Читать книгу A Companion to Medical Anthropology - Группа авторов - Страница 12

Merrill Singer, Pamela I. Erickson, and César Abadía-Barrero

Medical Anthropology is a “baby boomer” of sorts. It came into being alongside the unprecedented interest in the health and wellbeing of Third World peoples in the aftermath of WWII when the world was full of the hope and possibility that science, in this case biomedicine, could alleviate human suffering due to infectious disease and malnutrition, and then help eliminate or control many of the world’s major health problems. Many anthropologists of that era worked with the international health community (WHO, USAID, UNICEF, etc.) to bring biomedicine to the world. The presumption guiding this effort was that shown the effectiveness of biomedicine and modern public health methods (e.g., the health value of boiling water before drinking it), while addressing contextual and cultural barriers to change, people would readily adopt new ways and the threat of many diseases would begin to diminish. Seven decades later, a large proportion of the morbidity and mortality in our world is still due to the same tenacious problems of malnutrition, pregnancy-related complications, infectious diseases, and lack of access to high-quality health care. Although some of the diseases, like HIV/AIDS, are new, one old disease but only one, smallpox, has been eliminated. With economic development, the so-called Third World was re-branded in terms of the size of each country’s economy as low- or middle-income countries. With more “development,” these countries started to experience a mixed epidemiologic profile: “diseases of poverty,” on the one hand (Farmer 2003), and chronic conditions such as cancer, diabetes, and cardiovascular disease, on the other. The raising awareness of the world interconnectedness demonstrated how health profiles depended on key social determinants of global health such as living and working conditions; level of education; neighborhood characteristics; and access to water, sanitation, and health care services which are exacerbated by escalating levels of poverty, inequalities, war, genocide, and greed (Singer and Erickson 2013).

The political economic systems that have resulted from unconstrained capitalism and global free market policies married to a scientific positivism whose advocates thought they would save the world have become systems of structural violence (Galtung 1969) that are especially damaging to the poor and marginalized peoples of the planet. As Farmer (2003:1) indicates, structural violence refers to “a host of offenses against human dignity [including]: extreme and relative poverty, social inequalities ranging from racism to gender inequality, and the more spectacular forms of violence that are uncontested human rights abuses….” Medical anthropologists waver between people-centered approaches that include individual experiences and collective realities of lived marginalization and “social suffering” (Biehl and Petryna 2013; Kleinman et al. 1997), and infrastructures of violence, historical trauma, and systems of oppression. As Langer (1996:53) asserts, “We need a special kind of portraiture [and a special language] to sketch the anguish of people who have no agency in their fate because their enemy is not a discernible antagonist, but a ruthless racial ideology, an uncontrollable virus, or, more recently, a shell from a distant hillside exploding amid unsuspecting victims in a hospital or market square.”

If this were not enough, health problems have become more severe and widespread due to globalization (e.g. with the alteration of food supplies or migrants facing a range of aggressions in the host countries) (Castañeda 2019; Horton 2016; Perro and Adams 2017) global warming (with higher rates of heat stroke and other heat-related problems) (Baer and Singer 2018, Singer 2019 ), and environmental restructuring and degradation (with more pollutants and chemicals in the air, soil, water, and everyday use items), all of which interface with each other to effect syndemics (Singer 2009a), ecosyndemics (Singer 2009b), and ecocrises interactions (Baer and Singer 2018; Singer 2009c, 2010, 2019, 2021). Indeed, at least in the United States, life expectancy is declining and, at the same time, a myriad of mental health problems, metabolic and immune conditions, drug overdose, and gun violence are reaching “epidemic” proportions and affecting younger and younger generations (Perro and Adams 2017). We are in a situation in which health improvements and innovations coexist with longstanding inequalities and even worsening health indicators. The ever increasing costs of care given the for-profit characteristics of the pharmaceutical, biotechnology, and health delivery industries continue with minimal national or global regulations (Sunder Rajan 2017). The push for insurance-based privatization policies has been globally enforced in the Sustainable Development Goals as “Universal Health Coverage” (Abadía-Barrero and Bugbee 2019). As health care financing and metrics take over health decisions (Adams 2016; Metzl and Kirkland 2010; Mol 2008; Mulligan 2014), the most fundamental health care interventions, such as child and maternal health or immunizations, continue to receive funding and health technologies in the form of vertical programs, adding to the historical disregard of comprehensive primary health care and inter-sectorial approaches. Within this scenario, medical anthropologists are effectively conducting research that bridges the local with the global to ask questions such as why certain indicators and not others count in global health? whose agenda is considered more important behind national and global decisions? what sets of problems, contradictions, and obfuscations are evident as people are funded to improve certain indicators but are required to disregard other health frameworks that they might deem as important? how are power, bureaucracy, technologies and health delivery interconnected and how these shape the experiences of patients and health care personnel? how are diseases shaped and changed historically, biologically, politically and socioculturally? By asking such questions, medical anthropology’s biocultural approach opens dialogues and debates with public policy, clinical medicine, political economy, public health, and health care systems and management, among other fields of research and intervention.

It is estimated 700,000 people died from AIDS-related illnesses in 2020, most of them in developing countries. Over 4 million people have died of COVID-19 and over 3 million more died from tuberculosis and malaria. Infectious disease accounts for about 29% of under-age-five child deaths in developing countries, and malnutrition plays a role in about half of these deaths (WHO 2005). When these diseases interact – HIV, for example, interacts adversely with tuberculosis, malaria, and malnutrition (Abu-Raddad et al. 2006; Gandy and Zumla 2003; Gillespie and Kadiyala 2005; Herrero et al. 2007) – the consequences are multiplied exponentially. Moreover, maternal mortality takes one in 74 women each year away from their families (World Health Organization 2004). Syndemic infection during pregnancy adds a significant additional level of risk to what is already a risky situation for most women in the Third World (Ayisi et al. 2003). Other less attended to and “neglected diseases” kill millions more people each year 2008. Sometimes called tropical diseases, they are, as Nichter (2008:151) stresses, “diseases of poverty, development, and political ecology – not climatic happenstance.” Notably, they, too, tend to occur in overlapping geographic zones and to involve polyparasitism or other comorbidities and harmful disease interactions (Hotez et al. 2006). COVID-19 also interacts synergistically with various non-communicable diseases or conditions—including diabetes, obesity, severe asthma, respiratory, and cardiovascular diseases—with serious health consequences.

As Nichter’s comment suggests, our world is one of great health disparities and inequalities in health status, access, and treatment that closely mirror social disparities and prevailing structures of non-egalitarian social relationship. Because health is the foundation of civil society, it has tremendous impact on political stability. The heightened anxiety surrounding the 2003 SARS, 2009 “swine flu” (H1N1 influenza), and our current 2020–2021 COVID-19 pandemic scares represented global expressions of a fragile perceived susceptibility in our new and dangerous twenty-first century world. While certainly there are areas in which health has improved, such as access to clean water in some locales, improvements in sanitation in many places, and progress in antenatal care, all of which are reflected in declining rates of child mortality, as the World Health Organization (2008:6) observes, the progress that has been made in health in recent years has been deeply unequal, with convergence toward improved health in a large part of the world, but at the same time, with a considerable number of countries increasingly lagging behind or losing ground. Furthermore, there is now ample documentation of considerable and often growing health inequalities within countries.

From its beginning medical anthropology was defined as “…the cross-cultural study of medical systems and … the bioecological and sociocultural factors that influence the incidence of health and disease now and throughout human history” (Foster and Anderson 1978:1). Thus, it has long had a broad mandate to understand and interpret human beings – their behavior, their diseases and illnesses, their medical systems and the place of each of these in the encompassing sociocultural system (Erickson 2003). Medical anthropology was professionalized as a subfield within the discipline in the 1960s. At 60 years of age, it has a history of both venerated founders (George Foster, Cecil Helman, Arthur Kleinman, Charles Leslie, Hazel Weidman, Charles Hughes, Benjamin Paul, Pertti and Gretel Pelto, Arthur Rubel, among many others) and contested theoretical paradigms that have followed broader theoretical shifts in the discipline. There are now a range of medical anthropology journals and programs around the world, some hosted within anthropology departments, and others in interdisciplinary fields, such as global health.

Academic medical anthropology in the twenty-first century encompasses the domains of individual experience, discourse, knowledge, practice, and meaning; the social, political, and economic relations of health and illness; the nature of interactions between biology and culture; the ecology of health and illness; the cross-cultural study of ethnomedical systems and healing practices; and the interpretation of human suffering and health concerns in space and time (Baer et al. 2003; Erickson 2008; Joralemon 1999; Lock and Scheper-Hughes 1996; McElroy and Townsend 2009; Nichter 1992; Sargent and Johnson 1996; Scheper-Hughes and Lock 1987; Singer and Baer 2007). Applied medical anthropology takes on the responsibility of making research useful for clinical or health educational applications, for influencing health policy, or for effecting social justice (Erickson 2003; Rylko-Bauer et al. 2006; Singer and Baer 2007), continuing the founding theme of bettering the public health. Despite our different interests, “our great strength is our diversity of theory and method, our holistic approach, our willingness to cross disciplinary boundaries, and our insistence on social justice” (Erickson 2003:4).

Companion to Medical Anthropology is meant not to serve as a full history of the subdiscipline (although many components of the field’s history are discussed), or as an encyclopedia (although essays on many key topics are included), nor as an annual review of medical anthropology. Rather, we have identified scholars who we believe have something important to say about some of the major topics and themes in medical anthropology. For this second edition, we asked authors, some from the first edition and some new, to write an original or significantly updated chapter that addresses current issues, controversies, and state of the field for their particular area of expertise from their own perspectives, and to hypothesize about the future trends and directions in their areas of expertise: where we are, what the major and emerging issues currently appear to be, and what might lie ahead.

The book is designed to address students, scholars, and practitioners alike. Unavoidably, there are many more thematic and topical areas than could be included in this volume. Thus, Companion is not exhaustive and was not meant to be. We believe, however, that what you find in these pages will engage your interest, passion, and commitment to ensure that medical anthropology continues to matter in a world of enormous health challenges.