Читать книгу A Companion to Medical Anthropology - Группа авторов - Страница 37

Sobo (this volume) notes that medical anthropology has been dominated historically by two broad, contrasting perspectives: the symbolic/interpretive and the materialist, including a range of ecological and political economic perspectives. In the 1970s, as medical anthropology was growing as a defined subdiscipline of anthropology, bioculturally oriented medical anthropologists positioned themselves on the materialist side. Initially, they deployed ecological models that considered the interaction of host, pathogen, and environment (Armelagos et al. 1992). This ecological perspective was used to examine specific human–environment interactions where disease or other biological indicators of physiological perturbations (or stress) were evident. These causes of stress, the stressors, ranged from pathogens such as malaria to nutritional deficiency and psychosocial stressors. These early contributions clearly considered culture as part of the environment and took seriously how culture could buffer stressors or could be the source of stress.

Human ecology also served as a framework for examining the evolution of disease and disease processes in contemporary human populations, often framed in terms of epidemiological transitions (Armelagos et al. 2005). In the ecological model, the host could be an individual or a group, the environment was composed of social and cultural as well as climatic and bio-geographic conditions, and pathogens were broadened from infectious agents to a wider category of insults such as physical violence, psychosocial stressors, protein-energy deficits, and anthropogenic toxins and pollutants.

The promise of an integrative ecological model in medical anthropology led many to conclude that a theoretically coherent integration of biological, ecological, and cultural domains had been achieved (for a longer analysis, see Goodman and Leatherman 1998). Yet, Landy (1983, p. 187) suggests that although medical ecological perspectives gained considerable acceptance, they only gained a “broad tacit consensus.” Like elsewhere in anthropology, ecological models were soon critiqued by critical medical anthropologists such as Singer (1989) for lack of attention to global and regional processes, social relations of power, overly functionalist and homeostatic orientations, and their reliance on the biomedical models of disease. Singer (1989, p. 223) sums up the critique from the critical medical perspective, stating “The flaws in medical ecology…arise ultimately from the failure to consider fully or accurately the role of social relations in the origin of health and illness.”

At the same time that ecological models and the concept of adaptation were being challenged within cultural anthropology, critiques and reformulations were emerging from within evolutionary biology (Levins and Lewontin 1985) and also biological anthropology (Armelagos et al. 1992; Goodman et al. 1988; Leatherman 1996; Thomas 1998). These critiques were corrective responses to research in the 1960s and early 1970s, during which societies were seen as relatively closed and static, and human biologists were mainly focused on understanding genetic adaptations to stable physical and biotic extremes. However, two decades of research showed that human populations exhibited many more nongenetic (developmental, physiological and cultural, and now also epigenetic) responses than genetic responses to environmental stressors (Smith 1993). Thus, biological plasticity and sociocultural environments were recognized as the keys to understanding the human adaptive process (Hicks and Leonard 2014; Smith 1993).

Importantly, too, political-economic and sociocultural processes were largely ignored in the search for genetic adaptations. Groups living in challenging physical environments are often also living in social environments with limited access to means of production, wage work, political power, health care, and education. The resulting stressors with origins in relations of power, such as food insecurity and malnutrition, invariably had a greater impact on biology and health than did physical stressors such as high altitude and cold temperatures (e.g., Greksa 1986).

The “small but healthy” debate provides an example of the theoretical and applied significance of how bodies were read as adaptation or signs of stress. Developed by economist David Sekler (1981), the “small but healthy” hypothesis asserts that individuals who are short due to mild to moderate malnutrition (MMM) are nonetheless healthy and well-adapted, particularly to the circumstances of marginal food availability (Pelto and Pelto 1989, p. 11). Hence, economic and food resources need not be directed at them but rather, focused on the few who are suffering from more severe forms of malnutrition. In response, Raynaldo Martorell (1989) argued that while smaller people require fewer calories, their “smallness” entailed substantial social, behavioral, and biological costs. The same caloric deficit that causes slowed growth also decreases resistance to disease and ability to work and reproduce. As Pelto and Pelto (1989, p. 14) conclude, “…the concept of a ‘no-cost’ adaptation makes virtually no sense.” The “small but healthy” debate was key to a reexamination of the adaptation concept, and alerted many to the political implications of their science, in this specific case, whether or not millions of MMM Indian children would receive food aid.

Biocultural research in the 1990s increasingly became oriented toward documenting biological compromise or dysfunction in impoverished environments (as opposed to adaptations) and the biological impacts of social and economic change (Thomas 1998). Social environments took precedence over physical environments, and measures of stressors expanded to include psychosocial stressors and their impact on health conditions such as hypertension and immune suppression (e.g., Blakey 1994; Dressler and Bindon 2000; Goodman et al. 1988; McDade 2002). Yet, while it became relatively common to associate biological variation with some aspect of socioeconomic variation, the context and roots of the socioeconomic variation were infrequently addressed. For example, research on “modernizing” populations documented how devastating such changes can be on human biology and health but provided little or no information about processes of modernization (Bindon 1997). The socioeconomic conditions, workloads, and environmental exposures that contribute to diminished health were conceptualized as natural and even inevitable aspects of changing environments, rather than contingent on history and social and economic relations.

Critiques of the ecological model from critical medical anthropologists such as Singer (1989) led to spirited debate on the pages of Medical Anthropology Quarterly, including a defense of the ecological approach and biocultural paradigm in medical anthropology by Andrea Wiley (1992), a subsequent series of rejoinders and commentaries (e.g., Leatherman et al. 1993), and a collection of papers and commentaries on “Critical and Biocultural Approaches in Medical Anthropology” in 1996 (Baer 1996). These dialogues were formative in developing a critical biocultural anthropology that emerged from efforts to “build a new biocultural synthesis,” which was the focus of a Wenner-Gren symposium in 1992 (see Goodman and Leatherman 1998). The conference brought together cultural and biological anthropologists, many of whose work focused on human health, to consider how we might better formulate critical and political-economic biocultural approaches. A number of themes, presented later, emerged from discussions at the conference, the subsequent volume and further efforts to advance a critical biocultural approach to health and illness.