Going Global in Century XXI: Medical Anthropology and the New Primary Health Care

Article excerpt

I argue here that there is a need for medical anthropology to innovate conceptual and methodological tools to work effectively within complex social spaces created by the articulation of the global and the local in the liberal nonstate. The need for such innovation is suggested by a criticism of the local consequences of global neoliberal health reform and consideration of the potential practical health policies that emerge from such a criticism, especially the need for greater "community participation" in health. In this criticism I draw on the example of market-based health reform in postsocialist Mongolia. This example suggests that the applied medical anthropology of the future must be one that integrates across multiple levels of analysis, straddling the local and the global. It should cast a critical eye on local civil society, the local manifestations of global policy, and take an activist orientation to global health advocacy. Anthropologists must become master synthesizers, sensitive to local meanings, social processes, and structures. We should attend to the biological realities of sickness, be cognizant of the lines of power extending from global to local, and be able to wield this knowledge effectively within the emerging networks of global health governance.

Key words: globalization, primary health care, social capital, Mongolia

Small may be beautiful, but it may also be insignificant.

Comment attributed to a policy analyst of the Worldwatch Institute (Labonte 1997:92)

When we were at school we were taught the history of Marxism.... That it was a system based on economic principles. But it wasn 't, at least not here. You have seen the towns. In every one a theatre, a school, a clinic. This was not economics, it was idealism.... In this new world of the market there is no room for such idealism.... Now we have economics. If we have doctors it is only because we can pay for them. Not because they are right or necessary. This is what is difficult to accept... the end of idealism. It feels like a kind of barbarism.

A Mongolian's reflection on market reforms (Stewart 2000:151)

Century XXI: Medical Anthropology in the New World Order

Like many medical anthropologists, 1 have dedicated myself to applying a biosocial or biobehavioral approach to health. This perspective recognizes that effective intervention depends on understanding the constructed beliefs of individual peoples and the impact of these beliefs on the determinants of health and disease (Dunn and Janes 1986; Janes 1990). Yet such an approach has been complicated by the awareness that in each case there is a complex interplay between locally constructed beliefs and introduced Western science-based healing and public health strategies (Dressier 2001). This interplay has frequently made outcomes unpredictable. Partial acceptance by locals of Western medicine, superimposed on the remains of indigenous systems, has presented fresh problems as often as it has predicted the expected solutions. We often engage in community work among the poor, where acceptance of health care is further complicated by competing financial demands with higher priority-most often food, fuel, water, and shelter. In these local settings, our challenge has been to negotiate a path through a mine field of conflicting logics. We must balance the rationality imposed on our research models and intervention programs with the biophysical reality of human health and the local perspectives that individuals, families, and communities bring to understanding, coping with, seeking treatment for, and preventing health problems.

Anthropology has always been a discipline of small communities, the investigation of local worlds demarcated by geographic as well as social boundaries. Yet increasingly localities are positioned within grids of power, and it is in this era of political, economic, and cultural globalization that new social forms have emerged to wield this power (Appadurai 1996; Giddens 2000; Held et al. …