Orientations to the Body

The history of medical anthropology is to a large extent a history of scrutinizing and challenging Western assumptions about sickness, beginning with the distinction between biomedicine and traditional medicine. (Most medical anthropologists prefer the term biomedicine to the alternative terminology: scientific, modern, and Western medicine. For an explanation see Leslie.) At first glance the distinction appears to be a commonsense way to classify different kinds of medical systems; in practice it rests on a set of problematic assumptions.

First, it implies that traditional medical systems have something fundamental in common, whereas in reality so-called traditional systems are highly diverse in both their medical theories and their practices and share little as a category other than being different from biomedicine (Leslie and Young). Second, juxtaposing traditional medical systems with biomedicine implies that biomedicine is a monolithic system, beyond the reach of culture. However, social scientists have demonstrated significant variation in biomedical notions, technologies, and clinical practices both within communities and across cultures (Brodwin, 2000; Hahn and Gaines; Lindenbaum and Lock; Lock, 1993; Lock, Young, and Cambrosio). Third, comparing biomedi-cine to other medical systems also sets biomedicine as the standard of medical care because it is based on scientific principles; this conveys the idea that other medical systems are not as real or therapeutically effective.

A more useful way to compare medical systems across cultures is to start with the question, How do the beliefs and practices of a medical system orient healers and patients to their bodies? An answer from the Western perspective might be that because the body is the site of the pain and suffering associated with sickness, the body must be the focus of attention for patients and healers everywhere. In reality, medical systems are not equally interested in the body. Rather, those systems and their perspectives are distributed along a continuum that includes the biomedical perspective among many others.

At one end of the continuum are systems whose orientation to the body can be called externalizing in that their diagnostic and therapeutic ideas and techniques direct people's attention away from the sufferer's body. In those systems the medical gaze looks outward, scanning networks of people and beings (e.g., ancestral spirits, possession spirits, demons) for morally significant encounters and events involving the sick person or that person's close relatives. The diagnostic goal is to construct a useful etiology, that is, a string of circumstances and events that lead to the onset of suffering and distress and identify the ultimate source of the sickness. The therapist's goal in those systems is to insert himself or herself into the patient's sickness narrative and, once there, persuade or coerce the pathogenic agents to stop afflicting the patient. The classic account of diagnosis and treatment in an externalizing system is E. E. Evans-Pritchard's Witchcraft, Oracles, and Magic among the Azande (1937).

A sick person's body is a site of discomfort and distress, and in this sense sickness is the same all along the continuum. At the externalizing end, however, the patient's bodily experiences and transformations are mute. Typically, the body is a black box in that although people may have names for certain body parts and organs, they can posit no functions or systemic connections for them. Pain, suffering, and the visible transformations that accompany sickness and disease signify only themselves; they reveal nothing about processes and events that biomedicine recognizes are taking place inside. Although practitioners may give patients medicaments to take, those medicines are characteristically anodynes or substances that are intended to make the patient more comfortable while the actual cure is being pursued elsewhere. In short, in externalizing systems medical meanings and experiences are created and connected by discrete socio-logics rather than by a universal bio-logic (Lock and Gordon).

Anthropologists describe three broad types of therapeutic strategies that operate in externalizing medical belief systems: agonistic strategies, in which the goal is to eliminate or neutralize pathogenic agents; initiatory strategies, in which the goal is to bring the patient and the pathogenic agent into a permanent and manageable relationship (Boddy); and strategies of persuasion, in which the goal is to persuade the pathogenic agent through offerings or appeals to cease afflicting the patient (Lewis). Beyond these generalizations, externalizing systems are highly heterogeneous.

Biomedicine is at the opposite end of the continuum, among the internalizing systems, in which diagnosis and therapy orient patients and healers toward the body. Here sickness coincides with the limits of the body, and the goal of diagnosis and therapy is to get inside the body, to take control of its internal parts and processes. Circumstances and events outside the body are interesting only to the degree to which they lead to inferences about pathological processes taking place inside. It is in these systems that one finds theories of pathophysiology, the grammars that enable people to read bodily changes symptomatically.

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