- Email: [email protected]
Discussion on ray H. Elling's paper
Soc. Sci. & Med., Vol. 12. pp. 117 to 120.
0037-7856/7~/0401.4)117502.(X1/0
© PergamonPress Ltd. 1978. Printed in Great Britain.
D I S C U S S I O N O N RAY H. ELLING'S PAPER Reporter:
MARGARET MACKENZIE
Department of Anthropology, University of California, Berkeley, CA 94720
Elling began the discussion by talking about the development of his paper. Most countries are feeling pressure to provide better access to adequate health care at the same time as they are faced with rapidly rising costs. This dilemma is the fundamental problem confronting the World Health Organization (WHO): how to devise adequate health care coverage at feasible costs. Yet nowhere is there a consistent or comprehensive catalog or analysis of how nations organize scarce resources for health. Although there are anecdotal descriptions, studies such as those of Odin Anderson, Milton Rohmer, and Richard Wanerman, where the health systems of two or more countries are analyzed in terms of an explicit framework, are rare. Facets of health systems are examined with great contern for legitimate comparability in some works, the KerrWhite studies published by the Oxford University Press for example. After ten expensive years and many meetings of interdisciplinary health teams to define exactly what would be meant by utilization of a physician's services or 0fa hospital, and then attempts to measure these, the book appeared showing that there are indeed remarkable differences from country to country--West Germany has 12 or 13 visits to a physician per capita a year, Sweden 3.5, and the United States about 5. But the problem which Weber called ver~tehen remains. How are we to make sense of this information? The data may be fascinating, but what all that elaborate research has not done is to unfold the contexts within which the behavior was examined. What about the cultural expectations at different levels of the society, what about the actual distribution of facilities and services, and their structure and organization? We have no satisfactory general measure of health, but taking infant mortality or longevity as a beginning, remembering all the shortcomings, it is helpful to look at "contrasting cases". A close association exists between Gross National Product (GNP) and health. Although it is crucial to examine the distribution of G N P within countries, where the G N P is high infant mortality is low and life expectancy long, and vice versa. The length of life in Bangladesh is about 42 years compared with 72 or 73 in Sweden; the infant mortality is 139 per 1000 live births in India: that is, 139 of the children will have died by the age of one year, while in Sweden only 9 or l0 die, and in the United States 18 or so. Nevertheless, there are "contrasting cases", such as, Syria which has a low G N P but also a low infant mortality. Do these health levels, although they are calculated by such problematic measures, imply different kinds of health services? Many studies indicate that health levels generally are not determined by what is done in the health services, yet if an association is found can we infer that the way health services are organized produced it? Certainly it would not be enough to ask only about doctor-patient relationships, or for most countries of any size, to ask about a policy ordered by a central office and imposed across the whole country. Regional organization is worth further thought. For most countries, regions need to be intermediate units, probably not each town because that would lead to duplication of exotic equipment such as brain scanners. Waitzkin has written about the problem of investment of surplus capital, showing that in the United States when there is
no war, it is invested in the medical sphere, such as in coronary care units. Yet there is no evidence that these do any good. In fact there is some counter evidence from the United Kingdom, for example, showing that people sent home do better than those treated in coronary care units. But coronary care units still spring up. In part this happens in the U.S. because of the atomized market system, and because no real effort to establish regional units is made. It is an idea with some history, reaching back to the I920s; it was tried out even in pre-Revolutionary China in a Corneli-Peking University project, in Puerto Rico, and the services in the Soviet Union are based on it. With regional units as an ideal goal, what social, economic, and political conditions would support establishing regional units? Today throughout the world oppressed groups are trying to free themselves from colonial influences. Each has different characteristics, and they have reached different stages of development. To understand these movements, a typology is needed, a way of thinking about the organization of authority in society. Everyday terms are not sufficiently penetrating--parliamentary democracy, socialism, capitalism--so this paper focuses on centralization and decentralization of authority, and on authority as concerted or fragmented. Liberation movements seem to move towards a sociopolitical structure which is decentralized and concerted; an environment in which real coverage of the people with some form of adequate health care could be expected. The discussant for the session was Roger Jeffery, who began by saying that he found the paper a radical sandwich, with the middle section not fitting easily in between. The centralization/decentralization concept seemed weak, and in describing his ideal medical care system, Elling appeared to be doing exactly what he claimed he did not want to do: arguing like a social engineer, speaking to administrators who impose change from above. Jeffery was uneasy with the table illustrating the types of authority because any classification which combined India, the U.S. and the Federal German Republic ignored differences too significant to overlook. Social formations, the modes of production dominant in different settings, and international and multinational sets of relationships were not included. Finally, the table permitted movements in all directions at the same time, and any grid which gives no grounds for saying that there are tendencies to move one way or another, or that there are some inconsistent patterns, was not very helpful for the sorts of problems Jeffery wanted to analyze. The reason for the weaknesses was a failure to look at the ways in which medical care systems dominated by Nation-State apparatuses work as social control mechanisms. These mechanisms differ in different social formations and cannot be combined in an atheoretical way. Secondly, Elling neglected the role of medical services in the modes of production, including the mode of medical production. Ignoring these problems made it possible to put countries together in a framework such as the one in the table. To what extent is there relative autonomy between medical care systems and other systems in societies? Can medical care be detached? What range of variation is normal, and what variations should be studied to predict changes in a system? What chances are there for systems to get
117
l 18
Discussion
out of step with other patterns in society? Jeffery's research in post-colonial India has sought to explain, for example, why the Congress Party in 1938 produced a classic program for something like barefoot doctors, and why this program was not taken up. How can the fate of a similar document which came out in 1975 in India be predicted? Elling replied that he found the sandwich criticism good. He had used condensed officialese, but wanted to emphasize that the literature on regionalization showed a noticeable lack of concern for the way laymen would be involved in determining what their health problems and priorities are. He is convinced that this is central to achieving full regionalization. As for the interplay between the health system and its sociopolitical context, he is convinced that health and medical care systems are deeply embedded in the rest of society, and that the belief systems which orient people in different parts of social structure are interrelated. Having accepted the assignment by the conference organizer to talk on health systems as changing social systems, it seemed necessary to avoid an internal examination of technology or of flows of ideas, and to make some stab at moving back to the dynamics of change in the sociopolitical economic structure. Gananath Obeyesekere argued that the relationship between GNP and infant mortality is an illusion, shown by Sri Lanka where infant morality is low, 30-40 approximately, but economic conditions are abysmal, worse than the rest of Southeast Asia. Also, the life expectancy is equivalent to that of the West, 70.2 according to WHO. Scandinavian Marxist sociologists working in a village in South India found that by controlling for infant mortality, the life expectancy there shot up to 60, and in some instances, 70. But GNP has nothing to do with it. Children are dying from the time they are born until the age of 3 or 4. Over a three-year period the causes of infant deaths in the village were (1) neonatal tetanus, (2) diarrhea, and (3) fevers. In Sri Lanka, WHO statistics indicate that 9970 of the births are supervised professionally. That is the one variable involved. During the last 20 years, local politicians have realized that they must provide three things: a maternity ward, a road, and a school. So when Obeyesekere did fieldwork in one of the most isolated villages in 1956, even there 70% of the births were in the maternity ward. He believes the GNP is a spurious correlation with infant mortality because the real question is how to eliminate these preventable causes of death. He disagrees also with the Scandinavian Marxists, who said deaths were due to poor nutrition and to the economic infrastructure, because poor nutrition is characteristic of all levels of Indian society. EUing replied that his main point was that although a high correlation exists between infant mortality and GNP, study of places where this is not the case would be especially productive. Some countries with very low economic production have somehow found a system that gets health care and knowledge to low income and rural people, whereas in other countries resources are concentrated in the capital. In the Ivory Coast, for example, 60Fo of the health budget is spent on the medical school and the hospital in the capital city. Margaret Mackenzie asked Obeyesekere why he claimed that it was solely because births were professionally supervised that infant mortality decreased in Sri Lanka. If there were a road and a school, as well as a maternity ward, how did he know that they, and nutrition, had nothing to do with the improvement? Joseph Loudon also challenged Obeyesekere's crediting the midwives as the sole reason for the improvement in infant mortality. Speaking from experience working in South Africa in an area where the toddler death rate was 300-400 per 100,000, he found Obeyesekere's claim implausible. Rather. the successes Obeyesekere discussed implied
widespread acceptance of a whole range of other services he had not mentioned, and which his own clinical background suggested were symptomatic of a major change which was not purely technical, but was in fact a major change in culture. Obeyesekere reiterated that nutrition was not crucial but conceded that education was, especially since it was introduced at the same time as the other improvements. He added another item from WHO: that voluntary family planning has been dramatically successful in Sri Lanka, where the birth rate is moving towards that of Singapore which is close to Western rates. Mary Jo Good asked why the Sri Lanka politicians decided to introduce the innovations. Obeyesekere replied that he knew little about the decisions, except that one Cabinet Minister during the British period decided on cottage hospitals. Compulsory education, the elimination of illiteracy, and roads that brought a bus to every village had behind them some very important cultural factors. For example, the mystical Buddhist theme that it is meritorious for kings to provide hospitals for the poor. Ronald Frankenberg mentioned Scarlett.Epstein's study which showed that a village closer to development schemes became poorer while one further away changed. Recent work from Pakistan indicated that the enormous increase in GNP from the Green Revolution made the majority of the people much poorer than they had ever been. Even if the GNP and infant mortality figures were associated, the correlation may be completely unreliable. During his own fieldwork in Zambia, Frankenberg had been astonished by the infant mortality figure in the WHO handbook because the country had no registration of births. Officials at the Ministry of Health, when asked how they arrived at the figure, said that it came from the WHO handbook. The WHO officials said the Zambian Government told them. When he returned to the Zambian Government to ask them how they knew what to tell the WHO, the officials said, "We looked it up in the WHO handbook." Frankenberg objected to Elling's use of GNP because it was not broken down into classes and sections in the population. Recently WHO has been paying attention to rural preventive medicine rather than urban curative medicine. It has little chance of success. The reason for this situation is to be understood in the context of class struggles within and outside so-called developing countries. One must recognize and show by concrete studies, that the ruling classes do not have the same interest in medicine as the mass of the population. The situation in the Ivory Coast can be duplicated in many places; the same is true in Uganda and in Zambia. What happens, for example, is that someone in an elite position, such as a Permanent Secretary, who is dying, is flown overseas for treatment. His colleagues say, "Our country has no medical prestige, we must have a coronary care unit (or a kidney unit)." Immediately they build one--so they can die in their own special unit. As well as that, there is the exploitation of the third world by the U.S. and by England. Doctors are trained in India and they go overseas; doctors are trained in England and they go to the U.S. One has to look at a class situation on a world scale, then at what the class forces are within particular countries, and that is more significant than Elling's centralized/decentralized and concerted/fragmented distinctions. Elling agreed that of course it is necessary to know how the class struggle is going to work itself out in relation to his scheme of the organization of authority. Mary Jo Good addressed the issue of decentralization and class forces, both of which she thought might be accommodated by Elling's scheme. Given a centralized society and a particular set of class relations, one would expect a certain kind of medicine to be fostered by Govern-
Discussion ment or by private enterprise. Given a decentralized society and a similar set of class relations, one might expect different health services. It is necessary to study the ideological purposes the .health system serves. In Iran for example, the "barefoot doctor" being introduced certainly is not the same kind of person as in China. Instead of threatening the physicians who are an elite group from the upper class, they serve them. Arthur Kleinman emphasized that using technological resources without making any significant changes in poverty or in population pressure was unsuccessful, but a widespread belief persists that technological innovations will successfully remove sickness. While a few examples support this belief, by and large technology is only one of many contributing factors. Moreover, many situations arise where technology creates worse problems than those it is designed to remove--such as the widespread use of antibiotic injections for almost any complaint. Everett Mende!sohn discussed the methodological implications of trying to discover what it is that makes a difference in medical care. He mentioned a survey just after World War II in Maine that asked physicians what technology most affected the practice of medicine. In overwhelming numbers they listed the automobile. It made sense because the automobile gets people to professional centers for childbirth. Dr. Loudon also is convinced that medical technology is not sufficient to make a difference in health status, and is willing to stake his reputation on its not being that simple: he himself believes that the central difference is change in social performance and in culture, which has to do with how people live, and with what credence we and they give to different technological modes, different educational styles, and different ways of organizing people. Fairly early in development studies it was clear that the People's Republic of China was making a differ¢nce. What were they doing that made a difference'? How did they organize their population, how did they mobilize it? Were they or were they not introducing a belief system which had large segments of the population accepting ideas which changed their patterns of behavior, changed their relationship to society, to technology? In societies which are using a mixture of medical systems, which is the mixture that makes a difference'? What will people accept or not accept and under what conditions, and what are the differences across social class or religious boundaries that ~make a difference'~? Margaret Mackenzie said that she was trying to place Elling's paper within the context of the title of the conference because his paper, with its comparisons of GNP and infant mortality rates, seemed to be in a different arena from the others, and that this led her to ask Professor Leslie about how he had decided to organize the conference and what his goals were. Charles Leslie replied that there are two ways of organizing conferences: inclusive and exclusive. An exclusive way would be to build a study of medical systems that is sociological and cultural, putting aside all questions of ecological systems and of epidemiology. For example, William McNeill had said he could not understand why he had been invited because he felt he knew nothing about medical systems. But McNeilrs paper is an example of comparative method: he thought he noticed something about the Conquest of Mexico, then his mind switched to the plague in Renaissance Europe, then to the plagues in Rome, and then he perceived similar patterns in the epidemics among rabbits in Australia, so he compared evolutionary adaptation in a non-human organism to the patterns he saw in people. Finally, he stretched our notion of what a society is by considering those things that eat and are eaten by members of a society. Human beings then belong in a society of organisms co-existing as an historical entity, and McNeill looked at human history from this perspective. Leslie, in organizing the conference, did not
119
want to exclude that sort of comparison and he thought that Zimmermann, working at the other extreme of comparative method, would agree. Zimmermann is studying one learned physician in India, and a set of classical texts-but mainly a single text--and from that he is trying to produce some comprehensive patterns for South Asia, a whole civilization over several thousand years and many classes of people. The problem is the complementarity between difference conceptual structures and different realities. Zimmermann is not interested in the bacteria in the belly of the Brahmin, whereas the bacteria would be interesting to McNeill. How do we learn to shift gears within different conceptual frameworks? This can be viewed in a derogatory way as eclectic. But Leslie believes that it is useful to make sense' of human activity through a set of shifting perspectives and communication (and miscommunication) networks, and connections across boundaries. The idea of the conference is to bring together people with different concepts, knowledge of fact, and different interests, some of whom may not be interested in what some of the others are studying. But perhaps their minds will be stretched a little by the experience and they will realize complementarities between various kinds of study unrecognized before. In developing the conference, Leslie conceived of the medical system a s not having any bacteria in it, but as being a system of social relations in social institutions and cultural forms. Many study this field with very little historical and contextual knowledge, so that there are, as Paul Unschuld pointed out, Sinologists working in ways comparable with those of Zimmermann, studying classical texts and describing a system. The question is, how much is it useful to know of that for someone who is studying medicine in Zaire? The flow of doctors from India to England, and from England to the U.S. is the creation of a cosmopolitan medical system, a network of institutional interrelations and exchange of knowledge, so that a person can have an appendectomy in China or in Russia or in Zaire or in Paris, and possibly the surgeon would use similar surgical instruments, but with the operation being otherwise very different in context. An exclusive biomedical perspective would be blind to this point. How could one ask about the theoretical foundations for the comparative study of medical systems in an exclusive conference without throwing a lot of the world into shadow? Perhaps the light in this inclusive conference is too diffuse and people panic when they feel that too many ideas are being discussed, references being made to too many different kinds of things. They want intellectual closure. If the conference had included only psychoanalysts, or only Marxists or only French structuralists, there could have been easy closure, but it would be blind to the rest of the world. So this is a conference that does not look for closure, but perhaps afterwards people will keep up new contacts, and we can at least begin to say what the vocabularies are and where they direct study, and what directions seem to be most fruitful. Mendelsohn asked how t o escape methodological anarchy, the position that any method is as valid or as valuable as any other, in an inclusive context. Leslie replied that anarchy is one position. Jean-Claude Guedon thought that no-one had been arguing for the idea of intellectual closure, but that some had been arguing against the idea that people can come with a shopping bag of ideas, throw them on the table and say that this person can have that one, and that person the next one, and think that this would be an exchange of ideas. He himself in particular objected because embed: ded in that notion is a positivistic bias. Charles Leslie replied that he thought all the people there would continue to do the kind of work they were
120
Discussion
trained to do and that they were most interested in doing. The diversity of research would not be cut down. But there is value in bringing together different people who are doing different kinds of work so that they can have a chance to discover what they might learn from others and others from them. Frankenberg returned to the question of placing Elling's paper in the context of the conference, saying that in terms of social anthropology, it could be seen both as validating the value and encouraging the small-scale intensive study of a limited area either in space or in time. Secondly, it raised the question of the persistence of culture, or of ideology, in a situation of structural change and of change in practice. The third point was less obvious and as far as he knew had not been studied: the symbol system of the decision makers and the literal concreteness of the symbols which they adopt, such as hospitals and airports, and the problems these raise, for example, for the administrator who goes to Geneva and says, "Last year we changed the rates on such and such a disease", in opposition to the administrator who says, "Last year we spent $10,000,000 on a big new hospital and here is a photograph of it!" Mendelsohn said that there are times when we all need
to ask, what work are we involved in which is serving malignant ends, continuing to create dependent or oppressive situations? Not all methods are equally responsible; some do extend power and control to one group rather than another. One thing learned in the analysis of development studies in the last decade is that all those economic and social development techniques and funds poured out have concentrated wealth abroad, and by concentrating wealth, political power. Discussing the interaction of modern and traditional medicine without facing that makes the conference intellectually vulnerable. Obviously the problem is complex, but we have a responsibility to face it. Otherwise the position is a return to the maxim in Alice in Wonderland: "If you don't know where you're going, any road will get you there." It is necessary to ask what directions western knowledge and technique have taken and where they ought to go, and to assess what we learn in looking at other societies which have had permanent underclasses and permanent overclasses. When we analyze relationships do we further mythologize them, or do we probe them and see what kinds of social systems we have abetted, and whether we have perpetuated the restrictions of power to the few?
0037-7856/7~/0401.4)117502.(X1/0
© PergamonPress Ltd. 1978. Printed in Great Britain.
D I S C U S S I O N O N RAY H. ELLING'S PAPER Reporter:
MARGARET MACKENZIE
Department of Anthropology, University of California, Berkeley, CA 94720
Elling began the discussion by talking about the development of his paper. Most countries are feeling pressure to provide better access to adequate health care at the same time as they are faced with rapidly rising costs. This dilemma is the fundamental problem confronting the World Health Organization (WHO): how to devise adequate health care coverage at feasible costs. Yet nowhere is there a consistent or comprehensive catalog or analysis of how nations organize scarce resources for health. Although there are anecdotal descriptions, studies such as those of Odin Anderson, Milton Rohmer, and Richard Wanerman, where the health systems of two or more countries are analyzed in terms of an explicit framework, are rare. Facets of health systems are examined with great contern for legitimate comparability in some works, the KerrWhite studies published by the Oxford University Press for example. After ten expensive years and many meetings of interdisciplinary health teams to define exactly what would be meant by utilization of a physician's services or 0fa hospital, and then attempts to measure these, the book appeared showing that there are indeed remarkable differences from country to country--West Germany has 12 or 13 visits to a physician per capita a year, Sweden 3.5, and the United States about 5. But the problem which Weber called ver~tehen remains. How are we to make sense of this information? The data may be fascinating, but what all that elaborate research has not done is to unfold the contexts within which the behavior was examined. What about the cultural expectations at different levels of the society, what about the actual distribution of facilities and services, and their structure and organization? We have no satisfactory general measure of health, but taking infant mortality or longevity as a beginning, remembering all the shortcomings, it is helpful to look at "contrasting cases". A close association exists between Gross National Product (GNP) and health. Although it is crucial to examine the distribution of G N P within countries, where the G N P is high infant mortality is low and life expectancy long, and vice versa. The length of life in Bangladesh is about 42 years compared with 72 or 73 in Sweden; the infant mortality is 139 per 1000 live births in India: that is, 139 of the children will have died by the age of one year, while in Sweden only 9 or l0 die, and in the United States 18 or so. Nevertheless, there are "contrasting cases", such as, Syria which has a low G N P but also a low infant mortality. Do these health levels, although they are calculated by such problematic measures, imply different kinds of health services? Many studies indicate that health levels generally are not determined by what is done in the health services, yet if an association is found can we infer that the way health services are organized produced it? Certainly it would not be enough to ask only about doctor-patient relationships, or for most countries of any size, to ask about a policy ordered by a central office and imposed across the whole country. Regional organization is worth further thought. For most countries, regions need to be intermediate units, probably not each town because that would lead to duplication of exotic equipment such as brain scanners. Waitzkin has written about the problem of investment of surplus capital, showing that in the United States when there is
no war, it is invested in the medical sphere, such as in coronary care units. Yet there is no evidence that these do any good. In fact there is some counter evidence from the United Kingdom, for example, showing that people sent home do better than those treated in coronary care units. But coronary care units still spring up. In part this happens in the U.S. because of the atomized market system, and because no real effort to establish regional units is made. It is an idea with some history, reaching back to the I920s; it was tried out even in pre-Revolutionary China in a Corneli-Peking University project, in Puerto Rico, and the services in the Soviet Union are based on it. With regional units as an ideal goal, what social, economic, and political conditions would support establishing regional units? Today throughout the world oppressed groups are trying to free themselves from colonial influences. Each has different characteristics, and they have reached different stages of development. To understand these movements, a typology is needed, a way of thinking about the organization of authority in society. Everyday terms are not sufficiently penetrating--parliamentary democracy, socialism, capitalism--so this paper focuses on centralization and decentralization of authority, and on authority as concerted or fragmented. Liberation movements seem to move towards a sociopolitical structure which is decentralized and concerted; an environment in which real coverage of the people with some form of adequate health care could be expected. The discussant for the session was Roger Jeffery, who began by saying that he found the paper a radical sandwich, with the middle section not fitting easily in between. The centralization/decentralization concept seemed weak, and in describing his ideal medical care system, Elling appeared to be doing exactly what he claimed he did not want to do: arguing like a social engineer, speaking to administrators who impose change from above. Jeffery was uneasy with the table illustrating the types of authority because any classification which combined India, the U.S. and the Federal German Republic ignored differences too significant to overlook. Social formations, the modes of production dominant in different settings, and international and multinational sets of relationships were not included. Finally, the table permitted movements in all directions at the same time, and any grid which gives no grounds for saying that there are tendencies to move one way or another, or that there are some inconsistent patterns, was not very helpful for the sorts of problems Jeffery wanted to analyze. The reason for the weaknesses was a failure to look at the ways in which medical care systems dominated by Nation-State apparatuses work as social control mechanisms. These mechanisms differ in different social formations and cannot be combined in an atheoretical way. Secondly, Elling neglected the role of medical services in the modes of production, including the mode of medical production. Ignoring these problems made it possible to put countries together in a framework such as the one in the table. To what extent is there relative autonomy between medical care systems and other systems in societies? Can medical care be detached? What range of variation is normal, and what variations should be studied to predict changes in a system? What chances are there for systems to get
117
l 18
Discussion
out of step with other patterns in society? Jeffery's research in post-colonial India has sought to explain, for example, why the Congress Party in 1938 produced a classic program for something like barefoot doctors, and why this program was not taken up. How can the fate of a similar document which came out in 1975 in India be predicted? Elling replied that he found the sandwich criticism good. He had used condensed officialese, but wanted to emphasize that the literature on regionalization showed a noticeable lack of concern for the way laymen would be involved in determining what their health problems and priorities are. He is convinced that this is central to achieving full regionalization. As for the interplay between the health system and its sociopolitical context, he is convinced that health and medical care systems are deeply embedded in the rest of society, and that the belief systems which orient people in different parts of social structure are interrelated. Having accepted the assignment by the conference organizer to talk on health systems as changing social systems, it seemed necessary to avoid an internal examination of technology or of flows of ideas, and to make some stab at moving back to the dynamics of change in the sociopolitical economic structure. Gananath Obeyesekere argued that the relationship between GNP and infant mortality is an illusion, shown by Sri Lanka where infant morality is low, 30-40 approximately, but economic conditions are abysmal, worse than the rest of Southeast Asia. Also, the life expectancy is equivalent to that of the West, 70.2 according to WHO. Scandinavian Marxist sociologists working in a village in South India found that by controlling for infant mortality, the life expectancy there shot up to 60, and in some instances, 70. But GNP has nothing to do with it. Children are dying from the time they are born until the age of 3 or 4. Over a three-year period the causes of infant deaths in the village were (1) neonatal tetanus, (2) diarrhea, and (3) fevers. In Sri Lanka, WHO statistics indicate that 9970 of the births are supervised professionally. That is the one variable involved. During the last 20 years, local politicians have realized that they must provide three things: a maternity ward, a road, and a school. So when Obeyesekere did fieldwork in one of the most isolated villages in 1956, even there 70% of the births were in the maternity ward. He believes the GNP is a spurious correlation with infant mortality because the real question is how to eliminate these preventable causes of death. He disagrees also with the Scandinavian Marxists, who said deaths were due to poor nutrition and to the economic infrastructure, because poor nutrition is characteristic of all levels of Indian society. EUing replied that his main point was that although a high correlation exists between infant mortality and GNP, study of places where this is not the case would be especially productive. Some countries with very low economic production have somehow found a system that gets health care and knowledge to low income and rural people, whereas in other countries resources are concentrated in the capital. In the Ivory Coast, for example, 60Fo of the health budget is spent on the medical school and the hospital in the capital city. Margaret Mackenzie asked Obeyesekere why he claimed that it was solely because births were professionally supervised that infant mortality decreased in Sri Lanka. If there were a road and a school, as well as a maternity ward, how did he know that they, and nutrition, had nothing to do with the improvement? Joseph Loudon also challenged Obeyesekere's crediting the midwives as the sole reason for the improvement in infant mortality. Speaking from experience working in South Africa in an area where the toddler death rate was 300-400 per 100,000, he found Obeyesekere's claim implausible. Rather. the successes Obeyesekere discussed implied
widespread acceptance of a whole range of other services he had not mentioned, and which his own clinical background suggested were symptomatic of a major change which was not purely technical, but was in fact a major change in culture. Obeyesekere reiterated that nutrition was not crucial but conceded that education was, especially since it was introduced at the same time as the other improvements. He added another item from WHO: that voluntary family planning has been dramatically successful in Sri Lanka, where the birth rate is moving towards that of Singapore which is close to Western rates. Mary Jo Good asked why the Sri Lanka politicians decided to introduce the innovations. Obeyesekere replied that he knew little about the decisions, except that one Cabinet Minister during the British period decided on cottage hospitals. Compulsory education, the elimination of illiteracy, and roads that brought a bus to every village had behind them some very important cultural factors. For example, the mystical Buddhist theme that it is meritorious for kings to provide hospitals for the poor. Ronald Frankenberg mentioned Scarlett.Epstein's study which showed that a village closer to development schemes became poorer while one further away changed. Recent work from Pakistan indicated that the enormous increase in GNP from the Green Revolution made the majority of the people much poorer than they had ever been. Even if the GNP and infant mortality figures were associated, the correlation may be completely unreliable. During his own fieldwork in Zambia, Frankenberg had been astonished by the infant mortality figure in the WHO handbook because the country had no registration of births. Officials at the Ministry of Health, when asked how they arrived at the figure, said that it came from the WHO handbook. The WHO officials said the Zambian Government told them. When he returned to the Zambian Government to ask them how they knew what to tell the WHO, the officials said, "We looked it up in the WHO handbook." Frankenberg objected to Elling's use of GNP because it was not broken down into classes and sections in the population. Recently WHO has been paying attention to rural preventive medicine rather than urban curative medicine. It has little chance of success. The reason for this situation is to be understood in the context of class struggles within and outside so-called developing countries. One must recognize and show by concrete studies, that the ruling classes do not have the same interest in medicine as the mass of the population. The situation in the Ivory Coast can be duplicated in many places; the same is true in Uganda and in Zambia. What happens, for example, is that someone in an elite position, such as a Permanent Secretary, who is dying, is flown overseas for treatment. His colleagues say, "Our country has no medical prestige, we must have a coronary care unit (or a kidney unit)." Immediately they build one--so they can die in their own special unit. As well as that, there is the exploitation of the third world by the U.S. and by England. Doctors are trained in India and they go overseas; doctors are trained in England and they go to the U.S. One has to look at a class situation on a world scale, then at what the class forces are within particular countries, and that is more significant than Elling's centralized/decentralized and concerted/fragmented distinctions. Elling agreed that of course it is necessary to know how the class struggle is going to work itself out in relation to his scheme of the organization of authority. Mary Jo Good addressed the issue of decentralization and class forces, both of which she thought might be accommodated by Elling's scheme. Given a centralized society and a particular set of class relations, one would expect a certain kind of medicine to be fostered by Govern-
Discussion ment or by private enterprise. Given a decentralized society and a similar set of class relations, one might expect different health services. It is necessary to study the ideological purposes the .health system serves. In Iran for example, the "barefoot doctor" being introduced certainly is not the same kind of person as in China. Instead of threatening the physicians who are an elite group from the upper class, they serve them. Arthur Kleinman emphasized that using technological resources without making any significant changes in poverty or in population pressure was unsuccessful, but a widespread belief persists that technological innovations will successfully remove sickness. While a few examples support this belief, by and large technology is only one of many contributing factors. Moreover, many situations arise where technology creates worse problems than those it is designed to remove--such as the widespread use of antibiotic injections for almost any complaint. Everett Mende!sohn discussed the methodological implications of trying to discover what it is that makes a difference in medical care. He mentioned a survey just after World War II in Maine that asked physicians what technology most affected the practice of medicine. In overwhelming numbers they listed the automobile. It made sense because the automobile gets people to professional centers for childbirth. Dr. Loudon also is convinced that medical technology is not sufficient to make a difference in health status, and is willing to stake his reputation on its not being that simple: he himself believes that the central difference is change in social performance and in culture, which has to do with how people live, and with what credence we and they give to different technological modes, different educational styles, and different ways of organizing people. Fairly early in development studies it was clear that the People's Republic of China was making a differ¢nce. What were they doing that made a difference'? How did they organize their population, how did they mobilize it? Were they or were they not introducing a belief system which had large segments of the population accepting ideas which changed their patterns of behavior, changed their relationship to society, to technology? In societies which are using a mixture of medical systems, which is the mixture that makes a difference'? What will people accept or not accept and under what conditions, and what are the differences across social class or religious boundaries that ~make a difference'~? Margaret Mackenzie said that she was trying to place Elling's paper within the context of the title of the conference because his paper, with its comparisons of GNP and infant mortality rates, seemed to be in a different arena from the others, and that this led her to ask Professor Leslie about how he had decided to organize the conference and what his goals were. Charles Leslie replied that there are two ways of organizing conferences: inclusive and exclusive. An exclusive way would be to build a study of medical systems that is sociological and cultural, putting aside all questions of ecological systems and of epidemiology. For example, William McNeill had said he could not understand why he had been invited because he felt he knew nothing about medical systems. But McNeilrs paper is an example of comparative method: he thought he noticed something about the Conquest of Mexico, then his mind switched to the plague in Renaissance Europe, then to the plagues in Rome, and then he perceived similar patterns in the epidemics among rabbits in Australia, so he compared evolutionary adaptation in a non-human organism to the patterns he saw in people. Finally, he stretched our notion of what a society is by considering those things that eat and are eaten by members of a society. Human beings then belong in a society of organisms co-existing as an historical entity, and McNeill looked at human history from this perspective. Leslie, in organizing the conference, did not
119
want to exclude that sort of comparison and he thought that Zimmermann, working at the other extreme of comparative method, would agree. Zimmermann is studying one learned physician in India, and a set of classical texts-but mainly a single text--and from that he is trying to produce some comprehensive patterns for South Asia, a whole civilization over several thousand years and many classes of people. The problem is the complementarity between difference conceptual structures and different realities. Zimmermann is not interested in the bacteria in the belly of the Brahmin, whereas the bacteria would be interesting to McNeill. How do we learn to shift gears within different conceptual frameworks? This can be viewed in a derogatory way as eclectic. But Leslie believes that it is useful to make sense' of human activity through a set of shifting perspectives and communication (and miscommunication) networks, and connections across boundaries. The idea of the conference is to bring together people with different concepts, knowledge of fact, and different interests, some of whom may not be interested in what some of the others are studying. But perhaps their minds will be stretched a little by the experience and they will realize complementarities between various kinds of study unrecognized before. In developing the conference, Leslie conceived of the medical system a s not having any bacteria in it, but as being a system of social relations in social institutions and cultural forms. Many study this field with very little historical and contextual knowledge, so that there are, as Paul Unschuld pointed out, Sinologists working in ways comparable with those of Zimmermann, studying classical texts and describing a system. The question is, how much is it useful to know of that for someone who is studying medicine in Zaire? The flow of doctors from India to England, and from England to the U.S. is the creation of a cosmopolitan medical system, a network of institutional interrelations and exchange of knowledge, so that a person can have an appendectomy in China or in Russia or in Zaire or in Paris, and possibly the surgeon would use similar surgical instruments, but with the operation being otherwise very different in context. An exclusive biomedical perspective would be blind to this point. How could one ask about the theoretical foundations for the comparative study of medical systems in an exclusive conference without throwing a lot of the world into shadow? Perhaps the light in this inclusive conference is too diffuse and people panic when they feel that too many ideas are being discussed, references being made to too many different kinds of things. They want intellectual closure. If the conference had included only psychoanalysts, or only Marxists or only French structuralists, there could have been easy closure, but it would be blind to the rest of the world. So this is a conference that does not look for closure, but perhaps afterwards people will keep up new contacts, and we can at least begin to say what the vocabularies are and where they direct study, and what directions seem to be most fruitful. Mendelsohn asked how t o escape methodological anarchy, the position that any method is as valid or as valuable as any other, in an inclusive context. Leslie replied that anarchy is one position. Jean-Claude Guedon thought that no-one had been arguing for the idea of intellectual closure, but that some had been arguing against the idea that people can come with a shopping bag of ideas, throw them on the table and say that this person can have that one, and that person the next one, and think that this would be an exchange of ideas. He himself in particular objected because embed: ded in that notion is a positivistic bias. Charles Leslie replied that he thought all the people there would continue to do the kind of work they were
120
Discussion
trained to do and that they were most interested in doing. The diversity of research would not be cut down. But there is value in bringing together different people who are doing different kinds of work so that they can have a chance to discover what they might learn from others and others from them. Frankenberg returned to the question of placing Elling's paper in the context of the conference, saying that in terms of social anthropology, it could be seen both as validating the value and encouraging the small-scale intensive study of a limited area either in space or in time. Secondly, it raised the question of the persistence of culture, or of ideology, in a situation of structural change and of change in practice. The third point was less obvious and as far as he knew had not been studied: the symbol system of the decision makers and the literal concreteness of the symbols which they adopt, such as hospitals and airports, and the problems these raise, for example, for the administrator who goes to Geneva and says, "Last year we changed the rates on such and such a disease", in opposition to the administrator who says, "Last year we spent $10,000,000 on a big new hospital and here is a photograph of it!" Mendelsohn said that there are times when we all need
to ask, what work are we involved in which is serving malignant ends, continuing to create dependent or oppressive situations? Not all methods are equally responsible; some do extend power and control to one group rather than another. One thing learned in the analysis of development studies in the last decade is that all those economic and social development techniques and funds poured out have concentrated wealth abroad, and by concentrating wealth, political power. Discussing the interaction of modern and traditional medicine without facing that makes the conference intellectually vulnerable. Obviously the problem is complex, but we have a responsibility to face it. Otherwise the position is a return to the maxim in Alice in Wonderland: "If you don't know where you're going, any road will get you there." It is necessary to ask what directions western knowledge and technique have taken and where they ought to go, and to assess what we learn in looking at other societies which have had permanent underclasses and permanent overclasses. When we analyze relationships do we further mythologize them, or do we probe them and see what kinds of social systems we have abetted, and whether we have perpetuated the restrictions of power to the few?