Report of the workshop From Medical Pluralism to Medical Diversity?

Transcription

1 Report of the workshop From Medical Pluralism to Medical Diversity? On the 22 nd of June the MPI organized a brainstorming workshop on the topic: From Medical Pluralism to Medical Diversity?" Participants: Gabriele Alex Max Planck Institute for the Study of Religious and Ethnic Diversity, Department of Socio- Cultural Diversity Florian Besch Institute of Anthropology Göttingen, and South Asia Institute, Heidelberg Hans Jörg Dilger Free University Berlin, Institute of Social Anthropology Gill Green University of Essex, Department of Health & Human Sciences Viola Hörbst Centre of African Studies, Instituto Superior de Trabalho e Empresa, Lissabon University. Cor Hoffer GGZ Groep Europoort, Amsterdam Kristine Krause Humboldt University Berlin, Department of European Ethnology Harish Naraindas Jawaharlal Nehru University, Delhi, Centre for the Study of Social Systems, and South Asia Institute, Heidelberg Mark Nichter University of Arizona, Department of Anthropology Laurent Pordier French Institute Pondichery, and South Asia Institute, Heidelberg William Sax South Asia Institute, Heidelberg Angelika Wolf Free University Berlin, Institute of Social Anthropology 1

2 Introduction The goal of the workshop was to critically discuss the extent to which the concepts of diversity can enhance dicussions related to medical pluralism. We took the following premise as our starting point: The topic of Medical Pluralism the co-existence of diverse medical practices and forms of knowledge has long been a field of investigation within Medical Anthropology. But where earlier studies focused on how different healing resources and medical traditions in a given local context are utilised by patients and their therapy networks, research over the past few decades has moved into fields such as the professionalisation of traditional practitioners, competition amongst medical traditions in global health markets, the combination of different therapies in hospital settings, biodiversity and medicines as cultural heritage, the migration of medical experts, travelling knowledge practices, and the circulation of material medica within global networks. Discussion on diverse medical practices has identified a number of problems related to the conceptualisation of Medical Pluralism. The normative concept of pluralism relies on the idea that significant differences in a given social field can be governed through an institutionalised politics of recognition. Transferred to the context of medical knowledge, the notion of medical pluralism presupposes the equal coexistence of medical traditions and tends to obscure hierarchical positioning and conflict between different practices. From this perspective then, the existing power geometry between medical institutions, states, and international bodies, may be too readily overlooked. In recent years, studies have demonstrated that medical knowledge and practices are becoming more diverse internally, and that the boundaries between them are not as clear-cut as the discourse about systems would suggest. Instead of lazily assuming the existence of such boundaries, it seems there is more of interest to be gleaned through an exploration of when and how such boundaries are drawn, reinforced, or crossed. Taking the politically vested interests between different medical disciplines into account, scholars have made a strong case for looking at the terms medical pluralism and traditional or modern medicine as objects of study in their own right, since they form part of the field of enquiry. The idea of medical systems, which underlies much of the literature on medical pluralism, is another contentious area. Although a focus on the systemic character of codified medical knowledge in written sources other than biomedical textbooks has been an important contribution to the debate, the concept of systems reproduces the epistemology of biomedicine and perpetuates a tendency to construct single, bounded entities. The constant interchange and mutual influence of medical traditions, across both geographical and cultural space, the overlapping character of different medical practices, the latticed knowledge of medical experts, the interwoven appropriations of patients in the process of undergoing sickness and seeking cure such phenomena are inherently resistant to representation through the concept of systems. The aim of the workshop was to bring together different regional and topical expertise so as to revisit these debates on Medical Pluralism. Our intention was to create a dialogue between thematically and theoretically differing research strands within Medical Anthropology, such as religious healing, biodiversity, new medical technologies, and new theories on materiality. 2

3 Based on this exchange, we invited participants to critically interrogate the extent to which the notion of diversity permits a refocusing of the debate. Format of the workshop The format of the brainstorming workshop enabled the participants to work in smaller groups on specific questions and topics that were then discussed in general meetings. We were specifically interested in the multiple configurations of medical diversity, how these have been shaped and defined, how they have been or could be governed, how patterns and images of medical diversity emerge and change. The aims of the workshop were: To revisit the debate on medical pluralism, To identify crucial issues, To create dialogue between different regional expertise and theoretical approaches, To critically evaluate the surplus of a diversity perspective, To build up a future perspective: to develop theoretical concepts and to scope out fields of innovative empiral research. Outcomes: The workshop focused on three broad themes that were discussed in smaller groups: Governance, Representation, and Inequality. 1. Governance What do we mean by Governance? Nation-states combine forces with trans-state bodies and professional associations to achieve global public health, and to develop diagnostic criteria and manuals in order to standardise medical knowledge. The legislative function of states is also important with regard to health-related laws that aim to ensure an equality of access to health, and the standardisation of medical procedures, as well as the introduction of pharmaceuticals into national markets, the recognition of degrees and certificates, and so on. The coexistence of different medical practices and traditions should be assessed, then, with reference to the regulations of these nation-state and trans-state legal and structural frameworks. Medical knowledge is controlled and organized through these procedures and institutions, and is at the same time built into governing practices. At the level of patients and clients, these governing practices concern the production of identities through diagnosis and the consumption of medicines, as well as access to health care and the rights associated with 3

4 it. In these ways, medical diagnosis may be seen to reaffirm discrimination whilst simultaneously affording the subject a position to speak from, and thus as a link to a broader political sphere. The following points emerged from the workshop: The role of the state in health care delivery is changing, partly due to global stakeholders (NGOs, development organisations, religious organisations), which have become part of the national and international health care arena. At the same time, health care is taking place from below, citizens are responsible for their good health, health becomes the resonsibility of the individual. The co-existence of different practices, regulation, non-disciplined practitioners, insurances, takes place within different layers of governance. Participants remarked critically that diversity is a term that is itself used for governance purposes: Populations, people, and medical properties are are catregorised in order to chart differences. Any further thinking about "medical diversity" has to keep the affinity with these kinds of discourses in mind. 2. Politics of Representation Medical knowledge practices produce meaning, forming a part of local histories, cultural representations, ethnic and religious identities, and political affiliations and representations. This is reflected in the fact that medical diversity, when conceived as part of a wider cultural heritage, may be made a part of cultural diversity programmes protected under state and transstate laws. Minority groups claiming that particular healing resources, for example plants, and treatment practices, are part of their specific heritage, can use these cultural properties as a tool to aid their striving towards self-determination in the face of obstructive state authorities. Discourses concerning health and policy with respect to life, death, and human bodies (abortion, euthanasia, stem cells) are embedded in various other authoritative political, cultural, and religious self-representations, which produce and reflect moral values and notions of rationality. The preferencing of specific medical products and forms of treatment is bound up with other forms of identity politics, and may not only reinforce but even go so far as to generate them. 4

5 The crucial question emerging from the workshop was: Who are the actors and what are the modes of representation, and how do they relate to each other? 3. Social Reproduction and Inequality The relationship between medical diversity and issues of social reproduction and inequality has many aspects, ranging from hierarchical relations and processes of exclusion between or within medical knowledge traditions to inequality of access to healthcare to states of well-being. The consumption of medicines and the preferencing of specific medical traditions can be regarded as a practice of social distinction and social reproduction, where issues of representation and habitus may be observed and studied. Although one's state of health (e.g. disablement) or a medical diagnosis (e.g. infectious disease) may serve to reinforce exclusion from social participation, it may also provide a basis for claiming support and compensation (biological and therapeutic citizenship). A diversity perspective enables analysis as to whether multiple factors, such as gender, race, class, sexual orientation, and lifestyle, contribute to processes of exclusion and participation in health care provision. During the workshop it emerged that access is a central theme when discussing inequality. The questions are: Access to what, for whom, for whose benefit? Usually it is assumed that problematising access means access to biomedical care. - How about access to non-medical practices? - How about access of different actors to the health market? (consumers, pharmaceutical companies, patients) If we widen the notion of access we might also ask about access not only in case of sickness but access to well-being in general. 5

6 Final Discussion The leading questions for the final discussion were: Is medical diversity a more useful term than medical pluralism? Is it old wine in new bottles or does it offer an innovative perspective? The multivocal statements of participants can be summarised as such: General remarks: Historical perspective: Diversity is nothing new Diversity should not be conflated with heterogeneity Concept system is politically important Diversity needs to be understood as relational term Medical practices are part of political struggle Diversity is an important notion on political agendas Although it is crucial to look at internal diversity, it is equally important to ask: what unifies practices? Diversity perspective should include diversification within biomedicine Technologies create diversification Economics and financing behind medical diversity Diversity in health financing: social security arrangements Medical traditions are embedded in and influenced by identity politics Diversity perspective can be helpful for focusing on crosscutting and intersecting markers of difference Diversity within global health market is pushed to organise around commonalities because of pan-epidemics (biosecurity) Diversity perspective needs to employ disaggregated notion of state Medical diversity is a useful concept because: - it does not pin medicine down to system or place, it gives a new kind of lens, another kind of lever - it takes account of new developments like medical tourism - diversity is important on the political agenda and has become a management strategy, also in the field of medicine, health and curing - new technologies produce new diversifications - diversity catches the processual character of heterogeneity, whereas pluralism has a rather cemented stance For further investigation it would be interesting to look at ethnic diversity and medical diversity, especially under the following aspects: - Health citizenship - Access - Payment - Insurance - Exclusion 6

7 It can be a problematic concept because it reifies difference and is part of racialised politics and governance strategies: - Danger that diversity perspective wants to include too much - How can we guarantee particular local histories? - What is baggage of term diversity? Modernization paradigm? Neoliberal turn? - When and how and for whose benefit do differences become important? Final remarks The brainstorming workshop stimulated an interesting debate and scoped out the field of medical diversity in a very fruitful way. We are looking forward to the next event, which will take place in February