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The professional medicine of the West was known by several names until the early 1980s. The various sobriquets distinguished this medicine on the basis of an assumed rationality, scientism, modernity, and efficacy. These names included ‘Western medicine,’ ‘scientific medicine,’ ‘cosmopolitan medicine,’ ‘allopathic medicine,’ ‘modern medicine,’ and simply ‘medicine.’ The terms also asserted implicitly that there was an absence of cultural influence(s) on the theory and practice of this form of professional medicine. It was regularly contrasted with the medical traditions of other cultures, whether popular or professional. These others were labeled ‘ethnomedicines.’ Ethnomedicines were themselves evaluated in terms of Western medicine and, usually, found lacking, suggesting that others’ medicines were cultural in origin, but that of the West originated outside culture, and was ‘scientific’ (Hahn and Gaines, 1985); others practiced medicines that were based on ‘belief,’ while in the West, practice was based on ‘knowledge’ (Good, 1994). Research in the late 1970s and early 1980s from the perspective of interpretive social science, specifically interpretive medical anthropology, has challenged these assertions. The result has been the reconceptualization of medicine as ‘biomedicine,’ so labeled and defined as the professional ethnomedicine of the West (Gaines, 1979, 1992a; Gaines and Hahn, 1982; Hahn and Gaines, 1985). The designation emphasized the biological essentialism and reductionism of this form of medicine and distinguished it from other professional (ethno)medicines (Gaines and Hahn, 1982; Hahn and Gaines, 1985).
Any current consideration of the social and cultural construction of biomedical knowledge suggests that knowledge in medicine comes less from ‘discovery’ of natural realities of the body or of illness and more from creative constructions (Foucault, 1975). That is, biomedical realities, including the focal reality, biology (Gaines, 1982a, 2006), are built rather than discovered. The constructive practices have been shown to be not entirely rational processes (Stein, 1990). That is, biomedicine is itself a cultural construction, as is the case of other medicines, whether professional or popular.
Early studies of what we now call biomedicine were conducted in the 1950s and 1960s largely within sociology (e.g., Erving Goffman, Robert K. Merton, and Anselm Strauss). That work did not examine the social and cultural nature of biomedical knowledge; rather, the central sociological concerns were the nature and development of the profession and of professional status. Also of concern were medical social roles, socialization into the profession, and the impact of institutional ideology (Starr, 1982). The lack of a comparative basis inhibited sociology from recognizing the cultural principles that inform the theory and practice of biomedicine.
Central figures in the critique (from within) of biomedicine and psychiatry highlighted its limitations, especially its overly biological focus. There was also an emerging recognition of the limited cross-cultural applicability of its theory and practice (Engle, 1977, 1980; Kleinman, 1980, 1988a, 1988b).
Other studies had begun to consider professional medicines of other societies as more than folk medicines, such as the Asian professional medicines in India, China, and Japan (Kleinman et al., 1975; Leslie, 1976; Kleinman, 1980; Lock, 1980). Biomedicine came under comparative scrutiny in anthropology when symbolic perspectives, developed in the study of religion and psychological anthropology largely under the influence of Clifford Geertz, were incorporated into medical anthropology. The first such studies of ‘biomedicine’ gave it that name and applied interpretive lenses that revealed the culturally constructed nature of theory and practice (Gaines, 1979; Gaines and Hahn, 1982; Hahn and Gaines, 1985).
Studies of various specialties began to appear in this new vein of research, labeled ‘the anthropology of biomedicine’ (Hahn and Gaines, 1985) that, along with emerging scholarship in feminist studies, problematized biomedical knowledge and practice (Ehrenreich and English, 1973). This led to the discernment of the cultural nature of, for example, the origins of ‘standards’ of normal weight, height, coloring, intelligence, age, gender, or reproductive processes (Gaines, 1982, 2005; Wright and Treacher, 1982; Martin, 1990; Davis-Floyd and Sargent, 1996; Gould, 1996; Berg and Mol, 1998; Rapp, 1999).
A ‘sociocultural system’ such as biomedicine is a complex cultural and historical construction (Foucault, 1975) that is unfinished and is always in the making with a consistent yet dynamic set of beliefs, rules, and practices, many of which are shared with the external lay society in which they are found (Gaines, 1992a). Three central features of biomedicine as a sociocultural system have been distinguished: It is a distinctive domain of both knowledge and practice; it exhibits a division of labor with sanctionable rules of and for action; and it employs a variety of discursive means through which it produces and alters itself (Hahn and Gaines, 1985).
The Distinctive Domain Of Biomedicine
Biomedicine exhibits both specialized beliefs and knowledge as well as beliefs and knowledge shared with the wider society; that is to say, not all of its knowledge derives from a rational, scientific enterprise. However, it should be noted that science and biomedical sciences themselves are now viewed as cultural processes that are not independent of their respective cultural contexts (Latour and Woolgar, 1979; Gilman, 1985; Harding, 1993; Feldman, 1995; Berg and Mol, 1998; Biagioli, 1999; Brodwin, 2000; Duster, 2003). Biomedicine exhibits distinctive research and clinical practices not to be found in lay society. Some of its beliefs and knowledge (about biology, the body, psychology, social difference) are shared with other sciences and/or are based on other sciences. Biomedicine, however, often applies this knowledge in manners at variance with the conceptualizations of those sciences (Waxler, 1979; Gilman, 1985; Harding, 1993; Young, 1995; Gould, 1996; Black, 1998).
Biomedicine exhibits an internal hierarchy of its specialties. The criteria of stratification are several and include extent or degree of somatic intervention, the difficulties of training in the specialty, the social identity (i.e., gender, ethnicity, age) of patients, and the severity and complexity of conditions encountered in the work of the specialty. Social identity in biomedicine is, as in the wider society, a basis for discrimination in training and in practice. In practice, differences in treatment appear that are influenced by ethnicity and gender and appear in patient services, clinical work, and research, as well as in medical education (Scully, 1980; Morantz-Sanchez, 1985; Hinze, 1999; Sarver et al., 2003). Thus, in the west, surgery, has more prestige and financial rewards than does pediatrics, and analytic psychiatry, whose therapeutic modality is talk, has less cachet than biological psychiatry, which intervenes biologically. Women, the elderly, and children are considered lower status and so the practitioners attending to them also have less prestige and command lower rates of remuneration ( Johnson, 1985; Hinze, 1999).
A variety of discursive practices are found in biomedicine that are both embodied (in-person communication) and/ or disembodied (forms of media). That is, communication appears in a variety of forms such as lectures, symposia, talks, and conversations that are embodied, as well as disembodied forms such as examinations, slides, tapes/ DVDs, drawings, photographs, texts (both modern and historical), imaging, virtual bodies, and broadcast sounds and images. These discursive practices are ever-changing, suggesting new understandings about content, given that one must consider the medium to be at least part of the message (Gaines, 1991, 1992a). New modes of information gathering, for example, the newer imaging techniques (computerized tomography (CT), ultrasound, and positron emission tomography (PET) scans), clearly demonstrate the constructed nature of the subjects (Dumit, 2004). The nature and meaning of imaged subjects are contested and malleable. Often represented as reflected nature, the images are heavily interpreted representations that are made to serve a variety of purposes including the constructions of personhood and disease (Rapp, 1999; Brodwin, 2000; Mitchell, 2001; Dumit, 2004).
Biology As Culture
The focal subject of biomedicine is the human body. Biomedicine construes the body as a natural object and its pathologies as natural processes. As such, biomedicine assumes its view of the body, its processes and pathologies, are universal. However, this body differs from the body as found in other professional medicines in the East (Leslie, 1976; Lock, 1980; Leslie and Young, 1992) and in the West (e.g., England, France, Germany) (Gaines, 1982, 1991, 1992a; Lifton, 1986; Barkan, 1992; Payer, 1996). Differences include the location of illness, the aging of the body, the influence of emotion, and its physiology.
Within U.S. biomedicine, while a universal human biology is asserted, exceptions to that universality simultaneously are claimed, for example, ‘racial’ and gender ‘differences’ in course, outcome, and pharmacology. Biomedicine thereby gives authority to the various invidious and discriminatory distinctions made by the wider society (e.g., ‘racial,’ gender, and age distinctions). By means of its embodied and disembodied discursive practices, U.S. biomedicine creates ‘figures of speech’ (Gaines, 2006): the body discursively construed in a culturally specific ‘racial’ manner that is a central part of its ‘local biology’ (Gaines, 1992a, 2005, 2006). Thus, ‘race’ exists in U.S. biomedicine but not in other cultures’ professional medicines, where such conceptualizations do not influence professional medical practice. The new ‘racial medicine’ in the United States, ironically heralded as an advanced and more personal medicine, is an example of culture in the medical mind rather than of ‘progress’ (Gaines, 2006); rather than an advance, the new ‘racial medicine’ recalls constructions of difference from the nineteenth and early twentieth century eugenics (Black 2003; Duster 2003). Historically, groups were perceived as so biologically distinct that some did not need (or deserve) anesthesia in surgery (Pernick, 1985), while others did not deserve even to live (Lifton, 1986; Barkan, 1992; Black 2003).
So, too, biomedicine constructs the female body as deviant, as an inferior variant of the male (Laqueur, 1990; Fausto-Sterling, 1992, 2000) and sees it often as inherently disabled (Vertinsky, 1990; Wendell, 1996) and in need of control by biomedicine (Scully, 1980; Gaines, 1992b; Sherwin, 1992). The ‘naturalness’ of these ‘observations’ clearly reflects cultural constructions rather than discoveries in nature (Martin, 1987; Lock and Gordon, 1988; Haraway, 1991).
Authority And Hope
Biomedicine’s methods of research and its reporting of research in highly optimistic terms constitutes the ‘discourse of hope’ (DelVecchio Good, 1991) on which much of its authority is based. The influences of pharmaceutical companies (Lancet, 2002; Whitehouse, 2008), notions of human biology and the social categories invoked (e.g., ‘races’), the gendered ideology and praxis, and the specific local biology invoked collectively demonstrate the social and cultural construction of biomedical knowledge. But so, too, does the construction of Nature in biomedicine (and science) (Keller, 1992).
The domain of ‘Nature’ is believed to exist outside of the domain of culture and to be discovered by medical scientific research and clinical practice (Gordon, 1988). Biomedicine asserts that the objects of its gaze and practice, disease and people, are empirical, natural elements. Disease elements are classified in medical and psychiatric nosologies. Less formal, though nonetheless real, are the systems of social classification to be found in professional medical theory and practice in the United States. American medical theory and practice combines these two systems into a single discourse of the biology of pathology and its location. These form its geography of disease (Gilman, 1985; Farmer, 1999). Biomedicine locates disease in people rather than in the noxious social circumstances in which they live (Farmer, 1999). For example, psychiatry asserts that approximately 50% of women will experience a depressive episode in their lifetime. In the biological perspective, persons with a first-degree relative with depression are at increased risk for the disorder. Psychiatry sees this as an indication of a genetic component for the illness, and as indicating the genetic vulnerability of women. However, this model uses an implicit static temporal perspective. That is, if one considers a population over multiple generations, it would be impossible to find individuals who did not have a first-degree relative with depression, since more than half of the population at any given time is female. And, if one adds the proportion of males with depression, the notion of genetic vulnerability of those with relatives who have experienced depressive illness, as distinct from others, in fact, has little explanatory power.
Popular biases also appear in psychiatry. It is noteworthy that depression and schizophrenia, the two most biologized of psychiatric disorders, appear not to be universal (Waxler, 1979; Devereux, 1980; Kleinman and Good, 1985; Gaines and Farmer, 1986). In other cultures, one may find a complete absence of the disorders or, as in the case of schizophrenia, one finds that it is not chronic as is characteristic in the United States (Waxler, 1979; Devereux, 1980; Kleinman, 1988b). What is assumed to be a natural disorder with specific symptoms and course appears to be local, rather than a natural/biological universal. Another example is that of posttraumatic stress disorder (PTSD), a disorder that is based on a specific cultural psychology in which the mind is capable of keeping secrets from itself; that is, it depends upon the idea of an unconscious mind (Young, 1995). This unique psychology is expressed through a unique notion of the self (viz., Hallowell, 1967; Geertz, 1983) that has been shown to underlie U.S. psychiatric classifications (Gaines, 1982, 1992b). This self-concept is far from universal, thus making problematic the illness formulations predicated upon it in psychiatry or psychosomatic medicine.
In looking cross-culturally to affirm Western ideas of affliction, epidemiological studies extract symptoms from their meaningful context and from experience. Symptoms so discerned confirm to Western observers that a specific disorder exists. However, disorders found in other cultures outside of the West, such as semen loss in Ayurvedic medicine, can be found in the West using the same methodology, demonstrating the logical fallacy of this approach (Obeyesekere, 1985; Kleinman, 1988b).
The cultural construction of biomedical knowledge is also reflected in the variety of biomedicines found around the world. Rather than exhibiting a single understanding of biology and pathology, there are found a host of local biologies and their respective illnesses. Biomedicine is ‘indigenized’ when it moves from culture to culture and thus becomes plural (Kleinman, 1995). The biomedicine of Germany, for example, focuses on the heart and reflects its historical romantic tradition. The result is massive prescribing for heart ailments (cardiac insufficiency), the level of which is not found in other biomedicines (Payer, 1996; Vos, 2008). The French focus much less on the heart and more on general malaises related to emotion, with many pathological forms that are unique to them (Gaines, 1991). In France, polypharmacy is the rule whereas U.S. medicine seeks to use a single ‘magic bullet,’ a fast-acting medicament whose side-effects are often ignored. Such agents also are used to save time because ‘time is money’ in the Anglo-American tradition. However, in other medical traditions, such as France, Japan, and Africa, time is not an issue, and does not influence treatment choice or methods (Lock, 1980; Gaines, 1992a, 1992b; Payer, 1996).
In biomedicines outside of the United States, we also find that specialties are not the same and/or that they may have distinct activities grouped within them. Psychiatry in Great Britain is not as common a specialty as in the United States. There, it is largely for the treatment of the aged afflicted with forms of dementia (hence, it is usually called ‘old age psychiatry’). Proportionately, Great Britain has one-tenth the number of psychiatrists per capita as does the United States, a percentage that reflects its very different niche in the local medical and social worlds. In France, reanimation-anesthesiology is a medical specialty. However, it does not exist in the United States. The U.S. specialty of internal medicine was borrowed from German medicine. The borrowing of specialties and their logic and institutions is common. However, such borrowings always show the indigenization of biomedicine in the new context.
In research as in clinical practice, there are wide differences to be found in the practice of biomedicine. In AIDS research, we find striking differences in research methodologies in France and in the United States. Further, results are interpreted differently in the two countries, leading to varying conclusions based on the same data (Feldman, 1995), as is common in imaging technologies that tend to substitute medical interpretations for patient subjectivities (Mitchell, 2001).
Making Difference In U.S. Biomedicine
Pharmaceuticals aimed at specific groups are a trend in part fostered by drug companies and in part reflections of the (re)racialization of medicine in the United States. Old medicines may be repackaged and thus receive new patents if they have new uses or are combined with other medicines, also out of patent. For example, BiDil is now FDA-approved for cardiac failure, allegedly specifically for people classified as African-Americans. The research on this drug, a combination of two older drugs, had failed to demonstrate efficacy in ethnically mixed trials until a completely African-American sample was developed. Those who received the drug did markedly better than those who did not, suggesting to researchers that the drug was efficacious. The study actually showed that African-Americans who are treated for their cardiac conditions do much better than those who are not. The research did not demonstrate efficacy for the drug specifically for African-Americans, but the results were so interpreted by the medical community. Such would indicate a biogenetic basis for efficacy, a basis that cannot be demonstrated because of the fact that no two African-Americans have the same ancestry; for people in this social category have greatly varying ancestry in West Africa, Western Europe, or Native America (Gaines, 2005, 2006).
An area of great moment in contemporary biomedicine relates to pharmaceutical practices. Among many concerns is that of conflict of interest. Physician researchers may be influenced by the lure of status, financial reward, or the threat of reprisals by ‘pharma’ for negative evaluations of agents in clinical or other trials. The avoidance of such influence is a difficult and continuing problem for physicians and indicates a domain of social influence on biomedicine.
Related to pharma issues is the ‘discourse of hope’ in biomedicine (DelVecchio Good, 1998). In this discursive practice, we find that futile efforts or limited success in research are often presented in hopeful terms. Also present is a change of ethics in research, from an individual-based ethic of ‘do no harm’ to a communitarian ethic. This shift occurs when physicians claim that medications or other course of treatment may cause pain or discomfort and may not help the patient before them, but the treatment may, nonetheless, ‘help other patients in the future.’ This rationale appears most often in clinical studies where an agent thought to be efficacious is given to one group while a placebo is given to another. The outcome depends on differences in mortality and morbidity in the two groups. That is to say, one group is allowed to develop morbid conditions or worse while the other improves (if the trial is a success). However, this type of research is seen as unethical in several developed countries, where it is never ethical to allow patients to sicken and die under the medical gaze. Even so, the blinded clinical trial is still accepted gold standard in the United States, despite the lack of bioethical universality.
Limitations Of Biomedicine
The focus of biomedicine is, as its name implies, biology. In its cultural context, this becomes the biology of the individual. Such a clinical focus then leaves out the social locations and contexts of disease and illness (Farmer, 1999). Such a focus often blames the victims of socially induced ill health and absolves those guilty of establishing the contexts that promote poverty and ill health (Farmer, 2003). In terms of biomedical ethics, the dominant society in the United States (and biomedicine) tends toward a rights-based, individual ethic that reflects its Protestant value system (i.e., Northern European Protestantism) (Gaines, 1982; Post, 1995). However, such an ethic is in conflict or absent from the majority of the world’s cultures. Hence, much of the practice of U.S. biomedicine is inconsistent with the beliefs and values of other cultures. This inconsistency is problematic in a world increasingly tied together through immigration and cross-cultural labor movements. As examples, we note that in some cultures, the aged are more valuable than the young and, hence, should be saved first; in others, brain death is not defined as death ( Japan) as it is in the United States; and informed consent is difficult, even unethical, to procure in contexts other than that of the autonomous individual of the dominant (Northern) European culture of the West (Kilner, 1984; Gaines, 1998; Lock, 2001).
The knowledge of nature and biology in biomedicine, which are its focus of action, are culturally constructed, as is its social organization. As such, one must exercise caution when either is applied in circumstances or spheres outside of infectious conditions, in which biomedicine has shown great efficacy. The professional and popular ethnomedicines of other cultures also have much to offer for the alleviation of suffering in the world, including forms of suffering unknown to biomedicine, as do their nosologies and diagnostic and treatment methods. Biomedicine may be considered one of a number of professional ethnomedicines and, as such, both its limitations and advantages must be recognized.
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