A short introduction to medical anthropology, or: Why would culture be relevant for medicine?
The aim of the book
This handbook has the ambition to introduce the non-initiated reader into the universe of medical anthropology, showing different ways in which this discipline engages with, challenges and supports various therapeutic practices. Despite this goal, the book should not be read as an introduction to medical anthropology, rather as a guide for health professionals to the many ways cultural factors may interfere with their work.
The book is structured in a way that it can be read independently, but it also connects to another product of the project Healthy Diversity – a collective enterprise bringing together the perspectives of 6 European countries on the health sector, interculturality and medical anthropology. The Catalogue of Critical Incidents is a collection of mini case studies showing how cultural difference may trigger conflicts in the medical work. We classified these cases according to the main cultural dimensions they involve and we found that medical professionals hurt themselves with bigger probability to some dimensions than to others. These recurring dimensions include universal human themes, such as gender, the family, the body, concepts of life, death, sickness and wellbeing, relation to the individual and to the group – to name only a few. We call these dimensions “sensitive zones”. The problem with these universals is that no two cultural systems are interpreted in the same way and different interpretations tend to clash all the more because people usually take their own interpretation as the only valid one. To prove the contrary we invite the reader on a journey in space and time. Selecting some of the dimensions in question we present their cultural variability visiting different regions of the world and looking back to our own European heritage. These thematic mini-chapters bring more insights to the critical incidents and encourage the reader to relativise their own position.
In line with its aims, the book is composed of three parts. The introduction – besides giving instructions on how to use it – offers an explanation of the concept of culture that we propose. Part I. contains detailed reviews on some medical anthropological texts produced in the six partner countries: the UK, France, Austria, Italy, Denmark and Hungary. Although these texts necessarily reflect the social reality of their authors’ countries of origin, they transcend local issues and their themes nicely respond to each other. We hope that readers will not only find this presentation instructive but also a good read.
Culture in healing, healing in cultures
Anthropology studies is a vague philosophical entity: culture, while medicine is concerned with the very material manifestation of wellbeing of people. How can such different disciplines enter into conversation and what benefits this dialogue can bring to humankind?
In order to answer this question culture itself should be defined. Anthropology however does not offer a one-size fits all definition, it is not an exaggeration to state that there are as many concepts of culture as there are anthropologists out there in the field. Most anthropologists would still agree that culture is more or less like a lens through which humans look at the universe that surrounds them. While individuals receive this lens more or less ready made from their group (or groups) of reference, the lens itself does not precede humans. It is the product of the same human groups which it orients. Geertz’ web metaphor expresses this paradox. The famous American anthropologist compares humans to “an animal suspended in webs of significance he himself has spun”. Like for the spider, their universe makes sense to humans only from their point of suspension.
But culture is not only in the heads of people, it is translated in acts. It is made visible by forms of behaviours that we as humans learn from each other. It might sound counterintuitive to state that there is no form of human behaviour that is not learned. If humans are part of the natural world, and surely they are, then at least some of our behaviours must be inborn. In fact, this is the specificity of the human race: even our most natural acts – eating, drinking, procreating, giving birth, falling sick and dying – are coloured by cultural norms that we learn during socialisation.
Does it mean that all individual behaviour is necessarily cultural? This is a very relevant question in the medical field because the answer given to it will draw the thin dividing line between normality, deviance, pathology or idiosyncrasy. Some behaviours do not follow group patterns. The story of Maugli (Mowgli in English) might be a tale, but there are indeed a few documented cases of savage children, unfortunate creatures who grew up locked in a cave or in the wilderness deprived of human company. Gaspar Hauser is one of those. He and others like him lacked any cultural model to follow, so in their cases we cannot talk about socialisation. Gaspar never became a man like the others, but after he was discovered and joined the human community he soon learned to speak and interact in a sensitive manner with his fellows. Culture is similar to language. It is an inborn capacity to learn and interiorise cultural norms, but it remains inoperative as long as we do not learn a particular cultural grammar. And understandably we rely on others for that.
Other exceptions exist, drawing individuals away from the realm of culture. Autistic children are hampered in their cultural learning by their difficulty to relate to their environment. Mental illness transforms behaviour in ways that are culturally not accepted. Individual combination of preferences creates individualised idiosyncratic patterns that remain exceptional as they are not characteristic of any group. These exceptions however only reinforce the norm. Culture in fact draws the contours of normality in a given group. Anything outside of this realm is considered extraordinary, uncommon, irregular or abnormal. In the last instance is the group that sanctions a form of behaviour or belief as acceptable or non-acceptable, normal or abnormal.
This is where culture becomes highly important for medicine. Because a medical system has the vocation to maintain or enhance wellbeing, and wellbeing in all society is understood in terms of group norms. What obesity is for us was the beauty idealised in the times of the Venus de Milo. What looks like a pathology for me, might be normality for some other people. In a multicultural society telling the difference between pathology, cultural norm and idiosyncrasy is a constant challenge for anybody. For health professionals such a dilemma has got an additional stake: literally life and death might depend on the good answer.
Anne Fadiman’s book on the case of a Laotian child treated in the USA for epilepsy is a good example of the outmost relevance of culture in the medical system. This is a true story which describes what cultural misunderstandings between the family and the medical professionals led to the child’s death due to mistreatment. Fortunately, not all cultural clashes have such dramatic outcomes. In most cases cultural misunderstandings stop at a point where they leave the patient or the medical staff (or both) annoyed and frustrated. But it is important to recognise that cooperation and trust between the two sides form always the basic condition for effective healing.
For this reason it is in the elementary interest of the medical professionals to be able to recognise cultural patterns and differentiate these from deviance, pathology or individual characteristics. Deviance might be fought against with various means, pathology might be cured, but cultural behaviour or cultural expectations cannot be changed easily. When cultural differences create tensions the best way to avoid escalation is understanding, tolerance, adaptation or negotiation.
We call the capacity to mobilise these potentials intercultural competence. Intercultural competence is not only important for health professionals because it can help them avoid unnecessary tensions during their work but because it can protect them from making an erroneous diagnosis and choosing ineffective intervention.
One of the stories in our collection comes from a physiotherapist. She recalls having had an elderly female Roma patient. When the time came for rehabilitation she asked the woman’s husband to bring a pair of panties and sweatpants to the hospital because it is impossible to do physiotherapy with a patient in a nightgown. The man came back with a long skirt. The same request was made again with the same result. In the meantime the physiotherapist refused to work with the patient. The story could have continued like this if the professional had not had the good idea to consult with the patient’s daughter who explained that her father would never touch his wife’s panties and her mother certainly had no trousers at home. In traditional Roma culture everything that belongs to the lower part of the body is considered to be polluting, especially any object for a man that has got connection with the lower part of the female body. On top of that, traditional Roma women simply do not wear trousers. The solution was quickly found by the intermediary of the daughter and the therapy could start.
This is an example which shows how cultural knowledge may facilitate professional work. At the same time it is also important to remember that culture is not a closed box which we would be born into and we would remain in it until the end of our lives. It is more like a backpack which we carry along and which we fill with new stuff continuously while we may lose some of its content during a life time. It may also be imagined as a frame: like all frames at any point of time it is fixed, but during the life it might change; it may broaden or shrink. For this reason, for a person we prefer to speak of a cultural frame of reference, rather than of culture.
A frame of reference does not constitute a closed system with no way out. It is not homogenous and it allows contradictions. A frame of reference – just like the lens – helps us to understand the world. What prevents the physiotherapist from understanding her Roma patient is precisely her own frame of reference in which it is normal for a woman to wear sweatpants or for a husband to touch his wife’s underwear. The story is not about a cultural system clashing with normality, rather about the conflict between two different normalities. Substituting the word “culture” for “frame of reference” prevents closing the other in a cultural box.
Another story in our collection of critical incident highlights this danger. A nurse in Austria faces a shocking behaviour from a patient that she identifies as East European. When the patient is told to give a urine sample he attempts to urinate in front of her. The only way the nurse can make sense of the situation is by culturalising it. For her the strangeness of the patient’s behaviour comes from the fact that he is Hungarian. This way of evoking culture does not really help to understand the other, culture in this case might become a code covering prejudices and feeding stereotypes. Essentialising culture might be as harmful for the relation as culture blindness.
The health professional is indeed between a rock and a hard place. What is the right attitude in such a complicated situation? Well, we believe that the first step towards understanding the other leads through understanding oneself. Accepting that our frame of reference is as conjectural as anybody else’s is the necessary passage to accept difference. The attempt to reconstruct the frame of reference of the other demands patience and the capacity of relativisation. Mobilising ethnographic knowledge may be as a useful tool on this path as asking questions or engaging a cultural mediator. But empathy, mindful attention, observation and the ability to connect to others are also important capacities.
Having a close look at it, these skills are not only useful for treating patients from exotic cultures. Understanding from where the patient talks and discovering possible causes of ruptures in the communication line, because of diverging attitudes, expectations, mutual identity threats (to mention only a few possible causes of seemingly incomprehensible conflicts) probably facilitate professional work with any patient. In our approach the emphasis is not on culture-centred nursing, rather on anthropocentric healing. Repositioning the human with all their complexities in the centre of the medical system demands further moves, including relativising the veridical discourses of the biomedical system. Relativisation does not mean invalidating it, on the contrary. It allows realising its advantages on other medical systems, wherever these advantages are scientifically proven, while allowing it to enter in dialogue with other systems wherever such dialogue can improve its results.
Anthropocentric healing also demands a genuine social engagement from all professionals working on health issues. The concept of culture should not blind the medical staff to social disparities. The concept of culture we promote includes all diversities, not only the most taken for granted ethnic or religious variations. Again, changing the notion of culture for that of frame of reference might serve as a valuable safeguard, allowing to consider all factors and conditions determining a person’s position, including its social status. Wherever these factors engender or deepen health inequality, the interculturally conscious medical staff is asked to take a stand against it.
Samples of medical anthropology
The above considerations are not only ours. The issues raised in this introduction are very much those of medical anthropology. The reader can have empirical evidence. In the six partner countries of Healthy Diversity we scanned the production of medical anthropology over the past 10 years. We were looking for ethnographically grounded case studies and therefore excluded purely theoretical works or handbooks. We established that most papers, books and articles we found in this domain may be grouped in one or several of the following categories:
- understanding and explaining the structural causes of health inequalities
- understanding how different identities and especially the combination of various undervalued identity traits contribute to health inequalities
- understanding cultural and social variations in experiencing health and sickness
- understanding the differences between particular medical systems and their interactions
- understanding the difficulties of health workers in multicultural societies where they feel that they have to meet contradictory requirements
The chapters in Part I. follow this order of themes. In the section Health inequalities: barriers to access we find a Hungarian and an Austrian text. Hungary is not an immigration country. Its largest minority is the Roma community. The disparity in health between Roma and non Roma Hungarians have worried health professionals for many decades and a multitude of explanatory theses have been proposed. The article presented here offers explanation to a general question by investigating a particular disease (arteriosclerosis). Not surprisingly the Austrian article turns toward Austria’s own most important minority population, examining the health situation of immigrants.
The section Health and intersectionality explores intersectionality in different ways in three articles. The UK example brings together considerations of race, gender and sexual preference. The Danish case study looks at the combination of the migrant status and old age. The Italian article examines the health situation of migrant mothers, showing how the combination of the factors migration, gender and motherhood enhances vulnerability.
The section Cultural and social variations in experiencing health and sickness deals with cultural variations in the experience of disease and pain. Chagas disease is a non endemic illness in Italy, still it has high occurrence amongst Latin-American immigrants. Besides being seen as an “ethnic” disease it is also a mark of poverty. These markers have an influence on how people experience it. Kohnen’s paper on the perception of pain equally supports the idea that somatic perceptions are to some extent culturally bound. The article comes to the conclusion that experience of pain depends – amongst other things – on learned patterns of how to make sense of it.
The expression Medical pluralism refers to situations where different medical regimes co-exist within one cultural system. In these instances patients make strategic choices between available treatments, not infrequently combining these in different ways. The Hungarian example is the ethnography of a Chinese clinic in Budapest frequented by Hungarians. The French text deals with the case of antiretroviral therapy in Africa, looking for an answer to the question why the same medicine seems more efficient in Northern countries than in the South. The article presents interesting examples for the combination of different healing practices in Africa. The third article equally illustrates Northern health interventions in Africa, in the field of HIV/AIDS prevention, bringing a case study from Mozambique.
In the focus of the last section, Health professionals facing cultural difference, we zoom in on the perspective of health workers. Danish and British professionals seem to struggle alike as much with the experience of difference as with their own fear of appearing insensitive or incompetent when dealing with the perceived cultural other.
Part II. Sensitive zones
This part contains six small chapters. Each of them gives very concrete ethnographic examples for sensitive zones that our team have found most common in intercultural conflicts within the health sectors. The cross-cultural themes visited are:
- death and dying.