Pelto & Pelto/Medicine, Anthropology,

Community: An Overview

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Pertti J. Pelto Gretel H. Pelto

Medicine, anthropology, community: an overview

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Much discussion and debate in medical anthropology focuses on the relationships of anthropology to medicine and to the community. The definition of an appropriate relationship varies depending on whether a person is primarily identified with medicine, with a community, or with anthropology (1).

Medicine as Conceptual Field and as Social System There are several different ways in which medical anthropologists relate to the medica1 eshblishment or modern medicine (2). For some researchers the important idea is scientific medicine as a cultural system. For example,. Fabrega and associates have been concerned with "linking native conceptual traditions about illness with Western scientific medical knowledge" (Fabrega, 1974:7). In a similar' vein the focus of discussion in recent papers on the "hot-cold syndrome" has been on the cultural assumptions involved in "contact between modern and traditional forms of medicine" (Logan, 1973:392). The concepts of modern medicine are generally embodied in the medical practitioners, often identified in anthropological research literature as physicians or medical personnel. For example, George Foster, in discussing aspects of medical anthropology in applied contexts, refers to situations in which "medical personnel asked the anthropologists: what can you tell us about cultural and social factors that will help explain the attitude of people toward health centers?" (Foster 1969: 25). Although perhaps too many discussions have focused on the physician as the central figure representing medical personnel, quite a number of studies have also referred to public health nurses', health aides, and others involved in health care. The physician in medical anthropological discussions often turns out to be the psychiatrist. As a matter of fact, the major developments linking medicine and social/cultural anthropology, especially from about 1920 tothe 1950s and J960s, have reflected the affinities between psychiatry and anthropology. These affinities early in the period found. expression in culture-and-personality studies, which, gained new momentum with the rise of the community mental health movement of the early J960s ,(I-1ochstrasser an d Tapp 1970). It is interesting to note that during the late 1940s and throughout the J950s anthropologists increasingly developed tics with schools of public healtll: For ex~llnple, several of the applied projects in medical anthropology to which Fosler
'I his is the rirsl publication from th~~authors of this paper. All rights reserved .. Permission to reprint must be obtained and publisher. -- ------ - -

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----, Modernization, Cultural Pluralism, and Health Care I
refers were carried out in cooperation with public healt11 people who were working in community-based sanitation and disease,control Similarly, Margaret Clark's study, "Health in the programs (cf. Foster J969). Mexican-American Culture"

(1959), makes a number of references to public healtl1 nurses, medical sc;cial workers, and other community-oriented personnel in California public health departments. Ties and collaboration between anthropologists and public healtJ1 professionals came about to a considerable extent because of a common focus on communi-. ties (including those in developing countries). Public health people frequently encountered resistance to sanit:Jtion measures, vaccinations, prenatal clinics, and other programs, and anthropologists were in a position to eXfllain the "cultural to acceptance of modern health care. However, anthropologists became aware of the limitations inherent oration "public with public' heal tJ1 personnel. health has evolved basically As Hocl1strasser into a governmental arid largely barriers" in collabpreventive

and Tapp have po in ted out,

form of social medicine .... Most of its major centers of research, teaching and practice are now stationed outside or in a satellite relationship to the mainstream of American medicine." In effect, Hochstrasser and Tapp argue, many anthropologists have been allied WitJ1 a segment of the medical system that is "a very small, usually marginal and often ineffectual activity in rnost medical schools throughout th~ country" (1970:255). We now come to a central problem in the relationship of anthropology to the medical system. Anthropologists have been too slow in recognizing and in analyzing the complexities, especially the different distributions of power, in the many fcrred sectors of the mcdical establishmcnt. Too often antJuopologists have reto doctors or medical personnel as if they were a monolithic bloc in terms WjtJl homogeneous vicws and common assumptions about

of power and privilege, health care.

Ra ther significan t changes are ta'king place in the medica] system, especially within the United States, as federal legislative enactments move us slowly toward some system of national health insurance. New medical schools have been established which have proposed new definitions of the relationship between medical people and social and/or behavioral scientists. Hospitals are still the central bastions of health care and medical training, but current trends in health care place greater emphasis on ambula tory care, home care, and facilities and services outside tJle hospital. ments Anthropologists have paid too little and to the divergcnccs of bchavior, attention attitudes, to the drift of tJ1ese developand charactcristics of various

types of medical personnel. portance of ccrtain .trends

Also, they have not been sufficiently aware of tile imin medical education. During the late] 9(iOs medical

students took 111<J!ters into their own h<Jnds and pushed some medical activitics into economically deprived communities. Such student activism has subsided somewhat, but behind th<Jt movement ing number of mcdical schools is another, departments less heralded development. of community mcdicine In a growhave been

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. established that attempt to bridge care needs in communities. the gaps between clinical medicine

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and heaJtil-

With tile rapid expansion of community medicine, beginning in the 1960s, a significant new dimension has been added to the medical system-one that will hopefully munities, ment develop new links between medical schools, heaJtJl practitioners in comand social and/or behavioral scientists. A strong and growing movemedical schools seeks to push the focus of ntlention into
COI11-

within

munities through research on healtil-care systems dents in community-based training experiences. We suggest that anthropologists pay much to tile currents of change within medicine

and placement more attention

of medical than

stu-

tlley have in. in

and try to establish

lines of collaboration

Witil people in community medicine in order to participate meuicaJ stuuent training as well as to help build research community~oriented older relationships healtJl-care with psychiatry systems. This is not and public health

in new developments and action programs anthropology's

to say that

are unproductive.

Far fro111 it.

Without going into detail, we should note that the public healtll sector, itself, has shifted- away from a long-time concentration on infectious disease to tackle the very difficult areas of c1Honic i1lness, where sociocultural factors loom large as_ major contribu tors. We are emphasizing olle of the significant new developments thropologists, are now focusing community medicine and because medical as tile major here because it is personnel, like anarena of activity.

on the community

The Community The community has been the favorite haunt of anthropologists ever since Robert Redfield developed the community study, beginning witil his memorable research in Tepoztlan (1930). The focus in this type c:f research is on finite communities, different from other communities in the vicinity. They share similar cultural backgrounds but create distinct cultural styles in a particular microecological contex~. Antinopological research in communities is ch,lfacterized by participant observation, informal interviewing, and other flexible and ofttimes ilCarly undefinable data-gathering techniques. As a result anthropologists have been raUler closely attuned to the health needs and aspirations of tJle people they study and have come to identify with them and to accept indigenous hcaltil beliefs and practices as efficacious and commendable. This favorable attitude toward indigenous health and curing practices has, in our view, made a significant in coordinating traditional and modern contribution health
10 the efforts

of anthropologists

systems.

On U,e oUler hand, some antiuopologists working in applied health programs appear to have taken the view that modern medicine is much more efficacious 'than indigenous prac-tices cine to all peoples. community modern social margins activism health and that every effor.! should be made to spread Western medi As anthropologists came to be involved in various forms of in the late 1960s and early 1970s, one goal was to make on the economic and in a bind, for part more accessible to those people

care facilities of society.

AntJuopologists

were caught

somewhat

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Modernization,

Cultural Pluralism, and Health Care

I of the radical attack on anthropology during this period took the view that the focus on the beliefs and aspirations of minority enclaves in the United States avoided inaccessibility of the benefits of modern health facilities to these groups. On the other hand, community mental health outposts, particularly those based on the established medical models, were criticized for participating in the alienation of people from their folk medical practices and thus indirectly reducing medical alternatives (Ayala 1975). Although the locus of anthropological research and effort has most often. been the community, its primary conceptual focus has been on culture, usually de~ fined as the concepts, beliefs, and norms characteristic of particular, identifiable ethnic gl'oups. In tracommunity diversity of culture has been salient only when a particular community contained more than one identifiable ethnic group-for "example, in "mixed" communities with black, Chicano, Puerto Rican, and European ethnic groups. The cultural patterns within each of these ethnic groups has been assumed to be definable in relatively homogeneous or uniform terms. However, the uniformist or homogeneic treatment of cultural norms and beliefs, especially in relation to matters of health and disease, has come under increasing scrutiny and challenge (3). The sociologists Hessler and New have recently published an analysis of intraethnic diversity among the Chinese in Boston (see Chapter VI -8). Logan and Morrill (1977) have examined intracommunity diversity with respect to the "hot-cold syndrome" among Guatemalans. Woods and Graves (1973) have demonstrated significant differences in health-seeking behaviors in another Mayan group in Guatemala, and Schensul (1973) has commented on variations in behavior and attitudes among Chicanos in a Chicago community. Furthermore, the work by Woods and Graves offers some statistical evidence that cultural beliefs are not necessarily the major factors influencing people's health behavior. A paper by DeWalt and Pelto (in press) makes the same point with regard to food consumption patterns in a Mexican community. In both the Woods-Graves and DeWalt-Pelto studies, ec.bnomic factors appear to be more significant than ideational ones in influencing relevant behavior. From the perspective of some of this newer research, the community cannot be simply described in terms of cultural norms or a social system. People in communities are as complex in their health beliefs and behaviors as are the people in that amorphous system we refer to as the medical establishment.

Pelto & PeltolJ1Iedicine, Anthropology,

Community:

An Overview
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establishment

tllat

can lead

to problems

of cOTllmunication.

Anthropologists

can

negotiate understandings and behavioral in teractions between medical people and community people. TIlis model of Ule an Uuopologist's role often assumes that the problems of getting effective health care to the people arise from misunderstandings. Often it is necessary for healih workers cepts in congruence willi their own concepts TIlere because is logic in the culture an thropologists broker it makes to learn to use the people;s of modern medicine. model, experts health con-

and it has a great deal of appeal in a complex process.

cOJDmunica tions

Unfortunately, in practice there are often Botll anthropologists and medical people accepting a uniformist view of health-care

some serious problems with the model. have frequently been too simplistic in 'behavior 111at stresses cultural 'norms.

Anthropologists have led medical people to expect clear-cut answers to questions about the comlllunity. Yet tJle broker model can be a useful one, especiaJly when it is based on more complex views of communities and medical systems. However, there is ano111er dimension to consider. The culture-broker usually suggests some sort of equality of power between parties, gists are p-ainfully aware of the differences in power, model

but anlliropolo-

for people in the community

often lack political and economic leverage compared to people in the heal111-care system and in government agencies. Consequently, some antJuopologists have tried In identify ways to inject political power into their applied activities. Research politicaJ on behalf of organized power consumer groups niay be one way in which 1975). some and economic can be mobilized (Marchione

Conclusion As people in cOlllmunities and medical systems go through the process of redefining their relationships to each otJler, anthropologists must also develop new models for tJleir relationships to .both groups. Certainly, the directions of change all clear, and there are lllany competing views about what relationships are not at between

heal Ul-care providers and so-called consumers should be. Inevi!ably, an thropologists ond tJlcmselves in disagreement as weJl about what part they and other social scientists can play in helping to forge more satisfying relationships betwecn the J1ledicaJ establish men t and consumcr communities. Some an thropol ogists argue that better methdoJogical and theoretical tools are needed if they arc to playa constructive role. An approach to heal th -care issues focused on uniforl1list, cuI tural beliefs and an anecdotal, nonquantified plexities of all contemporary situations, style of research is inadcCJuate for the comeither witllin the United States or in other

parts of tJle world. One place for anthropologists to begin is to recognize that tl~e credibility of t!Jeir data depends, in part, on focusing on thc range of variation wiUlin both c0Il1l1l11nitiesandmedica! systems and on idenlifying intenelalionships among them. From there they must ond ways of making their data and insights useful for boul the rapidly changing seeking more effcctive heal th care. medical system and the coml1lunities of people

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1 -Notes
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1. We will be concerned mainly with cultural and/or social anthropology in this paper, at the same time recognizing that there arc areas of physical anthropology th,t relate closely to medical concerns. However, the work of medically oriented physical anthrupologists has not focused on community health systems as often as have the activities of cultural and/or sodalanlhro pologists. Any full treatment of medical anthropology must discuss the relationship of both physical and cultural anthropology to medical establishments and to the communities served by heal th-care systems. 2. The medical establishment or medical system refers to the social system(s) of modern or Western medicine, including hospitals and their personnel,. health-center organizations, physicians, nurses, dentists, and other members of health-care teams, as well as to the medical and dental schools in which professionals arc trained. It also includes various medical societies and other professional organizations. ' 3. Uniformist cultural theory refers to the tendency among anthropologists and others to describe a culture in termsof norms and standards thought to be essentially homogeneous or uniform for most well-socialized individuals of the given community or ethnic group.