Critical Medical Anthropologists Research Articles

Uneven geographies of COVID‐19: Reviewing geographical research agendas and concepts from a syndemics perspective

AbstractBuilding upon a review of geographic research agendas and concepts related to the uneven geographies of COVID‐19, this first of three articles debates the benefits of geographic analyses to the syndemic approach and, vice versa, of a syndemics perspective to geographic analyses. The syndemics perspective was proposed by critical medical anthropologists. It seeks to deepen the understanding of the structural dimensions and processes that lead to the convergence and cascading of multiple epidemics in specific population groups. Geographers have also highlighted the intersections of multiple health or other crises during COVID‐19, when the pandemic and global health emergency coincided with and escalated existing structural inequalities produced by the climate crisis, environmental degradation, political conflicts and war, socio‐economic disparities and poverty, social divisions, racism, hatred and violence, mental health problems and stress. Geographers have mobilized concepts such as scale, territory, borders and intersectionality to unravel the uneven unfolding and consequences of the global health emergency for diverse population groups. We therefore argue that geography has a lot to contribute to the understanding of the spatial and contextual dimensions of COVID‐19 as a pandemic as well as a syndemic – but it has so far not actively employed the latter concept's analytical lens. Mobilizing the syndemics approach can contribute to more comprehensive accounts of the structural dimensions and processes that continue and cascade in pandemics.

Eating and Feeding at the Margins of the State: Barriers to Health Care for Undocumented Migrant Women and the "Clinical" Aspects of Food Assistance.

In this article, I examine the various meanings of Mexican and Central American migrant women's utilization of private food assistance programs. I present findings from 20 months of ethnographic fieldwork conducted between 2008 and 2011 with migrant women, public health workers, and staff and volunteers of food assistance programs in Santa Barbara County, California. I discuss the barriers undocumented women face in accessing formal health care and the social and moral obligations that underpin these women's role in feeding others. I also document the ways in which private food assistance programs are orienting toward a focus on health in service delivery, and how women depend on provisions from these programs to support feeding practices at home. I argue that these findings are significant for current engagement by critical medical anthropologists in studying framings of "the clinic" and cultural beliefs about "deservingness."

Critical Anthropology of Global Health “Takes a Stand” Statement: A Critical Medical Anthropological Approach to the U.S.'s Affordable Care Act

The Affordable Care Act (ACA) of 2010--the U.S.'s first major health care reform in over half a century-has sparked new debates in the United States about individual responsibility, the collective good, and the social contract. Although the ACA aims to reduce the number of the uninsured through the simultaneous expansion of the private insurance industry and government-funded Medicaid, critics charge it merely expands rather than reforms the existing fragmented and costly employer-based health care system. Focusing in particular on the ACA's individual mandate and its planned Medicaid expansion, this statement charts a course for ethnographic contributions to the on-the-ground impact of the ACA while showcasing ways critical medical anthropologists can join the debate. We conclude with ways that anthropologists may use critiques of the ACA as a platform from which to denaturalize assumptions of "cost" and "profit" that underpin the global spread of market-based medicine more broadly.

The Anthropology of Organ Transplantation

Anthropology has been involved with the field of organ transplantation almost since its inception. As a rapidly growing subfield within biomedicine, transplantation has been analyzed as one more example of the technological imperative: the development and application of new procedures and techniques that bring, in their wake, major changes in how humans relate to their bodies. Anthropologists have been especially interested in the psychological adjustment of organ recipients as they come to terms with the sacrifices or deaths that were necessary to provide them with organs and as they respond to the presence of an outsider in their bodies. Critical medical anthropologists have focused more on donor issues, raising ethical questions about transplant tourism and the commodification of organs and challenging the universal validity of brain death as the death of a person.

Social Inequality and Health: A Commentary

Medical anthropologists have had a long interest in the subject of social inequality and health. Critical medical anthropologists (Farmer 1999; Singer 1986) and biocultural anthropologists (Goodman and Leatherman 1998; Thomas 1998) have all argued for the systematic study of structured economic and social inequality in communities and their impact on health. In this issue of MAQ, Ricardo Godoy and his colleagues add a new dimension to the anthropological study of this subject. My aim here is to provide a bit more background, to better contextualize their study. Although anthropologists have a deep interest in the subject of inequality and health, we have contributed proportionately little to the debate. The inverse association between socioeconomic status (SES) and health, and the related positive association between social integration and health, are probably the most widely replicated of any associations observed between social variables and health outcomes. And, the SES–health relationship is certainly the most often replicated association of these two relationships. Social epidemiology is the field that has contributed the most to this literature (Berkman and Kawachi 2000). This of course will be familiar to the many medical anthropologists who are acquainted with the literature in epidemiology. Regardless of who is doing the research, however, the question remains: why? What is it about social inequality that leads to ill health? This may seem like a silly question when you consider the grinding poverty (or absolute material deprivation) under which some people live as described in the ethnographic literature by, for example, Nancy Scheper-Hughes (1992). Her careful ethnographic description of the desolate poverty experienced by many living in a Brazilian favela (or “shantytown”) makes it clear that some people are sicker because they are poor, oppressed, and exploited. On the other hand, it is not such a crazy question when you look at the socioeconomic gradient in health found in Michael Marmot’s Whitehall study (Marmot 1994). Whitehall, of course, refers generally to the British civil service. From the housekeeping staff to the titled ministers, the inverse gradient in health can be seen. Granted, the differences in health may not be as great as those between the poorest Brazilians and Brazilian members of the international elite, but the gradient, nevertheless, is there. And, these British civil servants are fortunate to live in a society with a national health care service and with the economic wherewithal

Changing biocultural perspectives on health in the Andes

New directions toward biocultural approaches to health and illness in Andean peoples have emerged since the original Health in the Andes volume was published in 1981. The reformulation of these perspectives was stimulated in part by the growth of political-economic perspectives in Andean ethnography and by critiques of medical ecology by critical medical anthropologists. This paper provides a brief history of changing biocultural perspectives on Andean health, and contrasts two projects dealing with Andean biology and health carried out in the 1960s and 1980s in the District of Nuñoa in Southern Peru. The recent Nuñoa research provides one example of a more critical biocultural approach that attempts to integrate perspectives from ecology and anthropological political economy. The utility of the approach is explored through the Nuñoa case study, which focused on the reproduction of illness and poverty in Andean households in contexts of social and economic change. Findings of this research are compared with recent work in the Andes to illustrate how a more critical biocultural perspective can better articulate with the diversity of approaches in medical anthropology and Andean health studies.

The misconstruction of critical medical anthropology: A response to a cultural constructivist critique

Since its emergence over a decade ago as a distinct theoretical framework, critical medical anthropology (CMA) has engaged in debate and dialogue with various other perspectives within medical anthropology, particularly clinical anthropology, medical ecology, and, to a lesser degree, postmodernism. While at least two genres of CMA have emerged, both of which are involved in a dialogue with each other, proponents of other perspectives often misread or “misconstruct” the agenda of CMA as both a theoretical framework and a strategy for health activism. This essay in particular critiques this process among proponents of the interpretative or cultural constructivist perspective. On a positive note, however, I urge critical medical anthropologists and cultural constructivists within medical anthropology to enter into a dialogue with each other because their two perspectives, despite the presence of obvious epistemological differences, share commonalities.

Bringing political ecology into critical medical anthropology: a challenge to biocultural approaches.

This essay presents an effort to incorporate the "environment" into critical medical anthropology. Rather than relying upon the multifactorial approach characteristic of medical ecology or biocultural approaches in medical anthropology, it urges critical medical anthropologists to turn to the burgeoning literature on eco-Marxism, eco-socialism, or political ecology in their efforts to develop a political ecology of health. Given that political ecologists generally advocate democratic eco-socialism as a meaningful alternative to the capitalist world system, this essay also presents a critical examination of the environmental record of post-revolutionary societies.

The evolution of bipedalism and assisted birth.

eview of the cross-cultural literature on childbirth reveals that isolated birth is either virtually unknown or a rarely achieved ideal (Konner and Shostak 1987; Trevathan 1987; for an exception to this pattern, see Sargent 1989). In almost every known routine circumstance a birthing woman alerts someone else of her condition and is subsequently attended to by a close female relative, a friend, or a midwife. Although she may communicate her needs and physical experiences to her attendant, it is often the case that the other person makes most of the decisions about the birthing process. In addition, the larger historically rooted social group may have already made decisions about where birth is to take place, what position the woman will be in when she delivers, what artifacts will be used during delivery (Jordan 1987), who receives her newborn infant, and how she may or may not behave during labor and delivery. Only in rare instances can a woman act and behave exactly as she wishes during the birth process. But has this always been so? Some critical medical anthropologists argue that biology and evolutionary history tell us little about experiences we have today, particularly as they relate to power and control over our own individual bodies and minds (see, for example, Singer 1989). They suggest that it is primarily the contemporary sociopolitical context in which we are embedded that determines where we deliver our babies and what happens to them and ourselves during and after birth. In this commentary I argue that understanding something about our historical and evolutionary past can help us understand several contemporary health issues, including childbirth. I imagine that many scholars would agree that historical circumstances are crucial for understanding our present conditions, but I want to push that domain back 5 million years, before birth was social, before anyone except the individual birthing female herself had power over birth. I suggest that the evolutionary transformation of a nonbipedal prehominid into a bipedal hominid first transformed birth from an individual to a social enterprise. With that, control over birth was also transferred from the individual giving birth to the person in attendance. In other words, selection for bipedalism set hominids on a trajectory toward the elaboration of cultural systems of authoritative knowl-

Limitations of quantitative research in the study of structural adjustment

Sociologists and, more recently, critical medical anthropologists have been arguing for a refocusing of the analysis of health and health care towards a perspective which considers the broader global political economy. In the context of the debt crisis and IMF/World Bank-inspired structural adjustment policies, the political economy theoretical perspective is becoming even more relevant in the analysis of health underdevelopment in many ‘Third World’ countries. This study focuses on the direct and indirect effects of the Jamaican debt crisis and structural adjustment programmes on health care services and health standards. In this paper it is argued that there are methodological problems using quantitative data when studying the effects of structural adjustment. In addition to providing a limited account of the effects, it is argued that the basic problem is a matter of the availability and reliability of the quantitative data in many ‘Third World’ countries. It is argued that some of these problems could be overcome by the application of qualitative micro-level analysis. This type of methodology is important to ascertain the effects of global processes at the grass roots level and to gain insights into what those working in the health sector are experiencing and what they perceive as the effects, if any, of structural adjustment policies. This has often been missing from the impersonal accounts offered by quantitative research on the subject to date.

How critical can clinical anthropology be?

In recent years a dialogue has occurred between critical medical anthropologists and clinical anthropologists about the possibility of developing a critical clinical anthropology. Although critical medical anthropology aims to merge theory and praxis, I argue that achieving this goal in a biomedical clinical setting will be extremely difficult if not impossible. In pursuing their commitment to social action, critical medical anthropologists need to establish connections with other groups including: labor unions, ethnic minorities, women's organizations, environmentalists, and self-help groups, in the struggle to create a healthy society.

The possibilities and dilemmas of building bridges between critical medical anthropology and clinical anthropology: A discussion

Critical medical anthropologists ultimately aspire to merge theory and praxis in their desire to promote experiential health as opposed to the functional health associated with contemporary political economics around the world. As part of this endeavor, Anne L. Wright and Thomas M. Johnson expressed in their session on ‘Toward a Critical Clinically Applied Anthropology’ the hope of synthesizing critical medical anthropology and clinically applied work. They have graciously invited me to serve as one of the discussants of this symposium, as I have been a proponent of critical medical anthropology [I] and a critic of conventional clinical anthropology [2]. I will focus on three basic questions relevant to the aims of this symposium: (1) How ‘critical’ are each of the articles? (2) In what ways, if any, do each of them build a bridge between critical medical anthropology and clinical anthropology? and (3) What strategies do they propose for the creation of a truly humane health care system and society? Each of the authors operates with a somewhat different conception of critical medical anthropology and with a different assessment of the plausibility for synthesizing critical medical anthropology and clinical anthropology. With this thought in mind, it should be noted that many analyses that adopt the rubric ‘critical medical anthropology’ bear little resemblance to the framework that Singer and I delineated when we coined this term [3]. This development has prompted me at times to wonder whether the decision to change the Political Economy of Health Interest Group into the Critical Anthropology of Health Interest Group was not premature, even though at the time I was one of the supporters of this change. In its aftermath, we saw an array of papers adopting straight phenomenological, ethnomedical, and conventional clinical anthropological approaches appearing in sessions bearing the label ‘critical medical anthropology’. As a response to this development, Soheir Morsy [4] proposed in a panel discussion titled, ‘Getting Back to the Basics in Critical Medical Anthropology,’ at the 1988 American Anthropological Association Meeting that the label critical medical anthropology is counter-productive. In a rejoinder to her argument, Singer [S] advises that the label ‘critical medical anthropology’ should be retained but that its content and boundaries need to be better defined. Perhaps much of the problem with defining the content and the boundaries as well as the goals of critical medical anthropology lies in establishing what is ‘critical’. As Singer, Johnsen, and I argued in our delineation of critical medical anthropology,