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Images of health, illness, and healing are key media through which societies and groups struggle with central values and beliefs and negotiate social and political progress. The invention and implementation of techniques of health improvement have taken on many forms, including epidemic control, disease eradication, and combinations of environmental and individual behavioral change and medical advance. Yet definitions of health depend on normative and oftentimes conflicting values and contexts, which themselves are influenced by various transformations in economy and polity, science and technology, and culture. Such variables shape the conditions of health and are in turn affected by it. In attending to such reciprocal processes, anthropologists have demonstrated that health as an experience is irreducible to a set of strict criteria of physiological and mental competence or to a set of cultural differences. Only through concrete understandings of particular worlds of well-being and suffering and the way they are shaped by local histories and political economies can we possibly come to terms with the complex dimensions that protect or undermine human health. Health, seen in this way, is a construction as well as a contested way of being in the world.
- Images of Health and Diverse Experiences of Health
- Local Variations in Illness and Health
- Culture of Biomedicine
- Biotechnology and Health
Health and health practices are part of the inmost complexities of social existence, permeating the domains of politics, economics, and religion and almost always connected with dimensions that go beyond the body, such as interpersonal, family, and community relationships. Health is at once an end and a means. Explanations of the causes and patterns of health and disease often convey value judgments, senses of right and wrong and of accountability and blame, as well as reveal what is morally at stake in definitions of health and its failures. Medical anthropological studies have built upon historical and cultural analyses over a long period of time that indicate an array of difference with respect to the metaphors and meanings that signify health. These studies have emphasized cultural fabrics that give coherence and depth to these meanings such that cosmology and ethical traditions come to define the body in states of sickness and well-being.
Anthropological studies focus on local contexts where health and illness are recognized and responded to. Such studies also trace the effects of global flows of commodities, information, finance, images, people, and pathogens on such worlds. Anthropologists have been as interested in the social roots and consequences of health (and illness) as in their cultural representations. But what most particularly characterizes the anthropological perspective is the use of ethnography to understand health, illness, and health care. Anthropological perspectives on health bring together individual and collective realities in the way they are organized, narrated, contested, and in every sense lived as social trajectories (Kleinman, 1995).
What anthropologists have learned through research in different societies is a story of diversity in experiences of health and health care giving, as well as of the ways social relationships and emotional processes interfuse in the mediation of health-relevant experiences. The meanings of health range from holistic and organic interpretations to hyperindividualistic ones. While biomedicine has treated health as a separate domain, popular meanings and interpretations of healthy states are often inseparable from other moral, political, and economic domains. Anthropologists have been particularly concerned with the transformations in health as those transformations express differences in power, social position, and social inequality, particularly as experienced by marginal groups and individuals. But in recent years, equal interest has been devoted to studies of health professionals, bureaucrats, and scientists who contribute to the public definition of health and health problems. Culture affects health as much through the culture of biomedicine and bureaucratic institutions as through the popular culture; indeed in the age of wide-ranging social media the two are closely related.
Applied medical anthropology addresses issues such as the ones raised and addresses them at the policy level. In heterogeneous societies such as North America and Western Europe, cultural differences continue to matter in the health field in large part because of differences in health conceptions which affect the panoply of health-relevant practices, from popular assessments of risks and responses to them to the uses and misuses of health care resources. Those differences contribute to different health outcomes for people; but they also contribute to different health systems, which are themselves undergoing transformation due to both local and global economic and social changes.
Images of Health and Diverse Experiences of Health
The contemporary world contains impressive variations of images of health, modes of health maintenance, efforts at prevention, and illness experiences. Much of this variation is subsumed under what demographers and epidemiologists have termed the ‘health transition.’ This phrase refers to an increase in life expectancy, decline in mortality, and overall decrease in infectious diseases in the twentieth century by means of interventions such as vaccinations and dietary improvements. Health status measures have been introduced and are continually revised to develop policy, planning, and evaluation; these measures shape ideas of health and health improvement according to specific indices that promote interventions and sociobehavioral change. The health transition has also been accompanied by major changes in patterns of morbidity, increases in chronic degenerative diseases, old and new epidemics, and behavioral and mental pathologies and is thus more complex than its original conceptualization (Chen et al., 1994). The very economic, technical, and industrial development that has benefited so many coexists with ongoing massive societal disruptions. Developing countries, for example, are experiencing the social and health costs of rapid urbanization and economic restructuring, costs that are confirmed in statistical increases of preventable disease and chronic illness, and borne in terms of health problems such as infant mortality, life-threatening dehydration, urban violence, and hunger (Scheper-Hughes, 1992; Bourgois, 2002). Such acts as war, political persecution, and homicide contribute to a deliberate production of suffering and death. The era of infectious diseases is by no means past as the spread of HIV/ AIDS, multidrug resistant tuberculosis, and other infectious diseases suggest. The collapse of public health measures and treatment regimens, demographic changes, migration, and other human actions intensify the flows and resistance of pathogens. It is through such mechanisms that Paul Farmer has shown the ways social forces alter disease distribution and contribute to the persistence of new microbial conditions; indeed, the way “social forces and processes come to be embodied as biological events” (1999: p. 5). The appearance of these disorders, closely correlated with poverty and social inequality, challenges the notion of a single biological etiology for disease and illustrates that these infectious diseases are mediated by multiple interacting causes that require anthropological inquiry and policy intervention.
The burden of chronic diseases such as heart disease, cancer, stroke, diabetes, and asthma continue to be distributed unevenly across minority groups. Yet statistics also disclose impressive variations. In the United States, for example, there is the so-called Latino Epidemiological Paradox: Latinos, who generally experience a low socioeconomic status, nonetheless, have health outcomes that are either equal or better than non- Hispanic whites. African Americans, by comparison, experience significantly higher rates of infant mortality, death, diabetes, HIV/AIDS, heart attacks, strokes, and homicides. Differences in levels of institutionalized racism, dietary patterns, and the influence of the Spanish language as a protective barrier have been pointed to as possible explanations for this paradox. Notably, health indices of Latino immigrants worsen from generation to generation in the United States, owing to increased assimilation, a loss of balanced diet, chronic insecurity, as well as limited accessibility of health care services (Hernandez and Charney, 1998; Galvez, 2011; Waldstein, 2010; Holmes, 2013).
The latest cluster of disorders to receive attention in the health transition is the rising rates of substance abuse, violence, psychological trauma, depression, suicide, and related mental health problems (Desjarlais et al., 1995). This group of health problems has increased to epidemic proportions both in developed and developing societies. Anthropological studies indicate that these problems often cluster together in settings of deep poverty and societal breakdown. They are compounded by the fact that services tend to be limited, and health care financing and resources are inadequate. Many psychiatric hospitals in China, Russia, and Latin America and elsewhere continue to rely on a model of care involving prolonged stays in locked wards with antipsychotic medication and maltreatment (Phillips et al., 2013; Gostin and Gable, 2004). Anthropological interventions have gone beyond explication of the ‘soft’ variables underpinning mental health problems and focus on the ways social, economic, and political contexts shape the formation, distribution, and manifestation of disorders. Thus in the anthropological perspective, health problems and social problems are inseparable; health policies and social policies are viewed as necessary complements in defining criteria and techniques of successful rehabilitation.
Local Variations in Illness and Health
In response to emerging sets of health issues, anthropologists have identified the need for cross-cultural studies of health, healing, and morbidity in local contexts. One thread linking these studies is the importance of understanding patterns of everyday life experience, local knowledge, and social networks that influence personal agency and access to health care, as well as biosocial modes of transmission of diseases. From this perspective, health is seen as not simply originating in individuals themselves or deriving strictly from social forces, but as being engendered in complex interactions between individuals and their social contexts (Leslie and Young, 1992; Good et al., 2010; Inhorn and Wentzell, 2012; Lock and Nguyen, 2010). Such lived responses may occur in contexts of medical pluralism where several therapeutic systems coexist in one cultural setting; or in circumstances in which symptoms are subject to several distinct classifications, diagnoses, and hence, therapeutic courses of action or, once again, where different moral and religious values shape health-promoting and disease-preventing activities related to diet and life style practices and support. By stressing contingencies and by detailing local histories of particular places and peoples undergoing many kinds of social change, ethnographies of health and medicine highlight the way that particular worlds define health and conceive of health equity, while also illuminating the ways in which risks to disease and illness interrelate.
It is not surprising that ethnographers have focused on illness whose event structure is relatively defined. Emphasized is the experience of illness as an interpersonal phenomenon as it is narrated through stories of illness. Ethnographies disclose how suffering is transformed through language and cultural meanings into distinctive illness, narratives whose shared metaphors, voices, and genres represent distinctive experiences and political processes. This transformation, in turn, shapes the lived experience of illness through embodiment of cultural meanings and social relations into body-self processes.
Ethnographers have also focused on different mediating processes – ritual, devotional practices, music, and poetics – that structure a sociosomatic continuum between moral and emotional states. This approach relates to the concept of ‘local biologies’ by which is meant the different means of relating social worlds and biological processes such that those processes become particularized. Examples include Margaret Lock’s demonstration of fundamental differences in the experiences of menopausal symptoms and the aging process among women in Japan and North America (1993); Lawrence Cohen’s contrast of distinctive interpersonal experiences of dementia in India and the West (1998); Rayna Rapp’s description of how experiences of class in the United States and technologies of the female reproductive life cycle come to alter experiences of pregnancy, infertility, abortion, and delivery (1999); and Adriana Petryna’s analysis of biological citizenship and the deep vulnerabilities left behind by state interventions and failures to intervene in a nuclear crisis (2013).
Ethnographers have also analyzed the trajectory and outcome of illness experiences on the social course of illness. Thus Benedicte Ingstad and Susan Reynolds Whyte (2007) and others have shown how disability is as much a product of social definitions and restrictions and opportunities of access as it is a physical or functional limitation or disease, thus turning disability into an experience of potential wholeness and health. Other anthropologists have investigated societal responses to highly stigmatized disorders that respond to feelings of threat with practices aimed at marginalizing sufferers. Still others have studied experiences of chronic conditions like chronic fatigue syndrome, chronic pain syndrome, and fibromyalgia – disorders that are in a limbo of partial or minimal authorization where patients feel discredited or discreditable because of the lack of social legitimacy. Research here shows how patients often resist biomedical responses that are perceived as undermining and delegitimating.
More recently, this area of research has expanded well beyond biomedically defined conditions to include a variety of forms of violence – structural, political, domestic – that represent significant threats to health. Here researchers of violence have shown how different societal idioms of those institutions authorized to deal with social problems – legal, welfare, religious, and of course medical – construct distinctive objects of programs and policies that not only differ greatly, but that coerce different courses of health and disease and outcomes of these conditions (Biehl, 2013; Das, 2006; Farmer, 2004; Han, 2012; James, 2010; Bourgois and Schonberg, 2009). Perhaps the largest field of anthropological inquiry has examined the varieties of community healing systems that parallel state institutions. Studies of herbalists, shamans, and other folk practitioners (and practices) illustrate how experience is manipulated, how meaning is negotiated, and how illness comes to serve some societal ends such as social control, cultural remembering, and political resistance. The point being that the collective significance of illnesses goes beyond individual and even familial concerns and plays a role in how societies remember, how social reality is legitimated, and how social worlds change (Adams, 2013; Biehl, 2007; Dilger and Luig, 2010; Hyde, 2007; Livingston, 2012; Kohrman, 2005; Langwick, 2010; Nguyen, 2010; Rivkin-Fish, 2005; Wendland, 2010).
The anthropology of health and medicine largely began as an applied field. There continues to be important segments of the field that seek application in public health and biomedical settings and in the policy arena. Such applied work classically demonstrated that health beliefs could either facilitate or become a substantial barrier to implementing policies and progress (Paul, 1955). More recently, anthropologists have engaged the nongovernmental, administrative, and political dimensions of international health agencies and the policy development process indicating how community organization can positively inform health and social programs in arenas such as HIV/AIDS prevention, cancer or infectious disease control, and family planning (Hahn, 1999). Hence, anthropology has moved from a stance of critique of application to a stance of generating novel applications combining anthropological knowledge and public health technologies to enhance health.
Nowhere is this better seen than in the recent attention to global health initiatives. Such initiatives and programs are booming in the United States and have begun also to displace earlier framings of the field (such as ‘international health’). Anthropologists are engaged in empirical and theoretical investigations of global health-related programs and epistemologies and are concerned with the actual impacts of these initiatives on medical care, citizenship, and governance (Farmer et al., 2013; Biehl and Petryna, 2013; Hahn and Inhorn, 2008; Singer and Derrick Hodge, 2010; Janes and Corbett, 2009; Nichter, 2008; Rylko-Bauer et al., 2009). Multiple theoretical ideas, methods, and epistemic frameworks cohabit within the broad enterprise of global health. Anthropologists engaging this field have pointed to the tensions between private markets and public interests in the design of collective and individual health. They attend to the breakdowns in public health systems and to the myriad social determinants of health (such as education, water, sanitation, vector control, air pollution, and violence prevention) that make people vulnerable to disease in the first place, as well as the humanitarian, legal, and experimental settings that make up new infrastructures of humanitarianism, survival, and global patient life – and where law and medicine become deeply personal (Redfield, 2013; Petryna, 2009; Fassin, 2009; Ticktin, 2011). Through intervention into these fields and analysis of how global health programs are implemented, received, or improvised, anthropologists have pointed to the limits of traditional evidence-making practices and models of care delivery, as well as to the moral values underpinning large-scale health designs. In measuring the value that interventions have for people, anthropologists have illustrated both intended and unintended consequences of these interventions on those in need and how they are ‘contested or resisted at different social scales,’ thus challenging the certainties of planners and implementers alike.
Culture of Biomedicine
Distinctions between health and disease or illness are patterned according to norms. Norms of health and disease often emerge through a combination of statistics patterns, public consensus around desirable health outcomes, and social definitions and responses to deviance (Mechanic, 1997). The extent to which biomedical norms have achieved a position of preeminence in health care systems and definitions of disease is undeniable. Biomedicine’s success in eradicating certain diseases and prolonging life shows that norms, however value-laden and socially constructed they may be, can indeed be health-enhancing (DelVecchio Good, 1995). Yet anthropological studies have questioned biomedicine’s reductionism, primary value of efficiency, and authority in mediating interpretations of health, illness, and suffering (Good, 1994; Kleinman, 1995); they point to the fact that physiological measures alone fail to capture the subjective, social, and even racialized dimensions of health (Rouse, 2009; Mattingly, 2010; Montoya, 2011; Fulwiley, 2011; Lee et al., 2008). The growth of biomedicine, its characteristic quality of redefining social problems as health problems needing biomedical intervention, and its global cultural reach have also been analyzed. That biomedicine has been closely allied with the growth of industrial capitalism has led many ethnographers to examine biomedicine as a deep conduit of social regulation and discipline influencing all sectors of life, from definitions of disability to norms of occupational health, to definitions of mental illness and fitness (Turner, 1995; Martin, 2009). This process has led to strong critiques regarding the necessity and indeed at times harmfulness of biomedical interventions, particularly with respect to the unpredictable side effects of technical procedures and drugs used to diagnose and treat patients. Public concerns over medically induced adverse effects (known as iatrogenesis) are reflected in current debates over the consumption of psychiatric drugs by preschool children in the United States, for example. Cross-cultural studies reveal the extent to which this integration with local experience is contested or resisted by highlighting: the many discrepancies between biomedical knowledge and subjective accounts of illness and health; the moral and religious tensions underlying choices of medical systems; and the degree to which distinctions between health and disease are rooted (or uprooted) by global ideologies and beliefs.
Attention to the international political economic context in which biomedicine operates is central to understanding how ideas of health modify, as well as to understanding the modes through which they are integrated as a set of values and practices in local contexts. As with nonbiomedical healing traditions, pharmaceuticals too are a compelling theme in the anthropology of health and medicine because they link individual understandings of disease and therapeutic practice with broader scientific and political–economic regimes of health (Whyte et al., 2002; Petryna et al., 2006; Ecks, 2013). The pharmaceutical industry is the major producer of today’s therapeutic armamentarium. In more than 70% of all medical doctor visits in the United States, doctors will prescribe or continue to provide a medication to a patient. On average, two drugs or ‘drug mentions’ have been documented per medical visit. Sustaining this pill-taking, life is a complex globalized system of drug testing and drug development. In capturing the trajectory of pharmaceuticals (including their regulatory dimensions, clinical testing, industrial production, and mass consumption), anthropologists have made critical inquiries into notions of ‘best evidence’ as well as changing boundaries between the normal and the pathological in worlds of commodified health. From local and national ethnographic perspectives, they engage the regulatory and international politics of patents and intellectual property and evolving health-as-human-right paradigms and infrastructures, and have assessed the impact of market-driven medicine on cultures of care, public health, and ethics.
Biotechnology and Health
In response to the large influence that public health has achieved in our times, many due to the advances of biomedicine and advances in technology, the power of state action in the public domain, and market forces, health has increasingly become a specialized domain. The history of public health is punctuated by major advances in population-level health in the nineteenth and early twentieth centuries, through sanitary and workplace improvements, housing, and nutrition. In recent years, public health priorities are shifting from social medicine (with its attention to the social determinants of health) to individually targeted health promotion. The launching and completion of the largest biology project ever conceived – the decoding and mapping of the human genome – has already accelerated this process of individualizing health vis-a-vis the genetic profiling of diseases and increased prognostic information. For example, silicon chips embedded with hybrid bits of DNA can test for various genetic conditions in individuals. Such ‘self-quantifying’ diagnostic tools are refocusing medical practice away from intervention to risk factor analyses and disease prevention.
The diseases individuals might be predisposed to, how they might react to particular medicines, and what health-promoting behaviors they might adopt to prevent future illness are all encompassed in this revolution (Rabinow, 1996; Eisenburg, 1999; Hamdy, 2012; Sanal, 2011; Roberts, 2012; Edmonds, 2010; Brotherton, 2012; Taussig, 2009; Fischer, 2009; Sharp, 2006; Dumit, 2012). Genomic information and the multitude of genomic sequences represent novel, but as yet largely unrealized, targets for therapeutic intervention. In short, the ‘life sciences industry’ – knowledge of the genetic code and how to manipulate it and therapeutic promises – is transforming diagnostics and intensifying screening for genetic disorders, often state-mandated (Timmermans and Buchbinder, 2012), but it has yet to usher in a new age of personalized treatment. As consumers embrace incremental self-improvement via genomic knowledge, the prospect of widespread genetic testing has prompted concerns about how such information is being used to discriminate against those labeled as predisposed to genetic risks. Historically, such discriminations took the form of restricting or denying insurance coverage or employment. Inherent inequalities of access to health care can also limit the effectiveness of new technologies.
The success of biotechnology highlights the growing demand for health as a market sector. It attests to the power of biomedicine as a rationality in everyday life (in the organization of health care and delivery, policy analysis, legal procedures) that comes up against other forms of knowledge such as religion, and that coexists with older power structures related to family, gender, ethnicity, and class. Health as commodity, to be objectified, bought, and sold in the marketplace has led to new freedoms to pursue health as an individual project, but also raises dilemmas and creates new risks: who is caretaker of genomic information? Who will have access to genetic therapies? These questions highlight some of the dangers regarding the social uses of genetic knowledge in the genomic and postgenomic era; they make it difficult to say what counts as success in this drive toward health and profits, a drive which has both sacred and secular sources and consequences.
The tradeoff between benefits to individuals and risks to populations of any given new technology must also be carefully assessed. For example, over a decade ago xenotransplantation promised to end the so-called shortage in donor organs by engineering transplantable animal organs. While breakthrough technologies might save the life of a few, they pose dangers to populations in terms of the resistant viral strains and antibodies that might develop as a result of such transplant procedures. Another example of the way scientific advancement produces new social risks is found in the case of the traffic in human organs. Such traffic has been afforded by the availability of cyclosporine, among other things. This availability, combined with demand for human organs, has turned vulnerable populations in Brazil, South Africa, and India into potential organ suppliers. Inconsistencies across the globe regarding the rights of donors as well as the lack of follow-up care for many of them have lead to prolonged suffering or premature deaths, or both. Processes related to the globalization of the life sciences industry demand ethnographic attention to technical advances in terms of their development and diffusion; patterns of accessibility and differences of improved health outcomes across socioeconomic divides; and new forms of health and vulnerability these advances engender.
As the life sciences redraw human experience and redefine life chances, anthropologist have turned their gaze once again to social relations, namely, to the moral dimensions and necessities of care and caregiving, particularly in the context of chronic disease such as dementia, diabetes, cancer, and addiction and global health and end-of-life care (McLean, 2006; Norwood, 2009; Mol, 2008; Taylor, 2008; Garcia, 2012; Kaufman, 2006; Manderson and Smith-Morris, 2010). Care is fundamental to the managing of illness but it is often taken for granted or undervalued within professional medical practice and broader political and moral economies of health care. Anthropologists have described caregiving as “the close experiential language of actually doing it” (Kleinman, 2009: p. 292). The elderly, disabled, or chronically or terminally ill run the risk of being ‘unmade’ without the intimate practices of care that protect them as recognized persons. Anthropological studies of caregiving in cancer wards, hospitals, nursing homes, and hospice settings have pointed to the unexpected kin and social networks that sustain openness toward the humanity of the care recipient that an overly technical biomedical approach might foreclose.
Images of health, illness, and healing have become key media, a ‘fragile salvation,’ through which societies and groups struggle with central values and beliefs, and negotiate social and political progress. The invention and implementation of techniques of health improvement have taken on many forms, including epidemic control, disease eradication, and combinations of environmental and individual behavioral change and medical advance. Yet definitions of health depend on normative and oftentimes conflictual values.
Health as an individual goal coexists with new threats to health worldwide. The spread of advertising for cigarettes or the dumping of expired pharmaceuticals in low-income countries are all part of the globalization of disease. Under such conditions, what was once health, now becomes disease. Health maintenance and promotion, once so influential a concept, can be undermined owing to new political and economic realities.
Contexts of health are themselves undergoing changes and are influenced by transformations in economy and polity, in science and technology, and in culture. These contexts shape the conditions of health and are in turn affected by it. These processes demonstrate that health as an experience is irreducible to a set of norms of physiological and mental activity, or strictly to a set of cultural differences. Only through concrete understandings of particular worlds of suffering and the way they are shaped by local histories and political economies can we possibly come to terms with the complex human dimensions that protect or undermine health. Health, seen in this way, is a construction as well as a contested way of being in the world.
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