In closing this little series on health care, I thought I would discuss an issue I find personally compelling, and one I think contributes something interesting to discussions about the provision of health care to others. The issue is essentially the epistemology of disease – how do we define what makes an illness and what constitutes a cure? More importantly, what should our commitments be when bringing our own system of care (that is, the primarily scientific model of allopathic medicine) to cultures that do not incorporate its definitions of health? The issue also resonates, of course, within our own society, as “alternative” modalities such as chiropractic and acupuncture—founded on radically different conceptualizations of the human body—vie for insurance coverage alongside traditional “Western” medicine. Though it’s problematic to posit a “we” when discussing the exportation of allopathic medicine, hopefully Wesleyan students will indulge me in temporarily accepting the system of surgery and chemical treatment that constitutes the majority of the services dispensed under Medicare and Medicaid, as “our” medicine.
In cultures which conceptualize health as dependent on the material features of medical objects, such as color or consistency, allopathic pills, and syringes may not be perceived as relevant to the problem at hand. For example, one study of pregnant women in South India found that iron supplements (which happened to be black pills) provided by the local team of American doctors were seen as dangerous, because of the belief (drawn from ayurvedic conceptualizations of the body) that black-colored food and medicines “heated up” the body and interfered with fetal development. The project, initially designed to combat high rates of anemia among these mothers, was stymied in part because administrators could not secure iron pills in any other color.
A team of American and British psychiatrists dispatched to Puerto Rico met even more conceptually profound difficulties when attempting to treat what they saw as schizophrenia among patients who practiced (what these researchers referred to as) Spiritism. Spiritists considered hallucinations to be normal components of spirit possession, which was seen as part of the healing process for other conditions, for which the Western psychiatrists did not even have diagnostic categories. The definitions of mental health were simply incommensurable.
In our own country, chiropractic has faced a similar set of difficulties. Though patients consistently report satisfaction with the treatment, allopathic medicine cannot account for why, because nowhere in the allopathically defined human body do nerves operate in the way assumed by chiropractic. Chiropractic has found some coverage under Medicaid, but only under the sorts of appointment and fee schedules common for standard physical therapy, which works with an utterly different understanding of how to heal. Moreover, chiropractic epistemology of the body is only partially accepted; that is, spinal treatments are covered, but though chiropractic claims relevance for a wide variety of ailments, patients seeking treatment for other parts of the body, or for more broadly diffuse illnesses, will not receive coverage unless their practitioner covertly miscodes his or her Medicaid reimbursement forms.
The epistemology of the body is tied to a range of political, cultural, and scientific debates. I bring it up because my knee has been bugging me and I’m out of Naproxen. I mentioned in the last column that I bashed it up at Senior Cocktails—well, it turns out I have chondromalacia, allopathy-speak for the pain that results when cartilage between the patella and the femur gets chipped from a sharp impact. The back of the kneecap, now partially missing the cushioning cartilage, grinds against the end of the femur whenever my knee bends through a certain angle, and it hurts. Naproxen sodium, the active ingredient in Aleve, brings down the inflammation caused by this friction and lets my knee bend smoothly.
I don’t indulge in this detail to demonstrate that allopathic medicine clearly got it right in my case—the point is that my own understanding of the body is utterly saturated by the conceptualizations of orthopedics and biochemistry. And yet of all over-the-counter medications, anti-inflammatories such as ibuprofen and naproxen sodium are most easily confused with sugar pills in randomized trials. In other words, people who take ibuprofen for headaches are the most likely to be satisfied by a placebo. The Naproxen I got from the Health Center came in a clean white bottle with a tinfoil seal—I’m assuming it is what it says on the label. But I also want to assume that it is, because if I don’t, my knee might start hurting again.
Cultural relativism is an important concern for a variety of international endeavors. But I find it particularly fascinating in health care, where the objects of contention are the human body (and its environment), this thing which seems to exert its own reality so persuasively, And at stake in finding the right blend of relativism and epistemological imperialism is the experience of our bodily existence, whatever our standards may be.
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