2002 Writing at the Margin of the Margin_ Medical Anthropology in Southern Europe

5/20/2018 2002 Writing at the Margin of the Margin_ Medical Anthropology in Southern Eu...

http:///reader/full/2002-writing-at-the-margin-of-the-margin-medical-anthropolog

Anthropology & Medicine, Vol. 9, No. 1, 2002

Writing at the margin of the margin: medical

anthropology in Southern Europe

(Accepted date: 1 December 2001)

JOSEP M. COMELLESDepartament dAntropologia i Treball Social Filosoa, Institut dEstudis Avancats, Universitat

Rovira i Virgili, Tarragona, Spain

ABSTRACT This critical review explores the problems posed in Southern Europe by the recent

development of medical anthropology, focusing on three issues: the problems derived from

research in languages other than English, the idiosyncratic developments of social and cultural

research within European continental health sectors, and the theoretical specicity of Southern

European medical anthropologies.

Tout ce qui est ferme est par le temps detruit. (Du Bellay, Antiquites

de Rome, circa 1525)

Writing at the margin

Two books by Arthur Kleinman (1995) and Robert Hahn (1995) tackle the

problem of the boundaries between biomedicine and anthropology. Both au-

thors are physicians and anthropologists, a professional background quite com-

mon among medical anthropologists. The former includes an interesting

discussion about the liminal condition of the doctor anthropologist. Kleinman

discusses his role in the North American academic world and includes a

self-appraisal of his intellectual and professional career. His book is a statement

about the role played by history and political economy in the development of

medical systems and health professional cultures, something that was neglected

in Kleinman s previous book (1980). Hahn (1995) suggests that anthropology

should formulate an anthropological medicine as an alternative to the so-called

crisis of biomedicine in the late decades. He rejects the possibility of a medical

anthropology practised by anthropologists without previous medical or nursing

training. Although they are well-established anthropologists and Kleinman is

one of the leaders of medical anthropology, both are reluctant to completely

Correspondence to: Josep M. Comelles, MD, PhD, Departament dAntropologia i Treball Social

Filosoa, Institut dEstudis Avancats, Universitat Rovira i Virgili, Tarragona, Spain. E-mail:

[email protected]

ISSN 1364-8470/print/ISSN 1469-2910/online/02/010007-17 2002 Taylor & Francis Ltd

DOI: 10.1080/1364847022 0139983



8 J. M. Comelles

abandon medicine. They are both looking for a new ambiguous medical and

anthropological identity to maintain their commitment to medicine. They are

also checking the marginality of medical anthropology within anthropology.

I, too, am a doctor, who has moved to anthropology, so I can understand

their difculty in abandoning medicine. It is a big advantage for us to be able

to change our identity, from time to time, from anthropology to medicine, from

medicine to anthropology, and to develop medical anthropology in c ountries

with little tradition of social anthropology. I like to play this changing role, and

place myself in the boundaries of the history of medicine, social medicine,

psychiatry, sociology or anthropology. This ambiguous identity only makes

sense in an anthropological home context because the social science scene in

medicine in our countries is somewhat confusing and for most doctors anthro-pology is bizarre, linked to craniology or palaeontology, or sometimes identied

as some kind of philosophy.

The main problem is not entirely the lack of social recognition of medical

anthropology in medical settings. It is also the lack of social recognition of

medical anthropology within European social anthropology. It is difcult to

accept an anthropologist who is also a doctor as a member of a professional

group whose ideas about medicine and hea1th professionals are critical. In the

late 1980s, to hear expressions like medical anthropology is not anthropology

was common in some anthropological arenas. At the same time, European

anthropologists like Auge (1986) were sceptical about the real existence of such

a eld. This liminal position, in Turners terms (1988), is the consequence of

the negative attitude of two well-dened academic professions, towards those

who inhabit boundary areas. We are facing a problem that is linked to the

construction of professional identities. Since doctor anthropologists are doctors

and play the role of doctors, it is easier for them to open a professional space

for anthropology in biomedical sciences. So, this long-term strategy tries to

reproduce our medical embodiment, but does not allow us to embody our social

anthropologist role in the same way. Even so, in day to day interaction, we are

well placed in biomedical or nursing networks, and we project our intellectual

production on biomedical, public health or nursing settings. Most of our readers

are not anthropologists, and when we write we attempt to transfer our anthropo-

logical scope to biomedical and nursing meta-languages. This process led to a

considerable number of interdisciplinary elds autonomous from generalanthropology and with complex relationships between them (see Menendez,

1991). The growing presence of medical anthropology, even in Europe in the

eld of sociomedical research and nursing studies, has no counterpart in

anthropology. Even a brief look at the major anthropological periodicals like

American Anthropologist, Current Anthropology in America, or Man, L Homme or

l Uomo in Europe shows little presence of this eld.a Some anthropologists

disagree, as Auge did, with clinical applied anthropology that sometimes heavily

depends on medical interests and ideas. This might be the reason why pure

anthropologists sometimes do not recognise us to be one of their numbers.

Kleinman and Hahn s diagnoses are placed in this context, and this explains the



Writing at the margin 9

marginal or outsider condition of the doctor anthropologist. I agree with

their statements even though I cannot help thinking of one thing. Arthur

Kleinman is at the heart of medical anthropology, but still considers himself to

be marginal. I wonder what he makes of our marginality, European medical

anthropologists, who are at the furthest boundaries of medicine and anthro-

pology.

The margin of the margin

Looking to medical anthropology in Europe, I can nd another degree of

marginality in the margin of both margins. It rises from the fact that most of us

think, work and write in languages other than English. Diffusion in the majornon-English scientic languages, including French, Japanese, Portuguese, Ger-

man, Chinese or Spanish, is limited by its scant presence in the international

bibliographic catalogues.b The presence of languages like Dutch, Scandinavian

or Slavic is anecdotal in the searches in Medline, Excerpts, Current Contents and

on. In medical anthropology linked to medical literature, this is more evident,

because most scientic medical literature is now in basic, not in literary, English.

This is a consequence of the development of technical medical English. This

kind of English is useful for doctors, in spite of their residence, to write about

biomedical research in a comprehensible way. Is this basic medical English a

good tool for medical anthropology? I believe that this is a crucial point. In my

own case, I live in a bilingual country: my mother tongue and teaching language

are Catalan and I have written most of my professional work in Spanish. I

cannot write good Catalan. Under Francos regime, when I studied, Catalan

was not taught in schools. I learned to write Spanish, and I nd difcult to write

well in a second language. There are few good bilingual writers. I am not an

exception. This is the most common situation of medical anthropologists

throughout Europe. They do their PhD in Dutch, Swedish, Italian, German,

French, Spanish, Catalan, Serb-Croat, and so on. They publish a part of their

work and they teach in their own language, and from time to time they publish

in English to show the world (what world?) who they are. It is a strange

marginality, because English provides the brokerage between my Northern

European colleagues and me. I do not need brokerage with my colleagues who

speak Portuguese, Italian or French. We do not renounce our languages. Thisis important because a high level of comprehension and the Esperanto of

English are not required. We do not feel as we do when we speak English, that

we are speaking a 300-word language in order to be understood. The conscious-

ness of this position may have some advantages. We are anthropologists and our

training to manage cultural distance is a fundamental tool in anthropological

research. It distances us of our research subjects. It distances us, at the margins,

with theoretical or methodological polemics or debates that rise from to the

hegemonic cores of the discipline. Sometimes we take distance and we can

examine them with some scepticism. This attitude is not a feature of a vulgar

anti-gringo or anti-Anglo-Saxon attitude. It may be the consequence of a



10 J. M. Comelles

long tradition of Mediterranean scepticism that has guided us to mistrust any

kind of dogma and to look at all the Great Truths with some irony. Perhaps this

is because we come from countries shaped by the omnipresence of the Church

and the State, and we live in the far boundaries of the economic empires. We

are accustomed to distance ourselves from the theoretical positions of Anglo-

Saxon anthropology that discovers Gramsci, Basaglia or De Martino 30 years

after us. We have learned how to survive at the margin of the margin. This

position might not be completely disadvantageous, in spite of the lack of

diffusion of scholar work written in languages other than English. Using

non-English languages to publish or research, we are closed out in a ghetto.

Therefore, writing and reading in English they are also in theirown ghetto. We

must be bilingual because the hegemony of English has imposed only onelanguage. This is also the rst step toward a universal way of thinking. We need

to be present in the English-speaking space; we are conscious of the marginal

condition of our English writings (and this one is a good example), which are

juggling efforts in basic English. These efforts allow us an anecdotal presence in

Kleinmans marginality. Our pidgin does not allow us to manage literary nesse.

How can we translate in English, which is our second, third or fourth language,

the idioms of distress explained in the Catalan, Basque, Portuguese or Italian of

our informants? How can we explain in English research projects linked to

specic historical and cultural contexts and which are not related to the

theoretical and methodological problems of interest to the 2000 members of the

Society of Medical Anthropology? These interests are often presented as the

core scientic questions in medical anthropological theory; they are really often

the consequence of the distribution of academic power in the American univer-

sities built upon the impact index. For them, our central interests may be local

anecdotes, or bizarre examples of European quality. These arguments are not

the consequence of a personal anecdote. They are crucial in a European context.

An European homeland is a fundamental part of the actual process of globalisa-

tion, so the European identity is not the euro, or the European Union. This is

a way of managing extreme historical and cultural diversity. The European

cultural and social diversity is the European identity. We must protect it. Our

identity project is not shaped by the idea of the melting pot, or the manifest

destiny. We are sceptical of these ideas. It is not possible in Europe to consider

Danish, Dutch, Catalan, Italian, Spanish and so on as aboriginal languages tobe classied by some Bureau of European Folklore as survivals. European social

and cultural diversity is not the product of survivalism. This diversity is the

product of a fascinating and diverse historical process of political, social and

cultural development. Welfare state and welfare policies are not the same in the

different countries, which have considerable cultural diversity as a consequence

of long-term particular historical processes. Medicine and health care show this

diversity. Each country has developed particular models for the provision of care

embedded in popular culture (see Castel, 1995). In this way, medical anthropo-

logical research develops out of highly idiosyncratic problems in each national

structure.




European anthropology or European anthropologies?

The development of social and cultural anthropology also shows considerable

diversity within Europe. The conventional professional model of anthropological

practice, largely built around the ethnography of local worlds, by long and

extensive eldwork, generally in aboriginal societies, has not been the rule

everywhere in Europe. It was the consequence of a specic development in the

United States done by Boas, Malinowski, Radcliffe-Brown and others.c

European anthropology shows a different development, which centres on the

image of the armchair anthropologist as the best example of a great scholar, a

marginal presence of colonial studies, and the development of an important

home folklore in Slavic and Scandinavian countries. The genealogy of anthro-

pology in most European countries shows the persistence of the professional

institutionalisation of anthropology in the late 19th century related to the

autonomous development of physical anthropology, philology and archaeology

and the marginality of ethnology abroad and homeland folklore (Comelles,

1997).

The most common mistake in recent European anthropology might have been

to apply mechanically in the Continent the professional shaping of American

professional anthropology as a universa1 model of anthropology. Nobody took

in account or the differences in university organisation and professional cultures

in Europe, or the different social and cultural adjustments of professionals as

organic intellectuals in each national context. In this arena, the recent develop-

ment of medical anthropology, and particularly that of home medical anthro-pology, should be discussed by placing it in specic biomedical and nursing

contexts. This specicity must be explained in comparative terms. On the one

hand, it should be adjusted to the changes of the position of social or cultural

anthropology as a social discipline in each country. On the other, it should be

placed it in very different biomedical and nursing contexts framed in a diverse

mosaic related to the development of public welfare and health policies.

I cannot make a global presentation here of this idiosyncratic panorama. My

aim is to concentrate on some general features in the European context: the rst

one is the absence of social sciences in European biomedicine in 20th century;

the second one, the reluctance of European professional social and cultural

anthropology to accept applied anthropology.

The relevance of social science in classical medicine

The biggest mistake in the historiography of Anthropology is to build a

legitimisation of what is the discipline around an idiosyncratic development in

professional anthropology in the United States before the Second World War.

So, the previous ethnographic or ethnologic must have been done all over the

world by amateurs.

Historical evidence shows that ethnographic-like practice,d ethnography and

anthropology have been, still are and can be narrative genres that are character-



12 J. M. Comelles

istic of medicine, religion, another professions, in spite of their role in the

shaping of 20th century anthropology. The future, the present or the past

production of these medical, jural, or religious genres should not be interpreted

in terms of anthropology, law studies, sociology or history avant la lettre, but in

terms of their meaning within the practice and the theory of medicine, religion

or other professions. We can nd ethnographic-like descriptions based on

naturalistic frameworks linked to classical philosophy and classical medicine

from the times of Hippocrates to the late 20th century (Comelles, 1996). These

narrative genres placed in other professional contexts developed from the

development of technical and naturalistic medicine in classical Greek and in

Galen writings (Garca Ballester, 1981, 1995). Hippocratic texts, particularly

Airs, Waters and Places (Hipocrates de Cos, 1986) and Epidemics (Hipocrates deCos, 1989), developed two complementary models for technical medical writ-

ing. A narrative one that uses local knowledge as an instrument to shape medical

practice and place it into society (Alvarez Millan, 1999; Garca Ballester, 1995)

and another that described individual episodes of sickness in environmental

contexts based on the intellectual matrices of Epidemics. This is the origin of

current clinical writing. Both genres consider clinical narrative and ethno-

graphic-like practice as the pillars of the comprehension of the sickness context,

its etiological interpretations and the therapeutic implications that make it

possible for itinerant physicians to become a part of the community in which

they work.e

Medical practice proposed to intervene in suffering by interpreting aetiology

from rule-based observation of the natural environment. This style of observa-

tion is valuable if local knowledge is fundamental. It shows the difference

between doctors and other healers. The efforts to establish criteria for classifying

eld observations and to record them orderly are related to the need to develop

a medical narrative genre, the role of which was to place the practitioners as

brokers between public authorities and popular classes.

Doctors local knowledge was constructed on what is known today as partic-

ipatory observation. An attitude that assumed sickness as a face-to-face experi-

ence in which there is not a unidirectional ow of technical knowledge, but

complex transactions that lead to a constant reworking of the scenarios of

practice (Comelles, 1998). Recovering these experiences are fundamental in

forming an ethic that in turn structures the cultural image of physicians andreinforces their social and cultural legitimacy (Lan Entralgo, 1987). These

dimensions of experience can be present in medical texts that deal with what the

good doctors practice should be like. The duties of the good doctor show to the

student or the neophyte that the role of the emotions, the subjectivity of

experience and personal commitment to the c ommunity, involved a personal

local experience, which is unrepeatable, and non-comparable.

The irrelevance of social science in biomedicine

The hegemony of observation over listening is a consequence of the birth of the




clinic (Foucault, 1978). It means that physicians, as anthropologists, are trapped

by the temporal limits of their observations, and by a related notion of time. The

description of current diseases is a tranche de vie as in the naturalist novels.

Description of the environment is a cyclical reality governed by the rhythm of

the seasons. Time is done away with in favour of space. Realism and naturalism

are narrative procedures opposed to the narrative models of historicism but also

to those of the writing of legends, tales or myths. They look for a distant regard

in relation to the expression of the patient subjectivity that masks the symptoms

by using cultural idioms of distress in a way that is different from how the

physician understands and assesses them.f

Biomedicine abandoned ethnography as a main technique in its practice

because of its criticism against subjectivity. Doctors role evolved toward anobjective and positivistic practice related to experimentalism and critical with

pure empiricism (Hersch Martnez, 2001). At the same time doctors looked for

an intellectual legitimisation in the academic world. Doctors, who were in

America or in Europe armchair anthropologists, like Broca or Lombroso (see

Peset, 1984) mutated in Europe to doctor humanists fonder of philosophy,

literature or history than of anthropology. The hegemony of the hospital in

clinical knowledge, diagnosis and treatment oriented medical writing in favour

of clinical and epidemiological genres. Ethnographic writing, linked to local

knowledge, was relegated to a marginal position because eld observations

about the natural, cultural or social context were not important in the shaping

of medical knowledge based on experimental medicine. The empirical knowl-

edge of the general practitioner became the subject of suspicion. Ethnographic-

like practice had counterbalanced clinical practice in a context in which the

cultural image of the physician and his presence in the community was con-

structed from his local knowledge, and mediated between the local and the

general policies of public health. The hegemony of clinics moved doctors to

abandon their former condition of social scientists in Virchows terms.

Even so, in Europe, ethnographic reports written by doctors did not disap-

pear: there are hundreds of medical folklore reports and up to the mid 20th

century thousands of medical topographies around the world. These reports are

now marginal or anecdotal pieces of qualitative methodologies under the

hegemony of clinical and epidemiological reports.

Their survival, as subordinate medical genres, could be explained by theirfunction of establishing the cultural or social boundaries of biomedicine in rural

or aboriginal settings. Ethnographic description, in a biomedical context of

experimental and positivistic thinking, reinforces the enlightened idea that

relates poverty, ignorance and superstition, and places popular medical practices

in an arena to be acculturate by the progress of science and civilisation. Histories

and stories of medicine and doctors, and medical folklore, were fundamental if

biomedical hegemony were to be assured in popular culture. The former

legitimated the medical model as the pinnacle of an evolutionary process of

intellectual and technical advances, while the latter, ethnography, established its

cultural limits. Medical folklore reports aimed to build a regional or local



14 J. M. Comelles

pattern of the features of popular medicine, and consciously ignored the

integration of popular medicine in the world.g Their aim is not to discover the

sense and the place of popular medicine in culture or in a specic community,

but to dene the practices that, from the medical viewpoint, do not belong to

it. Popular or folk medicines are medical ideas, not anthropological ones.

Doctors accepted cultural or social evolutionism as an explanatory theory

useful to explain popular health practices and ideas as survivals. The persistence

of these ideas can be checked today (Erkoreka, 1985). In any case, this

evolutionism might not be seen as a form of historicism. Biomedicine assumes

vulgar evolutionism because it is the product of a stratigraphic idea of life and

society constructed by means of empirical patterns that are used to characterise

every historic period, without considering conict and social transformations, orby reducing them to almost mechanical, random processes of cultural diffusion.

This is a positivistic archaeology, not anthropology.

A doctor should be objective, because his legitimacy as a clinician is based on

this quality. As an ethnographer, the practitioner becomes the teller of a reality,

the aim of which is complicity with his readers, generally other physicians, also

other educated readers. They nd this complicity in these ethnographic

accounts, which are portraits of their practice or mirrors of their shared

experiences. Nevertheless, as Falteri (1989) has pointed out, doctor ethnogra-

phers never write detailed descriptions of their own practice as rural or urban

physicians. To do so would mean questioning the dialectics that exist between

medical and popular practices, the complex processes of mediation between the

intellectual and the popular classes and the local conditions of medicalisation. It

was impossible for clinical ethnographers to place themselves in a more critical

position. They were committed during medicalisation as apostles of science and

modernity. Introducing a critical methodological approach in their writing

would mean developing a conception of dialectic and not stratigraphic history

and questioning the cultural or social limits of their practice. Therefore, they did

not. Their goal was no longer social medicine, only an anecdotal description of

the survival of popular medicine that was outside their own practice.

In Giuseppe Pitres epistemology (1896, pp. IXVI), popular medicine might

be placed in the framework of clinical methodology and epistemology.h This

results in the fragmentation of cases and parts of the body that so characterises

modern medicine being projected above popular knowledge. He wanted todevelop a new ethnographic framework within which data could be collected

about the popular medicine of the peasants of Sicily. Disease aetiologies ceased

to be related to the environmental, social or cultural context as in neo-

Hippocratic theories. The emphasis was on the description of actual diseases

and therapeutics. History was unimportant. Ethnography became a positivistic

description of facts, not an explanation of the survival of the old medical

theories in popular knowledge.

With Pitres methodology medicine forgot that its own history could be used

as an instrument for explaining its practice and the process of medicalisation.

Medicine invents a tradition to explain the theoretical Greek roots of




biomedicine, but is reluctant to accept the idea than others can write the history

of medicine. Doctors must write history of medicine, or medical folklore,

because only doctors know medicine. Medical training now focuses on hospitals.

Students receive little information about the limits of clinical epistemology.

Clinical training becomes a dogmatic routine, which combines observation,

listening and documentation. The role of observation and listening in the

diagnosis decreases while the role of technology increases. Medical routines

have become an idiosyncratic model for thinking and describing reality, a

professional culture which is centred on a highly reied face-to-face relationship

with the patient, and which is reluctant to assume the doctors commitment

with society, present in Virchows times (see Rosen, 1972).

The intellectual legitimisation of medicine in Europe adds to the developmentof experimental science the reication of the sick body, and a medical rhetoric

about humanism. Hundreds of medical lectures during the 19th century explain

how the medical practice should be. Indirectly these lectures describe a very

different situation. In the 20th century, medical discourse became more sophis-

ticated incorporating phenomenology. The intellectual or theoretical framework

were not materialismas in neo-Hippocratismor Marxism, but phenomeno-

logical approaches to the individual and moral experiences of illness (Lan

Entralgo, 1961). Authors like Sigerist (1987) linked medicine with politics and

economy. Von Weiszacker, like Freud, or in Spain Lan Entralgo theorised

about the face-to-face relationship between a patient suffering and getting help

from his doctor.

Medical humanism generates another medical genre, which is different from

the naturalism associated to ethnography, and from the positivism of clinical or

epidemiological writing. There is a subtle barrier full of ambivalence between

the medical genres in the strict sense and the purely literary texts that some

doctors write quite separately from their practice. The former are medical,

professional texts that help them to consolidate their prestige in the profession

while the latter provide the physician with an intellectual identity as a humanist

that goes beyond their dimension as men of art, and legitimates their philan-

thropic approach to patient. The literary writing of contemporary doctors

provides a humanist explanation for a biomedicine which reies sickness and

reduces suffering to a sign as a strategy for intellectualising what until then had

been an essentially practical and applied profession. This change from medicalto literary writing is a universal feature of the medical profession in the 19th and

20th centuries. The free composition of the latter belongs to a world that lies

beyond biomedicine. It shares characteristics of historical and literary narratives

on hagiography and professional legitimisation that contributes to the emerg-

ence of the cultural image of the physician. There is no conict while this barrier

is clear. Conict does arise, however, when the two types of discourse overlap

and dilute the hegemonic biomedical identity in a context in which local

knowledge no longer plays a role in the shaping of medical practice. Even if this

dualism can be checked in the entire Western world, there are some differences

between the United States, and Europe. Let me propose a comparative example


http:///reader/full/2002-writing-at-the-margin-of-the-margin-medical-anthropology

16 J. M. Comelles

to stress it, on the basis of the work of two great doctors who both identify

themselves as medical anthropologists. They are deeply different. Fabrega

wrote, as physicians we are concerned with medical problems of individual

persons. The patients aches and physiological constraints become our c oncern;

and our efforts are directed to helping him. The emotional and social conse-

quences of disease to the individual and his family invariably enter in the picture

also, and in varying degrees our efforts in treatment are affected by these

factors (Fabrega, 1974, p. XIII). We, the doctor. As a doctoralthough, he is

also an anthropologisthe uses a highly reied conception of disease. Although

in the quotation he does make a concession to other dimensions of disease, he

does not formulate them very differently from how the 19th century clinicians

did so. Medical practice is for him a mixture of diagnosis, treatment and supportthat necessarily involve a lack of discussion about the cultural roots of disease.

This is Fabrega, the physician. On the following page, he says, Social scientists,

who note and describe the regularities in the way people behave and conduct life

and who then study factors that may explain these regularities, have increasingly

been drawn to problems associated with disease (Fabrega, 1974, p. XIV). Note

the change in the narrative style. A leader of modern medical anthropology

identies himself as a physician and looks on social scientists as others. It should

be asked, then, whether his purpose is social science, or a form of reintegrating

social science into medicine within a project that is essentially medical, and only

collateral to anthropology. The rest of the book reveals that Fabregas problem

is not medicine, but the limited conception of medicine that leads to the current

model of practice. When faced with the critical attitude of questioning all of this,

Fabrega adopts an ambivalent position. He wants to explain to doctors that their

practice does not allow them to understand the non-biological dimensions of

disease. This is not an obstacle to dividing disease into two sub ideas, disease

and illness and attributing one of them to medicine and the other to social

sciences, because in his book he attempts to show precisely the opposite. Here,

Fabrega is trapped by his double status of physician and anthropologist, by his

commitment to both disciplines. In spite of Fabregas attitudes about eth-

nomedicine, in disease and social behaviour, the main regard is about medical

practice in Western contexts, in a home context. Therefore, Fabrega is a

professional social anthropologist in an American context of big spread of social

and cultural anthropology.Pedro Lan Entralgo is one of the greatest historians of medicine of 20th

century. He describes himself as a medical anthropologist, in a Spanish

context and time which has not developed social and cultural anthropology.

La n Entralgo worked largely on Hippocratic medicine to establish a historical

basis to doctor patient relationships, to improve actual medical practice (1983).

In a more recent period, he has moved from history of medicine to medical

anthropology, a philosophical dissertation about the being of a doctor in the

world (1984). His discourse connects clinical practice to a relational ethic whose

roots are to be found in the notion of phylia in classical medicine but he leaves

it to the individual will of the subjects whether they comply with the agenda. He




does not empirically investigate what is done, but proposes an ethic and some

values that are compatible with the biomedical model being accepted as the

pinnacle of a secular evolutionary process. The individualisation of the relation

between the physician and the patient makes social and cultural variables

unimportant and reduces their weight in medical epistemology.

La n Entralgo is the witness of a transitional stage of medicine in Europe.

Medicine was then moving from the patients home to the hospital and from a

largely privately owned health system to a public one. In some way, his work

expresses disenchantment with the important changes that the European medi-

cal profession was undergoing. For him, medical history, or medical anthro-

pology are not historical or anthropological elds, but medical ones that can be

developed essentially by doctors.Fabrega encourages the development of a universal eld of applied multidis-

ciplinary research on medicine, which is not reserved for doctors. La ns position

is different. He wants to keep and to reinforce intellectually the moral values and

the ideological and political power of classical medicine in Europe. For four

decades Lans work and conceptions about medical anthropology have been the

main obstacle to the presence of social and cultural medical anthropology in

medical schools in Spain, and even in some countries of Latin America.

The marginality of medical anthropology in Southern Europe

The major European schools of social and cultural anthropology have not been

interested in medicine. In studies on magic, medicine and religion, a genre

largely developed in overseas European anthropology, medicine was marginal,

and there was very little interest on medical problems. Most of the ethnogra-

phers of European medical folklore were doctors. They wrote for doctors. The

big surveys of European folklore placed popular medicine into customary

practices, not as popular medicine les (see Amades, 1980). They were for

folklorists, not for doctors.

The boundary between medical folklore and folklore is very important in

Europe. There is a breakdown between the two intellectual traditions, which do

not mix, because their meaning is different. The former looks searches for the

cultural border of biomedicine. The latter places medical data in a global

pattern of culture whose aim is ethnic or national identity. Ethnography becamea subordinate literary genre in biomedicine. The anthropology that remained in

European medicine was physical anthropology: genetics, racial studies, or as

applied elds, forensic anthropology, or the application of the Lombrosian and

eugenic theories. On the other hand, the development of social or cultural

anthropology took place as academic overseas ethnology, or folklore studies

developed as specic national traditions in continental Europe. We do not nd

any kind of applied medical anthropology. The very rigid structure and the

hyper-academicism of European universities are an obstacle to multidisciplinary

work. Each eld of knowledge tends to be autonomous, and medical schools are

very conservative structures, which are largely closed to the social sciences. This



18 J. M. Comelles

is the reason why anthropological research was absent from medicine or nursing

studies in Europe before 1980. The exception is Italy. The rst applied medical

anthropological researches was carried out in the late 1950s (Seppilli, 1954,

1959).i For 40 years, Italian anthropologists have worked with doctors on health

education and promotion in the Centro Sperimentale di Educazione Sanitaria in

Perugia (see Bartoli, 1976, 1986). This was not a coincidence. It was a specic

project and a professional commitment, based on a Marxist criticism of the

limits of positivistic folklore and with an active position of intervention (Seppilli,

1983, 1996). In this debate the work of Ernesto de Martino, a great anthropol-

ogist and historian of religion, is crucial. In 1959 he began research on

tarantism, which is probably the rst big home project on medical applied

anthropology in Europe (De Martino, 1994), and continued with a longtradition of research o n medical popular culture and applied anthropological

work.j It is quite easy to understand the silence which surrounds the develop-

ments in Italian medical anthropology. Latvian anthropologists write in Italian,

and this language is not now universal language. Ideologically, the most of them

were Marxist, committed to political struggle. Their work was linked to national

leftwing culture, and may appear to be far from the hegemonic anthropological

theories of the 1960s or 1970s.

The politica1 commitment of Italian anthropology, and its criticism of

positivistic ethnography, which followed Pitres methodology, seems to be a long

way from the empiricism of hegemonic American cultural and social anthro-

pology. De Martinos path looks for an integration of history and ethnography

based on Gramsci and Croces work. The consequence for Latvian anthro-

pology was a radical break in the organisation of research: the role of the team

rather than the sole investigator, the ethnographers commitment, the handling

of historical documents as ethnographic accounts, the vindication of history.

The empirical and relativistic radicalness of hegemonic anthropology could not

understand this dimension of the problem because it feared history. In order to

be able to understand it, it would have had to deny its own historicity and put

it in the epistemological context in which it wanted to place the problem. De

Martinos work at home opened the space of a new anthropological identity far

from the schedule built by Boas, Malinowski and Radcliffe Brown. Thus

creating an anthropology at home before the current debate about anthropology

at home. De Martino is now a myth in recent Italian anthropology. He has hada profound inuence on health education projects, the development of Italian

medical anthropology, the debate about medical intervention in society and the

shaping of popular culture, based on Gramscis analysis on organic intellectuals

and popular culture (see Pandol, 1992).

Critical Latin American medical anthropology is based on De Martino and

Gramscis inuence in Argentina and in Mexico (see Aguirre Beltran, 1986;

Menendez, 1991). Spanish medical anthropology in turn was inuenced

through Latin America.k This is not a coincidence. Popular medical culture

embeds religion, biomedicine, empirical popular knowledge and health care

delivery institutions. The shaping of popular culture as a process, which is




subordinate to medicalisation, cannot be understood without history. The

relationships between medical anthropology and history are crucial in Southern

European medical anthropology, particularly in Italy and Spain. It is impossible

to understand popular knowledge and practices in Europe without any reference

to the historical shaping of health professions. It is impossible to understand

medicalisation without an analysis about the inuence of Roman Catholic

religious discourse on miracles and cures. It is impossible to study health seeking

behaviours without taking account the long development of institutions which

provide care services from the late Middle Ages to the end of the 20th century.

In a European context, the process health/disease/care and popular medical

knowledge cannot be understood without reference to the history, and

specically to the history of medicine. The main reason for this is the role ofhealth professionals and medical institutions in the process of medicalisation,

and the development of health and social welfare policies.

In this theoretical discussion, Southern European and Latin American medi-

cal anthropologies have developed an ambiguous relationship with the North

American medical anthropology. On one hand, there is acute criticism against

its strong empiricism and anti-historicism (see Menendez, 1990), and its

disregard of the historical context of health in Latin America or Southern

Europe. On the other, we can nd clear inuences from Taussig (1980) and

Young (1982) works. The idea of an anthropology of sickness seems to be closer

to the theoretical positions of the Europeans than an anthropology of disease or

illness (see Comelles & Mart nez; 1993; Martnez & Comelles, 1994).

This discussion inuenced the shaping of anthropological identity for many of

us because we were obliged to work at home in a context dominated by the idea

of anthropology based on eldwork far away from home. On a second level, we

assume the link between historical work articulated with ethnography. This was,

in the late 1970s, a breakdown in an anthropology that was looking for an

international recognition by placing itself in an international anthropological

orthodoxy. The debate between medicine, anthropology and history is not easy

in Europe. Medicine and history have strong academic position and professional

identity. This is not the case of anthropology, which is looking for a new identity

in a changing world. Placing medical anthropology in the boundaries of medi-

cine, anthropology and history raises considerable problems of academic and

professional identity: a medical anthropologist o ught to mutate from historians,doctors or anthropologists in elds that are in the very margins of each

discipline. As anthropologists committed to qualitative and ethnographic

methodologies, we disagree with trends that simplify the role of political

economy and history to a formula synthesised in general notions such as

Western societies or medicalisation. Under the hegemony of clinical or epidemi-

ological methodologies in medicine or public health, we defend qualitative

methodologies and we ght side by side with historians for a social history of

medicine.

Except in France, Latin-speaking anthropologies in Southern Europe and in

Latin America are anthropologies at home, even if some researchers work



20 J. M. Comelles

overseas. We are our objects. In Europe, we share the object with historians,

lawyers, doctors or sociologists. Even our classical object of study, the folklore

of European peasantry, is today a marginal relic. To incorporate history by

anthropologists or anthropology by historians or sociologists into Southern

Europe has three effects. First, the blurring of limits between medical anthro-

pology, medical history, and medical sociology. Second, the development of

common areas of interest centred around the process of health/disease/care in

popular classes or marginal groups, and nally, the development of the health

professions and institutions and their relations with the shaping of popular

culture. They are all home processes, in the sense we are using the term here.

This panorama has some idiosyncratic features, particularly that a lot of research

in the eld of social sciences and health is performed by doctors or amateurs.In professional terms medical history, sociology and anthropology are under-

developed. Therefore, amateurism in most cases is far from the theoretical and

methodological development of these elds, even if he keeps a singular position

within medicine. By this way, the eld of social and cultural studies on

medicine in Southern Europe is not in the same position as Kleinman or Hahn

reports in the United States because of professional academic segmentation and

the absence of social scientists in medical and nursing education and training.

This absence is related to an idiosyncratic process derived from the specic

conditions of deployment of health institutions and professional training. The

result is that social scientists carry out little empirical research on health and that

doctors have in part appropriated research into social health and the teaching of

medical sociology and anthropology. This they have done in three ways: by

assuming the development and evolution of the eld, reinventing the eld by

placing it in the framework of a diffuse idea of medical humanities, and taking

an obsolete idea of medical anthropology linked to folklore. In any case, the

development of Southern European medical anthropology shows such a com-

mon path between anthropologists and historians of medicine with very large

overlapping areas of interest. This led to a revision of the role of ethnographic

sources and of ethnography in biomedical and nursing research at the dawn of

the 21st century.

Acknowledgements

Translated by John Bates (Servei Linguistic, URV), and revised by Xavier Allue,

MD, PhD (URV). This research is part of a research project into the develop-

ment of medical anthropology. It started with a genealogy of medical anthropo-

logical schools (Comelles & Martnez, 1993; Martnez & Comelles, 1994),

followed by a project on medical ethnographic writing (Comelles, 1996, 1997,

1998a,b). The outline of this paper was presented in the international meeting

Medical Anthropology at Home in Zeist (The Netherlands), in April 1998. I

am grateful for the fruitful comments of Alvina Putnina, Susan Reynolds, Els

van Dongen, Ivo Quaranta, Xavier Allue, Enrique Perdiguero, Sjaak van der

Geest and Ian Robinson.




Notes

(a) The major European periodicals in medical anthropology in Europe are Curare and Eth-

nomedizin, both German, Anthropology and Medicine in English, AM in Italian, and Medische

Anthropologie in Dutch. In Spanish, there is not a specic periodical.

(b) In the well-known handbooks on medical anthropology written by Sargent and Johnson

(1996), or by Helman (1990), there are very few non-English references. Most are French

translations.

(c) I follow the ideas about the development of anthropological practice expressed by the

medical anthropologist Eduardo Menendez in some of his writings (1977, 1991, 1997). He

discusses the main changes in anthropological practice following the genealogical model, and

in his latest papers he discusses the problems raised by the specialisation trends in recent

anthropology.

(d) I prefer this term. Ethnography is a neologism from the Enlightenment (Vermeulen, 1994),

and it would be an anachronism to apply it without criticism to narratives based on listening

or observation in natural settings.

(e) Hippocratic texts also contain ethical and jural narratives that describe the relation between

the professional and the patient (Lan Entralgo, 1987).

(f) Medical narratives are linked to the natural history narratives developed by modern science

and are alternatives to the old natural history narratives that were open to fantasy. In the

reports of rural or urban doctors, the time schedule follows them on their way from the home

of one patient to another. The description begins with descriptions of the slum or the

household. A description of the time schedule in institutions is very different. Time in an

institution is perceived as a cyclical and regular routine in which the patient careers are

placed (Allue Martnez, 1996).

(g) Ethnographic writing has been restricted to those practitioners whose professional task is still

heavily committed to local knowledge in rural areas or in the slums of the big cities. Only a

few of them use ethnographic texts to denounce the blights of society that shows the loss ofinuence of local knowledge on medical practice.

(h) The epistemological and methodological breakdown of medical folklore was Pitres work

(1896). Pitres conception of medical history and folklore, as a genre at the service of a

medical project, is on the margin of his other condition as a folklorist. This dissociation in

his triple role as rural physician, as medical ethnographer and classical folklorist is not free

of tensions and his methodological attempt to dene an idea of popular medicine through

medical theory reveals some overlaps with the conceptual framework of folklore. For further

information about Pitre, see Cocchiara ( 1938, 1941), Bronzini (1983), G entile (1994), and

Comelles (1996).

(i) For an overview on Italian anthropology, see Clemente et al. (1985) and Comas (1985).

(j) His work was mainly interested in discussing popular culture and the role of brokerage of

social scientists in social and cultural change. Gramsci, Crook, and German cultural history

inuenced De Martino. His eld research was done during the 1950s, generally on subjects

related to magical practices and popular religion. For an approach to De Martino, see

Pandol (1992, 1993).

(k) About medical anthropology in Spain, see Comelles and Paris (1986). The main bibliogra-

phies are Pujadas et al. (1980), and Perdiguero et al. (2000). Perdiguero (1992, 1993) has

discussed the relationships between history of medicine and medical anthropology.

References

AGUIRREBELTRAN, G. 1986. Antropologi a Medica. Mexico City: La Casa Chata.

ALLUE MARTINEZ, M. 1996. Sauver sa Peau. Paris: Seli Arslan.

ALVAREZ MILLAN, C. 1999. Graeco-Roman case histories and their inuence on Medieval clinical

accounts. Social History of Medicine, 12(I), 1944.



22 J. M. Comelles

AMADES, J. 1980. Folklore de Catalunyal: Costums i Creences. Barcelona: Editorial Selecta.

AUGE, M. 1986. LAnthropologie de la maladie. In POUILLON, J. ed. Anthropologie. Etat des Lieux.

Paris: Le Livre de Poche, 7785.

BARTOLI, P. 1976. Processi di comunicazione, educazione sanitaria e lorta per la salute, il ruolo

dei servizi di medicina preventiva. In Atti del Convegno La Ricerca in ltalia sulla Comunicazioni

di massa. Firenze: Amaldo Fomi, 197206.

BARTOLI, P. 1986. Antropologia culturale e educazione sanitaria. Antropologia Medica, 1, 1316.

BRONZINI, G. B. 1983. Antropologia e rnedicina popolare: note sugli studi dei positivisti italiani.

La Ricerca Folklorica, 8, 1317.

CASTEL, R. 1995. Les Metamorphoses de la Question Sociale: Une Chronique du salariat. Paris:

Fayard.

CLEMENTE, P. et al. eds. 1985.LAntropologia italiana: un secolo di storia. Rome: Gius, Laterza and

Figli.

COCCHIARA, G. 1938. La vita e larte del popolo siciliano nel museo Pitre. Palermo: Ciuni Ed.COCCHIARA, G. 1941. Giuseppe Pitre e le tradizioni popolari. Palermo: Ciuni Ed.

COMAS, J. 1985 La Antropologia ltaliana a traves del lnstituto italiano di antropologia. M exic o City:

Universidad Nacional Autonoma de Mexico.

COMELLES, J. M. 1996. Da superstizioni a medicina popolare: la transizione da un concerto

religioso a un c oncerto m edi co. AM Rivista della Societa italiana di antropologia medica, 12,

5789.

COMELLES, J. M. 1997. The fear of (ones own) history. on the relations between medical

anthropology, medicine and history. Dynamis, 17, 3768.

COMELLES, J. M. 1998a. From ethnography to clinical practice in the construction of the

contemporary State. In GREENHOUSE, C. J. ed. Democracy and Ethnography: Constructing

identities in Multicultural Liberalstates. Albany: State University of New York Press, 233

254.

COMELLES, J . M. 1998b. P arole de medeci n: le recit sur la pratique d ans la medeci ne contempo-

raine. In LAPLANTINE, F. eds. Recit et connaissance. Lyon: Presses Universitaires de Lyon,

799816.

COMELLES, J. M. & MARTINEZ HERNAEZ, A. 1993. Enfermedad, Culturay Sociedad. Un ensayo sobre

las relaciones entre la Antropologfa Social y la Medicina. Madrid: Eudema.

COMELLES, J. M. & PARIS, S. 1986. La antropologa de la medicina en Espana. Jano, 7 17, 8497.

ERKOREKA, A. 1985. Analisis de la medicina popular vasca. Bilbao: Etniker-Bizkaia.

FABREGA, H. 1974. Disease and Social Behavior. Cambridge: MIT Press.

FALTERI, P. 1989. La medicina popolare. Umbria. In SEPPILLI, T. ed. Le tradizioni popolare in

Italia. Medicine e magie, 160165. Milan: Electa.

FOUCAULT, M. 1978. Naissance de la clinique. Paris: PUF.

GARCIABALLESTER, L. 1981. Experiencia y especulacion en el diagnostico galenico. Dynamis, 1,

203225.

GARCIABALLESTER, L. 1995. Elementos para la construccion de las historias clnicas en Galeno.

Dynamis, 15, 4766.GENTILE, G. 1994. Giuseppe Pitre (18411916). Palermo: Sellerio.

HAHN, R. 1995. Sickness and Healing: An Anthropological Perspective. Cambridge: Yale University

Press.

HELMAN, C. G. 1990. Culture, Health and Illness. London: Wright.

HERSCHMARTNEZ, P. 2001. Plantas medicinales: relato de una posibilidad conscada. El estatuto de

la ora en la biomedicina mexicana. Mexic o, D F: INAH.

HIPOCRATES DECOS. 1986. Tratados Hipocrtiticos Il. De los aires, las aguas y los lugares. Sobre los

humores. Sobre los atos. Predicciones I. Predicciones Il. Premoniciones de Cos. Madrid: Editorial

Gredos.

HIPOCRATES DECOS. 1989. Tratados Hipocraticos V: Epidemias. Madrid: Gredos.

KLEINMAN, A. 1980. Patients and Healers in the Context of Culture. Berkeley: University of

California Press.




KLEINMAN, A. 1995.Writing at the Margin: Discourse between Anthropology and Medicine . Berkeley:University of Califomia Press.

LAINENTRALGO, P. 1961. Enfermedad y pecado. Barcelona: Ediciones Toray.

LAINENTRALGO, P. 1983. La relacion medico-enfermo. Historia y Teora. Madrid: Alianza.LAINENTRALGO, P. 1984. Antropologia medica para clnicos. Barcelona: Salvat.

LAINENTRALGO, P. 1987. La Medicina Hipocratica. Madrid: Alianza.MARTINEZ HERNAEZ, A . & COMELLES, J. M. 1994. La medicina popular. Los l mites culturales del

modelo med ico? Revista de Dialectologa y Tradiciones Populares, 39(2), 109136.

MARTINO, E. DE 1994. La terra del rimorso. Contributo a una storia religiosa del sud. Milan: IlSaggiatore.

MENENDEZ, E. L. 1977. Nuevos objetos de estudio de la antropologia social. In Actas de la XVMesa Redonda de la Sociedad Mexicana de Antropologia. Mexico City: Sociedad Mexicana de

Antropologa, 7582.

MENENDEZ, E. L. 1990. Antropologa Medica. Orientaciones, desigualdades y transacciones. Mexico,

DF: CIESAS.MENENDEZ, E. L. 1991. Deniciones, indeniciones y pequeos saberes. Alteridades, 1(1), 2133.MENENDEZ, E. L. 1997. Holisticos y especializados: los usos futuros de la Antropologia. Nueva

Antropologia, 5253, 938.

PANDOLFI, M. 1992. Beyond Gramsci and De Martino: medical anthropology in contemporanyItaly. Medical Anthropology Quarterly, 6(2), 162165.

PANDOLFI, M. 1993. Le self, le corps, la crise de la presence. Anthropologie et Societes, 17(12),5777.

PERDIGUERO, E. 1992. Historia de la medicina y la antropologia. Quaderns dantropologies, Numero

Especial, 715.PERDIGUERO, E. 1993. Historia de la medicina y antropologia de la medicina. In ROMANI, O. &

COMELLES J. M. eds. Antropologa de la salud y de la medicina. Santa Cruz de Tenerife:Asociacion Canaria de AntropologosFAAEE, 3556.

PERDIGUERO, E., COMELLES, J. M. & ERKOREKA, A. 2000. Cuarenta anos de antropologa de lamedicina en Espana (19602000). In PERDIGUERO, E. & COMELLES, J. M. eds. Medicina y

cultura. Estudios entre la antropologa y la medicina. Barcelona: Bellaterra, 353446.PESET, J. L. 1984. Ciencia y marginacion. Negros, locos y criminales. Barcelona: Crtica.PITRE, G. 1896. Medicina Popolare Siciliana. Torino: Carlo Clausen.

PUJADAS, J. J., COMELLES, J. M. & PRAT CAROS, J. 1980. Una bibliograa comentada sobreantropologia medic a. In KENNY, M. & MIGUEL, J. M. eds.La Antropologa Medi ca en Espana.

Barcelona: Anagrama, 323353.

ROSEN, G. 1972. The evolution of social medicine. In F REEMAN, H., LEVINE, S. & REEDER, L. G.eds. Handbook of Medical Sociology. New Jersey: PrenticeHall, 3062.

SARGENT, C. F. & JOHNSON, T. M. eds. 1996. Medical Anthropology: Contemporary Theory andMethod. New York: Praeger.

SEPPILLI, T. 1954. Contributo alla formulazione dei rapporti tra passi igienico-sanitaria ed

etnologia. Atti della XLV Riunione della Societa Italiana per il progresso delle scienze. Roma:Istituto di Antropologia della Universita di Roma, 320.

SEPPILLI, T. 1959. Il contributo della antropologia culturale alla educazione sanitaria.

LEducazione sanitaria, 4(34).SEPPILLI, T. 1983. La medicina popolare in Italia, Avvio ad una nuova fase della ricerca e del

dibattito. La Ricerca Folklorica, 8, 37.SEPPILLI, T. 1996. Antropologia medica: fondamenti per una strategia. AM Rivista della Societa

italiana di a ntropologia medica, 12, 722.SIGERIST, H. 1987. Civilizacion y Enfermedad. Mexico City: Instituto Nacional de Salud Publica.

TAUSSIG, M. 1980. Reication and the consciousness of the patient. Social Science & Medicine,

14B, 313.TURNER, V. W. 1988. El proceso ritual. Estructura y antiestructura. Madrid: Taurus.

VERMEULEN, H. F. 1994. Origins and Institutiona1ization of ethnography and ethnology inEurope and the USA 17711845. In VERMEULEN, H. F. & ALVAREZ ROLDAN, A. eds.

Fieldwork and Footnotes. London: Routledge.YOUNG, A. 1982. The anthropologies of illness and sickness. Annual Review of Anthropology, 11,

25785.

2002 Writing at the Margin of the Margin_ Medical Anthropology in Southern Europe

Documents

Transcript of 2002 Writing at the Margin of the Margin_ Medical Anthropology in Southern Europe