Toward a critical medical anthropology

The presentation of sessions on 'Beyond Medical Anthropology: A Political Economic Critique of Health' and 'Toward a Critical Medical Anthropology' at the Annual Meeting of the American Anthropological Association in 1983 signalled a growing recognition that medical anthropology needs a critical analysis of the socio-medical context in which it has emerged. The first session, organized by Stephen Graft and Athena McLean, consisted primarily of papers by graduate students at Temple University. The other session, organized by John Johnsen and Hans Baer, was designated an Invited Session of the Society for Medical Anthropology. In large measure this Special Issue of Social Science & Medicine grew out of proceedings at these two sessions. Earlier versions of the Introduction and essays included herein were presented by Hans Baer, John Donahue, Athena McLean and Merrill Singer. Another paper was published in Issues in Political Economy o f Health Care edited by John McKinlay [1]. The essays by Margaret Lock and Ken Stebbins were presented in other sessions of the AAA meeting. The essay by Nancy Scheper-Hughes and Anne Lovell was added to this Special Issue to expand the range of topics and issues. It may seem presumptous to label our approach critical. After all, most medical anthropologists view their discipline as a critical endeavor that challenges the assumptions of the'disease model in biomedicine. We contend, however, that this critical perspective is limited to lower levels of analysis and ignores the political economy. Most of this research concerns tribal and peasant communities where practitioners of Western biomedicine come into contact with members of a subproletariat or ethnic minority. Despite the growing recognition that anthropologists should make comparative studies of medical systems, they have for the most part ignored the burgeoning literature on the political economy of health [2]. Although we do not oppose research on social relationships and small communities (indeed we see it as an essential component of a critical medical anthropology), we maintain that it must be conducted with the recognition that disease, illness, and treatment occur within the context of the capitalist world system [3]. The critical perspective we want to nourish and extend has its taproot in Marx, Engels, C. Wright Mills and similar analysts. We are concerned with the ways power differences shape social processes, including research in medical anthropology. Like Navarro [4], Krause [5], Doyal [6], Elling [7] and Waitzkin [8], we feel that the dominant ideological and social patterns in medical care are intimately related to hegemonic ideologies and patterns outside of medicine. While a perspective on capitalism is an important starting point for a critical medical anthropology, it is insufficient for a fully developed approach. A critical medical anthropology will have to address the nature of health concepts and practices in precapitalist and socialist-oriented societies. We hope that other anthropologists will extend a critical perspective to tribal and pre-capitalist societies. In time, a more complete critical medical anthropology will follow in the footsteps of Marx [9], Engels [10], Terray [11], Hindess and Hirst [12], Godelier [13] and Kahn and Llobera [14], who have used dialectical materialism to analyze kinship, political, economic and religious institutions in pre-capitalist social formations. Most of the essays in this symposium deal with capitalist societies. Schneider, Lock and McLean's papers focus on health-related issues in the core and Scheper-Hughes and Lovell and Stebbins' essays in the semi-periphery. Singer's essay examines the social production of alcoholism in a wide array of capitalist societies as well as some socialist-oriented societies. John Donahue's essay examines primary health care in Nicaragua, a country in the periphery but which is struggling to construct its own form of socialism. The work of Donahue and medical anthropologists such as Peter K. New [15], who was examining health care in the People's Republic of China prior to his recent death, should help develop a critical medical anthropology of socialist-oriented societies. A critical approach must define health as access to and control over the basic material and non-material resources that sustain and promote life at a high level o f satisfaction. A key component of health is struggle. While the ultimate character of health care systems is determined outside the health sector, significant forms of struggle take place within this sector and help to shape its institutions. Consequently, a dialectical examination of contending forces in and out of the health arena that impinge on health and healing becomes an essential task of building a critical medical ant, h~opology. A critical medical anthropology must address questions of who ultimately controls biomedical institutions and the implications of such control. By doing so we will achieve deeper insights into health and illness than are presently provided by middle-range