Medical Nemesis
PART III
Cultural Iatrogenesis
Introduction
We have dealt so far with two ways in which the predominance of
medicalized health care becomes an obstacle to a healthy life: first,
clinical iatrogenesis, which results when organic coping capacity is
replaced by heteronomous management; and, second, social iatrogenesis,
in which the environment is deprived of those conditions that endow
individuals, families, and neighborhoods with control over their own
internal states and over their milieu. Cultural iatrogenesis represents
a third dimension of medical health-denial. It sets in when the medical
enterprise saps the will of people to suffer their reality.1 It is a
symptom of such iatrogenesis that the term "suffering" has become
almost useless for designating a realistic human response because it
evokes superstition, sadomasochism, or the rich man's condescension to
the lot of the poor. Professionally organized medicine has come to
function as a domineering moral enterprise that advertises industrial
expansion as a war against all suffering. It has thereby undermined the
ability of individuals to face their reality, to express their own
values, and to accept inevitable and often irremediable pain and
impairment, decline and death.
To be in good health
means not only to be successful in coping with reality but also to
enjoy the success; it means to be able to feel alive in pleasure and in
pain; it means to cherish but also to risk survival. Health and
suffering as experienced sensations are phenomena that distinguish men
from beasts.2 Only storybook lions are said to suffer and only pets to
merit compassion when they are in ill health.3
Human health adds openness to instinctual performance.4 It is something
more than a concrete behavior pattern in customs, usages, traditions,
or habit-clusters. It implies performance according to a set of control
mechanisms: plans, recipes, rules, and instructions, all of which
govern personal behavior.5 To a large extent culture and health
coincide. Each culture gives shape to a unique Gestalt of health and to
a unique conformation of attitudes towards pain, disease, impairment,
and death, each of which designates a class of that human performance
that has traditionally been called the art of suffering.6
Each person's health is a responsible performance in a social script.7
How he relates to the sweetness and the bitterness of reality and how
he acts towards others whom he perceives as suffering, as weakened, or
as anguished determine each person's sense of his own body, and with
it, his health. Body-sense is experienced as an ever-renewed gift of
culture.8 In Java people flatly say, "To be human is to be Javanese."
Small children, boors, simpletons, the insane, and the flagrantly
immoral are said to be ndurung djawa (not yet Javanese). A "normal"
adult capable of acting in terms of the highly elaborate system of
etiquette, possessed of the delicate aesthetic perceptions associated
with music, dance, drama, and textile design, and responsive to the
subtle promptings of the divine residing in the stillness of each
individual's inward-turning consciousness is ampun djawa (already
Javanese). To be human is not just to breathe; it is also to control
one's breathing by yogalike techniques so as to hear in inhalation and
exhalation the literal voice of God pronouncing his own name, hu
Allah.9 Cultured health is bounded by each society's style in the art
of living, feasting, suffering, and dying.10
All
traditional cultures derive their hygienic function from this ability
to equip the individual with the means for making pain tolerable,
sickness or impairment understandable, and the shadow of death
meaningful. In such cultures health care is always a program for
eating,11 drinking,12 working,13 breathing,14 loving,15 politicking,16
exercising,17 singing,18 dreaming,19 warring, and suffering.
Most healing is a traditional way of consoling, caring, and comforting
people while they heal, and most sick-care a form of tolerance extended
to the afflicted. Only those cultures survive that provide a viable
code that is adapted to a group's genetic make-up, to its history, to
its environment, and to the peculiar challenges represented by
competing groups of neighbors.
The ideology
promoted by contemporary cosmopolitan medical enterprise runs counter
to these functions.20 It radically undermines the continuation of old
cultural programs and prevents the emergence of new ones that would
provide a pattern for self-care and suffering. Wherever in the world a
culture is medicalized, the traditional framework for habits that can
become conscious in the personal practice of the virtue of hygiene is
progressively trammeled by a mechanical system, a medical code by which
individuals submit to the instructions emanating from hygienic
custodians.21 Medicalization constitutes a prolific bureaucratic
program based on the denial of each man's need to deal with pain,
sickness, and death.22 The modern medical enterprise represents an
endeavor to do for people what their genetic and cultural heritage
formerly equipped them to do for themselves. Medical civilization is
planned and organized to kill pain, to eliminate sickness, and to
abolish the need for an art of suffering and of dying. This progressive
flattening out of personal, virtuous performance constitutes a new goal
which has never before been a guideline for social life. Suffering,
healing, and dying, which are essentially intransitive activities that
culture taught each man, are now claimed by technocracy as new areas of
policy-making and are treated as malfunctions from which populations
ought to be institutionally relieved. The goals of metropolitan medical
civilization are thus in opposition to every single cultural health
program they encounter in the process of progressive colonization.23
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1 F. J. J. Buytendijk, Allgemeine Theone der menschlichen Haltung tmd
Bewegung (Berlin: Springer, 1956). Through a comparison with other
species, he comes to describe man as a physiologically and
psychologically self-structuring organism. For an orientation in
English on the German literature in this field see H. O. Pappe, "On
Philosophical Anthropology," Australasian Journal of Philosophy 39
(1961): 47-64.
2 Adolf Portmann, Zoologie und das
neue Bild des Menschen (Hamburg: Rowohlt, 1956). Man has no built-in
evolutionary mechanisms that would lead him to an equilibrium; his
creative availability gives to his environment (Umwelt) characteristics
different from those it has for other species: it turns habitat into
home.
3 Peter Sedgwick, "Illness, Mental and
Otherwise: All Illnesses Express a Social Judgment," Hastings Center
Studies 1, no. 3 (1973): 19-40.
4 Viktor von
Weiszäcker, Der Gestaltkreis: Theoric der Einheit van Wahmehmm und
Bewegen, 4th ed. (Stuttgart: Thieme, 1968; 1st ed. 1940).
5 Henry E. Sigerist, A History of Medicine, vol. 1, Primitive and
Archaic Medicine (New York: Oxford Univ. Press, 1967). Erwin H.
Ackerknecht, "Primitive Medicine and Culture Patterns," Bulletin of the
History of Medicine 12 (November 1942): 545-74. Sigerist states:
"Culture, whether or not primitive, always has a certain configuration.
. . . The medicine of a primitive tribe fits into that pattern. It is
one expression of it, and cannot be fully understood if it is studied
separately." Ackerknecht exemplifies this integration of culture and
medicine in three tribes: the Cheyenne, Dobuan, and Thonga. For a
classic description of this integration see E. E. Evans-Pritchard,
Witchcraft, Oracles and Magic Among the Azande (New York: Oxford Univ.
Press, 1937), pt. 4, 3. I argue here that health and my ability to
remain responsible for my behavior in suffering are correlated. Relief
from this responsibility correlates with a decline in health.
6 It is not easy to study medical culture without a straitjacket. F. L.
Dunn, "Traditional Asian Medicine and Cosmopolitan Medicine as
Adaptative Systems," mimeographed, Univ. of California, n.d. Dunn
indicates an important bias in most published research on medical
cultures. He claims that 95% of the ethnographic (and also
anthropological) literature on health-enhancing behavior and on the
beliefs underlying it deals with curing and not with the maintenance
and expansion of health. For literature on medical culture seen with
the blinkers of the behavioral technician: Marion Pearsall, Medical
Behavioral Science: A Selected Bibliography of Cultural Anthropology,
Social Psychology and Sociology in Medicine (Lexington: Univ. of
Kentucky Press, 1963). See also Steven Polgar, references in note 19,
p. 18 above. Elfriede Grabner, Volksmedizin: Probleme und
Forschungsgeschichte (Darmstadt: Wissenschaftliche Buchgesellschaft,
1974), provides an anthologv of critical studies on the history of
ethnomedicine.
7 On the cultural uniqueness of
health: Ina-Maria Greverus, Der territoriale Mensch: Bin
literaturanthropologischer Versuch zum Heimatphänomen (Frankfurt:
Athe-naum, 1972). W. E. Muhlmann, "Das Problem der Umwelt beim
Menschen," Zeitschrift für Morphologia und Anthropologia 44 (1952):
153-81. Arnold Gehlen, Die Stele im technischen Zeitalter,
Sozialpsychologische Probleme in der industriellen Gesellschaft
(Hamburg: Rowohlt, 1957). P. Berger, B. Berger, and H. Kellner, The
Homeless Mind (New York: Vintage Books, 1974).
8
Herbert Plüge, Der Mensch und sein Leib (Tübingen: Niemeyer, 1967). F.
J. J. Buytendijk, Mensch und Tier (Hamburg: Rowholt, 1958). F. J. J.
Buytendijk, Prolegomena to an Anthropological Physiology (Pittsburgh,
Pa.: Duquesne University Press, 1974).
9 Clifford
Geertz, "The Impact of the Concept of Culture on the Concept of Man,"
in Yehudi A. Cohen, ed., Man in Adaptation: The Cultural Present
(Chicago: Aldine, 1968).
10 Erwin H. Ackerknecht,
"Natural Diseases and Rational Treatment in Primitive Medicine,"
Bulletin of the History of Medicine 19 (May 1946): 467-97, is a dated
but still excellent review of the literature on the functions of
medical cultures. Ackerknecht provides convergent evidence that
medicine plays a social role and has a holistic and Unitarian character
in primitive cultures that modern medicine cannot provide.
11 Hans Wiswe, Kulturgeschichte der Kochkunst: Kochbücher und Rezepte
aus zwei Jahrtausendm (Munich: Moos, 1970). Fred Binder, Die
Brotnahrung: Auswahl-Bib-liographie zu ihrer Geschichte und Bedeutung,
Donau Schriftreihe no. 9 (Ulm: Deutsches Brotmuseum E.V., 1973). Ludwig
Edelstein, Ancient Medicine: Selected Papers of Ludwig Edelstein, C.
Lilian and Owsei Temkin, eds. (Baltimore: Johns Hopkins, 1967). See the
chapter on dietetics in antiquity.
12 Salvatore P.
Lucia, Wine and the Digestive System: A Select and Annotated
Bibliography (San Francisco: Fortune House, 1970).
13Lucien Febvre, "Travail: Evolution d'un mot et d'une idée," Journal
de psychologie normale et pathologique 41, no. 1 (1948); 19-28.
14 Richard B. Onians, The Origins of European Thought About the Body,
the Mind, the Soul, the World, Time and Fate (1951; reprint ed., New
York: Arno, 1970). H. E. Sigerist, "Disease and Music," in Civilization
and Disease (Chicago: Univ. of Chicago Press, 1943), chap. 11, pp. 212
ff.
15 Giinter Elsasser, "Ausfall des Coitus als
Krankheitsursache in der Medizin des Mittelalters," in Paul Diepgen et
al., eds., Abhandlung zur Geschichte der Medizin und der
Natunuissenschafien, no. 3 (Berlin, 1934). Robert H. van Gulik, Sexual
Life in Ancient China (Atlantic Highlands, N.J.: Humanities Press,
1961).
16 Werner Jaeger, Paideia: The Ideals of
Greek Culture (New York: Oxford Univ. Press, 1943), vol. 3, chap. 1,
"Greek Medicine as Paideia," pp. 3-45.
17 Edward N.
Gardiner, Athletics of the Ancient World (New York: Oxford Univ. Press,
1930). M. Michler, "Das Problem der westgriechischen Heilkunde,"
Sudhoffs A rchiv 46 (1962): 141 ff.
18 Fridolf
Kudlien, "Stimmübungen als Therapeutikum in der antiken Medizin,"
Ärztliche Mitteilungen 44 (1963): 2257-8; for a digest of this article
see L. Heyer-Grote, Atemschulung als Element der Psychotherapie
(Darmstadt: Wissen-schaftliche Buchgesellschaft, 1970). Johanna
Schmidt, "Phonaskoi," in Pauly-Wissowa, Real-Encyklopädie (1941), 20,
pt. 1:522-6.
19 A. W. Gubser, "Ist der
Mittagsschlaf schädlich?" Schweizerische Medizinische Wochenschrift 97,
no. 7 (1967): 213-16. Jane Belo, Trance in Bait, preface by Margaret
Mead (New York: Columbia Univ. Press, 1960). Kilton Steward, "Dream
Theory in Malaya," Complex: The Magazine of Psychoanalysis and Related
Matters 6 (1951): 21-33.
20 Ibn Khaldun, The
Muqaddimah: An Introduction to History, trans. Franz Rosenthal,
Bollingen Series XLIII, 3 vols. (Princeton, N.J.: Princeton Univ.
Press, 1967). Writing towards the end of the 15th century Ibn Khaldun
observed the conflict between the craft of medicine required by
sedentary culture and its luxury and Bedouin medicine, which was based
mainly upon tradition and individual experience. See especially 2:373-7
and 3:149-51.
21 F. N. L. Poynter, ed., Medicine
and Culture, Proceedings of a Historical Symposium Organized Jointly by
the Wellcome Institute of the History of Medicine, London, and the
Wenner-Gren Foundations for Anthropological Research, N.Y. (London:
Wellcome Institute, 1969). See for the conflict between metropolitan
medicine and various traditions. On the use of one hospital to create
the new category of "mental disease" in Senegal, see Danielle
Storper-Perez, La Folie colonisée: Textes à I'appui (Paris: Maspero,
1974).
22 The Western idea that health in the
abstract is a property of man could not develop except parallel to the
idea of mankind. Carlyle suggests that both ideas first took
recognizable form in the toast of the victorious Alexander to the
homo-ousia (like-naturedness) of men. Combined with the idea of
progress, the Utopia of healthy mankind came to prevail over the ideal
of concrete and specific patterns of functioning characteristic for
each tribe or polis. On this see H. C. Baldry, The Unity of Mankind in
Greek Thought (Cambridge: University Press, 1965), and Max Muehl, Die
antike Menschheitsidee in ihrer geschichtlichm Entwicklung (Leipzig:
Dietrichsche Verlagsbuchhandlung, 1928). Sidney Pollard, The Idea of
Progress: History and Society (New York: Basic Books, 1968), deals with
the ideology of human progress in relation to concrete history and the
politico-economic aspects complementing philosophy.
23 To study this clash in Latin American history, see, on
ethnomedicine, Erwin H. Ackerknecht, "Medical Practices," in Julian
Haynes Steward, Handbook of South American Indians, vol. 5, The
Comparative Ethnology of South American Indians (1949; reprint ed.,
Saint Clair Shores, Mich.: Scholarly Press, 1973), pp. 625-43. On
medical colonization, see Percy M. Ashburn, The Ranks of Death: A
Medical History of the Conquest of America (New York: Coward-McCann,
1947). An important work, throwing light on the history of medicine and
on the conquest. Francisco Guerra, Historiografía de la medicina
colonial hispano-americana (Mexico: Abastecedora de impresos, 1953), is
more bibiographical than historiographical, but indispensable. No
comprehensive study of the imperialism of European medical ideology in
Latin America is available. For a first orientation, see Gonzalo
Aguirre Beltran, Medicina y magia: El proceso de aculturación en la
estructura colonial (Mexico: Institute Nacional Indigenista, 1963).