the Tent Big
Various answers to the cri de coeur notwithstanding, Christie Kiefer’s contribution to the definitional debate (1975) bemoaned the “irritating question” to begin with (p. 1). Kiefer worried that in trying to delimit the subfield we may cause it to wither on the vine. The quality that makes the field helpful and interesting, he said, is its very disorderliness. This only makes us “seasick” he says because “medicine thrives on orthodoxy” (p. 1); the quest to define medical anthropology reflects, he suggested, an infection with medicine’s quest for “exactitude” (p. 2). Contrasting “certainty on the one hand and meaningfulness on the other,” Kiefer argued that we should “stoutly insist” on keeping medical anthropology undefined and indeterminate.
While SMA and some of the cognate associations that emerged globally have offered various concrete definitions of the subfield’s focal concerns, and medical anthropology does have a sociocultural emphasis overall, it has matured into an inclusive arena for scholarship concerning health as a biocultural phenomenon. Furthermore, as Hsu and Potter argue, the field is “polymorph”: there are no “distinctive national styles of doing medical anthropology; diversity prevails even within a single language community [and] trans-Atlantic exchanges have always drawn on a serious engagement with research in Asia, Africa, Meso- and South America” (2012, p. 1). Likewise, Metzner and Warren position medical anthropology as a “global discipline” (2018, p. 551).
That said, many today (Metzner and Warren included) advocate increased postcolonial perspective in the discipline, particularly when working in regions that have served as research laboratories for the Global North. Mvetumbo, Oware, Yotebieng, and Syvertsen further the call for decolonization, urging colleagues working in the Global South to reduce dependency on theory generated in and for the Global North – dependency supported not just by the latter’s intellectual hegemony but by related structural factors in the Global South that make it “a challenge knowing what other researchers in our own space or country are doing” (2020).
FOUDATIONAL CONCEPTS
From Health to Sickness
Most early medical anthropologists defined health (and most still do) as a broad construct, consisting of physical, psychological, and social well-being, including role functionality. What was novel in emerging medical anthropology, however, was a distinction increasingly drawn between “disease” – biomedically measurable lesions or anatomical or physiological irregularities – and “illness” – the culturally structured, personal experience of being unwell, which entails the experience of suffering.
The effort to hash out such distinctions reflected the prioritization of a meaning-centered focus and growing use of the emic-etic framework, absorbed through linguistics. “Etic” constructs (such as the temperature represented on a thermometer) are meant to be universally applicable or culture-free. The problematic assumption of one true empirical reality notwithstanding, etic constructs are opposed to “emic” ideas: ideas (and note the implication there) that cultural insiders have about themselves and their worlds. “Disease” was an etic, universally measurable entity. “Illness” (the emic perception) was not. As such, illness could refer to a variety of conditions cross-culturally, some of which might not exist in other cultural worlds.
Thinkers of the day soon realized that, however helpful, this disease-illness dichotomy recapitulates the mind-body dichotomy that, even then, some criticized biomedicine for trafficking in. This view took fuel in part from the bourgeoning rift between positivist-minded and interpretive or hermeneutic scholars – a rift often termed the “two cultures” or science-humanities split, a la Charles Percy Snow (1993 [1959]). The problem was that while disease, as the dichotomy defined it, was bodily, illness was conversely mental: Disease was thus attributed a real, concrete, scientific factuality or objectivity that illness, as a subjective category, could be denied (see Hahn 1984).
A second criticism of the dichotomy hinged on the fact that both disease and illness were individual attributes. The term illness referred, as it still often does, to an individual’s social relations, but generally only insofar as these caused the illness (e.g., when an offended party placed a hex) or as the illness leaves the individual unable to fulfill social or role obligations. Some scholars working in the 1970s wanted to link suffering more palpably to the social order by examining how macro-social forces, processes, and events (such as capitalist trade arrangements) could culminate in public health problems and poorly functioning health systems (again, see Hahn 1984). Some recommended using the term “sickness” when highlighting larger social processes (see Frankenberg and Leeson 1976).
Medical Systems?
This definitional work occurred hand in hand with efforts to disassemble then-prevalent understandings regarding the nature of cultural systems. For instance, Arthur Kleinman’s 1978 contribution to the “What is Medical Anthropology?” conundrum accused his predecessors of reductionism. Kleinman denigrated the era of “sweeping comparative generalizations” and “ideal-type categorization,” which he painted as “superficial” and as couched at “too abstract a level to be relevant” (pp. 661–662). He argued instead for a medical anthropology that can “examine health and sickness beliefs as they are used in the usually exigent context of social action” (p. 661; emphasis in original). While the essay never said so explicitly, it in effect provided early support for a process-based theory of culture. It also questioned strongly “the tacit assumption… that medical systems are more or less homogenous, unchanging, and single” (p. 662).
More immediately, however, pointing to the importance of “microquestions” and adopting an anti-universalizing stance, the essay applauded the then-current growth of promising research using semantic network analysis methods. Referring particularly to the work of his Harvard colleague Byron Good, Kleinman lauded the study of sickness as “culturally constituted networks that link symbolic meanings to physiological and psychological processes and the personal experience of sickness, on the one side, and to social situations, relationships, and stressors on the other” and the circumvention of “biological language” that this allowed for (p. 663).
In short, rather than simply cataloging and classifying cultural practices, artifacts, and ideas (part of the archival tradition that did have its merits in anthropology’s early days), much work in this decade was devoted to identifying and understanding the various cultural forces within a given milieu that shape health and health-related experiences, ideas, and actions. And it wasn’t just semantic analyses that prospered. So did the meaning-centered approach to symbolic analysis, or what was to become known as the Geertzian tradition of interpretive anthropology. Also, a good deal of work (including Kleinman’s) took place through the study of illness narratives, using discourse analysis theories and methods and, later, phenomenology.
Anthropologists by this time had also come to understand, largely under the leadership of Charles Leslie, that highly elaborated medical traditions such as Ayurvedic, Unani, and Chinese medicine were dynamic, and porous, interacting with various local and global forces. The role of nationalism in keeping these “great traditions” of medicine vibrant also was theorized (see Leslie 1980). The general focus on how health-related experiences are shaped and expressed or given meaning locally was thus now complemented by efforts to examine how forces seen then as external to culture did the same.
Working in conditions of explicit change, first under the post-World War rubric of “development” and later as part of an acknowledged postcolonial transformation (see Marcus 2005), anthropologists increasingly studied, and created comparative frameworks for making sense of, health seeking, medical pluralism, and medical syncretism. Epistemological questions regarding evidentiary standards and modes of logic in medical decision-making were now raised more vociferously; theorists became concerned with the tendency to favor scientific or biomedical
