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Since its inception, medical anthropology has had an applied orientation; much of the work done by medical anthropologists is concerned with understanding and responding to pressing health issues and problems around the world as they are influenced and shaped by human social organization, culture, and context. Despite its strong emphasis on addressing practical health issues, initiatives within the discipline have tended to be guided by one or another of several alternative theoretical per- spectives. While the boundaries between these frame- works for explaining health in a socio-cultural context have not been always sharply defined, and, although there have been disagreements about which are the leading the- oretical approaches at any point in time, most medical anthropologists are influenced in their work by the dom- inant theories within the field.

Several efforts have been made to describe and con- trast the most influential theories within medical anthro- pology. In his book Sickness and healing: An

anthropological perspective, Robert Hahn (1995) identi-

fied three dominant theoretical frameworks within med- ical anthropology, including environmental/evolutionary theories, cultural theories, and political/economic theo- ries. In his book, Medicine, rationality, and experience:

An anthropological perspective, Byron J. Good (1994)

identified four theoretical orientations found in medical anthropology: the empiricist paradigm, the cognitive par- adigm, the meaning-centered paradigm, and the critical paradigm. Finally, in Medical anthropology in ecological

perspective, Ann McElroy and Patricia Townsend (1996)

also discussed four approaches, namely medical ecologi- cal theories, interpretive theories, political economy or critical theories, and political ecological theories. Despite these varying ways of grouping and ordering conceptual

and explanatory models in medical anthropology, it is evident that there is general agreement that there are a small number of identifiable clusters of theory guiding the work that is done within the field. Prominent among these is the perspective that has been labeled either criti- cal medical anthropology (CMA) or, less frequently, political economic medical anthropology (PEMA) (Baer, Singer, & Susser, 2002; Morsy, 1996).

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During its formative phase, explanations within medical anthropology tended to be narrowly focused on the micro level and involved explaining health-related beliefs and behaviors at the local level in terms of specific ecological conditions, cultural configurations, or psychological fac- tors. From the perspective of CMA, these traditional approaches, while providing insight into the nature and function of folk medical models, tended to ignore the wider causes and determinants of human decision-making and action. From the critical vantage, explanations that are limited to accounting for health-related issues in terms of the influence of human personalities, culturally consti- tuted motivations and understandings, or even local eco- logical relationships are inadequate because this distorts and hides the structures of social relationship that unite (in some, often unequal fashion) and influence far-flung indi- viduals, communities, and even nations. A critical under- standing, by contrast, involves paying close attention to what Mullings (1987) has called the “vertical links” that connect the social group under study to the larger regional, national, and global human society and to the configura- tion of social relationships that contribute to the pattern- ing of human behavior, belief, attitude, and emotion. For the last 150 years, this broader, encompassing perspective has been known as political economy, although, as Morsy (1996) emphasizes, its deeper roots can be traced to the thinking of Abdul Rahman Muhammad Ibn Khaldun, a 14th century North African scholar.

Despite the frequency with which the term “political economy” is used in the social science literature, it is not certain that a clear understanding of the term exists. In part, this confusion may be rooted in the fact that the most common meanings attached to the term have changed over time. Eric Wolf, in his seminal political economic study entitled Europe and the People Without History,

examined the nature of this socio-linguistic change and its underlying causes. As Wolf (1992, pp. 7–8) emphasizes, the field of political economy predates and was parent to contemporary social sciences such as sociology, anthro- pology, economics, and political science. Until the mid- dle of the 19th century, political economy referred to study of “the wealth of nations,” which included the pro- duction and distribution of wealth within and between political bodies and the social classes that composed them. But events at mid-century led the global field of political economy to fragment, and research into the nature and varieties of human society split into separate (and unequal) specialties and disciplines (Wolf, 1992).

The key events in question, namely the rise to dom- inance of the capitalist mode of production and of a set of opposed social classes brought into existence by it, dis- rupted the unity not only of social inquiry but, ultimately, the pre-existent frameworks of cohesiveness and health configurations of all societies around the globe as well. By mid-century, the specter of revolution hung in the air in Europe and eventually found expression in the armed clashes of a looming class war. In the midst of mounting turmoil, the question of the nature of social solidarity and social order was raised as a burning issue of structurally determined scholarly interest, suggesting the usually unspoken social function of much academic inquiry. The field of sociology branched off from political economy with the expressed mission of delving into the structure of social relations and social institutions. The new disci- ple came to define the core challenge as understanding the character of the bonds and associated cohesion- generating beliefs and customs that tie individuals together to form families, small groups, institutions, and whole societies. Quickly the early sociologists came to view ties among individuals and the development of com- munity as the casual engine driving the functioning and unity of society. In this way, the issues of concern to polit- ical economy, including how ties among individuals are shaped by the relations among classes in the production of national and international wealth, were submerged.

While sociology focused its attention on the grand industrial societies brought into existence by the rise of capitalism, anthropology, its exotic sister discipline, devel- oped as the study of the small-scale, non-Western societies situated in the interstitial spaces between and within indus- trial centers. Under the methodological banner of direct observation in natural settings, anthropologists came to

concentrate their investigative lens on the subtle details and unique social and cultural configurations of individ- ual cultural cases, while, as noted, ignoring, for the most part, the sweeping processes and broader social relations that transcend micro populations historically tying them to each other and to developments within capitalist mode of production (e.g., the emergence of the national corporation and later the multinational corporation and subsequent rise of globalism). Wolf (1992) argues that all the contemporary social sciences, each of which now has developed its own approach to (and subdiscipline con- cerned with) health issues, owe their existence to a shared rebellion against political economy, which had been their parent discipline.

In the aftermath of this transition, and with the rise of a new set of conventional perspectives within the social sciences, those individuals who still attempted to promote a critical political economic orientation tended to be mar- ginalized within their respective disciplines. As Navarro (1986) argues, even the terms of political economic dis- course have been tainted. In mainstream scholarship, con- cepts and terms such as class struggle, capitalism, and imperialism are frequently treated as rhetorical and are dismissed by the dominant schools. Further, such terms often are written between quotation marks, presumably to alert the reader that they are under suspicion. Marxists who submit papers to social science journals commonly are instructed to rewrite their papers using “fewer value- laden terms” that are more attune to prevalent sociologi- cal thought.

Despite discrimination, an academic tradition of polit- ical economy of health survived and the literature associ- ated with this perspective began to grow during the 1970s, becoming considerable during the 1980s and 1990s. Adherents, individuals who embrace the notion that social inequality and inequality of power in society are primary determinants of health, health-related behavior, and health care, see the critical approach as offering a much needed corrective for the disciplinary fragmentation of social sci- ence that hides the relationship among economic systems, political power, and social ideologies (Wolf, 1992).

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Medical anthropology as a distinct, named subdiscipline of anthropology can be traced to the 1950s. Otto von

Mering (1970, p. 272), however, contends that the formal relationship between anthropology and medicine is much older and began when Rudolf Virchow, a renowned pathologist interested in social medicine, helped to estab- lish the first anthropological society in Berlin. Indeed, Virchow influenced Franz Boas, the father of American anthropology, while he was affiliated with the Berlin Ethnological Museum during 1883–1886 (Trostle, 1986, p. 45). Nevertheless, the keen political economic per- spective that Virchow fostered did not really have its impact on medical anthropology until the 1970s.

The initial effort to develop a distinct critical orien- tation within medical anthropology can be traced to the symposium “Topias and Utopias in Health” at the 1973 Ninth International Congress for Anthropological and Ethnological Sciences, which ultimately developed into a volume with the same title (Ingman & Thomas, 1975). Six years later, a consciously critical perspective within medical anthropology was launched by Soheir Morsy’s (1979) review essay entitled “The Missing Link in Medical Anthropology: The Political Economy of Health.” Morsy’s article, as well as exposure to the polit- ical economy of health literature, particularly the work of Vincente Navarro, a progressive physician with extensive training in the social sciences, prompted Hans Baer (1982) to write a short review of this corpus of literature and its relevance for medical anthropologists. Beginning in 1983, Baer and others began organizing scholarly ses- sions at anthropological meetings and editing and writing articles, special issues of journals, and books on critical medical anthropology (Baer, 1996; Baer, Singer, & Johnson, 1986; Crandon-Malamud, 1991; Farmer, 1999; Frankenberg, 1980, 1981; Morsy, 1993; Scheper-Hughes, 1990; Singer, 1986, 1989; Singer & Baer, 1995; Singer, Baer, & Lazarus, 1990). Central to this effort has been the “making social of disease” (Frankenberg, 1980, p. 199).

The emergence of CMA reflects both the turn toward political–economic approaches in anthropology in general and an effort to engage and extend the broader political economy of health tradition by marrying it to the micro- level understandings of on-the-ground behavior in local settings and socio-cultural insights of medical anthropol- ogy. As Morsy (1996) notes, the critical approach to health in medical anthropology is distinctive not simply because of its scope and concern with the macro level, but more importantly by its commitment to embedding culture in historically delineated political–economic contexts. The goal is not to dismiss the contributions of microanalyses

of illness and healing but rather to extend the realization of the relevance of culture to issues of power, control, resistance, and defiance associated with health, illness, and healing (Morsy, 1996).

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Health

Conventionally, within the dominant perspective of bio- medicine, health has tended to be thought of as the absence of disease. The World Health Organization (WHO), recognizing the shortcomings of this biomedical model of health, sees health as the possession of complete physical, mental, and social well-being (WHO, 1978). What are the barriers to achieving well-being of this sort? From the critical perspective, in the contemporary world, such barriers include social inequality, class, gender, racial, and other discrimination, poverty, structural vio- lence, social trauma, relative depravation, being forced to live or work in a toxic physical environment, and related factors. Consequently, within CMA health is defined as access to and control over the basic material and non- material resources that sustain and promote life at a high level of satisfaction. Health is not some absolute state of being but an elastic concept that must be evaluated in a larger socio-cultural context.

Disease

Even under the best of circumstances, human beings inevitably find themselves confronted with disease or ill- ness. As it is for biomedicine, a central question for med- ical anthropology must be: What is disease? It is clear why this question is important to biomedicine. Medical anthropologists, however, have tended to avoid the ques- tion altogether by defining “disease” (i.e., clinical mani- festations of ill health) as the domain of medicine and “illness” (i.e., the sufferer’s experience of those manifes- tations) as the appropriate arena of anthropological inves- tigation. From the perspective of CMA, however, defining disease as beyond the concern or expertise of anthropologists is a retreat from ground that is as much social as it is biological in nature. Disease varies from society to society in significant ways because of organic, climatic, or geographical conditions, but also because of

the ways productive activities, resources, and reproduc- tion are organized and carried out, and because of the living and working conditions that flow from the social distribution of resources. From the CMA perspective, discussion of specific health problems, apart from their social contexts, only serves to downplay social relation- ships underlying environmental, occupational, nutri- tional, residential, and experiential conditions. Disease is not just the straightforward result of a pathogen or physiological disturbance. Instead, a variety of social problems such as malnutrition, economic insecurity, occupational risks, industrial pollution, substandard housing, and political powerlessness contribute to sus- ceptibility to disease (Baer, Singer, & Johnson, 1986). In short, disease is as much social as it is biological. In this light, the tendency, be it in medicine or in medical anthro- pology, to treat disease as a given, as part of an immutable physical reality, contributes to the tendency to neglect its social origins. CMA strives, in McNeil’s (1976) terms, to understand the nature of the relationship between microparasitism (the “tiny organisms,” malfunctions, and individual behaviors that are the proximate causes of much sickness) and macroparasitism (the social relations of exploitation that are the ultimate causes of much dis- ease). For example, an insulin reaction in a diabetic postal worker might be seen in a very reductionist mode as an excessive dose of insulin that causes an outpouring of adrenaline, a failure of the pancreas to respond with appropriate glucagon secretion, etc. However, a critical perspective would tend to lead a researcher to investigate whether the postal work skipped breakfast because of being late for work, the psychobiological effects of the derisive demands of a supervisor, or the inability to break for a snack because of pressure from above to increase productivity, or, more broadly, the health consequences of the structure of class forces in U.S. society that ensures capitalist domination of production and the moment to moment working lives of working people like postal employees (Woolhandler & Himmelstein, 1989).

Syndemics

As part of its effort to identify and understand health within the intersecting frameworks of political economy and bio-social causality, the CMA approach to the study of disease is characterized by the investigation of a set of factors including biology, epidemiology, sufferer and community understandings of the disease(s) of concern,

and the social, political, and economic conditions that may have contributed to the development of ill health. To help frame this “big picture” approach to the conception of diseases, critical medical anthropologists introduced the concept of “syndemic” in the mid-1990s (Singer, 1994, 1996). While biomedical understanding and prac- tice, traditionally, have been characterized by the ten- dency to isolate, study, and treat diseases as if they were distinct entities that existed separate from other diseases and independent of the social contexts in which they are found, CMA, by contrast, focuses on trying to understand social and biological interconnections as they are shaped and influenced by inequalities within society. 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), interacting synergistically with each other inside human bodies and contributing, as a result of their interaction, to excess burden of disease in a population. As Millstein (2001), the organizer of the Syndemics Prevention Network at the CDC, notes, syndemics occur when health-related problems cluster by person, place, or time. Importantly, the term syndemic refers not only to the temporal or locational co-occurrence of two or more diseases or health problems, but also to the health conse- quences of the biological interactions among co-present diseases. For example, researchers have found that co- infection with HIV and Mycobacterium tuberculosis (MTb) augments the immunopathology of HIV and accelerates the damaging progression of HIV disease (Ho, 1996). At the same time, studies have shown that because HIV damages human immune systems, individ- uals with HIV disease who are exposed to TB are more likely to develop active and rapidly progressing tubercu- losis compared with those who are HIV negative. The important feature of syndemics is not just co-infection but enhanced infection due to multiple disease interactions. Importantly, beyond the notion of disease clustering in a social location or population and the biological processes of disease interaction, the term syndemic also points to the determinant importance of social conditions in dis- ease interactions and consequences. For example, as Paul Farmer (1999, p. 13) argues, if we look at the persistence of TB in poor countries and its resurgence among the poor in industrialized countries, we find that it is impos- sible to understand its marked patterned occurrence— in the United States, for example, disproportionately

striking those in homeless shelters and in prisons— without assessing how social forces, such as political violence and racism, come to be embodied and expressed as individual pathology (Farmer, 1999). Living in poverty increases the likelihood of exposure to the bacteria that causes TB because of overcrowding in poorly ventilated dwellings. Research in homeless shelters has shown that they are a focal point of TB transmission among the poor. Once infected, the poor are more likely to develop active TB, both because they are more likely to have multiple exposures to the TB bacteria (which 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. Also, poverty and dis- crimination place the poor at a disadvantage in terms of access to diagnosis and treatment for TB, effectiveness of available treatments because of weakened immune sys- tems, and ability to adhere to TB treatment plans because of structurally imposed residential instability and the fre- quency of disruptive economic and social crises in poor families. As the case of TB suggests, diseases do not exist in a social vacuum nor solely within the bodies of those they inflict, and thus their transmission and impact is