|GATE - 2/85 - Health, Water and Sanitation (GTZ GATE, 1985, 56 p.)|
by Dorothea Sich
It is true that, historically, medical anthropology is an offshoot of ethnology; but the scientific interest in medical anthropology today, i.e., the relevant questions posed, originate - in Germany- primarily in the field of medicine. One cause of this is doubtless the fact that many doctors who have returned from developing countries have had first-hand experience of urgent problems in the sphere of interaction between modern medicine on the one hand and people with foreign cultures and their own medical systems on the other. These problems are associated both with the efficiency of modern medicine in a foreign cultural environment, as well as with the disquieting question as to the harmlessness of modern medical considerations in medicine transfer and cultural change in non-Western countries.
Such problems often assume frigthening dimensions, and to me it seems dangerous if no academic institution is created to deal with them, documenting facts with due scientific objectivity, offering them for discussion and taking the trouble to process them.
There is, moreover, the serious problem that people who have such experience have difficulty in being accepted at academic institutions in Germany at all. As far as professional prospects for members of the medical profession are concerned, experience in the Third World is more a drawback than an advantage. It makes re-integration more difficult: not only because it represents a loss of protection at home, but also because one usually has to forget one's experience abroad, and the questions it has raised, if one is to stand any chance of re-integration. Medical practice in Germany offers practically no opportunity for processing this experience, unless one were found in a medical anthropological context. But - as already mentioned ethnomedical context. But - as already mentioned - medical anthropology so far has no "right of abode" at academic level in Germany.
Medicine and culture
Yet within modern medicine, and especially with regard to the development of theory, medical anthropology is faced with a huge task. in research, teaching and practice it has to contribute to the processing of cultural influences on modern medicine, and it is in the course of developing concepts on the basis of this task. The task is related to an objective consideration of the relationship between medicine and culture at individual, social and cultural level. One of the central concepts here is the understanding of medicine as a cultural system or subsystem which, as it were, obeys cybernetic laws. Medical anthropologie needs partner sciences such as the social scienes, history, languages and linguistics, literature, religious sciences, and others besides. The context of its assignments is determined by questions which originate primarily from medicine, and concern the relationship between medicine and culture. The method to be applied will depend on the question, and for interpretation the expertise of the relevant partner sciences will be called on. Medical anthropology is interdisciplinary in the true sense of the word.
If training in medical anthropology is to deserve its name it must have a training objective based on the relevant subject matter. It must include the ability to cover - objectively both modern and traditional medical systems and their components (such as subsectors, healing authorities, institutions and social safeguards etc.) and to compare these. The point of departure for this is firsthand experience of disease, and not the healing process, as is often mistakenly assumed. It is this first-hand experience of disease which, in the final analysis (directly or indirectly) gives the medical system of a culture its economic, behavioural and conceptual characteristics and only in this context structures the healing process. Another important aim of training is therefore to teach what phenomena to look for in an illness. In other words, the medical anthropological case study. This includes the individual and social process of becoming ill, the course of accompanying sensations (weakness, pain, fear etc.) cognitive processing (definition, incorporation in a system of classification), empirical and scientific treatment of the disease by laymen and specialists, the biopathologic process in the sense of modern scientific medicine, etc. For research this means that these aspects have to be recorded in various cultures, if possible with comparable parameters.
It will have become clear from the comments in the foregoing that from the ethnomedical stand of medical anthropology we still know very little about medicine in our own culture. But the same applies to other cultures. The ethnographies so far published leave a great deal to be desired at all points in their descriptions of medical systems. Here there is a pioneering task of the first order to be tackled, both for ethnology and for medicine. However, if it is accomplished, it may pave the way to a comprehensive theory of the relationship between medicine and culture, and thus also to a well founded understanding of medicine in our own culture, too.
Medicine transfer and cultural change
The questions being asked publicly about our own system of medicine are indicative of the fact that we ourselves are in a period of rapid cultural change; we see signs of this everywhere, and medicine itself is specially affected by it. However, rapid cultural change in medicine is also a phenomenon which has occured worldwide, as a result of the transfer of medicine to foreign cultures. It provides indicators, both for us and in the Third World, that the rapid cultural change in medicine, with a range of several medical alternatives being offered simultaneously - we are talking about medical pluralism - can be dangerous for the individual patient. I gave an example of this in a monograph (Sich 1982) on obstetrics in Korea. It would be beyond the scope of this article to discuss the problem in greater detail, but there are several other facts which support this hypothesis. The phenomenon of the self-help groups is without doubt one aspect of the phenomenon of cultural change here. Now, however, it must be considered one of the really positive aspects of cultural change in medicine, as far a I can judge the situation.
In Germany we have two scientists - not medical men - who have considered associated questions from the standpoint of the medical anthropologist and who deserve to be mentioned here. They are the medical historian Paul Ulrich Unschuld at Munich University, and the social anthropologist Paul Hinderling at the Sociopsychological Research Centre for Development Planning in Saarbrukken.
For my own understanding of the internal structure of medical systems I still tend to adhere to the classification and definitions proposed by the American Arthur Kleinman (A. Kleinman 1980). He distinguishes between external and internal factors which structure a cultural medicine system or respectively a health care system. The external factors include political, economic and social structures as well as historical and environmental determinants. They have been covered thoroughly in research and I shall not discuss them here. It should, therefore, be pointed out that research has largely neglected the cultural factors, or what Kleinman calls the internal structure of the 'health care systems'; the system as a cultural device. These internal systems are comparable in different cultures, both in developing countries as well as in modern societies. Kleinman's model can be illustrated as 3 overlapping circles corresponding to the sectors of the medical (health care) system.
The popular culture sector
The largest of these sectors is the "popular culture sector." The basis of this sector is the individual, the family, the social network, the community. It is a lay sector, not professionalized, without specialists. Here, illness is first perceived and experienced, by the individual, in the family, at work. It is here that the important aspects in illness develop, or respectively they develop in accordance with the patterns laid down in the culture: interactions, decisions, roles, relationships, interaction settings, institutions. These structures correspond to one another in both traditional and industrialized societies. Of course the contents are different, but in principle they are comparable. And naturally the contents change with cultural change in a system. Here in Germany, the non-professional self-help groups and home nursing fall into this category. Then there are the sectors of popular medicine and professionalized medicine, which overlap with the popular culture sector and can overlap with one another, and in which the layman receives help from specialists. The choice of specialist or healer has its basis in the individual freedom of choice of the people in the popular culture sector. However, even when people are treated in one of the specialist sectors they return to the popular culture sector, evaluate what has happened themselves or with their contact groups, and decide what is to happen next. (Here too I recognize that self-help groups and family care play an important role in our society.) This is the basic pattern; here in Germany, of course, it is strongly influenced by the insurance companies, yet it probably retains some of its validity none the less. This popular culture sector has been paid just as little attention in ethnological research into other cultures as it has here in research in the context of medicine or social sciences. Nevertheless, it is the most important sector for understanding the health behaviour of a community. When an illness occurs, something like the following happens in this sector: perception of symptoms, with a corresponding emotional connotation. Definition and evaluation of the illness (slight, severe, chronic, acute, general medical, psychiatric etc.). Decision as to what action should be taken (self-care, domestic medicine, consultation of a specialist). Application of the (possibly personally) prescribed treatment. Assessment of the result of treatment, also with the corresponding emotional connotation.
The professionalized sector
The moment another sector is approached, the layman is confronted with a different world of concepts, namely that of the specialists. An exchange of explanatory models, those of the layman on the one hand and of the specialists on the other, should now take place. However, this only happens to a limited extent. We know that today's doctors only partially understand the ideas of their patients and that it is only possible to convey a part of their knowledge to the layman. In the professionalized sector perception, definition, interpretation and evaluation are subject to different criteria from those in the popular culture sector. In particular, evaluation in the professionalized sector is largely devoid of emotion. But afterwards the individual returns to the lay sector, and then another evaluation of what happened in the professionalized sector takes place. Here, emotion is not eliminated.
According to this classification, the professionalized sector comprises the representatives of an organized health care system. In Germany this is the modern, scientifically founded medicine sector. In advanced cultures, e.g., India or China, Aryuveda or Chinese medicine belong in this sector as well. But it also includes all the subdisciplines which exist under the hegemony of modern medicine, such as nature cure medicine, medicinal baths etc.
The 'folk sector' includes the nonprofessionalized specialists - miracle healers, shamans, witch doctors etc. - about whose effectiveness we know next to nothing.
Patients vacillate from sector to sector of a medical system. Although the institutions of the professionalized sector have an overwhelming influence on opinion and behaviour, and we are well informed about them, we know little or nothing about the popular culture sector and how it influences the areas in which we have not conducted corresponding investigations. It may be mentioned in passing that the behaviour in the popular culture sector has a retroacitve effect on the behaviour of the specialists; the example of the self-help groups clearly demonstrates this. A number of other examples could also be cited (e.g., in obstetrics, "rooming in" and allowing the husband into the delivery room; indication for caesarean section in developing countries as a result of predictions by soothsayers). Patients as well as healers have to be studied and understood in the context of their culture-specific medical system. Only thus is a transcultural comparison of systems, and a comparison of system components possible - in particular with regard to their efficiency. As already pointed out, cultural medical systems originate as a reaction of a social system to illness. And although they seem chaotic (as far as the popular culture sector is concerned) they nevertheless form structures, e.g., the self help groups, and in particular specific interaction patterns.
Illness and disease
We come now to the second important concept in medical anthropology which I should like to explain, namely 'disease' and 'illness'. The dichotomy between these two definitions - illness and disease - represents a key concept in this discipline. The primary, or supraordinate, or comprehensive concept is sickness. According to Kleinman, disease is a dysfunction of a biological or psychological process. Illness, on the other hand, is the psychosocial experience and the significance of the experience.
In medical anthropology illness is the important concept. For medical specialists, on the other hand, disease is the principal object of interest. Illness is a reaction of the individual - and in the social context - to disease. Illness includes the perception, attention, designation, emotional reactions, cognitive processing, and evaluation of disease as a biological aberration. The illness process is the communication and interaction process in the context of the family and social relations. Illness is a conversion of disease (as a biological aberration) into behaviour and experience. It is a personal, social, and cultural reactin to disease. It is an attempt to make sense of the biological process of disease as a disrupting factor in the life process, and to control it.
Therefore, medical anthropology is concerned with the dimensions of illness: with the individual and social process of falling ill, the course of accompanying sensations (pain, weakness, fear), the cognitive processing (naming, assignment to a system of classification); with the empirical and scientific treatment of the sickness and the biopathological process as it is understood in modern scientific medicine.
The point of departure and the basis for processing all concepts and investing them with meaning is the medical anthropological case study. It is then possible to study certain parameters in large groups and to compare different groups. Together with other information, e.g., from literature, sociology, semantics etc., the cultural medical system can then be constructed. The author shows that both here in the western World as well as in Third-World countries, medical anthropology is more important than the defenders of traditional medicine are prepared to admit. The difficulties at present facing medical anthropology as a scientific discipline, especially in the Federal Republic of Germany, are also pointed out.
L'de ethnomcale d'un cas donne constitue le point de drt et les bases de l'blissement de tous les concepts et de leur risation. Il est alors possible d'effectuer un examen des paremes donnes pour des groupes importants et de procr des comparaisons de groupes. En association ave d'autres ments d' information d'ordre littire, sociologique, sntique, historique, etc, il est alors possible de construire un syst mcal culture!. L'auteur dntre que, tant dans notre monde occidental que dans les pays du Tiers Monde, I'ethnomcine revune importance plus grande que la mcine classique ne veut l'admettre. En m temps, I'auteur souligne les difficultauxquelles l'ethnomcine en tant que science se volt actuellement confronten Rblique frale d'Allemagne.
Punto de partida y base pare la elaboracie todos los conceptos y su contenido es el estudio etnomco de cada cave. Es posible entonces analizar determinados parametros en grandes grupos y establecer comparaciones entre os. En combinacion otras informaciones, por ejemplo de la literatura, sociolog semica, historia, etc., puede construirse luego el sistema medico-cultural. La autora demuestra que la etnomedicina, tanto en nuestros paises del mundo occidental como en los del Tercer Mundo, tiene une importancia mucho mayor que la que hasta ahora ha querido concederle la medicine acadca. Al mismo tiempo se exponen tambiles dificultades con que tiene que luchar todav precisamente en la Repa Federal, la etnomedicina como ciencia.