Sociology of Health & Illness Vol. 29 No. 4 2007 ISSN 0141–9889, pp.

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Globalisation and medicine in Trinidad

David L. Reznik1, John W. Murphy2 and Linda Liska
Belgrave2
1
Department of Sociology, University of Florida
2
Department of Sociology, University of Miami

Abstract In a qualitative study of urban Trinidadians who work in the medical

industry, the concept of medical globalisation was provisionally analysed.
Two research questions were addressed: what is globalisation, in the context
of mainstream medicine, and how is this process manifested in everyday
practices? Four fundamental principles of medical globalisation emerged
from in-depth interviews and analysis of observational materials: (1) the notion
of history as an autonomous force with globalisation as the latest stage,
(2) the expansion of ‘Total Market’ philosophy as a driving social force,
(3) the fragmentation of society into atomistic, self-interested, and competitive
individuals, and (4) the adoption of a ‘centralised’ set of ideals as the normative
core necessary for social order. In this paper, findings from this investigation
and their implications are discussed. In particular, medical globalisation is
linked with major themes in medical sociological theory including dualism
and medicalisation.

Keywords: development, globalisation, medicine, Trinidad

Introduction

Studying concrete changes in medicine offers a useful perspective for understanding the
otherwise abstract process of globalisation. In this study, the philosophical tenets and
empirical realities of ‘medical globalisation’ were analysed in one of the more prominent
geopolitical spaces in Third World development: urban Trinidad. In the Western hemisphere,
Port of Spain and its surrounding areas represent a model of economic, political, and social
progress that other ‘developing’ countries have been advised to follow. Urban Trinidad, there-
fore, provides an appropriate point of focus for studying globalisation, and to understand
what might be witnessed in the future of medicine across the ‘developing’ world.
Two research questions were addressed: what is globalisation, in the context of mainstream
medicine, and how is this process manifested in everyday practices? Four fundamental
principles of medical globalisation emerged through qualitative research with urban
Trinidadians who work in the medical industry: (1) a notion of history as autonomous,
(2) the expansion of ‘Total Market’ ideology, (3) an atomistic view of the individual, and
(4) ‘centered’ social imagery. In this paper, findings from this investigation are presented
and their implications are discussed.
© 2007 The Authors. Journal compilation © 2007 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd.
Published by Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
 Globalisation and medicine in Trinidad 537

Literature review

A review of the literature on globalisation and medicine reveals that the concept of medical
globalisation as such has not been clearly or comprehensively defined. Most studies have
conceptualised the relationship between globalisation and medicine in roughly two ways:
analysis of macro trends in global health/healthcare and anthropological fieldwork studying
the micro practices of alternative, or non-mainstream, medical cultures. Therefore, the
‘experiential link’ of praxis, between the abstract process of globalisation and the everyday
practices of those involved in mainstream medicine, has not been sufficiently addressed.
This study attempts to understand this experiential link by investigating ‘meanings
as social products, as creations that are formed in and through the defining activities of
people as they interact’ (Blumer 1969: 5). By presenting the way the basic principles of
globalisation and the concrete social realities of Trinidadian mainstream medicine
mutually reinforce one another, this study represents a significant contribution to the
literature by linking the micro and macro levels in a new conceptual framework called
medical globalisation.
The literature review will be split into two sub-sections according to the ways in which
medical globalisation has been heretofore conceptualised: macro and micro analyses. A
critical review, presented in the final sub-section, will reveal the limitations of both these
elements. Ultimately, this study is shown to supply an alternative, praxis-oriented appraisal
of medical globalisation that has not been undertaken thus far.

Macro analyses
Much work has been done analysing historical trends in health within the context of
globalisation. Watts (2003) describes the ‘globalisation of disease’ as a process dating back
to 1450. Lee (2003) focuses specifically on the ‘evolution’ of more contemporary globalised
public health crises, including HIV/AIDS, cholera, and malnutrition. Even governments
have issued research reports that analyse the development of new ‘global health threats’
(U.S. Government 1997).
While some characterise the recent reduction of contagious diseases in so-called First
World countries as an ‘epidemiological transition’ (Mittman, Murphy and Sellers 2004),
others describe a more fundamental shift in disease patterns that involves an overall rise in
cardiovascular diseases, cancers, diabetes, as well as other chronic conditions and violent
traumas in developing countries worldwide (Waters 2001). And several other works expose
the impact of globalisation on the worldwide environment, and consequently global health
(Beck 1992, Brundtland 2000, Gersh 2000, Scarlott 2000, Turner 2001, Martens 2002).
Research has also focused on broad developments in the social institution of medicine
due to globalisation. McKinlay and Marceau (2002) posit that the consequences of globali-
sation and the information revolution have been a major ‘extrinsic factor’ in ending ‘the
golden age of doctoring’. In this respect, Van der Geest et al. (1996) discuss the changing
distribution and use of pharmaceuticals in newly ‘globalised’ social settings. Still others
examine the effects of globalisation on medical education (Eckhert 2002) and professional
associations (Lewers 2000).
Finally, several projects have revealed large-scale shifts in healthcare delivery caused by
globalisation. Several studies outline the neoliberal policy reforms that have led to a global
convergence between private and public models of healthcare (Turner 1987, Altenstetter
and Björkman 1997, Carpenter 2000). A joint US-Mexico conference on health systems
in an era of globalisation outlines initiatives to increase international co-operation
© 2007 The Authors
Journal compilation © 2007 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd
538 David L. Reznik, John W. Murphy and Linda Liska Belgrave

(Freeman et al. 1995). And Sen (2003) offers a critique of the increasing privatisation of
social services by presenting case studies of worsening health inequalities in the Third World.
The studies mentioned above are considered macro analyses because they make broad,
sweeping statements about global trends in health, medicine, and healthcare. This type of
research uses aggregated economic and epidemiological data from massive international
institutions like the World Health Organization (WHO). Therefore, they present theories
about globalisation and medicine that are abstracted from lived realities.
Research and theories based only on discussions of historical trends and large-scale
quantitative data, however, may not be relevant to people’s everyday lives, which are firmly
situated in a local social context. In fact, such assessments can actually distort social reality
to the point where they become meaningless in the ‘real world’. In this regard, Blumer (1969)
writes that research needs to return to ‘the empirical social world’ of everyday experience.
Macro analyses, such as those just mentioned, do not offer an in-depth understanding
of this empirical social world, because they fail to capture the interplay between the local
social context of people’s everyday lives and macro processes. Thus, these studies fail to
establish the experiential link of medical globalisation.

Micro analyses
Through fieldwork, medical anthropologists have attempted to ‘excavate the quite unexpected
niches where many profound effects of [globalisation] can be accessed’ (Seremetakis 2001:
68). Thus, these researchers advocate studying the impact of globalisation by examining the
shifting local medical practices of indigenous cultures. Central to this type of research has
been the identification of research participants who use or practice alternative healing, or
are considered ‘outside the mainstream’ of medical culture.
Several projects embody this vision for research. Ayora-Diaz (1998) uses interviews with
patients and practitioners of local medicines in the highlands of Chiapas, Mexico, to illustrate
the ongoing struggle against the globalised ‘rationality of cosmopolitan medicine’. Likewise,
Nigenda et al. (2001) describe the flourishing ‘non-biomedical health care practices’ in a
rural state of Mexico. Napolitano and Flores (2003) offer the perspective of practitioners
of ‘complementary and alternative medicine’ in urban Mexico. Using ethnography, Janes
(2002) describes the shifting traditions in Tibetan medicine. And Jagtenberg and Evans
(2003) analyse the threat of globalisation to local ecologies through a case study of the
Mapuche people’s use of herbal medicine in southern Chile.
Although these researchers engage in the empirical work missing in macro analyses, their
studies still suffer from limitations. In particular, a ‘pre-occupation with boundaries’
(Clifford 2003) haunts their research. Accordingly, medical anthropologists tend to ignore
mainstream medicine, and instead focus solely on ‘fringe’ cultures that practice alternative
medicine on the outskirts of mainstream society. These researchers view ‘cosmopolitan’ or
Western medicine, which has become mainstream in most cultures around the world, to be
inherently aligned with the macro process of globalisation. Therefore, those involved in
mainstream medicine are thought to be unable to reflect critically on globalisation. Instead,
fieldwork is done only with ‘marginalised’ cultures, or indigenous peoples, perceived to
be resisting globalisation through micro practices because they have not adopted certain
official standards of development and technology use.
A focus on micro practices, however, does not capture fully the mutual reinforcing praxis
between the abstract process of globalisation and everyday medical practice. Instead,
‘mainstream’, or government-sanctioned, medicine, is perhaps a more effective area of
analysis, since most people receive this sort of healthcare. In short, mainstream medicine
should be studied precisely because it is thought to be so closely aligned with the macro
© 2007 The Authors
Journal compilation © 2007 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd
 Globalisation and medicine in Trinidad 539

processes of globalisation. Therefore, identifying the experiential link between mainstream

medicine and globalisation, specifically the everyday experiences of those involved in this
system of provision, is important for conceptualising medical globalisation.

Critical review
While valuable in their own right, both types of research – macro and micro analyses – are
limited in capturing a satisfying understanding of medical globalisation. The first category
of research fails to link broad historical trends in health, medicine, and healthcare to
people’s concrete experiences. These researchers’ theoretical discussions, therefore, remain
abstract and removed from the everyday practice of medicine. The second style of research,
while focusing on lived realities, overlooks a key population for understanding how medical
globalisation is itself constituted. By focusing solely on what they perceive as ‘boundary’
cultures and local micro practices, medical anthropologists fail to examine the mutual
reinforcement of mainstream medical practices and the abstract process of globalisation.
In this study, an attempt was made to address these limitations. First, the concrete
experiences of people across a variety of local social contexts in urban Trinidad were
ascertained through qualitative in-depth interviews. Macro historical trends were therefore
linked to everyday experience. And second, the focus of this study was the mutual reinforc-
ing link between the experiences of those Trinidadians involved in what the government
considers to be ‘mainstream medicine’, or those practising or working in/with the officially
sanctioned field of medicine, and globalisation.
As Rubin and Rubin (1995) write, those who reside metaphorically within a ‘cultural/
topical arena’ can provide the most important experiential understanding of that arena. In
this case, mainstream medicine becomes an arena full of complex and shifting meanings,
experiences, institutions, and practices. This situation, therefore, must not be ignored, but
investigated, in as straightforward a manner as possible, if the praxis of medical globalisation
is to be accurately understood.

Trinidad, globalisation and medicine

To contextualise this study’s analysis of medical globalisation appropriately, the economic,

historical, political, and social specificities of Trinidad should be discussed. This context is
particularly important since postcolonial Trinidad is thought to represent a model of
progress that other developing countries should follow. Trinidad thus provides an appropriate
point of focus for studying the concept of medical globalisation, and for understanding
what might be witnessed in the future across the ‘developing’ world.
Since Independence in 1962, the process of globalisation in Trinidad has been conceived
popularly as the developmental path to modernity (Allen 1998: 79). Nowadays Trinidadi-
ans believe they live in a ‘schizoid landscape’ (Riddell 2003: 598) with stark distinctions
between old and new, change and continuity. The ‘belief in the empowerment of humanity
through technological knowledge’ has established itself as a dominant ideology (Maingot
1998: 4). Ultimately, Trinidadians, now more than ever, orient themselves to globalisation
(as ‘modernisation’) with the idea that ‘there is no alternative’ (Riddell 2003: 610).
Like so many other developing countries, an IMF/World Bank sponsored divestment
programme during the 1980s fundamentally ‘changed the rules guiding macroeconomic
behavior’ in Trinidad (Maingot 1998: 6). This resulted in a shift from ‘Keynesianism to
neo-liberalism, from a welfare government to a pay-as-you-go entity, from public to more
private provision of services, and from an internal, state-led development to a laissez-faire
© 2007 The Authors
Journal compilation © 2007 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd
540 David L. Reznik, John W. Murphy and Linda Liska Belgrave

system’ (Riddell 2003: 596). Through increased participation in the global marketplace,
Trinidadian society has rapidly become a more consumer-oriented culture (Maingot 1998:
24). Therefore, the state’s responsibility has become ‘the efficient and effective operation of
the market mechanism’ (Riddell 2003: 603).
The implications for medicine in Trinidad of these globalising trends are important to
note. Changing international immigration laws have allowed First World countries to drain
Trinidad of its highest trained doctors and nurses (Riddell 1998: 608–9). This change has
decreased the government’s ability to control public acute and emergency care costs (Aarons
1999). At the same time, official government recognition of ‘scientific’, or Western, medicine
has undermined traditional practices. This move has led to the importation of expensive
Western biomedical technology and medications as well as the creation of an overarching
regulatory and disciplinary body to monitor the practice of local medicine (Aarons 1999).
Likewise, a state-sponsored initiative has been undertaken to provide basic public healthcare
for the poor, while expanding the private sector of healthcare services for elites (Sen 2003).
Inevitably, a gaping inequality in Trinidadian healthcare has arisen, with ever-shrinking
medical resources allocated for the overwhelming majority of the population. As a result,
the average duration of interaction between a doctor and patient in Trinidad’s public health
facilities has been reduced to three minutes, a particularly discouraging figure when compared
with the average waiting time of more than two and a half hours (Singh et al. 1999: 36).
At a more cultural level, Western ‘hegemonic ideals of the body’ have catalysed
bodily practices and medical procedures to reduce signs of ‘blackness’ (Allen 1998: 81).
The body itself has become part of consumer culture with the domain of healthcare mov-
ing increasingly from medical facilities to the shopping mall and private sports centres
(Allen 1998: 75).
Thus the literature indicates that the macro process of globalisation has had a significant
impact on Trinidadian society, particularly healthcare and medicine. However, analysis of
how everyday mainstream medical practice mutually reinforces globalisation has largely
been ignored. This study will attempt to provide such insight.

Methods

The purpose of this study was to explore the meaning urban Trinidadians working with
mainstream medicine gave to globalisation, including any effects globalisation might have
had on the way medicine is practised, physicians’ relation with patients, and so forth.
Accordingly, a qualitative, inductive research methodology was used to analyse the
experiences of study participants. In-depth interviews elicited data to help understand the
varied meanings participants have given to medical globalisation.
A 13-day research trip to Trinidad, funded by a summer research grant from the Center of
Latin American Studies at the University of Miami, was undertaken in July of 2004. Twelve
in-depth interviews with various individuals involved in the field of mainstream medicine
were conducted along Trinidad’s urban East-West Corridor in and around Port of Spain.
Through the help of a sponsor, an initial set of study participants was selected based on
Rubin and Rubin’s (1995: 66) recommended criteria for study participation: knowledge of
the research subject, willingness to talk, and diversity in perspectives. To supplement these
initial perspectives, a form of network sampling helped secure additional interviews during
the course of the fieldwork.
In the end, the study sample included the following participants, all working in medically-
related capacities: three private pediatricians; three NGO personnel; two academics; a
© 2007 The Authors
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 Globalisation and medicine in Trinidad 541

government health official; a public hospital nurse; a midwife; and a journalist. All
interviews were audio-taped and transcribed. Each interview lasted approximately one
hour. Several participants provided observational materials for data analysis, including
newspaper articles, pamphlets, and other printed materials.
Data analysis was informed by Glaser and Strauss’ (1967) framework for ‘grounded
theory’ research. In this manner, the transcribed interview data and observational materials
were read and analysed repeatedly to discover key concepts, or categories. A simultaneous
reading of the literature on globalisation theory revealed four fundamental tenets that
resonated with groupings of interrelated categories. Ultimately, these category groupings
emerged as preliminary themes of medical globalisation.
For the purposes of maintaining confidentiality, quotes are presented in the section below
without the use of any pseudonyms, numbers, or descriptive characteristics. All participants
contributed equally to the findings in this section; no particular set of participants dominate
the quotes referenced below.

Results

Four preliminary themes emerged from participants’ descriptions and experiences with
medical globalisation: (1) the notion of history as an autonomous force with globalisation
as the latest stage, (2) the expansion of ‘Total Market’ philosophy as a driving social force,
(3) the fragmentation of society into atomistic, self-interested, and competitive individuals,
and (4) the adoption of a centralised set of ideals as the normative core necessary for
social order.

Autonomous history
All of the participants at one point or another made reference to globalisation as a process
that was divorced from human agency. According to these participants’ responses, history
is an autonomous path, rather than a product of human social interaction. Specifically,
globalisation is thought to be an objective stage of development that is outside the bounds
of human control.
When asked to define globalisation, one participant summarised it in the following way:

What comes to mind to me is development as a country from one state to the other to
the next. I would say in my mind when I hear globalisation I strictly think of Third
World to First World . . . It is achieved by adapting to what it is out there, adapting to
other cultures . . . I just see it is moving from Third World to First World and the outside
world having more influence on what we do as a country.

Globalisation was thus understood as a historical opportunity for countries like Trinidad
to advance along a linear path of progress. Adaptation to other cultures is to be considered
beneficial, particularly if this adjustment is to the ‘First World’, which is perceived to be
furthest along this path of advancement.
According to some participants, this abstract, uni-linear developmental track consists of
stages, and globalisation represents the latest. Understanding development in this manner,
they often chided Trinidad for its lack of progress through these various stages: ‘In our
growing-up, we seem to have missed out somewhere in the middle, we’ve tried to reach
there without going through the other stage’. Thus, participants repeatedly described
Trinidadian society as ‘lagging behind’ the more ‘developed’ world.
© 2007 The Authors
Journal compilation © 2007 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd
542 David L. Reznik, John W. Murphy and Linda Liska Belgrave

Although participants described the future of Trinidad’s medical landscape in different

ways, they made a common underlying assumption: eventually, medicine is necessarily
going to ‘advance’ along the aforementioned linear path. They often indicated a sense of
helplessness with respect to the ‘inevitability’ of history. In effect, they described globalisation
as an autonomous force that is completely immune to the best efforts of the public:

I’m not sure that we can do anything about [globalisation] . . . I don’t think realistically
that this is something I would be over-concerned about, because we can’t stop it. You
know, we can’t stop it.

A sense of alienation pervaded these conceptions of time and history. Participants per-
ceived globalisation as an historical mandate with a teleological end that served its own
purposes regardless of human desires. Believed to be a necessary part of historical devel-
opment, they described globalisation as an uncontrollable social force:

You can do anything you want, nobody can stop [globalisation] . . . It’s something that
you can’t stop, no matter where you are in the world . . . It’s not going to stop. You have
to live with it. Your research will see that you will have to live with it.

Participants conceived themselves as being pushed along an autonomous path of

progress, and only in abiding by the logic of globalisation could they hope to continue
‘moving forward’.
Ultimately, participants and observational materials revealed a feeling of uncertainty and
powerlessness about the future. A newspaper editorial, resounding with desperation in the
wake of the worsening state of healthcare in Trinidad, asked, ‘Can someone tell me where
our health service is going?’ As such, globalisation was understood to dance to the beat of
its own drum, leaving participants with the feeling that ‘we don’t know what will eventually
come’.

The ‘Total Market’

The most common way study participants saw the inexorable process of medical globalisation
manifest itself in their daily lives and practices was through what Hinkelammert (2002)
calls the ‘Total Market’ philosophy, a neo-liberal economic theory that attempts to transform
all social reality into a commodified market exchange.
As one participant put it, ‘globalisation basically means expanding markets’. Accordingly,
social order becomes increasingly conceived as an economic competition whereby all social
interaction is based on laws of supply and demand. The ideology of free markets is given
greater importance than any alternative human desires or needs.
Many participants noted that with globalisation, a new consumer mentality had taken
hold that was strongly influenced by a ‘market morality’. One participant used an anecdote
to describe this overall change in Trinidadian society:

. . . [parents] will tell you they can’t afford to get . . . medicine . . . but the kid is dressed
in the latest sort of Air Jordans and the whole Nike gear and everything else, which
obviously money has to be spent to buy that, because that is the priority rather than
ensuring that they get good quality food . . .

Consumption patterns are thus increasingly dominating Trinidadian social life, with citizens
striving to copy the materialism characteristic of North America and Europe.
© 2007 The Authors
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 Globalisation and medicine in Trinidad 543

Image 1 Page from a Year 1 primary school textbook

Because of this preoccupation with consumerism, corporate marketing geared towards

increased consumption and materialism has become ubiquitous. Many participants
discussed the adverse effects of increasingly pervasive advertising on Trinidadian society.
One participant provided a photocopied page from a Year 1 primary school textbook
(Image 1) to demonstrate the proliferation of marketing messages to the youngest segment
of society.
According to the study participants, the effects of this expanding market mentality
have reached Trinidadian mainstream medicine. Many described the problem of profits
increasingly taking precedence over public health needs. As one participant noted:

[Globalisation manifests itself ] in a medicalising or professionalising of tasks and roles

that were performed by ordinary people. It has been manifest in promotion of ideas, of
commercial products having a higher value than natural processes that people use . . .

Thus, medicine has become increasingly a private practice, with less concern for the public
and the medical needs and wishes of these persons. As one participant put it, referring to
the growth of direct-to-consumer pharmaceutical advertising in Trinidad, ‘you can basically
market anything and there are no controls for health or any matter’.
A ‘Total Market’ philosophy and its manifestation in medicine are perhaps most
clearly illustrated in the current restructuring of the Trinidadian healthcare system. As one
© 2007 The Authors
Journal compilation © 2007 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd
544 David L. Reznik, John W. Murphy and Linda Liska Belgrave

participant explained, ‘the private healthcare market is increasing, certainly by the number
of private healthcare institutions that are being developed’. Hence medical practice is
becoming increasingly a for-profit industry, with the patient transformed into a consumer
of the physician’s products and services.

Atomistic Individualism
Commensurate with the advance of ‘Total Market’ philosophy in Trinidadian society, many
participants noted that there was an increasing individualism taking hold with medical
globalisation. Stressing the cohesion that once existed in Trinidad, they expressed concern
with the atomism and fragmentation that had become commonplace as a result of the
changing times:

People almost don’t have anyone to look up to, or they feel everybody is involved in
something and everybody is out for what they can get and everybody is looking after
number 1 instead of caring about the communities.

As this quote illustrates, participants feel that a sense of social responsibility has eroded
over time, thereby eviscerating any concern for the common weal and community spirit.
According to many participants, this individualism has manifested itself quite clearly in
medicine. A new form of healthcare, characterised by self-interested parties involved in a
zero-sum struggle for personal gain, is becoming increasingly common. As one participant
points out, medical practice has thus become infused with a fundamental sense of disunity:

In the healthcare sector, we find that there is distrust and dysfunction between the patient,
the caregiver and the facilitator, which is the government. And the issue of technology,
while [patients] are dazzled by the technology in healthcare, it is combined with a
distrust, not from the technology per se, but from the people who make the evaluation
and the treatment. Because there is a prevailing sense that everyone is after money . . .

In particular, participants chronicled how medical globalisation had eroded the possibility
of establishing a dialogue between physician and patient. In talking about the past, they
described patients as able to explain their maladies without time limitations, while doctors
were preoccupied with understanding the suffering of patients. Nowadays, however,
physicians have become involved increasingly in momentary, standardised, and fleeting
encounters with patients, with little to no attention paid to any particular circumstances
or idiosyncrasies.
Regarding the future, participants saw globalisation as moving Trinidadian medicine
toward the more impersonal model of ‘First World’ medical practice, despite the realisation
that this model has serious problems. As one participant indicated:

When I went to [America], I’d never seen healthcare managed so badly, I could not
believe! It was like a total disconnect. The doctors have no time to talk, they have the
attendants, therapists, but no time to talk with the patients. So this disconnect, I think
you [Americans] can learn from that with us, that feeling of collective [between doctor
and patient]. Although we’re losing it because we’re adapting. So while you’re trying to
get us, we’re copying you. We’re trying to emulate you . . .

Thus because of the perceived inevitability of globalisation as a macro historical process

divorced from human agency, medical practitioners are expected to move toward more
© 2007 The Authors
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 Globalisation and medicine in Trinidad 545

atomistic relations with patients despite the traditional community-centered spirit of medical
practice in Trinidad.
Ultimately, participants described mainstream medical practice in Trinidad as having
shifted to a more individualistic model consistent with medical globalisation. Self-interest now
rules as the dominant moral axiom, thereby limiting the ability of a co-operative relation-
ship to develop between doctor and patient, or between the healthcare system and the public.

‘Centered’ ideals
A final theme of medical globalisation that emerged out of participants’ responses was the
importance of following unified ideals. These ideals are ‘centered’ in that they are abstract
and thought to be universal, rather than recognised to represent a particular perspective
(Luhmann 1982). These ideals are thought to be necessary for integrating a society that
has been reduced to self-interested atoms. By following the dictum of absolute doctrines,
the individualistic fragmentation of Trinidadian society is thought to be resolvable.
Several participants noted the importance of adhering to a single, universal message as
a key aspect of globalisation. When asked to define globalisation, one participant echoed
this sentiment: ‘[globalisation is] for all of us to focus on the same objectives, say the same
things’. This quote illustrates the belief that assimilating to a common standard will ensure
social harmony and reduce the antagonisms increasingly plaguing Trinidadians as a result
of globalisation.
As many participants pointed out, however, centered ideals have made Trinidad a self-
denying culture, constantly striving to adhere to foreign standards rather than taking pride
in homegrown ideas. In particular, ‘expertise’ and technical standards from the more
‘developed’ societies have become idealised prescriptions for modernity and sophistication.
In the words of one participant, ‘we feel that we must bring in foreigners because they
know better’.
With specific regard to medical practice, participants spoke of medical globalisation
resulting in a shift towards more ‘Westernised’ medicine:

. . . we focus a lot on what can be done for illnesses after they occur and we expect, or
people would like to expect, what they see being talked about in societies with more
sophisticated medical systems. And that isn’t always the case, and so they feel that it
is a deficiency. I don’t think, I don’t think medicine has really become global in the sense
that we don’t see other influences coming from other countries; it’s largely North
American influences coming in . . .

Another participant advocated ‘looking to America’ and ‘getting proper equipment’, even
for ‘strange diseases we’ve never come across in Trinidad’.
Participants also mentioned Trinidadians’ shifting attitudes about health and their
increased desire to conform to more rationalised, technically-measured lifestyles.
Specifically, participants pointed out Trinidadians’ increasing use of advanced medical
technologies at the expense of more traditional notions of health maintenance: ‘Now our
people believe in machines rather than in their bodies and nature itself’.
On a policy level, participants again cited the restructuring of the Trinidadian healthcare
system as an example of the wholesale adoption of a foreign model, or as one participant
put it, ‘a direct copy from Britain’. Along the same lines, a newspaper editorial remarked
on the Trinidadian government’s focus on ‘systems integration’ as the answer to Trinidad’s
public health ills. The technological imperative at the heart of the Western model
(automated data collection and documentation, standardised forms and registers and
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546 David L. Reznik, John W. Murphy and Linda Liska Belgrave

the computerisation of all record systems) was thus idealised as the most effective means
for solving Trinidadian health problems.
Mainstream medical practice in Trinidad has thus increasingly begun adhering to
Westernised standards of high-technology and other related ‘modernising’ projects as part
of medical globalisation. As many participants pointed out, medical globalisation produces
a pervading feeling that adoption of these ‘centered’ ideals represents the only means for
development and social order.

Summary
Through interviews with urban Trinidadians involved in the medical industry, four key
principles of medical globalisation emerged. The first, and perhaps most important, was
the idea that globalisation is an abstract, autonomous, evolutionary process of history that
is beyond human control. Additionally, according to participants, the current historical
epoch is characterised by the ‘Total Market’, or the advance of market logic into all aspects
of social life, including medicine. Participants noted how the ‘Total Market’ has produced
a growing sense of atomistic individualism in Trinidadian society, particularly in health-
care. And finally, participants described ‘centered’ social ideals, including the expertise and
technical sophistication of Western medicine, as necessary to resolve health crises within
the increasingly fragmented social context brought about by medical globalisation.

Discussion

In this section, an attempt will be made to consolidate, contextualise, and account for the
findings of this study. Specifically, the participants’ descriptions of medical globalisation
will be discussed vis-à-vis two key theoretical concepts in the literature on medical sociology:
dualism and medicalisation. These themes are also representative of important theoretical
debates in the literature on globalisation, including the issues of structure vs. agency, the
individual vs. society, hegemony in knowledge production, and the nature of social interaction.

Dualism in participants’ accounts of history and knowledge

Trinidad is a geopolitical space with a long history of Western colonial rule and postcolonial
economic dependency. This tragic historical legacy has had a significant impact on popular
consciousness in Trinidad. Socialised within a colonial/postcolonial context, Trinidadian
society has been inundated with the Western tradition of thought, most significantly
dualism (Miller 1994). This belief in the fundamental distinctions between subjectivity and
objectivity has important implications for the way participants in this study conceived
medical globalisation.
In particular, the dualist historical narratives of ‘historicism’ (Popper 1964) and
‘developmentalism’ (Nisbet 1969) run across the various discussions of medical globalisation
by participants in this study. They viewed time and history as autonomous forces that
stand above and outside the individual, and thus dictate human action. In other words,
they saw the micro processes of everyday medical practices as determined by, rather than
mutually constitutive of, the macro historical process of globalisation.
Participants thus understood medical globalisation as a distinct stage on the macro stage
of history separated completely from their quotidian existence. Often they characterised
globalisation as irreversible and progressive, thereby suggesting that history has a singular
autonomous path of development. Accordingly, abstract ideals such as the ‘Total Market’,
technological progress, and socio-cultural development are understood as historical
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 Globalisation and medicine in Trinidad 547

imperatives that cannot be controlled. Ultimately, all social life is thought to reside within
the purview of unalterable historical laws and mandates.
As a result, participants foresaw an inevitable replacement of traditional medical
practices and healthcare models by Western high-technology medicine and an increasingly
privatised healthcare system. Even the traditional relationship between doctor and patient
in Trinidad, once thought to be better than the ‘First World’, was described as unable to
withstand the pressures of the macro forces of history. Ultimately, participants advocated
the adoption of practices that characterised the most ‘progressive’ societies, most notably
the United States.
Another theoretical principle that emerges from Trinidad’s history of immersion in
Western dualism is the theory of knowledge known as realism. This epistemology is
characterised by the idea that the knower is separable from what is known (Murphy 1989).
Thus, valid knowledge has to overcome and transcend all sources of contingency, so that
its supposed objective purity is not contaminated by subjectivity. Positivist science, through
the increasing use of technology, is understood as the only competent way of ‘truly’ seeing
the ‘real world’, thereby reaching what Comte (1953) considered to be the highest stage
of knowledge.
Realism was prevalent in the participants’ discussions of the importance of science and
technology in medicine. They described the ‘First World’ as representing advanced scientific
knowledge uniquely capable of resolving Trinidad’s healthcare problems because of the
prominence of technical expertise and high-tech equipment there. Medical globalisation
thus appears as a macro historical process promoting the logic of objectivity and a
progressively rationalised medical system.

Medicalisation as a result of individualism and the ‘Total Market’

As another consequence of its colonial heritage, Trinidadian society has been pervaded
by a Westernised, atomistic account of the individual. Historically, the colonial policy of
‘divide and rule’ was implemented in Trinidad by the colonial regimes (the Spanish,
French, and British respectively) to highlight the differences between persons of Hindu and
African descent, transient labour and settler/slave, and customary practice and common
law (Sheller 2003: 125). The multidimensionality of these distinctions, along with local
elites’ shifting allegiances, ensured a perpetual tension among Trinidadians that has been
manifested in a social psychology of individualism (Brereton 1981).
Since Independence, urban Trinidadian social life has been characterised by an even
greater sense of fragmentation. As part and parcel of the post-Independence project
of ‘development’, a ‘consumer culture’ guided by the ‘pragmatism’ of opportunity-cost
calculations (Maingot 1998: 24–5) has emerged. And the government’s intensified adoption
of ‘modernising measures’ has led to ‘the construction of intensely parochial identities’
(Maingot 1998: 7), highly-charged racial tensions (Niranjana 2001), and a sharp increase
in violent crime (Payne and Sutton 2001: 166). All the while, the ‘invisible hand’ of the
market, as Adam Smith (1909) put it, has been posited as the appropriate mechanism for
instilling social order.
Trinidadian healthcare has been affected by this growing atomistic individualism and
market logic. The holism between mind, body, and spirit associated with many traditional
medical practices has been superseded by Western ‘rationalism’, with its disembodiment
and fragmentation of the body (Allen 1998: 86–7). Also, the growing emulation of Western
healthcare delivery has emphasised ‘patient self-determination’ and a preoccupation with
individualised, private healthcare to the detriment of a ‘communitarian [public health]
ethic’ (Aarons 1999: 23).
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548 David L. Reznik, John W. Murphy and Linda Liska Belgrave

These social factors are apparent in the participants’ discussions of medical globalisation.
From family life to medical practice, participants described globalisation as advancing
individualism and materialism as the guiding principles of modern social life. Participants
also discussed the growing importance of market mechanisms in maintaining social stability
and the proper allocation of medical goods and services.
The accelerated emergence of this market morality in Trinidadian mainstream medicine
has also spurred significant increases in the number of everyday activities brought under
the purview of the medical industry (Allen 1998). Viewed as an industry of service providers
rather than a community of healers, the medical field has a new primary responsibility: the
attraction and retention of patients-as-customers.
In this vein, participants complained that patients are exposed to more direct pharma-
ceutical advertising than ever before. They also voiced concern over the increasingly
expanding definitions of disease. Finally, participants cited the public idealisation of
Western medical technologies regardless of their actual utility in patient care. Overall, then,
the individualism and the market logic behind medical globalisation appear to push growing
numbers of otherwise healthy people into becoming patients who purchase unneeded
healthcare goods and services on the medical market.

Conclusion

As this study demonstrates, there is an obvious relationship between the macro trends of
globalisation in Trinidad and the everyday lived experiences of the Trinidadian mainstream
medical community. Although the abstract historical process of globalisation is neither
autonomous nor a determinant of human agency, participants demonstrated that this process
can be internalised as if this were the case. Such internalisation is manifested in persons
adjusting their everyday activities, including medical practices, to the norms that are thought
to be imposed and outside of their control. Ultimately, as was the case in this study, the
realm of experience begins to simply reflect the historical conditions that are conceived to
exist sui generis (Durkheim 1972).
Hence there appears to be a strong ideological element that occludes these Trinidadians
from recognising the intertwined, mutually reinforcing praxis of their subjective activity
and objective historical conditions. As Mannheim (1936) points out, ideology emerges
when ruling groups propagate a mode of thinking that allows an idea to obscure the real
material conditions of social life, thereby stabilising the power relations of the status
quo. When this mode of thinking becomes part of the ‘collective unconscious’, reality is
obscured and otherwise resolvable social crises are legitimated and thought to be a part
of human nature or social reality. Ultimately, then, ideology negates the ‘real, sensuous
activity’ (Marx 1964) of the human subject, converting social life into a predetermined
self-fulfilling prophecy, or what Marcuse (1964) calls a ‘one-dimensional’ mode of
existence.
In this particular case, medical globalisation is sustained by an underlying belief in the
inevitability of historical cycles and development. But such historical autonomy is a myth
and must eventually be substantiated at the level of experience. In other words, persons
must begin to believe in this inevitability and reinforce publicly this outlook.
In this study, the participants have seemed to internalise this belief in historical inevitability
and continually reiterate the need to adapt to historical trends. Indeed, such adaptation is
thought to be wise and lead to further growth. And as a result of voicing this opinion, the
mythical autonomy of medical globalisation is further established. The continuation of this
© 2007 The Authors
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 Globalisation and medicine in Trinidad 549

cycle, moreover, helps to establish the necessity of medical globalisation and related out-
comes in the mind of the public.
One way to undermine such ideological conceptualisations of medical globalisation is by
negating any attempt to divorce the macro realm of history from the micro realities of
everyday living. Future scholarly research on medical globalisation can help in this regard
by emphasising the interplay of praxis and ideology, rather than continuing to separate the
macro and micro realms of experience. Ultimately, as Trinidadian intellectual C.L.R. James
(1977) argued, a better future for social living, including medicine, lies in a more critical,
praxis-oriented investigation of the present.

Address for correspondence: David L. Reznik, Department of Sociology, University of

Florida, 1111 SW 16th Avenue no. 158, Gainesville, FL 32601 USA
e-mail: dreznik@ufl.edu

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