Rev. Latino-Am. Enfermagem2010 May-Jun; 18(3)459-66www.e.docx

Rev. Latino-Am. Enfermagem
2010 May-Jun; 18(3):459-66
www.eerp.usp.br/rlae
Corresponding Author:
Flavio Braune Wiik
Universidade Estadual de Londrina. Centro de Letras e Ciências
Humanas.
Departamento de Ciências Sociais
Campus Universitário. Caixa-Postal 6001
CEP 86051-990 Londrina, PR, Brasil
E-mail: [email protected]
Anthropology, Health and Illness: an Introduction to the
Concept of
Culture Applied to the Health Sciences
Esther Jean Langdon1
Flávio Braune Wiik2
This article presents a reflection as to how notions and behavior
related to the processes of
health and illness are an integral part of the culture of the social
group in which they occur.
It is argued that medical and health care systems are cultural
systems consonant with the
groups and social realities that produce them. Such a

comprehension is fundamental for the
health care professional training.
Descriptors: Culture; Anthropology; Health Care; Health
Sciences.
1 Anthropologist, Ph.D. in Anthropology, Full Professor,
Universidade Federal de Santa Catarina, SC, Brazil.
Email: [email protected]
2 Social Scientist, Ph.D. in Anthropology, Adjunct Professor,
Universidade Estadual de Londrina, PR, Brazil.
Email: [email protected]
Original Article
460
Antropologia, saúde e doença: uma introdução ao conceito de
cultura
aplicado às ciências da saúde
O objetivo deste artigo foi apresentar uma reflexão de como as
noções e comportamentos
ligados aos processos de saúde e de doença integram a cultura
de grupos sociais onde
os mesmos ocorrem. Argumenta-se que os sistemas médicos de
atenção à saúde,

assim como as respostas dadas às doenças, são sistemas
culturais, consonantes com os
grupos e realidades sociais que os produzem. A compreensão
dessa relação se mostra
fundamental para a formação do profissional da saúde.
Descritores: Cultura; Antropologia; Atenção à Saúde; Ciências
da Saúde.
Antropología, salud y enfermedad: una introducción al concepto
de
cultura aplicado a las ciencias de la salud
Este artículo presenta una reflexión acerca de como las nociones
y comportamientos
asociados a los procesos de salud y enfermedad están integrados
a la cultura de los
grupos sociales en los que estos procesos ocurren. Se argumenta
que los sistemas
médicos de atención a la salud, así como las respuestas dadas a
la enfermedad son
sistemas culturales que están en consonancia con los grupos y
las realidades sociales
que los producen. Comprender esta relación es crucial para la
formación de profesionales
en el área de la salud.

Descriptores: Cultura; Antropología; Atención a la Salud;
Ciencias de la Salud.
Introduction
Perhaps it seems out of place to address the theme
of culture in a journal dedicated to the Health Sciences
or to argue that the concept of culture can be useful
for professionals of this area. Everyone has a common
sense idea of what “culture” means. We say that a person
“has culture” when he or she has a higher education,
comes from a family of a good socio-economic level or
understands the arts and philosophy. It is normal to
consider that a “good patient” “has culture” sufficiently
to comprehend and follow correctly the instructions
and warnings given by the health professional. This
patient is contrasted with the one “without culture”, the
more “difficult” patient who acts incorrectly through
“ignorance” or who is guided by “superstitions”.
In this article, we will discuss another notion of

culture, the analytical concept that is fundamental to
anthropology. Culture, as conceived by anthropology,
also serves as an instrumental concept for health
professionals conducting research or health intervention
among rural or indigenous populations, as well as in urban
contexts characterized by patients belonging to different
social classes, religions, regions or ethnic groups. These
patients present unique behaviors and thoughts with
regard to the experience of illness, as well as particular
notions about health and therapeutic practices. These
particularities do not come from biological differences,
but from those that are social and cultural in nature.
In short, our point of departure is that everyone has
culture and that it is essentially culture that determines
these particularities. Moreover, questions related to the
processes of health and illness should be considered from
the perspective of the specific socio-cultural contexts in
which they occur.

This assumption about the role of culture is not
exclusive to anthropological knowledge, and theorists,
researchers and professionals in the health fields
- particularly those in medicine and nursing - have
embraced it since the second half of the 1960s(1-2).
They support the idea that biomedicine is a cultural
system and that the realities of clinical practice should
be analyzed from a transcultural perspective. Likewise,
they draw attention to the relevance of the use of
qualitative methods and techniques in health research, in
particular, the ethnographic method(3). Conjoined to these
reflections, are theoretical and philosophical premises
found at the intersection of health and culture, between
the imponderables observed in practical intervention
by health professionals in the face of cultural theory,
between cultural relativism and universal human rights,
and between the demands of a health profession and the

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Rev. Latino-Am. Enfermagem 2010 May-Jun; 18(3):458-65.
more theoretical and reflexive space of anthropology(4).
This theme has been addressed in the Latin American
Journal of Nursing through publication of results of
studies and research conducted by health professionals
and academics(5-7). Using the ethnographic method and
interpretive analysis, these studies point out that the
patient’s construction of the meaning of illness is central
and which is superimposed upon that of biomedical
causality and rationality. For example, in a study
conducted with oncological patients, it was observed
that the symbolism of radiotherapy from the patients’
perspective and constructed throughout the treatment
process, proved to be a powerful organizer and arranger
of the patient’s experience against disruptions caused
by the disease and its therapy. Likewise, the influence

of religious belief has been observed to positively
affect the survival of total laryngectomy patients who
are surrounded by socio-affective religious networks
accompanying them and praying for their healing.
On the other hand, these studies call attention to the
challenges and paradoxes inherent in the ethnographic
method that require simultaneously the researcher’s
immersion in the quotidian socio-cultural universe of
the group (of patients) to be investigated and distancing
so that the investigator does not assume ethnocentric
postures. They also question the factibility between the
use of interpretivism, which tends toward hermeneutic
subjectivity, and the construction of knowledge according
to scientific objectivity.
An instrumental concept of culture
The universe that encompasses the conceptual
definition of culture is extremely complex and diverse,
the common divisor of anthropology’s various analytical-

theoretical currents and fomenter of their epistemological
and methodological approaches(8-9). Considering the
purpose of this article, we will limit ourselves to discussing
some essential and instrumental aspects linked to the
concept of culture, which, in turn, will be used in the
typological and analytical construction proposed.
Culture can be defined as a set of elements that
mediates and qualifies any physical or mental activity
that is not determined by biology and which is shared by
different members of a social group. They are elements
with which social actors construct meanings for concrete
and temporal social interaction, as well as sustain
existing social forms, institutions and their operating
models. Culture includes values, symbols, norms and
practices.
From this definition, three aspects should be
emphasized so that we can comprehend the meaning
of socio-cultural activity. Culture is learned, shared, and

patterned(10). In affirming that culture is learned, we are
stating that we cannot explain the differences in human
behavior through biology in an isolated way. Without
denying its important role, the cultural(ist) perspective
argues that culture shapes biological and bodily needs
and characteristics. Thus, biology provides a backdrop
for behavior, as well as for the potentialities of human
formation and development. However, it is the culture
shared by individuals of a society that transforms
these potentialities into specific, differentiated, and
symbolically intelligible and communicable activities.
Based on this assumption, being a man or woman, a
Brazilian or a Chinese does not depend on one’s respective
genetic composition, but on how that person, through and
because of culture, will behave or think. Ethnographic
studies on sexual behavior patterns according to gender
have indicated that there are wide variations in the
behavior of the sexes and that these variations are based

on what people have learned from their culture about
what it is to be a man or a woman(11-12).
Culture is shared and patterned, because it is
a human creation shared by specific social groups.
Material forms, as well as their symbolic content and
attributions, are patterned by concrete social interactions
of individuals. Culture is a result of their experiences in
determined contexts and specific spaces, which can be
transformed, shared and permeated by different social
segments. Although the content and forms inherent in
each culture can be understood and replicated individually
– conferring to the culture the character of internalized
and embodied personal experience – the concerns of
anthropology are i) to identify cultural patterns shared
by groups of individuals; ii) to deduce what is common in
the actions, allocation of meaning, and significance and
symbolism projected by the individuals on the material
and “natural” world; iii) to reflect on the experience

of living in society, including of that of becoming sick
and caring for one’s health, as a highly intersubjective
and relational experience, mediated by the cultural
phenomenon.
In order to illustrate our argument, we can observe
different cultural patterns regarding the types of food
and diet. In Brazil, the combination of rice and beans
is fundamental for a meal to be considered complete.
Without them, even with presence of meat, many say
their hunger is not satisfied. Others always need a meat
dish to feel well fed. They can even leave the table
462
hungry, after eating a hearty dish of Chinese food filled
with mixed vegetables with little meat. But a Chinese
feels completely satisfied with a primarily vegetarian

meal.
Not only is what to eat determined in a particular
way by culture, but also when to eat as well. Most
Brazilians eat the largest meal of the day at noon to
“digest the food well” and to be “well-fed for work” until
the late afternoon. It is common to claim that eating a
lot at night, especially eating “heavy food” is bad for the
stomach. In turn, North Americans, who do not miss
rice and beans, generally eat less at noon and a large
quantity of “heavy” food (in the eyes of the Brazilians)
in the evening before sleeping. For them, food in
abundance at noon is inappropriate and hinders the
afternoon’s work. From this perspective, culture defines
social standards regarding what and when to eat, as
well as the relationship between types of foods that
should or should not be combined, and, consequently,
the experience of satisfying hunger, or not, is both
socially and biologically determined. It is biology’s task

to indicate basic nutritional needs and to determine the
limitations of foods considered toxic.
In affirming that culture is tied to all physical or
mental activity, we are not alluding to a patchwork quilt
composed of pieces of superstitions or behavior lacking
in intrinsic coherence and logic. Fundamentally, culture
organizes the world of each social group according to its
own logic. It is an integrating experience, holistic and
totalizing, one of belonging and interacting. Consequently,
culture shapes and maintains social groups that share,
communicate and replicate their ways, institutions, and
their principles and cultural values.
Given its dynamic nature and intrinsic politico-
ideological characteristics, culture and the elements
that comprise it are mediating sources of social
transformation, highly politicized, appropriated, modified
and manipulated by social groups throughout their
history, guided by the intentions of the social actors

in the establishing of new socio-cultural patterns and
societal models.
Moreover, each group interacts with a specific
physical environment, and culture defines how to
survive in this environment. Due to the creative and
transformative character, inherent in human cultures, in
interaction with the natural world, we find the existence
of various different solutions for societies’ survival
within the similar environments. Human beings have
the capacity to participate in any culture, to learn any
language, and to perform any task. However, it is the
specific culture into which they are born and/or raised
that determines the language(s) they will speak, the
activities they will develop, and their position and
potential for social mobility in the social structure.
Language, social roles and positions are governed by
age, sex and other cultural variables that influence the
bodily techniques and aesthetic patterns adopted, as well

as the social roles performed according to ideal types
informed by the kinship system and other institutions
of the society to which a person belongs. Finally, in
this dialogue between the individual and society, culture
is both the subject and object. This happens, because
throughout a lifetime, individuals are gradually socialized
by/in the cultural patterns current in their society and
which are constructed through daily social interaction,
as well as through ritual processes and institutional
affiliations. They are responsible for the transformation
of individuals into social actors, into members of a
certain group that mutually recognize each other. As
social actors, they learn and replicate the principles
that guide ideal patterns of valued and qualified types
of action, those of behavior, dress, or eating habits, as
well as techniques for diagnosis and treatment of illness.
Moreover, the socialization of individuals is responsible
for the transmission of meanings about why to do it.

The why to do has special importance as it allows us
to understand the integration and the logic of a culture.
Culture, above all, offers us a view of the world, that is,
the perception of how the world is organized and how to
act accordingly in a world that receives its meaning and
value through culture. Thus, as previously discussed, it
is the culture of a group that provides social actors with a
classification and value system of those foods considered
edible or not, defines the techniques and environments
for obtaining food, and classifies, organizes and assigns
values to various types of food, such as “good”, “weak”,
“strong”, “light”(13).
To present another example: the concept of
cleanliness and hygiene are fundamental categories
present in all cultures. Every culture establishes its
categories of things, classifying them as “clean and
pure” or “dirty and impure”(14), as well as determines
which practices and knowledge are associated with

these categories that contribute to their maintenance,
classification and distinctions. However, the definitions
about what is considered “clean” or “dirty”, “pure” or
“impure” are as varied as the multiplicity of human
cultures found in the world. This variation reflects
a fundamental assertion in the construction of the
field of anthropological knowledge: the paradoxical
463
Langdon EJ, Wiik FB.
confirmation of the diversity and unity encompassed by
cultural phenomenon that is, at the same time, one and
universal, diverse and specific.
Among the Barasana Indians of the Colombian
Amazon jungle(15), apart from ants with cassava (manioc
bread), the diet consists of meat or fish obtained by the
men and eaten with cassava made by the women. When

a hunter is lucky, upon returning to the longhouse, he
delivers the largest portion of meat to the most senior
man of his extended family. His wife or wives cook the
meat in a large pot and put it on the floor in the center of
the house. Then, the senior man first calls the men to eat
according to hierarchical rules based on age groups and
prestige. Afterwards, he calls the women, though not
always all of them. Children are never called to eat when
the pot contains the meat of large animals or fish.
In addition to the social rules based on hierarchy and
distribution of power that regulate food consumption,
all foods and those who prepare or ingest them, are
regulated by cultural principles of cleanliness and purity,
known by the Barasana as witsioga. Witsioga consists of
a substance present in the food, especially meat, which
is dangerous for small children and people of certain
age groups or in liminal states, such as those entering
puberty or participating in shamanism initiation,

pregnant or women in post-partum, and those who are
ill. Since manioc bread is considered a “pure” food, that
which has been touched by the hand of a person eating
meat is contaminated it for those in liminal states.
The Barasana have a complex classification of
animals and fish that are witsioga. They classify them
according to size, behavior, etc. There are also principles
that regulate a series of practices and actions that can
and cannot be performed after eating meat, besides the
hygienic practices intended to cleanse this substance
from the people who eat meat that contains witsioga.
Witsioga also regulates the diagnosis, origin and etiology
of diseases, and, in turn, is linked to the cosmology of
the Indians. The world is controlled by beings (“spirits”)
and witsioga attracts evil spirits that attack people who
are classified as weak or vulnerable.
This example illustrates that when we are faced
with the customs present in other cultures, we should

try to understand their why. By doing this, we avoid
an ethnocentric comprehension of them, that is, judging
Barasana culture according to our own values and
classification of the world and not according to theirs.
The fact that they eat ants, eat from the same pot, eat
with their hands scooping up food with pieces of manioc
bread, and share a single gourd for drinking, might
cause a certain repulsion, since “ants are not food” and
“eating food from a pot on the floor is dirty”. Also, one
might consider the category witsioga to be “superstition”
since such behavior is opposed to what we comprehend
to be “healthy” and “clean” according to biomedical
rationality.
The anthropological perspective requires that, when
faced with different cultures, we do not make moral
judgments based on our own cultural system and that
we understand other cultures according to their own
values and knowledge - which express a particular view

of the world that orients their practices, knowledge and
attitudes. This procedure is called cultural relativism.
It is what allows us to comprehend the why of the
activities and the logic of meanings attributed to them,
without ranking or judging them, but only, and, above
all, recognizing them as different!
Many other examples could also be drawn from
ethnographic research conducted by the health
professionals cited in this article(4-7). All of them lead
us to reflect on issues related to health habits, rituals,
techniques of care and attention, and restrictions with
regard to the use of therapeutic practices (e.g. blood
transfusion, organ transplantation or even abortion);
all of these are mediated by cultural systems distant
from, or even opposed to, the cultural standards which
underlie the construction of the biomedical system and
with which health professionals are trained.
We have used examples taken from a society

whose culture is very distant, one characterized as a
simple society. However, in a complex society like Brazil,
which, in addition to being stratified by social classes,
is comprised of numerous ethnic groups and population
segments exhibiting diverse religious and regional
customs, we find internal cultural differences and inter-
group variations. Although these groups share aspects
of a general culture, identified as the so-called “Brazilian
culture”, but we must recognize that these collectivities
that make up the Brazilian population have different
views of the world and perceive reality in a diverse
ways, generating a complex and intertwined socio-
cultural mosaic. This complexity is the background of
the context that articulates health, culture and society,
and in which professionals and researchers in the field
of health are inserted.
Culture, society and health
If we accept that culture is a total phenomenon

and thus one which provides a world view for those
464
who share it, guiding their knowledge, practices and
attitudes, it is necessary to recognize that the processes
of health and illness are contained within this world view
and social praxis.
Concerns with illness and health are universal
in human life and present in all societies. Each group
organizes itself collectively - through material means,
thought and cultural elements - to comprehend and
develop techniques in response to experiences or
episodes of illness and misfortune, whether individual
or collective. As a consequence, each and all societies
develop knowledge, practices and specific institutions
that may be called the health care system(1).

The health care system comprises all components
present in a society related to health, including knowledge
about the origins, causes and treatments of disease,
therapeutic techniques, its practitioners, and the roles,
standards and agents in interaction in this “scenario”.
Added to these are power relationships and institutions
dedicated to the maintenance or restoration of “the
state of health”. This system is supported by schemes
of symbols that are expressed through the practices,
interactions and institutions; all are consistent with the
general culture of the group, which in turn, serves to
define, classify and explain the phenomena perceived
and classified as “illness”.
Thus the health care system is not disconnected
from other general aspects of culture, just as a social
system is not dissociated from the social organization of
a group. Consequently, the manner by which a particular
social group thinks and organizes itself to maintain

health and face episodes of illness, is not dissociated
from the world view and general experience that it has
with respect to the other aspects and socio-culturally
informed dimensions of experience. Comprehension
of this totality makes it possible to apprehend the
knowledge and practices linked to the health of the
individuals that form a society’s cultural system and
intellectual and moral heritage. Thus, if we do not know
that the Barasana category of witsioga is linked to
their cosmology, to the classification of food and to the
state/status of the people, we do not comprehend the
importance given by them to the ways taken as correct
and “pure” for the preparation and consumption of food.
It would also be difficult to comprehend the importance
of this concept within their concerns for health or to
convince them that in an environment with few sources
of protein, prohibiting meat for young children and
breastfeeding women may affect their growth if they do

not have another adequate protein source.
A health care system is a conceptual and analytical
model, not a reality itself, for the understanding of
social groups with whom we live or study. The concept
helps to systematize and comprehend the complex set
of elements and factors experienced in daily life in a
fragmented and subjective manner, be this in our own
society and culture or in that of an unfamiliar one.
It is important to understand that in a complex
society such as the Brazilian one, there are several
health care systems operating concurrently, systems
that represent the diversity of the groups and cultures
that constitute the society. Although the state medical
system, which provides health services through the
National Health System (SUS), is based on biomedical
principles and values, the population, when sick, uses
many other systems. Many groups do not seek medical
doctors, but use folk medicine; others use medical-

religious systems, and others seek multiple alternative
health systems throughout the therapeutic process. To
think of the health care system as a cultural system
helps us to comprehend this multiplicity of therapeutic
itineraries.
The Cultural System of Health
The cultural system of health emphasizes the
symbolic dimension of the understanding of health and
includes the knowledge, perceptions and cognitions
used to define, classify, perceive and explain disease.
Each and all cultures possess concepts of what it is to be
sick or healthy. They also have disease classifications,
and these are organized according to criteria of
symptoms, severity, etc. Their classification, as well as
the concepts of health and illness, are not universal and
rarely reflect the biomedical definitions. For example, in
Brazil, and mau olhado (evil eye)(16) are folk illnesses
that deny biomedical diagnosis and treatment. These

diseases are classified according to their particular
symptoms and causes that guide their diagnosis and
therapeutic practices chosen. Only folk specialists have
the knowledge to diagnose and treat them.
In this way, culture provides etiological theories
based on the worldview of a group, and these theories
can frequently indicate multiple causes for an illness
episode, and they can be thought of as “mystical” and/
or “non-mystical”. Among the “non-mystical”, or natural
causes, we find theories and perceptions about the body
that attribute its poor functioning to the ingestion of
certain inadequate foods, climate, social relationships
or work conditions. These theories, in turn, provide
a basis for preventive medicine linked to behavior and
465
Langdon EJ, Wiik FB.

hygiene, as well as to elements linked to a curative
medicine. The “mystical” causes frequently combine with
the “non-mystical” and may indicate the need for more
than one type of treatment, for example: one to heal the
physical body and another to heal the spiritual or social
body(17). Etiological theories that include “natural causes”
are accompanied by treatments based on knowledge
of herbs and techniques of body manipulation to treat
bodily symptoms. Ignorance or negation of their efficacy
demonstrates the bioscientific ethnocentrism often present
when evaluating other cultural systems of health care.
The Social System of Health
The system of health care is both a cultural system
and a social system of health. The social system of health
is composed of its institutions, organization of the health
specialists’ roles, rules of interaction, as well as power
relationships inherent to it. Commonly, this dimension
of the system of health care also includes specialists not

recognized by biomedicine, such as folk healers (massage
therapists, benzedeiras, curandeiros) or religious and
faith healers (pastors, priests, benzedeiras, shamans,
spiritists, and others), shaman, pajés, pais-de-santo).
In the world of each social group, experts have
a special role to perform concerning the treatment of
illness, and patients have certain expectations about how
this role will be developed, which illnesses the specialist
can cure, as well as a general idea about the therapeutic
methods he will employ.
In complex societies, besides the traditional
specialists mentioned above, we also find practitioners
of Chinese and Oriental medicine. In the last ten years
we have also seen a growing demand for practitioners
and therapists belonging to what has been called the
“new age”(18). Within the same city, there are specialists
practicing several alternative therapeutic methods
(reflecting different cultural systems of health care),

which are selected or rejected according to factors such
as religion, economic conditions, family experience and
social networks, as well as other political and/or legal
factors (such as the persecution by the State of a given
nonofficial therapeutic practice)(16).
Studies in Health, Culture and Society in Brazil
In Brazil, studies and research on health, culture
and society have multiplied significantly in the last
twenty years(19). In the last decade, Anthropology of
Health has been consolidated as a space for reflection
and for academic and professional training of doctors,
nurses and other professionals in the Area of the Health
of the country(19). There are interdisciplinary university
centers and research groups involving anthropologists
and researchers and intellectuals of collective and public
health, dedicated to the investigation of cultural, social
and politico-economic aspects linked to health issues(19).
Some publication collections have discussed the

experience of sickness and the sick body in light of issues
such as gender, religion, representations of healing and
illness narratives(20-21). Recent ethnographies describing
medical contexts, such as hospitals or clinics, have been
published(22-23). The Editor of the Foundation Oswaldo
Cruz (FIOCRUZ) has published the Anthropology and
Health Collection since the mid-1990s, whose volumes
have contributed to the dissemination of production
originating from research centers and national graduate
programs directed toward the area of health. Reports in
Public Health, also published by FIOCRUZ, has produced a
large number of articles focused on contemporary health
issues, such as STD/AIDS, structure and functioning
of health services, evaluation of health policies and
indigenous health.
Conclusions
Although subject to internal contradictions and,
consequently, potential sources of predicaments, the

values, knowledge and cultural behavior linked to
health form a socio-cultural system which is integrated,
holistic and logical. Therefore, issues relating to health
and sickness cannot be analyzed in isolation from
other dimensions of social life that are mediated and
permeated by cultural meaning. Health care systems
are cultural systems, compatible with human groups
and their social, political and economic realities that
produce and replicate them. Accordingly, for theoretical
and analytical purposes, the biomedical system of health
care should also be considered a cultural system, as any
other ethnomedical system. Therefore, interpretations
of and interventions in health and illness processes - be
they observed for individuals-patients or for biomedically
trained health professionals - must be analyzed and
evaluated using the concept of cultural relativism, thus
avoiding, ethnocentric attitudes and analysis by these
professionals and theorists.

In the end, we are all subjects of culture and
experience it in several ways, including when we become
sick and seek treatment. However, when we act as
professionals and researchers from the Area of Health,
we encounter cultural systems different from our own
(or in which we have been trained), without applying
466
relativism to our own medical knowledge. This happens,
especially in the health field, because in the modern
and rational West, we naturalize the medical field,
attributing to it universal and absolute truth, distancing
it from culturalized forms of knowledge, where truth is
particular, relative and conditional.
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Received: Ap. 22th 2009
Accepted: Nov. 16th 2009
Copyright of Revista Latino-Americana de Enfermagem (RLAE)
is the property of Escola de Enfermagem de
Ribeirao Preto, Universidade de Sao Paulo and its content may
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C O M M E N T A R Y
Ethnography and the Making of Modern Health
Professionals

Vincanne Adams • Sharon R. Kaufman
Published online: 4 May 2011
� Springer Science+Business Media, LLC 2011
…it is particularly incumbent on physicians in this time of
instability and
change to concern themselves with medicine in its largest social
sense – with
that part of medicine that cannot be construed in terms of
laboratory findings
and standard protocols alone. To be a medical citizen is to
concern oneself
both with the realm of politics and social justice and with
clinical judgment.
—Charles Rosenberg, Our Present Complaint: American
Medicine Then
and Now
Charles Rosenberg’s call to arms for the training of health
professionals as
optimal medical citizens—concerned with politics, social justice
and clinical
judgment—recalls a long history of social science engagement
with the socio-
economic and political sources and contexts of medical practice
(Rosenberg 2007).
Social scientists equipped with ethnographic and analytical

insights have offered
critiques from ‘‘the outside’’ for years, noting how biomedicine
engages, knowingly
or not, in iatrogenesis (Illich 1982), capitalist exploitation
(Navarro 1976),
domination (Freidson 1970)and reductionism (Gordon 1988),
that it disregards
the social conditions of knowledge production (Young 1982)
and that it turns life
cycle processes and behaviors into objects requiring medical
intervention (Conrad
1992; Zola 1972) for example. The examination of medicine as
a social and cultural
system that reproduces problems of social inequality or
injustice, rather than
eradicating them, never seems to slow. The route by which this
reproduction occurs,
V. Adams (&)
Medical Anthropology, School of Medicine, University of
California, San Francisco, San Francisco,
CA, USA
e-mail: [email protected]
S. R. Kaufman
Medical Anthropology, UCSF Institute for Health and Aging,

University of California,
San Francisco, San Francisco, CA, USA
e-mail: [email protected]
123
Cult Med Psychiatry (2011) 35:313-320
DOI 10.1007/s11013-011-9216-0
more often than not, is through the knowledge, practice and
development of health
professionals, but seldom has analytic focus been explicitly on
the health
professionals themselves. With this in mind, this fine collection
marks a significant
moment in social science analyses of biomedical, and especially
clinical, knowledge
and practice by taking as its focus the training of—that is, the
production of ethical,
practical and practicing—health professionals. This collection
investigates how
some of these previously identified problems persist, creating
vexing new ethical
challenges for us all. It offers insights that should be read by all
health professionals

in training, and we heartily welcome it.
The articles cover a wide range of contexts and problems—from
clinical rounds
in elite medical schools to rural services for dentists in training,
from US struggles
with cultural competency to global health struggles with cross-
cultural poverty.
Together, they expose the profound influence of contemporary
forms of rationality
and ethicality on the restructuring of health care, the shaping of
health professional
subjectivity and the goals of medicine. The pathways of training
and treatment they
interrogate derive from business models of education and
‘service delivery,’ in
which measurability is the key method and outcome. They
question the benefit of
efforts to standardize and quantify health care routines. They
expose the hidden
costs of new strategies to encourage empathy, cultural
sensitivity, and knowledge/
practice of compassionate expertise. The articles show how
efforts to transform

patients, health professionals and health care organizations into
more effective
practice machines often fail, sometimes miserably, and in
almost all cases arouse a
set of ethical questions about how to get things right. Do
medical reforms that insist
on recognizable and quantifiable modules in order to maximize
efficiency and
generalizability really make for a better kind of medicine, or
even one that is
measurably more efficacious? Do efforts to require cultural
competency result in
more culturally appropriate care or do they reproduce cultural
stereotypes and
ethnocentrism/racism? Do routines of rural care or service in
under-resourced
nations or communities make better doctors and dentists, or do
these encounters
reproduce structural problems that reinforce social inequality?
The authors in this collection offer new insights on all of these
conundrums and
more. They underscore how market-based tools are affecting
ethical sensibilities
and work routines. Students and professionals must learn how to

recognize and
manage the new objects of value in the biomedical
infrastructure—the ‘‘best
practices,’’ ‘‘cultural competence,’’ and routine practice rituals
in which medical
competence is enacted. The main actor in this restructuring is
the assemblage of new
pedagogical and health care technologies that permeate health
professional
activities today, and these articles document the ways in which
those technologies
govern practitioners’ understandings of ethical comportment,
appropriate care, what
ails the patient and what can and should be done about it. Those
technologies
include, for example, the electronic medical record; computer
based teaching tools
of all sorts; the standardized patient; the problem oriented
patient presentation;
models of ‘cultural competency training; and routinization of
class difference as a
diagnostic tool in poor settings.
This collection draws attention to the linkages of governance
which are forged

between infrastructural and bureaucratic demands on the one
hand, and what it takes
314 Cult Med Psychiatry (2011) 35:313–320
123
to be a ‘good’ clinical-citizen/practitioner on the other. The
explorations demonstrate
the ways in which health professionals come to constitute
‘‘themselves as moral
characters’’ (Brada; Shaw and Armin; Stonington) and as
‘‘ethical clinical-citizens’’
(Rivkin-Fish) while also ‘‘being protocoled into oblivion’’
(Pine) or otherwise
(re)-skilled in today’s market-driven health care delivery
system. They show that
many of these training protocols, despite being designed to
overcome the problems of
social inequality, actually reinforce social injustices,
commodified health care, and a
blaming of the victims of poverty and global inequality. At the
same time, these
articles point to the fraught nature of this ratcheting back and
forth between a hoped

for, new and improved medicine by way of streamlined,
quantifiable training, and the
unintended and undesired outcomes that such reforms produce.
They reveal how
difficult it is to become a health professional who is engaged in,
as Rosenberg notes,
not only good clinical judgment (based on laboratory tests and
standard protocols) but
also in actions to redress the social causes of inequality and
injustice that underlie
medicine’s persistent shortcomings and blind spots. By
emphasizing the centrality of
structures of power and the social relationships and enactments
that render the
consequences of those structures invisible in the formation of
health professionals,
this collection serves as a stimulus for further social science
explorations of medical
epistemology and the organization of training and care. It
suggests that despite all
these years of reform, much of which was inspired by previous
critical engagements,
we still have a long way to go.

Holmes, Jenks, and Stonington stress in their introduction that
these articles stand
on the shoulders of anthropologists and sociologists who began
investigating
biomedicine as a sociocultural system decades ago. Attention to
the intellectual
roots of this collection reminds us of some of the enduring
thematic concerns for
analysts of biomedical knowledge and practice. The more recent
regimes of training
and truth-making that this collection explores illustrate newly
powerful dimensions
of the biomedical enterprise that demand social science
investigation and critique.
Beginning with her 1957 essay, ‘‘Training for Uncertainty,’’
Renee Fox has
documented over nearly a half century the ways in which
uncertainty has affected
the organization of training and the everyday work of medicine,
and the ways
uncertainty intersects with physician understandings of
treatment, prognosis and
suffering (Fox 1957). Her 1980 article, ‘‘The Evolution of
Medical Uncertainty,’’

described how uncertainty at the bedside was heightened by
scientific and
technological developments in the 1970s which enabled medical
progress in
diagnosis, treatment and prevention at the same time as those
developments
increased overall risk awareness (of powerful therapeutic side-
effects; of research)
and fostered new (and perhaps unrealistic) expectations about
health, longevity and
the elimination of disease. The result, she wrote, is that, ‘‘The
development of
scientific medicine, then, has both uncovered and created
uncertainties and risks that
were not previously known or experienced’’ (Fox 1980).
When Fox revisits the scope of uncertainty in 2000, she
describes its enduring
tenacity and most recent forms—the result of the emergence and
re-emergence of
infectious disease, the ascendance of genetic knowledge,
therapies, and technol-
ogies, the problems of iatrogenesis and medical error and the
constraints of
evidence-based medicine on the hallowed doctor–patient

relationship. She notes, for
Cult Med Psychiatry (2011) 35:313–320 315
123
example, that increased diagnostic and treatment capabilities
produce prognostic
data and that physicians are under greater pressure than ever
before to make clinical
predictions, which they are loathe to make and not trained to
deliver. Epistemo-
logical uncertainty, too, runs through medical practice and the
medical literature.
The shifting nature of medical knowledge is made more
troublesome by the
demands of evidence-based medicine which constantly replaces
old truths with new
knowledge and which leads to questions about which evidence
is good enough (Fox
2000). Her studies on these topics moved beyond socialization
theory to illustrate
how health professional ethical knowledge and practice are
organized by the
contours of science and the move towards managed care. Along

with others, she
emphasized that bioethics, in its focus on logico-rational
principles of analytic
philosophy, ignores the topics of health disparities, unequal
power relations and
poverty as ethical problems that are foundational to disease and
illness and integral
to medicine (Fox 1990, 2000). Her work drew connections
among medical training,
practice and the formation of ‘‘medical citizenship’’ that
Rosenberg, in the epigraph
above, later describes and that this collection further explores.
Physician sensibility, scientific and institutional developments
and the links
between them are emplaced firmly in the broader realm of the
social in the essays
assembled by editors Margaret Lock and Deborah Gordon, in
Biomedicine
Examined (1988). That collection was among the earliest to
strongly demonstrate
‘‘the social and cultural character of all medical knowledge’’
(p. 7) and the ways in
which medical and scientific practice are inherently social
enterprises, interdepen-
dent with society. The volume sought to dismantle the idea that
biomedicine, and

the sciences on which it rests, represent an objective and value-
free form of
knowledge ‘‘which claim neutrality and universality’’ (p. 19).
The essays reveal how
structures of medical practice are socially constructed, how
values strongly shape
what physicians do and that disease categories and definitions
are not given but
rather are created, represented and understood in institutional,
cultural, and
historical contexts. Above all, the volume illustrates that
biomedicine is not a
monolithic entity, but rather that it is comprised of specific
practices, rituals and
ideologies, all well within the realm of social analysis.
From the 1990s, analyses of the many forms and features of the
biomedical
enterprise have stressed its location in political and economic
webs of power
relations in which health disparities flourish and social justice
languishes. The role
of the ‘technological imperative’ in medicine, central to US
medicine from the mid-

twentieth century, has become even more dominant as evidence-
based medicine
supports an expansive clinical trials industry and the creation of
more therapeutics
for more conditions—but only for those who can gain access to
them. The
‘biotechnical embrace’ (Good 2001) is now a world-wide
phenomenon, contributing
to new forms of ‘‘ethical self-formation’’ among practitioners
(Stonington) and the
development of a dual discernment of appropriate, ethical care
depending on
whether one is practicing medicine ‘here’ or ‘there’ (Brada;
Rivkin-Fish). Greater
fragmentation in health care delivery, greater emphasis by
health care organizations
on models of efficiency for training and practice, the
normalization of differential
treatments in affluent and poor settings, and computer-guided
diagnosis, treatment,
charting and goal setting all have changed clinical medicine and
the ways in which
123

trainees and professionals learn to ‘do’ medicine, to ‘be’
clinicians and to function
within medicine’s highly varied organizational environments
(Holmes and Ponte;
Pine; Taylor; Shaw and Armin). These most recent
developments are the crux of the
matter in this collection. What these articles show us has
unsettling implications for
the future of medicine as a practice in which healing and social
justice can thrive.
Recognition is the large, unifying theme that runs through these
articles—that is,
what students and professionals are taught to recognize as the
skills that constitute
clinical-ethical citizenship in the market-driven, standardized,
and high-tech health
care arena today. Each article explores how what many would
call ‘‘new and
improved’’ techniques that clinicians and clinicians-in-training
learn actually govern
their understandings of patients, treatments, and their own
clinical-ethical expec-
tations of caregiving in particular settings. Each portrays

specific tools now
considered essential or optimal for clinical development and
practice. Thus, we have
the following, for example: standardized cultural competency
training modules in
which ‘competence’ about diversity can be measured to track
practitioner
‘improvement’ in understanding cultural difference, and the
slippage between
categorical vs. reflexive thinking these modules produce (Shaw
and Armin; Jenks);
the rise of computer based Health Information Technology
systems designed to
reduce clinical error but which actually conceal labor shortages
in the nursing
profession that may be the true cause of higher rates of medical
error (Pine); the
problem-oriented patient presentation that creates both a
‘‘categorizable, recogniz-
able and generic’’ patient/case and a professional physician but
dehumanizes the
patient and the doctor–patient relationship (Holmes and Ponte);
the use of students-
in-training to serve the globally and locally underserved and

uninsured and the
mystification, rather than exposure, of local and global social
inequalities (and
cultural stereotyping) that these reproduce (Brada, Rivkin-Fish);
the standardized
simulated patient performance, considered the best method
(because it is
standardized) for representing illness and suffering and thus for
measuring ‘‘clinical
skills’’ but that also becomes a site for ethical induction and
innoculation (Taylor);
and the jarring ethnographic possibility of breakthrough
moments when reflexivity
enables the health professional to reflect critically on
biomedicine and embrace the
possibility of ‘‘not knowing for sure’’ what to do (Stonington).
The authors in this
volume agree that clinicians come to embody the logics of a
new clinical gaze
through those tools. That is, clinicians learn what to recognize
about patients and
about themselves through those tools of medical reform. ‘‘Re-
skilling’’ technologies
and educational strategies mandate new ways of knowing
patients, systems of

service delivery and above all, the new kinds of ethical
opportunities that clinicians
need to embrace.
The entrenched moral economies of health care settings shape
clinician
sensibilities as well, as many of the articles in this collection
show. Here, the
analysis of misrecognition is as important as that of recognition.
‘‘Skilling’’ health
professionals for work in ‘resource-poor’ and ‘community’
settings, for example,
ends up reinforcing stereotypes of the poor as responsible for
their ill health and
treating cultural difference as a problem of medical
incompetence. Such efforts sit
awkwardly next to the growth of required programs in cultural
competency across
US medical schools. Deliberation over how to appropriately
represent ‘‘cultural
123
difference’’ as a problem of self vs. other may or may not be
hitting the mark if

larger problems of abject poverty and the commodification of
health (literally—one
has to be able to afford health to have it) are overlooked. These
problems of
commodified health care infrastructures are deeply vexing to
professionals,
including those in training, when they are asked to engage in
efforts to both save
money and organize their treatments and caregiving in ways that
are not ideal and,
in fact, at odds with their reasons for such a career choice. Here
too are problems of
misrecognition.
When read as a group, the essays raise important questions
about how to enable
and empower health professionals who want to engage in
activism, social justice,
and socio-political reform without transmuting these efforts into
personal strategies
for ethical choice. How can the ethical struggles of health
professionals in training
today be made to bear fruit in the real world? Health
professionals arrive to their

training with pre-formed ideas about the sources and causes of
the health problems
they will confront. What is the responsibility, then, of the
institutions that teach
them, and what sort of ethics become embodied in the choices
these schools make
about how and what kinds of training will be required? Where
misrecognitions are
seen with the institutionalization of things like ‘‘cultural
competency,’’ ‘‘rural
service work,’’ ‘‘simulated trauma’’ or even ‘‘SOAP’’ notes,
we might also pose the
question of how to better prepare students in the health
professions for a life of
clinical work—in which patient problems extend far beyond
what they ‘‘present’’ in
the clinic; treatment options have less to do with standard of
care and more to do
with the uneven distribution of resources; and health
professional understandings of
patient problems and treatment options reach deep into the
kinds of cultural
knowledge(s) that are shaped and reproduced by the structural
inequalities of the

larger (global) health care delivery landscape. Efforts toward
social justice and
health advocacy start, as these articles illustrate, with individual
ethical reflection on
the nature of one’s work, one’s place in the world, and one’s
personal sense of
effectiveness as a health professional, but such personal
commitments can have
effects far beyond one’s expectations. The articles are an
outstanding start for
re-invigorating discussion about medical pedagogy and practice
in today’s market-
based context for health care delivery.
Finally, this collection offers an important new methodological
insight. The
articles, without explicitly stating so, reveal how ethnography
can serve as both a
social scientific method and a unique approach to medical
practice. These articles
take medical anthropology beyond a critique from the outside,
beyond analyses of
biomedicine as a cultural system. They show that ethnography
can be useful for
remaking the ‘‘medical citizens’’ Rosenberg hopes for so that

they can practice with
a greater knowledge of the socio-cultural-economic sources of
inequity and thus
with some conceptual tools for their amelioration.
The volume Lock and Gordon assembled in 1988 illustrated that
biomedicine is
not objective, neutral and universal. Their goal was to show
how social science
exploration of the inner logics, local practices and social
production of the many
forms of biomedicine might improve knowledge about the
rationales for actual
practices. The articles in this collection highlight some of the
still recalcitrant
rationales for practice (cultural stereotyping; reducing the
patient to assessment,
123
plan, etc.), and they describe the more recently adopted
justifications for
streamlining, quantifying and generalizing training techniques.
But going farther,

this CMP collection recognizes that many of the problems that
have plagued
medicine are not going away and that some are being introduced
or re-introduced
through new technologies and fiscal mandates. Efforts to
standardize training by
using real people as simulated patients still create ‘‘cases’’ that
can be fragmented
into objectivized parts, even when the real life problems of
simulators bleed into the
‘‘fake’’ performance of disease. Political economic critiques
that lead to reforms in
health care training and make it possible for students to serve
poor patients may
only reproduce the social inequalities they seek to redress. The
routinization of
medical practices aimed at generating better standards of care
may distance patients
from their caregivers in new and frightening ways.
These articles suggest that new types of medical and caregiving
engagements
may be possible through careful ethnography. No longer are
health professionals

fully caught in the webs of objectification and reductionism that
come along with
enculturation in the medical profession; caregivers in training
are themselves not
uniform nor uniformly positioned in their ethical embrace of
market-based
mandates. They struggle with how to be and with how to see
their efforts in
ways that will serve their patients and resonate with the kind of
medical citizen they
wish to become. The authors show how ethnographic methods
can be part of the
arsenal of doing ‘‘medicine in its largest social sense’’ (to refer
back to Rosenberg).
Efforts to overcome the boundaries of disciplinary divides
between anthropology,
medical anthropology, and medicine are, perhaps the strongest
contribution of this
collection. We applaud the editors and contributors for using
ethnography as a
potential intervention in clinical practice and training.
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Copyright of Culture, Medicine & Psychiatry is the property of
Springer Science & Business Media B.V. and its
content may not be copied or emailed to multiple sites or posted
to a listserv without the copyright holder's
express written permission. However, users may print,
download, or email articles for individual use.

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