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The Coming of Age of Critical Medical

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Sm. Sci. Med. Vol. 28, No. 11, pp. 1193-1203, 1989 0277-9536/89S3.00+ 0.00
Printed in Great Britain. All rights reserved Copyright 0 1989Pergamon Press plc

THE COMING OF AGE OF CRITICAL

MEDICAL ANTHROPOLOGY

MERRILL SINGER
Hispanic Health Council, 98 Cedar St, Hartford, CT 06106, U.S.A.

Abstract-This paper reviews the development over the last 15 years of a broadening critical trend in
the field of medical anthropology by: (1) examining shortcomings of conventional medical anthropology
that led to interest in critical alternatives; (2) examining historical and occupational factors that tend
to conservatize the subdiscipline; (3) reviewing the body of literature produced thus far by its adherents;
and (4) suggesting directions for future work.

Key wor&-medical anthropology, critical analysis, political-economy

“We seem to have taken a wrong turn in under-
standing at some critical point in the past, a false
choice that bedevils our thinking in the present.”
ERIC R. WOLF
The wrong turn in anthropological thinking to which
Wolf calls our attention was the ideographic shift
ushered in by Boas, Malinowski and other ethnog-
raphers of their era. Argues Wolf,
Fieldwork-direct communication with people and partici-
pant observation of their ongoing activities in siru-became
the hallmark of the anthropological method. . . Yet the
very success of the method lulled its users into a false
confidence. It became easy for them to convert merely
heuristic considerations of method into theoretical postu-
lates about society and culture [l, p. 131.
Yet, while ethnography provided the fuel, the motor
driving the turn towards conceptualizing human
groupings as autonomous, self-created, and self-
maintaining cultural systems was not, as Wolf (21well
recognizes, a mere fortuitous feature of method.
As the offspring of colonialism (a parentage captured
in Leeson’s [3] depiction of the discipline as ‘colonial-
ism’s social science’), anthropology played a historic
role in extending the very political-economic pro-
cesses that transcend, weld together, and even bring
into being (as well as destroy) reputedly separate and
autochthonous societies and cultures. According
Magubane and Fat-is:
The most specific contribution of anthropology to the col-
onial enterprize is ethnography. . . The micro-investigation
of cultural entities to emphasize their uniqueness provided
a vital basis for the policies of divide and rule [4, p. 991.
Awareness of the skeletons in the anthropological
closet led to calls for the decolonialization of the
discipline (or even for its deconstruction). For Wolf
and others, this means a critical turn toward political-
economy and to Marx. These offer theories and
methods for understanding the present world holisti-
cally in terms of the growth of the world-system,
the penetrating effects of capitalism, and the determi-
nant role of class, sex, and race on social behavior.
In some areas, progress is evident. Anthropology
now has its Leacocks, Asads, Magubanes, Goughs,
Nashs, Friedmans, Godeliers, Roseberrys, Blochs,
and O’Laughlins among others [5]. But the discip-
line is no longer unified, it is fragmented into a host
of specialty areas. In some subfields the appear-
ance of a critical trend has been slower going than
others. It is with the ongoing process of correcting the
effects of anthropology’s wrong turn in thinking
within medical anthropology that I am concerned
with here.
MEDICAL ANTHROPOLOGY IN QUJLSTION
In the mid-1960s there were no journals, text-
books, or scholarly organizations specific to medical
anthropology [6]. The subject of its inquiry was not
well defined, its practitioners lacked a coherent pro-
fessional identity, and the writings of incipient medi-
cal anthropologists were scattered throughout the
anthropological, medical, and public health litera-
tures. Much has changed in 20 years. Today, there are
at least 4 journals, a growing number not only of
textbooks, but edited collections, book-length mono-
graphs, and book series, and the Society for Medical
Anthropology is one of the largest units of the
American Anthropological Association. Still, a grow-
ing sense exists among some, perhaps many, medical
anthropologists that there are significant limitations
to in the perspectives, approaches, models, and theories
of the subdiscipline.
This malaise has had various expressions. In 1977,
Kiefer, then the editor of the now defunct Medical
Anthropology Newsletter, raised the questions: “Is
medical anthropology part of the solution to
Mankind’s problems? Is it one of the problems?’ [7,
p. 11. Some researchers began to wonder aloud if the
first of these queries would have to be answered in the
negative and the second in the affirmative. Several
Third World anthropologists, in particular, devel-
oped incisive critiques (8-121. Shortcomings of con-
ventional medical anthropology that contributed to
the rise of the critical trend include the following:
microlevel circumscription, neglect of social relations,
medicalization, and ecological reductionism.
First, medical anthropology is criticized for
restricting its focus and analysis to the microlevel,
as if the groups and communities it studies are

1193
 1194 MERRILLSINGER
independent actors responsible for unilaterally build-
ing, owning, and operating the self-contained theaters
of their social dramas. The obfuscation of restricted
microlevel focus is seen in the emphasis given to
“the ritual and symbolic realm in culture, [while]
the political and economic issues which affect the
health and health behavior of populations [are]
not.. . widely considered” [13, p. 5611. As a result,
medical anthropology to a large degree became an
examination of the cultural determinants of illness,
curing, and resistance to biomedicine with little con-
sideration of “the importance of the social forma-
tions in which ‘cultural factors’ occur” [14, p. 481.
This failure to locate microlevel behaviors, beliefs,
and meaning systems within encompassing and deter-
minant social structures, relations, and processes is
termed “socioculturalism” by Onage [9]. Ignored
in socioculturalist writings is Janzen’s [15, p. 1291
reminder that “[no] anthropological generalization
is worth more than its understanding of political
process”. As Aidoo [1 I], O’Neal [16], and Chavez
[17] emphasize, for the Third World, Fourth World,
and labor migrant peoples that have drawn the
lion’s share of anthropological attention, understand-
ing health-related issues necessitates an often over-
looked examination of colonial and neocolonial
experiences.
Second, conventional medical anthropology is
scored for its handling of the concept of social
relations, which it understands not as the structuring
configuration of power alignments that pervades
every arena of social life and is embodied in all
institutions in society, but rather as the character of
interpersonal bonds between particular individuals or
small groups. The doctor-patient relationship, for
example, as Schoepf (18, p. 1121 indicates, is not,
as it has sometimes been treated, “an internally
balanced and self-maintained dyadic social system”.
Rather, the character of doctor-patient interaction is
structured by a wider field of class and other relations
embedded within, but not always directly visible
from, the clinical setting. Failure to locate personal
relations, face-to-face interactions, social networks,
social support systems, and other ties of a similar
order within the encompassing and determinant set of
social relations has been a significant weakness of
mainstream medical anthropology.
Third, is the problem of the medicalization of
medical anthropology. Indeed, there is a growing
sense that Ptlanz’s criticism of medical sociology on
this score applies as well to medical anthropology.
“Overwhelmed by the complex of values upheld by
medicine” [19, p. 5681, medical anthropologists have
taken professional roles and developed analytic con-
cepts that reinforce the medical monopoly over
human suffering. Witness the oft applauded disease/
illness dichotomy. Taussig [20], in a landmark
critique of both medicine and conventional medical
anthropology, laid bare the act of reification central
to diagnosis. Disease, seen only as a malfunction-
ing in biological or psychological processes [21],
possesses a phantom-objectivity. Through our denials
of “the human relations embodied in symptoms,
signs, and therapy, we not only mystify them but we
also reproduce a political ideology in the guise of a
science of (apparently) ‘real things’-biological and
physical thinghood” [20, p. 31. Lost in the political act
of transforming names into things is the capacity for
critical awareness. Lost in the embrace of medical
reification and a clinically reproduced commoditized
reality is the capacity for a critique of medicine.
What results. . is the desocialization of sickness and
medicine. The primacy of the individual is emphasized while
social determinants are reduced, fragmented, or distorted
[22, p. 1361.
One expression of medicalization, recent calls for
anthropologists to engage in a “mandate for clinical
relevance” [21]-by providing physicians with both a
window on the patient’s construction of illness and a
culturally sensitive bedside manner, also is criticized.
Warns Taussig, “there lurks the danger that the
experts will avail themselves of that knowledge only
to make the science of human management all the
more powerful and coercive” [20, p. 121. Such calls
reveal also the extent to which medical anthropology
takes biomedicine at face value ignoring its political-
economic functions, including: (1) profit-making; (2)
physical reproduction of the working class; (3) social
control; (4) social reproduction of class and other
power relations; and (5) cultural hegemony [23]. That
analyses which present this critique of biomedicine
have been met by red-baiting [24] suggests that the
political-economic role of doctoring is not wholly
outside the consciousness of its practitioners.
Last, the medical ecology perspective, which has
achieved ‘a broad tacit consensus’ in medical anthro-
pology [25, p. 1871 is found wanting [26]. Typically,
writings that adopt this perspective abstain from
analysis of critical relational factors, such as owner-
ship of the means of production, export of capital,
extraction of profit, and racial and sexual oppression,
that underlie and ultimately determine human
response to the physical environment. Rather, a
politically and economically (and hence socially) con-
structed environment is treated as natural and
diseases with a social origin are interpreted as
“measures of the effectiveness with which human
groups . . . adapt” to nature (27, p. lo]. Given the
source of many of the dominant environment-
shaping processes in the contemporary world, the
reading of disease rates as measures of environmental
fitness takes on the political function of victim-
blaming; enfeebling, thereby, medical anthropologi-
cal insight.
CONSERVATIZING FEATURES OF
MEDICAL ANTHROPOLOGY
Considering the concern elsewhere in anthropology
with developing a critical perspective [28], a concern
that achieved its zenith during the very period that
medical anthropology was consolidating, why did
medical anthropology remain isolated so long from
critical thinking? Some general reasons have been
identified by Gruenbaum, who notes that:
anthropologists get lost in the fascinating minutiae of
experiences in the field; the fragmentation of social science
is often simply accepted by respecting the ‘territory’ of
economists, historians and political scientists whenever
we step outside the confines of exotic cultures; and it has
been our professional tradition to leave policy decisions
[to others] [14, pp. 47481.
 The coming of age of critical medical anthropology
More specific to medical anthropology, although
stemming from a general characteristic of the disci-
pline, failure to develop a critical perspective is
traceable to the inattention given to institutional
actors with major parts in the health field inter-
nationally, such as manufacturers of medical com-
modities, government health and development
agencies, international lending institutions, profes-
sional medical associations, and private health
foundations [29]. Medical anthropologists have been
disinclined to answer Nader’s [30] admonishment
to ‘study up’. As a consequence, “the existing
power structures have remained untouched” [ 19,
p. 5731.
Finally, there are the ways that perspectives within
medical anthropology have been shaped by the
origin, institutional place, and composition of the
subdiscipline. While ethnomedical interest within
anthropology is of considerable age, medical anthro-
pology as a distinct and organized phenomenon
is predominantly a result of the influence of the international
public health movement and clinical medical activities on
ethnomedical research in cultural anthropology. . . Ethno-
medicine’s identification with organized medicine and public
health. . caused it to splinter from anthropology. . . . Like
medical sociology, the integrity of medical anthropology
is challenged by increased involvement in health policy
research and clinical program development and evaluation
(31, p. 12981.
Batalla [8] argues that applied work within and for
medical and other bureaucracies tends to have signi-
ficant conservatizing effects. Applied work seeks to
avoid rapid social change and consequent potential
for social and cultural disruption,
Sometimes it looks as if those who work along the road of
slow evolution intend to achieve only minimal changes, so
that the situation continues to be substantially the same; this
is, in other words, IO change what is necessary so rhar rhings
remain the same. Those who act according to such a point
of view may honestly believe that their work is useful and
transforming; however, they have in fact aligned themselves
with the conservative elements who oppose. . . structural
transformations [8, p. 921.
Trapped in a restricted role as the translator of
cultural knowledge to health care providers [32],
appointed the task of discovering “how to get
patients and healthy laymen to do things that medical
practitioners consider good for them” (33, p. 651,
selected “to provide apologia for sponsors’ mis-
takes” (31, p. 13011, and given responsibility to
depoliticize issues in health politics [34], medical
anthropologists in applied employment may tend to
overlook the social production of illness, political
factors underlying the medical construction of
disease, the medicalization of social problems, the
social control functions of medicine, the blame-the-
victim components of medical ideology, structural
inequities in health care provision, the reproduction
within medical professions of power structures out-
side of medicine, and the role of medicine in the
reproduction of exploitive class, gender, and race
relations [29].
Indeed, medical anthropologists often are seduced
by the magic spell of medicine [35], a spell consisting
of (questionable but usually unquestioned) claims
1195
of efficacy, comparatively high social status, political
legitimacy, and considerable (though delegated)
power within society. The stature of medicine is such
that for many anthropologists biomedicine serves
as “the reality through the lens of which the rest
of the world’s cultural versions are seen, compared,
and judged” [36, p. 41. Given Hunter’s reminder
that clinicians have dominated medical anthro-
pology since its inception [31], especially its theor-
etical perspectives, this is not so surprising. In addi-
tion, medical anthropologists increasingly have
traded the discipline’s traditional holism for a
reductionistic replication of medicine’s fine-grained
division of knowledge and labor. The consequence
of the ongoing medicine-like specialization within
anthropology (the logical extension of which would
be an interest group within the Society for Medical
Anthropology for every ‘disease’) is, as Baer indi-
cates, “even further erosion in medical anthropology
of the limited critical perspective of biomedicine
and [the] larger world economic system. . .” [37,
P. 64.
In sum, the microscopic focus and all but over-
powering ideographic slant of anthropology’s colo-
nial past on the one hand, and the often co-opting
nature of applied employment on the other, act as
powerful barriers to the emergence of critical perspec-
tives within medical anthropology. Still, over the last
several years, scattered attempts to plant the seeds of
critical thinking in medical anthropology have blos-
somed into an emergent critical trend with mounting
visibility in the field.
CRITICAL MEDICAL ANTHROPOLOGY IN REVIEW
Troubled by the issues discussed above and grow-
ing increasingly aware that medical anthropology was
developing in seeming ignorance of the burgeoning
literature on the political economy of health, some
medical anthropologists began to wonder about the
misdirection of their field and to posit the creation
of a new medical anthropology that corrects the
defects of the socioculturalist and adaptationist
approaches with the insights of what Elling terms the
progressive-holistic perspective.
Work from . . . [this] perspective understands societies as
involving class conflict and sees the state apparatus and
medical-health systems as mediating this conflict in favor of
the ruling class in capitalist societies. The historical develop-
ments and political-economic conditions are viewed as
primary, with value orientations and beliefs flowing from
these fundamental conditions 138, p. 2361.
The initial effort to forge a critical redirection for
medical anthropology can be traced to the sym-
posium ‘Topias and Utopias in Health’ at the 1973
IXth International Congress for Anthropological and
Ethnological Sciences, which ultimately developed
into a volume with the same title. In his review of
the political-economy of health literature, written a
decade after the International Congress, Baer [39,
p. 161 notes that “Topias . . . remains the only major
book in the medical anthropological literature that
includes political economic interpretations”.
An explicit turn toward the political-economy of
health tradition within medical anthropology awaited
1196 MERRILL SINGER
Morsy’s ‘The Missing Link in Medical Anthro-
pology: The Political Economy of Health’ published
in 1979 (401. In this and a number of subsequent
papers, Morsy [41, p. 1591 advocated adoption of
“a political economy perspective which undermines
the idealist, reductionist and dualist approaches”
characteristic of much medical anthropology.
Morsy’s work helped to inspire Baer’s [39] review,
noted above, which not only offered a handy (if
problematic) definition of political-economy of
health (“a critical endeavor which attempts to under-
stand health-related issues within the context
of the class and imperialist relations inherent in
the capitalist world-system”), but helped to intro-
duce many medical anthropologists to the political-
economy of health literature. Over the next several
years the number of medical anthropologists con-
cerned with critical alternatives began to grow, as
did their impact on medical anthropology symposia
and literature. By the 1987 American Anthropolog-
ical Association Annual Meeting, a shared sense
had emerged that critical medical anthropology had
come of age as an important perspective within the
discipline.
Beyond its critique of the limitations of conven-
tional anthropology and its advocacy of broader
frames of reference, what has this new approach
achieved thus far or failed to achieve; what are its
major themes and key concepts; what differences
have emerged among its adherents? While answers to
some of these questions have been alluded to already,
this section will concern itself with developing fuller
responses.
Among the major contributions of critical medical
anthropology are the following: (1) examination of
the social origins of disease and ill health in light of
the world economic system; (2) analysis of health
policy, health resource allocation, and the role of the
State in Third World nations; (3) re-thinking of the
contemporary understanding of medical pluralism;
(4) development of a critique of biomedical ideology,
practice, and structure; (5) attending to the role of
struggle in health and health care; (6) re-examination
of the microlevel of the individual, including illness
behavior and illness experience, within the context of
macrolevel structures, processes, and relations; and
(7) investigation of health and health programs in
socialist-oriented countries. Each of these will be
discussed in turn.
Study of the social origins of illness has a con-
voluted history in the health and social sciences. It
is a field, Waitzkin concludes, that began with Engels
but has “been largely forgotten and then rediscovered
with each succeeding generation” [41, p. 771. Within
medical anthropology, it is a subject that attracted
negligible attention until the emergence of the critical
trend. In the last several years, critical medical
anthropologists attempted to correct this short-
coming through studies of malnutrition [43-45],
environmental and occupational health problems
[ 13,46-48], substance abuse [49, 501, infant mortality
[51], and emotional conflicts and disorders [52-551
in terms of the structural contradictions of capitalist
production and the for-profit character of capita-
list distribution. Consider the issue of malnutrition.
In an article deemed sufficiently enlightening to be
reproduced in one of the most widely read collections
of medical anthropology papers, Newman [56] argues
the following about its causes:
On a gross world basis the American Geographical Society
(1953) maps show that the areas of undernutrition and
malnutrition closely coincide with the tropical and warmer
temperate regions of backward food producing techno-
logies. To a considerable extent the nutritional deficiency
diseases are distributed by climate zones, are often worse at
certain seasons, and are sometimes related to specific food
crops. When these deficiency diseases reach epidemic pro-
portions, they appear to represent the worst lags in man’s
adaptation to his nutritional environment.
By contrast, in his study of Cauca Valley in the
tropical country of Columbia, where 50% of the
children are malnourished, Taussig [43] found it
necessary to consider the effects of a burgeoning
agribusiness sector, the World Bank, U.S. multi-
national corporations, USAID, the Rockefeller
Foundation, U.S.-based private consulting firms,
U.S. and Columbian university staff and the like.
Except by examining the role of powerful national
and international forces with vested interests in the
production or protection of profit, Taussig found it
impossible to understand malnutrition in a fertile
region that exports cash crops to the U.S. Similarly,
Davison [44] argues that efforts to account for hunger
in Haiti, the tropical breadbasket of the French
empire in the 18th century, only in terms of ecological
or cultural factors, eliminate from consideration the
effects of several hundred years of colonial and
neocolonial extraction from the island. Critical med-
ical anthropology studies such as these demonstrate
the necessity of situating the examination of ill health
within the “wider field of force” [l], i.e. the global
social relations (often implemented by multinational
corporations, facilitated by international lending in-
stitutions, and supported by ‘development’ agencies)
that determine what is produced, how it is produced,
and who benefits (or suffers) from production. As
Scheper-Hughes shows in her work in yet another
tropical setting, Northeast Brazil, conventional per-
spectives that
interpret the extremely high rates of death and disease. in
the developing world as the almost inevitable consequences
of largely impersonal ecological, climactic or demographic
conditions. obscure.. the role of economic relations
in the social production of morbidity and mortality . . [5I,
p. 5351.
The need to reinsert societal cases back into the
world economic system for understanding also can be
seen in critical medical anthropology studies of the
relationship between the State, health policy, and
resource allocation. For many of the cases of tradi-
tional interest to anthropology, this means an exam-
ination of contemporary health policy and practice in
relation to the legacy of colonialism and the develop-
ment of underdevelopment on the one hand and the
emergence of neocolonialism and the functioning of
a comprador elite on the other.
Several critical medical anthropologists have
examined the health policies of colonial regimes
[3, 11, 14, 571. These accounts parallel Lasker’s
description of the role of health services in the Ivory
Coast.
 The coming of age of critical medical anthropology
Study of the Ivory Coast reveals the many ways in which
French colonizers, clearly the dominant group until inde-
pendence, relied on the Western health system to further
their economic and political aims. As the goals of colonial
rule changed over time, so did the nature of medical care
organizations. The result has been a highly unequal alloca-
tion of services, benefiting primarily the French and those
Africans who were considered important for the mainte-
nance of a productive economy and of political stability.
Although many individuals who worked in the health
services in the colonies were motivated by humanitarian
concerns and many positive results were achieved in improv-
ing health, it should nevertheless be. . . clear. . that the
health system was developed primarily to promote French
interests [58, p. 2781.
With independence, colonialism commonly gave
way to a pseudo-independence in which the class
structure created by the colonial regime served as a
foundation for maintaining the metropolis-satellite
relationship, and in which the health care sector
remained shackled to the colonial past and the neo-
colonial present. As Whiteford [59] reveals in her
research in the Dominican Republic, under pressure
or persuasion from without, Third World countries
adopt health care policies and programs designed to
maintain ties with the capitalist core rather than
improve the health of their populations. Features
of the medical sector identified by critical medical
anthropologists in dependent capitalist countries
include: (1) provision of a costly and centralized
biomedicine to the national bourgeoisie (and the
military) that is woefully ill-suited to the health care
needs of an underdeveloped country; (2) maintenance
of a highly centralized and rigidly organized health
system with decision-making power concentrated at
the top; (3) production of medical specialists that
rapidly are drained into the lower echelons of the
health systems of developed countries; (4) creation of
a market for imported pharmaceuticals and other
medical commodities; and (5) emergence (or continu-
ation in ever changing form) of a lower tier of health
workers and folk healers who treat the rural as well
as urban masses.
On the whole, as McDermott [60, p. 1981 shows in
her study of health policy in Hong Kong, State
intervention “has done little more than further im-
plant and solidify biomedicine”. A more general
conclusion of critical medical anthropology is illus-
trated by Stebbins [60. p. 1391in his work on Mexican
health policy, namely that State intervention in health
care without a significant reallocation of resources
“addresses symptoms rather than causes of disease
and is not likely to significantly improve the health
status of the people who are most in need of such
assistance”. State intervention, in fact, most com-
monly serves not to challenge but to reproduce
inegalitarian social relations. The process also has
been described in a First World case by S. Morgen
[62] in her analysis of State cooptation of a feminist
health clinic.
The above list of features of the medical sector
suggests that the medical pluralism described in
numerous conventional medical anthropology re-
ports does not float in the ratified air of symbolic
meanings and explanatory models, but, as Franken-
berg [63, p. 1981insists, is anchored to class divisions.
This point is illustrated in a study of hypoglycemia by
1197
Singer and his co-workers. Relative to the diverse
explanatory models (EMS) associated with this con-
dition, they note the following.
Medical pluralism is . . a product of a larger social
dynamic. The EMS involved in the hypoglycemia contro-
versy represent alternative, yet intertwined, mystifications of
social etiology, produced and defended by different strata
within the medical system and within society generally [64].
An important issue in the study of medical plural-
ism is the role of the State. In the Third World, State
support for folk medicine appeals to popular anti-
imperialist sentiment but is often shallow; “Members
of the ruling class whose ailments require deeper
penetration look to injections, drugs or surgical
intervention from the West” [63, p. 1981. Even in
situations where explicit financial or legal support for
traditional medicine is lacking, governments “like to
keep traditional medicine alive, because it is recog-
nized that traditional physicians take some of
the strain off Western doctors in dealing with self-
limiting disease” [89, p. 1351. More broadly, it has
been argued that traditional medicine is allowed and
even fostered by the State as a means of handling
the potentially disruptive ‘human fallout’ associated
with capitalist development (including market pen-
etration, proletarianization, urban migration, and
poverty) that is not easily fitted to the diagnostic
categories and treatment modalities of biomedicine.
Thus, folk medicine has been described as being
“compensatory and accommodative rather than cor-
rective” [66, p. 1661. In sum, the success of folk and
heterodox healing systems in capitalist countries is
contingent upon gaining “acceptance from strategic
elites who are seeking solutions to the contradictions
of capitalist-intensive medicine and/or by patients
who demand forms of treatment neglected by ortho-
dox medicine” [67, p. 31, as Baer found in his studies
of chiropractic and osteopathy in the U.S. and
Britain.
Additionally, argues Taussig [68], much folk heal-
ing in the contemporary world, or what he calls
“shamanism in its colonized form”, cannot be under-
stood in isolation from the history of social relations
and the restructuring of social life produced by
capitalism. For example, there is the source of the
folk healer’s magic. The power of the indigenous
healer, he asserts, lies in his/her ability to manipulate
an imagery created in the colonial encounter: an
imagery of wild men and savages, of threatening
disorder at the margins of proper society, of bloody
terror and uncompromising brutality (projected on to
natives by colonial masters of such arts), of recal-
citrant paganism in need of Christian discipline. In
appealing to the spirits, to African Gods and
Amerindian culture heroes, to devil figures of all
kinds (as these spirit beings were rendered in Chris-
tian understanding), to rhe very entities that are said
to cause sickness and misfortune, the folk healer seeks
to tap the power of disorder attributed by the colo-
nialist to pagan religion and culture. Thereby, the
“political events of conquest and colonization . . .
become objectified in the contemporary shamanic
repertoire as magically empowered imagery capable
of causing as well as relieving misfortune” [68,
p. 367. And, not unrelatedly, it is the magic power
1198 MERRILLSINGER
of capitalist society-a power demonstrated daily in
technology, in science, in the flood of commodities-
that the Third World patient hopes to tap in seeking
biomedical treatment. Writing of Columbia and
of plantation workers who cannot earn enough to
keep starvation at bay, Taussig [68, p. 278) describes
in some detail the inappropriateness of biomedical
‘cures’.
Yet amazingly awful and absurd as they are, [biomedical]
services supplied by the official medical system and its
university-trained doctors, backed by the multinational
corporations of ‘science’, agribusiness, and pharmaceuticals,
are sought by many. This optimistically desperate search is
testimony to a magical attraction, in this case to officialdom
and to ‘science,’ no less and probably a good deal greater
than that involved in the magic of so-called magical
medicine.
The attention accorded folk medicine by con-
ventional medical anthropology is another issue of
concern to critical medical anthropologists. While
some have interpreted this as further expression of
anthropology’s preoccupation with anything pur-
portedly traditional to the neglect of everything trans-
formed, Harrison contends a more explicitly political
function.
Traditional healers became fashionable for anthropologists
and other social sciences because [such research] gave
former colonial nations access to the local population’s
thought patterns and medicines. . . . As a result, colonial
powers.. . are able to maintain a presence in these countries
. . . under the guise of helping them develop new local level
low cost health care delivery systems [69, p. 131.
The nature of biomedicine, the dominant medical
system in both developed countries and the Third
World, also has been a topic of interest to critical
medical anthropology, as it has been increasingly for
medical anthropology generally. Recent work by
conventional medical anthropologists focuses on the
analysis of biomedicine as a cultural system, the
problematics of medical roles, the dynamics of med-
ical discourse, and the thought-worlds of physicians
in clinic contexts. By contrast:
A critical medical anthropology must address questions
of. : (1) Who has power over the agencies of biomedicine?
(2) How and in what form is this power delegated? (3) How
is power expressed in the social relations within the health
care delivery system? (4) What are the economic, socio-
political and ideological ends and consequences of the
power relations that characterize biomedicine? and (5) What
are the principal contradictions of biomedicine and arenas
of struggle in the medical system? [70, pp. 95-961.
Answers to these types of questions, it is contended,
provide the macrolevel context for considering other
issues on the agenda of medical anthropology. For
example, in addressing the last of these questions in
a study of prenatal care in a public clinic, Lazarus [71]
identifies three major contradictions of biomedicine:
(1) the asymmetrical relationship between doctors
and patients (a relationship that replicates class,
racial, and sexual hierarchies in society generally
[72]); (2) emphasis on the training of resident physi-
cians rather than the provision of care to patients;
and (3) a division of labor within the clinic that
divides the patient into a poorly coordinated series
of clinical functions bureaucratically delegated to
an array of specialists (e.g. nurses, clerks, aides,
physicians).
The differences in the analytic approach to
biomedicine taken by conventional and critical
medical anthropologists can be illustrated with an
example. Efforts by mainstream medical anthro-
pologists to analyze clinical discourse began with the
assumption that it entails a set of “transactions across
diverse explanatory models or conceptual systems”
[73, p. 1941. Negotiations between doctors and
patients are examined in terms of the differing models
of reality possessed by each party to the interaction.
Critical theorists, like Young [74], however, argue
that the starting point for the examination of such
discourse lies in an appreciation of the social relations
underlying and determining discourse production.
Consequently, it is insufficient to simply assert that
medical discourse is socially constructed, it is neces-
sary to recognize that it is “constructed in ways
which produce only conventional meanings, i.e. ones
resonant with the dominant ideology” in society [74,
p. 1341, a fact demonstrated by Waitzkin in his
studies of the micropolitics of the doctor-patient
encounter [75]. Others, like Susser, add that it is
misleading to assume a priori that non-medical
groups embrace folk explanatory models. This
assumption “tends to underestimate the impact of
modem work experiences, income, political power,
and class relations on social perceptions of health and
illness” [13, p. 5621. While it is a strength of anthro-
pology to never expect uniformity across populations
(or even within populations), this strength becomes a
weakness if it produces inattention to the unifying
effects of phenomena like proletarianization, com-
modification, and mass advertising.
Generally, the critical approach to biomedicine is
concerned with locating “the clinical relationship and
the whole medical complex within its encompassing
political-economic framework so as to remind us that
physicians and patients alike are but two layers in a
larger social dynamic characterized by inequality,
dominance, and.. . struggle” [76]. While it is recog-
nized that physicians have the upper hand in the
doctor-patient relationship and that this position
of power is utilized for self-interested and system-
maintaining non-medical goals, the medical arena (or
any other social field) cannot be thought of as
comprised solely of dominating actors and domi-
nated objects. Rather, the clinical encounter is a
“combat zone of disputes over power and over
definitions” [20, p. 91. In a case study of an HMO
obstetric patient, Singer argues that the prevailing
liberal view of
an active, aggressive male physician in control of health
care, and a female patient that is a passive victim, mani-
pulated and dominated is faulty. Instead, we have accounts
of the aatherina of intelliaence. the mobilizing of allies, the
formulating of-strategies,-and the pressing of demands; in
short, a narrative of struggle and combat in the very heart
of physician-controlled territory.
The lesson is clear: until we fully realize that social
process in the medical arena is shaped not by the
unrestrained will and might of potent oppressors but
by an ongoing clash between those best served and
those least served by existing medical institutions,
 The coming of age of critical medical anthropology
and between those most in control of and those least
in control of medical knowledge, procedures, and
technology, we will misunderstand . . . [clinical pro-
cess] [76]. Such examples express a fundamental
understanding of critical medical anthropology,
namely that it is problematic to assume that, because
power is concentrated in macrolevel structures, the
microlevel is mechanically determined from above.
Lost in a mechanistic understanding of the construc-
tion of daily life is appreciation of the role played by
conflict and struggle in all social relationships in and
out of health care.
This discussion underlines the importance of a
critical focus on the microlevel, including the level of
individual experience and behavior. In addressing
this realm, Scheper-Hughes and Lock stress that
critical medical anthropology must part company
with the political-economy of health tradition over
the latter’s tendency to “depersonalize the subject
matter. . . by focusing on the analysis of social sys-
tems and things, and. . . neglecting the particular,
the existential, the subjective content of illness, suffer-
ing, and healing as lived events and experiences”
[77, p. 1371. In their view, critical medical anthro-
pology must bridge the macro-Marxist/micro-
phenomenologic divide so as give voice “to the
submerged, fragmented, and muted subcultures of
the sick and disabled” [77, p. 1371.
Others, following Mills, maintain that the starting
point for comprehending individual ‘troubles’ must
be a careful analysis of “the structural transforma-
tions that usually lie behind them” [78, p. 11. Con-
cretely, this insight takes several forms. For Taussig
[201], it means analyzing not just the suffering but
also the social relations mapped into disease. Sufferer
experience is understood thereby as process con-
structed and reconstructed in the behavioral arena
between socially constituted categories of mean-
ing encoded in symptoms on the one side and the
political economic forces that shape the context and
content of daily life and relationship on the other.
For example, in a study of Haitian folk nosology,
Davison and co-workers trace the relationship
between two illnesses: jibromm (a spoiled ball of
blood in the womb believed to threaten the life of a
developing fetus) and pedisyon (a condition in which
a fetus remains in the womb indefinitely in an under-
developed state). They argue:
We see in thejbromm concept what appears to be a creative
reconstruction of Haitian reproductive illness beliefs under
changed social circumstances, Just as pedisyon emerged
among rural Haitians as a route to action.under conditions
of French cultural hegemony, fibromm has developed
among urban migrants under conditions of a new, bio-
medical hegemony. Doctors, who are known to be powerful
healers and are even said to be God’s representatives, are
not interested in pedisyon, which they dismiss as super-
stition. A woman complaining of fibroma is another matter.
The transformation of pedisyon into fibromm, an alchemy
that transpires within the realm of folk culture, changes an
illness that can only be treated by folk healers into one that
can only be treated by doctors [79, p. lo].
At the heart of this interpretation is the under-
standing that individual experience is fitted to popu-
lar conception of legitimate illness expression and
that both experience and popular conception are
SS”**!I,--H
1199
conditioned by the prevailing structure of social
relations.
The process of embodying experience of material
conditions and social relations in illness has been
referred to as somatization [771. As Kleinman indi-
cates [80, p. 561, under capitalism, somatization is
“frequently an emblem of worker dissatisfaction,
demoralization, and alienation”. More generally, he
asserts, “persons who are at greatest risk for power-
lessness and blocked access to local resources are
most likely to somatize” [80, p. 1741, regardless of
the political-economic context. Sensitivity to this
phenomenon avoids entrapment in both the medical
conception of illness as individual and the narrow
commonsense interpretation that the inner life of
feelings and experiences is unique, particular, and
personal. When, as is the case under capitalism, even
human feelings are transformed into commodities
produced under alienating conditions for sale on the
market, the individual and his/her illness can only be
understood in relation to macrolevel relations and
processes [81].
Finally, critical medical anthropology looks
beyond the confines of the capitalist core or periphery
to health and health care in countries struggling to
break free of the capitalist economic system. Issues
of concern in this regard include: (1) what Elling [38,
p. 2071 has termed the “close intertwining of health
systems with their political-economic contexts at
national and world-system levels”; (2) the nature and
differences between socialist-oriented and capitalist
social formations and their respective understandings
of health and approaches to health care; (3) the
similarities and differences in the health sectors of
the array of socialist-oriented societies; (4) the rela-
tive effect of political-economic change on the organi-
zation, operation, and efficacy of the health care
system; and (5) factors beyond political-economy that
influence health and health care following social
transformation.
Thus far, only a small number of critical medical
anthropologists have worked in socialist-oriented
societies, and only one, Donahue [82], has completed
a book-length account. In his various writings on the
health sector in Nicaragua, one of the poorest, least
developed, and most threatened of socialist-oriented
societies, Donahue concludes that the
health care system is moving toward a model of primary
health care which is decentralized and oriented to local
needs, especially in the rural areas. Yet, within the [health]
Ministry itself there are interests which could direct the
health care system more to urban and professional demands.
. . . An analysis of the process of change within Nicaragua
suggests that the revolution in health, even in an optimal
‘decentralized-concerted political environment. . is being
negotiated.. .The strides made in health care since 1979
are abundant evidence of the political will to improve the
health and well-being of the Nicaraguan people. Yet, the
ultimate success of the revolution in health will depend
on how the actors are able to confront the internal pressures
to professionalize the process and the external pressures to
destabilize it [83, p. 1561.
Central to Donahue’s analysis is recognition that
socialist transformation tends to be accompanied by
(1) a far reaching re-organization of the health care
system; (2) an increase in popular involvement in
1200 MERRILL SINGER
health policy decision-making and implementation;
and (3) improved health. However, seizure of the
State apparatus does not immediately nor auto-
matically eliminate class divisions within society,
disparities in access to health care knowledge, and
self-serving behaviors by health care professionals.
Cuba, which has had a longer period to consolidate
its revolutionary transformation in health care and in
society generally, has been examined by Guttmacher.
She notes a marked improvement in health but adds
that while “socioeconomic status no longer objec-
tively determines one’s access to health services as it
does in market-centered societies . . . traditions and
modes of behavior shaped by previous inequalities
still may limit people’s actual use of services” [84,
p. 5171. Beyond the health care sector, Guttmacher
[85] reports the continued existence of occupational
and environmental health and safety risks, despite
a sincere movement toward preventive medicine in
socialist-oriented societies.
Broader comparisons of health and health care in
socialist-oriented and capitalist countries have been
assembled recently by several critical medical anthro-
pologists [86-881. While it is recognized that much
work in this area remains to be done, there is
agreement that a significant difference exists
between socialist health and capitalist health. This
difference, reflected in the health improvements following
the establishment of a socialist-oriented state, appears to be
an outgrowth of the social investment of national resources.
This investment takes several forms, including more equi-
table distribution of income, commitment to improved
literacy and public education, special attention to the prob-
lems of the most subordinated sectors of the population (e.g.
the working class, minorities and women) and . . changes in
the health care system [8i’J
Debate exists, however, concerning: (1) the necessity
of socialist transformation for broad improvements
in health care in Third World countries [89]; (2) the
extent of popular involvement in the health care
systems of socialist-oriented societies [88]; (3) the
source of health problems in these societies [80,85];
and (4) the specific similarities and differences
between health care and health in socialist-oriented
and capitalist societies [87].
CONCLUSION
Having established the need for medical anthro-
pology studies to be situated in the wider sphere of
social relations, contributors to the next phase in the
development of critical medical anthropology must
begin to address a number of issues. Included among
these are the following.
First, critical medical anthropologists must deter-
mine the relationship of their project to the political-
economy of health. Needed is a rigorous critique
of the political-economy of health literature (an
endeavor begun by L. Morgan [90]) and a clarifi-
cation of the distinctive contribution of anthropology
to the critical study of health and healing. Already a
debate is emerging between those critical medical
anthropologists for whom it seems completely appro-
priate that a portion of their work involve macro-
analysis focused on entities like cross-national
systems and large scale institutions and those who
maintain that critical microanalysis should be our
special domain of activity.
Second, the means of appropriately analyzing
micro-macro relations must be addressed. While
ethnographic research provides us with rich data
from the microlevel, there is a tendency in the critical
medical anthropology literature to assert rather than
to specifically demonstrate detenninance by struc-
tural factors outside the local setting. As Pelto and
DeWalt indicate, “postulated relationships among
levels need some clearer delinations, in terms of
empirical, observable social units” [91, p. 1871. Criti-
cal medical anthropologists must enhance the corpus
of research and analytic methods suited to this task,
including, perhaps, the development of research
approaches designed to simultaneously investigate
linkages between several levels of health and social
systems.
Third, in investigating connections among levels,
we must cast our gaze in both directions. To reiterate
Frankenberg’s [63, p. 2061 call, we must demonstrate
clearly “what effects are produced at the local level
by national and international social processes; and
what is coming from the local level in return” (empha-
sis added). Recognizing that the course of social
life inside and outside the health arena involves
contention between individuals and groups with
conflicting social interests and unequal abilities to
mobilize power, we must sharpen our attention to the
issue of implicit and explicit struggle as it is mani-
fested in illness expression, clinical interaction, rela-
tions among health care systems and providers, and
health-related movements and organizing efforts by
patients, workers, and oppressed populations.
Fourth, the exact meaning of the term critical
medical anthropology will eventually need to be
considered. Currently, several different orientations
are fellow travelers with a common passport. While
it is not necessary that the range of critical
approaches be narrowed to some allegedly ‘correct’
perspective, it is appropriate to begin clarifying the
critical content of critical medical anthropology. In
part, this will involve a clarification of the relation-
ship of critical medical anthropology to the contri-
butions of Marx and Engels among others.
Fifth, the importance of biomedicine in the world
and its strategic location as “a primary interface
between the capitalist class and the working class”
[92, p. 6031 demands that it receive increased atten-
tion. While a start has been made in this area, there
is much work to be done in clarifying and accounting
for its expressions cross-culturally, its political-econ-
omy functions, the nature of the relations it fosters,
the character of its co-existence with a range of
alternative healing systems, and the world views it
generates.
Sixth, the specific relations between biomedicine
and capitalism require further study. Brown’s [93]
pioneering study provides an approach similar to that
employed in ethnohistorical studies in anthropology
and thus offers a method for further work in this area.
Also important is McLean’s [94] analysis of therapy
as a form of production that reflects the larger
production process in capitalist society.
Seventh, where possible, further on-the-ground
studies of socialist health care would help address
 The coming of age of critical medical anthropology
many of the unanswered questions about the rela-
tionship between political-economy and health care
organization, social transformation and improve-
ments in health, and the specific functioning of health
care institutions in a socialist context.
Finally, there is the issue of praxis. How can critical
medical anthropology serve counterhegemonic ends
in both the short and long run? While the ways health
care workers [75] and international health agencies
[95] can move in this direction have been offered,
what specific role might anthropology and its practi-
tioners play in the creation of a new medical system
and what might that new system be? In attending to
the development of a critical praxis, the following
remarks of Conrad and Schneider [96, p. 771 deserve
our close consideration:
the fundamental issue is who controls what model and what
are the consequences. To merely substitute a social model of
health and a new set of social health experts without altering
the existing medical dominance is surely problematic; its
likely result is the extension and reproduction of prevailing
power relations. If the social model of health were grafted
onto the existing medical system, it might truly encourage
the medical control of everything.
Acknowledgements-Special thanks are extended to Hans
Baer, Fuat Yalin, Lani Davison, Ronald Frankenberg,
Vicente Navarro, and Nancy Scheper-Hughes for reading
and providing comments on all or parts of earlier versions
of this paper.
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