By: Nadia Benjelloun

Would you ever consider medicine to be anything short of being grounded in science? Health culture is a domain often tied to the medical field, and in return, the medical field is a shared element that is present globally, and across societies. Throughout all ages, while medicine has evolved (for the better), it has always stemmed from ground-breaking research and systematic investigation, in other words, science.

Science is seen as an accumulation of knowledge necessary for the benefit of society. Broadly speaking, science and the growth and development of a given society go hand in hand, and one cannot happen without the other. Being the self-enterprising carpetbaggers that humans are, medical advancement in science is one of few public sectors that goes unprecedentedly unquestioned.

Although it may generally be clear that culture has a heavy influence on patterns of behavior of a social unit, one would not normally think that culture also greatly impacts the biomedical world. In fact, there are tie-ins that extend to not only the cultural, and social, but even linguistic and political levels. The study of bio-culture examines these aspects, and anthropology sheds light on both, the construction and reconstruction of the narrative surrounding biomedicine and our understandings of it.

Construction refers to the dynamic and ever-changing understandings and attributes to social categories as defined by a given society. Categories include but are not limited to, race, gender, class, health, political status, death, etc. Reconstruction as the term would suggest, is to reassemble something again. But in this context, it refers to the analysis of subtexts, and recompiling that information through a different gaze. That gaze might be shaped by, as it would with construction, culture. Given these two conditions, one can now judge that the foundations of biomedicine to be a lot more miscellaneous than expected at face-value.

Our comprehension of the processes involving sickness, disease, treatment, and illness are assumed to be the same everywhere. And although, some of these words may be used interchangeably, they do not mean the same thing. Sickness, in anthropological application, means all the unwanted variations in the physical, social, and psychological dimensions of health. Disease means the biological and clinical manifestation of those unwanted variations in an organism that cause a change in either physical or chemical function. At last, illness refers to the human experience and perception of those unwanted variations or alterations in health. Illness is key to having a comparative understanding of how relative medicine actually is.

At first glance, it would seem like the representation of such divergences can only be in the form of resources; put simply, less developed countries have less resources, therefore they deal with health differently as they can only do so much. Then surely, it is the more developed countries that have better suited methods of medicine, and more appropriate conceptions of health, (however it may be branched in culture), right? This is a reductionist way of thinking that relies far too much on rationalism.

Take leprosy for instance. Leprosy is a known infection caused by a bacterium, but more importantly, it is curable. Despite the readily available treatment, leprosy in the U.S is heavily feared. While there is education and campaigns in fighting stigma against leprosy, lepers are shunned. “society must protect itself from such a disease by isolating those who are afflicted, and that the moral ideology regarding leprosy is society’s justification for its own self-protection” (Waxler,2010). Pop culture and literary representation of lepers as unwanted, deformed, and limbless people contributes to the fears that have nothing to do with the biological causes of the disease. Historical context, though, can clarify this.

In Hawaii, in the 1950s, leprosy was believed to be hereditary because cases of leprosy increased directly in proportion to Chinese immigrants. As a result, the Chinese were scapegoated and rejected from society. Similarly, lepers in India were expelled from villages to become beggars. This was characteristic of other societies too. “We say of a deviant community member ‘He’s like a leper’. Doctors in Indian hospitals refuse to see cases; attendants of Ceylonese hospitals refuse to change dressings; wives begin divorce proceedings when husbands are diagnosed as lepers; patients leave villages to become urban beggars. In some societies, then, routine treatment is neither given nor received. Responses to the disease by patient, family, and doctor are strongly influenced by social expectations, and not simply by the biological characteristics of leprosy.” (Waxler, 2010) Accustomed to such social responses they’re constantly confronted with, affected individuals will have a penchant for self-shame and self-disgust. Consequently, they become reclusive. “Even if patients are cured the stigmatization can remain leading to obstacles to resumption of a normal life.” (Kumari, Wikramasinghe, Madhavi, 2017). On that note, readers may begin to suspect that stigmatization of leprosy, or the very act of placing stigma on disease holders of any kind, may be universal. But that is not true.

In Sri Lanka, while there is no explicit stigmatization at a public scale, individuals would stigmatize themselves. However, lepers stay at home, and families remain intact. A welcoming community is formed amongst patients. Journalist Ross Velton investigated the stigma of leprosy in Sri Lanka in 2016. He found that at Hendala Leprosy Hospital, while there were adults that did not need medical care nor were infectious, were living there anyway. “They’ve fallen in love and married one another. They’ve learned professions and become artists and musicians. They’ve managed to build the community they couldn’t find in the outside world.” (Velton, 2016) Eventually, fear and rejection disappeared over time.

Tanzania and Nigeria are more agreeable examples. Like Sri Lanka, patients in Tanzania continue to live with their families. Initiatives are taken to educate the masses on the disease and focus on finding methods for treatment. In Nigeria, lepers live normal lives. Leprosy is fully accepted and not treated any differently from any other disease. “Although leprosy is common, modern methods and theories not understood, and traditional treatments probably ineffective, no one is afraid.” (Waxler, 2010) This is an obvious contrast with the U.S, where treatment is widely available, and the mechanism of the disease thoroughly understood, but lepers of that society are treated as an isolated case from the average citizen. If one were to only type in the disease in the search engine, a plethora of resources will present itself, including detailed prognoses, patient stories, counseling, and blog writings. This gives the person diagnosed with the disease a means to learn “how to have” the disease based on the expectations and norms of their social group. In other words, individuals take on the “sick role.” While the biological manifestation of a disease itself is a constant anywhere, its meaning of possessing the illness varies by culture.

The next question then, might be how do such cultural definitions come to be? There isn’t a simple answer, nor a straightforward explanation. But for the context of biomedicine, it can first be broken down to understanding, by being made aware of the social construction of authoritative knowledge.

Authoritative knowledge is just one of many existing branches of epistemological thinking. Specifically, authoritative knowledge is simply the knowledge that is agreed to be the one most relevant to the situation. As Brigitte Jordan described it, “the power of authoritative knowledge is not that it is correct, but that it counts.” In the medical field, it is not a matter of truth, but a matter of value. The range of value relies on rationality, and drawing attention to the one who holds the most relevant rationality is the one who holds the most status in a social group. In this case it would be a physician. A physician has unquestionable authority in a clinical setting because “they know what they’re doing.” A woman “knowing” she is pregnant before doing a medical test is irrelevant because the only knowledge that is acceptable in this scenario is based on an analysis result or a doctor’s diagnosis. It doesn’t matter that the woman’s intuition is right because only by going to a doctor’s could she “really tell.”

A study was done on cases of court-ordered cesarean sections in the United States (Jordan and Irwin 1987,1989, 1989; Irwin and Jordan 1987) that revealed several women that insisted they knew they didn’t need a c-section but were given one against their will anyway. None of those sections were necessary for the delivery of their babies but were done because the medical knowledge they were subjected to called for it. The women’s view did not count.  “From the court-ordered section cases I learned that women that escaped sections had powerful social networks within which their vision of reality was upheld and supported. They also usually were able to remove themselves physically from the hospital. The ones who got the sections were the ones who did battle with the prevailing view alone or as an isolated couple on alien territory. They were often women who were poor, foreign, and illiterate.” (Jordan 1989) Another example would be a woman in labor. A woman would know she is ready to push out the baby when her bodily experiences display conditions for her to push. But if a physician isn’t present for vaginal examination to check the dilation of the cervix, she would be asked by a nurse or technician assistant to suppress the urge to push until one is. “What counts is the technologically, and procedurally based knowledge of the physician that is inaccessible to the woman, but without which the birth is not allowed to proceed.” (Jordan, 1990) A woman would have to endure hours of pain in delayed labor (which could potentially result in complications) until a doctor gives the green flag. From the janitor, receptionist, technicians, nurses, medical students, residents, to the primary doctors, there are varying levels of authoritative knowledge; it’s a hierarchy by which that knowledge is distributed and determines the decision-making processes.

However, it could be argued that authoritative knowledge is necessary to produce reliable results. Why wouldn’t there be authoritative knowledge? Surely it is logical to abide by authoritative knowledge, as that would guarantee order and organized management in its execution. The premise is an alternating relationship of justification and acquired true belief. Western methods of medical approach are backed up by reasonability, that reasonability being that their acquired knowledge is from rational sources, therefore making their application of it, justifiable. But what are the qualifications for justification? To avoid a regressive dead-end, the focus here will be on systematic, analytical, and empirical knowledge acquisition, essentially science. “My father’s brother is my uncle”, is derived by analytical knowledge of understanding what those terms mean and is independent of experience. It is absolute truth that validates fact, therefore is a true belief. Someone who learns of, and acquires a true belief is put in a justly position to execute it, regardless of experience because the outcome will always be the same. A person who knows the directions of a location, even without having ever before gone to that location themselves, is still eligible to lead others or direct them to that location. Ironically, however, the practice of medicine depends on seasoned experience. Additionally, medical competency is characterized by skills that are considered value-free yet are developed by the very knowledge and factual techniques that are were chosen for their sentiment of value (for their value is what makes it valid). Furthermore, authoritative knowledge, which is birthed from such a paradoxical structure, does not just take place within the walls of one social unit, but cross-culturally as well. That being said, Western knowledge specifically, is deemed to best express the criteria of valued and valid acquired knowledge, and is prioritized over knowledge produced elsewhere, and will be used as a standard for evaluation.

Yet still, it could be argued that in that line of adherence to the science model, it could only be expected that the probable outcome is that the West will dominate in various visions of knowledge. If they best use their foundations for educational discretion, why shouldn’t they set the standard? At this point, readers should keep in mind and remember, that by the hands of the same above-described thinking, science has also engendered reasons for racism, like environmental determinism¹, which was used as a justification for enslavement and colonialism. In addition, literacy was associated with rationality, and because the ones colonized did not speak the same language as the colonizers, they were thought to be incapable of rational thinking, therefore apt to be subclass citizens. Literacy was also linked to religion, as communication is key to conveying “the Great Chain of Being” ²; a missionary can’t preach if the one they’re targeting can’t understand what they were saying in the first place. For that reason, colonists were judged to be pagans, therefore having no souls, and by that logic, were subhuman and “en-slavable”. On top of that, there have been attempts to use science as an indicator of racial superiority or inferiority through physical and biological distinctions in the human population. ³

Going back to the previously mentioned paradox, the framework of study under which medicine is done, features detachment from humanistic tendencies, even though the overarching purpose of medicine is to deliver humanity a product of goodwill.

In Medical school, students are taught to reconstruct the human body into an object. Since medicine is introduced as a science, students learn to separate the patient’s body from the patient as a person. “The body is newly constituted as a medical body, quite distinct from the bodies with which we interact in everyday life.” (Good, Good,1993) Individuals cases are analyzed as a problem to be solved with a diagnosis as the aim. Being able to reach that diagnosis reflects competency as a physician. Because students are so pressured on achieving the background skills to produce that diagnosis, (provided for by their science classes) they slowly become disconnected from the human factor of being a physician, essentially delivering “care.”⁴

A study done in Harvard Medical School interviewed students on their struggle to balance the demand to master the hard-cold facts of scientific knowledge that’ll make them competent doctors, and the call for being cordial healthcare providers. It was agreed among most students that the former of the duality took the priority as they gained more clinical experience and progressed in their studies. “As they begin to redefine the object of the medical gaze in the language of science and the body, medical students express nostalgia for the commonsense view of human suffering, feeling that they will lose precisely those qualities they most hoped to bring to medicine.”(Good,Good,1993) Many students described themselves feeling “changed” by the end of their studies; they think of bodies as machine-like and think differently about personal boundaries. “It was second semester that we started anatomy and I remember going into peer group, and saying, ‘I’m changing. Something’s happening here.’ ” (Good, Good,1993) While the core of the applied sciences are constants, the delivery and execution of medical knowledge has subtexts that influences the gaze of both the educator and the learner. Medical systems, therefore, are not neutral and without underlying agendas. Biomedicine is dictated by circumstantial frameworks; depending on historical and social context, the prestigious discipline generates a set of values, assumptions, code of conduct, and beliefs that are not cultural-free. In its regard for professionalism and respectable expertise, is the by-product makings of hierarchies.

One might be prompted to think, What then? What’s to be done? Can the supposed indifferent, rigid, traditions of medicine be observed without the expense of its subjective antithesis, or vice versa? Should the medical system be questioned? Should our judgment for the education and training of biomedicine be remodeled? This will be left rhetorical. But one thing is clear at most. To be welcoming to the challenging of such ideas. Acknowledgement and openness to discourse is a first step.

The University of New England⁵ for instance, is an institution known for its reputable programs in the health sciences. Its tag line is “Innovation for A Healthier Planet.” But how do we begin innovation for a healthier planet, when we aren’t innovative in our critique? If unwilling to depart from homogeneous theories, methods, and mindsets, how dare we expect or hope for meritorious and incorruptible policy-making in global health and related domains? Indeed, the “what’s best” question is open-ended. But a concept in mind is only reciprocal in action.

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References:

Good, Byron, and Good, Mary. “Learning Medicine” The Construction of Knowledge at Harvard Medical School, 1993, ls-tlss.ucl.ac.uk/course-materials/ANTH3007_57586.pdf.

Jordan, Brigitte. Authoritative Knowledge and Its Construction, 1997, https://bbcswebdav/pid-1835524-dt-content-rid-16100979_1/courses/20719-201902-ANT-211-A/Jordan%20Authoritative%20Knowledge.pdf

Kumari, Wikramasinghe, Madhavi, 2017

Velton, Ross. Pulitzercenter. “Sri Lanka: Leprosy’s Forgotten Generation.” Pulitzer Center, 5 Jan. 2017, pulitzercenter.org/project/asia-sri-lanka-leprosy-infection-disease-stigma.

Waxler, Nancy E. 2010 Learning to be a leper: a case study in the social construction of illness.

1 Environmental Determinism is the belief that the physical environment (landscapes and climate) is the sole influence of human behavior and social development. During the “scramble of Africa”, because the terrain, fauna and flora was different from that of Europe, its inhabitants were devalued. The quality of water and soil, in addition to the climate, was seen as a cause of their darker skin, and therefore deemed lesser than whites.

2 The Chain of Being is the view that the universe exists in a hierarchy that begins with God, followed by angels, humans, animals, plants, matter and then nothingness. Slaves were determined lower than animals. The higher up the chain the being was, the higher level of intellect, virtue, and superiority that being possessed.

3 During the 19^th century, pseudoscientific phrenological methods attempted to link intelligence and behavior to brain shape. Skull sizes of different ethnicities were compared to determine rankings of evolution and ability “to be civilized”

4 In the medical context, “care” encompasses the language, the values, and “the personal” as opposed to the competency of having an objective scientific background. By being a “caring” healthcare provider, the physician listens to the patient, is compatible, conveys information well, and is respectful of the patient’s point of view as well as cultural background.

5 The United States campus.