Читать книгу The Wiley Blackwell Companion to Medical Sociology - Группа авторов - Страница 64

The options available to people seeking health care vary greatly across countries and cultures. As Cockerham explains (2010: 208), even in a modern, developed country like the US, people may not look at modern medicine as the only or right option. In the discussion of culture and health, reference must be made to the wide range of healing options found in most societies today. For the sake of clarity, let us consider all healing options as falling into three general categories: the modern or Western biomedicine system; traditional medicine systems; and popular medicine. A medical system is understood as “a patterned, interrelated body of values and deliberate practices governed by a single paradigm of the meaning, identification, prevention and treatment of … illness and/or disease” (Press 1980: 47). Traditional medical systems flourished well before Western biomedicine and their history goes back more than one millennium. Three ancient healing traditions are considered to be the most important: the Arabic, Hindu, and Chinese healing traditions (Leslie 1976: 15–7). However, there is a revival of interest in the two best-known traditional medicine systems: traditional Chinese medicine (Unschuld 1985) and Hindu or Ayurvedic medicine (Basham 1976). Popular medicine refers to “those beliefs and practices which, though compatible with the underlying paradigm of a medical system, are materially or behaviorally divergent from official medical practice” (Press 1980:48). Popular medicine is also labeled “complementary” and “alternative” medicine or therapies (Quah 2008; Sharma 1990).

In contrast to the modest attention given by researchers to power and dominance in the traditional healing system, the intense concern with the preponderance and power of Western biomedicine is evident in the work of Foucault (1973) and Goffman (1968a, 1968b), and has been documented and analyzed in detail by Freidson (1970), Starr (1982), and Conrad and Schneider (1992) among others. These authors refer to Western biomedicine as practiced in Western industrialized countries and beyond (Quah 1989b, 2003). Interestingly, in the second decade of the twenty-first century Western biomedicine continues its rapid scientific advance and leads in public health (Quah 2018), but, given increasing costs and the large migration waves of indigent communities across continents, Western biomedicine is less accessible to poor people compared to traditional and other healing systems (Benatar and Ashcroft 2017; Sanders et al. 2017).

Healing systems are constantly evolving and two features of their internal dynamics are relevant here: divergence and pragmatic acculturation. Divergence in a healing system is the emergence of subgroups within the system supporting different interpretations of the system’s core values. The notion of “detached concern” in medical education is a good illustration of cultural divergence. In her comparative study of medical schools, Renée Fox (1976) investigated the assumed resilience of six value-orientations (in Parsons’ sense) at the core of Western biomedicine: rationality, instrumental activism, universalism, individualism, and collectivism, all of which comprise the ethos of science and detached concern, a value she assigned specifically to Western biomedicine practitioners. Fox observed that these values of biomedicine are subject to reinterpretations across cultures. She found “considerable variability in the form and in the degree to which they [the six value-orientations] are institutionalized” (Fox 1976: 104–06) even within the same country as illustrated by the situation in four major medical schools in Belgium in the 1960s representing basic cultural rifts: “Flemish” versus “French,” and “Catholic” versus “Free Thought” perspectives. Forty years later, in their systematic review of research on “detached concern,” Underman and Hirsfield (2016) identified a divergent trend: the recognition of empathy as an important component of medical education and ethical medical practice.

A manifestation of pragmatic acculturation in a healing system is the inclination of its practitioners to borrow ideas or procedures from other systems to solve specific problems without necessarily accepting the core values or premises of the system or systems from which they do the borrowing (Quah 2003). To illustrate: some traditional Chinese physicians use the stethoscope to listen to the patient’s breathing, or the sphygmomanometer to measure blood pressure, or the auto-clave to sterilize acupuncture needles, or a laser instrument instead of needles in acupuncture (Quah and Li 1989; Quah 1989a: 122–59). Norheim and Fonnebo (1998) illustrate the practice of pragmatic acculturation among young western biomedicine practitioners in Norway who learned and practiced acupuncture. Pragmatic acculturation has also facilitated the provision of western biomedical services to peoples from other cultures. Ledesma (1997) and Selzler (1996) studied the health values, health beliefs, and the health needs of Native Americans to improve the provision of relevant Western biomedical services to their communities. Adapting the type and mode of delivery of modern health care services to serve the needs of traditional peoples is receiving more serious attention from health care providers. Although pragmatic acculturation requires Western biomedicine practitioners to change or adapt their usual practices and assumptions, it is worthwhile if it attains the objective of making health care services more accessible to communities in need (e.g. Harmsen et al. 2008).

The presence and relative success of groups and institutions (for example, the medical profession, hospitals, and other health care organizations) involved in the provision of health care unfold in the context of culture. Arthur Kleinman (1980) highlights the relevance of the “social space” occupied by health systems. He identified significant differences among ethnic communities and the subsequent impact of cultural perceptions of mental illness upon the structure of mental health services. The influence of culture on the provision of mental health services is studied widely. Studying mental health in Vietnam, McKelvy and colleagues (1997: 117) found that “there is no profession specifically dedicated to hearing the woes of others. Talk therapy is quite alien to the Vietnamese”. Similarly, the traditional Vietnamese perception of child behavior and their “narrow” definition of mental illness help to explain their skepticism on the need for child psychiatric clinics.

Adding to social science research on the link between culture and health is the systematic discussion of culture within the realm of bioethics, including the nuances of informed consent, its meaning and interpretation among different ethnic groups (Turner 2005). Similarly, governments and health authorities recognize the importance of culture in illness prevention and the provision of healthcare services. One interesting example is the US Surgeon General’s Report on Mental Health (USDHHS 1999) and the supplement report on “Mental Health: Culture, Race and Ethnicity” (USDHHS 2001). The Supplement was intended as a collaborative document with social scientists and it became “a landmark in the dialogue – political and scientific – regarding health disparities in the United States” (Manson 2003: 395); and “more than a government document” as it discusses the significance of ethnicity in the planning and provision of preventive and curative mental health services (Lopez 2003: 420).