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The medicalization of anthropology: A critical perspective on the critical-clinical debate
Sec. Sri. Med. Vol. 30, No. 9, pp. 945-950, 1990 Printed in Great Britain. All rights reserved
0277-9536190
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Copyright ‘i: 1990Pergamon Press plc
THE MEDICALIZATION OF ANTHROPOLOGY: A CRITICAL PERSPECTIVE ON THE CRITICAL-CLINICAL DEBATE LYNNM. MORGAN Department of Sociology and Anthropology,
Mount Holyoke College, South Hadley, MA 01075, U.S.A.
Abstract-The recent intensity of debate between clinical and critical perspectives can be attributed, in part, to increasing job competition among medical anthropologists in an unfavorable economic climate. If, as analysts predict, a decline occurs in academic and health sector jobs over the next few decades, the increasing medicalization of the field of anthropology will have unintended negative consequences. Awareness of these economic conditions may allow-for some degree of disciplinary and theoretical rapprochement. Key wordr-critical
anthropology,
clinical anthropology,
INTRODUCTION ‘Clinical’ anthropologists, those employed and conducting research within biomedicine, are now deciding whether and how to fit their work into the political+conomic perspective used by ‘critical anthropologists. They wonder whether macroanalysis offers a place for their detailed examinations of provider-patient interactions, cognitive processes, and explanatory models. They ask whether there is room within the critical perspective for anthropologists to work alongside clinicians to improve patient care. Many have acknowledged that there will be no easy fit between clinical and critical perspectives [l-4], in part because of institutional and epistemological disparities. The papers in this collection are designed to show that clinical and critical perspectives need not be mutually exclusive. These papers bridge artificial divisions between the work of healers, the suffering of patients, and the political-economic context. They show that the critical perspective is not necessarily antithetical to the clinical setting. What remains to be explained, then, is why clinical and critical anthropologists disagree so vehemently on a number of issues, such as the most appropriate unit of analysis or the relative importance of symbolic analysis. The answer, I submit, can be reduced to two themes: what they think, and where they work. Theoretical issues have been thoroughly discussed in the literature, yet few anthropologists have analyzed their own discipline’s opportunities for employment or the effects of the job market on theoretical predilection. This paper summarizes briefly the theoretical differences characterizing clinical and critical anthropology before examining employment conditions of medical anthropology
.
DIFFERENCESOF THEORY Valid, significant theoretical issues are being discussed today in the context of the clinical-critical debate [4-71. Some of these arguments are reminiscent of earlier days, when anthropologists appropri945
medical anthropology
ated the distinction between a sociology of and sociology in medicine [8] to justify the value of applied anthropology. Without reiterating 15 years of debate, I offer here a selective summary of major theoretical points of contention. Critical anthropologists have in common a commitment to understanding the distribution of power and wealth and its effects on health and healing. Critical medical anthropology, broadly defined, is a materialist theoretical orientation brought to bear on biomedicine, which it situates within a broad political+conomic context. To this extent, critical medical anthropology is consonant with a political economy of health [9]. It differs from strict political-economic approaches in its ability to show interconnectedness between micro- and macro-levels of social interaction. Critical medical anthropologists are less eager than other political-economists of health to generalize about the determinants of sociomedical knowledge and practice, preferring instead to remain grounded in geographic, historical, and cultural specificity [lo]. Singer says: Critical medical anthropology maintains that discussion of specific health problems apart from macrolevel political and economic issues only serves to mystify social relationships that underlie environmental, occupational, nutritional, residential, and experimental conditions. . . . Importantly, the ultimate origin of these problems is not environmental or biological but social, namely the existence of inherently oppressive social relationships of production and expropriation [ll, p. 1291. renditions of critical anthropology emphasize the relationship between sociopolitical formation, economic strategies, and disease profiles [12], following in the footsteps of political economists from other disciplines [13-161. Not all critical anthropologists adhere to orthodox Marxism. Some prefer a phenomenological and humanistic, yet politically informed, approach to sickness and healing [ 17, 181. Clinical anthropologists, in contrast, are defined more by where they are employed and conduct their research than by adherence to one broad body of theory. They typically work in hospitals or schools of Marxist
946
LYNNM. MORGAN
medicine rather than in academic departments, often in psychiatry and psychology, and usually in the United States. As a result. their work is necessarily more concerned with individual patient care and the micro-context of medicine. They use a combination of meaning- and interpretation-centered theories, including symbolism, semiotics, and hermeneutics, with emphasis on illness narratives, explanatory models, and decision-making [19,20]. But these orientations are also used by many critical anthropologists [21-231. Meanwhile, clinical anthropologists may also use the political+economic approach described above [24]. Clinical anthropologists are not defined by a single theoretical predilection, for although I will argue that one’s site of employment injuences one’s views on theory, it does not automatically determine one’s theoretical affinities. Another difference between critical and clinical anthropologists concerns the relative application of their findings. Clinical anthropologists may be asked to offer constructive suggestions about individual treatment plans, while critical anthropologists function more as social critics, often filling the role of intellectual pessimists. This role does not appeal to doctors or hospital administrators, who are unimpressed by theoretical discussions that do not relate to patient care [3]. Clinical anthropologists must find other ways, then, to get their message across to providers. Many have chosen to teach: “It is our belief that rather than simply attacking the biomedical model or grandiosely arguing for an anthropological medical practice, anthropologists and behavioral scientists in their role as cIinica1 teachers should develop clinical models and techniques that may be added to the physician’s repertoire” [25, p. 27, emphasis in original]. Clinical anthropologists cannot reject biomedicine, because they would be unable to communicate with providers if they used a different epistemological framework. Furthermore, they would likely lose their jobs if they alienated the powers-that-be in the hospitals. Pragmatists Chrisman and Maretzki say, “In order to . . . adapt and to contribute in a health science school, the anthropologist must understand and work within the confines of the reductionist and action oriented clinical style of health practitioners” [3, p. 81. Clinical anthropologists may pay a price for conforming, if their professional obligations conflict with their academic training and political commitments. Stein says, “Obsession with status anxiety often leads to official acceptance-legitimacy-but with the inner sense of having betrayed one’s ideals” [26, p. 661. Clinical anthroplogists are sometimes accused of having been coopted. For example, one critic charges, “calls for clinical relevance often take biomedicine at face value, largely ignoring its social role as a mechanism for social control, capital accumulation, systemic legitimation, and reproduction of class, racial, and gender inequalities” [7, p. 641. Serious constraints undoubtedly face those anthropologists who work in the service of biomedicine, but likewise the critical anthropologists who seek to transform medicine will need to cultivate allies who support capitalist biomedicine. Critical anthropologists face charges about the application of their findings, too. Some say their ideas
and tone are too radical, emotional, and selfrighteous to have any positive effect on the medical system. Some say their insights have little pertinence outside academia [2]. It is true that developments in critical theory have not greatly affected medicine, despite calls to praxis: “A critically applied medical anthropology could develop around the potential of transforming symbolic and largely unconscious protest into more instrumental, collective, and conscious action” [27, p. 139; emphasis in original]. Even some critical anthropologists wonder whether their thinking can be applied beyond the ivory tower. Singer organized a symposium on this topic at the 1988 meeting of the Society for Applied Anthropology. He concluded that critical medical anthropology can change medical practice. Those who deny this, he says, would reify medicine, perceiving it as irresistible to change. He suggests that biomedicine would be more appropriately viewed as “dynamic, contradictory expressions of overt and covert struggle between dominant groups who promote a system that enhances control and subordinate groups who demand care” [28]. Mao Tse-Tung said, “Let a hundred flowers blossom, a hundred schools of thought contend.” The papers in this volume are designed to show that there is room in medical anthropology for both clinically-applied and critical approaches, for grand theory and microanalysis. As Kleinman has recently written, “The advancement of the anthropology of health will not come through the dominance of a single paradigm concerning proper research questions and methodologies” [29, p. 696). Synthesizingor at least tolerating-the diverse existing approaches is absolutely crucial to a holistic understanding of disease and healing. There is a need for people who are willing to train medical students, coordinate international health-development projects, act as patient advocates, and consult with hospital administrators, as well as those who will critique the existing system and suggest alternatives. Yet the disagreements among colleagues seem now more vitriolic than ever. Rifts between meaning-centered and Marxian medical anthropologists can be dated to the well-known exchange between Taussig, speaking for the phenomenological-Marxists, and Kleinman, Eisenberg, and Good, speaking for the meaning-centered clinical anthropologists. Taussig took his colleagues to task for counseling physicians on how they could use their ‘explanatory model’ to improve patient treatment and compliance [21]; in turn, Eisenberg and Kleinman lambasted Taussig for the “absurd lengths” to which he took his “self-proclaimed Marxist analysis” [30,31]. More recently, critical medical anthropology is criticized in comments by Csordas, Estroff, and Sindzingre in a collection edited by Ronald Frankenberg, called ‘Gramsci, Marxism, and phenomenology: essays for the development of critical medical anthropology’ [32]. An analogous exchange also appeared in Current Anthropology, in the comments on an article by Browner, Ortiz de Montellano, and Rubel. The authors advocate a more systematic, empirical methodology in cross-cultural ethnomedical research. In his defiant riposte, Janzen writes, “An important reason that meaning-centered medical an-
The medicalization of anthropology
thropology has emerged in recent decades is not some conspiracy against ‘real’ science but the difficulty of identifying a ‘real world’ of the disease entity and its consequences without considering culture or meaning” [33. p. 6951. Responding to the same article, Good writes, “The argument that medical anthropology has remained ‘particularistic, fragmented, disjointed, and largely conventional’ and that this is a result of an interest in meaning and in the symbolic and epistemological dimensions of illness and health is a disturbing indictment” [34, p. 6931. The theoretical basis for disagreement has been well aired in the literature. One relatively-unexamined reason for the continuing antipathy, I believe, has to do with increasing job competition in an unfavorable economic climate. THE
MEDICALIZATION PARADOX
OF
ANTHROPOLOGY
OF
SUBSISTENCE
AND
THE
Few have examined anthropologists’ attempts to safeguard and expand their professional market in today’s advanced capitalist economy, although some have analyzed similar issues farther from home. Justice, for example, traced the slow pace of rural health reforms in Nepal in part to self-interest, turf-protection, and a desire for job security on the part of health employees [35]. A few perceptive individuals have suggested that similar concerns influence the actions of anthropologists in general [36], and medical anthropology in particular [7,37]. The critical-clinical debate might be illuminated by a reflexive, self-critical examination of anthropologists’ work, relationship to the means of production, and the increasing medicalization of anthropology. This paper offers but a few preliminary suggestions for initiating such a discussion. The rise of medical anthropology as a field occurred simultaneously with the expansion of the medical-industrial complex into international markets, beginning in the 1940s. International health opportunities for anthropologists have continued to expand [38], but in the 1950s attention turned to the domestic front as well: “As cultural anthropologists developed expertise in advising on the design of health delivery systems for non-Western peoples, it became evident that anthropological skills and approaches could be applied to the delivery of health care in modern, heterogeneous societies” [39]. The tenets of medical anthropology were taught to graduate students as far back as the late 195Os, by pioneers such as George Foster, Benjamin Paul, and Steven Polgar. Unchecked growth in the field began in the 197Os, when job prospects overall for PhD anthropologists were dismal. Medical anthropology was seen as the exception; a way to be an anthropologist and still be employable. Medical anthropology is still a fast-growing specialization within anthropology, as shown in Table I. In 1967-68 only about 3% of dissertations listed in the American Anthropological Association’s Guide to Departments concerned human health or disease; by 1987 that percentage had risen to nearly 11%. It is difficult to ascertain precise numbers of medical anthropologists, because those claiming the label have different levels of training and specialization.
Table
1.
947 Medical
percentage
anthropology
of total
Year
dissertations
dissertations
Total
Medical
dissertations
dissertations
1967-68
as
143
%
4
2.8
1972-73
301
14
4.6
1976-77
468
28
6.0
1980-81
394
23
5.8
1983-84
221
14
6.3
1987-88
357
Source:
Frequency
Anthropological ments
based
anthropology concerning with
derived
Association on
the
from
dissertations
were
of dissertations
thropology
concerning
lyses and
not directly
the American
Guide
dissertation
any aspect of human
the exception
10.9
39
counts
craniofacial related
a
in anthropology
to title.
defined health
DepartMedical as those
or disease
in physical or skeletal
anana-
to paleopathology.
Even the Society for Medical Anthropology (SMA) does not know how many people call themselves ‘medical anthropologists’, although with around 1500 members the SMA is one of the largest units of the American Anthropological Association. A few programs offer the PhD in medical anthropology, but many more offer ‘concentrations’ with uncounted numbers of graduates. There are also a growing number of post-doctoral programs for those who wish to don the title. These are all signs of the increasing medicalization of anthropology. Interest in medical anthropology is obviously tied to continuing growth in the biomedical industry [40, pp. 95-1231, as well as to social trends such as the so-called ‘humanization’ of medical training. Health costs continue to account for a significant percentage of the inflation rate in the U.S., national health expenditures are skyrocketing (from $349 per capita in 1970 to S1837 per capita in 1986) and Americans spend an increasing proportion of their Gross National Product on health (7.4% in 1970 to 10.9% in 1986) [41, p. 861. In 1986, 7.4% of the civilian U.S. working population was employed in the health sector [41, p. 3791. Low-skilled jobs in medicine top the list of fastest growing occupations projected for the year 2000, surpassing even the occupational expansion projected for the computer industry [41, p. 3751. Forecasters estimate, however, that the heyday of medical-industrial expansion may be over. An overall slowdown in the rate of growth is projected by the U.S. Bureau of Labor Statistics compared to years past. There was a 5.6% average annual growth rate in health services employment between 1970 and 1980, a 3.7% average annual increase between 1980 and 1986, and a projected 2.9% increase between 1986 and 2000 [41, p. 3801. In addition, the social class and economic status of health professionals will inevitably decline as proprietary corporate monopolies come to control the health sector. Contraction in the health market may mean that the anthropologist’s skills will be needed less in hospital settings in coming years. The academic job market will offer no viable alternative for graduating medical anthropologists, with the possible exception of those with expertise in epidemiology or international health. New professorships are not likely to be offered in light of declining numbers of 18-21 year olds in the population and
948
LYNNM. MORGAN
declining undergraduate enrollments. The situation may be eased for a few years when the children of baby-boomers reach college age in the 1990s and a significant proportion of current anthropology professors retire. Nonetheless, colleges and universities will likely meet much of their short-term need for anthropologists by drawing from the existing pool of ‘gypsy scholars’, who they will employ in short-term, nontenure track appointments. The probability of obtaining an academic job within 3 years of graduating with the PhD in anthropology declined from approx. 80% in 1965 to 40% in 1980 for men, and from 70% in 1965 to 40% in 1980 for women: “the sexes are now equal in their misery” [42]. An optimistic assessment of the market for anthropology PhD’s, published in 1975, predicted that “between 1982 and 1990, for every 100 anthropology Ph.D’s produced, seventy-one will not be able to find academic positions” [43, p. 7681. That assessment has not been far from the truth. The development and elaboration of academic specializations necessarily lag behind expanding economic opportunity. This accounts for the increasing numbers of PhD students who began studying medical anthropology in the early 1980s who may graduate to unemployment in the late 1980s and 1990s. Specialization in medical anthropology is still perceived as a hedge against unemployment, as evidenced by a recent article urging teachers to train undergraduate students in medical anthropology [44], but in the absence of concrete evidence to the contrary, this claim will be harder to sustain as a glut of medical anthropologists finds it difficult to find work. Herein lies the paradox of subsistence. Teachers, researchers, and university programs depend on continued growth and professionalization of the health sector (in universities as well as hospitals), even though critical anthropologists make their living by assailing the growth of capitalist biomedicine. But now the growth is beginning to slow, prompting fears that larger numbers of medical anthropologists may find themselves competing for even fewer jobs in an already insecure market. Phillips said in 1985, “The current financial retrenchment of the medical institution and the more conservative atmosphere of the nation are making social science teaching progressively less important in clinical departments,‘* and “CAA’s [clinically applied anthropologists] have been the beneficiaries and are now in danger of becoming the victims of social and economic trends within medicine” [4, p. 341. Medical anthropologists are certainly aware of the intense job competition in the marketplace currently, and those who train medical anthropologists must be concerned about job prospects for future graduates. Consequently, I suggest that some of the debates between clinical and critical anthropologists reflect a justified anxiety about economic contraction and an awareness that competition may soon intensify. Part of the debate between critical and clinical anthropologists can thus be viewed in terms of changing economic circumstances, although of course it would be gross reductionism to attribute all debate to a question of money. Nonetheless, as jobs become more scarce, medical anthropologists must be concerned with solidifying professional legitimacy,
carving out a secure job niche, and determining the types of skills that will be saleable. necessary, and ethically defensible. These are serious considerations, often ignored even by those critical anthropologists who claim to understand the determinant role of economics (see [7] for a notable exception). Irwin Press, an enthusiastic proponent of clinically-applied anthropology and free enterprise, acknowledges quite openly that economics will motivate career choices. He recommends extra training in hospital administration for anthropologists: “Many young colleagues in the present job-scarce market are already returning to school for additional certification in law, public health, business, and other professions: why not hospital administration as well?” [45, p. 691. Chrisman and Maretzki stress the need to persuade hospitals that anthropologists will bring a good return on the investment: “Practical strategies need to be developed in clinically apphed anthropology to demonstrate how we can justify our existence in economic terms” [3, p. 121. Those anthropologists who earn high salaries in medical schools and hospitals know the seductive benefits of earning high wages in the U.S. socioeconomic context. This is a reality that academic critical anthropologists infrequently acknowledge, for all their emphasis on political economy. Kleinman posed a question central to the clinicalcritical debate when he asked, “Whose interest does this professional stranger support?” [I, p. 1121. Equally important, I think, is how anthropologists choose among options to support their own interests. Critical medical anthropologists pretend to be unconcerned about money, suggesting instead that sustenance may be derived from moral satisfaction. They could be accused of romanticizing the relative poverty of the academy while exaggerating the extent of their intellectual freedom. But judging by the struggles for better compensation and benefits occurring within the academy, clinical anthropologists have no monopoly on financial self-interest. Academics too have a profoundly-developed sensibility for going where the money is, as they respond to government RFPs, accept high-paying consulting jobs, and receive grants from corporate businesses and philanthropies. Good causes are not served any better by ignoring the fact that salary considerations are important to the kind of work anthropologists do. It would be helpful, I think, to investigate further the effects that employment and the economic environment may have on one’s theoretical stance. Meanwhile, the papers in this volume demonstrate that there is no absolute, unidirectional relationship between where one works and what one thinks. Clinical anthropologists have been forthright about the effects work has on their modes of thought and expression [4], but critical anthropologists have been less inquisitive about the effects of the academic environment on their own intellectual development. Perhaps it is not surprising that critical anthropologists have been more prone to criticize others than to analyze themselves. One exception is Hans Baer, who suggests that medical anthropology, with its increasing emphasis on clinical work, has begun to replicate the medical division of labor. He quotes a sociologist who writes, “Seduced by the magic spell of medicine,
The medicalization of anthropology involved in the medicalization of society and of sociology itself, he becomes, whether he likes it or not, the public relations man of medical organizations in which and for which he [or, increasingly, she] works” [7, p. 651. I would suggest that those involved in the critical-clinical debate should begin to address bread-and-butter issues, specifically future employment prospects, as one way of better understanding the disagreements among colleagues and perhaps forging a more unified front to present to prospective employers.
CONCLUSION
Medical anthropologists all make a living from human suffering, by analyzing some social aspect of disease and healing. Whether they study the macro-level of global economy or the micro-level of provider-patient communication, they are selecting different portions of the same overarching social process. This analytic continuum makes it possible to argue that rapprochement is possible notwithstanding the economic reasons underlying theoretical discord. There is cause for concern only when an anthropologist resolutely ignores either the macro- or micro-level, or argues chauvinistically that adherence to one theoretical paradigm necessarily precludes consideration of another. The critical-clinical debate has made it more difficult for people to be guilty of such reductionisms. Clinical anthropologists now acknowledge material constraints, and critical anthropologists recognize the meta-messages encapsulated in the briefest clinical encounter. Adherents of the critical perspective have suggested that the role of the medical anthropologist can be subversive in a positive sense, because anthropologists can use their knowledge to unveil the ideological substrate of biomedicine, render it less potent, and perhaps even help improve the health of individuals and societies. This goal can better be accomplished, however, if anthropologists work together, collectively, to resist economic marginalization and to integrate the social components of health and healing into medical practice and public policy. Clinical and critical medical anthropology are not antithetical, but anthropologists will be able to cooperate more closely with one another if they are conscious and critical of the economic circumstances that determine their place in society. Acknowledgemenrs-Thanks to Sylvia Forman, David Givens, Eugene Hammel, Pertti Pelto, and Merrill Singer for assistance in gathering data for this paper. I gratefully acknowledge the comments of James Trostle, Anne Wright, and the reviewers of an earlier draft of the manuscript.
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0277-9536190
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Copyright ‘i: 1990Pergamon Press plc
THE MEDICALIZATION OF ANTHROPOLOGY: A CRITICAL PERSPECTIVE ON THE CRITICAL-CLINICAL DEBATE LYNNM. MORGAN Department of Sociology and Anthropology,
Mount Holyoke College, South Hadley, MA 01075, U.S.A.
Abstract-The recent intensity of debate between clinical and critical perspectives can be attributed, in part, to increasing job competition among medical anthropologists in an unfavorable economic climate. If, as analysts predict, a decline occurs in academic and health sector jobs over the next few decades, the increasing medicalization of the field of anthropology will have unintended negative consequences. Awareness of these economic conditions may allow-for some degree of disciplinary and theoretical rapprochement. Key wordr-critical
anthropology,
clinical anthropology,
INTRODUCTION ‘Clinical’ anthropologists, those employed and conducting research within biomedicine, are now deciding whether and how to fit their work into the political+conomic perspective used by ‘critical anthropologists. They wonder whether macroanalysis offers a place for their detailed examinations of provider-patient interactions, cognitive processes, and explanatory models. They ask whether there is room within the critical perspective for anthropologists to work alongside clinicians to improve patient care. Many have acknowledged that there will be no easy fit between clinical and critical perspectives [l-4], in part because of institutional and epistemological disparities. The papers in this collection are designed to show that clinical and critical perspectives need not be mutually exclusive. These papers bridge artificial divisions between the work of healers, the suffering of patients, and the political-economic context. They show that the critical perspective is not necessarily antithetical to the clinical setting. What remains to be explained, then, is why clinical and critical anthropologists disagree so vehemently on a number of issues, such as the most appropriate unit of analysis or the relative importance of symbolic analysis. The answer, I submit, can be reduced to two themes: what they think, and where they work. Theoretical issues have been thoroughly discussed in the literature, yet few anthropologists have analyzed their own discipline’s opportunities for employment or the effects of the job market on theoretical predilection. This paper summarizes briefly the theoretical differences characterizing clinical and critical anthropology before examining employment conditions of medical anthropology
.
DIFFERENCESOF THEORY Valid, significant theoretical issues are being discussed today in the context of the clinical-critical debate [4-71. Some of these arguments are reminiscent of earlier days, when anthropologists appropri945
medical anthropology
ated the distinction between a sociology of and sociology in medicine [8] to justify the value of applied anthropology. Without reiterating 15 years of debate, I offer here a selective summary of major theoretical points of contention. Critical anthropologists have in common a commitment to understanding the distribution of power and wealth and its effects on health and healing. Critical medical anthropology, broadly defined, is a materialist theoretical orientation brought to bear on biomedicine, which it situates within a broad political+conomic context. To this extent, critical medical anthropology is consonant with a political economy of health [9]. It differs from strict political-economic approaches in its ability to show interconnectedness between micro- and macro-levels of social interaction. Critical medical anthropologists are less eager than other political-economists of health to generalize about the determinants of sociomedical knowledge and practice, preferring instead to remain grounded in geographic, historical, and cultural specificity [lo]. Singer says: Critical medical anthropology maintains that discussion of specific health problems apart from macrolevel political and economic issues only serves to mystify social relationships that underlie environmental, occupational, nutritional, residential, and experimental conditions. . . . Importantly, the ultimate origin of these problems is not environmental or biological but social, namely the existence of inherently oppressive social relationships of production and expropriation [ll, p. 1291. renditions of critical anthropology emphasize the relationship between sociopolitical formation, economic strategies, and disease profiles [12], following in the footsteps of political economists from other disciplines [13-161. Not all critical anthropologists adhere to orthodox Marxism. Some prefer a phenomenological and humanistic, yet politically informed, approach to sickness and healing [ 17, 181. Clinical anthropologists, in contrast, are defined more by where they are employed and conduct their research than by adherence to one broad body of theory. They typically work in hospitals or schools of Marxist
946
LYNNM. MORGAN
medicine rather than in academic departments, often in psychiatry and psychology, and usually in the United States. As a result. their work is necessarily more concerned with individual patient care and the micro-context of medicine. They use a combination of meaning- and interpretation-centered theories, including symbolism, semiotics, and hermeneutics, with emphasis on illness narratives, explanatory models, and decision-making [19,20]. But these orientations are also used by many critical anthropologists [21-231. Meanwhile, clinical anthropologists may also use the political+economic approach described above [24]. Clinical anthropologists are not defined by a single theoretical predilection, for although I will argue that one’s site of employment injuences one’s views on theory, it does not automatically determine one’s theoretical affinities. Another difference between critical and clinical anthropologists concerns the relative application of their findings. Clinical anthropologists may be asked to offer constructive suggestions about individual treatment plans, while critical anthropologists function more as social critics, often filling the role of intellectual pessimists. This role does not appeal to doctors or hospital administrators, who are unimpressed by theoretical discussions that do not relate to patient care [3]. Clinical anthropologists must find other ways, then, to get their message across to providers. Many have chosen to teach: “It is our belief that rather than simply attacking the biomedical model or grandiosely arguing for an anthropological medical practice, anthropologists and behavioral scientists in their role as cIinica1 teachers should develop clinical models and techniques that may be added to the physician’s repertoire” [25, p. 27, emphasis in original]. Clinical anthropologists cannot reject biomedicine, because they would be unable to communicate with providers if they used a different epistemological framework. Furthermore, they would likely lose their jobs if they alienated the powers-that-be in the hospitals. Pragmatists Chrisman and Maretzki say, “In order to . . . adapt and to contribute in a health science school, the anthropologist must understand and work within the confines of the reductionist and action oriented clinical style of health practitioners” [3, p. 81. Clinical anthropologists may pay a price for conforming, if their professional obligations conflict with their academic training and political commitments. Stein says, “Obsession with status anxiety often leads to official acceptance-legitimacy-but with the inner sense of having betrayed one’s ideals” [26, p. 661. Clinical anthroplogists are sometimes accused of having been coopted. For example, one critic charges, “calls for clinical relevance often take biomedicine at face value, largely ignoring its social role as a mechanism for social control, capital accumulation, systemic legitimation, and reproduction of class, racial, and gender inequalities” [7, p. 641. Serious constraints undoubtedly face those anthropologists who work in the service of biomedicine, but likewise the critical anthropologists who seek to transform medicine will need to cultivate allies who support capitalist biomedicine. Critical anthropologists face charges about the application of their findings, too. Some say their ideas
and tone are too radical, emotional, and selfrighteous to have any positive effect on the medical system. Some say their insights have little pertinence outside academia [2]. It is true that developments in critical theory have not greatly affected medicine, despite calls to praxis: “A critically applied medical anthropology could develop around the potential of transforming symbolic and largely unconscious protest into more instrumental, collective, and conscious action” [27, p. 139; emphasis in original]. Even some critical anthropologists wonder whether their thinking can be applied beyond the ivory tower. Singer organized a symposium on this topic at the 1988 meeting of the Society for Applied Anthropology. He concluded that critical medical anthropology can change medical practice. Those who deny this, he says, would reify medicine, perceiving it as irresistible to change. He suggests that biomedicine would be more appropriately viewed as “dynamic, contradictory expressions of overt and covert struggle between dominant groups who promote a system that enhances control and subordinate groups who demand care” [28]. Mao Tse-Tung said, “Let a hundred flowers blossom, a hundred schools of thought contend.” The papers in this volume are designed to show that there is room in medical anthropology for both clinically-applied and critical approaches, for grand theory and microanalysis. As Kleinman has recently written, “The advancement of the anthropology of health will not come through the dominance of a single paradigm concerning proper research questions and methodologies” [29, p. 696). Synthesizingor at least tolerating-the diverse existing approaches is absolutely crucial to a holistic understanding of disease and healing. There is a need for people who are willing to train medical students, coordinate international health-development projects, act as patient advocates, and consult with hospital administrators, as well as those who will critique the existing system and suggest alternatives. Yet the disagreements among colleagues seem now more vitriolic than ever. Rifts between meaning-centered and Marxian medical anthropologists can be dated to the well-known exchange between Taussig, speaking for the phenomenological-Marxists, and Kleinman, Eisenberg, and Good, speaking for the meaning-centered clinical anthropologists. Taussig took his colleagues to task for counseling physicians on how they could use their ‘explanatory model’ to improve patient treatment and compliance [21]; in turn, Eisenberg and Kleinman lambasted Taussig for the “absurd lengths” to which he took his “self-proclaimed Marxist analysis” [30,31]. More recently, critical medical anthropology is criticized in comments by Csordas, Estroff, and Sindzingre in a collection edited by Ronald Frankenberg, called ‘Gramsci, Marxism, and phenomenology: essays for the development of critical medical anthropology’ [32]. An analogous exchange also appeared in Current Anthropology, in the comments on an article by Browner, Ortiz de Montellano, and Rubel. The authors advocate a more systematic, empirical methodology in cross-cultural ethnomedical research. In his defiant riposte, Janzen writes, “An important reason that meaning-centered medical an-
The medicalization of anthropology
thropology has emerged in recent decades is not some conspiracy against ‘real’ science but the difficulty of identifying a ‘real world’ of the disease entity and its consequences without considering culture or meaning” [33. p. 6951. Responding to the same article, Good writes, “The argument that medical anthropology has remained ‘particularistic, fragmented, disjointed, and largely conventional’ and that this is a result of an interest in meaning and in the symbolic and epistemological dimensions of illness and health is a disturbing indictment” [34, p. 6931. The theoretical basis for disagreement has been well aired in the literature. One relatively-unexamined reason for the continuing antipathy, I believe, has to do with increasing job competition in an unfavorable economic climate. THE
MEDICALIZATION PARADOX
OF
ANTHROPOLOGY
OF
SUBSISTENCE
AND
THE
Few have examined anthropologists’ attempts to safeguard and expand their professional market in today’s advanced capitalist economy, although some have analyzed similar issues farther from home. Justice, for example, traced the slow pace of rural health reforms in Nepal in part to self-interest, turf-protection, and a desire for job security on the part of health employees [35]. A few perceptive individuals have suggested that similar concerns influence the actions of anthropologists in general [36], and medical anthropology in particular [7,37]. The critical-clinical debate might be illuminated by a reflexive, self-critical examination of anthropologists’ work, relationship to the means of production, and the increasing medicalization of anthropology. This paper offers but a few preliminary suggestions for initiating such a discussion. The rise of medical anthropology as a field occurred simultaneously with the expansion of the medical-industrial complex into international markets, beginning in the 1940s. International health opportunities for anthropologists have continued to expand [38], but in the 1950s attention turned to the domestic front as well: “As cultural anthropologists developed expertise in advising on the design of health delivery systems for non-Western peoples, it became evident that anthropological skills and approaches could be applied to the delivery of health care in modern, heterogeneous societies” [39]. The tenets of medical anthropology were taught to graduate students as far back as the late 195Os, by pioneers such as George Foster, Benjamin Paul, and Steven Polgar. Unchecked growth in the field began in the 197Os, when job prospects overall for PhD anthropologists were dismal. Medical anthropology was seen as the exception; a way to be an anthropologist and still be employable. Medical anthropology is still a fast-growing specialization within anthropology, as shown in Table I. In 1967-68 only about 3% of dissertations listed in the American Anthropological Association’s Guide to Departments concerned human health or disease; by 1987 that percentage had risen to nearly 11%. It is difficult to ascertain precise numbers of medical anthropologists, because those claiming the label have different levels of training and specialization.
Table
1.
947 Medical
percentage
anthropology
of total
Year
dissertations
dissertations
Total
Medical
dissertations
dissertations
1967-68
as
143
%
4
2.8
1972-73
301
14
4.6
1976-77
468
28
6.0
1980-81
394
23
5.8
1983-84
221
14
6.3
1987-88
357
Source:
Frequency
Anthropological ments
based
anthropology concerning with
derived
Association on
the
from
dissertations
were
of dissertations
thropology
concerning
lyses and
not directly
the American
Guide
dissertation
any aspect of human
the exception
10.9
39
counts
craniofacial related
a
in anthropology
to title.
defined health
DepartMedical as those
or disease
in physical or skeletal
anana-
to paleopathology.
Even the Society for Medical Anthropology (SMA) does not know how many people call themselves ‘medical anthropologists’, although with around 1500 members the SMA is one of the largest units of the American Anthropological Association. A few programs offer the PhD in medical anthropology, but many more offer ‘concentrations’ with uncounted numbers of graduates. There are also a growing number of post-doctoral programs for those who wish to don the title. These are all signs of the increasing medicalization of anthropology. Interest in medical anthropology is obviously tied to continuing growth in the biomedical industry [40, pp. 95-1231, as well as to social trends such as the so-called ‘humanization’ of medical training. Health costs continue to account for a significant percentage of the inflation rate in the U.S., national health expenditures are skyrocketing (from $349 per capita in 1970 to S1837 per capita in 1986) and Americans spend an increasing proportion of their Gross National Product on health (7.4% in 1970 to 10.9% in 1986) [41, p. 861. In 1986, 7.4% of the civilian U.S. working population was employed in the health sector [41, p. 3791. Low-skilled jobs in medicine top the list of fastest growing occupations projected for the year 2000, surpassing even the occupational expansion projected for the computer industry [41, p. 3751. Forecasters estimate, however, that the heyday of medical-industrial expansion may be over. An overall slowdown in the rate of growth is projected by the U.S. Bureau of Labor Statistics compared to years past. There was a 5.6% average annual growth rate in health services employment between 1970 and 1980, a 3.7% average annual increase between 1980 and 1986, and a projected 2.9% increase between 1986 and 2000 [41, p. 3801. In addition, the social class and economic status of health professionals will inevitably decline as proprietary corporate monopolies come to control the health sector. Contraction in the health market may mean that the anthropologist’s skills will be needed less in hospital settings in coming years. The academic job market will offer no viable alternative for graduating medical anthropologists, with the possible exception of those with expertise in epidemiology or international health. New professorships are not likely to be offered in light of declining numbers of 18-21 year olds in the population and
948
LYNNM. MORGAN
declining undergraduate enrollments. The situation may be eased for a few years when the children of baby-boomers reach college age in the 1990s and a significant proportion of current anthropology professors retire. Nonetheless, colleges and universities will likely meet much of their short-term need for anthropologists by drawing from the existing pool of ‘gypsy scholars’, who they will employ in short-term, nontenure track appointments. The probability of obtaining an academic job within 3 years of graduating with the PhD in anthropology declined from approx. 80% in 1965 to 40% in 1980 for men, and from 70% in 1965 to 40% in 1980 for women: “the sexes are now equal in their misery” [42]. An optimistic assessment of the market for anthropology PhD’s, published in 1975, predicted that “between 1982 and 1990, for every 100 anthropology Ph.D’s produced, seventy-one will not be able to find academic positions” [43, p. 7681. That assessment has not been far from the truth. The development and elaboration of academic specializations necessarily lag behind expanding economic opportunity. This accounts for the increasing numbers of PhD students who began studying medical anthropology in the early 1980s who may graduate to unemployment in the late 1980s and 1990s. Specialization in medical anthropology is still perceived as a hedge against unemployment, as evidenced by a recent article urging teachers to train undergraduate students in medical anthropology [44], but in the absence of concrete evidence to the contrary, this claim will be harder to sustain as a glut of medical anthropologists finds it difficult to find work. Herein lies the paradox of subsistence. Teachers, researchers, and university programs depend on continued growth and professionalization of the health sector (in universities as well as hospitals), even though critical anthropologists make their living by assailing the growth of capitalist biomedicine. But now the growth is beginning to slow, prompting fears that larger numbers of medical anthropologists may find themselves competing for even fewer jobs in an already insecure market. Phillips said in 1985, “The current financial retrenchment of the medical institution and the more conservative atmosphere of the nation are making social science teaching progressively less important in clinical departments,‘* and “CAA’s [clinically applied anthropologists] have been the beneficiaries and are now in danger of becoming the victims of social and economic trends within medicine” [4, p. 341. Medical anthropologists are certainly aware of the intense job competition in the marketplace currently, and those who train medical anthropologists must be concerned about job prospects for future graduates. Consequently, I suggest that some of the debates between clinical and critical anthropologists reflect a justified anxiety about economic contraction and an awareness that competition may soon intensify. Part of the debate between critical and clinical anthropologists can thus be viewed in terms of changing economic circumstances, although of course it would be gross reductionism to attribute all debate to a question of money. Nonetheless, as jobs become more scarce, medical anthropologists must be concerned with solidifying professional legitimacy,
carving out a secure job niche, and determining the types of skills that will be saleable. necessary, and ethically defensible. These are serious considerations, often ignored even by those critical anthropologists who claim to understand the determinant role of economics (see [7] for a notable exception). Irwin Press, an enthusiastic proponent of clinically-applied anthropology and free enterprise, acknowledges quite openly that economics will motivate career choices. He recommends extra training in hospital administration for anthropologists: “Many young colleagues in the present job-scarce market are already returning to school for additional certification in law, public health, business, and other professions: why not hospital administration as well?” [45, p. 691. Chrisman and Maretzki stress the need to persuade hospitals that anthropologists will bring a good return on the investment: “Practical strategies need to be developed in clinically apphed anthropology to demonstrate how we can justify our existence in economic terms” [3, p. 121. Those anthropologists who earn high salaries in medical schools and hospitals know the seductive benefits of earning high wages in the U.S. socioeconomic context. This is a reality that academic critical anthropologists infrequently acknowledge, for all their emphasis on political economy. Kleinman posed a question central to the clinicalcritical debate when he asked, “Whose interest does this professional stranger support?” [I, p. 1121. Equally important, I think, is how anthropologists choose among options to support their own interests. Critical medical anthropologists pretend to be unconcerned about money, suggesting instead that sustenance may be derived from moral satisfaction. They could be accused of romanticizing the relative poverty of the academy while exaggerating the extent of their intellectual freedom. But judging by the struggles for better compensation and benefits occurring within the academy, clinical anthropologists have no monopoly on financial self-interest. Academics too have a profoundly-developed sensibility for going where the money is, as they respond to government RFPs, accept high-paying consulting jobs, and receive grants from corporate businesses and philanthropies. Good causes are not served any better by ignoring the fact that salary considerations are important to the kind of work anthropologists do. It would be helpful, I think, to investigate further the effects that employment and the economic environment may have on one’s theoretical stance. Meanwhile, the papers in this volume demonstrate that there is no absolute, unidirectional relationship between where one works and what one thinks. Clinical anthropologists have been forthright about the effects work has on their modes of thought and expression [4], but critical anthropologists have been less inquisitive about the effects of the academic environment on their own intellectual development. Perhaps it is not surprising that critical anthropologists have been more prone to criticize others than to analyze themselves. One exception is Hans Baer, who suggests that medical anthropology, with its increasing emphasis on clinical work, has begun to replicate the medical division of labor. He quotes a sociologist who writes, “Seduced by the magic spell of medicine,
The medicalization of anthropology involved in the medicalization of society and of sociology itself, he becomes, whether he likes it or not, the public relations man of medical organizations in which and for which he [or, increasingly, she] works” [7, p. 651. I would suggest that those involved in the critical-clinical debate should begin to address bread-and-butter issues, specifically future employment prospects, as one way of better understanding the disagreements among colleagues and perhaps forging a more unified front to present to prospective employers.
CONCLUSION
Medical anthropologists all make a living from human suffering, by analyzing some social aspect of disease and healing. Whether they study the macro-level of global economy or the micro-level of provider-patient communication, they are selecting different portions of the same overarching social process. This analytic continuum makes it possible to argue that rapprochement is possible notwithstanding the economic reasons underlying theoretical discord. There is cause for concern only when an anthropologist resolutely ignores either the macro- or micro-level, or argues chauvinistically that adherence to one theoretical paradigm necessarily precludes consideration of another. The critical-clinical debate has made it more difficult for people to be guilty of such reductionisms. Clinical anthropologists now acknowledge material constraints, and critical anthropologists recognize the meta-messages encapsulated in the briefest clinical encounter. Adherents of the critical perspective have suggested that the role of the medical anthropologist can be subversive in a positive sense, because anthropologists can use their knowledge to unveil the ideological substrate of biomedicine, render it less potent, and perhaps even help improve the health of individuals and societies. This goal can better be accomplished, however, if anthropologists work together, collectively, to resist economic marginalization and to integrate the social components of health and healing into medical practice and public policy. Clinical and critical medical anthropology are not antithetical, but anthropologists will be able to cooperate more closely with one another if they are conscious and critical of the economic circumstances that determine their place in society. Acknowledgemenrs-Thanks to Sylvia Forman, David Givens, Eugene Hammel, Pertti Pelto, and Merrill Singer for assistance in gathering data for this paper. I gratefully acknowledge the comments of James Trostle, Anne Wright, and the reviewers of an earlier draft of the manuscript.
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