Anthropology & Medicine, Vol. 9, No.

1, 2002

Writing at the margin of the margin: medical

anthropology in Southern Europe
(Accepted date: 1 December 2001)

JOSEP M. COMELLES
Departament dAntropologia i Treball Social Filoso!a, Institut dEstudis Avancats, Universitat
Rovira i Virgili, Tarragona, Spain

ABSTRACT This critical review explores the problems posed in Southern Europe by the recent
development of medical anthropology, focusing on three issues: the problems derived from
research in languages other than English, the idiosyncratic developments of social and cultural
research within European continental health sectors, and the theoretical speci!city of Southern
European medical anthropologies.

Tout ce qui est ferme est par le temps detruit. (Du Bellay, Antiquites
de Rome, circa 1525)
Writing at the margin
Two books by Arthur Kleinman (1995) and Robert Hahn (1995) tackle the
problem of the boundaries between biomedicine and anthropology. Both authors are physicians and anthropologists, a professional background quite common among medical anthropologists. The former includes an interesting
discussion about the liminal condition of the doctor anthropologist. Kleinman
discusses his role in the North American academic world and includes a
self-appraisal of his intellectual and professional career. His book is a statement
about the role played by history and political economy in the development of
medical systems and health professional cultures, something that was neglected
in Kleinman s previous book (1980). Hahn (1995) suggests that anthropology
should formulate an anthropological medicine as an alternative to the so-called
crisis of biomedicine in the late decades. He rejects the possibility of a medical
anthropology practised by anthropologists without previous medical or nursing
training. Although they are well-established anthropologists and Kleinman is
one of the leaders of medical anthropology, both are reluctant to completely
Correspondence to: Josep M. Comelles, MD, PhD, Departament dAntropologia i Treball Social
Filoso!a, Institut dEstudis Avancats, Universitat Rovira i Virgili, Tarragona, Spain. E-mail:
jmce@tinet.fut.es
ISSN 1364-8470/print/ISSN 1469-2910/online/02/010007-17 2002 Taylor & Francis Ltd
DOI: 10.1080/13648470220139983

J. M. Comelles

abandon medicine. They are both looking for a new ambiguous medical and
anthropological identity to maintain their commitment to medicine. They are
also checking the marginality of medical anthropology within anthropology.
I, too, am a doctor, who has moved to anthropology, so I can understand
their dif!culty in abandoning medicine. It is a big advantage for us to be able
to change our identity, from time to time, from anthropology to medicine, from
medicine to anthropology, and to develop medical anthropology in countries
with little tradition of social anthropology. I like to play this changing role, and
place myself in the boundaries of the history of medicine, social medicine,
psychiatry, sociology or anthropology. This ambiguous identity only makes
sense in an anthropological home context because the social science scene in
medicine in our countries is somewhat confusing and for most doctors anthropology is bizarre, linked to craniology or palaeontology, or sometimes identi!ed
as some kind of philosophy.
The main problem is not entirely the lack of social recognition of medical
anthropology in medical settings. It is also the lack of social recognition of
medical anthropology within European social anthropology. It is dif!cult to
accept an anthropologist who is also a doctor as a member of a professional
group whose ideas about medicine and hea1th professionals are critical. In the
late 1980s, to hear expressions like medical anthropology is not anthropology
was common in some anthropological arenas. At the same time, European
anthropologists like Auge (1986) were sceptical about the real existence of such
a !eld. This liminal position, in Turners terms (1988), is the consequence of
the negative attitude of two well-de!ned academic professions, towards those
who inhabit boundary areas. We are facing a problem that is linked to the
construction of professional identities. Since doctor anthropologists are doctors
and play the role of doctors, it is easier for them to open a professional space
for anthropology in biomedical sciences. So, this long-term strategy tries to
reproduce our medical embodiment, but does not allow us to embody our social
anthropologist role in the same way. Even so, in day to day interaction, we are
well placed in biomedical or nursing networks, and we project our intellectual
production on biomedical, public health or nursing settings. Most of our readers
are not anthropologists, and when we write we attempt to transfer our anthropological scope to biomedical and nursing meta-languages. This process led to a
considerable number of interdisciplinary !elds autonomous from general
anthropology and with complex relationships between them (see Menendez,
1991). The growing presence of medical anthropology, even in Europe in the
!eld of sociomedical research and nursing studies, has no counterpart in
anthropology. Even a brief look at the major anthropological periodicals like
American Anthropologist, Current Anthropology in America, or Man, L Homme or
l Uomo in Europe shows little presence of this !eld.a Some anthropologists
disagree, as Auge did, with clinical applied anthropology that sometimes heavily
depends on medical interests and ideas. This might be the reason why pure
anthropologists sometimes do not recognise us to be one of their numbers.
Kleinman and Hahn s diagnoses are placed in this context, and this explains the

Writing at the margin

marginal or outsider condition of the doctor anthropologist. I agree with

their statements even though I cannot help thinking of one thing. Arthur
Kleinman is at the heart of medical anthropology, but still considers himself to
be marginal. I wonder what he makes of our marginality, European medical
anthropologists, who are at the furthest boundaries of medicine and anthropology.
The margin of the margin
Looking to medical anthropology in Europe, I can !nd another degree of
marginality in the margin of both margins. It rises from the fact that most of us
think, work and write in languages other than English. Diffusion in the major
non-English scienti!c languages, including French, Japanese, Portuguese, German, Chinese or Spanish, is limited by its scant presence in the international
bibliographic catalogues.b The presence of languages like Dutch, Scandinavian
or Slavic is anecdotal in the searches in Medline, Excerpts, Current Contents and
on. In medical anthropology linked to medical literature, this is more evident,
because most scienti!c medical literature is now in basic, not in literary, English.
This is a consequence of the development of technical medical English. This
kind of English is useful for doctors, in spite of their residence, to write about
biomedical research in a comprehensible way. Is this basic medical English a
good tool for medical anthropology? I believe that this is a crucial point. In my
own case, I live in a bilingual country: my mother tongue and teaching language
are Catalan and I have written most of my professional work in Spanish. I
cannot write good Catalan. Under Francos regime, when I studied, Catalan
was not taught in schools. I learned to write Spanish, and I !nd dif!cult to write
well in a second language. There are few good bilingual writers. I am not an
exception. This is the most common situation of medical anthropologists
throughout Europe. They do their PhD in Dutch, Swedish, Italian, German,
French, Spanish, Catalan, Serb-Croat, and so on. They publish a part of their
work and they teach in their own language, and from time to time they publish
in English to show the world (what world?) who they are. It is a strange
marginality, because English provides the brokerage between my Northern
European colleagues and me. I do not need brokerage with my colleagues who
speak Portuguese, Italian or French. We do not renounce our languages. This
is important because a high level of comprehension and the Esperanto of
English are not required. We do not feel as we do when we speak English, that
we are speaking a 300-word language in order to be understood. The consciousness of this position may have some advantages. We are anthropologists and our
training to manage cultural distance is a fundamental tool in anthropological
research. It distances us of our research subjects. It distances us, at the margins,
with theoretical or methodological polemics or debates that rise from to the
hegemonic cores of the discipline. Sometimes we take distance and we can
examine them with some scepticism. This attitude is not a feature of a vulgar
anti-gringo or anti-Anglo-Saxon attitude. It may be the consequence of a

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J. M. Comelles

long tradition of Mediterranean scepticism that has guided us to mistrust any

kind of dogma and to look at all the Great Truths with some irony. Perhaps this
is because we come from countries shaped by the omnipresence of the Church
and the State, and we live in the far boundaries of the economic empires. We
are accustomed to distance ourselves from the theoretical positions of AngloSaxon anthropology that discovers Gramsci, Basaglia or De Martino 30 years
after us. We have learned how to survive at the margin of the margin. This
position might not be completely disadvantageous, in spite of the lack of
diffusion of scholar work written in languages other than English. Using
non-English languages to publish or research, we are closed out in a ghetto.
Therefore, writing and reading in English they are also in their own ghetto. We
must be bilingual because the hegemony of English has imposed only one
language. This is also the !rst step toward a universal way of thinking. We need
to be present in the English-speaking space; we are conscious of the marginal
condition of our English writings (and this one is a good example), which are
juggling efforts in basic English. These efforts allow us an anecdotal presence in
Kleinmans marginality. Our pidgin does not allow us to manage literary !nesse.
How can we translate in English, which is our second, third or fourth language,
the idioms of distress explained in the Catalan, Basque, Portuguese or Italian of
our informants? How can we explain in English research projects linked to
speci!c historical and cultural contexts and which are not related to the
theoretical and methodological problems of interest to the 2000 members of the
Society of Medical Anthropology? These interests are often presented as the
core scienti!c questions in medical anthropological theory; they are really often
the consequence of the distribution of academic power in the American universities built upon the impact index. For them, our central interests may be local
anecdotes, or bizarre examples of European quality. These arguments are not
the consequence of a personal anecdote. They are crucial in a European context.
An European homeland is a fundamental part of the actual process of globalisation, so the European identity is not the euro, or the European Union. This is
a way of managing extreme historical and cultural diversity. The European
cultural and social diversity is the European identity. We must protect it. Our
identity project is not shaped by the idea of the melting pot, or the manifest
destiny. We are sceptical of these ideas. It is not possible in Europe to consider
Danish, Dutch, Catalan, Italian, Spanish and so on as aboriginal languages to
be classi!ed by some Bureau of European Folklore as survivals. European social
and cultural diversity is not the product of survivalism. This diversity is the
product of a fascinating and diverse historical process of political, social and
cultural development. Welfare state and welfare policies are not the same in the
different countries, which have considerable cultural diversity as a consequence
of long-term particular historical processes. Medicine and health care show this
diversity. Each country has developed particular models for the provision of care
embedded in popular culture (see Castel, 1995). In this way, medical anthropological research develops out of highly idiosyncratic problems in each national
structure.

Writing at the margin

11

European anthropology or European anthropologies?

The development of social and cultural anthropology also shows considerable
diversity within Europe. The conventional professional model of anthropological
practice, largely built around the ethnography of local worlds, by long and
extensive !eldwork, generally in aboriginal societies, has not been the rule
everywhere in Europe. It was the consequence of a speci!c development in the
United States done by Boas, Malinowski, Radcliffe-Brown and others.c
European anthropology shows a different development, which centres on the
image of the armchair anthropologist as the best example of a great scholar, a
marginal presence of colonial studies, and the development of an important
home folklore in Slavic and Scandinavian countries. The genealogy of anthropology in most European countries shows the persistence of the professional
institutionalisation of anthropology in the late 19th century related to the
autonomous development of physical anthropology, philology and archaeology
and the marginality of ethnology abroad and homeland folklore (Comelles,
1997).
The most common mistake in recent European anthropology might have been
to apply mechanically in the Continent the professional shaping of American
professional anthropology as a universa1 model of anthropology. Nobody took
in account or the differences in university organisation and professional cultures
in Europe, or the different social and cultural adjustments of professionals as
organic intellectuals in each national context. In this arena, the recent development of medical anthropology, and particularly that of home medical anthropology, should be discussed by placing it in speci!c biomedical and nursing
contexts. This speci!city must be explained in comparative terms. On the one
hand, it should be adjusted to the changes of the position of social or cultural
anthropology as a social discipline in each country. On the other, it should be
placed it in very different biomedical and nursing contexts framed in a diverse
mosaic related to the development of public welfare and health policies.
I cannot make a global presentation here of this idiosyncratic panorama. My
aim is to concentrate on some general features in the European context: the !rst
one is the absence of social sciences in European biomedicine in 20th century;
the second one, the reluctance of European professional social and cultural
anthropology to accept applied anthropology.
The relevance of social science in classical medicine
The biggest mistake in the historiography of Anthropology is to build a
legitimisation of what is the discipline around an idiosyncratic development in
professional anthropology in the United States before the Second World War.
So, the previous ethnographic or ethnologic must have been done all over the
world by amateurs.
Historical evidence shows that ethnographic-like practice,d ethnography and
anthropology have been, still are and can be narrative genres that are character-

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J. M. Comelles

istic of medicine, religion, another professions, in spite of their role in the

shaping of 20th century anthropology. The future, the present or the past
production of these medical, jural, or religious genres should not be interpreted
in terms of anthropology, law studies, sociology or history avant la lettre, but in
terms of their meaning within the practice and the theory of medicine, religion
or other professions. We can !nd ethnographic-like descriptions based on
naturalistic frameworks linked to classical philosophy and classical medicine
from the times of Hippocrates to the late 20th century (Comelles, 1996). These
narrative genres placed in other professional contexts developed from the
development of technical and naturalistic medicine in classical Greek and in
Galen writings (Garca Ballester, 1981, 1995). Hippocratic texts, particularly
Airs, Waters and Places (Hipocrates de Cos, 1986) and Epidemics (Hipocrates de
Cos, 1989), developed two complementary models for technical medical writing. A narrative one that uses local knowledge as an instrument to shape medical
practice and place it into society (Alvarez Millan, 1999; Garca Ballester, 1995)
and another that described individual episodes of sickness in environmental
contexts based on the intellectual matrices of Epidemics. This is the origin of
current clinical writing. Both genres consider clinical narrative and ethnographic-like practice as the pillars of the comprehension of the sickness context,
its etiological interpretations and the therapeutic implications that make it
possible for itinerant physicians to become a part of the community in which
they work.e
Medical practice proposed to intervene in suffering by interpreting aetiology
from rule-based observation of the natural environment. This style of observation is valuable if local knowledge is fundamental. It shows the difference
between doctors and other healers. The efforts to establish criteria for classifying
!eld observations and to record them orderly are related to the need to develop
a medical narrative genre, the role of which was to place the practitioners as
brokers between public authorities and popular classes.
Doctors local knowledge was constructed on what is known today as participatory observation. An attitude that assumed sickness as a face-to-face experience in which there is not a unidirectional "ow of technical knowledge, but
complex transactions that lead to a constant reworking of the scenarios of
practice (Comelles, 1998). Recovering these experiences are fundamental in
forming an ethic that in turn structures the cultural image of physicians and
reinforces their social and cultural legitimacy (Lan Entralgo, 1987). These
dimensions of experience can be present in medical texts that deal with what the
good doctors practice should be like. The duties of the good doctor show to the
student or the neophyte that the role of the emotions, the subjectivity of
experience and personal commitment to the community, involved a personal
local experience, which is unrepeatable, and non-comparable.
The irrelevance of social science in biomedicine
The hegemony of observation over listening is a consequence of the birth of the

Writing at the margin

13

clinic (Foucault, 1978). It means that physicians, as anthropologists, are trapped

by the temporal limits of their observations, and by a related notion of time. The
description of current diseases is a tranche de vie as in the naturalist novels.
Description of the environment is a cyclical reality governed by the rhythm of
the seasons. Time is done away with in favour of space. Realism and naturalism
are narrative procedures opposed to the narrative models of historicism but also
to those of the writing of legends, tales or myths. They look for a distant regard
in relation to the expression of the patient subjectivity that masks the symptoms
by using cultural idioms of distress in a way that is different from how the
physician understands and assesses them.f
Biomedicine abandoned ethnography as a main technique in its practice
because of its criticism against subjectivity. Doctors role evolved toward an
objective and positivistic practice related to experimentalism and critical with
pure empiricism (Hersch Martnez, 2001). At the same time doctors looked for
an intellectual legitimisation in the academic world. Doctors, who were in
America or in Europe armchair anthropologists, like Broca or Lombroso (see
Peset, 1984) mutated in Europe to doctor humanists fonder of philosophy,
literature or history than of anthropology. The hegemony of the hospital in
clinical knowledge, diagnosis and treatment oriented medical writing in favour
of clinical and epidemiological genres. Ethnographic writing, linked to local
knowledge, was relegated to a marginal position because !eld observations
about the natural, cultural or social context were not important in the shaping
of medical knowledge based on experimental medicine. The empirical knowledge of the general practitioner became the subject of suspicion. Ethnographiclike practice had counterbalanced clinical practice in a context in which the
cultural image of the physician and his presence in the community was constructed from his local knowledge, and mediated between the local and the
general policies of public health. The hegemony of clinics moved doctors to
abandon their former condition of social scientists in Virchows terms.
Even so, in Europe, ethnographic reports written by doctors did not disappear: there are hundreds of medical folklore reports and up to the mid 20th
century thousands of medical topographies around the world. These reports are
now marginal or anecdotal pieces of qualitative methodologies under the
hegemony of clinical and epidemiological reports.
Their survival, as subordinate medical genres, could be explained by their
function of establishing the cultural or social boundaries of biomedicine in rural
or aboriginal settings. Ethnographic description, in a biomedical context of
experimental and positivistic thinking, reinforces the enlightened idea that
relates poverty, ignorance and superstition, and places popular medical practices
in an arena to be acculturate by the progress of science and civilisation. Histories
and stories of medicine and doctors, and medical folklore, were fundamental if
biomedical hegemony were to be assured in popular culture. The former
legitimated the medical model as the pinnacle of an evolutionary process of
intellectual and technical advances, while the latter, ethnography, established its
cultural limits. Medical folklore reports aimed to build a regional or local

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J. M. Comelles

pattern of the features of popular medicine, and consciously ignored the

integration of popular medicine in the world.g Their aim is not to discover the
sense and the place of popular medicine in culture or in a speci!c community,
but to de!ne the practices that, from the medical viewpoint, do not belong to
it. Popular or folk medicines are medical ideas, not anthropological ones.
Doctors accepted cultural or social evolutionism as an explanatory theory
useful to explain popular health practices and ideas as survivals. The persistence
of these ideas can be checked today (Erkoreka, 1985). In any case, this
evolutionism might not be seen as a form of historicism. Biomedicine assumes
vulgar evolutionism because it is the product of a stratigraphic idea of life and
society constructed by means of empirical patterns that are used to characterise
every historic period, without considering con"ict and social transformations, or
by reducing them to almost mechanical, random processes of cultural diffusion.
This is a positivistic archaeology, not anthropology.
A doctor should be objective, because his legitimacy as a clinician is based on
this quality. As an ethnographer, the practitioner becomes the teller of a reality,
the aim of which is complicity with his readers, generally other physicians, also
other educated readers. They !nd this complicity in these ethnographic
accounts, which are portraits of their practice or mirrors of their shared
experiences. Nevertheless, as Falteri (1989) has pointed out, doctor ethnographers never write detailed descriptions of their own practice as rural or urban
physicians. To do so would mean questioning the dialectics that exist between
medical and popular practices, the complex processes of mediation between the
intellectual and the popular classes and the local conditions of medicalisation. It
was impossible for clinical ethnographers to place themselves in a more critical
position. They were committed during medicalisation as apostles of science and
modernity. Introducing a critical methodological approach in their writing
would mean developing a conception of dialectic and not stratigraphic history
and questioning the cultural or social limits of their practice. Therefore, they did
not. Their goal was no longer social medicine, only an anecdotal description of
the survival of popular medicine that was outside their own practice.
In Giuseppe Pitre`s epistemology (1896, pp. IXVI), popular medicine might
be placed in the framework of clinical methodology and epistemology.h This
results in the fragmentation of cases and parts of the body that so characterises
modern medicine being projected above popular knowledge. He wanted to
develop a new ethnographic framework within which data could be collected
about the popular medicine of the peasants of Sicily. Disease aetiologies ceased
to be related to the environmental, social or cultural context as in neoHippocratic theories. The emphasis was on the description of actual diseases
and therapeutics. History was unimportant. Ethnography became a positivistic
description of facts, not an explanation of the survival of the old medical
theories in popular knowledge.
With Pitre`s methodology medicine forgot that its own history could be used
as an instrument for explaining its practice and the process of medicalisation.
Medicine invents a tradition to explain the theoretical Greek roots of

Writing at the margin

15

biomedicine, but is reluctant to accept the idea than others can write the history
of medicine. Doctors must write history of medicine, or medical folklore,
because only doctors know medicine. Medical training now focuses on hospitals.
Students receive little information about the limits of clinical epistemology.
Clinical training becomes a dogmatic routine, which combines observation,
listening and documentation. The role of observation and listening in the
diagnosis decreases while the role of technology increases. Medical routines
have become an idiosyncratic model for thinking and describing reality, a
professional culture which is centred on a highly rei!ed face-to-face relationship
with the patient, and which is reluctant to assume the doctors commitment
with society, present in Virchows times (see Rosen, 1972).
The intellectual legitimisation of medicine in Europe adds to the development
of experimental science the rei!cation of the sick body, and a medical rhetoric
about humanism. Hundreds of medical lectures during the 19th century explain
how the medical practice should be. Indirectly these lectures describe a very
different situation. In the 20th century, medical discourse became more sophisticated incorporating phenomenology. The intellectual or theoretical framework
were not materialismas in neo-Hippocratismor Marxism, but phenomenological approaches to the individual and moral experiences of illness (Lan
Entralgo, 1961). Authors like Sigerist (1987) linked medicine with politics and
economy. Von Weiszacker, like Freud, or in Spain Lan Entralgo theorised
about the face-to-face relationship between a patient suffering and getting help
from his doctor.
Medical humanism generates another medical genre, which is different from
the naturalism associated to ethnography, and from the positivism of clinical or
epidemiological writing. There is a subtle barrier full of ambivalence between
the medical genres in the strict sense and the purely literary texts that some
doctors write quite separately from their practice. The former are medical,
professional texts that help them to consolidate their prestige in the profession
while the latter provide the physician with an intellectual identity as a humanist
that goes beyond their dimension as men of art, and legitimates their philanthropic approach to patient. The literary writing of contemporary doctors
provides a humanist explanation for a biomedicine which rei!es sickness and
reduces suffering to a sign as a strategy for intellectualising what until then had
been an essentially practical and applied profession. This change from medical
to literary writing is a universal feature of the medical profession in the 19th and
20th centuries. The free composition of the latter belongs to a world that lies
beyond biomedicine. It shares characteristics of historical and literary narratives
on hagiography and professional legitimisation that contributes to the emergence of the cultural image of the physician. There is no con"ict while this barrier
is clear. Con"ict does arise, however, when the two types of discourse overlap
and dilute the hegemonic biomedical identity in a context in which local
knowledge no longer plays a role in the shaping of medical practice. Even if this
dualism can be checked in the entire Western world, there are some differences
between the United States, and Europe. Let me propose a comparative example

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J. M. Comelles

to stress it, on the basis of the work of two great doctors who both identify
themselves as medical anthropologists. They are deeply different. Fabrega
wrote, as physicians we are concerned with medical problems of individual
persons. The patients aches and physiological constraints become our concern;
and our efforts are directed to helping him. The emotional and social consequences of disease to the individual and his family invariably enter in the picture
also, and in varying degrees our efforts in treatment are affected by these
factors (Fabrega, 1974, p. XIII). We, the doctor. As a doctoralthough, he is
also an anthropologisthe uses a highly rei!ed conception of disease. Although
in the quotation he does make a concession to other dimensions of disease, he
does not formulate them very differently from how the 19th century clinicians
did so. Medical practice is for him a mixture of diagnosis, treatment and support
that necessarily involve a lack of discussion about the cultural roots of disease.
This is Fabrega, the physician. On the following page, he says, Social scientists,
who note and describe the regularities in the way people behave and conduct life
and who then study factors that may explain these regularities, have increasingly
been drawn to problems associated with disease (Fabrega, 1974, p. XIV). Note
the change in the narrative style. A leader of modern medical anthropology
identi!es himself as a physician and looks on social scientists as others. It should
be asked, then, whether his purpose is social science, or a form of reintegrating
social science into medicine within a project that is essentially medical, and only
collateral to anthropology. The rest of the book reveals that Fabregas problem
is not medicine, but the limited conception of medicine that leads to the current
model of practice. When faced with the critical attitude of questioning all of this,
Fabrega adopts an ambivalent position. He wants to explain to doctors that their
practice does not allow them to understand the non-biological dimensions of
disease. This is not an obstacle to dividing disease into two sub ideas, disease
and illness and attributing one of them to medicine and the other to social
sciences, because in his book he attempts to show precisely the opposite. Here,
Fabrega is trapped by his double status of physician and anthropologist, by his
commitment to both disciplines. In spite of Fabregas attitudes about ethnomedicine, in disease and social behaviour, the main regard is about medical
practice in Western contexts, in a home context. Therefore, Fabrega is a
professional social anthropologist in an American context of big spread of social
and cultural anthropology.
Pedro Lan Entralgo is one of the greatest historians of medicine of 20th
century. He describes himself as a medical anthropologist, in a Spanish
context and time which has not developed social and cultural anthropology.
Lan Entralgo worked largely on Hippocratic medicine to establish a historical
basis to doctor patient relationships, to improve actual medical practice (1983).
In a more recent period, he has moved from history of medicine to medical
anthropology, a philosophical dissertation about the being of a doctor in the
world (1984). His discourse connects clinical practice to a relational ethic whose
roots are to be found in the notion of phylia in classical medicine but he leaves
it to the individual will of the subjects whether they comply with the agenda. He

Writing at the margin

17

does not empirically investigate what is done, but proposes an ethic and some
values that are compatible with the biomedical model being accepted as the
pinnacle of a secular evolutionary process. The individualisation of the relation
between the physician and the patient makes social and cultural variables
unimportant and reduces their weight in medical epistemology.
Lan Entralgo is the witness of a transitional stage of medicine in Europe.
Medicine was then moving from the patients home to the hospital and from a
largely privately owned health system to a public one. In some way, his work
expresses disenchantment with the important changes that the European medical profession was undergoing. For him, medical history, or medical anthropology are not historical or anthropological !elds, but medical ones that can be
developed essentially by doctors.
Fabrega encourages the development of a universal !eld of applied multidisciplinary research on medicine, which is not reserved for doctors. Lans position
is different. He wants to keep and to reinforce intellectually the moral values and
the ideological and political power of classical medicine in Europe. For four
decades Lans work and conceptions about medical anthropology have been the
main obstacle to the presence of social and cultural medical anthropology in
medical schools in Spain, and even in some countries of Latin America.
The marginality of medical anthropology in Southern Europe
The major European schools of social and cultural anthropology have not been
interested in medicine. In studies on magic, medicine and religion, a genre
largely developed in overseas European anthropology, medicine was marginal,
and there was very little interest on medical problems. Most of the ethnographers of European medical folklore were doctors. They wrote for doctors. The
big surveys of European folklore placed popular medicine into customary
practices, not as popular medicine !les (see Amades, 1980). They were for
folklorists, not for doctors.
The boundary between medical folklore and folklore is very important in
Europe. There is a breakdown between the two intellectual traditions, which do
not mix, because their meaning is different. The former looks searches for the
cultural border of biomedicine. The latter places medical data in a global
pattern of culture whose aim is ethnic or national identity. Ethnography became
a subordinate literary genre in biomedicine. The anthropology that remained in
European medicine was physical anthropology: genetics, racial studies, or as
applied !elds, forensic anthropology, or the application of the Lombrosian and
eugenic theories. On the other hand, the development of social or cultural
anthropology took place as academic overseas ethnology, or folklore studies
developed as speci!c national traditions in continental Europe. We do not !nd
any kind of applied medical anthropology. The very rigid structure and the
hyper-academicism of European universities are an obstacle to multidisciplinary
work. Each !eld of knowledge tends to be autonomous, and medical schools are
very conservative structures, which are largely closed to the social sciences. This

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J. M. Comelles

is the reason why anthropological research was absent from medicine or nursing
studies in Europe before 1980. The exception is Italy. The !rst applied medical
anthropological researches was carried out in the late 1950s (Seppilli, 1954,
1959).i For 40 years, Italian anthropologists have worked with doctors on health
education and promotion in the Centro Sperimentale di Educazione Sanitaria in
Perugia (see Bartoli, 1976, 1986). This was not a coincidence. It was a speci!c
project and a professional commitment, based on a Marxist criticism of the
limits of positivistic folklore and with an active position of intervention (Seppilli,
1983, 1996). In this debate the work of Ernesto de Martino, a great anthropologist and historian of religion, is crucial. In 1959 he began research on
tarantism, which is probably the !rst big home project on medical applied
anthropology in Europe (De Martino, 1994), and continued with a long
tradition of research on medical popular culture and applied anthropological
work.j It is quite easy to understand the silence which surrounds the developments in Italian medical anthropology. Latvian anthropologists write in Italian,
and this language is not now universal language. Ideologically, the most of them
were Marxist, committed to political struggle. Their work was linked to national
leftwing culture, and may appear to be far from the hegemonic anthropological
theories of the 1960s or 1970s.
The politica1 commitment of Italian anthropology, and its criticism of
positivistic ethnography, which followed Pitre`s methodology, seems to be a long
way from the empiricism of hegemonic American cultural and social anthropology. De Martinos path looks for an integration of history and ethnography
based on Gramsci and Croces work. The consequence for Latvian anthropology was a radical break in the organisation of research: the role of the team
rather than the sole investigator, the ethnographers commitment, the handling
of historical documents as ethnographic accounts, the vindication of history.
The empirical and relativistic radicalness of hegemonic anthropology could not
understand this dimension of the problem because it feared history. In order to
be able to understand it, it would have had to deny its own historicity and put
it in the epistemological context in which it wanted to place the problem. De
Martinos work at home opened the space of a new anthropological identity far
from the schedule built by Boas, Malinowski and Radcliffe Brown. Thus
creating an anthropology at home before the current debate about anthropology
at home. De Martino is now a myth in recent Italian anthropology. He has had
a profound in"uence on health education projects, the development of Italian
medical anthropology, the debate about medical intervention in society and the
shaping of popular culture, based on Gramscis analysis on organic intellectuals
and popular culture (see Pandol!, 1992).
Critical Latin American medical anthropology is based on De Martino and
Gramscis in"uence in Argentina and in Mexico (see Aguirre Beltran, 1986;
Menendez, 1991). Spanish medical anthropology in turn was in"uenced
through Latin America.k This is not a coincidence. Popular medical culture
embeds religion, biomedicine, empirical popular knowledge and health care
delivery institutions. The shaping of popular culture as a process, which is

Writing at the margin

19

subordinate to medicalisation, cannot be understood without history. The

relationships between medical anthropology and history are crucial in Southern
European medical anthropology, particularly in Italy and Spain. It is impossible
to understand popular knowledge and practices in Europe without any reference
to the historical shaping of health professions. It is impossible to understand
medicalisation without an analysis about the in"uence of Roman Catholic
religious discourse on miracles and cures. It is impossible to study health seeking
behaviours without taking account the long development of institutions which
provide care services from the late Middle Ages to the end of the 20th century.
In a European context, the process health/disease/care and popular medical
knowledge cannot be understood without reference to the history, and
speci!cally to the history of medicine. The main reason for this is the role of
health professionals and medical institutions in the process of medicalisation,
and the development of health and social welfare policies.
In this theoretical discussion, Southern European and Latin American medical anthropologies have developed an ambiguous relationship with the North
American medical anthropology. On one hand, there is acute criticism against
its strong empiricism and anti-historicism (see Menendez, 1990), and its
disregard of the historical context of health in Latin America or Southern
Europe. On the other, we can !nd clear in"uences from Taussig (1980) and
Young (1982) works. The idea of an anthropology of sickness seems to be closer
to the theoretical positions of the Europeans than an anthropology of disease or
illness (see Comelles & Martnez; 1993; Martnez & Comelles, 1994).
This discussion in"uenced the shaping of anthropological identity for many of
us because we were obliged to work at home in a context dominated by the idea
of anthropology based on !eldwork far away from home. On a second level, we
assume the link between historical work articulated with ethnography. This was,
in the late 1970s, a breakdown in an anthropology that was looking for an
international recognition by placing itself in an international anthropological
orthodoxy. The debate between medicine, anthropology and history is not easy
in Europe. Medicine and history have strong academic position and professional
identity. This is not the case of anthropology, which is looking for a new identity
in a changing world. Placing medical anthropology in the boundaries of medicine, anthropology and history raises considerable problems of academic and
professional identity: a medical anthropologist ought to mutate from historians,
doctors or anthropologists in !elds that are in the very margins of each
discipline. As anthropologists committed to qualitative and ethnographic
methodologies, we disagree with trends that simplify the role of political
economy and history to a formula synthesised in general notions such as
Western societies or medicalisation. Under the hegemony of clinical or epidemiological methodologies in medicine or public health, we defend qualitative
methodologies and we !ght side by side with historians for a social history of
medicine.
Except in France, Latin-speaking anthropologies in Southern Europe and in
Latin America are anthropologies at home, even if some researchers work

20

J. M. Comelles

overseas. We are our objects. In Europe, we share the object with historians,
lawyers, doctors or sociologists. Even our classical object of study, the folklore
of European peasantry, is today a marginal relic. To incorporate history by
anthropologists or anthropology by historians or sociologists into Southern
Europe has three effects. First, the blurring of limits between medical anthropology, medical history, and medical sociology. Second, the development of
common areas of interest centred around the process of health/disease/care in
popular classes or marginal groups, and !nally, the development of the health
professions and institutions and their relations with the shaping of popular
culture. They are all home processes, in the sense we are using the term here.
This panorama has some idiosyncratic features, particularly that a lot of research
in the !eld of social sciences and health is performed by doctors or amateurs.
In professional terms medical history, sociology and anthropology are underdeveloped. Therefore, amateurism in most cases is far from the theoretical and
methodological development of these !elds, even if he keeps a singular position
within medicine. By this way, the !eld of social and cultural studies on
medicine in Southern Europe is not in the same position as Kleinman or Hahn
reports in the United States because of professional academic segmentation and
the absence of social scientists in medical and nursing education and training.
This absence is related to an idiosyncratic process derived from the speci!c
conditions of deployment of health institutions and professional training. The
result is that social scientists carry out little empirical research on health and that
doctors have in part appropriated research into social health and the teaching of
medical sociology and anthropology. This they have done in three ways: by
assuming the development and evolution of the !eld, reinventing the !eld by
placing it in the framework of a diffuse idea of medical humanities, and taking
an obsolete idea of medical anthropology linked to folklore. In any case, the
development of Southern European medical anthropology shows such a common path between anthropologists and historians of medicine with very large
overlapping areas of interest. This led to a revision of the role of ethnographic
sources and of ethnography in biomedical and nursing research at the dawn of
the 21st century.
Acknowledgements
Translated by John Bates (Servei Linguistic, URV), and revised by Xavier Allue,
MD, PhD (URV). This research is part of a research project into the development of medical anthropology. It started with a genealogy of medical anthropological schools (Comelles & Martnez, 1993; Martnez & Comelles, 1994),
followed by a project on medical ethnographic writing (Comelles, 1996, 1997,
1998a,b). The outline of this paper was presented in the international meeting
Medical Anthropology at Home in Zeist (The Netherlands), in April 1998. I
am grateful for the fruitful comments of Alvina Putnina, Susan Reynolds, Els
van Dongen, Ivo Quaranta, Xavier Allue, Enrique Perdiguero, Sjaak van der
Geest and Ian Robinson.

Writing at the margin

21

Notes
(a) The major European periodicals in medical anthropology in Europe are Curare and Ethnomedizin, both German, Anthropology and Medicine in English, AM in Italian, and Medische
Anthropologie in Dutch. In Spanish, there is not a speci!c periodical.
(b) In the well-known handbooks on medical anthropology written by Sargent and Johnson
(1996), or by Helman (1990), there are very few non-English references. Most are French
translations.
(c) I follow the ideas about the development of anthropological practice expressed by the
medical anthropologist Eduardo Menendez in some of his writings (1977, 1991, 1997). He
discusses the main changes in anthropological practice following the genealogical model, and
in his latest papers he discusses the problems raised by the specialisation trends in recent
anthropology.
(d) I prefer this term. Ethnography is a neologism from the Enlightenment (Vermeulen, 1994),
and it would be an anachronism to apply it without criticism to narratives based on listening
or observation in natural settings.
(e) Hippocratic texts also contain ethical and jural narratives that describe the relation between
the professional and the patient (Lan Entralgo, 1987).
(f) Medical narratives are linked to the natural history narratives developed by modern science
and are alternatives to the old natural history narratives that were open to fantasy. In the
reports of rural or urban doctors, the time schedule follows them on their way from the home
of one patient to another. The description begins with descriptions of the slum or the
household. A description of the time schedule in institutions is very different. Time in an
institution is perceived as a cyclical and regular routine in which the patient careers are
placed (Allue Martnez, 1996).
(g) Ethnographic writing has been restricted to those practitioners whose professional task is still
heavily committed to local knowledge in rural areas or in the slums of the big cities. Only a
few of them use ethnographic texts to denounce the blights of society that shows the loss of
in"uence of local knowledge on medical practice.
(h) The epistemological and methodological breakdown of medical folklore was Pitre`s work
(1896). Pitres conception of medical history and folklore, as a genre at the service of a
medical project, is on the margin of his other condition as a folklorist. This dissociation in
his triple role as rural physician, as medical ethnographer and classical folklorist is not free
of tensions and his methodological attempt to de!ne an idea of popular medicine through
medical theory reveals some overlaps with the conceptual framework of folklore. For further
information about Pitre`, see Cocchiara (1938, 1941), Bronzini (1983), Gentile (1994), and
Comelles (1996).
(i) For an overview on Italian anthropology, see Clemente et al. (1985) and Comas (1985).
(j) His work was mainly interested in discussing popular culture and the role of brokerage of
social scientists in social and cultural change. Gramsci, Crook, and German cultural history
in"uenced De Martino. His !eld research was done during the 1950s, generally on subjects
related to magical practices and popular religion. For an approach to De Martino, see
Pandol! (1992, 1993).
(k) About medical anthropology in Spain, see Comelles and Paris (1986). The main bibliographies are Pujadas et al. (1980), and Perdiguero et al. (2000). Perdiguero (1992, 1993) has
discussed the relationships between history of medicine and medical anthropology.

References
AGUIRRE BELTRAN, G. 1986. Antropologia Medica. Mexico City: La Casa Chata.
ALLUE MARTINEZ, M. 1996. Sauver sa Peau. Paris: Seli Arslan.
ALVAREZ MILLAN, C. 1999. Graeco-Roman case histories and their in"uence on Medieval clinical
accounts. Social History of Medicine, 12(I), 1944.

22

J. M. Comelles

AMADES, J. 1980. Folklore de Catalunyal: Costums i Creences. Barcelona: Editorial Selecta.

AUGE, M. 1986. LAnthropologie de la maladie. In POUILLON , J. ed. Anthropologie. Etat des Lieux.
Paris: Le Livre de Poche, 7785.
BARTOLI, P. 1976. Processi di comunicazione, educazione sanitaria e lorta per la salute, il ruolo
dei servizi di medicina preventiva. In Atti del Convegno La Ricerca in ltalia sulla Comunicazioni
di massa. Firenze: Amaldo Fomi, 197206.
BARTOLI, P. 1986. Antropologia culturale e educazione sanitaria. Antropologia Medica, 1, 1316.
BRONZINI, G. B. 1983. Antropologia e rnedicina popolare: note sugli studi dei positivisti italiani.
La Ricerca Folklorica, 8, 1317.
CASTEL, R. 1995. Les Metamorphoses de la Question Sociale: Une Chronique du salariat. Paris:
Fayard.
CLEMENTE, P. et al. eds. 1985. LAntropologia italiana: un secolo di storia. Rome: Gius, Laterza and
Figli.
COCCHIARA, G. 1938. La vita e larte del popolo siciliano nel museo Pitre`. Palermo: Ciuni Ed.
COCCHIARA, G. 1941. Giuseppe Pitre` e le tradizioni popolari. Palermo: Ciuni Ed.
COMAS, J. 1985 La Antropologia ltaliana a traves del lnstituto italiano di antropologia. Mexico City:
Universidad Nacional Autonoma de Mexico.
COMELLES, J. M. 1996. Da superstizioni a medicina popolare: la transizione da un concerto
religioso a un concerto medico. AM Rivista della Societa` italiana di antropologia medica, 12,
5789.
COMELLES, J. M. 1997. The fear of (ones own) history. on the relations between medical
anthropology, medicine and history. Dynamis, 17, 3768.
COMELLES, J. M. 1998a. From ethnography to clinical practice in the construction of the
contemporary State. In GREENHOUSE, C. J. ed. Democracy and Ethnography: Constructing
identities in Multicultural Liberalstates. Albany: State University of New York Press, 233
254.
COMELLES, J. M. 1998b. Parole de medecin: le recit sur la pratique dans la medecine contemporaine. In LAPLANTINE , F. eds. Recit et connaissance. Lyon: Presses Universitaires de Lyon,
799816.
COMELLES, J. M. & MARTINEZ HERNA EZ, A. 1993. Enfermedad, Culturay Sociedad. Un ensayo sobre
las relaciones entre la Antropologfa Social y la Medicina. Madrid: Eudema.
COMELLES, J. M. & PARIS, S. 1986. La antropologa de la medicina en Espana. Jano, 717, 8497.
ERKOREKA, A. 1985. Analisis de la medicina popular vasca. Bilbao: Etniker-Bizkaia.
FABREGA, H. 1974. Disease and Social Behavior. Cambridge: MIT Press.
FALTERI, P. 1989. La medicina popolare. Umbria. In SEPPILLI , T. ed. Le tradizioni popolare in
Italia. Medicine e magie, 160165. Milan: Electa.
FOUCAULT, M. 1978. Naissance de la clinique. Paris: PUF.
G ARCIA BALLESTER, L. 1981. Experiencia y especulacion en el diagnostico galenico. Dynamis, 1,
203225.
G ARCIA BALLESTER, L. 1995. Elementos para la construccion de las historias clnicas en Galeno.
Dynamis, 15, 4766.
G ENTILE, G. 1994. Giuseppe Pitre` (18411916). Palermo: Sellerio.
HAHN, R. 1995. Sickness and Healing: An Anthropological Perspective. Cambridge: Yale University
Press.
HELMAN, C. G. 1990. Culture, Health and Illness. London: Wright.
HERSCH MARTNEZ, P. 2001. Plantas medicinales: relato de una posibilidad con!scada. El estatuto de
la "ora en la biomedicina mexicana. Mexico, DF: INAH.
HIPOCRATES DE COS. 1986. Tratados Hipocrtiticos Il. De los aires, las aguas y los lugares. Sobre los
humores. Sobre los "atos. Predicciones I. Predicciones Il. Premoniciones de Cos. Madrid: Editorial
Gredos.
HIPOCRATES DE COS. 1989. Tratados Hipocraticos V: Epidemias. Madrid: Gredos.
KLEINMAN, A. 1980. Patients and Healers in the Context of Culture. Berkeley: University of
California Press.

Writing at the margin

23

KLEINMAN, A. 1995. Writing at the Margin: Discourse between Anthropology and Medicine. Berkeley:
University of Califomia Press.
LAIN ENTRALGO, P. 1961. Enfermedad y pecado. Barcelona: Ediciones Toray.
LAIN ENTRALGO, P. 1983. La relacion me dico-enfermo. Historia y Teora. Madrid: Alianza.
LAIN ENTRALGO, P. 1984. Antropologia medica para clnicos. Barcelona: Salvat.
LAIN ENTRALGO, P. 1987. La Medicina Hipocratica. Madrid: Alianza.
MARTINEZ HERNAEZ, A. & COMELLES, J. M. 1994. La medicina popular. Los lmites culturales del
modelo medico? Revista de Dialectologa y Tradiciones Populares, 39(2), 109136.
MARTINO, E. DE 1994. La terra del rimorso. Contributo a una storia religiosa del sud. Milan: Il
Saggiatore.
MENENDEZ, E. L. 1977. Nuevos objetos de estudio de la antropologia social. In Actas de la XV
Mesa Redonda de la Sociedad Mexicana de Antropologia. Mexico City: Sociedad Mexicana de
Antropologa, 7582.
MENENDEZ, E. L. 1990. Antropologa Medica. Orientaciones, desigualdades y transacciones. Mexico,
DF: CIESAS.
MENENDEZ, E. L. 1991. De!niciones, inde!niciones y peque!os saberes. Alteridades, 1(1), 2133.
MENENDEZ, E. L. 1997. Holisticos y especializados: los usos futuros de la Antropologia. Nueva
Antropologia, 5253, 938.
PANDOLFI, M. 1992. Beyond Gramsci and De Martino: medical anthropology in contemporany
Italy. Medical Anthropology Quarterly, 6(2), 162165.
PANDOLFI, M. 1993. Le self, le corps, la crise de la presence. Anthropologie et Societes, 17(12),
5777.
PERDIGUERO, E. 1992. Historia de la medicina y la antropologia. Quaderns dantropologies, Numero
Especial, 715.
PERDIGUERO, E. 1993. Historia de la medicina y antropologia de la medicina. In ROMANI, O. &
COMELLES J. M. eds. Antropologa de la salud y de la medicina. Santa Cruz de Tenerife:
Asociacion Canaria de AntropologosFAAEE, 3556.
PERDIGUERO, E., COMELLES, J. M. & ERKOREKA, A. 2000. Cuarenta an os de antropologa de la
medicina en Espana (19602000). In PERDIGUERO, E. & COMELLES, J. M. eds. Medicina y
cultura. Estudios entre la antropologa y la medicina. Barcelona: Bellaterra, 353446.
PESET, J. L. 1984. Ciencia y marginacion. Negros, locos y criminales. Barcelona: Crtica.
PITRE`, G. 1896. Medicina Popolare Siciliana. Torino: Carlo Clausen.
PUJADAS, J. J., COMELLES, J. M. & PRAT CAROS, J. 1980. Una bibliogra!a comentada sobre
antropologia medica. In KENNY, M. & MIGUEL, J. M. eds. La Antropologa Medica en Espana.
Barcelona: Anagrama, 323353.
ROSEN, G. 1972. The evolution of social medicine. In FREEMAN, H., LEVINE , S. & REEDER, L. G.
eds. Handbook of Medical Sociology. New Jersey: PrenticeHall, 3062.
SARGENT, C. F. & JOHNSON, T. M. eds. 1996. Medical Anthropology: Contemporary Theory and
Method. New York: Praeger.
SEPPILLI, T. 1954. Contributo alla formulazione dei rapporti tra passi igienico-sanitaria ed
etnologia. Atti della XLV Riunione della Societa Italiana per il progresso delle scienze. Roma:
Istituto di Antropologia della Universita` di Roma, 320.
SEPPILLI, T. 1959. Il contributo della antropologia culturale alla educazione sanita`ria.
LEducazione sanitaria, 4(34).
SEPPILLI, T. 1983. La medicina popolare in Italia, Avvio ad una nuova fase della ricerca e del
dibattito. La Ricerca Folklorica, 8, 37.
SEPPILLI, T. 1996. Antropologia medica: fondamenti per una strategia. AM Rivista della Societa`
italiana di antropologia medica, 12, 722.
SIGERIST, H. 1987. Civilizacion y Enfermedad. Mexico City: Instituto Nacional de Salud Publica.
TAUSSIG, M. 1980. Rei!cation and the consciousness of the patient. Social Science & Medicine,
14B, 313.
TURNER, V. W. 1988. El proceso ritual. Estructura y antiestructura. Madrid: Taurus.
VERMEULEN, H. F. 1994. Origins and Institutiona1ization of ethnography and ethnology in
Europe and the USA 17711845. In VERMEULEN, H. F. & ALVAREZ ROLDAN, A. eds.
Fieldwork and Footnotes. London: Routledge.
YOUNG, A. 1982. The anthropologies of illness and sickness. Annual Review of Anthropology, 11,
25785.