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Tutorial Essay, M.Sc. Medical Anthropology Michaelmas Term, 2nd Week Paper 1: Introduction to Medical Anthropology by Barbara Gerke Introduction This paper discusses the approach of disease taxonomy and illness taskonomy in the light of Mark Nichter‟s descriptions of diarrheal diseases (1996:111-134). His focus is on bloody diarrhea and its culturally informed assessment and treatment. Nichter‟s approach is further applied to three different cases from Iranian and Tibetan cultural backgrounds, highlighting and discussing diverse aspects of taskonomy and taxonomy. Disease Taxonomy and Illness Taskonomy Nichter begins his argument discussing illness categories and how they are influenced by connotative and denotative aspects of illness identities. The latter comprise physical signs of disease (diarrhoea, stool consistency and smell, etc.) and concurrent symptoms (such as fever, a rash or pain), as well as aspects of severity, duration and progress of symptoms (Nichter 1996:115). The former include a multi- dimensional understanding of illness. All connotative aspects frame, reframe or negotiate illness identity in context (Nichter 1989 and Bibeau 1981). Figure one shows a summary of the multi-dimensional connotative aspects that are mentioned in Nichter‟s examples of diarrheal diseases, and that eventually form the understanding of what he calls illness taskonomy, in contrast to disease taxonomy. In the light of the current pluralistic approaches in medical anthropology, which account for ambiguities and contingencies in the illness event, Nichter makes it a point to describe the differences in taxonomy and taskonomy of illness identities. Nichter defines disease taxonomy as “a systematic presentation of logical relations between illness categories based on a “rational man” model of cognitive thought.”(Nichter 1996:117). This reductionistic approach is often found among cosmopolitan medical practitioners, who are trained in looking at disease as merely a physiological dysfunction of the body. The „rational man„ model of knowledge sources its data from methods known as „KAP type surveys‟, involving clear cut answers to predetermined questions in terms of knowledge, attitude and practice (Green 1986 in Nichter 1996:117). That this approach is not enough to reach a deep understanding of multidimensional illness-related factors becomes evident from Nichter‟s explanations on illness taskonomy. His understanding of illness taskonomy is based on Dougherty and Keller (1982) to which he adds insights from Wittgenstein‟s (1985) theory of „language games‟ and „words as tools‟ and Bourdieux‟s (1990) discussion of „practical logics‟ (Nichter 1996:129, note 11). Nichter criticises the limitations of the taxonomy model by suggesting a wider approach in methodology as well as in looking at the multi-dimensional aspects while defining illness categories. He is aware of the challenges and difficulties such multiple research methods imply for the practical life of an anthropologist in the field. Figure two summarises the methods used in taxonomy and taskonomy approaches mentioned in his article. The example given from Anne Fadiman (1997) in the essay question, elucidates the advantages of a taskonomy approach: it made the environmental health programme in the village fairly successful. In contrast, the taxonomy approach, in which the biomedical doctors and nurses failed to win the co-operation of the villagers because of their „claim‟ to hold “all the knowledge”, was unsuccessful. The fact that the ethnographer placed himself on the same platform than the Hmong villagers, made an exchange really possible. This type of cross-cultural co-operation seems to express the greatest challenge of anthropologists in the field and corresponds to a quotation by Heisenberger that was given to me in Germany before coming to Oxford: “Wenn zwei verschiedene Arten des Denkens sich wirklich treffen, das heisst, wenn sie wenigstens soweit zueinander in Beziehung treten, das eine echte Wechselwirkung stattfindet, dann kann man darauf hoffen, dass neue und interessante Entwicklungen folgen.” Similar cases in the light of Nichter’s disease taxonomy and illness taskonomy In his paper “The heart of what‟s the matter” Byron J. Good (1977:1:25-58) describes two case studies of „heart distress‟ prevalent mostly among women in Iran. Both cases illustrate how the taskonomy approach is absolutely necessary to address the complexities that bring forth the illness label „heart distress‟. To take up the first case (Good:1997:34) of Mrs. T. who is 27 years old and has five children, connotative aspects of her illness identity, include: Her socio-economic surroundings: the poverty of eleven people living in two rooms with one single kitchen and no running water. Her educational back-ground: complete illiteracy, so that she cannot even go alone to the market. Her social relations: her poor parents and an ill brother. Her marital conflicts: her desire to avoid pregnancy and still satisfy her husband. Her use of contraceptive pills, which were suggested to her by educated neighbours. But, as she was illiterate, she associated the contraceptive pill with 2 abortion and took a month supply in an effort to abort her last child. Her intake of contraceptive pills also increased her heart palpitations and upset nerves. Her moral and cultural restrictions: She often felt like screaming, knowing that this was a source of great embarrassment as the voice of a woman should not be heard outside her courtyard. The taskonomy approach to illness takes all of these aspects into account to understand the illness identify and classification. The taxonomy of her distress would simply note her physical symptoms and concurrent signs: Lack of strength and blood, pounding heart, upset nerves, lack of meat on her bones, depression, a feeling of her heart being squeezed. As a result, she received a vitamin tonic from the doctor, and herbal medicines from a health practitioner for her weakness and heart distress. Her illness did not change because the multiple causes did not change, and the doctors – Western as well as naturopathic – had no insight in, or influence on her surrounding conditions. Good stresses the social and historical realities of the patient, calling for a new approach in disease theory, which was just developing at that time (1970s) among medical anthropologists. Good introduces „semantic illness networks‟. He defines „medical semantics‟ as the “theory of how the meaning of medical language is constituted” (Good 1977:26). He argues that apart from theories of disease, “we need a new understanding of the relationship between medical language and disease.” (Good 1977:26). In the above case he analyses the main emerging problems of „female sexuality‟ and „oppression of daily life‟ (Good 1977:41) by looking at relationships between word meanings in Iranian culture, such as pregnancy - menstrual blood - dirty blood - contraceptive pill (Good 1977:42). He concludes that the illness category „heart distress‟ is a complex circle of stress factors common to Iranian woman. Women‟s sexual potency and ability to attract men is explicitly expressed in Iranian folk literature and Persian folk ideology. Centuries of history have shaped the restrictions of hiding female sexual potency behind walls and veils. Menstrual blood is considered impure and a thread to personal piety and the purity of the household (Good 1977:44). For most illiterate women a direct protest is still unthinkable. Consequently, the problem gets transferred to the physical realm, which again is culturally determined. The heart is the seat of the soul and feelings in traditional Galenic medicine (Good 1977:36) and is used linguistically to express emotions and feelings of anxiety and affection. Good explains how the illness gets semantically linked to the heart because of the semantic network that the heart has with feelings of anxiety, sexuality, menstruation and pregnancy (Good 1977:48). To take the discussion further, I would like to discuss the issue of taskonomy in the humoural understanding of traditional medical systems, for example, Tibetan 3 medicine. In the following I briefly analyse whether the illness categories in Tibetan medicine are taxonomic or taskonomic. Considering that disease taxonomy focuses only on physical signs and symptoms, the humoural approach seems to offer a taskonomic understanding of illness. A Tibetan doctor will diagnose a patient mainly through pulse and urine analysis as well as interviewing him/her about diet and life style. The aim is not to identify the disease but to come to an understanding of the imbalance of the humours. The medical philosophy behind this approach pursues a holistic understanding of the human being in body, speech and mind relationships, embedded in the macrocosmic environment which is understood to be ruled by the same elements and humours than the physical condition. To take the example of a rlung (the humour predominated by the wind element), the pulse diagnosis will lead to an understanding that there is for example a predominance of rlung in the heart. From this holistic understanding of the vital concept of rlung, the doctor will ask the patient if there is sleeplessness, anxiety or worries, back pain, exposure to cold weather or foods and drinks with a strong rlung- increasing tastes and qualities (e.g. strong coffee, tea, raw and cold food, cold drinks, astringent foods). This may not imply a detailed understanding and questioning of socio-economic surroundings, moral obligations or social relationships, as Nichter suggests. However, in principle the approach could be called taskonomic, because it implies a multi-dimensional understanding of illness categories, beyond the physical body symptoms. The illness classification labelled „rlung disorder‟ includes that the disorder is influenced by imbalanced mental, emotional, physical, environmental, spiritual, behavioural and food aspects of life. That this holistic approach in Tibetan medicine is often not practised today is another issue. The semantic illness network being taken out from ist original Tibetan surrounding should be one point to consider. One event that keeps coming to my mind while writing this essay is a case of tuberculosis that occurred among a group of Tibetan medical students during my year at medical school in Darjeeling, India, in 1992. The illness event shows how powerful medical taxonomies are, even among Tibetan medical practitioners. The school had been newly established in the house of the Tibetan doctor who was in his mid-60s at the time and had been trained in Tibet. He did not speak English, taught only in Tibetan, and the school affairs were managed by his yonger brother who had received training in community health care by Christian missionaries in Darjeeling. One lay teacher and the students, a group of 17 young Tibetans, aged 20 to 25, some of them monks, were occupying the basement of the house, which consisted of one class room and six living rooms. All were simply furnished, cold, concrete rooms. Three students had to share one room, and all students had to share 4 a common toilet, one bathroom and a kitchen. There was no running water and each student had to carry his bucket of water from a nearby stream every day. The Darjeeling climate (2400 meters altitude) was cold and damp over three summer and four winter months a year. The food consisted of rice, thin lentil soup and a few vegetables, sometimes noodles soup with small pieces of meet or white bread with chilly sauce, no fruits or salads. The structure of living symbolised well the Tibetan hierarchical system. The Lama lived on the top floor in large, warm, well-furnished wooden rooms, the students on the cold, damp concrete basement. I, being a foreign student and a woman, was offered a guestroom on the first floor, sharing the bathroom with the family of the Lama‟s brother. I was offered meals with the family, but insisted on eating with the students for the few weeks I was there (before making my own living arrangements), wishing to be a part of the group to the extent possible despite our extreme cultural differences. It was obvious to all of us students and our lay teacher that the living conditions and the diet were not at all in accordance with the humoural balance and the holistic approach of medicine we were studying every day. But it was hard to arrange for changes in the Tibetan system of complete obedience to the authority of the school. Over the weeks, some students developed coughs and colds, tiredness and weakness, which at times were treated with Tibetan medicine by the Lama physician, but did not improve. Complaints about living conditions remained unnoticed till the day a student coughed up blood in his room. It was the physical symptom of „coughing blood‟, that was taken seriously and brought about medical action. The entire class had to go to the missionary medical centre for x-rays and BCG tests. Two students were diagnosed with tuberculosis and had to leave the school. The label of the disease as „tuberculosis‟, identified through the Western medical missionary authority, brought improvement in living conditions thereafter. Moreover, social pressure from the town society and the damage that the label „tuberculosis‟ had done to the name of the school in public was a strong influence on the school authorities to act. This tuberculosis case shows that, although the connotative aspects of the illness (cold, wet rooms, overcrowed living conditions, poor diet, shortage of water, lack of hygiene, weakness and persistent cough of students) are identified by a large number of members of the group (students and lay teacher), the „change agent‟ that moves authority is the taxonomy of the disease, the denotative sign of „coughing blood‟ and the label „tuberclosis‟, which is solely informed by Western medical standards and supported by public opinion. 5 Conclusion This essay summarises the understanding of illness taskonomy and disease taxonomy as advocated by Mark Nichter (1996). The connotative and denotative aspects of illness identity and labelling show the advantage of the multi-disciplinary approach of taskonomy to understand the complex illness event. (figure 1) Illness taskonomy requires a wide range of research approaches to be studied in detail, compared to simplified taxonomy research methods. Both are summarised in figure 2. Nichter‟s approach is applied to a case of „heart distress‟ (Good 1977), a cultural phenomenon among women in Iran. The case study adds dimenion to Nichter‟s concept by introducing the issue of medical semantics. Finally, the discrepancy between taskonomy and taxonomy in traditional medicine is elucidated through an example of the Tibetan medical understanding of a rlung illness, which stands in sharp contrast to prevalent practises of the tradition in a case of tuberculosis. The tuberculosis case in a Tibetan medical school shows the power that disease taxonomy has in Asian societies. These societies are under a strong influence of Western medicine, which directs medical action even among traditional practitioners. While Nichter‟s illness taskonomy is an advanced and pluralistic approach to understand and study illness identities in different societies, it remains a fact that disease taxonomy is still the prevalent limiting attitude towards illness events in many countries. Future studies and publication using Nichter‟s approach will hopefully contribute to a continuing change in human attitudes towards multi- dimensional aspects of illness events. References Nichter Mark 1996: “Health Social Science Research on the Study of Diarrheal Disease: A Focus on Dysentery” in: Anthropology and International Health: Asian Case Studies. Amstedam: Gordon and Breach Publishers. 111-134. Good Byron J. 1997: “The Heart of what‟s the Matter” in: Culture, Medicine and Psychiatry. Dordrecht: D. Reidel Publishing Company. 1:25-58. 6
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