CMA Part 1: The 'C' in Critical Medical Anthropology stands for 'curious', 'confused', 'contemplative'...

Making sense of Western biomedicine, while also being part of it.

Michaelmas term’s courses left me with more questions than answers. Twice a week from October-December, my class would come together to discuss readings primarily about Critical Medical Anthropology (CMA). With “Medical Anthropology” already hard enough to define—often when asked what we study, we’d start with “ah funny you ask…’” followed by a pause and desperate glances at each other for support, and finally, “well, it kinda goes like this…”—adding the “Critical” doesn’t make it easier at all.

Some of the books we’ve read in this course!

How I’ve come to understand CMA is that it (critically) analyzes the biomedical model of care and its resulting medical system. It draws on the political economy of health, along with power dynamics that influence healthcare delivery and social determinants of health. Specifically, we examined concepts such as structural violence, overmedicalization, biopower, and what it means to suffer. Despite some dated terms, Baer et al. (1986) provides a succinct summary of what CMA entails—trust me, this is a very short paper compared to the amount of reading we have to do in this program…

“The medical systems of complex societies are characterized by pluralism. These systems are plural rather than pluralistic in that biomedicine enjoys a dominant status over heterodox and ethnomedical practices. This dominant status is legitimized by laws which give biomedicine a monopoly over certain medical practices, and limits or prohibits the practice of other types of healers.” - pg. 96

Medical pluralism quickly jumps out at me in this paper; there are so many different forms of medicine, all of which address many different definitions of health and illness. How one culture (broadly defined) perceives their experience of being sick is vastly different from another’s, compelling people to act differently. In medical school, however, we are often taught that this one way of doing things is the only correct way. Although more medical schools are starting to appreciate other forms of healing, biomedicine—and its Western traditions of reductionism and positivism—is still centered. What would it mean for us to decenter Western biomedicine among the realm of medicines?

I recently had a conversation with a friend on this topic where I had incorrectly conflated Western biomedicine with evidence-based medicine (EBM). Obviously believing in the principle that we must be able to show a treatment works well if we are going to use it, I shifted my argument to: we need to put more research into these other forms of healing so that they can become ‘evidence-based’, but the issue is, due Western society’s bias towards Western biomedicine, we aren’t able to shift our attention to supporting such research! This made sense to the both of us at that time, and we carried on with our evening walking home from Balliol College.

However that comfort did not last long. My point was challenged by another friend on another walk who reminded me of the Western-centric ideals to becoming ‘evidence-based'. Perhaps Western biomedicine and EBM are similar after all! My friend asked me: should we hold these other forms of healing to a standard that is rooted in Western definitions of effectiveness?

For instance, EBM studies how a treatment ‘works’ based on visualizable and quantifiable data. You can graph and calculate the relative risk reductions (RRR), absolute risk reductions (ARR), and numbers needed to treat (NNT) for a given treatment to see if it is likely to help an individual patient. These are undoubtedly important metrics and I do not challenge EBM’s goal of clarifying our understanding of drug effectiveness. Instead, I aim to highlight that these metrics are nevertheless grounded in Western values and perspectives of dichotomy (harm vs. benefits), objectivity, and the directly measurable. Applying them to other forms of healing may not, in the end, work.

In fact, wouldn’t subjecting these other forms of healing to such Western scientific scrutiny perpetuate the power dynamics that already allow Western worldviews to dominate? “You have to do things this way because it is the ‘right’ way”. Wouldn’t doing so maintain the very colonial and imperial power dynamics that uphold health inequities? That prevent marginalized communities from accessing culturally-safe care?

In Anne Fadiman’s The Spirit Catches You and You Fall Down, this difference in worldviews and lack of collaborative partnership is one of the reasons Lia Lee is unable to access timely care. For an entanglement of reasons, the family hesitates in following the Western biomedical treatments so central to the physicians’ tunnel-vision; instead, they opt for Hmong treatments that the physicians do not understand nor even try to understand. In my own previous research, I’ve also seen this bias translate to the Indigenous mental health field in Canada, where services using Indigenous approaches or Two-Eyed Seeing (adopting both Indigenous and Western approaches) are accredited based on solely Western values, consequently creating barriers to governmental funding and thus care delivery.

How did our medical system get here? Perhaps it starts at the level of us students. For those who have been through the medical school interview process, one question that is often found in preparatory materials goes along the lines of:

• you have a patient who has some kind of illness, such as cancer, in which you know there is a biomedical treatment that can potentially cure them,

• the patient is thinking of going to [insert ‘foreign’ country name here] to seek an alternative therapy that you are unsure of, but doubtful*, whether it will have the same curative outcome,

  *at least this is often the connotation, especially if the therapy is of non-Western origin,

  What do you do?

I would, as many other interviewees, have been inclined to answer ‘counselling the patient on risks and benefits of each option—unintentionally hinting there is a greater risk with pursuing the second option—but ultimately respecting their autonomy, etc.’… But now, I wonder if this question inherently privileges the first option over the other, priming our brains for our future career. I wonder if we should instead ask: what is the patient’s conception of health and illness and what does healing look like to them? Is it to be potentially cured and have a prolonged life? Or is it something else?

Ultimately after this course, I am left feeling curious, confused, and contemplative. I still believe in the legitimacy of EBM, but I ask myself and my future self how to carve out a practice of ‘good’ care, that leverages all forms of healing (not just biomedicine). I also wonder how we can ensure that this care is beneficial and meets a certain standard… which I am still trying to grasp.

If you have any thoughts on any of this, I’d love to hear them!

- jas <3