Medical Anthropology

Arvilla Chapin Payne-Jackson. 21st Century Anthropology: A Reference Handbook. Editor: H James Birx. Volume 1. Thousand Oaks, CA: Sage Reference, 2010.

Medical anthropology is the discipline in anthropology that addresses disease and the health care systems developed to cope with disease. Medical anthropologists study the spectrum of cultural and biological factors that have contributed to health, disease, and health care systems throughout human experience from cross-cultural, historical, and evolutionary points of view. They address a wide variety of health and health care issues including cultural barriers to therapeutic and preventive health care; issues of bioethics; the effect of pandemics, epidemics, and natural disasters; the impact of public policy on health care, practitioner-patient communication in hospitals, clinics, private, and ethnomedical practices; nutrition; perceived etiologies and their effect on therapeutic approaches to healing; differences in the cultures of biomedical, ethnomedical, and other alternative health care systems; ethnographic studies of healers, their patients and families, and their support systems; different types of practitioners (biomedical, alternative, ethnomedical, religious) and the science and technology and medicines used in their practices as well as how cross-cultural and societal differences shape biological and psychological reactions to suffering. Medical anthropology is highly interdisciplinary lending itself to ecology, geography, economics, linguistics, medical sociology, biochemistry, genetics, serology, anatomy, paleopathology, epidemiology, medicine, nursing, and public health, among other disciplines.

Medical anthropology is distinct from other social sciences in three ways: (1) It covers a wider temporal and geographic scope of the experience of human health from paleontological and archaeological research through the ethnographic studies of modern day health care systems. (2) It attempts to identify and understand both the socio-cultural and bioecological factors that define and characterize health, illness, and disease. (3) It uses an extensive combination of both qualitative and quantitative methods. Quantitative methods help identify disease patterns, standard patterns of social behavior, and social and economic factors that affect disease and health. Qualitative methods help ascertain the fundamental, unspoken cultural ways of life and values that form the foundation of a society’s health care system and help decipher the relationship between a society’s normative, or ideal culture (what people say things ought to be), versus real culture (what people actually do) (Joralemon, 1999, p. 13).

History of Medical Anthropology

Four contributing sources to the foundation of medical anthropology have been (1) biological anthropology, (2) ethnographic studies of health care systems, (3) the culture and personality movement of the 1930s and 1940s, and (4) the post-World War II international public health movement, which has led to a global consciousness of the effect of disease on societies.

Early Studies

The Exotic

he early pre-World War II ethnographic studies of medical traditions and health care practices of non-Western societies focused on the magico-religious beliefs (magic, sorcery, witchcraft, and religion) in relation to health and sickness, underlying perceived causes of illness (natural, spiritual, or occult), types of practitioners, and the corresponding healing practices. E. E. Evans-Pritchard’s Witchcraft, Oracles, and Magic Among the Azande (1937) is a classic example from this era. His and other studies of the time provided insight into the underlying cultural premises of medical knowledge, procedures, customs, rituals, and roles of the different types of practitioners (natural, spiritual, and occult) as well as the relationship between the environment, how people made a living, the political and social organizations in a society, and perceived causes of illness and disease.

William H. R. Rivers (1924), a British physician and experimental psychologist; Erwin H. Forrest Clements (1932), an anthropologist; and Ackerknecht (1942, 1971), a physician and anthropologist, are three well-known scholars who made significant contributions to the early studies of health care. They were influenced by historical diffusion and functional theory, the dominant approaches used by anthropologists in the early 20th century. Diffusionists attempted to establish classification systems for given cultural domains (e.g., etiology of illness) and the subtypes within that domain (e.g., natural, spiritual, and occult). Once a domain and its subtypes were determined, they were used to identify the cultural domains in other societies and trace their diffusion from geographic centers. Functional theory treated cultures as a whole made up of parts with each part contributing to the maintenance of the society as a whole.

William H. R. Rivers (1924) was the first to attempt to systematically relate the practice of medicine to other characteristics of culture and social organization. In a series of lectures at the Royal College of Physicians (1915-1916), he presented a classification of the cultural domain of etiology of illness. The model was based on early 20th-century attempts to classify discernable explanations of disease causation in traditional, or primitive, medicine as being either magical or religious. He identified three types of disease causation: (1) those caused by human agents through the use of magic and sorcery; (2) those caused by a spiritual or supernatural agency, such as deities, spirits, or breaking of taboos; and (3) those that result from a natural agency or natural processes. He also related perceived disease etiology to type of curer or practitioner sought out for treatment.

Rivers’s (1924) findings were based on two basic propositions. First, that medical practices in primitive medicine are not random, meaningless, and disconnected customs but rather that they are based on “definite ideas concerning the causation of disease… [and are] both logical and systematic and in some respects more rational than our own” (pp. 51-52). Second, that traditional primitive medical practices and beliefs comprise a social institution, “a social process, subject to the same laws, and to be studied by the same methods as other social processes” (p. 55). Despite these revelations, which ran contrary to the scientific view at the time, primitive medicine continued to be treated as being unscientific due in part to the magico-religious nature of the perceived etiologies and treatments (see Foster & Anderson, 1978; Good, 1994). Rivers saw primitive medicine and modern medicine as two separate, incompatible entities of study in which magico-religious beliefs and practices of primitive medicine could not be considered in the same realm as naturalistic-scientific modern medicine (Wellin, 1977).

Anthropologist Forest Clements’s work “Primitive Concepts of Disease” (1932) undertook a systematic diffusionist “culture-trait” approach to the analysis of non-Western medical beliefs and practices. He identified five etiological categories: sorcery, breach of tabu, object intrusion, spirit intrusion, and soul loss. The distribution of these traits was then mapped on a worldwide basis and the chronological sequences, pathways of diffusion, and geographic centers for each of the traits were postulated. Clements’s work added credence to the concept that all cultures develop systems of health care that define disease (see Wellin, 1977).

Erwin Ackerknecht (1942) is attributed with being the first to establish medical anthropology as a subfield of anthropology. He applied functional theory to the ethnographic study of medical beliefs and practices of non-Western cultures. He was influenced by British functionalists, the French sociologist Marcel Mauss, Boasian tradition, and in particular Ruth Benedict at Columbia University. Many of the essays Ackerknecht wrote during the 1940s and 1950s are included in Medicine and Ethnology: Selected Essays (1971). He explored from a cultural relativistic perspective how the perceived cause of a disease reflected lines of social tension in a society and how the threat of being accused of causing an illness by witchcraft or sorcery could operate as a powerful sanction to maintain the status quo by preventing deviation from social norms.

Ackerknecht (1942) was among the first to argue that disease concepts were culturally constructed: “What is disease is, in the last instance, not a biological fact but a decision of society” (p. 167). He differed from Clements in that he focused on the total cultural configuration of a society, not individual cultural traits. He also did not see primitive medicine as a single entity but rather that each culture had its own system. A medical system was viewed as an integral part of a society as a whole but varied from society to society in how it was interrelated to other parts of a society. Disease in non-Western cultures was seen to be an artifact of customs and beliefs and divorced from the nature and distribution of disease and adaptation to the environment. He also saw primitive medicine as a totally separate entity from Western “scientific-based” medicine (see Wellin, 1977).

Physical (Biological) Anthropology

Physical (biological) anthropologists have contributed to the understanding of how human evolution and cultural factors influence disease and human health. The biological approach examines morphological, physiological, and genetic variation among people living in different kinds of conditions. Their interest in human biology, human growth and development, genetics, and serology parallels areas of interests of biomedicine. Biological anthropologists share common interests with medical anthropologists in their study of “the distribution of disease, physiological adaptations to disease and social factors related to health status” (Brown, 1998, p. 2). Evolutionary theory concerns understanding disease in the past and understanding what past diseases may tell us about contemporary health issues. The second biological approach concerns morphological, physiological, and genetic variation among people living in different kinds of conditions.

Culture and Personality

he culture and personality movement of the 1930s and 1940s brought anthropologists and psychiatrists together to study how personality and the sociocultural environment are interrelated. A wide range of topics were investigated during this time: (a) the nature/nurture debate, (b) sibling rivalry, (c) instinct, (d) aggression, (e) culture-bound syndromes, (f) the cross-cultural applicability of Freud’s theory to mental illness, and (g) the universality of biomedical-psychiatric categories (see Pool & Geissler, 2005).

Studies during this period were primarily theoretically oriented but others focused on how to improve health care. Ruth Benedict’s (1934) Patterns of Culture is a seminal theoretical work of the period. According to Benedict, each culture selects a few personality traits from the pool of characteristics of “human potentialities” that become the unique personality of a culture that in turn influence the personality traits of people living in that culture. Representative studies that focused on improving health care included the Leighton’s (1941) study of introducing modern health care to the Navahos, the Devereaux’s (1940) study of therapeutic fitness on a schizophrenic ward, and Joseph’s (1942) description of how cultural differences about the roles of biomedical physicians and Indian patients in Southwest America hampered therapeutic interaction.

International Public Health Movement: Post-World War II

Anthropologists began work in the international public health field in the 1930s and 1940s. In 1942, the United States partnered with several Latin American countries to address public health concerns. But it was the international public health movement after World War II that helped to crystallize the role of anthropology in the study of disease and medical health care systems. Applied medical projects during this period attempted to solve health problems in particular cultures. Among the early backers of public health projects was the Rockefeller Foundation sponsoring applied projects, such as Philips (1955) hookworm campaign in Ceylon. After World War II, the applied roots of medical anthropology were extended through cooperative foreign aid programs initiated in countries in Asia and Africa. The early programs were administered through the International Cooperation Administration and later through the United States Agency for International Development and the United Nations World Health Organization (WHO). The primary goals of the programs were to stamp out epidemics, improve water supplies, and identify factors that hindered and/or facilitated the carrying out of and success of the aid programs. It was also during the 1950s that anthropologists were first assigned to official positions in international health organizations: Cora DuBois at WHO, Benjamin Paul at the Harvard School of Public Health, and George Foster at the Institute for Inter-American Affairs, among others (see Baer, Singer, & Susser, 1997).

Among the most influential works of the post-World War II movement was Benjamin Paul’s edited work Health, Culture and Community: Case Studies of Public Reactions to Health Programs (1955). This work was a major contribution to the field of applied anthropology and public health. The focus of this work was to investigate “the immediate situation where medicine and community meet” (p. 4). He introduced social science methodology into the study of medical health care systems. His work revealed that in order for Western-based medical intervention programs to be successful it was necessary to take into account local beliefs about how health and illness are defined and manifested and the perceived causes of and treatments for illnesses. He was concerned with examining how a traditional medical system reacted to the introduction of new health-related practices and how traditional practices in turn influenced the contributing medical system. Other works during this period that contributed to the development of the field of medical anthropology were Caudill’s (1953) survey of anthropological studies in the field of health care in “Applied Anthropology in Medicine” and Scotch’s (1963) general literature review of medical anthropology.

As a result of the work of medical anthropologists in the international public health arena, several universals of medical systems were identified: (a) Every culture has a medical system; (b) disease is pathologically defined, but illness is culturally defined; (c) medical systems have both preventive and therapeutic sides; (d) medical systems provide the etiology of an illness and the appropriate treatments; (e) a disease theory system answers the question, Why did this happen to me; (f) medical systems play important roles in approving of and supporting social and moral cultural norms including the control of aggression; (g) disease theory systems play a role in the conservation of medical practices; and (h) traditional medical systems often play an important role in national identity and pride (Foster & Anderson, 1978, pp. 38-47).

Society for Medical Anthropology

The brief history of the Society for Medical Anthropology is found on two Web sites: the Society for Applied Anthropology Web site (www.sfaa.com) and the Medical Anthropology Web site (www.medanthro.net). While the beginning of medical anthropology can be traced back to the turn of the 20th century, it was not until the 1960s that a more formal organization began to take shape and is known today as the Society for Medical Anthropology. The earliest origins of the Society for Medical Anthropology are traced to the Roster of Anthropologists, Physicians and Others Who Have Special Interests in Medical Anthropology—the name of the organization at the time. The group changed its name to the Organization of Medical Anthropology (OMA) in 1967. At the 1968 annual meetings of the American Anthropological Association (AAA), the OMA offered its first workshop and changed its name to the Group of Medical Anthropology. At the 1970 American Anthropological Association (henceforth AAA) Annual Meetings, the OMA was renamed the Society for Medical Anthropology (SMA) and adopted its constitution and officially became a section of the AAA. Today, the SMA is one of the largest sections in the AAA.

The major journals affiliated with the SMA include Medical Anthropology Quarterly, Medical Anthropology, Culture, Medicine and Psychiatry, Social Science and Medicine, and Ethnomedizin. The SMA has close ties with the Society for Applied Anthropology; the Association for Anthropology and Gerontology; the Society for the Anthropology of Food and Nutrition; Medical Anthropology Students’ Association; AIDS and Anthropology Research Group; Alcohol, Drug, and Tobacco Study Group; Bioethics Interest Group; Clinically Applied Medical Anthropology; Complementary and Alternative Medicine (CAM); Integrative Medicine Group (IM); Council on Anthropology and Reproduction; Council on Infant and Child Health and Welfare; Council on Nursing and Anthropology; Critical Anthropology of Global Health Study Group; Disability Research Interest Group; Global Health and Emerging Diseases Study Group; Pharmaceutical Studies Group; and Science, Technology, and Medicine (STM) Group (www.medanthro.net).

Today: Global Health

The works of medical anthropologists have contributed to both the theoretical and empirical understanding of the relationship between culture, medical knowledge, and practice. Several basic themes and questions addressed by medical anthropologists today are (a) the development of systems of medical knowledge and health care; (b) the roles of healers in the well-being of societies through the study of patient-practitioner relationships and the relationships between different types of health practitioners; (c) the integration of alternative and complementary medical systems in culturally diverse environments; (d) the interactions among and impact of biological, environmental, and social factors on health and illness at both individual and community levels; (e) the impact of general political and economic forces on the health of individuals and communities and the interplay between social structures (e.g., political and economic arrangements), ecological settings, and disease-causing agents; and (f) the effects of biomedicine and biomedical technologies (www.en.wikipedia.org/wiki/medical_anthropology).

Basic Concepts and Terms

As in any discipline, the jargon used has specific definitions that often vary from the lay definition of those terms. Baer et al. (1997, pp. 4-12) discussed several basic concepts and terms used in medical anthropology in the study of health care systems and issues related to health, disease, and illness: health, disease, illness, curer/ practitioner, medical system, medical pluralism, biomedicine, and ethnomedicine. The basic definition for each term is given below.

In 1978, WHO defined health as “not merely the absence of disease and infirmity but complete physical, mental and social well-being” (Baer et al., 1997, p. 4). The limits of this definition have come under question by critical medical anthropologists who argue that the definition should be expanded to include “access to and control over the basic material and nonmaterial resources that sustain and promote life at a high level of satisfaction” (p. 4).

Medical anthropologists differentiate between disease, which is generally defined as a pathological or physiological disorder, infection, or malfunction of the body, and illness (sufferer experience), which is defined as a culturally constructed concept of how people conceive of a particular physical state as being deviant from the normal state (Baer et al., 1997, pp. 6-7). Brown (1998, pp. 8-9) summarized the conceptual significance of the distinction of disease/ illness in the study of the social construction of illness behavior including the sick role, medical decision making, seeking of treatment, and the social production of health (see Weller & Romney, 1988; Young, 1980).

Foster and Anderson (1978, pp. 148-153) identified six social roles of illness: (1) Illness provides release from unbearable pressure, (2) illness helps account for personal failure, (3) illness may be used to gain attention, (4) hospitalization may be a vacation, (5) illness may be used as a social control device, (6) illness may be a device to expiate sin.

In reaction to the existence of threats posed by disease, each culture develops a medical system that consists of culturally based learned behaviors and beliefs that include a theory of disease causation and treatment. Curers or practitioners are specific people with special knowledge who know how to diagnose and treat sickness. Medical pluralism is the coexistence of different medical systems within one society (Baer et al., 1997, pp. 7-11).

Biomedicine, also referred to as scientific, allopathic, Western, or cosmopolitan medicine, among other terms, focuses on the pathology and external causes of disease (e.g., germs, viruses, bacteria) and symptoms while emphasizing treatment of disease more than prevention (Baer et al., 1997, pp. 11-13). Ethnomedicine refers to the culturally constructed health care systems of any society. Other terms associated with ethnomedicine are terms such as folk medicine or popular medicine. Until the turn of the 21st century, biomedicine and ethnomedicine were treated as separate systems with the scientific-biomedical approach seen as uniform, objective, and not culturally constructed. Lynn Payer’s (1988) study of biomedicine in England, Germany, France, and the United States clearly demonstrated that biomedicine is not a uniform medical system but is also a culturally constructed system of medical care that varies from one culture to another.

Approaches

Brown (1998, p. 2) gave an overview of the two basic approaches used by medical anthropologists to address questions related to disease and health care—the biocultural and cultural approaches. He points out that variation in theoretical orientations and application of different methods for research and analysis exist within each of these approaches.

Biocultural Approach

The biocultural approach examines the ways in which people adapt to their environment and how the changes they make in their environment improve or worsen their health conditions. Topics investigated from a biocultural approach include disease in human evolution, health and medicine, human biological variation, human growth and development, paleopathology, bioarchaeology, and the history of health and culture and political ecologies of diseases.

Cultural Approach

The cultural approach examines the underlying ideas, beliefs, and values used in the classification of illness and medical systems developed for the treatment of illness. Topics investigated include belief and ethnomedical systems, the social construction of illness and the social production of health, healers in cross-cultural perspective, culture, illness and mental health, and critical medical anthropology.

Applied Approaches

Applied medical anthropologists apply anthropological theory and method to specific medical problems. The two main areas of application in medical anthropology are clinical studies and public health. Clinical studies have focused attention on understanding the differences between patient-and doctor-explanatory models in an effort to improve communication and health outcomes. The public health area of application focuses on public health policy making, program development, and interventions that are culturally sensitive, address local needs, and secure support of local communities (Brown, 1998, pp. 16-17).

Pool and Geissler (2005) pointed out that “applied medical anthropology is aimed at solving health problems in particular settings…. Theoretical medical anthropology is aimed at understanding the functioning of medical systems as cultural phenomena and develop more general theories about underlying processes” (p. 31).

Theoretical Approaches

The classification of theoretical perspectives in the research of medical anthropologists varies. For example, Byron Good (1994) in Medicine, Rationality, and Experience: An Anthropological Perspective discussed four theoretical approaches: (1) the empiricist paradigm, (2) the cognitive paradigm, (3) the meaning-centered paradigm, and (4) the critical paradigm. Ann McElroy and Patricia Townsend (2009) in Medical Anthropology in Ecological Perspective discussed four theoretical approaches: (1) medical ecological theories, (2) interpretive theories, (3) political economy or critical theories, and (4) political ecological theories. Joralemon (1999) identified the cultural constructivist or interpretive approach, the ecological or ecological/evolutionary approach, the critical medical approach, and the applied medical approach. The following section summarizes the basic tenets of the primary theoretical approaches used by medical anthropologists.

Ecological/Evolutionary Theoretical Medical Approach

Until the 1960s, the theoretical orientation of studies in medical anthropology was based primarily on a sociocultural approach. In the 1960s, the theoretical orientation shifted to a more biological approach. The ecological/evolutionary approach is a biocultural approach to the study of disease that applies the concept of human adaptation to the dimensions of disease. Examining the interaction among a population’s ecological system, its health conditions, and its forms of adaptation provides ways to examine how humans adapt to different environments and social and cultural changes.

Alexander Alland (1970), one of the first proponents of the approach, argued that humans either do or do not adapt to environmental challenges by genetic, physiological, or cultural changes. Three basic premises underlying the medical ecological approach are (1) environmental adaptation is a measure of health while disease indicates disequilibrium, (2) disease mirrors human biological and cultural evolution, and (3) biomedical disease categories are universal. McElroy and Townsend’s Medical Anthropology in Ecological Perspective (1979) is a work built on Alland’s model extending the approach to include a more political-ecological orientation. This approach is closely associated with that of medical epidemiologists, ecologists, and medical geographers (p. 3).

The ecological model has been criticized for not recognizing the effect of the structure of social relationships on influencing which cultural constructions rise to power. Critical medical anthropologists raise two basic questions: (1) Whose social realities and interests are expressed in specific cultural constructs? (2) What were the historical realities that gave rise to them? They also criticize the ecological approach for considering only the external reality of nature and not the evolutionary history of hierarchical social structures that result in the evolution of the political economy of human society (Baer et al., 1997, p. 23).

Cognitive Theoretical Medical Approach

Farmer and Good (Pool & Geissler, 2005, pp. 34-35) define that the focus of the cognitive theoretical approach is to reveal and describe the underlying cultural conventions and ideas that structure people’s interpretations of illness. This approach examines how societal and individual variations in the cognitive processing vary from one culture to another. Early studies focused on the classifications of symptoms of illness, diseases, causes of illness, and types of healers and how they are organized in relation to each other including patterns of health care seeking. Cognitive anthropologists examine cultural models of particular disorders, their cross-cultural variation, and the levels of consensus about them among individuals. Some focus on illness narratives, their cultural shaping, and the cultural models that underlie their production. They look for the relation of formal properties of illness models to the natural discourse, context, and performance characteristics of illness representations.

Criticism leveled at the cognitive approach focuses on illness representations being simply abstracted “mentalistic terms” that do not take into account the social and historical factors that have contributed to the illness meanings. They admonish cognitive anthropologists for paying little attention to the pragmatic and performative dimensions of the illness models that are presented in formal, semantic terms. They also note that the methods used to elicit the cognitive models may, in fact, be an artifact of the methods themselves and the mode of elicitation (Farmer & Good, 1991).

Cultural Constructivist, Cultural Interpretive, Meaning-Centered Medical Approach

The cultural-interpretive theoretical approach to medical anthropology began in the 1970s when Arthur Kleinman (1978, 1980) argued that medical systems were cultural systems and that “explanatory models” could best explain how illnesses are understood by all those who participate in an illness experience—the individual, the family, the practitioners. Cultural-interpretive anthropologists explore the cultural construction of illnesses and the responses to disease. Explanatory models provide insight into perceptions held about etiology, diagnosis, pathology, physiology, possible consequences, and the appropriate treatments for an illness. An individual’s construction of his or her explanatory model of an illness may differ from that of the practitioner as a result of cultural, ethnic, and social differences. The result is mis-communication between practitioners and patients. Kleinman advocated for medical anthropologists to work in clinical settings in order to elicit patient-explanatory models of illnesses and thereby facilitate doctor/patient relations and communication.

Good (1994) attributed the development of the cultural-interpretive approach as a direct response to the ecological/ evolutionary approach. The underlying difference between the two approaches is that the ecological approach treats disease as part of nature and is therefore external to culture, while the cultural-interpretive approach sees disease as an explanatory model or cultural construction of human reality. Cultural-interpretive researchers work with patients and practitioners in clinical environments in their investigation of explanatory models. This differs from the methods used by researchers of the cognitive approach who used formal elicitation methods to determine the underlying codes and structure of people’s interpretations of illness.

Byron Good and Mary-Jo Delvecchio Good developed the “meaning-centered approach” to the study of illness that builds on the basic suppositions of the interpretive approach (B. Good, 1977; Good & Good, 1980, 1982). “The meaning of illness for an individual is grounded in—though not reducible to—the network of meanings an illness has in a particular culture” (Good & Good, 1980, p. 176).

Critical medical anthropologists cite the interpretive and meaning-centered approaches for not paying attention to the asymmetrical power relations in the clinical setting and how such imbalance in power contributes to the maintenance of social dominance (Baer et al., 1997, p. 25).

Critical Medical Theoretical Approach

The critical medical-anthropology approach combines Marxist theory and dependency theory to analyze the effect of the global political-economic systems on local and national health. Press (1990, p. 1001) listed three primary concerns of the critical medical anthropology approach: (1) How do capitalism, imperialism, and/or Western technology affect health care in third world nations? (2) What roles do logistics and availability of, allocation of, and access to biomedical resources play in both the non-Western and industrialized nations? (3) What is the role of biomedicine as a means of spreading world capitalism?

Critical medical anthropology addresses questions such as “(1) Who has power over agencies of biomedicine? (2) How and in what forms is this power delegated? (3) How is this power expressed in the social relations of the various groups and actors that comprise the health care system? (4) What are the principal contradictions of biomedicine and associated arenas of struggle and resistance that affect the character and functioning of the medical system and people’s experience of it?” (Baer et al., 1997, p. 27).

The critical medical approach focuses on practice rather than symbols and meaning and promotes experiential health versus the functional health associated with global political economies. Critical medical anthropology is concerned with how wealth, power, and socioeconomic status affect the patterns and distribution of disease and challenges the underlying suppositions of the biomedical disease model. It examines how the representations and misrepresentations of illness operate to strengthen the control of the wealthy and powerful as well as the forms of resistance by those who are suffering illness and distress. Critical medical anthropologists propose that an analysis of power relations in the delivery of health services should distinguish four major levels of analysis: (1) the macrosocial level, (2) the intermediate social level, (3) the microsocial level, and (4) the individual with a goal of synthesizing the macrolevel, the middle level, and the microlevel (Baer, 1990, pp. 1011-1012).

One problem Press (1990) cited for the critical approach is that it offers little insight into “on the ground medical organization, staff/patient interaction, and the culture of patienthood in specific cases of disease or illness” (p. 1001).

Critical Interpretive Approach

The critical-interpretive approach synthesizes the critical medical-anthropology approach and the explanatory model approach by incorporating a microlevel and macrolevel approach to understanding health care. The explanatory model provides insight at the microlevel into patient beliefs, while critical medical anthropology reveals the social, economic, and political dimensions that influence health care. In the critical-interpretive approach, medical knowledge is not conceived of as an autonomous body but as rooted in and continually modified by practice and social and political change.

Nancy Scheper-Hughes and Margaret Lock (1987) challenged the nature of the biomedical separation of “mind from body, spirit from matter, and real from unreal” (p. 6) in their proposed critical-interpretive approach. Lock and Scheper-Hughes (1990) defined the task of critical-interpretive medical anthropology as first to “describe the culturally constructed variety of metaphorical conceptions (conscious and unconscious) about the body and associated narratives and then to show the social, political and individual uses to which these conceptions are applied in practice” (p. 44). They identify the body in three ways: (1) the individual body, or “body-self,” and the vulnerability of the body as it is experienced in health and sickness; (2) the social body represents the state of health of nature, society, and culture itself. If the body is healthy, then it is a model of “organic wholeness.” If it is sick, then it is a model of disharmony, conflict, and disintegration and vice versa; (3) the body politic represents the regulation, surveillance, and control of both the individual and collective body in “reproduction and sexuality, work, leisure and sickness” (Lock & Scheper-Hughes, 1990, pp. 45-70).

Methods

Most medical anthropologists are trained in cultural anthropology and use the cultural approach, theory, and research methods of anthropology in the study of health care, but they also draw on other social-behavioral sciences including biology, psychology, epidemiology, nutrition, clinical, and social sciences. Qualitative research uses a multimethod approach in data collection, also referred to as triangulation of data. Triangulation provides a method by which the researcher can arrive at an in-depth understanding of the phenomenon being studied by using a combination of multiple methodological practices, empirical materials, perspectives, and observers in a single study. This strategy adds rigor, breadth, complexity, richness, and depth to any research.

Among the traditional methods used by anthropologists in qualitative work are structured and unstructured interviewing, participant observation, direct observation, key consultant interviews, in-depth interviews, focus groups, life histories, systematic interviews, questionnaires, household and community surveys, mapping (physical and social), network analysis (clique and structural equivalency), decision modeling, and photography. Before the turn of the 21st century, new methods were being developed that allowed anthropologists to conduct rapid assessment of health care issues and concerns.

Trotter (1991) discussed the new methods developed for rapid assessment. Rapid methods are used “to identify key issues, cultural domains, health beliefs and sociocultural conditions that might act as either barriers to the success of the proposed health project, or to act as supporting mechanisms that would allow the project to succeed” (p. 187). The rapid-assessment techniques can be divided into three groups: (1) those that assist in determining the content and limits of cultural domains in the area of health care (e.g., free listings), (2) those used to determine the basic structural framework of cultural domains (e.g., triads, pile sorts, and scales), and (3) those that explore the consensual properties of a cultural domain (e.g., consensus theory approach) (Trotter, 1991, pp. 187-188; see also Bernard, 2002; Gladwin, 1989; Pelto & Pelto, 1996; Young, 1980).

Future Directions

Singer (1989) proposed that the four theoretical approaches used by medical anthropologists should be integrated to maximize their full potential in addressing health care issues. Baer et al. (1997) reported advances in the integration of three of the primary theoretical models. Medical ecologists moved toward a more political-ecological orientation. Interpretive medical anthropologists acknowledged, attempted, and produced work that took into account political and economic issues. Critical medical anthropologists became more sensitive to political ecology and the significance of political economy in the construction of meaning.

Integration of the different medical-anthropological theoretical approaches provides three major benefits to the study of health care and to the understanding of the factors that affect diseases, the effectiveness of treatments and health care delivery from local communities to the global community. Specifically, integration provides a means for medical anthropologists (1) to examine the ecological, biological, and cultural factors affecting diseases and their treatment; (2) to take into account the political and economic forces that have an effect on disease patterns and access to health care resources; and (3) to provide for the possibility of the needed health-based interventions (Joralemon, 1999, p. 12).

The 21st century offers multiple opportunities for interdisciplinary approaches to the study of health issues. Physician-anthropologist Cecil Helman (1994) called for future research to involve “adopting a much more global perspective—a holistic view of the complex interactions between cultures, economic systems, political organizations and ecology of the planet itself” (p. 338). But an interdisciplinary approach is equally important. Medical anthropology’s recognition of the interrelationship among disease patterns, a society’s belief and value system, and its socioeconomic structure lends a complementary approach to epidemiology’s study of the distribution and determinants of disease (Trostle & Sommerfeld, 1996, p. 253; see also Glass & McAtee, 2006; Janes, Stall, & Gifford, 1986). Medical anthropology provides public health care programs with insights into local cultural beliefs and values. These insights help reduce barriers to interventions and foster an increase in cooperation between traditional and biomedical practitioners. Medical anthropologists working on the international projects provide insights into the culture of international health programs and policies and their effect on health care delivery. As the global community shrinks and epidemics and pandemics become more common, a fully integrated, interdisciplinary approach to health care will provide the most effective approach to meeting the challenges of global health care.