Allopathy Goes Native

Traditional Versus Modern Medicine in Iran

Agnes Loeffler

• Publisher: I.B. Tauris
• Year: 2017
• ISBN:
  9781786722553
• Edition: 1
• Topic: Histoire
• Subtopic: Histoire sociale

Allopathy is often described as 'western' medicine, the antithesis of homeopathy, yet all medical systems are infused with culture-specific values, ideas and beliefs. Agnes Loeffler's insightful and original book investigates how allopathic knowledge, theories and practice guidelines come to be understood and applied by practitioners in a non-western context. Based on research amongst doctors in Iran, Loeffler describes how the system of allopathic medicine has adapted to local explanations of health and disease and to the economic, social and religio-political realities framing contemporary Iranian life and culture. This approach simultaneously problematizes the view of allopathic medicine as a 'western' entity exerting a hegemonic influence over non-western cultures, and provides a rare glimpse of the complexities of modern Iran society - exploring the interfaces between culture, health and the experience of illness.

Chapter 1

Introduction

When I set out to study how allopathic medicine was practiced in the Islamic Republic of Iran in the 1990s, I was prepared, as a cultural anthropologist, to see it reflect the worldview of the people who used it. I was less well prepared, however, for the degree to which that worldview influenced the manner in which physicians and their patients alike came to terms with the tenets promulgated in medical school. The process of how medical doctors in Iran make sense of their profession became a fascinating study. My research was complicated by a lack of models in the anthropological literature for studying non-Western allopathic medicine, and by logistical problems of doing ethnographic fieldwork in Iran. In the following, I will describe the theoretic background of my research, goals and assumptions, and present a short synopsis of my findings.

Allopathic Medicine as a Cultural System

Researchers in the field of medical anthropology are engaged with mapping out the interface between culture, health and the experience of illness. This interface comprises two inter-related domains. “Biocultural” medical anthropology focuses on the relationship between human biology, culture and the environment and explores how the evolution and distribution of diseases is impacted by cultural and socio-political forces.¹ The “cultural” approach to medical anthropology, to which this study contributes, explores the manner in which culture mediates the identification of ill health and shapes people’s responses to illness. It shares with cultural anthropology in general the insight that human thought and behavior in all aspects of life reflect assumptions about people’s relations to the material and immaterial worlds. Medical systems, regardless of the biological basis of disease, are suffused with culture-specific values, ideas, beliefs, and themes that also inform other domains of culture.

The cultural basis of medical systems is readily appreciated when one looks at “exotic” health-practices. Shamans, spirits, magic and witchcraft, flows of energy, cosmology, ancestors, the evil eye and violated taboos are integral to conceptualizations of disease etiologies the world over.² For example, Ponapeans of the Caroline Islands attribute certain skin disorders to the violation of totemic food taboos (Fischer, Fischer, and Mahoney, 1959); Dobueans of New Guinea believe disease to be caused by violation of property protected by an incantation (Fortune, 1963); in Latin America, the disease susto is attributed to the flight of a person’s soul due to fright or shock (Rubel, 1964); in traditional Chinese medicine, disease is thought to be caused by derangements in the flow of energy through the body (McNamara and Ke, 1995.) The “exoticism” of these beliefs is due not to their cultural derivation, however, but to the fact that they are foreign to our own assumptions about health and disease. Indeed, our own assumptions, such as those embodied in allopathic medicine, are just as culturally derived and culturally specific as are the others.

Before turning to the social scientific literature addressing the cultural basis of Western medicine, I need to say a few words about why I use “allopathy” rather than any of the other terms for this body of medical knowledge and practice popularly used in the literature. Each of the terms “biomedicine,” “Western,” “cosmopolitan,” and “scientific” is fraught with difficulties, and none uniquely describes what it intends to signify. Other “medicines,” from shamanism to herbalism, are practiced in the West and in cosmopolitan centers. Many, like the Ayurvedic and Unani medical systems, can claim a conceptual basis in human biology. At the same time, the medicine dominant in the West is practiced all over the world, not just the West, and its adherence to purely scientific principles has been seriously questioned not just by anthropologists but by its own practitioners.³ Most importantly, before the term “biomedicine” was even coined, this medical system has had a name of its own, viz., allopathy or allopathic medicine.⁴

The word “allopathy” is derived from the Greek allos, differing from the normal or usual, and pathos, suffering, and is defined as “a therapeutic system in which a disease is treated by producing a second condition that is incompatible with or antagonistic to the first” (Stedman, 1990). Thus, an infection is treated with an “antibiotic,” fever with an “antipyretic,” disorders of heartbeat with an “antiarrhythmic.” Its name draws attention to a basic, grounding concept or philosophy that distinguishes it from other Western biomedical systems such as homeopathy and osteopathy. The former is based on the principle “like cures like” (e.g., a fever will diminish when the body is exposed to an agent causing the temperature to rise), while osteopathy is based on the premise that, as long as its skeletal support is properly aligned, the body can heal itself.

Already its name is a clue to allopathic medicine’s historical and cultural origins. In 19th century Europe and the United States, allopathy faced major competition for recognition, authority and ultimately clientele from other medical systems, such as homeopathy and osteopathy (Duffy, 1979; Starr, 1982). In the United States, allopathic medicine came to dominate the health-related arena to the extent that it no longer needed to be nominally distinguished; it became simply “medicine.” In part, this dominance can be traced to the enormous successes allopathic medicine had in curing, preventing and eradicating diseases which have caused endless suffering throughout human history. But just as important in establishing its dominance were historical social, political and economic forces (Baer, 1989; Starr, 1982). Allopathic medicine in the United States garnered the support of the capitalist establishment of the late 19th and early 20th centuries by molding itself into a “scientific” discipline. Osteopathic medicine was able to hang on to a modicum of respectability by imitating allopathy in its moves toward professionalization and by conforming to the American [Allopathic] Medical Association’s (AMA) demands of a medical training curriculum (Duffy, 1979; Starr, 1982). Homeopathy, unwilling or unable to bend, fell completely into disfavor. By the 1930s, all 22 of the homeopathic medical schools that had been operating at the turn of the century had been forced to shut down (Rogers, 1998).⁵

Thus, since its conception, allopathic medicine has existed in a social, political and cultural arena. This has been the subject matter of medical anthropologists, philosophers, historians and scholars of culture and the media for the past fifty years. Their studies have taken as entrance points the history of allopathic medicine, the doctor-patient relationship, health policy, medical ethics, medical education, patient narratives of health and disease, health management decision making, the relationship of allopathic medicine to political and economic systems, textbooks of allopathic medicine, and physicians’ self-reflections.⁶ From these studies is emerging an increasingly detailed description of allopathic medicine as an “ethnomedicine.” It is structured on the same principles upon which the dominant, modernist, Western vision of reality is based: on materialism, reductionism, objectivity, rationality and distinction between mind and body (Good, 1994; Kleinman, 1995; Lock and Scheper-Hughes, 1990; Martensen, 1995; Romanucci-Ross et al., 1997; Young, 1997). While allopathic medicine is ostensibly concerned with the “biology” of disease, every instance related to allopathic practice has individual, social, economic and political ramifications. Medicine is a social event, it posits people in social relationships and engages them in social contexts. It is therefore necessarily culture bound, culturally constructed and culture-constructing.

One of the insights gained by opening allopathy up to critical inquiry is that its disease nosology, contrary to allopathy’s claims, is not universally applicable. For example, it turns out to be notoriously difficult to establish a classification of psychiatric diseases which holds cross-culturally (Angel and Thoits, 1987; Lucas and Barrett, 1995). Some diseases, such as amok, susto, or latah, while causing very real suffering locally, find no specific correlates in allopathy’s Diagnostic and Statistical Manual of Psychiatric Disease (American Psychiatric Association, 2000; see, e.g., Chowdhury, 1996; Schieffelin, 1996). Other diseases meticulously and minutely described in the DSM, on the other hand, such as depression, anorexia and schizophrenia, are found elsewhere with a remarkably different symptomatology (Kleinman, 1998; Pliskin, 1987).

Non-psychiatric diseases identified by allopathic medicine as biologic “givens” also show considerable cross-cultural variation. The experience of pain, for example, varies not so much with the biology of pain perception as with ethnicity and differences in sociocultural values (Bates and Edwards, 1998; Good et al., 1992; Zborowski, 1969). Menopause, identified by allopathic medicine as symptoms unavoidably linked to changes in sex hormone activity in middle-aged women and as a stressful life event, is such a non-issue among Japanese women (Lock, 1993) that it does not even have a name.⁷ And controversies within the allopathic field itself over the recognition of “pre-menstrual stress,” for example, or “fibromyalgia” or “post-traumatic stress,” as “real” diseases, attest to the ongoing redefinition of biology as allopathy’s methodologies and theories meet cultural prejudices (DeCherney and Pernoll, 1994; Groopman, 2000; Young, 1995). In other words, despite their presumably biological origin and universal nature, the manner in which symptoms are recognized, grouped and classified is culturally informed and culturally restricted.

The Meanings of Illness and Disease

A second insight that has emerged from studies of the cultural basis of medicine is that the experience of being ill is a process of “making sense” of disease. In the anthropological literature, “disease” is defined as a set of symptoms and signs referable to a pathologic process, while “illness” is the patient’s response to feeling not-healthy (see e.g., Chrisman and Johnson, 1990; Eisenberg, 1977; Fabrega, 1971; Kleinman, 1980, 1988). Disease is a diagnosis, a hypothesis as to a pathophysiologic process and a guideline for its treatment; illness incorporates all the personal, social and existential implications of being afflicted with a disease. The meaning each individual patient gives to the experience of being ill, whether alone or with the help of his or her “therapeutic community” of therapists, doctors, relatives, nurses or friends, addresses practical, personal, existential and soteriological questions. Why am I sick? Why now? What effects will my illness have on my family? What should I do to get well? Is anything to be gained by my suffering?

Through the process of being experienced as an illness, diseases are abrogated from the biologic and incorporated into cultures’ semantic realities. Their names are infused with symbolic meaning and values and in turn become metaphors for the prevailing social and moral orders. For example, in Western cultures, cancer is understood in terms of loss of control (Sontag, 1978) and its treatment modeled as a type of warfare (DiGiacomo, 1987). AIDS, and infections in general, are seen as incursions of foreign, unknown and physically and morally contaminated agents into the sanctuary of the self (Farmer, 1992; Martin, 1994; Sontag, 1989). In Iran, the diagnosis “high blood pressure” attests to stressful social relationships. Thus, through a culture’s semantic networks, the illness experience ties the healthy and the sick, “healers” and their patients together to a common philosophy of life, and at the same time turns disease into a commentary on conditions of life and stress. The culture-specific perceptions of ill health do not necessarily give prompt answers to the questions being ill raises but rather provide a broad frame within which the meanings of suffering from a disease are formulated.

Allopathic medicine restricts its sense-making to the biological definition of disease and its implication for therapy. It recognizes the experience of being ill as located in culture, society and psychology, and therefore not properly part of the domain of medicine, or even really relevant to the natural history of diseases or the outcome of therapy. Allopathic medicine is not concerned with existential and symbolic meanings. Indeed, during my own training in (allopathic) medical school, the extra-biological aspect of being ill was addressed only to the extent that we were vaguely advised to incorporate into our practice an “awareness” of the disease/illness distinction, of the patient’s illness experience, and of social factors which have a bearing on disease distributions and outcomes.

Medical Pluralism

Despite allopathic medicine’s claim to universality, and, by extension, exclusivity, the meaning it contributes to being ill is very limited. Its limitations are highlighted in the setting of medically pluralistic societies. At least as soon as allopathic medical services are introduced to any society, more than one system of thought and behaviors pertaining to health and disease co-exist. Patients and their caretakers then sift through competing explanations and therapies in search not only of a cure but of the illness’ meanings and implications. Regardless of its alleged or even demonstrable superiority in treating disease, in medically pluralistic settings allopathic medicine becomes just another therapeutic strategy. Thus the use of therapeutic options must be understood in their cultural and social contexts.

Studies of medically pluralistic societies have focused on patients’ or therapeutic communities’ decision-making strategies, on the factors that go into consideration of what should and can be done about particular illness episodes (see, e.g., Brodwin, 1992; Early, 1982; Fabrega, 1976; Janzen, 1978; Kleinman, 1980; Myntti, 1988; Romanucci-Ross, 1969). These include socio-economic variables such as education, the availability of healers and resources, and the value given to maintaining health as weighed against all implied costs. Thus, any kind of medicine, to be adopted and become effective, must be deemed worth its emotional, psychological, social and economic price. At the same time, the therapeutic strategies offered must “make sense” to the patient – they must contribute culturally-consistent meaning to the illness experience.

Indigenous cultural conceptions have posed and continue to pose considerable resistance to allopathic medicine’s interventions and recommendations. Examples illustrating this point are almost endless. The social meaning of communion and partnership in sharing needles among drug users in the United States hampers the acceptance of clean needles distributed at no cost (Connors, 1995). Surgery is only reluctantly accepted by traditional Navajo, who sanctify the integrity of the body (Alvord, 1999). Jehovah’s Witnesses’ belief that blood carries an individual’s life or soul leads them to prefer death over a transfusion of blood from another person (Filkins, 1998; Stotland, 1999). Antibiotics may be rejected by Iranians in case of an infection because of the popular idea that they potentiate a fever.

To help overcome cultural barriers to acceptance of allopathic recommendations, medical anthropologists have been called on to elucidate cultural values, conceptions or themes which impact community health and patient compliance (Chrisman and Johnson, 1990; Coreil, 1990). Ideally, the local social concomitants and conceptual dimensions of illness, once identified, can be addressed in therapeutic and preventive measures (Carlson, 1996; Ingman and Thomas, 1975; Singer, 1998; Singer et al., 1998). Such insights have found recognition, for example, in clinics serving “ethnic” populations (Haviland, 1990; Lamberg, 2000; Willard and LaDue, 1988); in the acceptance of terms such as “illness narratives” in medical schools (Brown, 1998; Eisenberg, 1988; Kleinman, 1988); in the application of concepts and methodologies derived from anthropology in psychiatric therapy (Rush, 1996); and in the incorporation of “social soundness analyses” in medical development projects (Allman, 1988; Wood, 1990).

The Puzzle of the Native Practitioner of Allopathic Medicine

In the context of medical pluralism, the position of “native” practitioners of allopathic medicine becomes a curious one, for native medical doctors can be placed on both sides of a great divide of understanding. On the one hand they are born and bred “natives,” acculturated to their own culture, socialized as local men and women. They receive primary education together with their own future patients, they are sick in their own culture, and they learn to negotiate the pluralistic medical system before they are accepted to allopathic medical school. On the other hand, they have systematically and rigorously learned allopathic medicine, i.e., acquired a body of knowledge based on non-indigenous principles, and are now offering this knowledge to members of their own culture.⁸ The puzzle of the native practitioner of allopathic medicine is how a physician reconciles allopathic and native cultural theory, knowledge and practice.

Despite the universality of the dual identity of the native allopathic practitioner, the anthropological literature by and large ignores tensions inherent in this role. Indeed, the image of native medical doctors that emerges there tangentially is one-dimensional and simplistic. Both in critical political-economic discussions of “biomedicine”⁹ and in discussions of the “micro”-level of medical practice,¹⁰ native allopathic physicians are portrayed as allied with the dominant culture of the United States and therefore as distanced from their patients. Allopathic medicine is described as a Western export like blue jeans or Coca-Cola, a commodity imposed monolithically upon a vulnerable and clueless population, a hegemonic presence insensitive to local needs and cultural nuances and threatening to native medicines and native social orders alike. In the same vein native allopathic practitioners are invariably portrayed as removed from and condescending to those patients who hold on to native interpretations of disease, as unwilling to engage in discourse with their patients, as unwilling to offer their services to that segment of the population most in need of them, and as arrogant in their assumption that their patients’ health status is linked to socioeconomic and educational factors over which no one but the patients themselves have control.

I will not argue that this characterization is entirely wrong; it is, however, shallow. No doubt identification with power, technology and the social status and material comforts that many medical doctors enjoy creates a distance between them and the traditional life ways of their patients. But this does not mean that they can forget their own culture when they practice medicine or that they will or ever could become either “acultural” or “Westernized,” or that one physician could stand in for another at any time or any place.

Some anecdotal accounts address the “nativeness” of indigenous allopathic practitioners. A Navajo surgeon writes compellingly of the confusions that arise when living in two conceptual worlds at once and of how her practice improved when she began to integrate Navajo customs in her surgical practice on a Navajo reservation (Alvord, 1999). Janzen (1978) writes that, while African medical professionals behave in the clinic according to international standards of practice, at least at the time they themselves become ill, they “tend to act like their kinsmen” (p. 217). Finkler (1998, 2000) mentions that Mexican physicians incorporate folk understandings of disease causation, such as anger, nerves or fright, into their “allopathic” ones. Nunley (1996) describes how Indian psychiatrists base their practice on pharmaceutical drugs and electric shock therapy rather than on psychotherapy so as to identify psychiatry as a scientific/technological discipline, as well as to satisfy patients’ demands for polypharmacy, which is a criterion of “good” medicine in Ayurvedic herbalism. Payer (1988) describes how the practice of allopathy in European countries reflects defining cultural values or national themes. In Japan, allopathic physicians bring Japanese moral arguments to bear on the definition of brain death (Lock, 1995). In China, the concept “neurasthenia,” derived from 19th century allopathic medicine, has acquired legitimacy by acquiring a distinctive, culturally-consistent, local meaning (Lee and Wong, 1995). Feldman (1993) describes how French and American physicians’ use of different metaphors to conceptualize HIV and AIDS results in different treatment and research strategies and goals.

These reports suggest that adoption of the allopathic medical system involves not simply an overlaying or supplanting of native conceptualizations by new ones but a process of amalgamation. As we have already seen, medical systems are not confinable just to disease nosologies and treatment strategies, and the feeling of being healthy or ill does not occur in a cultural vacuum. As applied medical anthropologists have shown us, the better the tenets of allopathic knowledge and practices can be made consistent with the philosophical, existential, ethical and...

Table of contents

• Front Cover
• Title Page
• Copyright Page
• Contents
• Note on Transliteration
• Acknowledgements
• Chapter 1 Introduction
• Chapter 2 The Contexts of Fieldwork
• PART ONE IRANIAN CONCEPTUALIZATIONS OF HEALTH AND DISEASE
• Chapter 3 Iranian Explanations for Ill Health
• Chapter 4 Key Concepts: Nature, Purity and Balance in Relation to Health
• Chapter 5 How Allopathic Knowledge and Practice are Interpreted in Distinctly Iranian Terms
• PART TWO THE CONTEXTS OF MEDICAL PRACTICE
• Chapter 6 The Economic Context of Allopathic Practice
• Chapter 7 Roots of Authority: Knowledge
• Chapter 8 The Relationship of `Elm to Medical Practice
• Chapter 9 Medical Knowledge and Islamic Ideals
• Chapter 10 Conclusion
• Endnotes
• Bibliography
• Back Cover