Soc. Sci. & Med.. Vol. 12. p. 95. 0037-7856,'78/0401-0n95502.(10/0 © Pergamon Press Ltd. 1978. Printed in Great Britain.

D I S C U S S I O N O N A R T H U R KLEINMAN'S PAPER

Reporter: ANTHONY.THOMAS

University of North Carolina, Chapel Hill, NC 27514

As a preface to discussing some of the main points in his paper, Arthur Kleinman expressed his belief that medical anthropology should be relevant to the education of phys- icians and to the practice of general medicine. Kleinman stressed that theory should be the grounding for clinical practice. He also emphasized that medical systems are both social and cultural systems, and cited the following passage in his paper:

"To divorce the cultural system from the social system aspects of health care in society is clearly untenable. The title of this paper merely reflects an emphasis on the cultural dimension. I am sure that other participants at the Conference will make the alternate emphasis."

In his prepared commentary Ronald Frankenberg criti- cized Kleinman for asserting that you cannot talk about culture without situating it socially, but then going ahead to do exactly that. Frankenberg said that in Kleinman's Parsonian approach, conflict is a failure to communicate instead of a process intrinsic to the system. In contrast, he would ask, "Where is the principal contradiction'?" Frankenberg argued that medical anthropology should show the nature and importance of the structural oppositions in the practices which generate the different explanatory models of clinicians and patients elaborated by Kleinman.

Professor Frankenberg noted that the relationship be- tween pupil and teacher, patient and doctor, and certainly

that of employee and employer have common character- istics. Citing the work of Rolf Dahrendorf, Frankenberg stated that structurally based conflict exists in all authority relationships. Consequently, in regard to both theoretical and practical considerations, Frankenberg advised Klein- man that it is necessary to situate the analysis of a cultural system within a system of political economy, not just to give lipservice to the presence of both social and cultural systems. Furthermore, Frankenberg asserted that to change a medical system, critical analyses of it must be located outside the conventional framework of medical practice.

Frankenberg strongly disagreed with the assumption that a generic concept of health systems is useful for com- parative purposes. He felt that the effort to define concepts of this sort was a return to 19th century philosophical anthropology and also that it reflected a naive psycho- logical structuralism. Frankenberg expresses his theoretical position by arguing that you can only understand health systems by characterizing the social formations in which they are embedded. Further, he asserted that you have to 4o this by looking to the production relations in those systems. He maintained that these relations do not only include the production of goods and services, but they also include the production of health and disease and above all the production of knowledge.

95