# Medical Anthropology

## Theories and Methods


### Learning Outcomes

By the end of this section, you will be able to do the following:
1. Discuss the importance of cross-cultural comparison and cultural relativism in study of human health.
2. Explain why both objectivity and subjectivity are needed in the study of health.
3. Discuss ethnographic research methods and their specific applications to the study of human health.
4. Summarize the theoretical frameworks that guide medical anthropologists.

### The Importance of Cultural Context

Culture is at the center of all human perspectives and shapes all that humans do. Cultural relativism is crucial to medical anthropology. There is a great degree of variety in the symptoms and conditions that cultures note as significant indicators of diminished health. How the sick are treated varies between cultures as well, including the types of treatments prescribed for a particular sickness. Cultural context matters, and health outcomes determined by culture are informed by that culture’s many parts. The United States, for example, relies heavily on biomedicine, treating symptoms of mental and physical illness with medication. This prevalence is not merely an economic, social, or scientific consideration, but all three. A cultural group’s political-economic context and its cultural beliefs, traditions, and values all create the broader context in which a health system exists and all impact individuals on a psychosocial level. Behaviors such as dietary choices and preferences, substance use, and activity level—frequently labeled as lifestyle risk factors—are all heavily influenced by culture and political-economic forces.
While Western cultures rely upon biomedicine, others favor ethnopharmacology and/or ritual healing. Medical anthropologists must attempt to observe and evaluate ethnomedical systems without a bias toward biomedicine. Medical anthropologists must be cautious of tendencies toward ethnocentrism. Ethnocentrism in medical anthropology takes the form of using the health system of one’s own culture as a point of comparison, giving it preference when analyzing and evaluating other systems. An American anthropologist who studies ethnomedicine in the Amazon River basin must be careful to limit their bias toward a biomedical approach as much as they can. That is not to say that subjective experience and opinion need be discarded entirely, merely that bias should be acknowledged and where necessary limited. Admitting bias is the first step in combating it. Being aware of one’s own ethnocentrism allows an anthropologist to analyze culture and medicine more truthfully.

### Methods of Medical Anthropology

Medical anthropology is a highly intersectional subfield of anthropology. The field addresses both the biological and social dimensions of maladies and their treatments. Medical anthropologists must thus become comfortable with a wide-ranging tool kit, as diverse as health itself. Like all anthropologists, medical anthropologists rely on qualitative methods, such as ethnographic fieldwork, but they also must be able to appropriately use quantitative methods such as biometrics (including blood pressure, glucose levels, nutritional deficiencies, hormone levels, etc.) and medical statistics (such as rates of comorbidities, birth rates, mortality rates, and hospital readmission rates). Medical anthropologists can be found working in a myriad of endeavors: aiding public health initiatives, working in clinical settings, influencing health care policy, tracking the spread of a disease, or working for companies that develop medical technologies. The theories and methods of medical anthropology are invaluable to such endeavors.

### Qualitative Methods

Within medical anthropology, a number of qualitative research methods are invaluable tools. Qualitative methods are hands-on, first-person approaches to research. An anthropologist in the room or on the ground writing down field notes based on what they see and recording events as they happen creates valuable data for themselves and for others.
Participant observation is a methodology in which the anthropologist makes first-person observations while participating in a culture. In medical anthropology, participant observation can take many forms. Anthropologists observe and participate in clinical interactions, shamanic rituals, public health initiatives, and faith healing. A form of participant observation, clinical observations allow the anthropologist to see a culture’s healing practices at work. Whether a doctor is treating COVID-19 or a shaman is treating a case of soul loss, the anthropologist observes the dynamics of the treatment and in some cases actually participates as a patient or healer’s apprentice. This extremely hands-on method gives the anthropologist in-depth firsthand experience with a culture’s health system but also poses a risk of inviting personal bias.
Anthropologists observe a myriad of topics, from clinical interactions to shamanic rituals, public health initiatives to faith healing. They carry these firsthand observations with them into their interviews, where they inform the questions they ask. In medical anthropology, interviews can take many forms, from informal chats to highly structured conversations. An example of a highly structured interview is an illness narrative interview. Illness narrative interviews are discussions of a person’s illness that are recorded by anthropologists. These interviews can be remarkably diverse: they can involve formal interviews or informal questioning and can be recorded, written down, or take place electronically via telephone or video conference call. The social construction of sickness and its impact on an individual’s illness experience is deeply personal. Illness narratives almost always focus on the person who is ill but can at times involve their caregivers, family, and immediate network as well.
Another method commonly used in medical anthropology, health decision-making analysis, looks at the choices and considerations that go into deciding how to treat health issues. The anthropologist interviews the decision makers and creates a treatment decision tree, allowing for analysis of the decisions that determine what actions to take. These decisions can come from both the patient and the person providing the treatment. What religious or spiritual choices might make a person opt out of a procedure? What economic issues might they face at different parts of their illness or sickness? Health decision-making analysis is a useful tool for looking at how cultures treat sickness and health, and it highlights a culture’s economic hierarchies, spiritual beliefs, material realities, and social considerations such as caste and gender.

### Quantitative Methods

Quantitative methods produce numeric data that can be counted, correlated, and evaluated for statistical significance. Anthropologists utilize census data, medical research data, and social statistics. They conduct quantitative surveys, social network analysis that quantifies social relationships, and analysis of biomarkers. Analysis of census data is an easy way for medical anthropologists to understand the demographics of the population they are studying, including birth and death rates. Census data can be broken down to analyze culturally specific demographics, such as ethnicity, religion, and other qualifiers as recorded by the census takers. At times, an anthropologist may have to record this data themselves if the available data is absent or insufficient. This type of analysis is often done as a kind of background research on the group being studying, creating a broader context for more specific analysis to follow.
Also important to medical anthropologists are analyses of medical statistics. The study of medical records helps researchers understand who is getting treated for what sickness, determine the efficacy of specific treatments, and observe complications that arise with statistical significance, among other considerations. Analysis of census data combined with medical statistics allows doctors and other health providers, as well as medical anthropologists, to study a population and apply that data toward policy solutions. Famous examples include the World Health Organization’s work on health crises such as HIV/AIDS, Ebola, and COVID-19.
Questionnaires are more personal to the anthropologist, allowing them to ask pointed questions pertinent to their particular research. Surveys make it possible for anthropologists to gather a large quantity of data that can then be used to inform the questions they ask using qualitative methods. Distribution methods for surveys vary and including means such as personally asking the questions, releasing the survey through a health care provider, or offering online surveys that participants choose to answer.
These are the most common methods used by medical anthropologists. Different theories are influential in determining which of the methods a particular research might favor. These theories inform how an anthropologist might interpret their data, how they might compose a study from beginning to end, and how they interact with the people they study. Combined with more general anthropological theory, each anthropologist must craft a composite of theory and method to create their own personalized study of the world of human health.

### Theoretical Approaches to Medical Anthropology


### Social Health

Biomedicine, the science-based ethnomedical system practiced in the United States, recognizes the impact physical health and mental health have on one another: when one falters, the other does as well. There is an increasing awareness in biomedicine of a third type of health, social health, which has long been recognized by many ethnomedical systems around the world. Each of the theoretical approaches to medical anthropology demonstrates that to develop a holistic understanding of human well-being, it is necessary to include mental, physical, and social health. Social health is driven by a complex set of sociocultural factors that impact an individual or community’s wellness. At a macro level, it includes the cultural and political-economic forces shaping the health of individuals and communities. An individual’s social health also includes the support a person receives from their extended social network, as well as the social pressures or stigma a person may face and the meaning that they ascribe to their experiences. Just as mental and physical health strongly influence one another, when a person’s social health falters, their physical and/or mental health declines as well.
Physical environments—whether they are natural, constructed, or modified environments—shape cultural adaptations and behaviors. People living on islands and people living in deserts inhabit very different environments that inform their cultures and affect their biology. On the other hand, culture often affects how humans interact with their environments. People who work in offices in Los Angeles and hunter-gatherers in the Amazon River basin interact with their environments differently, relying upon very different subsistence patterns and sets of material culture. Culture also informs human biology. Eating a lot of spicy foods changes a person’s biophysiology and health outcomes, as do dietary taboos such as refusing to eat pork. These dietary choices inform biology over generations as well as within a single lifetime.

### The Biocultural Approach

The biocultural approach to anthropology acknowledges the links between culture and biology. Biology has informed human development and evolution, including the adaptations that have made culture, language, and social living possible. Culture, in turn, informs choices that can affect our biology. The biocultural approach analyzes the interaction between culture, biology, and health. It focuses on how the environment affects us, and the connections between biological adaptations and sociocultural ones. The biocultural approach draws on biometric and ethnographic data to understand how culture impacts health. The effects of environment on biology and culture are apparent in the treatment of survivors of the Fukushima Daiichi nuclear accident that occurred in 2011 in Japan. Studies regarding the genetic health of survivors focus on the combination of environmental damage and social stigma in Japan due to their potential exposure to radiation.

### Symbolic Approach

Other theoretical approaches ask different types of questions. What does it mean to be a patient? What are the social expectations for the behaviors of a person diagnosed as suffering from a particular sickness? Why is it symbolically meaningful for a treatment to be prescribed by a medical doctor? These are questions typically asked by those utilizing a symbolic approach to medical anthropology. The symbolic approach focuses on the symbolic thinking and beliefs of a culture and how those beliefs affect social and especially health outcomes.
A person’s beliefs affect how they perceive treatments and how they experience illness. The most obvious example of the symbolic approach at work is the placebo effect. If a person believes that a treatment will be effective, this belief will affect their health outcome. Often in medical trials, people who believe they are receiving a treatment but are in fact receiving a placebo, such as a sugar pill, will demonstrate physiological responses similar to those receiving an active substance. Accounting for the placebo effect is an important consideration for all medical studies. The opposite of the placebo effect, the nocebo effect, occurs when a person believes they are not receiving an effective medicine or that a treatment is harmful. Common to both phenomena is the importance of meaning-centered responses to health outcomes. One of the most potent examples of this is voodoo death, when psychosomatic effects—that is, physical effects created by social, cultural, and behavioral factors—such as fear brought on by culture and environment cause sudden death. Related to the symbolic approach of medical anthropology is the symbolic interaction approach to health utilized by medical sociologists. Both approaches recognize that health and illness are socially constructed concepts. The symbolic interaction approach to health focuses on the roles of the patient, caregiver, and health care provider and the interactions that take place between people occupying these roles.

### Medical Ecology

Another major medical anthropology theory is medical ecology. Pioneered by Paul Baker and based on his work in the Andes and American Samoa in the 1960s and 1970s, medical ecology is a multidisciplinary approach that studies the effects of environment on health outcomes. Examples of these environmental influences include food sources, environmental disasters and damage, and how environmentally informed lifestyles affect health. Whereas the biocultural approach looks at the intersection of biology and culture, medical ecology focuses instead on how environment informs both health and the culture surrounding it.
A popular example of these connections can be observed in what are termed Blue Zones, certain locations around the world where a significant number of people regularly live exceptionally long lives, many over a century. These communities can be found in the United States, Japan, Columbia, Italy, and Greece. Common links between people who live in these places include a high-vegetable, low-animal-product diet (eggs and fish are the exception), a lively social life and regular activity, and a strong sense of cultural identity.
A negative example of the links between environment and health can be viewed in the Flint, Michigan, water crisis. In this case, pollution of the city water system negatively affected health outcomes due to high exposure to lead and Legionnaires’ disease. Studies, including a long-term study by the National Institutes of Health, confirm that the water, central to the larger environment of Flint, negatively affected citizens of all ages, with particular harm caused to children and the elderly.

### Cultural Systems Model

Culture is a chief consideration in another theory, the cultural systems model. Cross-cultural comparison is a core methodology for anthropology at large, and the cultural systems model is ideal for cross-cultural comparison of health systems and health outcomes. Cultures are made of various systems, which are informed by sociocultural, political-economic, and historical considerations. These systems can include health care systems, religious institutions and spiritual entities, economic organizations, and political and cultural groupings, among many others. Different cultures prioritize different systems and place greater or less value on different aspects of their culture and society. The cultural systems model analyzes the ways in which different cultures give preference to certain types of medical knowledge over others. And, using the cultural systems model, different cultures can be compared to one another.
An example of the cultural systems model at work is Tsipy Ivry’s Embodying Culture: Pregnancy in Japan and Israel (2009), which examines pregnancy and birth in Israel and Japan. A particular focus is how state-controlled regulation of pregnancy and cultural attitudes about pregnancy affect women differently in each society. Despite both societies having socialized medicine, each prioritizes the treatment of pregnant women and the infant differently.
In the Israeli cultural model for pregnancy, life begins at a child’s first breath, which is when a woman becomes a mother. Ivry describes a cultural model that is deeply impacted by anxiety regarding fetal medical conditions that are deemed outside the mother’s and doctor’s control. As every pregnancy is treated as high risk, personhood and attachment are delayed until birth. The state of Israel is concerned with creating a safe and healthy gene pool and seeks to eliminate genes that may be harmful to offspring; thus, the national health care system pressures women to undergo extensive diagnostic testing and terminate pregnancies that pass on genes that are linked to disorders like Tay-Sachs disease.
Japan, facing decreasing birthrates, pressures women to maximize health outcomes and forgo their own desires for the sake of the national birth rate. The cultural model for pregnancy in Japan emphasizes the importance of the mother’s body as a fetal environment. From conception, it is a mother’s responsibility to create a perfect environment for her child to grow. Mothers closely monitor their bodies, food intake, weight gain, and stressful interactions. In Japan, working during pregnancy is strongly discouraged. Ivry noted that many women even quit work in preparation for becoming pregnant, whereas in Israel mothers work right up to delivery.
The cultural systems model also allows medical anthropologists to study how medical systems evolve when they come into contact with different cultures. An examination of the treatment of mental illness is a good way of highlighting this. While in the United States mental illness is treated with clinical therapy and pharmaceutical drugs, other countries treat mental illness differently. In Thailand, schizophrenia and gender dysmorphia are understood in the framework of culture. Instead of stigmatizing these conditions as illnesses, they are understood as gifts that serve much-needed roles in society. Conversely, in Japan, where psychological diagnoses have become mainstream in the last few decades and pharmaceutical treatment is more prominent than it once was, psychological treatment is stigmatized. Junko Kitanaka’s work on depression in Japan highlights how people with depression are expected to suffer privately and in silence. She links this socially enforced silence to Japan’s high stress rates and high suicide rates (2015). The cultural systems model offers an effective way to evaluate these three approaches toward mental illness, giving a basis of comparison between the United States, Thailand, and Japan. Assigning ethnomedicine the same value as biomedicine rather than giving one primacy over the other, this important comparative model is central to the theoretical outlook of many medical anthropologists.
The cultural systems model encompasses a myriad of cross-disciplinary techniques and theories. In many cultures, certain phrases, actions, or displays, such as clothing or amulets, are recognized as communicating a level of distress to the larger community. Examples include the practices of hanging “the evil eye” in Greece and tying a yellow ribbon around an oak tree during World War II in the United States. These practices are termed idioms of distress, indirect ways of expressing distress within a certain cultural context. A more psychologically driven consideration is the cause of people’s behaviors, known as causal attributions. Causal attributions focus on both personal and situational causes of unexpected behaviors. A causal attribution for unusual behavior such as wandering the streets haplessly could be spirit possession within the context of Haitian Vodou, while in the United States behaviors such as sneezing and blowing one’s nose might be attributed to someone not taking care of themselves.
Causal attributions can be important to one’s own illness. Anthropologist and psychiatrist Arthur Kleinman has concluded that if doctors and caregivers were to ask their patients what they think is wrong with them, these explanations might provide valuable information on treatment decisions. One patient might think that their epilepsy is caused by a spirit possession. Another might suggest that their developing diabetes in inevitable because of their culture and diet. These beliefs and explanations can guide a doctor to develop effective and appropriate treatments. The approach recommended by Kleinman is known as the explanatory model. The explanatory model encourages health care providers to ask probing questions of the patient to better understand their culture, their worldview, and their understanding of their own health.

### Political Economic Medical Anthropology

Another medical anthropology approach is critical medical anthropology (CMA), which is sometimes referred to as political economic medical anthropology (PEMA). Critical medical anthropology has a specific interest in the inequalities of health outcomes caused by political and economic hierarchies. Critical medical anthropology advocates for community involvement and health care advocacy as ethical obligations. Defining biomedicine as capitalist medicine, this approach is critical of the social conditions that cause disease and health inequalities and of biomedicine’s role in perpetuating these systemic inequalities. CMA is also interested in the medicalization of social distress, a process that has led to a wide range of social problems and life circumstances being treated as medical problems under the purview of biomedicine.
Systemic racism and structural violence create many negative health outcomes. Structural violence refers to the way in which social institutions, intentionally or otherwise, harm members of some groups within the larger society. Structural violence can affect things such as life expectancy, disability, or pregnancy outcomes and can lead to distrust of medical systems. The Tuskegee syphilis study, a decades-long “experiment” that studied the long-term effects of syphilis in Black men under the guise of medical treatment, is a prime example of structural violence at work within the United States medical system. Black men involved in the study were not told they had syphilis and were denied medical treatment for decades, with most dying of the disease. The government’s internal mechanisms for halting unethical studies failed to stop this experiment. It was only when public awareness of what was happening resulted in an outcry against the study that the experiments were stopped.
Another area of interest to medical anthropologists working with a CMA approach is how medical systems might be inherently biased toward or against certain segments of society. The research of anthropologist Leith Mullings demonstrated a lifelong focus on structures of inequality and resistance. Her work in Ghana examined traditional medicine and religious practice through a postcolonial lens, which was critical of the colonial legacy of structural inequality she observed. Her work in the United States also focused on health inequalities, with a special interest in the intersection of race, class, and gender for Black women in urban areas. It has been documented that some doctors in the United States regularly ignore the pain of women, and this is especially true in cases where the doctor displays racial bias. This tendency has been cited in several studies, including a study in The New England Journal of Medicine that found that women are more likely to be misdiagnosed for coronary heart disease based on the symptoms they give and pain levels reported (Nubel 2000). Another study in the Journal of Pain found that women on average reported pain 20 percent more of the time than men and at a higher intensity (Ruau et al. 2012). Another example of research that takes a CMA approach is Khiara Bridges’s 2011 Reproducing Race, which brings a critical lens to pregnancy as a site of racialization through her ethnography of a large New York City hospital. This medical racism contributes to the higher rates of African American infant and maternal mortality.
Merrill Singer has done work on the role of social inequalities in drug addiction and in cycles of violence. This work has led to his development of the concept of syndemics, the social intersection of health comorbidities, or two health conditions that often occur together. For example, Japan’s hibakusha, or atomic bomb survivors of Hiroshima and Nagasaki, do not live as long as Japan’s normally long-lived population and are more likely to develop multiple types of cancer and other diseases tied to their exposure to nuclear radiation. In addition to these health risks, they face heavy discrimination from the larger Japanese population due to misinformation regarding nuclear radiation and radiation contamination. This discrimination carries over to the descendants of hibakusha, who have a higher rate of cancer than the average Japanese population despite having no detectable genetic damage from the atomic bombings. Studies are ongoing as to the cultural, economic, and genetic causes of this cancer. Syndemics is highlighted in the near-century-long struggle for numerous conditions caused by the atomic bombings to be recognized as related to the atomic bombings and thus treated by the Japanese government.
Critical theories of health are an applied method, analyzing medical systems and applying critical theory, often with the goal of improving the system or improving policy. Recommendations for improvements often come out of research but may also be the starting point of a research project, as part of a data-finding mission to highlight disparity in health outcomes. Whether it is systemic racism in biomedical treatment or power discrepancies in ethnomedical rituals, critical theories of health are a key part of exploring medicine in action and understanding real medical consequences. From birth to the grave, social inequalities shape health outcomes, life expectancy, and unnecessary human suffering. Critical medical anthropology scholarship demonstrates the social forces shaping disease and health, from drug addiction to the impacts of climate change. This work becomes a self-evident call of action. It is medical anthropology in action.