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June 09, 2009

On Clinical Anthropologists

As most readers of MH Blog know, while I am no social scientist, I am, shall we say, an exceedingly friendly outsider when it comes to (medical) anthropology.  I read widely in the field, attempt to understand the implications of anthropological research for all manner of topics (e.g., pain, stigma, ethics, religion and medicine, etc.), and count it a great fortune that I have ongoing dialogue with several medical anthropologists.

Why so? After all, it is hardly as if, say, health psychology or medical sociology has nothing to offer the medical humanist.  Why am I particularly attracted to anthropology? The short answer is 'who knows;' why is any one person attracted to one field over another? There are many interesting answers to this question, but the majority of these, in my view, will vary widely depending on the context and the persons involved.

The longer, pedantic answer is that if nothing else, I think a medical humanist is or ought to aspire to be a social and cultural scholar as to medicine and medical practice.  If indeed the study of culture is central to the MH, then how, pray tell, can one pretense to get at that inquiry without guidance and insight from the very discipline which arguably centers the study of culture? 

In any case, in my travails at a medical school and an academic medical center, I have often wondered why it is that I have encountered so few "clinical" anthropologists, or medical anthropologists working in clinical settings, at the bedside, so to speak, and on staff at hospitals.  I do not mean to suggest that such practice is unheard of, but it certainly is not de rigeur the way clinical ethicists have become in clinical setting.  I do not have much of an answer to this question, but I have felt for some time that the relative lack of a continuing presence for anthropologists in the clinical setting -- not just doing time-limited field research -- is something of a loss, if not for the anthropologists, then for the rest of us, who could, IMO, benefit greatly from the insights and approaches regarding that most complicated of creatures -- humans, and human culture.

Just for example, I have often wondered how different my local world would be if it were anthropologists in charge of designing, implementing, and teaching cultural humility, instead of the relatively thin but conventionally dominant and poorly named "cultural competence."  How much richer would the learning opportunities be?

On the H-MED-ANTHRO listserv, a participant queried whether any of the members had any experience in clinical settings, and one of the answers struck me as so important, I requested and received permission to repost it here.  The question was posed by Nick Jefferson-Lenskyj from the University of Queensland (which serves large numbers of indigenous Australians), and the reposted answer is authored by Lissie Wahl:

"I work as a medical interpreter at one of the clinics of  a hospital in the Boston area, considered top in the country.

In day to day practice, I work with doctors,  trying to bring in the complex interaction of body, subjectivities, power, and historical context.  For the most part (definitely not always), I find medical providers grateful, respectful, and appreciative, often affording me treatment as full colleague and provider.

Ironically, however, the part I play is neither sanctioned by the clinic's (to me, apparently anachronic and) hierarchical administrative structure, where medical interpreters stand below secretaries and receptionists (in terms of the power to read meaning into situations), and by the developing 'field' of medical interpretation itself, where insurance companies' terror reigns and renders physicians the only ones recognized as in capacity to embue a medical encounter with meaning.

Medical providers, whether in the fields of primary care, mental health, physical and occupational therapy, or other, know otherwise. Yet, in the context of money-driven medical administrative practices (medical interpretation included), the work of an anthropologist (in my specific case) or culture 'broker' (as with medical interpreters in general) remains an invisible job at the bottom of the 'medical administrative pit.'

Returning to the question posed below, yes, I work with providers in anthropologically relevant ways, but, no, I have no power or space for implementing in any way whatsoever what I learn.  Moreover, I am threatened with getting 'written up' (given a warning) if I ever mention the word 'discrimination,'

As an anthropologist I find the process painful and challenging.  As a person, I find having to submit from day to day to an unspoken 'gag rule' very difficult,  particularly after having worked for nearly three decades in and around the Amazon, where indigenous peoples value highly self-determination and struggle to instill co-responsibility in all processes (whether of medicine, natural resource administration, or life in general).  How they contrast to what I see now as deemed desirable in a 'top notch hospital.'

Lissie Wahl, Ph.D.

P.S.  The Department of Global Health and Social Medicine at Harvard Medical School gave me shortly after I arrived, given the kind intervention of a primary care provider, an institutional affiliation that allowed me to do the kind of anthropological thinking I was prohibited from carrying out openly through the medical institutions where I currently work (to the extent I can do anything at the end of a 60 hour work-week, which I think  crystallizes further the marginality of interpreters and cultural brokers). It is quite ironic to see the significant weight  given by non-specialists to the term 'culture' in the medical field."




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Very interesting article. I have never really thought of anthropology in medicine and so I really enjoyed your points.

Leigh Turner has been asking these questions for some time now (cf.: 'Bioethics in a Multicultural World: Medicine and Morality in Pluralistic Settings,' Health Care Analysis, Vol. 11, No. 2 (June 2003): 99-117). Here's his faculty page from the Center for Bioethics, University of Minnesota: http://www.ahc.umn.edu/bioethics/facstaff/turner_l/home.html

Of course it was not long ago that anthropology itself acknowledged its long-standing infatuation with "the other" (i.e., the exotic, foreign, etc.) and began to focus its theories and methods "inward" as it were, upon the very societies and cultures that gave birth to the discipline.

Hey Patrick,

I'm not sure if you know, as I have mentioned it on MH Blog, but Leigh Turner is one of my "must-read" authors, and I enthusiastically endorse virtually everything he has to say on this subject.

Re the second point, that is eminently fair, I think. I am obviously biased, because everyone tends to think what they "do" is most important, but I have heard medical anthropologists intimate that the study of illness in culture is crucial because examining the associated phenomena provides a window into virtually every meaning-making endeavor employed in a given society -- life, death, suffering, birth, etc.


I thought I recalled you mentioning him before, but just in case...! Turner kindly sent me copies of some of his articles a few years ago so I avail myself of every opportunity to mention him.

On the "window thing," I suspect that's true.

A lot of us pick up cross cultural medicine by experience (we learn from our patients and from sensitive physician teachers).

But the only articles I read about cross cultural medicine were so broad ("Asian" attitudes, or equating Mexico to all Latin America) and theoretical (full of jargon) that I didn't find them much help.

Have you read the book that teaches medical ethics by using great literature? Similar stories might be a lot more helpful...when I worked with the Navajo, they told me I'd learn more from Hillerman than anthropology books...

As for interpreters, I agree...but in rural areas, it's a problem...

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