Applying Medical Anthropology

Many people in the fields of medicine and public health do not understand the potential role that anthropology could play in the development of public health policy. Medical anthropology can contribute a unique perspective to informing public health policy decisions.

•   Shady Past? Socio-cultural anthropology has undergone significant theoretical and pragmatic changes over the past half-century. As a discipline, anthropology has been criticized for its role in imperial conquest. During colonial times, anthropologists often accompanied colonial explorers and military in order to facilitate their work, this is often referred to as 'the handmaiden era' in the history of anthropology's history. It is said that in this role, anthropologists gained the trust of natives using their linguistic proficiency and cultural awareness in order to assist the colonial state in the implementation of policies that ultimately led to further oppression and disempowerment (Pels and Salemind).

•  Because of this past, social and cultural anthropology have turned towards a more critical, reflexive and holistic approach since that time. This 'reconstruction' of anthropology has resulted in an increase in criticism of those structures that had previously been assumed as 'right' and inherently 'good'.  
• Scheper-Hughes writes about how social scientists have typically been blind to the unequal power relationships that have been harmful to informants. She calls for anthropologists to take a critical stance against such structural and institutional violence ("Coming to Our Senses").

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ANTHROPOLOGY OF PUBLIC HEALTH

• Hans Baer defines critical medical anthropology as that which "aspires to merge theory and praxis in [a] desire to promote experiential health as opposed to the functional health associated with contemporary political economics around the world" (1011). Since the emergence of critically applied medical anthropology, several anthropologists have brought this brand of anthropological enquiry to the world of public health policy. 
•  Anthropologists have been involved in public health for many years. However, prior to Critical Medical Anthropology (CMA), many medical anthropologists played the role of 'cultural brokers' (Scheper-Hughes "Three Propositions"). They were often involved in mediating between populations and policy makers in much the same way in which medical anthropologists mediated between clinician and patient, or social anthropologists between colonizer and colonized.

o   Inadvertent as it may have been, utilizing anthropology in this role in public health often inherently used techniques of "victim blaming ― that is, seeing the poor health of a population as the sole result of its culture, instead of looking also at their particular economic or social situation" (Helman 5).

o   Clearly, there was a need for the anthropology of public health to adopt a similar perspective to that of critical medical anthropology- those who critically appraise the work of policy makers and their policies' unintended negative effects upon the target population.

o   That "which remains passionately concerned about ill-health and deprivation and the need for public policy; but also remains committed to a rigorous and critical analytical perspective".

• Public health's primary concern is to improve the health of a population. Turnock states that there are "five basic sciences of public health: epidemiology, biostatistics, environmental science, management sciences and behavioral sciences" (20).

• It would seem that despite great anthropology's potential for informing health policy, its actual contribution is quite small ― seeing that it is grouped with a half-dozen behavioral sciences as one of the five informants of policymaking.

o   The reason for anthropology's minimized role in health policy development is likely founded in its primary methodological approach: ethnography. Thanks to an unabashed focus on individuals and small groups, many involved in the process of policymaking have argued that the data that generated by anthropological research is less valuable because it does not lend itself to broad 'scientific' extrapolation, as does epidemiological data. Ethnographic research involves observing and conducting interviews with a small group of people. With such small numbers, it is possible to argue that these individuals could easily be unrepresentative of the general population. (argument)

But  ethnographic inquiry has the potential to generate a great deal of rich information which can influence policy development. There are four ways anthropology can influence public health policy in ways that epidemiology or other methods cannot. 

(A) The ability to see culture in its proper context in the social world and how culture affects all 

       research.

(B) The ability to pick up on minute and seemingly irrelevant details.

(C) Independence from biomedical goals and hegemony allows medical anthropologists to add a 

       critical voice to the public health discourse.

 (D) Provision of objective, qualitative data in an otherwise quantitative field.

WHAT DOES ANTHROPOLOGY BRING TO PUBLIC HEALTH POLICY DEVELOPMENT?

A - Integrated Perspective of Culture

•   When striving to understand disease etiology among a given population, public health specialists and human ecologists often use a 'multifactorial model of disease' (Curnow and Smith). This is a model in which there are a number of distinct factors that are thought to contribute to disease in the population.

o   Culture is one of these factors, alongside many others, including: genetics, environment and so forth. The factorial model seems consistent with earlier medical anthropological research, relating to the method of the clinically applied anthropologist.

o   By involving anthropologists on a clinical level it is possible to reduce the impact of the culture 'factor' on disease prevalence.

•  Many medical anthropologists see this model of disease as outdated and inaccurate because "it reduces the investigation of social and cultural aspects of disease to discrete, static, quantifiable 'beliefs' held by the study population" (Parker and Harper 1-2).

o   A modern conception of culture, as accepted by most anthropologists is significantly more complex and all-encompassing. In contemporary medical anthropology, it is believed that all research, even the most subjective and scientific, is rooted in the culture and experience of those who interpret and publish the results.

• Medical anthropologists can contribute significantly to public health policy by providing this perspective to aid by providing an alternative to the entrenched factorial model of disease in the world of public health.

B ― Holism

•  The new medical anthropology's "inclusion of 'the whole'" (Porter 139) is another important tool that has the potential to be of great use in policy development. Anthropology is involved in seeing the entire situation in a given community. This involves participant observation in order to capture the smallest details in the events of individuals' lives. This also involves study of the macro-level forces and structures that are acting on people that cause them to behave the way they do.

• The importance of anthropology's holism also relates to dispelling the notion of the factorial model. The factorial model sees culture in isolation from all other factors. This type of reasoning can lead to what Helman calls 'victim blaming'. The same pattern can be observed in public health policy if culture is considered isolated from political, social and economic factors. 

o   Heald provides an example from her research on HIV/AIDS policy in Botswana:

Little money was pledged to the development of medical infrastructures… instead, a dangerously infectious disease was combated only by programs that urged individuals to try and avoid it as best as they could in a situation where there was no means of knowing who was infected and who was not and, in the main, no way of finding out (30).

o   Maintaining input from an anthropological perspective is important in order to avoid this kind of counter-productive policy being developed. It is important to utilize a holistic approach to illness in order to identify all pertinent factors that contribute to a given pandemic. 

C ― Critical Perspective

• The third feature unique to the new medical anthropology making it a valuable contributor to public health practice is its freedom from the theories and views of western biomedicine. Biomedicine, epidemiology and the other contributing sciences are inherently reductionist and hence have a very narrow scope in which to view the phenomenon of illness or epidemic. Everything is expected to have an explanation grounded in biology or 'science'.

o   One of the distinguishing features of the new medical anthropology is its tendency to be critical ― especially of the hegemonic structure of biomedicine. Scheper-Hughes states that: "our work should be at the margins, questioning premises, and subjecting epistemologies that represent powerful, political interests to oppositional thinking" ("Three Propositions" 196). This type of oppositional thinking is important in generating new theories and in promoting necessary discourse to effectuate much needed change in public health systems.

o   Anthropology's inward looking critical perspective of medicine and public health makes the data that it generates very important to the development of further policy. Scheper-Hughes states that it is "imperative to position ourselves squarely on the side of human suffering" ("Three Propositions" 196).

o   Criticism of biomedicine is necessary to stimulate improvements in structures or programs that are already firmly entrenched. Critical medical anthropology is able to provide this unique perspective to the field of public health.

o   Many medical anthropologists remain critical of anthropological research that is funded by interests vested in biomedicine. This type of funding arrangement may prohibit a fully critical interpretation and thus "compromises what anthropology has to offer as a discipline" (Parker and Harper 2).

D ― Qualitative Analysis

•  The fourth significant contribution that anthropology makes to the development of public health policy is its qualitative approach to data collection. This is also unique to anthropology among all of the sciences that inform public health policy. The qualitative methodology of ethnography separates anthropology from all of the natural sciences and many of the social sciences

o   Ian Hocking asserts that “quantitative analysis requires extensive categorization. Many of the categories that are used are in essence constructs of the investigators and do not even exist in the worldview of the informant. This creates a false perception of reality in the minds of policymakers that cannot be avoided through structured, quantitative analysis”.

o   Heavy reliance upon pre-designed questions, combined with spending limited periods of time in the field, inevitably structures the 'qualitative' in terms defined by the researcher rather than the researched; and this may well be at the expense of understanding the very people they seek to assist.

o   True ethnographic data strives to sidestep these misunderstandings and misrepresentations by coming to an understanding of the worldviews of its participants. This is in contrast traditional public health research, which imposes a foreign view upon informants, or counts them and in doing so categorizes them into culturally constructed groups that support the researchers' own agenda.

o   Before appropriate policy can be developed it is crucial to gain a solid understanding of the situation and more importantly, how those affected think and feel about the situation. This understanding can only be gained through ethnographic inquiry.

o   Porter explains the importance of qualitative ethnographic research in policy development through the use of the statistical concept of the outlier. He states that as an epidemiologist, outliers skew data in ways that don't seem to make sense. Therefore oftentimes epidemiologists will seek for rational, explainable reasons to exclude outliers from datasets. He goes on to explain that it is important to look "for ways of supporting the outlier to speak" (140). He has found that narratives derived through qualitative anthropological research methodologies allow him to discover this voice - the voice of "those who are normally unheard in the current international political climate" (139).

THE APPLICATION OF CMA TO PUBLIC HEALTH RESEARCH

• Anthropology is well-positioned to play a key role in the informing of health policy to address these issues.

o   `Critical medical anthropology has the potential to be a great force towards informing public health policy that is focused on the macro-level underlying causes of poor health in a population. Anthropology's distinct character as integrated, critical, holistic and qualitative makes it a very potent force in encouraging public health policy in a similarly critical direction.

Over the last 25 years, anthropologists have come at odds with development experts. The "cultural ignorance" of development experts was creating problems, some catastrophic that could easily be avoided. This ignorance was based on the ethnocentrism

• Nutrition and Educational projects in Indonesia
• HIV/AIDS Prevention: Sex Workers in the Congo
• Medical Anthropology in the USA