The social sciences get short shrift at medical school. We scratch the surface of ethics and law, learn there exists something called the biopsychosocial model, and have practical sessions on speaking to others of different cultures (which in my medical school involved members of the largely Caucasian teaching staff telling a predominantly South Asian student body how to speak with the local Bangladeshi community). There were of course some useful aspects; Greenhalgh et al paper on “Health beliefs and folk models of diabetes in British Bangladeshis” [1] offered a glimpse at what culturally appropriate health care may look like. Psychiatry lectures introduced us to the “medical gaze” [2] and began to open up the power relationships between doctor and patient. Sociology in medical school is treated as little more than a side interest by students; what use after all is a knowledge of how structural violence may determine the cause of health compared to the very real harm you may inflict on a patient if you cannot read their ECG or chest x-ray.
Whilst I managed to largely escape my hospital postings without needing a too detailed understanding of the relationship between culture and health, in general practice the relationship becomes unavoidable. Faced with any gap in my knowledge, my instinctive reflex is to do a degree in it and thus it is I find myself a student of Brunel University’s excellent masters programme in medical anthropology. The concept of “medical gaze” very quickly rears its head, as Foucualt states:
Facilitated by the medical technologies that frame and focus the physicians’ optical grasp of the patient, the medical gaze abstracts the suffering person from her sociological context and reframes her as a ‘case’ or a ‘condition’. [2]
To the medics on the course it quickly feels that the anthropologists have an “anthropological gaze”. They see corrupting power relationships in the most innocent of doctor and patient relationships and find fault in seemingly benevolent actions. When I read about Scheper-Hughes talking of how medicalisation depoliticizes suffering I want to angrily reply quoting Virchow that “the physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction”, but then I read her words again:
Medicalization mystifies. It isolates the experience of misery and it domesticates people’s anger. There is power and domination to be extracted from the defining of a population as ‘sick’ or ‘nervous’. To acknowledge hunger (which is not a disease but a social illness) would be tantamount to political suicide [3]
It reminds me of how often I treated patients with anti-depressants – not for neurotransmitter imbalance, but for their misery caused by cuts to their welfare. How easy it is for me to re-frame their unhappiness as depression than as a social ill. Similarly, it is easier to label non-compliant patients as troublemakers who don’t wish to engage rather then see their acts as forms of resistance in a system where I hold the power.
Much of my studies in anthropology thus far has consisted of reading monographs or articles from field studies which invariably make use of anecdote to convey their message. In today’s evidence based medicine world, where anecdote lies firmly at the bottom of the hierarchy, it can be all too easy to dismiss the message being conveyed.
At other times anthropology has made me wonder whether I ever engaged with my medical textbooks. As a Marxist (admittedly long lapsed), how did I fail to see that my obstetrics and gynecology textbooks contained metaphors of a capitalistic age (as written about by Emily Martin). Labour is the work women do to reproduce, obstetricians manage labour, menstruation is excretion of waste products and ovarian failure is break down of the machine.
Medicine (with the honourable exception of psychiatry) tends to lack the ability to criticize its very fundamentals. Anthropology, with its roots in colonialism, is endlessly self critical. Having been used by colonial administrators to help control indigenous populations, the discipline tends to side with those who lack power. For doctors, this can sometimes make for difficult reading. Yet anthropology too can have a taste for the exotic. Theories of cannibalistic practice were widely reported to be the cause of kuru in Paupa New Guinean anthropologists, yet mortuary practices seem equally likely to blame (albeit less headline grabbing) [4]. Similarly in the early days of the AIDS epidemic, the abnormally high rates of HIV in Haitians was attributed to voodoo practices rather than the more mundane poverty and sexual tourism from its richer neighbor, the United States of America [5]. Anthropology has its dangers too; anthropologist and infectious disease specialist, Paul Farmer, talks of mistaking culture with structural violence at the beginning of his career [5], a mistake many doctors make without always being conscious to the fact.
It is perhaps difficult to make a correlation with anthropological knowledge leading to improvements in my clinical practice (though admittedly I stand only at the threshold of the discipline). It does however allow me a clearer insight into my profession, my practice, and most importantly – my patients.
References
[1] Health beliefs and folk models of diabetes in British Bangladeshis, Greenhalgh et al, BMJ 1998;316:978
[2] The Birth of the Clinic: An Archeology of Medical Perception. Michel Foucault, 1963
[3] The Madness Of Hunger, Nancy Scheper-Hughes, New Internationalist issue 209 – July 1990
[4] The Cannibal Within, Lewis F. Petrinovich, 2000
[5] Infections and Inequalities, Paul Farmer, 1999
