Medical Systems Crossculturally

What people do for health depends to a large degree on how they understand the causes of an illness. Etiological concerns have, for a long time, underpinned cross-cultural health research because etiological notions provide an excellent focus for contrasts and comparisons. Much work has focused on categorizing so-called systems of healing and curing (herein, "medical systems").

One simple model casts illness as either "internalizing" or "externalizing." Internalizing systems focus on proximate physiological mechanisms. They give primacy to biological or physical signs that can mark a disease's progression (Young, 1976/1986). Illness is an individual problem, not a social problem. In contrast, externalizing systems ascribe importance to events outside of the ill individual's body. Such systems view pathogens as purposive; often they are human or anthropomorphized. Diagnostic activity focuses on discovering what brought the (now ill) individual to the pathogenic agent's attention, provoking the attack. Externalizing systems focus on ultimate causes, not proximate ones.

Using the externalizing-internalizing model, Young (1976/1986) offers some interesting suggestions regarding the evolution of health systems. He holds that internalizing systems evolve from externalizing systems when societies grow complex.

Externalizing systems focus on social and cosmo-logical relations. They are interlinked with other cultural domains, such as religion, and have little conceptual autonomy (Young, 1976/1986). Many have noted that, in small-scale societies, beliefs about illness etiology often connect with beliefs about all kinds of misfortune, including interpersonal conflicts and geological disasters. But internalizing systems are highly autonomous. So, for example, health is treated as separate from legal or religious issues. Young explains this in relation to the division of labor seen in complex societies.

In small-scale societies, specialization is uncommon and the division of labor is low. Young (1976/1986) argues that this explains the overlap between healing and other cultural domains. Large-scale societies have complex labor division patterns that include specialization and engender distinctions between cultural domains. The conceptual autonomy of internalizing systems is linked to this. The fragmentation of cultural realms in large-scale societies supports internalizing systems, which focus on the body, paying little heed to legal, religious, and other dimensions of life.

The contrast between "naturalistic" and "personalis-tic" medicine focuses directly on social relations (Foster, 1976). Naturalistic models explain sickness as due to impersonal forces or conditions, including cold, heat, and other forces that upset the body's balance. Personalistic approaches, however, ascribe illness to active external agents. The agent involved in a given case may be human (such as a sorcerer), or non-human (such as an evil force or ancestral ghost). Accident or chance have no role in illness here as they do in naturalistic explanations; in per-sonalistic systems, illness is the direct result of an agent's purposive act. Therefore, people need to be certain that their social relations, with the living and the dead, and with deities and other agentic forces, are well maintained. If not, others may be provoked to take actions leading to one's ill health.

While etiological questions do have importance, categorization can also rest on the organizational characteristics of the systems in question. For example, medical systems can be categorized as either "accumulating" or "diffusing" according to whether they entail accumulated, formalized teachings or, rather, encourage the fragmentation of medical knowledge (Young, 1983). Practitioners in diffusing systems generally do not communicate with one another; their knowledge is often secretly held. Accumulating systems, on the other hand, amass knowledge, generally in written form. Knowledge is shared at conferences and through professional associations and formal training institutions. Biomedicine, Chinese medicine, and Ayurveda are examples of accumulating systems.

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