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Ronald Frankenberg
Centre for Medical Social Anthropology
University of Keele
Guest Editor

Gramsci, Culture, and Medical Anthropology:

Kundry and Parsifal? or Rat’s Tail to
Sea Serpent?

The articles in this theme issue are introduced in the context of the
thought of the Italian Marxist, Antonio Gramsci. I suggest that his con­
cept of hegemony is well known to medical anthropologists but not well
understood, and an attempt is made to place it in the broader context of
his life and work. / particularly emphasize Gramsci's ideas concerning
the part played by culture (and by "intellectuals” who develop and
transmit it) in all societies in ‘ 'the late bourgeois world. ’ ’ Healers are an
important type of intellectual, and healing ideologies play an important
part in hegemonic struggles. This is well illustrated at’thepersonal level
by the material presented in articles on the relationship between popular
and biomedical beliefamong womep in Haiti and between stroke patients
and their doctors in California. In the public sphere, Islamic clinics in
Cairo and curative rituals among the Manjak of Guinea-Bissau can also
be fruitfully seen in these terms. Finally, I draw an analogy between the
presentation by L^vi-Strauss of some mythicalfigures, who change char­
acter as they change spheres of existence, and the way that culture
changes its meaning when it is seenfrom different perspectives in anthro­
pology.

It’s quite possible that some of my opinions are exaggerated or unjust. Only Cu­
vier was capable of reconstructing a mastodon or a megatherian from a tiny bone,
and there’s always the risk of reconstructing a sea serpent from a rat’s tail.
—Antonio Gramsci, Letter to Giulia, 30 December 1929—

All men are intellectuals, one could therefore say: but not all men have in society
the function of intellectuals. . . . Thus, because it can happen that everyone at
some time fries a couple of eggs or sews up a tear in a jacket, we do not neces­
sarily say that everyone is a cook or a tailor.
—Antonio Gramsci, Selectionsfrom the Prison Letters—

ntonio Gramsci was bom in the small town of Ales in Sardinia in 1891.

A His father was a respectable government official whose disgrace in Gram-

sci’s childhood condemned the family to poverty and stmggle. Gramsci’s

324
Introductions 325

own educational career was fraught with hardship and near starvation. From early
childhood he was hunchbacked, sickly, and of stunted growth. He studied lin­
guistics at the University of Turin and, influenced by his elder brother, became
involved in the Socialist Party there. He began to write as a journalist, editor, and
drama critic in 1919. After playing a prominent part in the first factory occupa­
tions by workers at the Fiat plants, he was one of the founders of the Italian Com­
munist Party (PCI) in 1921. Despite his parliamentary immunity, as general sec­
retary of the PCI he was arrested by Mussolini’s Fascist government in 1926.
Imprisoned by direct order of II Duce, he remained a prisoner until his death in a
Rome nursing home in 1937. Before being imprisoned, he wrote a crucial analysis
of the problem of the Italian mezzogiorno and especially the relationships, actual
and potential, of the proletarianized northern working class to the poor southern
peasants. His main works published posthumously are his prison letters (Lawner
1975) and his prison notebooks (Gramsci 1971).'
As a Sardinian, disabled, often a dissident Communist, prisoner, married to
a Russian woman he was rarely able to see even before his imprisonment, father
of two children (one of whom he never saw), he viewed Italy and the world with
creative multiple alienation. The ways in which he transformed Marxism in par­
ticular and social science in general are only just being appreciated, and even
now, as 1 shall suggest, they suffer from too rapid and insufficiently attentive as­
similation. His attempts in the prison notebooks to understand the role of intel­
lectuals and of culture in the dynamic of the political economy of the “late bour­
geois world” (Fischer 1963) could be and ought to be used to give his ideas a
crucial importance for a critical medical anthropology. His development of the
concept of “hegemony” may prove particularly important to medical anthropol­
ogists, as I believe the articles in this volume show, since the shared “hege­
monic’ ’ values of patients and doctors in Western society are at the core not only
of the transfer of medical technology but also of the transfer of ideology in general
(Comaroff 1988).
Gramsci’s Marxism can be seen, at least initially, as a playful Marxism of
uncertainty. One of his early writings as a journalist published in Turin in 1916 is
a bitter/comic account of a factory doctor entitled “A Veterinary Surgeon on
Film.” It is (alas) a rare account of a direct observation by Gramsci of medicine
at work.
At 11:30 a.m. in the plant’s medical consultation room, the workers are standing
around in groups waiting for the visit of the veterinary surgeon who looks after
them. Yes, he’s a vet, say the patients, because all he gives you for examination
is a single glance. True, the workers can speak, they know how to express what
they feel, but by God, we all know that they fabricate their symptoms, they ex­
aggerate them to get a holiday, to give themselves a good time. And so it’s as
though they can’t speak, as though they were work-shy brutes—and so the doc­
tor becomes a veterinary surgeon. The deduction is simple but highly logical.
[Gramsci 1977:15-16]
A more typically Gramscian suggestion is his proposal to study quantita­
tively and concretely the distribution of intellectuals and the forms of cultural or­
ganization in particular countries focused mainly on education and religion, to­
gether with newspapers, magazines, and publishing in general. He does add,
however:
326 Medical Anthropology Quarterly

Other professions include among their specialised activities a fair proportion of

cultural activity. For example, doctors, army officers, the legal profession.
[Gramsci 1971:342; 1975:1394]

In an earlier, less developed set of notes (Gramsci 1975:846) under the head­
ing “Intellectuals, traditional intellectuals,” he writes:
One category of these intellectuals, perhaps because of its prestige and social
function within primitive society, the most important outside the “church,’ is that
of ‘doctors’ in the broadest sense, that is to say all those who ‘struggle’ or seem
to struggle against death and disease—it will be important to come to terms with
Arturo History ofMedicine. One must remember that there has been
a connection between religion and medicine, and that in some areas there is still:
some hospital organisational functions are carried out by religious, as well as the
fact that where you find doctors you also find priests (exorcism, sundry assist­
ance, etc.). Many major religious figures either were also or were thought to be,
great ‘healers’: the conception of miracles as far as the resurrection of the dead.
For kings as well the idea that they could cure by laying on of hands survived for
a long time.

My present interest in Gramsci is thus overdetermined. In current critical

medical anthropology in the United States, expressions like “hegemony of bio­
medicine” or “struggle for hegemony between pluralistic medical systems or ex­
planatory models” are used frequently, but this quantity does not always enhance
the quality of analysis because the power of‘“hegemony” as aGramscian concept
is not realized either in the sense of understanding or of making real. On occasion
Gramsci is cited as a mere stepping stone on the path through Frankfurt to Gad-
amer by those who are not convinced that simple, straightforward theories are the
best first approach to complex, tortuous realities. Further, the National Health
Service in Britain and the pattern of medical care elsewhere in Europe and in the
United States are the sites of complex hegemonic struggles between both classes
and occupational groups, including patients, the aged infirm, and the chronically
sick. Thatcher understands the war of position and knows that the destruction of
the right to free health care means more than merely saving money. Popular con­
sent to its disappearance in Britain would be a major victory in her double war
against the notion that society exists (rather than an aggregate of individuals with
families as the largest significant unit of action) and against “sociological ex­
cuses” for those unwilling to accept her view of how the worthy should behave.
Right-wing theorists in the United States have also always recognized the
crucial hegemonic significance of health politics both at home and, for example,
through the agency of allies in Central America and elsewhere. The long-term
history of the Soviet Union and the recent history of China both illustrate how
changes in direction of health-politics initiate, reinforce, and reflect fundamen­
tally diverse approaches to revolutionary change. In this issue Soheir Morsy’s
article discusses the complexity of the Egyptian situation and shows the return of
a Trojan Horse to North Africa, where Islamic culture provides—not for the first
time in Egyptian history—an ambivalent hegemonic ideology concealing in lay­
ers the interests of West Asian oil companies, British high-tech hospital exporters,
and USAID.
Gramsci’s definition of Marxism as the “philosophy of praxis” resonates
with the concern of medical anthropology for the existential problems of the phys-
Introductions 327

ically and/or socially disadvantaged. Gramsci rejected but also understood

Croce’s view of an overly economistic Marxism as theology. His standpoint on
this provides a retrospective mirror to the discontents of the current individual
scholar/activist toward an often abstract, society-focused materialist practice that
overlooks or ignores the practical material experience of the sick individual.
That many of the so-called theoreticians of historical materialism have fallen into
a philosophical position similar to mediaeval philosophy and have turned eco­
nomic structure" into a kind of hidden god is probably demonstrable, but what
does that signify? It’s as if one wanted to judge the religion of the Pope and the
Jesuits by talking about the superstition of Bergamo peasants. [Gramsci, Letter
to Tatiana, 1 December 1938, in Lawner 1975:189?

Nevertheless, Gramsci, without choice both in his personal experiences and

in his willed interpretation of Marxism, eschewed the inevitabilities of a falsely
perceived certainty. His favorite expression, drawn from Romain RoUand (and
recently vulgarized through beheading by Craxi in the last Italian election), pes­
simism of the intellect, optimism of the will,” is a reflection of this attitude
first learned, perhaps, as a result of coming from the one unsuccessful branch of
a successful and established Sardinian family. His school days—unexpectedly
made uncertain by the poverty and difficulty caused by the politically maneuvered
imprisonment of his father for theft—and the harsh deprivations of his student
years, when he nearly starved, were not merely the expected hardships of the sons
of peasants or proletarians. The development of disability from his earliest child­
hood and his chronic ill health and pain throughout his life were other sources of
both self-acknowledged alienation and determination to overcome. It would deny
his understanding to suggest that these experiences directly taught him that the
oppression of capitalist society reached out beyond the walls of the factory or the
boundaries of the sharecropping plot and inside the walls of prisons and hospitals
for the chronically sick poor. His early experiences, however, certainly did create
the knowledge of conditions which, almost accidentally, enabled him to leam and
ultimately to teach the philosophy of praxis through the Prison Notebooks, and in
relation to chronic sickness, through the Prison Letters as well. He saw his letters
as a commentary on the distant and recent past directed from a present, so alien­
ated as to be absent, toward a future that he knew to be for other selves and groups
rather than for himself as a living organism. They provide a personal phenome­
nological account of a mindful body that can be used as a bridge between lived
experience and social analysis (see Frankenberg 1988).^
Playfulness may seem more difficult to justify, although he was proud that
during his period as a drama critic between 1916 and 1920 he was among the first
to recognize Pirandello’s theater as a subtle critique of society. Again, when the
exigencies of the prison library left him with nothing else to read, he turned with
profit to criticism of serial light romances and feuilleton culture and drew conclu­
sions about the role of Protestantism and Catholicism in history by comparing the
detective feats of Sherlock Holmes and Father Brown. Above all I see as intellec­
tually playful his openness to new ways of seeing Marxism and developing the
Leninist concept of hegemony in a new situation. In his first letters from captivity,
while still on remand on the island of Ustica, he expressed pleasure at being cham­
pion stone thrower, at being stronger than his comrades, and at keeping in good
328 Medical Anthropology Quarterly

spirits: “The little sprite in my head who always manages to find the humorous
side of things kept me in good spirits all along” (Lawner 1975:63).
Alas, while the sprite survived for many years, at least on the evidence of
the letters, it unsurprisingly died a victim of insomnia, pain, and the cumulative
frustrations of exercizing solitary will against political despair. Playfulness does
not, to me or to Gramsci, imply a lack of serious intent. He was scathing toward
the witty and the socially popular who replaced ‘ ‘truth, seriousness and profundity
with a quip that makes people laugh” (Forgacs and Nowell-Smith 1985:73), but
he was among the first to recognize the power of Pirandello, whose “comedies
are so many hand grenades that explode in the brains of the spectators, bringing
down banalities, wrecking feelings and ideas” (Forgacs and Nowell-Smith
1985:83).
Gramsci shares with anthropology the insight of seeing the importance of
culture in the broadest sense, and he begins to document for Italy, for the Soviet
Union (in his brief analysis of his wife’s mental breakdown), and for the United
States (in his notes on Fordism) the close and inseparable interrelationships within
“serious” culture; the expressive aspects of production, political action, and
health; and the culture of plays and of play. This is an important, even essential
part of his contribution: his recognition that (and his determination to discover
why and how) the power of a ruling class, exercised through the state, does not
merely dominate but ultimately comes to merge with civil society. The ruling
class dominates by force but directs through the contradictory but consensual
commonsense of culture. The combination of apparently merely instrumental
force with apparently merely expressive ideas is what constitutes hegemony, and
certain intellectuals are in this regard most often more powerful agents both in its
maintenance and in its overthrow than the militia or the armed revolutionary van­
guard. With hindsight one can suggest that Foucault’s notion of capillary, diffuse,
uncentralized power is in one sense anticipated by Gramsci and seen in the cap­
illary culture of all-pervasive hegemonic popular thought.
The role of what Gramsci calls the “organic” intellectuals of a class is to
emerge from, or at least cleave to, that class and to engage in a struggle to main­
tain or challenge the hegemony of the ruling bloc. In terms of our concerns, we
do not consult physicians and have their social and medical views forced upon us.
We consult them because we already share their views, and even if we desert them
for alternative healers or self-help, we carry our shared culture alongside our re­
jection. This shared culture and the individualist view of sickness are well brought
out in the articles in this issue.
Gramsci argued in his theory of hegemonic ideology that mature capitalism
is entrenched as much in the minds of its potential enemies as in those of its per-
during friends. He further suggested that revolution was not enough or even pos­
sible without prior and simultaneous invasion and infiltration of both the heights
and depths of culture by the organic intellectuals of all the oppositional groups,
not just the proletarian vanguard. It may even be that the voices crying in the
particular wilderness of the United States are the chronically sick and disabled
among the ethnically, elderly, and gender disadvantaged, and that the proletarian
“vanguard” has to be baptized with their fire before it becomes convinced of its
messianic role. In Gramsci’s view, the war of maneuver between classes has to
be prepared and planned for the future moment. The war of position between the
Introductions 329

exponents of culture (i.e., the struggle for hegemony) is continuous and omni­
present and has to be lived now and always. It is with this background that we
have to turn to further discussion of approaches to culture and to intellectuals, in
the context of anthropology in general and medicine, sickness, and healing in
particular.
The statement of Singer and his colleagues in this volume that “The cen­
trality of the culture''^concept to the anthropological imagination is undisputed”
must, of course, be read in the historically and geographically specific context in
which it is situated. For despite Malinowski’s concern with the “imponderabilia
of daily life” (the culture that dared not speak its name lest biologists relegate its
analysts from the glories of scientific achievement to the curiosities of mere lit­
erature), Oxford mainstream British social anthropologists, in their attempts to
consecrate an orthodoxy through their Association under the influence of a view
of Durkheim mediated through Radcliffe-Brown, for many years fought against
the idea of culture as the central concept within anthropology, while recognizing
it as a legitimate (if high) concern for Arnold, Eliot, and Leavis. The (at the time)
alarming break between the Evans-Pritchard of the Oxford Inaugural (much later
revealed as written by Radcliffe-Brown) and the earlier analyses of the Nuer and
Shilluk, on the one hand, and the Marett lecture and subsequent work, on the
other; the almost post-modernist multiplication of nuanced but unexplicated met­
aphor that seemed at first to adorn rather than deepen Fortes’s structural analyses
of Tale lineage and clan; and Gluckman’s recognition, after his quasi-Marxist
positivist political economy beginnings, of the dialectic of custom and conflict—
all opened a back door, a tradesmen’s entrance, to U.S. scholars’ continuing con­
cern with culture. In 1966 ASA published Anthropological Approaches to the
Study of Religion (Banton 1966), a loosely reined stalking-horSe led in by Turner
and Geertz. It was then only a matter of time until culture once again became the
universal language (even lingua franca!) of anthropology. In keeping with Par­
kinson’s second law, the edifice (the ASA volumes) that was to celebrate the or­
thodoxy merely marked the end of the beginning of its decline, so by 1987 even
Leach had to notice that he had been attacking a chimerical target and pointed
with all the wonder of the newly converted to the discovery that the contextuali-
zation of artifactuality (human reality to,Vico and Gramsci) and the construction
of artificiality (fiction to Leach) had much in common. Perhaps his long absence
from mathematics and his unsurprising lack of knowledge of Gramsci explains
his forgetfulness of the difference between similarity and congruence (Mac­
Donald and Tonkin 1989).
As Singer, Davison, and Gerdes point out, taking culture as a central concept
does not mean either that all anthropologists contextualize it in the same way or
that the choices made are independent of those trends within intellectual life at
large and of the philosophies of progress or reaction with which Gramsci struggled
in his prison cell. The most important of these philosophies he formulated as ex­
isting in two complementary and equally erroneous reductionist guises, an idealist
immanentism of the right and a materialist positivism of the left (represented by
Bukharin internationally).
Lawner (1975:19) defines “Immanentism [as] ... a theory according to
which'no external forces operate on the historical process, the process itself, con­
taining the prime motor, causes, and end of its development,” and points to
330 Medical Anthropology Quarterly

Gramsci’s claim that the philosophy of praxis (Marxism) is the only consistent
immanentistic conception/ Elsewhere he says that Marxism purifies rather than
merely metaphorizes the concept/
This, of course, is one reaction (not confined to Marxists or critical anthro­
pologists) to cultural immanentists like Geertz. Turner and Geertz, united in the
richness of their ethnographies and the importance they ascribe to understanding
culture from within, are nevertheless divided by the former’s Catholic Catholicism
and impulse to universalize by emphasizing the transcendental/ Singer and his
colleagues respond to Geertzian thick description not by rejecting it or denying
the carriers of culture’s ability to spin webs of significance. They argue that di­
visions of interest within the society make those significances plural rather than
unitary, and that some actors have to be seen as spinning webs of mystification.
Cultures [they write] not only generate meaning, they also produce legitimation
for inequality, justification of subordination, denials of exploitation, and dis­
guises for oppression.

They also introduce a transcendentalism, if only of the middle range. For

they are describing and analyzing not merely a clash of cultures, that of cosmo­
politan biomedicine in conflict with that of local Haitian women, but also a clash
of political economy in which biomedical categories and personnel are used to
establish and maintain control over the Haitian people, men and women alike, by
a foreign economic imperialism acting through compradors. From a Gramscian
standpoint, Singer, Davison, and Gerdes might be seen as having an inadequately
dialectical view of the contradiction between mystification and significance and
also as seeing culture as an arena of imposition rather than as a site of hegemonic
struggle. Nevertheless, their account of the way that Haitian women shift their
terminology and their presentations of symptoms for the real and needed short­
term gain of treatment, at the price of long-term consent to the hegemonic ideol­
ogy, provide just the kind of study of “how and why” that Gramsci set out to
stimulate.
Neither phenomena nor philosophies have one specific opposite. Cultural
immanentism may, as I have suggested, be situated on a continuum with the tran­
scendent, a Turner-Geertz axis, or with a sometimes equally transcendent pro­
gression toward political economy or society. Nor does this exhaust the possibil­
ities. Within the Hegel-Marx-Croce-Gramsci complex itself lies the possibility of
an often neglected phenomenological approach based on the construction of per­
sonal meaning/being. It is usual in determinist interpretations to place the em­
phasis on Marx for having said that men do not make their own history “under
circumstances chosen by themselves.” Nevertheless, he did precede this with the
statement, ‘ 'Men make their own history’ ’ (see Bologh 1979 and Sartre 1960 for
phenomenological interpretations of Marx). Like all processes, Marxist under­
standing can be and often is reduced to structure, not least by Marxists like Buk­
harin. Gramsci’s thought, like Marx’s, is not immune to being viewed reductively
as a fixed node in a static network, although it demands to be seen as a moment
in many temporal processes. The dictum quoted by Singer and his colleagues from
Roy Wagner that an anthropologist is someone who has undergone a “conversion
experience” and who can therefore be defined as someone who uses the word
“culture” with hope—or even with faith—provides a nice counterpoint to Gram-
Introductions 331

sci’s contrast of .optimistic will with pessimistic intellect. When first arrested,
Gramsci in fact set himself a program of personal as well as scientific discovery
in letters to his mother and sister-in-law, and he sought to maintain it until, and
even after, the moment of despair.
True, I don’t think my position is very brilliant. But all things in life are colored
by our attitudes towards, and feelings about, them. I’m quite calm and view
everything with great equanimity and confidence. If the near future is dark,
things will get better afterwards. [Letter to Mother, 6 June 1927, in Lawner
1975:89-90]
In Sharon Kaufman’s article on the phenomenology of boundaries we see
how chronic stroke patients in California seek to live with their disabilities and
make them meaningful in a cultural environment in which they are enclosed
within an inner shell of shared medical (hegemonic) assumptions with their doc­
tors and an outer shell of the shared commonsense values of U.S. liberal capital­
ism and the Protestant ethic. She argues convincingly and exemplifies in fasci­
nating detail how the phenomenological study of existential response enables us
to understand unmet expectation, and she points in her final paragraph to the need
for similar studies to take into account analyses of medical knowledge, authority,
and intervention (cf. Hahn 1985).
The ideology that is shared but that cannot be lived, either by the stroke pa­
tients or by their doctors, is that disease comes from outside to invade the body
but dc«s not affect the mind, is episodic or acute and by working hard can be cured
by the cooperation of the afflicted individual with her/his doctor. Both fashiona­
ble holistic and old-style biomedical disease models are equally grounded in and
trapped by mind/body dualism, and each seems to lead (from some conservative
points of view, beneficially) to a contradictory combination of patient-blaming
and increasing medical control. Biological pathology and life course pathology
are either equated or seen as mutually reinforcing. In the words of Scheper-
Hughes and Lock (1987:27):
We would suggest the usefulness to the body politic of filtering more and more
human unrest, dissatisfaction, longing, and protest into fhe idiom of sickness,
which can then safely be managed by doctor-agents.
This medicalization, of course, was not intended to be read as always, or
even usually, a conspiracy, although it is 9ften tempting, while overestimating
the class or group consciousness of one’s friends, to underestimate that of one’s
enemies. As the concept of hegemony perhaps implies, ruling classes and their
organic intellectuals know whence comes the butter on their bread, the oil on their
pasta, or the relish on their nsima.
Chronic sickness (because it is in Kaufman’s view existentially transforma­
tive, dehumanizing, compromising, and destructive of one’s life world) forces
attention, more sharply than acute sickness, on the whole body, the home envi­
ronment and family stnicmre and dynamics, and the social environment in which
they exist. The decline of the extended family and the growth of poverty mean
that the problems raised by chronic sickness are objectively insoluble, and thus
conditions are created that make it possible for a hegemonic struggle for new non­
capitalist, non-individualist, non-dualist forms of that society of which Reagan
and Thatcher deny the existence. The individual, the family, or the couple cannot
332 Medical Anti iropology Quarterly

manage even if, as in Kaufman’s second case, financial resources have been pru­
dently accrued. For the stroke patient, as for the limbless Diane (Frank 1986),
ability to walk is the polysemic symbol of achievement and thus, for those who
cannot achieve it, of failure, which simultaneously suggests that they have failed
society and that society has failed them.’
The uncertainties from which chronic stroke patients suffer are reinforced
and caused, as in all disease, by uncertainty of outcome (in chronic and latent
disease, like AIDS, by prolonged uncertainty of outcome) and by the hegemonic
consensual misprisal in Western society of those labeled as old or otherwise un­
productive (Phillipson 1982). Kaufman’s boundaries express the dialectics of he­
gemony. Stroke patients live in a few days or weeks what Gramsci lived in a
lifetime of deformity and ten years of declining health in prison. Their experience
provides a battleground for ideology; like a factory or an oppressive family, it
does not guarantee a battle, let alone a victory. The contradictions within hege­
monic consensus can be tolerated and endured or exposed and fought against.
In Kaufman’s and in Singer, Davison, and Gerdes’s articles, the personal is
the latent political; the analysts have brought this to light, and Gramsci’s ideas
may serve to set and see it in a wider context. In contrast, van Binsbergen and
Morsy document the publicly political.
Morsy’s article adds another dimension to the exploration of the complexity
of hegemony, for she describes phantom hegemonic struggles masquerading as
and concealing the real. Because ideologies, like people, may become what they
pretend to be, the analysis of such contradictions is of vital importance. Islam is
not the region-wide hegemonic ideology that it appears to be on the surface; often
it is mere rhetoric. Thus following the “socialistic” reforms of Nasser and influ­
enced by outside pressure and financing from USAID, Egypt under Sadat and his
successors has turned, like many other countries, to privatization and individual­
ization of health services, while at the same time almost abandoning alt pretense
of providing comprehensive service to the poor majority. Alongside and (at first
sight) in opposition to this trend, there has been an “Islamic Medical Revival,”
a considerable growth of clinics attached to mosques and other religious founda­
tions. Such clinics, however, conceal high-tech, positivist medicine and reward­
ing employment opportunities for Western-trained doctors behind an Islamic fa­
cade and, in fact, serve to legitimate the “existing political/economic structure,
albeit in an Islamic garb.” The threadbare nature of the latter is revealed by the
ideological emphasis on reforming individual man, rather than on the state or the
institutions of civil society. This enables the proprietors of these clinics to tap not
only Egyptian state finance but also to publicly receive monies from “Islamic”
foundations, financed from sheikly oil revenues, as well as secretly to accept large
subventions from European powers and the United States. Thus a syncretic he­
gemonic ideology, described as Islamic but securely based in Western capitalist
individualist values, at once masters and uses Islam in a way nicely symbolized
by both the import of women’s traditional dress from London and the diversion
to Cairo from the major hospitals and clinics of Western Europe and the United
States of “health tourists” seeking expensive treatments. Attempts by opposi­
tional political groups to follow historical precedent and use medical institutions
in the same way as the Islamic foundations are tolerated until they become too
Introductions 333

challenging, whereupon the coercive power of the state “stick” is used against
them as the state “carrot” of financial aid is used for the Islamic institutions.
In counterpoint to the stroke patients who have shared Gramsci’s physical
experience and been moved toward a certain sharing of his intellectual perception,
so Wim van Binsbergen has shared Gramsci’s intellectual difficulties. He has
studied a society whose people do not see their world in Cartesian terms and has
had to analyze a hegemonic cosmology that identifies Body and Land. The Man-
jak present, in different historical and cultural terms, Oliver Goldsmith’s semi-
metaphorical similar identification (from his poem, “The Deserted Village”):
111 fares the land, to hastening ills a prey,
Where wealth accumulates, and men decay.

Van Binsbergen’s intellectual problem mirrors Gramsci’s in seeking to ad­

vance toward the
synthesis that combines Marxism (sophistication in the handling of power and
production and distrust of symbolism sui generis), with symbolism (sophistica­
tion in the description and analysis of a symbolic order, and distrust of economic
reductionism). [van Binsbergen, personal communication, 1988]

He has done this within a context of sharing, as far as possible, in the forms
of struggle of a people, the Manjak, who live in Guinea-Bissau, itself a symbol
of emergent African socialism for Europeans and North Americans. His specific
problem of mental illness and the efficacy of indigenous treatment for it led him
first of all to hypothesize (influenced by Meillassoux) and then to reject the notion
that mental illness would result from youthful and perhaps female rebellion
against controlling, even oppressive, elders. He concluded, on the contrary, that:
Manjak society ... is characterized by a remarkably wholesome balance in its
internal symbolic and authority structure, as well as its relation with the outside
world (through migrancy combined with very strong and persisting ritual ties
with home). Gerontocratic relations appear to prevent, rather than generate, in­
sanity; and incipient mental problems appear to be redressed and corrected at an
early stage, invariably by invoking a combination of local rituals, always in­
cluding the cult of the Land.

Manjaks fall ill, he suggests, when outside society and especially bureau­
cratic structures and capitalist institutions take excessive control at the expense of
home ties, their own culture, and the central symbolic role of the elders.
It appears, then, that the divisions within Manjak society are of minor im­
portance to the Manjak themselves compared to the threat from outside, and that
they are, at least at the present conjuncture, subsumed within hegemonic agree­
ment about the symbolically and hoped-for inviolate Land, which is in turn sym­
bolized by an underlying notion of the
Perfect Body, which is whole and fertile, which is closed unto itself to such an
extent that it no longer has orifices, that it no longer has needs that necessitate
the passing of external substances from outside to inside (or even from inside to
outside), and that by virtue of this perfection places itself outside the chain of
human and social exchange, dependence and manipulation, and at the apex of
filiation.
334 Medical Anthropology Quarterly

Van Binsbergen’s analysis in all its detail stands for itself and parallels rather
than derives from the analysis of culture in European society, which Gramsci had
started to thir^ about but had no opportunity to develop. As van Binsbergen asks,
why should a Marxist-inspired approach to religion confine itself to the capitalist
mode of production, and, to paraphrase him, why should we suppose that the
approach itself is immune to the dialectics of reversal and change? His approach
also parallels the approach of David Lan (1985), who in a very different culture
elsewhere in Africa shows how hegemonic “preventive” spirit possession cults
not only maintained a unity in diversity between Kore Kore and Shona in normal
times but were mobilized in the war for Zimbabwean independence against the
whites. After independence was achieved, they simultaneously emphasized the
unity of the nation and exacerbated the disunity of Shona and Ndebele.
My discussion ends with an analogy drawn from an allegory about an alle­
gory, a myth about a myth. To L6vi-Strauss, mythical thinking is perhaps the
essence of the culture that Singer and his associates see as central. In his discus­
sion of Wagner’s Parsifal (1985), Levi-Strauss suggests that in earlier versions
of the myth, the messenger of the Grail (like culture in anthropology?)
alone is privileged to circulate between'the supernatural and terrestrial worlds,
[and] has a twofold nature and a changing appearance. She is a radiant beauty
when she comes from the other world, and a hideous witch when she embodies
the temporary'curse that weighs upon her.
This opposition explains the motif of the necessary question, which we know
to be important in the ancient versions of the Grail story. A spell has disrupted
communication between those two worlds, which are distinct—although for the
Celtic mind, it is possible to pass from one to the other. Since that break in com­
munication, King Arthur’s court, which represents the terrestrial world, has been
on the move constantly, waiting for news. In fact. King Arthur never holds court
until someone has announced an event to him. Thus, this terrestrial court is in
quest of answers to questions that are perpetually posed by its anxious agitation.
In symmetrical fashion, the court of the Grail, whose immobility is symbolised
by the paralysis of the King’s lower limbs, offers, likewise perpetually, an an­
swer to questions that no one asks it. [L6vi-Strauss 1985:230-231]
Wagner’s version is about two worlds, one unremittingly evil, the other
equally good at the same level. (Here Levi-Strauss, as always, proves himself
insufficiently dialectical—complementarity yes, but never for him the unity of
opposites.)
These two types . . . illustrate the two complementary solutions that human
beings have devised for two problems of communication. One problem is ex­
cessive communication, too direct, too rapid, and therefore fatally virulent; the
other problem is an overly slow, if not interrupted communication, which causes
inertia and sterility. . . . Thus, the problem, in mythological terms, would be to
establish an equilibrium between the two opposite worlds. To do so, one should
probably, like Parsifal [and, like Kundry, the messenger/sorceress—L6vi-
Strauss, Wagner, and their predecessors are at best latent feminists!], go into and
come out of the one world and be excluded from and re-enter the other world.
Above all, however,. . . onemust know andnotknow. Inotherwords, one must
know what one does not know, durch Mitleid wissend (“knowing through com­
passion”)—not through an act of communication but through a surge of pity
[empathy?], which provides mythological thinking with a way out of the di-
Introductions 335

lemma in which its long unrecognized intellectualism has risked imprisoning it.
[L6vi-Strauss 1985:232-234]

It is difficult for us to escape Cartesian dualism and to avoid seeing our an­
alytic thought about illth as distinct from the synthetic embodied experience of
sufferers. We want comfortably to separate Marxist analysis from phenomeno­
logical imagining and to label and separate ourselves accordingly. On the way to
prison, Gramsci met a Sicilian whom he knew to have been arrested, like his own
father many years before, for mixed criminal and political reasons.
We introduced ourselves. The Sicilian stared at me for a while, then asked,
“Gramsci, Antonio?’’ Yes, Antonio! 1 answered. “It can’t be,’’ he said, “An­
tonio Gramsci must be a giant, not a little squirt like you.’’ He didn’t say any
more, just withdrew to a comer, sat down on an unmentionable object and, like
Marius above the ruins of Carthage, meditated on lost illusions. During all the
time we had to stay in the same room, he avoided speaking to me and didn’t even
say good-bye at the end. [Lawner 1975:73]

Gramsci embodied (and thus enminded too) the unity of thought and feeling,
meaning and practice, optimism and pessimism, victory and defeat—and above
all the inextricably tangled interaction of biological and social ill being. His per­
sonal and political writings can help make the humblest medical anthropologist a
Parsifal or a Kundry.

Notes

The original version of this introduction was given at the University of Kent at Can­
terbury as part of a memorial workshop to Derek Allcom (1928-1986) who, in very dif­
ferent circumstances, nevertheless resembled Gramsci in the volume and excellence of the
unpublished work he left behind. I learned, first by listening to him as a fellow student 30
years ago and later by reading Gramsci, that Marxism was not the prediction of certainties
but rather asking questions and relentlessly, but with good humor, pursuing the answers in
life as well as theory without ever expecting final solutions.
Correspondence may be addressed to the author at the Centre for Medical Social An­
thropology, University of Keele, Staffordshire UK ST5 5BG.
'No complete versions of either the Letters or the Notebooks are available in English.
In Italian, the standard edition of the Letters, last revised in 1965, does not include a group
of letters not generally available for political and other reasons until collected together in
April 1987 and issued as part of a two-volume edition of all the letters by the newspaper,
L'Unitd, on the 50th anniversary of Gramsci’s death in 1987. The period about which there
is controversy is discussed in Paolo Spriana’s Gramsci in Carcere e il Partito, a new edition
of which also appeared in 1988, given away with L’Unitd. An English translation of the
1977 edition of this work was published by Lawrence and Wishart in 1979.
^Gramsci was not to know how, with the accession of Pope John XXIII and the ini­
tiation of Vatican II, the simplicities of Bergamo were, in 1958, to combine with the sub­
tleties of the Vatican in an attempt, parallel to Gramsci’s in relation to the party, to bring
the mission of the Church “in harmony with the new conditions of the times’’ (Hebble-
thwaite 1984:51).
^ “It appears I spent a whole night discoursing about the immortality of the soul, in a
realistic and historical sense, that is, as the survival of all our useful and necessary acts,
and their incorporation into the universal historic process regardless of our own wishes,
etc.” (Letter to Tania, 24 July 1933, quoted in Fiori 1970: 276, and appearing in another
translation in Lawner 1973: 257)
336 Medical Anthropology Quarterly

^“La ‘speculazione’ (in senso idealistico) non ha introdotto una trascendenza di

nuovo tipo nella riforma filosofica caratterizzata dalle concezione immanentistiche? Pare
che solo la filosofiadellaprassisia laconcezioneconsequentemente‘immanentistica’.. . .
Si potrebbe scrivere un nuovo Anti-Duhring che potrebbe essere un ‘anti-Croce’ da questo
punto di vista, riassumendo non solo la polemica contro la filosofia speculativa, ma anche
quella contro il positivismo e il meccanicismo e le forme deteriori della filosofia della
prassi” (Gramsci 1975 11932-33): 1477; English translation, Gramsci 1971:371).
*“Di solito quando una nuovo concezione del mondo succede a un precedente, il
linguaggio precedente continua a essere usato, ma appunto viene usato metaforicamente.
Tutto il linguaggio e un continuo processo di metafore, e la storia della semantica 6 un
aspetto della storia della cultura: il linguaggio € insieme una cosa vivente ed un museo di
fossili della vita e della civiltd passate. ... II termine ‘immanenza’ nella filosofia della
praxis ha un suo precise significato, che si nasconde sotto la metafora e questo occorreva
definire e precisare; in realtd: questa definizionc sarebbe stata veraraente ‘teoria.’ La filo-
Sofia dalla praxis continua lafilosofia dell’ immanenza, ma la depura di tutto il suo apparato
metafisico e la conduce sul terreno concrete della storia. L’uso 6 metaforico solo nel senso
che la vecchia immanenza 6 superala, e stata superata, tuttavia 6 sempre supposta come
anello nel processo di pensiero dacui d nato il nuovo. (Gramsci 1975:1438; English trans­
lation 1971:450; italics added). (Gramsci, partly trained in linguistics by Matteo Bartoli
during his truncated university career in Turin, retained a lively interest in the nature of
linguistic metaphor and metaphorical language. Unfortunately I have not had time to ex­
plore his discussion of the implication of an anatomical metaphor for the economy or his
metonymic argument that the mechanization of labor by day is paralleled by the mecha­
nization of nocturnal sexual experience.)
*Geertzin 1980 described “social drama” as a “form for all seasons” (1983:27-28),
and Turner replied (1982:106-107).
’This has been suggested as being of wider importance in United States society by
Scheper-Hughes and Lock (1987:17-18).

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