The Cultural Meanings and Social Uses of Illness

The Cultural Meanings and Social Uses of Illness A Role for Medical Anthropology and Clinically Oriented Social Science in the Development of Primary Care Theory and Research Arthur Kleinman, MD Cambridge, Massachusetts Basic research that is conceptually and methodologically in novative and that fosters long-term research programs should play a role in the academic development of primary care, alongside more practical applied studies of specific clinical problems. A creative tension between the two has been a dis tinctive attribute of academic medicine and should be fostered in family medicine and other primary care disciplines. The bio- psychosocial model offers a paradigm for the incorporation of clinically oriented social science research as one basic science approach in which primary care researchers can receive ad vanced training and pursue an academic career. The author briefly illustrates such a career with reference to studies (his own included) on the social uses and psychocultural meanings of illness. Somatization, a major problem in primary care, is illuminated by such a clinically applied social science research framework. Developing the scientific basis of an academic dis cipline involves intellectual education in systematic scholar ship to create and critique concepts as much as it requires training in the application of rigorous research design and powerful statistical techniques. Two levels of academic endeavor should de studies of discrete, salient, health care problems velop in primary care if family medicine and the based on specific methods and instruments taken other primary care disciplines are to become via from epidemiology, health services research, bio ble academic enterprises: (1) practical applied medicine, and psychiatry that are drawn upon to study highly focused, operationalized research Presented at the North American Primary Care Research questions; and (2) concepts, theoretical models, Group Meeting, Columbus, Ohio, May 20, 1982. From the and research approaches that can contribute to a Department of Social Medicine, Harvard Medical School, the Department of Anthropology, Faculty of Arts and Sci unique scholarly discourse on primary care and ences, Harvard University, and the Department of Psychia that can provide the intellectual foundation for try, Harvard Medical School at The Cambridge Hospital, Cambridge, Massachusetts. Requests for reprints should self-contained research programs which together be addressed to Dr. Arthur Kleinman, Department of An create a science of clinical practice. thropology, 330 William James Hall, Harvard University, Cambridge, MA 02138. On level 1 there may not be, nor need there be, ® 1983 Appleton-Century-Crofts THE JOURNAL OF FAMILY PRACTICE, VOL. 16, NO. 3: 539-545, 1983 539 MEANINGS AND USES OF ILLNESS understanding of the conceptual basis of the re essence of what has come to be recognized as the search methods imported into primary care, and best in academic clinical medicine. This system indeed nonclinician researchers trained in applied atic tension between theory and practice is what or even basic science may be brought in to apply keeps academic medicine vitally oriented to prac them. But on level 2, researchers struggle with the tical problems while at the same time avoiding be translation of concepts from other fields into new coming either (1) unscientific or pseudoscientific, ways of conceptualizing and analyzing health care or (2) overly scientific and clinically irrelevant. problems. They create new methods or remake old That there is often an imbalance in some disci ones. They, moreover, ask questions and search plines toward the latter and in others toward the for answers at a fundamental level, rethinking core former does not invalidate this goal; it only indi clinical concerns. Level 1 researchers often do not cates how important it is to maintain this difficult possess advanced research training, or if they do, balance at the heart of clinical science. Further, it usually is not in a basic science. Rarely do they this is the appropriate model for how the primary see themselves as contributing to scientific in care disciplines need to develop if they too are to quiry. They are clinicians who are trying to answer achieve academic success. particular clinical questions. For them the best may be the enemy of the good. They want to be able to apply some highly specific research tech niques and statistical skills for highly practical purposes. These technologists want their scientific skills to be “good enough” for performing particu lar research tasks. They are not questioning theory or building long-term research programs whose individual projects are intended to set out and test Current Status of Research a line of reasoning. Indeed, it is frequently crucial When applied to the primary care disciplines, to the success of such applied studies that their what does this admittedly ideal-type model reveal? completion is feasible in a relatively restricted First, on the applied level, family medicine and time frame. This means that they usually cannot the other primary care disciplines are already off explore a question in great depth. to a reasonable start. Primary care practitioners In contrast, level 2 scholars see themselves have drawn on the relevant methodologies of bio very much as scientists who are about the lifetime medicine, epidemiology, health services research, labor of building a separate field of scientific in and clinical psychiatry and psychology to conduct quiry. They have been systematically trained to be individual projects. Researchers from these other conceptually sophisticated, to enter, under super disciplines are acting as collaborators. The data vision, a major intellectual tradition, review its base is greatly expanding. A critical mass of re sources and the current status of its academic dis searchers has been created that is actively debat course, and engage in critical ongoing dialogue on ing future academic directions. These are no small its core themes and findings. Masters of the ideas achievements. This practical level of research, behind their techniques, these researchers take even in the presence of severe budgetary con theoretical questions extremely seriously and aim straints, will continue to grow and mature; its to build methods and collect data to systematically principal contribution will be the data it generates advance rigorous and critical testing of ideas. about important clinical problems and the academic I hey provide their academic disciplines with intel infrastructure it builds in schools of medicine, lectual power and scientific status. both of which will help establish the primary care In biomedicine it is the creative tension be disciplines as legitimate academic enterprises. tween each of these levels, sometimes even in the On the second level hardly anything is seen yet. same researcher, and the distinctive but related Where are the concepts being built and pulled to interests they support which sustain that remark gether into original theory, where are the new ably productive dialectic between applied and methodologies being created to test hypotheses, basic knowledge, clinical and intellectual en where are there systematic attempts to train re deavor, trade and science that strikes one as the searchers to translate relevant work from other 540 THE JOURNAL OF FAMILY PRACTICE, VOL. 16, NO. 3, 1983 MEANINGS AND USES OF ILLNESS disciplines, not this particular technique or that program. Clinical scholars should be trained who particular experimental design, but key concepts become primary care epidemiologists, others who that can help build a major research program? become primary care health services researchers, (One of the few signs of this happening is the early, and still others who link primary care to specific but important, effort of Medalie’s family medicine medical social sciences (anthropology, sociology, group at Case Western Reserve to form a research social psychology). There should also be primary program containing several and varied studies cen care physicians trained in relevant biological re tered on the understanding of the family’s contri search approaches. This cohort of young academ bution to social support and its influence on health ics would conduct work on both level 1 and level 2, maintenance and illness outcome.) In the absence but principally the latter and, it is to be hoped, would of substantial endeavor on level 2, there is a seri receive long-term support from their institutions ous imbalance in the creative dialectic between and academic disciplines to build careers as schol applied and fundamental science in primary care, ars. Around them would coalesce research groups and this raises the distinct danger of allowing engaged in the elaboration of well-defined re practical research to stagnate and slowly slide into search projects. technology divorced from intellectual concern, One particular area of level 2 research that fam which eventually must mean poor science or no ily medicine and other primary care disciplines can science of primary care at all, and no clinical and should actively cultivate, is medical anthro scholars in the real sense of that evocative term. pology and other clinical social sciences. The pri Lacking level 2 contributions, primary care may mary care disciplines could become the major become merely a testing ground for other fields’ venue for the introduction of social science into scientific

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