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5 Applied Anthropology and Health and Medicine

Linda M. Whiteford and Linda A. Bennett

lntroduction Would you like to reduce the spread of HIV/AIDS? Help improve commu- nication between practitioners and their patients? Unravel the complexities of alcohol or drug abuse? Assist local communities in fighting a cholera epi- demic? These are all things that applied medical anthropologists do. Applied medical anthropologists do many more things as well: they teach in medical schools and in departments of anthropology, consult with inter- national health organizations, and work with local governments and non- governmental organizations. In this chapter, we will share some of the excitement about applied medical anthropology that we experience and describe its historical roots and contemporary applications.

What is applied medical anthropology, and where does it fit in the field of anthropology as a whole? Medical anthropology is a relatively recent major addition to the field of anthropology, gaining momentum in the United States in the 1960s and 1970s, with critical pioneering studies a decade earlier. Some, however, trace the conceptual roots of applied medi- cal anthropology to British colonial experiences and the use of social observers in lndia, Africa, and Melanesia. This chapter tells a story of the early development of the field, illustrates some of its current applications, and imagines some fluture directions its practitioners might take. Case stud- ies from the authors'experiences are used to exemplify major concepts and applications of applied medical anthropology to the domains of health and medicine.

t20 Applied Anthropology

Medical anthropologists are often trained in the four-field approach of anthropology, comprised of knowledge from cultural, biological, iinguistic, and archaeological studies. This provides medical anthropology with unusual breadth and depth, allowing medical anthropologists to burld on findings from forensic biology, ethnopareontology, historicJ reconstructions of disease, and the linguistic and cultural patterns employed in the social construction and understanding of disease.

In general, medical anthropology seeks to understand the interplay between culture and biology, particularly as that interplay is expressed in health and illness and in their associated belief and pru.ti.. ,yr,"-r. By sys- tem we mean the conceptual framework that rinks variables together follow- ing particular and specific rules. As Joralemon notes (lggg, l3), medical anthropology is not unique in attempting to understand the interpray between culture/biology and humans/disease. However, it can be differenti- ated from the other medical social sciences by two factors: first, by its wider geographic range and time spread because it builds on archaeol'gical and paleontological research, and, second, by its explicit focus on the- cultural and biological determinants of disease. we can think about the rvays in which cultural rules about disease recognition and treatment intersect with germ pathology of disease; that intersection is what medical anthropologists refer to as the biocultural synthesis.

The importance of conceptualizing and analyzing this biocultural synthe- sis had led some medical anthroporogists to acquire special training. while they are being trained in anthropolog,y, often speciarizing in either Jociocur- tural or biological anthropology, they often acquire additional expertise in allied^fields, such as public health, nutrition, counseling, nursing, or medi- cine' Some graduate programs in anthropology offer splcializeJcourses in medical as well as applied anthropology. others now even offer students the chance to acquire two degrees simultaneously: one in applied anthropology, the other in public health. This duar training, combined rvith an in-aepitr education in anthropology, makes medical anthropology an immensely var_ ied field, with practitioners studying such subjects u. pr"nutut testing, genetic counseling, immigration laws and health policy, a$ng in u crori-Julturul perspective, and even the forensic analyses ofethnic cleansing.

For this chapter, we conceptualize health as a state of being, an equilib- rium of sorts in which one's physiologicar, emotional, and mental functions work in harmony. we also think of medicine as a curtural system of knowr- e.dge a1d practice designed to promote and maintain that harmony. Using these definitions of health and medicine as complex, interrelated, und .on- structed systems, we can see how necessary it is to employ what is referred to as a biocultural perspective or synthesis in medical unri,.opology. A bio_

Applied Anthropolog;t and Health and Medicine tzt

cultural perspective is one that integrates knowledge of biologrcal systems with knowledge of cultural systems. That perspective acknowledges the co- primacy and power of both biology and culture and recognizes that their interplay forms an integral part of biocultural analysis.

Current anthropological interests in health and medicine continue a history of analysis of the complex interactions of physical/ideational and cultural/ biological systems, which has become known as medical anthropology. As if that were not complicated enough, most medical anthropologists are also applied anthropologists. Some might argue, as we do, that all medical anthropology is applied anthropology. That is, all research in medical anthropology has direct or indirect applications to human health and medicine.

Medical anthropologists now teach and conduct research in medical schools, in schools of nursing and public health, and in more traditional set- tings such as anthropology departments. They also work in state depart- ments of health and national health agencies such as the Centers for Disease Control and Prevention (CDC), for international health agencies like the World Health Organization (WHO) and the U.S. Agency for Inrernational Development (USAID), and for nongovernmental organizations (NGOs) such as the Red Cross, to name a few. It is clear that anthropologists make contributions in numerous arenas in an effort to better our understanding of health and medicine. Knowledge that is generated by medical anthropolo- gists, be they teachers, researchers, consultants, or practitioners, has applied implications and often results in changes in policies, programs, or practices. That is why we think that all medical anthropology is applied, whether in universities, international agencies, or local consulting.

Applied medical anthropologists come from a variety of theoretical, epis- temological, and methodological orientations. That is, although they all may be interested in some aspect of the dynamic interplay between cultural beliefs, practices, and physical expressions, they approach the design of their research or analysis from a number of distinct bases. In this chapter we will discuss some of these perspectives. Regardless of approach, whether political/economic, interpretive, ecological, critical, or hermeneutic, applied medical anthropologists tend to share a commitment to the holistic perspec- tive of anthropology, that is, a perspective that takes into account the larger nonbiological context. Such an approach Lakes into account multiple rele- vant factors rather than narrowing in on a single aspect. In medical anthro- pology, we draw heavily upon the biological and cultural facets of the human experience of health and illness. An ability to consider the cultural context in which actions occur and a capacity to bridge what is too often thought of as a conceptual chasm between culture and biology make the applications of a medical anthropology perspective of great utility not only

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in anthropolog"- but also in allied fields such as medicine, social work, nurs- ing, addictions research, and public health policy and practice.

Historical Overview and Current Theoretical Approaches

In all cultures, humans create systems of thinking and behavior to protect themselves from future possibilities of becoming sick, having bad luck, and suffering ill fortune. All people have beliefs and practices designed either to keep them healthy or to make them healthy if they fall ill. Have you ever taken vitamin C when you thought you were getting sick? Have you ever had a good luck charm, worn a lucky shirt, or saved a four-leaf clover? Peo- ple in other cultures do similar things. In all societies people develop cul- tural systems designed to maintain health or restore individuals to healthy states. These cultural systems of beliefs and practices vary widely, and they may include patterns of dietary constraints, behavioral admonitions, recourse to spiritual or specialist guidance, and self-diagnosis and treatment. Going to a doctor, a midwife, a mental health counselor, a spiritualist, or a pastor are examples of relying upon specialists to help maintain or return to health. Neighbors, mothers, sisters, grandmothers, and other friends and fanrily members also form part of the system of information and communi- cation we use.

In the early part of the twentieth century, F-uropean colonial expansion into the Pacific islands, India, and Africa brought colonial administrators into contact with cultures radically different from their own. The Dutch, French, and British governments found themselves trying to control people whose cultural beliefs and practices rvere unintelligible to them. They turned to people they called social observers, whose job it was to observe and understand local rules, regulations, and cultures. In turn, these social observ- ers were to help the colonial administrators understand and rule the colo- nies. Some of the social observers were members of the foreign office; others were physicians or educators; and many became what today we would call anthropologists. Anthropologists and social observers like E. E. Evans- Pritchard and W. H. R. fuvers were introduced firsthand to non-Western cultures in places like Melanesia, the Nuer, and the Azande through their government's activities in those areas. They became intrigued by how social relations and cosmological beliefs were tightly intertwined. They learned how people defined who was a member of their family and how those kin relations were shaped not by biology but by cosmology (religious beliefs). They noticed and described how systems of religion and social organization reflected and supported those kinship systems of beliefs and practices.

Apptied Anthropology and tlealth and Medicine t23

One result of the colonial expansion was the development of a rich body

of literature describing beliefs and practices of non-Western peoples. Some

of those early social observers, like Evans-Pritchard and Rivers, sought to

conceptually link their analyses of non-Western systems of beliefs and prac-

tices used in magic and religion to those Western practices used to try to

keep people sale and in good health' Magrc, religion, and medicine, they

,u*, *"r" all systems of thought based on assumPtions with sometimes lim- ited physical evidence. Rivers, who was a physician as well a social observer, found his experience with Melanesian practices to be directly

applicable to the situation of the shell-shocked British soldiers. As a result of

his field observations, he challenged the accepted wisdom of the time in

Britain about how to "treat" soldiers thought to be suffering from shell shock.

The accepted medical practice during World War I (and in previous wars)

was to treat soldiers who suffered from unseen or psychological wounds by

forcing them back into the field of war immediately or by labeling them as

cowards. Soldiers were not encouraged to speak about what they saw or

their fears. Rivers, however, believed that their minds needed healing and

that the wounded men were not necessarily cowards trying to escape the

front lines. His decision to give soldiers time to recover from what they had

seen and experienced and a chance to speak about the experience was

almost prescient of what has come to be called post-traumatic stress disorder

(PTSD) some tlO years later.

lbr many, medical anthrop<llogy is traced to a much later start-in the 1950s and l9(i0s-with two seminal bo<-rks: Benjamin Paul's edited collec-

tion, Health, Culture, and Communit\: Case Studies of htblic Reaction to Health

Ilogranu (l!)55) and Rene Dubos's Man Adapting(1965). Paul's book is a clas-

sic in both applied and medical anthropology. He presented a cultural "sys-

tems model" that embedded responses to public health medicine within the

contrasting set of traditions and expectations of the clients' culture and com-

munity. His case studies are exemptars of cultural systems in conflict. The

chapters are drawn from Paul's consulting work at Many Farms, Arizona,

where the U.S. Public Health Service provided clinical health care to the

Navajos. The clinic was new and well staffed, and the Public Heath Service

was particularly concerned when few Patients attended. Diabetes, tuberculo-

sis, alcoholism, and many other illnesses associated with poverty and isola-

tion wcre common on the reservations, yet few people attended the clinic.

Paul and several other anthropologists were asked to observe the clinic and

help the l\blic Hcalth Service administrators understand why the clinic was so underutilized.

The anthropologists found that a series of barriers existed. Cultural differ-

ences in expected behaviors and anticipated outcomes, in combination with

t24 Applied AnthropologSr

contrasting perceptions of modesty, manners, and time, created an almost. insurmountable gulf between the practitioners and the clients they were to serve. The cultural expectations of the public health practitioners were based on their training with non-Navajo groups, and this led the physicians and nurses to expect their patients to come to the clinic at the appointed time, to look the public health official in the eye, and to declare a set of physical medical symptoms. The cultural expectations of the Navajos, on the other hand, were based on religious cycles related to weather, crops, and seasons in which time was fluid and based on complex rituals rather than on clocks and months. l'ixed time appointments were not part of their lives. In addition, cultural norms of modesty prevented many Navajos from making direct eye contact and prescribed an unspoken set ofrules concerning which relatives and nonrelatives could be spoken to. Navajo beliefs about illness causation were olten at odds with those held by the public health doctors and nurses. The lack of shared understanding about personal presentation, time, who could be spoken to, and even whose names could be spoken caused serious communication problems. These problems were, in par! resolved when the anthropologisrs helped the clinic staff see that the prob- lems stemmed from cultural differences rather than a lack of need or a lack of respect. Understanding differences about when and how things should be done, what could make one sick, the range of ways to get better, and even how to talk about these things made it possible to design policies and prac- tices that bridged the two cultural sysrems.

Paul's book was seminal for the development of the field because ir clearly articulated the need to contextualize medical care as a cultural sys- tem that may or may not fit with other cultural systems. Until that time, little attention had been paid to the cultural biases of both practitioners and patients or to the fact that those biases were rooted in cultural systems. The Many Farms experience is classic because the models were so distinctive: the public health service practitioners were trained to emphasize efficiency, science, confidence, punctuality, and individuality, whereas the Navajo clients' model of the world emphasized humility, modesty, respect" spirituality, and community. In retrospecl we can see that a clash between these models of the world is avoidable, and now more attention is paid to patient-practitioner interactions, their communication patterns, and their cultural systems of belief and practice.

whereas Ben Paul's model laid the groundwork for a systems approach to applied medical anthropology in the United States, Rene l)ubos's contri- bution to the evolving specialization was his book Man Adapting (1965). Along with Dubos's earlier book rhe Mirage of Health(lg5g), it provided the basis for articulating the biocultural and ecological perspectives. Dubos sug-

Applied Anthropology and Health and Medicine t25

gested that, although there may be negative aspects to human adaptability, it was that very ability to be adaptive that allowed humans to survive in diver- gent and constantly changing environments. ln the lg60s and 1970s, the key terms denoting the biocultural perspective were adaptation and ecological and featured evolutionary themes (Janzen 2001,32). Adaptation, according to McElroy and Townsend, involved "changes, modifications, and variations enabling a person or group to survive in a given environment" (2004, l4). They went on to note that humans "adapt through a variety of biological mechanisms and behavioral strategies" (14). With an ecological perspective, the focus is on the interrelationships between the various components seen to constitute an ecosystem: populations and their environment (37). This perspective continues to capture the attention of medical anthropologists by providing a useful and practical method to connect humans to their environ- ment through both biology and behavior.

Charles Leslie also shaped the nascent field of medical anthropology in significant ways. Leslie's writings from 1960 to 2000 took the field to new horizons. Although his contributions are many, his book from 1g76, Asian Mcdkal Systems: A Comparatite Study, was seminal because it introduced many medical anthropology students to the tremendous variation in medi- cal systems throughout Asia and the rest of the world.

Contem porary Applied Medical Anthropology Contemporary applied medical anthropologists look at how people in

different societies, as well as in their own, ritualize universal life stages: birth and death, childhood, and old age. Such life stages provide researchers a common biological experience that can be examined using the biocultural perspective. Birth, for instance, occurs biologically the same way among all humans but with immense variation in practice across cultures. The biology of birth does not vary. Babies are born in a limited number of ways: vagi- nally or by caesarian section (surgery). However, the cultural range of birth practices is exceptional. Some societies, the United States, for instance, encourage women to give birth in sterile, medically controlled rooms with men or women in gloves, masks, and gowns. However, among the Bariba of Benin, women are expected to give birth alone, often away from their homes and the prying eyes of family or friends (Sargent 1982). Still other societies welcome the presence of family members-children, fathers, moth- ers, and sisters-while the woman labors and gives birth. Why is there such cultural variation on a universal biological process? According to those who have studied the social context of the biocultural synthesis of birth, birthing rituals reflect the norms and needs of the society of which they are a part.

126 Applied AnthropologSt

BrigitteJordan's (lg7ti, 1997) studies of women in four different cultures showed how the rules about who attends the birth and even the physical position of the laboring woman-whether she sits in a birthing chair, squats back on her heels on the floor, or lies on her back with her legs strapped onto a horizontal table-all depend on the cultural beliefs about life and death, gender relations, power and authorit/, and religion. Jordan's work opened up a whole area of research in applied medical anthropology and, equally importantly, provided women, their famiries, and thlir medical assistants with knowledge of alternative ways to situate the birth: with a mid- wife, at home, in a birthing room at a medical facility, with famiry or without them. For many women, this research transformed the birth experience into a more positive and emotionally significant moment in their lives.

Gender-another universal cultural category-also has provided an important focus for medical anthropology. Just as Jordan and others researched how birth is culturally situated, questions of how biocultural cat- egories like gender shape medical experiences have stimulated anthropolo- gists to ask why women are treated differently than men in, for instance, clinical settings in the United States. In the lg80s and lgs)0s, medical anthropologists sought to understand how the cultural biases toward a group become replicated in rheir medical trearmenrs (Sargent and Brettell lgg6; Rapp 1981),2001; Ginsberg lg89). others explored the consequences of cul- tural biases on the medical treatment of various ethnic and socioeconomic groups. Do African Americans receive the same quality of care in the united States as non-African Americans? Do the poor in Britain receive the same type of medical attention as the rich? Do immigranrs in l'rance receive the same quality of care as the native-born French? These are all examples of the kinds of issues that caphrre the attention of medical anthropologists as they apply their anthropological training in cultural analysis to medical sy*stems.

Investigating the cultural underpinnings of beliefs and practices associ- ated with various universal life stages provides important information that helps us understand both cultural variation and the reasons for the continua- tion of such cultural practices. The application of the results of medical anthropological studies such as those of.Jordan .r Sargent may be part of the original research design, or it may lollow .nce the research has found a pub- lic audience.

The emergence and reemergence of communicabre diseases is another area of contemporary research among applied medical anthropologists. The reemergence of deng'e fever, the geographic spread of malaria, and the emergence of new diseases such as HIV/AIDS and SARS require the ste- reoscopic and biocultural approach that has become the hallmark of applied medical anthropology. Anthropologists have made significant contributions

Applied AnthropologSr and Health and Medicine 127

to understanding the sociocultural basis of risky behaviors implicated in the spread of communicable diseases (Page and Tiotter lggg). For instance, in an effort to reduce the spread of HIV/AIDS, researchers at the Hispanic Health council in Hartford, connecticut, studied the cultural rules that shaped patterns of HIV/AIDS transmission. They interviewed men and women who used sex for income or as barter. They interviewed homeless women and men, sex workers, and others to learn if there were alternatives to sex exchange or if the use of condoms was an option in reducing trans- mission (Romero-Daza, Weeks, and Singer 2003). Although gender and eth- nicity were certainly categories considered in the research, the political variables that controlled access to resources, jobs options, and education were considered primary in their analysis.

Theoretica I Approaches The example from the Hispanic Health Council demonstrates what is

known in medical anthropology as a critical medical perspective. This approach focuses on class structure and access to resources and modes of production (Singer 1992; Baer t989). It brings together many of the con- cerns held by those studying health and medicine by looking at economic patterns and their distribution as related to socially constructed categories such as gender, class, and ethnicity. That is, the economic underpinnings of cultural systems and how they affect health and health care became an explicit focus of research (Singer et al. 1998; Morsy 1996; Whiteford l9g5). The political economy of health (Morsy 1996), or critical medical anthropor- ogy of health (Singer and Baer 1995), brings a more Marxist and political orientation to framing the research question. This framework pays explicit attention to dilferences in socioeconomic levels as they affect peoples' access to health care and economic resources. It focuses on the unequal distribu- tion of wealth and power as they affect health outcomes.

This is one of the several perspectives currently employed in the analysis of health and medicine. In addition to the critical medical perspective, the three other most frequently encountered are the ecological/evolutionary approach, the interpretive approach to health, and the clinically applied approach. In addition, consensus and cultural modeling is sometimes con- sidered a fifth approach. Each is associated with a central set of concepts that shape the research design, data analysis, and interpretation of findings.

The ecological/evolutionary approach emphasizes the biocultural syn- thesis between biological and environmental conditions (McElroy lg90; McElroy and Townsend l9tl9, 1996; Leatherman, Goodman, and Thomas 1993), employing the concept of adaptation as a key tool for analyzing the

t28 Applied Anthropologlr

interactions. In m:rnv ways, this approach is a direct descendent of the writ- ings of Dubos and others in the early history of the subdiscipline. In con- temporary medical anthropology, some biocultural research focuses on microevolutionary processes within the context of particular and changing environments. Studies of malaria and sickle cell anemia are good examples of the gains from such an approach (Frisancho 1981).

The interpretive approach, sometimes referred to as the constructivist appr<lach, Lakes as key ideas that experiences of health and illness are culturally constructed and their interpretation may include the experiences of the suf- ferers themselves. Those experiences can only be understood by recourse to the cultural assumptions from which they emerge (Scheper-Hughes and Lock l!)87; Kleinman, Das, and Lock 1997).

Any one of these approaches may be utilized in applied and clinical set- tings. Somc anthropologists place clinical medical anthropology in a cate- gory separate from applied anthropology, just as others conceptualize epidemiology as a separate theoretical perspective, distinct from applied anthropology. We see each as a cluster of techniques used in the application of medical anthropological theories and practice. Epidemiology (the study of the determinants and distribution of disease) comprises concepts and methods that can usefully be employed in conjunction with anthropological theories and applied to medicine and health. Although medical anthropol- ogy is strengthened by attending to epidemiologrcal data, epidemiology without the encompassing cultural context is quite limited and often results in misleading conclusions. In order to truly understand disease within its behavioral, cultural, social, political, economic, and environmental milieus, it is essential to look beyond epidemiologcal data.

Cultural models and consensus theory is also used in medical anthropol- ogy to investigate the relationship between peoples' cognitive models and health statuses (Weller and Romney lgtttt). Cultural models are frameworks designcd to represent how people think about something in particular, for instance high blood pressure, diabetes, or other health problems (Dressler l9{)6a, l1)9(ib). Consensus theory is based on the assumption thar if a certain level of agreement is achieved about the model of disease causation (a con- sensus), then the constructed model is an accurate reflection of the cultural beliefs of the group. In the cultural model approach, data are collected as responses to questions posed to cultural representatives, rather than exclu- sively based upon observations of behavior.

In all these approaches, a concern with ethics and ethical conduct is cen- tral, and thus, ethical issues have come into mainstream applied medical anthropology discussions. Federally mandated lnstitutional Review Boards (lRBs) began in the 1970s to review research proposals in an attempt to pro-

Applierl Anthropology and Health nnd Medicine 129

tect research subjects. Initially, IRBs were established to protect research subjects from possible untoward effects of clinical medical research; how- ever, most universities now mandate that research proposals involving humans bc approved by their institutional review board. Applied medical anthropologists using patient medical records, for instance, must demon- strate they have secured permission from both the medical institution and the patient. In addition, researchers must devise measures to ensure that patient confidentiality is protected. Research among people who are dis- ablcd, very young, elderly, or in some way considered to be members of vulnerable goups must be conducted in such a way that the subjects are protected.

Likewise, many activities of interest to applied medical anthropologists c<luld put either the researcher or the subject in legal danger. Interviews, for instance, on barriers to medical care for immigrants are fraught with difficul- ties because of potential recriminations if the person being interviewed does not have the necessary legal status or could lose his or her rights to medical care. Researchers who observe illegal activities while studying homelessness must take steps to protect subjects involved as well as themselves.

Anthropologists in academia, as well as those practicing anthropology outside of its confines, are faced with difficult questions: Do universal ethical standards exist? Are all values situationally and culturally relative, or are there some absolute values? They question the ethics of selling human organs, of selling human knowledge, and even of selling, trading, or borrow- ing cultural traditions (Marshall and Daar 2000). Professional organizations such as the Society for Applied Anthropology (SfAA) and the American Anthropological Association (AAA) developed codes or guidelines for the ethical practice of anthropolog/, but infringement of these codes carries few professional consequences. Although these codes are desig'ned to cover the practices of all anthropologists, some would argue that the research con- ducted by medical anthropologists might be more intrusive than other anthropological research because it often deals with biological materials or practices.

Anthropologists specializing in ethics, such as Patricia Marshall (Marshall and l)aar 2000), ask whether, for instance, the international proliferation of human tissue "gi[ts" will change the way we conceptualize both gift and exchange if human organs are the commodity of use. Other themes in the field question the ethics of using people for research to enhance the knowl- edge of the discipline, and some seek ways to protect people from being used by anthropologrsts for career development. Codes of ethics, IRBs, and federal policy concerning the Protection of Human Subjects are all designed to reduce the endangerment of people being studied.Justice, equity, respect

F

r30 Applied Anthropologlr

for diversity, autonomy of decisions, and a commitment to the leveling of the playing field for all participanrs are key ethical issues (Whireford 2000).

How ls All This Applied? This quick review of some of the history and trends in medical anthropol-

ogy begs the question: How is this research applied? We know applied med- ical anthropologists are policymakers and advisors. We know them as administrators and practitioners. we know they work as consultants and advocates. In each of those roles, they apply principles and theories from anthropology to data generated using medical anthropological methods. And they are all engaged in the resolution of human social problems, such as improving access to medical care for the disenfranchised, alerting the public through careful research to the hidden inequities brought about by racial, ethnic, and gender prejudices, and reflecting critically on the unob- served status quo.

As we suggested at the beginning of this chapter, we see all medical anthropologrcal research as having applied components; however, some- times they need to be made more explicit. we began by identifying three seminal works, each embodying a concept that has become central to applied medical anthropology: Ben Paul's use of a systems model, Rene Dubos's development of the concept of the biocultural synthesis, and charles Leslie's use of a comparative framework. Each of these concepts (although not necessarily simultaneously) provides a bridge between research and application. They allow research in medical anthropology to be applied in the development of health care policy, practice, and programs. Jordan's work (1978, 1997) helped transform birthing practices in the United States; it gave a rationale for birthing rooms in hospitals, increased the use of midwives, gave people permission to employ a variety of physical positions during labor and birth, and changed hospital policies ro allow family mem- bers to be present during the birth.

Likewise, Paul Farmer's eloquent indictment of the use of brame and ste- reotyping to associate HIV/AIDS with a particular group of people contrib- uted to a reevaluation of hospital admission policies (Farmer lgug, lgg2, 1999). Medical anthropology was also applied to uncover policies that dou- bly disenfranchised drug-using pregnanr women, by both purting them in jail immediately following the birth and separating them from their new- borns. Medical anthropology research brought to light the unequal applica- tion of the maternal drug-screening policy and the harm being done to poor women and their babies (whiteford and vitucci lggT). public concern later resulted in the policy being challenged and changed. Both Myra Bluebond-

Applied AnthropologSr and Health and Medicine l3 t

Langer's (1978) andJill Korbin's (1981) work with dying and chronically ill children, which demonstrated the need for the children to be included in medical decision making, changed hospital policies about children's rights and their roles in being able to make decisions about their care. Whether the topic is HIV/AIDS, children's mental health, spouse abuse, or community participation in medical care, the work of applied medical anthropologists is often used to make a difference. It does so by documenting patient and prac- titioner experiences; assessing systems of care; contextualizing medicine in its personal, political, and economic frameworks; and finding patterns where none were found before.

Policymakers (and their legislative aides) are not the only group that ben- efits from the application of medical anthropological research. Practitioners such as social workers, addiction counselors, nurses, and physicians use anthropologists to help them reach and treat their clientele more effectively. Anthropologists like Michael Agar (1973, 1980, 1996; Agar, Underwood, and Woolard l9tll), Merrill Singer (1992, 1996, 1999, 2000), and Robert Tiotter (Tiotter, Bowen, and Potter 1995) and others have all found that their research on alcohol, heroin, and other addictions has been used by policy- makers and practitioners alike. Some populations are particularly difficult for social service providers to reach and are often invisible to the public. For example, homeless people or domestic violence victims have been made visible through the work of medical anthropologists like Kim Hopper (1988, 1990, l99l) orJay Sokolovsky (1993, 1997a, 1997b). By making these invisi- ble groups visible, anthropologists help make programs and policies take them into account.

Applied medical anthropology shares a natural affinity with public health. The work of medical anthropologists is used in both public health classrooms and agencies. For instance, the work ofJeannine Coreil used cognitive or deci- sion-making models and helped to design therapeutic interventions like self- help groups for filariasis sufferers in Haiti (2004). Holly Mathews conducted a decision analysis of social support mechanisms for women with breast cancer in the United States (1987, 1990, 1998). Some medical anthropology research is designed specifically to be used by policymakers. Carol Bryant's research on the U.S. federal Women,Infants, and Children (WIC) program (1993,2001), for instance, used focus groups to gather women's perceptions of its uses and limitations. The research resulted in a revitalization of that program nation- wide. Her work combined careful analysis of the policies, services, and prac- tices in the WIC programs she studied, illuminated by the women's words and descriptions that were gathered during focus groups. Their voices captured and amplified the research findings generated by the analysis of programs and policies, resulting in real and measurable policy changes.

t32 Applied AnthropologSr

Areas of Current tnterest As we have emphasized,-conremporary applied medical anthropologists

continue the legacy of Ben paur, Rene Dubos, and charres Leslie by focus- ing on cultural systems, using a biocultural perspective, or employing com_ parative analysis in their research. often medical anthropologists focus on the interplay of culture and biology on life stages; the effects of-sociocurtural categories like gender, race, and ethnicity on the distribution and treatment of disease; and factors accounting for the emergence and reemergence of infectious and contagious diseases such as maluria, dengue fever,"sh61sr., tuberculosis, and HIV/AIDS.

The HIV/AIDS epidemic provides both an impetus and urgency fbr applied medical anthroporogists to work toward prevention by unierstand- ing behavior within its politicar, economic, and medicar c.ntexts. The epi- demic has made it clear that no magic vaccine is going t' contror its spread. Even if such a vaccine were avairable, the costs of pro,riding it t. ail the peo- ple at risk would be prohibitive; therefore, ,rher ways hale to be found to control the disease. The key is to understand the beliefs that underlie the behaviors implicated in the spread of the disease (Ferdman lgg5, 19g6, 191)0a; Singer 1992, 199(i; touer et al. 2000).

what Evans-Pritchard and Rivers noriced i. the early 1900s is still true a century later. Behaviors are embedded in larger and nrore encompassing belief systenrs, and to understand the behaviors, we must study the rarger cultural system. AIDS researchers found that behaviors associated with high risks of negative outcomes (i.e., unprotected sex or sharing needres increases the chance of spreading HIV/AIDS) are extremely diffic*urt to change with- out understanding how those behaviors fit and-in some sense-!.ouide positive outcomes within a larger set of options, alternatives, and risks (Ferd- man 19u5, 1990b; Singer lgg2, lggti; Tiouer er al. 2000). Intervenrion poli- cies that fail to recognize the rarger cognitive rures of the intended population lail to reach the intended population.

Medical anthropology is also applied through program assessments and evaluations, program a1j qolicy monitoring, and pol-icy development and advocacy. Partners in Health (pIH), un NGO organized by Iraul Farmer and others, epitomizes hou, applied medical u',thropolrgy can be effec_ tive.ly used in advocacy research. Farmer, an anth.oporogis"i u'd physician, both practices medicine and applies anthrop'logy Uy U"ing on the grouna with local people in clinics in Haiti, I'eru, Russia, a'd

-cuba. Simurta-

neously, PIH works to understand the larger grobar politicar a.d econonric picture that shapes those rocal rearities (Fa.nrer lggg, lgg2, 20t)r). The work by PIH and Farmer crearry and eroquentry situates disease in the con-

Applied Anthropologlr and Health and Medicine t33

text of disparities and inequalities. Co-morbid diseases, such as HIV/AIDS and tuberculosis (TB), exist in conjunction with prejudice and poverty. Advocates like Farmer and PIH give life and leadership to the fight for jus- tice and equity by applying medical anthropology on a global scale.

Infectious and contagious diseases like HIV/AIDS and TB attract the attention of applied medical anthropologists, as do diseases once thought to be controlled and almost eradicated. The spread of malaria and dengue fever continues to increase, both in the number of cases and also in its geo- graphic range (Brown 1997, 1998; Whiteford 1997; Coreil 1997). Like HIV/ AIDS, both malaria and dengue fever have no vaccine, and such prevention is unlikely to be developed. Unlike HIV/AIDS, malaria and dengue fever rarely result in death but, rather, they result in prolonged poor health and increased susceptibility to other diseases. The primary hope in controlling HIV/AIDS, malaria, dengue, and other infectious diseases lies in our ability to understand peoples' beliefs and practices that are implicated in the spread of these diseases.

Just as life stages, biocultural categories, and infectious and contagious diseases have drawn applied medical anthropologists' interest, chronic dis- eases like heart disease, hypertension (Dressler 1996a, 1996b; Dressler, Baliero, and Dos Santos 1997), and diabetes (Weller et al. 1993; Weller and Baer 2001)are all areas in which anthropologists and clinical researchers are currently working together. Dressler has been working for almost two decades with his Brazilian counterparts-a team that includes physicians and social scientists-to understand relationships among cultural models, lifestyles, hypertension, and heart disease. His work has furthered our understanding of the theory and methods behind consensus modeling and chronic disease research.

Alcohol and drug addiction continues to be a major area of applied med- ical research with many anthropologists actively engaged in understanding the cultural construction of addiction (Bennett and Ames l9fl5; Douglas 1990; Eber ll)95; Heath 2000; MacAndrew and Edgerton l9(i9; Marshall le79).

Case Study: The Disease Concept of Alcoholism Medical anthropologists, in particular, have contributed to the debate on

the disease concept of alcoholism. What exactly is meant by the disease con- cept of alcoholism or addiction more generally? When people attribute the etiology, devel<lpment, or expression of alcoholism to biological factors, they are articulating this concept. Arthur Kleinman's work helps put this somewhat specific idea into a broader theoretical framework. When Kleinman published Patients and Healers in the Context of Culture in l9tl0,

r34 Applied Anthropologlr

he articulated a theoretical dichotomy in medical anthropology between ill- ness and disease within the overall phenomenon of sickness: "Drjeass refers to a malfunctioning of biological and,/or psychological processes, while the terrn illness refers to the psychosocial experience and meaning of perceived disease" (11)tt0, 72). Kleinman submiued this distinction as an ideal dichot- omy, not necessarily as reality. He noted that professional practitioners, such as physicians, are more oriented toward viewing sickness as a disease, whereas nonprofessional practitioners tend to be more inclined toward the illness perspective. He observed that for chronic disorders, such as alcohol- ism, it can be particularly difficult to distinguish between illness and disease. As this case study demonstrates, one's orientation can be critical for construct- ing an understanding of the source, course, and treatment of alcohorism.

Noel chrisman (l9tt5) focused precisely on the question of whether alco- holism is an illness or a disease. He referred to the earlier writing of Horatio l'abrega Jr., who defined disease as "altered body states or processes that dcviate frorn norms as established by western biomedical science" (1972, 213). Similarly, Leon Eisenberg rook the position that *patients suffer ,ill- nesses'; physicians diagnose and treat'diseases"' (ll)77, ll). In considering alcoholism, chrisman observed that *neither alcoholism as an illness nor as a disease is well defined" within the biomedical health culture (lgtts, l4). A long-standing debate revolves around issues such as the role of psychosocial versus genetic factors in the susceptibility of certain individuals to alcohol- ism. chrisman noted that the psychosocial and biorogrcal complexity of alcoholism has made it very difficult to arrive at any consensus about the specific factors that "cause" alcoholism. He also observed that because there is no consensus about the disease/illncss dichotomy of alcciholism, health practitioners diagnose and treat alcoholism in a variety of ways. In other words, they take particular approaches that are congruent with their world- view of alcoholism. These approaches include the moral, social, spiritual, and biological (l9tt5, 15).

The moral-medical model of alcoholism has provoked lively and relevant discussion to which anthropologists and sociohrgists, in particular, have con- tributed. In addressing American beliefs about alcoholism, Genevieve Ames reviews the history of the moral-medical model (lgti5) that is particularly relevant to our understanding of the etiology, course, and treatnrent of alco- holism. Ames noted that in the disease concept, alcoholism is vierved as a progressive disease that can be divided into symptomatic phases. The pri- mary distinction between being an alcoholic and a nonalcoholic is the stage rvhen the drinker loses control of alcoholic beverage consumption. In con- trast to the moral model prominent du'ing the temperance and prohibition eras in the early twentieth century, in which drinkers were deemed responsi-

Applied Anthropologilt and Health and Medicine r35

ble for their drinking and its consequences, the medical model evolved after World War II as medical professionals and alcohologists depicted alcohol- ism as a series of stepping stone experiences with alcoholic beverage con- sumption (Jellenik 1952, 1960). This shift in thinking about alcoholism still does not have full support across the United States, but alcoholism has become viewed less and less as a sign of moral weakness. This shift could be heralded as a positive development in the public mindset toward dealing effectively with alcoholism. Working clinically with alcoholics from a medi- cal (or disease) perspective, for example, can relieve them from at least some of the blame of their addiction.

Or does it really work that way? From the perspective of American fami- lies living with an alcoholic parent, accountability for the alcoholism is com- plicated (Bennett l1)95). This study asked how family members incorporated the concepts of illness versus disease and the moral versus medical model into their comprehension and explanation of alcoholism. Drawing on a sub- set of ten alcoholic families interviewed in a study of family cultural influ- ences on the well-being of school age children, Bennett examined the interview transcripts f<rr sLatements about accountability for alcoholism. These statements, as glimpses of worldviews, were organized into three d<,rmains: causes, forms, and consequences o[ alcoholism. Three other con- cepts are important to consider: shame, guilt, and blame. These are com- mon emotional responses to "irresponsibility" around drinking and drinking-related behavior. Such emotional responses are more likely to emerge in families rvhen the alcoholic and family members subscribe to a moral model of alcoholism rather than a medical model. At the other end of the spectrum, if thc family endorses the medical model, the alcoholic and the family are much less likely to feel or express shame, guilt, or blame. However, if the alcoholic does not find a way to resolve the problem, such emotional rcactions are more likely to emerge. AII ten families studied evi- denced all three of these emotions in their attempts to resolve the question of who or what was responsible for the alcoholism.

Iieyond this generalization, though, there was wide variation among the families and family members about these emotions. With regard to the cause, or etiology, of alcoholism, no one interviewed suggested that its eti- ology was biological or genetic. Instead, these were the five most often noted precipitating influences: (l) family pressure to drink or not drink; (2) traumatic life events; (3) occupational situation; (4) emoti<lnal problems in the family; and (5) loving alcohol. This final influence is the one that is rnost likely to connect with the disease/biological/genetic causation. Among all fanrilies interviewed, however, "I loved the stuff from the start" was a rare response. One particular impetus to drink came from the wider

136 Applied Anthropologlr

political-social context: the Vietnam War. Wartime experiences repeatedly came to the fore in discussions with one couple, who identified this as the time when the husband began drinking with a vengeance: "Vietnam changes the life of everyone who goes through it. I don't suppose I am the same person I was before I went over. It nrade indelible changes in my psyche. A lot of drunks came back from Vietnam" (author's fieldnotes, n.d.)

Contrary to the opinion that alcoholics and their families spend much of their lives in denial about alcoholism, it is tnore accurate to see them as using various cog'nitive and behavioral strategies to grapple with the prob- lem and resolve it. Understanding this is important for designing effective intervention strategies for families with alcoholism. Relating the emic per- spectives of these husbands and wives in trying to account for the cause of alcoholism, Bennett concluded that they clearly draw upon an illness rather than a disease model. They tend to view alcoholism neither as a moral nor as a medical phenomenon in terms of its etiology. However, in attempting to find a solulion to the problem, they do expect the alcoholic, with the help o[ others, trl resolve the problem. At this point, the *sickness" of alcoholism is still regarded in Kleinman's terms as an illness, but if no solution is reached, the family begins to regard alcoholism and the alcoholic in moral terms.

The following quote shorvs the complexity of one wife's understanding of her husband's lifelong extremely heavy drinking and how she tries to encompass the disease concept within her understanding:

With drinking, you get to the point of saturation where you can't do anything about it, and it's affecting your life so much you try to push it away. There is only so much you can take, and then you don't want any more part of it. I've known for a fevv years that alcoholism is a dis- ease, but the thing is how long can you live with a disease and go along as if it's all right. There is a point you get to and then, the hell with it, I've had enough and want no part of it because the disease is getting lo you lhet (Bennett 1995, 17)

This woman's struggle to comprehend alcoholism demonstrates the impor- tance of taking a biocultural perspective in research on addictions.

In addition to studying topics like birth and reproduction, chronic and contagious diseases, and alcohol and drug abuse, two others areas stand out as examples of applied medical research: ethnomedicine and health systems analysis. Finerman and Sackett (2003) demonstrated, for example, how eth- nomedicine and traditional curing remain embedded in contemporary [am- ily health in the Ecuadorian Andes. Their m()st recent study revealed that most plants grown in Saraguro home gardens are intended for medicinal

Applied AnthropologSt and Health and Medicine 137

application and that the selection of healing herbs cultivated in gardens is

tailored to suit the unique health needs of the household, Kedia and van

Willigen (2001) provided an example of the place of the health system within the broader sociopolitical system of India. Specifically, they exam-

ined the impact of forced population displacement (due to building hydro

electric dams) on the mental health of older people living in Northern India.

Methods Used by Applied Medical Anthropologists in Studying Health and Medicine

Applied medical anthropologists have found a number of ways to study

health and medicine, relying on the traditional anthropological toolkit of

techniques employed in ethnographic studies, such as participant observa- tion, surveys, and oral histories (Angrosino 1987, 1989, 2002; LeCompte

and Schensul 1999a, 1999b; LeCompte et al. 1999). But they have also developed new methodologies like rapid appraisal (RAP) (Scrimshaw and

Hurtado l9tl7), community elicitation, and network models (Tiotter et al.

20{)t)). RAPs were designed to be used in community health appraisals, and

they require shorter periods of fieldwork. RAPs often involve both commu-

nity members and people from outside of the community to design ques- tions that elicit responses about illness categories and locally specific names.

This is a critical step in being able to discuss health and illness beliefs and

practices using locally appropriate words. The use of local terminology allows people to speak comfortably and allows researchers to learn names of

illnesses, diagnoses, and treatment modes. Rapid research techniques have

been f<rund to be effective ways to collect basic information for many appli-

cations to medical anthropology, including designing health care Programs' especially in primary health areas (Pelto and Pelto 1996). Scrimshaw and Hurtado (l9tt7) developed the Rapid Assessment hocedures manual to be used

in evaluating health care programs and nutrition Programs. By using the RAP approach, they found that "[a] great deal of practical, diagnostic, and

applied work can be accomplished in a shorter time by using a simple approach'(l9tl7, l).

Applied medical anthropologists train in the theories and methods of tra-

ditional anthropology but then superimpose or integrate methods derived

from other disciplines to expand their toolkits. Epidemiology, which we defined earlier as the study of the determinants and distribution of disease,

provides population-based data on who is getting sick, what groups of peo-

ple are sick, and locations where people got sick, and who is getting well'

Although there are valuable discussions about the application of epidemio-

logical techniques to anthropology research (McCombie 1990), some

r

138 Applied AnthropologSt

applied medical anthropologists (Janes, Stall, and Gifford 1986; Tiostle 1986; Tiostle and Sommerfeld 1996; Yacoob and Whiteford 1995) appear to have found them useful. They used epidemiology to provide a measurable set of indicators from data gathered on a large scale, with specific ranges of time and space, within which to contextualize ethnographic analysis.

Focus group research also has become a popular and useful technique for gathering information about identified themes, and at least one university provides a biannual conference on focus group research and application. Earlier we mentioned Carol Bryant's work using focus groups to gather col- loquial terms and ideas about particular topics, which enabled her to use that initial set of interacticlns to shape further research. Sometinres focus groups are used to teach the researcher what the target population thinks about a product or a program. Once the focus groups are completed, that data can be used to shape questionnaires or other research instruments to gather larger numbers of responses.

Oral history techniques, although not unique to applied medical anthro- pology, have been used effectively to understand the experience of being disabled (Frank 1980, 2000), the kinds o[ personal interactions people have with health care professionals (M. H. Becker 1974) and living with stigma- tized conditions such as infertility (G. Becker 1990; Sandelorvski 19911). An oral history might entail soliciting informati<>n about a person's personal experience and perspectives on a specific health issue. By collecting oral his- tories from different people with varying viewpoints about a common health problem, we reach a better understanding of complex health problems.

The lntegration of Theory, Concepts, and Methods Applied medical anthropologists have contributed to our understanding

of health and medicine in a variety of ways: by contributing to interdiscipli- nary, collaborative investigations of health problems, by applying theoreti- cal models from anthropology to medical s)'stems, and by incorporating ethnogr-aphic and other anthropological methods to global problems. The biocultural perspective, in particular, of'fers significant advances over less inclusive analyses of health. The foll<lwing case study is an example of how applied medical anthropological research uses the concepts, research meth- ods, and theories to work with a community to desig'n an appropriate and long-lasting intervention.

Case Study: Cholera Epidemic in Ecuador This case study exemplifies how interdisciplinary and collaborative

research using traditional anthropologrcal field methods, along with focus

Applied Anthropologlr and Health and Medicine 139

groups and epidemiological record reviews, pr<lvided critical and practical insights into understanding the transmission of cholera in two rural Andean states during the 1990s cholera epidemic in South America.

In March 1991, the El Tor cholera pandemic hit Ecuador. By the time it began to subside 2.1 months later, more that 85,000 cases of cholera had been identified, almost 1,000 people had died, and many more cases had gone undiagnosed. Cholera is caused by water-borne bacteria, making com- munities with unreliable or insecure water supplies the most vulnerable to and at risk for the disease. Indeed, epidemiological data showed that fully ttO percent of the cases in Ecuador came from a corner of the country with the poorest and most marginalized citizens. Within months of the onset of the epidemic, the Ecuadorian Ministry of Health (MOH), along with the Pan American Health Organization (PAHO), WHO, and other international governmental and nongovernmental aid organizations, had successfully reduced the transmission, particularly in urban areas, through health educa- tion campaigns and improved access to water and sanitary facilities.

In the rural areas mostly populated by indigenous groups, the epidemic continued unabated. In an attempt to break the chain of transmission in the rural areas, the MOH requested aid lrom a variety of international aid donors; one was USAID, which contracted with the Environmental Health Project (EHP) to undertake an in-depth investigation of cholera-related behaviors in the communities at greatest risk of contracting and continuing the spread of the disease. An international, interdisciplinary team, which included an applied medical anthropologist, a physician/epidemiologist, and a community educator, was brought to the project. The aim of the project was the development and implementation of what came to be named the Community Participatory Intervention (CPI) model, based on the following assumptions: (l) Members of the community needed to lead the community in its fight against the disease-the fight had to be a grass- roots movement; (2) simultaneously, local concepts of risk, disease and health, as well as local beliefs and behaviors had to be elicited; (3) biological information about the disease vectors and environment needed to be shared; and finally, (4) a culturally appropriate, locally designed, and region- ally sustainable intervention had to be agreed upon.

The research and implementation took place over an l8-month period in four rural communities in the two Andean states with the highest cholera rates. Using an ecological framework, the project gathered information about water resources, land tenure patterns, community organization, health statistics, and the regional public health system. Ethnographic techniques were used to train local participants to elicit community terms and catego- ries related to health beliefs and behaviors implicated in oral and fecal

140 Applied Anthropologlr

transmissions. Participatory teams were recruited from local communities; regional multidisciplinary teams were brought together from regional health and educational agencies. The MOH coordinated the activities.

within a year of the implementation of the cpl model, the number of new cholera cases in the research sites dropped drastically (from 32,430 cases in 1992 to only ti,tt83 cases in lg93). And the reductions were sus- tained. Equally important, the rates of other water-borne diseases dropped significantly and the reduction was sustained. Two years (and even ten years) later, some of the participants trained in the cpl model were still local health advocates, and the model implementation sites demonstrated lower water-borne infection rates than did neighboring communities and states where the cPI model was not implemented. Not only did water-borne infec- tious disease rates drop, but local leadership was also developed as part of the CPI n'rodel.

why did the cPI model work? It worked because the participating com- munities were anxious for relief from the visible and often deadly threat of cholera. when the project began, almost every househord in the study com- munities had lost someone, and everyone knew someone who had died from cholera; people were very motivated. But the model also actively vali- dated local knowledge and local understandings of the threats-from cholera as well as from other sources-that people perceived in their surroundings. This validation of local beliefs, in conjunction with the incorporation of new inlormation about disease vectors, provided local inhabitants with means to combat cholera.

The model worked because, although the focus was oir cholera, it was not an exclusive focus. other foci were brought to light by ethnographic inter- views and team members'experiences. It worked because it followed commu- nity-based research with community-determined actions and interventions. creative health education and leadership training were not the only means used to combat cholera. The locally desi5'ned intervention combined com- munity leadership, new information about disease transmission, and a commitment from the community to participate. New, closed water con- tainers kept hands from dipping into them. The containers also had a spigot that could be easily cleaned. Locally available chtorine was used to disinfect water. Each of these factors shaped the outcome, and, with this combination, the project succeeded. communities beyond the original research site became so excited about the water containers and the partici- patory training that they also asked for the cpl process to be conducted in their community. Participants lrom the original intervention communities created a small group to train other communities, thereby spreading the intervention.

Applied AnthropologSr and Health and Medicine l4l

The CPI model succeeded on many levels. It was grounded in the local community but had support from regional, state, and national offices of the government. It trained local people in things they were interested in and concerned about. And the results were transferable to other communities, were locally sustainable, and resulted in national policy changes. As one Ecuadorian CPI team member noted, "People have been changed by partic- ipating in the project; before they were quiet, compliant, and unquestioning. Now they express their opinions, question others and feel they are right."

Future Directions The worldwide HIV/AIDS pandemic has brought into sharp focus the

need for social science researchers to work closely with medical researchers and forces us all to look at new ways to prevent the spread ofdisease and to understand thc underlying causes, not only the biological basis for disease but also the cultural conditions that enhance and accelerate it. HIV/AIDS is emblematic of but one of the consequences o[ unequal distribution of wealth and access to resources throughout the world.

Applied medical anthropologists have significant contributions to make in our understanding of disease prevention and to the reform of health care systems. Following the trajectory begun by Ben Paul and others, the systems approach directs medical anthropologists to identify the various pieces of a system and how they fit together and to consider how change in one ele- ment affects the entire system. In health care reform, this view is particularly critical because o[ the various and often competing perspectives, such as those of the clients, practitioners, and insurers-whether they are private or public. Governments throughout the world are struggling to provide health care in a privatizing world where not all voices are heard equally. Anthro- pologists have a role to play in providing data and analysis of these different system changes and their consequences.

The ability to conceptually bridge culture and biology (the biocultural synthesis) and its evolutionary basis are critical components of applied med- ical anthropology.Just as Dubos perhaps hoped, the vigorous subdiscipline continues in new and innovative directions largely because of its apprecia- tion for how culture and biology are inexorably intertwined. Addictions research, f<rr instance, demonstrates this meshing of boundaries between the cultural construction of disease and the physiological understanding of its expression.

Charles Leslie recently wrote that medical anthropology has cultivated a "humanistic interdisciplinary natural science tradition" (2001, 437). One would hope (and imagine) that the future of the discipline will continue that

142 Applied Anthropologlr

tradition. The future is harder to realize than to imagine, but we agree with Leslie that "most anthropologists have considered the discipline, and our recent subdisciplinary part of it, to be more than science. It has been a worldview, an occupation, a way of life, an entertainment, and . . . an exis- tential search for meaning" (2001, 437). Let us hope that students and others will continue to recognize the importance of the humanistic and scientific tradition of applied medical anthropologv.

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