The latest issue of The Lancet features a large section on asthma which includes a wonderful short essay by medical anthropologist Ian Whitmarsh, titled “Asthma and the value of contradictions.” Whitmarsh, who is an assistant professor in the Department of Anthropology, History and Social Medicine at UCSF, recently published a monograph based on his fieldwork following a genetics-of-asthma study carried out in Barbados, Biomedical ambiguity: race, asthma, and the contested meaning of genetic research in the Caribbean (Cornell UP, 2008).
In the Lancet piece, Whitmarsh reflects more broadly on the etiological and diagnostic ambiguities of asthma, giving a brief history of the varied accounts and interventions that have surrounded asthma over the past century or so:
“[D]iscordance has historically been foundational to the category of asthma in British and American medical research. Since the end of the 19th century, asthma has been viewed as neurosis or physiological predisposition; caused by dust, pollution, heredity, parental emotions, the unclean modern home (carpets harbouring dust mites), or the continually cleaned modern home (underexposure to infections); and treated with stimulants and depressants, dieting, steroids, and various tonics. Yet despite this diversity, what is striking about modern medicine’s approach to asthma is not the plurality of definitions, causes, and diagnostic techniques, but rather the attempt to reduce this plurality,” (Whitmarsh 2010).
Whitmarsh notes that issues of categorization carry over into clinical settings in a deeply significant way:
“The process of consuming asthma treatments from the doctor is a translation of medical meanings and practices. In this context, taking (or not taking) the inhaled steroid may reflect a patient’s suspicion about what their doctor is hiding in his or her concern about the patient’s possibly fearful attitude towards the pharmaceutical. With the prescription, parents and patients are accepting some part of the medical system of categorisation, giving some authority to it, while at the same time, by determining when and how they consume the prescription, are placing a part of it under their jurisdiction,” (Whitmarsh 2010).
Somewhat strikingly (at least in the context of a mainstream medical journal), he also makes an argument for the value of ambivalence and contradiction in regard to biomedicine:
“Ambiguity denotes spaces of irresolution—unfinished, still to be understood and interpreted. Our modern approach to disease often disavows such ambiguity: one rereads cultural interpretations to find hidden or further meanings; why reread a diagnosis? The extreme consistency of the modern medical designation can be precisely what gives patients pause—a claim to certainty amid evident uncertainty that may lead some people to seek out other interpretations. The cultural contradictions of asthma go beyond a view of the condition as a spectrum, a concept of ambiguity that relies on a single criterion of differentiation. In the ambivalence of culture, contradictory meanings can not only be maintained but can also reinforce each other. To the question “Asthmatic as an identity or as a temporary condition?” culture will answer: yes. In the ambivalence of culture, contradictory meanings keep each other in doubt,” (Whitmarsh 2010).
For those interested in reading more about Whitmarsh’s research in Barbados, in addition to the book he has published a number of articles, including this excellent 2008 piece from American Ethnologist:
“Biomedical ambivalence: Asthma diagnosis, the pharmaceutical, and other contradictions in Barbados.” American Ethnologist, 35(1): 49-63, February 2008.
In recent years in Barbados, the interaction of multinational pharmaceutical companies, the Ministry of Health (MOH), and international biomedical research has resulted in a focus on pharmaceuticals in public health intervention and the production of an expansive category of asthma. This article explores the views and uses of this process based on fieldwork conducted with doctors, nurses, pharmacists, MOH officials, and patient families involved in asthma care. Following ambiguities and contradictions in the significance of biomedical objects, I argue that this integration of pharmaceutical markets occurs with a foundational instability. Such ambiguity and contradiction are central to both the efficacy and undermining of global economic processes, including “pharmaceuticalization.”
If you have a subscription, you can read Ian Whitmarsh’s article in The Lancet in its entirety here: “Asthma and the Value of Contradictions,” The Lancet 376(9743): 764-5, September 4, 2010.
Image from Images from the History of Medicine, National Library of Medicine