SciELO - Scientific Electronic Library Online

 
vol.67 issue1The socio-rhetorical force of 'truth talk' and lies: The case of 1 JohnSalt for the earthen oven revisited author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Article

Indicators

Related links

  • On index processCited by Google
  • On index processSimilars in Google

Share


HTS Theological Studies

On-line version ISSN 2072-8050
Print version ISSN 0259-9422

Herv. teol. stud. vol.67 n.1 Pretoria Jan. 2011

 

AGVA FESTSCHRIFT

 

Medical anthropology as an antidote for ethnocentrism in Jesus research? Putting the illness–disease distinction into perspective

 

 

Pieter F. Craffert

Department of New Testament and Early Christian Studies, University of South Africa, South Africa

Correspondence to

 

 


ABSTRACT

Medicine often has side-effects or unintended consequences that are more harmful than the original disease. Medical anthropology in general and the illness–disease distinction in particular has been introduced into historical Jesus research with the intent to protect it from medicocentrism and thus to offer ways of comprehending sickness and healing in the world of Jesus and his first followers without distorting these phenomena by imposing the biomedical framework onto the texts. In particular the illness–disease distinction is used for making sense of healing accounts whilst claiming to cross the cultural gap. Based on an analysis of the illness–disease distinction in medical anthropology and its use in historical Jesus research this article suggests that instead of protecting from ethnocentrism this distinction actually increases the risk of ethnocentrism and consequently distorts in many instances the healing accounts of the New Testament.


 

 

Introduction

It is remarkable how frequently medical anthropology in general and the illness–disease distinction in particular are nowadays invoked in New Testament scholarship to facilitate ethnocentric-free cross-cultural interpretation. John Pilch suggests that insights from medical anthropology in general and the illness–disease distinction in particular will facilitate 'cross-cultural communication, understanding, and interpretation' (2000b:130). He maintains that concepts such as illness and disease, healing and curing 'have eliminated or at least minimized the risk of falling into medicocentric interpretations' (2010:147). John Dominic Crossan (1994:80) argues that insights from cross-cultural anthropology, such as the 'basic distinction' between illness and disease in medical anthropology, 'prevent us from projecting some current American presuppositions back into the ancient Mediterranean world'. For Eric Eve (2002:353), Kleinman's 'careful distinction' between illness and disease is devised for cross-cultural comparison and may be applicable to the ancient Mediterranean and therefore also to the gospel accounts. Richard Horsley claims that reductionist psychological explanations can be avoided when stories about demon possession are interpreted by means of critical medical anthropological categories. In particular the illness–disease distinction gives him the license to treat cases of demon possession as instances of political-economic exploitation whilst exorcisms are seen as events of opposition to imperial rule (see 2008b:43). In his words, 'critical medical anthropologists have recognized that illness often involves particular relationships of power, domination, and deprivation' (2008a:85).

If these insights were true, they would provide powerful interpretive tools for understanding Jesus' healings as historical acts whilst ethnocentric misinterpretation would be avoided. However, the truth is that taxonomic schemes, however necessary and indispensable for research, can also be the source of error and obfuscation when dealing with nature, history or reality. The first step in determining whether these claims are valid would be to ask how the distinction functions in medical anthropology and whether it in fact is a proper tool for cross-cultural interpretation.

 

Medical anthropology and the illnessdisease distinction

In the English language, the terms illness and disease are synonymous and often difficult to distinguish from sickness. However, in both medical and medical anthropological circles a distinction is often made: physicians treat (and cure) diseases and patients experience (and are healed from) illnesses.

Within the biomedical paradigm1 a conceptual distinction emerged between symptoms and signs. Symptoms are 'subjective feelings reported by the patient' whilst signs are 'objective indications of disease detectable by the physician' (Evans 2003:31). This is clearly illustrated by Howard Spiro from the Yale Medical School who remarks:

As a biomedical physician, I like to discriminate between the disease, which is what the physician or the imaging technologies can detect, and the illness, what the patient feels. For me, as a gastroenterologist, disease is the stomach ulcer; dyspepsia, its pain, is the illness.

(in Harrington 1997:211; see also Helman 1981:551)

However, for at least two related reasons the application of this distinction to cross-cultural settings is problematic.

 

The fluidity of terms

The first reason is that the definition of both terms illness and disease is rather fluid. This can be illustrated by looking at the term disease which is complex and imprecise in many respects. For one, it is not always easy to identify something as a disease. Spiro remarks that the distinction between disease and illness is rather 'fuzzy' (1997:45) and illustrates it by asking whether hypertension is a disease or an illness. What about cancer and high cholesterol (see 1997:46)? In chronic disorders such as diabetes, ischemic heart disease or asthma it is difficult to distinguish the disease form the illness (see Kleinman 1980:74). Furthermore, it is widely acknowledged that sickness can occur in the absence of disease (see, e.g. Kleinman 1980:74) whilst someone can have a disease (such as, asymptomatic hypertension or HIV infection) without being sick (see Eisenberg 1977:11; Helman 1981:551).

The view of disease as merely physical, biological or related to viruses, bacteria and the like does not even hold up within the biomedical paradigm. In fact, within the biomedical circles of the World Health Organization (WHO) the term disease is today used for a broad spectrum of sicknesses, the majority of which is probably sociogenic (see, e.g. Winkelman 2009:39).2 Even within the world of biomedicine few would think of disease as purely organic or biological. Disease, the medical anthropologist Merril Singer remarks, 'must be understood as being as much a social as a biological product' (1990:182).

Hence, it should be kept in mind that the term disease is nowadays used (in a narrow sense) to describe sicknesses that have organic or physical causes or to describe (in a wider sense) any organic and physical manifestation of sickness (immaterial whether the cause is infectious or social). It should be noted that Murdock uses the term illness synonymous with this broad definition of disease as 'any impairment of health serious enough to arouse concern, whether it be due to communicable disease, psychosomatic disturbance, organic failure, aggressive assault, or alleged accident or supernatural interference' (1980:6).3 In this definition the term, illness equals that of disease as covering the whole spectrum of sicknesses.

It should by now be apparent that both terms have more than one meaning (definition) which defies the notion of an illness–disease distinction. But there is a second reason that demonstrates this even more forcefully.

 

What medical anthropologists do, why they do it and how they do it

The second reason why the application of the illness–disease distinction to cross-cultural settings is not obvious is to be found in what medical anthropologists do, why they do it and how they do it. Therefore, as background to an understanding of the illness–disease distinction, three observations about medical a nthropology will briefly be presented.

 

Medical anthropology exists by virtue of biomedicine

Medical anthropologists are anthropologists who since the end of World War II work primarily in the field of medicine and health care. Therefore, Singer notes that the 'job description' of medical anthropology, is 'a service sector for biomedicine' (1990:179; see also Inhorn 2010:268). Most medical anthropologists are socialised in biomedicine and struggle with cross-cultural interpretation because of the differences between biomedicine and the variety of health care systems they encounter. Lock and Scheper-Hughes (1990:49) point out that one of the biggest challenges for medical anthropology is 'to come to terms with biomedicine'. The paradox is that the cross-cultural gap exists precisely because of the dominance (and contribution) of biomedicine, and the challenge is not whether biomedicine will be included in a cross-cultural interpretive process but how to account for it. Or, as Rhodes says: 'Western biomedicine and medical anthropology are intimately connected. Many medical anthropologists work in biomedical settings or study problems that have been defined in biomedical terms' (1990:159).4

Although it was not until the 1960s that the term medical anthropology was used and appreciated in anthropological circles (see Foster 1978:3), its roots go back to interest in physical anthropology,5 ethnomedicine, culture and personality studies6 and international public health.7 The only branch that actually concerns itself with the understanding of non-Western medical systems is ethnomedicine. The antecedents of ethnomedicine are to be found in the work of the pioneer anthropologists who looked at all aspects of traditional life, including sickness and health care. When examining the fruits of medical anthropology, one way is to distinguish between theoretical,8 clinically applied medical anthropology and critical medical anthropology. Much research in medical anthropology is conducted in conjunction with medical and health care personnel and fits into international public health programmes (see Foster 1978:8–9; Rhodes 1990:159). Critical medical anthropology, however, understands health issues 'in light of the larger political and economic forces that pattern interpersonal relationships, shape social behavior, generate social meanings, and condition collective experience' (Singer 1990:181; see Rhodes 1990:159). Critical medical anthropology has contributed to insights about the causes of and conditions for sickness that go far beyond the reductionistic view of the 'germ theory' found in the biomedical paradigm. The important point to note is that medical anthropology exists by virtue of the biomedical paradigm and is not a way of bypassing it.

 

Medical anthropology is no safeguard against ethnocentrism

Given their proximity to biomedicine, and, like all other anthropologists their involvement in cross-cultural interpretation, medical anthropologists are not immune to the infections from ethnocentrism.9 In fact, medical anthropology as such is no safeguard against ethnocentrism, since, as the medical anthropologist Robert Hahn points out, the socialisation of anthropologists in biomedicine 'has led to two visions within the field of medical anthropology as a whole, sometimes to double vision within single practitioners' (1995:3).10

The first ethnocentric vision, called medicocentrism,11 follows when the superiority or universality of biomedicine is taken for granted in cross-cultural interpretation and results in alien sickness and healing episodes being dressed up in biomedical garments. As Foster (1976:773) himself a medical anthropologist complains, more often than not it happens that 'anthropologists filter the data of all exotic systems through the lens of belief and practice of the people they know best'; and if that system is biomedicine the result is medicocentrism (for a detailed discussion of this, see Rhodes 1990).

The second ethnocentric vision in medical anthropology is called xenocentrism:

In the second vision, common in analyses of non-Western medical systems, researchers have professed to reveal the local medical 'reality' in its own terms; in their concern not to impose their own vision on those they study, these researchers have assumed that the local, indigenous explanations of the world of sickness and healing are valid. [The xenocentric vision assumes] that the cultures of others have exclusive access to the truth – at least in their home setting.

(Hahn 1995:3)

By repeating the concepts, assumptions or descriptions of an alien health care system in a biomedical context is not to avoid ethnocentrism12 but to avoid cross-cultural interpretation. In other words, in cross-cultural interpretation ethnocentrism is avoided neither by imposing the biomedical paradigm (e.g. DSM-IV) nor by adopting the native's point of view or the local explanation of phenomena (e.g. a so-called culture-bound syndrome). In both instances a linear comparison between health care systems results in the truth of one system being imposed onto another – xenocentrism is just the flip side of medicocentrism but equally ethnocentric (see Figure 1 for a schematic representation).

The (ethnocentric) shortcoming of both visions can be illustrated by means of the two sides of the same coin (Figure 1). On the one side is the question whether or not concepts from the DSM-IV or the ICD-1013 can be used across cultural boundaries.14 On the other side is the question whether there really are conditions (so-called culture-bound syndromes) that are incomparable to those in other cultures.

Whilst the very term culture-bound syndrome15 presupposes that some sicknesses are culture-free or culture-blind, it can always be asked whether a certain condition in one culture is not similar to that in another. Secondly, as insights from the multifaceted position of sickness show, humans are not only constrained by culture but also by biology, mind, society and environment. Thirdly, the comparative view shows that local explanations neither exhaust phenomena nor describe them exclusively. The truth of the matter is that cross-cultural interpretation cannot take place without shared concepts. If we are trapped in our frameworks research across cultures is impossible.16

 

Analytical models for cross-cultural interpretation can pretend to be ethnocentric-free

The third and last observation is that only analytical models for cross-cultural interpretation can pretend to be ethnocentric-free. The hallmark of a scientific or analytical model, Engel (1980:543) points out, 'is that it provides a framework within which the scientific method may be applied' for analysis and comparison. In order to be used for analytical and comparative interpretation of phenomena across cultural boundaries, the scientific method needs a theoretical place to stand: 'Observation and understanding are built from categories, hypotheses, and principles of knowledge ... one could not begin the reconstruction of knowledge without a conceptual platform' (Hahn 1995:3).17 Or, in the warning of Berry: 'Without some established framework for making cross-cultural comparisons, I can only foresee an accumulating hodge-podge of unrelated anecdotal studies' (1969:127).

The structure of an analytical model can be illustrated by means of the African cooking-pot model. The analogy of the three legs of the African cooking pot suggests that between the emic logic of the culture itself and the etic logic of the dominant Western biomedical paradigm there is 'the actual incidence, qualitative and quantitative, of disease' (Worsley 1982:328). And the body of scientific knowledge about sickness and healing is much more extensive than that contained by any particular ethnomedical model or health care system, biomedical or otherwise. Instead of a comparison (or clash) between two opposing health care systems (the biomedical and a local paradigm) the interpretive problem can be presented as a three-way process in which the analytical model of the interpreter serves as fixed point of comparison.

This suggestion is based on at least two theoretical principles.

The first is that analytical models are different from operational folk or local health care models. A scientific or analytical model itself is not a health care system (it does not operate as a local health care system within a particular culture). Therefore, an analytical model is not the basis of any dogma, medical or otherwise, and consequently, there is a huge difference between practitioners of any health care system and cross-cultural interpreters trying to make sense of a variety of health care systems. Unlike actual health care models, scientific models are modified and discarded if they are no longer useful.

Secondly, a model of reality is not reality itself and this is particularly true of local health care systems. Consequently, as suggested by Hahn (see 1984:14, 18, 19), a distinction should be made between a model and what it models, an account of phenomena and what is accounted for. Health care systems, be it the biomedical or any other health care system, are partial models of the human experience of sickness and not the totality of sickness. Although all health care models are rational (and the biomedical model is based on science), none is in itself an analytical or scientific tool. Despite the worldwide dominance of biomedicine since the previous century (see Hahn 1995:131), the biomedical model remains a culture specific folk model of sickness and healing (see Fabrega 1975; Hahn 1995:15) and is in itself not a scientific model. Whilst all health care systems with various degrees of success highlight particular features of sickness, none captures it in totality. The body of knowledge about sickness is far more extensive than that of any one system's presentation.

 

Intercultural models for cross-cultural interpretation

Scholars concerned with ethnocentrism (medicocentrism or xenocentrism) in either biomedicine or medical anthropology are promoting intercultural models (the third leg of the tripod) for the cross-cultural interpretation of sickness and healing. Such models contain ideal typical descriptions of sickness and healing that are multifaceted because they refer to the body, mind, society and environment as contributing factors in sickness and healing. The hallmark of such models is that they do not go back beyond the 19th century germ theory of disease but are not trapped there because all of them see health and illness as 'i