Discussion on David McQueen's Paper
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Soc. Sci. & Med.. Vol. 12, pp. 75 to 77. U037-7856/78/0401-0075$02.00/0 Pergamon Press Ltd. 1978. Printed in Great Britain.
DISCUSSION ON DAVID McQUEEN'S PAPER
Reporter: PAUL U. UNSCHULD, lnstitut fiir Geschichte der Pharmazie, Philips-Universit/it
Marburg, Marburg, West Germany
The study of health care systems of different cultures has proceeded to where most authors are aware of "category fallacies" that result from imposing our own notions on cultures alien to us.
There is one decisive limitation in cross-cultural com- parison of contemporary health care systems. The phenom- enon of development can only vaguely be included in any such study. One may perhaps, as this author has done in one study, accept a general model of mankind's advance through cultural stages, and take cultures in existence today which more or less correspond to these stages to compare their medical systems. Many questions cannot be answered by such an approach. Most important are the epistemological changes that occur over time. Cross- cultural comparison of contemporary medical systems can- not explain why paradigms concerning causation and character of illness become obsolete, or even heterodox, and are replaced by other paradigms.
Medical historians have portrayed the developments in the West from ancient Greece up to our present time as moving step by step closer to truth. This explanation of conceptual changes is irrelevant when one faces a situation where one "false" paradigm, such as the concepts of demonic medicine, is replaced by another "false" paradigm, as is religious medicine with its belief in sinful behavior as the cause of disease. Was there better evidence that led to this epistemological change in ancient China? Only for those who accepted that particular religion as their new Weltansclmuung. Changes in Weltanschauung may have an effect on epistemological changes in health care and our initial enquiry must be extended to why and when these changes occur. Obviously this issue has to be dealt with if one wishes to understand the nature of basic paradigms in the field of health care.
This and other limitations of the cross-cultural compari- son of contemporary health care systems suggest the need to take history into account. What may seem to be a logi- cal and unavoidable step, the exchange of ideas between medical history and anthropology, is bound to create con- troversies.
One of the first questions raised focused on the meth- odological problem of finding categories broad enough to cover "all systems" across time and cultural barriers. Charles Rosenberg asserted, "Any set of categories broad enough to really reflect adequately things that must be covered by every culture are so broad as to not be analyti- cally useful. It also has the danger of wrenching a particu- lar part or component of a certain institution out of a particular culture per se."
Similarly, Everett Mendelsohn said, "I can't believe for an instant that a concept of health or disease, of healing or illness is translatable across all cultural or societal boundaries or across time. My assumption is that they are not. To move across all cultural barriers and time to talk about the function of the healer befuddles rather than clarifies." Arthur Kleinman added that it would be "a fun- damental error to assume categories to persist throughout a series of cultures. This would immediately suggest which evidence is acceptable and which we won't use."
Several suggestions were made to avoid such category fallacies. Charles Rosenberg mentioned, "If one assumes
that there are real biological processes you can agree on, as for instance measles or cholera, that becomes a sampling device which may be legitimate because you may look at how different cultures respond to the same defined inci- dent." This approach creates various problems, one of them being the fact that few descriptions of "disease" in historical materials are full and accurate enough to allow a correct diagnosis in modern termS. With the patient at hand diagnosis can often be reached only with sophisti- cated differential devices.
Arthur Rubel dissented from Rosenberg's proposal by asserting, "It is a poor start to begin with the disease cate- gories of modern medicine. One should look, for instance, at misfortune and see how people cope. Then look at the literature and see whether things that we call diseases fall away from other kinds of misfortune. This would provide a better chance to look cross-culturally and see whether there are some generic commonalities." Everett Mendel- sohn brought another dimension into the discussion by asking, "Where are practices or cognitive structures in a society or cultural system embedded? What do they serve, and who do they serve?" Horacio Fabrega added, "The question must be, what is it that one wants to explain? One can explain people's theories of disease and the way these change. The constraints placed on the behavior of sick people, whatever their definition is. How do people's behaviors in the midst of disease change across time or across social segments? What is the structure of medical practice? What was the role of the practitioner?"
The question of whether one could find suitable cate- gories to cover "all systems" stimulated a heated contro- versy over whether modern Western medicine was incom- parable to any other health care system, and whether it was permissible, as Dr. McQueen had suggested, to pursue Holton's thematic approach in medicine. This had led him to a categorical linking of "object intrusion" with the "germ theory " which causeel Charles Rosenberg to voice strong doubts: "Things are different in the West. Certain emotional aspects are the same in 1976 as they were in 1376. There are, however, elements within the system that are quite different, they are the results of unique aspects of Western intellectual and institutional development. Wes- tern medicine has been connected with science in a very complicated way. There are institutions within that system for rewarding innovation and creating innovation. Differ- ent kinds of social options and structures were created within which the physician interacts with the patient. That can't be ignored. In examining Western medicine one has to be aware of the timeless elements, and one also has to be aware that there is this unique interaction between a cognitive level of analysis, and the institutional change proceeding from that realm, and the ongoing activities of the physician. The dynamics between those two realms is what makes it unique and what creates the particular exis- tential reality that we deal with at any particular moment in time."
Frank Blackford agreed to a uniqueness of Western medicine but took strong exception to the elements Charles Rosenberg had mentioned: "I think institutions to reward innovation are certainly characteristic of a lot. of other traditions; this is certainly true in India and I
think in China as well." Everett Mendelsohn suggested that the boundaries of medicine or science rather than the core may reveal uniqueness or commonalities: "It is at the boundaries of the interactions between the institutional and theoretical levels that indeed you see where within a society this activity is going on, how it is practiced, how it is legitimated and whether its concepts cross the boun- daries or not."
Part of the discussion was devoted to the role medical history has played so far in advancing our knowledge of the characteristics and commonalities of health care sys- tems. In this context Stephen Kunitz pointed out that "many of the histories that have been written are based upon what literate people have produced in the past. A large proportion of the people were illiterate and to a large extent they don't appear in history. Much of the history of medicine that one reads is primarily a chronicle of what learned physicians or healers in a particular society have believed. That may not correspond to the way many lay people' behaved, or to many of the beliefs of other practi- tioners."
Iago Gaidston reacted to this by stating: "What were learned physicians writing about? They were not writing just out of the air. If you take, for example, the Epidemics of Hippocrates, who does he write about? The tinman, the ieatherworker. Just because we have medical people writing does not mean that the points of view they write about are necessarily representative of their belief in politi- cal somethings and so on."
Kunitz replied: "Much of the history that one reads seems to reflect particular groups in a society and what you frequently do not get when you read history of medi- cine is a sense of What non-professionals or non-healers were doing. I presume if you go back to the original sources you get a different sense of what is going on." Joe Loudon added: "Some wrote about the illiterate people but they wrote for those who could read, not for those they were writing about."
Charles Rosenberg, who has taken great efforts to add the dimension to medical history that was claimed to be traditionally neglected, explained: "The history of medicine has been an intellectual history in that it has been a history of what one might call high-cultural ideas with a casual assumption that there is some relationship between behav- ior as seen in doctor-patient relationships and behavior as a series of ideas that people have in their heads about why they are sick and what is the cause of it. I think that in the last ten years or so there has been a shift towards an interest in what we might call the behavioral aspects of medical history. In some of my own studies I attempt to use a variety of sources to show what actual medical practice was like. I have attempted to show the relationship between a certain cogn