Some controversy surrounds the fact that all the categorization schemes discussed above entail central contrasts. Many would argue that it is a mistake to cast medical systems as simply one or the other of a given contrasting pair. Rather, the contrasts may be thought of as occupying a continuum, with each system containing some of each emphasis. When determining a classification, the researcher must ask not which ideal type a given system represents but which of a given contrasting emphasis is most salient or primary in that system. So, for example, while biomedicine in practice may entail some personal-istic touches (e.g., when a physician refers to an outcome as being in the hands of god), the overarching emphasis is naturalistic and for that reason it is classified as such.
On the other hand, not all systems will be easily classifiable because some systems explicitly accept both aspects of a contrast and focus on either one depending on the illness or condition in question. Take, for example, the old intrusion versus extrusion contrast (Clements, 1932). This model contrasts the bodily "intrusion" of substances or essences to the "extrusion" of such as the cause of illness. Extrusion would include, for example, soul loss, or the loss of blood, or even the non-absorption or leaching of nutrients, as with diarrhea. In intrusion-caused illnesses, on the other hand, noxious substances (e.g., poisons, germs, evil spirits) pierce or infiltrate the body's barriers. Illness due to bleeding and illness due to soul loss are classified together in this model as extrusion-caused; germs and evil spirits are both categorized as intrusive. However, treatments for germ-caused or spirit-caused illness can differ. In any case, one medical system can allow for both intrusion and extrusion illnesses. So in some cases the question is not which of a given contrast dominates, but how the two are linked and under what conditions one or the other predominates.
Here, it is worth noting that not all medical systems are all that systematized; sometimes, what is actually referred to as a system is only loosely aggregated. Care must be taken to avoid reifying the terminology used to talk about diverse ways of dealing with health and illness, thus creating the impression that a culture's loosely aggregated set of beliefs and practices is actually a highly systematized structure.
Further, systems (whether loosely or tightly systematized) typically entail sub-systems. For instance, the formal U.S. healthcare system includes not only medicine as it is technically defined, but also nursing, the child-life specialty, social work, occupational therapy, etc. Medical systems generally include a diverse array of practitioners, such as herbalists, chemists, surgeons, bone setters or body workers, midwives, sorcerers, priests, and shamans (Loustaunau & Sobo, 1997). Within any given cultural group's medical system, diverse practitioners' work—and their understandings of how health is produced, maintained, and compromised—may or may not overlap.
When does a culture's loosely coupled system stop counting as one loosely coupled system and start counting as several distinct systems? This question has not been sufficiently considered as yet, but the answer may lie in the degree to which the various components compete with each other for clients. That is, in a loosely coupled system, the sub-systems each serve distinct, diverse needs. But in a pluralist system (comprised of two or more distinct medical systems) components may be in competition, each claiming to be able to meet the same needs, albeit in a different fashion. Again, the distinction is not an all-or-nothing one; there may be a continuum and some systems (using that term in its broadest sense) may be more or less pluralistic than others.
In addition to maintaining caution regarding all-or-nothing contrasts, medical anthropologists must be aware that classifying a system is not the ultimate goal of our discipline. Classifications are helpful only as they propel us forward in theoretical contributions to the field, or make helpful action possible.
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