 210

8 The Biopolitics of Life: Biotechnology, Biocapital, and Bioethics 212

Introduction and Overview 212

Critical Health Anthropology and Biotechnology 212

Science, Nature, and Culture 213 Biocapital: Bodies of Profit 215

viii Contents

Reproductive Technologies 216

Divisible Bodies 220

Bringing the Lab into the Field: Anthropology and the Neurosciences 222

Molecular Biotechnologies: Tiny Pieces, Giant Infrastructures 224

The Story of hGH—Growing up Growth Hormone 227

The Culture of PCR 228

Visualization Technologies 229

When Technologies Combine 230

Ancestry, Families, and Genetics: Biotechnology and Belonging 233

9 Strategies and Visions for a Healthier World 240

Introduction and Overview 240

Global Capitalism 240

Democratic Eco-Socialism as a Pathway for a Healthier World 242

Health Anthropology as an Action-Oriented Endeavor 247

Source Material for Students 251

Glossary 255

References 260

Index 300

Students often do not bother with the prefaces to assigned textbooks, and for understandable reasons. The comments of authors about their book are not going to be on any test and it is the contents of the book, its ideas, concepts, theory, and examples, not the book as a product of author labor or the goals and intentions of authors, that is of most immediate concern to the student reader. We hope, in this instance, that these remarks capture some student attention because they deal with an important conceptual issue and provide a glimpse behind the curtain of book publishing. When the first (2007) and second (2012) editions of this book were published, the authors recognized that while medical anthropology was not the most fitting name for the field our book was introduc- ing to students, it was the established and widely accepted term. Indeed, medical anthropology was a label that smuggled in a lot of problematic baggage. Since the last edition, however, our discomfort grew to the point that in 2016, along with our colleagues Debbi Long and Pamela Erickson, we published a paper in a leading anthropology journal entitled “Rebranding Our Field: Towards an Articulation of Health Anthropology.” We feel strongly that the time has come to retitle medical anthropology using a more appropriate label that better reflects conceptual developments in the field. Our subfield, as shown clearly in the chap- ters of this book, has a wide range of concerns that includes a keen focus on biomedicine and other ethnomedical and health-care traditions. But the work of those we have come to call “medical anthropologists” addresses multiple other issues that are not specific to medicine or healing, including understanding health and illness within society and within the complex social and political-economic systems created by globalization. Consequently, we proposed the name “health anthropology”; this better describes the core issue that unites the subfield. We called for dropping the term medical anthropology because, as has long been recognized by many in the field, it is limiting and misleading, and reflects the hegemony of biomedicine at various levels. This renaming does not preclude health anthropologists working on or within biomedical, complementary, and alternative medical or indigenous medical settings, as reflected in the fieldwork of all of the coauthors of this book. It was our intention, however, that in its third edition this book be renamed Introducing Health Anthropology: A Discipline in Action to reflect the true breadth of the field.

This is where good intentions ran into marketing realities. Our book, and its title, were known, and Introducing Medical Anthropology was widely used as a textbook, the second-best-selling core text on the market in our topical niche. In our publisher’s reasonable approach to their business it was not seen as a good idea to change the title of an established text. The book was seen as having instant name recognition for professors who might assign it in a class. Changing the title, the publisher felt, could cause confusion to teachers and to bookstores looking to order books for classes. As one reviewer of our proposed name change commented, “Why not continue to use it as a marketing tool to appeal to the

Preface

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x Preface

widest number of folks?” For these reasons, the title has not changed in the third edition, but the text has been updated to reflect our concerns on this matter. Throughout this text, if not on the cover, we use the terms “health anthropol- ogy,” “health-oriented anthropology,” and “health anthropologists.”

One thing that has changed is the addition of Debbi Long and Alex Pavlotski as coauthors, which, based on their areas of expertise and fieldwork experience, allow us to further examine the wide range of issues investigated in a health-oriented anthropology.

One of the goals of the third edition of this book is to affirm that health-oriented anthropologists are very involved in the process of helping, to varying degrees, to change the world around them through their work in applied projects, policy initiatives, and advocacy. Not all anthropologists teach in a col- lege or university—many are involved full time in directly applied work—and most who do teach medical anthropology courses are involved in application. Moreover, as the landscape of academia endures major transformations, with underpaid adjunct labor now increasingly replacing stable faculty positions, anthropologists must find creative ways to bring their skill-sets out of the ivory tower and into the world. Our subdiscipline both addresses specific health issues and analyzes them in their broader context. In other words, we seek to under- stand health-related issues and to use this knowledge in improving human health and social well-being.

A second goal of this book is a presentation of the fundamental importance of culture and social relationships in health and illness. Through a review of the key ideas, concepts, methods, and theoretical frameworks that guide research and application in health-oriented anthropology, the book makes the case that illness and disease involve complex biosocial processes and that resolving them requires attention to a range of factors beyond biology, including local systems of belief, structures of (often unequal) social relationship, the development and globalization of new technologies, and environmental and climatic conditions.

Finally, through an examination of the issue of health inequality, such as exposure to pesticides among farmworkers, unequal access to health care, the role of poverty in the spread of disease, or environmental degradation and envi- ronment-related illness, this book underlines the need for an analysis that moves beyond cultural or even ecological models of health toward a comprehensive biosocial approach. Such an approach integrates biological, cultural, and social factors in building unified theoretical understandings of the origin of ill health, while contributing to the building of effective and equitable national health-care systems. In this manner, health anthropologists have a broad vision of planetary health and seek to be part of a collective process aimed at creating a healthier world for both humanity and the biosphere. The ultimate goal is prevailing over the social causes of disease, the structures of social injustice that diminish well-being, and the social forces driving environmental destruction, including human-created or anthropogenic climate change. For us, ultimately, bringing these issues into the classroom, especially in a time when health has become a daily issue of deep concern, is of far greater importance than the specific way the field is labeled.

Merrill Singer is professor in the Departments of Anthropology and Com- munity Medicine at the University of Connecticut. Dr. Singer has published 290 scholarly articles in peer-reviewed journals and book chapters, and has authored, co-authored or edited thirty-three books. His research and writing have addressed syndemics, HIV/AIDS and STDs in highly vulnerable and disad- vantaged populations, illicit drug use and drinking behavior, infectious disease, community and structural violence, and the political ecology of health, including the health consequences of climate change. Dr. Singer has been awarded the Rudolph Virchow Professional Prize, the George Foster Memorial Award for Practicing Anthropology, both the AIDS and Anthropology Research Group’s Distinguished Service Award and its Clark Taylor Professional Paper Prize, the Prize for Distinguished Achievement in the Critical Study of North America, and the Solon T. Kimball Award for Public and Applied Anthropology from the American Anthropological Association.

Hans A. Baer is Principal Honorary Research Fellow in the School of Social Political Sciences at the University of Melbourne. He has published twenty-one books and some 190 book chapters and articles on a diversity of research top- ics, including Mormonism, African American religion, sociopolitical life in East Germany, critical health anthropology, medical pluralism in the United States, United Kingdom, and Australia, the critical anthropology of climate change, and Australian climate politics. His most recent books are Democratic Eco-Socialism as a Real Utopia (2018), and Urban Eco-Communities in Australia: Real Utopias or Market Niches? (with Liam Cooper, 2018).

Debbi Long is senior lecturer in global studies at RMIT University (Melbourne, Australia). She is a critical health anthropologist and a pioneer of hospital eth- nography in Australia. She is an experienced health ethnographer, having under- taken fieldwork in Turkey, Swaziland (eSwatini), and in a variety of contexts in Australian public hospitals, including maternity, spinal, intensive care, and dialy- sis units. She has worked as a consultant in clinical organization and management on projects including quality improvement, patient safety, behavior change, and in industrial relations contexts. Recent research has included family violence education and compensation industry analysis. She has taught at undergraduate and postgraduate levels in anthropology departments; international development programs; medical, nursing, and allied health programs; and in indigenous foun- dation and support programs.

Alex Pavlotski is teaching fellow at Auckland University, New Zealand, and an honorary research fellow at Latrobe University in Australia. He is an anthro- pologist and graphic artist. Alex has conducted fieldwork with comic artists in

About the Authors

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xii About the Authors

Japan, and in Australia with an urban LGBTQI+ community; with CEOs and accountants across the country; and with recipients of government disability payments. His PhD thesis was on the global movement subculture of parkour, a multisited ethnography undertaken across twenty-four cities in eight nations. His research interests are psychological and neuroanthropology, visual represen- tation in ethnography, cross-cultural communication, masculinity in leadership research, organizational ethnography, systems design, mind-body connectivity, and reactionary identities.

1

1 Healing requires a legitimated, credible and culturally appropriate system.

—Mildred Blaxter (2004:43)

Introduction and Overview

In this chapter, we begin the process of defining and differentiating health an- thropology in light of the range of disciplines concerned with health. We initi-

ate this introduction to health anthropology by presenting three case studies. We then address both the practical and theoretical work and contributions of health anthropology, differentiate health and illness as technical terms in the discipline, engage the issue of health inequality, review the history of health anthropology, and compare and contrast health anthropology with other health-related fields including discussion of multidisciplinary collaboration.

Encountering Health Anthropology People who encounter the term medical anthropology, or, as explained in the preface, “health anthropology,” for the first time often are puzzled by what it means. Is it the study of how medicine is practiced, what doctors, nurses, or traditional healers from other health-care systems actually do? Or is it the study of what it means and feels like to be sick? Perhaps it is the study of folk illnesses in different societies? Might it be the application of cultural knowledge to the actual treatment of diseases? All these questions, in fact, can be answered in the affirmative. Health anthropology addresses each of these issues—and far more. A starting premise of health anthropology is that health-related issues, including disease and treatment, how and why one gets sick, and the nature of recovery, are far more than narrow biological phenomena. These processes are all heavily influ- enced by environmental, political-economic, social-structural, and sociocultural factors as well. Consequently, health anthropology has developed a bio-sociocul- tural approach in its effort to address health as an aspect of the human condition.

To take one example, health anthropologists ask questions such as the following: Could we really understand the AIDS pandemic and respond to it effectively simply by studying the human immunodeficiency virus, its impact on cells of the body, and medical interventions designed to stop the virus from destroying the immune system? Would we not also need to know how to reach and effectively engage those who are at greatest risk for infection, to figure out the structural and situational factors that contribute to their involvement in risky behaviors, to know how much they know and what they feel about AIDS and how these factors influence their behaviors, and to determine whether the ways

Introduction to the Anthropology of Health

1CHAPTER 1 INTRODUCTION TO THE ANTHROPOLOGY OF HEALTH

2 Chapter 1

we go about interacting with them in the community and in the clinic draw them closer or push them away from our treatment programs? In other words, beyond biology clearly there are critically important areas of knowledge in the ongoing fight against the now about forty-year-old AIDS epidemic. Now, if we think about the AIDS epidemic as a global problem, a global pandemic, with different routes of infection, different populations at risk, different beliefs and behaviors associated with HIV/AIDS in diverse settings, and different health-care systems in different parts of the world or even different parts of a single country, we begin to get an initial sense of why a social science like anthropology might—as it certainly has—have a significant role to play in addressing the AIDS epidemic. This is of no small importance; we know from available research that HIV/ AIDS is destined to take a greater toll on our species, proportionately and in terms of absolute numbers, than the bubonic plague, smallpox, and tuberculosis combined. Consider the epidemic in South Africa, the country with the highest burden of HIV/AIDS in the world. As Didier Fassin (2007a:261) points out, “In one decade, the rate of HIV infection went from less than 1 percent to over 25 percent of the adult population and AIDS became the main cause of death for men and women between 15 and 49 years of age,” with an expected drop in average life expectancy in the country of as much as twenty years. Moreover, the global pandemic has helped to shape the social, cultural, and health worlds of people all over the planet, whether or not they are always aware of it. Within the broader story of the devastating impact of HIV/AIDS, however, there are many differing local narratives that together comprise the complex mosaic of the pandemic. The work of health anthropologists has been part of that story in many places and the same is true for a vast array of other health issues. Moreover, health anthropology, while sometimes contributing to cultural explanations of HIV/AIDS risk behavior, has struggled in recent years to counter explanations that fail to address the fact that the global economy or capitalism and social inequality are the primary driving forces in the epidemic (Hlabangane 2014).

    

Three Case Studies in Applied Health Anthropology Coping with Cystic Fibrosis

The Reynolds family has two children. Carl is five and Stuart is seven. The younger of the two boys has cystic fibrosis (CF), the most common fatal genetic disease in the United States. Cystic fibrosis causes the body to produce a thick- ened form of mucus that clogs the lungs, leading to repeated bacterial infec- tions and increasing lung damage. While the median age of survival among CF sufferers has been rising, most people with the disease do not live very far into adulthood before they succumb. Day-to-day care of a child with CF commonly falls on family members who must learn to cope with both a painful prognosis and the demands of responding to the patient’s menacing symptoms, including pou

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