Eddie Rooke 1
What Can Medical Students Learn From Anthropology?
Most medical practitioners would find it difficult to give a definition of
anthropology and may not be acquainted with information on how factors such as
ecology, culture, and politics influence the health of a society. To many Western-style
medical practitioners (biomedical physicians), culture is something linked to noncompliance and misunderstanding and has no place in hospitals and clinics. It is hard
to dispute the massive benefits that the world has gained from biomedical progress,
but increasingly more people are growing disenfranchised with biomedicine, both in
Canada and around the world. As a medical student with an appreciation for
anthropology, I have always felt that biomedicine has much to gain from the social
sciences. This paper is my attempt to provide an introduction to medical
anthropology for medical students by discussing three main theories regarding
health and sickness: medical ecology, health systems theory, and critical medical
anthropology. I will also comment on an emerging theory, anthropological medicine,
and on research that might be of particular interest to medical students. Following
this, I will comment on the theory that seems most relevant and applicable to
medical students.
Medical Ecology
The holistic and interdisciplinary approach to looking at health and disease is
known as medical ecology. This approach tries to account for the many variables in
the environment that affect health: “medical ecologists view health and disease as
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reflections of relationships within a population, between neighboring populations,
and among the life forms and physical components of a habitat.” (McElroy and
Townsend, 2004: 2)
Ann McElroy and Patricia Townsend are major contributors to the ecological
model of medicine and favor it because it can incorporate the efforts of many
disciplines,
such
anthropology,
as:
physical
medicine,
traditional
anthropology,
healing,
environmental
archaeology,
studies,
and
cultural
applied
anthropology. Their theory of medical ecology relies on three central premises. The
first is that disease is caused by a “chain of factors related to ecosystem imbalances,”
(2004: 30) in addition to the clinical reasons for disease. The second premise is that
culture, biology, and physical environment are in constant interaction with each
other and health and disease arise out of this relationship (2004: 30). Thirdly,
environment is not solely the physical environment, but also the culturally created
environment that all human being live in (2004: 30). This includes buildings, farms,
slums, villages, and also social stratification, values systems, and worldviews.
McElroy and Townsend also utilize adaptation as part of health and medical
anthropology. They describe adaptation as “changes, modifications, and variation
enabling a person or group to survive in a given environment.” (2004:14) They go on
to say that “health is one measure of environmental adaptation, and that health can
be studied through ecological models.” (2004:14) There are many studies that
illustrate the role of adaptation between health, culture, and environment, but few
are more famous than the rising prevalence of sickle cell anemia in conjunction with
malaria in West Africa. Sickle cell anemia is a genetic variation that offers some
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innate protection from the illness caused by malaria. It was found that, as agriculture
became more common in West Africa, there was an increased risk of contracting
malaria because the environment had changed to one that fostered the growth of the
mosquito that carries malaria (Livingstone 1958 in Hanh, 1995: 60). Livingstone
(1958) concluded that, “the shift to agriculture thus fosters the introduction of
malaria, which in turn increases the likelihood that populations with high
frequencies of heterozygous sickle cell trait will survive.” (in Hanh, 1995: 60)
Finally, medical ecology theorists note the effect of politics and economics on
societal health. McElroy and Townsend believe that politics and economics play a
major role in the health of a community or society and state these as entities that
“must be considered in any model of ecology and health.” (2004: 31)
Health Care Systems
The health care systems theory is a widely recognized “cultural” theory of
health devised by psychiatrist-anthropologist, Arthur Kleinman. Kleinman believes
that health practices are part of a larger system of beliefs and values present in each
culture. Through cross-cultural analysis, Kleinman has discovered trends and
universals that he believes are crucial to understanding and comparing health care
systems. He theorizes on the components, factors, and influences that shape the
dynamics of a health care system. Kleinman describes internal and external forces
that determine the structure of a health care system; the universal clinical functions
of a health care system; how explanatory models affect health, outcomes, and
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relationships; the dynamics of therapeutic relationships; and how health care
systems are socially and culturally constructed.
A health care system contains all “health related components of society” and
therefore, “must be studied in a holistic manner as socially organized responses to
disease” (Kleinman, 1980: 24). Kleinman believes that in order to understand
universals such as patients, healers, illness, and healing we must view actions in the
context of cultural environment. By studying health care systems this way, we can
begin to make cross-cultural comparisons, which will eventually lead to
generalizations (Kleinman, 1980: 8).
The social reality of a group of people is created and perpetuated by the
community’s institutions, beliefs, values, ideologies, history, and worldview.
Likewise, clinical reality is created and influenced by these same forces. This means
that realities can vary, sometimes to great degrees, between societies, social groups,
professions, communities, families, and individuals (Kleinman, 1980: 36).
The structure of a health care system is heavily influenced by external factors
such as environment, economy, politics, history, and co-existing institutions.
Although these forces greatly affect health care systems, this theory is primarily
concerned with factors influencing the inner structure of health care systems. The
inner structure of a local health care system is broken down into 3 sectors: the
popular sector, the professional sector, and the folk sector. The popular sector is
usually the most robust in a given society: “In the United States and Taiwan, roughly
70 to 90 percent of all illness episodes are managed within the popular sector.”
(Kleinman, 1980: 50) This level contains the beliefs and actions of individuals,
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families, social networks, and communities and regulates the entrance into the
professional and folk sectors (Kleinman, 1980: 50). The professional sector is
comprised of groups of organized professionals, which may include western style
medicine, Ayurvedic medicine, or traditional Chinese medicine (Kleinman, 1980: 54).
When professional health care is brought to a new society, it undergoes a process
called indigenization, which is the change and modification made to it so that it suits
the local clinical realities. The third sector of a health care system is the folk sector,
which includes any non-professional group, or specialist group. Folk practices are
often classified as either sacred or secular.
Health systems theory identifies 5 main (clinical) functions that can be used
for comparison and analysis purposes (Kleinman, 1980: 71). These functions are:
1. The cultural construction of illness as psychosocial experience.
2. The establishment of general criteria to guide the health care seeking
process and to evaluate treatment approaches that exist prior to and
independent of individual episodes of sickness.
3. The management of particular illness episodes through communicative
operations such as labeling and explaining.
4. Healing activities per se, which include all types of therapeutic
interventions, from drugs and surgery to psychotherapy, supportive care,
and healing rituals.
5. The management of therapeutic outcomes, including cure, treatment
failure, recurrence, chronic illness, impairment, and death. (Kleinman,
1980: 71-72)
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Kleinman writes about the difference in explanatory models, which are “the notions
about an episode of sickness and its treatment that are employed by all those
engaged in the clinical process.” (1980: 105) Explanatory models are found in every
health system in the world, and like clinical reality, they differ between societies,
communities, families, and individuals. Even more importantly they can differ
significantly between patient and healer in all the different sectors of a health care
system (Kleinman, 1980: 105). Explanatory models attempt to answer 5 questions:
“(1) etiology; (2) time and mode of onset of symptoms; (3) pathophysiology; (4)
course of sickness (including both degree of severity and type of sick role – acute,
chronic, impaired etc.); and (5) treatment.” (Kleinman, 1980: 105)
One last important aspect of Kleinman’s health systems theory is his
description of the variables in “practitioner-patient interaction.” (1980: 207)
Important variables that can be determined are: institutional setting (specific
location among the different sectors and subsectors); characteristics of the
interpersonal interaction (number of participants, amount of visits and length of
consult, formal or informal, attitudes and views); idiom of communication (method
of communicating, explanatory model compatibility); clinical reality (sacred or
secular, disease oriented or illness oriented, symbolic or instrumental interventions,
therapeutic expectations, and locus of responsibility); and therapeutic stages and
mechanisms (structures involved, mechanism of change, adherence, termination,
and evaluation of outcome) (Kleinman, 1980: 207-208).
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Critical Medical Anthropology
Critical medical anthropology (CMA), which is closely associated with the
approach of political economy, is a major theory with many contributors. This theory
tends to focus on biomedicine (western, biologically based). Although there are
differences in beliefs and emphases, there are a few main and ubiquitous ideas that
are unique to CMA. CMA states that it is not sufficient to look at illness and its causes
without a thorough analysis of its relationship to the overarching political and
economical forces:
Critical medical anthropology understands biomedicine not solely as a
socially constructed system embedded in a wider cultural pattern, nor
only a as mechanistic and depersonalizing structure with important
social controls functions in contemporary society, but more broadly in
terms of its relationship with the truly global capitalist world economic
system (Singer and Baer, 1995: 33).
To critical medical anthropologists, power structures at the macro-social
level, intermediate-social level, micro-social level, and individual level, all influence
the health of a society (Singer and Baer, 1995: 63). Adherents of critical medical
anthropology do not ignore the impact of socially constructed realities, environment,
and ecology, but are weary of these factors distracting from the larger more ominous
factors (Baer, 1996 in Schnurr, 1998: 5). Critical medical anthropologists have been
know to criticize ecological/adaptive theories of health for ignoring the ways power
regulates access to health resources and determines who is at risk for illness (Hanh,
1995).
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The roots to CMA rest in Marxism, but not all critical medical anthropology
theorists and practitioners are strict followers of Marx. Singer and Baer believe that
the class struggle is an essential aspect to CMA:
Pivotal to the worldview of critical medical anthropology is recognition of
class and related race and gender antagonism as the defining
characteristics of capitalist society and the reigning world-system.
Classes have inherently conflicted social interests, in that, at its heart,
capitalism is a system designed to promote the ability of one class to
control and expropriate the labor of other classes (1995: 61).
Scheper-Hughes has contributed a significant amount of work towards the
maturation of CMA and is credited with bringing the theory in touch with the lived
experiences of suffers (Singer and Baer, 1995: 44-45). A central premise of CMA is
that the capitalist mode of production and consumption, as well as its current
hegemony, have led to great inequalities and power differentials. It also sees
biomedicine as a structure that helps to perpetuate this capitalist system through
both its unquestioned authority and for-profit agenda (Singer and Baer, 1995: 62).
Besides commenting on the structures and forces that contribute to sickness
and disease, CMA attempts to confront the medicalization of social issues.
Medicalization is the transformation of sickness due to social inequality, into a
medical diagnosis. This process diverts the blame of the illness from society onto the
individual or at least covers up the social and avoidable causes of the illness such as
poverty, racism, and exploitation (Schnurr, 1999: 8) Although controversial among
academics, many CMA practitioners believe that a crucial role of CMA is to stand up
Eddie Rooke 9
against the institutions that contribute to inequality and oppression and therefore
bad health. Singer and Baer write in their book, Critical Medical Anthropology that
“CMA asserts that its mission is consciously emancipatory and partisan: it aims not
simply to understand but to change culturally inappropriate, oppressive and
exploitive patterns in the health arena and beyond” and believe that this approach is
preferential to the “folly of so-called value-free social science.” (Singer and Baer,
1995: 61)
Anthropological Medicine
Robert Hanh has his own approach to medical anthropological theory. Hanh
makes it clear that theories, which do not account for the constant interaction of
different levels of society, are problematic. He analyzes the three major schools of
thought in medical anthropology (environmental/ecological/adaptation, cultural,
and political economy/CMA) and comes to the conclusion that many of their
elements are useful and can be used in conjunction to fully understand sickness and
health in a society. Hanh, however, gives priority to critical medical anthropology:
“while I believe that a comprehensive theory of sickness and healing must consider
adaptation and culture, my own theory would begin with the position of critical
medical anthropology.” (1995: 75) Hanh lists four reasons why CMA is an important
theoretical starting point. First, he believes that it is essential to take note of how
interactions in social settings are highly influenced by forces far removed from local
interactions. Second, Hanh believes that critical anthropology is right in addressing
the uneven distribution of sickness and power in the world, which is vital to
Eddie Rooke 10
understanding a society’s health. Third, CMA acknowledges that theory is a product
of culture and is open to this criticism. Finally, Hanh believes that theory and
research must be used as tools to correct injustices and inequalities and not to justify
them.
Hanh believes there is a crisis in health care around the world including in the
biomedical strongholds: North America and Europe. There are nearly 50 million
Americans without any health insurance (Miller, 2008), the expectations of
physicians and patients are often worlds apart (Hanh, 1995: 262), and patients do
not feel involved in their treatment plan and are bitter about their physician’s
income (Hanh, 1995: 263). Meanwhile, physicians are dissatisfied with practice, do
not feel they are respected by their patients, are frustrated with bureaucratization,
and are annoyed by insurers scrutinizing their work (Hanh, 1995: 263-264). Hanh’s
theory is founded in the principle that medicine does not need to function this way
and could work much better for patients and physicians:
In brief, anthropological medicine is a theory and practice that gives
primacy to sickness – conditions of patients as conceived and unwanted
by themselves – that accepts the social and cultural roots of both
professional and lay ideas and attitudes about sickness; that fully
recognizes the etiology of sickness in social and cultural as well as
physiological and environmental conditions; that also acknowledges
sociocultural effects in therapy and healing processes and respects the
social context of healing; and that addresses the well-being of healers and
their patients alike. It integrates a sociocultural perspective with a
Eddie Rooke 11
biological one at the core of medical education, medical practice,
research, and institutional arrangements (1995: 264-265).
Anthropological medicine offers 6 principles that can help remedy the illnesses
found in clinical medicine, public health, and international health. One of the core
beliefs in anthropology is the importance of listening. By hearing and understanding
a patient’s beliefs about sickness and health, life and death, and bodily functions the
likelihood of developing a treatment plan and mutual understanding is greatly
increased (Hanh, 1995: 275). The past shows that listening has led to successful
health programs such as the Polela Health Center in South Africa (Trostle, 1986 in
Hanh, 1995: 277).
Anthropological medicine recognizes the importance of understanding the
context in which people live, such as their social environment, economic status,
access to resources, and their exposure to sickness. Medical practitioners may need
to become ethonographers (Stein, 1982 in Hanh 1995: 280) in order to come up with
a treatment plan that is appropriate to the patient. Otherwise, it may be overlooked
that the patient does not have the money for medication, access to three meals a day
to take medication with, or that they have other day-to-day hardships that take
priority over managing their disease or illness.
There is a tendency to lump people who appear to be of one ethnic group into
a category of beliefs. This tendency can lead to many problems in healing, so
anthropological medicine prescribes recognizing intraethnic variability. There is a
long list of factors that can affect beliefs of people from a region: level of education,
place of birth, age of immigration, rural life, urban life, degree of involvement in local
Eddie Rooke 12
traditions, experience with the medical system, income, occupation, religion, and age
(Harwood, 1981 in Hanh, 1995: 281). Studies have found that great variability in
beliefs about illness exists within the ethnic categories of “Black”, “Hispanic”, and
“Asian/Pacific Islanders” (CDC, 1993a, qtd. in Hanh, 1995: 282). A study by Brieger
showed that even among communities in Western Nigeria that all identified as
Yoruba, there were large differences in health priorities (1984 in Hanh, 1995: 282).
Anthropological medicine addresses the need for “explaining, translating,
and brokering” in health care systems (Hanh, 1995: 282). Tests, procedures, and
prevention programs may not be understood by people within a health care system;
therefore, bilingual and multicultural practitioners and aides are needed in order to
reach an understanding between patients and practitioners (Hanh, 1995: 283).
Patients often enter the medical system with their own beliefs, taboos, and
practices regarding health; which should be respected. These differences in behavior
need not be barriers, they simply require that the practitioners and patients
accommodate for each other’s needs (Harwood, 1981 in Hanh, 1995: 285).
One final principle of anthropological medicine is the need to care for medical
practitioners. The needs of all those involved in health have traditionally been
ignored, as Stein says in 1982, “For the most part we instruct future clinicians as
though they as persons, are not really present. We hope that their years in
professional training have effectively socialized out of them any and all subjectivity –
the bane of scientific, objective medicine.” (qtd in Hanh, 1995: 287) The long hours,
stressful environment, and emotionally challenging cases can be very trying on
practitioners that do not have effective coping mechanisms. Unfortunately, “routine
Eddie Rooke 13
ways of caring for physicians themselves, particularly as they are affected by the
demands of their work, have not been widely established.” (Hanh, 1995: 287)
The practice of anthropological medicine in clinical settings makes the
experience of the patient’s illness central to treatment and acknowledges the social
environment in which that person lives. Arthur Kleinman and his colleagues, Good
and Eisenberg, stress the importance of disclosing the different explanatory models
(1978 in Hanh, 1995:270) in clinic so that the patient and practitioner are able to
create an understanding and a plan for treatment that is appropriate (Katon and
Kleinman, 1981 in Hanh, 1995: 270). George Foster (1987) describes a fallacy that
he calls the “silver platter model”, which is also known as the “empty vessel” fallacy
(Hanh, 1995: 272): when information, technology, or expertise is offered to an
individual or a group from the biomedical regime it is assumed to be needed to fill a
void or to provide an explanation where one did not exist previously. In reality, there
was likely an explanation already in place that was more culturally appropriate,
which is why attempts to introduce biomedical concepts to people and groups often
fails when adequate understanding has not been reached. Anthropological case
studies and research have described ways of packaging, accommodating, and
explaining that make information, technology, and expertise palatable not only to
specific cultural groups, but to entire societies as well.
Other Interesting Theory in Medical Anthropological
This next section is devoted to highlighting any other provocative
anthropological theory that is not necessarily a “grand theory”. The importance of
Eddie Rooke 14
the placebo effect, the socialization of medical students, and knowledge and practice
in biomedicine have been analyzed by anthropologists and have led to some very
interesting theories. I will briefly outline them here as I feel they are relevant to the
purpose of this paper.
The Placebo Effect
A placebo is a medical intervention that produces a desirable effect for the
patient; however the mechanism of this effect is unknown or cannot be proven
scientifically. Building on the work of scholars before him, Daniel Moerman has
studied the placebo effect and how it affects healing in ethnomedicine and
biomedicine. Moerman argues that biomedicine is guilty of ignoring the placebo
effect and regard it as unscientific, when in reality, it is as much a part of Westerm
medicine as ethnomedicine. His goal is not to discredit the efficacy of biomedicine
but to demonstrate the validity of symbolic healing in western cultures and cultures
around the globe.
Moerman illustrates the placebo effect by examining angina pectoris and two
procedures that have been devised by surgeons to deal with patients’ symptoms. The
first technique was through indirect revascularization and was reported to have
68% symptomatic improvement (Moerman, 1997: 244). After a double blind study
was conducted, it was found that the symptomatic reduction by this technique
“could be accounted for by placebo effects, and therefore should be discontinued.”
(Moerman, 1997: 244) The second technique is the infamous coronary bypass
surgery. Studies have shown that this procedure is successful in reducing symptoms
Eddie Rooke 15
“in 80 to 90 percent of patients with severe stable angina pectoris.” (Moerman, 1997:
245) However, a study by Gott and his colleagues in 1973 found a significant number
of patients reported reduction of symptoms even when their arteriography showed
that their bypass graphs were not functioning (in Moerman, 1997: 246). Moerman
believes that this case and others like it are compelling evidence for symbolic healing
and its legitimacy and that “the form of medical treatment as well as its content can
be effective medical treatment.” (Moerman, 1997: 241. Emphasis in original)
Knowledge and Practice in Biomedicine
Some fascinating work has been done in anthropology regarding knowledge
and practice in biomedicine. A central belief that is held about biomedicine is that its
practices are based in scientific evidence, but there is a wealth of evidence to show
that this is not the case (Hanh, 1995: 149). McKinlay has found that “many medical
interventions are accepted, adopted, and widely used in practice without valid
evidence, sometimes with detrimental effects and often at enormous expense.”
(1981 qtd. in Hanh, 1995: 150) New procedures are often accepted by physicians
after a promising report and eventually the procedure is accepted by the medical
community and the public (McKinlay, 1981 from Hanh, 1995: 149). McKinlay found
that randomized controlled trials are not done until after the procedure has become
standard and argues that they should always be done before the procedure is
adopted (1981 from Hanh, 1995: 150). After studying adoptions and scientific
evidence behind many medical techniques and procedures, Thomas Chalmers
estimated that only 5 % of current medical procedures had been validated with
Eddie Rooke 16
controlled clinical trials (1974 from Hanh, 1995: 150). It has also been found that
physicians use their personal experience as their primary source of knowledge and
clinical reasoning, which many believe is contradictory to the scientific process
(Hanh, 1995: 151).
Socialization of Students
Medical school is notorious for its heavy workload and extensive training.
Anthropologists have asked the questions, “how do students deal with this
workload?” and “what social transformations happen during those long years of
training?” Becker and his colleagues found that students are forced to abandon their
“idealistic goal of acquiring all there is to know” about treating patients (1961 from
Hanh, 1995: 157). It becomes clear to them that there is too much for them to learn
so they instead focus on what “they need for their exams and for later practice.”
(Hanh, 1995: 157) During this time, it was found that students learn to deal with
uncertainty and patients in an objective, detached manner to prevent getting
emotionally involved (Fox, 1956 from Hanh, 1995: 158). Medical students were
found to deal with the uncertainties of medical training, knowledge, skill, treatment,
and diagnosis by specializing (effectively narrowing their knowledge base) and by
adopting “a school of thought, its rationale and its practice, so that they need not
repeatedly consider alternatives.” (Light, 1979 qtd. in Hanh, 1995: 159) Students
were also believed to develop “a cloak of competence” in order to convince
themselves, their patients, and their preceptors that they had the knowledge, and
skills necessary to treat patients (Haas and Shaffir, 1987 from Hanh, 1995: 159).
Eddie Rooke 17
What Can Medical Students Learn From All This?
Medical students could learn a lot from seriously analyzing how medical
anthropological theories relate to their field of study. There is such a wealth of
theory and research in anthropology that can be considered useful and this is just a
small sample. My goal now is to look at this research critically, through the eyes of a
medical student/aspiring anthropologist, to discuss some very important questions:
“What is most relevant to medical students?”, “What will make their future practice
more satisfying and effective?”, and “What information will alter their views of
health and illness?” I will begin with a sketch of a typical medical college class, based
on my own college, and will then discuss what theories and insights from this
sampling of medical anthropology will be “applicable” to medical students. I will
start with the macro perspectives of CMA and medical ecology, and progress to
cultural medical anthropology and anthropological medicine, which offer insight into
micro-level medical issues. Furthermore, I will touch on some additional work that
may be of particular interest to medical students that does not fit into any one of the
above theories.
In Canadian medical schools there is a fair amount of diversity in age, cultural
backgrounds, socioeconomic status, and worldviews. This transformation from a
predominantly white, male profession can likely be attributed to our multicultural
society and the selection process for medical students. There is no direct entry into
Canadian medical colleges from high school and all applicants are interviewed prior
to offer of admission. As a result, there are a number of applicants who have had
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previous careers or exposure to other health fields, business, music, athletics, social
science, humanities, and research. That being said, there are often pre-requisite
courses in the sciences required by the college and many applicants are from various
fields in science who enter university intent on becoming physicians. Many students
come from families with a strong academic emphasis and others from so called “blue
collar” families. At the end of the day, the majority of medical students are young, of
European descent (although there is a large minority of minorities), have a
background in science, are from upper middle class families, and enjoy eating pizza.
I begin with critical medical anthropology because it offers insight into the
issue of “who gets sick and why”, which is a vital question to ask if we are ever to
prevent illness effectively. CMA asserts that we cannot understand health and
sickness within a society or on the global scene without understanding the processes
that perpetuate inequality. As mentioned above, mode of production, consumption,
and exploitation are characteristics of our capitalistic society. It is the values of the
few that create the ideologies that perpetuate unequal access to resources vital for
health. Privatization of health services has made access to care nearly impossible for
the billions living in poverty and among poverty. It is vital that medical professionals
have a full understanding of the consequences of health for-profit. By its very nature,
privatized health care means that only the financially privileged have access to care.
The effects of privatized medicine are not felt by the people living in the upper
middle class, which is the background of many medical students, so it is essential in a
time where our national organizations are lobbying for private clinics that our soonto-be professionals understand the consequences of privatization.
Eddie Rooke 19
Our medical system perpetuates inequality among classes. Medical education
is mostly accessible only to individuals who are wealthy or very educated, and so
perpetuates the classism we currently have in society. Likewise, the power
differentials are played out in clinical situations every single day. Students need to
recognize that society’s perception of them as doctors can negatively affect
treatment. Although there are practicing doctors who recognize the problems in our
system, many students are passively taught to perpetuate the power differentials by
the doctors they train under. They learn to objectify patients, to see them as a
disease or pathology, and to believe that the answers to their medical problems lie in
their biomedical knowledge rather than in the patient’s experience. The result is a
quick, impersonal interview; a rushed physical exam; a treatment plan made with
little or no patient involvement; and little mutual understanding or satisfaction. This
style of medicine has been recognized to be problematic and medical schools now
teach interviewing techniques that deal with the patient’s feeling, ideas about
causation, how the illness affects the day-to-day functioning of the patient, and the
expectations of the patient (know as FIFE: Feeling, Ideas, Functioning, Expectations).
“FIFE-ing”, however, does not survive medical school as practicing doctors assure
students that it is unrealistic and unnecessary to FIFE patients in “the real world”.
Since the bulk of medical training happens in hospitals, with doctors, it seems that in
order for initiatives to take root that are aimed at a more pleasant and egalitarian
health care experience, practicing physicians must be educated too. This education
could prevent those in health care from mistaking a seedling for a weed.
Eddie Rooke 20
Medicalization is the process of turning issues that are social in nature into
clinical issues. It is important for students to realize that in for-profit medicine it
benefits pharmaceutical companies to make social issues into medical issues because
it means that they can provide and create drugs to “treat” the condition.
Medicalization can also act as an alibi for difficult social/societal problems such as
obesity,
atherosclerosis,
smoking,
armchair
sports,
and
binge
drinking.
Medicalization takes blame, and therefore action, away from the societal level.
Perhaps the most important aspect of CMA is its dedication to justice and
equality. If medical colleges taught CMA’s knowledge about the great inequalities
being perpetuated in the world and explained that health systems both cause and
react to injustice and inequality in society, they could build many generations of
enlightened and progressive medical professionals. It could, in fact, change the face
of medicine.
Medical ecology is another perspective that is capable of analysis at the macro
and micro-level of health care. The value in medical ecology for the medical student
is the idea of inter-connectedness of biotic structures, abiotic structures, and culture
that make up the environment (McElroy and Townsend, 2004:29). A change in this
environment may have implications at the human population level, all the way down
to the tissue level. This is the only model that directly considers biology as an
important factor to health. The medical ecology model states, “there is no single
cause of disease”, which is an important notion for medical students to understand,
as no one gets sick outside of an environmental context.
Eddie Rooke 21
The idea of adaptation is an interesting academic concept and can help
explain some current health phenomena, but it can also be problematic. The idea
that health is a measure of adaptation can be misleading. It can have the effect of
placing blame for poor health on a community that has “not adapted well” to its
conditions, when it is through political and economic inequality that this change to
the environment has occurred in the first place. The concept of adaptation also
implies superiority of certain groups and is apolitical and ahistorical. I agree with the
CMA’s criticisms of adaptation and believe that learning about adaptation and its
problems would actually be an important exercise in critical thought for medical
students. Things aren’t always as they appear.
Arthur Kleinman is often cited for his many contributions to cultural medical
theory by describing the socially constructed nature of health care systems, the three
internal structures of health care systems, the universal clinical functions,
explanatory models, and the therapeutic relationship. Kleinman’s health systems
theory is focused on how culture affects health, especially in clinical circumstances,
and that understanding social reality can greatly influence compliance, results, and
satisfaction. The essential points for medical students to take away from Kleinman’s
work is that a person’s values, ideologies, traditions, and beliefs about sickness
influence clinical reality; including how patients present their illnesses, how they
communicate, who they go to for healing, and how they view biomedicine. Each
patient has his/her own explanatory model, which is their belief about why they are
ill and what treatment is needed. It is vital that medical students understand that
explanatory models differ greatly from person to person and that mutual disclosure
Eddie Rooke 22
of explanatory models can be very effective in ensuring compliance, understanding,
and attaining greater satisfaction, and better results.
Medical students may also benefit from understanding the role of the popular
health sector, the professional health sector, and the folk health sector.
Understanding the local practices and lay understanding of disease can help a
physician uncover issues of non-compliance or any misunderstandings about
treatment. Medical students should learn to respect the popular and folk health
sectors, as it is in these sectors that the majority of health issues are “treated”.
Anthropological medicine echoes some aspects of the other theories
mentioned above and also brings new ideas into the spotlight. The most valuable
contribution of this theory to medical students is the practical solutions it brings to
building a more satisfying biomedical paradigm in this period of crisis. Doctors need
to listen to their patients and negotiate a treatment plan with them. Health, as we
have seen, is culturally constructed and has different meaning for all of us. For this
reason physicians must not assume that they know what is best for their patients
and should be careful not to assume they know the values or beliefs of their patients.
The practice of exchanging explanatory models is incredibly valuable for
understanding and is a part of cultural brokering that must happen between patient
and physician.
Medical students must be aware of the different clinical beliefs, expectations,
and taboos that people from different cultures possess especially in a multicultural
country like Canada. Understanding the “empty vessel” fallacy can prevent
misunderstanding and remind students that they must never assume that a patient
Eddie Rooke 23
or a group does not have their own way of explaining and dealing with sickness and
can help facilitate the transferring of knowledge.
The well-being of physicians is severely overlooked in most medical systems
and it is time we start thinking about the health of our healers. Our medical system is
crowded, hectic, and hyper-focused on efficiency, and biological causes for disease. If
we are to create a system that works for the people of Canada, we must become
open-minded, patient-focused, and efficacy-oriented, not efficiency-oriented. This
can be done in part by following the principles of anthropological medicine.
We know that health and sickness are socially created, and so it follows that
healing is symbolic by nature. The placebo effect is a powerful phenomenon that is
testimony to the symbolic nature of healing. It is important for medical professionals
to know that what they are taking part in each day carries great cultural importance
to patients and can greatly impact their healing. This is motivation to develop a more
humanistic health care experience for the ill and to learn to recognize the
importance and validity of traditional healing.
Reflecting on the practices in medicine and their experimental nature is an
important exercise for health professionals. We say that biomedicine is scientific and
conveniently forget the strong history of experimentation and trial and error that we
continue to perpetuate. Direct, personal experience is perhaps the oldest and most
effective way of learning, but we must also reflect on how our biases can affect our
ability to treat in the face of new evidence or “promising reports”.
Medical school is a period full of stress and anxiety for many students. They
are in a socialization process like no other. If medical students understood, that what
Eddie Rooke 24
they are going through is normal or expected, it could potentially alleviate some of
this stress. Dealing with the information overload is particularly difficult for many
and accepting that uncertainty is a part of being a physician may help students
develop more effective coping mechanisms, rather than locking themselves away
with their books. Understanding this process and the way physicians have learned to
cope also allows us some insight into why the medical system seems slow to change.
If it is a coping mechanism to not change one’s practice, then it makes sense why
physicians and other professionals in health often seem unwilling to change their
ways. Perhaps if there was less pressure on physicians and students to know
everything and to have all the answers, it would be easier for them to change their
practices and adopt new beliefs about illness and health.
Researching this paper has been a thought-provoking and stimulating
experience. The insight and knowledge that medical anthropologists offer to
understanding and improvement of the healing process is remarkable and incredibly
valuable. This paper is a humble attempt to illustrate the variety of applications and
uses that medical anthropology offers, particularly to biomedical students who will
soon be practicing in our multicultural medical system and our rapidly globalizing
world. It is my hope that this paper will be of value to medical students by granting
them insight into the ecological, cultural, and political nature of health care.
Eddie Rooke 25
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