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
I found this work exceptionally useful since I am writing about traditional healing in the context of high levels of medical pluralism in South Africa. In a paper that will appear as "The market for healing and the elasticity of belief: Medical pluralism in Mpumalanga, South Africa" for a volume entitled Health and Healing in Africa; new arenas and emerging markets (African Studies Centre, E J Brill African Dynamics Series, edited by M. Dekker & R. van Dijk, 2010), for instance, I try to make the argument that what is called 'healing' is not a single-criterion category, but is like what Wittgenstein famously called 'family resemblance'. In other words, ‘ambiguous’. There is nothing that connects all forms of healing except this 'family resemblance' that consists of overlapping similarities and the fact that clients recognise it as 'healing'. Could this also be the case in asthma? It is a ‘familyh resemblance’ category? I found especially enlightening the description of mutually exclusive aetiologies. In my work, I am finding that this depends in part on the fact that people that I work with do not always think in terms of a ‘body’ as the ‘thing’ that is being healed. I argue "Whether of not healing has occurred and what has actually been healed—body, mind, social relations, spirit, or blood—[healing] often remains ambiguous, but … ambiguity is a necessary and unavoidable property of healing. Healing here takes many pathways but not all of them lead to health." One source of ambiguity, in other words, is cultural notions about what is being healed, and that this may be variable.
I was therefore particularly interested to read a similar argument about the value of ambiguity. In the case I am describing, ambiguity in results of medical/healing interventions (including biomedical treatment) that cause deep ambivalence in people's attitudes toward healing since no therapy/treatment is clearly better than the others. Biomedically-trained practitioners often do little better than traditional healers, partly because the primary diseases–HIV infection, AIDS, TB, diabetes, common viral infections–manifest in many ways, and over long periods. Most people (i.g South Africans of all colours) know a little bit about a vast range of healing options and use many at one time; thus it is not always clear which one might work or which don't. Ambiguity is a signal characteristic of the whole medically pluralistic context.