Frank Et Al 2010 Chronic Conditions Well-Being and Health in Global Contexts in Manderson and Smith-Morris

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Chronic Conditions, Health, and

Well-Being in Global Contexts
Occupational Therapy in Conversation
with Critical Medical Anthropology
G E LYA F R A N K , C A RO LY N B AU M , A N D M A RY L AW
Medical anthropologists know that our perspectives on chronic disease and

illness provide much-needed critiques of the hegemony of biomedicine and
insights into clinical applications. But can we make our voices heard and influ-
ence action in places where it makes a difference? For several decades a crisis
in academic jobs for social scientists has meant that interdisciplinary and inter-
professional initiatives may define some of the most important opportunities in
medical anthropology for years to come (Inhorn 2007c). Despite its phenomenal
growth and success relative to anthropology overall, the subfield of medical
anthropology has not been immune from these challenging conditions. Medical
anthropology has strong partnerships with public health, bioethics, and nurs-
ing. In this chapter, we sketch some foundations for a more concerted interface
of medical anthropology with occupational therapy in scholarship, practice,
Copyright © 2010. Rutgers University Press. All rights reserved.
and, importantly, professional developments.

Occupational therapy is a practice profession founded in the United States
in 1917. Its practitioners address health promotion, wellness and quality of life,
rehabilitation, and function. The profession’s practice base in the United States
has been mainly in medical and school settings, and a vibrant community
practice has been emerging internationally, in tandem with World Health Orga-
nization (WHO) initiatives in human rights, disability studies, and progressive
revisions in the International Classification of Function. Occupational therapy’s
core approach is the use of everyday activities with people to improve or regain
their capacity to participate in a meaningful and satisfying life. Historically, its
scope of practice has been primarily with people who have chronic illnesses
and disabilities—physical, cognitive, developmental, and psychiatric. The term
occupation, in the context of the development of this field of practice, refers to
engagement in life activities. It goes far beyond what some might think of as
230
Chronic Conditions, Fluid States : Chronicity and the Anthropology of Illness, Rutgers University Press, 2010.
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CHRONIC CONDITIONS, HEALTH, AND WELL-BEING 231
work; it includes the activities necessary to care for self and others, productive
activities related to paid or volunteer employment, school- and literacy-related
activities, and social engagement in family and community life.
Medical anthropologist Elisa Sobo (2004), writing on the interface between
pediatric medical practice and children with special needs, has reflected that
anthropologists generally see ”health” as a broad construct, consisting of physi-
cal, psychological, and social well-being, including role functionality. Occupa-
tional therapy’s definition is remarkably congruent. Based on the belief that all
people need to engage in occupation in relation to survival, health, well-being,
and life satisfaction, occupational therapy is a “profession whose focus is on
enabling a person (i.e., individual client) or a group of persons (i.e., group,
community, or an organization client) to access and participate in activities that
are meaningful, purposeful, and relevant to their lives, roles, and sense of well-
being” (American Occupational Therapy Association 2000: 3).
In this chapter, we bring together medical anthropology (Frank) and
occupational therapy (Baum and Law) and suggest how closer alignment can
benefit the two professions. As argued elsewhere, medical anthropology and
occupational therapy together with disability studies can produce and circu-
late more powerful discourses and practices to mitigate disempowering effects
of chronic conditions on everyday life (Frank and Zemke 2008). People with
disabilities and chronic conditions comprise perhaps 10 or 12 percent of the
world’s population. Disability is linked disproportionately with poverty and
social exclusion, a situation that is particularly acute in industrializing coun-
tries and struggling economies.
Medical anthropologists have demonstrated how biomedical, political–
economic, and demographic trends create specific configurations of depen-
dency and needs for chronic care. Leaders in the profession of occupational
therapy are acutely aware of the challenges of defining and providing services
to enhance opportunities for people and families with chronic conditions to
live meaningful, purposeful lives. Both professions focus on access to the range
of opportunities and activities that people may expect to enjoy in their soci-
ety. Medical anthropology typically takes a critical view of power differentials
and cultural framings that produce structural inequalities, while occupational
therapy typically intervenes at the level of individuals and their families. What
would a profession look like if it were equipped with both approaches?
What Medical Anthropologists Need to Know about

Occupational Therapy and Its Transformations:
A Cultural History in North America
Occupational therapy describes itself as working at the interface of the person

and environment, to widen and enrich the dynamic space of meaningful activ-
ity that it calls “occupation.” A thumbnail ethnography of the occupational
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232 GELYA FRANK, CAROLYN BAUM, AND MARY LAW
therapy profession today, based on two of its flagship textbooks, shows that the
profession’s own diagnostic and treatment categories are decidedly nonmedical
(Crepeau et al. 2003; Christiansen 2007). Diagnosis and treatment aim to sup-
port and enhance the “occupational performance” of patients and clients. The
profession focuses on returning, sustaining, or enhancing people’s participation
in their expected or desired lifeworlds. The experience of disability or chronic
conditions includes the client and family’s perspectives. Treatment is tailored to
each individual’s unique needs and interests. It is client centered.
Knowledge is organized, in the profession’s terminology, around the “intrin-
sic factors” that support performance and “extrinsic factors” that are grounded
in social, cultural, and environmental context. From a medical anthropology
perspective, this dichotomous tendency to view the mind-body as an organism
(“intrinsic factors”) apart from culture (“extrinsic factors”) calls for closer criti-
cal analysis. The profession strives to reintegrate the relationship between the
biological (individual) and social (environment) spheres. This is a place for a
more informed conversation between occupational therapy and medical anthro-
pology, at a moment when critical perspectives are moving to the forefront in
both professions.
Occupational Therapy’s Pragmatist Heritage:

Experience, Emergent Realities, Social Democracy
Occupational therapy remains perhaps the sole practice profession that self-
consciously carries forward an intact pragmatist philosophy of action and
experience (Breines 1986), and accordingly, its history and practice reflect a per-
vasive tension between holism and reductionism (Kielhofner and Burke 1977).
Epistemologically, the tension plays out as the tendency of the profession to
push up against biomedicine’s positivist science with constructivist and critical
impulses (Denzin and Lincoln 2008). Philosopher John Dewey, at the University
of Chicago from 1894 to 1904, and social ethicist Jane Addams, founder of the
Hull House Settlement and eventual recipient of the Nobel Peace Prize, were
the key pragmatists whose perspectives can be found in occupational therapy
(Seigfried 1996, 2002; West 1989; Westbrook 1991).
Dewey’s Chicago years were marked by a shift from pure academic phi-
losophy to pedagogical practices. He founded the famous Laboratory or “Dewey
School” at the University of Chicago in 1896 and aimed to engage the intrinsic
interest of children in meaningful, developmentally relevant activities that
would draw out their capacity to inquire more about the world and experience
their “doing” as related to valued participation in the social world. His theories
of progressive education, published originally in 1900, hinged crucially on his
concept of occupation: “An occupation is active or motor; it finds expression
through the physical organs—the eyes, hands, etc. But it also involves continual
observation of materials, and continual planning and reflection, in order that
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the practical or executive side may be successfully carried on” (Dewey 1990: 133).
This definition, which underlies occupational therapy, exemplifies the mind–
body holism, experimentalism, and open-ended adaptativeness of occupational
therapy’s pragmatist orientation.
Dewey’s pedagogy put his philosophy and politics in action (Dewey 1944). As
philosopher and social critic Cornel West (1989) notes, the school was not only
to serve as a model of how meaningful and enriching education could take place,
but also to make a practical intervention into the national debate on education.
This practical intervention was, for Dewey, a form of political activism in that the
struggle over knowledge and over the means of its disposal was a struggle about
power, about the conditions under which cultural capital (skills, knowledge,
values) was produced, distributed, and consumed. In sharp contrast to curric-
ulum-centered conservatives and child-centered romantics, Dewey advocated
an interactive model of functionalistic education that combined autonomy with
intelligent and flexible guidance, relevance with rigor and wonder.
Clearly, the impulses of occupational therapy were shaped in networks and
debates of the Progressive Era (1890–1920) about socialism, feminist theory,
antimilitarism, mental hygiene, the arts and crafts movement, and the settle-
ment movement (Boris 1986; Lears 1981; Zinn 2003; see also Breines 1986; Levine
1986; Quiroga 1995). Briefly, in 1908, Addams, Dewey, and others helped to found
the Chicago School of Civics and Philanthropy, which held some of its courses at
Hull House, and eventually became the University of Chicago’s graduate School
of Social Service Administration. Another founder, Julia Lathrop, also a Hull
House resident, served as the first woman commissioner of mental health in
Illinois, and brought the Swiss psychiatrist Adolf Meyer, in his early career as
neuropathologist at Kankakee, into the Hull House networks leading to success-
ful reforms of the Illinois state mental institutions. Later, in 1908, Meyer invited
Lathrop to help found the National Committee for Mental Hygiene and launch
a national movement for mental health reform. In the same year, 1908, Lathrop
collaborated with Reform rabbi Emil Hirsch to introduce the training course in
“Invalid Occupations” for hospital attendants.
Social worker Eleanor Clarke Slagle attended this first course in Invalid
Occupations. Shortly after, in 1910, Adolf Meyer contacted Julia Lathrop to rec-
ommend an occupational therapist to work with him in his new position at the
Johns Hopkins Medical School in Baltimore. She sent Slagle, who under Meyer
developed a new form of occupation-based treatment called “habit training”
(Loomis 1992). Slagle returned to Chicago and to Hull House in 1915 to establish
the Henry B. Favill Memorial School of Occupations, under the auspices of the
Illinois Mental Hygiene Society, the first professional school for occupational
therapists (Breines 1986). In 1917, with colleagues from several professions,
Slagle helped found the National Association for the Promotion of Occupational
Therapy (later renamed the American Occupational Therapy Association),
and immediately helped to broker the U.S. Surgeon General’s recruitment of
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occupational therapists as “reconstruction aides” to help rehabilitate military

personnel wounded in World War I. Slagle’s was the predominant influence
on occupational therapy in the first half of the twentieth century: From 1923
through her retirement in 1942, however, Slagle was director of occupational
therapy in the New York State Department of Mental Hygiene, where she
amassed a staff of more than two hundred occupational therapists. Through
most of this period, from 1923 through 1937, Slagle also served as executive direc-
tor of the American Occupational Therapy Association (American Occupational
Therapy Association 1967: 18).
Meyer and Slagle’s habit-training belied the somewhat rigid sound of its
name. The approach provided opportunities for patients with mental illness to
engage in pleasurable, meaningful, and productive activities that were adjusted
to the patient’s level of attention, emotional needs, and readiness for more com-
plex challenges. The goal was to gradually move patients from long-term chronic
care on backward to eventual community reintegration. In common with his
friends and colleagues William James and John Dewey, Meyer viewed habit in
daily life as an organizing substrate of life, one that focuses and regulates the use
of energy, and also frees the individual for more creative encounters with real-
ity (Christiansen 2007). Meyer advocated the use of natural rhythms of work,
rest, and play as a means to awaken interest through occupations and hence
promote more adaptive habits and life satisfaction (Meyer 1921/1983). He held
the pragmatist’s optimistic view that even severe chronic symptoms could be
ameliorated, even if not cured.
A Paradigm of Occupation—Tensions with Biomedicine
Occupational therapy is not isomorphic with biomedicine largely because of its

insistence on pragmatist understandings of experience and action. Hence, there
has been an ongoing tension that has been characterized from within the pro-
fession as between holism (everyday experience) and reductionism (biomedi-

cine) (Kielhofner and Burke 1977; Kielhofner 2004). Occupational therapists
work with every known medical category of chronic condition—including AIDS,
cerebral palsy, cognitive impairments, developmental disabilities, congestive
heart failure, epilepsy, emphysema, head trauma, major depressive disorder,
schizophrenia, sensory integrative disorders, stroke, rheumatoid arthritis, spina
bifida, spinal cord injury, stroke, low vision, and more.
Like every profession, occupational therapy has a distinctive way of framing
problems, its own diagnostic categories, reasoning procedures, treatment goals,
and methods of intervention (Abbott 1988). Occupational therapy focuses on
the person, what the person wants and/or needs to do (“occupation”), and the
environment in which a person lives, offering interventions to promote health
and participation. On the one hand, occupational therapists work directly with
patients to reduce incapacity due to impairment and to build skills. On the
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other hand, practitioners understand that environments can be enabling or

can present barriers to participation of those with chronic conditions and their
families. Unquestionably, culture is crucial to definitions of “chronic condition,”
“person,” “family,” “environment,” “participation,” and “barriers.” And power is
essential to promote change.
The alignment of occupational therapy in World War I with national agen-
das helped the profession expand but dampened the exuberant reformism of
the Hull House phase. Alignment with the U.S. Surgeon General allowed for
recruitment and training of hundreds of occupational therapists (“reconstruc-
tion aides”). The Surgeon General limited recruitment to young females, initiat-
ing a pattern of gender segregation and gender stratification in the profession
with respect to the institutions of health care (yet although occupational
therapists in United States are over 90 percent female, remarkably few feminist
analyses have appeared in the professional literature; see Frank 1992; see also
Pollard and Walsh 2000).
In World War II, the military again expanded the employment and status of
occupational therapists, but with greater reductionism in occupational therapy
interventions for both physical and psychiatric conditions (Gritzer and Arluke
1985; Kielhofner and Burke 1977). Yet occupational therapy’s leaders managed to
resist wholesale takeover by the new specialty of physical medicine (physiatry)
and to continue to call for more holistic approaches (Colman 1992). The goal
continues to be to promote health and wellness through meaningful activity—
that is, through occupation.
By the 1950s, in the civilian sector, occupational therapy’s pragmatist
impulses were almost entirely subordinated to medicine, given the American
medical profession’s rise to sovereignty by consolidating, in the analysis of soci-
ologist Paul Starr (1982), cultural authority, control of the market, and backing
of the state. Through the 1960s, the profession became an adjunct to medical
treatment of chronic illnesses and disabilities, and its scope of practice and
rationale were increasingly reshaped and truncated by scientific reductionism

(Kielhofner and Burke 1977). As leaders in the profession complained, occupa-
tional therapy was in danger of losing its identity and becoming no more than a
set of splintered treatments for discrete aspects of specific diagnoses. Likewise,
the patient’s skills were in danger of being splintered.
Occupational therapy sought to find its way back to its initial “paradigm of
occupation” through the leadership of Mary Reilly. A former captain in the U.S.
Army Medical Specialist Corps, and self-described “bricoleur,” Reilly provided
intellectual firepower to change the profession from within, beginning with
curriculum reform (Reilly 1958, 1969). Occupational therapy’s curriculum was
then, as now, nationally accredited. Reilly argued the need to push back against
medical dominance and to put occupational rather than medical knowledge at
the core of the curriculum and to raise entry into the profession to master’s
degree level.
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The strategy of professional empowerment through control over curriculum

was carried forward by Elizabeth J. Yerxa (1967, 1979, 1983) with faculty at the
University of Southern California, resulting in the creation of a new doctoral
degree program in 1989 in a new discipline called occupational science (Yerxa et
al. 1990; see also Clark et al. 1997; Zemke and Clark 1996). Occupational science
was, in this founding statement, “the study of the human as an occupational
being including the need for and capacity to engage in and orchestrate daily
occupations in the environment over the lifespan” (Yerxa et al. 1990: 6). The new
discipline has spurred professional development and interdisciplinary research
around a pragmatist core in North America, Australia, New Zealand, Scandinavia,
the United Kingdom, Western Europe, South Africa, and countries in East Asia.
Occupational Therapy’s Encounters with Social Theory
Social theory in occupational therapy could be better elaborated and examined

through the lens of a critical medical anthropology (Scheper-Hughes 1994;
Singer and Baer 1995). Like many practice professions seeking to add dimensions
of experience and meaning in research, it turned at first to ostensibly value-free
naturalistic methods such as ethnography and grounded theory. Importation of
qualitative methods into occupational therapy was at first similarly atheoretical
(Kielhofner 1981, 1982a, 1982b).
How might occupational therapy research and practice look if building
interventions in light of cultural theories? How might occupational therapy
address Alzheimer’s disease as a marker of modernization’s effect on kinship
and beliefs about personhood in India (Cohen 1998); shifting cultural con-
structions and political intersections of feminist theory, disability studies, and
rehabilitation in the life of women with disabilities in the United States (Frank
2000); the impact of media representations, new technologies, and networks of
care in China (Kohrman 2005); the moral ambiguity of biomedicine and family
dilemmas posed as a result of medical technology at the end of life under late
capitalism (Kaufman 2005); or the moral understanding of illness and debility
produced through colonialism and industrialism in an African nation such as
Botswana (Livingston 2005)?
In the 1960s, Reilly reached out to mainstream mid-twentieth-century
functionalist sociology to restore a social dimension to occupational therapy
discourse, research, curriculum, and practice. The resulting approach or frame-
work for knowledge, known as “occupational behavior,” offered a biologically
informed model of human development wedded to the conservative role theory
of Harvard sociologist Talcott Parsons. Despite the tendency of Parsonian sociol-
ogy to reify the normal, and thereby delineate deviance, Reilly’s occupational
behavior approach took an open and emergent view of the person–environment
relationship by way of the metascience approach known as dynamic systems
theory (Reilly 1974).
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By the 1980s, scholarly development was urgently needed in occupational

therapy in the academy. Departments throughout the country found themselves
under threat of extinction unless they demonstrated fuller credibility, with
doctoral-degreed, tenure-track faculty producing research in high-impact peer-
reviewed journals. Similar pressures were affecting the much larger, better rec-
ognized, and more fully funded profession of nursing (Corbin and Strauss 1988),
and in an impressive phenomenology of nursing knowledge and expert practice
(Benner 1984). Both nursing and occupational therapy were facing up to the
residue of prejudices in Western culture and in the academy against knowledge
and practices associated with manual activity and female-gendered work (Frank
1992; Rose 1986).
The American Occupational Therapy Foundation (AOTF) initiated and
funded a participatory action research project, the Boston Clinical Reasoning
Study. The resulting publications included the books Healing Dramas and Clinical
Plots: The Narrative Structure of Experience (Mattingly 1998) and Clinical Reason-
ing: Forms of Inquiry in a Therapeutic Practice (Mattingly and Fleming 1994). The
project built upon research on practical reasoning by Mattingly’s mentor Don-
ald Schön (1983). The parallels between Benner’s and Mattingly’s projects are
instructive about the material production of the two female-gendered profes-
sions in the mid-1980s and their ethnographic approaches and elite theories of
the action and the social world to effectively disclose the rich dimensionality of
their practice. Medical anthropologists need to give much more careful scrutiny
to occupational therapy practice in Mattingly’s (1998) study of clinical practice,
which has contributed the much-cited concept of narrative emplotment—that
is, the anticipation of future storied outcomes through meaningful action in
a figured world. Occupational therapy provided a particularly strong venue
for observing emplotment because of the profession’s pragmatist orientation
toward experience, time, and action.
A body of work by occupational therapist and medical anthropologist Juli
Evans McGruder, begun in the 1990s, aimed to inform culturally sensitive and
antiracist practice related to mental health in the United States and in Zanzibar
(Evans 1992a, 1992b, 1992c; McGruder 2003, 2004a, 2004b; Cena et al. 2002).
Her publishing reveals a very different style of reporting in occupational therapy
and theoretical depth anthropology, suggesting that the two disciplines were not
reading each other’s work. Occupational therapist and anthropologist Virginia
Dickie focused on women’s craft production and the anthropology work as it
related to well-being (cf. Dickie and Frank 1996; Frank 1996a).
Grounded theory, not ethnography, is unquestionably the most widely
used of all the qualitative methods in the practice professions such as nursing,
education, and occupational therapy. Both grounded theory methods and social
justice inquiry fit pragmatist emphases on process, change, and probabilistic
outcomes. The pragmatist conception of emergence recognizes that the real-
ity of the present differs from the past from which it develops. With respect to
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occupational therapy research using grounded theory, it is crucial that a deeper

engagement with critical approaches and social theory move analyses beyond
the initial discovery of grounded categories and basic social processes (Frank
1997). Ethnographic approaches should add not only greater theoretical acu-
ity to occupational therapy studies, but also a more powerful appreciation of
context—that is, how environments are shaped by physical, geographical, social,
cultural, political, ethno-racial, gender, economic, and class-based systems of
enablement and oppression.
Despite the door opening to ethnographic and narrative approaches, the via-
bility of occupational therapy departments in the academy in the United States
is increasingly linked to funding from the National Institutes for Health (NIH),
National Institute for Disability and Rehabilitation Research (NIDRR), and the
Centers for Disease Control (CDC). Major federal funders mainly have supported
positivist-oriented, interdisciplinary team-based research (e.g., Baranek et al.
2008, Cascio et al. 2008), with a preference for randomized clinical trials ( Clark
et al. 1997, 2001). The specific contributions of occupational therapy researchers
may not always be identifiable when presented within a rehabilitation paradigm
(cf. Ottenbacher et al. 2008, 2009 ). However, the long-running Boundary Cross-
ing Grant, funded by the National Institute of Child Health and Human Develop-
ment, an NIH agency, is an ethnographic study based solely in an interpretative
approach, reporting on the relationships of African American mothers and their
children with chronic illnesses and disabilities with professional care providers.
The study illuminates the narrative construction of family experiences and how
common themes permit families and caregivers to “partner up” to support the
children’s participation and functioning in daily life (Lawlor 2003, 2009; Lawlor
and Mattingly 2009; Mattingly 2003, 2006; Mattingly and Lawlor 2001).
Occupational Therapy, Disability Studies,

Critical Medical Anthropology
Occupational therapy goals are similar in principle to those first articulated by

Disability Studies Movement and Independent Living Movement activists in the
1970s (Frieden and Spencer 1985). Disability activists proposed a critical “inde-
pendent living paradigm” to counter the prevailing “rehabilitation paradigm”
(deJong 1979; see also Crewe and Zola 1983; Scotch 1984/2001; Charlton 2000).
Disability studies activists gained passage of the Rehabilitation Act of 1973 and
later the Americans with Disabilities Act of 1991. The movements gave rise to the
interdisciplinary field of disability studies with its cultural studies focus on the
relationship between production and circulation of media representations and
power (cf. Davis 2006). Disability studies has recently added a critical dimen-
sion to occupational therapy perspectives on the use of assistive technology,
social construction of disability, and the effect of resource distribution on par-
ticipation (e.g., Hammel and Finlayson 2003a, 2003b; Nepveux 2006).
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The discourse on environmental constraints lends itself to occupational

therapy’s core pragmatist concerns with democratic participation (Law et al.
2007; McManus et al. 2006; Mihaylov et al. 2004; Welsh et al. 2006). Occupa-
tional therapists have been able to make use of ecological models that are widely
shared across health professions internationally (Hancock and Perkins 1985).
Critical medical anthropology and disability studies scholarship can deepen the
usefulness of such models, however, by illuminating the differential effects of
power through Foucauldian, late Marxist, feminist analyses (cf. Scheper-Hughes
1994, 1987; Rose 2007; Levin and Browner 2005). The intersection of critical med-
ical anthropology, disability studies, bioethics, and feminist theory is already a
leading area where occupational therapy work in neonatology, developmental
care, community programming for adults with autism, and sensory integra-
tive therapy can complement and develop anthropological insights (Landsman
2003, 2004; Landsman and Van Riper 2007; Ginsburg and Rapp 1995).
Medical anthropologist and disability studies scholar Devva Kasnitz discusses
how rapprochement might be further achieved (2008; also see Kasnitz 2001,
and Kasnitz and Shuttleworth 2001). Citing Shakespeare’s (2006) and Thomas’s
(2007) work, Kasnitz suggests that disability scholarship has gone too far in
rejecting all impairment-based descriptors and approaches. When the agenda
is healthcare policy, according to their views, the polarization of medical model
versus social model of disability is faulty and does a disservice to the potential
well-being of some people with chronic conditions. With others, they call for a
“sociology of impairment” as well as of disability (Hughes and Paterson 1997).
Kasnitz’s move opens a new and potentially productive conversation between
occupational therapy, critical medical anthropology, and disability studies.
The Social Production of Health in Global North and South:

Occupational Therapy in World Perspective
World systems and dependency theories help to explain the history, distribu-
tion of occupational therapy, and its patterns of practice internationally, as
elaborated in a fuller analysis by Frank and Zemke (2008; also Block, Frank et al.
2008). Most occupational therapists practice in the United States and Europe,
according to World Federation of Occupational Therapists statistics on member-
ship in national associations. American and British influences after the First and
Second World Wars fueled the expansion and influence of occupational therapy
profession internationally, which was exported as an “allied health” component
of biomedicine and rehabilitation (see also Wilcock 2001).
At the present moment, however, a critically informed international move-
ment has emerged to promote practice with populations ignored or actively
oppressed by mainstream institutions. The Occupational Therapy without
Borders movement and its networks of colleagues operate within mainstream
institutions, but also—and perhaps mainly—outside conventional healthcare
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systems (Watson and Swartz 2004; Kronenberg and Pollard 2005). They often
collaborate with NGOs and local partners using microcredits and other mecha-
nisms to create viable and sustainable economic and social development proj-
ects. Adding a sharp political analysis otherwise absent from the discipline and
thrust of occupational science and other mainstream academic approaches in
occupational therapy, the Occupational Therapy without Borders work concerns
itself with the problem originating with the inception of the WHO definition
of health in 1946, and discussed cogently by critical medical anthropologists
Betty Wolder Levin and Carole Browner (2005)—that is, how to conceptualize
“health” as well-being in the positive sense, not merely as the absence of disease
or infirmity.
In this way, occupational therapy practice is reaching beyond the clinic and
even the basically medical model of Community Based Rehabilitation (CBR),
with its focus on the individual, promoted by the United Nations since the
1980s. The relative power of the profession in the United States to disseminate
knowledge and practice calls for coherent critical analyses. But it will not be
enough to focus on environmental barriers affecting specific populations and
interventions, no matter how well-guided by disability studies and other social
justice concerns (e.g. Block, Ricafrente-Biazon, et al. 2005; Block and Rodriguez
2008). We must now also focus on the chronic conditions that afflict the profes-
sion, as occupational therapists strive to improve the quality of life for individu-
als, families, and communities in both the Global North and Global South.
Children and older adults tend to be considered the most vulnerable sec-
tors of any population, and together consume most healthcare resources in the
Global North. Nearly a third of occupational therapy practitioners in the United
States work with adults age sixty-five years or older (29.6 percent) (American
Occupational Therapy Association 2000: 11). Yet there is a critical shortage of
occupational therapists to address problems of people of all ages living with
chronic illnesses and disabilities. The U.S. Department of Labor, Bureau of
Labor Statistics, predicted a 27 percent surge in jobs for occupational therapists

in the United States for the decade 2004-2014, a trend driven by biomedical,
functional, and social structural challenges of aging (http://www.bls.gov/oco/
ocos078.htm, accessed 11/14/09).
Meanwhile, the absolute numbers of older adults is growing worldwide,
which will likely increase their contact with occupational therapists. The num-
ber of older adults will increase from 6.9 percent to 12 percent—that is, from 550
million to 973 million people worldwide (Kinsella and Velkoff 2001). Further,
it is the developing countries of the Global South that now are rapidly going
through the “demographic transition” in which the aging population is occu-
pying an ever greater proportion of the total population. At the same time we
are seeing a change in the causes of death with a shift from infectious disease
and acute illness to chronic and degenerative conditions. Thus the burden of
care of sick and disabled older adults in these countries—many of which lack a
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well-developed state-supported social welfare infrastructure or system of medi-

cal care—will fall on families with decreasing numbers of younger people avail-
able to provide resources and care.
There is a great need to manage chronic health conditions so that a people
can age “in place” with dignity and make contributions to their families and
their communities. In the United States we refer to “independent living,” but
we understand that “interdependent living” may be a more experience-near
concept. Occupational therapy’s response is to promote the integration of
healthy practices into everyday life—while realizing that the conditions to do so
are often controlled by forces and entities other than the individuals, families,
and communities affected. Nearly 80 percent of all persons over sixty-five in the
country have at least one chronic health condition and 50 percent have at least
two (National Center for Chronic Disease Prevention 1999).
While the majority of older adults are healthy and managing their everyday
life activities, others face limitations that lead to social isolation and activity
restriction. As people age, they accumulate life experiences and their occupa-
tional histories grow and diversify, with likes and dislikes, along with customs
and expectations from their respective cultures and societies affecting how they
respond to help to remain active (Law 2002). The biological changes inherent
in the aging process create challenges, yet many older adults have a tremendous
amount of reserve capacity as evidenced by the large number of active octoge-
narians in our society today. For many, age-dependent changes are not sufficient
to produce difficulties in everyday performance (Hooyman and Kiyak 2005). If
occupational therapists are able to help older adults compensate for, adapt to,
and accommodate to limitations that stem from biological changes it becomes
a major resource to families, and particularly to women, as most of the care of
vulnerable populations is provided by the family and other informal caregivers,
typically female.
In addition to so-called “normal aging,” our society today is challenged
with the increasing prevalence of chronic illnesses in older adults, including

type 2 diabetes, hypertension, stroke, cancer, and heart disease (Moody 2002).
Although these illnesses have a genetic component, they are known to stem
largely from unhealthy lifestyle patterns and choices (Rowe and Kahn 1997).
Such behaviors are related to the absence of meaningful occupation (i.e., living
a sedentary lifestyle) or the engagement in potentially harmful occupations (i.e.,
smoking, overeating). Therefore, in addition to the necessity for older adults
to do something, it is essential for them to choose what they do wisely, on the
basis of long-term health-related outcomes, to ensure maximum quality of life
as they age (Foster et al., forthcoming). Scarcely any attention is paid except by
occupational therapists to the question of the specific needs of people aging
who already have chronic conditions and disabilities.
If we look to practical, multidimensional models of “successful aging,”
such as Rowe and Kahn’s (1997), performing occupations helps in three key
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components: (a) the avoidance of disease and disability, (b) the maintenance of
cognitive and physical capacity, and (c) active engagement with life. Crowther
and colleagues (2002) expand the model to include spirituality, a phenomenon
that requires occupational therapists to understand not only the unique needs
and thoughts of individuals and the meanings they attach to their occupations,
but also an appreciation of dynamic local traditions, meaningful venues for
action, and local knowledge. We are finding that healthful occupations serve
a preventative function against age-related illnesses that result in long-term
disability (Everard et al. 2000; Law 2002; Rowe and Kahn 1997). This engage-
ment can reduce the burden of care on families, communities, and our nation’s
institutions when people’s functional capacity begins to decline—and also cre-
ate opportunities for occupational therapists to work both in healthcare and
community facilities. At the same time, our goal should be to keep people out
of institutions unless absolutely necessary, and to humanize institutional and
especially nursing home care.
Occupational therapists are being called on to bridge between medical
and community care. The advances in technology (smart home monitoring,
robotics, assistive technology, and even programmed electrical stimulation to
support muscle movement) is making it possible for persons with cognitive and
mobility limitations to live independently. Occupational therapists will interact
with engineers, designers, and architects to enable environments that remove
barriers that threaten the independence and health of persons with disabili-
ties. There is also an important role for occupational therapists to partner with
employers to prevent work-related injuries and illness, transition injured work-
ers back to work, and support the needs of workers with disabilities.
Let us turn to the situation of children. Most children with chronic condi-
tions and disability live in communities rather than institutions. The prevalence
of childhood disability and limitations to participation in daily activities has
been found to be 6.5 percent in the United States (Newacheck and Halfon 1998),
4.2 percent in Canada (Statistics Canada 2002), and 4.6 percent in Australia
(Bradbury et al. 2000). Children are dependent—by definition. Children with dis-
abilities, however, tend to have less control over their day-to-day activities than
children without disabilities. Their participation in everyday activities differs
and reflects more time spent in self-care and passive activities within their home
environment (Brown and Gordon 1987; Law et al. 1999). Environmental barriers in
home, community, education, and policy prevent children with disabilities from
developing satisfying patterns of social participation (Law et al. 2007). The situa-
tion is exacerbated by the tendency of parents, teachers, medical personnel, and
policy makers to make decisions for children with disabilities at ages when their
peers without disabilities have more autonomy and control (Law et al. 1999).
Canadian occupational therapists working within the Canadian single-payer
universal healthcare system experience more freedom to spend time in commu-
nity settings working with families on issues of social participation than their
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counterparts in the United States. Until recently, however, the primary focus of
children’s treatment centers in Canada and other developed countries has been
to ameliorate the effects of disability by changing the child’s skills to facilitate
normal development. There was little consideration of the rights of children and
integration into community life—perspectives introduced by the independent
living and disability studies movements (Gliedman and Roth 1980). The built
environment, production of space, increased classification, the perception of
disability as deviance, and distribution of power create disabling environments.
The separation of private and public space—and decreased political influence
of the home and families—are mirrored in city planning, gated communities,
inner cities, and in workplaces, households, schools, shopping districts, and
transportation networks.
How has society created environments that are so stubbornly restrictive for
children with chronic conditions and disabilities? A Foucauldian (1973, 1975)
perspective on the diffuse technologies of biopower helps to explain why barri-
ers are so pervasive and resistant to change. Research in occupational therapy
from this perspective shows that design limitations are only a manifestation
of disabling regimes of knowledge (discourses) that begin with measurement
of surface characteristics, lead to categorical and statistical norms, and end
with marginalizing “difference” (Law et al. 1999). Naming the historical roots
of power, the relationship between power and knowledge, and the institution-
alization of quantifiable classifications in society are not part of occupational
therapy’s working vocabulary and techniques. But they do govern the conditions
in which practice takes place. Families speak about being forced to live in “two
worlds”—a world of “normality” and a world of “disability,” while in reality they
and their child’s occupational therapists experience the child’s abilities on a
continuum (Law et al. 1999).
Speaking realistically, the North American sector of the profession must
deliver science-driven responses that hold up empirically—for example, in reha-
bilitation medicine where neuroscience theories and emerging technologies for

brain imaging are having a powerful impact on the construction of knowledge
and on patient outcomes (Dumit 2004; Rose 2007). We state these questions in
the ordinary language of North American occupational therapists’ concerns—
with the expectation that dialogues with medical anthropology (and especially
a critical medical anthropology) may alter their everyday clinical framing and
focus (cf. Ong and Collier 2005). Occupational therapy seeks to:
■ Understand the role of sensory, motor, cognitive, psychological, and

physiological mechanisms on the development of skills and abilities that
support daily life and how these mechanisms change with health condi-
tions, injury, maturation, and/or aging.
■ Determine the impact of biological and environmental factors on activity
performance and participation in daily life.
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■ Develop means of measuring cognitive, physiological, neuro-behavioral,

and psychological capacities of individuals as they engage in tasks neces-
sary to support daily life.
■ Develop measures that are sensitive to learning, behavioral, or compen-
satory strategies that support recovery, adaptation, and environmental
interactions.
■ Develop, apply, and evaluate personal, environmental, and activity-specific
interventions to promote health, rehabilitate function, and prevent sec-
ondary conditions that threaten an individual’s independence and quality
of life.
■ Determine the efficacy of interventions that contribute to optimal develop-
ment, recovery, prevention, and compensatory strategies for older adults.
World Anthropologies, World Occupational Therapies
Some occupational therapy clinician-scholars are attempting to reconfigure

North American concepts, theory, and practice in non-Western settings (e.g.,
Minato and Zemke 2004a, 2004b; Zemke 2004). Japan ranks second in the
number of occupational therapists and its practice reflects the influence of the
United States. The Japanese Ministry of Health and Welfare established the first
occupational therapy school in 1963 with a teaching staff mostly of occupational
therapists from the United States (Japan Association of Occupational Therapy,
http://www.jaot.or.jp/e-history.html). Michael Iwama (2005), Tomoko Kondo
(2004), and Etsuko Odawara (2005), who received their doctorates in North
American programs, have been attempting to develop more culturally sensitive
treatment models in Japan. Their efforts parallel the new literature by anthro-
pologists attempting to foreground culture-near concepts about culture in Japan
(Yamashita 2006). And these efforts, in turn, contribute to the emerging articu-
lation of world anthropologies (Ribeiro and Escobar 2006) and world medical
anthropologies (Saillant and Genest 2007; Baer et al. 2004).

We must ask why these Japanese anthropologists and Japanese occupational
therapists are not in conversation with one another working on topics like aging
and senility in Japan. Medical anthropologist have indeed been producing work
on daily occupation, the culturally mediated experience of the body and bodily
performance, and function and performance “in place” over the life span in Japan
(Traphagan 2000, 2002, 2003, 2004, 2008; also Yamamoto-Mitani and Wallhagen
2002). At present the medical anthropology literature is underrecognized and
underutilized, despite the likelihood that it could help to counterbalance the
hegemony of North American occupational therapy concepts and practices.
There is pressing need in the Global South (and among resource-poor and
disempowered communities elsewhere) for trained professionals to provide
knowledge and interventions to improve opportunities for people with chronic
illnesses, disabilities, and otherwise disrupted lives. The WHO (2004) has
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redefined its approach to disability in terms of the right of all people to social
participation with dignity. A broad, often radical movement focused on social
justice publishes under the rubric Occupational Therapy without Borders (Kro-
nenberg and Pollard 2005; Watson and Swartz 2004). New models of a critical
social occupational therapy practice include collaborative models for social
transformation, to address structural violence associated with neoliberalism
and globalization and other inequities in development policies (cf. Galheigo
2005; Frank and Zemke 2008).
Australian- and Canadian-based occupational therapists building on the
liberatory potential of occupational science, propose a social justice agenda
(Townsend and Wilcock 2004; Townsend and Whiteford 2005). Leaning on theo-
ries of social justice in law, philosophy, and politics, they carve out a distinctive
meaning for the concept of “occupational justice.” In doing so, they extend a
disability studies discourse of equal access and opportunities for people—not
only with disabilities, but incarcerated populations, refugees in internment
camps, marginalized classes, excluded ethno-racial groups, and those disadvan-
taged by gender—to engage in the range of meaningful, purposeful, valued, and
rewarding activities (“occupations”) in their society. Much of this work takes an
explicit political perspective: Simó Algado and Burgman (2005), for example,
describe a project that mobilized and trained former teachers and families in
Kosovo to facilitate expressive and increasingly joyful play activities for children
emotionally traumatized or physically injured by war.
Occupational therapists claim a radical political edge by working with
populations oppressed related to their occupations in Europe, Latin America,
Asia, and Southern Africa, so bringing it closer than ever to the conventional
fields and interests of medical anthropology. Kronenberg and Pollard (2005)
propose a heuristic of “political activities of daily living” (pADLs) for students
and practitioners. The “pADL” shorthand is a send-up of the stock rationale
for occupational therapy services under the rehabilitation paradigm—that is,
assisting people with disabilities to take care of their daily basic biological and
minimal self-care functions, known as activities of daily living (ADLs)—such as
bathing, toileting, oral hygiene, and grooming. The small p serves as a playful
reminder to occupational therapists to question therapeutic situations as to the
hidden power dimensions that can result in disempowering outcomes.
This shift to a political practice of occupational therapy informed by mainly
left social theorists such as Marcuse, Foucault, Freire, Sen, Chomsky—and a
host of occupational therapy theorists (mainly female)—moves the profession
beyond advocacy toward participation in social transformation (Pollard et al.
2008). We find a parallel here with the conversation in anthropology about
creating a more “public anthropology” and “reclaiming applied anthropology”—
calling for the profession of anthropology to become more performative, more
practice oriented, morally refocused, collaborative, and action oriented (Rylko-
Bauer et al. 2006; Lassiter 2005; see also Field and Fox 2007).
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With substantial contributions from occupational therapy consultants, the

WHO has revised its view of disability and health. WHO’s International Clas-
sification of Function in disability and health was developed in the 1980s with
a then cutting-edge disability studies model that distinguished among “impair-
ment” (biological), “disability” (function), and “handicap” (social). The Interna-
tional Classification of Function (WHO 2001) now more broadly embraces goals
of social participation with dignity, acknowledging that health is determined
mainly by social, economic, and political conditions.
Conclusion
Anthropology and occupational therapy meet once again, but at a new moment,
where both professions are poised to deal with health in a global context from
a critical standpoint. In calling for deeper conversations and more active insti-
tutional linkages we perhaps tread a pioneer path for other health professions
that are inherently more interested in health and well-being than in elimina-
tion of disease. Yet medical anthropology is not a practice profession working
directly with populations. It is an academic field. The American Occupational
Therapy Association includes thirty-nine thousand members, a cohort three
times the size of the American Anthropological Association. According to the
U.S. Department of Labor, the number of occupational therapists is actually
about a hundred and thirty thousand. Despite cyclical economic recessions,
occupational therapists are in high demand and employment opportunities will
continue to rise.
In the sophisticated interdisciplinary academic environments in which
occupational therapy must survive, stronger institutional ties are needed with
medical anthropology, public health, disability studies, and other fields that
can help to build social theory and critical standpoints affecting not only clini-
cal encounters and lifeworlds of suffering, but the profession itself. An applied,
clinical, and interpretative (constructivist) medical anthropology that is already

in place should and must continue to explore and report on the lifeworlds and
experience of patients and suffering. The value of a critical medical anthropol-
ogy for occupational therapy will figure largely in contributing to the empower-
ment of the profession itself—and thereby its ability to help improve lives of
people with chronic conditions. The question that occupational therapy should
prompt critical medical anthropologists to ask is: Together what can we do?
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12

Chronic Conditions, Health, and

Medical anthropologists know that our perspectives on chronic disease and

and, importantly, professional developments.

What Medical Anthropologists Need to Know about

Occupational therapy describes itself as working at the interface of the person

Occupational Therapy’s Pragmatist Heritage:

occupational therapists as “reconstruction aides” to help rehabilitate military

A Paradigm of Occupation—Tensions with Biomedicine

Occupational therapy is not isomorphic with biomedicine largely because of its

fession as between holism (everyday experience) and reductionism (biomedi-

other hand, practitioners understand that environments can be enabling or

rationale were increasingly reshaped and truncated by scientiﬁc reductionism

The strategy of professional empowerment through control over curriculum

Occupational Therapy’s Encounters with Social Theory

Social theory in occupational therapy could be better elaborated and examined

By the 1980s, scholarly development was urgently needed in occupational

occupational therapy research using grounded theory, it is crucial that a deeper

Occupational Therapy, Disability Studies,

Occupational therapy goals are similar in principle to those ﬁrst articulated by

The discourse on environmental constraints lends itself to occupational

The Social Production of Health in Global North and South:

Labor Statistics, predicted a 27 percent surge in jobs for occupational therapists

well-developed state-supported social welfare infrastructure or system of medi-

with the increasing prevalence of chronic illnesses in older adults, including

bilitation medicine where neuroscience theories and emerging technologies for

■ Understand the role of sensory, motor, cognitive, psychological, and

■ Develop means of measuring cognitive, physiological, neuro-behavioral,

World Anthropologies, World Occupational Therapies

Some occupational therapy clinician-scholars are attempting to reconﬁgure

anthropologies (Saillant and Genest 2007; Baer et al. 2004).

With substantial contributions from occupational therapy consultants, the

clinical, and interpretative (constructivist) medical anthropology that is already

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