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Culture, Health and Illness. Fifth edition. Cecil Helman. New York: Oxford University

Press, 2007. vii + 501 pp.

Brian McKenna

University of Michigan-Dearborn

Department of Behavioral Sciences

In 1984, Cecil Helman, a South African trained physician, wrote a compact red book

whose primary purpose was to bring the insights of medical anthropology to biomedical

professionals. The 242-page, nine by six-inch offering was called "Culture, Health and

Illness: An Introduction for Health Professionals." Over the past quarter century, as

medical anthropology has exploded, so has his text and its reach. The fifth edition,

released in 2007, has expanded into a 501 page book, and the subtitle is now gone,

abandoned in the 4th edition (2000). It is no longer aimed at just health professionals but

for a much wider audience. Significantly, the book asserts that it will "cover all the major

developments of recent years" in the field.

This "fully revised" fifth edition is "the leading international textbook on the role of

cultural and social factors in health, illness, and medical care" according to Helman. The

text has been used "in over 40 countries in universities, medical schools and nursing

colleges." If true, then medical anthropologists had better pause and take notice since the

work is now the public face of medical anthropology at many powerful institutions,

including an important sector of biomedicine. JAMA and the Lancet are among its many

salutories. Does the book do as it says? Are all major developments covered? Further,

what does it have to say about the overarching cultural context of neoliberal capitalism

and its effect on health and illness?

Helman's book competes in a crowded field. Unlike 1984, there are a number of

introductory textbooks to choose from in 2007. I've used four of them in my classes: The

Anthropology of Medicine (3rd edition, Romanucci-Ross et al., 1997), Medical

Anthropology and the World System (2nd edition, Baer et al., 2003), Medical

Anthropology (Pool and Geissler, 2006), and Exploring Medical Anthropology (2nd

edition, Joralemon, 2006). Abiding by the anthropological demand to provide the social

context of any inquiry, all four provide some level of critical discussion on competing

theoretical schools and provide a brief history of medical anthropology. Curiously, and

contrary to his plan to cover "all major developments in recent years," Helman does not

mention three of these four texts in his own book (he does cite "World System" but

restricts himself to the older 1997 version) nor does he effectively theorize debates within

the subdiscipline. Omitted is any mention of Bourdieu's concept of habitus, Foucault's

theory of biopower or the fundamental critique of neoliberal capitalism, which have all

helped to advance medical anthropology in recent years. Medical anthropology

luminaries such as Benjamin Paul, Jean Comaroff, and physician/anthropologist Rudolf

Virchow are nowhere to be found.

These names are found, however, in another 2007 text that asks, "how has medical

anthropology developed since the first manuals were published in the United States more

than thirty years ago?" Like Helman's "Culture, Health and Illness," (which it cites)

"Medical Anthropology: Regional Perspectives and Shared Concerns," (Saillant and

Genest eds. 2007) attempts to cover the major developments of recent years, looking at

the field in Canada, the Netherlands, Switzerland, the U.S., the U.K., Brazil, Mexico,

France, Mexico, Spain, Italy and Germany. Saillant trenchantly describes the recent

movement to demedicalize medical anthropology and escape from "a question that has

haunted medical anthropology since its beginnings. . .the question of its dangerous liaison

with a profession that represents the establishment, biotechnological capitalism and a

pernicious form of biopolitics, all too often to gain credibility, and sometimes accepting

the role of a pale sociocultural variable in certain collaborations with medical

professions." Sentences like that are nowhere to be found in Helman's book, which omits

a sustained critical account of biomedicine as put forward by a host of medical

anthropologists and other scholars. Helman, being a member of both professions,

attempts to culturally broker the two adversarial worlds of critical social science and

biomedicine in his book. But in so doing he mostly presents medical anthropology as a

consensus enterprise: he smoothes over important disciplinary and other theoretical

conflicts and focuses on how biomedical professionals might benefit from a mountain of

cultural insights. This liaison is dangerous.

Helman's book has 19 chapters and more than 90 short case studies (each about 200-300

words), highlighted in pink boxes. A significant minority of the case studies are based on

events in the UK. The original eleven chapters from the 1984 edition are all present, in

various degrees of update. Six have retained their precise chapter titles: Introduction: The

Scope of Medical Anthropology, Doctor-Patient Interactions, Pain and Culture, Diet and

Nutrition, Ritual and the Management of Misfortune, and Cultural Factors in

Epidemiology. The five other original chapters have minor wording changes: "Culture

and Pharmacology" has added the subtitle "drugs, alcohol and tobacco," "Caring and

Curing" has added the subtitle "the sectors of health care," "Cultural aspects of Stress and

Suffering" (added is "Suffering"), "The Body: cultural definitions of anatomy and

physiology" ("body" was added) and "Cross-cultural (was formerly "transcultural")

Psychiatry." I'll discuss the eight newer chapters later.

Some of the eleven original chapters have changed little over the years and often the

references are quite old. For example 50 of the 56 references in the 2007 Doctor-Patient

Interaction (DPI) chapter were also in the 1984 edition, in almost exactly the same order.

A quick calculation uncovered that the average year for a DPI reference in the 2007

edition was 1982, a quarter of a century ago. Similarly, the 2007 chapter on Culture and

Pain retains 23 of its 27 references from the 1984 edition. Also, in an unusual

organizational style, most of the book's references and footnotes are not included in the

book. Instead there is a "key references" section at the end of each chapter directing the

reader to the "Culture, Health and Illness" website "for the full list of references for this

chapter." In order to gain access to the references one has to perform yet another step and

register for a password, delivered later by a marketing agent. The process of requiring

readers to register and deliver personal information reflects a level of control and a profit

oriented approach. I would have preferred ready access to footnotes to learn the quality

and currency of the data.

The essential message of these familiar chapters is to respect the world's wide-ranging

cultural diversity in health and medical practices. This remains an important message.

Helman is a critic of "modern medicine," and criticizes its reductionist approach. "The

model of modern medicine is mainly directed towards quantifying physiochemical

information about a patient, rather than the less measurable social and emotional factors,"

he says. Helman wants readers to recognize the vast amount of medical pluralism in order

to improve medical care and treatment. By honoring rather than dismissing alternate

worldviews, Helman believes that better clinical communication will take place, thus

improving health outcomes. Adopting the interpretive anthropology stance of Arthur

Kleinman, Helman establishes a framework that conceives of three health sectors in the

medical world: popular, folk and professional. He defines concepts such as explanatory

models, the illness/disease split, the mind/body dualism, body image, the stigma of

disability, the medicalization of birth, sacred versus profane foods, and alternate

conceptions of time, blood and infant feeding practices. A central concern is to recognize

"the meaning of the disease for the individual patient and those around him."

There are eight other chapters in the book. Three were available in the 2000 (4th) edition:

Gender and reproduction, Medical anthropology and global Health, and New Research

Methods in medical anthropology. Five chapters are new to this edition and include

Migration, globalization and health, Telemedicine and the Internet, New bodies, new

selves: genetics and biotechnology, The AIDS pandemic, and Tropical diseases: malaria

and leprosy. Many topics are dealt with including: the age of diasporas migration of

weapons, the health of refugees, migration of capital jobs, and debt, cybertherapy and its

critique, cultural aspects of screening for genetic disorders, the use of traditional healers

in AIDS care and an extended discussion of primary health care. These additional

chapters signal an important recognition by Helman that the interpretive dimension of

medical anthropology is insufficient in its ability to capture the plethora of research

topics, methodological approaches and global health problems that constitute the diverse

field of medical anthropology today.

Despite these additions, the text is torn by a tension between an older medical

anthropology of the 1970s and 1980 (that focused on validating alternate medical

traditions) and the newer medical anthropology. Saillant and Genest refer to the 70s and

80s as "classic medical anthropology" which is now "replaced by another concern,"

focusing on human rights, violence, social justice and structural inequality. Helman

struggles to overcome a radical discontinuity between his earlier vision of medical

anthropology whose principle frame of reference was the biomedical clinic with a more

critical vision that recognizes, with Margaret Lock, "how medical anthropology and

environmental anthropology are in some senses inseparable," as forces contesting the raw

power of capitalist culture.

Helman wants to bring social and environmental knowledge into health professions

education. He argues that "[modern medicine's] weakness lies in ignoring the social and

psychological events that preceded the onset of symptoms." He calls medical education a

"form of enculturation," that focuses on disease care, not community health. At the same

time he is critical of those critics who valorize externalities as more important than the

clinic. In later chapters he discusses a wide-ranging number of problems and forms of

social suffering associated with a migratory world drenched in poverty. However many of

these problems are presented in piecemeal fashion, fragmented throughout the text, or

added on as later considerations. Generally speaking he fails to show how to specifically

confront these problems within the DPR (a terrain he privileges) or give precise models

for how one can practice community oriented primary care medicine (which is only

introduced in the next-to-last chapter) in an oppressive political environment. Ironically,

the manner in which ideas are presented, often in a segmentary fashion, can assist in

reproducing biomedical hegemony in that while several social medicine etiologies are

addressed, they are often segmented as "add ons" in later chapters. This parallels the

sociology of knowledge in the specialized disciplinary worlds of biomedicine and health

professions education, where critical knowledge, unreimbursable as it often is, sits at the

margins.

A good example is evident in how he discusses cancer and its relationship to

environmental health. Remarkably, these two enormous subjects – cancer and

environmental health – are not conjoined in any substantial discussion, and crucially, are

not integrated in his prescriptions for the doctor-patient interaction. Ignoring the great

quantity of epidemiological and other scientific data drawing the connections between

environmental health on world cancer statistics, which could take up several chapters,

Helman instead talks about the impact of diet on cancer. He cites figures from the World

Cancer Research Fund and the American Institute for Cancer Research that concludes

"that 30-40 percent of cancer cases throughout the world, or 3-4 million cases a year,

could be prevented by dietary means." Helman details ten health recommendations that

flow from this position which include: a high intake of fruit and vegetables, the

avoidance of cured and smoked meats and so on. While important, this advice leaves out

much that is more important from a structural perspective. At one point Helman discusses

environmental pollution (e.g. air pollution, food additives, smoke) as being associated

with "lay theories of Illness causation." He adds, with Herzlich, that these "modern

notions of environmental pollution were, in many cases, a return to more traditional

theories of miasmas, or 'dirty air' as cause of disease."

Medical anthropologist Martha Balsham contests simple anti-cancer diet and exercise

protocols in health education and the DPR. In her study, "Cancer in the Community:

Class and Medical Authority," Balshem documented how a Philadelphia "lay

community" rejected health educators advice to stop smoking, improve their diets and

schedule regular screening tests, instead blaming industrial pollution from nearby

chemical plants and air pollution from traffic as the major causes of cancer in their

community. Balshem juxtaposed the assumptions behind the two competing sets of

illness etiology, the biomedical and the "lay community," and determined that both had

rational bases for being labeled legitimate knowledge. Balshem is unmentioned in

Helman's text.

The focus on lifestyle changes has the net effect of encouraging health professionals to

focus on diet and exercise when making their prescriptions about cancer avoidance in the

DPR, while omitting other kinds of advice. One can imagine a cancer sufferer in the

clinical setting with an explanatory model indicting the local chemical factory. Her story

goes unaddressed, uninterrogated and untreated. Instead, following their ideological

training, her doctors abide by a pathophysiological rationality that works to conceal the

social origins of sickness and as a result operates to suppress protest and, generally, to

support the ideological and cultural hegemony of dominant classes, as critical medical

anthropologists have correctly described it. This is true for wide ranging environmental

injuries. For example, in her groundbreaking ethnographic research anthropologist

Elizabeth Guillettte (1998) found that children from two similar towns nestled in the

Yaqui Valley, one of Mexico's largest agricultural areas, demonstrated strikingly different

neurological capabilities as a result of differential exposure to pesticides. One town was

beholden to pesticides since the 1950s while the other town opted for traditional farming

and shunned pesticides. Pesticide exposed children lacked energy, were saddled with

significant learning disabilities, and have coordination problems. Physicians are

extremely unlikely to diagnose these problems as the embodiment of agribusiness. Along

these lines Helman does not sufficiently explore how biomedicine itself is steeped in

reification, what Rhodes calls an "aura of factuality" a nosiology that makes something –

like "cancer" – appear entirely natural when it is, in fact, socially created. As

anthropologist Jean Comaroff puts it, in the face of a potentially lethal disease, under

Western capitalism, a person is jolted "with an alienated image of the self, caught in the

opposition between psyche and soma, and cut adrift from the wider social and moral

context, we attempt to impose 'meaning' upon an estranged world." Rhodes, Guillette

and Comaroff are unmentioned in the book.

There are models for effective environmental engagement in the DPR. In October 2003,

anthropologist turned physician Ruth Etzel released the second edition of "Pediatric

Environmental Health." under the auspices of the American Academy of Pediatrics.

The "Green Book," as it is known, is a groundbreaking clinical handbook that offers

concise summaries of the evidence that has been published in the scientific literature

about environmental hazards to children, and provides guidance to pediatricians

about how to diagnose, treat, and prevent childhood diseases linked to environmental

exposures. Environmental knowledge has difficulty crossing borders into official

medical knowledge systems because scientists, physicians, and government officials

are regularly censored, suppressed or deprived a decent living for truthfully doing

their environmental work, as epidemiologist Devra Davis documents in "When

Smoke Ran Like Water, Tales of Environmental Deception and the battle Against

Pollution (2002." Helman devotes just 16 pages, or 3% of the book to environmental

health, focusing on global warming and motor cars. He laments the million yearly

deaths from motor vehicles. But Devra Davis reports that more people are killed

worldwide from air pollution than car accidents. A great many important

environmental health studies in the literature are not referenced in Helman's book.

For example, in 2002 the Journal of the American Medical Association released the

results of a groundbreaking 16-year study showing that the lung cancer risks of

breathing soot-filled air in polluted cities is comparable to the health risks associated

with long-term exposure to second hand smoke.

Again, Helman details several important social medicine topics, but he also marginalizes

critical issues that would make his text more balanced, for example, his discussion of

iatrogenesis. It is not until page 96 that Helman discusses iatrogenic theorist Ivan Illich,

and when he does so, the sentences are sparse. He seemingly dismisses Illich by referring

to his ideas a mere "claims," and devotes just a paragraph to "biomedicine's iatrogenic

effects," which Helman claims are "now widely known to the public." But there are a

large number of iatrogenic effects unknown to the public or even physicians. For example

few emergency physicians know that a typical CT scan of the chest is equivalent to four

hundred chest x-rays. As Devra Davis describes in her forthcoming book, The Secret

History of the War on Cancer (2007), "a single CT scan today can give half the dose that

was shown to induce cancer in those who survived the atomic bomb blasts in Japan." In

my ethnographic eldwork at a Michigan medical school, the lay

community was invited to help create the medical curriculum for

students. They solicited the aid of John McKnight, a student of Illich's

who wrote a valuable book called "The Careless Society: Community

and its Counterfeits." McKnight argues that the medical complex has

converted citizens into clients. "Clients are people who relinquish their

power to the expertise of a professional. Citizens, on the other hand,

engage in politics: they challenge authority in the process of grappling

with questions of equity and justice." The medical schools basically

ignored the lay community's work. (McKenna in preparation). Also

ignored was the work of physician Robert Mendelson, author of "Confessions

of a Medical Heretic," who recommends that medical schools establish a department of

ethics and justice, and a department of iatrogenic disease, "in which all medical

specialties will be required to demonstrate how their methods can produce disease and

disability." References to McKnight and Mendelson would improve Helman's book.

Helman provides an excellent discussion of the placebo affect and the nocebo effect. I

really liked this section of the book. It is invaluable for health professions education. He

mentions Daniel Moerman's 1979 work but makes no mention of Moerman's spectacular

2002 book, "Meaning, Medicine and the 'placebo effect," in which Moerman makes

critical new points. I've used that book in my classes. Helman references the "health-

wealth" epidemiological research in passing. I would have added a reference from

Richard Wilkerson's excellent "The Impact of Inequality: How to Make Sick Societies

Healthier (2005).

Helman cites Community-oriented primary care as a strategy but does not make reference

to it until page 434, when the book is winding down. According to Helman, the role of

COPC "is to assess the specific health needs and problems of a particular community, to

raise awareness of the role of cultural beliefs and behaviors in their health (and health

care), and to act as their advocates to the medical and other authorities where necessary."

There is much activity in this area reported by the WHO and other groups that could have

been referenced as a model of action. For example there is Paul Nutting's classic

"Community-Oriented Primary Care, From Principle to Practice (1987) as well as works

by Paulo Freire, Jack Geiger and Sidney Kark's work from South Africa. I have

employed all these texts when I worked as a medical education evaluator. Indeed, COPC

is a fecund area that can be a conduit to perform local health action. It is surprising then,

that Helman didn't link this discussion with his otherwise useful section called, "cultural

factors in the epidemiology of disease." There he lists ninety-four bullet points that

require epidemiological investigation including important items such as investigating the

relationship of occupations to disease, the modes of human waste dispersal, and whether

personal hygiene is neglected or encouraged. Remarkably this is almost exactly the same

list as the 2000 edition. Required is more than a laundry list.

Social theorist Zygmunt Bauman argues that "culture is a knife against the future."

Culture, for Helman, is more akin to Tylor's conception, "a set of guidelines (both

explicit and implicit) that individuals inherit as members of a particular society" that tells

them how to view, experience and behave in the world. Gramscian ideas of culture as

struggle, resistance and conestation over power are not part of Helman's fundamental

framework. Rather than a call for unbarred criticism, Helman's book accommodates to a

professionalist ideology in that it seeks to find what is "right" in the work of others, not

what is wrong. What Gouldner (1970) said of professional sociology is true for this

rhetorical style where the watchwords become "continuity, codification, convergence,

and cumulation." In this view, historical struggle comes not through polemic, struggle

and conflict, but through consensus. But culture is not just a spoon making lucky dips

into a diverse set of medical ice cream jars. It is also a knife against the future, a future

constituted by what Henry Giroux calls "the terror of neoliberalism." As anthropologist

David Harvey describes it, "The neoliberal determination to transfer all responsibility

back to the individual has doubly serious effects. As the state. . . .diminishes its role in

areas such as health care, public education, and social services, which were once so

fundamental to embedded liberalism, it leaves larger and larger segments of the

population exposed to impoverishment. The social safety net is reduced to a bare

minimum in favor of a system that emphasizes personal responsibility. Personal failure is

generally attributed to personal failings, and the victim is all too often blamed."

Medical anthropology needs to place a scalpel against a culture that works to make

millions of people disposable (witness the Iraq War and the U.S. government's response

to Hurricane Katrina), turn nature into a tap and sink, increase social inequality, eliminate

dissent, proletarianize health professionals, invade the clinical setting with insurance

capital, speed-up clinical work so that doctors do not have sufficient time to explore

explanatory models, deprive tens of millions access to care (which in the age of AIDS

and malaria is very important). Helman's book does not adequately describe this

fundamental contradiction of our age, a time when "culture, health and illness" issues are

captive to deep-seated political forces that are relentless in their movements towards

authoritarian cultures. The crisis is urgent.

Helman's book is powerful in its illustration of how medical pluralism matters. It is a vast

improvement on earlier editions that sidestepped many issues in global health. Its critical

discussion of placebo and nocebo in medicine and culture is a valuable pedagogical

service. Helman has assembled a great quantity of material that makes his perspective of

medical anthropology more accessible. But the book also glosses over many important

developments and many of the topics it addresses need more current research. Further,

the book omits discussion of many major theoretical developments over recent years.

There is much to say positive about this book and no doubt it will be said. But the book's

liaison with biomedicine did indeed prove dangerous because the conflict between

critical social science and biomedicine is, in the end, irreconcilable.

... Por lo tanto, se asume que el modelo biomédico es suficiente para su explicación de enfermedad y trastorno. No obstante, se pone en valor que los factores culturales influyen en la presentación de los diversos trastornos psiquiátricos (Anderson, L et al., 2003;Bhugra&Mastrogianni, 2004;McKenna, B. 2008). ...

En las últimas décadas, los movimientos migratorios han hecho que cada vez acudan más pacientes de otras culturas en nuestras consultas. Muchas veces, síntomas definidos como psicóticos o delirantes se explican, en parte, por un componente cultural. No hay duda de que la cultura influye en cómo las personas experimentan sus emociones, en cómo y en qué términos las expresan, y dónde buscan ayuda. Los síndromes vinculados a la cultura, son síndromes psiquiátricos estrechamente relacionados con determinados aspectos culturales en su formación o manifestación psicopatológica, abarcando ciertas manifestaciones conductuales, afectivas y cognitivas observadas en culturas específicas. Las manifestaciones clínicas que presentan suelen ser diferentes de las de los trastornos psiquiátricos que se encuentran en las clasificaciones occidentales existentes. En esta revisión se describirán las características de los síndromes vinculados a la cultura, veremos si están limitados a sociedades específicas o son las áreas culturales las que definen los criterios, si se deben considerar síndromes variantes de trastornos considerados como "universales" (neuróticos, afectivos, psicóticos o de personalidad), si todos los trastornos están "ligados a la cultura" y si son estables en el tiempo, así como sus manifestaciones clínicas y el manejo de los cuadros más frecuentes. Palabras clave: Psiquiatría de enlace, síndrome culturales, cultura, psicosis, disociación; factores socioculturales.

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