Medicine & Culture

1. Medicine & Culture 15 week, 36 credit final year option in Anthropology

2. Main Themes • The cultural and social embeddedness of all disease concepts and ‘medical’ practices • ‘Medicine’ no less than ‘culture,’ is a set of competing discourses and practices, within situations characterised by the unequal distribution of power (cf. Frank 1999) • Medical anthropologists differ enormously in the kinds of questions they ask and insights they achieve through various approaches; this course draws attention to these differences in order to learn from them

3. Course Overview • Week 1: Introduction • Week 2: Biomedicine and the Birth of the Clinic • Week 3: From Shamanism to Placebo • Week 4: Phenomenology and Embodiment • Week 5: Narrative Approaches 1 • Week 6: Narratives Approaches 2 • Week 7: Critical Medical Anthropology • Week 8: Unequal Publics • Week 9: Applied Anthropology and the Exigencies of the Clinic • Week 10: Tutorials

4. Format of the Course • 2-3 students will be responsible for ‘facilitating’ the first hour of each seminar. • Student facilitators are expected to (1) identify and discuss the key themes of the week, and (2) plan and moderate the in-class discussion of readings. • Presentations, film clips, role-play, debates, case studies, participatory techniques, small-group discussions, and large-group discussions. • Facilitators may find it helpful to meet with the Course Tutor during office hours to discuss plans for the week’s session.

5. Materials for the Course • Course Document • Study Direct: download and print key readings, download PowerPoint presentations from lecture • only those that are not available through online journals will be posted on SyD • Websites and blogs: • http://openanthcoop.ning.com/ • http://neuroanthropology.net/ • http://www.medanthro.net/ • http://www.somatosphere.net/

6. Course Instructor • Dr Paul Boyce • Arts C307 • Office Hours: Thursdays 1.30pm-3pm • Email: p.boyce@sussex.ac.uk

7. Sample dissertation titles • Genetics, genetic diseases and personhood • Channelling the universal energy: a study of Reiki* • Shamans, traditional healers and Western biomedicine • Understanding CFS in relation to structural violence • ‘You say he was shattered by his experience?’: PTSD and the politics of diagnosis • ‘It’s time to make our voices heard’: power and resistance in contemporary psychiatry • Organ transplantation and the brain-death criteria: reassessing social conceptions of the mind-body relationship in light of ‘post-death’ • FGM is torture, not a culture: proposing a role for medical anthropology in the female circumcision debate • How has access to the internet affected the experiences of being a breast cancer patient? • Acculturation, appropriation, and antagonism: integrating acupuncture into a Western medical system*

8. A Potted History of Medical Anthropology • 1950s: • professionalisation of the discipline • disenchantment with efficacy and equity of biomedicine • new funding opportunities after WWII • 1960s: • medical anthropology becomes distinct from studies of ritual, symbolism, modes of thought • development of an applied field/international aid

9. A Potted History of Medical Anthropology • 1970s: • Arthur Kleinman (illness versus disease) • interest in pragmatic and everyday aspects of health • ‘the body’ begins to emerge as a organising frame • 1980s: • studies of medicine in the West (biomedicine) • critical medical anthropology • political economies of health • ‘resistance’ (e.g., to capitalism) becomes a pervasive theme

10. A Potted History of Medical Anthropology • 1990s: • continuing interest in biomedicine, esp. HIV/AIDS • science studies • global political economy of health • narratives, social suffering • 2000s: • growing health crises (including migration, ‘social exclusion’) • health activism and citizenship • new technologies (NRTs, vaccines, internet, hospital infections, cyborgs, genetic screening)

11. Byron Good: Four Orienting Approaches • Empiricist (belief and behaviour): medical knowledge is normative, focus on individual actor and choice • Cognitive (classification and structure): describing cultural models of categorization, emotion, psychology, illness, ethnomedicine • Interpretive (meaning-centred): looks at relationship between culture and illness, experience, embodiment, narrative • Critical (political economy and cultural critique): medical language and practices are ideological, disguising unequal relations of power (Byron Good 1994)

12. Key Concepts • Disease: Abnormalities in the structure or function of organs and organ systems (esp. as defined by biomedicine) • Illness: A person’s (patient’s) subjective experience of malaise • Sickness: A‘performance,’ which includes social recognition (‘legitimation’) of the problem and participation by more than just healers (e.g. kin, workplace, etc). (Scheper-Hughes & Lock 1987:10)

13. Disease vs. Illness • ‘A key axiom in medical anthropology is the dichotomy between two aspects of sickness: disease and illness. Disease refers to a malfunctioning of biological and/or psychological processes while the term illness refers to the psychosocial experience and meaning of perceived disease…’ (Kleinman 1980:72) • Where does this distinction come from? • What kinds of divisions of academic labour might result from these distinctions? • ‘natural science’ approach to disease as prior and universal • ‘social science’ approach to illness, involving questions of meaning (cf. Comaroff 1982)

14. Disease Illness Object Subject Fact Value Physician Patient Biology Psychology Nature Culture Disease:Illness::Nature:Culture

15. ‘Outside the significance that man voluntarily attaches to certain conditions, there are no illnesses or diseases in nature’ (Sedgwick in Joraleman 1999: 2). • ‘What, are there no diseases in nature? Are there no infections and contagious bacilli? Are there not definite and objective lesions in the cellular structures of the human body? Are there not fractures of bones, the fatal ruptures of tissues, the malignant multiplications of tumorous growths? Are not these, surely, events of nature?’ (Sedgwick in Joraleman 1999:3)

16. ‘Yet these, as natural events, do not – prior to the human social meanings we attach to them – constitute illnesses, sicknesses, or diseases. The fracture of a septugenarian’s femur has, within the world of nature, no more significance than the snapping of an autumn leaf from its twig: and the invasion of a human organism by cholera-germs has no more the stamp of “illness” than does the souring of milk by other forms of bacteria.’ (Sedgwick in Joraleman 1999: 3)

17. Key Concepts • Aetiology: an explanation of the cause or origin of a disease • Affliction: the cause or state of mental or bodily pain, distress, grief, or misery • Epistemology: a branch of philosophy concerned with the nature of knowledge • Explanatory model (EM): attributed to Arthur Kleinman, an EM is comprised of ideas about a particular episode of sickness and treatment (e.g., a patient’s explanatory model may diverge considerably from that of a physician)

18. Key Concepts • Health belief model (HBM): a model of health behaviour that assumes that people’s actions are rationally determined by (and follow directly from) their pre-existing ‘beliefs’ • Medical pluralism: the existence of different (oftentimes competing) medical traditions within a single society • Popularisation: (1) when aspects of biomedicine ‘filter down’ to the popular sector, (2) the increasing use of aspects of foreign medical traditions (e.g. Tibetan medicine in Mexico)

19. Week 2: Biomedicine and the Birth of the Clinic • Ferzacca, Steve. (2000). ‘“Actually I Don’t Feel that Bad”: Managing Diabetes and the Clinical Encounter’ • Foucault, Michel. (1989). ‘Introduction,’‘Space and Classes,’ and ‘Open Up a Few Corpses’ from The Birth of the Clinic • Good, Byron. (1994). ‘Chapter 3: How Medicine Constructs its Objects’ from Medicine, Rationality, and Experience • Lock, Margaret and Nancy Scheper-Hughes. (1996). ‘A Critical-Interpretive Approach in Medical Anthropology: Rituals and Routines of Discipline and Dissent.’ • Pinto, Sarah.(2004). ‘Development without Institutions: Ersatz Medicine and the Politics of Everyday Life in Rural North India.’

20. The Birth of the Clinic (Foucault,1973) • Foucault questions the accepted truth that modern medicine was born in Ancient Greece, lost, and reclaimed in early 19th century… • …when Enlightenment triumphs of autopsy made the body ‘known’ • Foucault shows instead that: • empirical medicine was established in the 17th century • that clinical practice declined after the French revolution • that autopsies had in fact been carried out throughout 1700s

21. The ‘Official’ History of Medicine? • The history of medical knowledge is that of progress over time… • …in which nature becomes gradually discovered and known effectively and scientifically… • …and disease itself is ‘universal’ in the sense of being prior to society or culture… • …meaning that social factors are separate from (and ancillary to) medicine or science (Wright and Treacher 1982)

22. Bentham’s Panopticon (1785), and the Medical Gaze

23. The Birth of the Clinic (Foucault,1973) • Interested in power/knowledge in the ‘disciplinary society’ • panopticism • the medical gaze • Looks at clinical practice c1800 in Paris • the importance of clinical practice for… • …the construction of man as an object and subject of knowledge • New concepts of disease emerge in association with the creation of a new ‘individual’ after the French revolution • related to new forms of regulating and organising the poor

24. Lessons from Foucault • The ‘clinic’ is a place of categorization, diagnosis, enumeration, and knowledge production • Through which the patient becomes ‘known’ in particular ways to both him/herself and to the clinician • Clinical ways of ‘seeing’ are not pure and direct but rather are shaped by discourses of disease, the body, and the individual that came to the fore in the late 18th century • The clinic itself is the product of diverse historical currents, to which it was ‘born’ at a particular moment in time

25. The Hidden Curriculum • ‘Students were encouraged to learn new narrative forms, to create medically meaningful arguments and plots with therapeutic consequences for patients. In this process, they sharpened their biomedical “gaze” and developed their clinical reasoning. Throughout these exercises [patients’] social histories and emotional states, and their lives outside of the hospitals…was largely irrelevant; these data from daily life were regarded as “inadmissable evidence”.’ (Hafferty 1998)

26. Social Constructionism • Is concerned with how knowledge, social phenomena, and perceptions of reality develop in particular historical, social, and political contexts • e.g., Foucault’s example of the development of the modern body as an object (and subject) of medicine and science • Pushes us to ask: • Are claims to knowledge supported by reality? • Or are they social constructs?

27. Social Constructionism • Uses of social constructionism (Hacking, 1999): • Unmasking, refuting ‘ideology’ and official histories • Shows the contingent and historical nature of social reality • Misuses of social constructionism (Hacking, 1999): • Histories sometimes anachronistic, decontextualised • Is the natural world adequately addressed?

28. Questions to Consider for Week 2 • How, according to Byron Good (1994), does biomedicine ‘construct’ its objects? • Where does the authority and legitimacy of doctors come from? (see especially Pinto 2004) • When does ‘self-care’ become ‘non-compliance’? (see Ferzacca 2000) • What are the ‘three bodies’ (Lock and Scheper-Hughes 1996), and how do they relate to the development and practice of biomedicine?