CAPITULO 1. MARCO REFERENCIAL
1.1 GENERALIDADES
1.1.3 Metodología de abordaje
Between my first conversation with Margaret Lock and my discussion with Manfred Porkert lay seven years of intensive
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research. With the help of many friends and colleagues I was able to gradually bring together the various pieces of a new conceptual framework for a holistic approach to health and healing. The need for such a new approach had been evident to me ever since the May Lectures, and after meeting Lock I began to see the outlines of the framework that would slowly emerge over the years. In its final formulation it would repre sent a systems view of health corresponding to the systems view of life, but, in the early days, in 1976, I was still very far from
such a formulation.
The philosophy of classical Chinese medicine seemed ex tremely attractive to me, since it was fully consistent with the world view I had explored in
The Tao of Phrsics.
The big ques tion, of course, was how much of the Chinese system could be adapted to our modern Western culture. I was very eager to discuss this with Lock, and several weeks after our first con versation I invited her again for tea, with the purpose of talkingspecifically about this problem. In the meantime, Margaret and I had got to know each other much better. She had been a guest lecturer at my seminar "Beyond the Mechanistic World View" at DC Berkeley. I had met her husband and her chil dren, and had spent many hours listening to delightful stories about their experience of Japanese culture.
Lock warned me right away about the pitfalls of com paring medical systems from different cultures. "Any medical
system," she insisted, "including modern Western medicine, is a product of its history and exists within a certain environ mental and cultural context. As this context keeps changing, the medical system will also change. It will be modified by new economic, political, and philosophical influences. Any health-care system, therefore, is unique at a certain time and within a certain context."
Given this situation, I wondered whether it was at all helpful to study medical systems from other cultures.
"I would strongly question the usefulness of any medical system as a model for another society," Lock replied; "and, in fact, we have witnessed Western medicine fall flat on its face again and again in developing countries."
" Maybe," I ventured, "the purpose of cross-cultural com parisons would be not so much to use other systems as models for our culture, but rather as mirrors, so that we can better
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recognize the advantages and shortcomings of our own ap proach."
"That can certainly be very helpful," Lock agreed. "And you know, you will find in particular that not all traditional cultures have approached health care in a holistic way."
I found this remark very intriguing. "Even if the ap proaches of these traditional cultures are not holistic," I ob served, "their fragmented, or reductionistic, approaches may be different from the one that dominates our current scientific medicine. And to see that difference might be very instructive."
Lock agreed, and to illustrate the point she told me a story of a traditional healing ceremony in Africa in which someone was afflicted by witchcraft. The healer assembled the entire village for a long political debate, during which the population split into several lineages which brought forth a se ries of accusations and grievances. During all that time, the sick person lay on the side of the road rather neglected. "The entire procedure was primarily a social event," Lock commented. "The patient was merely a symbol of conflict within the society; and the healing, in that case, was certainly not holistic."
This story led us to a long and fascinating discussion of shamanism, a field that Lock had studied in some detail but which was completely foreign to me. "A shaman," she told me, "is a man or woman who is able, at will, to enter into a non ordinary state of consciousness in order to make contact with the spirit world
on behalf of members of his or her commu
nity."
Lock insisted on the crucial importance of the last part of this definition, and she also emphasized the close link of the patient's social and cultural environment to shamanistic ideas about disease causation. Whereas the focus of Western scien tific medicine has been on the biological mechanisms and phys iological processes that produce evidence of illness, the princi pal concern of shamanism is the sociocultural context in which the illness occurs. The disease process is either ignored alto gether or is relegated to secondary significance. "When a West ern doctor is asked about the causes of illness," Lock explained,"he will talk about bacteria or physiological disorders; a sha man is likely to mention competition, jealousy and greed, witches and sorcerers, wrongdoing by a member of the patient's family, or some other way in which the patient or his kin failed to keep the moral order."
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This comment stayed in my mind for a long time and helped me greatly to realize, several years later, that the con ceptual problem at the center of our contemporary health care is the confusion between disease processes and disease origins. Instead of asking why an illness occurs and trying to modify the conditions that led to it, medical researchers focus their attention on the mechanisms through which the disease oper ates, so that they can then interfere with them. These mecha nisms, rather than the true origins, are often seen as the causes of disease in current medical thinking.
While Lock was speaking of shamanism, she often re ferred to the "medical models" of traditional cultures, as she had done before when we discussed classical Chinese medicine. I found this somewhat confusing, especially since I remembered that people at the May Lectures had often referred to "the medi
cal model" when they meant Western scientific medicine. I therefore asked Lock to clarify the terminology for me.
She suggested that I should use the term "biomedical model" when referring to the conceptual foundation of modern scien tific medicine, since it expresses the emphasis on biological mechanisms, which distinguishes the modern Western approach from medical models in other cultures and from models coexist ing with it in our own culture.
"Most societies show a pluralism of medical systems and beliefs," Lock explained. "Even today shamanism is still the most important medical system in most countries with large rural areas. Besides, shamanism is also very much alive in the major cities of the world, especially in those with large popula tions of recent migrants." She also told me that she preferred to speak of "cosmopolitan" rather than "Western" medicine be cause of the global extension of the biomedical system, and of "East Asian" rather than "classical Chinese" medicine for sim ilar reasons.
We had now reached the point where I could ask Lock the question I was most curious about: How can we use the lessons learned from a study of East Asian medicine to develop a sys tem of holistic health care in our culture?
"You are really asking two questions that need to be ex amined," she replied. "To what extent is the East Asian model holistic, and which of its aspects, if any, can be adapted to our cultural context? " Once more I was impressed by Lock's clear
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and systematic approach, and I asked her to comment on the first aspect of the problem-holism in East Asian medicine.
"It might be useful to distinguish two kinds of holism here," she observed. "In a more narrow sense, holism means to consider all aspects of the human organism as being intercon nected and interdependent. In a broader sense, it means to rec ognize, in addition, that the organism is in constant interplay with its natural and social environment.
"In the first, narrow sense, the East Asian medical system is certainly holistic," Lock continued. "Its practitioners believe that their treatments will not just remove the principal symp toms of the patient's illness but will affect the entire organism,
which they treat as a dynamic whole. In the broader sense, however, the Chinese system is holistic only in theory. The interdependence of organism and environment is acknowledged in the diagnosis of illness and is discussed extensively in the medical classics, but as far as therapy is concerned, it is usually neglected. You see, most contemporary practitioners have not read the classical texts; these are studied mainly by scholars who never practice medicine."
"So East Asian doctors would be holistic in the broader, environmental sense in their diagnosis but not in their thera pies? "
"That's right. When they make their diagnosis, they spend considerable time talking to the patients about their work situa tions, their families, and their emotional states, but when it comes to therapy they concentrate on dietary counseling, her bal medicine, and acupuncture. In other words, they restrict themselves to techniques that manipulate processes inside the body. I have observed this again and again in Japan."
"Was this also the attitude of Chinese doctors in the past?" "Yes, as far as we can tell. In practice the Chinese system was probably never holistic, as far as the psychological and so cial aspects of illness are concerned."
"What do you think was the reason?"
"Well, part of it was certainly the strong influence of Confucianism on all aspects of Chinese life. The Confucian sys tem, as you know, was mainly concerned with maintaining the
social order. Illness, in the Confucian view, could arise from inadequate adjustment to the rules and customs of society, but the only way for an individual to get well was to change, so
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that one would fit the given social order. My observations in Japan have shown me that this attitude is still deeply in grained in East Asian culture. It underlies modern medical therapy in both China and Japan."
It was clear to me that this would be a major difference between the East Asian medical system and the holistic ap proach we were now trying to develop in the West. Our frame work would certainly have to include psychologically oriented therapies and social activism as important aspects if it were to be truly holistic. Margaret and I, both being strongly mo tivated by our political experience of the sixties, agreed com pletely on this point.
Throughout my conversations with Margaret Lock I had the strong feeling that the philosophy underlying East Asian medicine is very much in agreement with the new paradigm that is now emerging from modern Western science. Moreover, it was evident to me that many of its characteristics should be important aspects of our new holistic medicine as well-for
example, the view of health as a process of dynamic balance, the attention given to the continual interplay between the hu man organism and its natural environment, and the importance of preventive medicine. But how would we begin to incorporate these aspects into our system of health care?
I realized that Lock's detailed study of medical practice in contemporary Japan would be extremely helpful to answer this question. She had told me that modern Japanese doctors use traditional East Asian medical concepts and practices to deal with diseases that are not too different from those in our society, and I was very eager to hear what her observations had taught her.
"Do modern Japanese doctors actually combine Eastern and Western approaches?" I asked.
"Not all of them do," Lock explained. "The Japanese adopted the Western medical system about a hundred years ago and most Japanese doctors today practice cosmopolitan medi cine. But, as in the West, there has been growing dissatisfaction with that system. You know, the kind of criticism you heard during your May Lectures-that has been expressed also in Japan. And in response the Japanese are now increasingly re valuating their own traditional practices. They believe that traditional East Asian medicine can fulfill many functions be-
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yond the capacities of the biomedical model. The doctors who are part of this movement do combine Eastern and Western techniques. They are known as
kanpo
doctors, by the way.Kanpo
literally means the 'Chinese method.' "I asked Lock what we in the West could learn from the Japanese model.
"I believe that one factor is especially important," Lock began after a moment of reflection. "In Japanese society, as all over East Asia, subjective knowledge is highly valued. In spite of their extensive training in the scientific approach to medi cine, Japanese doctors are able to accept subjective judgments both their own and their patients'-without feeling that this is a threat to their medical practice or their personal integrity."
"What kind of subjective judgments would these be?" "For example,
kanpo
doctors would not measure tempera tures but would note their patients' subjective feelings about having a fever; nor do they measure the duration of an acu puncture treatment-they simply determine it by asking the patient how it feels."The value of subjective knowledge is surely something we could learn from the East," Lock continued. "We have be come so obsessed with rational knowledge, objectivity, and quantification that we are very insecure in dealing with human values and human experience."
"And you feel that human experience is an important as pect of health?"
"Of course! It is the central aspect. Health itself is a sub jective experience. Intuition and subjective knowledge are also used by every good physician in the West, but this is not ac knowledged in the professional literature and is not taught in medical schools."
Lock maintained that several key aspects of East Asian medi cine could be incorporated into a Western holistic medical sys tem if we adopted a more balanced attitude toward rational and
intuitive knowledge, toward the science and the art of medicine. In addition to the aspects we had already discussed, she empha sized especially that the responsibility for health and healing would not rest so heavily with the medical profession in such a new approach. "In traditional East Asian medicine," she ex plained, "the doctor never took on complete responsibility; it was always shared with the family and with the government."
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