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Krankheit und kultur: Eine einfuhrung in die ethnomedizin
Book Reviews
432
industry, the picture is a very depressing one indeed. Taylor echoes sentiments expressed by Ron Wing (ABPI) in an eariier paper in which-wing claims that the industry is being discredited bv erouns of misguided ‘liberal idealists.’ Taylor backs up td claim by drawing on the findings of ABPI opinion research which shows, to take one example, that ‘around 90% of the U.K. population understands the role of animal experimentation in medicine, in development and testing’ (this left me breathless). Now. as the mass of the population have such apparentIy high and sophisticated levels of understanding, the criticisms of the industry cannot possibly reflect the opinion of a mass public but are rather generated by an elite of ‘opinion farmers’. In this process, Esther Rantzen and the Women’s movement perform key roles! Still breathless, I moved on to Maddox’ paper. Here, I was reassuringly informed, and I had to read the sentence several times, that ‘side-effects (of drugs) are almost always unavoidable in the long run’ (p. 138), and we should all be realistic about this. The industry does its best, and the case for strict liability, in his view, is thus both inequitable and divisive. In the final set of papers, ‘Economic Aspects’, Dr Michael Burstall (Universitv of Surrey) . and Professor John Dunning (University of Reading) discuss the process and implications of decentralisation within the global pharmaceutical industry, and Duncan Reekie (University of Witwatesrand) discusses the effect on pricing and profits of changes in consumer demand patterns in response to technological innovation. The other two papers in this session (Lord Ralph Harris, Institute of Economic Affairs and Dr Clarke Wescoe, Sterling Drug Inc.) are inspired by the conviction that the market economy is good per se while state interventionism is bad. According to this view, a major negative consequence of state interventionism in Britain is that the NHS (the ‘free’ health service) has suppressed the development of voluntary hospitals and private insurance. Moreover, the NHS has prevented medical care from becoming one of the major growth services. Interestingly enough, the weakness of this position is identified and highlighted in the final discussion by Tony Culyer, who calls into question some of the more fiercely ideological assumptions heId by certain participants. His message is clear and uncompromising: any standard lower than the highest is a standard the industry cannot afford. Let us hope that the industry will heed this message. To conclude: there is no doubt that the pharmaceutical industry has made an important contribution to world health (see the discussion paper of Dr Balu Sankaran, WHO). Nonetheless, out of 16 substantive papers, only one is focused on the Third World. There is not a single contribution in which the profound and ethical problems associated with animal experimentation in the industry are seriously raised. The references to animals, as with serious critics of the industry, are both defensive and derisory. For the industry, then, “The danger of the 1990’s is that a continuation of today’s unbridled and simplistic criticism by the partially informed, whether in fields of animal rights, Third World, or even the management of Western health care programmes, will produce a diminution of the resource available to discover, develop and distribute the benefits which, science can realistically achieve in the next decade” (Ron Wing, President of the Association of the British Pharmaceutical Industry). Department of Sociology Uninicersityof Lancaster Bailrigg, Lancaster, England
GTE
CURRIE
Krankheit und Kultur: Eine Einfuhrung in die Ethnomedizin
(Sickness and Culture: An Introduction to Medical Anthropology),by BEATRIX F'FLEIDERERand WOLFGANG BICHMAN.
Foreword by THOMASMARETZKI.Verlag. Berlin, 19Sj. 263 pp. No price given. This is an important book for medical anthropology in Germany and German-speaking countries. Written from the perspective of an experienced ethnographer (Pfieiderer) and an anthropologically engaged physician (Bichman), Krankheif und Kulfur is an authoritative introduction to the field which draws on the authors’ many years of field experience in India and Africa, respectively. It makes accessible to German speakers for the first time the conceptual formulations and substantive contributions of American and British medical anthropology. Major chapters deal with medical systems in historical perspective, cultural foundations of illness classifications, healer/patient interaction, medical pluralism and, finally, primary health care in developing countries. These topics are discussed with a special focus on South Asia and Africa, the authors’ geographic areas of expertise. The book is intended for professionals and others involved in medicine and international development as well as for use in courses on medical anthropology and on medicine in developing countries. Krankheit und Kultur, however, has much to offer beyond a well-written introduction to the subject matter of medical anthropology. It traces the development of European, and particularly German, medical anthropology (‘Ethnomedizin’). I found particularly interesting the discussion of the origins of the modern field of Ethnomedizin which is rooted in a branch of medicine called ‘medizinische Anthropologie,’ first established in the 17th century. It is enriched by a long tradition of interest in European folk medical systems and has received new impetus from the necessity to provide appropriate medical care to foreign ‘guest workers’ who have swelled the ranks of the German work force in the last decades. An additional factor was German development assistance provided to Third World countries, including the education of foreign physicians and health care workers. Contemporary German Ethnomedizin, then, took shape based on this tradition but, as the authors point out, was also substantially shaped by American and, to some extent, British medical anthropology. Given the long-standing preoccupation of German ethnology with culture trait analysis, it is gratifying to see that the authors employ throughout a broad cultural, historical and sociopolitical framework which locates the proper domain for medical anthropology (and its application) in the universe of human relations. Illness episodes and individual acts of healing are consistently presented as arising from the social environment in which they occur. The political role of cosmopolitan medicine is highlighted by the translation of ‘cosmopolitan’ medicine as ‘cosmopolitical’ (kosmopolitische) medicine, thereby calling into question the neutrality of the term and throwing into relief the role of western medicine in establishing and maintaining power relationships. The political grounding and political efficacy of cosmopolitan medicine with its ties to the interests of former colonial powers and to those of Third World elites forms part of a sophisticated analysis of health care systems and health seeking behavior. While clearly written, this is not just an introductory text. There are trenchant original analyses of several issues. For example, the authors provide one of the most comprehensive and insightful discussions of the history of medical systems in Africa and India, illuminating the complex relationships between the interests of missionary churches, colonial powers and the populations concerned. There is an excellent analysis of the role of the World Health Organization in Third World development, particularly through its sponsorship of the idea of primary health care (PHC) and its attendant goal of Health for All by the year 2000. The concept of PHC, as originally envisioned, would demand social structural transformation. It deemphasizes the sick individual, focusing instead on the
Book Reviews social and environmental causes of illness, insists on active involvement of communities in defining and solving their health problems, and delegates curative medicine to a comparatively minor role. In the post-colonial climate of Africa and India. under the pressure of insufficient coverage with cosmopolitan health services. the concept of primary health care was eagerly espoused. It was also quickly coopted by planners who ignored the necessity for social and political reforms and instead concentrated on the extension of medical coverage into communities. Technical and technological measures, such as training of village health care workers and traditional birth attendants, immunization programs. or the introduction of oral rehydration therapv are less likely to threaten the interests of the prevaihng power structure than fundamental reform. This book, which sees medical anthropology neither as a theoretical nor an applied discipline, but rather an ‘applicable’ one. should be in the library of any scholar, practitioner or planner who reads German. It will prove to be a valuable resource for a better understanding of the ways in which ‘cosmopolitical’ medicine has maintained its structural superiority in spite of the fact that the bulk of health care in developing countries continues to be provided by traditional medicines. Depariment of Anthropology Michigan Sfare University Easr Llmsing. Mich. U.S.A.
B~r~t-rr~ JORDAN
Child Abuse and Neglect: Cross-Cultural Perspectives,edited
by JILL KORBIN.University of California Press, Berkeley, Ca!if. 1981. 217 pp. Sl8.50 (paper) S7.95 With the development of every new field-and child abuse with its special status as one of our master social problems of the late 20th century represents one such case-it is essential to question the key concepts, generalizations and theoretical orientations in use for their possible cultural or class bias. This is especially necessary in a pluralistic society such as the United States where family structure and parenting practices vary enormously across class, region and ethnic group, and where child abuse has been identified as particularly predominant in some social groups (that is, more of it has been identified and treated in poor, singleparent. welfare-recipient and minority families). Are these epidemiological statistics an artifact of cultural misunderstanding, of the greater surveillance and mistrust of poor, single-parent and minority parents, or a reflection of the differential stresses to which the poor and other minorities are exposed? These are crucial questions for physicians, social workers, family therapists, child care workers and others who must deal on a daily basis with the identification of, and interventions in, child abuse and neglect. But these questions are of equal interest to social and behavioral scientists wanting to understand the nature of parentxhild interactions and their consequences for child health and development. Korbin’s volume offers a much needed opening gambit in applying the basic anthropological principles of cautious cultural relativism and the comparative method to the problem of understanding child abuse and neglect. It should be taken as a corrective to the alarmingly uncritical and non-reflexive child abuse literature that has proliferated in recent years. The chapters contributed by several cultural anthropologists explore the cultural, symbolic, social, economic and ecological logic that inform child treatment practices in societies very different from our own. Overall, the volume is both balanced and informative. There is no attempt to suspend all moral judgement in the face of cultural differences. In the absence of international criteria for defining child abuse one can still label as ‘abusive’ behaviors that threaten the survival, health and wellbeing of particular children poffenberger in Korbin (Ed.), p. 711.
433
Korbin’s very useful introduction and her summary chapter raise and attempt to answer key questions regarding the universality of child abuse and neglect, the conditions under which it most commonly occurs, and-getting to the very heart of the matter-how child abuse is to be recognized and defined in cultures characterized by very different conceptions of parenting, childhood and child training. She suggests the usefulness of cultural analysis at three conceptually distinct levels: understanding normative practices of child treatment that may be viewed as abusive by the outsider; distinguishing normative from deviant parenting in different social and cultural contexts; distinguishing individual, idiosyncratic child abuse from survival strategies that may be a product of social or institutional abuse (e.g. inrenfionalchild neglect vs the effects of poverty). The volume is most successful with respect to the first level of analysis, and the book contains excellent ethnographic accounts and culturally sensitive interpretations of such normative child-rearing practices as painful initiation rites in New Guinea and sub-Saharan Africa (Langness: LeVine and Levine): child fostering in native South America (Johnson); preferential treatment of sons in rural India (Poffenberger); adult play with children’s genitals in Turkey (Olson). The volume is somewhat less successful in exploring deviant parenting, i.e. actual child abuse and neglect cross-culturally. This is a function of the relative newness of anthropology to the field (Korbin is the first anthropologist to map out and define this field for the discipline), and the absence of comparable statistics from societies in which child abuse is not recognized as a social or a medical problem. Hence, the discussions of child abuse and neglect tend to be anecdotal, inferential and strongly interpretive of very limited data. Despite these limitations the book makes several important contributions. It clearly demonstrates the importance of cultural analysis to the field, and it upsets a number of conventional wisdoms and interpretations. The much favored psychodynamic and social learning theory that child abusers were themselves abused as children is not supported by the Chinese example (Korbin). The belief that ‘child battering’ is universal (which has been suggested by sociologists who specialize in domestic violence) is also found lacking insofar as this ‘classic’ form of child abuse is rare or absent in many of the societies discussed in the Korbin volume. The volume should be acquired reading for all professionals involved in defining and treating child maltreatment. Departmenl of Anthropology Universiry of California Berkeley, Cal& U.S.A.
NANCY SCMPER-HUGHES
Routine Complications. Troubles with Talk Between Doctors and Patients, by CASDICEWEST. Indiana University Press, Bloomington, Indiana, 1984. 199 pp. $27.50 In Routine Complications, Candice West introduces a theoretical perspective and research methodology that will enhance our understanding of medical encounters as interactive events. A leading practitioner of the emerging sociological disipline of conversational analysis, West makes the goals, arguments, insights and promise of this discipline readily accessible to those who may not be familiar with this approach to the study of social action. A recurrent theme in West’s theoretical exposition is the rejection of conventional ‘derivationist’ models of the doctor/patient relationship. These models tend to reduce the medical encounter to the acting out of well-rehearsed behavioral scripts that reflect normative expectations. West also traditional approaches to research on challenges doctor/patient encounters. Methods that simply classify and count certain behaviours, or rely on after-the-fact inter-
432
industry, the picture is a very depressing one indeed. Taylor echoes sentiments expressed by Ron Wing (ABPI) in an eariier paper in which-wing claims that the industry is being discredited bv erouns of misguided ‘liberal idealists.’ Taylor backs up td claim by drawing on the findings of ABPI opinion research which shows, to take one example, that ‘around 90% of the U.K. population understands the role of animal experimentation in medicine, in development and testing’ (this left me breathless). Now. as the mass of the population have such apparentIy high and sophisticated levels of understanding, the criticisms of the industry cannot possibly reflect the opinion of a mass public but are rather generated by an elite of ‘opinion farmers’. In this process, Esther Rantzen and the Women’s movement perform key roles! Still breathless, I moved on to Maddox’ paper. Here, I was reassuringly informed, and I had to read the sentence several times, that ‘side-effects (of drugs) are almost always unavoidable in the long run’ (p. 138), and we should all be realistic about this. The industry does its best, and the case for strict liability, in his view, is thus both inequitable and divisive. In the final set of papers, ‘Economic Aspects’, Dr Michael Burstall (Universitv of Surrey) . and Professor John Dunning (University of Reading) discuss the process and implications of decentralisation within the global pharmaceutical industry, and Duncan Reekie (University of Witwatesrand) discusses the effect on pricing and profits of changes in consumer demand patterns in response to technological innovation. The other two papers in this session (Lord Ralph Harris, Institute of Economic Affairs and Dr Clarke Wescoe, Sterling Drug Inc.) are inspired by the conviction that the market economy is good per se while state interventionism is bad. According to this view, a major negative consequence of state interventionism in Britain is that the NHS (the ‘free’ health service) has suppressed the development of voluntary hospitals and private insurance. Moreover, the NHS has prevented medical care from becoming one of the major growth services. Interestingly enough, the weakness of this position is identified and highlighted in the final discussion by Tony Culyer, who calls into question some of the more fiercely ideological assumptions heId by certain participants. His message is clear and uncompromising: any standard lower than the highest is a standard the industry cannot afford. Let us hope that the industry will heed this message. To conclude: there is no doubt that the pharmaceutical industry has made an important contribution to world health (see the discussion paper of Dr Balu Sankaran, WHO). Nonetheless, out of 16 substantive papers, only one is focused on the Third World. There is not a single contribution in which the profound and ethical problems associated with animal experimentation in the industry are seriously raised. The references to animals, as with serious critics of the industry, are both defensive and derisory. For the industry, then, “The danger of the 1990’s is that a continuation of today’s unbridled and simplistic criticism by the partially informed, whether in fields of animal rights, Third World, or even the management of Western health care programmes, will produce a diminution of the resource available to discover, develop and distribute the benefits which, science can realistically achieve in the next decade” (Ron Wing, President of the Association of the British Pharmaceutical Industry). Department of Sociology Uninicersityof Lancaster Bailrigg, Lancaster, England
GTE
CURRIE
Krankheit und Kultur: Eine Einfuhrung in die Ethnomedizin
(Sickness and Culture: An Introduction to Medical Anthropology),by BEATRIX F'FLEIDERERand WOLFGANG BICHMAN.
Foreword by THOMASMARETZKI.Verlag. Berlin, 19Sj. 263 pp. No price given. This is an important book for medical anthropology in Germany and German-speaking countries. Written from the perspective of an experienced ethnographer (Pfieiderer) and an anthropologically engaged physician (Bichman), Krankheif und Kulfur is an authoritative introduction to the field which draws on the authors’ many years of field experience in India and Africa, respectively. It makes accessible to German speakers for the first time the conceptual formulations and substantive contributions of American and British medical anthropology. Major chapters deal with medical systems in historical perspective, cultural foundations of illness classifications, healer/patient interaction, medical pluralism and, finally, primary health care in developing countries. These topics are discussed with a special focus on South Asia and Africa, the authors’ geographic areas of expertise. The book is intended for professionals and others involved in medicine and international development as well as for use in courses on medical anthropology and on medicine in developing countries. Krankheit und Kultur, however, has much to offer beyond a well-written introduction to the subject matter of medical anthropology. It traces the development of European, and particularly German, medical anthropology (‘Ethnomedizin’). I found particularly interesting the discussion of the origins of the modern field of Ethnomedizin which is rooted in a branch of medicine called ‘medizinische Anthropologie,’ first established in the 17th century. It is enriched by a long tradition of interest in European folk medical systems and has received new impetus from the necessity to provide appropriate medical care to foreign ‘guest workers’ who have swelled the ranks of the German work force in the last decades. An additional factor was German development assistance provided to Third World countries, including the education of foreign physicians and health care workers. Contemporary German Ethnomedizin, then, took shape based on this tradition but, as the authors point out, was also substantially shaped by American and, to some extent, British medical anthropology. Given the long-standing preoccupation of German ethnology with culture trait analysis, it is gratifying to see that the authors employ throughout a broad cultural, historical and sociopolitical framework which locates the proper domain for medical anthropology (and its application) in the universe of human relations. Illness episodes and individual acts of healing are consistently presented as arising from the social environment in which they occur. The political role of cosmopolitan medicine is highlighted by the translation of ‘cosmopolitan’ medicine as ‘cosmopolitical’ (kosmopolitische) medicine, thereby calling into question the neutrality of the term and throwing into relief the role of western medicine in establishing and maintaining power relationships. The political grounding and political efficacy of cosmopolitan medicine with its ties to the interests of former colonial powers and to those of Third World elites forms part of a sophisticated analysis of health care systems and health seeking behavior. While clearly written, this is not just an introductory text. There are trenchant original analyses of several issues. For example, the authors provide one of the most comprehensive and insightful discussions of the history of medical systems in Africa and India, illuminating the complex relationships between the interests of missionary churches, colonial powers and the populations concerned. There is an excellent analysis of the role of the World Health Organization in Third World development, particularly through its sponsorship of the idea of primary health care (PHC) and its attendant goal of Health for All by the year 2000. The concept of PHC, as originally envisioned, would demand social structural transformation. It deemphasizes the sick individual, focusing instead on the
Book Reviews social and environmental causes of illness, insists on active involvement of communities in defining and solving their health problems, and delegates curative medicine to a comparatively minor role. In the post-colonial climate of Africa and India. under the pressure of insufficient coverage with cosmopolitan health services. the concept of primary health care was eagerly espoused. It was also quickly coopted by planners who ignored the necessity for social and political reforms and instead concentrated on the extension of medical coverage into communities. Technical and technological measures, such as training of village health care workers and traditional birth attendants, immunization programs. or the introduction of oral rehydration therapv are less likely to threaten the interests of the prevaihng power structure than fundamental reform. This book, which sees medical anthropology neither as a theoretical nor an applied discipline, but rather an ‘applicable’ one. should be in the library of any scholar, practitioner or planner who reads German. It will prove to be a valuable resource for a better understanding of the ways in which ‘cosmopolitical’ medicine has maintained its structural superiority in spite of the fact that the bulk of health care in developing countries continues to be provided by traditional medicines. Depariment of Anthropology Michigan Sfare University Easr Llmsing. Mich. U.S.A.
B~r~t-rr~ JORDAN
Child Abuse and Neglect: Cross-Cultural Perspectives,edited
by JILL KORBIN.University of California Press, Berkeley, Ca!if. 1981. 217 pp. Sl8.50 (paper) S7.95 With the development of every new field-and child abuse with its special status as one of our master social problems of the late 20th century represents one such case-it is essential to question the key concepts, generalizations and theoretical orientations in use for their possible cultural or class bias. This is especially necessary in a pluralistic society such as the United States where family structure and parenting practices vary enormously across class, region and ethnic group, and where child abuse has been identified as particularly predominant in some social groups (that is, more of it has been identified and treated in poor, singleparent. welfare-recipient and minority families). Are these epidemiological statistics an artifact of cultural misunderstanding, of the greater surveillance and mistrust of poor, single-parent and minority parents, or a reflection of the differential stresses to which the poor and other minorities are exposed? These are crucial questions for physicians, social workers, family therapists, child care workers and others who must deal on a daily basis with the identification of, and interventions in, child abuse and neglect. But these questions are of equal interest to social and behavioral scientists wanting to understand the nature of parentxhild interactions and their consequences for child health and development. Korbin’s volume offers a much needed opening gambit in applying the basic anthropological principles of cautious cultural relativism and the comparative method to the problem of understanding child abuse and neglect. It should be taken as a corrective to the alarmingly uncritical and non-reflexive child abuse literature that has proliferated in recent years. The chapters contributed by several cultural anthropologists explore the cultural, symbolic, social, economic and ecological logic that inform child treatment practices in societies very different from our own. Overall, the volume is both balanced and informative. There is no attempt to suspend all moral judgement in the face of cultural differences. In the absence of international criteria for defining child abuse one can still label as ‘abusive’ behaviors that threaten the survival, health and wellbeing of particular children poffenberger in Korbin (Ed.), p. 711.
433
Korbin’s very useful introduction and her summary chapter raise and attempt to answer key questions regarding the universality of child abuse and neglect, the conditions under which it most commonly occurs, and-getting to the very heart of the matter-how child abuse is to be recognized and defined in cultures characterized by very different conceptions of parenting, childhood and child training. She suggests the usefulness of cultural analysis at three conceptually distinct levels: understanding normative practices of child treatment that may be viewed as abusive by the outsider; distinguishing normative from deviant parenting in different social and cultural contexts; distinguishing individual, idiosyncratic child abuse from survival strategies that may be a product of social or institutional abuse (e.g. inrenfionalchild neglect vs the effects of poverty). The volume is most successful with respect to the first level of analysis, and the book contains excellent ethnographic accounts and culturally sensitive interpretations of such normative child-rearing practices as painful initiation rites in New Guinea and sub-Saharan Africa (Langness: LeVine and Levine): child fostering in native South America (Johnson); preferential treatment of sons in rural India (Poffenberger); adult play with children’s genitals in Turkey (Olson). The volume is somewhat less successful in exploring deviant parenting, i.e. actual child abuse and neglect cross-culturally. This is a function of the relative newness of anthropology to the field (Korbin is the first anthropologist to map out and define this field for the discipline), and the absence of comparable statistics from societies in which child abuse is not recognized as a social or a medical problem. Hence, the discussions of child abuse and neglect tend to be anecdotal, inferential and strongly interpretive of very limited data. Despite these limitations the book makes several important contributions. It clearly demonstrates the importance of cultural analysis to the field, and it upsets a number of conventional wisdoms and interpretations. The much favored psychodynamic and social learning theory that child abusers were themselves abused as children is not supported by the Chinese example (Korbin). The belief that ‘child battering’ is universal (which has been suggested by sociologists who specialize in domestic violence) is also found lacking insofar as this ‘classic’ form of child abuse is rare or absent in many of the societies discussed in the Korbin volume. The volume should be acquired reading for all professionals involved in defining and treating child maltreatment. Departmenl of Anthropology Universiry of California Berkeley, Cal& U.S.A.
NANCY SCMPER-HUGHES
Routine Complications. Troubles with Talk Between Doctors and Patients, by CASDICEWEST. Indiana University Press, Bloomington, Indiana, 1984. 199 pp. $27.50 In Routine Complications, Candice West introduces a theoretical perspective and research methodology that will enhance our understanding of medical encounters as interactive events. A leading practitioner of the emerging sociological disipline of conversational analysis, West makes the goals, arguments, insights and promise of this discipline readily accessible to those who may not be familiar with this approach to the study of social action. A recurrent theme in West’s theoretical exposition is the rejection of conventional ‘derivationist’ models of the doctor/patient relationship. These models tend to reduce the medical encounter to the acting out of well-rehearsed behavioral scripts that reflect normative expectations. West also traditional approaches to research on challenges doctor/patient encounters. Methods that simply classify and count certain behaviours, or rely on after-the-fact inter-