- Email: [email protected]
More than just “interesting!”
Social Science & Medicine 50 (2000) 1171±1175
www.elsevier.com/locate/socscimed
Editorial
More than just ``interesting!'' Anthropology, health and human rights Having just completed six years as Senior Editor for the Medical Anthropology Section of Social Science and Medicine I appreciate the opportunity to say a few words to the journal's readers. First of all, I would like to thank the many authors and reviewers with whom I have had contact for your contributions to the journal and for the privilege of working with you. What I wish to highlight in this editorial is the shared view that anthropology ought ®rst and foremost to be a critical discipline (i.e. Diamond, 1974), and that in order to best understand patterns of health and disease, and the most appropriate ways in which these can be improved, the gaze of medical anthropologists must also be critically inclusive and set on a whole range of social, political and economic, as well as on cultural factors. The group known as the ``critical medical anthropologists'' attempts such an approach, and I ®nd much in common with them. But I am also suggesting that those who do not necessarily see themselves as ``critical medical anthropologists'', as this has been de®ned, can, nevertheless, take a critically encompassing stance in terms of the subjects of their study. It is fortunately now no longer provocative to assert that an anthropological perspective is imperative for improving medical care and public health. This is especially so in the multicultural societies of our shrinking world in the age of globalization. Its relevance for public health has gained recent credence not only as a result of its role in helping to combat the AIDS pandemic, but also as a result of the many past public health eorts which are seen to have failed because of not having taken sucient note of socio-cultural factors. Anthropology provides much more than just ``interesting stories'', as opposed to the `real stu' of epidemiology and the biomedical sciences for positive public health intervention, which was a frequently held position of not so many years ago (Heggenhougen and
Pedersen, 1997). The claim that socio-cultural factors play a signi®cant, and sometimes even a dominant role in determining the distributions of health and illness, is no longer revolutionary within public health, and anthropologists' accounts are now certainly deemed as much more than ``just interesting stories''. The sociocultural roots of disease are now increasingly recognized by clinicians and public health specialists as well as by medical anthropologist (i.e. Van Devanter and Mailman, 1999; Bradley, 1991, p. 28). An understanding of cultural factors can contribute greatly to enhance medical therapeutic as well as health disease preventive and health promotive activities. Yet, while cultural factors are crucial, a major role of medical anthropology, whether directly related to medicine and public health or not (and I ®rmly believe medical anthropology must be much more than clinical anthropology, though that is also a part) is also to direct our focus to the total context of people's lives Ð to the wider ``social roots of disease'' Ð and particularly to the deleterious elements in most societies of violence, inequity and marginalization, pointing to issues such as power, dominance, paternalism and racism, and their implication for how diseases are created, distributed and treated. Recognizing the multifactorial etiology of most diseases, interdisciplinarity has become key. More than any other discipline anthropology is by de®nition integrative, and we must attempt to understand and to present our studies in terms of the full matrix of such interrelated social forces. Jointly, these factors constitute the roots of disease. This is particularly so, since despite the considerable human rights and health achievements of the last century, as we enter the next millennium we see in our own back yard, and certainly as we look further a®eld, a world in terrible crisis. A crisis constituted by a pandemic of war, civil strife and violence of other kinds,
0277-9536/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 9 9 ) 0 0 4 1 6 - 5
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Editorial / Social Science & Medicine 50 (2000) 1171±1175
and perhaps more perniciously, by growing inequity, structural violence and the marginalization of increasing numbers of people throughout the world. The consequences are terrible for their health and welfare, and for that reason alone it requires our attention, but the physical and mental health of the more privileged of us are also inescapably aected (Farmer, 1999; Heggenhougen, 1999). For the sake of (all of) our health, perhaps even of our survival, this crisis must be examined and engaged. We all know aspects of this crisis full well: at a time of tremendous (average ) economic growth and soaring stock markets (despite the `Asian crisis') we live in a world of increasing inequity, and of the pauperization of vast numbers of people. This is a detriment not only to those directly involved (though to them it is most signi®cantly so) but to us all, making it intuitive that issues of health and human welfare must be considered as inseparable from those of equity and human rights. While many may still identify with, and live most of their lives within the con®nes of, small, local communities, these are no longer untouched wholes, or ``untainted'' villages. The over-whelming forces of globalization, of functional apartheid and structural violence (Heggenhougen, 1995), of human rights abuses (Mann et al., 1994), and of what has long been recognized as ``commerciogenic'' pathologizing forces of a capitalism out of control (New York Times, 1995; Greider, 1997; UNDP, 1997; Stanley, 1999), are facts of life, not only in urban centers, but are insidious also in the local settings which anthropologists know so well. Anthropology has, and must continue in greater measure, to provide a critical look at this crisis; it must contribute to an engagement with a broad set of issues by which we may hope to formulate ways in which we can extract ourselves from the morass in which we, as humans on a fragile earth, are being engulfed at an ever increasing speed. If the de®nition of anthropology remains both ``an understanding of, and a concern for, the human condition (in all its varieties)'', then we must pay particular attention to the deleterious elements in most societies which cause havoc in peoples lives and contribute directly to patterns of disease. In this regard, some medical anthropologists have spoken of an anthropology of aiction (Scheper-Hughes, 1990, 1995, 1996) and others of an anthropology of suering (Farmer, 1996; Kleinman, 1996; Kleinman and Kleinman, 1996), writ large. An encompassing, and inherently anthropological, critical perspective becomes more imperative than ever. And, our gaze must be at once local, national and international. What we know as ``medical anthropology'' comes, of course, in many forms, and the focus of attention is varied. This is only as it should be. The articles in this journal attest to this eclecticism. Much has been writ-
ten about this, including in numerous medical anthropology textbooks. My intention here is not to review this, once again, nor to deny the contributions made by scholars working on speci®c projects within a wide range of perspectives and topics, but rather to make a plea, especially to medical anthropologists, but also to public health and medical professionals in general, that no matter the speci®city of our inquiry, we also include in that inquiry a discussion of how not only culture, but the totality of socio-cultural factors jointly impinge on the lives of the people we study. Without making an interconnection between both immediate and fundamental factors aecting people's health (Link and Phelan, 1995), without seeing the problem of our inquiry within the full light of local and larger global forces, any understanding of the health of individuals, or the epidemiology of groups, will be but fractional. And, similarly, consequent interventions for improvement may be limited and only short lived. As I live and work in the United States let me focus brie¯y on that country in terms of my ``national gaze'', while full well recognizing anthropologists from other countries can ®nd similar evidence of crisis where they are. One way to discuss the crisis in the US may be to suggest the co-equal importance of ethnicity and power (or class) Ð racism and inequity Ð not only for medical practice but for the general health of North Americans. In 1994, US Representative Bernard Sanders, an Independent from the State of Vermont, provided evidence of the increasing pauperization of a larger and larger segment of the US population: ``The gap between rich and poor in America is wider than at any time since the 1920s. . . . The real wages of American productive workers have dropped by 20% over the past 20 years . . .. While the rich get richer, one in 10 American families now feed their children only with the aid of food stamps . . .. The richest 1 percent of American now own 37% of the nation's wealth, more than is owned by the entire bottom [???] 90% of Americans'' (The Capital Times, 1994, editorial page). ``From 1979±89 the income of the poorest 20% of all families (in the US) fell 10% while that of the richest 1% of families increased 105%'' (Fernandez, 1994). The US has one of the highest proportions of its citizens living below the poverty line of any industrialized country. In view of such evidence to the contrary, it is remarkable that the myth of the class-less society persists. In 1995, Dr John Kiely, chief of the Infant and Child Health Studies Branch of the National Center for Health Statistics revealed, with some apparent surprise, as a result of a study of 21,583 mothers, that the US did in fact re¯ect social-class health status dierences; a relationship which by now should have been common knowledge. Dr Kiely and colleagues found
Editorial / Social Science & Medicine 50 (2000) 1171±1175
that the Infant Mortality Rate was 60% higher for children born to mothers living below the poverty line than for those above it. The dierence was twice as high when the ®rst four weeks were ruled out. He went on to note that ``Other factors controlled for, poverty had as big an eect as mother's marital status, age and education, cigarette smoking during pregnancy, the timing of the ®rst prenatal care visit and race (my emphasis) . . . . The relationship was stronger among married women, in women who were older than 18 and white women '' (my emphasis) (New York Times, 1995, p. A32). Since the US does not collect mortality and morbidity statistics by class, race (or ethnicity) has become a marker for class. One consequence of this is ``victim blaming'' and scape-goating of, especially, Afro-Americans and members of the dierent Latino communities, who, because of social inequities and factors such as racism and other forms of prejudice, of which we are quite familiar, are disproportionately represented among the poorer segments of the US population. The signi®cance of class (occupation, education and income) dierences is camou¯aged by presumed ethnic health indicator dierences Ð with the implication that these dierences are somehow inherent in, or derived from, the unique characteristics of these ethnic groups. The conditions in which oppressed minorities exist become a problem of their own making Ð their own ``de®cits'' and ``de®ciencies'' Ð in one rhetorical stroke. It is evident that the strength and vibrancy of the US is in no small measure due to its diversity, to its rich mix and interaction of cultures and ethnicities, which, especially as they each maintain their power and unique characteristics, empower and bene®t us all. Much of the potential of this heterogeneity has been, and is being, realized. Yet, there are those in this country who can justi®ably claim that American history was, and in a large measure continues to be, the story of racial and ethnic and other group tensions and clashes Ð of racism and discrimination (Fox, personal communication). We may think this was a problem of the past and that other issues should now take prominence, yet the 1995 Kaiser Foundation (with the Washington Post and Harvard University) report, ``The Four Americas: Government and Social Policy Through the Eyes of America's Multi-racial and Multi-ethnic Society'' states clearly that, ``Whites stand alone in their misperceptions of the real-life circumstances that African-Americans face'' (Brodie, 1995, p. 2). And whether related to ethnicity, gender or class, those in dominant positions in society are often those least knowledgeable about their less privileged compatriots. Unfortunately others suer disproportionately from these misperceptions. There is currently considerable debate in the US,
1173
also within the Afro-American community, about armative action as a means to rectify past and present inequities (and the consequences of these). But, as suggested by Lani Guinier, if we think of this in a dierent than usual way, we may also consider armative action as an opportunity for us all ``to use the experiences of those on the margins to reshape the whole''; and to rethink what concepts such as ``optimal'', ``quality'' and ``competence'' really are within our dierent, and dynamic, contexts (Guinier, 1996). It is not just a matter of a better division of the pie, but of the creation of a better pie, as we enter the next millennium. To note that the US is also a society divided Ð or at least dierentiated Ð by gender, the Kaiser report shows that of whites who were ``strongly committed'' to the government addressing problems of African Americans 67% were women and 33% were men'' (Brodie, 1995). Internationally, the crisis is even worse, though inter-linked with that in the United States, and anthropologists such as Paul Farmer (1999) in his recent Inequities and Infections and public health authors such as Laurie Garrett (1994) Ð especially in her chapter, ``Thirdworldization: the interaction of poverty, poor housing and social despair with disease'', in her book, The Coming Plague Ð have written poignantly about this. On a much more modest scale, my recent commentary in the journal Health and Human Rights (Heggenhougen, 1999) similarly attempted to speak of social pathologies evident throughout the world which must receive our attention if health is to improve. The fact that military hardware and illicit drugs constitute two of the world's largest markets is one way to begin to describe this crisis, as is the tobacco industry's pushing of cigarettes throughout the world (even as inroads are made against cigarettes in the US). Globalization, which is now a fact of life even for seemingly small and isolated rural communities may have certain bene®ts, also for disenfranchised communities (and these should not be ignored but encouraged to ¯ourish), but according to the UNDP (1997) globalization is primarily a detriment to the lives of the world's poor; ``. . .national governments go out of their way to attract foreign direct investment by oering to relax labour or health standards, that will hurt the poor and set o a `race to the bottom' that will lower standards worldwide'' (UNDP, 1997, p. 90). More than 40% of world trade is controlled by less that 400 of the world's largest corporations, 50 of which are among the worlds 100 largest economic entities (the other 50 being countries). Ten percent of the world's poorest countries have less than 0.5% of world trade, half their rate a decade ago (UNDP, 1998). The poorest 20% of the world's population share in only 1.1% of the world's wealth, with 1.3 billion people living on
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Editorial / Social Science & Medicine 50 (2000) 1171±1175
$1 or less a day and millions dying of starvation each year. Seventy percent of those living in absolute poverty are women and indigenous communities are consistently among the poorest segment of any society (Buvenic et al., 1996, p. 16±18). There are more than a 100 million street children in the world and the number of orphans in the most precarious of circumstances (due to AIDS and war) is increasing at an alarming rate. The economic disparity between the top and the bottom 20% of the worlds population has tripled since the 1960s to more than 1:82 (UNDP, 1998) Ð some say it is as high as 1:140 (Werner, personal communication). Income disparities of third world workers in corporation factories and those of upper management and CEOs are obscene ratios reaching more than 100,000 to 1 (Cavanaugh and Broad, 1996, p. 21; Holtz, 1997; National Labor Committee Report, 1966). These statistics go on and on (Heggenhougen, 1999). Examining the web of factors contributing to the growing gaps which isolate and alienate us Ð enriching a few and impoverishing the many more Ð within nations and internationally, is, I believe, a major task of medical anthropology, and should constitute a larger and more central position within the medical anthropological and general social science literature. This must be done, even as we work hard to establish and improve speci®c public health eorts, be these rural clinics, sanitation projects, vaccination programs, support of street children and orphans or local income generating and loan schemes, such as, for example, the Grameen Bank (Yunus, 1999). Medical anthropologists attempting to positively impact the health of those among whom we have lived and studied abroad or at home, and thus the health of us all, must, and do, produce far more than ``interesting stories'', as we attempt to focus on, and grapple with, the immediate and the more distant (the more fundamental), both at the same time (Link and Phelan, 1995). Our contributions to local eorts to improve the health of people must be juxtaposed with the national and international crisis which aicts us all, and with an examination of the root causes of inequity and the growing pauperization of the world. In the world in which we now live, the task is one of being anthropologists of ``health and equity'', anthropologists of ``health and social justice'' (Farmer, 1999).
References Bradley, D.J., 1991. Malaria Ð whence and whither? In: Target, G.A.T. (Ed.), Malaria Ð Waiting for the Vaccine. Wiley, New York, pp. 13±29. Brodie, M. 1995. The four Americas: government and social policy through the eyes of America's multi-racial and
multi-ethnic society. A Report of The Washington Post/ Kaiser Family Foundation/Harvard Survey Project, Kaiser Foundation, Menlo Park, CA. Buvenic, M., Gwin, K., Bates, L., 1996. Investing in women: progress and prospects for the World bank. Overseas Development Council, Washington DC. Capital Times, 1994. `Views of the capital times Ð pauperization of America'. The Capital Times 8 August, editorial page. Cavanaugh, J., Broad, R., 1996. `Global reach: workers ®ght the multinationals'. The Nation 21 March, 21±24. Diamond, S., 1974. Search of the Primitive: A Critique of Civilization. Transaction Books, New Brunswick. Farmer, P., 1999. Inequities and Infections. University of California Press, Berkeley. Farmer, P., 1996. `On suering and structural violence: a view from below'. Daedalus 125, 261±283. Fernandez, G. 1994. Poverty, Democracy and Market Economy, South American Peace Commission (Chile) and DESCO (Peru). Garrett, L., 1994. Thirdworldization Ð The interaction of poverty, poor housing and social despair with disease. In: Garrett, L. (Ed.), The Coming Plague Ð Newly Emerging Diseases in a World out of Balance. Penguin Books, London, pp. 457±527. Greider, W., 1997. One World, Ready or Not: The Manic Logic of Global Capitalism. Simon & Schuster, New York. Guinier, L. 1996. Presentation to the E Pluribus Unum?: American National Identities Conference. Stanford University, Palo Alto, CA. Heggenhougen, H.K., 1995. Editorial: the epidemiology of functional apartheid and human rights abuses. Soc. Sci. Med 40, 281±284. Heggenhougen, H.K., 1999. Are the marginalized the slagheap of economic growth and globalization? Disparity, health, and human rights. Health and Human Rights 4 (1), 205±213. Heggenhougen, H.K., Pedersen, D., 1997. Beyond quantitative measures: the relevance of anthropology for public health. In: Detels, R., et al. (Eds.), Oxford Textbook of Public Health3rd ed., vol. 2, pp. 815±828. Holtz, T.H. 1997. Transnational corporations and codes of conduct: impacts on human rights and health (manuscript). Kleinman, A. (Ed.), 1996. Social Suering (special issue). Daedalus 125 (1). Kleinman, A., Kleinman, J., 1996. The appeal of experience: the display of images Ð cultural appropriations of suering in our times. Daedalus 125, 1±24. Link, B.G., Phelan, J., 1995. Social conditions as fundamental causes of disease. J. Health Human Behavior 1995, 80±94. Mann, J., Goston, L., Gruskin, S., Brennan, R., Lazzarini, Z., Fineberg, H., 1994. Health and human rights. Health and Human Rights 1 (1), 6±23. National Labor Committee Report, 1996. The U.S. in Haiti: How to Get Rich on 11 Cents an Hour. National Labor Committee Education Fund, New York. New York Times, 1995. Infant deaths tied to poverty, study con®rms, New York Times, 15 December, A32.
Editorial / Social Science & Medicine 50 (2000) 1171±1175 Scheper-Hughes, N., 1990. Three propositions for a critically applied medical anthropology. Soc. Sci. Med 30, 189±197. Scheper-Hughes, N., 1995. The primacy of the ethical Ð propositions for a militant anthropology. Current Anthropology 36, 409±440. Scheper-Hughes, N., 1996. Small wars and invisible genocides. Soc. Sci. Med 43, 889±900. Stanley, A. 1999. Pope is returning to Mexico with new target: capitalism. New York Times, 22 January, A1. UNDP, 1997. Human Development Report. Oxford University Press, Oxford. UNDP, 1998. Human Development Report 1998. Oxford University Press, Oxford. Van Devanter, Mailman, N.J., 1999. Prevention of sexually
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transmitted diseases: the need for social and behavioral science expertise in public health departments. AJPH 89, 815±818. Yunus, M., Jolis, A. 1999. Banker to the poor: micro-lending and the battle against world poverty.
H.K. Heggenhougen Harvard Institute for International Development, Harvard University, 8 Story Street, 5th Floor, Cambridge, MA 02138, USA E-mail address: [email protected]
www.elsevier.com/locate/socscimed
Editorial
More than just ``interesting!'' Anthropology, health and human rights Having just completed six years as Senior Editor for the Medical Anthropology Section of Social Science and Medicine I appreciate the opportunity to say a few words to the journal's readers. First of all, I would like to thank the many authors and reviewers with whom I have had contact for your contributions to the journal and for the privilege of working with you. What I wish to highlight in this editorial is the shared view that anthropology ought ®rst and foremost to be a critical discipline (i.e. Diamond, 1974), and that in order to best understand patterns of health and disease, and the most appropriate ways in which these can be improved, the gaze of medical anthropologists must also be critically inclusive and set on a whole range of social, political and economic, as well as on cultural factors. The group known as the ``critical medical anthropologists'' attempts such an approach, and I ®nd much in common with them. But I am also suggesting that those who do not necessarily see themselves as ``critical medical anthropologists'', as this has been de®ned, can, nevertheless, take a critically encompassing stance in terms of the subjects of their study. It is fortunately now no longer provocative to assert that an anthropological perspective is imperative for improving medical care and public health. This is especially so in the multicultural societies of our shrinking world in the age of globalization. Its relevance for public health has gained recent credence not only as a result of its role in helping to combat the AIDS pandemic, but also as a result of the many past public health eorts which are seen to have failed because of not having taken sucient note of socio-cultural factors. Anthropology provides much more than just ``interesting stories'', as opposed to the `real stu' of epidemiology and the biomedical sciences for positive public health intervention, which was a frequently held position of not so many years ago (Heggenhougen and
Pedersen, 1997). The claim that socio-cultural factors play a signi®cant, and sometimes even a dominant role in determining the distributions of health and illness, is no longer revolutionary within public health, and anthropologists' accounts are now certainly deemed as much more than ``just interesting stories''. The sociocultural roots of disease are now increasingly recognized by clinicians and public health specialists as well as by medical anthropologist (i.e. Van Devanter and Mailman, 1999; Bradley, 1991, p. 28). An understanding of cultural factors can contribute greatly to enhance medical therapeutic as well as health disease preventive and health promotive activities. Yet, while cultural factors are crucial, a major role of medical anthropology, whether directly related to medicine and public health or not (and I ®rmly believe medical anthropology must be much more than clinical anthropology, though that is also a part) is also to direct our focus to the total context of people's lives Ð to the wider ``social roots of disease'' Ð and particularly to the deleterious elements in most societies of violence, inequity and marginalization, pointing to issues such as power, dominance, paternalism and racism, and their implication for how diseases are created, distributed and treated. Recognizing the multifactorial etiology of most diseases, interdisciplinarity has become key. More than any other discipline anthropology is by de®nition integrative, and we must attempt to understand and to present our studies in terms of the full matrix of such interrelated social forces. Jointly, these factors constitute the roots of disease. This is particularly so, since despite the considerable human rights and health achievements of the last century, as we enter the next millennium we see in our own back yard, and certainly as we look further a®eld, a world in terrible crisis. A crisis constituted by a pandemic of war, civil strife and violence of other kinds,
0277-9536/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 9 9 ) 0 0 4 1 6 - 5
1172
Editorial / Social Science & Medicine 50 (2000) 1171±1175
and perhaps more perniciously, by growing inequity, structural violence and the marginalization of increasing numbers of people throughout the world. The consequences are terrible for their health and welfare, and for that reason alone it requires our attention, but the physical and mental health of the more privileged of us are also inescapably aected (Farmer, 1999; Heggenhougen, 1999). For the sake of (all of) our health, perhaps even of our survival, this crisis must be examined and engaged. We all know aspects of this crisis full well: at a time of tremendous (average ) economic growth and soaring stock markets (despite the `Asian crisis') we live in a world of increasing inequity, and of the pauperization of vast numbers of people. This is a detriment not only to those directly involved (though to them it is most signi®cantly so) but to us all, making it intuitive that issues of health and human welfare must be considered as inseparable from those of equity and human rights. While many may still identify with, and live most of their lives within the con®nes of, small, local communities, these are no longer untouched wholes, or ``untainted'' villages. The over-whelming forces of globalization, of functional apartheid and structural violence (Heggenhougen, 1995), of human rights abuses (Mann et al., 1994), and of what has long been recognized as ``commerciogenic'' pathologizing forces of a capitalism out of control (New York Times, 1995; Greider, 1997; UNDP, 1997; Stanley, 1999), are facts of life, not only in urban centers, but are insidious also in the local settings which anthropologists know so well. Anthropology has, and must continue in greater measure, to provide a critical look at this crisis; it must contribute to an engagement with a broad set of issues by which we may hope to formulate ways in which we can extract ourselves from the morass in which we, as humans on a fragile earth, are being engulfed at an ever increasing speed. If the de®nition of anthropology remains both ``an understanding of, and a concern for, the human condition (in all its varieties)'', then we must pay particular attention to the deleterious elements in most societies which cause havoc in peoples lives and contribute directly to patterns of disease. In this regard, some medical anthropologists have spoken of an anthropology of aiction (Scheper-Hughes, 1990, 1995, 1996) and others of an anthropology of suering (Farmer, 1996; Kleinman, 1996; Kleinman and Kleinman, 1996), writ large. An encompassing, and inherently anthropological, critical perspective becomes more imperative than ever. And, our gaze must be at once local, national and international. What we know as ``medical anthropology'' comes, of course, in many forms, and the focus of attention is varied. This is only as it should be. The articles in this journal attest to this eclecticism. Much has been writ-
ten about this, including in numerous medical anthropology textbooks. My intention here is not to review this, once again, nor to deny the contributions made by scholars working on speci®c projects within a wide range of perspectives and topics, but rather to make a plea, especially to medical anthropologists, but also to public health and medical professionals in general, that no matter the speci®city of our inquiry, we also include in that inquiry a discussion of how not only culture, but the totality of socio-cultural factors jointly impinge on the lives of the people we study. Without making an interconnection between both immediate and fundamental factors aecting people's health (Link and Phelan, 1995), without seeing the problem of our inquiry within the full light of local and larger global forces, any understanding of the health of individuals, or the epidemiology of groups, will be but fractional. And, similarly, consequent interventions for improvement may be limited and only short lived. As I live and work in the United States let me focus brie¯y on that country in terms of my ``national gaze'', while full well recognizing anthropologists from other countries can ®nd similar evidence of crisis where they are. One way to discuss the crisis in the US may be to suggest the co-equal importance of ethnicity and power (or class) Ð racism and inequity Ð not only for medical practice but for the general health of North Americans. In 1994, US Representative Bernard Sanders, an Independent from the State of Vermont, provided evidence of the increasing pauperization of a larger and larger segment of the US population: ``The gap between rich and poor in America is wider than at any time since the 1920s. . . . The real wages of American productive workers have dropped by 20% over the past 20 years . . .. While the rich get richer, one in 10 American families now feed their children only with the aid of food stamps . . .. The richest 1 percent of American now own 37% of the nation's wealth, more than is owned by the entire bottom [???] 90% of Americans'' (The Capital Times, 1994, editorial page). ``From 1979±89 the income of the poorest 20% of all families (in the US) fell 10% while that of the richest 1% of families increased 105%'' (Fernandez, 1994). The US has one of the highest proportions of its citizens living below the poverty line of any industrialized country. In view of such evidence to the contrary, it is remarkable that the myth of the class-less society persists. In 1995, Dr John Kiely, chief of the Infant and Child Health Studies Branch of the National Center for Health Statistics revealed, with some apparent surprise, as a result of a study of 21,583 mothers, that the US did in fact re¯ect social-class health status dierences; a relationship which by now should have been common knowledge. Dr Kiely and colleagues found
Editorial / Social Science & Medicine 50 (2000) 1171±1175
that the Infant Mortality Rate was 60% higher for children born to mothers living below the poverty line than for those above it. The dierence was twice as high when the ®rst four weeks were ruled out. He went on to note that ``Other factors controlled for, poverty had as big an eect as mother's marital status, age and education, cigarette smoking during pregnancy, the timing of the ®rst prenatal care visit and race (my emphasis) . . . . The relationship was stronger among married women, in women who were older than 18 and white women '' (my emphasis) (New York Times, 1995, p. A32). Since the US does not collect mortality and morbidity statistics by class, race (or ethnicity) has become a marker for class. One consequence of this is ``victim blaming'' and scape-goating of, especially, Afro-Americans and members of the dierent Latino communities, who, because of social inequities and factors such as racism and other forms of prejudice, of which we are quite familiar, are disproportionately represented among the poorer segments of the US population. The signi®cance of class (occupation, education and income) dierences is camou¯aged by presumed ethnic health indicator dierences Ð with the implication that these dierences are somehow inherent in, or derived from, the unique characteristics of these ethnic groups. The conditions in which oppressed minorities exist become a problem of their own making Ð their own ``de®cits'' and ``de®ciencies'' Ð in one rhetorical stroke. It is evident that the strength and vibrancy of the US is in no small measure due to its diversity, to its rich mix and interaction of cultures and ethnicities, which, especially as they each maintain their power and unique characteristics, empower and bene®t us all. Much of the potential of this heterogeneity has been, and is being, realized. Yet, there are those in this country who can justi®ably claim that American history was, and in a large measure continues to be, the story of racial and ethnic and other group tensions and clashes Ð of racism and discrimination (Fox, personal communication). We may think this was a problem of the past and that other issues should now take prominence, yet the 1995 Kaiser Foundation (with the Washington Post and Harvard University) report, ``The Four Americas: Government and Social Policy Through the Eyes of America's Multi-racial and Multi-ethnic Society'' states clearly that, ``Whites stand alone in their misperceptions of the real-life circumstances that African-Americans face'' (Brodie, 1995, p. 2). And whether related to ethnicity, gender or class, those in dominant positions in society are often those least knowledgeable about their less privileged compatriots. Unfortunately others suer disproportionately from these misperceptions. There is currently considerable debate in the US,
1173
also within the Afro-American community, about armative action as a means to rectify past and present inequities (and the consequences of these). But, as suggested by Lani Guinier, if we think of this in a dierent than usual way, we may also consider armative action as an opportunity for us all ``to use the experiences of those on the margins to reshape the whole''; and to rethink what concepts such as ``optimal'', ``quality'' and ``competence'' really are within our dierent, and dynamic, contexts (Guinier, 1996). It is not just a matter of a better division of the pie, but of the creation of a better pie, as we enter the next millennium. To note that the US is also a society divided Ð or at least dierentiated Ð by gender, the Kaiser report shows that of whites who were ``strongly committed'' to the government addressing problems of African Americans 67% were women and 33% were men'' (Brodie, 1995). Internationally, the crisis is even worse, though inter-linked with that in the United States, and anthropologists such as Paul Farmer (1999) in his recent Inequities and Infections and public health authors such as Laurie Garrett (1994) Ð especially in her chapter, ``Thirdworldization: the interaction of poverty, poor housing and social despair with disease'', in her book, The Coming Plague Ð have written poignantly about this. On a much more modest scale, my recent commentary in the journal Health and Human Rights (Heggenhougen, 1999) similarly attempted to speak of social pathologies evident throughout the world which must receive our attention if health is to improve. The fact that military hardware and illicit drugs constitute two of the world's largest markets is one way to begin to describe this crisis, as is the tobacco industry's pushing of cigarettes throughout the world (even as inroads are made against cigarettes in the US). Globalization, which is now a fact of life even for seemingly small and isolated rural communities may have certain bene®ts, also for disenfranchised communities (and these should not be ignored but encouraged to ¯ourish), but according to the UNDP (1997) globalization is primarily a detriment to the lives of the world's poor; ``. . .national governments go out of their way to attract foreign direct investment by oering to relax labour or health standards, that will hurt the poor and set o a `race to the bottom' that will lower standards worldwide'' (UNDP, 1997, p. 90). More than 40% of world trade is controlled by less that 400 of the world's largest corporations, 50 of which are among the worlds 100 largest economic entities (the other 50 being countries). Ten percent of the world's poorest countries have less than 0.5% of world trade, half their rate a decade ago (UNDP, 1998). The poorest 20% of the world's population share in only 1.1% of the world's wealth, with 1.3 billion people living on
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$1 or less a day and millions dying of starvation each year. Seventy percent of those living in absolute poverty are women and indigenous communities are consistently among the poorest segment of any society (Buvenic et al., 1996, p. 16±18). There are more than a 100 million street children in the world and the number of orphans in the most precarious of circumstances (due to AIDS and war) is increasing at an alarming rate. The economic disparity between the top and the bottom 20% of the worlds population has tripled since the 1960s to more than 1:82 (UNDP, 1998) Ð some say it is as high as 1:140 (Werner, personal communication). Income disparities of third world workers in corporation factories and those of upper management and CEOs are obscene ratios reaching more than 100,000 to 1 (Cavanaugh and Broad, 1996, p. 21; Holtz, 1997; National Labor Committee Report, 1966). These statistics go on and on (Heggenhougen, 1999). Examining the web of factors contributing to the growing gaps which isolate and alienate us Ð enriching a few and impoverishing the many more Ð within nations and internationally, is, I believe, a major task of medical anthropology, and should constitute a larger and more central position within the medical anthropological and general social science literature. This must be done, even as we work hard to establish and improve speci®c public health eorts, be these rural clinics, sanitation projects, vaccination programs, support of street children and orphans or local income generating and loan schemes, such as, for example, the Grameen Bank (Yunus, 1999). Medical anthropologists attempting to positively impact the health of those among whom we have lived and studied abroad or at home, and thus the health of us all, must, and do, produce far more than ``interesting stories'', as we attempt to focus on, and grapple with, the immediate and the more distant (the more fundamental), both at the same time (Link and Phelan, 1995). Our contributions to local eorts to improve the health of people must be juxtaposed with the national and international crisis which aicts us all, and with an examination of the root causes of inequity and the growing pauperization of the world. In the world in which we now live, the task is one of being anthropologists of ``health and equity'', anthropologists of ``health and social justice'' (Farmer, 1999).
References Bradley, D.J., 1991. Malaria Ð whence and whither? In: Target, G.A.T. (Ed.), Malaria Ð Waiting for the Vaccine. Wiley, New York, pp. 13±29. Brodie, M. 1995. The four Americas: government and social policy through the eyes of America's multi-racial and
multi-ethnic society. A Report of The Washington Post/ Kaiser Family Foundation/Harvard Survey Project, Kaiser Foundation, Menlo Park, CA. Buvenic, M., Gwin, K., Bates, L., 1996. Investing in women: progress and prospects for the World bank. Overseas Development Council, Washington DC. Capital Times, 1994. `Views of the capital times Ð pauperization of America'. The Capital Times 8 August, editorial page. Cavanaugh, J., Broad, R., 1996. `Global reach: workers ®ght the multinationals'. The Nation 21 March, 21±24. Diamond, S., 1974. Search of the Primitive: A Critique of Civilization. Transaction Books, New Brunswick. Farmer, P., 1999. Inequities and Infections. University of California Press, Berkeley. Farmer, P., 1996. `On suering and structural violence: a view from below'. Daedalus 125, 261±283. Fernandez, G. 1994. Poverty, Democracy and Market Economy, South American Peace Commission (Chile) and DESCO (Peru). Garrett, L., 1994. Thirdworldization Ð The interaction of poverty, poor housing and social despair with disease. In: Garrett, L. (Ed.), The Coming Plague Ð Newly Emerging Diseases in a World out of Balance. Penguin Books, London, pp. 457±527. Greider, W., 1997. One World, Ready or Not: The Manic Logic of Global Capitalism. Simon & Schuster, New York. Guinier, L. 1996. Presentation to the E Pluribus Unum?: American National Identities Conference. Stanford University, Palo Alto, CA. Heggenhougen, H.K., 1995. Editorial: the epidemiology of functional apartheid and human rights abuses. Soc. Sci. Med 40, 281±284. Heggenhougen, H.K., 1999. Are the marginalized the slagheap of economic growth and globalization? Disparity, health, and human rights. Health and Human Rights 4 (1), 205±213. Heggenhougen, H.K., Pedersen, D., 1997. Beyond quantitative measures: the relevance of anthropology for public health. In: Detels, R., et al. (Eds.), Oxford Textbook of Public Health3rd ed., vol. 2, pp. 815±828. Holtz, T.H. 1997. Transnational corporations and codes of conduct: impacts on human rights and health (manuscript). Kleinman, A. (Ed.), 1996. Social Suering (special issue). Daedalus 125 (1). Kleinman, A., Kleinman, J., 1996. The appeal of experience: the display of images Ð cultural appropriations of suering in our times. Daedalus 125, 1±24. Link, B.G., Phelan, J., 1995. Social conditions as fundamental causes of disease. J. Health Human Behavior 1995, 80±94. Mann, J., Goston, L., Gruskin, S., Brennan, R., Lazzarini, Z., Fineberg, H., 1994. Health and human rights. Health and Human Rights 1 (1), 6±23. National Labor Committee Report, 1996. The U.S. in Haiti: How to Get Rich on 11 Cents an Hour. National Labor Committee Education Fund, New York. New York Times, 1995. Infant deaths tied to poverty, study con®rms, New York Times, 15 December, A32.
Editorial / Social Science & Medicine 50 (2000) 1171±1175 Scheper-Hughes, N., 1990. Three propositions for a critically applied medical anthropology. Soc. Sci. Med 30, 189±197. Scheper-Hughes, N., 1995. The primacy of the ethical Ð propositions for a militant anthropology. Current Anthropology 36, 409±440. Scheper-Hughes, N., 1996. Small wars and invisible genocides. Soc. Sci. Med 43, 889±900. Stanley, A. 1999. Pope is returning to Mexico with new target: capitalism. New York Times, 22 January, A1. UNDP, 1997. Human Development Report. Oxford University Press, Oxford. UNDP, 1998. Human Development Report 1998. Oxford University Press, Oxford. Van Devanter, Mailman, N.J., 1999. Prevention of sexually
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transmitted diseases: the need for social and behavioral science expertise in public health departments. AJPH 89, 815±818. Yunus, M., Jolis, A. 1999. Banker to the poor: micro-lending and the battle against world poverty.
H.K. Heggenhougen Harvard Institute for International Development, Harvard University, 8 Story Street, 5th Floor, Cambridge, MA 02138, USA E-mail address: [email protected]