Underlying the medicalization of contemporary life is the broader phenomenon of medical hegemony, the process by which capitalist assumptions, concepts, and values come to permeate medical diagnosis and treatment. Antonio Gramsci, an Italian political activist who fought against fascism under Mussolini, developed this concept as an elaboration upon Marx and Engels' observation that the ideas of the ruling class are, in every age, the ruling ideas in society. Whereas the ruling class exerts direct domination through the coercive vehicles of the state apparatus (e.g., the government, courts, military, police, prisons), hegemony, as Femia (1975) observes, is exercised through the institutions of civil society such as the educational system, religious institutions, and the mass media. Hegemony refers to the process by which one class exerts control of the cognitive and intellectual life of society by structural means as opposed to coercive ones. Hegemony is achieved through the diffusion and constant reinforcement throughout the key institutions of society of certain values, attitudes, beliefs, social norms, and legal precepts. Doctor-patient interactions also constitute an arena of hegemonic interaction. Studies of these interactions show that they commonly reinforce non-egalitarian hierarchical structures in the larger society by (1) stressing the need for the patient to comply with a social superior's or expert's judgment, and (2) directing patient attention to the immediate causes of illness (e.g., pathogens, diet, exercise, smoking) and away from structural factors (over which physicians feel they have little control). For example, although a patient may be experiencing job-related stress caused by an onerous work environment, the physician may prescribe a sedative to calm the patient rather than challenging the power of an employer or supervisor over employees. In the contemporary world, globablization is a primary engine of medical hegemony. As Whiteford and Manderson (2000) stress, the forces shaping the contemporary health scene, for example health care and health practices around the world, including those promoted by the main international lending institutions upon which many countries are fiscally dependent, derive from Western domination and reflect Western values of rationality, competition, and progress, in all of which contexts there is an implicit assumption that with modernization local "traditional" institutions and structures in and out of health care will be replaced by Western alternatives.
Regardless of their degree of complexity, all health care systems are based upon a dyadic core consisting of a healer and a patient in interaction. The healer role may be occupied by a generalist, such as the shaman in prein-dustrial societies or the family physician in modern societies. It may also be occupied by a complex array of specialists from herbalists to oncologists even within a single society. Rather than a single medical system, contemporary societies can sport a pluralistic set of healing traditions, some of indigenous origin within particular subgroups in society and others imported from other societies. Medical pluralism, which flourishes in all class-divided societies, tends to mirror the wider sphere of unequal social relationships, with the patterns of hierarchy among co-present medical systems being based upon the reigning structure of class, caste, racial, ethnic, regional, religious, or gender distinctions. It is perhaps more accurate to say that national medical systems in the modern or postmodern world tend to be "plural," rather than "pluralistic," in that biomedicine enjoys a dominant status over all heterodox and ethnomedical practices. In reality, plural medical systems may be described as "dominative" in that one medical system generally enjoys a pre-eminent status vis-à-vis other medical systems (Baer, 1989). While within the context of a dominative medical system one healing tradition attempts to exert, with the support of elites of society, dominance over other medical traditions, people are quite capable of the simultaneous use of quite distinct medical systems.
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