|9 The New Wave of Ethnographies in Medical Anthropology|
|图书名称：Writing at the Margin: Discourse between Anthropology and Medicine|
图书作者：Arthur Kleinman ISBN：
出版社：Berkeley: University of California Press 出版日期：1995年
In the past few years more ethnographies on subjects squarely in medical anthropology, or relevant to it, have been published a book-length volumes than in the previous four decades. That many of these books are also written at a high level of scholarship and are attracting attention from many outside the field makes their significance all the greater. Whereas articles in academic journals and book chapters once were the chief means of publishing academic work, even as recently as five years ago, now book-length monographs are appearing so frequently that they are transforming the very way we think about medical anthropology as a scholarly field. Though impressive in sheer number, the appearance of a gathering wave of ethnographies in medical anthropology should not come as a surprise. The field has grown; scholars who have devoted their careers to it are publishing their magna opera; and the field has attracted excellent students, many of whom are now publishing revised versions of their dissertations at the very outset of their careers. Anthropologists from outside the sub-discipline have been drawn to its subject matter to a degree they could not have imagined in the days when medical anthropology was perceived by other social anthropologists as theory-averse. How could they not be attracted when so many of its topics—from the body-self as a site for contesting ethnic identity, through the human consequences of violence and forced displacement, and on to the project to develop technological control of the human genome—have come to rank among the most challenging intellectual and policy questions of our era. And, of course, the presence of book series—especially the prolific and long-running University of California Press series—has opened a special space for publications by medical anthropologists.
Even as recently as the mid- 1980s, it was far from clear that publications in medical anthropology would take this crucial turn. At that time, there was substantial pressure for researchers to publish in a variety of types of academic journals. These included new journals in medical anthropology which were actively competing for high-quality articles; journals in general anthropology, where academic editors, sometimes grudgingly, were coming to recognize that medical anthropologists were engaging issues of theoretical importance to the discipline as a whole; and, not least of all, journals in biomedicine, mental health, and international public health which were "discovering," yet again, the salience of anthropological contributions. Applied anthropologists had long been effective at getting their research across in the format of the short article. Biological anthropologists, doing what I imagine now would be called biomedical anthropology, also have followed that model. But social anthropologists have had a much harder time of it. Not only did ethnographers write much longer articles—short ethnographic papers being something of an oxymoron—but even long articles could not easily encompass the ethnographer's theoretical excursions, detailed descriptions of context, and discursively interpretive prose. The result was highly unsatisfactory.
Ethnography, like biography and social history, requires space, a lot of it. The book-length monograph provides that, and more. It enables the ethnographer to find an intellectual horizon that is appropriate to the subject matter. It offers the possibility of engaging different scholarly literatures and of presenting research findings—masses of them—by different means. In order to build the scaffolding of scholarly materials that makes cultural analysis convincing and authorizes the ethnographer to apply that analysis to different problems and special themes, the author composes an iterative process that goes back and forth across ethnographic context, social theory, and key issues. The sedulous reader of ethnography, being a devotee of detail, expects to become absorbed in the intricacies of thought and experience that represent an alternative way of being-in-the-world. While coherence and analytic power count for something, so too do reflexive voice, style, thickly described ethnographic materials, and aperçus that illuminate a local world, often in order to challenge a putative universal or to critique the world of the ethnographer, a not-so-silent subject in many ethnographic monographs.
If all of this sounds old-fashioned, that is one of the arresting charms of ethnography. In place of our era's egregious emphasis on minimalist interpretation, ethnography develops, meanders, even circles back; it goes on and on. Ethnography's very format attests to its marginality to the rest of social science. From the perspective of biomedical science, it is, together with historical narrative and philosophical argument, part of the humanities, not the sciences. And yet physicians and many other professionals are often attracted to ethnographies for that very reason; these genres greatly widen the scope of intellectual possibilities and they put one in touch with different modes of experience, different life worlds, including novel ways of regarding one's own experience.
In keeping with the idea of the margin that I used in the Introduction to describe my own work, I would press this image further as a means of understanding why ethnographies are effective, at least in the realm of health and healing. The ethnography book challenges the basic conventions; it offers an alternative construction in an alternative style. It creates another world and compares it with the taken-for-granted one in order to obtain critical leverage. And it does so with thoroughness. That it is principally (though by no means entirely) qualitative sets it off from almost all other methods used in the health sciences. It belongs to the no-man's-land that runs between science and the humanities. Because it does not fit with the other forms of knowledge construction in the health field, ethnography has been well positioned to represent other things that are also at the margin of medicine, such as lay perspectives, the experiential aspects of illness and care, alternative medicine, the local community context of policy and practice, deviance, and the myriad problems, ordinary and extreme, that are constantly passing into and out of biomedical authorization. The marginality of ethnography has made it a more appropriate means of representing pluralism, reflexivity, and uncertainty, and of drawing upon those aspects of health and suffering to resist the positivism, the reductionism, and the naturalism that biomedicine and, regrettably, the wider society privilege. That ethnography also comes in a book-length form with the proviso that talking and living with people are crucial to research practice and that theories and facts are inseparably linked in a constructionist circle is an irony still so challenging to the way the health professions do their everyday business that it concentrates the power (to threaten and to liberate) of the medical margin.
Because dozens of first-rate ethnographies have been published in recent years, medical anthropologists need to come to terms with the possibilities, and of course the limitations, of ethnography as a genre. What sorts of things does it do best? What sorts of things does it not do well? In this chapter, I review examples from the new wave of medical ethnographies in order to evaluate their contribution. I spent several years reading these works, teaching a number of them in a graduate seminar, and sifting the still larger pile of monographs for appropriate examples. I came away from these exercises with a new appreciation of the extraordinary intellectual energy in medical anthropology today. This essay will not provide a comprehensive sense of the field. Rather it represents how I see medical anthropology through the lens of ethnography.
I think these books open to readers what is most interesting in this field in this era. On the whole, their effects have been remarkably positive. That there is also reason for disquiet, or at least uncertainty, is a sign that these works are effective enough at carving the imagery of the field to project even those surfaces that represent ethnography's and medical anthropology's limits.
While most of the books are written by medical anthropologists on subjects that are central to the field, a few are included for other reasons. The overlap between psychological anthropology and medical anthropology can be (and often has been) considerable. I include several works that belong as much to the former as to the latter. I also include ethnographic works in general anthropology because the theme of suffering they address is so relevant that whatever their authors intended, they have taken on a life of their own in medical anthropology.
These volumes address long-standing questions in the intersection of society and health, some already prefigured in preceding sections of this book, as well as new subjects that I take to be of related interest. Thus, I come back to the culture of biomedicine through studies of menopause, aging, and traumatic memories as well as through the counterexamples offered by Asian medical systems. And I press further the discussion of sociosomatic relationships in normality and pathology with the assistance of ethnomusicological, performance-based, and aesthetic studies. The strategy of reviewing the work of others greatly extends my own competences and materials, making it possible to return to old subjects via new routes, and to explore new ones in old ways. This chapter can be read, then, in light of what has gone before, as a colloquy between the work of others and my own work in medical anthropology.
By ending with a review of books, I also seek to promote a different kind of reading of ethnographies than is usually published. As I complained in the Introduction, too often in reviews of the scholarly literature, treatment of even a major book is published as a one- or two-sentence summary that ends up caricaturing a work that is complex and multifaceted. Because cultural interpretation is itself so concerned with the thick description of difference, this treatment is at the very least a dismaying irony. To overcome this practice, a review of books that devotes time and space to the authors' words and their effect upon a long-term student of the subject seems the right thing to do. It also allows me to emphasize the process of partaking in scholarly engagement with the literature as the crucial intersubjective practice of participation in the building of an academic field.
Medicine as a Social Idiom
Libbet Crandon-Malamud (1991) organizes a useful ethnography of medical pluralism in the highlands of Bolivia around a single idea that seems so implausibly simple at first, the reader is alarmed that it may not be adequate to support an entire volume. Her research takes origin from Paul Unschuld's (1975) radical suggestion that we turn the professional commonsense idea that medicine is an end in itself on its head, and in its place come to view medicine as a primary resource—like capital—which because it is fungible can be used to acquire (or create) a secondary resource that is even more significant in local social life. When medical pluralism exists, explains the author, medicine can be used to obtain secondary resources such as social relations and material goods that can support social mobility. Even in talking about medicine, villagers are redefining and negotiating social identities. Boundaries in the village she studies are relatively fluid across social status and even ethnic identity. Ultimately, the force responsible for maintaining and altering their permeability is the political economy. Medicine is only one of the pores in the boundary layer through which social entrances and exits are arranged. Thus, even people's evaluation of medical efficacy, surely much to the consternation of health professionals and health services researchers, is subordinated to other more central processes in the social context. Doctors may think patients are visiting their clinics because of symptoms and treatments, but in fact the visits are bound up in a much larger and more fundamental social process.
The reader's initial skepticism over the simplicity of the central idea is only deepened by the author's tendency to treat the concept rather woodenly and to repeat it, as if she herself harbored some unexpressed doubt for which the repetition of this explanation provided reassurance. In fact, the analysis is impressive and would be even more convincing if the author let the ethnography roam outside the tight confines of the analytic framework. The Bolivian highlands are populated by three overlapping groups: mestizos, formerly of high status and now, four decades after the revolution, well on the way toward impoverishment; Aymara Indians, many of whom are peasants; and Methodist Aymara, a relatively recent urban group who are engaged in commerce and rising in status. Between these groups ethnicity masks class relations and becomes a mode for negotiating the meaning of social identity. Local medical traditions are open to this social mosaic. Choice of a healer can be analyzed in extra-medical terms of solidarity, resistance, accommodation, empowerment; so can clinical work: "etiology is a metaphor of history, and use of … metaphors in medical dialogue is an attempt to change history" (p. 46).
Four key metaphors of social life are deployed in diagnosis and treatment: insatiable hunger, vulnerability of subordination, victimization, exploitation. These metaphors participate as social idioms in the expression and working out of mestizo and Aymara and Methodist antagonisms. To the outsider's surprise, medicine is the most effective method for conversion from one social position to another.
Crandon-Malamud interprets the etiological agency of kharisiri —a phantom who magically removes the fat from the kidneys of victims. In an earlier historical period, the phantom was popularly held to be a Franciscan priest who gave the fat to the bishop to make holy oil. By 1977, the phantom was believed to be a mestizo who traded in human fat. Thus, the insatiable hunger of the supernaturals for human beings represents the changing history of Bolivian elites, all of whom, it seems, exploit Aymara Indians.
It may sound repetitive, but the argument—a more complex one than was originally articulated—is effectively put.
For example, how can Crandon-Malamud be so sure that
Does the ethnographer, in the face of such chaos, feel the need to provide the missing order? What follows are subtle case descriptions, at times illustrated with great sensitivity with drawings by the author's daughter, an impressive artist, who seems to want to evoke the forlorn silence of a more ambiguous and perhaps even more dangerous setting than that which her mother presents. Although the author seems preoccupied with making her case airtight, it is the large space of the ethnography itself which allows readers to become so involved in the indigenous world in the first place that they can begin to question the strict limits the author places on the interpretation.
Wisely, the author comments: "Diagnosis is subjected to dialogue; dialogue opens diagnosis to debate" (p. 204). We in fact do come to appreciate that "people compete and negotiate to monopolize the control of the consumption of opinions and thereby gain some power, which can later be used to get something else: resources, legal protection, loyalty, or security" (p. 207). Yet, the reader might well ask, don't highland Bolivians ever go to practitioners because they want to feel better or receive medications? Don't they ever go just because they are faced with troubling symptoms, which must at least sometimes be symbols that stand for themselves (Wagner 1986)? Or because whatever medical practice they choose at the end-stage of sickness is indeed the ultimate resource? Readers who can put aside such questions will find important conclusions.
Without doubt, the author convinces us that at least for certain residents of the village she calls Kachitu, the evaluation of medical efficacy takes place neither in the idiom of symptoms nor in that of practitioners' interventions, but rather "within the context of interests in such secondary resources." From the Fat of Our Souls may be one of the clearest demonstrations of this cultural construction of efficacy , one of the most difficult issues in all of medical anthropology. Land, agricultural goods, jobs, privileges, power—any or all may be implicated in the question of efficacy. Making this point with impressively concrete detail is a major achievement, and one that could not have been accomplished without the scope and the depth of the book-length ethnography.
And this is the note the volume could and should have ended on. Instead, we get a final, clearly unintended, shock. Notwithstanding an earlier critique of positivism, we come across page after page of tables in appendixes, which register the quantitative data from a survey that is too small and unsystematic to be statistically significant, but is filled with a simplistic categorization of illness beliefs: "magical," "natural," "psychological" (none of which is central to the core theme of the book). Could it be that in spite of the frequent repetition of the interpretive model, the author still feels the need to convince us that the conclusion is really valid because the survey demonstrates consensus on the folk categories? If so, the demonstration is both unnecessary and beside the point of the ethnography. Thus, this otherwise useful ethnography ends with a final, surprising irony. This is after all a modernist volume filled with a deft certainty about what is at stake and a dogged determination to come to one overwhelming point; it eschews the uncertainty and paradox of postmodernist prose. And yet, the irony of the ending lends itself to a postmodernist critique of the uses of ethnography. Crandon-Malamud needs to make the point that medicine is taken up in much broader social processes, certain of which have almost nothing to do with sickness and therapeutic remedies per se, and which cannot therefore be understood if the focus on illness and care is too narrowly that of the medical professionals. In so doing, she tells us (inadvertently) about the ethnographer's need to appropriate medical themes for the purposes of social theory, so that we come to see that the social anthropologist too is taken up in much broader social processes, certain of which may seem to have little to do with her subject matter, but which become consequential. If Crandon-Malamud had made the suffering of the leading characters in her story as various and plural as she makes their health care system, whose description is indeed impressive, doubtless the theory would have been less tightly integrated, but the ethnography would have been more compelling.[*]
A rather different approach to medicine as social idiom is taken by Christopher Taylor (1992), whose Milk, Honey, and Money: Changing Concepts in Rwandan Healing takes its intellectual origins from the French ethnographer and sometime medical anthropologist Marc Augé's distinction between three "socio-logics" in ethnographic analysis and from gift exchange theory. Augé's Gallic tripartite organization of social analysis includes (1) the logic of difference in symbolic phenomena, (2) the logic of reference that relates symbolic difference and difference in the social order, and (3) the logic of events, which relates the first two levels of analysis to their historical genealogy. As we shall see, Taylor applies this framework both to Rwandan society's culture of healing and to specific healing "events." These logics of the social world also enable Taylor to draw upon the society-wide transformation of the socio-logic of the gift to the socio-logic of the commodity as a basic turn in the cultural history of healing in Rwanda. Subsequent tragic events in Rwanda—genocide, massive displacement of populations, starvation, deadly epidemics—make the reader wonder if Taylor's peaceful account could possibly be of the same Hutu and Tutsi groups. The fate of his ethnography will be forever affected by this immense, historical transformation, almost as if his book belonged to the prehistory of the Rwanda we have all come to see on the nightly news, an archetype of the inhumanity and death of a broken society. We need to put aside these images to engage this ethnography, but at last we must return to the juxtaposition to bring Taylor's work into historical perspective.
The term for "man" in Kinyarwanda, umugabo , derives from kugabo, "to give." Thus, the idea of gift giving is built into the cultural category of the person, both as generosity in personality and as reciprocation in social relationships. The Rwandan gift-exchange relationship also "embodies spiritual power" (p. 5). Taylor follows Marcel Mauss's classical formulation fairly closely. Similarly, he stays close to Chris Gregory's (1982) reformulation of the Marxist notion of the commodity as an alienable object from whose exchange no social bond necessarily results and which "appears" to operate independent of human agency, lending commodities their "animate capacity" to be "fetishized."
In Rwanda, under the system ubuhake (abolished in 1954), a Tutsi cattle patron gave a cow to a Hutu client in exchange for prestations of beer, agricultural goods, labor, and loyalty in warfare. In turn, the patron protected his clients from the exactions of other Tutsi. The client possessed usufruct rights to the cow's milk and in its male offspring, but female offspring had to be returned to the patron. This feudal political scaffolding extended from Tutsi king to vassals and down to Hutu cultivators.
Taylor uses these concepts as well as those of reciprocity and redistribution to understand the transformation of socio-logics in Rwandan society from personal domination in the regime of gift exchange to abstracted domination in the regime of commodity exchange.
A crucial part of socio-logic for Rwandan healing is the dialectic between flow and blockage, which carries the exchange logic from the social body into the physical body. Fluids flow or are blocked. Isibo , flow as a noun, connotes the flowing of cattle and warriors and the flow of force or élan; the verb gusibo, from which it derives, means "to plug, fill up, obstruct." The one implies the other. Flow is openness, continuity, but it also implies blockage, interruption, closure. In this symbolic system, a key role is played by liquid gifts: honey, beer, porridge, but also milk, semen, blood, and even rain.
Pathology is depicted as blocked flow or hemorrhagic flow. Witches and poisoners, agents of pathology, block flow. "Illness is often seen as a perturbation in the movement of one or more bodily humors, a movement whose cause comes from outside the self—from witches and spirits" (p. 21). The same symbolic dialectic carries over into Rwandan political discourse and into the spiritual sphere in the relationship of human, bovine, and divine fertility and well-being. Power is flow, of rain, rivers, blood, semen, milk, honey, and so on. Problems arise when flow is arrested. Conflict in "social life perennially disrupts orderly fluid movement" (p. 75).
Healing techniques work within the socio-logic of removing blockage and enabling flow. Through extended case studies, Taylor shows how the female body comes to be viewed both as the site of blockage in gift exchange and under the socio-logic of commodity exchange. Yet, in the latter the problem and the treatment turn more on issues of individual fulfillment than on those of social reproduction of the kinship group. Thus, the changing political economy works through the symbolic system to alter the understanding of pathology and treatment outcome. Money is not like other things that flow; it changes the very nature of the social process.
Taylor's analysis is enriched by his readings in Francophone medical anthropology, especially the work of Augé, Françoise Heritier, and René Devisch. Across the three socio-logics, Taylor shows that the flow/blockage symbolic idiom creates a homology between cosmological, ecological, political, and medical concepts and practices that together form a sociosomatic reticulum for society-mind-body interactions. Whereas the homology is impressively elaborated under the gift exchange regimen, when Taylor attempts to deploy it to criticize capitalist practices, the dualistic analysis gets exaggerated.
"If Rwandan gift logic is characterized by the flow/blockage dialectic, capitalist culture appears to reverse the relation between flow and blockage. Blockage (project making, accumulation) becomes positively valued" (p. 203). It is simply not convincing either as conclusion or methodology when Taylor states that internal causation is to the body as supply/demand is to the market, or that autonomy is to the person as the market is to society (p. 212).
But in spite of somewhat overdoing the rhetoric, Taylor's contribution is to show that symbolic analysis can be used to illuminate ordered historical transformation in a healing system and in its relationship to politics and the economy, at least prior to 1994, a year of disorder and horror. The ethnographic stories he tells of therapy sessions are effective in illustrating the symbolic terms of his analytic model. Taylor shows himself to be the intellectual heir of Victor Turner (1967), whose depiction of an entire symbolic system of healing is perhaps still the most formidable undertaking in this tradition of anthropological analysis. Moreover, unlike Lévi-Strauss, Taylor does not misapply psychoanalysis as a quick and dirty fix, deux ex machina, to shore up the account of how symbols heal. Rather he stays with the micropolitics of relationships, where his data are grounded and his analysis is most convincing, leaving psychosomatic issues for other researchers who possess ethnographic materials that are more appropriate for such interpretation.
Taylor's volume also is rich enough in detail to let the reader see the limits of this revivification of the program of symbolic analysis. Current anthropological sensibility makes it increasingly difficult to support the idea of shared symbolic systems whose logic is so tight and extensions are so visible that they can be traced directly from cosmology through politics to therapeutic practices. In order to maintain this position, the complexities of everyday social life, the uncertainties basic to social transactions, and the openness of politics and history to novel developments have to be discounted, while the unity of symbolic meanings has to be overvalued and a blind eye turned to instances where the system breaks down, simply does not apply, or is contested from within. Taylor's work, like Crandon-Malamud's, is backward-looking toward a time of greater confidence in social determinacy and in the uniformity of social systems. At the end the reader is left with an analytic strategy that claims too much, and that is unable to encompass the serious complexities in how social change relates to health and health care. Nonetheless, in pressing the symbolic program to its limits, Taylor shows us just what the approach can and cannot accomplish in medical anthropology.
More troubling still is the dismaying juxtaposition between Taylor's Rwanda of the past and the nightmarish Rwanda of the present. The very word conjures imagery of extreme dislocation; the contemporary reader is mortified by an account of balance and stability. The interpretation of social change as the transformation of gifts into commodities and the relationships of blockage and flow is not likely to help much in making sense of the political catastrophe. That truly enormous human disaster has changed the very conditions of health and health care, as it has of so much else. It has likely also changed the relationships of Tutsi and Hutu for generations to come, making much of the cultural analysis obsolete, perhaps anachronistic. The horrors of 1994 also make writing about Rwanda a wholly different genre. Symbolic analysis clearly is not an adequate approach to the chaos of societal disintegration, where the cultural universe itself is either shattered or seemingly irrelevant. This suggests that perhaps Taylor's analysis also inverts the picture of earlier social upheavals in Rwanda by providing much more coherence than social experience is likely to have possessed.
One almost wants to say that after the Rwandan nightmare, modernist accounts of social order seem improbable at best and perhaps in future will be regarded as impossible. But this is unfair because it is ahistorical. Taylor wrote about, and in his own small way contributed to, the intellectual construction of an era in Rwanda that is gone, a world that no longer exists. The new era requires a theory of extreme upheaval, a semiotics of violent chaos, a phenomenology of desperate failure. While even those accounts will require cultural grounding and symbolic exegesis, their vector, we must assume, will be toward the ethnography of disordered states.
Since W. H. R. Rivers, a psychiatrist, pioneered ethnographic fieldwork early in this century, a number of anthropologist-physicians have conducted ethnographies (e.g., Fabrega 1974; Field 1960; Kleinman 1980, 1986; Lewis 1975, 1980; Taussig 1980; and more recently Cohen 1992; Farmer 1992; Littlewood 1993, among others); yet, perhaps none, including Rivers, has come closer than Stephen Frankel (1986) to writing what I shall call a medical ethnography. A medical ethnography is a description of a society through a medical lens, a systematic focus on the health-relevant aspects of social life. Frankel, who earlier had practiced general medicine among the Huli of the Southern Highlands of Papua New Guinea, returned as a Cambridge-trained social anthropologist to write The Huli Response to Illness . His general description of the social context fairly quickly settles on diagnosis, illness experience, and treatment. Indeed, Frankel includes a survey of morbidity (pp. 60–72), even though he never departs from an ethnographic mode of writing. Yet, that mode of writing is as much medical (particularly British medical cadences resonate in the ear) as anthropological. The style is concise, direct, and crisply pragmatic, even when Frankel discusses Huli cosmology, social organization, or symbolic meanings of life and death and the spirits. That Frankel also includes ecology, the history of epidemics, and the Huli's conceptual underpinnings of ideas of risk and resilience fits in well with an effort to canvass all the dimensions of the Huli life world that are relevant to health.
The Huli cosmology contrasts rather fundamentally with the mainstream views of experts in social development and international health; it all but mocks the deep faith in secular progress:
Indeed, the Huli, not tongue-in-cheek but accurately, blame recent decline on the coming of Europeans. Over the past decades, social change has brought epidemics of venereal diseases and malaria, deterioration of the soil, and worsening of other ecological conditions.
As with many anthropological descriptions of New Guinea communities, Frankel emphasizes the ethos of individualism, person-based social networks, and tensions between the sexes. Fully one-third of marriages, for example, end in divorce. Every ethnographer eventually shows the colors of his "school." Frankel does not waste much time in getting down to classic interests of British social anthropology: Huli illness categories represent the social order, Frankel announces:
Just because the point has been so well established that it reads today like a cliché should not lessen its significance, as is the case with the news that the Huli practice prevention through protective rituals and regard health as a social as well as a physical state, a fragile quality to strive for. These are widely shared aspects of ethnomedicine that must be telling us about central facts in social responses to illness. Nonetheless, if this were all there was to the ethnography, the reader, dutifully educated, would find the book tedious. But beneath the cool prose and dour, even somber medical outlook the ethnographic gaze twinkles and occasionally sparkles; Frankel has much more to tell us. Some authors need only a few sentences to warm up, others require a few pages. Frankel finally gets to the subjects taht excite him on page 55. Interestingly, the first of these is literally a subject on the surface, not in the depths, which brings out his multiple skills as a medical ethnographer: "The skin, as the visible aspect of the body, mediates between an individual's inner state and others' appreciation of him" (p. 55). The quality of the inner state is visible in the appearance of the skin. The shine or luster of the skin forms a semantic network with social effectiveness, good health, and resilience. "Bad skin," in contrast, is a physical-moral state of "dirt," "defect," "decrepitude" in the body and in social states. Health is personified as the beautiful skin, vigor, and striving of young men; ill health is incarnated as a "shabby," sickly, impoverished "recluse." The description reminded me of Kenneth Read's (1955) writing on the moral-somatic status of "skin" for the Gahuku-Gama, elsewhere in Papua New Guinea (see chap. 3 in this volume). That the Huli suffer greatly from skin diseases overcodes this category.
For Frankel particularly noteworthy is the association between illness and death, which is not at all inappropriate in a setting of high child mortality where adults too may succumb quickly to a serious infectious disease. "Some who feel ill from any cause, when asked how they are, may simply reply, 'homedo ' (I am dying)." For the Huli, "dying is a vulnerable condition in continuity with demise, from which recovery is likely. Homayo , he died, can be said of a corpse, or of someone who was very ill but is now all right" (p. 59).
The Huli must now be counted among that vast cross-continental arc of peoples for whom a concept of vitality or life force is central. Bu, life force, refers to "breath," the pulsation of the heart, and also to "the drive which activates all other functions" (p. 83). In serious illness, bu is "smothered."
So much for the idea that the debate on "brain death" is an issue unique to technologically advanced societies.
It is also impressive that even within this medicocentric study, Frankel finds that the social processes of litigation and retribution and compensation are more important than medical treatment for the members of Huli society. "The presence of illness may constitute evidence of a legitimate grievance, and the resolution of the conflict represents treatment of the illness" (p. 134). Huli women, we are told, "use" illness strategically to draw attention to grievance and to resolve its sources—a finding that again comes close to a universal in medical anthropology, though it can be generalized to other categories of the powerless.
In the final pages, Frankel shows how the social idiom of balance, reciprocity, and compensation works its way through the actions of the patient's therapy management group, is involved in responses to violence, and connects a view of the fragility of society to a view of the impermanence of personal health and well-being. Frankel ends on a grand theme common to studies in medical anthropology, as we have already seen in Crandon-Malamud's book, namely, medical pluralism. Diversity, he shows, is of long standing in Huli society, where the indigenous medical culture has plural aspects and alternatives.
Here, then, in the space of a thin monograph, with much insight into social process but limited elaboration of theoretical models, many of the traditional concerns in medical anthropology are addressed. Ethnography is appropriated to the interests of medicine, and narratives and numbers are combined in the text. This is best seen in the survey of morbidity, which shifts the perspective and the language of description from anthropology to clinical epidemiology. Viewed from the vantage of the 1990s, Frankel's work seems to harken back to an earlier era, much as Taylor's and Crandon-Malamud's do, but for a different reason. The alignment of subject matter is overbalanced toward traditional public health and clinical concerns. The appropriate contrast is with a more recent ethnography by the physician-anthropologist Paul Farmer.
Farmer's AIDS and Accusation: Haiti and the Geography of Blame (1992) is a large-scale effort to combine history, epidemiology, and social experience within a thick description of suffering in rural Haiti. It largely succeeds. Farmer's objective is to narrate the meanings of the AIDS epidemic in Haiti against a daunting set of backdrops: the depressing cycles of Haitian history, the equally depressing history of the AIDS epidemic, the epidemiology of AIDS in Haiti, and the local experiences of Haitians in the impoverished village of "water refugees," Do Kay, where he has conducted both field research and medical assistance projects. The "geography of blame" adds an additional backdrop: the international relations of Haiti with the United States and with the international political economic order. Like Frankel, Farmer moves fluidly between ethnography and clinical epidemiology, but he also is just as deft in crossing the boundaries with history and political economy.
AIDS, Farmer makes chillingly clear, was "the last thing" for the people of Do Kay. Forced out of their ancestral homes when their valley was flooded for a hydroelectric development project that provided them neither water nor electricity, villagers have been able to barely survive in a setting of great privation. The HIV infection for many has intensified that world of poverty into an ethos of desperation. Farmer's ethnography of suffering insists that to understand the meaning of AIDS, the ethnographer needs to continually relate the long cycle of political economic oppression with the short cycle of illness.
What is at stake for the villagers? Farmer indicates that this is a complex issue that touches on the interpenetration of moral and religious experience with intergenerational poverty and political oppression. When asked "How are you?" the villagers of Do Kay answer, "I'm fighting with life." Farmer does not present a picture of passive victims. Rather his account is about struggling, coping, resisting, and the complex mix of deeply human practices that make both rational choice theory and vulgar Marxist melodramas of the socially determined lives of the oppressed seem serious distortions. By the late 1980s, Haitian peasants were "intentionally politicizing their discourse" (p. 58). Farmer argues that this reorganization in the uses of narratives "revolved around questions of agency in suffering ."
Farmer transits from the large picture to the village and then again to the backdrop through three chapters that each present the illness narratives of a different sida sufferer. These are examples of what might be called, in line with Farmer's dual role as ethnographer and clinician, witnessing individual suffering in a space of social suffering. Indeed, Farmer's skill is to make the transition between macrosocietal and microvillage levels of suffering fluid and compelling. Dieudonne, one of the subjects of these chapters, observes: "sida is a jealousy sickness" (p. 106). He goes on, "What I see is that poor people catch it more easily. They say the rich get sida ; I don't see that. But what I do see is that one poor person sends it to another poor person. It's like the army: brothers shooting brothers. The little soldier (ti solda ) is really one of us, one of the people. But he is made to do the bidding of the State, and so shoots his own brother when they yell 'Fire!' Perhaps they are at last coming to understand this."
Farmer tells the shameful story of the erroneous yet disastrous blame placed on Haiti early in the epidemic as its source. This story also played down the contribution to dissemination of this deadly sexually transmitted disease by gay men from North America who frequented Haiti for sex tourism. Farmer also narrates the equally sad story of the way WHO and CDC models of AIDS at first obscured the chief current form of transmission of HIV in Haiti, heterosexual sex, most efficiently from male to female. Both stories are about the larger economic, political, and historical sources of vulnerability in the West Atlantic system.
"Turning and turning in the widening gyre," Farmer analyzes AIDS and sorcery, AIDS and racism, and AIDS and empire (the Western Atlantic system). In each domain, he shows that the established center does not hold; things as they are—as they are usually presented in culturally authorized discourses, medical and popular, that is—do fall apart. There are really two epidemics: AIDS and blame. The latter, concerned with sorcery, AIDS-related discrimination, and conspiracy theories, arises as "one social group attributes unsavory motives to another" (p. 245). These epidemics are also heterogeneous with different dynamics and effects. Farmer sketches those effects as they devastate lives. The anthropology of suffering, he concludes, is an amalgam of the historical, political, economic, and cultural sources and consequences of affliction: overlapping circles that can arrest one at a specific point but need to be visualized as an intersecting whole. Farmer succeeds better than any other author of a medical ethnography at illustrating this canonical conception in the discipline.
It is a sign of cumulative strength shared among the younger generation of ethnographers that Farmer is not hampered by factional differences over "biomedical" and "critical" anthropology labels, but freely passes between questions in virology and political history. The accessibility of his writing to a wider audience in the social and health sciences also, it is to be hoped, is a sign of the intentions of the new cohort of physician-anthropologists. This accessibility is gained at a cost, however; a cost that that cohort should consider. Farmer's engagement with social theory is less extensive than it could have been, and the historical critique, written with such obvious passion, is less nuanced than the past—so uncertain when it is lived, so clear when it is "history"—deserves. Haiti, to be sure, is a grossly flagrant case of imperialism, racism, and not-so-benign neglect. And yet as Farmer's three illness narratives so poignantly show, the depiction of human complexity can only enrich our appreciation of the social processes at work in the systemization of suffering.
Yet another strategy for conducting a medical ethnography is to write from within another cultural form of medicine, and to do so by explicitly eschewing comparison with biomedicine. Judith Farquhar's Knowing Practice: The Clinical Encounter of Chinese Medicine (1994) is a strong version of such a strategy. Her account results from study of the practice of traditional Chinese medicine (TCM) in the Guangzhou College of TCM in China.
Farquhar seeks to get at indigenous clinical priorities in medical work (p. 2; what I have elsewhere called "clinical reality," Kleinman 1980:120, 132). "In close relation to this everyday practical form, the collective accumulation of expertise through scholarship, teaching, and healing generates doctors as embodiment of virtuosity, a form of experience that links practice to history and practitioners to knowledge" (p. 2). The object of enquiry is kanbing , "looking at the illness," which doctor and patient do together in a clinical encounter in which "the doctor does not have the power to reject any sign reported by the patient; patients … retain a sense of being the experts, the authority of last resort, on their own illness."
Dissecting the cultural practice of kanbing leads Farquhar to center her ethnography on the indigenous model of practice from classification to prescription. Although she often buttresses her interpretation with information from observations of clinical practice, most of her scholarly material is textbook descriptions written by and for practitioners. Rather than emphasize the classics, however, Farquhar works with recent publications from the Guangzhou College of TCM and from other traditional medical schools in China. A cornerstone of her analysis is her description of bianzheng lunzhi —the practical rationality guiding differentiation of symptoms/signs into a syndrome and determination of therapy. Entire chapters are devoted to the diverse components of the diagnostic process, including: ba gang (the eight rubrics—cold/hot, interior/exterior, depletion/repletion, yin/yang), bingyin (illness factors), zangfu (visceral systems of function), wei qi ying xue (the Warm Illness school's four-sector theory), liu jing (the Cold Damage school's six warps). For illustration, the author returns from time to time to three paradigmatic textbook cases that she discusses from these differing angles, but she also draws upon much direct quotation from published texts.
It is simply not feasible in a short space to recreate the elaborately detailed evocation of practice that this ethnographer-sinologist describes. There is nothing comparable in the English language literature. For each of the elements in the diagnostic process, for example, she offers a precise cultural interpretation of its expedience. Thus, for chuanhua (transmission and transformation of pathology through the four temporal sectors of a syndrome's defensive qi , active qi , constructive qi , and blood sector), she takes the reader on a journey through the "complex entailments … space, time, and quality" in which theory and practical action are "inseparable" (p. 118). Or to take an example from the therapeutic aim of the indigenous model of clinical practice, treatment methods (zhifa ) are presented not simply as therapies—herbal remedies, acupuncture, breathing exercises—but much more tellingly as an integrated process of knowing and acting:
Thus, linghuo , connoting both efficacy and virtuosity, flexibility and sensitivity, is presented as a form of clinical judgment in action that relates the collective experience of the medical archive and the personal experience of the practitioner in the process of healing (p. 168). Is it any wonder then that Farquhar never saw "two experienced doctors mobilize precisely the same protocol in their clinical work" (pp. 133–134)? Rather than nature, truth, or law, "the social values of effectiveness, responsiveness, and service and the personal values of virtuosity and connoisseurship—goodness in several senses of the word—dominate Chinese medical texts" (p. 174).
Given the Chinese perspective that the world undergoes relentless transformation, that all things are fluid, it is not at all surprising that TCM's therapeutic orientation is the management of recovery—a continuous constraining of change toward healthier directions. Drawing upon "a coordinated use of 'logically inconsistent' methods to produce a nuanced specificity" (p. 222), Farquhar's analysis of therapeutics is as detailed as her analysis of syndromal classification. Her gaze never leaves the core clinical process. This is very much an internalist account. Though much of what Farquhar covers could be understood as relating to anthropological debates about technical and performative rationality, the culture of institutions and professions, "biopower," and long-standing medical anthropological comparisons of Asian and Western "science," she maintains a strict discipline, avoiding these larger issues, with only a few exceptions, including an unfortunate defense of falsifiability and a useful examination of the relationship of knowledge to social life. Otherwise, the ethnography sticks to kanbing .
Because of the fidelity to the description of the clinical encounter, it is astonishing that we learn so little about particular practitioners, particular patients, or particular encounters. Rather her concern is the ideal-typical. Thus, the cases that get her attention are from textbooks, not from her participant observation. The diversity and complexity of actual clinical encounters is not her interest. Nor is she especially interested in the influence on practice of changing institutional, political, or economic realities, which in the case of Guangzhou has been extensive in recent years. There are points in the analysis when one feels almost suspended in a timeless ethnographic present reaching back into the ancient formative period of Chinese medical texts. Yet even those classic texts are not what Farquhar's ethnographic sinology is about. While this rigorous pursuit of a single object of enquiry is courageous and highly productive, it is also disconcerting. The sinology dominates the study so completely that ethnography may be the wrong word to describe either the research methodology or the book. Although Farquhar worked in a danwei (work unit), we learn very little about it. There is no local world in much of the book. Observations about local prescriptions take up much more space than descriptions of clinical transactions. The lived experience of patients is absent, but so is the lived experience of practitioners—their uncertainty, their stake in particular cases (or treatments).
Nor do we have what Michael Herzfeld (1987:x) calls "an anthropology that makes an ethnographic problem of itself [that] offers pragmatic insight into the social worlds that it examines and to which it belongs." Still less are we presented with the usual materials and techniques of cultural analysis that are present in the burgeoning field of cultural studies of science and technology (compare the review below of Margaret Lock's contribution). What we do have is nonetheless important: a powerful evocation of practical epistemology in the sinological tradition that makes a serious, if oddly self-constrained, contribution to the study of East Asian medicine and that suggests new uses for at least certain aspects of ethnography in the philosophy and history of science.
Music and Medicine
One of the more interesting directions that ethnographies of healing have taken is to explore the place of music in healing rituals and in the healing process. Work in this tradition builds upon useful contributions of ethnomusicologists (e.g., Feld 1982) and in fact overlaps with their subdiscipline. Because rhythm is an "ordered and recurrent alternation of strong/weak elements" that occurs in "breathing, walking, running, dancing, speaking, drumming, and other vital and expressive processes" and because it is also "the periodicity of molecular activities, of geophysical, business, sleep-wake or metabolic cycles, of mood swings, of oscillations in the electrical activity of the cells of the cerebral cortex or of variable qualitative changes in other biological and physiological processes," the idea that rhythm, and other musical processes too, may mediate changes between the social world and the inner, psychobiological world of the person has intrigued medical anthropologists (You 1994a). Social processes such as relationality and reciprocity might even be modeled in terms of rhythms that are actualized in phases of time as synchronized or resonating changes that jump from social networks to neural networks. Because there are so few other candidates for even drawing rough analogies with society-mind-body mediation, music suggests itself, along with absorption and the attentional processes of trance states, as a leading candidate. That music is a ubiquitous component of indigenous healing rituals, and of many activities in which trance is induced for other purposes as well, adds significance to this interest. In the Chinese tradition, for example, sinologists have long connected ideas of order, yin/yang, and rhythmicity to a network of cosmological, sociomoral, and physiological connections emphasized in various texts of traditional Chinese medicine (Granet 1968; Needham 1954; Sivin 1987; You 1994b); music has often been used as the source of metaphors to illustrate this connection: for example, harmony.
Recent ethnographies by Carol Laderman (1991) and Marina Roseman (1991) explore the relationship between music and medicine in the Malaysian peninsula among Malay and Temiar, respectively. Both volumes are broadly concerned with the aesthetics of healing performances in local rituals. After reviewing both books, I will turn to a third ethnography, by Robert Desjarlais, Body and Emotion (1992), which describes a study of Yolmo Sherpa shamans in Nepal, because Desjarlais presses even further the issue of the poetics and aesthetics of therapy. Then I will examine Thomas Csordas's The Sacred Self: A Cultural Phenomenology of Charismatic Healing (1994), which applies culture theory vis-à-vis a rapprochement of semiotics and phenomenology to the study of how symbols heal.
Laderman's Taming the Winds of Desire: Psychology, Medicine, and Aesthetics in Malay Shamanistic Performance (1991), her second volume in the University of California Press series "Comparative Studies of Health Systems and Medical Care," centers on the Malay construction of angin (inner winds) as a chief source of personality, desire, and health. "Everyone is born with angin, the traits, talents, and desires representing our ancestors' heritage, but some have more, or stronger, angin than the common run," reports one informant (p. 68). The inner winds accommodate a Malay ethnopsychological theory of temperament, vulnerability, and resilience. There is a typology of personality types based on the angin's types of desires. The inner winds are a source of capriciousness; the thwarting or blocking of the inner winds can result in sadness or sickness. Freely blowing or sublimated inner winds keep the person and society healthy. If ignored or repressed, angin will create sakit berangin —sickness due to blockage of the inner winds—with symptoms of backaches, headaches, digestive problems, dizziness, asthma, depression, or anxiety.
Treatment aims to free the inner winds so that they can express their desires. Treatment also relates to complementary ideas of hot-cold humoral balance, protection of the spirit or force of life, semangat, and a strong Malay emphasis on the individuality of the person.
Bomohs, the Malay shamans, counteract the "hot" breath of invading spirits that threaten the "fortress" of the individual self. In the Malay séance the shaman, rather than the patient, enters trance to incarnate spirits. The bomoh helps certain patients, however, to enter trance states through his influence on the vital force and inner winds intrinsic to their individuality. Trance, during which patients say they feel high winds blowing within their chests, a claim the ethnographer corroborates from her own trance experience, puts patients in touch with their inner world, their inner being. Whereas the shaman becomes possessed, the patient, under the shaman's control, acts out repressed parts of her inner personality. "Patients in trance feel the Inner Winds as experiential reality rather than merely metaphor" (p. 95). Thus, cultural norm is validated by personal experience, while personal desire is fulfilled through cultural expression.
Laderman specializes in the ethnographic account of the main peteri, the elaborate ritual that the bomoh conducts to heal the pain of patients who are suffering from problems of the inner winds, the vital force or invasion by external spirits. The shaman mobilizes, in Laderman's fetching phrase, the patient's spiritual immune system (p. 61). The bomoh counteracts the hot breath of invading spirits with his own vital breath, made "cool" by incantation. Bomohs "are usually well acquainted with life circumstances of patients" (p. 44). They ask psychosocially telling questions and practice what Laderman characterizes as a kind of psychotherapy with similarities to Jungian analysis. Much of the book is made up of detailed descriptions of main peteri healing rituals. The book ends with an entire main peteri performance, including the Malay words, translation, and the musical score.
The shaman should possess a beautiful voice. The words he sings are powered by his breath. The shaman's inner wind emerges in the performance and transfers efficacy to the patients he treats. But the meaning of the words he sings is also part of the performative construction of efficacy. The audience, including most notably the patient's family, also has a stake in seeing that performative efficacy is achieved. The performance seeks to contribute to order in the human microcosm, in the social macrocosm, and in the cosmos. But it is constrained by a factor that Laderman identifies as the chief cultural constraint on symbolic order in the Malay community: folk practices like the main peteri are contested by Islamic religious commitments. They conflict with each other. Regrettably, Laderman does not examine in any depth the implications of this seemingly important instance of cultural contestation for healing.
Taking up the idea of Gilbert Rouget (1985) that trance universally involves music, with acceleration, stresses, and syncopation, Laderman points out that the main peteri's music does not display syncopation. She does indicate, however, ways in which the music of the ritual weaves a subtle harmony between patient and healer, a harmony that even if it can't be generalized on symbolic grounds to the community is seen by informants as necessary for healing to occur. Laderman analyzes three main peteri rituals in detail, of which the story of the "stifled talent" and the séance for a sick shaman are impressive examples of her theory of how indigenous therapy works. Paradoxically for the reviewer of ethnography, it is precisely this detailed working through of events, which gives the ethnography book its distinctive analytic power, that, because of its very length and detail, cannot be instated in the review.
Although Laderman's book is successful in many of the tasks it sets for itself, there are a few problems reminiscent of difficulties found in the volumes already reviewed. The analysis at times is too deterministic, too complete for the subtle personal and interpersonal problems described in the case vignettes. The ritual seems too multisided to try to interpret in full. Both cases and ritual performances expand beyond the frame of the analysis; the artistry of ethnography makes them come alive. They are too vitally human for encapsulation in a totalizing social theory.
Once again the ethnographer seems to search for the same control in the ethnography that the shaman seeks in the patient's trance and treatment. Curiously, while the angin of the patient is freed and refreshed as a result of the performance of the ritual, the performance of the ethnography fastens down the imaginings of the reader, forcing conclusions such as a fairly flat portrayal of personality and the distant analogy to Jungian therapy that seems strained. The discussion of placebo response is too narrowly organized around Thomas Scheff's (1979) idea of catharsis. This is an interesting notion to be sure—but it is one that is overly valued by the author at the expense of other perspectives on the placebo process that might have enriched her interpretation. This overmanagement of the interpretive process contrasts strikingly with the graceful depiction of the performances and the sensitive discussion of the ethnographer's own inner experiences during the rituals. It is also surprising that so little is made of performance theory—a rich vein in cultural analysis—to develop the theoretical implications of the analysis, which on the whole seem surprisingly thin when contrasted with the thick description of the performance. A final reaction: why is so little done in the analysis with all the musical materials that are presented? The reader is led to feel that there will be much more ethnomusicological method in the interpretation than actually occurs. It is as if the author is presenting a resource for others, who are better trained in ethnomusicological practices, to analyze. But the reader who works through the text and recorded performances will feel, as I did, disappointed that after so much effort so little is forthcoming in the way of demonstration of what technical analysis of musical performance can add to the interpretation. Laderman's fine descriptions make us feel much can be added, but we are never shown what that extra value is. This is especially noticeable in the gap between the standard assertion that symbolic performances heal and the absence of a convincing demonstration of what mediates that healing process.
Marina Roseman, an ethnomusicologically trained anthropologist, who apparently consulted on Laderman's research, possesses the methodological skills to conduct such a demonstration. Her book, Healing Sounds from the Malaysian Rainforest: Temiar Music and Medicine (1991), sets out to bridge the divide between theories of symbolic healing and ethnographic analysis. The setting is the deep interior, where there is an "intricate interpenetrability of settlement and forest" (p. 4), which is architecturally represented in stilt houses with spaces between bamboo slats in the floor and higher up on walls that allow an opening, fraught with local implication, between the community and the jungle. For these hunter-horticulturalists, the social system turns on generalized reciprocity; the cultural system invokes homology between detachable souls in plants, animals, landforms, and humans (head and heart souls). "Bounded souls can be liberated as unbounded spirit during dreams, trance, and illness … unbounded souls make interaction and the flow of information possible between human and non-human entities" (p. 6).
Spirits of the jungle and settlement can engage humans as helpful guides or as malevolent causes of illness. Spirit guides in dreams bestow a song on the dreamer: "singing that song during ceremonial performance, the person becomes imbued with the voice, vision, and knowledge of the spirit guide" (p. 6). Transformed by the spirit into a medium, the guided person can diagnose and treat illness.
In the local imagery, songs are paths. Choruses of singers follow the path as they sing contrapuntally with the mediums. Mediums sing of the route traversed by the spirit guide during its travels. Knowing the real path in the jungle, of course, can be the difference between life and death. Illness is said to result when the person's head soul gets lost. Treatment is the singing of a "way": finding the head soul and leading it back to the settlement. The key metaphor in song involves travel along paths between two different domains of knowledge: music and healing.
Roseman builds her analysis on performance theory, especially the conveying of symbols through "ritual frames; aesthetic distance; performance roles; audience participation and commitment to the performance reality" (p. 15). She also takes seriously Temiar performance theory, which holds, less abstractly and more to the point of society-mind-body transformations,
Longing, attraction, enticement—all mediate between humans and spirits. Detachment and reattachment of bounded souls is an idea that underlies Temiar music and medicine. Bounded souls—tied to the conditions of everyday life, health, and safety—can be liberated as unbounded souls, the stuff of dreams and trance and singing and also of illness and other dangers.
Roseman places the performance theory in the context of a broader social theory that we have already encountered in certain of the other ethnographies. For the Temiar—a social group organized, like the Huli, Hutu, and Tutsi, around reciprocity—halting the flow of goods (not reciprocating) puts the affected person in a state of unfulfilled wanting that makes that person vulnerable to misfortune. Good exchange is good health. Connection is crucial; separation dangerous. The social dialectic is between "the cultural subscript of sociocentric interdependence" and "the continual reinstatement of an independent, bounded self" (p. 47).
The Temiar spirit medium-healer is the Halaa : a person with the capability to receive songs from spirit guides during dreams and later on with the ability to "manifest those spirit guides when singing the songs and trancing during ceremonial performance" (p. 53).
"Temiar mediums are singers of the landscape, translating the rainforest environment—jungle, field, and settlement—into culture as inhabitant spirits emerge, identify themselves, and begin to sing in dreams and ritual performances" (p. 58). The Halaa creates the cultural experience in the intersubjective space of the ritual as the flow of the spirit guide through the song in the symbolic form of a cool spiritual liquid. In this felt experience of the symbolic, cosmology, humoral theory, music, and healing merge. The dislocation of the illness experienced as loss of the soul is counterbalanced in healing by the song of landscapes that locate the spirits.
The Temiar healing ritual overlaps, and alternates, the singing of male medium and female chorus in keeping with the egalitarian social organization and system of generalized exchange. The interweaving in sound and movement announces, and undermines, differences: individual/community, male/female, jungle/settlement, human/nonhuman, bounded/unbounded. Through symbolic inversions and conjunctions in ritual performance, these differences are transcended. Tellingly the Temiar themselves refer to trancing as "transforming."
Roseman illustrates the dynamic process of symbolic transformation she has installed in the interpretation through an account of the Temiar's aesthetics of longing. "The duple rhythm of these beating tubes [male-female pairs of bamboo-tube stampers beaten by the chorus of women against a log in alternation] is linked in a web of local meanings that extends from pulsating sound of the rainforest to the beating of the human heart" (p. 151). The spirits are set in motion and the sentiment of longing—which pervades the spirit guide-medium relationship—is modulated through these fraught sounds and dance steps. Sound becomes remembrance; trance forgetfulness.
"In everyday life," writes Roseman, the calls of the cicada "are said to move one's heart to longing for a loved one" (p. 157). Pulsing at the frequency of the heartbeat, the cicada's song is said to make the heart whirl and thereby invokes the remembrance of deceased relations or of longing for a lover. "This aesthetic sensibility links longing and remembrance with the pulsating sounds of bird calls, insect sounds, and the bamboo-tube stompers of ceremonial trance-dancing sessions" (p. 158). The music-invoked longing has to do with absences and that which is "unobtainably distant."
Thus, the sentient metaphor of connecting and separating is found in the primary experience of the singing, in the representational form of the song, and in the invoked experience of illness/healing. Transformation in Temiar ethnomusicology and ethnomedicine is "a momentary intermingling of self and other" (p. 172). Thereby, concludes Roseman, "aesthetic configurations participate in a comprehensive pattern of reality and become therapeutically effective" (p. 184).
But just how does that mediation occur? Roseman's prose pulls us toward an acceptance of her conclusion: the style is resonant with the subject matter, the conclusion is prefigured, all the elements are assembled for understanding how social space and bodily space commingle. We are even told when it has happened. Yet, the analysis stays very much at the surface of things. What is missing is a deep study of the mediation itself. Neither the music nor the cases are described in enough detail to make the reader feel the conclusions are adequately supported. If a problem with Laderman's book is too much ethnographic material with too little close interpretation, a problem with Roseman's volume is too much interpretation with too thin an ethnography. Both are noble failures: noble failures in Ivan Morris's (1975:xiii–xv) use of the term to speak to the Japanese tradition's valuing of courageous acts that even their authors know cannot succeed, not only because they are fine attempts, but because nobody else has succeeded fully either. And each instructs by what it lacks: a convincing demonstration of the process of symbolic mediation. Laderman provides all the materials but doesn't carry through the analysis; Roseman draws the conclusion and shows us each of the components in the analysis, but doesn't link them together. For all the remarkably resonant things she has to say about healing, Roseman is unable to open up the fine processes of healing because her ethnography is not rich enough in events, situations, or lives to sustain such an illumination of how intertextuality and polyphony actually transform persons through performance (see Feld and Fox 1994, for a discussion of what such an ethnomusicological ethnography of mediation might require). Both works, however, provide a firmer basis than has heretofore been available for finer-tuned, more broadly integrative studies.
While it is not a study of musical performance, Robert Desjarlais's Body and Emotion (1992) does wrestle with issues in the aesthetics of illness and healing similar to those Laderman and Roseman engage. Although his ambitious ethnographic account is also too limited in findings to fully succeed, he does carry the study of specifying how healing is mediated in therapeutic rituals deeper into the phenomenology of the sensuous experience of therapeutic change. That promising direction is taken by another study of the therapeutic process, Thomas Csordas's The Sacred Self (1994), which will complete our review of the mediation of healing.
Aesthetics, Performance, and the Experience of Healing
Desjarlais's intention is well captured by the quotation from George Eliot's Middlemarch that opens his account:
The "ordinary human life" to which Desjarlais seeks to give voice is the world of Yolmo Sherpas, ethnic Tibetan people who live in north central Nepal. In this beautifully crafted volume, Desjarlais draws on his participation in healing ceremonies as an apprentice of a barefoot, illiterate shaman (bamboo ) called Meme. During the ceremonies, Desjarlais entered into a trance state that
Later on, Desjarlais reports, "I felt that my body developed a partial, experiential understanding of their world, from the ways in which they held their bodies to how they felt, hurt, and healed" (p. 13).
To explore the experiential world of Yolmo "soul loss" and the shaman's search for lost souls, Desjarlais uses his own liminal experiences to engage "the sensory, the visceral, the unspoken." For ethnographers in the tradition of cultural phenomenology, such as Michael Jackson and Paul Stoller, Desjarlais holds, the researcher needs to cultivate "negative capability"—Keat's appreciation of Shakespeare's genius of "being in uncertainties, mysteries, doubts, without any irritable reaching after fact or reason" (p. 34). This is the cultural sensibility that enjoins "a visceral engagement with symbolic forms" (p. 35); it is not an immediate empathy, but an understanding of the poetics and aesthetics of experience built up out of a prior understanding of the social order. Thus, Desjarlais's description of Yolmo bodies interweaves the somato-symbolic imagery of Tantric anatomy, the cultural architecture of the built environment, the structure of social relationships, and moral processes. Like Pierre Bourdieu's (1977) analysis of the homology between the physiology of the body and the structure of the Algerian house, Desjarlais shows a similar symbolic architectural principle that bridges the Yolmo house, bodily habitus, and moral meanings. Thus, "motifs" of inner/outer, depth/surface, openings/closures "pervade Yolmo understandings of psychology, knowledge, and medicine" (p. 45). Illness is penetration of spirits, ghosts, and other malignant forces into the body; healing works to "throw" demons out of the house of the body. In spite of separations, these boundaries are permeable and continuously crossed. They are the source of vulnerability and also of therapeutic efficacy.
For Desjarlais, the village he studied as well as particular families he came to know and the bodily processes of villagers involved in the shamanistic séances in which he participated, all contain a core structural tension between independence and interdependence that shapes the micropolitics—the political "physiology"—of each domain. Yolmo social organization derives from a historical conflict between kinship ties and temple-based inter-household alliances. This tension shapes relationships of exchange, hospitality, mutual support, and status. Status hierarchy is mapped onto household relations, where it conflicts with individual life trajectories. In the village as a whole, the "household's" place in the political hierarchy is more important today than the "family's" place in the lineage. In the family as in the village, individuals relate to each other through both hierarchical and egalitarian principles. Fission and fragmentation of the village and the family are a constant threat in Yolmo society. A household balances between autonomy and interdependence as does its members.
Desjarlais writes that Yolmo cultural sensibility extends this conflicted metaphor of social order deep within the body, where the sems (heart-mind) conflicts with the klad pe (brain). Emotions arise within the sems, and the emotionally laden sems travels outside of the body to the place and time envisioned in dreams. The klad pe is the inner, moral censor that sediments out of social hierarchy into interior space. This conflict deep within the person recreates the conflict in village and family. Fragmentation of villages and dispersal of villagers into multiethnic settings under the political forces of the present era ramify into division of families and the inner experience of dispersal and loss. The aesthetics of both illness and healing experiences—the tacit cultural forms, values, and sensibilities that lend styles and felt qualities to modes of being-in-the-world—take origin from this cultural system. For Desjarlais, then, ritual performance emerges out of the aesthetics of the everyday.
Thus, the Yolmo experience of the body as a fragile harmonium—unified and whole but liable to fragment because of the inherent tension between constituent parts—informs their way of being ill and undergoing treatment. In illness, the body is experienced as "incomplete, adulterated, off-balance, lacking" (p. 73). Soul loss is an omnipresent threat, in which the body declines and the life forces are diminished. Curing involves the experiences of restoration and homeostatic balance. Health involves self-resistance and control, the latter closely connected not only to the social interests already mentioned, but also to the kinesthetic attentiveness to surroundings that is salient for a mountain people.
Desjarlais's methodology is to examine common aspects of Yolmo experience—pain, sadness, the sensibility of loss—and then to interpret them through the interweaving of bodily experiences, poetry that casts such feelings into the intersubjective space of the collective, the Buddhist literary tradition, and ritual performances. Thus, Yolmo "heartache" is deconstructed as a special form of Buddhist dukkha (suffering). Its ritualization in the experiences of informants is used to animate the emotion and its role in pathology and healing. But at the same time, "heartache" is embedded in the Yolmo context of the social organizational instability of "companionship, intimacy … relationality" and also harmony, order, and homeostasis (p. 108). Making up a summary list like this in place of the fine-grained analysis of poetry and felt sensibility, especially the way Desjarlais elaborates their interconnection, seriously distorts a methodology that convinces the reader through the very process of aesthetic interpretation that it installs. Indeed, Desjarlais's skill as a writer of evocative prose is at the center of his methodology, which might be described as recreating the collective sensibility of therapeutic transformation.
The song creates a collective sentiment of the commonality of loss and separation for those who are bereaved, for those who are ill, and for others such as young women who experience the homesickness of moving out of their natal family into the household of their husbands. The expression of emotion, which takes place in a shared idiom under the strong social constraint of an ethic of self-restraint that fosters support, strengthens bonds, and gives voice to pain, is the source of their efficacy. Until this point, the analysis, though impressively fine-grained, follows a course worked out by various theorists of the poetics of everyday experience; now it builds upon the ethnographic base in a more original direction.
The poetics of Yolmo songs, we are told, model the transformation of bereavement and healing. "Yolmo heartaches" entail a sense of loss, abandonment, and separation. These events are occasioned by pitfalls specific to Yolmo social life: the separation of family members, the patrilocal travels of women, the death of children and elders. Since the pitfalls are common ones, sentiments of tsher ka imply a core emotional pattern, a "plot" that narrates a loss, a separation, a sense of abandonment: the consequences of these events (weary bodies, pained hearts), and then a struggle to avoid, escape, or transcend those burdens. The pattern of experience accords with other sufferings. Earlier we learned that threats of loss, dispersal, and fragmentation disturb the physiology of Yolmo bodies, households, villages. Tsher ka is the visceral correlative of these images. Its dark presence speaks of broken bodies, lost birds, and downhill descents.
Desjarlais, who laments the limits of symbolic analysis to get at the process of change, goes beyond the language of representation to use such terms as "incarnate," "animate," "resonance," "similitude" to evoke the aesthetic sensibilities of illness as a cultural mode of being; the same terms are crucial to his approach to healing. These "assume common structures, like disparate musical notes come to form distinct and well-known melodies" (p. 156). Healing for Yolmo is about arousing or rejuvenating the spirit and life force. The shaman "lends image to a felt sensibility," like an expert art critic evaluating a painting. Healing, we are told repeatedly, works through the felt experiences of the rites. "Shamanic rites of protection demarcate the geography of Yolmo forms, accenting what belongs within a body or household and what does not. The core experience pivots on an image that is instantaneous, mimetic, without narrative time" (p. 190). The body is reconstructed as closed, defended, protected, its boundaries maintained. This occurs through the symbolic analogy with the order of the house and the cosmos. It is the experience of the image, however, not the image as a representation, that produces the effect. That effect "incarnates" the experiences of sociopolitical tensions, interpersonal tensions (interdependence versus autonomy), and bodily distress. "Healing rites catalyze an ontology of experience patterned by a play of flow and stoppage, ingress and egress: ghosts are drawn, life forces relived, and body surfaces cleaned and protected" (p. 194). Thus exorcism is literally experienced as expulsion from the body. Healing is not so much about the meaning of transactional symbols as it is about the kinesthetic actions those symbols evoke. Mimesis allows the shaman's movement to move the patient to feel that movement, say, of pain leaving the body.
The shaman "changes how a body feels by altering what it feels. His cacophony of music, taste, sight, touch, and kinesthesia activate a patient's senses" (p. 206). For soul loss, he alters "the sensory grounds of a spiritless body" (p. 206).
Desjarlais's model is a performative one. The healer's rites "lighten a heavy body" due to soul loss because "they activate the senses to spark sensibilities distinct from those of malaise" (p. 210). These sensibilities are part of Yolmo aesthetics of healthy experience: namely, the feelings of "presence, vitality, harmony, and repletion." The shamanic strategies of recovering lost vitality include: "selective attention to detail, an evocation of the senses, a mimetic presentation of a tangible reality, an invocation of the 'here,' and the use of wild images to induce attentiveness" (p. 218). Kinesthesia is used by the shaman to incorporate life, power, vitality in the body. And that is how patients experience healing, as an entering into the body of the vital and the powerful, felt "like a jolt of electricity" (p. 221).
An ethnography that dares so much, especially by installing a language of evocation and animation, assumes a weighty responsibility that the ethnographic narratives must support. If those narratives are limited, the ethnography is likely not to succeed completely. Nor does Desjarlais escape from this predicament. In spite of considerable repetition of the central themes, with a measure of cumulative success, the examples seem too trim and undeveloped to carry the argument. Rather, the incandescent language and fluid interpretations seem to outdistance the findings. The idea of being healed because you are made to feel different or better also begins to seem less and less like a highly original reversal of the commonsensical and more and more like tautology. That is to say, the theoretical elaboration of the aesthetics of everyday life, unlike their brilliantly effective evocation, leaves something central that is unfinished. To his credit as an ethnographer, Desjarlais makes no attempt to disguise this limitation. Indeed he ends his impressive postmodernist account with a sensitive reflection on uncertainty and the limits of interpretation that is just what readers would expect of a writer who is so remarkably attuned to the inner tone of social experience.
In The Sacred Self: A Cultural Phenomenology of Charismatic Healing, Thomas Csordas reports on nearly twenty years of study of healing in the Catholic Charismatic Renewal movement. His thesis is that Charismatic Renewal, like religious healing systems generally, involves "an experiential specificity of effect": "that transformative meaning dwells, to borrow a phrase from the poet William Blake, in the 'minute particulars' of human existence taken up in the healing process. To approach that specificity, we must identify the locus of efficacy" (p. 3). For Csordas, "the locus of efficacy is not symptoms, psychiatric disorders, symbolic meanings, or social relationships, but the self in which all of these are encompassed." Thus, the problem of efficacy turns on the development of "a theory of self that will allow for the experience of the sacred as … an element that constitutes one kind of the specificity we seek" (p. 4). That theory of the self, argues Csordas, should begin with an understanding of the self as "indeterminate capacity to engage or become oriented in the world, characterized by effort and reflexivity" (p. 5). The self is a "conjunction" of the experience of the body, the culturally created world, and situational specificity. The self is an embodied orientation to the world, a locus for perception, says Csordas following Merleau-Ponty, the French phenomenological psychologist. This is the existential, preobjective grounds of experience, prior to cultural construction of the "person," yet based in the social formation of the habitus, argues Csordas, who melds the views of Merleau-Ponty with those of Bourdieu. The habitus—the socially informed body—is the locus of mediation of human practices, potentialities, and actions that are always and everywhere indeterminate. And it is this very indeterminacy that is the source of transformation and transcendence, in everyday life, in religion, and in healing. Csordas's ambitious theoretical aim is to unite the languages of phenomenology and semiotics—the conceptual frames of Merleau-Ponty and Bourdieu—around the intersubjective worlds within which healing is actualized. "To be healed is to inhabit the Charismatic world as a sacred self" (p. 24).
For Charismatics, the self can be "wounded" or "broken" and healed by divine power, and it can achieve spiritual growth.
Csordas presents findings from his study of Charismatic healers and patients in the late 1980s in New England who engage in three types of healing that parallel the same tripartite structure of the self: "physical healing" for illnesses of the body, "inner healing" for emotional distress, and "deliverance" from the negative effects of evil spirits. He interprets the repertoire of Charismatic healing techniques under six general headings: empowerment (e.g., annointing, laying on of hands, glossolalia), protection (e.g., calling on the Virgin Mary), revelation (e.g., prophecy and visions), deliverance (e.g., casting out spirits, cutting ancestral bonds), sacramental grace (e.g., Eucharist and confession), and emotional release (forgiveness). But Csordas's chief concern is to develop a theory of how healing works through the transformation of the experiences of patients. Pointing to experiences such as changing habitual posture and altering bodily modes of attention, Csordas proposes that religious healing realizes "incremental efficacy" at the "margin of disability" through four specific therapeutic processes: the disposition of supplicants, experience of the sacred, elaboration of alternative possibilities, and actualization of change.
Csordas explicates this theory in the study of religious images. These he interprets not as representations or things, but as acts in the embodied consciousness that contribute to the actualization of performative efficacy. Thus, revelatory images engage sensory modalities. They are "a sense of" or "infused knowledge" in the modalities of vision, olfaction, hearing, proprioception, and also emotion. Csordas presents quantitative data from his interviews as well as detailed reports to support his argument for the performative force of therapeutic images. These images act in the body through the mediation of sensory, intersubjective, and cultural "force" to change habitual experience, including the experience of the self. In the late-twentieth-century North American cultural context, that alteration "incarnates" spontaneity, control, and intimacy in the social experience of the self as the locus of therapeutic efficacy.
There is a remarkable rigor in the effort Csordas makes to build an elaborate set of theoretical models out of the interweaving of ethnographic findings and densely detailed summaries of relevant theoretical literature. But that very strategy of writing, which yields highly original formulations, also creates problems. The writing is dense, which is as much the problem of the phenomenological tradition as it is Csordas's own predilection for long, complex sentences; the ethnographic descriptions appear in dribs and drabs; and the reader can watch the theory set up the presentation of the data, which then are made to stand for what they have already been prefigured to mean. At its best, the last gives an exhilarating sense of cumulative development and completion; at its worst, it seems forced and comes perilously close to tautology. Csordas is at his best when he stays close to his ethnography, as in his discussion of Charismatic "healing of memories," where he finally does present fuller accounts of the experiences of patients undergoing the process of therapy that are rich enough to support the elaboration of a theory of the "specificity" of efficacy with ethnographic exactness. This clearly is the case with the three ethnographic features that Csordas isolates in the description of the healing of memories: (1) the emergence of memories that hold autobiographical import but that are attributed to revelation; (2) the construal of those memories as traumas and the forgiving of the trauma perpetrators; and (3) the privileging of imagined performance of the trauma or enactment of some other troubled scenario with Jesus in the role of healer. Less coherent is Csordas's application of object-relations theory from psychoanalysis to understand alterity in the self as basis for the construction of the sacred self. Csordas is on sturdier grounds when he applies Edward Casey's (1987) phenomenological analyses of imagining and remembering to his materials.
In one of the most satisfactory meshes of theory and description, Csordas deploys Merleau-Ponty's idea of the presubjective to understand how patients who are experiencing demons switch the codes of experience from being in control to giving up control to another, often alienated, part of the self. Out of that code switch, culture, working through collective meanings, is what objectifies self into demon. Here Csordas has opened up a usable space to relate cultural, intersubjective, and psychological processes in understanding the experience of affliction, the experience of transformation when demons are cast out, and the instauration thereby of the experience of grace. Another impressive ethnographic success, with assistance from the writings of the phenomenological psychologist Erwin Strauss, is the application of the theory to the cultural phenomenology of "falling" in a Charismatic healing practice called "resting in the Spirit."
At his very best, Csordas can demonstrate that efficacy can only be understood through cultural ontologies that enjoin the anthropologist to work out changes in individual experiences in an epoch's context of changing collective experiences. Thus, healing for Charismatic Catholics in late-twentieth-century North America must be different not only from healing in other religious traditions but, more to the point, from healing in other Catholic communities in other historical contexts, because of the shift in cultural experience. It is one thing to say this, which other researchers do; it is quite another to demonstrate it, which is Csordas's chief accomplishment, a key achievement.
What Csordas does not succeed in doing is proving to the reader that the theory of self is essential for the framework required to understand healing. His most convincing ethnographic examples of healing, tellingly, are ones where the analysis of bodily practices and inter-subjective interactions does not seem to require an ontology of the self. In developing a usable cultural psychology for medical anthropology, Csordas indirectly, and counter to his stated intention, suggests that it may be feasible to bypass a theory of the self altogether, since his model replaces self-awareness not only with somatic modes of experiencing, but with "processes of orientation and engagement." These processes are so thoroughly interpersonal they suggest that what is needed is a more serviceable social psychology and a brand new social physiology (p. 278).
At the Margin of Medical Anthropology
The margins of medical anthropology, with psychological anthropology, feminist studies, and the wider array of ethnographic concern with other forms of social suffering, contain works that hold different sorts of relevance. In her provocative ethnography The Last Word: Women, Death, and Divination in Inner Mani, Nadia Seremetakis (1991) looks at death rituals through "the optic of death": "death rites as an arena of social contestation, a space where heterogeneous and antagonistic cultural codes and social interests meet and tangle" (pp. 14–15). Death is the domain of women in Mani, a remote, inhospitable, violent territory in Greece where women, she claims, have been dominated by men, the church, the state, and, most recently, "medical rationalities." The women of Mani sing moiroloi (laments) that connote the crying of their fate. Their performances of grieving validate their ponos (pain). "Pain is crucial for truth-claiming strategies of Maniat women" (p. 4): it is a form of sociopolitical resistance, Seremetakis avers, through which women come to speak the last word on the culture of Mani.
Women were traditionally caught up in the clan warfare, alliances, and blood feuds of the region. They embody the kinship ethic of caring and tending the living, the dying, and the dead. Women mediate birth—the passage from outside to inside the local world—and death: the passage from inside to outside. Mourning obligations and personal grieving lasts for years, and includes participation in exhumation, where women divine the moral condition of the dead. The symbolism associated with the feminine in Mani includes pollution and destructive contact. And yet in screaming for the dead, the women themselves have the image in mind of a bent woman who stands up and stretches out to express her gendered personhood through a death lament, a lament that for the author mediates between worlds, contests the forms of this-worldly dominance, and offers an alternative commentary on suffering and much of the rest of social experience as well.
For the women of Mani, their experience of pain is of a burning fire that "liquifies" the self into tears. Pain is a "holocaust" (p. 115). Women's fate is to endure pain and labor for others. "Through pain Maniat women link kinship, the division of labor, agricultural and domestic economies—all male-dominated institutions—into an experiential continuum" (p. 115). Their pain authorizes the truth claims of their ritual laments to reveal fate, the forced entrance of the outside into the inside world. This passage of fate through the mediation of the female body into the social order is not only a form of social memory, but a teleological critique of male-dominated ideologies of modernization and urbanization.
The crucial event for the playing out of this socio-logic is the funeral, where death is rationalized by medical, social welfare, state, and even church rationalities, and that rationalization is resisted and ultimately undone by the female mourners (pp. 163–166). Those mourners transform soma (their body and the body of the dead) into sema (a key cultural sign). Seremetakis's analysis of ritual laments at the exhumation of the bones of the dead discloses that women are cynical because of their understanding of fate. By offering the last word, they use irony to authorize an alternative form of social memory that claims the male-dominated social order is "false" (p. 218).
Up to this point, Seremetakis's symbolic analysis seems so well founded in ethnographic description that, despite its flamboyant rhetoric, the view she offers of the morality and politics of women's experiences appears reasonable. But the book ends with a provocation so extreme that it vitiates the strong program of feminist analysis. Seremetakis's ending moves her from scholar to partisan of divination as holistic knowledge for women in their resistance to men.
Women and men are treated as pawns in a binary opposition that is so fundamental they never seem to interact. Divination becomes the antithesis of rational technical practice: the former is always good, the latter always bad. This extreme ideological separation raises serious questions about the validity of the ethnography. Seremetakis is to be complimented on another count, however, because, unlike most ethnographers of death and social mourning, she deals, at least partially, with the experience of grieving. It is a telling comment on the interests of anthropologists that the huge corpus of ethnographies of social mourning practices has so little to say about the social experience of bereavement. Seremetakis is interested in that symbolizing experience. Yet, since her interpretation rejects any psychological (or existential) orientation, she ends up unable to examine the emotional response of real people to real losses. The quite marvelous case descriptions are only deployed to authorize her symbolic analysis of collective experience; the personal experiences of the arresting tragedies she describes go largely unexamined (p. 156). Grief, for all its deeply resonant subjectivity, is handled largely as a source of powerful cultural symbols. Because she has provided effective and affecting descriptions, however, the reader feels he has the evidence he needs to argue with the author that these cases are about lived tragedies in everyday experience—including states of "endurance" and "martyrdom" as local forms of suffering—that require an examination of the cultural ontology of social experience as a complement to the symbolic analysis (pp. 144, 156, 201). Nonetheless, the Seremetakis ethnography is a good example, at least prior to its concluding pages, of the power that feminist readings of the contestation, fragmentation, and multiplicity of social life can bring to subjects that are of high salience to medical anthropology.
In passing from Seremetakis to Nancy Scheper-Hughes (1992), we may be going from the frying pan of provocation to the fire of accusation, yet the ethnography—Death without Weeping: The Violence of Everyday Life in Brazil —is one no medical anthropologist can (or should) avoid encountering. Scheper-Hughes traces the lineaments of her ethnography back to her early experience as a Peace Corps volunteer in the 1960s in a terribly poor favela, Bom Jesus, in northeastern Brazil where she lived as well as carried out community organization. "What, I wondered, were the effects of chronic hunger, sickness, death, and loss on the ability to love, trust, have faith, and keep it in the broadest senses of these terms?" (p. 15). For Scheper-Hughes: "The horror was the routinization of human suffering in so much of impoverished Northeast Brazil and the 'normal' violence of everyday life" (p. 16). She returned to conduct anthropological field research and to continue her community development work at various periods over the next several decades.
Bom Jesus is dry and dirty; there is very little water, and what water is available is polluted. She describes both personal and collective thirst, as well as deep anxiety over water and hunger. The average favela family with eight members uses ten gallons of water a day; the average Marin County household used four hundred gallons per day during the water restrictions brought on by the Northern California drought of the late 1980s. The historic backdrop to this local world of thirst and hunger is by now an all-too-well-known one of colonial "greed, exploitation, and retaliation," followed by the dominance of sugar plantation monoculture, destruction of peasant cultivators, rural-urban migration, and the development of a social system of middle-class bosses, working-class poor, and two groups at the very margin of social class dynamics: pobrezinhos, the "truly poor," "struggling souls" who are seasonal workers in the fields without security; and pobritoes, the "truly wretched," who literally have nothing and are occupied day and night with the most basic requirements of survival. This last group includes the physically disabled, the chronically mentally ill, and the "walking corpses" of the chronically sick poor.
Scheper-Hughes describes the local world as the outcome of a dynamic social process in which an older sugar plantation economy and a newer industrializing economy interpenetrate in such a way that tension between hierarchy and democratic trends becomes intense enough to create a divided, chaotic, anarchic society. In this fragmented local world, her research subjects are the Matutos : "They are the little people, the no-account people, those whose features, clothing, gait, and posture mark them as anachronisms in modern Bom Jesus." Darker, smaller (stunted owing to inadequate nutrition), the Matutos maintain a self-image of being weak, wasted, worn out. The descendants of slave, runaway slave, and Indian populations, they are under the pressure of racism and "operate in a world of gifts and favors, barter and cunning, loyalties and dependence, rumor and reputation" (p. 91). Rejecting the idea of a culture of poverty, Scheper-Hughes comes very close to describing just such a local ethos, which she represents as predicated on cynicism, pessimism, desperation, anomie, promiscuity, exploitation, predation, and abandonment. Patron-client interaction, which is the chief model of relations outside of the community, linking it to the wider city, "locks the social classes into a ruse, a travesty of interaction in which exploitation parades as benevolence and passive aggression masquerades as fawning dependency" (p. 125).
At times, Scheper-Hughes's view of the community becomes unsympathetic and accusatory. It is a bad-faith economy—financial and moral, she claims (p. 126). It is out of this bleak view that the central theme of the ethnography emerges: "where the threat of hunger, scarcity, and unmet needs is constant and chronic, traditional patterns of triage may determine the allocation of scarce resources within the household" (p. 135). As a result, the male head of the household may abscond, teenage children may run off via sexual unions or just disappear, and young, sickly infants and small children may undergo a kind of desperate neglect in the context of the slow starvation of the family. The upshot is a routinization of child death with a frighteningly high infant mortality rate of 116 per 1,000 live births, to which the rest of society has become indifferent. Even the mothers of dying children participate in a (necessary?) misrecognition, an anankastic misrepresentation that keeps them from seeing that hunger and starvation are at the root of child sickness and death.
Babies who are viewed as doomed because of their fraility are allowed to die of "mortal neglect" (p. 342). Mothers are placed in a situation where no mother should ever be placed. They are led to accept a "holy indifference" (p. 363). "Failed" babies are stigmatized. There are negotiations over terminality which in the local moral world can mean the option of withdrawing support. The doomed child, like Christ, is said to need to die to redeem the lives of others. The social construction of household triage leads to a terrible pragmatism in which salvage, neglect, and uncertainty are worked out. Mothers show pity, not grief, and resignation or indifference, not effective resistance. For Scheper-Hughes the misrecognition and indifference place a veil over the state, which is the ultimate source of responsibility for this terrible violence of everyday life.
Scheper-Hughes first seems to accept an earlier criticism by Marilyn Nations and L. A. Rebhun (1988) that she is blaming the victims by presenting them as unfeeling and negligent/incompetent in mothering, but later on she disagrees with them, specifically when she suggests that the mothers do not (cannot allow themselves to?) experience deep emotion. Clearly, Scheper-Hughes's own response is ambivalent, as how could it not be? At times she seems to indict the mothers and the community as broken, predatory, and dangerously failing in the tasks of everyday life; at other times she sees the denizens of Bom Jesus in a more sympathetic light as engaging in the tactics of survival under almost impossible odds; then again, at other places in this very long book, they become heroes and heroines in a cultural melodrama of capitalist oppression.
About the only hopeful event is the possibility carnaval offers of a space of forgetting, being subversive, and offering resistance. "If the everyday world is structured by the metaphor of the luta in which suffering (sofrimento ), pain (dor ), and sickness (doenca ) mask one's passage through time and space along the path that leads inevitably to death, then once a year carnaval ruptures the linear and tragic trajectory" (p. 481). But in fact little in the way of effective criticism or resistance erupts into public space. The poor of Bom Jesus are not rebels, they are skeptical of radical solutions, though the author seems to want to maintain the hope that they might revolt. Rather, by keeping the peace and enduring, they tell us about an even more terrible turn in the ontology of suffering that Scheper-Hughes does not explore: namely, that men and women can endure, survive, and even adapt to the most inhuman of conditions. Though Scheper-Hughes mentions transcendence and transformation, we don't see much of it in her description, and the thrust of the ethnography makes the reader doubt that these terms could be anything but a romantic reaction to the mundane horror of it all. There are no heroes here.
Scheper-Hughes's considerable artistry helps her to conclude something valuable about the place of social and personal meaning and action in the desperate world she has so impressively recreated for her readers: "in granting power, agency, choice, and efficacy to the oppressed subject, one must begin to hold the oppressed morally accountable for their collusions, collaborations, rationalizations, 'false consciousness,' and more than occasional paralysis of will" (p. 533). The ambiguity of her summary seems right to this reader for a subject in which the humanity of the victims is at war with the social reality of their participation in the victimization.
Scheper-Hughes's ethnography, despite many strengths, also has a number of problems. At times the voice of the author is shrill and polemical. Her use of "bad faith" as a criticism hints at a tendency to be extreme and one-sided that is generally controlled, yet occasionally bursts through the scholarly constraints. Calling the favela a bad-faith economy is not only one-sided but contrary to the generosity that the author otherwise extends to its members (pp. 126–127). Calling most physicians and anthropologists exemplars of bad faith because they fail to recognize the secret indignation of the poor and the hunger pains of starving communities is so extreme a claim as to render this part of the ethnography suspect of exaggeration and name-calling (pp. 167–177, 209). Whereas the section on the lived experience of hunger is an effective description of the everyday reality of chronic starvation and its effects (pp. 135–140), the equally important section on hunger and sex (pp. 163–166) is uncharacteristically superficial, as if this was one area of collective and personal life into which she felt constrained not to trespass. Why? The view of nervoso (nerves) as an idiom of hunger is original and important, but surely nervoso is a social idiom for other kinds of distress as well. Scheper-Hughes's account of the experienced meaning of nerves as hunger alone is an example of anthropological reductionism to a single source.
In the course of this one-sided argument about "somatization," Scheper-Hughes discounts much of medical anthropology, for which this topic has been an important issue over several decades. Many of the conclusions she draws about the social sources and consequences of bodily forms of distress are presented as if they were original; in fact they represent long-standing conclusions in the field. For example, she accuses me of writing too narrow a medical and cognitive account of somatization, based upon the idea of defense mechanisms, which she dismisses with a wave of the hand; yet most of the conclusions she draws about somatization in 1992 (pp. 186, 195) are in fact conclusions I drew in my major publication on the subject in 1986, Social Origins of Distress and Disease , a work she fails to cite. The idea of defense mechanisms is not the main point Joan Kleinman and I make in the 1985 paper Scheper-Hughes does cite (p. 185). At the least, this self-serving lapse is a matter of poor scholarship.
Other problems include a tendency at times for a "good guys, bad guys" analysis that, precisely because the ethnographic descriptions are so thickly human and morally complex, seems simplistic and out of place (p. 244). The rhetoric heats up to revolutionary levels at these times, but given the atrocities she witnesses and the author's openness about her two-sided role as ethnographer and community organizer, this is readily understandable. The analysis properly accuses the state for its not so invisible hand in creating human misery. Yet the author would do well to push the political analysis further. Inasmuch as we live in a time of failed states—the former Yugoslavia, Liberia, Somalia, Rwanda, Cambodia, Afghanistan—where violence, which seems nearly uncontrollable, emerges out of anarchic ethnic and class and factional conflict, one might well wonder whether the inhabitants of Bom Jesus suffer only from the brutalities of state repression and the routinization of poverty, or perhaps also from an absence of social control because the state is unwilling to be present or incapable of exerting responsible local authority. If so, and sometimes the author seems to suggest that one of these alternatives may be the case, the analysis needs to go more originally beyond the conventions of the critique of the abuses of state power, to more fully interpret the failure of the state as a source of security and protector of well-being where the problem is the absence of appropriate state power. In a volume that in other ways is so ambitious and important, there is surprisingly little done to build original social theory about the violence of everyday life.
The author, in an act of courage and moral engagement, takes a child away from a mother who is neglectful, almost morally neglectful (p. 343). Yet elsewhere in the book she criticizes middle-class Brazilians for doing the same thing. This would seem to be a double standard that calls for self-reflective enquiry. What we get instead is a description of a melodrama in which the author has become a chief actor with lines that are often hyperbolic, and therefore a missed opportunity for some deeper critical reflection (see p. 436). This problem probably explains why the analysis of women and grieving is less convincing than in Seremetakis's ethnography. It also keeps the author from probing into the complexities of person and actions on the part of her friend Biu. The photo of Biu (p. 466) is hauntingly complex; the biographical description is richly suggestive and highly germane; but there is little analysis of how Biu is to be understood. That Scheper-Hughes shies away from too intricate a description of a good friend whose behavior is personally troubling to her is understandable. But because Biu is such a larger-than-life protagonist in the book Scheper-Hughes's reticence leaves the reader ultimately disappointed.
Here, then, is an ethnography of considerable importance and deft artistry that works hard to be a serious contribution to the study of human misery as well. That it is marred by the problems I have noted also needs to be taken into account in summing up the value of the work. In his introduction to Emile Zola's Germinal, Leonard Tancock, the masterly translator, defends Zola against those critics who contend that the author exaggerates the suffering of the immiserated mid-nineteenth-century French miners who are the subject of his narrative. "It is," says Tancock, "a grandiose epic poem of human misery and the revolt of the oppressed, but in no sense a true account of affairs as they could ever have existed at a given time." That is to say, to produce the effect he wanted the tale to have on readers, Zola took liberty with details, dates, and occurrences. Scheper-Hughes's narrative also carries telltale signs of exaggeration, including a powerful narrative line stuffed with all the classical tropes of desperation and squalor, compression of events, selective presentation of detail, illiterate women whose voices are almost too fluidly eloquent, and a very thin line between the author's incandescent sense of injustice and her disciplined ethnographic description of "the facts" of everyday life. The reader wonders if this is tragedy masquerading as ethnography—an epic of wretchedness, not a social scientific treatise. Whatever it is, it is memorable, a major achievement, and will be, as the author intended, a provocation to other researchers of human suffering.
At about the same time that Death without Weeping appeared, Pierre Bourdieu published La Misère du Monde (1993), a volume of studies under his direction by his students and coworkers. This book, too, has to do with the violence of everyday life, in this instance among the poor in France and North America. A huge (900 pages), unwieldy, and fragmented collection, the "testimonies" of misery that its authors present are stitched together by Bourdieu with a running commentary that is complex and not always coherent. Yet Bourdieu's remarks occasionally flash with brilliant originality as he too grapples with the frustrating crosscurrents in everyday worlds of brutality and wretchedness. These are ideas that ethnographers of social suffering will find helpful in formulating theory for their difficult subject.
For example, in his introductory "Lecteur," Bourdieu writes about the "misery of position," the social tragedy that comes from being placed in a more or less fixed position in the social order, which he contrasts with the "great misery" of the worst of social worlds and circumstances. Bourdieu theorizes that because of the hierarchy of positioning, there is a "characteristic suffering of the social order." This is due especially to placement in localities where there are no functioning institutions, where people are survivors of "an immense collective disaster" like the closing of factories, for which he has in mind American inner-city ghettos and impoverished, immigrant Parisian banlieues (suburbs). The social tragedy of its occupants also results from the collision of social interests. He describes one such banlieue where a factory had closed, leaving behind an urban desert, a big avenue without trees, without houses, walling in discrimination, despair, and fatalism among the survivors. Here the state is absent—there are no schools, no health institutions, not even police. Commenting as well on essays in the volume by Loïc Wacquant about the south side of Chicago and Philippe Bourgois on Manhattan's Spanish Harlem, Bourdieu writes about the lieu , the point of space where an agent is situated, a locality for memory and emotion, a social site characterized by its relative position vis-à-vis other social localities, so that the lieu can be characterized by what is not in it. Writing of how the lieu also materializes hierarchy, social distance, and political appropriations, Bourdieu argues for the theorizing of social space as the relationship between the distribution of agents and goods that defines the value of different socially reified fields. Later on in his comments on "The Struggle for the Appropriation of Space," Bourdieu brings habitus and the habitual into juxtaposition with habitat in order to suggest how his theory of symbolic, cultural, and linguistic capital can be applied to understand how social space and bodily space intersect. While never entirely convincing, and at times it is characteristically elliptical, Bourdieu's prose is a crucial struggle to develop social theory that will support comparative ethnographies of social suffering, so that ethnographers can go beyond personification to understand social misery as social experience. In this respect, La Misère du Monde , for all its wordiness, points to a telling absence in Scheper-Hughes's account. Death without Weeping does not offer a social theoretical interpretation to match its extraordinary intensity of descriptive prose. Yet, without social theory, it is uncertain how different ethnographies of the violence of everyday living can construct an ethnographic subject that differs from that of psychologists or novelists. I would hazard the suggestion, therefore, that the search for social theories of the human misery of violence, poverty, and oppression will preoccupy the next generation of ethnographers.
The Ethnography of Medical Education and Biomedical Science
Two of medical anthropology's senior members, who are among the most theoretically oriented in the field—Byron Good and Allan Young—have published many influential articles since the late 1970s. Curiously, both are publishing their first single-author book in the mid-1990s. Not surprisingly, then, both books are extraordinarily rich combinations of social theory and ethnography. Both Good and Young began their careers with studies of illness and healing in the non-Western world: a Turkish community in Iran and an ethnic region of Ethiopia, respectively. Both later turned to biomedicine in their own society: Good to the study of how medical students are initiated into the biomedical gaze, and Young to an ethnography of a clinical center for the treatment of posttraumatic stress disorder (PTSD) which is the basis for an exploration of psychiatric science. Taken together, these contributions substantially extend our understanding of the cultural grounds of biomedicine and of science generally. It is not accidental that two senior practitioners of medical anthropology have settled on the anthropology of science and technology. This is becoming a central topic in the discipline, even if the number of ethnographies of biomedical science is still quite limited. Reviewing both contributions will enable me to return to several themes developed in the essays in part 1 of this book.
Byron Good's (1994) Medicine, Rationality, and Experience: An Anthropological Perspective, hot off the press at the time I am writing this chapter, is a serious contribution to theory in medical anthropology and in anthropology more generally. Based upon the Lewis Henry Morgan Lectures that he gave at the University of Rochester in 1990, one of anthropology's most prestigious lecture series, Good's book packs together a variety of things including theoretical explorations across virtually the entire field of medical anthropology, several ethnographic chapters, and reexamination of anthropology's long-standing debate on rationality. His ideas will be discussed and debated over the years to come because they offer seminal observations on so many different themes in medical anthropology. It is not my purpose here to review the entire book; instead I focus narrowly on the book's main ethnographic contribution, a study of the education of medical students at Harvard Medical School. Although presented in only a single chapter, in fact the ethnographic materials in this chapter are the grounds for much of Good's analysis of medicine, science, and rationality, and they in turn are effective precisely because Good has prepared the way in his earlier chapters.
Good's orienting concern is well summarized by the chapter's title, "How Medicine Constructs Its Objects." He observes that "medicine formulates the human body and disease in a culturally distinctive fashion " (p. 65; italics are in the original). Medical students are taught in this distinctive manner an approach to the reality of diagnosis and the nature of treatment that seems "natural" and outside of culture. To the contrary, insists Good, "biology is not external to but very much within culture " (p. 66; italics are in the original). This large claim Good identifies as a continuation of Foucault's (1972) examination of the changing objects of medicine historically. But it is not the French historian and philosopher of science but rather Ernst Cassirer (1955) of the Philosophy of Symbolic Forms who provides Good with a modus operandi : namely, Cassirer's idea of "formative processes." In the long-term European debate between empiricism and idealism, Cassirer, a Kantian up to a point, proposed that symbolic forms (culture) organize reality distinctively. Cassirer was interested in the "formative principles" in language, myth, religion, art, and science that give to life its particular cultural shape. The formative principles create their own symbolic forms, which in turn constitute reality. The objects of religion, mythology, aesthetics, and science are those crucial symbolic forms. "The 'objects' of medicine are similar kind" (p. 68). Foucault's (1972) notion of the discursive practices subsumed under a particular discourse and the contemporary social anthropological concern with "practice" (Ortner 1994) are viewed by Good as ways of approaching this study of the symbolic mediation of reality, including medical reality. For Good, the materialist and moral components of medicine's symbolic forms are exemplified in "the role of medicine in mediating physiology and soteriology" (p. 70).
Medical students learn to construct medical reality through the practices of "seeing," "writing," and "speaking," which they undertake from day one in the medical school. For Good, medical education commences with anatomy: "entry into the human body" (p. 72). In anatomy laboratories the body as they have known and lived it is made over into a medical object. Reflecting on his own participant observation, Good observes: "One of the most shocking moments in anatomy lab was the day we entered to find the body prepared for dissecting the genitalia, the body sawn in half above the waist, then bisected between the legs. Students described their shock not at close examination of the genitalia, nor simply at the body being taken apart, but rather at the dismemberment, and at dismemberment that crossed natural boundaries."
Students are self-reflexive about learning a new way of seeing: along tissue planes, through gross dissection, under the microscope in finer and finer detail. Learning medicine is learning to reconstruct the world anew, medically. "Modern imaging techniques give a powerful sense of authority to biological reality. Look in the microscope, you can see it. Electron microscopy reveals histological concepts as literal. Look for yourself—there it is!" (p. 74).
In learning to see medically salient objects, students learn a hierarchical order of biological reality. The patient with the symptoms of a pathological entity like arthritis is compared to the pathological anatomical specimen. The gross specimen is compared to the microscopic picture; the latter is further reduced to derangement in biochemical processes at the molecular level. Thus, a student tells Good how he first learned about schizophrenia as behavior, then about genetics, and thereby came to see it as a disordered protein, still unknown, but lurking in nature as the "concrete" locus of the affliction. The strategy of teaching is to deconstruct a health problem by projecting a hierarchy of images from epidemiological slides of population-based data, through slides of individual patients, to slides at ever lower levels of the biological order of pathology. Like "the great chain of being" in an earlier epoch of Western civilization in which the ontological order is presented from animals to God, the late twentieth century's biological order instates a central hierarchy, but one in which "lower" rather than "higher" forms of reality are more fundamental. Thus, Good describes the cultural practices through which biological reductionism becomes the central vision of the medical student. Reductionism for the student is not epistemological commitment; rather, it is an active process of ontological genesis (objectification) of medical objects out of human problems.
From medical seeing, Good turns to learning medical writing and speaking. He demonstrates with examples from the experiences of Harvard medical students that the write-up of a medical case "is not a mere record of a verbal exchange. It is itself a formative practice, a practice that shapes talk as much as it reflects it, a means of constructing a person as a patient, a document, and a project" (p. 77). Writing authorizes the neophyte physician as an expert with a certain methodological expertise. It also organizes the interactions with the patient. Interviewing, writing, and speaking before a clinical audience instruct students on how to edit the person and the context out of the account of the disease and its treatment, the key elision in converting pathos into pathology.
Good dissects student presentations as a genre of storytelling. "Virtually every student remembers the pain of telling a story poorly and enraging a resident or attending" (p. 79). The clinical presentation uses rhetorical strategies to "persuade your audience," as one of Good's medical students aptly puts it. "Students," observes Good, "become quickly aware of the performance dimension. They rehearse presentations, learn to give them without notes, even to make up details if they do not remember exactly, and are very aware of the response" (p. 80).
Clinical stories, for Good,
Seeing, writing, and talking "medically," the student is authorized to be a participant in a Wittgensteinian "language game" that in turn creates a "way of life"—an ontology of being medical. And that ontology has "tremendous consequences in the real world" (p. 81). As one of the protagonists in his striking excerpts from interviews with informants troublingly puts it:
Good demonstrates how the experiences of students in the totalizing environs of the hospital socialize them into a hierarchy whose control is exerted through the transformation of the arbitrary into the logical, the symbolic into the real, and that also teaches them to misrecognize what is "cultural" for what is "natural." In conducting this demonstration, Good is at pains to avoid posing the conventional criticisms of medicine that would seem to flow from his accounts. His cultural deconstruction has a more original and fundamental purpose. To understand "medicine as a symbolic formation," Good avers, it must be seen to contain not only the rational-technical organization of physiology, but also an existential, or as he puts it, soteriological dimension (p. 84). The medical student is part of a "moral drama" of human fear and suffering, and of a confrontation with death. When the moral erupts into the domain of the technical-rational, however, it is misrecognized as yet another technical-rational object. Thereby the life world is colonized by an instrumental rationality that cannot possibly engage moral questions. And yet, Good observes, based upon a long experience in medical settings, "Medical practice can never fully contain the moral and the soteriological" (p. 85). Students—not all but still many—want a passionate engagement with this human side of sickness. And this desire to be a healer of persons persists, in spite of all the technical training, in clinical practice. This is what makes medicine the particular form of experience that it is. But Good has even another turn of the screw in store for the reader.
"What I am suggesting is that medicine is deeply implicated in our contemporary image of what constitutes the suffering from which we and others hope to be delivered and our culture's vision of the means of redemption" (p. 86). In an epoch with a commitment to the cultural prisms of materialism and individualism, health replaces salvation. Thus, salvation becomes a hidden part of medicine's powerful technology and also contributes to popular outrage about the practice of medicine.
Regrettably, Good's discussion of this crucial question is barely long enough to set it firmly on the table. How do medical students and practitioners experience the soteriological? What is the ontology of redemption in medical work? What are its forms cross-culturally, especially when biomedicine is practiced outside the Judeo-Christian tradition, where redemption's lineaments are culturally authorized? Good deploys his formidable analytic structure to address many important aspects of illness, care, and medical science, aspects that will make his book influential, yet the theme of salvation, so resonant and so original, is not unpacked much further. A rapprochement between medical anthropology, the anthropology of religion, and anthropological approaches to ethics would seem a next step in the conversation on the culture of medicine that Good's impresive mix of social theory and ethnography so usefully facilitates.
That medical science and practice is a domain in which the moral, the existential, and the scientific traffic is a conclusion that Allan Young's (in press) account of posttraumatic stress disorder does not find inappropriate. Young's The Harmony of Illusions examines the emergence of PTSD as a collective representation and as a new object in psychiatric science in order to understand "Western rationality" as consisting of a culturally specific way of narrating certain events and of asserting epistemological privilege. Leaning on the work of Ludwik Fleck (1979), Young takes the title of his ethnography from the idea that "rational inference is a way of narrating the production of facts, rather than a technique used for producing them." Fleck, himself a biological scientist, held that "scientific facts" are products of "thought collectives," networks of scientists with particular "thought styles." For Fleck, the "thought collective" is engaged in knowledge production and communication. The peculiar "thought style" of a collective, in Young's reformulation, is an assemblage that includes technologies, rhetorics, and paradigms. The stability of a network of scientists' agreements on concepts, methods, and outcome is not based in their rationality but is what Fleck, referring to the achievement of the collective's social process of knowledge production, calls "the harmony of illusions." It is this harmony of illusions based on the entire social apparatus of science as a form of social production that gives the scientist the sense of something in the real world that resists his studies and constrains his thinking. In actuality, every scientific object is a "technophenomenon" created out of the socially constructed process of rational-technical production. Only in after-the-fact accounts do scientists narrate a different story about the scientific process that separates it from the "reality" of its objects, the phenomena it studies and produces.
Young proceeds from a theoretical grounding in the anthropology of science to explore the gap between scientists' (and philosophers') formulations of the rationality of science as rule-guided by ideas of inference, contradiction, and falsifiability and the anthropological interpretation of the process of scientific work. The latter is closer to a view of science as the stuff of analogical thinking—metaphors, models, narration—working through instances and applications in local settings from which the particular is elaborated into the general. Much of Young's book is an effort—almost wholly convincing to my mind—to interpret PTSD as an example of these (and other) social processes.
Thus, Young shows how the community of researchers comes together, creates its object (traumatic memory), establishes its preformed template for generating knowledge, advocates official diagnostic status, creates consensus on instruments of measurement, authorizes the "validity" of findings/facts and diffuses and promotes the official narrative of what PTSD is and how it should be treated. Were Young's account an airtight blow-by-blow description of the forging of "entity" through community out of "meanings," it would be much less arresting than it is. What gives this volume its exhilarating effect are its extraordinary digressions. For in telling his story, Young tells many side and sub and supra stories, all part of the major account, yet several of which take on a life of their own, much to the fascination of the reader.
For example, Young dilates on constructions of probability in a section that starts off as an argument about testability, reliability, and validity, yet ends up with a surprising detour through the writings of statisticians and others whose work bears upon the much wider issue of the scientific meaning of "facts." Similarly, an arresting discussion of the social organization of time in scientific discourse is spun out of Young's interest in fallibility. But to my mind, the most intriguing discussion is Young's account of W. H. R. Rivers's contribution to the "discovery" of "traumatic memories."
Rivers initially appears in the ethnography near the beginning of the manuscript during Young's historical survey of the problem of war-related trauma in the Great War and the way such traumas were handled by military psychiatry. This is a much more detailed account than is needed if Young's point is to show how the psychiatric formulation of war neuroses is constrained by the experience of war, the work of psychiatrists, and the lineaments of psychiatric discourse. Indeed, this almost certainly is Young's purpose, but once he has gotten into the scholarship, it is as if Young does not want to let go. And thank goodness he doesn't. Because what is astonishing about the chapter is what Young tells us about Rivers. To my knowledge, no one else makes the claim that from the beginning (in his classical ethnographies) through the middle years of neurological experiments and development of psychological constructs, right through to the final phase of clinical work, Rivers's greatly diverse contributions carry a unity, a coherence of framework that links such seemingly disparate domains as his ideas about suggestion, pathogenic and therapeutic; protopathic and epicritic neurological sensitivity; mimesis, sympathy, and intuition; the simple and dynamic unconscious; and the treatment of "shell shock," hysteria, and neurasthenia. Usually, Rivers is portrayed in medical anthropology as something of a romantic failure. Brilliant contributor to at least four separate fields—social anthropology as ethnography, experimental neuropathology, comparative psychology, and psychotherapy—Rivers's failure, it is assumed (and I, too, held the assumption), is that he does not leave behind him a legacy of an integrated field.
That is to say, while Rivers certainly did medical anthropology in one phase of his distinguished career, he did not build a program for medical anthropology as a field. If Young's reading is correct, then Rivers's contribution must be rethought as having succeeded in bridging ethnography, social theory, psychosomatics, and psychotherapy with a set of principles that laced together theory, methods, and practice in an exemplary, if heretofore unappreciated, manner. That this is not the received version has more to do with the great flood tide of psychoanalysis which Pierre Janet, like so many others, saw burying alternative programs, including, Young suggests, Rivers's, in the sand of oblivion.
Young's contagious affection for Rivers leads him to question as well the dichotomous portrayal of the electrical treatment practiced by Lewis Yealland and the talk therapy practiced by Rivers as the classical materialization in treatment of Britain's fundamental divide between silent working-class soldiers, who are punished for suffering hysterical paralysis in the face of battle, and upper-class officers afflicted with neurasthenia, who are talked out of their remorse-laden dilemmas. Young gives us a sense of how cultural historians like Eric Leed and Elaine Showalter and novelists like Pat Barker have overcoded a divide that is more and more porous, fuzzy, and complexly human. Young's reconstruction of the case is a tour de force that could stand entirely on its own as an independent essay. Yet when woven into the book-length account it is not at all an unnecessary digression, but rather a highly instructive parenthesis that evokes the larger moral questions of how we understand warfare's traumatic effects at the same time that it develops the historical background for the military and psychiatric emergence of PTSD.
That same plethora of space encourages Young to include entire transcripts of group psychotherapy sessions in a Veterans Administration Hospital's "Center" for the treatment of Vietnam veterans suffering from PTSD as rich primary materials for understanding the discursive practices by which a psychoanalytic approach to trauma is used to construct the problem, to control the process, and to create the outcome of treatment—the social experience of efficacy—and its evaluation. Young's sensitivity in limiting his interpretation of these sessions makes the ethnographic materials all the more powerful as a demonstration of the social production of cure/treatment failure.
The limitations of this work are few, yet important. The description of the treatment unit is thin, as is discussion of the specific persons and groups engaged in PTSD as a collective project. Young is much more comfortable at interrogating or deconstructing the historical record and philosophical texts than he is in pursuing the interpretation of how the treatment sessions change the participants. Much of this story implicates American culture, yet the engagement with questions of power in American history and ethnography is limited. Surprisingly, Young has written himself largely out of the account. Yet, as a participant in the Vietnam War era, we need to learn more about how he is positioned. None of these problems seriously limits the significance of Young's accomplishment. At the end, we are led back to the moral and political abuses that American politicians, military leaders, and policy planners perpetrated on American soldiers, who quite obviously themselves became perpetrators as well as victims. Traumatic memories are more than objects of professional practice and scientific inquiry; they are a particular instance of the human atrocity of war for combatants and noncombatants alike. PTSD is part of this nasty legacy. For here medicine, politics, and morality are inescapably connected in cultural processes that construct the experience of trauma as well as the experience of diagnosing and treating its sources. (See chap. 8 above.) And here, too, science is implicated in the politics of history. As the Vietnam War recedes as memory of a distant past, the DSM-IV widens the criteria so that traumatic memory can encompass the fashionable human problems of the new world disorder.
Margaret Lock (1993a), Allan Young's colleague at McGill, has also written a book that contributes to the anthropology of biomedical science, although this is only one of its sides. Encounters with Aging: Mythologies of Menopause in Japan and North America is a curious, yet powerful, ethnography. It is curious from the perspective of ethnography because the research framework is a large survey of Japanese women regarding their experiences and ideas of menopause. Thus, there is no community or even network that grounds the study. Rather Lock and her associates traveled to many different settings in Japan to interview the survey's respondents, few of whom they knew well and many of whom lived and worked in locales that they did not study. What organizes the respondents' narratives is a focus on the social experience of aging in Japan and the place of menopause in that large cultural, moral, and political context. Playing off quantitative data against personal stories, Lock succeeds in creating an ethnographic focus that includes the cultural forms of Japanese society and their multifarious, contradictory, and changing contours. Against that huge ethnographic landscape, she contrasts materials from studies of menopause in Canada and the United States by sociologist colleagues—Patricia Kaufert and Sonja McKinley—with whom she has collaborated. The outcome is a success at comparative research that is even more impressive precisely because this style of work is becoming uncommon in anthropology.
Lock draws on the many studies she has conducted in Japan and her comprehensive knowledge of Japanese history and society to create a richly textured backdrop for her narratives and numbers. What starts out as research on menopause quickly takes on a much larger theme, as it becomes clear that the subject matter—as the book's title insists—is really aging, particularly the aging of women. Japanese women across the social spectrum do not seem fixated on the end of menstruation as a time of disruption or decrepitude. Nor are symptoms like hot flashes and drenching night sweats, which are common-place in North America, either widely experienced by menopausal Japanese women or disturbing. The symptoms they focus upon, when they focus on complaints (and many don't), are different ones—shoulder stiffness, for instance. Konenki, the relevant Japanese term, "means something more encompassing than the end of menstruation … part of a general aging process in which greying hair, changing eyesight, and an aching and tired body appears to have more significance than does the end of the menstrual cycle" (p. 6). Konenki conveys the idea of "change of life," but even that is contradicted and contested by respondents. Konenki "is not a subject that generates a great deal of anxiety or concern" (pp. 10, 14). There is "no deep sense of loss at this time of life" (p. 45).
What regret there is, for some but by no means all Japanese respondents, is "about the way in which choices made by their parents when the women were very young imposed major limitations on what they can realistically expect to do in middle age" (p. 50). Many were simply not educated for jobs in the workforce, but were prepared only for marriage and family life. The burden of taking care of sick elderly relatives comes across in the narratives as a constraint on midlife options. But criticism of this or any other part of their life of service in the family is balanced by many positive aspects of that role which is seen as "natural" to the social experience of women. The narratives of aging informants provide Lock with a prism to refract the light of anthropological critique on the moral order of Japanese society. She canvasses, inter alia, the "natural" subjugation of women (p. 83), the domestic "cult of productivity" (p. 89), the image of the "good wife and wise mother" (p. 89), and the priority of interpersonal good over subjective desire in order to understand how cultural themes organize the life course of Japanese women. Yet within the norms she discloses the paradoxes: "society values hard work, perseverance, and self-discipline; but running a small modern household for a husband absent most of the time requires few of these virtues" (p. 101). Women work hard within the family and in a variety of positions outside, yet critics castigate them for boredom, a life of luxury and selfishness: "a moral disease accompanies the physical symptoms of konenki " (p. 103).
It is to Lock's credit as an ethnographic analyst sensitive to the complexity of ethnographic contexts that she evokes and then deconstructs this and other myths not because she wishes to expose a "different" reality, but because she wishes to show that social reality itself is plural and heterogeneous; it is formed, she avers, by a dynamic dialect between culture and psychobiology that sponsors multiple and differing outcomes. The narratives she recounts are filled with the peculiar details of distinctive lives and life worlds. Reading them, we feel we are brought into the midst of the multiplicity of experiences of aging Japanese women as fully as if we had read the relevant sections of highly condensed novels. Contrasting survey data with narratives empowers Lock to go back and forth between particular and shared themes.
Of the latter, the ones that impress themselves most insistently on the book are "fatigue from misery" (p. 123), the sacrifices of daughters-in-law in the generation born in the prewar era, who do not expect the care they have devoted to their elderly in-laws to be devoted to them, the "illusion of indolence," and the changing modes of social experience which make the feel of life as well as its meanings transitory. Lock shows the role of mythologies of aging as ideology in Japanese society, where that ideology supports the interests of a conservative order that has produced economic success and social harmony at the expense of personal flourishing. She provides many illustrations, enough to show us the atypical as well as the normative. The marvels of narrative are the intricacies of detail which color experience and enable us to appreciate the fine grain of improvisation, novelty, and difference that make life so much more than a model or statistic can convey. Lock lets the transcripts of her recordings proceed. She plays them at length so that we feel we get to know her respondents. And those respondents, it turns out, have a lot to say, much more than is coded into their numerical answers on the questionnaire. Yet there is also ample interpretive commentary so that the book is hers, not theirs.
At times, Lock seems frustrated with her subjects' passivity in the face of systematic pressure to be restrained and accepting of the naturalness of the ideology of male-dominated families. Lock clearly wants these Japanese women to fight back. Yet, though most of her informants seem resigned, they are not altogether unhappy. They find meaning and satisfaction as wives and mothers. The very process of naturalization gives them important status and even identity. And they are not terribly bothered by menopause, even though some, and perhaps many, regret the constraint on the self. Maturation within the Japanese social order is not "a search for a 'true,' autonomous self but rather a lifelong process … in which individuals come to understand themselves first and foremost as social beings, as products of units and forces larger than themselves and without which they could not exist" (p. 202). There is also self-cultivation, albeit in this decidedly social idiom, and Lock lets us see that, including its resonance with the "theme of self-discipline culminating in eventual escape from the toil of this world" that has cachet in the religious contour of Japanese history (p. 206).
The large body of materials on child development in Japanese society are put to excellent use in support of the overall argument. Hence, we learn how habitus is formed out of the cultural phenomenology of sensibility to the interpersonal as the bodily grounds of social life. Of the emotions, Lock suggests that loss and depression are not nearly as salient in the social experience of middle-aged Japanese women as they are in the West. Rather anger (more often irritability) and its control are central to the Japanese experience. Thus, the Japanese comparison undercuts leading Western perspectives on the life cycle.
"Reflecting on the entire female life span, we would say that middle age in Japan is relatively inviting, a transition from which individuals can both look back over the previous fifty years and forward to the next thirty and, given financial security, usually report good fortune and happiness. Nonetheless, a closer look at some of the narratives of middle-aged women reveals that beneath the surface of apparently unruffled lives a good deal of 'low-profile' resistance (Scott 1990, p. 198) takes place much of the time" (p. 240). This is the part of Lock's analysis which is least successful; probably because we would need ethnographic description of families and work settings over time in order to reveal the subtleties and longer-term effects of such techniques of resistance as "retreatism," "ritualism," and divorce.
Lock's success as an analyst comes in no small measure from her honesty about the kinds of data she doesn't possess and therefore the limits on her interpretation. How many researchers working with so much information and with so much at stake in the analysis would conclude as she does that no single pattern or cluster of relationships emerges from the study? There is no simple mapping of konenki onto distressing personal or family situations. The same sensibility to the refractory heterogeneity of social experience characterizes Lock's portrait of the diversity of medical responses. There is no doctor bashing, but neither is there any camouflaging of the confusion in the changing patterns of medical practice. Danger looms less from medicalization from the medical profession than from the building pressure of the drug industry. Nor does Lock fail to see the potential political danger of an essentializing, indigenous culture-biology discourse that picks up on racialist sentiment about "being Japanese."
There is another side to this book. Lock is effective at contrasting the sensitivity of the Japanese discourse on konenki to cultural peculiarity with the concern of North American and European discourses to sustain the universal nature of menopause. The making of menopause in the West is a story so substantial that it almost escapes from the limits of the book as Lock leads us through two centuries of Western medical writings. Yet, again her history as much as her anthropology is scrupulous about not caricaturing traditions. As she states, "there was (and is) no simple unveiling of scientific knowledge and no ready consensus in the medical world on an accurate representation of the menopausal transition; on the contrary, argument and speculation were (and remain) rife" (p. 317).
Lock's passion is clearly aroused when she describes the tendentious arguments of medical researchers in the West to the effect that menopause is a hormone-deficiency disease requiring endocrine replacement therapy, and when she attacks a misogynist psychoanalytic portrayal of the menopause that reads in the 1990s like an indictment of an entire discipline.
Menopause, Lock concludes, "is neither fact nor universal event but an experience that we must interpret in context" (p. 370). Her ethnography, like others featured in this review, is concerned with lived experience as the key to unlocking the mysteries of the social world. That understanding, she observes frequently, should be of "an intimate exchange between biology and culture" (p. 372) that shows that both are malleable and mutually constructive. Both are forms of local knowledge, of local experience.
Lock is also serious about theory. The prologue and epilogue frame the research and the review of the literature with a discussion of the way ideology enters into scientific discourse as well as into embodiment and subjectivity, with a reflection on the relationship of subjectivity and objectivity, and with an argument about the making of women as agents of social reproduction and as scientific facts. Particularly appealing is her discussion of the politics of knowledge, about which she gives so many telling examples in the book's 387 pages of text.
Any good book, and this is a good book, shows its limitations in building its strengths. Lock's combination of survey and ethnography points toward the culture-biology dialectic, yet doesn't say much about how it may be mediated. Perhaps this is because she tends to focus on the absence of hot flashes among Japanese women rather than on their own key symptoms. The reader suspects much more could be made of the social experiences of shoulder stiffness and fatigue among Lock's respondents as the interpenetration of memory, meaning, and moral physiology. But to do so would mean grounding them in interpersonal worlds. And so effective is Lock's description that we easily forget that this is not a study of any particular community. Also, for all the emphasis on the wider compass of aging, Lock's review of historical and ethnographic works does not engage the literatures in the history and anthropology of aging as much as one would expect. Although Lock makes excellent use of the work of Ian Hacking on the normal as norm and ideal, she doesn't choose to interrogate her own statistical data from this perspective.
Finally, the concluding interlude on hegemony seems stretched because the cultural account she has written is so sensitive to the multiplicity of social life. It is as if at the very end of her important volume, Lock felt the need to reassure herself that she was encompassing power sufficiently; hence the last few paragraphs on medicalization seem forced. Clearly, the hegemony she must deal with is much more diffused in family, work, and community. And what kind of hegemony can it be anyway if she can so convince us of pluralism, diversity, and change. One suspects that the nemesis is not medical but bodily. Japanese women do not routinely experience menopause as distress but neither do they experience life-cycle constraints and patriarchal oppression as distress. The hegemony perhaps is in the cultural illusion of bodily harmony, to put Fleck's attractive term to a different use, as social and personal well-being. And here perhaps Lock's aging Japanese women do get the last word, for by outliving men and crafting lives of significance, they suggest that the very idea of a burden or crisis of aging Japanese women is not their problem (strictly speaking it is a problem of their mothers and mothers-in-law) any more than menopause is, and it may not be their society's either. I take that to be one of the surprises that Margaret Lock wants her readers to consider.
There are other important ethnographies in this gathering wave besides those I have reviewed. The ethnography books written by Martha Balsham (1993), René Devisch (1993), Faye Ginsburg (1989), John Janzen (1992), Roland Littlewood (1993), Mark Nichter (1989), Lorna Rhodes (1991), Carolyn Sargent (1989), Unni Wikan (1990), and Francis Zimmermann (1987), to mention only a few, are serious and innovative contributions to the broad field of medical anthropology. They deserve to be reviewed too, but it is simply infeasible to describe them all. Although this review is restricted, I have tried to illustrate at least certain of the contributions that are remaking medical anthropology today. Their success means that there is no single agenda that dominates the field; instead, there are multiple styles, plural subjects, different methodologies, distinctive visions. In each ethnography, the working through of anthropology's cultural program and current concerns in social analysis takes a special turn. What is shared among the books derives as much from the recalcitrance of medical subjects as from the project of cultural analysis. After two decades in medical anthropology, I feel heartened by the quality of the ethnography, and by the promise it holds for scholarship. I do not doubt that ethnography is medical anthropology's most important contribution. Yet, as Charles Leslie has reminded the practitioners of this interdisciplinary field, the measure of its success must also include evidence that it matters for people in the world outside the academy. That will require additional steps that bring medical ethnographies into the domain of policies, programs, and practices.
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