Anthropology's Contribution to Public Health Policy Development

CROSSROAdS

Anthropology’s Contribution to Public Health Policy development

Dave Campbell*

Many people in the felds of medicine and the unequal power relationships that have been public health do not understand the potential role harmful to informants. She calls for anthropologists that anthropology could play in the development to take a critical stance against such structural and of public health policy. The intention of this article institutional violence (“Coming to Our Senses”). is to provide readers with an understanding of Holism has also become an important the unique perspective that medical anthropology hallmark of modern ethnography. Even the most could contribute to informing public health policy basic concept of classic anthropology – culture – decisions. has been rethought: “the modern view of culture is Socio-cultural anthropology has undergone to stress the importance of always seeing it within signifcant theoretical and pragmatic changes over its particular context... ‘culture’ cannot – and should the past half-century. As a discipline, anthropology never be – considered in a vacuum” (Helman 4,7). has been criticized for its role in imperial conquest. These fundamental changes in the broad discipline During colonial times, anthropologists often of socio-cultural anthropology have manifested accompanied colonial explorers and military in order themselves in each of its related sub-disciplines. to facilitate their work, this is often referred to as ‘the This paper will examine these changes in the sub- handmaiden era’ in the history of anthropology’s discipline of medical anthropology, and particularly history. It is said that in this role, anthropologists how these changes allow anthropology to make a gained the trust of natives using their linguistic contribution to public health policy development. profciency and cultural awareness in order to assist the colonial state in the implementation of RECENT EVOLUTION IN MEdICAL ANTROPOLOgy policies that ultimately led to further oppression and Anthropologists have been interested in disempowerment (Pels and Salemind). medical practices for many decades; however, Such critiques, among others, have led medical anthropology as a distinct subfeld is a to a signifcant redirection of anthropological relative newcomer in the world of academia. The thought and theory (Lewis). Social and cultural identifcation of the feld of medical anthropology anthropology have turned towards a more critical, is generally attributed to William Caudill in his refexive and holistic approach since that time. paper from 1953 entitled “Applied Anthropology This ‘reconstruction’ of anthropology has resulted in Medicine” (McElroy). Since that time Medical in an increase in criticism of those structures Anthropology has established a degree of that had previously been assumed as ‘right’ and independence from its parent discipline of social inherently ‘good’. Scheper-Hughes writes about and cultural anthropology. Despite this how social scientists have typically been blind to autonomy, medical anthropology’s disciplinary evolution has been greatly affected by the changes in social anthropology. *To whom correspondence should be addressed: Ethnomedicine was the frst of the subfelds Dave Campbell of medical anthropology to develop. The premises University of Calgary of this ideology was that gaining an understanding Email: [email protected] of local medical beliefs and practices could be Vol. 13 No. 1 Anthropology 77

benefcial in the provision of biomedical services a population as the sole result of its culture, instead to people in cultures where biomedicine was of looking also at their particular economic or social new and unknown. McElroy states that “Since situation” (Helman 5). Farmer further elaborated on the 1940s anthropologists have helped health this issue: care providers understand cultural differences in health behaviours” (3). Emphasis on this aspect of Scholars often weaken their medical anthropology led to the development of the contributions to an understanding ‘Explanatory Model’ framework (Kleinman) and the of infectious diseases by making benchmark volume ‘Clinically Applied Anthropology’ “immodest claims of causality.” These (Chrisman and Maretzki) among many others. claims are immodest because they are These works focused heavily on doctor-patient wrong or misleading. They are immodest interaction and how anthropology can be used as a because they distract attention from the tool in biomedicine. modest interventions that could treat This thinking was followed by a new wave and often enough cure people. And they of thinking that parallels the turn to refexivity in are immodest because they distract social anthropology. In 1983, the term ‘critical attention from the preventable social medical anthropology’ was introduced (Baer). This disorder that exacerbates biological new brand of medical anthropology was similar to disorder. (5) the new refexive social anthropology in that it was critical, holistic and inward looking: “it is the work Clearly, there was a need for the of anthropology turned in upon ourselves, our own anthropology of public health to adopt a similar society” (Scheper-Hughes “Three Propositions” perspective to that of critical medical anthropology. 196). Scheper-Hughes goes on to draw explicit Van Willigen defnes a dichotomy between parallels between colonial social anthropology and ‘anthropology in policy’ and ‘anthropology of policy’ clinical medical anthropology by saying that medical (164). This semantic technicality differentiates anthropologists played a vital role in establishing between anthropologists who assist policy makers the cultural hegemony of biomedicine. She calls for (reminiscent of clinically applied anthropology) and medical anthropologists to break with the feld of those who critically appraise the work of policy western medicine and distance themselves in order makers and their policies’ unintended negative to look back upon biomedicine objectively. effects upon the target population. Parker and Harper describe the anthropology of public health ANTHROPOLOgy Of PUBLIC HEALTH as that “which remains passionately concerned Hans Baer defnes critical medical about ill-health and deprivation and the need for anthropology as that which “aspires to merge theory public policy; but also remains committed to a and praxis in [a] desire to promote experiential health rigorous and critical analytical perspective” (2). as opposed to the functional health associated with With its new critical and refexive contemporary political economics around the world” perspective, anthropology has a lot to contribute to (1011). Since the emergence of critically applied the development of health policy. The feld of public medical anthropology, several anthropologists health – and more generally, policy development – have brought this brand of anthropological enquiry requires research contributions from a multitude of to the world of public health policy. disciplines. Williams states that “a multidisciplinary This is not to say that medical anthropology approach could best address the public health is new to public health. Anthropologists have been needs of a population” (Williams 1). involved in public health for many years. However, Public health’s primary concern is to prior to Critical Medical Anthropology (CMA), many improve the health of a population. This broad- medical anthropologists played the role of ‘cultural scope approach has brought epidemiology to brokers’ (Scheper-Hughes “Three Propositions”). be the most infuential discipline in health policy They were often involved in mediating between because by using methodical sampling methods populations and policy makers in much the same way one can theoretically extrapolate conclusions about in which medical anthropologists mediated between the state of health of entire populations. Turnock clinician and patient, or social anthropologists states that there are “fve basic sciences of public between colonizer and colonized. Inadvertent as it health: epidemiology, biostatistics, environmental may have been, utilizing anthropology in this role science, management sciences and behavioural in public health often inherently used techniques of sciences” (20). “victim blaming – that is, seeing the poor health of 78 Anthropology 2010

It would seem that despite great Many medical anthropologists see this anthropology’s potential for informing health policy, model of disease as outdated and inaccurate its actual contribution is quite small – seeing that it because “it reduces the investigation of social is grouped with a half-dozen behavioural sciences and cultural aspects of disease to discrete, static, as one of the fve informants of policymaking. quantifable ‘beliefs’ held by the study population” The reason for anthropology’s minimized role in (Parker and Harper 1-2). This factorial notion health policy development is likely founded in its of disease seems to involve the reasoning that primary methodological approach: ethnography. factors of disease causation such as biology and Thanks to an unabashed focus on individuals environment are beyond the reach of culture. A and small groups, many involved in the process modern conception of culture, as accepted by of policymaking have argued that the data that most anthropologists is signifcantly more complex generated by anthropological research is less and all-encompassing. In contemporary medical valuable because it does not lend itself to broad anthropology, it is believed that all research, even ‘scientifc’ extrapolation, as does epidemiological the most subjective and scientifc, is rooted in the data. Ethnographic research involves observing culture and experience of those who interpret and and conducting interviews with a small group of publish the results. people. With such small numbers, it is possible As a result of past discussions and debates to argue that these individuals could easily be within the feld, contemporary medical anthropology unrepresentative of the general population. is equipped to see beyond the established factorial Despite the uphill battle that faces model of disease. Similar discussions have taken anthropologists in the public health sector, it is place in medical anthropology such as those imperative to continue the work, as ethnographic surrounding the Cartesian dualism paradigm. This inquiry has the potential to generate a great deal is a dichotomy between the mind and the body of of rich information which can infuence policy an individual. This worldview is characterized by a development. In the following section, I will describe mechanistic view of disease etiology, very similar to four ways anthropology can infuence public health that in the factorial model. The Cartesian paradigm policy in ways that epidemiology or other methods continues to be used in western biomedicine and was cannot. (A) The ability to see culture in its proper accepted in medical anthropology for many years. context in the social world and how culture affects Only recently, under the context of the ‘new’ critical all research. (B) The ability to pick up on minute version of medical anthropology, has this concept and seemingly irrelevant details. (C) Independence come under the microscope. Scheper-Hughes and from biomedical goals and hegemony allows Lock argue for the need to problematize such a medical anthropologists to add a critical voice to the seemingly simple dualism. They claim that it is not public health discourse. (D) Provision of objective, as straightforward an issue as it may seem. They qualitative data in an otherwise quantitative feld. challenge “medical anthropologists and clinicians to view humans and the experience of illness and wHAT dOES ANTHROPOLOgy BRINg TO suffering from an integrated perspective” (Scheper- PUBLIC HEALTH POLICy dEVELOPMENT? Hughes and Lock 10). While it may be argued that clinicians have A – Integrated Perspective of Culture held on to “the Cartesian Legacy,” anthropologists When striving to understand disease have been working for years at developing such etiology among a given population, public health an integrated perspective. Medical anthropologists specialists and human ecologists often use a can contribute signifcantly to public health policy ‘multifactorial model of disease’ (Curnow and by providing this perspective to aid by providing Smith). This is a model in which there are a number an alternative to the entrenched factorial model of of distinct factors that are thought to contribute disease in the world of public health. to disease in the population. Culture is one of these factors, alongside many others, including: B – Holism genetics, environment and so forth. The factorial The new medical anthropology’s “inclusion model seems consistent with earlier medical of ‘the whole’” (Porter 139) is another important tool anthropological research, relating to the method of that has the potential to be of great use in policy the clinically applied anthropologist. By involving development. Anthropology is involved in seeing anthropologists on a clinical level it is possible to the entire situation in a given community. This reduce the impact of the culture ‘factor’ on disease involves participant observation in order to capture prevalence. the smallest details in the events of individuals’ Vol. 13 No. 1 Anthropology 79

lives. This also involves study of the macro-level and subjecting epistemologies that represent forces and structures that are acting on people that powerful, political interests to oppositional thinking” cause them to behave the way they do. (“Three Propositions” 196). This type of oppositional The importance of anthropology’s holism thinking is important in generating new theories also relates to dispelling the notion of the factorial and in promoting necessary discourse to effectuate model. The factorial model sees culture in isolation much needed change in public health systems. from all other factors. This type of reasoning can To this day, one often hears allegations lead to what Helman calls ‘victim blaming’. The against anthropology for its past as the same pattern can be observed in public health ‘handmaiden’ of colonialism. As a result of having policy if culture is considered isolated from political, to defend itself from these claims, the discipline has social and economic factors. Heald provides an become very critical of hegemonic power structures example from her research on HIV/AIDS policy in that are involved in neo-colonial oppression of the Botswana: afficted and underprivileged. Biomedicine is a classic example of such a potentially oppressive Little money was pledged to structure. Several accounts exist that describe the development of medical how “the doctor has replaced the priest as the infrastructures… instead, a dangerously custodian of social values” (Turner 37-38). For infectious disease was combated only example, one author writes a detailed account of by programmes that urged individuals to how the Public Health institution in the Philippines try and avoid it as best as they could in functions as an emissary of the state in subjecting a situation where there was no means of people to foreign practices in order to effectuate knowing who was infected and who was control and domination over the public (Anderson). not and, in the main, no way of fnding Anthropology’s inward looking critical perspective out (30). of medicine and public health makes the data that it generates very important to the development Maintaining input from an anthropological of further policy. Scheper-Hughes states that it is perspective is important in order to avoid this kind “imperative to position ourselves squarely on the of counter-productive policy being developed. side of human suffering” (“Three Propositions” It is important to utilize a holistic approach to 196). Anthropologists have gone from being the illness in order to identify all pertinent factors handmaidens of colonial power to advocates for the that contribute to a given pandemic. John Porter, afficted and suffering. Many of the other sciences an epidemiologist, has said of anthropology: that contribute to health policy share biomedicine’s “The discipline concentrates on what is actually mechanistic paradigm. Criticism is necessary to happening and looks to ‘the root’ of where things stimulate improvements in structures or programs come from” (Porter). Whether this ‘root’ at the level that are already frmly entrenched. Critical medical of social interactions between individuals, a cultural anthropology is able to provide this unique nuance or the macrocosmic structures that impact perspective to the feld of public health. a given population, anthropological methods of In order to remain in a good position investigation have proven reliable in identifying it. to criticique biomedicine, it is important that anthropology maintain its distance from the C – Critical Perspective biases and philosophies of western medicine. The third feature unique to the new medical Many medical anthropologists remain critical of anthropology making it a valuable contributor to anthropological research that is funded by interests public health practice is its freedom from the theories vested in biomedicine. This type of funding and views of western biomedicine. Biomedicine, arrangement prohibits a fully critical interpretation epidemiology and the other contributing sciences and thus “compromises what anthropology has to are inherently reductionist and hence have a very offer as a discipline” (Parker and Harper 2). narrow scope in which to view the phenomenon of illness or epidemic. Everything is expected to have D – Qualitative Analysis an explanation grounded in biology or ‘science’. The fourth signifcant contribution that One of the distinguishing features of the anthropology makes to the development of public new medical anthropology is its tendency to be health policy is its qualitative approach to data critical – especially of the hegemonic structure of collection. This is also unique to anthropology among biomedicine. Scheper-Hughes states that: “our work all of the sciences that inform public health policy. The should be at the margins, questioning premises, qualitative methodology of ethnography separates 80 Anthropology 2010

anthropology from all of the natural sciences and qualitative anthropological research methodologies many of the social sciences. Ian Hacking explains allow him to discover this voice – the voice of why qualitative data is so important in his critique “those who are normally unheard in the current of statistical data: “The fetishistic collection of overt international political climate” (139). statistical data about a population has as its motto ‘information and control’ but it would more truly THE APPLICATION Of CMA TO PUBLIC HEALTH be ‘disinformation and mismanagement’” (280). RESEARCH His premise is that quantitative analysis requires Thus far, this article has sought to extensive categorization. Many of the categories underscore the importance of the development of that are used are in essence constructs of the the critical perspective in medical anthropology. investigators and do not even exist in the worldview As has been described above, this is a crucial of the informant. This creates a false perception of component of medical anthropology’s contribution reality in the minds of policymakers that cannot be to public health. avoided through structured, quantitative analysis. Despite anthropology’s strengths outlined A similar critique was voiced by Parker above, a common critique of CMA is that it is overly and Harper, about supposed qualitative research idealized and not in line with the realities of the world. conducted by many traditionally quantitatively- However, Peacock states that “pragmatism and oriented social scientists. searching critique need not be mutually exclusive” (12). Rylko-Bauer et al. contend that anthropology’s Heavy reliance upon pre-designed future viability as a discipline lies in its ability to questions, combined with spending continue applying critical notions in the formulation limited periods of time in the feld, of pragmatic solutions. They claim that “practice inevitably structures the ‘qualitative’ in is part of the discipline’s destiny and needs to be terms defned by the researcher rather at the centre of discussions about anthropology’s than the researched; and this may well future” (187). They not only stress how important be at the expense of understanding the it is for anthropology to take a practical stance, but very people they seek to assist (3). further elaborate how such is possible:

True ethnographic data strives to sidestep A meaningful convergence of these misunderstandings and misrepresentations methodologically sound, critical, by coming to an understanding of the worldviews refexive, and engaged anthropology – a of its participants. This is in contrast traditional convergence that builds on and learns public health research, which imposes a foreign from the extensive past experience of view upon informants, or counts them and in doing putting anthropology to use – will free us so categorizes them into culturally constructed up to focus on differences that actually groups that support the researchers’ own agenda. do matter in the real world. (187) Harper states: “one of the best ways to understand a situation is to spend extended periods of time The discipline of public health is at the interacting with those involved” (59). Before point of making a major decision, largely because appropriate policy can be developed it is crucial of a publication known as the Black Report, which to gain a solid understanding of the situation and showed a very strong correlation between the more importantly, how those affected think and feel income and health of a population (Hamlin). about the situation. This understanding can only be gained through ethnographic inquiry. Public health remains at a crossroads. Porter explains the importance of qualitative The choice is between a narrow focus ethnographic research in policy development on health service issues and the health through the use of the statistical concept of the problems of individuals on the one hand, outlier. He states that as an epidemiologist, outliers or a refocus on the major underlying skew data in ways that don’t seem to make sense. causes of population health on the other. Therefore oftentimes epidemiologists will seek for (Beaglehole and Bonita 2-3) rational, explainable reasons to exclude outliers from datasets. He goes on to explain that it is important Anthropology is well-positioned to play a to look “for ways of supporting the outlier to speak” key role in the informing of health policy to address (140). He has found that narratives derived through these issues. This article has focused on the Vol. 13 No. 1 Anthropology 81

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