Politics, on a local, national and global level, play an intricate role in the health of all individuals. As Smith-Nonini said, “a medical anthropology approach to analysis helps bring the critical role of political and economic factors, as well as the medical and public health cultures that shape programs, into view” (Smith-Nonini 2009:613). The political economy approach to medical anthropology specifically targets the macro-level decisions and factors that effect health.
This provides a new perspective on the interconnected nature of disease transmission, infection and treatment. However, culture is frequently used as catch all for anything without a clear explanation, when much of what is attributed to culture is, in fact, caused by socioeconomics and politics. The critical medical anthropology (CMA) approach allows researches to explore the underlying causes of an issue, rather than solely identifying it as an aspect of “culture,” in order to introduce the concept of structural violence and to analyze the economics of health.
Sources and Methods I based my writings largely on four publications. Daniel Hruschka’s article, “Culture as an explanation in population health” is a meta-analysis of anthropological studies’ use of “culture” to explain various phenomena. His work shows that only half of studies/articles propose pathways for action by “culture” and even fewer actually test these pathways. I also used “On Suffering and Structural Violence” in Pathologies of Power, by Paul Farmer.
He uses the examples of two real people to portray the harms of structural violence. He uses statistics to show the two stories are a microcosm, then discusses the “axes” of oppression: gender, race/ethnicity and sexuality, in order to show the complexities of systematic discrimination. Third, Sandy Smith-Nonini’s “Neoliberal Infections and the Politics of Health” in Anthropology and Public Health uses New York and Peru as case studies for the effect of political and economic decisions on Tuberculosis outbreaks.
Finally, Donald Joralemon, in “Chapter 4: Expanding the Vision of Medical Anthropology” of Exploring Medical Anthropology compares and contrasts different approaches to medical anthropology, using examples to show the advantages and disadvantages of the various styles. The Overuse of Culture The lack of specificity of the term “culture” presents a problem, given it’s increasing use in anthropological and sociological studies. Hruschka defined culture by saying, “the term has retained a core meaning, as values, beliefs, norms, and behaviors that we learn from others” (Hruschka 2009:2).
This definition of culture is broad, as are most, due to the expansive categories included within. It provides many pathways, mechanisms and ways in which culture can be relevant in any given situation. However, this also allows culture to be used as a default or fall back explanation when the real cause for something is difficult to identify. Because so many things are encompassed in culture, this seems reasonable, but actually hides further research opportunities and may result in incorrectly characterizing an issue.
Additional problems arise when you ask for proof of the importance of culture in specific instances: “Among the frequent references to culture as a factor in health disparities, the precise mechanisms by which cultural factors influence health outcomes are rarely clarified” (Hruschka 2009:1). The supposed effects of culture are stated, but how it influences health decisions, risk-taking behaviors or access to quality health care is unclear.
In about half of articles reviewed by Hruschka, explicit pathways for culture’s influence are provided, but even these frequently lack evidence. This means that explanations of culture are often not empirically sound which obfuscates the real causes. By creating a barrier to understanding important factors in treatment, this decreases efficacy in health care and the usefulness of these studies. By using more specific pathways, an attempt can be made to quantify the nebulous effects of culture (Shea, 02/02/16). Where CMA Differs
Culture is defined not only by its internal effects on a society, such as the rituals, habits and opinions of those living within it, but by the external factors that shape and control our lives. Paul Farmer says “the role of cultural boundary lines in enabling, perpetuating, justifying, and interpreting suffering is subordinate to (though well integrated with) the national and international mechanisms that create and deepen inequalities” (Farmer, 2005:48-49). Culture is not independent of global political and economic factors.
These international forces are constantly at work, though they may be hard to find. This is where I believe CMA differs from other forms of medical anthropology: culture is taken as a piece of the whole, a part of the complex machinery that defines health. Culture cannot be used as an excuse to explain away disease, poverty and injustice abroad. Instead, the complex, overarching factors working at a global level are creating institutions that perpetuate such injustices. Farmer calls the negative consequences of these global inequalities and disparities “structural violence. He argues that the analysis of structural violence and “its contribution to human suffering” must account for the globalized world, the history of the country and various social factors, such as gender, ethnicity and socioeconomic status. Culturally specific circumstances, then, are not independent of the political economy strategy. Structural violence is the everyday inequalities and mistreatments that create an environment of suffering.
Global politics and economic policies are intricately woven into our fates, for better or worse. The ramifications of structural violence can be seen in the ymbiotic relationship of poverty and disease. This is an example of something that may be attributed to culture, but is better explained by an analysis of the economics of health within the society. Smith-Nonini reports that in Peru “one reason so many TB patients became noncompliant was because of the inconvenience and cost of taking public transport to a Ministry clinic” (Smith-Nonini, 2009:607). Poor Peruvians suffering from TB were unable to take hours out of their day to receive treatment when they have to work to support their families.
The decision between medicine and food usually goes towards the latter, due to the immediacy of the threat to survival. In general, the poor are less likely to have access to sufficient food, safe water and medical care, all of which increase the odds of contracting an illness and dying from it. On the other side of the issue, the sick usually cannot work, and treatment may burden their families, worsening their financial situation. In Peru, the epidemic was propagated by government services that didn’t adequately address the needs of the poor.
International neoliberal policy led to Peru’s economic crisis, which forced spending cuts and encouraged privatization. As was mentioned in class, the government agreed to properly fund and staff their anti-TB efforts only when the state’s public image was threatened (Shea, 02/04/16) The money of tourists and international investors, along with the international embarrassment of another epidemic, forced the government’s hand. Both global economic and political policies have clearly influenced disease spread and reactions to it. Criticisms and Defense of CMA
Though CMA has grown in support over the years, there are still criticisms of the approach from proponents of other methods. “The most significant point made against CMA is that by stressing political-economic forces that impinge on human health, it underplays or ignores biological and ecological factors” (Joralemon, 2010:46-47). This is a stance largely taken by ecological/evolutionary medical anthropologists. In an example such as the Peruvian cholera outbreak in 1991, poverty played an indirect causal role, but the infectious agent was a bacteria.
The argument here is that neither transmission nor the course of the disease are understandable through the politicaleconomy approach. I would agree that there are limits to this approach, as with any other. CMA needs to be paired with biomedical research to treat both the root causes (systemic inequality, leading to a lack of safe food and water, sanitation, and medical care) and the actual disease. This helps those currently suffering, while also working to protect future generations. This approach is the most holistic, incorporating biology, economics, politics and culture into the analysis.
Additional criticism comes from the interpretive perspective, which is exemplified in the book The Spirit Catches You and You Fall Down by Anne Fadiman. This approach attempts to discover the meaning of a disease on an individual’s life, and also at the societal level. Proponents argue that CMA depersonalizes those who are suffering, and overlooks the individual and culturally dependent nature of sickness (oralemon, 2010). Paul Farmer’s On Suffering and Structural Violence, however, combines CMA with accounts of individuals who were killed by disease, but also by structural violence.
He tells the story of Acephie Joseph, a poor woman from rural Haiti, who was one of the first to die of AIDS in her area. Her story is not unique, which is likely why Farmer chose to tell it: it encapsulates the very real and tragic effects of structural violence. A story like this, as mentioned by Keira, allows us to connect to and understand the story in a way that statistics alone cannot (Meiser, 02/04/16). CMA goes deeper than the umbrella term of “culture” to analyze the true causes behind disease.
It allows a multilevel analysis of the political and economic factors that effect health, and highlights the institutionalized violence of inequality. While the approach is not perfect, it addresses disease and the factors that influence it on a large scale. It doesn’t ignore the importance of biology or the suffering of individuals, and allows space for the integration of other methods. Overall, CMA is the most useful of the approaches to medical anthropology, with its broad scope and cooperative capabilities.