Anthropology: What comes to mind?

Cecil Helman

Outline of the day

• 9-10.30 Introduction: What is medical anthropology? How has it engaged with medicine and public health?

• Central themes/debates in medical anthropology

– Illness/disease distinction– Embodiment– Metaphor/language in relation to illness– Lay and medical models of the body– Medical culture and power

Timetable (continued)

• 10-30-10.45 Break• 10.45 – 12.30 Chronic illness/pain• Doctor-patient communication• 12.30-2.00 Lunch• 2.00-2.30 Cultural expressions of

distress/somatisation• 2.30 -4.30 (with break) Anthropology and GP

training

What is medical anthropology?

• Cultural construction of illness and suffering, illness experience, medical knowledge and healing practices

• Study of the body and lifecycle from childhood to old age

• Critique of production of biomedical knowledge and power relations this entails

Anthropological methods

• Participant observation/ethnography• Focus groups/semi-structured interviews:

‘qualitative methods’• Rapid participatory methods• Newer methods: use of camera, videos• Importance of stories: link between anthropology

and medicine• By the nature of their work, GPs already have

many anthropological skills

History of medical anthropology

• Sub-field of social anthropology: study of illness, healing and cosmology

• Application to clinical medicine:anthropology is good to ‘think with’ but has it failed to engage?

Critical medical anthropology

• ‘Social suffering’ (Kleinman et al 1997) and the impact of inequalities/poverty and racism on bodies and lives

• Health as a human right• Cultural and economic politics of communities

& how these affect individuals

Paul Farmer

Nancy Scheper-Hughes

Philippe Bourgois

Psychiatry and medical anthropology

• How are ‘normality’ and ‘abnormality’ defined in different cultural settings?

• How does mental disorder present differently?• Are diagnostic criteria applicable globally?• How is psychiatric knowledge/practice culturally

constructed?• Why is mental illness diagnosed more among

Afro-Caribbeans in the U.K.?• ‘Culture-bound’ syndromes?

Anthropology’s engagement with public/international health

• Arose from repeated failures of health programmes & wish to engage on particular issues (e.g. safe motherhood, condom promotion, diarrhoeal disease, vaccine uptake)

• Anthropologist as ‘cultural consultant’/critic of cultural naivete in design and piloting of health promotion campaigns

Example 1 - Kuru: Papua new Guinea 1950s

Example 2 - Smallpox and the goddess Sitala

Example 3 - Anthropology and HIV/AIDS

Quick brainstorm

• What are the challenges you experience as clinicians that anthropological thinking might help you with?

Central themes of medical anthropology

• Illness versus disease (Eisenberg 1977)• ‘Lay’ explanatory models are (Kleinman):‘idiosyncratic and changeable, and heavily

influences by both personality and cultural factors. They are partly conscious and partly outside of awareness and are characterised by vagueness, multiplicity of meanings, frequent changes, and lack of sharp boundaries between ideas and experience’

Embodiment• A way around the mind-body split central to Western and

biomedical culture• A way of understanding lived experience• Seminal paper by Scheper-Hughes & Lock (1987):

individual, social and political bodies as interconnected• Work with GPs around embodiment (Jaye 2003): some

respondents saw the task of re-embodying patients as a central concern in general practice.

‘In general practice…you have an ongoing relationship with the self. You really have to live with people in the way that you don’t in other specialties. So I think from the general practice point of view, embodiment is very important. I mean it is what you’re there for in many ways, is to help people become embodied, to own themselves again.’

Metaphors of illness

• Metaphors make meaning; they reflect public anxieties about the moral nature of illness and suffering

• e.g. HIV as plague, contagion, war• Sontag’s (1978) work on cancer • As doctors we should see language as coded messages from sufferers, as ‘messages in a bottle’, & work

with them (Scheper-Hughes & Lock 1986)

Public health/medical discourse

• Highly cultural and reality-shaping• Medical jargon and effect on patients; how patient

experience is ‘re-packaged’ in clinical letters• Example: debate around organ donation and ethnic

minorities (Cierans & Cooper 2011)

Medical culture & the clinical gaze

Lay & medical models of the body

• Body as machine (mind-body split)• Taught to look for objective signs• GP’s domain = ‘the social’ in eyes of many

doctors• Lay models of the body e.g. – Emily Martin’s (1999) cultural analysis of

reproduction– Margaret Lock’s (1995) account of menopause in

Japan vs N. America

Chronic illness/pain: group work

• The problem of ‘chronicity’: what does it do to patient’s sense of self? What does it mean to live ‘well’ (or not) with chronic illness? Does it makes a difference if disability is visible or invisible (e.g. pain)?

• What are the moral and cultural meanings ascribed to chronic illness/pain? e.g. fibromyalgia; epilepsy; COPD

• What are the particular challenges GPs face in working with these patients? What do patients want from you and what do you offer them?

Chronic illness/pain

• The problem of chronicity: fusion of identity with diagnosis; ‘I am…’ vs ‘I have…’ illnesses (Estroff 1995)

• Private/invisible vs public/invisible• The power of labelling: stigma, self-stigma and blame• Holistic perspective (Helman 2007): – Temporal– Social– Cultural/symbolic– Biological/clinical– Political/economic

Doctor-patient communication

Watch the video clip (Verghese TED talk)•What are the ritual/symbolic elements of the doctor-patient relationship?•‘Consultations with a doctor are actually transactions between lay and medical explanatory models’ (Kleinman). Discuss. What are the potential pitfalls in a consultation?•What is the role of narrative in a consultations? How do doctors try and shape patients’ narratives?

Doctor-patient communication

• Problems in clinical consultations (Helman 2007): – misinterpreting distress; – incompatibility of explanatory models; – disease without illness or illness without disease;– problems of terminology; – treatment/ ‘non-compliance’/ competing

definitions of ‘success’; – the context for each party

Cultural expressions of distress/somatisation

• What does somatisation mean to you? Give examples of somatisation that come up in your clinical practice?

• Given examples of somatisation encountered in your clinical practice. How do you know these patients are ‘somatising’? How does culture mould somatic symptoms?

• What are the challenges/dilemmas? How do you work with ‘somatising’ patients?

• Are there any problems with the concept of somatisation?

Various interpretations of somatisation (Kirmayer & Young 1998) • an index of disease • a symbolic expression of intrapsychic conflict

(Freudian view – hysteria etc)• an indication of a specific psychopathology• an idiomatic expression of distress• a metaphor for experience• an ‘act of positioning’ in their local world• a form of social commentary or protest

How does culture influence expression of somatic symptoms? (Helman 2007)• Provides language and idiom without which

sensations cannot be expressed• Provides concepts of health and disease

without which symptom cannot be interpreted

• Defines culturally sanctioned illness behaviour without which symptoms can’t be presented to others

Criticisms of concept of somatisation

• Is it racist/racialising?• Does the term suggest an ‘abnormal’ process

of which the patient is the author/morally responsible?

• It cannot escape from mind-body dualism

Anthropology and GP training

Read ‘Cultural competency’ article (Kleinman& Benson 2006)

•What anthropological ways of thinking can we bring to GP training? Which particular ideas/concepts might be helpful?•What strategies can improve doctor-patient communication?•How can we impart this to GP trainees?

Bringing anthropology into clinical practice

• Be ‘culturally competent’ (but in a fluid way reflecting ‘mini-ethnography’ approach) (Kleinman & Benson 2006), reflect on own assumptions and respect diversity of expressions of ‘dis-ease’ and distress

• Think about context and work with it• Deal with illness AND disease• Enable narrative and play a role in the search for

meaning• Maintain awareness of medical power/culture• Be reflexive

References• Cierans C., Cooper J. (2011) Organ donation, genetics, race and

culture: the making of a medical problem. Anthropology Today 27(6): 11-14.

• Estroff S. (1993) Identity, disability and scizophrenia: the problem of chronicity. In Lindenbaum S., Lock M. ed. Knowledge, power and practice: the anthropology of medicine and everyday life. University of California Press.

• Helman C. (2007) Culture, Health and Illness. Fifth edition. Hodder.• Helman C. (2006) Suburban Shaman: Tales from Medicine’s

Frontline. Hammersmith Press. • Jaye C. (2004) Talking around embodiment: The views of GPs

following participation in medical anthropology courses. Medical Humanities 30: 41-8.

• Kirmayer L., Young A. (1998) Culture and somatisation: Clinical, epidemiological and ethnographic perspectives. Psychosomatic medicine 60 (4): 420-430.

• Kleinman A., Das V., Lock M. (1997) Social suffering. University of California Press

• Kleinman A., Benson P. (2006) Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS Medicine 3(10):.

• Lock M. (1995) Encounters with ageing: mythologies of the menopause in Japan and North America. University of California Press.

• Martin E. (1999) [1987] The woman in the body: a cultural analysis of reproduction. Beacon Press.

• Scheper-Hughes N., Lock . (1986) Speaking truth to illness: metaphors, reification and a pedagogy for patients. Medical Anthropology Quarterly 17 (5): 137-140.

• Scheper-Hughes N., Lock M. (1987) The mindful body: a prolegomenon to future work in medical anthropology. Medical Anthropology Quarterly 1 (1): 6-41.

• Sontag S. (1978) Illness as Metaphor.

Some suggestions for reading

• Bourgois P. (1995) In search of respect: selling crack in El Barrio. University of Cambridge Press.

• Farmer P. (2001) Infections and inequalities: the modern plagues. University of California Press.

• Helman C. (2006) Suburban Shaman: Tales from Medicine’s Frontline. Hammersmith Press.

• Kleinman A. (1989) The illness narratives: suffering, healing and the human condition. Basic books.

• Scheper-Hughes N. Death without weeping: the violence of everyday life in Brazil. University of California Press.

• Setel P. A plague of paradoxes: AIDS, culture and demography in northern Tanzania. University of Chicago Press.