Medical Anthropology and The World System 2004
Medical Anthropology and The World System 2004
Medical Anthropology and The World System 2004
World System
Second Edition
Preface vii
I. What Is Medical Anthropology About? 1
1 Medical Anthropology: Central Concepts and Development 3
2 Theoretical Perspectives in Medical Anthropology 31
II. The Social Origins of Disease and Suffering 55
3 Health and the Environment: From Foraging Societies to the
Capitalist World System 57
4 Homelessness in the World System 83
5 Legal Addictions, Part I: Demon in a Bottle 97
6 Legal Addictions, Part II: Up in Smoke 143
7 Illicit Drugs: Self-Medicating the Hidden Injuries of
Oppression 169
8 AIDS: A Disease of the Global System 227
9 Reproduction and Inequality 283
III. Medical Systems in Social Context 305
10 Medical Systems in Indigenous and Precapitalist State
Societies 307
11 Biomedical Hegemony in the Context of Medical Pluralism 329
vi Contents
chapters that explore the social origins of specific health problems that
Ida Susser and Merrill Singer have explored in their research efforts. Part
III (“Medical Systems in Social Context”) consists of two chapters that
examine the diversity of medical systems created by people in both in-
digenous, archaic states and modern societies in their efforts to cope with
disease. Finally, the single chapter in Part IV (“Toward an Equitable and
Healthy Global System”) is based upon a premise of critical medical an-
thropology that argues for a merger of theory and social action that serves
indigenous peoples, peasants, working-class people, ethnic minorities,
women, gays/lesbians, and others who find themselves in subordinate
positions vis-à-vis ruling elites and transnational corporations. As part of
an effort to transcend the contradictions of the capitalist world system as
well as the remaining socialist-oriented societies, we propose the creation
of a democratic ecosocialist world system and the pursuit of health as a
human right.
This book is the 2nd edition of Medical Anthropology and the World Sys-
tem, which appeared in 1997. While numerous textbooks are now available
for introductory undergraduate courses, this is the only one that draws
primarily upon critical medical anthropology—a perspective that has
achieved some prominence in the subfield over the course of the past
twenty years or so. In some ways, this textbook is an expansion of a more
theoretical book titled Critical Medical Anthropology, which drew heavily
upon Singer and Baer’s earlier efforts, in collaboration with numerous
colleagues (including Susser), to develop a “critical medical anthropol-
ogy” (Singer and Baer 1995). In that critical medical anthropology (CMA)
has now “come of age” and has evolved into one of the major perspectives
and a popular one, particularly among younger faculty members and stu-
dents, we feel that the time is more than ripe for an undergraduate text-
book from this perspective.
Philosophically, this volume seeks to contribute to the further devel-
opment of what we call “critical anthropological realism.” In modern an-
alytic philosophy, realism is the perspective that claims that objects,
events, and beings in the world exist externally to us and to our experience
of them; there is, in other words, an acceptance of a reality independent
of our conception of it. As anthropologists, who, by design, seek to have
close encounters with the peoples of the world and their ways of being
and knowing, it has long been evident in the diversity of worldly concep-
tions that exist that humans do not ever know the external world directly
but only through theory-laden participation and observation. And culture
is the source of all theories of the world and hence of all experiences of
it. Indeed, even systematic observation, or what we call science (which
includes our own systematic observation as anthropologists), is recog-
nized as cultural in origin and function. Additionally, as anthropologists,
we have come to appreciate a form of philosophical relativism known as
x Preface
“cultural relativism,” which is the notion that beliefs and behaviors must
be studied and understood in their natural social context. Ripped from
their cultural contexts, behaviors as humane as life-saving surgery or the
ritual veneration of one’s ancestors, can be ridiculed as practices of inferior
beings or fools. Cultural relativism teaches us respect for other ways of
being and knowing, as well as humility about our own approaches to
worldly knowledge. Nonetheless, as scientists, our work does not stop
with the observation and description of peoples and their endless array
of beliefs and behaviors, but moves from there to the analysis and expla-
nation of human ways of being, that is to say, to the analysis and expla-
nation of culture (including our own culture, and including science as
culture). However, given that, in the words of Cornell West (1999: xv-xvii),
our goal as critical scientists is to confront “the pervasive evil of unjusti-
fied suffering and unnecessary social misery in our world,” we avoid
allowing our cultural relativism to “give in to sophomoric relativism
(‘Anything goes’ or ‘All views are equally valid’)” or “to succumb to
wholesale skepticism (‘There is no truth’).” Rather, we use our anthro-
pological respect and appreciation (indeed, our celebration) of peoples of
the world to analytically critique (and, as activist scholars, to publicly
oppose) beliefs, behaviors, and social structures that promote structural
violence and social suffering.
PART I
What Is Medical
Anthropology About?
CHAPTER 1
Medical anthropology concerns itself with the many factors that contrib-
ute to disease or illness and with the ways that various human popula-
tions respond to disease or illness. Although the human body is the
complex product of at least five million years of a dialectical relationship
between biological and sociocultural evolution, it is a system subject to a
multiplicity of environmental assaults as well as to the deterioration that
inevitably accompanies aging. Its processes are not only shaped by phys-
iological variables but also mediated by culture and by emotional states.
In this chapter, we introduce some key concepts developed in medical
anthropology that we use repeatedly in this book. These concepts should
enable students to comprehend more clearly the relationship between
health-related issues and the sociocultural processes and arrangements of
the modern world. We also present a brief history of medical anthropology
as a subdiscipline of anthropology—one that has the potential to serve as
a bridge between physical anthropology and sociocultural anthropology.
As we show, medical anthropology has drawn from a variety of theo-
retical perspectives within anthropological theory and social scientific the-
ory. While these perspectives offer important insights into health-related
issues, the authors of this volume work within a theoretical framework
generally referred to as critical medical anthropology. The authors, with
many other medical anthropologists, utilize this critical approach in the
belief that social inequality and power are primary determinants of health
and health care. Although critical medical anthropology as a theoretical
perspective will be discussed in greater detail in chapter 2, along with
various other theoretical perspectives within medical anthropology, suf-
4 Medical Anthropology and the World System
fice to say at this point this perspective views health issues within the
context of encompassing political and economic forces that pattern human
relationships; shape social behaviors; condition collective experiences; re-
order local ecologies; and situate cultural meanings, including forces of
institutional, national, and global scale. The emergence of critical medical
anthropology reflects both the turn toward political-economic approaches
in anthropology in general, as well as an effort to engage and extend the
political economy of health approach (Baer, Singer, and Johnsen 1986;
Morgan 1987; Morsy 1990).
Health
The World Health Organization (WHO) defines health as “not merely
the absence of disease and infirmity but complete physical, mental and
social wellbeing” (WHO 1978). The notion of “wellness” has also become
a key concept within the holistic health movement. The human concern
with wellness, however, is not a recent one. As chiropractor-anthropolo-
gist Norman Klein (1979: 1) so aptly observes, “Well-being is a human
concern in all societies—in part because humans, like other life forms, are
susceptible to illness.” Health, more than merely a physiological or emo-
tional state, is a concept that humans in many societies have developed
in order to describe their sense of well being. Many medical anthropolo-
gists regard health to be a cultural construction whose meaning varies
considerably from society to society or from one historical period to
another.
Taking a neo-Marxian perspective, Sander Kelman views health within
the context of a system of production (1975). He makes a distinction be-
tween “functional health” and “experiential health.” The former he de-
fines as a state of optimum capacity to perform roles within society,
particularly within the context of capitalism, to carry out productive work
that contributes to profit-making. “Experiential health” entails freedom
from illness and alienation and the capacity for human development, in-
cluding self-discovery, self-actualization, and transcendence from alien-
ating social circumstances. Whereas “functional health” is an inevitable
component of social life under capitalism, “experiential health” tended to
occur in many simple preindustrial societies and could theoretically occur
again under modern societies based upon egalitarian social relations. Be-
fore casting its attention to state or complex societies, cultural anthropol-
ogists focused their research efforts upon indigenous societies. Indeed,
Medical Anthropology 5
Disease
Even under the best of circumstances, human beings inevitably find
themselves confronted with disease or illness. As it is for biomedicine, a
central question for medical anthropology is, What is disease? It is evident
why this query is important to biomedicine. As the nature of its impor-
6 Medical Anthropology and the World System
Sufferer Experience
Medical social scientists have become increasingly concerned about suf-
ferer experience—the manner in which an ill person manifests his or her
disease or distress. Margaret Lock and Nancy Scheper-Hughes (1990),
who refer to themselves as critically interpretive medical anthropologists,
reject the long-standing Cartesian duality of body and mind that pervades
biomedical theory (Lock and Scheper-Hughes 1990). They have made a
significant contribution to an understanding of sufferer experience by de-
veloping the concept of the “mindful body” (Scheper-Hughes and Lock
1987). Lock and Scheper-Hughes delineate three bodies: the individual
body, the social body, and the body politic. People’s images of their bodies,
either in a state of health or well being or in a state of disease or distress,
are mediated by sociocultural meanings of being human. The body also
serves as a cognitive map of natural, supernatural, sociocultural, and spa-
tial relations. Furthermore, individual and social bodies express power
relations in both a specific society or in the world system.
Sufferer experience constitutes a social product, one that is constructed
and reconstructed in the action arena between socially constituted cate-
gories of meaning and the political-economic forces that shape daily life.
Although individuals often react to these forces passively, they may also
respond to economic exploitation and political oppression in active ways.
In her highly acclaimed and controversial book Death without Weeping: The
Violence of Everyday Life in Brazil, Scheper-Hughes (1992) presents a vivid
and moving portrayal of human suffering in Bom Jesus, an abjectly im-
poverished favela or shantytown in northeastern Brazil. She contends that
the desperate and constant struggle for basic necessities in the community
induces in many mothers an indifference to the weakest of their offspring.
While at times Scheper-Hughes appears to engage in a form of blaming
the victim, she recognizes ultimately that the suffering of the mothers,
their children, and others in Bom Jesus is intricately related to the collapse
of the sugar plantation, which has left numerous people in the region
without even a subsistence income. Most of the residents of Bom Jesus
8 Medical Anthropology and the World System
Medical System
In responding to disease and illness, all human societies create medical
systems of one sort or another. All medical systems consist of beliefs and
practices that are consciously directed at promoting health and alleviating
disease. Medicine in simple preindustrial societies is not clearly differen-
tiated from other social institutions such as religion and politics. The re-
ality of this is seen in the shaman, a part-time magicoreligious practitioner
who attempts to contact the supernatural realm when dealing with the
problems of his or her group. In addition to searching for game or lost
objects or related activities, the shaman devotes much of his or her atten-
tion to healing or curing. When curing a victim of witchcraft, the shaman
among the Jivaro, a horticultural village society in the Ecuadorian Ama-
zon, sucks magical darts from the patient’s body in a dark area of the
house, at night because this is believed to be the only time when he can
interpret drug-induced visions that reveal supernatural reality (Harner
1968). The curing shaman vomits out the intrusive object, displays it to
the patient and his or her family, puts it into a little container, and later
throws it into the air, at which time it is believed to fly back to the be-
witching shaman who originally sent it into the patient.
Even though physicians in industrial societies often purport to practice
a form of medicine distinct from religion and politics, in reality their en-
deavors are intricately intertwined with these spheres of social life. In his
classic analysis of body ritual among the Nacirema, which has been re-
produced in many introductory anthropological books, Horace Miner
(1979) challenges North American ethnocentrism by showing that our
own customs are no less exotic than those of simple preindustrial societies.
Nacirema is simply American spelled backwards and refers to a “magic-
ridden” people whose “medicine men” (physicians) perform “elaborate
ceremonies” (surgery) in imposing temples, called latipos (hospitals). The
medicine men are assisted by a “permanent group of vestal maidens [fe-
male nurses] who move sedately about the temple chambers in distinctive
costume and headdress” (Miner 1979: 12). In a somewhat more serious
vein, Rudolf Virchow, the well-known nineteenth-century pathologist and
an early proponent of social medicine declared that politics is “nothing
but medicine on a grand scale” (quoted in Landy 1977: 14). By this, he
simply meant that, just as in government, medicine is filled with power
struggles and efforts to control individuals or social groups. Although
medical anthropologists and other medical social scientists routinely use
the term medicine as a heuristic or analytical device, it is important to
Medical Anthropology 9
Medical Pluralism
Regardless of their degree of complexity, all health care systems are
based upon the dyadic core, consisting of a healer and a patient. The healer
role may be occupied by a generalist, such as the shaman in preindustrial
societies or the family physician in modern societies. It may also be oc-
cupied by various specialists, such as an herbalist, a bonesetter, or a me-
dium in preindustrial societies or a cardiologist, an oncologist, or a
psychiatrist in modern societies. In contrast to simple preindustrial soci-
eties, which tend to exhibit a more-or-less coherent medical system, state
societies manifest the coexistence of an array of medical systems, or a
pattern of medical pluralism. From this perspective, the medical system of
a society consists of the totality of medical subsystems that coexist in a
cooperative or competitive relationship with one another. In modern in-
dustrial societies one finds, in addition to biomedicine, the dominant
medical system; other systems such as chiropractic, naturopathy, Christian
Science, evangelical faith healing; and various ethnomedical systems. In
the U.S. context, examples of ethnomedical systems include herbalism
among rural whites in Southern Appalachia, rootwork among African
10 Medical Anthropology and the World System
Biomedicine
In attempting to distinguish the Western medical system that became
globally dominant during this century from alternative systems, social
scientists have employed a variety of descriptive labels, including regular
medicine, allopathic medicine, scientific medicine, modern medicine, and
cosmopolitan medicine. Following Comaroff (1982) and Hahn (1983),
most medical anthropologists have come to refer to this form of medicine
as “biomedicine.” Hahn (1983) argues that in diagnosing and treating sick-
ness, biomedicine focuses primarily upon human physiology and even
more specifically on human pathophysiology. Perhaps the most glaring
example of this tendency to reduce disease to biology is the common
practice among hospital physicians of referring to patients by the name
of their malfunctioning organ (e.g., the liver in Room 213 or the kidney
in Room 563). A fourth-year chief resident interviewed by Lazarus (1988:
39) commented, “We are socialized to—disease is the thing. Yeah, I slip.
We all do and see the patient as a disease.” As these examples illustrate,
the central concern of biomedicine is not general well being nor individual
persons per se but rather simply diseased bodies.
In essence, biomedicine subscribes to a type of physical reductionism
12 Medical Anthropology and the World System
that radically separates the body from the nonbody. Hahn notes that bio-
medicine emphasizes curing over prevention and spends much more
money on hospitals, clinics, ambulance services, drugs, and “miracle
cures” than it does on public health facilities, preventive education, clean-
ing the environment, and eliminating the stress associated with modern
life. Biomedicine constitutes the predominant ethnomedical system of Eu-
ropean and North American societies and has become widely dissemi-
nated throughout the world.
Within the U.S. context, biomedicine incorporates certain core values,
metaphors, beliefs, and attitudes that it communicates to patients, such as
self-reliance, rugged individualism, independence, pragmatism, empiri-
cism, atomism, militarism, profit-making, emotional minimalism, and a
mechanistic concept of the body and its repair (Stein 1990). For example,
U.S. biomedicine often speaks of the war on cancer. This war is portrayed
as a prolonged attack against a deadly and evil internal growth, led by a
highly competent general (the oncologist) who gives orders to a coura-
geous, stoical, and obedient soldier (the patient) in a battle that must be
conducted with valor despite the odds and, if necessary, until the bitter
end. Erwin (1987) aptly refers to this approach as the “medical militari-
zation” of cancer treatment. Conversely, according to Hanteng Dai, a Chi-
nese physician who has worked with cancer patients in Arkansas, both
health personnel and members of the therapy management group in the
People’s Republic of China tell cancer patients a white lie by referring to
their condition as being something less serious in order to spare them
from purported mental anguish. Given that cancer constitutes a break-
down of the immune system, it is interesting to draw attention to Emily
Martin’s (1987: 410) observation that the main imagery employed in pop-
ular and scientific descriptions of this system portray the “body as nation
state at war over its external borders, containing internal surveillance sys-
tems to monitor foreign invaders.”
It is important to stress that biomedicine is not a monolithic entity.
Rather, its form is shaped by its national setting, as is illustrated by Payer’s
(1988) fascinating comparative account of medicine in France, Germany,
Britain, and the United States. He argues that French biomedicine, with
its strong orientation toward abstract thought, results in doctor visits that
are much longer than in German biomedicine. French biomedicine also
places a great deal of emphasis on the liver as the locus of disease, in-
cluding complications such as migraine headaches, general fatigue, and
painful menstruation. Conversely, German biomedicine regards Herzin-
suffizienz, or poor circulation, as the root of a broad spectrum of ailments,
including hypotension, tired legs, and varicose veins. Both German and
French biomedicine relies more heavily than U.S. biomedicine on the ca-
pacity of the immunological system to resist disease and therefore de-
emphasizes the use of antibiotics. In contrast to U.S. biomedicine, they
Medical Anthropology 13
preeminent medical system in the world not simply because of its curative
efficacy but as a result of the expansion of the global market economy.
orated upon Marx and Engels’s observation that the “ideas of the ruling
class are, in every age, the ruling ideas.” Whereas the ruling class exerts
direct domination through the coercive organs of the state apparatus (e.g.,
the parliament, the courts, the military, the police, the prisons, etc.), he-
gemony, as Femia (1975: 30) observes, is “objectified in and exercised
through the institutions of civil society, the ensemble of educational, re-
ligious, and associational institutions.” Hegemony refers to the process by
which one class exerts control of the cognitive and intellectual life of so-
ciety by structural means as opposed to coercive ones. Hegemony is
achieved through the diffusion and reinforcement of certain values, atti-
tudes, beliefs, social norms, and legal precepts that, to a greater or lesser
degree, come to permeate civil society. Doctor-patient interactions fre-
quently reinforce hierarchical structures in the larger society by stressing
the need for the patient to comply with a social superior’s or expert’s
judgment. Although a patient may be experiencing job-related stress that
may manifest itself in various diffuse symptoms, the physician may pre-
scribe a sedative to calm the patient or help him or her cope with an
onerous work environment rather than challenging the power of an em-
ployer or supervisor over employees.
Syndemics
One effect of the kind of reductionist thinking in health that tends to
dominate biomedical understanding and practice is the tendency to iso-
late, study, and treat diseases as if they were distinct entities that existed
separate from other diseases and from the social contexts in which they
are found. Critical medical anthropology (as described more fully in the
next chapter), however, seeks to understand health and illness from a
holistic biological, sociocultural, and political economic perspective
(sometimes called critical bioculturalism) that runs counter to the domi-
nant reductionist orientation. This approach attempts to identify and un-
derstand the determinant interconnections between one or more health
conditions, sufferer and community understandings of the illness(es) in
question and the social, political, and economic conditions that may have
contributed to the development of ill health. To help frame this kind of
big picture dialectical thinking in health, critical medical anthropologists
introduced the concept of “syndemic” (Singer 1994, 1996) as a new term
in epidemiological and public health thinking. At its simplest level, and
as now used by some researchers at the Centers for Disease Control and
Prevention (CDC), the term syndemic refers to two or more epidemics
(i.e., notable increases in the rate of specific diseases in a population) in-
teracting synergistically with each other inside human bodies and con-
tributing, as a result of their interaction, to excess burden of disease in a
population. As Millstein (2001: 2), organizer of the Syndemics Prevention
16 Medical Anthropology and the World System
may push dormant bacteria into an active state) and because they are more
likely to have pre-existent immune system damage from other infections
and malnutrition. Finally, poverty and discrimination place the poor at a
disadvantage in terms of access to diagnosis and treatment for TB, effec-
tiveness of available treatments because of weakened immune systems,
and ability to adhere to TB treatment plans because of structurally im-
posed residential instability and the frequency of disruptive economic and
social crises in poor families. As the case of TB suggests, diseases do not
exist in a social vacuum or solely within the bodies of those they inflict,
and thus their transmission and impact is never merely a biological pro-
cess. Ultimately, social factors, like poverty, racism, sexism, ostracism, and
structural violence may be of far greater importance than the nature of
pathogens or the bodily systems they infect.
As the discussion above suggests, syndemics are not merely co-
occurring epidemics in populations that are embodied as co-infections
within individual patients, they include the interaction of diseases (or
other health conditions, e.g., malnutrition) as a consequence of a set of
health threatening social conditions (e.g., noxious living, working or en-
vironmental conditions or oppressive social relationships). In other words,
a syndemic is a set of intertwined and mutually enhancing epidemics
developed and sustained in a community because of harmful social con-
ditions and injurious social relationships.
For example, one of the major threats to health worldwide is malnutri-
tion. The Bread for the World Institute estimates that over 800 million
people in developing countries are chronically malnourished and that at
least half of the 31,000 children under five years of age who die every day
in the world are victims of hunger-related causes. Even in a highly de-
veloped country like the United States, over 11 million people cannot
afford to adequately feed their families. It is a well-recognized fact that
malnourished people tend to have compromised immune systems and
are thus particularly vulnerable to infections. For example, influenza can
be more harmful (with great lung involvement) and last longer in indi-
viduals with nutrient deficiencies. However, recent research has begun to
suggest that malnourishment may not only allow pathogens like viruses
to flourish, it may contribute to them becoming more lethal. Thus, Dr.
Melinda Beck of the University of North Carolina found that the normally
harmless virus Coxsackie B3 (which is most commonly associated with
light fever and a short-term rash in children) could produce a life-
threatening heart disease in malnourished adults (Beck and Levander
2000). In individuals whose diets are deficient in certain key nutrients
(e.g., selenium, an anti-oxidant enzyme found in whole grain wheat and
vegetables that the body uses to combat oxidative stress) Coxsackie virus
may mutate to produce viral strains with deadly potential. Beck was able
to demonstrate this effect in animal experiments. According to Beck (BBC
18 Medical Anthropology and the World System
News 2001), “We believe our findings are both important and potentially
disturbing because they suggest nutritional deficiencies can promote ep-
idemics in a way not appreciated before. What we found conceivably
could be true for any RNA virus—cold virus, AIDS virus [human im-
munodeficiency virus] and Ebola virus.” This type of harmful synergism
between Coxsackie virus and malnutrition exemplifies the syndemic
process.
A dangerous synergism can also be seen in the relationship between
poverty, poor childhood nutrition, and later heart disease. Epidemiolog-
ical research in England and Wales by Barker and Osmond (1986) dem-
onstrated a close association between geographic areas with current high
mortality rates for ischemic heart disease (and previous high rates of in-
fant mortality and other indicators of high rates of poverty and malnu-
trition) during the period that the adults coming down with heart disease
were children. According to these researchers, it appears that exposure to
poor nutrition early in life created a high susceptibility for ischemic heart
disease later in life as malnourished children grew up and were subse-
quently exposed to changing dietary patterns (e.g., a diet with heightened
levels of dietary cholesterol). As this research affirms, poor diet is one of
the direct routes through which social conditions and inequality impact
health and contribute thereby to sydemical enhancement of illness and
disease. In other research, Evans (1997) and co-workers found an associ-
ation between severe life stress and early disease progression among in-
dividuals with HIV disease. Stress, a common consequence of poverty,
discrimination, and other forms of social suffering, appears to be another
route through which oppressive social conditions find expression in clini-
cal outcomes.
Another syndemic example involves the interactions among substance
abuse, street/domestic violence, and AIDS. Singer (1996) has proposed
that the interrelations of these health and social factors constitute a mu-
tually enhancing syndemic, which he calls SAVA (an acronym formed
from substance abuse, violence and AIDS). In inner city, low-income com-
munities, he argues (Singer 1996: 99), substance abuse, violence and AIDS
“are not merely concurrent, in that they are not wholly separable phe-
nomena. Rather, these three closely linked and interdependent threats to
health and well being . . . constitute a major syndemic that already has
taken a devastating toll . . . and threaten to wreck further pain and havoc
in the future.” While the link between substance abuse and AIDS is widely
recognized (see chapter 8) other interconnections warrant further study,
such as the role of an AIDS diagnosis in enhancing levels of drug use, the
impact of violence victimization on subsequent drug use and AIDS risk,
and the conditions under which drug use and drug craving lead to en-
hanced levels of violence. While considerable work has been done on
patterns of drug use and on the relationship of AIDS transmission to risk
Medical Anthropology 19
United States Agency for International Development). Paul (1969: 29) saw
anthropologists as being “especially qualified by temperament and training
. . . [for] the study of popular reactions to programs of public health carried
out in foreign cultural settings.” In retrospect, the writings of Paul and
many of his contemporaries strike many medical anthropologists, particu-
larly those of a critical bent, as unduly naive about the nature and function
of United States-sponsored international health programs. Their work,
which was conducted at the peak of the Cold War, exhibited a profoundly
Eurocentric ideological cast that included an implicit biomedical bias.
Some anthropologists became involved in efforts to facilitate the deliv-
ery of biomedical care to populations in the United States. For example,
Alexander and Dorothea Leighton, anthropologists who conducted exten-
sive research on the Navajo, became involved in the Navajo-Cornell Field
Health Project, which was established in 1955 (Foster 1982: 190). This pro-
ject resulted in the creation of the role of “health visitor,” a Navajo para-
medic and health educator who served as a “cultural broker” or liaison
between the Anglo-dominated health care system and his people. As part
of the larger effort to deliver biomedical health services and to ensure the
compliance of patients, many medical anthropologists turned to ethno-
medical approaches that sought to elicit the health beliefs of their subjects.
Clinical anthropology, as a distinct branch of medical anthropology, be-
gan to develop in the early 1970s as part of a larger effort to humanize
the increasingly bureaucratic and impersonal aspects of biomedical care.
Nevertheless, medical anthropologists such as Otto von Mering had been
working in clinical settings since the early 1950s (Johnson 1987). Arthur
Kleinman (1977), a psychiatrist with an M.A. in anthropology, urged
medical anthropologists to assume a “clinical mandate” under which they
would help to facilitate the doctor-patient relationship, particularly by
eliciting patient “explanatory models” (EMs), or the patient’s perceptions
of disease and illness, that would help the physician to deliver better
medical care. In addition to seeking to reform biomedicine, although cer-
tainly not significantly to change it, clinical anthropology has focused at-
tention on searching for alternative health careers for anthropologists
during the 1980s and 1990s. The tight academic job market prompted
many anthropology students to seek careers in medical anthropology be-
cause it held out the hope of providing employment in nonacademic set-
tings, including clinical ones.
A long symbiotic relationship has existed between medical anthropol-
ogy and medical sociology (Conrad 1997; Good and Good 2000). Various
people, such as Peter Kong-Ming New, Ronald Frankenberg, Ray H. Ell-
ing, and Meredith McGuire, have served as disciplinary brokers between
medical sociology and medical anthropology. Medical anthropologists
have often relied upon medical sociological research, particularly in their
research on aspects of biomedicine and national health care systems. For
22 Medical Anthropology and the World System
in 1995, in Gabon in 1996, in Uganda in 2000, and Gabon in late 2001 and
early 2002. Unlike other the highly contagious hemorrhagic fever viruses,
which tend to have an animal or insect vector that spreads the disease,
Ebola (for which a vector has not yet been identified) is spread by contact
with the blood or other bodily fluids and tissues of an infected person.
The Ebola virus has been identified as a member of the virus family called
Filoviridae, a group characterized by a thread like appearance. However
deadly, these viruses are usually only 800 to 1000 nanometers (nm) long
(1nm is equal to one-billionth of a meter). There remains no known cure
or vaccine for Ebola.
In 1993, the Four Corners region of the western United States was
rocked by the appearance of Hantavirus. Characterized by a mild onset
with flu-like symptoms, the disease rapidly progresses to kidney failure
with internal bleeding. Victims in the Four Corners outbreak hemorrhaged
so badly in their lungs that they suffocated in their own blood. Mortality
after infection has been found to be over 60% with the deadliest strains.
Over 60 species of birds and rodents have been identified as the vectors
for the 70 known strains of the virus.
Each of the cases of the disease outbreaks described above has been of
special concern to the public health field of epidemiology. This applied
discipline is concerned with understanding the “distribution and deter-
minants of disease” (Trostle and Sommerfeld 1996: 253) and using this
information to make social, physical, or other changes needed to prevent
further illness. Unlike, biomedicine, which primarily focuses on the treat-
ment of ailments in specific individuals, epidemiology addresses the
larger-level of the population with the intention of preventing new illness.
In other words, the goal of epidemiology is assessing the distribution of
disease with the intention of identifying “the risk factors that enable in-
tervention and, ultimately, control” (Agar 1996: 391). At the first reports
of a disease outbreak, epidemiologists, like those who work for the Cen-
ters for Disease Control and Prevention (CDC) in Atlanta, Georgia, rush
to the scene (often anywhere in the world). Their objectives include de-
termining the cause(s) of illness, the incidence rate (numbers over new
cases over time), the prevalence (total number of cases relative to the size
of the population at risk), the pathways of disease spread, and possible
methods for lowering disease morbidity and mortality. Specifically, as
Hahn (1999: 34) relates,
In the case of the 1976 Ebola outbreak, it was found that the nuns who
ran the Yambuku Mission Hospital began their work each day by putting
26 Medical Anthropology and the World System
out five syringes for use with the hundreds of patients who would need
injections. Occasionally, the syringes were cleaned with warm water to
clear blood clots and drying blood that interfered with needle efficiency,
but often a syringe was pulled from the arm of one patient, refilled with
medicine, and re-injected into another patient without cleansing. In this
way, a very effective (if completely unintended) method for viral trans-
mission was created, much like the one that has allowed HIV to move
rapidly among illicit injection drug users who are forced to re-use syringes
used by others because of a lack of access to sterile syringes. Other routes
of Ebola transmission also were identified, including mortuary practices
that exposed individuals to the infected body fluids of Ebola victims. Iden-
tification of these routes of transmission led to a rapid end to the 1976
Ebola outbreak.
With its focus on observable behaviors and actual social and physical
contexts of health and illness, as well as its concern with the population
level rather than the individual case of disease, it is recognized that epi-
demiology shares features with medical anthropology. Indeed, a number
of anthropologists and some epidemiologists have pointed out the bene-
fits of close collaboration between the two disciplines. To this union, ad-
vocates of collaboration argue, epidemiology brings a rigorous scientific
approach, an emphasis on quantitative data collection, and a specifically
applied orientation. Anthropology’s contribution includes an emphasis on
intensive qualitative investigation of behaviors and social relations in con-
text and a keen awareness of the importance of culture (and meaning) in
shaping people’s behavior as well as their willingness to change behaviors
to accommodate public health dictates.
Over the last several decades, collaborations of this sort have become
increasingly common, although they do not yet constitute standard prac-
tice. Singer, for example, has worked closely with a number of epidemi-
ologists in assessing social context factors that contribute to the extent of
HIV risk among injection drug users in three New England cities. Com-
bining anthropological emphasis on direct observation of actual risk set-
tings, social networks, and behaviors with an epidemiological focus on
rigorous measurement (e.g., using standardized surveys and the careful
structuring of participant sampling), the multi-disciplinary team con-
ducting this study has been able to identify key local context factors at
both the neighborhood and city levels that contribute to differences in
HIV risk and infection in different social environments. Findings such as
this are important in moving the field of AIDS prevention from efforts
built on a one-size-fits-all approach to the tailoring of prevention to fit the
specific characteristics of local social environments.
Despite the recognized benefits of interdisciplinary collaboration, a
number of anthropologists have been critical of epidemiology. Concerns
about the types of data that are valued and devalued (e.g., inattention to
Medical Anthropology 27
As most practitioners know, the comfortable truism about epidemiology that pub-
lic health schools teach their graduate students—that epidemiology is the basic
science of public health—is not actually true. It may be closer to reality to say that
politics is the basic science of public health (Moss 2000: 1385).
facile claims of causality, particularly those that scant the pathogenic roles of social
inequalities. Critical perspectives on emerging infections [for example] must ask
how large-scale social forces come to have their effects on unequally positioned
individuals in increasingly interconnected populations; a critical epistemology
needs to ask what features of disease emergence are obscured by dominant ana-
lytic frameworks (Farmer 1999: 5).
pology for much of its history. This parallel limitation suggests the poten-
tial benefits of the further development of critical epidemiology and
critical medical anthropology and of their collaboration in assessing and
responding to disease. In this collaboration, strong focus using method-
ologies that collect both qualitative and quantitative data, and integrate
them for purposes of analysis, would be applied to addressing the big
questions, such as what are “the precise mechanisms by which such forces
as racism, gender inequality, poverty, war, migration, colonial heritage,
and even structural adjustment program [such as those imposed by en-
tities like the World Bank and International Monetary fund before monies
will be loaned to developing countries] become embodied as [culturally
shaped] increased risk” (Farmer 1997: 524).
Today, medical anthropology constitutes an extremely broad endeavor
that no single textbook can possibly summarize. Students who are inter-
ested in further acquainting themselves with the scope and breadth of
medical anthropology as a subdiscipline are advised to consult the follow-
ing two important anthologies: (1) Medical Anthropology: Contemporary The-
ory and Method, edited by Carolyn F. Sargent and Thomas M. Johnson
(1996), and (2) Training Manual in Applied Medical Anthropology, edited by
Carole E. Hill (1991). At the theoretical level, medical anthropologists are
interested in topics such as the evolution and ecology of disease, paleo-
pathology, and social epidemiology; the political economy of health and
disease; ethnomedicine and ethnopharmacology; medical pluralism; cul-
tural psychiatry; the social organization of the health professions, clinics,
hospitals, national health care systems and international health bureau-
cracies; human reproduction; and nutrition. At the applied level, medical
anthropologists work in areas such as community medicine; public health;
international health; medical and nursing education; transcultural nurs-
ing; health care delivery; mental health services; health program evalua-
tion; health policy; health care reform; health activism and advocacy;
biomedical ethics; research methods in applied medical anthropology; and
efforts to control and eradicate a wide array of health-related problems,
including malaria, cancer, alcoholism, drug addiction, AIDS, malnutrition,
and environmental pollution. In many ways, the work of medical anthro-
pologists overlaps with that of medical sociologists, medical geographers,
medical psychologists, medical social workers, epidemiologists, and pub-
lic health people. In the past, medical anthropologists tended to focus on
health problems at the local level and, less often, at the national level.
Physician-anthropologist Cecil Helman (1994: 338) maintains that fu-
ture research in medical anthropology “will involve adopting a much
more global perspective—a holistic view of the complex interactions be-
tween cultures, economic systems, political organizations and ecology of
the planet itself.” He identifies overpopulation, urbanization, AIDS, pri-
mary health care, pollution and global warming, deforestation, and spe-
Medical Anthropology 29
Theoretical Perspectives in
Medical Anthropology
is quite impossible for humans somehow to strip these away and confront
AIDS in some kind of raw, culture-free natural state. Humans can expe-
rience the external material world only through their cultural frames; and
thus diseases, as they are known consciously and somatically by sufferers
and healers alike, are packed with cultural content (e.g., believing that
AIDS is a punishment from God or, as some people with AIDS have ex-
perienced it, an opportunity to turn their lives to more positive ends).
Even science is not a route to a culture-free account of the physical world,
as it too is a cultural construction.
Critical medical anthropologists agree with much in the interpretive
critique of the ecological model. The emphasis in its own critique, how-
ever, emerges from critical medical anthropology’s focus on understanding
the specific structure of social relationships that give rise to and empower partic-
ular cultural constructions, including medical anthropological theories.
Critical medical anthropology asks, “Whose social realities and interests
(e.g., which social class, gender, or ethnic group) do particular cultural
conceptions express, and under what set of historic conditions do they
arise?” Further, critical medical anthropology has faulted medical ecolog-
ical approaches for failing fully to come to grips with the fact that “it is
not merely the idea of nature—the way [external reality] is conceived and
related to by humans—but also the very physical shape of nature, includ-
ing of course human biology, that has been deeply influenced by an evo-
lutionary history of hierarchical social structures—that is to say, by the
changing political economy of human society” (Singer 1996: 497).
The problem inherent in conceptualizing the health aspects of the hu-
man/environmental relationship, in terms of adaptation, can be illus-
trated with the case of the indigenous people of Tasmania, an island that
lies just off the southeastern tip of Australia. Tasmania was successfully
inhabited by aboriginal people for over ten thousand years prior to the
arrival of Europeans at the end of the eighteenth century. Yet, building on
the work of Robert Edgerton, McElroy and Townsend cite the Tasmanians
as a case of maladaptation that led to the dying out of these people by
1876. They note:
In about 12,000 years of isolation from the mainland, the Tasmanians devolved,
losing the ability to make many tools, to make fire, and to construct rafts or cat-
amarans that would have allowed them to fish and travel. The division of labor
between men and women was inefficient, endangering women. Their political
ecology emphasized raiding, capture of women, and competitiveness between
tribal bands. During the cold season they went hungry, and their clothing and
housing were inadequate. . . . [In sum] their way of life was far from ideal, and
the society quickly collapsed after Europeans arrived. (McElroy and Townsend
1996: 112; emphasis in original)
world of social policies and actions. It can, however, escape its untenable
assertions that its reach for objectivity takes it beyond the influence of
social values or that only critical theory has a political agenda (e.g., Hahn
1995: 74).
Figure 2.1
Levels of Health Care Systems
40 Medical Anthropology and the World System
thropology has lagged in its attention to the nature and transforming in-
fluence of capitalism. As part of the larger effort of critical anthropology
in general to correct this shortcoming, CMA attempts to root its study of
health-related issues within the context of the class and imperialist rela-
tions inherent in the capitalist world system.
Biomedicine must be seen in the context of the capitalist world system.
According to Elling (1981a),
Some of the particular agents of the world-system operating in the health sector
include international health agencies, foundations, national bilateral aid programs,
all multinationals (especially drug firms, medical technology producers and sup-
pliers, polluting and exploiting industrial firms, agribusinesses, commercial baby
food suppliers, purveyors of chemical fertilizers and pesticides, and sellers of
population control devices), and a medical cultural hegemony supportive of the
activities of these agents on the world scene and in particular nations and locales.
At all levels the health care systems of advanced capitalist nations re-
produce the structures of class relations. The profit-making orientation
caused biomedicine to evolve into a capital-intensive endeavor heavily
oriented to high technology, the massive use of drugs, and the concentra-
tion of services in medical complexes. The state legitimizes the corporate
involvement in the health arena and reinforces it through support for
medical training and research in the reductionist framework of biomedi-
cine. Corporate-controlled foundations simply augment the state, at both
international and national levels.
At the international level, the World Bank has become a key player in
establishing health policies and making financial loans to health care en-
deavors. It loaned annually approximately $1.5 billion between 1991 and
1993, which placed it slightly ahead of WHO and UNICEF (cited in Walt
1994: 128). The World Bank has a strong influence on health policy as a
result of its practice of cofinancing resources from international and bi-
lateral agencies and matching funds from recipient governments. It also
conducts country-specific health sector analyses and makes proposals for
health care reform that are compatible with market-driven economies. As
a result of this emphasis on capitalist solutions to health problems, Walt
(1994: 157) argues, national policy makers sense “that Bank staff [appear
to be] more driven by pressure to lend than a desire for successful
implementation.”
Despite the fact that almost all Third World nations are supposed to be
politically independent, their colonial inheritance and their neocolonial
situation impose health care modeled after that found in advanced capi-
talist nations. Paul (1978: 272) argues “medicine has from the beginning
functioned in the service of imperialism, supporting logically the vora-
cious search for ever wider markets and profitable deals.” The ruling elites
Theoretical Perspectives in Medical Anthropology 41
challenge, which may be translated into new social movements and public
protest but may also create debate within existing formal institutions.”
who come into the most continuous and intimate contact with patients in
hospital settings. The medical hierarchies of advanced capitalist countries
are replicated in Third World nations, though various accommodations
are made to local customs and traditions.
Class struggle has become an explicit aspect of the intermediate social
level. While the trend toward unionization in U.S. hospitals first occurred
among its underpaid unskilled and semiskilled workers, it has also spread
to technicians, nurses, and even physicians. Factors serving to mitigate
demands by unionized hospital workers, however, include the shift of
costs from higher wages to consumers and the emergence of a “new pro-
fessional managerial class of hospital administrators” who are sometimes
willing to arbitrate with unions in return for disciplined workers (Krause
1977: 68–77). Furthermore, professionalization continues to be seen by
many health workers as a more viable approach for socioeconomic ad-
vancement, thus preventing them from forming an alliance with lower-
status workers. In recent years, many hospitals have turned to downsizing
their full-time nursing staffs by utilizing either temporary registered
nurses or licensed practical nurses and nurses’ aides as cheaper forms of
health care providers.
The Microlevel
The microlevel primarily refers to the physican-patient relationship and
what Janzen (1978) calls the “therapy management group.” The major
initial diagnostic task of the physician is heavily mediated by social factors
outside the examining room. Similar medical treatment, the other major
task of the physician, is not determined solely by the needs of the patient.
It also serves the special needs of physicians and other powerful sectors
within and outside the health care system. The physician role, in fact,
performs two key functions for the encompassing social system and its
existing distribution of power: (1) controlling access to the special prerog-
atives of the sick role and (2) medicalizing social distress. In the first, the
physician may limit access to the sick role by judging whether an indi-
vidual may or may not be excused temporarily from work. It must be
noted, however, that his or her power in this area is far from absolute, in
that most people adopt the sick role without consulting physicians. They
frequently consult with lay members of the therapy management group
in arriving at this decision. In the second function, according to the re-
ductionist model of disease in which physicians assign the source of dis-
ease to pathogenic or related factors, personal stress emanating from social
structural factors such as poverty, unemployment, racism, and sexism is
secluded from the potentially disruptive political arena and secured
within the safer medical world of individualized treatment. As Zola (1978)
argues, the ultimate function of both the gatekeeping and the medicalizing
44 Medical Anthropology and the World System
Certain strong emotions, especially anger and shock, can cause a person’s blood
to heat, thicken, or rise in the body. Blood can accumulate in the head, causing
headaches, stroke, or madness; it can lodge in the throat, causing suffocation; or
it can pass into the breast of a nursing mother, spoiling her milk and causing illness
to her baby. Blood can change color or become too ‘sweet’ or ‘sour’ as a result of
unsettling emotional experience as well as exposure to certain ‘hot’ and ‘cold’
foods and environmental agents.
Every society has many levels of sharing ideas about bodies: What is defined as
healthy, in one society might be considered unhealthily fat and ugly in another;
what is seen as thin and lean in one group might be defined as sickly in another.
Aging may also be defined as something to be either conquered, feared, accepted,
or revered.
As this statement suggests, attitudes about body size and fatness vary
considerably across societies. In North America, fatness is seen as both
unattractive and unhealthy and is interpreted as a sign of moral laxness
if not self-hatred. Studies show that American women who diet have
strong concerns about their self-control and associate weight gain with
greed (Counihan 1990). By contrast, among the traditionally nomadic
Moors of Mauritania, fatness, especially in women, is considered quite
attractive. The ability of a man to produce a fat daughter or to sustain a
Theoretical Perspectives in Medical Anthropology 47
fat wife demonstrates his wealth and secures him highly valued social
prestige. Consequently, daughters are force-fed large quantities of fatty
camel milk to help them gain weight. Girls generally accept this practice
because they know it will enhance their ability to attract a wealthy hus-
band. This sentiment is captured in a Moorish folk saying: “To be a woman
of quality, it is necessary to be a woman of quantity” (Cassidy 1991: 197).
Hearing about such beliefs and practices, North Americans are quick to
raise questions about the health risks of being overweight. As contrasted
with Moorish folk sayings, an American quip is that “No woman can be
too rich or too thin.” However, blanket statements about slimness and
health confuse cultural desires with clinical realities in several ways.
First, research shows that from a health standpoint the ideal weight for
a specific height increases with age (the best weight for someone at age
25, for example, is too thin for the same person at age 65). Second, while
morbidity increases with high weights, it does so for low weights as well.
Thirdly, there is a broad range for ideal weight for height ratios, with
relatively little change in health risk in increases within a 30–50 pound
range. Finally, the key relationship between body fat and morbidity is not
degree but distribution (i.e., where body fat is stored), with accumulation
of adipose in the abdominal area being notably riskier (for cardiovascular
disease, hypertension and cancer) than on the hips and thighs (Ritenbaugh
1991).
The differing ways people conceive and value the human body are evi-
dent not only in variations across societies but also within societies. Bour-
dieu (1984), for example, has analyzed critical differences in ideas about
body image across class and gender lines in Western society. Illustratively,
he notes (206) that the percentage of women who consider themselves to
be below average in beauty or think that they look older than they really
are is directly related to social class, with upper class women feeling “su-
perior both in the intrinsic, natural beauty of their bodies and in the art
of self-embellishment” with working class women, who have fewer re-
sources and time to invest in cultivating their bodies, being more likely
to express alienation from their body image. In that weight is linked cul-
turally in the United States with self control and with personal value, the
tendency of upper class individuals to be slimmer than members of the
working class (a reversal of nineteenth century weight distribution pat-
terns) serves not only as a visual marker of one’s class standing but as an
embodied affirmation and constant reminder of the innate superiority of
dominant social classes.
The work of culture on bodies is not merely conceptual, it is also physi-
cal. Tatooing and body piercing are contemporary illustrations of the ways
people actively engage in recreating their physical bodies to conform to
desired appearances. While participants often explain these practices as a
form of self-expression, their relatively sudden and widespread appear-
48 Medical Anthropology and the World System
ance, especially in certain age and social groups, suggests that cultural
forces and not merely individual tastes and values are at work. In fact,
throughout history, humans have reconfigured their bodies to conform to
cultural standards. Historically, among the Kwakiutl Indians of the north-
west coast, babies spent many hours fastened to cradle boards to create a
culturally valued flattened head shape. Foot binding of girls—to create a
tiny and non-functional foot—as practiced among wealthy families in
China traditionally, is another example of culturally dictated body shap-
ing. Other examples, like orthodontia and plastic surgery, indicate that
bodies are not only shaped by cultural values, but cultural values about
the body can be ensnared by and shaped by for-profit commercial pro-
cesses. Consequently, body reconfiguring has become big business, gen-
erating billions in new wealth for a variety of industries from workout
gyms and tanning salons to cosmetics and hair product manufacturers to
weight loss programs and dietary supplement distributors. Rather than
merely meeting a cultural demand for beauty enhancing products and
procedures, critics argue that corporate commodification of body imagery
generates feelings of inadequacy and worthlessness resulting in diseases
like anorexia and bulimia among vulnerable populations. As critical medi-
cal anthropologists Mark and Mimi Nichter observe, promoting
from the lower classes in their society, often several inches taller on av-
erage. These differences, which are linked to diet, access to health care,
and other factors, are first evident prior to birth and are well established
by the age of six years (Cassidy 1991).
Work-site exposure to toxic substances produces another type of bodily
difference between the classes. Reviewing the literature on this issue, Mil-
len and Holts (1990) note, for example, that half of the workers in factories
that produce industrial chromates have been found in both Mexico and
South Africa to have perforated nasal septums. Indeed, exposure to toxins
in manufacturing, mining, and farming is quite common among workers
in developing nations, producing a wide range of disease impacts on lives
and bodies. Environmental exposure to toxic substance also differentiates
the bodies of upper and lower classes. Dumping of toxins is much more
common in the poorer areas of poor countries than in wealthier locations,
even if the substances are produced in wealthy countries and shipped for
disposal to poorer ones. A wide range of industrial toxins, such as mer-
cury and lead, are dumped into the environment of poor countries each
year resulting in a host of damaging effects on the bodies of poor and
working class individuals. Similarly, poor neighborhoods are much more
likely than wealthy ones to be sited for garbage dumps or other waste
disposal locations.
Oths (1999) calls attention to another expression of the embodiment of
social relations in her analysis of the folk disease called “debilidad”
among highland peasants in Peru. The most common symptom experi-
enced by those who suffer from this culture-specific illness is pain in the
brain stem area with pain in the cranium being the second most common
complaint. Other symptoms include numbness, dizziness, and fatigue.
These discomforts tend to be endured stoically by sufferers without much
public complaint. Looking at debilidad in its social context, Oths con-
cludes that it is an expression of the embodiment of life’s accumulated
hardships. In the highlands of northern Peru, reproductive and productive
stresses generated primarily by the pressures of maintaining a living un-
der hard social and economic conditions lead to a culture-specific com-
plaint of debilidad, or exhaustion. . . . Those with debilidad can be shown
to have suffered more physically and psychologically over their lifetimes
(Oths 1999: 309).
The study of the mindful body in interconnected experiential, cultural,
social, and political economic contexts, with particular concern for the
ways social inequality is inscribed in bodies and bodies, in turn, are trans-
formed into consumers of self improvement commodities (or themselves
become commodities for sale for the improvement of others) are key topics
for critical medical anthropology. Implied in this wide range of concerns
is the belief that a critical perspective provides the conceptual framework
needed to analyze macro-micro connections (e.g., between individual ex-
50 Medical Anthropology and the World System
from oppressive health and social conditions. In sum, through their theo-
retical and applied work, critical medical anthropologists strive to con-
tribute to the larger effort to create a new health system that will serve
the people. This system will not promote the narrow interests of a small,
privileged sector of society. Its creation requires a radical transformation
of existing economic relationships.
The Bell Curve, as many have pointed out, the book is a case of bad science.
For example, Leon Kamin (1995), a professor at Northeastern University,
has shown how the book relies on concocted data, research findings con-
trary to those reported by Herrnstein and Murray, non-IQ data reported
as IQ findings, and similar distortions that are made to serve a predeter-
mined set of conclusions about African American inferiority. Based on his
analysis, Kamin (1995: 103) concludes, “The book has nothing to do with
science.” The problem here is not science per se but the rotten apple in an
otherwise healthy barrel.
Radical social constructionism takes a different approach in its critique
of science. As Haraway (1991: 186) explains, the goal of this perspective
is to find “a way to go beyond showing bias in science (that proved too
easy anyway), and beyond separating the good scientific sheep from the
bad goats of bias and misuse.” Instead, social constructionists seek to de-
construct “the truth claims of . . . science by showing the radical historical
specificity, and so contestability, of every layer of the onion of scientific . . .
constructions” (186). In other words, social reconstructionism is concerned
with showing that scientific knowledge (including that which falls into
the realm of good science) is produced under a particular and influencing
set of cultural and historic conditions and that the insights of science are
not discovered but socially crafted. As Latour and Woolgar (1986: 243)
argue, based on a careful ethnographic study of daily life in a scientific
laboratory, “Scientific activity is not ‘about nature,’ it is a fierce fight to
construct reality.” The underlying objective of science is to create order out
of the disorder of experience. But, Latour and Woolgar emphasize, the
order of science is constructed by scientists and is not inherent in nature.
In this view, the scientific method is a set of rules for constructing an order
that is so endowed with an aura of facticity and authority that it is em-
braced and treated by other scientists as fundamentally true.
In this light, it is the view of CMA that it is just as problematic not to see
the cultural (and political economic) in science as it is to see only the cultural
(and political economic) in science. A failure to see science as an activity that
emerged and operates within a given set of cultural circumstances is in-
fluenced by the worldview and values peculiar to those circumstances,
and serves particular social needs and groups found therein is to treat
science as a special case, different from other forms of human activity.
There is no justification for this kind of privileging of one form of human
endeavor over all others. Conversely, if science is to be treated as nothing
but culture, then surely it cannot be brought to bear in discerning the
accuracy or validity of any claim to truth. The Nazi claim, for example,
that Jews constitute a subhuman group cannot be refuted scientifically if
science is deconstructed as culture only. Franz Boas, a leader of modern
anthropology during its development in the United States, undertook pre-
cisely this kind of work. His books were burned by the Nazis in Germany
Theoretical Perspectives in Medical Anthropology 53
The operatives . . . must stand the whole time. And one who sits down, say upon
a window-ledge or basket, is fined, and this perpetual upright position, this con-
stant mechanical pressure of the upper portions of the body upon spinal column,
hips, and legs, inevitably produces the results mentioned. (Engels [1845] 1969:
190–93)
Since their emergence some five million years ago, humans have lived in
a delicate interaction with the rest of the natural habitat. Humans, of
course, are a part of nature. In contrast to other animal species, however,
we engage nature not directly, but through our sociocultural systems. Ac-
cording to Godelier (1986: 28), the natural environment is a “reality which
humanity transforms to a greater or lesser extent by various ways of acting
upon nature and appropriating its resources.” In other words, humans are
situated in an environment that entails both a natural dimension and a
culturally constructed one. This social environment is an intricate system
of interaction between nature and culture, which is created under specific
physical limits and imposes various material constraints upon human
populations. Experientially, of course, we cannot separate nature and cul-
ture. As humans we can only experience nature as we culturally construct
it, imbue it with meaning, and interact with it in ways that fit within our
particular cultural frames of understanding and emotion.
Technological innovations have enabled humanity to adjust to habitats
other than the savannah of East Africa, where it appears that the first
bipedal primates or hominids emerged. In the past, most anthropologists
believed that the adoption of farming or food production constituted an
evolutionary advance: the over foraging or food collection that resulted
in an improvement in human health and well being. Research by Richard
Lee and Irven DeVore (1976) among the San in the Kalahari Desert of
Southwest Africa, however, revealed that people in this desert-dwelling
foraging society worked fewer hours per day to provision themselves than
most farmers but were better nourished and generally healthier than their
58 Medical Anthropology and the World System
A relatively new scale of organization, [the] global culture has emerged within
only the past 200 years. . . . This global system has systematically absorbed large-
and small-scale cultures and is itself so homogenous that it could be treated as a
single culture. Industrialization has enriched, impoverished, and destabilized the
world. The global system was created by a commercialization process that reversed
the relationship between political and economic organization. Political organiza-
tion is now in the service of ever more powerful economic interests. The global
economy is primarily dedicated to the production of profit for the stockholders of
corporations. When the costs and benefits of global-scale culture are considered,
poverty must be added to inequality and instability, because the global system
contains economically stratified nations, which are themselves highly stratified
internally. (Bodley 1994: 16)
scribes as the capitalist world system. At any rate, the evolution of socio-
cultural systems has been accompanied, as Bodley (1996: 25) asserts, by
“a remarkable increase in the human sector of the global biomass (humans
and domestic plants and animals) and a corresponding reduction in the
earth’s natural biomass” or what environmental scientists refer to as bio-
diversity. The advent initially of agrarian state societies and later of cap-
italist industrial societies was accompanied by patterns of differential
power, social stratification, urbanization, population growth, increasing
production and consumption, resource depletion, and environmental deg-
radation. Indeed, John Bennett (1974: 403) alludes to an “ecological tran-
sition” in sociocultural evolution that entails a “progressive incorporation
of Nature into human frames of purpose and action” and evolution from
societies that were in relative equilibrium with the natural environment
to those that are in disequilibrium with it. According to Bodley (1985: 31),
“Social stratification, inequality, urbanization, and state organization . . .
set in motion a system that is almost inherently unstable.” Agricultural
practices in ancient states or civilized societies often were factors in en-
vironmental degradation. Large-scale irrigation in ancient Mesopotamia,
the area between the Tigris and Euphrates rivers in what is present-day
Iraq, resulted in the gradual accumulation of salts in the soil, which in
turn contributed to the collapse of Sumerian civilization after 2000 b.c.
The development of mercantile and later of industrial capitalism resulted
in an expanded culture of consumption that even further strained the
environment.
Juergen Habermas describes the destructive impact of capitalism upon
the global ecosystem as follows:
Foraging Societies
Ancient foragers appear on the whole to have enjoyed surprisingly
well-nourished and fulfilling lives. Table 3.1 presents data that compare
life expectancies in ancient foraging societies to later, more complex so-
cieties.
Although early hominids carried parasitic diseases that had also existed
among their pongid or ape ancestors, their low population densities and
migratory patterns tended to mitigate the disease load of specific foraging
bands. Nevertheless, despite a relative abundance of food and a low in-
cidence of infectious and chronic diseases, it appears that life, in terms of
life expectancy, during the Paleolithic or “Old Stone Age” (the vast period
from the earliest stone tools to the period just prior to the advent of farm-
ing) was often precarious. A heavy reliance upon a fluctuating and un-
predictable supply of large game and the existence of predators posed a
Table 3.1
Life Expectancies of Various Preindustrial Human Populations
significant risk for human populations, who had to rely upon handmade
weapons and fire as forms of protection. Big game hunting itself was a
highly dangerous endeavor that undoubtedly took the lives of many hunt-
ers. The retreat of the glaciers of the last Ice Age or Fourth Glacial period
(about ten thousand years ago) converted grasslands to forests, thus lead-
ing to the extinction of most of the big game animals that had subsisted
upon grass and upon which foragers had relied heavily for their food.
These climatic and environmental changes ushered in a period that ar-
chaeologists refer to as the Mesolithic, associated with a broad-spectrum
revolution that entailed a greater reliance on a wide assortment of small
and medium-sized game, such as deer and rabbit (which were far less
dangerous to hunt), as well as a wider diversity of plant foods. According
to Hunt (1978: 56) and as we can see from Table 3.1, “the evidence from
paleopathology indicates a quantum jump in the expectation of human
life at birth in the Mesolithic stage of cultural evolution (about ten thou-
sand years ago) followed by a plateau that lasted until medieval times.”
Furthermore, ancient as well as contemporary foraging societies lived
or continue to live in relative harmony with their respective econiches.
Nonetheless, it is important not to romanticize these societies or to believe
that we may return to a life of nomadic hunting, fishing, and gathering.
Additionally, these societies do leave their footprints on their environ-
ments. For example, foragers historically have used fire to clear the land-
scape of brush and trees in order to hunt game more effectively. This has
led to deforestation in many settings. Bison drives on the North American
plains, in which the Indians stampeded large herds over cliffs, led to mass
deaths of animals. In contrast to later societies, however, the adverse eco-
logical impact of the earliest human societies was minimal. The Mbuti
pygmies of the Ituri Forest in Zaire in central Africa, for example, base
their tendency to limit the consumption of animal protein upon their belief
that eating animals such as deer and elephants shortens their life span.
They maintain that in the primeval past they were vegetarians who could
have lived forever, but with the adoption of meat eating they embarked
upon a path that ultimately led to death.
Epidemiologist Frederick Dunn (1977: 102–3) makes several key gen-
eralizations about the health status of foraging populations:
“A Closer Look”
W HAT DO PR EHISTOR IC AND C ONTEM POR ARY
F ORA GERS TELL US A BOU T EATING AND LIV ING
R IGHT?
In The Paleolithic Prescription, physician S. Boyd Eaton, anthropologist
Marjorie Shostak, and physician-anthropologist Melvin Konner propose
Health and the Environment 63
Table 3.2
Parasitic Helminths and Protozoa in Four Foraging Groups
a general plan for healthy living in the modern world by adopting certain
dietary and exercise habits from prehistoric and contemporary foraging
societies (Eaton, Shostak, and Konner 1988). Indeed, they argue that our
biochemistry and physiology are much more in tune with an active no-
madic foraging lifestyle than with one in which most people are engaged
in relatively sedentary occupations (e.g., repetitive assembly-line work,
office work, or attending lectures and studying) and sedentary leisure
activities (e.g., spectator sports and television and movie viewing). As part
of their program for healthy living, Eaton et al. suggest that modern peo-
ple adopt a “stone age diet.” They contend that among foragers
Dietary quality is generally excellent, providing a broad base of proteins and com-
plex carbohydrates along with a rich supply of vitamins and nutrients. Dietary
quantity is occasionally marginal or deficient, but this is true of most agricultural
cultures as well—probably even more so. Maintenance of the forager diet is ac-
complished with a moderate work load, leaving ample time for the pursuit of
leisure activities. (Eaton, Shostak, and Konner 1988: 28)
Table 3.3
Late Paleolithic and Contemporary U.S. Dietary Compositions
from wild plant foods. Foragers drank water as their major and generally
only beverage. By and large they began to consume alcohol only after
contact with civilized societies. Indeed, alcohol served as an important
vehicle used by European societies for conquering not only foragers but
also indigenous populations in North America and the Pacific Islands.
Paleontological evidence indicates that prehistoric foragers exhibited
strength, muscularity, and leanness on par with outstanding contempo-
rary athletes. Both hunting and gathering demand great stamina. Men
track, stalk, and pursue game; and women walk long distances with heavy
loads of wild plants, wood, water, and young children. Although blood
pressure and blood sugar levels tend to rise with age among contempo-
rary North Americans, they remain low throughout life among foragers,
even among those who live to an advanced age. Cholesterol levels typi-
cally are much lower among foragers, as well as among horticulturalists
and pastoralists, than they are among people in industrial societies. The
San of Southwest Africa who are still able to live some semblance of a
traditional foraging lifestyle reportedly exhibit a low incidence of hyper-
tension, heart disease, low cholesterol, obesity, varicose veins, and stress-
related diseases such as ulcers and colitis (Lee 1979). The life expectancy
of San adults exceeds that of adults in many industrial societies. Con-
versely, they are more vulnerable to infant mortality, malaria, and respi-
ratory infections, as well as to accidents, because of the limited availability
of biomedical facilities. In the case of the Inuit, McElroy and Townsend
(1989: 28) report that while their diets are high in fat, they exhibit low
cholesterol levels, low blood pressure, and low rates of heart disease.
Health and the Environment 65
The late Paleolithic was a period when human existence was in accord with nature
and when our life-styles and our biology were generally in harmony. . . . [It was
also] a time when half of all children died before reaching adulthood, when post-
traumatic disfigurement and disability were distressingly common, and when the
comfort and basic security of life were orders of magnitude less than they are at
present [at least for the majority of people in the middle and upper classes in
industrial societies]. (Eaton, Shostak, and Konner 1988: 283)
program neglects the role that the heavy use of pesticides, preservatives,
radioactive materials, various forms of pollution, and other social envi-
ronmental factors play in the etiology of cancer. Furthermore, we must
ask why so many people in modern societies, including physicians and
nurses, engage in eating patterns and other forms of behavior, such as
smoking, heavy drinking, and overeating, that they know unequivocally
contribute to disease. It appears that many unhealthy behaviors constitute
mechanisms for coping with modern problems—alienating work, unem-
ployment or the fear of it, social isolation, lack of a sense of personal
fulfillment, and the frantic pace of life in which time has become equated
with money and in which full membership in a supportive community
has been replaced by partial membership in diverse social groups and
activities such as churches, hobbies, and self-help organizations.
Domestication forces human beings to deal at close range with animals throughout
their life cycles and to encounter their body fluids and wastes, as well as their
carcasses. Domestic dogs, as well as wild ones, can transmit rabies. In fact, they
are the major source of human infection. Domestic cats may harbor toxoplasmo-
sis. . . . Tetanus, one of the most dreaded diseases of recent history, is spread by
domestic horses and to a lesser extent by cattle, dogs, and pigs. It can also spread
to soil, but soil that has never been grazed or cultivated is generally free from
bacteria. (Cohen 1989: 45–46)
lithic sites in both the Old and New worlds demonstrates a recurrent
pattern of decreased stature, higher infant mortality, and increased phys-
iological stresses associated with malnutrition.
The nutritional quality of food in horticultural village societies tends to
be inferior to that of foraging societies. The major foods (e.g., manioc,
cassava, sweet potatoes, yams, bananas, plantains, etc.) among slash-and-
burn horticulturalists are high in bulk but low in nutrients. Although these
starchy tropical crops are good sources of food energy, they are poor
sources of protein. As a result, horticulturalists sometimes raise domes-
ticated animals, such as pigs in the case of highland populations in Papua
New Guinea. Most horticulturalists, however, lack domesticated animals
and rely instead upon hunting or fishing for their supply of animal pro-
tein. They also tend to work harder than foragers. Slash-and-burn horti-
culturalists need considerable time and energy to clear land and plant,
tend, and harvest their crops as well as hunt or raise domestic animals.
to use and control their natural environment, and the downfall of these
same civilizations was due to their failure to maintain a harmonious re-
lationship with nature.”
Population density played an even more crucial factor in human sus-
ceptibility to disease in agrarian state societies than it did in horticultural
village societies. For example, Cohen (1989: 49) contends that measles,
which may have come from a virus of dogs or cows, constitutes a “disease
of civilization” in that its “origins must be related to the growth of the
human population and its coalescence into dense aggregates or wide-
spread and efficient networks.” The appearance of the first cities in archaic
state societies made access to clean water and the removal of human
wastes problematic. Agriculture in many of these early states was based
upon large-scale irrigation systems, which often created the conditions for
vector-borne diseases such as malaria and schistosomiasis. Unequal access
to food supplies contributed to the emergence of malnutrition and, as a
consequence, greater susceptibility to disease among the economically ex-
ploited masses, particularly in urban areas.
In his classic Plagues and Peoples, historian William H. McNeill (1976)
demonstrates that epidemics have played a major role in the expansion
of agrarian states throughout history, especially in their incorporation of
indigenous societies. He suggests that three major waves of disease in the
past 2,000 years can be related to three major events of population move-
ments: the formation of trade linkages by sea and land early in the Chris-
tian era, the militaristic expansion of the Mongols in the thirteenth century,
and European expansion beginning in the fifteenth century. The de-
population of North and South American societies was a by-product of
European colonization that introduced alien infections from the Old
World. McNeill describes such imperialistic and mercantile processes as
expressions of “macroparasitism.” Whereas the term microparasites refers
to disease organisms, such as viruses, bacteria, protozoa, and helminths,
macroparasites are large organisms, including humans, that expropriate
food and labor from conquered or low-status groups. Although macro-
parasitism as a sociocultural phenomenon emerged during the Neolithic
period, P. Brown (1987: 160) maintains that it took on its most elaborate
form in state societies where it became manifested in “terms of tribute,
rent, sharecropping contracts, and other forms of ‘asymmetrical economic
exchange.’”
Although agriculture served to support an increased population, the
rise of civilization also contributed to a net loss of dietary diversity and
nutritional quality, particularly among peasants and economically mar-
ginal urbanites. As Cohen (1989: 69) notes, the “power of the elite not only
affects the quality of food for the poor but may undermine their access to
food, their very right to eat.” At the very same time that elites came to
enjoy sumptuous supplies of food imported from far-flung areas as well
Health and the Environment 69
Indeed, a measure of income disparity may not even be the most salient. The
significant differences between the global winners and global losers may turn on
such basic issues as the provision of clean water, access to shelter and health care
and the chances of surviving infanthood. (Cohen and Kennedy 2000: 151)
products per capita tend to have high infant mortality rates and low life
expectancies. Certain post-revolutionary or socialist-oriented countries,
such as China, situated in the periphery or semi-periphery exhibit a rela-
tively healthy populace because of the commitments that they have made
to eradicate malnutrition, improving sanitation, and providing both pre-
ventive and curative health services. Although Cuba remains a relatively
poor country and has faced enormous economic difficulties following the
collapse of the Soviet Union, it had an infant mortality rate of 7 per 1,000
live births and a life expectancy of 75.7 years in 1999 (United Nations
Development Programme 1999)—health statistics that compare favorably
with those of the United States, the leading and richest member of the
core.
Although globalization has been a feature of the capitalist world-system
since its inception, corporate and government policy makers throughout
the globe have increasingly relied upon a political-economic perspective
referred to as “neoliberalism” that essentially maintains that corporate
profit making will result in a trickle-down improvement of socioeconomic
and health conditions, with minimal state intervention, to address the
health and social needs of the poor. The World Bank’s neoliberal policy
of “structural adjustment,” however, has fostered privatization of social
and health services that in turn has adversely affected the poor around
the globe. The deleterious impact of neoliberalism upon the poor is doc-
umented in Dying for Growth (Kim, Millen, Irwin, and Gershman, eds.
2000), an ambitious and encyclopedic project emanating from the collab-
orative efforts of an interdisciplinary team, which includes several medi-
cal anthropologists, based at the Institute for Health and Social Justice in
Cambridge, Massachusetts.
Private multinational corporations and state corporations in both cap-
italist and post-revolutionary or socialist-oriented societies have created
not only a global factory but also a new global ecosystem characterized
by extensive motor vehicle pollution, acid rain, toxic and radioactive
waste, defoliation, and desertification. Anthropologist John Bodley (1996)
contends that the environmental crises provoked by “industrial civiliza-
tion” produces many social problems, including overpopulation, over-
consumption, poverty, war, crime, and many personal crises, including a
wide array of health problems. Indeed, some analysts, such as Andre
Gorz, argue that capitalism is on the verge of self-destruction because of
its emphasis on ever-expanding production:
Economic growth, which was supposed to ensure the affluence and well-being of
everyone, has created needs more quickly than it could satisfy them, and has led
to a series of dead ends which are not solely economic in character: capitalist
growth is in crisis not only because it is capitalist but also because it is encoun-
tering physical limits. . . . It is a crisis in the character of work: a crisis in our
Health and the Environment 73
Table 3.4
A Profile of Health in the Capitalist World-System
relations with nature, with our bodies, with future generations, with history: a
crisis of urban life, of habitat, of medical practice, of education, of science. (Gorz
1980: 11–12)
“A Closer Look”
“A Closer Look”
McGuire (1991: 60) note, “Many young males are socialized into taking
lots of risks and into feeling or appearing invulnerable; media messages
glorify speed and risk-taking.”
Despite the messages conveyed by advertisements promoting its sale
as well as by the mass media as a whole, the automobile is not merely a
toy or an extension of the male genitalia but a highly lethal machine.
Visitors to other countries, particularly Western Europe and Japan, have
noted that “automobilization” (Sweezy 1973: 7) has become a global phe-
nomenon. Along with industrial pollution, motor vehicles have trans-
formed many cities around the world, particularly ones in the Third World
such as Mexico City, into environmental disaster areas accompanied by a
wide array of health problems. Of the estimated 4.4 million tons of human-
generated pollutants emitted into the air of Mexico City in 1989, 76% were
produced by motor vehicles (Freund and Martin 1993: 67). In contrast, of
the 3.5 million tons of human-generated pollutants emitted into the air of
Los Angeles—America’s most polluted city—in 1985, 63% were created
by motor vehicles. The rush-hour motor vehicle speeds have been re-
ported to be 7 miles per hour in London, 12 miles per hour in Toyko, 17
miles per hour in Paris, and 33 miles per hour in Southern California
(Freund and Martin 1993: 2). Indeed, Sweezy (1973: 4) compares auto con-
gestion and pollution to the “outward symptoms of a disease with deep
roots in the organs of the body.” In other words, the automobile has be-
come a major form of assault on the social and ecological body. Motor
vehicles also are a major contributor to global warming (Alvord 2000:
70–71).
One of the major by-products of gasoline exhaust is benzoapyrene, a
carcinogenic chemical that is suspended in urban air. Motor vehicles emit
carbon monoxide, sulfur oxides, and nitrous oxides, which in turn con-
tribute to acid rain and human respiratory complications. The American
Lung Association estimated that in 1985 motor vehicle pollution contrib-
uted to some 120,000 deaths in the United States (Freund and Martin 1993:
29). Sixty percent of the residents of Calcutta, India, were found to have
pollution-related respiratory problems (Freund and Martin 1993: 67).
In addition to their destructive impact on the environment, motor ve-
hicles are a major source of accidents around the world. Freund and
McGuire (1991) present the following sobering statistics on auto accidents
in this country:
While the death rate due to auto accidents in the United States is by no means the
highest among the industrialized countries, some 43,000 to 53,000 Americans die
each year in such accidents, producing a death rate of over 26 deaths per 100,000
population. Worldwide, some 200,000 people died in traffic accidents in 1985.
There are approximately 4 to 5 million injuries related to motor vehicles in the
United States. Of these, 500,000 people require hospitalization. . . . Auto accidents
80 Medical Anthropology and the World System
are a leading cause of death for young people between the ages of five and twenty-
four; young males between the ages of fourteen and twenty-four are at highest
risk. Per passenger mile, cars are more dangerous than trains, buses, or planes.
(Freund and McGuire 1991: 59)
Motor vehicles also pose hazards for pedestrians and cyclists. The Na-
tional Safety Council reported some 6,600 pedestrian deaths and 800
cyclist deaths in 1989 in the United States (Freund and Martin 1993: 102).
Motor vehicle driving, particularly under congested conditions, also
induces stress and heightened blood pressure, contributes to medical com-
plications such as lumbar disk herniation, or motorist’s spine, and con-
tributes to sedentarization. Truck drivers in particular suffer a high rate
of back injuries. Furthermore, auto transportation discourages patterns of
sociability that are vital to mental health in that most motorists, especially
in First World countries, drive alone. With the decline of public transpor-
tation, especially in the United States, mothers in particular function as
chauffeurs for their children as they transport them hither and yon in
sprawling suburban developments. Low-income people often find them-
selves without adequate transportation in cities where an increasing num-
ber of jobs are located in the suburbs.
Public awareness of some aspects of motor vehicle transportation
reached new heights with the publication of Ralph Nader’s (1965) book
Unsafe at Any Speed. Although there have been efforts to reduce motor
vehicle accidents with the installation of seat belts and other safety devices
and, at least until 1995, a lowering of speed limits, such measures tend to
focus on altering individual behavior. Furthermore, the automobile in-
dustry lobby has consistently resisted the passage of regulations to require
air bags in cars. In reality, as Jacoby (1975: 141) observes, the victim of an
automobile accident is a “victim of an obsolete transportation system kept
alive by the necessities of profit.” Unfortunately, a powerful lobby con-
sisting of the automobile industry, petroleum companies, and trucking
companies, poses a power barrier to the development of effective public
transportations, especially in most American urban areas. Whereas heavy
trucks contribute more than 95% of the highway deterioration in the
United States, trucking firms pay only 29% of the country’s highway bill
(Freund and Martin 1993: 2).
It follows, following Freund and McGuire (1991: 60), that an ecological
approach to addressing the health consequences of the automobilization
of society requires “changing the social and physical environment (e.g.,
building safer highways), producing safer cars, and making many alter-
native ways of traveling available to drivers.” Unfortunately, the sanctity
of the automobile as an integral component of U.S. culture has virtually
gone unchallenged. In contrast, the Green movement in Western Europe
has mobilized as a counterhegemonic opposition to the automobilization
Health and the Environment 81
relative underdevelopment, external aggression, and, especially for the small, de-
pendent economies of the Third World, a disadvantaged position in the interna-
82 Medical Anthropology and the World System
tional market. The corresponding pressures to satisfy the material needs of the
populations, ensure adequate military defense, and continue producing and ex-
porting cash crops and raw materials for foreign exchange, have led to an em-
phasis by socialist policy-makers on the accumulation by the state, the uncritical
adoption of many features of capitalist development, and a largely abysmal record
vis-à-vis the environment (although there are exceptions, of course). (Yih 1990: 22)
Homelessness in the
World System
When we look around the cities of the United States in the second millen-
nium, homelessness appears to be a widespread and perhaps unchanging
condition. However, in most cities, homelessness reemerged as part of the
American experience only in the late 1970s and early 1980s (Dehavenon
1996). In fact, in New York City in 1975 the Governor’s Task Force counted
only thirty homeless families, whereas by the 1980s this figure had risen
to 5,000. The number of families seeking emergency shelter did not be-
gin to drop until the late 1990s and by 2001 homelessness had risen once
again to the high levels of the 1980s. In the same period, estimates of the
number of homeless individuals in New York City have varied from
35,000 to 100,000.
As many anthropologists have been recruited to conduct ethnographic
research in coordination with medical projects concerned with mental ill-
ness, tuberculosis, HIV, and other health issues, homelessness and its con-
struction have become controversial issues for medical anthropology. A
fundamental question concerns the causes of homelessness. Frequently,
there exists an underlying assumption that people may be homeless be-
cause of problems with mental health or learned behavior. In the course
of their research, anthropologists and other social scientists have consis-
tently found that homelessness is best explained in relation to housing
and poverty rather than specific mental problems. Many health problems
stem from deprivation or can be found among homeless people, but such
problems are not confined to the homeless. In contrast to much media
representation and many popular assumptions, mental illness and sub-
84 Medical Anthropology and the World System
stance abuse do not define this population, nor do such issues alone ac-
count for homelessness.
To understand homelessness, we need to see how it has been created in
different historical contexts and in different societies. A brief consideration
of the word homeless already shows us some of the issues to be addressed.
There are poor people without shelter all over the world. Mexico City, Rio
de Janeiro, and many other major cities in Latin America are surrounded
by shantytowns or informal settlements outside the formal municipal dis-
tricts. Favelas, squatter communities, have been the subject of much an-
thropological research in Latin America since the 1960s. Many cities in
Africa have been circled by growing squatter settlements for the past
thirty years. In Durban, South Africa, hundreds of thousands of Africans
moved into informal settlements surrounding the city after apartheid laws
restricting the movements of Africans were repealed. None of these pop-
ulations is usually referred to as homeless.
In the United States, the term homeless came into popular use in the
late 1970s as a way to describe the growing numbers of poor people who
were sleeping in the streets and public places. Later as many people tem-
porarily found overnight shelter in churches, warehouses, and armories,
municipalities began to count homeless populations. The 1990 census con-
tained an institutional recognition of the new homeless population, and
anthropologists were called upon to define and count street people for the
national statistics. Homelessness has become a predictable aspect of life
in American cities, and the fact that the phenomenon is qualitatively new
and different from experiences of poverty in the 1950s, 1960s and 1970s
has been quickly forgotten (Susser 1996).
In this chapter, we will briefly examine experiences of vagrancy and
poverty and their treatment by governments during the emergence of
capitalism in Europe and later in the United States. This will give us some
background for understanding poverty today and putting homelessness
in historical and geographical perspective.
Since Britain was the first country to develop industrial capitalism, we
will start there in looking for the roots of modern poverty and homeless-
ness. Vagrants and wandering poor people began streaming into London
in the sixteenth and seventeenth centuries. As feudal lords, entering com-
mercial wool production, found it more profitable to keep sheep on wide
areas of land, Enclosure Laws were introduced to allow the displacement
of serfs from their ancestral cottages and farm plots. As people flocked to
towns looking for work and for new ways to survive in an emerging
capitalist economy, they were separated from their hereditary ties with
the rural villages of Britain.
As many people were freed from agricultural serfdom, the creation of
wage labor was accompanied by a new form of insecurity in the form of
unemployment. The British government had to introduce a way of coping
Homelessness in the World System 85
with the poor, who had previously been tied to and supported by the land
of feudal lords. Throughout the sixteenth century in Britain the number
of beggars grew; the British government started first to register, license,
and count beggars and later to punish and enslave those without licenses.
Later, laws were passed that taxed local villages to provide funds to sup-
port the poor of their own districts (Piven and Cloward 1971).
In the nineteenth century, with the expansion of agriculture, the taking
over of common lands, and the introduction of machinery, many more
people found themselves out of work. The poor relief system was greatly
expanded to address this issue. In the United States as well as in Britain,
poorhouses were created, where people lived and were also forced to
work for their living, as the government authorities saw fit. Clearly, under
current usage, we would have called such people homeless. It was not
until the twentieth century that methods of controlling the destitute
through poorhouse residences and work requirements were abandoned
and other forms of public assistance were implemented in most industri-
alized countries.
Based on this brief history, let us now return to consideration of the
United States during the twentieth century. New institutions are usually
initiated in times of crisis, and the Great Depression was one such period.
After the financial crash of 1929, the population of the United States ex-
perienced unemployment rates through the 1930s of around 40%. New
words became popular, such as hobos, for individuals who crossed the
country looking for work, and Hoovervilles, for makeshift settlements set
up by families evicted from their homes because unemployment had
made it impossible to pay the rent or mortgage. These settlements around
the country, like the one in Central Park in New York, were named after
President Herbert Hoover, who in the depth of the Great Depression did
not believe the government was responsible for solving the unemploy-
ment situation. As a consequence he lost the presidency to Franklin De-
lano Roosevelt.
Anthropologists and sociologists have published studies of the hobos,
conceived of consistently as men. Surprisingly little attention was paid to
the squatter settlements known as Hoovervilles, where women and chil-
dren were also to be found. In 1934, President Roosevelt initiated the
Social Security Act to provide the first federal public assistance program
for widows and orphans: Aid to Dependent Children. No specific provi-
sion was outlined for homeless people, but public assistance did include
a calculation of the cost of rent and housing. However, having a home
was not made into a socially guaranteed right, which might have pre-
vented future homelessness. It was not until the new homelessness of the
1980s that the constitutional right to shelter began to be established in
some courts (Hopper and Cox 1982).
From the 1940s to the 1970s, high employment rates and the increasing
86 Medical Anthropology and the World System
for men, women, and families without shelter. Armories were opened up
as temporary shelter for homeless men and women; families were housed
in a variety of rundown hotels. Since that time, many legal battles have
been fought over the lack of provisions for housing homeless people and
an entire bureaucracy has been created to address the issue (Gounis 1992;
I. Susser 1999).
However, the basic problem of the increasing gap between rich and
poor and the difficulty for the poor to find homes or to retain their footing
in working class neighborhoods remains (Sharff 1998). In the 1990s, people
became homeless when the economy failed to provide work for the grow-
ing population of poor people. In 1996, after the welfare laws introduced
in the 1930s were replaced by Temporary Assistance to Needy Families
(TANF), which required welfare-recipients to find paid work, many peo-
ple found themselves working in such low-paid jobs that they could not
afford rent.
The U.S. media and much of the social science literature have focused
on the individual problems of homeless people. Homeless people suffer
from many health problems, including mental illness and substance
abuse. Some researchers have suggested that the increase in homelessness
was precipitated by the closing of state institutions for the mentally ill,
which was mandated by the Kennedy administration in the late 1950s.
However, large numbers of homeless people did not appear on the streets
until twenty years later. Increasing homelessness corresponds directly to
changes in the United States such as deindustrialization in the 1980s and
globalization since the 1990s, which have resulted in the loss of jobs com-
bined with a shift in public expenditure away from health care, social
services and public housing. Reductions in the federal budget for social
services, changes in real estate regulation and taxes, and the increasing
cost of housing, rather than individual issues such as mental illness and
substance abuse make people most vulnerable to homelessness in a wors-
ening economic situation (Hopper, E. Susser, and Conover 1987, Dehav-
enon 1996, I. Susser 1996).
Since the 1980s, homelessness has become one aspect of life frequently
experienced by poor working class people in the United States (I. Susser
2002). For example, it has been estimated that in the 1990s about 5% of
New York City’s poor population experience homelessness every year.
People find themselves doubling up in apartments with relatives long
before they end up in public shelters. Later they may pass through the
shelter system before they can find an affordable apartment. Many people
living in homeless shelters have children living in homes with friends and
relatives. In addressing the health problems of the homeless, researchers
have found that they must address the problems of access and continuity
of care throughout the growing poor population of the United States.
88 Medical Anthropology and the World System
homelessness and joblessness and for other homeless people might be the
immediate cause of their current situation. In either case, such problems
are common health issues among the homeless population. On many oc-
casions women and their children leave their homes and seek shelter to
escape battering and other forms of violence, frequently from their part-
ners (I. Susser 1998). However, as noted above, the causes of homelessness
in general must be sought in the lack of available, affordable housing for
people, whether or not they are mentally ill or addicted to drugs or al-
cohol. Historically, in the United States, low rent housing was available
for such people. However, in the 1980s and 1990s societal changes and
changes in federal funding priorities led to the loss of housing among the
poorest groups in the population.
Two of the increasingly serious health problems confronted by the poor
and homeless population in the United States of the 1990s were tubercu-
losis and HIV infection. The two conditions are directly related, as HIV
infection undermines the immune system and leaves individuals particu-
larly vulnerable to contracting tuberculosis. In the 1990s, it was estimated
that one-half of those individuals with active tuberculosis in New York
City were also HIV positive (Landesman 1993). Tuberculosis, which is
spread through respiratory secretions, has historically been associated
with poor housing conditions and poor nutrition. It should come as no
surprise that the problem resurfaced among people deprived of homes
and surviving on the margins of the U.S. economy. Crowded conditions,
such as those found in shelters and prisons, provide excellent breeding
grounds for the tuberculosis bacterium. Exacerbating this situation was
the dramatic cutback in clinics and preventive services addressing the
problem of tuberculosis in U.S. cities. Between 1960 and 1980 most of the
preventive network of clinics and community services constructed over
the previous sixty years to combat the tuberculosis epidemics of the nine-
teenth and early twentieth centuries were dismantled. As a result, between
1979 and 1986, the incidence of tuberculosis in New York City increased by
83%. Twenty to 30% of the people with tuberculosis were homeless (Lerner
1993). As tuberculosis resurfaced, cities had to attempt to rebuild lacerated
community prevention networks. New York City implemented monitoring
programs to make sure people took their medications. The implications in
the media and some of the health literature was that the reason tuberculosis
was spreading was that people, particularly poor people like the homeless
population, were not taking their medications. This blaming of the victim
ignored the systematic causes of the spread of tuberculosis in relation to
poor housing conditions and the dismantling of the preventive public
health system, which had in previous decades set up clinics in poor areas
that provided free x-ray screenings, free medications, and ongoing treat-
ment and evaluation for community residents.
HIV infection/acquired immunodeficiency syndrome (AIDS) is still in-
90 Medical Anthropology and the World System
creasing among poor and minority populations and also among those
who have lost their homes. For poor homeless men and women, the sale
of sexual services is one avenue through which to earn money. The need
for money may also be exacerbated by addiction to substances such as
crack cocaine. Among many people in the shelters, beset by violence and
hopelessness, attention to the prevention of HIV infection may appear too
distant a concern. Many may not envision themselves as living long
enough to die of AIDS. Epidemiological research in the shelters of New
York City suggests a high rate of HIV infection. Since people usually have
sexual relations and share needles and drugs with people in their net-
works, this puts shelter residents at even higher risk.
Hospitals are required to find adequate housing for people with AIDS
and are not supposed to return individuals with an AIDS diagnosis to the
streets. However, ethnographers interviewed people in the shelters who
were frequently readmitted to hospitals with AIDS complications and some
who eventually died while still homeless. Others were in fact housed in
special apartments, and some of these chose to return to be with their
friends at the shelters (I. Susser and Gonzalez 1992). Just as Wagner docu-
ments for a New England town, homeless people in New York developed
their own supportive communities around the shelter services, and many
chose to return to these social centers after they found other housing.
Ironically, in some cities, shelters have become an opportunity to offer
services to which poor people may not have previously had access. For
example, public health nurses worked in some homeless hotels in New
York City and contacted pregnant mothers to facilitate their access to pre-
natal care. In one hotel, they also printed a newsletter that discussed issues
such as the prevention of HIV infection. Similarly, in other shelters where
Ida Susser conducted research some forms of psychiatric evaluation ser-
vices were offered. Programs such as the Women, Infants, and Children
(WIC) program and day-care services were to be found in some shelters,
as well as programs to address substance abuse and the search for housing
(Christiano and Susser 1989; Susser 1993).
Anthropologists have been particularly involved in interdisciplinary
collaboration in such programs as the development of HIV prevention
programs in the shelters (Susser and Gonzalez 1992) and in evaluating in-
terventions in community psychiatry. As in the approach to HIV, most an-
thropologists working with homeless populations have seen themselves
both as researchers and as activists concerned with the improvement of
conditions faced by the population they serve (M. Singer 1995).
A team approach involving anthropologists with psychiatrists, case-
workers, and epidemiologists proved extremely effective in implementing
and evaluating an intervention for mentally ill homeless men in a shelter
in New York City (E. Susser et al. 1993). The purpose of the intervention
was to assist the homeless men in finding appropriate housing and to
Homelessness in the World System 91
and trust with mentally ill homeless men and their friends and relatives.
In spite of shifting locations from the streets to various sectors of the shel-
ter unsystem, institutionalization, and frequent disappearance of clients,
the anthropologists were able to maintain a 95% follow-up rate over a
period of two years. This was higher than the usually acceptable 80%
follow-up rates common to research conducted among educated middle-
income populations with permanent addresses and telephones (Conover,
Jahiel, Stanley, and Susser 1997). This study clearly shows the significance
of an anthropological approach, even in a quantitative epidemiological
experimental study. Because of the financial and theoretical support for
anthropology in this research, the anthropologists were able to gather im-
portant material for an ethnographic description of the lives of mentally
ill homeless men, documenting the constantly shifting population as it
moved from shelters to hospitals to prisons and back again. At the same
time, the anthropological connections provided an excellent research set-
ting for psychiatric epidemiologists.
In a related research project, anthropological researchers in a homeless
shelter for men in New York City were involved in a project to assist in
the prevention of HIV infection among mentally ill homeless men. They
initiated the production of a video to be made by the homeless men them-
selves for the shelter. Planning this project and filming it in the shelter
proved an important experience for the staff and the homeless men in
education concerning HIV infection. In addition, the video provided ma-
terial for anthropological analysis of the perceptions of homeless men con-
cerning sexuality, drugs, and the residents and staff of the shelter (I. Susser
and Gonzalez 1992). The video demonstrated the close connections in the
lives of the staff and the homeless men, their experiences with drugs and
AIDS, and the conflicts between the two groups around these issues. In
addition, it documented a problematic perception of women as evil and
as purveyors of disease, a further example of arguments which “blame
the victim” rather than comprehend the overall situation. In general, the
making of the video provided a forum for homeless men to work out
conflicts and attitudes concerning sexual orientation, HIV infection, and
other issues and to construct ways of addressing one another with respect
to AIDS prevention.
tion of unemployed wage laborers who are forced to move to the cities in
search of work. The development of expensive agricultural technology
combined with international corporate investment in agriculture has made
it increasingly difficult for small peasants to retain their land. As a result
there has been a loss of landholdings among the poorer peasantry and a
consolidation of income among corporate investors and peasants with large
enough landholdings to withstand the large debts accumulated in bad har-
vest years. The increasing inequality found in many rural areas has con-
tributed to the creation of a population of landless laborers. In contrast to
peasants who own their own land and may scrape a living from the sale
of produce, such people have lost their land and have to work for wages
like industrial workers. However, accompanying increasing agricultural
technology has been the reduced need for rural wage laborers. This in turn
has precipitated the waves of poverty-stricken populations that have
flooded Third World cities since the 1960s and continue to flow into unser-
viced areas of major municipalities.
Informal settlements lack major public health foundations. They lack
sewage facilities and electricity. They often lack paved roads and trans-
portation as well as running water and drinking water. In addition, they
are not easily covered by regulations and make the registration of births
and deaths or the tracking of health problems virtually impossible. Even
when residents of informal settlements find work and pay taxes, their
needs are often ignored in the spending of municipal funds.
Because of the frequent lack of running water and sewage facilities,
informal settlements are at risk for cholera and other infectious diseases.
In addition, because of the lack of industrial and environmental regula-
tion, informal settlements have been the sites of the some of the world’s
most tragic industrial disasters in recent history. In Bhopal in 1984, most
of the people who died when poisonous gas escaped from the Union
Carbide plant that manufactured fertilizers for Indian agriculture were
living in an informal settlement between the plant and the city limits.
Although regulations stated that the plant could not operate near the res-
ident population, the thousands of people housed in the informal settle-
ments on the outskirts of the city had not been considered by the plant
managers or the city government in evaluating safety concerns for the
continued operation of the plant.
“A Closer Look”
difficult to implement. For example, in 1992, the clinic that served Alex-
andra township in Johannesburg, South Africa, introduced a program
where a van drove mothers and their newborn babies home after child-
birth. In a township without street addresses and where people often had
to build their housing from cardboard and scrap metal, the clinic devised
this method to help keep in contact with mothers and newborn babies.
The reduction of infant mortality depends partly on follow-up care and
well-baby visits, which could not easily be implemented in the shifting
situations of South African shantytowns.
One approach to public health education in an informal settlement on
the outskirts of Durban in Natal, South Africa, was implemented by health
researchers and anthropologists concerned with the prevention of HIV
infection. In a shifting population with no fixed addresses, where political
violence made it difficult for outside health workers to visit or for people
to stay in one place, Ida Susser worked with a group of researchers who
found that the most effective way to reach the population was through
already-structured routes of political mobilization (Preston-Whyte et al.
1995). In a situation where telephones did not exist and shacks were
reached by narrow, winding, uphill mud paths, the researchers had to rely
on people familiar with the community to contact the residents. The public
health situation was made particularly difficult by the fact that this area
of Natal was the center of the Kingdom of Kwazulu, where political of-
ficials supporting the Zulu king were in competition for power with the
African National Congress (ANC), which was not associated with a par-
ticular ethnic group. In one part of the settlement that Ida Susser visited
in 1992, there were eleven political funerals in one week. For this reason,
many people moved quickly from place to place, to escape political re-
prisals and murder. Shacks were frequently burned down as residents
were suspected of being members of opposing political factions. It was
virtually impossible for an outside health worker to maintain direct con-
tact with large numbers of people.
In 1992 the researchers met with the local representatives of the ANC,
who organized regular meetings in the informal settlements. At that time,
the ANC was still struggling for political power in South Africa, and Af-
ricans had not yet been permitted to vote. An important woman leader,
Dr. Nkosazane Zuma, had mobilized a grassroots women’s marketing
cooperative in the informal settlement. Through her introductions the HIV
prevention team was able to attend meetings and recruit a local commu-
nity health worker. This local woman, an active and respected leader in
her own right, learned about the threat of HIV infection, safe sex, con-
doms, and female condoms. Using a bullhorn and arranging for space in
the back of a local store, she organized meetings where women could learn
about HIV infection and discuss methods of prevention.
Three years later, when Ida Susser and the anthropologist Eleanor
Homelessness in the World System 95
immunization, adequate nutrition, and access to health care for the poor
and uninsured. Similarly, in poor countries with a small population of
increasing wealth and a large population living in worsening poverty—
many without adequate housing—we find the breakdown of basic mea-
sures of public health and the resurgence of the threat of epidemics of
cholera and other more terrifying diseases and high rates of infant mor-
tality and shortened life expectancies.
C ONCLU SIONS
Social science research has made important contributions to under-
standing the lives of the poor and homeless in many parts of the world.
From both a theoretical and a practical perspective, critical medical an-
thropology, which as we have seen takes into account the political and
economic circumstances of health and disease, is essential to a clear un-
derstanding and documentation of the needs and voices of the majority
of the world’s population. In addition, in the face of the continuing and
increasing inequality we currently confront, the significance of fieldwork
to reach the people who do not have direct access to public institutions
and an activist approach to this fieldwork, which may assist in addressing
their needs, becomes more central all the time.
CHAPTER 5
if I were to say that I used drugs this afternoon, most people would be either
disappointed or amused to find that what I meant is that I drank a glass of beer,
98 Medical Anthropology and the World System
smoked a cigarette, and took two aspirin. Though alcohol, nicotine, and aspirin
are all psychoactive, they do not fit our stereotype of what a drug is.
That the only commonality among drugs is their label implies that the category
“drugs” is an arbitrary definition, a linguistic category that changes overtime. Yet
this is not to suggest that this linguistic category of drugs naturally emanates from
the voice of the people. We do not equally share in the task of making social
definitions . . . What becomes truth and gets accepted as reality benefits some
individuals and social groups more than others. (Matveychuk 1986: 9)
Alan Leshner (2001: 75), a former head of the U.S. National Institute on
Drug Abuse, “Addiction comes about through an array of neuroadaptive
changes and the laying down and strengthening of new memory connec-
tions in various circuits in the brain.” This reordering of brain anatomy
and biochemistry, which is believed to involve an array of cellular and
molecular changes, produces an uncontrollable compulsion or craving to
acquire and use drugs. It is this intense craving—rooted in the brain’s
acquired need for the substance(s) that created its new composition—that
is the essence of addiction. From this disease theory of addiction, compulsive
substance use is not a moral failing nor a lack of willpower, it is a con-
sequence of observable (using brain imaging techniques like magnetic
resonance spectroscopy) alteration of the brain (e.g., changes in brain
chemistry and neuron structure and functioning) that is produced by re-
peated exposures to powerful, quite literally mind-altering, substances
like alcohol, heroin, cocaine, or methamphetamine. Neuroscientists in-
volved in brain studies of addiction generally do not deny the importance
of social factors in creating the life conditions that lead some individuals
and not others to begin using psychoactive substances, to continue using
them steadily over time, and to using them at such regular and high dos-
ages as to produce (unintentionally from the standpoint of the user) the
types of brain alteration that transform voluntary use into an overwhelm-
ing, biologically driven compulsion. Thus, while “addiction as a brain
disease” adherents have concentrated their efforts on understanding the
ways brains change as a consequence of prolonged exposure to certain
substances, they view addiction as “the quintessential biobehavioral dis-
order” (Leshner 2001: 76). However, while recognizing that social factors
play a role in the development of addiction, they do not tend often to
explore the actual interplay between biology and social experience and
conditions that underlies obsessive desire. More importantly, they do not
fully factor in the issues of social inequality, oppression, and drug dealer
profit seeking as key social mechanisms driving the initiation and contin-
uation of substance use for many people. It is precisely this broader,
politically and economically informed integration of biological and socio-
cultural factors that critical medical anthropology seeks to bring to the
study of substance abuse research.
In chapter 1, we pointed out that substance abuse is one of a number
of health conditions that has been medicalized, meaning it has been de-
fined by society as a disease that requires biomedical treatment. To the
degree that the medicalization of substance abuse moves it from the realm
of moral blame punishment into the arena of treatment, this may have
beneficial outcomes for sufferers. In fact, of course, such movement has
never fully occurred and substance users are incarcerated in staggering
numbers. Even people who voluntarily enter into drug and alcohol treat-
ment never escape a strong sense of social condemnation and devaluation.
100 Medical Anthropology and the World System
the most versatile drug available, serving at various times and places as
a food (providing two hundred calories per ounce, although no vitamins,
minerals, or other nutrients), medicine (e.g., for symptomatic relief of pain
and insomnia), aphrodisiac, energizer, liquid refreshment, payment for
labor, and narcotic. Human use of alcohol is probably as old as agriculture
itself; even prior to the rise of Europe as a global world power, alcohol
had spread to or had been independently discovered in most parts of the
world (except in much of indigenous North America and in Oceania).
Some historic researchers have suggested that the oldest intentionally pro-
duced alcoholic beverages, dating to 6,000 years ago, were made from the
fruit of the date palms of the eastern Mediterranean and Mesopotamia
areas. Dates and the sap of date palms have one of the most concentrated
levels of naturally occurring sugar, a substance that is needed in adequate
levels for fermentation to occur. Beer use is documented from as early as
5,000 years ago in early Sumerian and Akkadia texts and alcohol produc-
tion is depicted in Egyptian murals from the Predynastic period.
In all societies in which it is consumed, alcohol is invested with special
cultural meanings and emotions, although sometimes, as in the case of
the United States, ambiguous and conflicted ones. It is probably not a
coincidence that according to the Random House dictionary the word
drunk has more synonyms than any other word in the English language;
indeed most students are capable of reciting quite a list of such terms.
Societal understandings of alcohol are culturally conditioned. Thus, wine
is not just a certain type of alcohol made from fruit. The Eucharist wine,
the very expensive bottle of imported French wine, and the cheap bottle
of rotgut passed around a group of huddled men on skid row may be
quite similar chemically but mean very different things culturally. Simi-
larly, in Islam drinking alcohol is sacrilegious while in Catholicism it can
be a sacramental act. Even within a single religion like Christianity, atti-
tudes vary. As anthropologist Genevieve Ames, who has spent much of
her career as an alcohol researcher, (1985: 439–40) indicates,
Although the American branches of some large church groups of Europe, such as
the Lutherans and Episcopalians, have not opposed moderate drinking, other re-
ligious groups, such as Baptists, Methodists, Presbyterians, Congregationalists,
and members of small and fundamentalist groups, have a history of strongly op-
posing alcohol use and drunkenness as sinful.
That alcohol can be dangerous “has been widely described for as long
as we have written records, and elaborate sets of legal, religious, and other
norms have been developed to regulate who drinks how much of what,
where, and when, in the company of whom, and with what outcomes”
(Heath 1990: 265). Alcohol, wherever and in whatever form it is con-
sumed, has been subject to cultural rules and regulations that do not apply
to other kinds of consumable liquids.
102 Medical Anthropology and the World System
• Stomach and intestinal ulcers can develop because constant alcohol use irritates
and degrades the linings of these organs.
• Blood pressure goes up as the heart compensates for a reduction in blood pres-
sure caused by alcohol, resulting in an increase in heart problems and strokes.
• Male reproductive cell (i.e., sperm) production goes down because of decreased
sex-hormone secretion from the hypothalamus/pituitary.
• Poor nutrition associated with regular inebriation decreases levels of iron and
vitamin B leading to anemia.
• Driving while under the influence of alcohol is a major cause of traffic accidents,
injuries and fatality. Alcohol impaired driving affects one in three Americans
during their lifetime. During 2000, almost 17,000 people in the U.S. died in
alcohol-related motor vehicle crashes, representing 40% of all traffic-related
deaths
• Because alcoholics lose balance and fall more often, they suffer regularly from
bruises and broken bones, especially true as they get older.
• Other significant diseases associated with alcohol use are fetal alcohol syn-
drome, bone disease, weakening of the immune system and cancers of the
mouth, tongue, esophagus, and larynx.
104 Medical Anthropology and the World System
survey show that more than 40% of people who began drinking before
their 15th birthday were diagnosed as alcohol dependent at some point
in their lives. Rates of lifetime dependence declined to approximately 10%
among those who began drinking at age 20 or older, regardless of gender
(Grant and Dawson 1997). Moreover, youth who start drinking before age
14 are 3 times more likely to be injured than those who begin drinking at
or after age 21.
In February 2001, Dr Gro Harlem Brundtland, the Director-General, of
the World Health Organization (WHO), summarized the current state of
the global problem of drinking among youth at the WHO European Min-
isterial Conference on Young People and Alcohol held in Stockholm Swe-
den. She noted that, worldwide, 5% of all deaths of young people 15–29
are caused by alcohol use. In Europe, she pointed out, among males in
this age group, the rate of alcohol-related mortality is one of every four
deaths. In parts of Eastern Europe, where drinking rates among youth are
particularly elevated, the figure may be as high as one in three deaths.
Over 55,000 young people in Eastern Europe died from alcohol-related
causes in 1999. Data from around the world indicate that, what Brundt-
land referred to as “a culture of sporadic binge drinking among young
people,” involving drinking large quantities of alcohol until intoxication,
is spreading both in technologically advanced and developing countries.
The cost of under-age drinking in the United States alone, she stressed
was estimated by the U.S. Department of Justice at nearly $53 billion in
1996. To counter this trend, Brundtland urged the adoption of strictly
enforced policies that reduce access to alcohol, including a minimum legal
drinking age, restrictions in the number of hours per day or days per week
that alcohol can be purchased, and limitations on the kind of outlets that
are licensed to sell alcohol. Also, she emphasized, restrictions on alcohol
advertising have been shown to be effective in lowering consumption.
Countries with a ban on alcohol advertising have a 16% lower level of
alcohol intake and a 23% lower number of traffic fatalities than countries
with no advertising limitations. For young people, research shows that
watching five additional minutes of alcohol advertising on television per
day is linked to an increase in daily alcohol consumption of five grams.
In conclusion, Brundtland observed that
Not only are children growing up in an environment where they are bombarded
with positive images of alcohol, but our youth are a key target of the marketing
practices of the alcohol industry. Over the past 10–15 years, we have seen that the
young have become an important target for marketing of alcoholic products. When
large marketing resources are directed towards influencing youth behaviour, cre-
ating a balanced and healthy attitude to alcohol becomes increasingly difficult. . . .
By mixing alcohol with fruit juices, energy drinks and premixed “alcopops,” and
by using advertising that focuses on youth lifestyle, sex, sports and fun, the large
alcohol manufacturers are trying to establish a habit of drinking alcohol at a very
106 Medical Anthropology and the World System
young age. Look at most web sites for alcohol products—they are clearly attempt-
ing to attract the young, with computer games, competitions and offers of prizes
and teenage fashion shows. Go to night clubs and teenage discos and you will
often find dangerous marketing techniques. In Great Britain, young people inter-
viewed for a research project told how they were offered deals that include ‘buy
one, get one free’ and even the so-called ‘never ending vodka glass’: buy one, get
unlimited refills (Brundtland February 2001).
Drinking on Campus
The contemporary North American research approach to measuring
drinking in terms of quantity, frequency, and beverage type dates to Ba-
con’s and Straus 1953 book Drinking in College. That college drinking
should be the starting point for an important historic trend in drinking
research seems appropriate given the considerable amount and intensity
of drinking that occurs on many college campuses. The “Monitoring the
Future” study (L. Johnson, O’Malley, and Bachman 1994), for example,
found that 91% of full-time college students report that they have con-
sumed alcoholic beverages. Approximately three-fourths (72%) reported
that they drank during the last thirty days (compared to only 63% of
young adults of a similar age who were not in college). Most notable are
the findings of this study concerning heavy drinking occasions (in which
at least five drinks are consumed in a row). Forty percent of college stu-
dents reported participation in heavy drinking bouts during the last two
weeks, compared to only 34% of the noncollege controls. Often this intense
drinking occurs at “chugalug” parties and during rapid-consumption
drinking contests, common weekend events on many campuses. In his
ethnographic study of a Rutgers University dorm, Moffat, for example,
notes:
By the early 1980s, alcohol use appeared to be almost out of control in American
college-age populations, and the adolescent drunk-driving death rate was very
high. Yet the students definitely did not agree with the new laws; or, more pre-
cisely, some of them did agree that many of their peers drank too much, but very
few of them felt it was fair or just to abridge their own freedom to drink. Drinking,
of course, was not the only issue. Drinking was really about partying, and partying
was really about sexuality. And sexuality was arguably at the heart of the pleasure-
complex that was college life as the students understood it (Moffat 1989: 123–24).
more likely among women who are divorced or separated. Binge drink-
ing, involving the consumption of five or more drinks per occasion on
five or more days in the past month, has been found to be most common
among women between the ages of 18–25. Problem drinking overall
among women is most common between the ages of 21 and 34, in other
words beginning during college age and extending into the early middle
years.
Importantly, existing research indicates that women’s bodies both ab-
sorb and metabolize alcohol differently than men’s bodies. Generally,
women tend to have a lower level of body water than do men of similar
body weight. As a result, when they drink alcohol, women achieve higher
concentrations of alcohol in the blood than men when they drink the same
amounts of alcohol (Frezza et al. 1990). Moreover, it appears that women
eliminate alcohol from the blood faster than men. It is believed that this
occurs because women have a higher liver volume relative to body mass
than do men. Related to these factors, women develop alcohol-induced
liver disease over a shorter period of time and after consuming less alcohol
than men (Gavaler and Arria 1995). Also, women are more likely than
men to develop alcoholic hepatitis and to die from cirrhosis. Animal stud-
ies suggest that women’s increased risk for liver damage may be tied to
some of the physiological effects of the female reproductive hormone es-
trogen. Enhanced risk of alcohol-induced impairment among women also
includes brain damage. Brain scan data show that an area of the brain
that is active in multiple brain functions is significantly smaller among
alcoholic women compared with both nonalcoholic women and alcoholic
men. Similarly, research on the heart has found that among heavier drink-
ers similar rates of heart muscle disease (i.e., cardiomyopathy) for both
men and women, despite the fact that women had a 60% lower level of
lifetime alcohol use. Finally, a number of studies report that moderate to
heavy alcohol consumption increases the risk for breast cancer among
women.
Beyond disease, women who drink heavily also are at enhanced risk
for violence victimization. One survey of female college students found a
significant relationship between the weekly drinking levels and the like-
lihood they would suffer sexual victimization. Another study found that
female high school students who used alcohol during the past year were
more likely than nondrinking students to be the victims of date-related
violence (e.g., shoving, kicking, or punching) (Gross and Billingham 1998,
Malik, Sorenson, and Aneshensel 1997). A history of heavy premarital
drinking by both partners is a known predictor of first-year aggression
among newlyweds. In some studies, problem drinking by wives has been
found to be associated with husband-to-wife aggression regardless of the
husbands’ drinking levels. Finally, although women are less likely than
men to drive after they have been drinking and to be involved in fatal
Legal Addictions, Part I: Demon in a Bottle 109
alcohol-related car crashes, they have a higher relative risk of driver fa-
tality than men at similar blood alcohol concentrations. Laboratory re-
search on the effects of alcohol on response to visual cues and other
driving-related tasks suggests that there may be gender differences in how
alcohol affects driving, with task performance levels lower for women
than men with similar levels of blood alcohol. Women’s overall lower rates
of drinking and driving probably stem from generally lower levels of risk
taking compared with men. Additionally, women are less likely to believe
that drinking and driving is an acceptable behavior. A national household
survey conducted in 1990, for example, found that 17% of women, com-
pared with 27% of men, agreed that it was permissible for a person to
drink one or two drinks before driving (Greenfield and Room 1997).
Despite these differences in belief, the ratio of female to male drivers in-
volved in fatal car crashes is increasing. In 1982, 12% of all drivers in-
volved in alcohol-related fatal crashes were women, by 1986 this figure
had risen to 16 percent.
An additional health risk associated with women’s drinking is fetal al-
cohol syndrome (FAS) and related disorders of children. FAS is defined
in terms of four criteria: (1) presence of known maternal drinking during
pregnancy; (2) a characteristic pattern of facial abnormalities in children;
(3) growth retardation; and (4) brain damage, often manifested by cog-
nitive or behavioral problems. When a baby shows signs of brain damage
following alcohol exposure during pregnancy but none of the other in-
dicators of FAS, the condition is called alcohol-related neurodevelopmen-
tal disorder (ARND). Researchers use both passive and active methods to
determine the incidence of FAS and ARND. The former approach uses
data collected from existing medical records, which often are based on
information recorded at birth, while in the latter approach, investigators
use a defined set of diagnostic criteria to screen all members of a selected
population for alcohol-related problems. Studies using the active ap-
proach have found FAS prevalence levels as high as 40 cases per 1,000
births in a community study of elementary school children in South Africa
(May et al. 2000). In the United States, a preliminary active assessment of
FAS in a single county in Washington State found a prevalence of 3.1 cases
per 1,000 first-grade students (Clarren et al. 2001). The minimum quantity
of maternal alcohol consumption required to produce adverse fetal con-
sequences is still unknown, however clinically significant damage is not
common in children whose mothers drank less than approximately five
drinks per occasion once per week. However, there is considerable diver-
sity in vulnerability to a given level of alcohol consumption during preg-
nancy, possibly reflecting differences in general health, nutritional status,
and social and environmental factors affecting women’s well being.
Generally, explaining gender differences in the effects of alcohol has
proved to be a challenge for health and behavioral scientists. Some look
110 Medical Anthropology and the World System
A man passes through four “apparitions” when drinking that represent the fol-
lowing “bloods.” Blood of the turkey, when a man is sober and cold. Blood of the
monkey, which comes to pass after a man has drunk a little. This is the best state
because the body warms up, and one becomes talkative, makes jokes, forgets his
worries, and is in condition to make love to a girl. Blood of the lion, which occurs
when a man has drunk even more. Now he loses his head, looks for arguments,
is easily offended, thinks of people who owe him money and has the courage to
go and ask them for it. Blood of the pig, which comes to pass if a man has drunk
too much. He cannot stand up and control himself, but can only fall down and
sleep like a pig. (Simmons 1962: 40)
The elders then ate the chicken and drank the beer from a pot that was
placed between the ancestor stones. After the beer drinking was over, a
small pot of the remaining beer was left for the ancestors. While ancestor
supplication was only one of many occasions for drinking among the
Tiriki, as indeed beer was the lubricant of all social interaction and rela-
tionship building among them, its use in this ritual context exemplifies
the socially structured nature of the drinking event in this society.
Despite richly detailed early accounts like these, drinking behavior was
not seen as an acceptable or valued topic for anthropological research
during this period, a stigma that has not completely disappeared even
today. This attitude is but one example of many that could be cited about
how the culture of anthropology shapes the issues that come to be seen
as legitimate topics of research within the discipline. Similarly, the disci-
pline has tended to adopt certain theoretical perspectives while avoiding
others. These patterns are not peculiar to anthropology, as they are found
in all fields of study. But this issue is of considerable importance to critical
medical anthropology, which is an approach that asks questions that tra-
ditionally have been avoided, especially in medical anthropology, includ-
ing questions about the use of alcohol. Pushing the field to explore issues
that have been neglected in the past is one of the goals of critical medical
anthropology.
During the 1940s, another development had a significant impact on
subsequent work on drinking by anthropologists. Interestingly, this was
a study carried out by a student. His name was Donald Horton, and he
was a student of sociology. Horton believed that “The strength of drinking
response in any society tends to vary directly with the level of anxiety in
that society” (Horton 1943: 293). Using data on fifty-six societies described
by anthropologists, he conducted a statistical test of association and found
statistically significant support for his hypothesis. In one of the most
widely quoted passages in cultural studies of alcohol, he concluded: “The
primary function of alcoholic beverages in all societies is the reduction of
anxiety” (Horton 1943: 223).
This was a bold assertion that attempted to explain why alcohol had
become such a widely (although not universally) used substance. Not
surprisingly, others questioned Horton’s conclusion and offered alterna-
tive theories to explain alcohol consumption. Peter Field (1962), for ex-
ample, in a restudy of Horton’s fifty-six cases, argued that drunkenness
in prestate societies is related less to the level of anxiety within individuals
than it is to the presence or absence of certain types of relations that bind
together the social group. Nonetheless, Horton’s work stands as an im-
portant methodological advance in answering questions about drinking
behavior cross-culturally (an approach that today is called hologeistic anal-
ysis). This type of large-scale comparison across populations to arrive at
generalizations about human behavior is one of the few distinct methods
114 Medical Anthropology and the World System
argue for the important functions that it serves. Whether it be the articulation of
social and cultural values . . . , the assertion of an ethnic identity . . . , or a means
of escaping the feelings of inadequacy engendered by social and cultural changes
. . . , the impulse has nearly always been to delineate the reasons that Indian people
drink as they do. . . .
the creation of the Alcohol and Drug Study Group of the Society for Medi-
cal Anthropology in 1979. Now over twenty years old, the Society contin-
ues to be a forum for networking and the sharing of ideas among
anthropologists involved in alcohol and drug use research. Further, the
evolution of the anthropology of drinking contributed to a definable im-
pact of anthropology on the broader multidisciplinary field of alcohol
research, sometimes referred to as alcohology.
Anthropologists bring a range of perspectives to the study of drinking,
but, as the discussion presented thus far suggests, the three features that
best distinguish traditional anthropological studies of alcohol use are
(1) the use of naturalistic study methods like ethnography that (2) allow
for an understanding of drinking within an encompassing sociocultural
context and in terms of the views of the people whose drinking patterns
are being studied so as (3) to suggest social policy and/or programs that
are appropriate for the population in question. For example, in describing
his research on drinking among Mexican Americans in South Texas, Trot-
ter (1985: 285) states, “The general thrust of the [ethnographic] research
. . . has been to determine culturally normative drinking patterns, to dis-
cover emic [i.e., insider] views of and values toward alcohol use and
abuse, and to make recommendations about the development of culturally
appropriate treatment of alcohol-related problems.” In the view of Mac
Marshall, an anthropologist who has devoted much of his career to the
study of substance use in Oceania, “The most important contribution an-
thropology . . . made to the alcohol field was in demonstrating to non-
anthropologists the importance of sociocultural factors for understanding
the relationship between alcohol and human behavior” (cited in L. Bennett
1988: 100).
A major part of the bacchanalian life-style of young men is given over to public
displays of drunken bravado. These displays are a basic part of growing into
manhood in Truk; they do not represent psychopathic or sociopathic behavior.
They are expected and accepted parts of contemporary Trukese life, just as warfare
and “heathen dancing” were regular parts of Trukese life a century ago.
particular alternative to warfare not been adopted. Would the society have
fallen apart? Would aggression have exploded into island-wide fratricide?
Or would the people of Truk have found less harmful venues for express-
ing pent-up hostility (e.g., through sports).
Acknowledging the value of Room’s critique, more recently some an-
thropologists have begun to articulate a more complex model of drink-
ing. Spicer (1997), in his assessment of American Indian drinking, for
example, has sought to present an understanding that matches the con-
tradictory functional/dysfunctional nature of this phenomenon. Says,
Spicer (1997: 307):
In his interviews with Indian drinkers, Spicer found many who were
quite concerned and troubled by their drinking, and regularly expressed
the kind of tolerance-build up and craving suggestive of the disease model
of addiction. Similarly, Garrity (2000: 252) points out that with an alcohol-
related death rate seven times the national level, Navajo Indian leaders
“consider alcohol abuse to be the most serious problem now facing the
Navajo people.” Although quite variable among Indian tribal groups, al-
cohol abuse is a factor in five of the leading causes of death for American
Indians nationally, namely motor vehicle crashes, alcoholism, cirrhosis,
suicide, and homicide. Death rates for crashes and alcoholism are 5.5 and
3.8 times higher, respectively, among American Indians than in the general
U.S. population. Among those tribes with high rates of alcoholism, it is
estimated that as many as 75% of all accidents, which are the leading cause
of death among American Indians, are alcohol-related.
Turning to the sociocultural component in drinking behavior, Spicer
(1997: 308–309) rightfully stresses a very critical point that is easily lost in
undersocialized explanations of addiction:
ior: life in a world system demands a global view.” For example, in 1988
Heath published a review of the dominant anthropological theories and
models of alcohol abuse and alcoholism. He cites the following nine the-
ories/models, some of which have already been discussed:
As this lists suggests, the dominant models of alcohol abuse and alco-
holism in anthropology are sociocultural or psychological in nature. The
politics and the economics of drinking, including the role of social in-
equality, social power to coerce, and the endless search for profit were not
on the agenda of the anthropology of drinking until the emergence of
critical medical anthropology.
Finally, Room raises two last points: (1) There is a tendency among
anthropologists to downplay alcohol problems so as to differentiate them-
selves from missionaries, colonialists, and other ethnocentric Europeans
found in Third World settings; and (2) anthropologists fail to recognize
alcoholism as a culture-bound syndrome (i.e., a condition peculiar to the
presence of cultural attitudes about individual self-control and responsi-
bility) and therefore do not see other kinds of health and social problems
associated with abusive drinking.
Perhaps the true importance of Room’s critique can be seen in Mar-
shall’s rethinking of his account of drinking patterns in Truk. In retrospect,
Marshall (1988: 362) came to recognize that the explanation offered in
Weekend Warriors “was essentially a functionalist one” and that he was
motivated by a desire to “debunk what [he] perceived as an overemphasis
on the problems associated with alcohol use in Truk.” He also realized
(Marshall 1990: 363) that he had “underplayed the extent of alcohol-
related problems in Truk because [he] did not find evidence for much
Legal Addictions, Part I: Demon in a Bottle 123
‘alcoholism’ of the sort discussed under the rubric of the disease model
of alcoholism.” Most important, with further research, Marshall came to
realize that while men in Truk may not view their drinking as problematic,
women certainly do! Women, in fact, effectively organized and pushed
the government to implement a prohibition law. Marshall (1990: 364) con-
cluded, “It became necessary to rethink Trukese alcohol use from a femi-
nist perspective. To have failed to do so would have been to offer a skewed
view of Trukese society in which the opinions and attitudes of half the
population went unrepresented.”
That there has been much skewing of this sort is precisely the issue
from the perspective of critical medical anthropology. It is from this in-
sight that this alternative perspective seeks to fill in the missing link in
anthropological studies of drinking and to build a political economy of
alcoholism and alcohol abuse. This is not to say, however, that heavy
drinking and frequent drunkenness necessarily lead to alcohol-related
problems. Additional visits to the Camba by Heath over the last thirty-
five years, for example, have convinced him that his original observations
were correct. He still can detect no indication that the Camba suffer from
“any of the so-called ‘drinking problems’ that are so deplored in many
cultures today, such as spouse- or child-abuse, homicide, suicide, injurious
accidents, . . . aggression of any sort, job-interference, psychological dis-
tress (on the part of the drinker or close relatives), social strain in the
family, trouble with legal authorities, or even physical damage that differs
in any significant way from that suffered by others in the area, who drink
less or abstain” (Heath 1994: 360).
Elsewhere, however, changes in a community’s way of life brought on
by changes in the dominant economic and political system or the com-
munity’s place in that system, in conjunction with efforts by alcohol man-
ufacturers to promote the sale of alcohol, have had definite and telling
effects. Before turning to examine this issue in greater detail through a
presentation of the critical medical anthropology perspective on alcohol,
we first present a somewhat lighthearted (but not unserious) “Closer
Look” at the way noncritical conventional views of alcohol problems come
to be perpetuated in society.
“A Closer Look”
A LCOHOLIS M I N C OM IC BOOK S:
INDIV IDU ALIZ ING A LC OHOL ADDIC TION
Superhero comic book characters, figures like Superman, Spider-Man,
the Hulk, and the X-Men, have been likened on occasion to the bigger-
than-life culture heroes who populate the colorful myths of preliterate
societies. Nonetheless, while considerable energy is expended on the col-
124 Medical Anthropology and the World System
trayed as giving up his control needs and asking Bethany for help. As
Bethany and Stark embrace, Stark drops his whiskey glass, which crashes
symbolically on the floor. Stark then proceeds to begin repairing his
alcohol-shattered relationships (following Step 9 of the Alcoholics Anon-
ymous twelve-step plan). While his resolve to quit drinking almost dis-
solves as he faces subsequent disappointments, Stark avoids relapse and
remains on the wagon. Tellingly, in Iron Man #129, he passes up an offered
glass of whiskey for a glass of mineral water. By giving up control
(through testimonial confession and leaning on others) Stark regains con-
trol (over his drinking and his life), although he can never return to mod-
erate social drinking again (or face immediate relapse) because he suffers
from a disease called alcoholism. So ends Stark’s confrontation with the
Demon in a Bottle.
This depiction of the nature of alcoholism is a culturally meaningful
one in contemporary U.S. society. Yet it is only one way of thinking about
the problem. Most notably, it is a very atomized portrayal, one that em-
phasizes alcoholism as a problem at the level of the individual person. Faced
with personal life problems, Stark turns to alcohol as a crutch, as an es-
cape, as a boost to a threatened ego. Unable to handle life’s challenges,
Stark also is unable to control his drinking. No mention is made of the
alcohol industry and its constant encouragement through advertisement
to escape life’s problems with a few relaxing brews with the guys. No
reference is included concerning the way U.S. culture teaches people to
think of life as a game (sometimes called the rat race) of individual success
and failure, in which all responsibility for achievement lies within the
individual, or the way the alcohol industry in its advertisements uses this
cultural theme to associate success with drinking in general or with the
drinking of particular brands of alcohol. Moving away from the level of
the individual using a somewhat limited culturological approach to look
at alcohol addiction in light of these wider socioeconomic forces is the
goal of the next section of this chapter.
Liquor is almost their only source of pleasure, and all things conspire to make it
more accessible to them. . . . [Drunkenness provides] the certainty of forgetting for
an hour or two the wretchedness and burden of life and a hundred other circum-
stances so mighty that the worker can, in truth, hardly be blamed for yielding to
such overwhelming pressure. Drunkenness has here ceased to be a vice. . . . Those
who have degraded the working man to a mere object have the responsibility to
bear. (Engels [1845] 1969: 133–34)
This pattern has continued from Engels’ day into the present. Between
1971 and 1981 in England, death attributed to cirrhosis rose by 25%, and
hospital admissions for alcoholism jumped by 50%.
According to the National Institute on Alcohol Abuse and Alcoholism
(1998), in 1997, Americans on average drank 2 gallons (7.57 liters) of al-
cohol per person a week. This translates into about one six-pack of beer,
two glasses of wine and three or four mixed drinks per week. However,
over one-third of adults do not consume alcohol, so the weekly consump-
tion levels among drinkers are actually higher. Moreover, 53% of all the
alcohol that is consumed in the United States occurs during very heavy
drinking bouts (i.e., on occasions when more than five drinks are con-
sumed) and another 25% is consumed during fairly heavy drinking oc-
casions (i.e., when three to four drinks are consumed). The 10% of heaviest
drinkers in the U.S. are estimated to consume as much as 60% of the
alcohol Americans drink. Each year, approximately 8% of people in the
U.S. aged 18 and older suffer from alcohol abuse and/or dependence.
Moreover, 18% of adults are estimated to experience at least one lifetime
episode of alcohol abuse or dependence. It is estimated that annually ap-
proximately 15% of children under age 18 (about 10 million children) are
exposed to familial alcohol abuse or dependence. Further, 43% of children
under age 18 (more than 28 million children) live at some point in house-
holds in which one or more adults were drinking abusively.
A comprehensive study of the national economic costs of alcoholism in
Sweden found 50 billion Swedish kronor, or about 10% of the GNP, was
spent on alcoholism treatment, social services, and preventive efforts or
was lost from production because of alcohol-related problems during the
1980s. The extent of health and social costs in European countries is un-
derstandable, given that Europe accounts for only one-eighth of the
world’s population but consumes about half of all recorded alcohol pro-
duced internationally (M. Singer 1986).
A particularly interesting European case is that of France, a country in
which drinking is known to be very well integrated with family and social
life, children begin drinking wine early in life, and drinking is frequent
(e.g., with many meals), but, in which, according to popular belief, health
consequences of drinking are limited. Indeed, studies show that the
French drink one-and-a-half times more per person than Americans.
However, what is often not as well known is the fact that the French death
rate from liver cirrhosis is also one-and-a-half times greater than that in
the United States. According to the World Health Organization, France
has the sixth highest adult per capita alcohol consumption level in the
world and alcohol is involved in nearly half of the deaths from motor
vehicle accidents, half of all homicides, and one-quarter of suicides. Com-
pared to other countries in Europe, French men have a high premature
death rate, which primarily is a consequence of alcohol consumption. It
Legal Addictions, Part I: Demon in a Bottle 129
is estimated that the health and social cost of alcohol for France is $18.5
billion (U.S.) each year.
Although there is no shortage of studies, reports, documents, and de-
scriptions detailing the alcoholism problem of advanced or middle-range
capitalist countries, the impact of the importation and sale of Western
alcoholic beverages in underdeveloped countries has been underreported
if not totally ignored, by anthropologists among others. Yet the World
Health Organization (WHO) estimates that in many underdeveloped
countries between 1% and 10% of the population can be classified as either
heavy drinkers or alcoholics. Cirrhosis has become a leading cause of
death for adults in a number of such nations. A case with particular poign-
ancy is that of the San people of southwestern Africa, long a focus of interest
within anthropology because of their retention of a social formation sug-
gestive of prestate society. Prior to the fall of its apartheid government,
South Africa occupied the home territory of the San. Cultural Survival, Inc.,
described the consequence for one group of San, the Ju/wasi:
Ju means person; /wa means correct or proper. They call themselves “the well-
mannered people,” but today their lives are marred by misery and violence.
Crowded together in makeshift settlements and unlivable housing projects around
the administrative town of Tshumkwe, and at police and army posts, Ju/wasi live
idle, debilitated lives. . . . Drunkenness unleashed jealousies and hatreds that arise
from being thrust into a cash economy where only a few get work [primarily as
soldiers for the South African army]. Shattered values and collapsing self-esteem
encourage drinking. Traditionally, Ju/wasi drank no alcohol, but when a liquor
store opened in Tshumkwe with a government loan [from the South African Bantu
development fund], drunkenness exploded. (Cultural Survival 1984)
Despite widespread use of alcohol in various spheres of social and cultural life of
traditional Zambian society, drunkenness was infrequent and alcohol problems
unknown. With the advent of colonialism, the alcohol scene changed considerably.
First, the availability of alcohol was no longer confined to periods of the year when
grain was in abundance, nor was brewing now a family affair confined to the
domestic setting. Secondly, due to ready availability and increased outlets for al-
cohol beverages, alcohol became a major commercial enterprise. . . . Changing
drinking habits gave rise to a number of alcohol related problems, including al-
coholism, road traffic accidents, and social and economic difficulties.
Similarly, for Mexico, William Taylor (1979: 69) argues that early com-
mercialization “contributed to social stratification, as individual entrepre-
130 Medical Anthropology and the World System
neurs acquired personal fortunes in the liquor trade, and may have
weakened the sacred and ritual significance of the drink.” Generally
speaking, in places where commercially produced and distributed alcohol
has come to be the dominant drink and traditional regulation of locally
produced alcohol has diminished, “more solitary drinking and more dis-
rupted and violence [are] associated with the drunken state” (57).
The precise process of transition from traditional to commericialized
drinking has been described in some detail by Robert Carlson (1992) for
the Haya of Tanzania. The Haya are a Bantu-speaking people whose staple
food crop is the banana. Prior to European intrusion into Haya territory
during the nineteenth century, the Haya began making a fermented
banana-sorghum beer that they referred to amarwa. A special kind of ba-
nana is grown for beer making. After harvesting, these bananas either are
buried in a pit or hung over the hearth to transform the starch they contain
into fermentable sugar. When the bananas are ripe, they are laid in a dug
out wooden trough where they are stomped into a pulp. Water, dried
grass, and sorghum are added to the mixture, and the trough is covered
with banana leaves and left to ferment for twenty-four hours. This process
produces a drink that consists of about 4.5% alcohol by weight. The Haya
recognize four levels of physical effects caused by beer drinking:
(1) okwehoteleza is marked by the absence of altered perception and refers
to drinking for refreshment to quench a thirst; (2) okushemera refers to
feeling happy or hilarious as a result of being full with banana beer;
(3) okushaagwa amarwa means being overcome by banana beer and losing
control of oneself; and (4) okutamiila is the word for being quite drunk,
staggering, and possibly getting violent while under the influence. Drink-
ing properly in Haya culture means never going beyond the second of
these four levels. Maintaining self-control is highly valued by the Haya.
Symbolically, restricting drinking to the first two levels expresses a key
Haya cultural value: subordination of individual desire to the rules of the
social group through self-control. With European contact the contexts,
quantities, and consequences of drinking have changed, however. Bars
are now operated in Haya territory, and people talk of drinking to forget
their problems. Most Haya interviewed by Carlson report that heavy
drinking and drunkenness are much more common than in the past. As
alcohol becomes a commodity that can be purchased in an impersonal
commercial exchange, the traditional cultural meanings activated by
drinking are diminished. In the process, the individual “is alienated from
his or her ability to articulate creatively the relationship between the nat-
ural and the symbolic orders; commodities take on a life of their own, and
the symbols that order their production are controlled by the economy
itself” (Carlson 1992: 57). By disrupting cultural constraints on alcohol
consumption, commercialization contributes to increased levels of drink-
ing and the potential for alcohol-related health and social problems.
Legal Addictions, Part I: Demon in a Bottle 131
Class Solidarity
Although Engels clearly understood the harmful effects of heavy drink-
ing, he also realized that social drinking can be an act of group solidarity
in the working class and, by extension, other oppressed groups as well.
For example, in his book A Shopkeeper’s Millennium, Paul Johnson (1978)
analyzed the role of drinking in the formation of the industrial working
class and working-class solidarity in Rochester, New York, during the
early 1800s. Rochester was the first of the important inland American cities
created by the commercialization of agriculture. By 1803, Rochester had
grown into a major marketing and manufacturing center serving a sur-
rounding agricultural area. Industrialization introduced a radical change
in the nature of work and social life in the city. Before industrialization,
production occurred in cottage industries in which employers and work-
ers toiled together in production and gathered together after work to share
a convivial drink to mark their day’s accomplishment. However, as cot-
tage industries grew into full-blown factories, employers “increased the
pace, scale, and regularity of production and they hired young strangers
with whom they shared no more than contractual obligations” (P. Johnson
1978: 51). With the profits gained from the shift from cottage to factory
capitalism, employers built new mansions in new wealthy enclaves at a
distance from their factories and the considerably more modest homes of
their workers. Through these changes, distinct class boundaries emerged,
and the previously narrow gap in the social fabric widened into a re-
markable abyss.
In the barrooms and taverns that dotted their neighborhoods, working
men and women forged an independent social life, shaped at every turn
by the capitalist maelstrom restructuring their world. Heavy drinking, a
feature of Western social life since the introduction of inexpensive distilled
spirits in the seventeenth century, became “an angry badge of working-
class status” (P. Johnson 1978: 60). Why drinking? According to Johnson:
The drinking problem of the late 1820s stemmed directly from the new relationship
between master and wage earner. Alcohol had been a builder of morale in house-
hold workshops, a subtle but pleasant bond between men. But in the 1820s pro-
prietors turned their workshops into little factories, moved their families away
from their places of business, and devised standards of discipline, self-control, and
domesticity that banned liquor. By default, drinking became part of an autono-
mous working-class social life and its meaning changed. (P. Johnson 1978: 60)
Legal Addictions, Part I: Demon in a Bottle 133
did not seize southern Africa for the purpose of extending civilization, as
picturesque a rationale as that may be, but rather to extract wealth, the
High Commissioner got things a bit twisted. At any rate, it is evident that
alcohol contributed greatly to the administration’s objectives.
Of note in this regard is Harry Wolcott’s comprehensive study of co-
lonial control of indigenous drinking in Bualaway, Rhodesia (now Zim-
babwe). Wolcott reports that the white-settler regime organized municipal
beer gardens for use by urban black workers. According to Wolcott (1974:
34), beer garden drinking “facilitated some pent-up hostility and frustra-
tion; it enhanced gaiety and exuberance; and it contributed to accepting
things as they were.” In short, he argues, white control of black drinking
“contributed nobly to maintaining the status quo in the relationship be-
tween Africans and Europeans” (Wolcott 1974: 19). This fact was recog-
nized by the colonial settler government. Thus, the white major of
Salisbury could proudly report: “The Rufaro Brewery has been an impor-
tant contributory factor to the level of happiness which we have been able
to maintain in recent times” (Wolcott 1974: 224).
Availability
Engels described a causal chain linking alcohol availability to con-
sumption rates and consumption rates to the prevalence of health and
social drinking-related problems. In part, his perspective on the causes of
alcoholism has been restated by Kendell (1979: 367), “what determines
whether a person becomes dependent on alcohol is how much he drinks
for how long rather than his personality, psychodynamics or biochemis-
try.” As opposed to many other human activities that have been labeled
social problems or deviant behavior, abusive drinking is not disjunctive
with socially acceptable patterns; it is merely an exaggeration of normal
behavior. In many social settings, not only is drinking tolerated, it is so-
cially sanctioned and rewarded. Consequently, “the difference between an
alcoholic and a ‘normal’ heavy drinker is quantitative, not qualitative”
(Robins 1980: 195), and availability therefore is an issue of investigative
concern.
Several researchers have examined the relationship among availability,
consumption rates, and health consequences. Bruun et al. (1975) have re-
ported a definite association between increased availability and increased
consumption. Likewise, several anthropologists have noted that high inci-
dence areas for drinking and cirrhosis among Native American populations
are associated geographically with off-reservation sources of supply.
Political Factors
In explaining availability, Engels, in part, discussed the role of the state.
Historical research suggests that state interest in alcohol consumption has
Legal Addictions, Part I: Demon in a Bottle 135
ing to its mission statement, the purpose of ICAP is two fold: (1) to help
reduce the abuse of alcohol worldwide and promote understanding of the
role of alcohol in society, and (2) to encourage dialogue and pursue part-
nerships involving the beverage alcohol industry, the public health com-
munity and others interested in alcohol policy. At first glance, the ICAP
would seem to be a nonprofit scholarly association concerned about the
problems of alcohol abuse. In fact, ICAP was set up and given its $2 mil-
lion a year operating budget by eleven giants of the global alcohol indus-
try, including Allied Domecq, Bacardi-Martini, Brown-Forman Beverages
Worldwide, Coors Brewing Company, Foster’s Brewing Group Ltd., Guin-
ness, IDV (which has since merged with Guinness), Heineken, Miller
Brewing Co., Joseph E. Seagram & Sons, and South African Breweries.
Many of these companies are well known to public health advocates as
pioneers in the targeted marketing of alcohol to the poor, young, and
addicted in the developing world and as opponents of public health pre-
vention initiatives. The parent company of IDV, Grand Metropolitan
(which owns Burger King, Pillsbury, and Haagen-Dazs), for example, ag-
gressively promoted Jose Cuervo in the Islamic country of Malaysia using
its “Lick, shoot, suck” promotion in which male drinkers were encouraged
to lick salt from a woman’s breasts, take a shot of the tequila, then suck
from the lime she holds in her mouth. Bacardi-Martini touted its Bene-
dictine D.O.M. (which is almost 40% alcohol) in Malaysia claiming it had
“health-enhancing” powers for new mothers.
In Great Britain, Allied Domecq, Bacardi-Martini and Diageo are all
members of The Portman Group, which actively opposed a British attempt
to prevent drunk driving by lowering the legal blood-alcohol level for
drivers. The Portman Group was found to be offering money to academics
to write anonymous critical reviews of the volume Alcohol Policy and the
Public Good, a book that was written by an international panel of alcohol
researchers to provide the scientific foundation for the World Health Or-
ganization European Alcohol Action Plan. In Europe, Seagram, Allied
Lyons, and Heineken belong to The Amsterdam Group, which sought to
take court action against France’s policies banning the televising of sports
events featuring alcohol advertising. Notably, in 1998, ICAP was able to
recruit the U.S. Center for Substance Abuse Prevention (CSAP) to co-issue
a report that questions everything from the damaging effects of binge
drinking to the causal relationship between alcohol and crime. Public
health advocates have criticized CSAP, which in the mid-1990s almost lost
its federal budget as a result of heavy alcohol industry lobbying of Con-
gress, for participating in issuing a report that obfuscates the scientific fact
that alcohol is a drug. Some interpreted CSAP’s action as caving in to Big
Alcohol. ICAP also issued a policy statement recommending that govern-
ments should join with the alcohol industry and private foundations in
Legal Addictions, Part I: Demon in a Bottle 137
Economic Factors
Engels appreciated that producers view the alcohol market as an ex-
pandable arena for profit making. It is probably on this topic that the
anthropology of drinking has been the weakest, despite the by-no-means-
recent influence of market forces in shaping drinking behavior in popu-
lations of traditional anthropological interest. For instance, Doyal (1979)
notes that in the late 1800s farmers in the mining areas of South Africa,
anxious to put grain surpluses to profitable use in distilleries, recognized
that achieving this objective “depended in greatly raising the level of al-
cohol consumption amongst blacks” (115). As this case suggests, drinking
behavior must be understood in terms of a wider field of social relation-
ships and, since the rise of capitalism, in light of capitalist relations of
production, processes of commodification and the dynamic, expansionary,
and oligopolistic arrangement of the capitalist market.
Since World War II, the major economic forces on the wider alcohol
scene have been: (1) an increasingly dominant transitional corporate sec-
tor; (2) a near-stampede to consolidate the almost $200 billion a year com-
mercial alcohol market; and (3) a well-financed and quite successful
promotional drive to expand consumption on a world scale, with changes
of enormous proportion carried out by powerful actors, with far-reaching
consequences.
The impact of these forces can be illustrated with the case of the U.S.
wine industry. In his analysis of California viticulture previously referred
to, Bunce points to the pivotal role played by the Bank of America, in
promoting its ascendancy in banking by securing a dominant position as
financier of the California wine producers. Along with the state, the Bank
of America was a prime mover in the shift to monopoly marketing. Sig-
nificantly, consolidation was not achieved smoothly nor always through
gentlemanly agreement. To discipline growers outside of its control, the
bank used “threats of credit withdrawal and when that failed, violence
and intimidation” (Bunce 1979: 45). Through these tactics, a high degree
of concentration of control ultimately was attained.
The four largest companies in 1947 controlled 26% of U.S. wine and
brandy shipments. By 1963 that figure was 44%, and in 1972 the four
largest firms had increased their share to 53% of the U.S. total. Similarly
the eight largest companies increased their hold over the market from 42%
in 1947 to 68% in 1972.
With concentration largely secured, the focus of industry attention
shifted toward capital investment in vineyards ($1 billion between 1969
138 Medical Anthropology and the World System
and 1973) and stimulation of the domestic market. Under the influence of
intense promotional efforts (see below), U.S. wine consumption doubled
during the 1970s, and the industry projected a similar goal for the future.
The potential of the domestic market was calculated by reference to Eu-
ropean standards; U.S. per capita consumption of wine in 1980 was eight
liters compared to seventy for Portugal, ninety-three for Italy, and ninety-
five for France (Cavanagh and Clairmonte 1983). A longer-range objective
of U.S. corporate wine producers is encroachment on the global wine mar-
ket, now dominated by Italy, France, and Spain.
A major development in the U.S. wine industry in recent years has been
the entrance of major corporations that produce diverse products. How-
ever, the level of corporate concentration in the wine industry pales by
comparison with distilled spirits and beer (although it becomes increas-
ingly inappropriate to separate these markets as multiple beverage con-
glomerates become the norm). Concentration “is most dramatic in the
brewing industry, which emerged from a small-scale, local activity with
significant regional variation into a capital-intensive industry, controlled
at national or even international levels, that markets a product that is
increasingly uniform” (Makela et al. 1981: 34). In the United States, three
phases of the evolution of the brewing industry are identifiable: (1) the
founding of the first commercial breweries during the colonial era and the
subsequent proliferation of small-scale, labor-intensive, local producers;
(2) the decline in the number of local breweries and rapid concentration
of the market following World War II, accompanied by enormous in-
creases in production and consumption; and (3) the emergence of oligop-
olistic dominance by the 1980s. The ten biggest producers now control
almost all of the domestic consumption. Expansion has not been confined
by national boundaries. The dwindling number of alcohol conglomerates
has made strong moves to gain a major share of foreign distilleries, bot-
tling plants, and retail outlets. Among major capitalist counties, interpen-
etration is extensive, while expansion into and domination of alcohol
markets in underdeveloped nations is advancing swiftly. Between 1972
and 1980, underdeveloped countries increased their alcohol imports four-
fold, from $325 million to $1.3 billion per year (Selvaggio 1983). Imports
of wine more than tripled during this period, with the Ivory Coast, Gua-
deloupe, and Brazil absorbing one-fifth of the total. Underdeveloped na-
tions now comprise one of the fastest-growing import regions for both
hard liquor and beer, with 15% to 25% of the global import totals.
In alcohol, as with other commodities, emergence of the global corpo-
ration has been accompanied by the formulation of a corporate worldview
that flies in the face of the anthropological use of that term. As defined by
Redfield (1953) for anthropology, worldview refers to the conception of
reality developed within a particular society. Increasingly, corporate lead-
ers eschew the concern with cultural variation inherent in this conception
Legal Addictions, Part I: Demon in a Bottle 139
and instead embrace a view of the world in which diverse peoples, lands,
and societies are lumped together to form a global market, a set of raw
materials, and a multisectorial labor force. Even the nation-state becomes
an insignificant feature of this global cognitive map. As summed up by
one corporate spokesperson: “The world’s political structures are com-
pletely obsolete” because they impede “the search for global optimization
of resources” (Barnett and Müller 1974).
The alcohol industry has been able to help recreate the world to fit its
own view by employing its enormous profits in an extensive advertising
campaign, estimated to cost over one billion dollars a year in the United
States and two billion worldwide. While industry representatives and
their hired scholars maintain that alcohol advertising is primarily geared
toward convincing existing drinkers to switch brands and that advertising
does not affect consumption rates, the findings of independent researchers
suggest otherwise.
A glimpse at some of the giants of the global alcohol industry affirms
this conclusion. Anheuser-Busch, the largest beer producer in the United
States., with control of about 48% of the national market, is also the
world’s largest brewer with 10.7% of the world market. The company
produces many brands of beer, including Budweiser, Bud Light, Busch,
Michelob, Red Wolf Lager, ZiegenBock Amber, and O’Doul’s (a nonalco-
holic beer). The company is truly global with investments or licensing
agreements in Asia, Europe, and Latin America and beer sales in more
than 80 countries. Anheuser-Busch also operates recreational theme parks
like Busch Gardens and SeaWorld, and water parks like Water Country
USA and Adventure Island. In 1999, the company had net profits from
alcohol sales of just under $10 billion and an advertising budget just over
$650 million, $20 million of which was specifically targeted to U.S.
Hispanics.
The third largest producer of hard liquor in the United States in 1999
was Joseph E. Seagram & Sons. The Seagram Spirits and Wine division of
the company made and distributed popular liquor brands like Chivas
Regal, Glenlivet, and Crown Royal in more than 190 countries and terri-
tories around the globe, with just under 7% of the world market. The
Seagram Beverage Company division produced low-alcohol beverages
like Seagram’s Coolers and Mixers. In 1999, Seagrams had just under $5
billion sales of its alcoholic beverages (which only comprised about 30%
of its total sales; much of the rest of its business being in the entertainment
and music industries with ownership of the contracts for performers like
Elton John, Sheryl Crow, Rob Zombie, Shania Twain and Jay-Z ). Reflect-
ing the constant drive toward consolidation, Vivendi Universal bought
out the Seagram Company and in 2001 sold its beverage units to liquor
giants Diageo and Pernod Ricard for over $8 billion.
140 Medical Anthropology and the World System
The privately owned E & J Gallo Winery, the world’s largest wine
maker, produces approximately 25% of all wine sold in the United States.,
in no small part as a result of its inexpensive jug brands, Carlo Rossi and
Gallo and its fortified bottom-drawer brand Thunderbird. Gallo cultivates
over 3,000 acres of vineyard land in Sonoma County, California, manu-
factures its own bottle labels and bottles, and is the leading U.S. wine
exporter. At the same time, Gallo imports and sells the Italian wine Ecco
Domani and is a leading brandy producer. Early in its history Gallo only
marketed wine in the low-to-moderate price range, but ultimately was
able to expand into premium wines such as Turning Leaf and Gossamer
Bay (which intentionally do not include the Gallo name on the label). With
an annual U.S. advertising budget of about $50 million, Gallo is able to
promote its products coast to coast.
C ONCLU SION
We began this chapter with a discussion of “What is a drug?” and
pointed out that there is no clearly agreed-upon definition. However, so-
cieties make choices and have legalized and even supported the con-
sumption of some mood-altering substances, while others have been
banned and those who possess, use, or distribute them are often punished,
sometimes severely. Alcohol is a drug that has broad use in human soci-
eties, and its consumption goes back to ancient times. Anthropologists
who have studied alcohol consumption in prestate societies have found
that its use is well integrated into the cultural fabric and generally is not
conceived of as presenting either a health or a social problem. Indeed,
anthropologists commonly have found beneficial consequences of drink-
ing in these kinds of societies. Studies of this sort have led to the formu-
lation of the sociocultural model of drinking within anthropology.
However, there have been challenges to the adequacy of the sociocul-
tural model. One type of challenge has come from alcohol researchers who
assert that anthropologists have not paid adequate attention to the neg-
ative consequences of drinking in the societies they have studied. Another
challenge incorporates this concern but argues as well that there is a need
to examine drinking behavior within a political economic model. The lat-
ter challenge is raised by critical medical anthropologists concerned about
the international transformation of drinking from a socially controlled,
culturally meaningful behavior in local communities into one that is
driven by the external political and economic interests of dominant groups
in the global economy. Viewed in this light, a set of questions and issues
about drinking emerge that have not tended to be asked by anthropolo-
gists in the past. Building on the early insights of Friedrich Engels, critical
medical anthropology seeks to broaden our understanding to include an
awareness of the ways drinking and its effects are shaped by interactions
Legal Addictions, Part I: Demon in a Bottle 141
study has demonstrated that the cultivated forms of the tobacco plant
(several different species have been domesticated) all have their origin in
South America. The wild ancestors of domesticated tobacco species are
not indigenous to the Caribbean area but are found in Peru, Bolivia, Ec-
uador, and Argentina. Very likely, the tobacco plant and the knowledge
for both cultivating and consuming it diffused from South America to the
Caribbean (perhaps through Mexico) along with various cultivated food
plants many years before the arrival of Columbus.
Other species of tobacco were indigenous to North America, and these
came to be among the most widely cultivated plants grown by the Indians
of what was to become the United States. Commonly, North American
Indian peoples mixed tobacco with other plants such as sumac leaves and
the inner bark of dogwood trees. In fact, the Indians of the Eastern United
States and Canada referred to the substance they smoked in their pipes
as kinnikinnik, an Algonquian word meaning “that which is mixed”
(Driver 1969). Different tribal groups consumed tobacco in different ways.
Among the Indians of the Northwest Coast, tobacco was chewed with
lime but not smoked. Among the Creek, it was one of the ingredients of
an emetic drink. The Aztecs ate tobacco leaves and also used it as snuff.
Distinct cigarettes with cornhusk wrappings were smoked in the South-
west (although this may not have been an indigenous means of con-
sumption). Smoking tobacco in pipes also was widespread.
Among Indian peoples, tobacco had both religious and secular uses.
Shamans, or indigenous healers, used tobacco to enter into a trance state
and communicate with spirit beings so as to diagnose the nature of a
health or social problem. It also was commonly used in rites of passage
to mark changes in an individual’s social status. Smoking tobacco com-
munally often was done to mark the beginning or continuation of an al-
liance between tribes or to make binding an agreement or contract.
As this description suggests, tobacco was deeply rooted in the indige-
nous cultures of many peoples of the New World. Given the ceremonial
controls on the frequency of consumption and the diluted form in which
tobacco was consumed, as well as the fact that inhalation of tobacco smoke
into the lungs was not emphasized, tobacco may not have been a signifi-
cant source of health problems among Indian people prior to European
contact.
However, with the diffusion of tobacco to Europe and with the rise of
industrial capitalism, tobacco was transformed from a sacred object and
culturally controlled medicament into a commodity sold for profit. With
the emergence and development of the tobacco industry and the intensive
promotion of cigarettes, the per capita consumption of tobacco increased
dramatically (especially in the early and middle decades of the twentieth
century), with significant health consequences. As Barnet and Cavanagh
Legal Addictions, Part II: Up in Smoke 145
(1994: 184) observe, “The cigarette is the most widely distributed global
consumer product on earth, the most profitable, and the most deadly.”
Indeed, tobacco, it has been said, is the one product that if used as
directed by the manufacturer will lead to certain disease and death. The
significant negative health consequences of smoking are now widely
known. Three commonly lethal diseases, in particular, have been closely
linked to the use of tobacco: coronary heart disease, lung cancer, and
chronic obstructive pulmonary disease. Other fatal or disabling diseases
known to be caused by or made worse by smoking include peripheral
vascular disease, hypertension, and myocardial infarction. Smoking also
causes cancer of the mouth, throat, bladder, and other organs. As anthro-
pologists Mark Nichter and Elizabeth Cartwright (1991: 237) argue, smok-
ing damages the health of families in three additional ways:
First, smoking leads to and exacerbates chronic illness, which in turn reduces
adults’ ability to provide for their children. Smoking also daily diverts scarce
household resources which might be used more productively. And third, children
living with smokers are exposed to smoke inhalation [i.e., passive smoking] and
have more respiratory disease.
span in the 6,813 men included in his sample. A flood of medical reports
with similar findings has followed ever since. Oftentimes, this information
does not reach the general public because of the influence of the tobacco
industry and its advertising dollar on the mass media. Several studies
have shown that magazines that carry a lot of cigarette advertising tend
not to include news items and articles on the negative health consequences
of smoking (Smith 1978; Tsien 1979). As Weis and Burke (1963: 4) note,
“The tobacco industry has a history of exerting financial pressure on pub-
lishers to suppress the printing of information which would impair to-
bacco sales. [When questioned,] one reason editors give for the lack of
media coverage of smoking is that health effects from smoking are not
‘newsworthy.’” Billboard companies similarly are reluctant to carry anti-
smoking messages because they depend on the tobacco companies for half
of their advertising income. These companies have refused to sell space
to the American Cancer Society for this reason. Even the 1970 legislation
passed by Congress banning radio and television advertising of tobacco
products did not have a major effect. Tobacco advertising dollars for other
forms of promotion, such as ads in women’s magazines, quickly increased
fivefold.
All of this was money well spent by the tobacco industry, which has
been described as a cash cow by industry analysts. Cigarette income en-
abled R. J. Reynolds to buy up Nabisco, Del Monte, and Hawaiian Punch.
Philip Morris used its tobacco dollars to acquire Miller Beer, Seven Up,
and General Foods. American Brands turned tobacco profits into owner-
ship of the Pinkerton guard company, sporting goods manufacturers, and
various other businesses. Through subsidies paid to tobacco growers and
the distribution of large quantities of tobacco to Third World Nations
through the Food for Peace program, the federal government has played
an important role in supporting the profitability of tobacco production.
Critical to the effort to keep the dollars flowing into the coffers of the
tobacco barons has been their effort to find new markets. Women have
been high on the advertising hit list, as have ethnic minorities and the
populations of developing nations. Another important and vulnerable
market is youth.
long, however, people who were treated with tobacco, and probably their
physicians realized as well that tobacco was a powerful mood-altering
drug that had recreational value. By 1600, smoking was a common prac-
tice of working people in the port cities of England and Ireland (Brooks
1952).
The shift from medicinal to recreational, mood-altering use of tobacco
by the poor and working classes of Europe (which, in fact, as we shall
explain below, was a kind of self-medication) produced a backlash against
smoking by the dominant classes and the church. Mintz (1985: 100), an
anthropologist who has studied the consumable commodities ensnared in
colonial trade, suggests that the reason for this hostile response lay in the
distinct “visible, directly noticeable” physical reaction that smoking pro-
duces, especially for the new user. Mintz (1985: 100) draws a contrast here
with sugar, another colonial commodity that became extremely popular
in Europe.
In all likelihood, sugar was not subject to religion-based criticisms like
those pronounced on tea, coffee, rum, and tobacco, exactly because its
consumption did not result in flushing, staggering, dizziness, euphoria,
changes in the pitch of voice, slurring of speech, visibly intensified physi-
cal activity, or any of the other cues associated with the ingestion of caf-
feine, alcohol, and nicotine.
These changes in comportment in working people appear to have been
threatening to the wealthier classes, who preferred a more passive, con-
trolled demeanor in socially dominated groups. Mintz also points out that
unlike tobacco, tea, coffee, and rum, all of which are dark in color, refined
sugar is white, the symbolic color of purity in Europe since ancient times.
Racialist symbolism of this sort (toward mood-altering products that come
from foreign lands with threatening dark-skinned peoples), argues Mintz,
may have been an underlying cultural influence on the moralistic oppo-
sition to tobacco as well as to tea, coffee, and rum.
In 1602, the first known antismoking tract was printed and distributed
in English cities. Entitled “Work for Chimney-sweepers: or A Warning for
Tobacconists,” it helped to launch a high-minded crusade against tobacco
use. The class character of this crusade became clear two years latter when
another tract, entitled “A Counterblaste to Tobacco,” appeared. Although
published anonymously, it was widely known to have been produced by
James I, the British king (Best 1983). In James’s view, smoking tobacco was
“A custome lothesome to the eye, hateful to the Nose, harmefull to the
braine, dangerous to the Lungs, and in the blacke stinking fume thereof,
neerest resembling the horrible Stigian smoke of the pit that is bottome-
lesse” (quoted in Eckholm 1978: 6–7). The moral tone of the growing
antitobacco effort, an approach later adopted as well by the alcohol
Legal Addictions, Part II: Up in Smoke 149
For imagine thou beheldes there such a fume-suckers wife most fearfully fuming
forth very fountaines of bloud, howling for anguish of heart, weeping, wailing,
and wringing her hands together, with grisly lookes, with wide staring eies, with
mind amazed. . . . But suppose withall thou shouldest presently heare the thundr-
ing eccho of her horrible outcries ring the clouds, while she pitifully pleades with
her husband thus: Oh husband, my husband, mine onely husband! Consider I
beseech thee, thy deare, thy loving, and they kind-hearted wife. . . . Why doest
thou so vainely preferre a vanishing filthie fume before my permanent vertues;
before my amourous imbracings; yea before my firme setled faith & constant
love?” (quoted in Best 1983: 175)
Smoking also was criticized at this early moment in its use by Euro-
peans for being harmful to health, causing insanity, sterility, birth defects,
and diverse other diseases. Moreover, critics began to taint smoking as a
lower-class habit, “of ryotous and disordered Persons of meane and base
Condition” (quoted in Best 1983: 175). Finally, in England, which at this
point depended on Spain as a source of tobacco, smoking was attacked
because it made the country dependent on one of its rivals in the imperial
struggle for empire.
Extending these efforts to build a moral argument against smoking,
King James in England began to enact policies to restrict tobacco con-
sumption. In 1604, he imposed an additional duty on imported tobacco,
raising the existing state tax by 4,000%. Through this dramatic step, he
hoped to put tobacco out of the reach of most people. James did not ban
tobacco completely for two reasons. First, because it was still being used
as a medicine, and second, because (contrary to the antismoking propa-
ganda of the era) addiction to the drug appears not to have been limited
to the lower classes. James sought to avoid the wrath of “Persons of good
Callinge and Qualitye,” that is to say, members of the wealthy classes and
nobility, who would have opposed a total ban on tobacco importation
(quoted in Best 1983: 175).
By contrast, a number of other northern countries and even one south-
ern European country, including Austria, Denmark-Norway, France, Ba-
varia, Cologne, Saxony, Württemberg, Russia, Sicily, Sweden, and
Switzerland, adopted criminal penalties to punish smokers. Usually the
penalties involved a small fine. However, Russia, at various times,
adopted quite harsh legislation that called for whippings, slit noses, tor-
ture, deportation to Siberia, and even death (Brooks 1952). Despite these
efforts, smoking continued to be popular. Thus, for example, in 1670 the
Swiss National Assembly issued an official degree stating “Although the
150 Medical Anthropology and the World System
period, the British government, like its rivals throughout Europe, was
attempting to expand its scope of authority. This “gave the king an eco-
nomic interest in the tobacco trade” (Best (1983: 178). Eventually, however,
the influx of tobacco from the colonies was so great that it even over-
whelmed the substantial English demand, causing a slump in the market.
The English turned to the other countries of Europe as potential new
markets for their surplus colonial production. By the latter part of the
seventeenth century, re-exporting came to account for the largest portion
of the British tobacco trade. To open up these new markets, the British
government send delegations to other nations to convince them that it
would be profitable to remove existing bans on smoking, import British
tobacco, and then tax it. In this way, the tobacco trade became a force in
England’s foreign policy. Ironically, “the English, who at the start of the
seventeenth century led Europe in an anti-tobacco crusade, came to profit
immensely by taxing and trading in the drug, and closed the century
serving as missionaries of smoking to the other governments of Europe”
(Best 1983: 180). There is, in fact, a double irony here. While the British
helped to open the French market to tobacco imports, during the Revo-
lutionary War against England, Thomas Jefferson and Benjamin Franklin
put up American tobacco as collateral for French war loans. These loans
helped to provide the rebellious colonists with the supplies they needed
to defeat the British. Russia, which had imposed the most stringent anti-
smoking laws, was one of the last European countries to remove all pen-
alties. In 1697, Peter the Great, the Russian czar, issued a decree permitting
the open sale and consumption of tobacco, although the government im-
posed high taxes on the lucrative trade.
In this way, tobacco was transformed from an illegal and widely con-
demned drug into a legal and economically important force in European
history, a source of revenue accumulation that helped to fund the trans-
formation from feudalist to capitalist production. In Best’s (1983: 182) as-
sessment, “Tobacco was vindicated, not because there was a revolution in
morality, but because governments discovered that it provided an eco-
nomic foundation for colonialism and a new source of tax revenue.” To-
bacco, in short, gained acceptance because of the role it came to play in
an emergent global economic system.
Mintz (1985) offers an additional reason for the vindication of tobacco
as a socially accepted and widely used drug. He lumps tobacco, coffee,
tea, chocolate, and sugar together as the “drug foods” that came to serve
as low-cost food substitutes for the laboring classes of Europe with the
rise of colonialism and industrial capitalism. As “drug foods” like tobacco
were adopted into the European diet, other more nutritious but more
costly food items diminished in importance. Further, increasing “the
worker’s energy output and productivity, such substitutes figured impor-
tantly in balancing the accounts of capitalism” (Mintz 1985: 148) by low-
152 Medical Anthropology and the World System
“A Closer Look”
All of the advertising space in the Hispanic community and on local buses
had been bought up by RJR Nabisco to use to advertise Newport ciga-
rettes. “Newport is everywhere,” said Barbara Marin, director of the
smoking-cessation project. “We had a lot of trouble getting space because
of the Newport campaign in the community” (quoted in Maxwell and
Jacobson 1989).
There is good reason for concern about the difficulty of reaching His-
panics with smoking-cessation education. According to Bruce Maxwell
and Michael Jacobson of the Center for Science in the Public Interest and
the authors of Marketing Disease to Hispanics, a number of indicators show
that rates of smoking are increasing markedly among Hispanics, as well
as among African Americans and other ethnic minorities, and that these
communities are being targeted by the tobacco industry. In the past, smok-
ing among Hispanics and African Americans tended to be lower than in
the general U.S. population, although rates among men from these com-
munities has been rising for several decades. The data for Hispanics, for
example, are telling. The 1982–83 Hispanic Health and Nutrition Exami-
nation Survey (HHANES), the most comprehensive study of Hispanic
health conducted in the United States in recent years, shows that 43.6%
of Mexican-American men were smokers, as were 41.8% of Cuban men
and 41.3% of Puerto Rican men. Among Hispanic women, Puerto Ricans
had the highest rate of smoking, 32.6%, with the rates for Mexican-
American and Cuban women being 24.5% and 23.1% respectively. In her
study of smoking among Puerto Rican adolescents in Boston, McGraw
(1989: 166–167) found that “Puerto Rican males had higher rates of current
smoking than any of the [adolescent] populations studied [by other U.S.
researchers] and lower quit rates than most.” These findings show that
while most population groups in the United States have been lowering
their smoking in recent years, rates have not been dropping for Hispanics;
and among women in the Hispanic community rates have been rising
noticeably. Currently, the HHANES data show that “Hispanic smoking
rates are substantially higher than those for Whites” (Haynes et al. 1990:
50).
The consequences are identifiable: “There is a big increase in lung cancer
rates among Hispanic males,” reports Al Marcus of the UCLA Jonsson
Comprehensive Cancer Center. “There is an epidemic out there,” says
Marcus, “and it hasn’t received a lot of attention. There aren’t a lot of
people studying cancer in Hispanics” (quoted in Maxwell and Jacobson
1989: 17).
Other studies support Marcus’s conclusions. Between 1970 and 1980,
the Colorado Tumor Registry reported a 132% jump in the rate of lung
cancer among Hispanics males, compared to a 12% increase for white
males (cited in Marcus and Crane 1985). Another study in Colorado found
an increase in lung cancer rates among Hispanic males that was several
Legal Addictions, Part II: Up in Smoke 155
times the increase among white males (Savitz 1986). Similarly, data from
New Mexico for the period from 1958 to 1982 show that deaths due to
lung cancer tripled for Hispanic males but only doubled for white males,
while the death rate for chronic obstructive pulmonary disease increased
six fold for Hispanic males but increased less than four fold for white
males (Samet et al. 1988). These increases in cigarette-related mortality are
connected to increases in smoking among Hispanics beginning in the
1960s. For example, a three-generation study of smoking among Mexican-
Americans in Texas by anthropologist Jeannine Coreil and coworkers
(Markides, Coreil, and Ray 1987), found rising rates of cigarette con-
sumption among Hispanics. Because there is about a twenty-year incu-
bation period between the beginning of smoking and the development of
cancer, it is expected that in coming years rates of tobacco-related diseases
will show marked increases for Hispanic males, and eventually for His-
panic females as well.
The existing data on African Americans show a similar pattern. The
1985 Health Interview Survey found that among all American males
thirty-five to sixty-four years of age, African-American males were the
most likely to be smokers. Similarly, African-American females between
the ages of thirty-five and seventy-four were more likely than similar-age
women of other ethnicities to be smokers. Were it not for very high rates
of smoking among Puerto Rican women twenty-five to thirty-four years
of age, African-American women would have had the highest smoking
prevalence rates in that age group too (Haynes et al. 1990). Currently,
approximately 30% more African Americans smoke than whites (Horan
1993).
Why are smoking rates going up among U.S. ethnic minorities, espe-
cially at a time when the public has been exposed to a lot of information
about the serious health risks of smoking? Suzanne Haynes of the Na-
tional Cancer Institute and her coworkers (1990: 49) conclude the
following:
One factor that may be responsible for the high rates of smoking in the Hispanic
populations is the impact of advertising on these populations. It is well recognized
that cigarette manufacturers are now targeting Hispanics and other minority pop-
ulations with increased expenditures to distribute their message.
If you look at the billboard advertising in the Hispanic community, you will find
that they all portray young, happy people who appear affluent, who appear very
light-skinned. Basically, it’s setting up billboards in poor, devastated communities
showing pictures of wealth and well-being that are absolutely false in terms of
what the billboards are advertising. (quoted in Maxwell and Jacobson 1989: 38)
Benson & Hedges, and Virginia Slims, was supporting one hundred
African American organizations with more than $1.3 million in donations.
R. J. Reynolds, maker of Winston, Salem, More, and Camel cigarettes, was
the largest single contributor to the United Negro College Fund schools.
Reynolds also sponsors minority golf, bowling, and softball tourna-
ments, another strategy that is common among tobacco manufacturers for
winning friends and influencing people. An article in the May 1985 issue
of the tobacco trade journal Tobacco Reporter indicates that Reynolds also
underwrites numerous Hispanic festivals across the country. Ignoring the
health effects of cigarettes, a company official is quoted in the article as
saying, “Our efforts reflect a growing practice of local groups and private
enterprises joining hands to preserve a heritage and, at the same time,
improve life in the communities in which Hispanics live” (p. 62). Pro-
motional expenditures of this sort by cigarette companies doubled be-
tween 1980 and 1983 and had reached $1 billion by 1986. Kenneth Warner
(1986: 58), a University of Michigan School of Public Health professor
notes, “Perhaps the least well-defined but potentially most important in-
stitutional impact of cigarette companies’ promotions is their contribution
to creating an aura of legitimacy, of wholesomeness, for an industry that
produces a product that annually accounts for about a fifth of all American
deaths.”
Like the Hispanic Smoking Cessation Research Project of San Francisco
mentioned earlier, a number of minority communities have attempted to
counter the effects of the smoking promotion efforts of the tobacco in-
dustry. For example, the Washington Heights-Inwood Healthy Heart Pro-
gram in New York has developed activities to educate Hispanic children
about the dangers of smoking and deception employed by cigarette com-
panies in their advertising campaigns. Targeted to fifth and sixth graders,
these activities include:
The World without Smoke Advertising Contest, an annual contest in which stu-
dents develop posters, poems, songs, and skits that show the truth about smok-
ing. Winners are honored at a ceremony attended by community leaders.
The Burial of Joe Camel, a mock funeral procession and service in which students
debunk the glamorous image of this youth-oriented symbol of the tobacco
industry.
Knock Down the Lies in Cigarette Ads, a game in which students compete to
expose the deceptions of cigarette advertisements.
Similarly, the Heart, Body, and Soul Project in Baltimore used spiritu-
ality and pastoral leadership to assist members of twenty-two African
American churches to quit smoking. These efforts show that it is possible
to fight back against the tobacco industry, but the billions of dollars spent
on promoting smoking far outweigh the potential effects of small, poorly
funded community-based antismoking projects.
158 Medical Anthropology and the World System
cial groups such as youth, women, and ethnic minorities. Unlike socially
approved rites of passage, such as a wedding or graduation, in an antic-
ipatory rite of passage members of the subordinate group seek to unilat-
erally claim passage to a higher status even though this has not been
sanctioned by the dominant group. In a somewhat different vein, Eckert
(1983) has suggested that smoking may be used by some youth to sym-
bolically express their membership in particular adolescent peer groups.
Several studies show that smoking among adolescents, for example, is
associated with perceived approval for smoking in a valued peer network
(Green 1979; Mittlemark et al. 1987). In her ethnographic study of smoking
among Puerto Rican adolescents in Boston, McGraw (1989: 392) strongly
emphasizes an important cultural dimension of this behavior:
Smoking [was found to be] a social behavior governed by cultural rules. It was
more than lighting a cigarette and inhaling its smoke. For many of the adolescents
who smoked, in fact, the physical results of smoking may have been the least
rewarding aspect of their use. Smoking was most often done with friends or others,
and infrequently alone. The sharing of a cigarette was an opportunity to create
new, or reaffirm old, social ties.
did not plant tobacco but only gathered wild species of the tobacco family,
it was not offered to the spirits. Similarly, he found that tobacco was used
by shamans for healing purposes only in those tribes who smoked it but
not among peoples who chewed or ate tobacco. It was Kroeber’s (1939)
contention that tobacco and particular patterns of consumption tended to
diffuse together as cultural packages among Indian groups, thus account-
ing for the distribution patterns that he found.
Using the same type of functionalist model described in the last chapter
for alcohol use, Black (1984) conducted an ethnographic study of the role
of tobacco use on the Tobian Islands of Micronesia. Prior to European
contact, the Tobian Islanders did not use tobacco. It was introduced to
them during the 1800s by trade vessels searching the Pacific for wealth to
bring home to Europe. In time, tobacco came to be incorporated socially
and symbolically into the web of Tobian culture. Tobacco is highly valued
on the islands and heavily smoked. But it still is not grown locally. Cig-
arettes still are obtained through trading with visiting ships, including
U.S. Navy vessels or Asian fishing boats. On the islands, tobacco is an
important marker of an individual’s social status. Because tobacco is
highly sought after and must come from off-island sources, those individ-
uals who control a supply reap the social benefits of becoming centers of
social attention. These individuals are noted for having “considerable
skill, immense social knowledge, and a good deal of self-control, fore-
thought and social autonomy” (Black 1984: 483). When tobacco supplies
on the islands become especially low, social gatherings, such as communal
meals, diminish in frequency. One reason for this loss of sociability, ac-
cording to Black, is that individuals become increasingly irritable and an-
tisocial as they withdraw from their nicotine addiction. To avoid social
conflicts, they stay to themselves as much as possible and wait as patiently
as possible for the next shipment of their drug of choice.
In a related study, Marshall (1979) examined the role of tobacco on the
Pacific islands of Truk. Like the people of the Tobian Islands, the Trukese
did not have tobacco prior to the arrival of European vessels. Nonetheless,
this lack of experience did not prevent the Trukese from avidly seeking
tobacco early in the contact period. The date at which tobacco first reached
Truk is unknown, but, like many other Pacific Islanders, the Trukese
seemed willing to do almost anything to obtain it. This weakness was of
course exploited by the traders who eventually moved into the area (Mar-
shall 1979: 36).
By the last of the 1870s, Marshall (1979: 36) reports, the Trukese were
“hopelessly addicted” to tobacco, holding it to be dearer than food or
drink. Christian missionaries who arrived in the area in the late 1800s
made giving up tobacco a symbol of Christian conversion.
In the modern period, Marshall notes, beginning at about eighteen or
nineteen years of age all young men in the village he studied begin smok-
Legal Addictions, Part II: Up in Smoke 161
ing. Girls, who are more apt to be involved in the church, are much less
likely to smoke. In a 1985 survey of, 1,000 adults in Truk, Marshall found
that only about 10% of women were current smokers, compared to over
70% of men (Marshall 1990). In Marshall’s (1979: 130) assessment,
Alcohol and tobacco have been thoroughly incorporated into the exclusive male
domain, so much so today that they have become primary symbols differentiating
young men from young women. Young men are under tremendous pressure to
use these substances; young women are under just as much pressure to avoid
them.
The tobacco grown in Palau undoubtedly was introduced by the Europeans long
ago. Despite the demand for it, only a few men know how to cultivate and treat
it successfully today. It is easier to buy imported plugs, twists, and cigarettes—if
one has the money—than to raise the local variety. Because of the demand, Amer-
ican cigarettes have become the leading import of the islands. Unlike betel chew-
ing, smoking is a man’s vice. A few young women furtively puff a cigarette when
they can get one, but men frown on this brashness, as do older women.
Vanoi once told me about Leon, a villager who joined the [Methodist] church and,
renouncing his belief in magic, openly mocked Vanoi’s legendary knowledge of
sorcery. One day the two met at a trade store where many villagers congregate to
gossip. Leon brashly told Vanoi that he was unafraid of his magic. Vanoi offered
Leon a cigarette and told him that if he doubted his, Vanoi’s, magic powers he
should smoke it. With everyone watching, Leon lit the cigarette and calmly inhaled
it to the end. That night he became violently ill. A week later he died.
Not surprisingly, people in the Trobriands are very cautious about ac-
cepting tobacco from powerful individuals who have knowledge of
sorcery. Among friends and relatives, however, smoking together is a com-
mon social activity.
Among the Sambia of New Guinea, the largest island in Melanesia,
Herdt (1987: 71) notes the psychosocial role of tobacco at the end of a day
of toil in the gardens: “Smoking and betel-chewing relax people, who turn
to gossip, to local news, to stories—the old men always ready to spin tales
of war and adventures of the past, the children always ready to hear the
ghost stories that make them wide-eyed and giggly with excitement.”
Communal smoking is not peculiar to the islands of the Pacific. Shostak
(1983) describes in some detail the strong desire for tobacco she encoun-
tered among the Kung! San of southern Africa, the frequent requests they
made of her for the substance, and the predominant method of consump-
tion. On the latter, she (Shostak 1983: 25–26) describes a typical smoking
occasion:
Bo filled an old wooden pipe, one he must have received in trade, with only the
bowl section intact. The mouthpiece is rarely used, even in new pipes. He opened
a small, worn cloth pouch where he had put the tobacco and filled the bowl. He
lit the pipe and inhaled deeply four or five times, trying to hold as much smoke
as he could, puffing his cheeks and holding his breath with each inhalation. With
the exhalation, he turned, spat in the sand, and handed the pipe to Nisa. She
smoked the same way and gave it to Kxoma and Tuma, who each did the same. . . .
The four of them were talking, exchanging news of their villages.
transnational tobacco corporations have found the Third World to be a much more
favorable political and social climate in which to do business, as compared to
developed countries. Third World governments, lacking currency, are quick to
embrace the revenues that come with tobacco sales, including bribes . . . and are
reluctant to enact restrictions against this source of revenue. Furthermore, low
164 Medical Anthropology and the World System
levels of awareness of the health risks of cigarette smoking and the scarcity of anti-
smoking campaigns further enhance the sales potential for tobacco products.
(Stebbins 1990: 229)
has thus far not been demonstrated among Western governments either. Western
governments, already well aware of the health consequences of tobacco use, could
potentially prevent a repetition of such tragedies in the Third World by pressuring
the international tobacco companies to reduce and even halt their exports to the
Third World. . . . Given the capitalist world economy in which Third World coun-
tries are embedded, the possibilities for avoiding a smoking epidemic are all the
more clouded. (Stebbins 1990: 233-34)
We maintain that the disease focus of child survival programs, like the individual
responsibility focus of antismoking campaigns, diverts attention away from the
political and economic dimensions of ill health. Saving the children, the symbols
of innocence, puts the United States in a favorable light in a turbulent world and
competitive international marketplace, but it also deflects attention from other
issues. One such issue is that families with young children represent a huge po-
tential market for American products, such as tobacco, which undermine house-
hold health. While U.S. support of child survival programs received significant
positive press coverage, tobacco quietly became the eighth largest source of export
revenue for the United States in 1985–86. (Nichter and Nichter 1994: 237)
The U.S. government, the Nichters point out, has exerted its influence
in developing a world market for tobacco in three identifiable ways. First,
since the 1930s, hundreds of millions of dollars of Commodity Credit Cor-
poration loans and price supports have gone to tobacco growers, enlisting
them to grow more tobacco. Because of these subsidies, an acre of tobacco
brings in sixteen times the profit from an acre of soybeans. Second, in the
twenty years following World War II, the government spent one billion
dollars buying up surplus tobacco from U.S. distributors and supplying
it to Third World countries, thereby helping to develop a craving for to-
bacco. Third, U.S. trade policy is designed to assist American tobacco
companies overseas. Countries like Japan, South Korea, and Thailand
have all been intensely pressured by the U.S. government to begin im-
porting tobacco or face stiff trade sanctions. In fact, the pressure on Asian
countries to increase tobacco consumption has been called “a new opium
war” (Ran Nath 1986).
Additionally, noting that 75% of tobacco cultivation occurs in the Third
World, the Nichters point out that international lending programs like the
World Bank and the Food and Agriculture Organization of the United
Nations actively make loans, extend advice, and provide seed and pesti-
cides to small farmers to help them enter into tobacco growing. Ostensibly
committed to the development of Third World nations, these programs
will, in the long run, help the Third World to develop a significant health
problem. Tragically, because of the limits on what these nations will be
able to spend on health care, most Third World victims of tobacco-caused
diseases will not benefit from advances in the medical treatment of these
conditions.
Contributing to this outcome will be the fact that the manufactured
cigarettes marketed by transnational tobacco corporations often have
much higher tar (the chemical source of health problems in cigarettes) and
nicotine (the chemical source of addiction to tobacco) levels than those
sold in the West. For example, the Nichters point out, the median tar level
in cigarettes sold in the United States is twenty milligrams per cigarette,
while in Indonesia it is almost double this level.
166 Medical Anthropology and the World System
C ONCLU SIONS
In this chapter, we have analyzed tobacco as a legal mood-altering drug.
We have attempted to show that tobacco is certainly as dangerous as, if
not more dangerous than any drug that currently is illegal. In fact, as we
have indicated through a historical analysis, tobacco itself was once illegal
in much of the Western world. However, particular historic, political, and
economic factors overwhelmed moral efforts to ban tobacco consumption.
Like other mood-altering consumables that Mintz has termed the “drug
foods” of the take-off phase of capitalist development, tobacco helped to
control the working class by providing brief chemical respite from the
grinding pressures and boredom of capitalist production. At the same
time, because of its broad appeal to working people and others, tobacco
offered a generous source of revenue to pay for the shift from feudal to
capitalist modes of production. The product of this historic coincidence was
the legalization of tobacco and the emergence of a highly profitable and
increasingly international tobacco industry, an industry with sufficient
profits to pour billions of dollars into advertising and promotion to spe-
cific market segments in the West and to all other countries around the
globe. The consequence, unfortunately, has been an enormous toll in hu-
man misery and death. As Stebbins (2001: 151) stresses, “Fighting Big
Tobacco is entirely different from combating most public health problems.
Unlike cigarettes, most infectious diseases and maternal and child health
problems do not provide profits to transnational corporations and gov-
ernments. Similarly, most public health problems are not exacerbated by
Legal Addictions, Part II: Up in Smoke 167
course, the earlier medical meaning of the term drug did not go out of
existence, contributing to the broader terminological/conceptual jungle
that surrounds this topic (e.g., use vs. abuse, addiction vs. dependence,
recreational vs. ritual use). More recently, there have been public health
efforts to expand the term drug to include legal substances like alcohol,
creating increasing use of the acronym AOD (alcohol and other drugs) in
professional discourse.
All regions of the world have their own particular histories with mind-
altering substances. Notably, in Europe, for example, unlike many other
parts of the world, drug ingestion did not develop as a central part of
religious ritual. Beginning at least as early as the Middle Ages, mood-
altering drugs were banned, and the herbalists who created and used
them were punished. Today, illicit drug abuse is commonly seen as a sig-
nificant health and social issue throughout Europe as well as many other
countries around the world. Indeed, drug abuse is known to be an inter-
national phenomenon, with the plants that produce mood-altering chem-
icals being grown in one country, processed into useable form in another,
and consumed primarily in a third country. With the development of an
extensive international system of illicit drug production, smuggling, and
sales, addiction itself has become internationalized. In an ironic twist, a
quick glance reveals that drugs are one of the things that brings the world
together to form, in Louis Lewin’s (1964: 4) apt if overly amiable phase,
“a bond of union between men of opposite hemispheres.” Globalization,
the term used with growing frequency to describe an ever more inter-
twined world economy, the so-called new world order, is nothing new in
the realm of mind-altering substances. The reason for this is that drug use
is and has been for a long time big business, and, in fact, many big busi-
nesses, from illicit drug smuggling organizations to legal financial insti-
tutions are involved in the action. In recent years, for example, a number
of otherwise austere and seemingly proper banking firms have been ex-
posed as important sources for the laundering of illicit drug dollars (i.e.,
hiding the source of great sums of money to avoid taxation through out-
right seizure by legal authorities). In 1985, money laundering was found
to be an $80 billion-a-year industry, with the majority of the money com-
ing from illegal drug sales and involving major banks and brokerage
houses throughout the United States. Curiously, as the result of the exten-
sive money-laundering operations involving Miami banks and with the
widespread use and trafficking of cocaine in that city, virtually every piece
of U.S. currency handled in South Florida is contaminated with micro-
scopic traces of cocaine (Inciardi 1986: 196).
Illicit drug abuse is an international phenomena involving especially
North America, Europe, Asia, and Latin America (and increasingly in
most other parts of the world as well). However, for our examination of
use patterns we will focus especially on the United States. Not only is the
Illicit Drugs: Self-Medicating the Hidden Injuries of Oppression 171
United States by far the largest consumer of illicit drugs, it also has tended
to set international direction in responding to illicit drug use both in the
areas of interdiction (trying to stop the drug trade) and treatment/pre-
vention efforts. However, cross-cultural comparison and contrast, as well
as a keen awareness of significant differences that operate at the local level,
distinctive hallmarks of the anthropological approach to understanding
human behavior, also will guide this exploration.
The specific consciousness-changing substances of concern in this chap-
ter can be classified into four subtypes (Embodden 1974) based on their
reported effects on users (while recognizing that the same drug can have
varied effects on different users or the same user at different times or
during different phases of a single occasion of use):
Some of the specific substances listed above have locally confined use
within specific regions (e.g., kava in Oceania), others have moved beyond
regional use to international popularity. Commonly, drugs that come to
have global patterns of consumption (e.g., coffee, tobacco, cocaine, heroin)
have been incorporated into licit or illicit large-scale production, distri-
bution, and promotion systems driven by profit seeking. Another char-
acteristic that differentiates various kinds of drugs, one that is of primary
interest to medical anthropology, is their impact on the health of users (or
others, such as family members of users or victims of drug-influenced
violence or accidents). The capacity of specific drugs to cause harm varies,
often depending on the concentration, dosage, method and social context
of consumption. The presence of adulterants and the mixing of different
kinds of drugs also can produce harm.
The social scientific literature on drug use is vast, with numerous books
as well as specialty journals like Addiction Research and Theory, The Journal
172 Medical Anthropology and the World System
of Drug Issues, and the American Journal of Drug and Alcohol Abuse. One of
the key themes that marks this literature is the constant process of change
in drug use patterns. This topic is particularly important from a health
perspective on mind-altering drugs because, as the AIDS epidemic re-
veals, modifications in drug use or the contexts in which drugs are con-
sumed can dramatically impact the health risks involved.
If anything has been learned from the history of drug use . . . it is that “drug
problems” are ever-shifting and changing phenomena. There are fads and fash-
ions, rages and crazes, and alternative trends in drugs of choice and patterns of
use.
Illicit drug use is dynamic. Within neighborhoods and across the United States the
popularity of any one drug waxes and wanes, a drug’s availability fluctuates, the
forms and modes of ingestion of drugs change, new drugs are introduced, and
people vary in their willingness to try and continue using various types of drugs.
Notable kinds of change in the drug scene, all of which have potential
health implications, include the following: 1) the introduction of brand
new drugs, such as the mid-1960s appearance of d-lysergic acid diethal-
amide (LSD or Acid); 2) the diversion of pharmaceuticals to street use,
such as the mid-1970s adoption of phencyclidine (PCP or Angel Dust), an
animal tranquilizer, among youthful drug users, or the appearance of both
street methadone (diverted by methadone patients who spit out their
medication and sell it on the street) and street Ritalin (methylphenidate,
a stimulant used to treat attention deficit disorder); 3) the marketing of
new forms of older drugs, such as the early 1980s appearance of crack
cocaine (powder cocaine hydrochloride mixed with water and sodium
bicarbonate and heated until a smokable rock is formed) or the late 1980s
spread from Asia to the U.S. of ice (a potent, more crystalline and smok-
able type of methamphetamine); 4) the mixing of new drug combinations,
such as the lacing of methamphetamine drugs like Ecstasy with heroin
Illicit Drugs: Self-Medicating the Hidden Injuries of Oppression 173
search), is an especially useful tool for tracking emergent drug use pat-
terns and for assessing some of their health implications. To learn about
the exact behaviors and material culture (i.e., drug paraphernalia) of drug
users, drug ethnographers routinely visit shooting galleries, get-off
houses, crack houses, abandoned buildings, homeless encampments,
wooded areas in otherwise urban settings, alleyways, drug user’s homes,
roof tops, and other illicit drug use locations, as well as drug copping
(acquiring) sites, homeless shelters, soup kitchens, street corners, and
other places where active drug users can be found, observed, and engaged
in conversation. In the course of this work, these ethnographers are able
to spot new drug-related behaviors, recently created or introduced drug
equipment, and the consumption of new (or newly combined or pack-
aged) mind-altering substances.
While they are lumped under a common label as drugs, substances
differ considerably, not just in their chemical composition, but also in the
ways they have been constructed (i.e., thought of and responded to)
within society and in terms of the risks to health (if any) that their use
creates at any point in time or within particular social contexts. For ex-
ample, while tea and coffee were introduced to Europe during the same
period (late 16th to early 18th centuries) and under similar circumstances,
the former acquired a culturally constructed image as a therapeutic drink
(which it retains) but the latter did not. In England, tobacco at first was
thought of by some people as a cause of moral corruption and vanity, and
was even linked with sorcery (resulting in punishments handed down by
the Inquisition), while coffee was believed to cause idleness and political
unrest among the working classes. In time, these constructed images were
replaced by others no less cultural in their shaping than the original con-
ceptions. While tobacco came (for a time) to be thought of as sophisticated
and even sexual, coffee and tea never achieved such a colorful reputation.
We begin an examination of some specific drugs and their changing health
and social significance by focusing on marijuana, the most widely used
psychotropic substance, after alcohol, among young people. Marijuana
has held quite differing culturally constructed images in different times
and among different groups, from a demon drug that caused madness to
an enhancer of social accord.
of those twelve to seventeen years old who had ever used marijuana dou-
bled from 14% to 28%, while among those eighteen to twenty-five years
old the increase was from 39% to 64%. By 1982, almost one-third of those
eighteen to twenty-five years old reported using the drug in the one-
month period prior to being interviewed (Miller 1983). While inner-city
youth had been using marijuana for many years, the relatively sudden
rise in use among economically and socially privileged youth led to
widely voiced concern about a growing drug problem. Social concern
about marijuana was not new, but marijuana’s rapid rise to being the illicit
drug most commonly used by all social sectors in American society, in-
cluding adolescents, significantly intensified the attention it received in
the media and elsewhere.
The contemporary field of drug prevention emerged in the late 1960s
in response to the increased rate of use of marijuana and other hallucin-
ogenic drugs like LSD among young people. This led to a series of studies
designed to understand why adolescents use such drugs. These studies
found that regular marijuana users tend to value nonconventionality and
sensation seeking but did not find evidence of greater psychopathology
among adolescent heavy users. Also, these studies did not identify a single
factor—like pursuit of pleasure, relief of boredom, psychic distress, peer
influence, or family problems—that could account for the widespread ex-
perimentation with marijuana (Jessor 1979).
Indeed, the appeal of marijuana has caused considerable frustration for
those in the substance abuse field because while experimentation with it
may serve as a gateway to the use of so-called harder drugs (like heroin
and cocaine) for some adolescents, for most adolescents this is not the
case. Indeed, the history of marijuana reveals that it has served different
roles in society at different times and been perceived in radically different
ways as a result. During the colonial era, marijuana or hemp was a cash
crop grown to provide material used in the production of both clothing
and rope, and it is still grown for these purposes. By the turn of the twen-
tieth century, marijuana was being sold as an over-the-counter medicine
for the relief of various minor aches and ailments. It appeared primarily
as an ingredient in corn plasters, in nonintoxicating medicaments, and as
a component in several veterinary medicines. Its status as a medicinal was
affirmed in the Pure Food and Drug Act of 1906, which required that any
quantity of marijuana be clearly indicated on the label of drugs or other
consumables sold to the public.
Then, during the 1920s, marijuana began to be used as a recreational
drug for its mood-and mind-altering effects. This phase began with the
transport of increasing quantities of marijuana from Mexico into the
United States after World War I. As the popularity of marijuana grew, a
significant social reaction occurred. The drug soon was labeled a danger-
ous narcotic and attempts were made to institute severe penalties for its
176 Medical Anthropology and the World System
ganja use is integrally linked to all aspects of working-class social structure; cul-
tivation, cash crops, marketing, economics; consumer-cultivator-dealer networks;
intraclass relationships and processes of avoidance and cooperation; parent-child,
peer and mate relationships; folk medicine; folk religious doctrines; obeah and
gossip sanctions; personality and culture; interclass stereotypes; legal and church
Illicit Drugs: Self-Medicating the Hidden Injuries of Oppression 177
sanctions; perceived requisites of behavioral changes for social mobility; and adap-
tive strategies.
Those who oppose the medical use of marijuana for cases like Braun-
stein’s argue that those who support medical use are really seeking gen-
eral legalization of marijuana. However, results from a statewide survey
in Maryland of adults eighteen years of age and older shows that while
the majority (87%) of Maryland residents surveyed believe that doctors
should be allowed to prescribe marijuana for medicinal reasons, only 27%
of those people also believe that possession of small amounts of marijuana
for personal recreational use should be legal (Center for Substance Abuse
Treatment 1997). It is likely that controversy over marijuana use will con-
tinue, as will the relationship between using marijuana and other harder
drugs like heroin and cocaine.
and colorful history of use. Western interest in their use began with the
discovery of quinine as a treatment for malarial fever. That a substance
derived from a plant could be used with great effect in the treatment of a
specific health problem generated an intense concern with discovering
other new drugs (i.e., medicines). As we saw with the use of marijuana,
placing the history of heroin and cocaine in historic perspective reveals
important insights about the political economy of drug use. While drug
use commonly is portrayed as either an individual problem (e.g., person-
ality disorder or inadequate socialization) or perhaps a reflection of col-
lapsing family values, a historic account shows that politics, economics,
and class and racial relationships play central roles in changing patterns
of drug consumption. Consequently, the political economic approach
taken in this volume tends to emphasize placing health issues in a historic
framework.
The Opiates
The opiates are a set of drugs derived from the flowering Oriental
poppy plant (Papaver somniferum), specifically from the white sap that
forms in the large bulb at the base of the flower. Opiates have an analgesic
effect; they inhibit the central nervous system’s ability to perceive pain.
In addition, they relieve anxiety, relax muscles, cause drowsiness, and
produce a sense of well-being or contentment. Continued use produces
tolerance, so that increased doses must be administered to achieve the
initial euphoria. The best-known consequence of continued use is the de-
velopment of physiological dependence or addiction. Once a user is
dependent, consumption is driven primarily by the desire to avoid with-
drawal symptoms such as chills, cramps, and sweats. Other than depen-
dence, opiates in and of themselves are not known to produce other bodily
damage (Chien et al. 1964).
The use of opium as a mood altering substance is known to date back
at least to ancient Middle Eastern Sumerian civilization, over 6,000 years
ago. The Sumerians used a form of picture writing in which the symbol
for the poppy plant represented the idea “joy” or “rejoicing” (Lindesmith
1965). Opium was used as a medicine in classic Greek civilization. Galen,
the last of the great Greek physicians of the classic period, for example,
described multiple beneficial uses of opium in medical treatment in some
detail, including relief from snakebites, deafness, asthma, and women’s
troubles. In addition, he commented on its popular use in the preparation
of cakes and candies that were sold by vendors in the streets. In Homer’s
Odyssey, it was a key ingredient that Helen of Troy used in her potion “to
quiet all pain and strife, and bring forgetfulness of every ill” (Homer’s
Odyssey). There is even speculation that the vinegar mixed with a sub-
stance called gall that according to Matthew 27:34 was offered to Christ
180 Medical Anthropology and the World System
on the cross contained opium (Inciardi 1986). In more recent times, opium
“was one of the products Columbus hoped to bring back from the Indies”
(Scott 1969: 11).
When the use of opiates began in the United States is not entirely clear,
but it is known to have begun during the colonial period. Critical to its
introduction was the work of one of the best-known British doctors of the
seventeenth century, a man named Thomas Sydenham. A founder of clini-
cal medicine, Sydenham advocated the use of opium as “one of the most
valued medicines in the world [which] does more honor to medicine than
any remedy whatsoever” (quoted in Musto 1987:69). In his view, without
opium, “the healing arts would cease to exist” (Scott 1969: 114). A student
of Sydenham, Thomas Dover, developed a form of opium known as Do-
ver’s Powder, which he prescribed especially for the treatment of gout. It
contained equal parts of opium, ipecac, and licorice and lesser parts of
saltpeter, tartar, and wine. Dover put his product on the market for over-
the-counter sale to the public in 1709. Interestingly, this was the same year
that Dover, an enthusiastic adventurer, rescued the castaway Alexander
Selkirk from the secluded Juan Fernandez Islands off the coast of Chile,
an event that inspired Daniel Defoe’s famous book Robinson Crusoe. Do-
ver’s powder was shipped from London to the British colonies and be-
came the most widely used opiate preparation for many decades. Its
lengthy popularity has resulted in its specific mention under the general
listing for “powder” in Webster’s dictionary. Defoe’s book was not the
only meeting point between opium and British literary developments dur-
ing this era. Samuel Taylor Coleridge, for example, composed his famous
poem Kubla Khan under the influence of opium, while Elizabeth Barrett
Browning, also a poet, was an avid opium user.
Despite its considerable popularity, Dover’s Powder was not without
competition. Introduction of the drug helped to launch the patent medi-
cine business in the New World. By the end of the eighteenth century,
patent medicines containing opium were readily available and widely
used. They were available in pharmacies, grocery stores, and general
stores and were touted widely by traveling medicine shows. In addition,
they could be purchased from printer’s offices or through the mails. These
so-called medicines were marketed under a host of personalized labels,
such as Ayer’s Cherry Pectoral, Mrs. Winslow’s Soothing Syrup, Mc-
Munn’s Elixer, Godfrey’s Cordial, Hooper’s Anodyne, the Infant’s Friend,
Scott’s Emulsion, and of course, Dover’s Powder. The titles of these med-
icines appear to reflect a period before mass industrial capitalism deper-
sonalized the relationship between products and their producers.
These potions were said to be good for a host of health problems, in-
cluding body pain, cough, nervousness, TB cures, diarrhea, dysentery,
cholera, athlete’s foot, baldness, and cancer. Many were marketed as
“women’s friends,” drugs used to calm women who were seen during
Illicit Drugs: Self-Medicating the Hidden Injuries of Oppression 181
Smoking opium is not our vice, and therefore, it may be that this legislation pro-
ceeds more from a desire to vex and annoy the “Heathen Chinese” in this respect,
Illicit Drugs: Self-Medicating the Hidden Injuries of Oppression 183
than to protect the people from the evil habit (quoted in Bonnie and Whitebread
1970: 997).
From this moment on, U.S. societal reactions to drug use and attitudes
about particular racial/ethnic groups have been closely intertwined.
In the case of Chinese opium smoking, a major underlying factor in
social condemnation was the depression that began in the 1860s and the
resulting redefinition of the Chinese as surplus labor. Originally, imported
to build the national railroad system and to work the mines, labor that
was unappealing to many U.S. workers, the Chinese later became scape-
goats of class frustration as the economy collapsed. This example reveals
an important aspect of U.S. experience with illicit drugs that is often hid-
den behind well-publicized events like so-called wars on drugs or media
hype about crack babies. As Helmer (1983: 27) has argued, “the conflict
over social justice is what the story of narcotics in America is about.”
The place of opium use in American society took a dramatic turn in
1803 with the discovery of morphine. The discoverer was Frederick Ser-
turner, a twenty-three-year-old German pharmacist’s assistant. Serturner,
who was attempting to isolate the chief alkaloid of opium, named the
substance morphine, after Morpheus, the Greek god of sleep. Ten times
more potent than raw opium, morphine was quickly realized to have tre-
mendous powers as a painkiller; morphine, in fact, remains the strongest
chemical pain reliever available. This fact became significant during the
American Civil War, a massively bloody conflict that threatened to over-
whelm the capacity of the mid-nineteenth century biomedical system.
Physicians turned to morphine as a means of handling the incredible num-
ber of war-inflicted wounds and amputations. This process was facilitated
by the invention of the hypodermic needle, which allowed the rapid in-
troduction of the drug.
The book entitled The Hypodermic Injection of Morphia, published in 1880
by H. H. Kane, described the benefits and deficits of the popularity among
doctors of morphine treatment
A product of widespread morphine use during and after the Civil War
was the emergence of a new medical condition called either “soldier’s
disease” or “army disease.” Its primary symptom was morphine craving
by those who had been medically treated with the drug. The treatment
184 Medical Anthropology and the World System
Habituation has been noted in a small percentage . . . of the cases. . . . All observers
agreed, however, that none of the patients suffer in anyway from this habituation,
and that none of the symptoms which are so characteristic of chronic morphinism
have ever been observed. (quoted in Ray 1978: 308)
This mistake grew out of the fact that morphine addicts going through
withdrawal stopped experiencing withdrawal symptoms when they were
given heroin. At the time, people did not understand the phenomenon we
now call cross-addiction (i.e., addiction to one opium product produces
addiction to all opium products). As a result of its alleged attributes, her-
oin use was strongly promoted in the over-the-counter pharmaceutical
market and became a very popular legal drug. Importantly, as P. Conrad
and Schneider (1980: 116) indicate,
For those of us who are accustomed to thinking of the typical modern-day opiate
addict as young, male, urban, lower-class, and a member of a minority group, 19th
Illicit Drugs: Self-Medicating the Hidden Injuries of Oppression 185
century addicts provide a sharp contrast. From all the data we have . . . it appears
that the typical 19th century addict was middle-aged, female, rural, middle-class,
and white.
Cocaine
During the late 1800s, another kind of drug also began to be popular
and widely sold in the legal market. Derived from the leaves of the coca
plant (Erythroxlon coca), the drug, called cocaine, had long been chewed
among the Indians of the Andes as a mild stimulant that eased breathing
at high altitudes and produced no health or social consequences. The an-
cient Inca revered coca and worshiped a god named Mother Coca (Antonil
1978). The Spanish invaders attempted to eliminate the chewing of coca
leaves, probably more because of its pagan religious connection than be-
cause of antidrug sentiment.
Toward the end of the century, however, a Corsican wine maker, Angelo
Mariani, began to import coca leaves from Peru to add to a new wine that
he produced called Vin Coca Mariani. The wine was an instant success
and was publicized as capable of lifting the spirits and eliminating fatigue.
Pope Leo XIII, an avid wine drinker, awarded Vin Coca Mariani a medal
of appreciation (Inciardi 1986), and a thirteen-volume set of books was
published to compile the testimonials of all the prominent figures who
praised Mariani’s famous wine (Andrews and Solomon 1975).
Eventually, the Vin Coca Mariani came to the attention of John Styth
Pemberton of Atlanta, who was in the patent medicine business. In 1885,
Pemberton developed a medicinal drink he registered as French Wine
Coca, which he asserted was a nerve stimulant. The following year, he
added additional ingredients and began to market it as a soft drink called
Coca-Cola. Eventually, over forty different soft drinks included cocaine.
By the 1890s, the patent medicine industry also began marketing the
drug for everything from alcoholism to venereal disease and as a cure for
addiction to opiate-based patent medicines. At the same time, several re-
searchers were attempting to isolate the stimulant in the coca leaves. This
was achieved in the 1860s by Albert Neimann. This pure form was of
interest to the armies of several countries as a means of getting soldiers
to work harder and was actually administered to Bavarian soldiers in the
1880s. The Parke-Davis Company, “an exceptionally enthusiastic producer
of cocaine, even sold coca-leaf cigarettes and coca cheroots to accompany
their other products, which provided cocaine in a variety of media and
routes such as a liqueurlike alcohol mixture called Coca Cordial, tablets,
hypodermic injections, ointments, and sprays” (Musto 1987: 7).
These developments caught the attention of a Viennese neurologist
named Sigmund Freud. As a sufferer from chronic fatigue, depression,
and other complaints, Freud became very interested in the stimulant ef-
186 Medical Anthropology and the World System
Freud gave the drug to his friends, his sisters, and his fiancée and con-
tinued to use it himself for several years, although he ultimately became
aware of potential problems with cocaine and ceased his involvement
with it. He was not, however, the only famous doctor to become involved
with the drug at this time. Another was William Stewart Halsted, one of
the founders of the Johns Hopkins Medical School, the prototype of the
modern American medical school. He became addicted to cocaine while
discovering its properties as an anesthetic. Similarly, William Hammond,
former surgeon general of the U.S. Army, pronounced cocaine as the of-
ficial remedy of the Hay Fever Association.
As with heroin, attitudes about cocaine were colored by racism.
Throughout the South, there was a fear that if blacks had access to cocaine
they “might become oblivious of their prescribed bounds and attack white
society” (Musto 1987: 6). Thus, in 1903, the New York Tribune quoted Colo-
nel J. W. Watson of Georgia asserting “many of the horrible crimes com-
mitted in the Southern States by colored people can be traced directly to
the cocaine habit” (quoted in E. Goode 1984: 186). Similarly, the New York
Times published an article entitled “Negro Cocaine Fiends Are a New
Southern Menace” that described blacks as “running amuck in a cocaine
frenzy” (quoted in E. Goode 1984:186). That African Americans were on
the receiving end of most of the racially motivated horrible crimes com-
mitted in the South during this period was of little consequence. As Musto
(1987: 7) notes,
The fear of the cocainized black coincided with the peak of lynchings, legal seg-
regation, and voting laws all designed to remove political and social power from
[blacks]. . . . One of the most terrifying beliefs about cocaine was that it actually
improved pistol marksmanship. Another myth, that cocaine made blacks almost
unaffected by mere .32 caliber bullets, is said to have caused southern police de-
partments to switch to .38 caliber revolvers. These fantasies characterized white
fear, not the reality of cocaine’s effects, and gave one more reason for the repression
of blacks.
One of the most injurious of these patent medicines is a drink prepared with
opiates, chiefly laudanum, under the name of Godfrey’s Cordial. Women who
work at home, and have their own and other people’s children to take care of,
give them this drink to keep them quiet, and, as many believe, to strengthen them.
They often begin to give this medicine to newly-born children and continue, with-
out knowing the effects of this “heart’s ease,” until the children die.
The ultimate social effect of the new federal law was to label the drug
user a criminal. In the aftermath of this labeling, drug use came to be
synonymous with deviance, lack of control, violence, and moral decay. As
Erich Goode (1984: 218) has written in his book Drugs in American Society,
“by the 1920s the public image of the addict had become that of a criminal,
a willful degenerate, a hedonistic thrill-seeker in need of imprisonment
and stiff punishment.” By this time, it is estimated that there were over
200,000 addicts in the United States, possibly as many as half a million
(McCoy, Read, and Adams 1986; E. Goode 1984).
Physicians were exempt from the Harrison Act, and they continued to
treat their addicted patients with opium and cocaine; as a result, thou-
sands of people continued legal drug use in this way for five years after
passage of the Harrison Act. Drug issues aside, the Harrison Act is of
importance in our understanding of health issues because it was an im-
portant step in the long-time effort of physicians to gain control over the
distribution of medicines and thereby secure their status as the dominant
force in U.S. health care. The Harrison Act granted “almost a monopoly
for physicians in the supply of opiates to addicts” (Musto 1971: 60).
In the aftermath of the Harrison Act, physicians set up clinics around
the country to dispense mood-altering drugs to addicted patients. In the
New York clinic, which was the one best known to the public, drugs were
handed out widely to those who claimed addiction. Some people even-
tually began to take their dose plus additional doses for resale on the street
to other addicts. Thus began the underground narcotics industry, a pattern
that later was repeated in New York with the mishandling of methadone
(and avoided elsewhere by strictly managing the distribution of both
drugs).
Before long the U.S. Treasury Department, which was assigned to en-
force the Harrison Act, began to press against the legal prescription of
psychoactive drugs even by doctors. Central to this drive was the growing
concern that drug use would spread from the working class “into the
higher social ranks of the country” (Helmer 1983: 16). In 1919, in the Su-
preme Court case of Webb v. United States, it was decided that a physician
could not prescribe a narcotic to an addict simply to avoid the pain of
withdrawal. In 1922, in a second Supreme Court case, United States v.
Behrman, the court ruled that narcotics could not be prescribed even as
part of a cure. The effect was to make it now impossible for addicts to
gain legal access to drugs: “The clinics shut their doors and a new figure
appeared on the American scene—the pusher” (A. McCoy, Read, and Ad-
ams 1986: 110).
At first, physicians resisted these new legal developments. In the twelve
years after passage of the Harrison Act, at least 25,000 physicians were
arrested on narcotics-selling charges, and 3,000 served time in jail as a
result. Thousands more had their licenses revoked. By 1923, all of the drug
Illicit Drugs: Self-Medicating the Hidden Injuries of Oppression 189
clinics, even those that had been fairly successful in weaning addicts off
drugs, were shut down. By 1919,there were 1,000 addicts brought up on
federal drug charges. By 1925,there were 10,000 arrests per year. At this
critical juncture, the Mafia, under the direction of Salvatore “Lucky” Lu-
ciano, made the decision to replicate its success in the illegal alcohol trade
and enter into the heroin business. While older Mafia figures had looked
down on drug dealing, Luciano saw a lucrative market. By 1935, he con-
trolled two hundred New York brothels and twelve hundred prostitutes,
many of whom were addicted to the heroin Luciano provided to pacify
his illicit workforce.
The end result of these developments was the emergence of an under-
ground drug subculture that functioned to enable addicts to gain access
to drugs and drug injection equipment and to avoid arrest. Alfred Lin-
desmith (1947), who studied addicts in 1935 in Chicago, was already able
to describe features of this “subculture” in some detail. In the period be-
tween 1925 and 1930, intravenous drug injection became standardized as
the preferred method of drug use. The origin of this technique of drug
use has been traced by O’Donnell and Jones (1968). Interviews with old-
time drug users suggest that intravenous injection was discovered several
times by individuals who were attempting intramuscular injection and hit
a vein accidentally. Some individuals who made this mistake (and who
were using large quantities of uncut heroin) paid for it with their lives in
the resulting drug overdose. However, others (who were using less or less-
pure heroin) found that an intravenous shot “was more enjoyable, and . . .
[there followed] a very rapid spread of the technique among addicts”
(128).
The drug subculture thrived through the 1930s, until World War II. As
various observers have noted, “It was the criminalization of addiction that
created addicts as a special and distinctive group and it is the subcultural
aspect of addicts that gives them their recruiting power” (Goode 1984:
222).
The drug subculture and illicit drug use were significantly disrupted
by the war. Channels of drug smuggling were blocked during this period,
and the flow of drugs into the United States dropped to a trickle. Con-
sequently, by the early 1940s, recorded rates of drug addiction in the
United States took a sudden drop. However, the decline was short-lived.
Soldiers who had used drugs overseas began to bring their addictions and
knowledge of drug use home with them. And it was in the ghettos and
barrios along the East and West coasts that drug injection found a new
home after the war, especially among young men whose hopes, raised by
a war against totalitarianism, were smashed by racism and the postwar
economic downturn.
In addition to the press of social conditions, the postwar U.S. inner-city
drug epidemic was the end result of several events, including the 1949
190 Medical Anthropology and the World System
In 1946 American military intelligence made one final gift to the Mafia—they
released Luciano from prison and deported him to Italy, thereby freeing the great-
est criminal talent of his generation to rebuild the heroin trade. . . . Luciano was
able to build an awesome international narcotics syndicate soon after his arrival
in Italy. . . . For more than a decade it moved morphine base from the Middle East
to Europe, transformed it into heroin, and then exported it in substantial quantities
to the United States—all without ever suffering a major arrest or seizure. (A. Mc-
Coy, Read, and Adams 1986: 114)
Two other factors, one involving unrestricted production and the other
unfettered sales, also were critical in reestablishing the drug trade. On the
production end, Schultheis (1983: 237) reports that from “the 1950s
through the Vietnam War era, the Nationalist Chinese in the Golden Tri-
angle were supplied, even advised, by the CIA; the involvement of the
Chinese in the opium and heroin business was excused because of the fact
that they carried out paramilitary and intelligence activities along the
Burma-Chinese border and elsewhere in the Triangle.” Of importance on
the marketing end of the heroin trade, Musto (1987: 236) notes, was
“[p]olice collusion with drug suppliers in communities like Harlem.”
Throughout the 1950 and 1960s, drug use continued to spread among
inner-city poor. However, societal response was minimal, as long as most
addicts were African American, Puerto Rican, Mexican American, or Na-
tive American. Beginning in the late 1960s, however, the number of white
drug users and drug addicts began to grow rapidly, as part of a general
rise in injection drug use in the United States. While it has never been
possible to know exactly how many drug addicts there are in the country,
all indirect measures point to a rapid increase in the number of regular
drug injectors just prior to the beginning of the AIDS epidemic. David
Musto, whose book The American Disease (1987) is a classic in the drug
field, estimated that the number of heroin injectors soared from around
Illicit Drugs: Self-Medicating the Hidden Injuries of Oppression 191
fifty thousand in 1960 to at least a half million in 1970. This number con-
tinued to escalate between 1970 and the late 1980s, with a slight decline
for a while during the mid-1970s. By 1987, based on aggregated data from
state alcohol and drug agencies, the National Association of State Alcohol
and Drug Abuse Directors, Inc. (NASADAD), concluded that there were
about 1.5 million drug injectors in the United States (reported in Turner,
Miller, and Moses 1989). About the same time, the Centers for Disease
Control and the National Institute on Drug Abuse both estimated that
there were approximately one million drug injectors in the country (Spen-
cer 1989).
In the drug field, this sizeable increase in the number of injectors, now
called injection drug users (IDUs), is seen as a consequence of several
factors: (1) there was a general population surge during these years, es-
pecially among teenagers and young adults, the age group (15–24 years)
most susceptible to drug involvement (C. McCoy et al. 1979); (2) an ex-
pansion of the gross national product created an increase in disposable
cash and “an unparalleled market for consumer goods and anything else
that promised to make a person feel comfortable, including drugs” (Musto
1987: 253); (3) the Vietnam War contributed to widespread alienation
among youth, leading to a weakening of traditional values and social
control mechanisms; (4) during the late 1970s, there was a considerable
jump in the availability of heroin and cocaine; and (5) the pre-Depression
generation’s experience with the harmful effects of drugs was not effec-
tively conveyed to the baby boom generation because the intervening
mid-century generation had little firsthand exposure to mood-altering
substances other than alcohol (Musto 1987). However, while it is likely
that all of these factors contributed to the widespread growth in and tol-
erance (in some social sectors) of drug use during the 1970s, they do not
fully account for the “graduation” (Page and Smith 1990) from noninjec-
tion gateway drug consumption (e.g., marijuana smoking) to injection
drug use, a transition that occurred disproportionately among urban mi-
nority youth during this period.
Examination of the available sources of information make it clear that
the 1-1.5 million IDUs in the United States are not evenly dispersed across
the national landscape; most are concentrated in cities. Further, they are
not evenly dispersed across the urban landscape, as most are concentrated
in particular neighborhoods. Although nonmedical injection drug use ap-
pears to have begun in the American South (O’Donnell and Jones 1968),
today there is a disproportionate concentration of IDUs in the northeast-
ern states. It is estimated, for instance, that between one-fourth and one-
half of all IDUs in the United States live in New York City (Turner, Miller,
and Moses 1989). Notably, African Americans and Latinos are over-
represented among IDUs. In New York City, the center of Northeast drug
use, the proportion of African Americans in the IDU population has been
192 Medical Anthropology and the World System
going up steadily since World War II (Chambers and Moffitt 1970). The
last National Institute on Drug Abuse nationwide drug abuse treatment
survey found that “New York had the highest combined percentage of
black and Hispanic enrollees in drug treatment” (L. Brown and Primm
1989: 5). These findings suggest the need to broaden the focus of attention
from the psychological characteristics of drug abusers and develop an
understanding of the social conditions that produce drug use and abuse.
This is what Singer has tried to do (reported on later in this chapter) in
his studies of drug use among Puerto Ricans in the United States.
during this era. Thus, Bennett and Cook (1990: 231) could conclude, “as
of the early 1970s, anthropology had not yet developed an explicit drug
research tradition, especially with respect to abuse of drugs.”
Sociology, by contrast, did develop an explicit drug research tradition,
and its origin is found in the work of Bingham Dai (1937: 645), who was
concerned with understanding addicts “as a group and the world they
live in.” His work fits within the tradition of “drug use as social deviance”
perspective, an approach that developed in the department of sociology
at the Chicago School during the 1930s (although, Dai himself also re-
ceived a year of anthropological training at Yale University in 1932–33).
The Chicago School viewed modern urban dwelling as a new way of life
that was best understood through the direct field observation of the nu-
merous small social settings (like particular work sites or neighborhoods)
and subgroups (e.g., street gangs, petty thieves, musicians) that comprise
sectors of the urban whole. Methodologically, the Chicago School utilized
a mixed approach that included naturalistic study in local community
context and a focus on insider perspectives, strategies that form important
components of the ethnographic method. Indeed, the Chicago fieldwork
tradition all but mandated that considerable focus be placed on learning
the point of view of the people under study, a sentiment that it shared
with the Malinowskian research tradition in anthropology. Additionally,
the Chicago School saw the city as a stressful environment that produces
a breakdown of social bonds, disorganization, individual isolation, de-
personalization, and deviance behavior. In short, life in cities is patholog-
ical and the behavior of urban dwellers, especially inner city populations,
reflects the urban social crisis. Drug abuse, consequently, is seen as a direct
expression of the deeply damaging effects of urban life.
In his quite formal and ecologically based account, in the book Opium
Addiction in Chicago, Dai (1937: 190–91), who spent most of his career as a
psychotherapist, expressed a view of drug addicts typical of his day:
If one were emotionally self-sufficient, it seems very unlikely that one would read-
ily accept the suggestion of a drug user and enchain one’s self to a practically
lifelong habit. By whatever name we may call it, the feeling of inferiority or in-
adequacy, this predisposing factor found in all of the addicts we have interviewed
when they first began the drug habit must not be ignored.
in the years after Lindesmith began to publish his research. However, the
body of ethnographic research on drug use that was beginning to develop
during the 1930s came to an abrupt halt with the Second World War. Not
only did the war block the flow of many drugs into the United States—
leading to a significant drop in the frequency of drug use and the number
of users—it also pulled potential drug researchers out of the field and into
the war effort. Ethnographic research on drug use did not begin to re-
gather momentum again until the late 1950s and early 1960s.
In the immediate post-World War II years, a period during which heroin
began to flow back into the United States in increasing quantities and the
number of inner city drug users began to rise quickly, one must turn to a
number of autobiographies penned by drug users (or former drug users)
to gain a socially contextualized and quasi-ethnographic account of drug
use during this period. Several books, including The Autobiography of Mal-
colm X, Manchild in the Promised Land by Claude Brown, Down These Mean
Streets by Piri Thomas, and Manny: a Criminal-Addict’s Story by Richard
Rettig, Manual Torres and Gerald Garret, are particularly important re-
sources in this regard. For Claude Brown, for example, heroin had become
such a power attract that by age 13 he could hardly contain his desire to
try it. He was introduced to drug use by his friends, especially a group of
older boys whom he greatly admired. They first taught him to use mari-
juana. When they moved on to heroin, which, among other names was
called “horse” at that time, he intensely wanted to join them. For several
months during 1950 all he could think about was his desire for heroin:
Horse was a new thing, not only in our neighborhood but in Brooklyn, the Bronx,
and everyplace I went, uptown and downtown. It was like horse had just taken
over. Everybody was talking about it. All the hip people were using it and snorting
it and getting this new high. . . . I had been smoking reefers and had gotten high
a lot of times, but I had the feeling that this horse was out of this world (C. Brown
1965: 111).
During these same years, in nearby Spanish Harlem, Piri Thomas, a boy
of mixed Puerto Rican and African American heritage, was a member of
the younger post-war generation that was coming of age and coming into
contact with drugs. He recalled one of his earliest encounters with mari-
juana at age 13. Drinking whiskey with several friends, one of them pro-
duced a “stick” of marijuana and asked if he would like some.
I put it to my lips and began to hiss my reserve away. It was going, going, going.
I was gonna get a gone high. I inhaled. I held my nose, stopped up my mouth. I
was gonna get a gone high . . . a gone high . . . a gone high . . . and then the stick
was gone, burnt to a little bit of a roach (P. Thomas 1967: 58).
Within a few years Thomas was not only regularly using but also selling
marijuana. Although his initial reaction to heroin, which was becoming
198 Medical Anthropology and the World System
widely used among his friend, was negative Thomas’ resolve to avoid
heroin was overcome by his need to prove he was not a punk. When a
peer thrust a dollar cap of heroin and a folded matchbook to use in sniffing
the powder at him, Thomas felt compelled to prove himself a worthy
companion: “All for the feeling of belonging, for the price of being called
‘one of us.’” (P. Thomas 1967: 204). The ability of heroin to take away all
pain, misery, and rejection made the drug instantly appealing to Thomas:
“All your troubles become a bunch of bleary blurred memories . . . ” (200).
Before long, Thomas’ life came to center on the drug. He’d “go to bed
thinking about [heroin] and wake up in the morning thinking about it”
(207).
The four autobiographical accounts noted above and related material
(e.g., Burroughs 1953) clearly reveal the development of the post-war drug
scene in the inner city. Building on the image of the cool marijuana user
of the depression and war years, the close of the Second World War ush-
ered in a period of significant increase in heroin use and heroin addiction.
The street addict became a common sight on inner city streets, as each
new generation of youth, boys and girls alike, sought to prove themselves
to their peers by adopting the valued image of a fearless drug adventurer.
Other options and role models were few, and none seemed to offer as
much opportunity to impoverished youth who felt they had to prove their
worth to their peers or face rejection in the one arena—the streets—that
offered any potential life validation. However, in the wake of the heroin
plague, Harlem and other U.S. inner cities changed. The sense of com-
munity that somehow had managed to survive the migration of African
Americans from the South and Puerto Ricans from the Island, the grinding
poverty they encountered in their new northern and Midwestern homes,
and the fierce racial discrimination that undercut self-esteem and self-
worth, now fell victim to widespread drug addiction among impover-
ished individuals who had no where to turn for drug money except
robbery, burglary, prostitution and other crimes against themselves, their
families, and their neighbors.
Nonetheless, rampant drug use in the inner city after World War II
did not attract much attention or real concern from the dominant society
or its social scientists, except to the degree that drug users were men-
tioned as either psychologically damaged or as criminal deviants in need
of harsh punishment. In the later part of the 1950s, however, an alter-
native to this reigning view of drug users began to appear. Its source
was the qualitative, interactive study of drug users. One of the first qual-
itative studies to mark this turning point was conducted by sociologist
Harold Finestone (1957) among African Americans in Chicago. Though
not based on field ethnographic research per se, Finestone’s office-based
qualitative interviews with approximately 50 African American heroin
addicts helped to focus social scientific attention on the existence of a
Illicit Drugs: Self-Medicating the Hidden Injuries of Oppression 199
world view and a subculture among drug addicts. In this work, Fine-
stone sought to describe the emically ideal African American drug user
role (the “cat”), the often illegal income generating activities needed to
sustain drug use (the “hustle”), and the use of drugs (the “kick”). As H.
Feldman and Aldrich (1990: 19) note, with Finestone drug studies began
a shift in emphasis away
from asking why people used drugs [and towards] asking how they went about
getting involved in drug use and how they remained involved . . .
[E]thnographers began to find their search for etiological influences in the social
world rather than the internal [psychological] world of experimenters.
Their behavior is anything but an escape . . . They are actively engaged in mean-
ingful activities and relationships seven days a week. The brief moments of eu-
phoria after each administration of a small amount of heroin constitute a small
fraction of their daily lives. The rest of the time they are actively, aggressively
pursuing a career that is exacting, challenging, adventurous, and rewarding. They
are always on the move and must be alert, flexible, and resourceful.
networks, the social settings that comprise drug users’ social environ-
ments, the folk systems used to classify drug users based on their social
status within the subculture, and the special argot or language system
developed to communicate issues of concern to drug users (and to hide
information from outsiders including the police). In short, emphasized in
the ethnographic literature on drug use from the 1960s onward was the
assertion that the lives of drug users are not without considerable cultural
order and socially constructed meaning. Drug getting and use as social
activities provide the framework for this order. As Preble and Casey (1969:
2–3) comment:
The heroin user walks with a fast purposeful stride, as if he is late for an important
appointment—indeed, he is. He is hustling (robbing and stealing), trying to sell
stolen goods, avoiding the police, looking for a heroin dealer with a good bag (the
street unit of heroin), coming back from copping (buying heroin), looking for a
safe place to take the drug, or looking for someone who beat (cheated) him—
among other things. He is, in short, taking care of business, a phrase which is so
common with heroin users that they use it in response to words of greeting, such
as “how you doing?” and “what’s happening?”
positive qualities of creativity, daring and resourcefulness that provide the impetus
for the top level solid guys (persons of established status) to rise to the top of the
street hierarchy . . . Their use of heroin solidifies a view of them as bold, reckless,
criminally defiant—all praiseworthy qualities from a street perspective.
In contrast to views that see IV drug use as simply a matter of individual pathol-
ogy, it is more fruitful to describe IV drug users as constituting a “subculture” as
this term has been used within sociological and anthropological research. . . . This
calls our attention to the structured sets of values, roles, and status allocations that
exist among IV drug users . . .
Illicit Drugs: Self-Medicating the Hidden Injuries of Oppression 201
I would spend time hanging around in the patients’ areas of the institution, lis-
tening and trying to learn how they viewed the world by attending to how they
talked about it. . . . After doing this for several months, and after conducting sev-
eral informal interviews and assembling a dictionary of slang, I began to worry
about being more systematic. So I worked up three interlinked methods to help
me display my understanding of the junkie world view.
handed a card or read a statement about some aspect of street drug use
life and asked to use his experience to complete the sentence), and the
hypothetical situation (in which the participant was told about a life sit-
uation drawn from prior data collection and asked to select from possible
courses of action). Based on these methods (both formal and informal),
Agar was able to construct an “experience near” account of key scenes,
concepts, relationships, artifacts, activities, and experiences that comprise
the street drug user’s life. Later, Agar was able to test the validity of some
components of his understanding of this lifestyle using street ethnography
and sociological survey in New York City. Another component of Agar’s
study was an attempt to understand the lives and behaviors of drug users
as patients in drug treatment. In other words, in addition to eliciting in-
formation about life on the streets, he also was concerned with the expe-
rience of life in an institution. Here, Agar was able to ethnographically
address some of the issues he encountered as he learned about staff atti-
tudes and assessments of patients. One of his insights in this regard was
that some of the very behaviors (e.g., strong skepticism, constant suspi-
cion, and testing of dependability) that staff cited as evidence that patients
were maladapted and lacked appropriate values, goals, and rules of
proper behavior, were in fact appropriate to (and acquired to insure) sur-
vival on the streets, where the threats are multiple and often come in
human form.
Using a somewhat different starting point, Dan Waldorf’s Careers in
Dope was based on a concept introduced into the Chicago research tra-
dition by Everett C. Hughes and first applied to drug use by Howard
Becker in his seminal study of the pathway to becoming a marijuana user
and the social contexts and relations that perpetuate drug use. The “ca-
reer” concept in drug research implies that, like a professional in a field
of employment (like becoming an anthropologist), it is possible to identify
somewhat standardized stages and transitions in the processual devel-
opment of a drug user’s life. The heroin drug-use career in the inner city,
argues Waldorf (1973: 6), begins early in life:
Heroin is seemingly everywhere in Black and Puerto Rican ghettos and young
people are aware of it from an early age. They know of heroin and addicts through
close scrutiny—they see the endless trade of money for white power; they see the
user nodding on the front stoop; they watch him “get off” in the communal bath-
room . . . ; they see his theft of the family TV set.
upon which these alternative identities and ideologies are based. He ob-
served that street drug users had to spend many hours each day planning
and carrying out some form of income generating hustle. Drug dealing,
he noted, was considered one of the better hustles available to street drug
users, although the primary career path open them in the drug trade was
as a low-level street juggler who sold small quantities of drugs to fellow
addicts.
At the terminal end of the “dope career,” Waldorf examined untreated
natural recovery from heroin addiction, a transition out of drug use, or
“retirement” in the career model, that many have assumed is not possible
or at least extremely rare. He found that many former heroin users
“drifted out” of drug use without significant problems because they had
never been highly committed to the drug or the drug user lifestyle. Wal-
dorf also led one of the first modern ethnographic studies of cocaine use
and later used an ethnographic approach to study longer term careers
among cocaine users. One of the important findings of the later study was
the identification of a protracted career path among some cocaine users
that involves continuous controlled consumption.
The Heroin Lifestyle Study (HLS) that lead to the writing of Life With
Heroin, was carried out in the inner city areas of Chicago, New York,
Washington, D.C., and Philadelphia. Study participants consisted of 124
African American men. All were regular heroin users and most had
“never received or wanted any form of drug treatment” (Hanson et al.
1985: 1). This disinclination to enter treatment was a primary focus of the
study. Specifically, the study was designed to “accurately pass on the rich,
descriptive firsthand accounts of the daily lives of Black heroin users . . . ;
and second, to search for and analyze emergent patterns which reveal the
complex social and psychological mosaic that comprises the contempo-
rary Black inner-city heroin lifestyle” (Hanson et al. 1985: 2). Ironically,
one of the important findings of the study concerns the validity of assum-
ing that there is a distinctive heroin lifestyle that is separate from the basic
lifestyle pattern of the surrounding inner city community. As two mem-
bers of the HLS research team note:
An unexpected finding is that the HLS men live rather structured lives in which
successive daily time periods are spent engaging in a variety of fairly predictable
and even conventional activities. Like men in straight society, they arise early in
order to spend many of their waking hours “on the job”—but in their case, this
usually means hustling in pursuit of the wherewithal to maintain their once-a-
day, relatively controlled heroin habits (Bovelle and Taylor 1985: 175–76).
Central to this argument is the idea that even when an item like a TV
is stolen that does not mean that it disappears from the economy, it is
merely redistributed (even if most of the monetary profits of drug sales
are extracted rather than recirculated in poor neighborhoods). Impor-
tantly, this study revealed how the underground and the aboveground
economies are, in fact, one economy, just as the HLS study showed that
mainstream culture and drug user culture were not terribly different.
Angel Dust: An Ethnographic Study, the last of the books mentioned
above, was a particularly important contribution for a number of reasons.
The edited volume was a product of a collaborative multi-sited ethno-
graphic study carried out simultaneously in four cities (Miami, Philadel-
phia, Chicago and Seattle) using a common research protocol. The study
was initiated because of reports that PCP (phencyclidine, an animal tran-
quilizer with hallucinogenic properties) was becoming popular among
some youth as a regularly consumed psychoactive drug. However, little
was known about recreational use of PCP. Agar (1980: 200) casually de-
scribes the origin and evolution of the study in the following terms:
A NIDA staff member with ethnographic tendencies (he had been a street worker
in New York) decided to try an ethnographic study. He asked that a small team
of ethnographers be assembled to get some preliminary feel for the situation . . .
[F]our ethnographers were selected who had done good ethnography with drug
users in the past. Further, because of their ongoing work, they all had rapport so
that they could begin work immediately. . . . The group met for 2 days to work
out a strategy for doing the ethnographies. Informal interviews were to be the
focus. In addition, the group came up with a four-page guide to specific items of
information that would be easy to get from each informant.
The study found that PCP had entered youth drug networks in all four
target cities in 1973, increased in popularity through 1974, and begun to
lose its appeal the following year (although it never completely disap-
peared from the youth drug scene and continues to have periods of re-
newed popularity). An examination of NIDA’s annual national survey of
drug use among high school seniors for the mid-1970s, however, did not
include findings on PCP use. As Feldman and Aldrich (1990: 22) remark,
“the PCP phenomenon entered the world of youth and diminished with-
out the national data system ever identifying it.” When questions about
PCP were finally added to the Monitoring the Future Study in 1979, life-
time prevalence for use among 12th graders was found to be 2.4% (falling
over the years to 1.4% by 1991).
The Angel Dust study also found that exclusive PCP use was rare and
that its greatest appeal was among especially restless youth who found
life to be generally boring and uninteresting. The participants in the study
appeared to be quite familiar with the drug’s effects and how to modulate
206 Medical Anthropology and the World System
Generally speaking there appear to be two factors that contribute to the impor-
tance of qualitative methodologies in the field of substance abuse research. First,
continually evolving patterns and trends of substance abuse . . . foster a fluid sit-
uation in which emergent and novel phenomena are integral facets of today’s drug
scene. . . . When attempting to construct meaningful data collection instruments
for drug-related research, the researcher must gain sufficient a priori familiarity
with the topic to frame appropriate, meaningful questions. Such knowledge is the
province and product of qualitative methodologies. . . . The second factor confirm-
ing the value of qualitative methods in the substance abuse field relates more to
the types of information required of research. . . . Clearly, qualitative research is
often the only appropriate means available for gathering sensitive and valid data
from otherwise elusive populations of drug abusers.
social concern about the health and economic toll of drug abuse is another
push factor). The result has been a significant expansion in the quantity
of studies (as well as an improvement in ethnographic methods and sam-
pling procedures), especially in terms of the development of fine-grained
examinations of the actual technologies and processes of drug use; the
structure of the interpersonal networks and social relations of drug users;
the immediate contexts of street drug consumption; the interrelationship
between drug use and a range of health risks; cross-site variation among
drug users including focused investigation of various drug user sub-
groups (e.g., drug injectors, crack users, women, minorities, adolescents,
and gay men and lesbians); and the political economic structures, policies,
and dominant social practices that foster drug use behaviors. Also on the
agenda of ethnographic research during this period was the study of pre-
vention and intervention programs, like syringe exchange and drug treat-
ment, targeted to addressing the health of drug users as well as patterns
and effects of drug user incarceration.
Much of the new ethnographic work, often supported by the National
Institute on Drug Abuse, the Centers for Disease Control and Prevention
or other public health institutions, was designed to elucidate AIDS (and
other health) risks among drug users (see Chapter 8). As funding in this
arena increased during the 1990s, a comparatively large number of eth-
nographers (many without prior histories in the street ethnography of
drug use or much awareness of prior field work with street drug users)
were recruited into the field. Often this new wave of neophyte drug re-
searchers worked in close collaboration with (and often under the super-
vision of) epidemiologists, psychologists, sociologists and researchers
from other disciplines. Drug ethnography, as a result, moved from the
independent task of an individual qualitative researcher immersed in a
local drug scene, usually in a major metropolitan area, into a team initia-
tive involving one or more ethnographers working in close concert with
quantitative researchers from other disciplines as well as with street out-
reach workers and survey interviewers. While demonstrably productive,
cross-discipline collaboration did not come without pains and frustra-
tions, with ethnographers sometimes feeling their work did not receive
due recognition. As a result, a number started as or moved on to become
the directors of their own multi-disciplinary, multi-method drug studies.
At the same time, they advocated successfully for the expanded inclusion
of ethnographers on the peer review committees established by the Na-
tional Institutes on Health and other funders to assess the scientific merit
of research grant applications.
Ironically, at the very moment that the contributions of ethnography to
drugs and AIDS and other public health research were gaining recogni-
tion, the ethnographically oriented social sciences were undergoing an
intense internal questioning concerning issues of researcher authority and
representation. The source of this re-thinking lay in a series of events and
208 Medical Anthropology and the World System
transitions and their impact on the life experiences and mood of people
living in the developed world in the late twentieth century, an era and a
social attitude that came to be called postmodern. Some saw the key event
in the rise of postmodernism being a reduction in the relative position of
American power and influence in the years after the War in Vietnam,
while others pointed to the lose of faith in the ability of the liberal welfare
state to create a meaningful, satisfying way of life. Among intellectuals
and scholars, the reigning array of broad, order-affirming social theories
about human behavior began to lose their explanatory appeal. In addition,
in anthropology in particular, a significant change occurred as the peoples
of traditional interest (i.e., those living in small communities and neigh-
borhoods scattered throughout the developing world) began increasingly
to speak out on their own behalf, sometimes in sharp criticism of the ways
in which they had been depicted in anthropological texts. Some anthro-
pologists somberly expressed doubt (recorded in an explosion of post-
modern anthropological publications) that they had the ability (as
outsiders) or the right (as members of dominant societies) to accurately
depict other ways of life and experience, the very objectives that had
driven the development of drug ethnography. Some wondered if field
studies, like capitalist penetration and re-ordering of traditional econo-
mies, were “unwarranted intrusions in the lives of vulnerable and threat-
ened peoples” (Scheper-Hughes 1992: 27). At their annual meetings,
anthropologists began to “hear of anthropological observation [described]
as a hostile act that reduces . . . ‘subjects’ to mere ‘objects’ of [anthropol-
ogy’s] discriminating, incriminating, scientific gaze” (Scheper-Hughes
1992: 27–28). In time, as this questioning and self-doubt gained steam, the
very future of ethnography as a legitimate approach to knowledge about
the social Other seemed in doubt (M. Singer 1990). Following Derrida’s
famous postmodern dictum: “There is nothing outside the text,” post-
modern anthropologists began shifting their focus of attention from the
lives and social worlds of peoples around the globe to the social processes
involved in the construction of anthropological texts, the writing conven-
tions that shaped textual uniformity, and the place of the author (and the
voice of research subjects) in the creation of the ethnographic text.
Drug researchers during this period were cognizant and concerned
about the issues and arguments of those expressing the postmodernist
critique of anthropology. In the face of the AIDS epidemic, which rapidly
was decimating the health and lives of injection and other drug users,
however, most ultimately choose
kinds of truths needed to establish programs to save people’s lives. (Kotarba 1990:
260)
The goal became not flawless ethnography but “good enough” ethnog-
raphy (Scheper-Hughes 1992), ethnography that, however partial, how-
ever shackled by dominant culture influences on anthropological
understandings, was accurate and insightful enough to make useful con-
tributions to efforts to respond to the multiple real perils facing at-risk
populations. Researchers who opted to walk this path were able to gain
new ethnographic awareness about the complex relationship between
drug use and health risk around the world. Interestingly, the anthropol-
ogists who spearheaded the critique of ethnography not only stuck with
the methodology but also came eventually to privilege the kind of multi-
sited ethnographic research that had been common in the study of drug
use since the examination of marijuana use in various Latin American
countries and the PCP and HLS studies.
While at times over the years the ethnographic approach has not been
always particularly popular in the world of drug research, the approach
proved its value in public health research in the time of AIDS. Ethnog-
raphers demonstrated that they can gain access to otherwise clandestine
groups and can describe variations and patterns of behavior in rich detail.
They commonly are able to reach the most active, hard-core drug users
(as well as dealers and other players in the drug trade from street syringe
sellers to those who cook cocaine to make crack in underground labora-
tories), the very people who are the most likely to suffer from a broad
spectrum of drug-related health problems, including overdose, HIV, other
STDs, TB, hepatitis, abscesses, and various other infections.
Early in the period of ethnography and AIDS risk studies, Friedman,
Des Jarlais and Sterk et al. (1990: 104) asserted, “[t]hese contributions show
the value of ethnographic and other field research techniques in social and
epidemiological investigation, and may well establish these previously
derogated techniques as legitimate tools of science.” Over the course of
the next decade, this expectation was realized. Critical events in the val-
idation of drug ethnography included a conference held in Chicago in
1979 that led to the volume Ethnography: a Research Tool for Policymakers in
the Drug and Alcohol Fields, the National AIDS Demonstration Research
project, which incorporated ethnography in a nationwide multi-sited ep-
idemiological study among drug injectors and their sex partners; the Co-
operative Agreement for AIDS Community-based Outreach/Intervention
Research, another National Institute on Drug Abuse funded multi-site
study that emphasized combined ethnographic/epidemiological collabo-
ration (sometimes called ethnoepidemiology); and the Needle Hygiene
Study, which illustrated the utility of ethnography in the identification of
previously unrecognized risk behaviors among drug users. In the study
210 Medical Anthropology and the World System
“I was willing, able, and ready to fight any I felt powerful, and I wouldn’t allow
anyone to put a damper on that.” But once he discovered tranquilizer, narcotic-
type drugs, [Waterston observed] Carl’s violence ended, and he was back in the
womb—warm, protected—and numb to the world emotionally.
shoplifting, burglary, and mugging, and because some of what they steal
is taken from the middle class and sold below market value to poor and
working people, they serve to control social unrest by redistributing social
wealth.
Applying the insights of the critical anthropologist Anthony Leeds
(1971: 15–16), Waterston concludes that so-called drug subculture should
not be viewed as a “bounded and self-perpetuating design for living,” but
rather as a set of social “responses to adversity as it is structured within
a particular social system.”
Merrill Singer (1995b) reports that during the nine-year period between
1941 and 1950, only twenty adolescents were admitted to Bellevue Hos-
pital in New York as drug addicts (six of them in 1950). However, in
January and February of 1951, sixty-five boys and nineteen girls were
admitted with this diagnosis. A study conducted in the early 1950s of
twenty-two of these youth, most of whom were Puerto Ricans and African
Americans, found that they “suffered psychologically from the discrimi-
natory practices and attitudes directed against their racial groups. They
feel more keenly than other national minorities that they live in an alien,
hostile culture. . . . They suffer almost continuous injuries to their self-
esteem” (Zimmering et al. 1951).
These youth were similar to Ramon Colon (pseudonym), a Puerto Rican
man interviewed by Singer in the late 1980s in Hartford, Connecticut. Born
in East Harlem in 1939, Ramon recalled that he first began to hear about
heroin from his friends in about 1947. He stated,
When heroin came into our neighborhood, we were 13 or 14 years old, in middle
school. Latinos, African Americans, and Italians all started using at the same time.
We would play stick ball in the street and pass a bag around to get loaded. We
didn’t know anything about addiction. Heroin was as easy to get as candy then,
it was everywhere and it was pure. One time the baseball player, Frankie Robin-
son, came to our school to talk and I bet every kid in that room had a bag of dope
in his pocket. I learned about it first from a neighbor who lived upstairs in our
building. I began to dip into his stuff. We frowned on guys that were shooting up
then. For the first six months it was just snorting. My brother put it up his nose
for four years before he started shooting. My cousin snorted for seven years. But
I told them they were wasting their dope and got them into shooting. I watched
some older boys shoot up on the roof at first. They would skin pop me. People in
our building would stash “works” [syringes and cookers] in the basement of the
building. I would find them. That was how I got my first set of works. Before
dope, it was really a nice neighborhood, nobody locked their doors. But with
drugs, everything deteriorated, it became mean. (quoted in M. Singer and Jia 1993:
231)
Puerto Rican drug users lean to inject drugs . . . and they learn to inject frequently.
Frequent injection among Puerto Rican IDUs . . . has evolved as a form of defensive
structuring . . . against the constant external threat of oppression (encountered as
experiences of injustice, discrimination, mistreatment, disrespect, and insult) and
the ever-present internal threat of experiencing painful somatized symptoms of
216 Medical Anthropology and the World System
oppression illness like guilt and shame. . . . Daily experience of somatized symp-
toms [i.e., the experience of emotional distress as physical manifestations], and
[Puerto Rican] cultural beliefs about rapidly eliminating them, provide motivation
for frequent [distress relieving] injection. (M. Singer 1999: 49)
Needle sharing . . . occurs for social reasons. Within small groups, it may reflect a
sense of camaraderie and trust. Sharing beyond one’s intimates reflects an ethic
of cooperation among addicts. Thus, needle sharing has become one of the well-
entrenched social mores of addiction subcultures, supporting ready access to
needles.
“Sharing” syringes and injecting in high risk environs like shooting galleries are
not maladaptive rituals of a vast drug subculture, and they do not necessarily
occur because of poor planning on the part of street-based injectors. On the con-
trary, these high-risk activities often continue as deliberate responses to what drug
injectors perceive as a more immediate threat than HIV infection. Laws criminal-
izing syringe possession have made drug injectors hesitant about carrying them,
especially during the times they are trying to obtain drugs. As a result, users are
frequently without syringes when they are ready and eager to inject.
health policies? (Castro and Singer 2004). As Michael Parenti (1980: 120–
21), a critical political scientist, has written,
Since we have been taught to think of the law as an institution serving the entire
community and to view its representatives—from the traffic cop to the Supreme
Court justice—as guardians of our rights, it is discomforting to discover that laws
are often written and enforced in the most tawdry racist, classist and sexist
ways. . . . Far from being a neutral instrument, the law belongs to those who write
it and use it—primarily those who control the resources of society. It is no accident
that in most conflicts between the propertied and the propertyless, the law inter-
venes on the side of the former.
While there are doctors and lawyers who are drug addicts (indeed,
those in demanding, stressful professions tend to have comparatively high
rates of substance abuse), the individuals who are most subject to needle
prescription and possession laws tend to be poor and African American
or Hispanic. These individuals have little in the way of status, wealth, or
power and hence little influence on lawmakers. Klein (1983: 33), a crimi-
nologist, in fact, argues that a review of the enactment of drug policies
shows that they are “part of a larger state project of social control.” Sim-
ilarly, the enforcement of possession and prescription laws is not auto-
matic. Indeed, “Nonenforcement of the law is common in such areas as
price fixing, restraint of trade, tax evasion, environmental and consumer
protection, child labor and minimum wage” (Parenti 1980: 123). A study
by the New York court system (reported in Parenti 1980) found that in-
dividuals arrested for small-time drug dealing receive harsher sentences
than those convicted of big-time security fraud, kickbacks, bribery, and
embezzlement, so-called white-collar crimes that tend to be committed by
comparatively wealthy white males. As these examples suggest, risk be-
havior among drug users unfolds within a sociopolitical context; and the
nature of class, race, and other relations that comprise this context may
be of far greater importance in determining risk than the rituals or values
of the subculture of drug users.
political rather than public health or social science ends. While working
for the New Jersey Department of Health, Glick Schiller was part of a
team that conducted a survey of a random sample of 107 people with
AIDS. In this sample, injection drug use and homosexual contact without
a condom were the two dominant routes of HIV infection. An examination
of the sociodemographic characteristics of the sample relative to these two
risk behaviors is noteworthy in light of society’s dominant images of gay
men and injection drug users.
In the sample, 64% of the African Americans and 63% of the whites
reported injection drug use. Prior to diagnosis with AIDS, 32% of the drug
users earned less than $10,000 a year, compared to 15% of the gay men in
the sample. However, 33% of both the drug injectors and the gay men fell
into the middle income category, between $10,000 and $20,000 year, and
about one-third of the drug injectors and half of the gay men had incomes
over $30,000 year. While 40% of the gay men had finished college com-
pared to only 3% of the drug injectors, 28% of the drug injectors and 23%
of the gay men had not gone beyond a high school level of education.
Very few individuals in the sample, regardless of route of infection, re-
ported professional occupations. Among gay men, over half reported
white-collar jobs, but mostly at lower levels such as clerks or data-entry
workers, and about a quarter reported blue-collar jobs. Among the injec-
tion drug users, about one-fifth reported having white-collar jobs, with
seven holding supervisory or skilled employment. About half of the drug
injectors had held blue-collar jobs, and only 13% had been unskilled work-
ers. Also, only a few of the drug injectors reported illegal activities as their
primary source of income. The drug users did not differ greatly from the
gay men in terms of stability of residence.
Based on these findings, Glick Schiller and coworkers (1994: 1343) con-
clude that
the assumed sharp differences between gay men and drug injectors could not be
found in their sample. The drug injectors did not stand out as a distinct group in
terms of their sociodemographic characteristics. Moreover, In their educational,
occupational, and residential histories, the intravenous drug users do not emerge
as a homogeneous group of hustlers or street people with a particularized sub-
culture. The data collected on their use of shooting galleries and sharing of needles
also do not substantiate a picture of homogeneous drug using subculture. . . . We
found that almost all respondents had ongoing ties with their families. This sim-
ilarity cut across risk group, racial and other demographic distinctions.
“A Closer Look”
stress that there are a number of ways in which treatment programs can
be said to be culturally targeted (M. Singer 1991).
Culturally sensitive programs attempt to be aware of and sensitive to the
cultural background of their clients (so as not to cause them any unnec-
essary offense), but they do not necessarily implement any specific treat-
ment modalities, institutional protocols, or environmental elements that
are based on the sociocultural backgrounds of their clients.
Culturally appropriate programs attempt to both know about and to use
knowledge about client cultural heritages to create a culturally familiar
treatment setting and hire a culturally matched program staff. Such pro-
grams may identify particular cultural values or practices and actively
reinforce them during the treatment process. For example, a number of
alcohol and drug treatment programs that serve Native Americans have
incorporated use of the sweat lodge, a traditional ritual element for Indian
peoples, as part of the treatment program. Similarly, Gilbert (1987) reports
on a California substance abuse treatment program targeted to Mexican
American women. In this program, because “active participation in dis-
cussions [is] not pushed or urged, women [are] able to develop confianza
(trust) [a traditional Mexican American cultural value] and take part in
group sessions at their own pace.”
Culturally innovative programs not only incorporate cultural elements in
their treatment program but also attempt to actively rework these ele-
ments so that they support the therapeutic process. Identified elements
are not treated as rigidly fixed and unchanging, but rather as fluid and
adaptable frames that potentially can be molded to meet new contingen-
cies. For example, Alasuutari (1990: 117–38) discusses the revamping of a
Finnish working-class drinking ritual as part of the intervention program
of the A-guild, an alcohol treatment program:
The first thing that attracts the attention of a newcomer in the guild meetings is
the importance of the coffee drinking ritual. When the first participants of the
morning meeting show up around ten o’clock, making coffee is the very first thing
they pay attention to. . . . Meanwhile, other guild members will show up one after
another, and the first comment they often utter is whether coffee is available or
whether it is being made. Men may also converse about the amount of coffee they
have already drunk during the morning, and compare the numbers of cups each
has consumed. . . . As in any ritual, there are rules which the participants
follow. . . . The particular importance of the coffee ritual . . . stems from [a] re-
placement logic. The social setting of the meetings has a remarkable resemblance
to that of a male drinking group. In that way, those coming to the guild from such
groups do not give up the spirit of male camaraderie found in the drinking group
which, it appears, is part and parcel of the desire for alcohol.
As long as the oppressed remain unaware of the causes of their condition, they
fatalistically “accept” their exploitation. Further, they are apt to react in a passive
and alienated manner when confronted with the necessity to struggle for their
freedom and self-affirmation. Little by little, however, they tend to try out forms
of rebellious action.
CONC LU SIONS
In this chapter, we have attempted to situate illicit drug use in a historic
understanding of its development and in terms of key cultural and political
Illicit Drugs: Self-Medicating the Hidden Injuries of Oppression 225
To date, not a single one of these associations has been convincingly shown to
explain disparities in distribution or outcome of HIV disease. The most well-
228 Medical Anthropology and the World System
demonstrated co-factors are social inequalities, which structure not only the con-
tours of the AIDS pandemic but also the nature of outcomes once an individual
is sick with complications of HIV infection.
As we move into the 21st century, and the third decade of AIDS, there
are almost 6 million new HIV infections every year in the world. While
AIDS: A Disease of the Global System 229
the death rate from AIDS in developed countries has been dropping, it
must be remembered that in the United States alone there are 40,000 new
HIV infections each year. Approximately 850,000 people in the U.S. are
living with HIV infection; about 450,000 have died from AIDS. It is esti-
mated that as many as 300,000 people in the U.S. are infected and do not
know it. While some people misguidedly think that the AIDS epidemic is
nearly over, in fact, we are still at the beginning of the epidemic. By the
end of the year 2000, there were approximately 40 million people in the
world living with HIV infection and another 22 million had already died
of the disease (8,000 per day). Over 13 million children have been or-
phaned by AIDS, with 95% of AIDS cases appearing in the world’s poorest
countries. HIV/AIDS is now the leading cause of death in sub-Saharan
Africa (the southern 46 of the 54 countries in Africa) and the fourth biggest
killer worldwide. To take but one example, in South Africa, 24% of preg-
nant women are HIV infected. AIDS is also spreading rapidly in Asia. In
Cambodia, for example, 2.5% of adults in the population are living with
HIV infection. According to the Joint United Nations Programme on HIV/
AIDS, AIDS is the most devastating disease ever faced by humankind.
The inability of nations, individually and collectively, to respond effec-
tively to the threat of HIV infection and AIDS suggests underlying di-
mensions of the global system that will be examined in this chapter.
Certainly the sudden appearance of AIDS in the early 1980s was a pro-
foundly unexpected occurrence, “a startling discontinuity with the past”
(Fee and Fox 1992: 1). Global public health efforts that date to the period
before the beginning of the AIDS pandemic, such as the successful small-
pox eradication program, “reinforced the notion that mortality from
infectious disease was a thing of the past” (McCombie 1990: 10). Conse-
quently, whatever the actual health needs of particular populations, the
primary concerns of the biomedical health care system had been the so-
called Western diseases, that is, chronic health problems, such as cancer
and cerebrovascular problems, common in a developed society with an
aging population. This surely has been the case in the United States com-
ments Brandt (1989: 367): “The United States has relatively little recent
experience dealing with health crises. . . . We had come to believe that the
problem of infectious, epidemic diseases had passed—a topic of concern
only to the developing world and historians.” However, with the appear-
ance and spread of AIDS and a growing number of other so-called “emer-
gent infectious diseases,” like Ebola, Lyme Disease, or Brazilian purpuric
fever, there has been a complete re-thinking of disease risk globally.
As a result of AIDS, in particular, but other diseases as well, the term
epidemic has been thrust back into the popular vocabulary in recent years.
Many definitions of this term exist. Marks and Beatty (1976), in their his-
tory of the subject, adopt a broad approach and include both communi-
cable and noncommunicable diseases that affect many people at one time.
230 Medical Anthropology and the World System
Epidemics (a word formed by joining epi or in with demos the people) are
conceptually linked to other words in the demic family of terms, including
endemics (from en or on), which are nonexplosive, entrenched diseases of
everyday life in particular communities, and “pandemics” (from pan or
all of), which are epidemics on a widespread or global scale.
AIDS in this sense is best described as a pandemic. It is now found in
every nation on the planet. Further, it has spread to people of every age,
race, class, ethnicity, gender, sexual orientation, and religion. However, as
noted in chapter 1, another useful term in thinking about AIDS is syndemic
in that AIDS is best understood in light of its bio-cultural and political
economic contexts. Unfortunately, to date no country or community that
has been struck by AIDS has been successful in stopping the spread of the
disease.
With the transmission of the virus to diverse new populations through
a number of routes of contagion tied to a range of behaviors, the pandemic
becomes ever more complex and can be said to be composed “of thou-
sands of smaller, complicated epidemics” in local settings and populations
(Mann et al. 1992: 3). These local epidemics reveal that in each setting
somewhat different subgroups are put at risk, but almost always it is those
who have the least power in society or are otherwise subject to social
opprobrium and public disparagement who are the most likely to be
infected.
Throughout its known history, HIV “has repeatedly demonstrated its
ability to cross all borders: social, cultural, economic, political,” but this
often has not brought people closer together to appreciate their common
plight and their shared needs as human beings (Mann et al. 1992: 3).
Rather, the pandemic generally has led to increased conflict and social
contestation, usually on preexisting lines of tension. Indeed, AIDS has
become probably the most political affliction visited upon the human spe-
cies in modern times. The disease caused by this “strange virus of un-
known origin” (Leibowitch 1985) reminds us, in fact, just how political
are all facets of health, illness, treatment, and health-related discourse.
This is an important point! Public health is never merely a medical issue,
it is always shaped and molded by structures of power and struggles over
power locally, nationally and internationally.
In sum, AIDS has revealed itself as a disease of social relationship—not
merely a social disease, but a disease of society as it is constituted as a
markedly stratified and widely oppressive structure. This occurs locally
within communities, nationally within the social systems of individual
countries, and internationally within the global system of nations. The
social features of the AIDS pandemic as it reflects and reveals aspects of
the global system, as well as social features of some of the local epidemics
that comprise the larger AIDS crisis, are explored in this chapter. To help
clarify the social dimensions of the AIDS pandemic as a disease of the
AIDS: A Disease of the Global System 231
“A Closer Look”
lic, saying, “We never can acknowledge her independence . . . which the
peace and safety of a large portion of our union forbids us even to discuss”
(quoted in Metraux 1972: 9). Fearful of the lessons of a triumphant slave
rebellion, the West condemned Haiti to the status of an international pa-
riah state, a position that was sustained through the projection onto the
former colony of an image of dangerous and bizarre Otherness (e.g., Loe-
derer 1935; Seabrook 1929). In the Western imagination, Haiti was con-
structed as “another world far from what they know as ordinary” (Barry,
Wood, and Preusch 1984: 337). Thus, voodoo, the indigenously formed
syncretic religious system of Haiti, became synonymous in the West with
evil, the epitome of so-called black magic, zombiism, strange trances, un-
earthly feats, and unbridled animalistic sexuality.
With the appearance of AIDS, this distorted portrayal was generalized
and Haitians themselves were represented as dangerously infectious and
life threatening by their very nature. By 1982, within a year of the iden-
tification of the first cases of what was to be termed AIDS (see below),
Haitians were labeled as a risk group by the U.S. Centers for Disease
Control. As a consequence, it was not long before being a Haitian “meant
that you were perceived as an AIDS ‘carrier’” and “the fact that AIDS was
found among heterosexuals in Haiti . . . [was read as] evidence that Haiti
was the source of the disease” (Gilman 1987: 102). The U.S. press carried
stories quoting Dr. Bruce Chabner of the National Cancer Institute, who
reported, “We suspect that this [disease] may be an epidemic Haitian vi-
rus” (quoted in Farmer 1992: 2). The politico-ideological context for these
developments lay in the well-established constructed images of Haiti.
The link between AIDS and Haiti, strengthened in innumerable articles
in the popular press, seemed to resonate with what might be termed a
North American “folk model” of Haitians. . . . The press drew upon read-
ily available images of squalor, voodoo, and boatloads of “disease-ridden”
or “economic” refugees. One of the most persistently invoked associations
related the occurrence of AIDS in Haitians to voodoo. Something that
happened at these ritual fires, it was speculated, triggered AIDS in cult
adherents, presumed to be the quasitotality of Haitians (Farmer 1990: 416).
The link with voodoo was asserted or suggested in both medical and
social science texts. In the October 1983 issue of Annals of Internal Medicine,
for example, two physicians from the Massachusetts Institute of Technol-
ogy suggested that it was “reasonable to consider voodoo practices a cause
of the syndrome” (Moses and Moses 1983: 565). Other bizarre or weird
features alleged to be characteristic of Haiti also were implicated.
Some U.S. researchers proposed that AIDS began with an outbreak of
African swine fever in Haitian pigs, and the swine virus had been passed
to humans. Others suggested that a Haitian homosexual may have con-
tracted the swine virus from eating undercooked pork, and then passed
it on to homosexual partners from the United States during acts of pros-
AIDS: A Disease of the Global System 233
titution. . . . Others proposed that Haitians may have contracted the virus
from monkeys as part of bizarre sexual practices in Haitian brothels (Sa-
batier 1988: 45).
As the critical medical anthropologist Paul Farmer notes (1990: 438),
“Even cannibalism, the most popular nineteenth-century smear, was re-
suscitated during discussions of Haiti’s role in the AIDS pandemic.” In
the dark light cast by such linkages, in 1990 the U.S. Food and Drug Ad-
ministration banned Haitians from donating blood.
All along, Haitian physicians studying the disease had produced evi-
dence to support an alternative, more mundane, although no less politi-
cally significant explanation of the high prevalence of AIDS among
Haitians. Research by these physicians found that most early cases could
be traced to Carrefour, a red-light prostitution center on the southern end
of the Haitian capitol of Port-au-Prince. Testing of stored blood samples
that were drawn from Haitian adults during an outbreak of dengue fever
in 1977–79 found that none carried antibodies to HIV. These data were
consistent with the hypothesis that HIV was not indigenous to the country
but had been introduced into Haiti in the late 1970s or early 1980s either
by tourists or by returning Haitians coming from the United States or
Europe (Pape et al. 1986). In addition to seeking an opportunity to pur-
chase inexpensive ethnic curiosities, acquire value-gaining primitivist
paintings, and take pictures of barefooted women balancing large bundles
on their heads as they walked passed traditional-looking thatched huts,
it is well known that many foreigners came to Haiti during the 1970s
tourist boom seeking sex. Thus, a Club Méditerranée was established in
Port-Au-Prince in 1980, and erotic accounts of available fun in the brilliant
Haitian sun were common in tourist guides of this period. Not surpris-
ingly, admitting to exchanging sex for desperately needed tourist dollars
was quite frequent among early Haitian AIDS patients.
Driven by poverty that was itself the product of Haitian subordination
to external economies and internal stratification, prostitution became a
means of survival for some rural migrants to Haiti’s crowded capitol city.
In short, the politics of AIDS among Haitians and other Caribbean peoples
are the politics of political-economic domination and, as a result, “the map
of HIV in the New World reflects to an important degree the geography
of U.S. neocolonialism” (Farmer 1992: 261). But this set of political rela-
tions was successfully submerged in more exotic accounts of Haitian
AIDS, images that exuded racism while they mystified hegemony. The
mundane and age-old tale of political-economic domination leading to
sexual domination, which is a good piece of the real story of Haitian AIDS,
remained hidden behind buried newfangled renditions of the master’s
fear of the rebellious subordinate. And, in various guises, this is a signifi-
cant part of the history and politics of AIDS everywhere, from the pre-
occupation with discovering the African origins of the epidemic to the
234 Medical Anthropology and the World System
The country with the largest number of [AIDS] cases, was also the country most
fully dependent on U.S. exports. In all the Caribbean basin, only Puerto Rico is
more economically dependent on the United States. And only Puerto Rico has
reported more AIDS cases to the Pan American Health Organization. . . . AIDS in
Haiti is a tale of ties to the United States . . . ; it is a story about unemployment
rates greater than 70 percent and tax-advantaged “free trade” zones. AIDS in Haiti
is about steep grades of inequality, both local and transnational.
about which we still are uncertain. The beginning of the AIDS pandemic—
not the point at which the virus began to spread in human populations,
but the point at which people began to recognize this was happening—is
not in dispute, however. During 1980, fifty-five young men in the United
States, primarily self-identified gay men, were diagnosed with various
diseases that ultimately came to be linked with AIDS. The health problems
of these men were noticed because they sought medical care; their phy-
sicians, in turn, unable to halt the infection with standard remedies,
sought approval to use a second-line antibiotic (pentamidine) from the
Centers for Disease Control. The first report of an emergent health prob-
lem suggested by the diseases of these men appeared on June 5, 1981, in
a widely read public health publication, the Centers for Disease Control’s
Morbidity and Mortality Weekly Report (MMWR). This article, which focused
on five cases from Los Angeles, did not mention that the people who were
coming down with an unusual form of pneumonia were gay men. On July
4, 1981, however, the same publication carried a second article entitled
“Kaposi’s Sarcoma and Pneumocystis Pneumonia among Homosexual
Men—New York and California.” This linkage of a rare cancer with a rare
pneumonia (caused by a harmless parasite for those with healthy immune
systems) in a geographically dispersed population defined by sexual ori-
entation was startling. The story was picked up immediately in both the
New York Times and the Los Angeles Times, and soon found its way into the
mass media throughout the country.
But epidemiologists and other health researchers were puzzled by the
epidemic that appeared to be breaking out around them. While it was
clear that the disease was linked to a breakdown in the body’s natural
defense system, the immune system, the cause of immunosuppression
(i.e., a breakdown of the immune system) was unclear. Was it the result
of environmental conditions, dietary practices, a promiscuous fast-lane
gay lifestyle, or the inhalation of amyl or butyl nitrite poppers to enhance
sexual or dance-floor arousal? No one was sure. There was less uncer-
tainty, or so it seemed, about who was becoming ill. In December 1981,
David Durack wrote an editorial for the New England Journal of Medicine
proposing a multifactorial disease model that centered on the interaction
between recurrent sexually transmitted disease and popper use as the
cause of immunosuppression in gay men. Before long, the term gay plague
had made its way into popular discourse. The new disease complex ap-
peared to single out and attack only gay men, particularly those with a
promiscuous lifestyle. Ultimately the term gay-related immune deficiency
(GRID) was suggested to label the new syndrome descriptively. In short
order, San Francisco, especially the heavily gay-populated Castro Street
area, came to be thought of as “AIDS City, U.S.A.” (Shilts 1987: 268) in
the popular imagination.
In this way, gay lifestyle became an intensified object of mainstream
236 Medical Anthropology and the World System
social derision; not only was it seen by many as being immoral, but now
it could be said to be life-threatening as well. Some people began to see
the new disease complex as divine punishment for violating religious pro-
hibitions against homosexuality. In time, the same language of blame and
punishment would be applied to illicit drug users infected with HIV and
Haitians as well. In this way—involving the social linkage of disease with
denigrated behaviors or identities—AIDS came to be a heavily stigmatized
disease. The extent of the stigmatization of AIDS was evident in the find-
ings of a nationally representative public opinion Internet survey in which
nearly one in five U.S. respondents (19%) agreed with the statement “Peo-
ple who got AIDS through sex or drug use have gotten what they de-
serve.” The stigmatizing attitude was found more often among men,
whites, individuals aged 44 years of age and older, people without a high
school diploma, and individuals who have annual incomes of less than
$40,000. Additionally, those who were less knowledgeable about HIV
were almost twice as likely to agree with the stigmatizing statement as
those who were correctly informed. Thus, 25% of those who answered
incorrectly that “it is likely for HIV to be transmitted from sharing a glass
with someone who is HIV-infected” or “by being coughed or sneezed
upon by an HIV-infected individual” were in agreement with the stig-
matizing statement, while only 14% of those who knew that HIV cannot
be transmitted in these ways agreed with the stigmatizing statement (Cen-
ters for Disease Control and Prevention 2000a).
As a result of stigmatization, people living with AIDS often come to
experience what has been called “a damaged sense of self.” Arliss (1997:
56) encountered an ethnographic example of this process during an inter-
view with Jack, an AIDS nurse who himself is infected with HIV:
I felt unclean like a leper or something, and the sort of prevailing attitude that
comes through from different people, particularly who should know better, who
don’t know better because they haven’t the disease yet, and you feel unclean.
Such thinking . . . was simply too farfetched for a scientific community that, when
it thought about gay cancer and gay pneumonia at all, was quite happy to keep
the problem just that: gay. The academy would not accept Rubinstein’s abstract
for presentation at the conference, and among immunologists, word quietly cir-
culated that [Rubinstein] had gone a little batty (Shilts 1987: 104).
The same pattern occurred among inner-city adult drug injectors, who
began exhibiting immunodeficiency disorders in the early 1980s. Consis-
tently, health officials “reported them as being homosexual, being
strangely reluctant to shed the notion that this was a gay disease; all these
junkies would somehow turn out to be gay in the end, they said” (Shilts
1987: 106).
By 1983, however, intravenous drug users (IDUs) constituted the ma-
AIDS: A Disease of the Global System 239
that a vaccine to stop the virus would be ready for testing in two years,
and, by implication, ready for human inoculation a few years after, an
achievement that over 25 years later has yet to be added to the “honor
roll” of medicine and science. The Heckler announcement created an in-
ternational stir. For several subsequent years a debate raged over whether
HIV was first isolated in France at the Pasteur Institute laboratory of Luc
Montagnier or in the United States at the National Cancer Institute labo-
ratory of Robert Gallo. Both labs were working feverishly on discovering
the pathogenic cause of AIDS. Heckler’s press conference, in fact, was
designed to cut off the French and patriotically to claim American credit
for the discovery of HIV as well as the profits to be gained by designing
a blood test to detect the virus. Anthropologically, these events are of
interest because they reveal the underlying political-economic nature of
scientific work. No less than disease, itself, the treatment of disease is far
more than a clinical issue, it is at the same time a very lucrative economic
one and a political one as well. Ultimately, Gallo and Montagnier agreed
to share credit for the discovery, but tension continued for years.
The April 11, 1983, issue of Newsweek magazine, which carried a cover
story labeling AIDS the “Public Health Threat of the Century,” signified
a new era in AIDS media coverage. Notes Shilts (1987: 267):
In the first three months of 1983, 169 stories about the epidemic had run in the
nation’s major newspapers and newsmagazines, four times the number of the last
three months of 1982. Moreover, from April through June, these major news organs
published an astonishing 680 stories.
a killer, while HIV-positive men said that they were no longer spending
as much time warning their friends to be careful about AIDS.
In response, in wealthy nations, by the late 1990s a kind of “AIDS fatigue”
set in, with people no longer wanting to hear or think about the disease.
This attitude seemed to be particularly strong among young gay men, some
of whom began to see condom use as unnecessary or even oppressive.
Avoiding condoms, a practice that came to be called barebacking, devel-
oped a set of vocal advocates. The consequence was a notable rise in risk
behavior in this population with expectable consequences. By 2001, the U.S.
Centers for Disease Control and Prevention reported that the new infection
rate for 23–29 year old white gay men in the United States had almost
doubled since 1997, going from 2.5% per year to 4.4%. Public health officials
began warning that if this rate continued, in five years, approximately 25%
of young gay men would be HIV positive. Even more alarming, among
Black young gay men, the rate was more than 14%.
Among people living with AIDS and their loved ones, AIDS activists,
researchers and others still strongly focused on the epidemic, the fear
began to grow that AIDS programs would begin to face significant cut-
backs. The height of this fear was reached in the weeks after September
11, 2001, in the wake of the brutal terrorist attack on the World Trade
Center in New York City and on the subsequent bioterriorist anthrax as-
sault using the U.S. postal system. As a result, the U.S. government ini-
tiated a massive budget restructuring, pouring billions of dollars in a war
against Afghanistan and in a radical beefing up of what came to be called
homeland security. The subsequent war on Iraq, and intensely challenged
federal effort to link the war to the fight against terrorism, became another
military drain on federal dollars. The prevailing fear among those con-
cerned about the ever rising number of people living with AIDS was that
terrorism would become “the new AIDS” in terms of federal spending
and public attention. Further dampening enthusiasm were reports of
growing drug resistance, as the virus mutated and became immune to
some of the best medicines available.
Tarantola, and Netter 1992). Across the Atlantic, there were over 100,000
diagnosed cases in Western Europe, while sub-Saharan Africa was rapidly
moving toward recording its two-millionth case, over 70% of the diag-
nosed cases in the world. Latin America accounted for 7.5%, and the Ca-
ribbean 2%; Southeast Asia, a locus of new infection at the time, reported
about 3% of the world’s AIDS cases. Even on the dispersed islands of
Oceania, there were about 5,000 AIDS cases. By 1992, AIDS cases had been
reported to the World Health Organization (WHO) from 164 countries,
including 52 countries in Africa, 45 in the Americas, 28 in Asia, 28 in
Europe, and 11 in Oceania. Between 1985 and 1990, there was a sevenfold
increase in the number of new AIDS cases reported to WHO (Mann, Tar-
antola, and Netter 1992). Given the fact that it is generally recognized that
WHO only receives partial data from many areas of the world, the number
of AIDS cases may have been even higher by 1992 than in those figures,
and the numbers continued to climb.
Thus, globally over 60 million people had been infected with HIV by
the end of the year 2001. AIDS is now the fourth biggest cause of death
in the world, with 24 million deaths attributed to the pandemic. Around
the world there are over 35 million people living with HIV disease. Each
year, another four million people are infected. The majority of these new
infections are among young, reproductive-age adults, with young women
being particularly vulnerable. About one-third of those currently living
with HIV/AIDS are 15–24 years of age, that is, in their early child-bearing
years. Most do not know that they have been infected. Many millions
more in the world have only limited knowledge about HIV including how
to protect themselves from infection. Projecting to the year 2005, the World
Health Organization estimates that 100 million people will be infected
around the world. Importantly, the largest health and social impacts of
the pandemic are yet to come.
A measure of these impacts can be seen by examining differences in
AIDS rates between highly developed and developing nations. In sub-
Saharan Africa, where the pandemic has been particularly harsh and
widespread, there have been 17 million deaths due to AIDS since the
beginning of the epidemic, another 25 million people are infected. The
average prevalence of HIV infection in sub-Saharan Africa is 8.8% among
those 15–49 years of age. However, in 16 countries on the continent, 10%
of people in this age range are infected. Notably, 172 children under the
age of five die of AIDS for every 1,000 births in the region. By contrast, in
the developed world the percentage is six per 1,000 births. If the preva-
lence of HIV disease goes up by 10% in a country, the Gross Domestic
Production will drop by 1% (Quinn 2001). Thus, it is estimated that by the
year 2010, sub-Saharan Africa will be 17% less productive than it would
have been had the AIDS pandemic never materialized. Some countries in
the region, like Botswana, have long surpassed the point of severe impact.
AIDS: A Disease of the Global System 245
By the end of 2001, 36% of the adult population in the country was already
infected. In southern Africa, the lifetime risk of being infected and dying
of AIDS is greater than 60% for those who are now adolescents. In the
hardest hit areas of the continent, life expectancy has already gone down
by 15 years and over the next 30 years may fall another 15 years. Given
the age group it is most likely to strike, AIDS has contributed to a tre-
mendous jump in the number of orphans. It is estimated that over 12
million children in Africa have lost one or both parents to the epidemic.
Significantly, 30%–50% of Africans dying with AIDS are co-infected with
tuberculosis (Quinn 2001).
One brighter spot on the African AIDS scene is Uganda. Based on a
program designed to engage religious, traditional, and civic leaders in a
full public discussion on AIDS as well as a coordinated effort that includes
prevention education in schools, community counseling for people living
with the disease, and widespread condom distribution (e.g., putting con-
doms next to bibles in hotel rooms), Uganda has been able to slow the
spread of HIV disease in its population. In the capital city of Kampala,
for example, the proportion of people with HIV fell from 31% in 1990 to
14% eight years later. However, the AIDS picture in Uganda is not all rosy.
The majority of Ugandan people living with AIDS cannot afford effective
treatment. With the pharmaceutical industry producing and setting prices
in order to make significant profit, the price of existing medications is too
high even for those AIDS drugs that have had their prices slashed because
of competition from generic medications manufactured in the developing
world.
This account of AIDS in Africa makes it clear that we are far closer to
the beginning of the history of the AIDS pandemic than we are to its end.
On a global scale, how are we to understand this history? Elizabeth Fee
and Nancy Krieger (1993: 323) have argued that
the history of AIDS does not simply present itself as a chronological succession of
events. It is a history that necessarily is constructed and that cannot simply be
inferred from the biological properties of HIV or the pathological realities of the
disease.
men and injection drug users. However, as elsewhere, the epidemic did
not accommodate wishful thinking about its ability to spread. By 1988–
89, the country was facing what it would later see as the first wave of a
major epidemic, with rates of infection rising to 40% among those engaged
in known high risk behaviors such as IDUs. The second wave of the ep-
idemic hit commercial sex workers. Testing among sex workers in the city
of Chiang Mai, a city in the north of the country, in 1989 found HIV
infection prevalence at 44%. By 1994, 31% of sex workers in the rest of the
country were also HIV-positive. At the time, it was estimated that there
were over half a million people with HIV infection in the country. Studies
in northeast Thailand confirmed that the primary means of HIV trans-
mission was through prostitution. In the provincial capital of Khon Kaen,
for example, four hundred professional sex workers, all women, were
identified. These women, who worked out of a variety of sites, including
massage parlors, brothels, barbershops, night clubs, restaurants, and
short-stay hotels, were found to have high rates of HIV infection. Research
in Thailand suggests that between a quarter and a half of Thai men have
frequented professional sex workers. Nonetheless, a community study of
married women in twelve villages in Khon Kaen Province showed that
most women did not believe themselves to be at risk for HIV infection.
The reason most frequently given by women for not believing they were
at risk was that their husbands never frequent professional sex workers
(Maticka-Tyndale et al. 1994). As these data suggest, gender relations and
gender inequality can be critical factors in AIDS transmission. Thailand,
in fact, is one of a number of sites in Asia where not only local level
prostitution is common but where international prostitution or sex tour-
ism flourishes. The practice involves individuals or groups of foreign male
visitors booking holiday vacations that include numerous visits to local
brothels, x-rated clubs, and massage parlors. These businessman’s holi-
days have created a lucrative income for those who run the sex trade
business. Girls and young women who wind up in the sex trade often are
duped into coming to urban areas from the countryside through bogus
offers of legitimate employment or access to education. Additionally, the
sex trade industry recruits and transports thousands of girls and women
across national boundaries, a process that is global in its reach. Cut off
from personal networks of social support, those caught in the cross-border
sex trade industry are particularly vulnerable to forced involvement in
risky sex and HIV infection.
Ultimately, the magnitude of the growing AIDS epidemic pushed the
Thai government into action beginning in the early 1990s. A nationwide
campaign was launched to reduce HIV transmission involving the pro-
motion of condom use during commercial sex. Led by the National AIDS
Prevention and Control Committee, chaired by the Prime Minister, and
involving active community participation by non-government organiza-
AIDS: A Disease of the Global System 249
The Caribbean
Permanently impacted by its post-contact history of colonialism and
slavery, the Caribbean has produced a collection of over 25 island societies
that differ in their political structures, ethnic compositions, dominant lan-
guages, and social histories. The islands also vary considerably by geo-
graphic and population size. Generally, rates of infection have risen
dramatically in the nations of the Caribbean during the 1990s, although
there is considerable diversity in the extent of the epidemic among the
islands. It is estimated that over 350,000 people in the Caribbean are in-
fected with HIV disease, with the average adult HIV prevalence rate
reaching 2% by the end of the 20th century. However, as has been seen,
the epidemic has been particularly harsh in some places, such as in Haiti,
which has an adult HIV prevalence rate of 5%, putting it among the top
ten countries in the world in HIV prevalence. Elsewhere in the Caribbean
there has been a slower but steady increase year by year in the rate of new
AIDS cases as the epidemic has progressed. For example, in Trinidad and
Tobago, there were 198 new AIDS cases in 1990, rising steadily to 677 new
cases in 1999. In Jamaica, the rate of increase in AIDS cases has been
steeper in recent years, rising from 62 new cases in 1990 to 892 in 1999.
By contrast, the islands of the Bahamas have demonstrated considerable
success in responding to the epidemic. In 1994, the Bahamas recorded 719
new cases of HIV infection, by 1999 the annual number of new cases had
fallen to 343. Similarly, while 280 died of AIDS in the Bahamas in 1995, in
1999 only 120 deaths were attributed to the epidemic. Other contrasts are
also noteworthy. Cuba, which launched an early and aggressive effort to
contain the spread of AIDS, including, temporarily, the quarantining of
infected individuals, has a comparatively low number of AIDS cases.
Thus, while Haiti (population: 7 million) had a seroprevalence rate (per-
AIDS: A Disease of the Global System 251
Ukraine, Belarus, and Moldova. In the Ukraine, for example, sexual trans-
mission was the primary route of infection until the end of 1994. In the
early months of 1995, however, rates of infection among IDUs in cities
like Odesa and Kikolayev began to skyrocket, jumping from 1,000 cases
to as many as 100,000 cases by 1997. Soon high rates of infection among
IDUs were being reported in all 25 regional capitals of the Ukraine. From
the cities, the epidemic spread to the countryside, following the diffusion
of injection drug use to rural areas. Within a year and a half of the spread
of HIV to IDUs in the Ukraine, HIV prevalence reached 31% in Odessa
and 57% in Nikolayev. Research in Odessa on risk behaviors among IDUs
that could account for such rapid transmission found that ready-filled
syringes provided by drug dealers and frontloading (removing the needle
from the syringe to inject drug solution from one syringe to another) from
a drug dealer’s syringe to the customer’s syringe were common practices.
Both of these behaviors could readily contribute to rapid HIV transmis-
sion among IDUs if dealers’ syringes are infected. Another study in the
Ukrainian city of Poltava found that 68% of IDUs reported drawing up
their drug solution from shared containers, a known risk practice. (Ball et
al. 1998). The result in many parts of the former Soviet Union has been
dramatic. For example, during the month of May 1996 over 750 new cases
of HIV infection were identified in the small Belorussian city of Svetlo-
gorsk, about 1% of the total population of the city (Ball et al. 1998).
China
While the first AIDS case in China was diagnosed in 1985, the HIV
epidemic in China remains a sleeping giant that is just beginning to stir.
While there is, as yet, no large-scale HIV epidemic in China, existing ep-
idemiological data affirm the potential for the rapid spread of infection.
Over the last 15 years, identified AIDS cases in China have gone from zero
to about 20,700. Currently, it is estimated that as many as 10 million people
may be infected with HIV by the year 2010 if no prevention is effectively
implemented. Injection drug use has been identified as a significant factor
in the spread of HIV/AIDS in China. While drug use was widespread in
China prior to the establishment of the existing government in 1949, in-
jection drug use was rare. The recent resurgence of drug use, and the
appearance of injection drug use, began in the early 1980s in rural areas
of the southwestern sector of the country, and have spread from there to
other regions and to urban areas. The Chinese Ministry of Health (1997)
has identified three primary phases in the spread of AIDS in the country.
During phase 1 (1985–88), there were a small number of cases, mostly
among individuals who had lived outside of China. During phase II
(1989–93), a period of limited HIV spread, a number of indigenous rural
drug users were diagnosed with HIV in Yunnan province. During phase
254 Medical Anthropology and the World System
III (1994– ), HIV spread beyond Yunnan, with infection being most com-
mon initially among IDUs and plasma donors (whose blood has been
packed with the donations of others and then returned to donors with the
plasma extracted). Currently, China may be entering a fourth phase, in-
volving multiple local epidemics that vary by province and county, with
differing epidemiological profiles, in which injection drug use (which has
become an increasingly common method of illicit drug consumption) re-
maining a significant source of new infections, including urban infection
(Sun, Nan and Guo 1994, Wu 1998).
Eleven of China’s 31 provinces now report more than 10,000 registered
drug users each, and it is now estimated that there are six million drug
users in the country, creating a significant pool for HIV infection and
transmission. Growing numbers of drug users, the spread of injection
drug use, increasing numbers of younger drug users, increasing numbers
of female drug users, the appearance of urban drug use, and raising rates
of HIV infection among drug users are the key characteristics of recent
drug use trends in China. To assess the extent of injection drug use and
HIV exposure through drug use, and to control these health risks, China
has implemented policies and sentinel surveillance studies. This body of
research shows that the sharing of drug injection equipment is widespread
and that HIV as well as hepatitis infection are spreading rapidly among
IDUs. To date, research on HIV and related health risks among drug users
in China has emphasized survey and surveillance methods that effectively
reveal the extent of many key behaviors of concern. However, thus far
there has been only limited qualitative and ethnographic assessment of
HIV risk among IDUs in China. This fact results in a narrow base upon
which to assess actual on-the-ground risk behaviors; specific contexts of
risk and risk promotion, pathways of risk diffusion; and the precise nature
of the social, environmental, structural and cultural factors that promote
or retard risk behaviors among Chinese IDUs. In recent years a number
of anthropologists have been working in China with the expressed pur-
pose of providing ethnographic insight on the growing AIDS epidemic in
the country.
Since the early 1980s, controlling illicit drug use has been one of the
priorities on the agenda of Chinese leaders throughout all levels of gov-
ernment. A number of regulations regarding the use of drugs were issued
during the 1980s and 1990s. These new laws included harsh punishment
of drug smugglers and mandatory treatment for users. The latter involves
four stages of involvement in the treatment process. The first stage is
called “voluntary home-based assistance to quit.” If the first stage does
not prove effective, the user is then referred to a “voluntary community-
based treatment center.” The third level of response is the “compulsory
treatment service” operated by narcotics control agencies and the strictest
AIDS: A Disease of the Global System 255
Lown and coworkers (1993: 101) attribute the rise in crack addition,
particularly in the African-American community, to radical changes in the
economic infrastructure of inner-city communities: “Previously, blacks
could compete for unskilled jobs but such employment has all but
256 Medical Anthropology and the World System
Poor women with limited marketable skills trade sex-for-crack because they are
addicted and because they have no other means of supporting their habit. Their
powerlessness and marginality fuel the sex-for-crack phenomenon. The position
of women in the underground economy mirrors their location in the mainstream
economy. . . . Drug-using male members of the underclass have a greater variety
of possible economic strategies than women.
A IDS A ND UR BA N POLIC Y
Roderick Wallace (1990) has analyzed the social distribution of AIDS in
New York City in terms of the social disorganization of poor neighbor-
hoods caused by changes in social policy, such as the withdrawal of es-
AIDS: A Disease of the Global System 257
“A Closer Look”
African American children are twice as likely to be born prematurely, die during
the first year of life, suffer low birth weight, have mothers who receive late or no
prenatal care, be born to a teenage or unmarried parent, be unemployed as teen-
agers, have unemployed parents, and live in substandard housing. Furthermore,
African-American children are three times more likely than whites to be poor, have
their mothers die in childbirth, live in a female-headed family, be in foster care,
and be placed in an educable mentally-retarded class. (Hope 1992: 153)
That malnutrition and hunger exist in the contemporary United States seems un-
believable to people in other nations who assume that Americans can have what-
ever they want in life. Even within the United States, most people are not aware
of domestic hunger or else believe that government programs and volunteer ef-
forts must surely be taking care of hunger that does exist here. (Fitchen 1988: 309)
Medical problems associated with heavy drinking have increased very dramati-
cally in the black population. Rates of acute and chronic alcohol-related diseases
among blacks, which were formerly lower than or similar to whites, have in the
AIDS: A Disease of the Global System 263
post war years increased to almost epidemic proportions. Currently, blacks are at
extremely high risk for morbidity and mortality for acute and chronic alcohol-
related diseases such as alcohol fatty liver, hepatitis, liver cirrhosis, and esophageal
cancer. (Herd 1991: 309)
While racial and ethnic minorities comprise about 27% of the U.S. popu-
lation, cumulatively just Blacks and Hispanics alone comprised 55.8% of
all AIDS cases diagnosed through the end of the twentieth century. More-
over, these two groups account for more then 66% of new AIDS cases in
the country, indicating that the segregation of AIDS as a disease of op-
pressed minorities is accelerating. The rate of infection among African
Americans is eight times greater than the rate for whites. Researchers
estimate that about 1 in 50 African American men and 1 in 160 African
American women are infected with HIV. Among women, 58% of all AIDS
cases are African American, and another 20% are Latina. Among children,
African American children represent almost two-thirds (65%) of all re-
ported pediatric AIDS cases. Among heterosexually transmitted cases,
Blacks accounted for 73% of new cases in the year 2000 compared to 14%
for whites. Similarly, AIDS is more prevalent among African American
and Latino gay men than among their white counterparts. Additionally,
a high percentage of adolescent AIDS cases occur among minority youth
(Centers for Disease Control 2001). The transmission of AIDS, of course,
has been closely linked to drug use. Drug injection and sexual transmis-
sion linked to crack use have become the primary sources of new HIV
infection in the United States. Among drug injectors with AIDS nationally,
about 80% are African American or Latino. In response to the worsening
AIDS epidemic among minorities, in May of 1998 the Congressional Black
Caucus of the United States requested that the Secretary of the Depart-
ment of Health and Human Services declare the HIV/AIDS epidemic in
the Black community a “public health emergency.” While this did not
happen, the president (Bill Clinton) did initiate new efforts to improve
the nation’s effectiveness in preventing and treating HIV/AIDS in the
African American, Hispanic, and other minority populations. By the end
of the twentieth century it was not evident that these new efforts had been
sufficient to stop the minority AIDS crisis.
Beginning in the mid-1980s, there was a dramatic rise in the incidence
of syphilis in the United States, “attributable to a very steep rise in infec-
tion among black men and women” (Aral and Holmes 1989: 63). While
rates of infection dropped below 5,000 cases per 100,000 population for
white men in 1985 and continued to decline through 1988, for African
American men the rate began climbing in 1985 and by 1988 was about
17,000 cases per 100,000 population. Among women, in 1988 there were
about 2,000 and 13,000 cases per 100,000 for white and African American
women respectively. By 1991, 85% of primary and secondary syphilis cases
264 Medical Anthropology and the World System
In the early years of the pandemic, anthropologists were slow to respond to this
rapidly emerging health problem. After the mid-1980s, however, this initial neglect
266 Medical Anthropology and the World System
was followed by serious engagement with the epidemic on the part of a large
number of anthropologists. More than two hundred of our colleagues have joined
the AIDS and Anthropology Research Group, a [subgroup] of the Society for Medi-
cal Anthropology. It is safe to assert that no topic in the entire field of anthropology
commands more attention and more scholarly involvement at the present time.
Through this strategy, Bolton was able to determine that high-risk sex-
ual behavior was quite common and quite accepted in the privacy of the
bedroom among gay men in Brussels. This finding was of importance
because health officials in Belgium had come to the conclusion, based on
several surveys, that gay men had significantly curtailed risky sexual be-
havior and that it was no longer necessary therefore to focus prevention
efforts on the gay community.
Another approach for going beyond self-reported sexual practices was
developed by Terri Leonard in her study of male clients of street sex work-
ers in Camden, New Jersey. Leonard conducted her research by hanging
out at an inner-city “stroll” area (a street where sex workers seek business
among pedestrians and the drivers of passing cars).
All men who attempted to solicit my services, assuming I was a sex worker, were
invited to participate in a “sex survey.” Men initiated contact using several ap-
AIDS: A Disease of the Global System 271
proaches. Some pulled up alongside the curb or onto a side street and, with en-
gines idling, engaged me in conversation. Some men parked alongside the street
and got out to make a phone call or have a drink in a nearby bar, initiating con-
versation en route. Some men “cruised” by several times per day, several days
per week, or once every few weeks before approaching. (Leonard 1990: 43)
Leonard found that twenty men out of the forty-nine she was able to
interview reported that they used condoms during commercial sex. How-
ever, despite this self-report, only five of the men actually had condoms
with them at the time they solicited sex with Leonard. Like Bolton’s work,
Leonard’s shows that ethnographic approaches can produce data that re-
flects actual rather than idealized behavior.
In cross-cultural settings, the study of sexual behavior may be especially
problematic, as cultural norms about and experiences with sex vary sig-
nificantly. For example, the spread of HIV in Africa has been attributed
primarily to heterosexual contact, and African male “hyperheterosexual-
ity” has been blamed for the sub-Saharan epidemic. Additionally, homo-
sexuality has been publicly condemned by a number of African leaders
as un-African behavior. As a result of this stigmatization, efforts to study
sexual practices, including same-sex contact, among African men are sty-
mied by respondent defensiveness and the fear of condemnation. Con-
sequently, Niels Teunis (2001) found in his attempt to study the role of
same-sex practices in the spread of HIV among men in Darkar, Senegal,
that such behaviors were hidden and their existence denied. Ultimately,
Teunis (with the aid of a street youth) learned of a bar with a homosexual
clientele. While he was able eventually to interview 42 men who engaged
in same-sex contact, as well as to participate with them in various social
activities, he quickly realized that these men operate with a code of secrecy
and live in fear that their behavior will be exposed with drastic conse-
quences. Under these conditions, Teunis was never able to tape-record his
interviews and was otherwise restricted in the methods of data collection
he could use (e.g., photography was not possible). Nonetheless, through
building relationships and maintaining high ethical standards (e.g., strict
confidentiality) he was able to document same-sex practices (e.g., anal sex)
and social roles (such as yauss men who engage in sex with men but do
not identify themselves on the basis of this aspect of their sexuality), and
to identify HIV prevention needs in this diverse population. In Teunis’s
assessment, given the intense secrecy that brackets sexuality in general
and same-sex behaviors in particular, in-depth ethnography, based on
long-term interaction, social participation, and rapport building, is the
preferred research method; other approaches, like public surveys, he ar-
gues, are unlikely to break through the protective wall of silence and
denial.
272 Medical Anthropology and the World System
As most Miamian drug injection behavior involves cocaine, which is not “cooked”
during the mixing process, whatever microbes are in the clean water will be in-
jected into the shooter. Even if the client uses a new set of works to inject the drug,
the water mixed with the drugs could be contaminated by exposure to [other
injectors’] contaminated syringes.
Risk for HIV transmission through water also occurs during needle rins-
ing. Explain Page, Smith, and Kane (1991: 76),
I used to work in the hospital [in prison]. My job was in the hospital. I set up all
the stuff for the doctor [e.g., syringes]. So, I was the guy selling the needles [to
other inmates]. I had access to needles; they’d tell me to destroy them [after use
274 Medical Anthropology and the World System
with a patient, but] I’d put them [aside instead]. . . . You know . . . they sent you
up on different floors, like guys with low crimes on the first floor. Bigger crimes
on the second floor, bigger crimes on the third floor, highest crimes on the top
floor . . . So, I always went straight to the top floor. Those were the guys that had
the C.O.s [correction officers] running the drugs [in] for them. So, I’d go over to
them and . . . every morning those guys would say, “Look man, I need fresh nee-
dles every day.” So, that’s how I took care of myself [i.e. his drug addiction] in
jail. “You need five set ups [syringes] every morning, you got them. Now grab me
a couple of bags [of drugs].” And they’d give it to you man, no questions, no wait.
When I got there [to the cells of customers], they’d slide that shit [drugs] under
the door . . . I took care of the guys! It’s something that you learn. (M. Singer et
al. 2001: 595)
Stories like these invert the socially dominant image of street drug users
as social failures and people lacking the intelligence or skills to succeed
in regular society. Rather, narratives like this one portray efficacious in-
dividuals with notable abilities, people who make things happen and get
things done even under trying circumstances. Whatever the veracity of
such stories, they reveal, by the cultural elements they express, that con-
trary to the assumptions of “straight society,” drug users embrace con-
ventional action- and achievement-oriented cultural values. While street
drug-users commonly are seen as socially marginal individuals, their sto-
ries appear to give voice to noticeably mainstream concerns and ideas.
Also found among the adventurous narratives of drug users are stories
that tell of close calls, narrow escapes, and heroic rescues. Commonly,
these narratives emphasize the grave threats that drug users face each day
on the street. Oftentimes, narrow escape narratives involve mistaken iden-
tities in which the wrong person or, alternately, a substitute (e.g., an ac-
cessible friend of the intended victim) is targeted for some form of
retribution stemming from a violation of trust in the drug trade (e.g.,
receiving drugs to sell and not turning in the money).
Great escapes from the police are also common as seen in the following
story told to the field team:
So, we was on the highway. I was smoking [rock cocaine] just looking around. He
was just driving. He was like doing fifty on the highway at night. The next thing
you know the narcs were pulling us over. I rolled down my window, I just shot
the stem [cocaine pipe] right out the thing and the lighter out the window. My
brother, I don’t know what he did with the cooker or whatever. I think he slipped
it under the seat or something. The needle, I don’t know what he did with it. They
took us out of the car. They searched us and everything. They made us drop our
underwear, lift up our socks, everything. And they didn’t find nothing!
This model extends to sexual intercourse among men who have sex with
other men. The individual who is penetrated during anal intercourse is
seen as playing the passive role, while his partner is viewed as fulfilling
a masculine role. In Brazilian society, the former are subject to consider-
able social stigma while the latter are “reasonably free within the context
of this system to pursue occasional or even ongoing sexual contacts with
both males and females without fear of severe social sanction” (Parker
1987: 161). Similarly, based on his research in Mexico, Joe Carrier (1989:
134) has noted that males who play the penetrative or insertive role
By contrast, in the United States, men who have sex with other men are
defined by society as being homosexual regardless of the role they play
during anal intercourse. Moreover, among self-identified gay men in the
United States, mutual penetration is common while distinct active and
passive roles, to the degree that they exist, tend to be constructed as per-
sonal preferences rather than distinct or enduring sexual identities. These
examples show that not only are sexual identities constructed somewhat
differently in different societies but that AIDS prevention must be sensi-
tive to these differences if it is to be effective in reaching individuals who—
whatever their specific sexual identities—are at risk for HIV infection
because of their sexual behaviors.
As seen in the examples described above, in their AIDS-related studies,
anthropologists have stressed the importance of (1) gathering data in nat-
ural social settings; (2) paying keen attention to the role of culture in shap-
ing behavior; (3) looking at insider understandings and identities;
(4) maintaining a holistic approach that recognizes the influence of range
of social factors on risk behavior; (5) paying attention to gender issues in
social life; and (6) using information gained through ethnographic ap-
proaches to build culturally targeted AIDS prevention programs.
To this set of anthropological approaches to AIDS risk research, critical
medical anthropology draws attention to the importance of political-
economic factors. As seen in the discussion of AIDS risk in southern
Africa, oppressive political and economic relations can be seen as macro-
parasitic causes of new infection. The failed effort by South Africa to main-
tain its internal system of apartheid exploitation as well as its regional
dominance by promoting a series of low-intensity wars of destabilization
against its neighboring countries produced social conditions that signifi-
AIDS: A Disease of the Global System 279
and Hispanic Americans combined; and (4) a chief elected official of the
locality (e.g., the mayor), in collaboration with appropriate health officials,
being willing to submit a letter to the Secretary of Health and Human
Services requesting a crisis response team. Developed originally by an-
thropologist Susan Scrimshaw and her co-workers, rapid assessment pro-
cedures, which involve rapidly implemented ethnographic studies on
targeted issues, have a well-documented history of success in public
health with a wide range of problems, including malaria, diarrheal dis-
ease, dengue fever, water sanitation, and natural disasters. In recent years,
the World Health Organization, Joint United Nations Programme on
HIV/AIDS, Doctors Without Borders (Medicins sans frontiers), and, the
United Nations International Drug Control Programme have conducted
rapid assessments on injection drug use and HIV in Eastern Europe, Rus-
sia, and the former states of the Soviet Union. In the U.S. initiative, which
was titled project RARE (Rapid Assessment, Response and Evaluation),
the cities of Detroit, Philadelphia and Miami were the first of 11 U.S.
metropolitan areas with large minority populations affected by HIV/
AIDS selected to receive federal assistance. Fieldwork in these three cities
began in September and October 1999 in each of the three cities. The Fed-
eral crisis team visited each of the cities to consult with a working group
(consisting of AIDS service providers, elected officials, public health work-
ers, and AIDS activists) approved by the chief local official to coordinate
local participation in project RARE. Local working groups then engaged
in a process to guide the assessment in terms of the selection of high risk
geographical areas in the city, groups engaged in risk behaviors, and
points of intervention that represented the leading edge of the HIV epi-
demic in that city. The working group also had the responsibility to select
a local field team (usually consisting of 8–12 AIDS and other outreach
workers, direct service providers, and community activists). The Federal
crisis team, consisting of several anthropologists, then provided field team
members (few of whom had prior research experience) with three days of
training on RARE assessment methodologies, analysis of data, and pre-
paring reports for the working group and chief elected official. Each field
team under the supervision of a lead ethnographer who was often an
anthropologist or other social scientist, used focus groups, rapid or in-
depth interviews, field observations, and social mapping to determine
what factors had been missed in prior AIDS intervention activities or
where unmet intervention needs were contributing to new infections. The
focus of data collection included previously unrecognized risk behaviors,
newer populations at risk, the role of temporary factors in risk (e.g., night
time vs. day time behavioral patterns), and high-risk settings. Given the
crisis nature of the AIDS epidemic in minority communities, all data col-
lection, analysis and recommendation develop was designed to be com-
pleted in four months time. In the initial three cities, reports and
AIDS: A Disease of the Global System 281
CO NCLU SION
As Farmer (1992: 262) notes, “One way to avoid losing sight of the
humanity of those with AIDS is to focus on the experience and insights
of those who are afflicted.” This is an extremely important point. While
the thrust of critical medical anthropology is to understand human health
issues in their sociohistoric and political-economic contexts, it also has
been emphasized in the CMA literature that we must pay close attention
to sufferer experience and agency. Sufferer experience, an arena long ne-
glected in the social science of health, increasingly has become a topic of
research interest. From the perspective of CMA, sufferer experience is a
social product, one that is constructed and reconstructed in the action
arena between socially constituted categories of meaning and the political-
economic forces that shape the contexts of daily life. Recognizing the pow-
erful role of such forces, however, does not imply that individuals are
passive and lack the agency to initiate change, and it certainly does not
mean that they are insignificant. Instead, it means that people respond to
the material conditions they face in terms of the set of possibilities created
by the existing configuration of social relations and social conditions.
Within this framework, it is vital that we remain sensitive to the individual
level of experience and action so that we never forget that the ultimate
goal of critical medical anthropology is to contribute to the creation of a
more humane health care system and more humane lives for all people.
CHAPTER 9
GENDER
Reproduction and the health of mothers and infants cannot be under-
stood separately from the gendered distribution of resources and the
division of labor in any society. Women’s access to education and em-
ployment has a direct effect on patterns of family size and the health of
the mother and child. Despite many improvements, women continue to
be disadvantaged with respect to men in employment and health and, in
general, poorer and minority women suffer poorer health with a direct
relationship between degree of disadvantage and the extent of health
problems (Hogue 2000: 21). In fact, many women and children are dying
from their experience of gendered discrimination (Freedman and Maine
1993). In 43 out of 45 poor countries surveyed, girls were less likely to
survive than boys (Heise 1993). Girls are less likely to be taken for treat-
ment should they fall ill and more likely to suffer from malnutrition,
which particularly affects their childbearing years (Miller 2000, Merchant
and Kurz 1993). Even female fetuses are less valued as, for example, when
amniocentesis was introduced in India, most of the fetuses aborted were
female (B. Miller 2000). Among poor households, the health effects of
gender, as measured in the morbidity and mortality statistics for women
in relation to men, are frequently magnified by lifelong nutritional dep-
rivation combined with lack of care in pregnancy and childbirth (Koblin-
sky et al 1993). Institutional discrimination against women combined with
household inequality is also manifest in the high maternal mortality rates
and infant mortality rates common in many poor regions (Goldman and
Hatch 2000, Koblinsky et al 1993). The World Health Organization esti-
mated that about 500,000 women die every year in childbirth and preg-
nancy, mostly from preventable causes (Freedman and Maine 1993).
did not keep cattle or goats, dairy foods were practically non-existent. In
addition, San women were physically active on a daily basis and often
walked twenty miles a day with their bands. Among such active women
with little excess fat, ovulation might start late and be irregular even
among adult women (Howell 2000, Lee 1979).
Since there was little dairy produce to substitute for mother’s milk and,
as the San did not grow cereals, there were few soft foods or alternate
sources of protein, and many foraging women breastfed their babies for
four or more years. This too contributed to a lack of excess fat and a
reduced likelihood that a woman with a young child would ovulate reg-
ularly. In fact, demographic research demonstrated that nomadic women
spaced their pregnancies, on average, about four years apart. However,
this was not simply a biological or natural consequence of diet, exercise,
and breastfeeding. The San adopted a variety of rules and practices which
prevented a new child from being an insupportable burden as the small
band wandered many miles on foot seeking food and water.
If the cultural strategies that limit fertility failed, foraging mothers faced
a tragic dilemma in which their options were limited and shaped by their
environment and access to resources. Under conditions of famine and
starvation, a San woman had the autonomy to decide how to cope. If a
mother did become pregnant again, before her last child could travel long
distances without being carried, she might try to abort the pregnancy or
not allow the infant to survive. Nisa (Shostak 1983) tells a story of a preg-
nant mother, wishing to save the life of her youngest child, whom she
sees as mortally threatened by the future infant in competition for nutri-
tion and resources. The mother gives birth outside the village, accompa-
nied only by her small daughter, and then abandons the new baby.
From the 1960s as vast stretches of foraging land were taken over by
cattle ranches and roads built through the desert, the San settled near bore
holes built by the local governments, raised a few cattle and goats and
received free supplements of grain. As people kept dairy animals and
more soft food was available for infants, women did not exclusively
breastfeed their babies as long and were more likely to ovulate and be-
come pregnant sooner and more often (Howell 2000). In addition, young
girls and women were expected to be more subordinate to men and the
learning of gendered sex roles by girls was more obvious, as young girls
played with dolls and young women were expected to obey their hus-
bands (Draper 1975).
For the first 70,000 years of human existence, societies survived by for-
aging and populations remained relatively stable. Since population size
is more directly limited by the number of women, anthropologists have
suggested that female infanticide was among the strategies used by for-
agers to maintain small populations, in order not to strain the resources
available (Harris and Ross 1987). A man can father any number of children
290 Medical Anthropology and the World System
at one time, whereas a woman can only carry a finite number of pregnan-
cies to term.
Populations began to increase with settled agriculture. Possibly, as some
researchers have argued, people had to work harder to produce food and
resorted to horticulture or herding animals, because they had to feed
growing populations. Since subsistence conditions required more inten-
sive labor, kin groups and lineages valued children as future workers.
However, societies still sought to culturally define household and popu-
lation size. Spacing strategies, such as the separation of the mother and
child from the father immediately after birth, and local abortion practices
were common in horticultural and pastoral populations.
In many societies, women established power in their descent group by
bearing children, and particularly sons, who would represent their inter-
ests later (Kabeer 1985, Gammetoft 2000). In contrast to the customary
requirements in Mediterranean states for a bride to be a virgin (Schneider
and Schneider 1996), women among many other peoples such as the Ka-
dar of Nigeria were highly valued if they had a child before marriage as
this demonstrated their fertility to their future husband and his kin, and
when the young girl married, the children joined her husband’s patrilin-
eage (M.G. Smith 1968: 113).
Barren wives, or women who did not have children, were often penal-
ized in such societies. However, biological fertility does not always limit
women’s access to influence through children. Mona Etienne (2001) de-
scribed the way in which barren women among the Baule in Ivory Coast
enhanced their political status by migrating to urban areas and adopting
children to maintain and later inherit their property in their rural village.
Only such connections insured a woman influence while she was alive
and a respectable funeral at her death.
Francis Nyamnjoh (2002), a sociologist from Cameroon, describes his
own upbringing and adoption by two social mothers besides his biological
mother and two men who regarded him as a social son, contributing to-
wards the cost of his education and providing him with land. His social
mothers and fathers (his biological mother had passed away and his bio-
logical father, whom he did not know well or like) attended his wedding.
Nyamnjoh notes that in the grassfields of Cameroon, among a vibrant,
changing population trying to negotiate the opportunities of the global
marketplace without losing their collective rights, migrants adopt children
in an effort to negotiate continuity in their native regions while traveling
far afield in their entrepreneurial activities.
Thus, in many pastoral and horticultural societies, in contrast to for-
agers like the San who had to carry their infants long distances, both men
and women had reasons to want a large number of children. As we noted
above, as the San settled more permanently around government dug bore-
holes, they also had more children, spaced closer in age (Howell 2000).
Reproduction and Inequality 291
Since children were highly valued, kin groups carefully defined through
marriage to which lineage or household they belonged. However, while
marriage defined a child’s status, sexuality and biological kinship were
not necessarily limited by these rules. Among the Nuer, for example, a
pastoral society in which people inherited cattle through their patrilineal
connections, a woman who had many cattle and whose husband had died,
could marry another woman (Evans-Pritchard 1940). This strategy al-
lowed the new wife to find her own partner to bear children for her
“ghost” husband’s patrilineage. Such offspring would help herd the cattle
and generally bolster the position of the first woman. Clearly, the new
children would have a biological father, but his status was irrelevant to
the status of the children who would belong to the lineage of the “woman-
husband” and her wife. Kathleen Gough (1971) demonstrated further that,
in the 1930s, a Nuer woman from a high status patrilineage, rather than
marrying into another Nuer descent group as prescribed by patrilineal
rules, might find a partner among ostensible “strangers” from the nearby
Dinka population and thus keep her children attached to her own
patrilineage.
Sharon Hutchinson and Jok Madut Jok (2002) have described the tragic
contemporary transformations of Nuer and Dinka gender relations in the
militarization of an independent state in the Sudan. As the Nuer and
Dinka have been drawn into ethnic conflicts over land, tribal allegiance
is no longer as flexible as it was and, sadly, women and children, previ-
ously interrelated through marriage and off-limits in battle, have become
the targets for greater and more brutal assault and killing (Hutchinson
and Jok 2002).
In many indigenous societies, while marriage clearly defined the status
and lineage of their children, both men and women were allowed a degree
of sexual freedom. In other societies, men but not women were allowed
such freedoms and in some societies, sexuality outside marriage is heavily
sanctioned for both men and women (Scheffler 1991). The relationship
between kin terms and customary practice has to be examined rather than
assumed (Scheffler 1991). Rules about gender, social reproduction, or the
rearing of children, may not necessarily correspond with biological repro-
duction, or sexuality. Indeed, some anthropologists have suggested that
they correspond more closely to rules about the division of labor (Leacock
1972). Frequently, the claims of family, motherhood and fatherhood are
negotiated to accommodate patterns of migration, investment and other
changes, such as wars and militarization. Differences between rules of
marriage and kinship and patterns of sexual behavior and biological links
become extremely important in understanding the transmission of genetic
traits or sexually transmitted diseases such as HIV/AIDS.
In Richard Lee and Ida Susser’s (Lee 2002) research in Botswana and
Namibia in the 1990s, they found that, although much has changed among
292 Medical Anthropology and the World System
be expected to care for his or her siblings, or, in fact, children might be
reared by adoptive parents.
With the advent of capitalist societies and later industrialization, pop-
ulations increased dramatically, but for several hundred years, health and
life expectancy decreased. In London, in the 1800s, for example, infant
mortality rates and the general death rates from disease were surpassing
the birth rate. The population would have declined dramatically if thou-
sands of migrants had not streamed into the city. Later, as wages increased
and sanitation improved in the new industrial cities, infant mortality rates
decreased and epidemics of the plague, cholera and other diseases became
less frequent (M. Susser, Watson, and Hopper 1985). However, even as
general conditions improved, women continued to die at younger ages
than men until the twentieth century (Hogue 2000).
From antiquity, states, like later governments in industrial societies,
were much involved in regulating women’s sexuality, controlling patterns
of reproduction and defining the status of children. In the 1960s, Jane
Schneider traced the virgin complex through North Africa and the Med-
iterranean to the changing relationship between pastoral societies and the
state (Schneider 1968). Many anthropologists have tried to understand the
strength of this honor and shame complex and the varying significance
of the enforcement of virginity before marriage. The Eurasian complex of
virginity, dowry, and patrilineality also has been associated with a class
system and the control of property as men seek to control women’s re-
productive capacity in order to insure inheritance in the men’s family
group (Goody 1976). Although Jack Goody has suggested that we view
dowry as woman’s property, many of those who have studied the dowry
in India have noted that the inheritance is completely controlled by men
and the value of the dowry assures only that the woman marry a man of
rank as the property passes from the bride’s family to the groom (Stone
and James 2001). The low value of women’s paid work and the reduced
value of her domestic role in the rearing of children in recent years has
contributed to the importance of the dowry in defining the economic value
of the woman and in some instances has led to murder, as men wish to
get rid of one wife in order to collect a new dowry from another woman
(Stone and James 2001).
Colonial governments, also, regulated marriage and sexual relations
(Etienne and Leacock 1980, Lockwood 2001, Stoler 1997). In Indonesia,
after 100 years of colonial rule, the Dutch administration legally forbade
European settlers to marry members of the local population in their efforts
to institutionalize racial divisions and control the colonized. In addition,
the transformation of societies under colonization often undermined co-
operative organization among women and decreased their political influ-
ence while increasing their workload in agriculture and domestic
responsibilities (Van Allen 2001, Guyer 1991). From this early period, al-
294 Medical Anthropology and the World System
though there was much variation in the local strategies of men and women
and the specific histories of resistance to colonialism, unequal employ-
ment opportunities, segregated living conditions, unequal health care pro-
visions and the institutionalized discrimination and regulation of women
among colonized populations set the scene for the differences between the
maternal and infant survival rates documented between peripheral, often
previously colonized, and core countries to this day (for discussions of
the issues of women and colonialism see Lockwood 2001).
From the 1940s, in the industrialized Western countries, with improved
housing, education and nutrition, the discovery and generalized distri-
bution of penicillin, vaccines, and other medical interventions and the
implementation of hospitalized childbirth in sterile conditions, many
more women survived labor and childbirth. In fact, World War II had an
interesting impact on women in the United States, as it represented the
first time the majority of women gave birth in hospital settings, funded
by the health insurance payments of soldiers. This shift, represented in
the high levels of access to medical care, also contributed to a nationwide
lowering of maternal mortality rates. While infant mortality rates dropped
dramatically and life expectancy increased for everyone, women actually
began to live longer than men (Goldman and Hatch 2000).
Throughout the twentieth century, maternal and infant mortality rates
have been decreasing in Western industrialized countries. This was a
gradual process and the survival rates for women and children of different
age groups varied over the time period. But, the health of poor men and
women and infant mortality rates for poor and minority populations did
not improve at the same rate as those with more wealth. In the past three
decades there has been an increasing gap in the United States between
the income, living conditions, and health of the poor and that of the better-
off (Pappas et al 1993, Susser 1989).
ers at age nine while most girls were allowed to stay with their mothers
through their teenage years (Susser 1993).
These family transformations are not a predicable or one-way process.
Ruth Milkman (1987), in her historic analysis shows the way American
women were encouraged to work outside the home during World War II:
day care was provided and the work was glorified in images of the hard-
working patriotic “Rosie the Riveter.” As servicemen returned after the
war, women lost their jobs. Simultaneously, images of motherhood and
home dominated the media. Such images were hardly brought into play
when the New York City administration was making decisions about
homeless children in the 1980s (Susser 1989, 1993).
Thus both individual goals and culturally approved roles for women
change at different historical moments, and patterns of reproduction and
child rearing reflect these changes.
LA BOR A ND C HILDBIRT H
In addition to looking at family-planning strategies, anthropologists
have described the different ways in which women have experienced
childbirth and contributed to our understanding that women can partici-
pate in decisions about childbirth and labor (Davis-Floyd 2001, Michael-
son 1988).
In pre-industrial Europe and the United States, labor and childbirth
were managed and controlled by women in the household, often with the
assistance of midwives or their equivalent. In the late nineteenth century,
as Western doctors were beginning to conduct scientific experiments and
to establish the medical profession, women were still active as midwives.
However, in the early twentieth century United States, as the medical pro-
fession became more rigorously licensed and depended on an extensive
education, women were excluded from such training. Childbirth became
less the sphere of midwives and more an arena of professional male doc-
tors. This process, sometimes called the medicalization of childbirth, in-
volved the introduction of anesthetics to reduce the pain of labor, which,
also, as the woman lost consciousness, placed labor further under the
control of medical authority (Wertz and Wertz 1979).
The conflicting issues related to the medicalization of pregnancy and
300 Medical Anthropology and the World System
However, this does not mean that women do nothing. On the contrary,
as another rural Vietnamese woman makes clear, “If you go to a hospital
in secret, who will know? If your husband wants more children and you
don’t, he can’t force you. You decide for yourself first. The husband’s
opinion is only a small part. For women, if you want a child, you have a
child. You don’t have to say anything to your husband until your stomach
is big, and then what can he do? . . . It’s all up to you” (Gammeltoft 1999:
187).
Since the 1980s, HIV/AIDS has emerged as a central concern in repro-
duction. Over the past twenty years, HIV/AIDS has also become a gen-
dered issue, as women worldwide are contracting the virus earlier and at
a greater rate than men (Piot 2001, Stein and Abdool Karim 2000). HIV
positive mothers can transmit the virus both through pregnancy and labor
(perinatally) and through breastfeeding.
Over the past two decades such transmission has become preventable.
In 2001, in Western societies, as well as in Brazil, Argentina, and Uruguay,
mothers may opt for testing prenatally and also be entitled to treatment
for themselves. Mothers in poorer countries who would not go for testing
for themselves, since almost always treatment is available for the baby
but not for the mother herself, will take the risk of testing for HIV/AIDS
knowing that it may save the baby. If the mother tests positive, she often
faces ostracism and stigma from her husband and family and a knowledge
of certain death. Nevertheless, she will be offered medications in the last
few months of pregnancy to take during labor. The baby will be given the
medications for a short period after birth. If the baby is exclusively breast-
fed or formula-fed, these simple procedures will reduce the perinatal
transmission of HIV. Sometimes the mother will continue to receive med-
ications for her own continued health but in most situations in poor coun-
tries worldwide the baby may live but no attention will be paid to the
courageous mother’s survival.
Many poor mothers in southern Africa and other parts of the world do
not yet have access to such preventive measures for their babies, nor treat-
ment for themselves, although there are ongoing efforts to improve this
situation. As a response to worldwide social movements that demand that
pharmaceutical companies provide affordable options for poor countries
and that wealthy countries contribute resources for public health in poorer
countries, medications are slowly becoming available for free or at lower
prices (Farmer, Connors, and Simmons 1996). However, government pol-
icies that neglect HIV/AIDS, combined with the domestic subordination
of women and the fact that many people do not live near clinics, or cannot
afford the transportation, or the clinics do not provide testing or treatment
still present challenges to prevention and care.
302 Medical Anthropology and the World System
spent on cosmetic surgery among the wealthy countries and the lack of
the most elementary prenatal care for women in poorer countries?
As in the nineteenth century, reproduction in the second millennium is
still intimately interconnected with the rights of women to autonomy, edu-
cation, and employment (Freedman 2000; Farmer, Connors, and Simmons
1996; I. Susser 2002). Reproductive health is also crucially determined by
the histories of colonialism, the uneven development of the world system
and the current impact of globalization. Globalization, which has involved
among other shifts, a massive privatization of public resources, has con-
tributed to the increasing gap between rich and poor within the world
system, as well as to the undermining of women’s autonomy with respect
to reproductive options as resources for reproductive choice and educa-
tion are increasingly limited.
A movement for the reproductive health rights of women must incor-
porate a recognition of women’s own abilities to strategize in any his-
torical situation (Freedman 2000, I. Susser 2002). International agencies or
movements can assist local women in creating spaces of autonomy, in
countering fundamentalist assumptions which limit access to reproduc-
tive choice and in providing the resources for education, the technologies
of birth control, the funds for medications and employment opportunities.
As we have seen from the historical record, with access to funds, health
facilities, employment and education, men and women themselves adapt
their reproductive strategies to the changing situations in which they find
themselves.
PART III
Medical Systems in
Social Context
CHAPTER 10
Medical Systems in
Indigenous and Precapitalist
State Societies
that the “later and present schism between healing and technological med-
icine begins in the occupational distinction between faith healers and
surgeons, and shamans, medicine men, and voodoo chiefs, on the one
hand, and herbalists, wound dressers, and midwives on the other” (Gros-
singer 1990: 76). He delineates three forms of pragamatic medicines:
(1) pharmaceutical medicine, which consists primarily of a wide variety
of herbal remedies; (2) mechanical medicine, which consists of surgical
techniques as well as techniques that simulate physiological processes
such as bathing, sweat-bathing, shampooing, massage, cupping, emetics,
burning, incision, and bloodletting; and (3) psychophysiological healing,
which relies on a wide variety of magical and psychotherapeutic tech-
niques such as the classic “sucking cure” (Grossinger 1990: 76–95), in
which a shaman orally extracts intrusive objects from a patient body. The
distinction between psychophysiological healing and spiritual medicine
is blurred. For the most part, however, spiritual medicine emphasizes the
spiritual origin of disease and views it as the “primary weapon of the
spiritual world” (Grossinger 1990: 99).
The spirits involved are sometimes specific ancestors who desire the
company of their loved ones or maybe the great god or a lesser god. The
Inuit generally attribute disease to soul loss or breach of a taboo. Soul
loss also serves as an explanation of disease among many groups in
western North America.
Among the Murngin, an Australian aboriginal people located in north-
eastern Arnhem Land, various forms of witchcraft are considered to be
the causes of many serious diseases and of almost all, if not all, deaths
(Reid 1983: 44). The Jivaro Indians of the Amazon Basin also believe that
witchcraft is the cause of the vast majority of diseases and nonviolent
deaths. Many African societies tend to attribute disease to the malevolence
of sorcerers or witches. Although disease etiology is important among the
Gnau, a horticultural society of the Sepik River region of New Guinea,
Gilbert Lewis (1986), a physician-anthropologist, notes that they often
merely accept disease as a fact of life, without attempting to explain or
treat it. The Gnau explain wounds, burns, and the like in obvious natu-
ralistic terms but generally ascribe most diseases to offended spirits.
Clements concluded that the attribution of disease to soul loss or a
magical intrusion of a foreign object had only a single point of origin,
from which it spread over the rest of the globe. He argued that attributing
disease to violation of a taboo had probably started independently in three
different places: Mesoamerica, the Arctic, and southern Asia. More re-
cently, Murdock (1980) argued that regional variations suggest an impor-
tant influence of diffusion of ancient ideas, noting the failure of some
explanations to appear in places isolated from the societies that already
share them. He observes that attribution of disease to the action of spirits
is almost universal, appearing in all but two of a world sample of 139
societies. Murdock examined the relation between the importance of spirit
explanation and several variables of general societal characteristics.
Foster and Anderson (1978) make a distinction between personalistic
and naturalistic theories of disease. In a personalistic system, disease em-
anates from some sort of sensate agent, such as a deity, a malevolent spirit,
an offended ancestral spirit, or a sorcerer. Naturalistic theories posit dis-
ease in terms of an imbalance among various impersonal systemic forces,
such as body humors in ancient Greek medicine or the principles of yin
and yang in traditional Chinese medicine. In Greek medicine as delineated
by Aristotle, the universe consists of four elements: fire, air, water, and
earth. People represent a microcosm of the universe and are composed of
four humors with four corresponding personality types: blood is associ-
ated with high-spiritedness, yellow bile with bad temper, black bile with
melancholia, and phlegm with sluggishness. Disease results from an im-
balance of the humors. The physician attempts to restore health by cor-
recting this imbalance.
In Chinese medicine, yang is associated with heaven, sun, fire, heat,
Medical Systems in Indigenous and Precapitalist State Societies 311
dryness, light, the male principle, the exterior, the right side, life, high,
noble, good, beauty, virtue, order, joy, and wealth. Yin is associated with
the earth, moon, water, cold, dampness, darkness, the female principle,
the interior, the left side, death, low, evil, ugliness, vice, confusion, and
poverty. A proper balance of yang and yin results in health. Excessive
yang, associated with heat, produces fever; and excessive yin, associated
with cold, produces chills.
While Foster and Anderson do not see the two types of etiological sys-
tems as mutually exclusive, they argue that personalistic explanations pre-
dominate among indigenous peoples as well as in certain state societies
such as West African ones and the Aztecs, Mayans, and Incas. Conversely,
naturalistic theories historically have been associated with certain great
traditional medical systems, such as traditional Chinese medicine and
Ayurveda and Unani in South Asia.
Morley provides a more elaborate typology of indigenous “etiological
categories” of disease in the form of a four-cell matrix, illustrated in Figure
10.1.
Supernatural causes ascribe disease etiology to superhuman forces,
such as evil spirits, ancestral spirits, witches, sorcerers, or the evil eye.
Nonsupernatural disease categories are “those based wholly on observed
cause-and-effect relationships regardless of the accuracy of the observa-
tions made” (Morley 1978: 2), such as profuse bleeding. Immediate causes
follow from nonsupernatural sources and account for sickness in terms of
perceived pathogenic agents. Ultimate causes posit the underlying sources
of misfortune as it affects a specific individual.
Based upon comparative data from 186 societies listed in the Human
Relations Area Files, George P. Murdock (1980) delineated an elaborate
typology of “theories of illness,” which is summarized in Figure 10.2.
While many of the categories in Murdock’s scheme are self-explanatory,
others are not. Theories of mystical causation posit illness to “some pu-
tative impersonal causal relationship” (Murdock 1980: 17). Theories of
animistic causation posit illness to “some personalized supernatural en-
Figure 10.1
Etiological Categories
Figure 10.2
Theories of Illness
tity—a soul, ghost, spirit, or god” (19). Theories of magical causation posit
illness to the “covert action of an envious, affronted, or malicious human
being who employs magical means to injure his victims” (21).
Murdock’s scheme of illness or disease etiology has the advantage of
illustrating the wide repertoire of explanations that peoples around the
globe have devised to explain their maladies and ailments. Conversely, it
is much more cumbersome than both Foster and Anderson’s scheme and
Morley’s scheme. At any rate, Murdock’s sample draws primarily from
indigenous societies but also from some archaic state societies such as the
Egyptians, the Babylonians, the Romans, the Japanese, the Aztecs, and the
Incas. Many societies rely upon multiple causes of illness or disease. Mur-
dock also reports on the relative frequency of theories of disease etiology
in various culture areas. Africa ranks very high in theories of mystical
retribution. North America “outranks all other regions in theories of sor-
cery, which occur in all of its societies without exception and are reported
as important in 83 percent of them” (Murdock 1980: 49). Conversely, South
America “ranks high in theories of spirit aggression, which are recorded
as present in 100 percent of its societies and as important in 91 percent of
them” (52).
Medical Systems in Indigenous and Precapitalist State Societies 313
105) relates, “A doctor gains full control over pharmacy by making allies
of the spirits who control the plants, animals, stones, and springs from
which he makes his tonics.”
As noted earlier, ritual or symbolic healing constitutes the principal
therapeutic technique in indigenous societies. Conversely, as we see in
chapter 5, biomedicine and professionalized heterodox medical systems
in modern state societies also rely upon the manipulation of a “field of
symbols” (Moerman 1979: 60). Dow proposes the possible existence of a
universal structure of symbolic healing that consists of the following
patterns:
In other words, symbolic healing occurs when both healer and patient
accept the former’s ability to define the latter’s relationship to the mythic
structure of their sociocultural system. As this observation implies, heal-
ing by its very nature often entails an element of faith in both healer and
patient. Healing rituals, however, have a broader field of concern in that
they are designed to mend wounds in the body politic within which the
patient is symbolically embedded.
One of the best examples of symbolic healing is the sing practiced
among traditional Navajo residing in northeastern Arizona and north-
western New Mexico. Conceptions of disease and therapy are central ele-
ments in their elaborate cosmology. Indeed, in large part Navajo religion
consists of a set of some thirty-six healing ceremonies (often referred to
as sings or chants), each lasting from one to nine nights and the interven-
ing days. The Navajo attribute disease to various causes, including sor-
cery, intruding spirits, and inappropriate actions on the part of the
afflicted person. In the singer’s hogan (Navajo dwelling), he creates a
mythic sand painting and then destroys it with his feet as a symbolic
enactment of the restoration of harmony in both the patient and his or her
social network. A Navajo sing blends together many elements—ritualistic
items such as the medicine bundle, prayer-sticks, precious stones, tobacco,
water collected from sacred places, a tiny piece of cotton string, sand
paintings, and songs and prayers. Sand paintings exemplify the centrality
316 Medical Anthropology and the World System
recall significant episodes of mythical drama. . . . The patient in his or her plight
is identified with the cultural hero who constructed a similar disease or plight in
the same way the patient did. . . . From the myth the patient learns that his or her
plight and illness is not new, and that both its cause and treatment are known. To
be cured, all the patient has to do is to repeat what has been done before. It has
to be done sincerely, however, and this sincerity is expressed in concentration and
dedication. The sandpainting depicts the desired order of things, and places the
patient in this beautiful and ordered world. The patient thus becomes completely
identified with the powerful and curing agents of the universe. (Witherspoon 1977:
167–68)
shamans (Rogers 1982: 27). In fact, Yakut male shamans adopted women’s
clothing and hairstyles. Much of the literature on shamans indicates that
many of them assume various unconventional lifestyles, such as homo-
sexuality, bisexuality, or transvestism. Conversely, while transvestism ap-
parently was common among shamans in various Siberian and North
American cultures, it reportedly has been uncommon in South American
indigenous cultures but did occur among the Mapache of Patagonia dur-
ing the nineteenth century (Langdon 1992). Shamans in many societies
are social recluses who choose not to enter into lasting social relationships
with others. As Gaines (1987: 66) observes, shamans are not peripheral or
marginal as a social category but rather as individuals.
Anthropologists and other scholars have characterized the psychody-
namic makeup of shamans in the following three ways: (1) as pathological
personalities, (2) as highly introspective and self-actualized individuals
with unique insights about the psychosocial nature of their respective
societies, and (3) as individuals who experienced an existential crisis but
became healed in the process of becoming a shaman.
Various anthropologists, particularly in the past, have argued that sha-
mans exhibit universally psychotic traits, such as hysteria, trance, and
transvestism (Ackerknecht 1971; Devereux 1956, 1957). The Russian eth-
nographer Waldemar Bogaras characterized Chuckee shamans as on the
“whole extremely excitable, almost hysterical, and not a few were half-
crazy” (quoted in I.M. Lewis 1989: 161). Weston LaBarre (1972: 265), who
made a case for the shamanic origins of religion as a by-product of the
use of hallucinogenic drugs, maintained “‘God’ is often clinically para-
noiac because the shaman’s ‘supernatural helper’ is the projection of the
shaman himself.” More recently, Ohnuki-Tierney (1980) has asserted that
Ainu shamanism is often associated with imu, a culture-bound syndrome.
Aside from the matter of the actual mental status of the shaman, shamanist
healing séances often impose considerable strain on the practitioner. A
California Indian shaman reported, “The doctor business is very hard on
you. You’re like crazy, you are knocked out and you aren’t in your right
mind” (quoted in Rogers 1982: 12).
In contrast to negative portrayals of shamans, anthropologists in more
recent times have presented shamanic behavior as a category of universal
psychobiological capacities. Shamans are often portrayed as insightful,
creative, and stable personalities who, while freely drawing upon indige-
nous traditions, transcend the limitations of their culture by creating their
own responses to new situations. In essence, shamans are viewed as hav-
ing a capacity to interpret the events of daily life more adequately than
the other members of the culture. Kalweit (1992: 222–24) characterizes the
shaman as a “spiritual iconoclast” who learns about humanity through
solitude and as a “holy fool” who is holy because he or she has been
healed. Murphy’s portrayal of the mental status of Inuit shamans on St.
Medical Systems in Indigenous and Precapitalist State Societies 319
Lawrence Island, Alaska, in the Bering Strait bear out this characteriza-
tion:
The well known shamans were, if anything, exceptionally healthy. . . . As for the
shamans who had suffered from psychiatric instability of one kind or another, it
has been suggested that shamanizing is itself an avenue for “being healed from
disease.” Whatever the psychiatric characteristics that may impel a person to
choose this role, once he fulfills it, he has a well-defined and unambiguous rela-
tionship to the rest of society, which in all probability allows him to function
without the degree of impairment that might follow if there were no such niche
into which he could fit. (Murphy 1964: 76)
only recover from the initiation crisis but may emerge strengthened and
enabled to help others.”
Unlike the schizophrenic, the shaman is not alienated from society and
performs a valued social role. Unfortunately, studies that emphasize the
therapeutic benefits of shamanism for the practitioner often downplay
shamanic practices of manipulation, deception, and, in some instances,
destruction. In reality, indigenous people often exhibit an ambivalent view
of shamans—on the one hand, holding them in high esteem and being in
awe of their abilities and, on the other, fearing and resenting them. The
Netsilik Inuit believe that if one can control the universe or its objects for
good purposes, one can also use that power for evil designs (Balikci 1963).
Hippler (1976: 112) makes an interesting point by asserting that shaman-
ism “could provide a life-style for the insightful observer of his own com-
munity who could act easily within its cultural limits and still, on the
other hand, provide a necessary identity to the individual who is almost
schizophrenic.”
Certain scholars have associated shamanism with foraging societies or
specific cultural areas, such as Siberia and North America (Walsh 1990:
15–17). More recent research, however, has tended to view shamanism as
a “globalizing” and “dynamic cultural-social complex in various societies
overtime and space” (Langdon 1992: 4). Despite the voluminous literature
on shamanism, most of the research on this topic has tended to be partic-
ularistic. From a CMA perspective, shamanism as a form of indigenous
healing appears to take different forms depending upon the economic
base of the society. Unfortunately, this issue still has not received much
systematic attention. Critical medical anthropologists still need to develop
an analysis of health beliefs and practices in precapitalist social formations
that parallels the general sociocultural analyses that various critical an-
thropologists have made of such societies. Bearing these thoughts in mind,
we present a modest effort to provide a broad perspective on shamanism
by examining it in the following contexts: (1) foraging societies,
(2) horticultural societies, and (3) indigenous cultures that have come into
intense contact with or have been absorbed by state societies.
The role of shaman or healer tends to be a relatively open one in for-
aging societies, as we will see in the following “Closer Look.”
“A Closer Look”
and applied to the skin to alleviate aches and pains, to treat abrasions,
cuts, and infections, and even to bring luck in hunting.
Most !Kung males and about a third of adult women seek to become
healers at one time or another. More than half of the adult males but only
10% of females succeed in doing so. Women tend to experience kia at the
Drum dance, at which they only may sing and dance, to the accompani-
ment of a male drummer. Women assert that num endangers the human
fetus and therefore often postpone seeking it until after menopause. Most
young women expect to learn kia for its own sake regardless of whether
they will eventually learn to heal. Whereas the healing of the Giraffe is
available to all, the healing in the Drum extends only to the dancers and
singers but not to the spectators. Although the !Kung are often portrayed
as one of the most sexually egalitarian societies in the ethnographic record,
the differential access to shamanistic healing between men and women in
this society provides some clues as to how healing over time became in-
creasingly a predominantly male preserve. Conversely, Katz (1982: 174)
suggests that the Drum may constitute a response to the “greater role
differentiation between the sexes and the loss of status for women which
accompanies sedentism” in !Kung society as it has come into contact with
the outside world.
In contrast to foraging societies, healing appears to be a somewhat more
privileged role in horticultural societies. In his generalizations about sha-
mans among the peoples of the tropical rain forests of South America,
most of whom are horticulturalists, Metraux observes (see Sharon 1978:
132) that male shamans may play a predominant role, with women sha-
mans, if they exist, exhibiting a modest role in comparison. Among the
Culina Indians of western Brazil, only men become shamans (Pollack
1992: 25). Approximately one out of every four Jivaro males becomes a
shaman, but no women apparently do (Harner 1968).
in the Malay Peninsula, most spiritualists or mediums are males who call
upon various spirit guides and sing in their communal healing ceremo-
nies. The wife of the medium serves as the cornerstone of the chorus
during healing performances and serves as a “particularly astute foil to
the medium’s wit during performances” (Roseman 1991: 76). Temiar me-
diums also heal patients on an individual basis and may call for a spirit
séance.
As compared to the shaman and spiritualist, who communicate directly
with the supernatural realm, the “diviner interprets symptoms, prognos-
ticates, and prescribes courses of action through mechanical, magical ma-
nipulations” (Wood 1979: 323). Whereas in traditional Navajo culture the
shaman or singer conducts a healing ceremony, various specialists diag-
nose disease through a combination of divination and visualization:
According to Wood (1979: 325), the herbalist is “probably the most prag-
matic of the traditional healers” in that “he or she frequently relies on the
knowledge gained during a lengthy training from an experienced prac-
titioner.” Among the Subanum on Mindinao Island in the Philippines,
virtually every adult functions as his or her own herbalist.
The shaman and other indigenous healers described in this chapter per-
sist in both archaic and modern state societies. In these settings, however,
they tend to serve primarily members of the lowest strata of society.
Phases with homeopathic magic (Unshuld 1985: 52–67). This medical sys-
tem “dominated Chinese medical literature and the approaches of edu-
cated practitioners and self-healing private citizens as well, at least among
the upper strata” for most of Chinese history until the modern era (Un-
shuld 1985: 223). Taoism drew upon demonic medicine and pragmatic
materia medica and introduced macrobiotics. Somewhat later Buddhist
monks offered medical treatment to the Chinese people as part of their
missionary efforts and as a fulfillment of their ethical obligation to assist
human beings (Unshuld 1985: 139).
Medical pluralism in the Greco-Roman world expressed itself in part in
the form of various medical sects. These included the rationalist or dog-
matists who maintained that physicians should rely upon reason to dis-
cern the roots of health, disease, and human physiology; the empiricists
who argued that theory is ultimately useless in medical practice; and the
methodists who asserted that medical care could be achieved by adhering
to a few simple rules that could be mastered in a half a year (Siraisi 1990:
4; Gourevitch 1998: 104–17). Galen, who was born in a.d. 129 in Pergamum
in Asia Minor, attempted to rise above the medical sectarianism of the
time by asserting that an imbalance of four bodily humors—hot, cold, dry,
and moist—resulted in disease (Strohmaier 1998: 139–142).
Medical pluralism was well in place in the agrarian tributary regimes
of the Arab world during the period a.d. 660–950 (Gran 1979). Islamic
culture combined the Galenic theory of disease and prophetic medicine,
which drew upon Mohammed’s views of health and disease (Strohmaier
1998: 146–153). Conversely, like earlier Christian mystics, Muslim mystics
also distrusted physicians and looked to God or Allah as the source of
cures. Islamic culture began to establish hospitals and hospices in the early
eighth century. These hospitals appear to have drawn their inspiration
from the assistance offered to the poor and sick at Christian monasteries
and other establishments. The services of these hospitals were initially
subsidized by philanthropy and later by public funds and reportedly were
free regardless of age, gender, or social status (Reynolds and Tanner 1995:
249). The Adubi hospital in Baghdad, built in a.d. 981, had twenty-four
physicians. The largest hospital in the Islamic world, with a capacity of
eight thousand beds, was established in Cairo in a.d. 1286 (Magner 1992:
138).
These hospitals provided their patients with a systematic treatment
based upon Greek notions of humoral medicine that included exercises,
baths, dietary regimens, and a comprehensive materia medica. Islamic
medicine also relied upon manipulation, bone setting, cauterizing, vene-
section, and minor eye surgery, but devalued major surgery because of
the religious prohibition on human dissection. The Al-Faustat hospital,
built in a.d. 872, organized its wards on the basis of gender, illness, and
the surgical procedure to be conducted. Furthermore, as in contemporary
328 Medical Anthropology and the World System
disease was not an outcome of specific power relations but rather a biological
individual phenomenon where the cause of disease was the immediately observ-
able factor, the bacteria. In this redefinition, clinical medicine became the branch
of scientific medicine to study the biological individual phenomena and social
medicine became the other branch of medicine which would study the distribution
of disease as the aggregate of individual phenomena. Both branches shared the
vision of disease as an alteration, a pathological change in the human body (per-
ceived as a machine), caused by an outside agent (unicausality) or several agents
(multicausality). (Navarro 1986: 166)
All the civilizations with great tradition medical systems developed a range of
practitioners from learned professional physicians to individuals who had limited
or no formal training and who practiced a simplified version of the great tradition
Biomedical Hegemony in the Context of Medical Pluralism 333
medicine. Other healers coexisted with these practitioners, their arts falling into
special categories such as bone setters, surgeons, midwives, and shamans. How-
ever, the complex and redundant relationships between learned and humble prac-
titioners, and between those who were generalists or specialists, full or part-time,
vocational or avocational, naturalist or supernaturalist curers, is clarified by pro-
fessionalization in the great tradition that defined the relative statuses of legitimate
practitioners and distinguished them from quacks. (Leslie 1974: 74)
People must constantly choose which gods to worship, and which forms of healing
power and moral legitimation to accept, and they know the practical consequences
of embracing one over the other. People know that distaining the lwa [Voodoo
gods] allies them with the centralized Catholic Church: a traditional source of
legitimation and advance. They know that fundamentalist conversion leads away
from local allegiances and would propel them into a transnational space, politi-
cally centered in North America (Brodwin 1996: 199).
Capitalism itself is divided . . . between the few sectors that make money as costs
rise—medical technology, drugs, hospital supply—and the majority, which suffer
increases in health coverage costs. The state acts with the majority of capitalist
sectors and is gradually restricting for-profit medicine. Doctors thriving as owners
of for-profit settings are already beginning to lose their advantage as regulation
tightens (Krause 1996: 8).
sult, certain heterodox practitioners, with the backing of clients and par-
ticularly influential patrons, were able to obtain legitimation in the form
of full practice rights (e.g., osteopathic physicians, who may prescribe
drugs and perform the same medical procedures as biomedical physi-
cians) or limited rights (e.g., chiropractors, naturopaths, and acupunctur-
ists). Lower social classes, racial and ethnic minorities, and women have
often utilized alternative medicine as a forum for challenging not only
biomedical dominance but also, to a degree, the hegemony of the corpo-
rate class in the United States as well as other advanced capitalist societies.
Regardless of the society, biomedicine attempts to control the produc-
tion of health care specialists, define their knowledge base, dominate the
medical division of labor, eliminate or narrowly restrict the practices of
alternative practitioners, and deny laypeople and alternative healers ac-
cess to medical technology. Despite the hegemonic influence of biomedi-
cine, alternative medical systems of various sorts continue to function and
even thrive not only in the countryside but also in the cities of the world,
including those in the United States. Ultimately, the ability of biomedicine
to achieve dominance over competing medical systems is dependent upon
support from “strategic elites” (or certain businesspeople, politicians, and
high-level government bureaucrats) (Freidson 1970). Biomedicine is un-
able to establish complete hegemony in part because elites permit other
forms of therapy to exist but also because patients seek—for a variety of
reasons—the services of alternative healers. Because of the bureaucratic
dimensions of biomedicine and the iatrogenic situations or mishaps oc-
curring in the course of biomedical treatment, alternative medicine under
the umbrella of the holistic health movement has made a strong comeback
even in North America and Western Europe. This eclectic movement in-
corporates elements from Eastern medical systems, the human potential
movement, and New Ageism as well as earlier Western heterodox medical
systems.
Alternative medical systems often exhibit counterhegemonic elements
that resist, often in subtle forms, the elitist, hierarchical, and bureaucratic
patterns of biomedicine. In contrast to biomedicine, which is dominated
ultimately by the corporate class or state elites, folk healing systems are
more generally the domain of common folk. Unfortunately, according to
Elling (1981b: 97), “Traditional medicine has been used to obfuscate and
confuse native peoples and working classes.” Ethnomedical practitioners
in the modern world have shown an increasing interest in acquiring new
skills and use certain biomedical-like treatments or technologies in their
own work, a process in which they often inadvertently adopt the reduc-
tionist perspective of biomedicine. Many Third Word peoples receive reg-
ular treatment from injection doctors and advice from pharmacists who
indiscriminately sell antibiotics and other drugs over the counter. Many
Ecuadorians now purchase natural medicines, which often are advertised
338 Medical Anthropology and the World System
After the Spanish conquest of Central and South America, ethnomedical practi-
tioners were forbidden to function as such because their curing techniques were
considered heretical. Around the middle of this century, doctors and pharmacists
in Bolivia pressured the Bolivian legislature to outlaw ethnomedical practices by
requiring licenses. Although a few noted middle-class herbalists obtained licenses,
others were unable to and were jailed. (Bastien 1992: 19)
Biomedical Hegemony in the Context of Medical Pluralism 339
it would be hypocritical for anthropology to scorn others for profiting from tra-
ditions in other cultures. Our livelihood too is earned on the basis of a Western
fascination with other cultures. We, like the tour operator, are in the business of
exploiting our informants for profit; the principal difference is that we legitimize
our activities by reference to the pursuit of scientific knowledge and produce pub-
lications in place of travel opportunities. (Joralemon 1990: 105)
Town shamans, who are mestizos, insist that they have obtained their
knowledge from the forest Indians. Conversely, the forest Indians look
downriver for the source of shamanic power, to the cities of Pucallpa and
Iquitos and to the ayahuasca shamans of the lower Ucayali and Amazon
Biomedical Hegemony in the Context of Medical Pluralism 341
rivers. In contrast to their view that the ayahuasca shamans possess the
curing power of the forest spirits, they look at their own shamans as rela-
tively impotent. On the surface, ayahuasca shamanism appears to function
as a hegemonic force in that the forest Indians have adopted a prototypical
colonial mentality. Conversely, the counterhegemonic component of sha-
manism lies in the belief that the forest spirits afflict people with disease
as a punishment for environmental damage caused to their domain. Cur-
ing entails a mediation of this imbalance through use of ayahuasca—a
vine that as both cultigen and wild plant symbolizes the transition from
domesticated space to full forest. In essence, as Gow (1994: 104) observes,
the “historical sorcery of ayahuasca shamanism is centered on that spatial
category that connects the forest and the city: the river.”
Shona spirit mediumship constitutes yet another example of how sha-
manism serves to mediate social tensions in colonial and postcolonial so-
cieties. Spirit mediums played an instrumental role in assisting guerrillas
belonging to the Zimbabwe African National Liberation Army (ZANLA)
to liberate the Shona people from the oppressive rule of the white-
dominated Rhodesian colonialist state (Lan 1985). Guerillas lived with a
number of spirit mediums in the Zambezi Valley and regularly received
advice from their ancestors that was mediated by the mediums who fa-
vored the return of appropriated lands to the peasantry. After the revo-
lution, many mediums encouraged women to participate in local politics.
Unfortunately, various mediums feel that they were not properly re-
warded for their support of the revolution after independence. According
to Lan (1985: 221), the Traditional Medical Practitioners Act implemented
by the Zimbabwean state “entrenches in law precisely that control over
the mediums that political authorities of the past, whether chiefs or district
commissioners, attempted to enforce in order to discredit mediums who
opposed them.”
In the case of another postrevolutionary society, the Soviet Union be-
ginning in the 1930s waged a campaign against shamans among the North
Khanty villagers of Siberia, labeling them “deceivers” and kulaks (rich
peasants) (Balzer 1991). While some shamans went underground or
turned to drinking, others rebelled against the repressive tactics of the
Soviet state. Whereas in the past Khanty shamanic séances tended to be
community events at which the patient received moral support from a
large number of people, during the Soviet period they evolved into ses-
sions which generally were conducted in secret or with only a few family
members present (Balzer 1987: 1091). In 1990 Vladimir Alekssevich Kon-
dakov, who identifies himself as a Sakha shaman (oiuun), established the
Association of Folk Medicine as part of a revival of shamanism in Siberia
(Balzer 1993).
Taman shamanism or balienism in Borneo represents an example of what
Winkelman termed the shaman/healer in the context of the capitalist
342 Medical Anthropology and the World System
world system (Bernstein 1997). Baliens tend to be women who have re-
covered from some sort of chronic emotional problem. They belong to
healing societies but do not generally associate with one another on an
informal basis. Some baliens do not actively engage in healing or attend
other ritualistic events. Shamanism has also become closely associated
with women in other state societies, such as eastern Asia, where, as Vi-
tebsky (1995a: 118) observes, “it has been subordinated to a Buddhist or
Confucian High Culture which is more male-centered.”
As noted earlier, many New Agers in advanced capitalist countries,
particularly the United States, are proponents of neoshamanism, a move-
ment that idealizes the shamanistic practices of Native American and
other indigenous peoples around the world. Vitebsky graphically de-
scribes the juxtaposition of traditional shamanism and neoshamanism:
In the jungles and the tundra, shamanism is dying. An intensely local kind of
knowledge is being abandoned in favour of various kinds of knowledge which
are cosmopolitan and distant-led. Meanwhile, something called shamanism
thrives in western magazines, sweat lodges and weekend workshops. The New
Age movement, which includes this strand of neo-shamanism, is in part a rebellion
against the principle of distant-led knowledge (Vitebsky 1995b: 182).
conditions for good health, i.e., nutrition, housing, water, sewage, etc.” (P.
Singer 1977: 14). In a similar vein, Velimirovic emphasizes the need for
structural changes that complement the utilization of indigenous healers:
There is no need to either copy a Western model or to settle for low-quality care
in coping with the health problems of the developing world. Indigenous healers
might perhaps be incorporated into a modern health care system in some places,
but they are not the only answer to lack of coverage. What is needed is the imag-
ination and the will to institute basic, low-cost health measures appropriate for a
particular country’s culture and level of socioeconomic development. For these
measures to succeed, transformation of the social structure may be a precondition.
(Velimirovic 1990: 59)
“A Closer Look”
brigades, they now concentrate on the county hospitals that provide medi-
cal teaching for health workers in the communes and brigades.
The hospital has 580 beds and 830 staff, including some 300 physicians,
300 nurses, and 230 administrators, technicians, and workers. It consists
of departments of infectious disease; surgery; internal medicine; pediat-
rics; obstetrics and gynecology; neurology and urology; radiology; com-
bined Western and traditional medicine; dentistry; and ear, nose, and
throat care. The hospital building is
laid out like a giant, three-story X, with a library providing a small fourth-story
cap. The legs of the X are the hospital wards; at their intersection are a double
staircase, auxiliary offices for radiology and laboratory tests, and a small phar-
maceutical factory. Administrative offices are in a separate building. (Henderson
and Cohen 1984: 47–48)
The one most commonly cited is “consultation with the masses” whenever major
plans or policies are being considered. These consultations may take place in small
work groups such as the infectious disease ward staff. For example, at one morn-
ing report the new economic campaign was explained to the staff and their opin-
ions solicited. Strong feelings about the proposed staff-to-bed ratio were freely
350 Medical Anthropology and the World System
offered, and the staff planned to request another physician and nurse for the ward.
To our knowledge, the ratio was not changed. . . . For decisions on the ward itself,
staff members are generally given a chance to participate in discussions about an
upcoming change. In addition to group discussions, special days for criticism are
regularly scheduled. (Henderson and Cohen 1984: 74)
In what we see as the first phase of its development, critical medical an-
thropology (CMA) struggled primarily with issues of self-definition
within academic medical anthropology. Now that CMA has come of age,
its proponents have begun to grapple more seriously with strategies for
creating healthier environments and more equitable health care delivery
systems. CMA is ultimately concerned with praxis or the merger of theory
and social action. Critical anthropology as the larger framework of CMA
poses the questions of “anthropology for what?” and “anthropology for
whom?” It wishes to move beyond an anthropology that all too often has
viewed the subjects of its research as museum pieces or populations to be
administered by bureaucratic organizations, such as governmental agen-
cies and, more recently, transnational corporations. Critical anthropology
strives to be part of a larger global process of liberation from the forces of
economic exploitation and political oppression.
As part of this larger endeavor, a panel of critical medical anthropolo-
gists examined various actual and potential forms of health activism at
the 1994 American Anthropological Association meeting, which had as its
theme “Human Rights.” This session, organized by Hans Baer and Ken-
yon Stebbins, was titled “Medical Anthropology in the Pursuit of Human
Rights.” Papers presented by panelists at this session recognized that criti-
cal medical anthropologists have questioned the reformist nature of
conventional social science education, the co-optation of clinical anthro-
pology, and the pro-physician bias of many biomedical intervention pro-
grams utilizing anthropological insights. The presenters, in so many
words, felt that they should not stand idly by until “the revolution” arrives
356 Medical Anthropology in the World System
to address health change. Like other critical medical social scientists, many
critical medical anthropologists work as health activists for women’s
health collectives, free clinics, ethnic community health centers, environ-
mental groups, AIDS patient advocacy efforts, antismoking pro-health
groups, national health care reform groups, and nongovernmental orga-
nizations (NGOs) in the Third World. These socially active critical medical
anthropologists view access to a healthy environment and comprehensive
and holistic health care as a human right, not a privilege or commodity
accessible to only a privileged few.
Reconceptualizing Socialism
The collapse of Communist regimes has created a crisis for people on
the left throughout the world. Many progressives had hoped that some-
how these societies, which were characterized in a variety of ways (e.g.,
state socialism, transitions between capitalism and socialism, state capi-
talism, and new class societies), would undergo changes that would trans-
form them into democratic and ecologically sensitive socialist societies.
Various progressives have advocated shedding the concept of socialism
and replacing it with terms such as “radical democracy” and “economic
democracy.” Stanley Aronowitz, as a major proponent of radical democ-
racy, observes that
While efforts to replace the term socialism with new ones are under-
standable given the fate of postrevolutionary or socialist-oriented socie-
358 Medical Anthropology in the World System
of the world’s population, managed to slightly increase its per capita energy
consumption and remained a major global consumer, accounting for 25
percent of the world’s commercial energy. . . . In comparison, China virtu-
ally reversed the figures, with 20 percent of the world’s population con-
suming 8 percent of the commercial energy. (Bodley 1996: 69)
For the immediate future, a “new socialist movement” needs to “focus
on concrete questions of people’s welfare, democracy, and survival” (Sil-
ber 1994: 266). Needless to say, health and eradication of disease are es-
sential components of survival.
Often confronted with human affliction, suffering, and distress, fieldwork in medi-
cal anthropology challenges the traditional dichotomies of theory and practice,
360 Medical Anthropology in the World System
thought and action, objectivity and subjectivity. The very nature of the subject
matter forces the researcher to seek out a position of informed compromise from
which it is impossible to act. (Lindenbaum and Lock 1993: ix-x)
can culture. While individual as well as familial rights in the medical arena
have their place, both bioethicists and medical anthropologists need to
consider the rights of patients and their families as members of social
groups, be they nation-states, social classes, racial and ethnic minorities,
women, gays and lesbians, disabled people, people with AIDS, etc. A
critical bioethics incorporates the concept of “social bioethics” as deline-
ated by Gallagher et al.:
For instance, work in bioethics is largely defined in terms of what may be char-
acterized as the narrower field of medical ethics; attention is focused on the moral
dilemmas that confront physicians, and the doctor’s point of view is generally
adopted. Problems specific to nurses are encountered far more rarely, and those
that might be experienced by occupational or respiratory therapists, pharmacists,
social workers, technicians, orderlies, or nursing assistants are seldom dealt with
at all (Sherwin 1992: 2–3).
single-payer health care system in the United States. Last, but not least,
Marcio Fabri dos Anjos, a Brazilian liberation theologian, also calls for
what we term a critical bioethics by arguing the following:
The poor constitute a class of persons who enter into medical encounters encum-
bered by health problems caused by a mesh of social relationships, including ex-
treme poverty, hunger, lack of opportunity, and poor health care. From this
perspective, medical ethics must be concerned with the causes of hunger and the
diseases which have become synonymous with particular social classes (dos Anjos
1996: 632).
1. Health care should be oriented toward improving quality of life rather than
profit making;
2. Health care should not engage in the exploitation of its providers;
3. Health care should “enlighten and empower people” (Sidel 1994: 559); and
4. Health care “should be provided in ways that eliminate financial barriers at the
time of need, permit the recipients to evaluate their care, [and] to select among
alternative services” (Sidel 1994: 558).
at the top and those at the bottom in the United States over the course of
the last 30 years, in particular, have been: (1) strong corporate influence
over the election of political candidates through massive campaign con-
tributions; (2) a historically weak labor movement compared to other ad-
vanced capitalist countries; (3) the absence of relatively strong labor, social
democratic, and socialist parties (e.g., such as the New Democratic Party
in Canada and the Greens and the Party of Democratic Socialism in Ger-
many); (4) a “winner-take-all” electoral system (as opposed to a system
of proportional representation) which makes it extremely difficult for
third party candidates to win, particularly in national elections; (5) the
existence of a large “underclass” or massive numbers of poor working-
class people, particularly among African Americans, Hispanic Americans,
and Native Americans; (6) the presence of a racist ideology that makes it
difficult for working-class people to mobilize against the corporate class
and its political allies; (7) pervasive corporate influence upon hegemonic
institutions, particularly the mass media and formal education; and (8) the
role of the culture of consumption, organized religion, and spectator
sports in deflecting attention from the pervasive corporate control of the
corporate economy. At any rate, within the context of U.S. society, we
argue that the pursuit of a universal health care system constitutes both
a significant venue of health praxis and expression of a critical bioethics.
Indeed, Howard Waitzkin, a critical medical sociologist and biomedical
physician, observes that the present U.S. corporate-driven health care sys-
tem raises significant ethical concerns:
For instance, there is concern that corporate strategies lead to reduced services for
the poor. While some corporations have established endowments for indigent care,
the ability of such funds to assure long-term access is doubtful, especially when
cutbacks occur in public-sector support. Other ethical concerns have focused on
physicians’ conflicting loyalties to patients versus corporations, the implications
of physicians’ referrals of patients for services to corporations in which the phy-
sicians hold financial interests, and the unwillingness of for-profit hospitals to
provide unprofitable but needed services (Waitzkin 2001: 19).
• the people whose lives and cultures anthropologists study (exercised by avoid-
ing deception, ensuring voluntary consent, protecting confidentiality, avoiding
exploitation, and avoiding doing harm)
• the general public (demonstrated by communicating honestly and considering
consequences of communication, and by using knowledge gained through re-
search for the public good)
• the discipline (maintained by protecting the discipline’s reputation, avoiding
plagiarism, justly treating colleagues, and showing them proper professional
respect)
• students and trainees (shown by treating them fairly, offering appropriate as-
sistance and guidance, giving recognition for their contributions to work, and
avoiding taking advantage of them in any way)
• employers, clients, and sponsors (expressed by being honest)
• governments (evidenced by being candid with government representatives and
by setting ethical limits on acceptable work assignments)
mane treatment by the police, prison guards, and court officials. Because
Spradley observed and interviewed members of all three of the later
groups, they too were his research subjects. Clearly urban homeless men
have considerably less power and voice in society than do the other social
groups in Spradley’s study. Consequently, Spradley had to confront the
issue of researcher allegiance in choosing what to do with his research
findings, including what to write and how to act in response to them. His
choice to fully report and initiate social action to correct the abuses his
research uncovered has been acclaimed as a model example of ethical
behavior in anthropological research (M. Singer 2000).
Applied Research
All of the issues of concern in basic research are also confronted in
applied research, but applied research faces some additional dilemmas.
In applied research, there is a conscious commitment to making social
change. The researchers involved, in other words, are not simply learning
about, describing, and analyzing the world as they find it, they are at-
tempting to use research to respond to a pressing human problem; in
effect, they are attempting to use research to help fix something in human
society that is deemed to broken. A vitally important question in all ap-
plied research, therefore, is: who decides there is a problem in need of
correcting, and it is this question that goes to the heart of the critical issues
of social inequality of power and decision making. For example, during
the late 1970s and early 1980s, because of continued poverty, a number of
developing countries began to default on their development loans from
the World Bank and International Monetary Fund. A number of economic
analysts who hold to what has been termed a neoliberalist philosophy
came to the conclusion that the main economic problem facing poor coun-
tries is that their national governments are too deeply involved in shaping
their economies (e.g., by keeping prices low on basic commodities and
health care) and were inhibiting the growth of privatization, free-market
activity, and a general rise in production levels that would benefit every-
one. Therefore, neoliberal economists and their supporters in the Ronald
Reagan administration in the United States, the Margaret Thatcher ad-
ministration in Great Britain, and the Helmut Kohl administration in Ger-
many called for a total restructuring of the economies of developing
nations, involving a reduction in the role of governments in the produc-
tion, sale and purchase goods, letting prices of goods be determined by
the market place, and lifting protective barriers to international trade and
investment. What has been the impact of these policies (developed by rich
countries) on health in poor countries? Applied medical anthropology
researchers at Partners in Health in Boston (Schoepf, Schoepf, and Millen
370 Medical Anthropology in the World System
2000) has drawn the following conclusions about the impact of structural
adjustment policies (SAP) on AIDS in developing countries:
Specific SAP measures, such as currency devaluation, not only shrink resources
that could improve AIDS prevention and the treatment and care of persons with
AIDS; they also precipitate social upheavals that accelerate the rate of HIV trans-
mission. Poverty and SAPs have undermined the viability of rural economies,
promoted mass labor migration and urban unemployment, worsened the condi-
tion of poor women, and left health systems to founder.
to help educate the police or other institutions that come into contact with
drug users about cultural expression of distress in the Puerto Rican com-
munity? Should all research projects that work with marginalized, low
income populations of highly at-risk drug users be required to establish
a credible system of aggressive, advocated referral into drug treatment
and culturally sensitive psychiatric and other medical services for all par-
ticipants (even for those who do not request such assistance)? These ques-
tions, which to some degree go beyond the usual ethical standards that
guide research at present, point to potential direction for the development
of new standards for research on vulnerable human subjects.
At the left end of this continuum . . . lies the use of the ethnographic encounter in
the service of anthropologically defined goals (e.g., broadening human under-
standing, expanding cultural knowledge). . . . At the other end of the continuum
is the use of the ethnographic encounter in the service of the Other, including
defending the right to self-determination or promoting access to needed resources
. . . (M. Singer 1990: 549).
National health insurance (NHI) has been on and off this country’s political
agenda since 1912, when Teddy Roosevelt, running for the presidency on the Pro-
gressive ticket, first advocated its enactment. Support for NHI has reemerged pe-
riodically—in the mid-1930s, the late 1940s, and the mid-1970s—yet it has never
come close to winning popular or congressional support. In the 1990s, the defects
of the health care system in the United States—costliness, inefficiency, and ineq-
uitable provision to the population—have prompted health specialists and the
public to turn their attention once again to NHI. (Ginzberg 1994: 51–52)
tute a form of “socialized medicine” (Fisk 2000: 69). Following the defeat
of the Kennedy-Griffiths Health Security Act, “Senator Edward Kennedy
and his AFL-CIO [American Federation of Labor-Congress of Industrial
Organizations] retreated from the single-payer concept and supported the
central role of private insurance companies in paying for health services”
(Bodenheimer 1993: 14). Ron Dellums, an African-American congressper-
son from Oakland and a member of Democratic Socialists of America,
prepared in 1972 the most progressive health care reform plan ever intro-
duced before Congress. His bill called for the passage of a Health Service
Act that would create a network of community-based prepaid health plans
coordinated at the regional level and serviced by salaried health care pro-
viders (Rodberg 1994). Community health boards would administer local
health facilities. Proponents of the Dellums bill included the American
Public Health Association, the Gray Panthers, and the United Electrical
Workers.
diatrics. The plan also provided an option for states to pursue a single-
payer system.
Under the Clinton plan, it was generally recognized that the big health
insurance companies would dominate national health care with an elab-
orate system of HMOs. Navarro (1994: 207) argues that “Managed com-
petition will mean corporate assembly-line capitalism for the masses and
their health care givers and continuing free choice and fee-for-service
medicine for the elites.” As has been the case for existing managed care
operations, heavy reliance upon advertising, marketing, and utilization
reviewers would have made managed competition a costly way of pro-
viding national health insurance. Chief executive officers (CEOs) would
have continued to be compensated extremely handsomely for transform-
ing their companies into profitable enterprises. For example, James Lynn,
CEO of Aetna, earned $23 million in 1990. Most analysts maintain that
the large insurance companies would be the winners under managed com-
petition, whereas the smaller health insurance companies would go out
of business. Indeed, Aetna, Prudential, Cigna, Met Life, and Travelers’
formed the Coalition for Managed Competition.
Managed care refers to any system that controls costs through closely monitoring
and controlling the decisions of health care providers. Most commonly, managed
care organizations (MCOs) monitor and control costs through utilization, in which
doctors must obtain approval from the insurer before they can hospitalize a pa-
tient, perform surgery, order an expensive diagnostic test, or refer to a specialist
outside the insurance plan. Although the terms HMO [health maintenance orga-
nization] and managed care increasingly are used interchangeably, HMOs represent
only one form of managed care, and most fee-for-service insurers now also use
managed care (Weitz 2001: 230–231).
The Pursuit of Health as a Human Right 375
The debt-laden acquisitions of the late 1990s—like the $8.8 billion Aetna buyout
of U.S. Healthcare—called for cost cutting in the delivery of services but, ironically,
raised health care costs for employers by adding on the expense of servicing
billion-dollar debts. By 1997, less than half of the health insurers made money.
Insurance rates then started going up at twice the rate of the years 1993–1996 (Fisk
2000: 278).
with managed care and the failure of the existing system or what some
term non-system to provide adequate health care to a significant portion
of the American people make it apparent that health care reform will be
a major societal concern now that we have begun the twenty-first century.
In paraphrasing Mark Twain, Graig (1999: 39) notes, “news of health care
reform’s demise is greatly exaggerated.” Whereas most corporate interests
and physician groups oppose the concept of a single-payer health care
system, various physician groups, grassroots groups, and legislators favor
it—a fact generally downplayed by the mainstream media. The single-
payer concept reemerged in January 1989 with the publication of a pro-
posal of the Physicians for a National Health Program (PHNP) in the New
England Journal of Medicine (Himmelstein and Woolhandler 1989). PHNP,
an organization with some 5,000 members in thirty-four chapters in
twenty-five states, advocates the creation of a single-payer Canadian-style
health care system in the United States. PHNP is not a left organization
per se, but much of its leadership is openly leftist and includes progressive
physicians such as David Himmelstein, Steffie Woolhandler, and Vincente
Navarro. Although the Canadian health care system has shortcomings of
its own, it clearly is more equitable than the U.S. health care system.
The United Nations Human Development Report “ranked Canada first
in the world with respect to health status, overall quality of life, and so-
cioeconomic status” (Lassey, Lassey, and Jinks 1997: 72). Canada’s three
major political parties, namely the Progressive Conservatives, the Liber-
als, and the New Democratic Party, support a single-payer, which was
approved in 1968, with strong labor support, in 1968 and fully imple-
mented in 1971 (Coburn 1999). In large part this is due to the fact that
Canada exhibits a stronger “collectivist culture” than does the United
States (Lemco 1994: 6). In contrast to the United States, the Canadian
health care system is, according to Birenbaum (1995: 176), “accepted
widely today by Canadian conservatives who oppose state intervention
as well as liberals who see the state as the mediator between conflicting
classes.” The Canadian system is premised on the notion that health care
is a right rather than a privilege.
The Canadian system, called Medicare, consists of ten provincial health
plans that must abide by certain national standards and that are funded
jointly by federal and provincial governments through corporate taxes,
personal taxes, property taxes, and taxes on gasoline, tobacco, and liquor.
The federal government exerts more control over the health care plans of
the Northwest Territories and the Yukon Territory than those of the prov-
inces. All Canadian physicians participate in the provincial or territorial
health plans. The federal government prepays each province about 40%
of medical costs, provided the provincial health insurance programs are
universal, comprehensive, portable (each province recognizes the others’
coverage), and publicly administered. Each province devises its own pay-
The Pursuit of Health as a Human Right 377
[The majority of large employers and their trade associations] most value control
over their own labor force, and the employment-based health benefits coverage
gives them enormous power over their employees. The United States is the only
country where the welfare state is, for the most part, privatized. Consequently,
when workers lose their jobs, health care benefits for themselves and their families
are also lost. In no other country does this occur. . . . The United States, the only
major capitalist country without government-guaranteed universal health care
coverage, is also the only nation without a social-democratic or labor party that
serves as the political instrument of the working class and other popular classes.
(Navarro 1995: 450)
States, where primary care providers are in scarce supply. Canada spends
about 9% of its GNP on health care, as opposed to the United States, which
spends 14%.
Despite its superiority to the U.S. system, the Canadian health care sys-
tem itself contains contradictions, including a hierarchy in the health labor
force as well as in the physician-patient relationship, very little commu-
nity control over health services or worker self-management within health
care settings, and relatively little emphasis on prevention. While all Ca-
nadians have access to health care, class-based inequalities persist in terms
of its utilization (Schwartz 1998: 540). The Canadian system relies less on
medical technology than some other advanced capitalist countries. Ac-
cording to Lassey, Lassey, and Jinks (1997: 85), “there were 0.46 magnetic
resonance imaging (MRI) units per one million population in 1987, com-
pared to 3.69 in the United States and 0.94 in Germany.” Substantial wait-
ing lists for selected surgical and diagnostic procedures occur. Conversely,
it is important to note that many American HMOs require substantial
waiting periods for medical appointments. The overall rates of hospital
use per capita in Canada exceed those in the United States, and patients
are generally cared for in a timely manner.
Unfortunately, the Canadian health care system faces external pressures
in large part due to the fact that, like the American system, it is embedded
in a capitalist political economy and world system (Armstrong and Arm-
strong 1996). According to Chernomas and Sepehri,
Contrary to the message of the AMA and the HIAA [Health Insurance Association
of America], the Canadian system not only works reasonably well—it pays for
universal access to ordinary medical care, maintains a generally high quality, is
administratively efficient, and restrains the growth of health care costs far more
effectively than any of the myriad cost containment schemes tried in the United
380 Medical Anthropology in the World System
during Jesse Jackson’s 1988 presidential bid and now functions as a strong
advocate of a single-payer health care system in the United States (Na-
varro 1989). Melvin Konner (1993), a physician-anthropologist, has pub-
lished a short book in which he critiques the Clinton administration’s
proposed managed competition plan and advocates a single-payer sys-
tem. As opposed to anthropological and sociological associations, several
professional associations, including the American Public Health Associ-
ation (APHA) and the National Association of Social Workers (NASW),
have endorsed the creation of a single-payer system in the United States.
The greater willingness on the part of APHA and NASW to make public
endorsements of national health care reform may be related in large part
to the high proportion of practitioners as opposed to academics in these
two organizations. In contrast to many practitioners of public health and
social work, academics often adopt an individualistic orientation that em-
phasizes career advancement rather than the implementation of social
change. Given the dismal academic job market in anthropology since the
early 1970s, a large number of anthropologists now work in nonacademic
positions as applied or practicing anthropologists. Many of these anthro-
pologists belong to the Society for Applied Anthropology, the National
Association of Practicing Anthropologists, and the Society for Medical
Anthropology.
The relevance of health care reform as a matter of anthropological con-
cern is attested to by what may have been the first session on this topic
presented at an American Anthropological Association meeting. Janet M.
Bronstein (University of Alabama at Birmingham) organized a session at
the 1994 meeting on “U.S. Health Care Reform: Origins, Development and
Impact.” Unfortunately, as Hans Baer noted in his comments as a dis-
cussant, none of the papers in the session referred to a single-payer system
as a potential model for health reform in the United States. Indeed, one
of the presenters argued that medical anthropologists should assist health
administrators in the implementation of total quality management—a
business-oriented approach that emphasizes increased surveillance of
health workers as an integral part of supposedly increasing efficiency or,
more accurately stated, profit making to an even greater extent that at
present in U.S. health care.
Although medical anthropologists have been reluctant to take public
positions on health policy to date, the ongoing debate on health care re-
form provides them with an opportunity to serve as advocates for changes
that will benefit many of the populations who have served as subjects of
their research within the border of the United States. Despite the demise
of the Clinton health plan and the defeat of the California initiative on a
single-payer system, health care reform is a topic that will remain in the
public spotlight for some time to come. Rather than being divided as they
were on the Clinton plan, grassroots organizations, professional associa-
382 Medical Anthropology in the World System
tions, and health activists may have a unique opportunity to rally behind
a single-payer system and force it onto center stage in the health care
reform debate.
As Flacks (1993: 465) argues, “The demand for a universal health-care
program . . . has the potential to politically unite very diverse movement
constituencies and to link these with middle-class voters.” Critical medical
anthropologists can serve as a vanguard within the Society for Medical
Anthropology and the American Anthropological Association to endorse
a single-payer health care system for the United States as a system-
challenging action. Such an effort can serve as a mechanism for linking
medical anthropologists, critical or otherwise, with a growing coalition of
grassroots groups, labor unions, and even professional associations that
favor the creation of a single-payer system in the United States. Ultimately,
the creation of a single-payer health care system will have to be part and
parcel of other non-reformist reforms in U.S. society. In pursuing the crea-
tion of a single-payer health care system, Milton Fisk (2000: 187–206) calls
for a “radical politics of reform” that would include a system of propor-
tional representation that would make it easier for a labor or socialist-
oriented party to win seats in various levels of government as well as an
alliance of various working-class groups (including labor unions). At even
a more profound level, however, even if the United States manages to
implement a national health care program, Waitzkin (2001: 175) asserts
that health policies must address social differentials in health statistics that
“remain closely linked to social class, racism, gender inequalities, work
hierarchies and exposures, and environmental problems.” Ultimately,
critical medical anthropology, as well as the critical medical sociology that
Waitzkin espouses, are committed to the eradication of these inequities
not only in this country but internationally.
Bibliography
Abramson, Hilary. 1998. “Big Alcohol’s Smokescreen.” Newsletter of the Marin In-
stitute for the Prevention of Alcohol & Other Drug Problems 13: 1.
Acker, P., A. Fierman, and V. Dreyer. 1987. “An Assessment of Parameters of
Health Care and Nutrition in Homeless Children.” American Journal of Dis-
eases of Children 141(4): 388.
Ackerknecht, Erwin. 1971. Medicine and Ethnology: Selected Essays. Baltimore: Johns
Hopkins University Press.
Adams, Vicanne. 1998. “Suffering the Winds of Lhasa: Politicized Bodies, Human
Rights, Cultural Difference, and Humanism in Tibet.” Medical Anthropology
Quarterly 12: 74–102.
Agar, Michael. 1973. Ripping and Running: A Formal Ethography of Urban Heroin
Addiction. New York: Seminar Press.
——— 1980. The Professional Stranger. Orlando: Academic Press.
Alasuutari, Pertti. 1990. Desire and Craving. Tampere, Finland: University of
Tampere.
Alland, Alexander. 1970. Adaptation in Cultural Evolution: An Approach to Medical
Anthropology. New York: Columbia University Press.
Alvord, Katie. 2000. Divorce Your Car: Ending the Love Affair with the Automobile.
Gabriola Island, BC, Canada: New Society Publishers.
Ames, Genevieve. 1985. “Middle-Class: Alcohol and the Family.” In The American
Experience with Alcohol, ed. Linda Bennett and Genevieve Ames, 435–458.
New York: Plenum.
Anderson, Robert. 1996. Magic, Science, and Health: The Aims and Achievements of
Medical Anthropology. Fort Worth: Harcourt Brace College Publishers.
Andrews, Charles. 1995. Profit Fever: The Drive to Corporatize Health Care and How
to Stop It. Monroe, ME: Common Courage Press.
384 Bibliography
Andrews, George, and David Solomon. 1975. The Coca Leaf and Cocaine Papers. New
York: Harcourt Brace Jovanovich.
Anjos, Marcio Fabri dos. 1996. “Medical Ethics in the Developing World: A
Liberation Theology Perspective.” Journal of Medicine and Philosophy 21:
629–37.
Antonil, T. 1978. Mama Coca. London: Hassle Free Press.
Aral, S., and K. Holmes. 1989. “Sexually Transmitted Diseases in the AIDS Era.”
Scientific American 264(2): 62–69.
Aretxaga, Begona. 1997. Shattering Silence: Women, Nationalism, and Political Sub-
jectivity in Northern Ireland. Princeton, NJ: Princeton University Press.
Arliss, Robert. 1997. Against Death: The Practice of Living with AIDS. Amsterdam:
Gordon and Breach.
Armelagos, George J., and John R. Dewey. 1978. “Evolutionary Response to Hu-
man Infectious Diseases.” In Health and the Human Condition: Perspectives on
Medical Anthropology, ed. Michael H. Logan and Edward H. Hunt, Jr.,
101-6. North Scituate, MA: Duxbury Press.
Armstrong, Pat, and Hugh Armstrong. 1996. Wasting Away: The Undermining of
Canadian Health Care. New York: Oxford University Press.
Arnold, David. 1993. “Medicine and Colonialism.” In Companion Encyclopedia of
the History of Medicine, Volume 1. ed. W. F. Bynun and Roy Porter, 1393–
1416. London: Routledge.
Aronowitz, Stanley. 1994. “The Situation of the Left in the United States.” Socialist
Review 23(3): 5–79.
Atkinson, Jane Monnig. 1992. “Shamanisms Today.” Annual Review of Anthropology
21: 307–330.
Bacon, Selden, and Robert Strauss. 1953. Drinking in College. New Haven, CT: Yale
University Press.
Baer, Hans A. 1982. “On the Political Economy of Health.” Medical Anthropology
Newsletter 14(1): 1–2, 13–17.
———. 1989. “The American Dominative Medical System as a Reflection of So-
cial Relations in the Larger Society.” Social Science and Medicine 28:
1103–12.
Baer, Hans A., ed. 1996. “Critical Biocultural Approaches in Medical Anthropol-
ogy: A Dialogue.” Special issue of Medical Anthropology Quarterly, n.s. 10(4).
Baer, Hans A., Merrill Singer, and John Johnsen, eds. 1986. “Towards a Critical
Medical Anthropology.” Special issue of Social Science and Medicine 23(2).
Baldo, M., and A. Cabral. 1991. “Low Intensity Wars and Social Determination of
HIV Transmission: The Search for a New Paradigm to Guide Research and
Control of the HIV/AIDS Pandemic.” In Action on AIDS in Southern Africa,
New York: Committee for Health in Southern Africa.
Balikci, A. 1963. “Shamanistic Behavior among the Netsilik Eskimos.” Southwestern
Journal of Anthropology 19: 380–396.
Ball, Andrew. 1998. “HIV Prevention among Injecting Drug Users.” In Global Re-
search Network Meeting on HIV Prevention in Drug-Using Populations. Be-
thesda, MD: National Institute on Drug Abuse.
Ball, Andrew, Sujata Rava, and Karl Dehne. 1998. “HIV Prevention Among In-
jecting Drug Users: Responses in Developing and Transitional Countries.”
Public Health Reports 113 (Supplement 1): 170–181.
Balzer, Majorie Mandelstam. 1987. “Behind Shamanism: Changing Voices of Si-
Bibliography 385
berian Khanty Cosmology and Politics.” Social Science and Medicine 12:
1085–1093.
———. 1991. “Doctors or Deceivers? The Siberian Khanty Shaman and Soviet
Medicine.” In The Anthropology of Medicine: From Culture to Method, 2nd ed,
ed. Lola Romanucci-Ross, Daniel E. Moerman, and Laurence R. Tancredi,
56–80. New York: Bergin & Garvey.
———. 1993. “Two Urban Shamans: Unmasking Leadership in Fin-de-Soviet Si-
beria.” In Perilous States: Conversations on Culture, Politics, and Nation, ed.
George E. Marcus, 131–64. Chicago: University of Chicago Press.
Banerji, Debabar. 1984. “The Political Economy of Western Medicine in Third
World Countries.” In Issues in the Political Economy of Health Care, ed. John
B. McKinlay, 257–82. New York: Tavistock.
Barker, D. and C. Osmond. 1986. “Infant Mortality, Childhood Nutrition and Is-
chaemic Heart Disease in England and Wales.” Lancet 43: 1077–81.
Barnet, Richard, and John Cavanagh. 1994. Global Dreams: Imperial Corporations and
the New World Order. New York: Simon and Schuster.
Barnet, Richard, and Ronald Müller. 1974. Global Reach. New York: Simon and
Schuster.
Barnett, Homer G. 1961. Being a Palauan. New York: Holt, Rinehart, and Winston.
Barrow, S. M., D. B. Herman, P. Cordova, and E. L. Struening. 1999. “Mortality
among Homeless Shelter Residents in New York City.” American Journal of
Public Health 89(4): 529–34.
Barry, T., B. Wood, and D. Preusch. 1984. The Other Side of Paradise. New York:
Grove Press.
Bartlett, Donald L., and James B. Steele. 1992. America: What Went Wrong? Kansas
City, MO: Andrews and McNeel.
Bastien, Joseph W. 1992. Drum and Stethoscope: Integrating Ethnomedicine and Bio-
medicine in Bolivia. Salt Lake City: University of Utah Press.
Batalla, G. 1966. “Conservative Thought in Applied Anthropology: A Critique.”
Human Organization 25: 89–92.
Bateson, Mary Catherine, and Richard Goldsby. 1988. Thinking AIDS. Reading,
MA: Addison-Wesley.
Battjes, Robert, and Roy Pickens. 1988. “Needle Sharing among Intravenous Drug
Abusers: Future Directions.” In Needle Sharing among Intravenous Drug Abus-
ers: National and International Perspectives, ed. Robert Battjes and Roy Pick-
ens, 176–83. Bethesda, MD: National Institute on Drug Abuse.
Baxter, E., and Kim Hopper. 1981. Public Places, Private Spaces. New York: Com-
munity Service Society.
BBC News Online. 2001. “Poor Diet Boosts Virus Power.” [cited 8 June].
Beck, Melinda, and Orville Levander. 2000. “Host Nutritional Status and Its Effect
on Viral Pathogen.” Supplement to Journal of Infectious Diseases 182: S93–S96.
Becker, Howard. 1953. “Becoming a Marijuana User.” American Journal of Sociology
59:235–42.
Becket, J. 1965. “Aborigines, Alcohol and Assimilation.” In Aborigines Now, ed. M.
Reay, 32–47. Sydney: Angus and Robertson.
Behar, Ruth. 1996. “Introduction: Out of Exile.” In Women Writing Culture, ed. Ruth
Behar and Deborah Gordon, 1–33. Berkeley: University of California Press.
Bennett, John. 1974. The Ecological Transition: Cultural Anthropology and Human Ad-
aptation. New York: Pergamon Press.
386 Bibliography
Bourdieu, Pierre. 1984. Distinction: A Social Critique of the Judgment of Taste. Cam-
bridge, MA: Harvard University Press.
Bourgois, Philippe. 1995. In Search of Research: Selling Crack in El Barrio. Cam-
bridge: Cambridge University Press.
Bovelle, E., and A. Taylor. 1985. “Conclusions and Implications.” In Life with Her-
oin, ed. B. Hanson. Lexington, MA: Lexington Books.
Bowie, Fiona. 2000. The Anthropology of Religion: An Introduction. Oxford: Blackwell.
Brandt, T. 1989. “AIDS in Historical Perspective: Four Lessons from the History
of Sexually Transmitted Disease.” American Journal of Public Health 78(40):
367-71.
Braunstein, Mark. 1997. “Marijuana Has Worked the Best in Easing Pain.” Hartford
Courant, (12 January): C1, C4.
Brenner, M. Harvey. 1975. “Trends in Alcohol Consumption and Associated Ill-
nesses.” American Journal of Public Health 65(12): 1279–292.
Brettel, Caroline, and Carolyn Sargent, eds. 2001. Gender in Cross-Cultural Perspec-
tive. Upper Saddle River, NJ: Prentice-Hall.
Brodwin, Paul. 1996. Medicine and Modality in Haiti: The Contest for Healing
Power. Cambridge: Cambridge University Press.
Brooks, Jerome. 1952. The Mighty Leaf. Boston: Little, Brown.
Brown, Claude. 1965. Manchild in the Promised Land. New York: Penguin.
Brown, E. Richard. 1979. Rockefeller Medicine Men: Medicine and Capitalism in Amer-
ica. Berkeley: University of California Press.
Brown, Lawrence, and Benny Primm. 1989. “A Perspective on the Spread of AIDS
among Minority Intravenous Drug Abusers.” In AIDS and Intravenous Drug
Abuse among Minorities, ed., 3–23. Rockville, MD: National Institute on Drug
Abuse.
Brown, Peter J. 1987. “Microparasites and Macroparasites.” Cultural Anthropology
2:155-71.
Brown, Peter J., and Marcia C. Inhorn. 1990. “Disease, Ecology, and Human Be-
havior.” In Medical Anthropology: Contemporary Theory and Method, ed.
Thomas M. Johnson and Carolyn Sargent, 187–214. New York: Praeger.
Browner, Carole. 2001. “The Politics of Reproduction in a Mexican Village.” In
Caroline Brettel and Carolyn Sargent, 460–70. Upper Saddle River, NJ:
Prentice-Hall.
Brundtland, Gro Harlem. 2001. Presentation on Current State Of The Global Prob-
lem Of Drinking Among Youth at WHO European Ministerial Conference
on Young People and Alcohol, Stockholm Sweden, February.
Bruun, Kettle, et al. 1975. Alcohol Control Policies in Public Health Perspective.
Vol. 25. Helsinki: Finnish Foundation for Alcohol Studies.
Buchan, William. 1784. Domestic Medicine: Or, a Treatise on the Prevention and Cure
of Diseases by Regimen and Simple Medicines. Philadelphia: Crukshank, Bell
and Muir.
Bunce, Robert. 1979. The Political Economy of California’s Wine Industry. Toronto:
Addiction Research Foundation.
Bunzel, Ruth. 1940. “On the Role of Alcoholism in Two Central American Cul-
tures.” Psychiatry. 3: 301–87.
Burroughs, William. 1953. Junkie. New York: Ace.
388 Bibliography
Derber, Charles. 1983. “Sponsorship and the Control of Physicians.” Theory and
Society 12: 561–601.
Devereux, George. 1956. “Normal and Abnormal: The Key Problem in Psychiatric
Anthropology.” In Some Uses of Anthropology: Theoretical and Applied, ed.
Joseph B. Casagrande and Thomas Gladwin, 3–48. Washington, DC: An-
thropological Society of Washington.
———. 1957. “Dream Learning and Individual Ritual Differences in Mohave Sha-
manism.” American Anthropologist 59: 1036.
Devine, Richard J. 1996. Good Care, Painful Choices: Medical Ethics for Ordinary Peo-
ple. Mahwah, NJ: Paulist Press.
Devisch, Renaat. 1986. “Belgium.” Medical Anthropology Quarterly, o.s., 17(4):
87–89.
Diamond, Stanley. 1974. In Search of the Primitive: A Critique of Civilization. New
Brunswick, NJ: Transaction.
Di Giacomo, Susan. 1999. “Can There be a ‘Cultural Epidemiology?’” Medical An-
thropology Quarterly 13: 436–457.
Di Leonardo, Micaela, ed. 1991. Gender at the Crossroads of Knowledge: Feminist
Anthropology in the Postmodern Era. Berkeley, CA: University of California
Press.
Dorris, Michael. 1990. The Broken Cord. New York: HarperCollins.
Douglas, Oliver. 1955. A Solomon Island Society. Boston: Beacon Press.
Dow, James. 1986. “Universal Aspects of Symbolic Healing: A Theoretical Anal-
ysis.” American Anthropologist 88: 56–69.
Doyal, Lesley (with Imogen Pennell). 1979. The Political Economy of Health. Boston:
South End Press.
Draper, Patricia. 1975. “!Kung Women: Contrasts in Sexual Egalitarianism in the
Foraging and Sedentary Contexts.” In Toward an Anthropology of Women, ed.
Rayna Rapp Reiter, 77–109. New York: Monthly Review Press.
Driver, Harold. 1969. Indians of North America. Chicago: University of Chicago
Press.
Drope, J., and S. Chapman. 2001. “Tobacco Industry Efforts at Discrediting Sci-
entific Knowledge of Environmental Tobacco Smoke: A Review of Internal
Industry Documents.” Journal of Epidemiology and Community Health 55(8):
588–94.
Dunn, Frederick. 1976. “Traditional Asian Medicine and Cosmopolitan Medicine
as Adaptive Systems.” In Asian Medical Systems: A Comparative Study, ed.
Charles Leslie, 133–58. Berkeley: University of California Press.
———. 1977. “Health and Disease in Hunter-Gatherers: Epidemiological Factors.”
In Culture, Disease, and Healing: Studies in Medical Anthropology, ed. David
Landy, 99–107. New York: Macmillan.
Eaton, S. Boyd, Marjorie Shostak, and Melvin Konner. 1988. Paleolithic Prescription:
A Program of Diet and Exercise and a Design for Living. New York: Harper
and Row.
Eaton, Virgil. 1888. “How the Opium Habit Is Acquired.” Popular Science 33:
665–66.
Eckert, Penelope. 1983. “Beyond the Statistics of Adolescent Smoking.” American
Journal of Public Health 73(4): 439–41.
Eckholm, E. 1978. Cutting Tobacco’s Toll. Worldwatch Paper #18. Washington, DC:
Worldwatch Institute.
392 Bibliography
Edelman, M. 1987. Families in Peril: An Agenda for Social Change. Cambridge, MA:
Harvard University Press.
Eliade, Mircea. 1964. Shamanism: Archaic Techniques of Ecstasy. New York: Pantheon
Books.
Elling, Ray H. 1981a. “The Capitalist World-System and International Health.”
International Journal of Health Services 11: 25–51.
———. 1981b. “Political Economy, Cultural Hegemony, and Mixes of Traditional
and Modern Medicine.” Social Science and Medicine 15A: 89–99.
Embodden, William. 1974. Narcotic Plants: Hallucinogens, Stimulants, Inebriants, and
Hypnotics—Their Origins and Uses. London: Studio Vista.
Engels, Friedrich. 1845. The Condition of the Working Class in England. Reprint, Lon-
don: Grenada, 1969.
———. 1972. The Origin of the Family, Private Property and the State. Edited by.
Eleanor Burke Leacock. New York: International Publishers.
Erwin, Deborah Oates. 1987. “The Military Medicalization of Cancer Treatment.”
In Encounters with Biomedicine: Case Studies in Medical Anthropology, ed. Hans
A. Baer, 201–27. New York: Gordon and Breach.
Estrada, Anthony, J. Rabow, and R. Watts. 1982. “Alcohol Use among Hispanic
Adolescents: A Preliminary Report.” Hispanic Journal of Behavioral Sciences
4: 339–51.
Estroff, Sue. 1993. “Identity, Disability and Schizophrenia: The Problem of Chro-
nicity.” In Knowledge, Power and Practice: The Anthropology of Medicine in
Everyday Life, ed. Shirley Lindenbaum and Margaret Lock, 247–86. Berkeley:
University of California Press.
Etienne, Mona. 2001. “The Case for Social Modernity: Adoption of Children by
Urban Baule Women.” ed. Caroline Brettel and Carolyn Sargent, 32–38. Up-
per Saddle River, NJ: Prentice-Hall.
Evans-Pritchard, E. E. 1937. Witchcraft, Oracles and Magic among the Azande. Oxford:
Oxford University Press.
——— 1940. The Nuer: A Description of the Modes of Livelihood and Political Institu-
tions of a Nilotic Peoples. Oxford, England: Clarendon Press.
Fabrega, Horacio, Jr. 1974. Disease and Social Behavior: An Interdisciplinary Perspec-
tive. Cambridge, MA: MIT Press.
——— 1997. Evolution of Sickness and Healing. Berkeley: University of California
Press.
Farmer, Paul. 1990. The Exotic and the Mundane: Haitian Immunodeficiency Virus
in Haiti. Human Nature 1:415–446.
———. 1992. AIDS and Accusation: Haiti and the Geography of Blame. Berkeley: Uni-
versity of California Press.
———. 1997. “AIDS and Anthropologists: Ten Years Later.” Medical Anthropology
Quarterly 11: 516–25.
———. 1999. Infections and Inequalities: The Modern Plagues. Berkeley: University
of California Press.
Farmer, Paul, Margaret Connors, and Janie Simmons, eds. 1996. Women, Poverty,
and AIDS: Sex, Drugs and Structural Violence. Monroe, ME: Common Cour-
age Press.
Farquhar, Judith. 1994. Knowing Practice: The Clinical Encounter of Chinese Medicine.
Boulder, CO: Westview Press.
Bibliography 393
Farrelly, M. C., D. L. Faulkner, and P. Mowry. 2000. Cigarette Smoking Among Youth:
Results from the 1999 National Youth Tobacco Survey. Washington, DC: Coor-
dinating Center for Evaluation and Applied Research, American Legacy
Foundation.
Fee, Elizabeth, and Donald Fox. 1992. “Introduction: The Contemporary Histori-
ography of AIDS.” In AIDS: The Making of a Chronic Disease, ed. Elizabeth
Fee and Donald Fox, 1–19. Berkeley: University of California Press.
Fee, Elizabeth, and Nancy Krieger. 1993. “Thinking and Rethinking AIDS: Impli-
cations for Health Policy.” International Journal of Health Services 23: 323–46.
Feldman, Douglas. 1985. “AIDS and Social Change.” Human Organization 44(4):
343–48.
Feldman, Douglas, and Thomas Johnson. 1986. The Social Dimensions of AIDS. New
York: Praeger.
Feldman, Harvey. 1973. “Street Status and Drug Users.” Society 10: 32–39.
Feldman, Harvey and Michael Aldrich. 1990. “The Role of Ethnography in Sub-
stance Abuse Research and Public Policy: Historical Precedent and Future
Prospects.” In The Collection and Interpretation of Data from Hidden Popula-
tions, Elizabeth Lambert, 12–30. Rockville, MD: National Institute on Drug
Abuse (NIDA Research Monograph #98).
Feldman, Harvey, Michael Agar, and George Bechner. 1979. Angel Dust: An Eth-
nographic Study Lexington, Mass.: Lexington Books.
Femia, Joseph. 1975. “Hegemony and Consciousness in the Thought of Antonio
Gramsci.” Political Studies 23: 29–48.
Feshbach, Murray, and Alfred Friendly, Jr. 1992. Ecocide in the USSR: Health and
Nature under Siege. New York: Basic Books.
Fiddle, S. 1967. Portraits from a Shooting Gallery. New York: Harper and Row.
Field, Peter. 1962. “A New Cross-Cultural Study of Drunkenness.” In Society, Cul-
ture, and Drinking Patterns, ed. David Pittman and Charles Snyder, 48–74.
Carbondale, IL: Southern Illinois University Press.
Fineberg, H. 1988. “The Social Dimensions of AIDS.” Scientific American, October,
128–34.
Finestone, H. 1957. “Cats, Kicks, and Color.” Social Problems 5: 39–45.
Firth, Rose Mary. 1978. “Social Anthropology and Medicine—A Personal Per-
spective.” Social Science and Medicine 12B: 237–45.
Fischer, P. 1987. “Tobacco in the Third World.” Journal of Islamic Medical Association
19: 19–21.
Fisk, Milton. 1980. Ethics and Society: A Marxist Interpretation of Value. New York:
New York University.
———. 2000. Toward a Healthy Society: The Morality and Politics of American Health
Care Reform. Lawrence: University Press of America.
Fitchen, J. 1988. “Hunger, Malnutrition, and Poverty in the Contemporary United
States: Some Observations on Their Social and Cultural Context.” Food and
Foodways 2: 309–33.
Fitzpatrick, Joseph. 1971. Puerto Rican Americans: The Meaning of Migration to the
Mainland. Englewood Cliffs, NJ: Prentice-Hall.
———. 1990. “Drugs and Puerto Ricans in New York.” In Drugs in Hispanic Com-
munities, ed. Ronald Glick and Joan Moore, 103–26. New Brunswick, NJ:
Rutgers University Press.
394 Bibliography
Flacks, Richard. 1993. “The Party’s Over—So What Is to Be Done?” Social Research
60: 445–70.
Flink, James J. 1973. The Car Culture. Cambridge, MA: MIT Press.
Foster, George M. 1982. “Applied Anthropology and International Health: Retro-
spect and Prospect.” Human Organization 41: 189–97.
Foster, George M., and Barbara Gallatin Anderson. 1978. Medical Anthropology.
New York: John Wiley and Sons.
Fox, Renee. 1990. “The Evolution of American Bioethics: A Sociological Perspec-
tive.” In Social Science Perspectives on Medical Ethics, ed. George Weisz, 201–
17. Dordrecht, Netherlands: Kluwer Academic Publishers.
Foucault, Michel. 1975. The Birth of the Clinic: An Archaeology of Medical Perception.
New York: Vintage.
Frankenberg, Ronald. 1974. “Functionalism and After? Theory and Developments
in Social Science Applied to the Health Field.” International Journal of Health
Services 43: 411–27.
———. 1980. “Medical Anthropology and Development: A Theoretical Perspec-
tive.” Social Science and Medicine 14B: 197–207.
———. 1981. “Allopathic Medicine, Profession, and Capitalist Ideology in India.”
Social Science and Medicine 15A: 115–25.
Freedman, Lyn and Deborah Maine. 1993. “Women’s Mortality: A Legacy of Ne-
glect.” In The Health of Women: A Global Perspective, ed. Marge Koblinsky,
Judith Timyan, and Jill Gay, 147–71. Boulder, CO: Westview Press.
Freidson, Elliot. 1970. Profession of Medicine. New York: Dodd, Mead and Co.
Freire, Paulo. 1974. Pedagogy of the Oppressed. New York: Seabury Press.
Freund, Peter S., and George Martin. 1993. The Ecology of the Automobile. Montreal:
Black Rose Books.
Freund, Peter S., and Meredith B. McGuire. 1991. Health, Illness, and the Social Body:
A Critical Sociology. Englewood Cliffs, NJ: Prentice-Hall.
Frezza, M., C. Padova, and G. Pozzato. 1990. “High Blood Alcohol Levels in
Women: The Role of Decreased Gastric Alcohol Dehydrogenase Activity
and First-Pass Metabolism.” New England Journal of Medicine 322(2): 95–99.
Friedlander, Eva, ed. 1996. Look at the World Through Women’s Eyes: Plenary Speeches,
Beijing ’95 New York: NGO Forum on Women.
Friedman, S., D. Des Jarlais, and J. Sotheran. 1986. “AIDS Health Education for
Intravenous Drug Users.” Health Education Quarterly 13: 383–93.
Friedman, Samuel, Don Des Jarlias, Claire Sterk, Jo Sotheran, S. Tross, J. Woods,
M. Sufian, and A. Abdul-Quader. 1990. AIDS and the Social Relations of
Intravenous Drug Users. Milbank Quarterly 68 (Supplement): 85–110.
Friedman, Samuel, Maryl Sufian, and Don Des Jarlais. 1990. “The AIDS Epidemic
among Latino Intravenous Drug Users.” In Drugs in Hispanic Communities,
ed. Ronald Glick and Joan Moore, 45–54. New Brunswick, NJ: Rutgers Uni-
versity Press.
Fuentes, Annette. 1997. “White Coats with Blue Collars.” In These Times (3 March):
17–19.
Gailey, Christine. 1998. “Feminist Methods.” In Handbook of Anthropological Meth-
ods, ed. Russell Bernard, Washington, DC: American Anthropological As-
sociation.
Gaines, Atwood. 1987. “Shamanism and the Shaman: Plea for the Person-Centered
Approach.” Anthropology and Humanism Quarterly 12(3&4): 62–68.
Bibliography 395
Glick Schiller, Nina, S. Crystal, and D. Lewellen. 1994. “Risky Business: The Cul-
tural Construction of AIDS Risk Groups.” Social Science and Medicine 38(10):
1337-46.
Godelier, Maurice. 1986. The Mental and the Material: Thought Economy and Society.
London: Verso.
Goffman, Irving. 1963. Stigma. Englewood Cliffs, NJ: Prentice-Hall.
Goldman, Marlene, and Maureen Hatch, eds. 2000. Women and Health. New York:
Academic Press.
Good, Byron. 1994. Medicine, Rationality, and Experience. Cambridge, England:
Cambridge University Press.
Good, Mary-Jo Delvecchio, and Byron Good. 2000. “Parallel Sisters”: Medical An-
thropology and Medical Sociology. In Handbook of Medical Sociology, 5th ed.,
ed. Chloe E. Bird, Peter Conrad, and Allen M. Fremont, 377–88: Prentice-
Hall.
Goode, Erich. 1984. Drugs in American Society. New York: Alfred A. Knopf.
Goode, Judith, and Jeff Maskovsky, eds. 2001. The New Poverty Studies: The Eth-
nography of Power, Politics, and the Impoverished People in the United States.
New York: New York University Press.
Goodman, Alan, and Thomas L. Leatherman, eds. 1998. Building a New Biocultural
Synthesis: Political-Economic Perspectives on Human Biology. Ann Arbor: Uni-
versity of Michigan Press.
Gordon, Robert. 1992. The Bushman Myth. Boulder, CO: Westview.
Gorz, Andre. 1973. Socialism and Revolution. Garden City, NY: Anchor.
———. 1980. Ecology as Politics. Boston: South End Press.
Gough, Kathleen. 1971. “Nuer Kinship: A Re-Examination.” In The Translation of
Culture: Essays to E.E. Evans-Pritchard, ed. T. O. Beidelman, London: Tavis-
tock Publications.
Gounis, K. 1992. “Temporality and the Domestication of Homelessness.” In The
Politics of Time, ed. H. Rutz, Washington, DC: American Ethnological Society
(Monograph Series # 4).
Gourevitch, Danielle. 1998. “The Paths of Knowledge: Medicine in the Roman
World.” In Western Medical Thought From Antiquity to the Middle Ages, ed.
Mirko Grmk, 104–38. Cambridge: Harvard University Press.
Gow, Peter. 1994. “River People: Shamanism and History in Western Amazonia.”
In Shamanism, History, and the State, ed. Nicholas Thomas and Caroline
Humphrey, 90–113. Ann Arbor: University of Michigan Press.
Graiz, Laurene A. 1999. Health of Nations: An International Perspective on U.S.
Health Reform. Washington, D.C.: Congressional Quarterly Press.
Gran, Peter. 1979. “Medical Pluralism in Arab and Egyptian History: An Overview
of Class Structures and Philosophies of the Main Phases.” Social Science and
Medicine 13B: 339–48.
Grant, B. and D. Dawson. 1997. “Age at Onset of Alcohol Use and Its Association
with DSM-IV Alcohol Abuse and Dependence: Results from the National
Longitudinal Alcohol Epidemiologic Survey.” Journal of Substance Abuse 9:
103–10.
Green, D. 1979. Teenage Smoking: Immediate and Long Term Patterns. Washington,
DC: National Institute of Education.
Green, E. M. 1914. “Psychoses among Negroes—A Comparative Study.” Journal of
Nervous and Mental Disease 41: 697–08.
Bibliography 397
Greenfield, T. and Robin Room. 1997. “Situational Norms for Drinking and Drunk-
enness: Trends in the US Adult Population, 1979–1990.” Addiction 92(1):
33–47.
Grinspoon, Lester, and James Bakalar. 1985. Cocaine: A Drug and Its Social Evolution.
New York: Basic Books.
Gross, W. and R. Billingham. 1998. “Alcohol Consumption and Sexual Victimiza-
tion Among College Women.” Psychological Reports 82(1): 80–82.
Grossinger, Richard. 1990. Planet Medicine: From Stone Age Shamanism to Post-
Industrial Healing. Berkeley, CA: North Atlantic Books.
Gruenbaum, Ellen. 1981. “Medical Anthropology, Health Policy and the State: A
Case Study of Sudan.” Medical Anthropology 7(2): 51–62.
———. 1983. “Struggling with the Mosquito: Malaria Policy and Agricultural De-
velopment in Sudan.” Medical Anthropology 7: 53–62.
Guyer, Jane. 1991. “Female Farming in Anthropology and African History.” In
Gender in the Crossroads of Knowledge: Feminist Anthropology in the Postmodern
Era, ed. Micaela di Leonardo, 257–78.
Habermas, Juergen. 1991. “What Does Socialism Mean Today? The Revolutions of
Recuperation and the Need for New Thinking.” In After the Fall: The Failure
of Communism and the Future of Socialism, ed. Robin Blackburn, 25–46. Lon-
don: Verso.
Hahn, Robert A. 1983. “Biomedical Practice and Anthropological Theory: Frame-
works and Directions.” Annual Review of Anthropology 12: 305–33.
———. 1995. Sickness and Healing: An Anthropological Perspective. Ann Arbor: Uni-
versity of Michigan Press.
Hahn, Robert A., et al. 1989. “Race and the Prevalence of Syphilis Seroactivity in
the United States Population: A National Sero-Epidemiologic Study.” Amer-
ican Journal of Public Health 79(4): 467–70.
———. 1999. Anthropology and the Enhancement of Public Health Practice. In
Anthropology in Public Health: Bridging Differences in Culture and Society, 3–
26. New York: Oxford University Press.
Haire, Doris. 1978. “The Cultural Warping of Childbirth.” In The Cultural Crisis of
Modern Medicine, ed. John Ehrenreich, 185–200. New York: Monthly Review
Press.
Handelbaum, Don. 1967. “The Development of a Washo Shaman.” In Culture,
Disease, and Healing: Studies in Medical Anthropology, ed. David Landy, 427–
38. New York: Macmillan.
Hanson, Bill, George Beschner, James Walters, and Elliot Bovelle. 1985. Life with
Heroin: Voices from the Inner City. Lexington, MA: Lexington Books.
Haraway, Donna. 1991. Simians, Cyborgs, and Women. New York: Routledge.
Harner, Michael. 1968. The Jivaro. Berkeley: University of California Press.
———. 1980. The Way of the Shaman: A Guide to Power and Healing. New York:
Bantam Books.
Harris, Marvin, and Eric Ross. 1987. Death, Sex, and Fertility: Population Regulation
in Preindustrial and Developing Societies. New York: Columbia University
Press.
Harris, Marvin, and Orna Johnson. 2000. Cultural Anthropology. Boston: Addison-
Wesley.
Haug, M. 1975. “The Deprofessionalization of Everyone?” Sociological Focus 8: 197–
213.
398 Bibliography
———. 1989. “A National Health Program for the United States: A Physician’s
Proposal.” New England Journal of Medicine 320: 102–8.
———. 1994. The National Health Program Book: A Source Guide for Advocates. Mon-
roe, ME: Common Courage Press.
Hippler, Arthur. 1976. “Shamans, Curers, and Personality: Suggestions toward a
Theoretical Model.” In Culture-Bound Syndromes, Ethnopsychiatry, and Alter-
nate Therapies, ed. William Lebra, 103–13. Honolulu: University of Hawaii
Press.
Ho, John. 1996. “The Influence of Coinfections on HIV Transmission and Disease
Progression.” The AIDS Reader 6(4): 114–16.
Hodges, Donald Clark. 1974. Socialist Humanism: The Outcome of Classical European
Morality. St. Louis: Warren H. Green.
Hogue, Carol J. Rowland. 2000. “Gender, Race, and Class: From Epidemiologic
Association to Etiologic Hypotheses.” ed. Marlene Goldman and Carolyn
Sargent, 15–25. New York: Academic Press.
Hope, K. 1992. “Child Survival and Health Care among Low-Income African
American Families in the United States.” Health Transition Review 2: 151–64.
Hoppal, Mihaly, and Keith D. Howard, eds. 1993. Shamans and Cultures. Los An-
geles: International Society for Trans-Oceanic Research.
Hopper, Kim. August 1992. “Counting the Homeless: S-Night in New York.” Eval-
uation Review 16(4).
Hopper, Kim, and L. Cox. 1982. “Litigation in Advocacy for the Homeless: The
Case of New York City.” Development: Seeds of Change 2: 57–62.
Hopper, K., E. Susser, and S. Conover. 1987. “Economics of Makeshift: Deindus-
trialization and Homelessness in New York City.” Urban Anthropology 14:
183–236.
Horan, Michael. 1993. “Are Minority Groups Winning the Fight against CVD and
Pulmonary Disease?” In Minority Health Issues for an Emerging Majority. Pro-
ceedings of the 4th National Forum on Cardiovascular Health, Pulmonary
Disorders, and Blood Resources, ed. 22–23. Washington, DC: National
Heart, Lung, and Blood Institute.
Horton, David. 1943. “The Functions of Alcohol in Primitive Societies: A Cross-
cultural Study.” Quarterly Journal of Studies on Alcohol 4: 199–320.
Howell, Nancy. 2000. Demography of the Dobe !Kung. Hawthorne: Aldine-
DeGruyter.
Hsiao, William C. 1995. “The Chinese Health Care System: Lessons for Other Na-
tions.” Social Science and Medicine 41:1047–55.
Hughes, Charles C. 1978. “Ethnomedicine.” In Health and the Human Condition:
Perspectives on Medical Anthropology, ed. Michael H. Logan and Edward E.
Hunt, Jr., 150–58. North Scituate, MA: Duxbury Press.
Hughes, Donald H. 1975. The Ecology of Ancient Civilizations. Albuquerque: Uni-
versity of New Mexico Press.
Hunt, Edward E., Jr. 1978. “Evolutionary Comparisons of the Demography, Life
Cycles, and Health Care of Chimpanzee and Human Populations.” In
Health and the Human Condition: Perspectives on Medical Anthropology, ed.
Michael H. Logan and Edward E. Hunt, Jr., 52–57. North Scituate, MA:
Duxbury Press.
400 Bibliography
Klein, Norman. 1979. “Introduction.” In Culture, Curers and Contagion, ed. Norman
Klein, 1–4. Novato, CA: Chandler and Sharp.
Kleinman, Arthur. 1995. Writing at the Margin: Discourse Between Anthropology and
Medicine. Berkeley: University of California Press.
———. 1977. “Lessons from a Clinical Approach to Medical Anthropological Re-
search.” Medical Anthropology Newsletter 8: 5–8.
———. 1978. “Problems and Prospects in Comparative Cross-Cultural Medical
and Psychiatric Studies.” In Culture and Healing in Asian Societies: Anthro-
pological, Psychiatric and Public Health Studies, ed. Arthur Kleinman, Peter
Kunstadter, E. Russell Alexander, and James L. Gale, 329–74. Cambridge,
MA: Schenkman Publishing Co.
Knox, R. 1987. “Hub Infant Deaths Up 32%.” Boston Globe (9 February):1, 5.
Koblinsky, Marge, Judity Timyan, and Jill Gay, eds. 1993. The Health of Women:
A Global Prespective Boulder, CO: Westview Press.
Koester, Stephen. 1994. “Copping, Running, and Paraphernalia Laws: Contextual
Variables and Needle Risk Behavior among Injection Drug Users in Den-
ver.” Human Organization 53: 287–95.
Koester, Stephen and Judith Schwartz. 1993. “Crack, Gangs, Sex, and Powerless-
ness: A View from Denver.” In Crack Pipe as Pimp: An Ethnographic Investi-
gation of Sex-for-Crack Exchanges, ed Mitchell Ratner, 187–205. New York:
Lexington Books.
Kolata, Gina. 1995. “New Picture of Who Will Get AIDS Is Crammed with Ad-
dicts.” New York Times (2 February): C3.
Konner, Melvin. 1993. Medicine at the Crossroads: The Crisis in Health Care. New
York: Pantheon Books.
Kotarba, J. 1990. “Ethnography and AIDS.” Journal of Contemporary Ethnography
19: 259–70.
Krause, Elliot. 1977. Power and Illness: The Political Sociology of Health and Medical
Care. New York: Elsevier.
———. 1996. Death of the Guilds: Professions, States, and the Advance of Capitalism,
1930 to the Present. New Haven: Yale University Press.
Kroeber, Alfred. 1939. “Cultural Elements and Distributions XV: Salt, Dogs, and
Tobacco.” Anthropological Records 6(1).
LaBarre, Weston. 1972. “Hallucinogens and the Shamanic Origins of Religion.” In
Flesh of the Gods: The Ritual Use of Hallucinogens, ed. Peter T. Furst, 261–78.
New York: Praeger.
———. 1989. The Peyote Cult. 5th ed. Norman: University of Yale Oklahoma Press.
Lamphere, Louise. 1987. From Working Daughters to Working Mothers: Immigrant
Women in a New England Industrial Community. Ithaca, NY: Cornell Univer-
sity Press.
Lamphere, Louise, Helena Ragone, and Patricia Zavella, eds. Situated Lives: Gender
and Culture in Everyday Life. New York: Routledge.
Lamphere, Louise, and Michelle Zimbalist Rosaldo, eds. Women, Culture and So-
ciety. Stanford, CA: Stanford University Press.
Lan, David. 1985. Guns and Rain: Guerrillas and Spirit Mediums in Zimbabwe. Berke-
ley: University of California Press.
Landesman, S. 1993. “Commentary: Tuberculosis in New York City—The Conse-
quences and Lessons of Failure.” American Journal of Public Health 83(5):
766–68.
Bibliography 403
Lerner, B. 1993. “New York City’s Tuberculosis Control Efforts: The Historical
Limitations of the ‘War on Consumption.’” American Journal of Public Health
83(5): 758–66.
Leshner, Alan. 2001. “Addiction is a Brain Disease.” Issues in Science and Technology
57(3): 75–80.
Leslie, Charles. 1974. The Modernization of Asian Medical Systems. In Rethinking
Modernization, ed. John Poggie, Jr., and Robert N. Lynch, 69–107. Westport,
CT: Greenwood Press.
———. 1976. Introduction. In Asian Medical Systems: A Creative Study, ed. Charles
Leslie, 1–12. Berkeley: University of California Press.
———. 1977. “Medical Pluralism and Legitimation in the Indian and Chinese
Medical Systems.” In Culture, Disease, and Healing: Studies in Medical An-
thropology, ed. David Landy 511–17. New York: Macmillan.
———. 1992. “Interpretations of Illness: Syncretism in Modern Ayurveda.” In
Paths to Asian Medical Knowledge, ed.Charles Leslie and Allan Young, 177–
208. Berkeley: University of California Press.
Lessinger, J. 1988. “Trader vs. Developer: The Market Relocation Issue in an Indian
City.” In Traders versus the State: Anthropological Approaches to Unofficial Econ-
omies, ed. G. Clark Boulder, CO: Westview Press.
Levin, Betty Wolden. 1990. “International Perspectives in Decision-Making in Neo-
natal Intensive Care.” Social Science and Medicine 30: 901–912.
Lewin, Louis. 1964. Phantastica: Narcotic and Stimulating Drugs—Their Use and
Abuse. London: Routledge and Kegan Paul.
Lewis, Gilbert. 1986. “Concepts of Health and Illness in a Sepik Society.” In Con-
cepts of Health, Illness and Disease: A Comparative Perspective, ed. Caroline
Currier and Meg Stacy, 119–35. Leamington Spa, England: Berg.
Lewis, I. M. 1989. Ecstatic Religion: A Study of Shamanism and Possession. 2nd ed.
London: Routledge.
Lieban, Richard W. 1990. “Medical Anthropology and the Comparative Study of
Medical Ethics.” In Social Science Perspectives in Medical Ethics, ed. George
Weisz, 221–39. Dordrecht, Netherlands: Kluwer Academic Publishers.
Lindenbaum, Shirley. 1987. “The Mystification of Female Labors.” In Gender and
Kinship: Essays Toward a Unified Analysis, ed. Jane Fishburne Collier and
Sylvia Junko Yanagisako, 221–43. Stanford, CA: Stanford University.
———. 1998. “Images of Catastrophe: The Making of an Epidemic.” In Political
Economy of AIDS, ed. Merrill Singer, 33–58. Amityville, NY: Baywood
Publishing.
Lindenbaum, Shirley, and Margaret Lock. 1993. “Preface.” In Knowledge, Power and
Practice: The Anthropology of Medicine and Every, ed. Shirley Lindenbaum
and Margaret Lock, ix-xv. Berkeley: University of California Press.
Lindesmith, Alfred. 1947. Opiate Addiction. Bloomington, IN: Principia Press.
———. 1965. The Addict and the Law. New York: Mayfield Publishing Co.
Lindesmith, Alfred, Anselm Straus, and Norman Denzin. 1975. Social Psychology.
Hinsdale, IL: Dryden Press.
Link, B., E. Susser, J. Phelan, R. Moore, and E. Streuning. 1994. “Lifetime and Five-
Year Prevalence of Homelessness in the US.” American Journal of Public
Health 84: 1907–12.
Bibliography 405
———. 1989. Medical Anthropology in Ecological Perspective. 2nd ed. Boulder, CO:
Westview Press.
———. 1996. Medical Anthropology in Ecological Perspective. 3rd ed. Boulder, CO:
Westview Press.
McGrath, Janet, et al. 1992. “Cultural Determinants of Sexual Risk Behavior for
AIDS among Baganda Women.” Medical Anthropology Quarterly, n.s., 6:
153–61.
McGraw, Sarah. 1989. “Smoking Behavior among Puerto Rican Adolescents: Ap-
proaches to Its Study.” Doctoral Dissertation, Department of Anthropology,
University of Connecticut.
McKinlay, John B. 1976. “The Changing Political and Economic Content of the
Patient-Physician Encounter.” In The Doctor-Patient Relationship in the Chang-
ing Health Scene, ed. Eugene B. Gallagher, 155–88. Washington, DC: U.S.
Government Printing Office (DHEW Pub. No. (NIH) 78–183).
McKinlay, John B. and Joan Arches. 1985. “Towards the Proletarianization of Phys-
icans.” International Journal of Health Services 15: 161–95.
McLaughlin, Andrew. 1990. “Ecology, Capitalism, and Socialism.” Socialism and
Democracy 10: 69–102.
McNeill, William H. 1976. Plagues and Peoples. New York: Anchor Books.
Mechanic, David. 1976. The Growth of Bureaucratic Medicine. New York: John Wiley
and Sons.
Meier, Matt, and Feliciano Rivera. 1972. The Chicanos. New York: Hill and Wang.
Merchant, Carolyn. 1992. Radical Ecology: The Search for a Livable World. New York:
Routledge.
Merchant, Kathleen, and Kathleen Kurz. 1993. “Women’s Nutrition Through the
Life-Cycle: Social and Biological Vulnerabilities.” In The Health of Women: A
Global Perspective, ed. Marge Koblinsky, Judith Tinyan, and Jill Gay, 63–91.
Boulder, CO: Westview Press.
Mering, Otto von. 1970. “Medicine and Psychiatry.” In Anthropology and the Behav-
ioral and Health Sciences, ed. Otto von Mering and Leonard Kasdan, 272–
307. Pittsburgh: University of Pittsburgh Press.
Metraux, Alfred. 1972. Voodoo in Haiti. New York: Schocken Books.
Michaelsen, Karen L., ed. 1988. Childbirth in America: Anthropological Perspectives.
South Hadley, MA: Bergin & Garvey Publishers.
Miles, Anne. 1998. “Science, Nature, and Tradition: The Mass-Marketing of Nat-
ural Medicine in Urban Ecuador.” Medical Anthropology Quarterly 12:
206–25.
Miliband, Ralph. 1994. Socialism for a Skeptical Age. London: Courage Press.Verso.
Millen, Joyce and Timothy Millen. 2000. “Dying for Growth: Transnational Cor-
porations and the Health of the Poor.” In Dying for Growth: Global Inequality
and the Health of the Poor, ed. Jim Kim, Joyce Millen, Alec, Irwin, and John
Gershman, 177–224. Monroe, ME: Common Courage Press.
Miller, B. 1998. “Partner Violence Experiences and Women’s Drug Use: Exploring
the Connections.” In Drug Addiction Research and the Health of Women, ed.
C. Wetherington and A. Roman, 407–16. Rockville, MD: National Institute
on Drug Abuse.
Miller, Barbara D. 2000. “Female Infanticide and Child Neglect in Rural North
India.” In Gender in Cross-Cultural Perspective, ed. Caroline Brettel and Car-
olyn Sargent, 492–507. Upper Saddle River: Prentice-Hall.
408 Bibliography
Miller, Judith. 1983. National Survey on Drug Abuse: Main Findings. Rockville, MD:
National Institute on Drug Abuse.
Mills, C. Wright. 1959. The Sociological Imagination. New York: Grove Press.
Millstein, Bobby. 2001. Introduction to the Syndemic Prevention Network. Atlanta:
Syndemic Prevention Network, Centers for Disease Control and Pre-
vention.
Miner, Horace. 1979. “Body Ritual among the Nacirema.” In Culture, Curers and
Contagion, ed. Norman Klein, 9–14. Novato, CA: Chandler and Sharp
Publishers.
Mintz, Sidney. 1985. Sweetness and Power. New York: Penguin Books.
Mittlemark, Maurice, et al. 1987. “Predicting Experimentation with Cigarettes: The
Childhood Antecedents of Smoking Study (CASS).” American Journal of Pub-
lic Health 77(2): 206–8.
Moerman, Daniel E. 1979. “Anthropology of Symbolic Healing.” Current Anthro-
pology 20: 59–80.
Moffat, Michael. 1989. Coming of Age in New Jersey. New Brunswick, NJ: Rutgers
University Press.
Monti-Catania, D. 1997. “Women, Violence, and HIV/AIDS.” In The Gender Politics
of HIV/AIDS in Women: Perspectives on the Pandemic in the United States, ed.
N. Goldstein and J. L. Manlowe, 442–251. New York: New York University
Press.
Moore, Lorna G., Peter W. Van Arsdale, JoAnn E. Glittenberg, and Robert A. Al-
drich. 1980. The Biocultural Basis of Health: Expanding Views of Medical An-
thropology. Prospect Heights, IL: Waveland Press.
Morgan, Lynn M. 1987. “Dependency Theory in the Political Economy of Health:
An Anthropological Critique.” Medical Anthropology Quarterly, n.s., 1(2):
131–55.
Morgan, Myfanwy. 1997. “Hospitals, Doctors and Patient Care.” In Sociology as
Applied to Medicine, ed. Grahman Scambler, 63–76. London: W.B. Saunders.
Morgen, Sandra. 1987. “The Women’s Health Movement.” In Women and the Poli-
tics of Empowerment, ed. Ann Bookman and Sandra Morgen, Philadelphia:
Temple University Press.
Morley, Peter. 1978. “Culture and the Cognitive World of Traditional Medical Be-
liefs: Some Preliminary Considerations.” In Culture and Curing: Anthropo-
logical Perspectives on Traditional Medical Beliefs and Practices, ed. Peter Morley
and Roy Wallis, 1–18. Pittsburgh: University of Pittsburgh Press.
Morrow, Carol Tupperman. 2003. Sick Doctors: The Social Construction of Profes-
sional Deviance. In Health and Health Care as Social Problems. Peter Con-
rad and Valerie Letter, eds., 297–316. Canada, Ont.: Rowann and Lexington.
Morse, Stephen. 1992. “AIDS and Beyond: Defining the Rules for Viral Traffic.” In
AIDS: The Making of a Chronic Disorder, ed. Elizabeth Fee and Daniel Fox,
23–48. Berkeley: University of California Press.
Morsy, Soheir. 1979. “The Missing Link in Medical Anthropology: The Political
Economy of Health.” Reviews in Anthropology 6: 349–63.
———. 1990. Political Economy in Medical Anthropology. In Medical Anthropology:
Contemporary Theory and Method, ed. Thomas M. Johnson and Carolyn F.
Sargent, 26–46. New York: Praeger.
Bibliography 409
Moses, Peter, and John Moses. 1983. “Haiti and the Acquired Immune Deficiency
Syndrome.” Annals of Internal Medicine 99(4): 565.
Moses, A. R. 2000. Epidemiology and the Politics of Needle Exchange. American
Journal of Public Health 90(9): 1385–96.
Mullings, Leith, and Alika Wali. 2001. Stress and Resilience: The Social Context of
Reproduction in Central Harlem. New York: Kluwer Academic Press.
Murdock, George Peter. 1980. Theories of Illness: A World Survey. Pittsburgh: Uni-
versity of Pittsburgh Press.
Murphy, Jane. 1964. “Psychotherapeutic Aspects of Shamanism on St. Lawrence
Island, Alaska.” In Magic, Faith, and Healing, ed. Ari Kiev, 53–83. New York:
Free Press.
Musto, David. 1971. “The American Anti-Narcotic Movement: Clinical Research
and Public Policy.” Clinical Research 29(3): 601–05.
———. 1987. The American Disease: Origins of Narcotic Control. New York: Oxford
University Press.
Mwanalushi, M. 1981. “The African Experience.” World Health, 14 August.
Nader, Ralph. 1965. Unsafe at Any Speed: The Designed-in Dangers of the Automobile
Industry. New York: Grossman.
National Cancer Center. 1999. Health Effects of Exposure to Environmental Smoke: The
Report of the California Environmental Protection Agency (Smoking and To-
bacco Control Monograph # 10). Bethesda, CA: US Department of Health
and Human Services, National Institutes of Health, National Cancer Insti-
tute (NIH Publication No. 99–4645).
National Center on Addiction and Substance Abuse. 1996. National Survey of Amer-
ican Attitudes on Substance Abuse II: Teens and Their Parents. New York: Co-
lumbia University.
National Institute on Alcohol Abuse and Alcoholism. 1998. “Drinking in the
United States: Main Findings from the 1992 National Longitudinal Alcohol
Epidemiologic Survey (NLAES).” U.S. Alcoholc Epidemiologic Data Reference
Manual, Volume 6. 1st edition. Bethesda, MD: NIAAA.
National Institute on Drug Abuse. 1994. Monitoring the Future Study: Trends in
Prevalence of Various Drugs for 8th-Graders, 10th-Graders, and High School Sen-
iors. Washington, DC: U.S. Department of Health and Human Services
(NIDA Capsules).
Navarro, Vincente. 1976. Medicine under Capitalism. New York: Prodist.
———. 1977. Social Security and Medicine in the U.S.S.R.: A Marxist Critique. Lex-
ington, MA: Lexington Books.
———. 1986. Crisis, Health and Medicine: A Social Critique. New York: Tavistock.
———. 1989. “The Rediscovery of the National Health Program by the Democratic
Party of the United States: A Chronicle of the Jesse Jackson 1988 Cam-
paign.” International Journal of Health Services 19: 1–18.
———. 1990. Race or Class versus Race and Class: Mortality Differentials in the
United States. Lancet 336:1238–1240.
———. 1994. The Politics of Health Policy: The US Reforms, 1980–1994. Oxford:
Blackwell.
———. 1995. Enact Health Care Reform. Journal of Health Politics, Policy and Law
20(3):455–462.
410 Bibliography
Page, J. Bryan, Prince Smith, and Normie Kane. 1991. “Shooting Galleries, Their
Proprietors, and Implications for Prevention of AIDS.” Drugs and Society
5(1/2): 69-85.
Pandolfi, Mariella, and Deborah Gordon. 1986. Italy. Medical Anthropology Quar-
terly, o.s., 17(4):90.
Pape, J., et al. 1986. “Risk Factors Associated with AIDS in Haiti.” American Journal
of Medical Sciences 29(1): 4–7.
Pappas, Gregory, S. Queen, W. Hadden, and G. Fisher. 1993. “The Increasing Dis-
parity of Mortality Between Socio-Economic Groups in the United States,
1960–86.” New England Journal of Medicine.
Parenti, Michael. 1980. Democracy for the Few. New York: St. Martin’s Press.
Parker, Richard. 1987. “Acquired Immunodeficiency Syndrome in Urban Brazil.”
Medical Anthropology Quarterly, n.s., 1: 155–75.
———. 1992. “Sexual Diversity, Cultural Analysis, and AIDS Education in Brazil.”
In The Time of AIDS, ed. Gilbert Herdt and Shirley Lindenbaum, 225–42.
Newbury Park, CA: Sage Publications.
Parker, Richard and Anke Ehrhardt. 2001. “Through and Ethnographic Lens: Eth-
nographic Methods, Comparative Analysis and HIV/AIDS Research.”
AIDS and Behavior 5(2): 105–14.
Parsons, Howard L., ed. 1977. Marx and Engels on Ecology. Westport, CT:
Greenwood.
Partridge, William L. 1987. “Toward a Theory of Practice.” In Applied Anthropology
in America, ed. Elizabeth M. Eddy and William L. Partridge, 211–33. New
York: Columbia University Press.
Paul, Benjamin. 1969. “Anthropological Perspectives on Medicine and Public
Health.” In Cross-Cultural Approach to Health Behavior, ed. R. Lynch, 26–42.
Madison, NJ: Fairleigh Dickinson University Press.
Paul, James A. 1978. “Medicine and Imperialism.” In The Cultural Crisis of Modern
Medicine, ed. John Ehrenreich, 271–86. New York: Monthly Review Press.
Payer, Lynn. 1988. Medicine and Culture: Varieties of Treatment in the United States,
England, West Germany and France. New York: H. Holt.
Petchesky, Rosalind P. 2000. “Sexual Rights: Inventing a Concept, Mapping an
International Practice.” In Framing the Sexual Subject: The Politics of Gender,
Sexuality, and Power, ed. Richard Parker, Regina Maria Barbosa, and Peter
Aggleton, 81–104. Berkeley: University of California Press.
Peto, Richard. 1990. “Future Worldwide Health Effects of Current Smoking Pat-
terns. Paper presented at WHO Workshop, Perth, Australia.
Peto, Richard, and A. Lopez, eds. 1990. Proceedings. Perth, Australia: Seventh
World Conference on Tobacco and Health.
Pfeiderer, Beatrix, and Wolfgang Bichman. 1986. Germany. Medical Anthropology
Quarterly, o.s., 17(4): 89–90.
Physicians’ Task Force on Hunger in America. 1985. Hunger in America: The Grow-
ing Epidemic. Boston: Harvard University School of Public Health.
Pirie, P., D. Murray, and R. Luepker. 1988. “Smoking Prevalence in a Cohort of
Adolescents, Including Absentees, Dropouts, and Transfers.” American Jour-
nal of Public Health 78(2): 176–78.
Pittman, David, and Charles Snyder. 1962. Society, Culture, and Drinking Patterns.
Carbondale, IL: Southern Illinois University Press.
412 Bibliography
Piven, Frances, and Richard Cloward. 1971. Regulating the Poor. New York: Vintage.
Pollack, Donald. 1992. “Culina Shamanism: Gender, Power, and Knowledge.” In
Portals of Power: Shamanism in South America, ed. E. Langdon, Jean Matteson,
and Gerhard Baer, 25–40. Albuquerque: University of New Mexico Press.
Preble, Edward, and J. Casey. 1969. “Taking Care of Business: The Heroin User’s
Life on the Streets.” International Journal of the Addictions 15: 329–37.
Preston, Richard. 1994. The Hot Zone. New York: Random House Publishers.
Prevention File. 1990. “Are Alcohol and Tobacco Companies Buying Their Way
into Black Communities?” Prevention File (Winter): 9–10.
Price, Jacob. 1964. “The Economic Growth of the Chesapeake and the European
Market, 1697–1775.” Journal of Economic History 24: 496–511.
Quam, Michael. 1994. “AIDS Policy and the United States Political Economy.” In
Global AIDS Policy. ed. Douglas Feldman, 142–59. Westport, CT: Bergin and
Garvey.
Quellet, Lawrence, Wayne Weibel, and Antonio Jimenez. 1995. “Team Research
Methods for Studying Intranasal Heroin Use and Its HIV Risks.” In Quali-
tative Methods in Drug Abuse and HIV Research, ed. Elizabeth Lambert, Re-
becca Ashery, and Richard Needle, 182–211, Rockville, MD: National
Institute on Drug Abuse (NIDA Research Monograph #157).
Quinn, Thomas. 2001. “Response to the Global AIDS Pandemic: The Global AIDS
Fund—Will It Be Enough and Will It Succeed?” The Hopkins HIV Report
13(5): 12–15.
Rabkin, Judith, Robert Remien, and Christopher Wilson. 1994. Good Doctor, Good
Patient. New York: NCM Publishers.
Rachal, J. Guess, et al. 1980. Drinking Behavior, vol. 1. Research Triangle Park, NC:
Research Triangle Institute.
Raffel, Marshall W., and Norma K. Raffel. 1994. The U.S. Health System: Origins
and Functions. 4th edition. Albany, NY: Delmar Publishers.
Ran Nath, Uma. 1986. Smoking: Third World Alert. Oxford: Oxford University Press.
Rapp, Rayna. 2000. Testing Women, Testing the Fetus: The Social Impact of Amniocen-
tesis in America. New York: Routledge.
Radliff, Eric. 1999. “Women as ‘Sex Worker,’ Men as ‘Boyfriends’: Shifting Iden-
tities in Philippine Go-Go Bars and Their Significance in STD/AIDS Con-
trol.” Anthropology and Medicine 6: 79–102.
Ratner, Mitchell. 1993. “Sex, Drugs, and Public Policy: Studying and Understand-
ing the Sex-for-Crack Phenomenon.” In Crack Pipe as Pimp: An Ethnographic
Investigation of Sex-for-Crack Exchanges, ed. Mitchell Ratner, 1–36. New York:
Lexington Books.
Ray, O. 1978. Drugs, Society, and Human Behavior. St. Louis: C. V. Mosby Co.
Redfield, Robert. 1953. The Primitive World and Its Transformations. Ithaca, NY: Cor-
nell University Press.
Reichard, Gladys. 1950. Navaho Religion: A Study of Symbolism. New York: Stratford
Press.
Reid, Janice. 1983. Sorcerers and Healing Spirits: Continuity and Change in an Aborig-
inal Medical System. Canberra: Australian National University Press.
Reiter, Rayna Rapp, ed. 1975. Toward an Anthropology of Women. New York:
Monthly Review Press.
Resnick, Hank. 1990. Youth and Drugs: Society’s Mixed Messages. Rockville, MD:
Office of Substance Abuse Prevention (OSAP Prevention Monograph #6).
Bibliography 413
Rettig, Richard, Manuel Torres, and Gerald Garrett. 1977. Manny: A Criminal-
Addict’s Story. Atlanta: Houghton Mifflin Co. Review Press.
Reynolds, Vernon, and Ralph Tanner. 1995. The Social Ecology of Religion. New York:
Oxford University Press.
Ripinsky-Naxon, Michael. 1993. The Nature of Shamanism: Substance and Function
of a Religious Meta. Albany: State University of New York Press.
Rittenbaugh,Cheryl. 1991. “Body Size and Shape: A Dialogue of Culture and Bi-
ology.” Medical Anthropology 13: 173–80.
Rivers, W.H.R. 1924. Medicine, Magic, and Religion. London: Kegan, Paul, Trench,
Trubner and Co.
Robb, J. 1986. “Smoking as an Anticipatory Rite of Passage: Some Sociological
Hypotheses on Health Related Behavior.” Social Science and Medicine 23:
621–27.
Robins, Lee. 1980. “Alcoholism and Labelling Theory.” In Readings in Medical So-
ciology, ed. David Mechanic, 188–98. New York: Free Press.
Rodberg, Leonard S. 1994. “Anatomy of a National Health Program: Reconsider-
ing the Dellums Bill after 10 Years.” In Beyond Crisis: Confronting Health Care
in the United States, ed. Nancy F. McKenzie, 610–15. New York: Meridian.
Rogers, Spencer L. 1982. The Shaman: His Symbols and His Healing Power. Spring-
field, IL: Charles Thomas.
Romanucci-Ross, Lola. 1977. “The Hierarchy of Resort in Curative Practices: The
Admiralty Islands, Melanesia.” In Culture, Disease, and Healing: Studies in
Medical Anthropology, ed. David Landy, 481–87. New York: Macmillan.
Room, Robin. 1984. Alcohol and Ethnography: A Case of Problem Deflation. New York:
Plenum.
Roseman, Marina. 1991. Healing Sounds from the Malaysian Rainforest: Temiar Music
and Medicine. Berkeley: University of California Press.
Rosenthal, Marilynn M. 1992. “Modernization and Health Care in the People’s
Republic of China: The Period of Transition.” In Health Care Systems and
Their Patients: An International Perspective, ed. Marilynn M. Rosenthal and
Marcel Frenkel, 293–315. Boulder, CO: Westview Press.
Rothstein, Frances. 1982. Three Different Worlds: Women, Men and Children in an
Industrializing Community. Westport, CT: Greenwood Press.
Rubin, Gayle. 1975. “The Traffic in Women: Notes on a ‘Political Economy’ of Sex.”
In Toward an Anthropology of Women, ed. Rayna Rapp Reiter, 157–210. New
York: Monthly Review Press.
Rubin, Vera, and Lambros Comitas. 1983. “Cannabis, Society and Culture.” In
Drugs and Society: A Critical Reader, ed. Maureen Kelleher, Bruce Mac-
Murray, and Thomas Shapiro, 212–18. Dubuque, IA: Kendall/Hunt.
Sabatier, Renee. 1988. Blaming Others. Philadelphia: New Society Publishers.
Sahlins, Marshall. 1972. Stone Age Economics. Chicago: Aldine.
Samet, Jonathan, et al. 1988. “Mortality from Lung Cancer and Chronic Obstructive
Pulmonary Disease in New Mexico, 1958–1982.” American Journal of Public
Health 78(9): 1182–86.
Sangree, Walter. 1962. “The Social Functions of Beer Drinking in Bantu, Tiriki.” In
Society, Culture, and Drinking Patterns, ed. David Pittman and Charles Sny-
der, 6–21. Carbondale, IL: Southern Illinois University Press.
Sargent, Carolyn, and Thomas M. Johnson. 1996. Medical Anthropology and Contem-
porary Theory and Method. Rev. ed. Westport: Praeger.
414 Bibliography
Schuart, Donald. 1998. The Limits of Health Insurance. In Health and Canadian
Society: Sociological Perspectives, David Coburn, Carl D’Arcy, and George M.
Torrance, eds., 536–48. Toronto: University of Toronto Press.
Schwartz, Justin. 1991. A Future for Socialism in the USSR. In Communist Regimes—
The Aftermath: The Socialist Register 1991, ed. Ralph Miliband and Leo Pan-
itch, 67–94. London: Merlin.
Scotch, Norman. 1963. “Medical Anthropology.” In Biennial Review of Anthropology,
ed. Bernard J. Siegel, 30–68. Stanford, CA: Stanford University Press.
Scott, J. 1969. The White Poppy. New York: Harper and Row.
Seabrook, W. 1929. The Magic Island. New York: Harcourt Brace and Co.
Seaman, Gary, and Jane S. Day. 1994. Ancient Traditions: Shamanism in Central Asia
and the Americans. Niwot, CO: University Press of Colorado.
Segall, M. 1983. “On the Concept of a Socialist Health System: A Question of
Marxist Epidemiology.” International Journal of Health Services 13: 221–25.
Selik, Richard, Kenneth Castro, and Marguerite Pappaioanou. 1988. “Racial/Eth-
nic Differences in the Risk of AIDS in the United States.” American Journal
of Public Health 79: 1539–45.
Selvaggio, K. 1983. “WHO Bottles Up Alcohol Study.” Multinational Monitor
4(9): 9.
Sharon, Douglas. 1978. Wizard of the Four Winds: A Shaman’s Story. New York: Free
Press.
Sherwin, Susan. 1992. No Longer Patient: Feminist Ethics and Health Care. Philadel-
phia: Temple University Press.
——— 1997. “Gender, Race, and Class in the Delivery of Health Care.” In Bioethics:
An Introduction to the History, Methods, and Practice, ed. Nancy S. Jecker,
Albert R. Jonsen, and Robert A. Pearlman, 392–401. Boston: Jones and Bart-
lett Publishers.
Shannon, Thomas R. 1996. An Introduction to the World-System Perspective. 2nd ed.
Boulder, CO: Westview Press.
Sharff, Jagna. 1998. King Kong on 4th Street: Families and the Violence of Poverty on
the Lower East Side. Boulder, CO: Westview Press.
Shilts, Randy. 1987. And the Band Played On. New York: St. Martin’s Press.
Shostak, Marjorie. 1983. Nisa: The Life and Words of a !Kung Woman. New York:
Vintage.
Shrivastava, P. 1987. Bhopal: Anatomy of a Crisis. Cambridge, MA: Ballinger Pub-
lishing Company.
Sidel, Victor. 1978. “The Right to Health Care: An International Perspective.” In
Bioethics and Human Rights: A Reader for Health Professionals, ed. Elsie L.
Bandman and Betram Bandman, 341–50. Boston: Little, Brown, and
Company.
———. 1994. “Health Care for a Nation in Need.” In Beyond Crisis: Confronting
Health Care in the United States, ed. Nancy F. McKenzie, 559–73. New York:
Meridian.
Sidel, Victor W., and Ruth Sidel. 1982. The Health of China. Boston: Beacon Press.
Silber, Irwin. 1994. Socialism: What Went Wrong? An Inquiry into the Theoretical and
Historical Sources of the Socialist Crisis. London: Pluto Press.
Silverblatt, Irene. 1991. “Interpreting Women in States: New Feminist Ethnohis-
tories.” In Gender at the Crossroads of Knowledge: Feminist Anthropology in the
416 Bibliography
Singer, Merrill, Lani Davison, and Gina Geddes. 1988. “Culture, Critical Theory
and Reproductive Illness Behavior in Haiti.” Medical Anthropology Quarterly
2: 370–85.
Singer, Merrill, Else Huertas, and Glen Scott. 2000. “Am I My Brother’s Keeper:
A Case Study of the Responsibilities of Research.” Human Organization 59:
389–400.
Singer, Merrill, and Zhongke Jia. 1993. “AIDS and Puerto Rican Injection Drug
Users in the U.S.” In Handbook on Risks of AIDS: Injection Drug Users and
Their Sexual Partners, ed. Barry Brown and George Beschner, 227–55. West-
port, CT: Greenwood Press.
Singer, Merrill, and Elizabeth Toledo. 1994. “Chemical Dependency and Preg-
nancy: Building a Community Based Treatment and Research Consortium.”
Paper presented at a meeting of the Society for Applied Anthropology.
Cancun, Mexico.
———. 1995b. “Oppression Illness: Critical Theory and Intervention with Women
at Risk for AIDS.” Paper presented at the American Anthropological As-
sociation Meeting, Washington, DC.
Singer, Merrill, Hans A. Baer, and Ellen Lazarus, eds. 1990. “Critical Medical An-
thropology: Theory and Research.” Special issue of Social Science and Med-
icine 30(2).
Singer, Merrill, Glen Scott, Wilson Scott, Delia Easton, Margaret Weeks. 2001. “War
Stories: AIDS Prevention and the Street Narratives of Drug Users.” Quali-
tative Health Research 11(5): 589–602.
Singer, Merrill, et al. 1991. “Puerto Rican Community Mobilizing in Response to
the AIDS Crisis.” Human Organization 50: 73–81.
Singer, Merrill, et al. 2000. “The Social Geography of AIDS and Hepatitis Risk:
Qualitative Approaches in Sterile-Syringe Access Among Injection Drug
Users.” American Journal of Public Health 90(7): 1049–56.
Singer, Merrill, and Charlene Snipes. 1991. “Generations of Suffering: Experiences
of a Pregnancy and Substance Abuse Treatment Program.” Journal of Health
Care for the Poor & Underserved 3: 325–39.
Singer, Philip. 1977. “Introduction: From Anthropology and Medicine to ‘Therapy’
and Neo-Colonialism.” In Traditional Healing: New Science or New Colonial-
ism, ed. Philip Singer, 1–25. London: Conch Magazine Limited.
Siraisi, Nancy G. 1990. Medieval and Early Renaissance Medicine: An Introduction.
Chicago: University of Chicago Press.
Siskin, Edgar E. 1984. Washo Shamans and Peyotists: Religious Conflict in an American
Indian Tribe. Salt Lake City: University of Utah Press.
Smith, Barbara Ellen. 1981. “Black Lung: The Social Production of Disease.” Inter-
national Journal of Health Services 11: 343–59.
Smith, M.G. 1968. “Secondary Marriage Among Kadera and Kagoro.” In Marriage,
Family, and Residence, ed. Paul Bohannon and John Middleton, 109–30. Gar-
den City, NJ: Natural History Press.
Smith, R. 1978. “The Magazine’s Smoking Habit.” Columbia Journalism Review
(January/February): 29–31.
Sobel, R. 1978. They Satisfy: The Cigarette in American Life. Garden City, NY:
Doubleday.
418 Bibliography
Spencer, B. 1989. “On the Accuracy of Current Estimates of the Number of Intra-
venous Drug Users.” In AIDS: Sexual Behavior and Intravenous Drug Use, ed.
C. Turner, H. Miller, and L. Moses, 429–46. Washington, DC: National Re-
search Council.
Spicer, Paul. 1997. “Toward a (Dys)functional Anthropology of Drinking: Ambiv-
alence and the American Indian Experience with Alcohol.” Medical Anthro-
pology Quarterly 11: 306–23.
Spiro, Melford. 1967. Burmese Supernaturalism. Englewood Cliffs, NJ: Prentice-Hall.
Stanley, Laura. 1999. “Transforming AIDS: The Moral Management of Stigmatized
Identity.” Anthropology and Medicine 6: 103–20.
Stavenhagen, Rodolfo. 1971. “Decolonizing Applied Social Science.” Human Or-
ganization 30: 333–57.
Stebbins, Kenyon. 1987. “Tobacco or Health in the Third World? A Political-
Economic Analysis with Special Reference to Mexico.” International Journal
of Health Ser 17: 523–38.
———. 1990. “Transnational Tobacco Companies and Health in Underdeveloped
Countries: Recommendations for Avoiding a Smoking Epidemic.” Social
Science and Medicine 30: 227–35.
———. 1994. “Clearing the Air: Introducing Smoking Restrictions in West Virginia,
America’s Leading Consumer of Cigarettes Per Capita.” Paper presented
at the American Anthropological Association Annual Meeting, Atlanta,
GA, November.
———. 1997. “Clearing the Air: Challenges to Introducing Smoking Restrictions
in West Virginia.” Social Science and Medicine 44: 1395–1401.
———. 2001. “Going Like Gangbusters: Transnational Tobacco Companies ‘Mak-
ing a Killing’ in South America.” Medical Anthropology Quarterly 15: 147–70.
Stein, Howard. 1990. American Medicine as Culture. Boulder, CO: Westview Press.
Stein, Leonard I. 1967. “The Doctor-Nurse Game.” Archives of General Psychiatry
16: 699–703.
Sterk, Clare. 1999. Fast Lives: Women Who Use Crack Cocaine. Philadelphia: Temple
University Press.
Stevens, Rosemary. 1986. “The Changing Hospital.” In Applications of Social Science
to Clinical Medicine and Health Policy, ed. Linda H. Akin and David Me-
chanic, 80–99. New Brunswick, NJ: Rutgers University Press.
Stoler, Ann Laura. 1991. “Carnal Knowledge and Imperial Power: Gender, Race,
and Mortality in Colonial Asia.” In Gender at the Crossroads of Knowledge:
Feminist Anthropology in the Postmodern Era, ed. Micaela di Leonardo, 51–
102. Berkeley: University of California Press.
Streefland, Pieter. 1986. “The Netherlands.” Medical Anthropology Quarterly, o.s.,
17(4): 91.
Strohmaier, Gotthard. 1998. “Reception and Tradition: Medicine in the Byzantine
and Arab World.” ed. Mirko Grmek, 139–69. Cambridge: Harvard Univer-
sity Press.
Substance Abuse and Mental Health Services Administration. 1996. Preliminary
Estimates from the 1995 National Household Survey on Drug Abuse. Washing-
ton, DC: Office of Applied Studies.
Sumartojo, Esther. 2000. “Structural Factors in HIV Prevention: Concepts, Exam-
ples, and Implications for Research.” AIDS 14(Supplement): 3–10.
Bibliography 419
Sun, X., J. Nan, and Q. Guo. 1994. “AIDS and HIV Infection in China.” AIDS 8
(Supplement 2): 55–59.
Susser, E., E. Valencia, and S. Conover. 1993. “Prevalence of HIV Infection among
Psychiatric Patients in a Large Men’s Shelter.” American Journal of Public
Health 83: 568–70.
Susser, Ida. 1991. “The Separation of Mothers and Children. “In The Dual City, ed.
J. Mollenkopf and M. Castells, 207–25. Newbury Park, CA: Sage
Publications.
———. 1993 “Creating Family Forms: The Exclusion Men and Teenage Boys from
Families in the New York City Shelter System, 1987–91.” Critique in An-
thropology 13: 267–83.
———. 1996. “The Construction of Poverty and Homelessness in U.S. Cities.” In
Annual Reviews in Anthropology 25: 411–25.
———. 1998. “Inequality, Violence and Gender Relations in a Global City”. New
York. Identities 5: 219–47.
———. 1999. “Creating Family Forms: The Exclusion of Men and Teenage Boys
from Families in the New York City Shelter System, 1987–91.” In Theorizing
the City: The New Urban Antheropology Reader, ed. Setha Low, 67–83. New
Brunswick, NJ: Rutgers University Press.
———. 2002. “Losing Ground: Advancing Capitalism and the Relocation of Work-
ing Class Communities.” In Time and Space: Global Restructurings, Politics,
and Identity, ed. David Nugent, 274–90. Stanford, CA: Stanford University
Press.
Susser, Ida, and M. Alfredo González. 1992. “Sex, Drugs and Videotape: The Pre-
vention of AIDS in a New York City Shelter for Homeless Men.” In Rethink-
ing AIDS Prevention, ed. Ralph Bolton and Merrill Singer, 169–84.
Philadelphia: Gordon and Breach Science Publishers.
Susser, Ida, and Zena Stein. 2000. “Culture, Sexuality, and Women’s Agency in the
Prevention of HIV/AIDS in South Africa.” American Journal of Public Health
90(7): 1042–48.
Susser, Mervyn. 1993. “Health as a Human Right: An Epidemiologist’s Perspective
on Public Health.” American Journal of Public Health 83: 418–26.
Susser, Mervyn, William Watson, and Kim Hopper. 1985. Sociology in Medicine.
New York: Oxford.
Sutter, Alan. 1966. “The World of the Righteous Dope Fiend.” Issues in Criminology
2: 177–222.
———. 1969. “Worlds of Drug Use on the Street Scene.” In Delinquency, Crime and
Social Process, ed. Donald Cressey and David Ward, 802–29. New York:
Harper and Row.
Swartz, Donald. 1998. “The Limits of Health Insurance.” In Health and Canadian
Society: Sociological Perspectives, 3rd ed., ed. David Coburn et al., 536–48.
Toronto: University of Toronto Press.
Sweezy, Paul. 1973. “Cars and Cities.” Monthly Review 24(11): 1–18.
Taussig, Michael. 1987. Shamanism, Colonialism, and the Wild Man. Chicago: Uni-
versity of Chicago Press.
Taylor, Carl E. 1976. “The Place of Indigenous Medical Practitioners in the Mod-
ernization of Health Services.” In Asian Medical Systems: A Comparative
Study, ed. Charles Leslie, 285–99. Berkeley: University of California Press.
420 Bibliography
Taylor, William. 1979. Drinking, Homicide and Rebellion in Colonial Mexican Villages.
Stanford, CA: Stanford University Press.
Tennet, R. 1950. The American Cigarette Industry: A Study in Economic Analysis and
Public Policy. New Haven, CT: Yale University Press.
Terney, Robert M. 1999. “Challenge to Universal Access to Health Care with Lim-
ited Resources.” In The American Medical Ethics Revolution: How the AMA’s
Code of Ethics Has Transformed Physicians’ Relationship to Patients, Profession-
als, and Society, ed. John B. Baker et al., 252–59. Baltimore: Johns Hopkins
University Press.
Teunis, Niels. 2001. “Same-Sex Sexuality in Africa: A Case Study from Senegal.”
AIDS and Behavior 5: 173–82.
Thayer, Millie. 2000. “Traveling Feminisms: From Embodied Women to Gendered
Citizenship.” In Global Ethnography: Forces, Connections, and Imaginations in
a Postmodern World, ed. Michael Burawoy, 203–35. Berkeley: University of
California Press.
Thomas, Anthony E. 1975. “Health Care in Ukambani Kenya: A Socialist Critique.”
In Topias and Utopias, ed. Stanley Ingman and Anthony E. Thomas, 266–81.
The Hague: Mouton.
Thomas, Piri. 1967. Down These Mean Streets. New York: Knopf.
Topley, Marjorie. 1976. “Chinese Traditional Etiology and Methods of Cure in
Hong Kong.” In Asian Medical Systems: A Comparative Study, ed. Charles
Leslie, 243–65. Berkeley: University of California Press.
Townsend, Joan B. 1999. “Shamanism.” In Anthropology of Religion: A Handbook,
ed. Stephen D. Glazier, 429–69. Westport, CT: Praeger.
Trostle, James. 1986. “Early Work in Anthropology and Epidemiology: From Social
Medicine to the Germ Theory, 1840 to 1920.” In Anthropology and Epidemi-
ology: Interdiscplinary Approaches to the Study of Health and Disease, ed. Craig
R. Janes, Ron Stall, and Sandra M. Gifford, Dordrecht, Netherlands: D.
Reidel.
Trostle, Jim and Johannes Sommerfeld. 1996. Medical Anthropology and Epide-
miology. Annual Reviews in Anthropology 25: 253–74.
Trotter, Robert. 1985. “Mexican-American Experience with Alcohol: South Texas
Examples.” In The American Experience with Alcohol, ed. Linda Bennett and
Genevieve Ames, 279–96. New York: Plenum Press.
Trotter, Robert, Richard Needle, Eric Goosby, Christopher Bates, and Merrill
Singer. 2001. “A Methodological Model for Rapid Assessment, Response,
and Evaluation: The RARE Program in Public Health.” Field Methods 13(2):
137–59.
True, William. 1996. Epidemiology and Medical Anthropology. In Medical An-
thropology: Contemporary Theory and Method, 2nd ed., 325–46. Carol Sar-
gent and Thomas Johnson, eds. New York: Praeger.
Tsien, A. 1979. “The Smoking Habits of Three News Magazines.” Master’s Thesis,
School of Journalism, Southern Illinois University.
Turner, C., H. Miller, and L. Moses. 1989. AIDS: Sexual Behavior and Intravenous
Drug Use. Washington, DC: National Academy Press.
Turshen, Meredith. 1977. “The Political Ecology of Disease.” Review of Radical Po-
litical Economics 9: 45–60.
———. 1984. The Political Ecology of Disease in Tanzania. New Brunswick, NJ: Rut-
gers University Press.
Bibliography 421
———. 1989. The Politics of Public Health. New Brunswick, NJ: Rutgers University
Press.
United Nations Development Programme. 1999. Human Development Report 1999.
New York: Oxford University Press.
United Nations Programme on HIV/AIDS. 2000. UNAIDS Report on the Global
HIV/AIDS Epidemic. Geneva, Switzerland.
Unshuld, Paul U. 1985. Medicine in China: A History of Ideas. Berkeley: University
of California Press.
U.S. Conference of Mayors. 1987. Status Report on Homeless Families in America’s
Cities: A 29-City Survey. Washington, DC: U.S. Conference on Mayors.
Vaughn, Megan. 1991. Curing Their Ills: Colonial Power and African Illness. Stanford,
CA: Stanford University Press.
Velimirovic, Boris. 1990. “Is Integration of Traditional and Western Medicine Re-
ally Possible?” In Anthropology and Primary Health Care, ed. Jeannine Coreil
and J. Dennis Mull, 51–78. Boulder, CO: Westview Press.
Vitebsky, Piers. 1995a. The Shaman. Boston: Little, Brown and Company.
Vitebsky, Piers. 1995b. From Cosmology to Environmentalism: Shamanism as all
Knowledge in a Global Setting. In Counterworks: Managing the Diversity of
Knowledge. Richard Farah, ed., 182–204. London: Routledge.
Virchow, Rudolf. 1879. Gesammelte Ahandlungen aus dem Gebeit der Oeffentlichen
Medizin under Seuchenlehre. Vol. 1. Berlin: Hirschwald.
Vogt, Irmgard. 1984. “Defining Alcohol Problems as a Repressive Mechanism: Its
Formative Phase in Imperial Germany and Its Strength Today.” International
Journal of the Addictions 19: 551–69.
Wagner, D. 1993. Checkerboard Square. Boulder, CO: Westview Press.
Waitzkin, Howard. 1981. “The Social Origins of Illness: A Neglected History.”
International Journal of Health Services 11: 77–103.
———. 1983. The Second Sickness: Contradictions of Capitalist Health Care. New York:
Free Press.
———. 2000. “Choosing Patient-Physician Relationships in the Changing Health-
Policy Environment.” In Handbook of Medical Sociology, 5th ed., ed. Chloe E.
Bird, Peter Conrad, Allen Fremont, 271–83. Upper Saddle River, NJ:
Prentice-Hall.
———. 2001. At the Front Lines of Medicine: How the Health Care System Alienates
Doctors and Mistreats Patients and What We Can Do about It. Lanham, MD:
Rowman & Littlefield Publishers
Waitzkin, Howard, and Barbara Waterman. 1974. The Exploitation of Illness in Cap-
italist Society. Indianapolis: Bobbs-Merrill.
Waldorf, Dan. 1973. Careers in Dope. Englewood Cliffs, NJ: Prentice-Hall.
Wallace, R. 1990. “Urban Desertification, Public Health and Public Order: ‘Planned
Shrinkage,’ Violent Death, Substance Abuse and AIDS in the Bronx.” Social
Science and Medicine 31: 801–13.
Wallerstein, Immanuel. 1979. The Capitalist World-Economy: Essays. New York:
Cambridge University Press.
Walsh, Roger N. 1990. The Spirit of Shamanism. New York: G. P. Putnam’s Sons.
———. 1997. “The Psychological Health of Shamans: A Reevaluation.” Journal of
the American Academy of Religion 45: 101–20.
422 Bibliography
Walt, Gill. 1994. Health Policy: An Introduction to Process and Power. London: Zed
Books.
Warner, Kenneth. 1986. Selling Smoke: Cigarette Advertising and Public Health. Wash-
ington, DC: American Public Health Association.
Warren, C. W., et al. 2000. “Tobacco Use by Youth: A Surveillance Report from the
Global Youth Tobacco Survey Project.” International Journal of Public Health
78: 890–920.
Waterston, Alisse. 1993. Street Addicts in the Political Economy. Philadelphia: Temple
University Press.
———. 1999. Love, Sorrow, and Rage: Destitute Women in a Manhattan Residence.
Philadelphia: Temple University Press.
Weaver, Thomas. 1968. “Medical Anthropology: Trends in Research and Medical
Education.” In Essays in Medical Anthropology, ed. Thomas Weaver, 1–12.
Athens: University of Georgia Press.
Weibel, Wayne. 1990. “Identifying and Gaining Access to Hidden Populations.”
In The Collection and Interpretation of Data from Hidden Populations, ed. Eliz-
abeth Lambert, 4–11. Rockville, MD: National Institute on Drug Abuse
(NIDA Research Monograph #98).
Weidman, Hazel H. 1986. “Origins: Reflections on the History of the SMA and Its
Official Publication.” Medical Anthropology Quarterly, o.s., 17(5): 115–24.
Weil, Robert. 1994. “China at the Brink: Contradictions of ‘Market Socialism,’ Part
I.” Monthly Review 46(7): 10–35.
Weiner, Annette. 1988. The Trobrianders of Papua New Guinea. New York: Holt, Rine-
hart, and Winston.
Weinreb, L., R. Goldberg, E. Bassuk, and J. Perloff. 1998. “Determinants of Health
and Service Use Patterns in Homeless and Low-income Housed Children.”
Pediatrics 102(3 pt 1): 554–62.
Weis, W., and C. Burke. 1963. “Media Content and Tobacco Advertising: An Un-
healthy Addiction.” Columbia Journalism Review (Summer): 6–12.
Weissman, P. et al. 1999. “Maternal Smoking during Pregnancy and Psychopa-
thology in Offspring Followed to Adulthood.” Journal of the American Acad-
emy of Child and Adolescent Psychiatry 38: 7.
Weitz, Rose. 2001. The Sociology of Health, Illness, and Health Care: A Critical Ap-
proach. 2nd ed. Belmont, CA: Wadsworth.
Werbner, Richard, ed. Postcolonial Subjectivities in Africa. New York: Zed Books.
Wertz, Richard, and Dorothy Wertz. 1979. Lying-In: A History of Childbirth in Amer-
ica. New York: Schocken Books.
Westermeyer, Joseph. 1974. The Drunken Indian: Myths and Realities. Psychiatric
Annals 4(11): 29–36.
White, Robert. 2000. “Unraveling the Tuskegee Study of Untreated Syphilis.” Ar-
chives of Internal Medicine 160(5): 585–98.
Whiteford, Linda. 1996. “Political Economy, Gender and the Social Production of
Health and Illness.” In Gender and Health: An International Perspective, ed.
Carolyn Sargent and Caroline Brettel, 242–56. Upper Saddle River: Prentice-
Hall.
Whiteford, Linda, and M. Poland, eds. 1989. New Approaches to Human Reproduc-
tion: Social and Ethical Dimensions. Boulder, CO: Westview Press.
Widom, C., T. Ireland, and P. Glynn. 1995. “Alcohol Abuse in Abused and Ne-
Bibliography 423
Zierler, Sally, et al. 2000. “Economic Deprivation and AIDS Incidence in Massa-
chusetts.” American Journal of Public Health 90: 1064–73.
Zimmering, Paul, et al. 1951. “Heroin Addiction in Adolescent Boys.” Journal of
Nervous and Mental Diseases 114: 19–34.
Zinn, Howard. 1980. People’s History of the United States. New York: Harper and
Row.
Zola, Irving Kenneth. 1978. “Medicine as an Institution of Social Control.” In The
Cultural Crisis of Modern Medicine, ed. John Ehrenreich, 80–100. New York:
Monthly Review Press.
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