Transcript Medical Anthropology - South Bristol GP trainers workshop

Anthropology: What comes to mind?
Cecil Helman
Outline of the day
• 9-10.30 Introduction: What is medical
anthropology? How has it engaged with
medicine and public health?
• Central themes/debates in medical
anthropology
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Illness/disease distinction
Embodiment
Metaphor/language in relation to illness
Lay and medical models of the body
Medical culture and power
Timetable (continued)
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10-30-10.45
Break
10.45 – 12.30
Chronic illness/pain
Doctor-patient communication
12.30-2.00
Lunch
2.00-2.30
Cultural expressions of
distress/somatisation
• 2.30 -4.30 (with break) Anthropology and GP
training
What is medical anthropology?
• Cultural construction of illness and suffering,
illness experience, medical knowledge and
healing practices
• Study of the body and lifecycle from childhood
to old age
• Critique of production of biomedical
knowledge and power relations this entails
Anthropological methods
• Participant observation/ethnography
• Focus groups/semi-structured interviews:
‘qualitative methods’
• Rapid participatory methods
• Newer methods: use of camera, videos
• Importance of stories: link between anthropology
and medicine
• By the nature of their work, GPs already have
many anthropological skills
History of medical anthropology
• Sub-field of social anthropology: study of
illness, healing and cosmology
• Application to clinical medicine:
anthropology is good to ‘think with’
but has it failed to engage?
Critical medical anthropology
• ‘Social suffering’ (Kleinman et al 1997) and the
impact of inequalities/poverty and racism on
bodies and lives
• Health as a human right
• Cultural and economic politics of communities
& how these affect individuals
Paul Farmer
Nancy Scheper-Hughes
Philippe Bourgois
Psychiatry and medical anthropology
• How are ‘normality’ and ‘abnormality’ defined in
different cultural settings?
• How does mental disorder present differently?
• Are diagnostic criteria applicable globally?
• How is psychiatric knowledge/practice culturally
constructed?
• Why is mental illness diagnosed more among
Afro-Caribbeans in the U.K.?
• ‘Culture-bound’ syndromes?
Anthropology’s engagement with
public/international health
• Arose from repeated failures of health
programmes & wish to engage on particular
issues (e.g. safe motherhood, condom
promotion, diarrhoeal disease, vaccine
uptake)
• Anthropologist as ‘cultural consultant’/critic of
cultural naivete in design and piloting of
health promotion campaigns
Example 1 - Kuru: Papua new Guinea
1950s
Example 2 - Smallpox and the goddess
Sitala
Example 3 - Anthropology and
HIV/AIDS
Quick brainstorm
• What are the challenges you experience as
clinicians that anthropological thinking might
help you with?
Central themes of
medical anthropology
• Illness versus disease (Eisenberg 1977)
• ‘Lay’ explanatory models are (Kleinman):
‘idiosyncratic and changeable, and heavily
influences by both personality and cultural
factors. They are partly conscious and partly
outside of awareness and are characterised by
vagueness, multiplicity of meanings, frequent
changes, and lack of sharp boundaries between
ideas and experience’
Embodiment
• A way around the mind-body split central to Western and
biomedical culture
• A way of understanding lived experience
• Seminal paper by Scheper-Hughes & Lock (1987):
individual, social and political bodies as interconnected
• Work with GPs around embodiment (Jaye 2003): some
respondents saw the task of re-embodying patients as a
central concern in general practice.
‘In general practice…you have an ongoing relationship with the self.
You really have to live with people in the way that you don’t in other
specialties. So I think from the general practice point of view,
embodiment is very important. I mean it is what you’re there for in
many ways, is to help people become embodied, to own themselves
again.’
Metaphors of illness
• Metaphors make meaning; they reflect public
anxieties about the moral nature of illness and
suffering
• e.g. HIV as plague, contagion, war
• Sontag’s (1978) work on cancer
• As doctors we should see
language as coded messages
from sufferers, as ‘messages in a bottle’, & work
with them (Scheper-Hughes & Lock 1986)
Public health/medical discourse
• Highly cultural and reality-shaping
• Medical jargon and effect on patients; how patient
experience is ‘re-packaged’ in clinical letters
• Example: debate around organ donation and ethnic
minorities (Cierans & Cooper 2011)
Medical culture & the clinical gaze
Lay & medical models of the body
• Body as machine (mind-body split)
• Taught to look for objective signs
• GP’s domain = ‘the social’ in eyes of many
doctors
• Lay models of the body e.g.
– Emily Martin’s (1999) cultural analysis of
reproduction
– Margaret Lock’s (1995) account of menopause in
Japan vs N. America
Chronic illness/pain: group work
• The problem of ‘chronicity’: what does it do to
patient’s sense of self? What does it mean to live ‘well’
(or not) with chronic illness? Does it makes a difference
if disability is visible or invisible (e.g. pain)?
• What are the moral and cultural meanings ascribed to
chronic illness/pain? e.g. fibromyalgia; epilepsy; COPD
• What are the particular challenges GPs face in working
with these patients? What do patients want from you
and what do you offer them?
Chronic illness/pain
• The problem of chronicity: fusion of identity with
diagnosis; ‘I am…’ vs ‘I have…’ illnesses (Estroff 1995)
• Private/invisible vs public/invisible
• The power of labelling: stigma, self-stigma and blame
• Holistic perspective (Helman 2007):
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Temporal
Social
Cultural/symbolic
Biological/clinical
Political/economic
Doctor-patient communication
Watch the video clip (Verghese TED talk)
• What are the ritual/symbolic elements of the
doctor-patient relationship?
• ‘Consultations with a doctor are actually
transactions between lay and medical
explanatory models’ (Kleinman). Discuss. What
are the potential pitfalls in a consultation?
• What is the role of narrative in a consultations?
How do doctors try and shape patients’
narratives?
Doctor-patient communication
• Problems in clinical consultations (Helman
2007):
– misinterpreting distress;
– incompatibility of explanatory models;
– disease without illness or illness without disease;
– problems of terminology;
– treatment/ ‘non-compliance’/ competing
definitions of ‘success’;
– the context for each party
Cultural expressions of
distress/somatisation
• What does somatisation mean to you? Give
examples of somatisation that come up in your
clinical practice?
• Given examples of somatisation encountered in
your clinical practice. How do you know these
patients are ‘somatising’? How does culture
mould somatic symptoms?
• What are the challenges/dilemmas? How do you
work with ‘somatising’ patients?
• Are there any problems with the concept of
somatisation?
Various interpretations of somatisation
(Kirmayer & Young 1998)
• an index of disease
• a symbolic expression of intrapsychic conflict
(Freudian view – hysteria etc)
• an indication of a specific psychopathology
• an idiomatic expression of distress
• a metaphor for experience
• an ‘act of positioning’ in their local world
• a form of social commentary or protest
How does culture influence expression
of somatic symptoms? (Helman 2007)
• Provides language and idiom without which
sensations cannot be expressed
• Provides concepts of health and disease
without which symptom cannot be
interpreted
• Defines culturally sanctioned illness
behaviour without which symptoms can’t be
presented to others
Criticisms of concept of somatisation
• Is it racist/racialising?
• Does the term suggest an ‘abnormal’ process
of which the patient is the author/morally
responsible?
• It cannot escape from mind-body dualism
Anthropology and GP training
Read ‘Cultural competency’ article (Kleinman&
Benson 2006)
• What anthropological ways of thinking can we
bring to GP training? Which particular
ideas/concepts might be helpful?
• What strategies can improve doctor-patient
communication?
• How can we impart this to GP trainees?
Bringing anthropology into
clinical practice
• Be ‘culturally competent’ (but in a fluid way reflecting
‘mini-ethnography’ approach) (Kleinman & Benson
2006), reflect on own assumptions and respect
diversity of expressions of ‘dis-ease’ and distress
• Think about context and work with it
• Deal with illness AND disease
• Enable narrative and play a role in the search for
meaning
• Maintain awareness of medical power/culture
• Be reflexive
References
• Cierans C., Cooper J. (2011) Organ donation, genetics, race and
culture: the making of a medical problem. Anthropology Today
27(6): 11-14.
• Estroff S. (1993) Identity, disability and scizophrenia: the problem of
chronicity. In Lindenbaum S., Lock M. ed. Knowledge, power and
practice: the anthropology of medicine and everyday life. University
of California Press.
• Helman C. (2007) Culture, Health and Illness. Fifth edition. Hodder.
• Helman C. (2006) Suburban Shaman: Tales from Medicine’s
Frontline. Hammersmith Press.
• Jaye C. (2004) Talking around embodiment: The views of GPs
following participation in medical anthropology courses. Medical
Humanities 30: 41-8.
• Kirmayer L., Young A. (1998) Culture and somatisation:
Clinical, epidemiological and ethnographic
perspectives. Psychosomatic medicine 60 (4): 420-430.
• Kleinman A., Das V., Lock M. (1997) Social suffering.
University of California Press
• Kleinman A., Benson P. (2006) Anthropology in the
clinic: the problem of cultural competency and how to
fix it. PLoS Medicine 3(10):.
• Lock M. (1995) Encounters with ageing: mythologies of
the menopause in Japan and North America. University
of California Press.
• Martin E. (1999) [1987] The woman in the body:
a cultural analysis of reproduction. Beacon Press.
• Scheper-Hughes N., Lock . (1986) Speaking truth
to illness: metaphors, reification and a pedagogy
for patients. Medical Anthropology Quarterly 17
(5): 137-140.
• Scheper-Hughes N., Lock M. (1987) The mindful
body: a prolegomenon to future work in medical
anthropology. Medical Anthropology Quarterly 1
(1): 6-41.
• Sontag S. (1978) Illness as Metaphor.
Some suggestions for reading
• Bourgois P. (1995) In search of respect: selling crack in El Barrio.
University of Cambridge Press.
• Farmer P. (2001) Infections and inequalities: the modern plagues.
University of California Press.
• Helman C. (2006) Suburban Shaman: Tales from Medicine’s
Frontline. Hammersmith Press.
• Kleinman A. (1989) The illness narratives: suffering, healing and the
human condition. Basic books.
• Scheper-Hughes N. Death without weeping: the violence of
everyday life in Brazil. University of California Press.
• Setel P. A plague of paradoxes: AIDS, culture and demography in
northern Tanzania. University of Chicago Press.