- Email: [email protected]
Discussion on David McQueen's Paper
Soc. Sci. & Med.. Vol. 12, pp. 75 to 77. © Pergamon Press Ltd. 1978. Printed in Great Britain.
U037-7856/78/0401-0075$02.00/0
DISCUSSION ON DAVID McQUEEN'S PAPER Reporter: PAUL U. UNSCHULD, lnstitut fiir Geschichte der Pharmazie, Philips-Universit/it Marburg, Marburg, West Germany
The study of health care systems of different cultures has proceeded to where most authors are aware of "category fallacies" that result from imposing our own notions on cultures alien to us. There is one decisive limitation in cross-cultural comparison of contemporary health care systems. The phenomenon of development can only vaguely be included in any such study. One may perhaps, as this author has done in one study, accept a general model of mankind's advance through cultural stages, and take cultures in existence today which more or less correspond to these stages to compare their medical systems. Many questions cannot be answered by such an approach. Most important are the epistemological changes that occur over time. Crosscultural comparison of contemporary medical systems cannot explain why paradigms concerning causation and character of illness become obsolete, or even heterodox, and are replaced by other paradigms. Medical historians have portrayed the developments in the West from ancient Greece up to our present time as moving step by step closer to truth. This explanation of conceptual changes is irrelevant when one faces a situation where one "false" paradigm, such as the concepts of demonic medicine, is replaced by another "false" paradigm, as is religious medicine with its belief in sinful behavior as the cause of disease. Was there better evidence that led to this epistemological change in ancient China? Only for those who accepted that particular religion as their new Weltansclmuung. Changes in Weltanschauung may have an effect on epistemological changes in health care and our initial enquiry must be extended to why and when these changes occur. Obviously this issue has to be dealt with if one wishes to understand the nature of basic paradigms in the field of health care. This and other limitations of the cross-cultural comparison of contemporary health care systems suggest the need to take history into account. What may seem to be a logical and unavoidable step, the exchange of ideas between medical history and anthropology, is bound to create controversies. One of the first questions raised focused on the methodological problem of finding categories broad enough to cover "all systems" across time and cultural barriers. Charles Rosenberg asserted, "Any set of categories broad enough to really reflect adequately things that must be covered by every culture are so broad as to not be analytically useful. It also has the danger of wrenching a particular part or component of a certain institution out of a particular culture per se." Similarly, Everett Mendelsohn said, "I can't believe for an instant that a concept of health or disease, of healing or illness is translatable across all cultural or societal boundaries or across time. My assumption is that they are not. To move across all cultural barriers and time to talk about the function of the healer befuddles rather than clarifies." Arthur Kleinman added that it would be "a fundamental error to assume categories to persist throughout a series of cultures. This would immediately suggest which evidence is acceptable and which we won't use." Several suggestions were made to avoid such category fallacies. Charles Rosenberg mentioned, "If one assumes 75
that there are real biological processes you can agree on, as for instance measles or cholera, that becomes a sampling device which may be legitimate because you may look at how different cultures respond to the same defined incident." This approach creates various problems, one of them being the fact that few descriptions of "disease" in historical materials are full and accurate enough to allow a correct diagnosis in modern termS. With the patient at hand diagnosis can often be reached only with sophisticated differential devices. Arthur Rubel dissented from Rosenberg's proposal by asserting, "It is a poor start to begin with the disease categories of modern medicine. One should look, for instance, at misfortune and see how people cope. Then look at the literature and see whether things that we call diseases fall away from other kinds of misfortune. This would provide a better chance to look cross-culturally and see whether there are some generic commonalities." Everett Mendelsohn brought another dimension into the discussion by asking, "Where are practices or cognitive structures in a society or cultural system embedded? What do they serve, and who do they serve?" Horacio Fabrega added, "The question must be, what is it that one wants to explain? One can explain people's theories of disease and the way these change. The constraints placed on the behavior of sick people, whatever their definition is. How do people's behaviors in the midst of disease change across time or across social segments? What is the structure of medical practice? What was the role of the practitioner?" The question of whether one could find suitable categories to cover "all systems" stimulated a heated controversy over whether modern Western medicine was incomparable to any other health care system, and whether it was permissible, as Dr. McQueen had suggested, to pursue Holton's thematic approach in medicine. This had led him to a categorical linking of "object intrusion" with the "germ theory " which causeel Charles Rosenberg to voice strong doubts: "Things are different in the West. Certain emotional aspects are the same in 1976 as they were in 1376. There are, however, elements within the system that are quite different, they are the results of unique aspects of Western intellectual and institutional development. Western medicine has been connected with science in a very complicated way. There are institutions within that system for rewarding innovation and creating innovation. Different kinds of social options and structures were created within which the physician interacts with the patient. That can't be ignored. In examining Western medicine one has to be aware of the timeless elements, and one also has to be aware that there is this unique interaction between a cognitive level of analysis, and the institutional change proceeding from that realm, and the ongoing activities of the physician. The dynamics between those two realms is what makes it unique and what creates the particular existential reality that we deal with at any particular moment in time." Frank Blackford agreed to a uniqueness of Western medicine but took strong exception to the elements Charles Rosenberg had mentioned: "I think institutions to reward innovation are certainly characteristic of a lot. of other traditions; this is certainly true in India and I
76
Discussion
think in China as well." Everett Mendelsohn suggested that the boundaries of medicine or science rather than the core may reveal •uniqueness or commonalities: "It is at the boundaries of the interactions between the institutional and theoretical levels that indeed you see where within a society this activity is going on, how it is practiced, how it is legitimated and whether its concepts cross the boundaries or not." Part of the discussion was devoted to the role medical history has played so far in advancing our knowledge of the characteristics and commonalities of health care systems. In this context Stephen Kunitz pointed out that "many of the histories that have been written are based upon what literate people have produced in the past. A large proportion of the people were illiterate and to a large extent they don't appear in history. Much of the history of medicine that one reads is primarily a chronicle of what learned physicians or healers in a particular society have believed. That may not correspond to the way many lay people' behaved, or to many of the beliefs of other practitioners." Iago Gaidston reacted to this by stating: "What were learned physicians writing about? They were not writing just out of the air. If you take, for example, the Epidemics of Hippocrates, who does he write about? The tinman, the ieatherworker. Just because we have medical people writing does not mean that the points of view they write about are necessarily representative of their belief in political somethings and so on." Kunitz replied: "Much of the history that one reads seems to reflect particular groups in a society and what you frequently do not get when you read history of medicine is a sense of What non-professionals or non-healers were doing. I presume if you go back to the original sources you get a different sense of what is going on." Joe Loudon added: "Some wrote about the illiterate people but they wrote for those who could read, not for those they were writing about." Charles Rosenberg, who has taken great efforts to add the dimension to medical history that was claimed to be traditionally neglected, explained: "The history of medicine has been an intellectual history in that it has been a history of what one might call high-cultural ideas with a casual assumption that there is some relationship between behavior as seen in doctor-patient relationships and behavior as a series of ideas that people have in their heads about why they are sick and what is the cause of it. I think that in the last ten years or so there has been a shift towards an interest in what we might call the behavioral aspects of medical history. In some of my own studies I attempt to use a variety of sources to show what actual medical practice was like. I have attempted to show the relationship between a certain cognitive view of the body and healing, the high-cultural view, at the one hand, and the actual interaction from doctor and patient on the other. There are a lot of things for historians to exploit that have not been exploited: hospital records, patent medicine advertisements, diaries, letters, etc." Arthur Kleinman made the point that a similar lack of representativeness as regards what happened on "the popular level" is true also for histories of East Asian medicine: "History of medicine in China has been distorted significantly by the writings of Needham, Sivin and Manfred Porkert simply because the history of high medicine in China was never the medicine of 90~ of the population. The medicine of the folk culture is not seen in the history of medicine texts. It is unfortunate to think that the texts that are now written on the history of medicine in China are really limited in a sense to the levels of literature that are institutionalized, as opposed to the culturally diffuse tradition. I think this is a modern example of where the power of politics comes in." • William McNeill indicated some of the reasons that may
have influenced the character of Western secondary sources on the history of Oriental medicines: "There were some rather isolated individuals who started studying the other medical high-literate traditions of China and India. The people on the whole who moved into Chinese and Indian medicine are arguing this is real truth, too, and are apologetic. They are concerned to act as antibody to the ethnocentric assumption that true medicine is only what happened from the Greeks to 1976. Yet among historians true medicine is Western medicine and everything else is somehow folklore, either off the track or on a track which is rather accidental. Historians of non-Western medicine thus developed a very strong apologetic tone in most of what they wrote, saying these people are just as smart as the Greeks, they are just as smart as the Europeans, they should be taken into account. As to the possibility of bringing together a medical history which looks across our own high cultural traditions in some more or less neutral sensei I have not seen such an attempt." That written medical history contains a strong apologetic element not only in histories of non-Western traditions was pointed out by Everett Mendelsohn: "The effort of writing history of medicine was taken up largely by physicians who either part-time or, at points in their life, fulltime, tt/rned to writing about these activities. They carried the assumptions of practitioners. Not that they were not at times critical, but these points of criticism were raised within the context of the practitioner. By and large the history of medicine has been apologetics rather than a critical analysis. Medicine and science have seen themselves as special phenomena that needed to be treated in a very different way from other history. You did not ask the hard social questions about it. It is a knowledge which seemed to have in the view of the holder of it a universality, it's a knowledge which didn't have immediate social reference. Questions we need to ask now are: "Where did it come from? What were the social forces that were behind it? What made it to proclaim to be normatively neutral.~ Paul Unschuld brought attention to the fact that the discussion so far had exclusively centered around medical history that was written already. The question whether the history of medical events of the past per se, assuming a proper perspective and methodology for their analysis, might serve as a theoretical source for the comparative study of health care systems had not been touched. Drawing on his own work in the history of medicine in China, Unschuld suggested that "certain aspects of medical systems are comparable over time to advance our understanding of what is going on in medicine. However, it is essential to first clarify what kind of a "system" one is looking at. Is it the system of health care distribution, of political organization of health care, of medical concepts, to name but three out of many more possible. Comparison of the many medical traditions that can be distinguished in Chinese history on a conceptual level seems to be a promising approach. This comparison of traditions within a civilization may show how the rise and fall of medical paradigms occurred by showing who gave support to specific concepts at what time, who continued to cling to concepts that become heterodox, and so on." Jean Claude Guideau was the most sceptical speaker with regard to utilizing history as a source for comparative studies in health care. While all the other participants focused on weaknesses of the traditional approaches in medical history, implying that it needed improvements to be useful, Guideau seriously questioned the entire linking of the two disciplines of anthropology and history: '°The whole point I see this afternoon of history being applied into other fields is that because of constraints brought about by disciplinary matrices some anthropologists feel that they encounter problems that they are not able to solve as well as they would like to, and perhaps by speaking to some historians they can adapt the methods of the
Discussion historians to their own field. I think this is an illusory phenomenon linked to very specific conditions of the production of knowledge. Let's look at how it has been suggested to do history today. One suggestion was "can we look in the past and see a situation we can describe in some way and then look at another situation in the past or present world and then do a comparison! This would be taking up the writings of historians and anthropologists to make a formal analogy of the two, and then draw a generalization from that. If you use history in s u c h a way you pervert the very notion of history. History can never be used as a bag of facts which then can be applied to
77
another field. History is very specific in its own approach. History will always look at one particular societal context with its specific forms of relationships, its specific forces that work, specific results. All we can do with history is choose, each one of us, a period in space and a population and then introduce all the tools that can work together in some integrated whole in which history would be the necessary way in which to see how that thing unfolds at that point at that time. If you do that, then the whole project of comparison between the medical systems using history as its base becomes completely fallacious."
U037-7856/78/0401-0075$02.00/0
DISCUSSION ON DAVID McQUEEN'S PAPER Reporter: PAUL U. UNSCHULD, lnstitut fiir Geschichte der Pharmazie, Philips-Universit/it Marburg, Marburg, West Germany
The study of health care systems of different cultures has proceeded to where most authors are aware of "category fallacies" that result from imposing our own notions on cultures alien to us. There is one decisive limitation in cross-cultural comparison of contemporary health care systems. The phenomenon of development can only vaguely be included in any such study. One may perhaps, as this author has done in one study, accept a general model of mankind's advance through cultural stages, and take cultures in existence today which more or less correspond to these stages to compare their medical systems. Many questions cannot be answered by such an approach. Most important are the epistemological changes that occur over time. Crosscultural comparison of contemporary medical systems cannot explain why paradigms concerning causation and character of illness become obsolete, or even heterodox, and are replaced by other paradigms. Medical historians have portrayed the developments in the West from ancient Greece up to our present time as moving step by step closer to truth. This explanation of conceptual changes is irrelevant when one faces a situation where one "false" paradigm, such as the concepts of demonic medicine, is replaced by another "false" paradigm, as is religious medicine with its belief in sinful behavior as the cause of disease. Was there better evidence that led to this epistemological change in ancient China? Only for those who accepted that particular religion as their new Weltansclmuung. Changes in Weltanschauung may have an effect on epistemological changes in health care and our initial enquiry must be extended to why and when these changes occur. Obviously this issue has to be dealt with if one wishes to understand the nature of basic paradigms in the field of health care. This and other limitations of the cross-cultural comparison of contemporary health care systems suggest the need to take history into account. What may seem to be a logical and unavoidable step, the exchange of ideas between medical history and anthropology, is bound to create controversies. One of the first questions raised focused on the methodological problem of finding categories broad enough to cover "all systems" across time and cultural barriers. Charles Rosenberg asserted, "Any set of categories broad enough to really reflect adequately things that must be covered by every culture are so broad as to not be analytically useful. It also has the danger of wrenching a particular part or component of a certain institution out of a particular culture per se." Similarly, Everett Mendelsohn said, "I can't believe for an instant that a concept of health or disease, of healing or illness is translatable across all cultural or societal boundaries or across time. My assumption is that they are not. To move across all cultural barriers and time to talk about the function of the healer befuddles rather than clarifies." Arthur Kleinman added that it would be "a fundamental error to assume categories to persist throughout a series of cultures. This would immediately suggest which evidence is acceptable and which we won't use." Several suggestions were made to avoid such category fallacies. Charles Rosenberg mentioned, "If one assumes 75
that there are real biological processes you can agree on, as for instance measles or cholera, that becomes a sampling device which may be legitimate because you may look at how different cultures respond to the same defined incident." This approach creates various problems, one of them being the fact that few descriptions of "disease" in historical materials are full and accurate enough to allow a correct diagnosis in modern termS. With the patient at hand diagnosis can often be reached only with sophisticated differential devices. Arthur Rubel dissented from Rosenberg's proposal by asserting, "It is a poor start to begin with the disease categories of modern medicine. One should look, for instance, at misfortune and see how people cope. Then look at the literature and see whether things that we call diseases fall away from other kinds of misfortune. This would provide a better chance to look cross-culturally and see whether there are some generic commonalities." Everett Mendelsohn brought another dimension into the discussion by asking, "Where are practices or cognitive structures in a society or cultural system embedded? What do they serve, and who do they serve?" Horacio Fabrega added, "The question must be, what is it that one wants to explain? One can explain people's theories of disease and the way these change. The constraints placed on the behavior of sick people, whatever their definition is. How do people's behaviors in the midst of disease change across time or across social segments? What is the structure of medical practice? What was the role of the practitioner?" The question of whether one could find suitable categories to cover "all systems" stimulated a heated controversy over whether modern Western medicine was incomparable to any other health care system, and whether it was permissible, as Dr. McQueen had suggested, to pursue Holton's thematic approach in medicine. This had led him to a categorical linking of "object intrusion" with the "germ theory " which causeel Charles Rosenberg to voice strong doubts: "Things are different in the West. Certain emotional aspects are the same in 1976 as they were in 1376. There are, however, elements within the system that are quite different, they are the results of unique aspects of Western intellectual and institutional development. Western medicine has been connected with science in a very complicated way. There are institutions within that system for rewarding innovation and creating innovation. Different kinds of social options and structures were created within which the physician interacts with the patient. That can't be ignored. In examining Western medicine one has to be aware of the timeless elements, and one also has to be aware that there is this unique interaction between a cognitive level of analysis, and the institutional change proceeding from that realm, and the ongoing activities of the physician. The dynamics between those two realms is what makes it unique and what creates the particular existential reality that we deal with at any particular moment in time." Frank Blackford agreed to a uniqueness of Western medicine but took strong exception to the elements Charles Rosenberg had mentioned: "I think institutions to reward innovation are certainly characteristic of a lot. of other traditions; this is certainly true in India and I
76
Discussion
think in China as well." Everett Mendelsohn suggested that the boundaries of medicine or science rather than the core may reveal •uniqueness or commonalities: "It is at the boundaries of the interactions between the institutional and theoretical levels that indeed you see where within a society this activity is going on, how it is practiced, how it is legitimated and whether its concepts cross the boundaries or not." Part of the discussion was devoted to the role medical history has played so far in advancing our knowledge of the characteristics and commonalities of health care systems. In this context Stephen Kunitz pointed out that "many of the histories that have been written are based upon what literate people have produced in the past. A large proportion of the people were illiterate and to a large extent they don't appear in history. Much of the history of medicine that one reads is primarily a chronicle of what learned physicians or healers in a particular society have believed. That may not correspond to the way many lay people' behaved, or to many of the beliefs of other practitioners." Iago Gaidston reacted to this by stating: "What were learned physicians writing about? They were not writing just out of the air. If you take, for example, the Epidemics of Hippocrates, who does he write about? The tinman, the ieatherworker. Just because we have medical people writing does not mean that the points of view they write about are necessarily representative of their belief in political somethings and so on." Kunitz replied: "Much of the history that one reads seems to reflect particular groups in a society and what you frequently do not get when you read history of medicine is a sense of What non-professionals or non-healers were doing. I presume if you go back to the original sources you get a different sense of what is going on." Joe Loudon added: "Some wrote about the illiterate people but they wrote for those who could read, not for those they were writing about." Charles Rosenberg, who has taken great efforts to add the dimension to medical history that was claimed to be traditionally neglected, explained: "The history of medicine has been an intellectual history in that it has been a history of what one might call high-cultural ideas with a casual assumption that there is some relationship between behavior as seen in doctor-patient relationships and behavior as a series of ideas that people have in their heads about why they are sick and what is the cause of it. I think that in the last ten years or so there has been a shift towards an interest in what we might call the behavioral aspects of medical history. In some of my own studies I attempt to use a variety of sources to show what actual medical practice was like. I have attempted to show the relationship between a certain cognitive view of the body and healing, the high-cultural view, at the one hand, and the actual interaction from doctor and patient on the other. There are a lot of things for historians to exploit that have not been exploited: hospital records, patent medicine advertisements, diaries, letters, etc." Arthur Kleinman made the point that a similar lack of representativeness as regards what happened on "the popular level" is true also for histories of East Asian medicine: "History of medicine in China has been distorted significantly by the writings of Needham, Sivin and Manfred Porkert simply because the history of high medicine in China was never the medicine of 90~ of the population. The medicine of the folk culture is not seen in the history of medicine texts. It is unfortunate to think that the texts that are now written on the history of medicine in China are really limited in a sense to the levels of literature that are institutionalized, as opposed to the culturally diffuse tradition. I think this is a modern example of where the power of politics comes in." • William McNeill indicated some of the reasons that may
have influenced the character of Western secondary sources on the history of Oriental medicines: "There were some rather isolated individuals who started studying the other medical high-literate traditions of China and India. The people on the whole who moved into Chinese and Indian medicine are arguing this is real truth, too, and are apologetic. They are concerned to act as antibody to the ethnocentric assumption that true medicine is only what happened from the Greeks to 1976. Yet among historians true medicine is Western medicine and everything else is somehow folklore, either off the track or on a track which is rather accidental. Historians of non-Western medicine thus developed a very strong apologetic tone in most of what they wrote, saying these people are just as smart as the Greeks, they are just as smart as the Europeans, they should be taken into account. As to the possibility of bringing together a medical history which looks across our own high cultural traditions in some more or less neutral sensei I have not seen such an attempt." That written medical history contains a strong apologetic element not only in histories of non-Western traditions was pointed out by Everett Mendelsohn: "The effort of writing history of medicine was taken up largely by physicians who either part-time or, at points in their life, fulltime, tt/rned to writing about these activities. They carried the assumptions of practitioners. Not that they were not at times critical, but these points of criticism were raised within the context of the practitioner. By and large the history of medicine has been apologetics rather than a critical analysis. Medicine and science have seen themselves as special phenomena that needed to be treated in a very different way from other history. You did not ask the hard social questions about it. It is a knowledge which seemed to have in the view of the holder of it a universality, it's a knowledge which didn't have immediate social reference. Questions we need to ask now are: "Where did it come from? What were the social forces that were behind it? What made it to proclaim to be normatively neutral.~ Paul Unschuld brought attention to the fact that the discussion so far had exclusively centered around medical history that was written already. The question whether the history of medical events of the past per se, assuming a proper perspective and methodology for their analysis, might serve as a theoretical source for the comparative study of health care systems had not been touched. Drawing on his own work in the history of medicine in China, Unschuld suggested that "certain aspects of medical systems are comparable over time to advance our understanding of what is going on in medicine. However, it is essential to first clarify what kind of a "system" one is looking at. Is it the system of health care distribution, of political organization of health care, of medical concepts, to name but three out of many more possible. Comparison of the many medical traditions that can be distinguished in Chinese history on a conceptual level seems to be a promising approach. This comparison of traditions within a civilization may show how the rise and fall of medical paradigms occurred by showing who gave support to specific concepts at what time, who continued to cling to concepts that become heterodox, and so on." Jean Claude Guideau was the most sceptical speaker with regard to utilizing history as a source for comparative studies in health care. While all the other participants focused on weaknesses of the traditional approaches in medical history, implying that it needed improvements to be useful, Guideau seriously questioned the entire linking of the two disciplines of anthropology and history: '°The whole point I see this afternoon of history being applied into other fields is that because of constraints brought about by disciplinary matrices some anthropologists feel that they encounter problems that they are not able to solve as well as they would like to, and perhaps by speaking to some historians they can adapt the methods of the
Discussion historians to their own field. I think this is an illusory phenomenon linked to very specific conditions of the production of knowledge. Let's look at how it has been suggested to do history today. One suggestion was "can we look in the past and see a situation we can describe in some way and then look at another situation in the past or present world and then do a comparison! This would be taking up the writings of historians and anthropologists to make a formal analogy of the two, and then draw a generalization from that. If you use history in s u c h a way you pervert the very notion of history. History can never be used as a bag of facts which then can be applied to
77
another field. History is very specific in its own approach. History will always look at one particular societal context with its specific forms of relationships, its specific forces that work, specific results. All we can do with history is choose, each one of us, a period in space and a population and then introduce all the tools that can work together in some integrated whole in which history would be the necessary way in which to see how that thing unfolds at that point at that time. If you do that, then the whole project of comparison between the medical systems using history as its base becomes completely fallacious."