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To the Instructor
Teaching medical anthropology is both exciting and
challenging. Undergraduates are able to relate to sick-
ness and healing because they have had some lim-
ited experience with them. Of course, many of your
students are thinking of careers in the health care
industry. Learning about the multiple causes of dis-
ease and the cultural variation in healing practices
makes students examine their own lives and culture
with a fresh perspective; one of the real satisfactions
of being a teacher comes from watching students get
excited by such an intellectual journey. It is also sat-
isfying when students become increasingly aware of
the health problems of others, especially the poor at
home and around the world. At the same time, teach-
ing medical anthropology is challenging because of its
amorphous nature and the astounding growth of the
body of theory and knowledge. How does a profes-
sor organize such a course? How do you decide what
examples to use?
This book is divided into two main parts. Part
I illustrates the variety of theoretical and analytical
approaches used by medical anthropologists. Part II
provides examples of those approaches as they relate
to a variety of health issues and problems; hence the
title of the reader—Understanding and Applying Medical
Anthropology. The first part of the book makes apparent
that we hold a very broad view of the scope of medical
anthropology and that we are committed to the tradi-
tional four-field approach of general anthropology. We
believe that the application of anthropological knowl-
edge—the job of making our research useful—is part
of the responsibility of all anthropologists. Aspects of
nearly all anthropological work are relevant to under-
standing and solving human problems. That is why
we use the term applying medical anthropology rather
than the narrower and more specific applied anthropol-
ogy (in both this and other edited readers). The latter
term refers to anthropological work done by an applied
anthropologist for a client on a problem identified by
the client. We think students want to read about anthro-
pological research and analysis on relevant topics, and
the second part of the collection provides some good
*The reference listings for all citations in To the Instructor, To the Student, and all chapter introductions and Conceptual
Tools sections are in the References section at the end of the book.
examples of such work. At times we have included
two or more selections on a similar topic in order to
enhance in-class discussions. Thus the organization of
this book suits a heterogeneous approach to a medical
anthropology course.
As far as we can tell, there is no agreement about
how a basic course in medical anthropology should
be taught. Almost 35 years ago, the first special pub-
lication of the new Society for Medical Anthropology
(SMA) concerned teaching medical anthropology; the
volume included nine different model courses (Todd
and Ruffini 1979*). The diversity of those courses—
ranging from ethnomedicine, to biomedical anthro-
pology, to family structure and health—was impres-
sive. Today, the SMA website has a section on teaching
resources that includes more than 50 syllabi.
Theoretical diversity has been a continuing hall-
mark of medical anthropology, and its importance is
reflected in most of the edited textbooks of the field.
However, the relatively few regular textbooks in the
field have had, by necessity, a more narrow theoreti-
cal focus, such as the ecological approach (McElroy
and Townsend 1996) and the cultural aspects of heal-
ing and medicine (Foster and Anderson 1978; Helman
1994; Strathern and Stewart 2010). Recently some new
books have provided a synthesis of medical anthro-
pology, even as the discipline has expanded and the
theoretical basis of research has become more sophis-
ticated (Anderson 1996; Hahn 1995; Janzen 2001;
Joralemon 1999; Nichter 2009; Singer and Baer 2012:
Wiley and Allen 2008; Winkelman 2008).
The first and second editions of this book were
well received. There is a need for a reader in medical
anthropology that includes original research articles
that can accompany the texts, ethnographies, and
case studies that we use in such courses. As we have
collected course syllabi from other medical anthro-
pologists over the years, we have been struck by
the diversity and richness of the teaching resources
available. For the first edition, we thought it would
be easy to assemble such a reader, but it turned out
to be quite a difficult task—partially because of the
8 To the Instructor
expanding breadth of the field and partially because
there are so many fascinating articles available. Our
first list included more than 220 articles, and when we
asked colleagues to help cut them down, they simply
suggested more titles. The list got much longer for the
second and third editions. It was a long and painful
process to make the selections.
In the end, we selected the readings with five cri-
teria in mind:
n Readability: reading levels appropriate for upper-
division undergraduates who have already taken
a basic anthropology course
n Diversity: a mix of classic articles and more recent
contributions
n Different theories: a range of orientations
n Level of difficulty: a range of theoretical difficulty
or sophistication
n Ethnographic variation
Many selections are from the standard professional
journals in the field, including Medical Anthropology
Quarterly; Medical Anthropology; Social Science and Med-
icine; Human Organization; Anthropology and Medicine;
and Culture, Medicine, and Psychiatry.
To add to the pedagogical value of this collection,
we have included section and reading introductions.
In section introductions, we emphasize the “concep-
tual tools” that are put to work in each kind of medi-
cal anthropology. Students should be reminded of the
central concepts before they start reading the details
of a particular case. In selection introductions, we
describe the context for the problem at hand by rais-
ing related issues and by listing some questions for
discussion. Most introductions and conceptual tools
sections include bibliographic suggestions for further
reading, which are listed at the back of the book. These
references may be useful for undergraduates who are
writing term papers or for graduate students who are
developing a stronger grasp of the field. There are,
of course, a great many other resources in medical
anthropology, many of which are available through
the Society for Medical Anthropology.
We are painfully aware that, owing to space
constraints, many important topics in medical
anthropology are not represented here, including eth-
nopharmacology, health policy, childbirth, gerontol-
ogy, embodiment, phenomenology, and specific clini-
cal cases. We hope that instructors using this book feel
free to contact us with their opinions about selections
that work (or do not work) and with suggestions for
future editions.
NEW TO THE THIRD EDITION
One of the main challenges in revising this reader has
been to update it without completely changing a text
that has been warmly received. The combination of
newer articles and “classics” was designed for maxi-
mum pedagogical benefit. We believe that the new
selections are great vehicles for teaching and encour-
aging class discussion. Many new articles are original
to this reader, written with an undergraduate audi-
ence in mind. We think that these new chapters—writ-
ten by many of the field’s leaders, including a number
of Margaret Mead Award winners—convey clearly to
undergraduates the current vitality and relevance of
medical anthropology.
We have reorganized the section and subsection
headings to fit current themes in medical anthro-
pology. In addition to section and article introduc-
tions—with thought questions for your students—a
context box appears at the end of the introduction
to each selection; these short pieces are intended
for more advanced students interested in knowing
where the articles fit within the intellectual history
of medical anthropology—and they often describe
the author’s larger research agenda and discuss why
this particular article was written. This background
information can help students to appreciate the read-
ing more fully. (The article’s original source citation,
when applicable, appears on the bottom of the chap-
ter-opening page, along with the book’s copyright
statement.)
Over the years we have heard positive feedback
about the conceptual tools introduction, especially from
students. Therefore, we have updated and expanded
these bullet points where appropriate.
To the Student
What initially sparked your interest in medi-
cal anthropology? The prospect of studying other
medical systems, such as shamanism? The thought
of discovering what made disease rates increase in
ancient societies? Your concern about the serious
health problems in the United States and through-
out the world? An interest in how people are affected
by chronic disease, or in the culture of Biomedicine?
All these topics—exotic and mundane—are related
to medical anthropology. Or maybe your interest is
related to your career ambitions or current work in
the health care field. Whatever the case, you will find
the study of medical anthropology to be intriguing
and intellectually rewarding.
We also hope that you find the study of medi-
cal anthropology to be relevant to your life—if only
because disease, illness, healing, and death are uni-
versal in the human experience. All cultures have
medical systems. Whether you participate in a medi-
cal system as a patient or a healer, there is real value
in understanding the big picture of how and why that
system works. But, as the title of this book suggests,
you first need to understand medical anthropology
before you use it to make a difference in the world.
As you skim through this book, notice the
extremely wide variety of topics included within
medical anthropology. This diversity is based on the
broad, holistic approach that anthropology takes to
the study of human biology and cultures. In the United
States, anthropology traditionally includes four fields;
biological or physical anthropology, archaeology, cul-
tural anthropology, and anthropological linguistics.
Medical anthropology is not one of the four fields;
rather, it involves the use of anthropological concepts
and methods from all four fields in the study of health,
disease, and healing. One of the hallmarks of medical
anthropology, therefore, is the theoretical and practi-
cal diversity within the field.
Most medical anthropologists, like most anthro-
pologists in general, concentrate on the cultural end
of the field. Many courses in medical anthropology
do not deal with evolutionary or biological questions.
Your course instructor will likely pick and choose
selections according to his or her orientation to the
field. That is as it should be, but we hope that you
will also see this book as a resource for independently
exploring other approaches.
We have selected the readings with you, the stu-
dent, in mind. Primarily, we picked selections that
contain interesting case studies or that are controver-
sial and might help to spark class discussions. But
we also wanted the selections to reflect diversity—in
terms of both sophistication and the areas of the world
represented. Some readings are classics in the field
written by famous anthropologists. Although these
articles may be older, they usually make for wonder-
ful reading. Most of the articles are from professional
scholarly publications (for example, Medical Anthro-
pology Quarterly; Medical Anthropology;
Social Science and Medicine; Culture, Medicine, and
Psychiatry; and Anthropology and Medicine), and they
will, on occasion, require concentrated reading on
your part. You may want to skim the article first to
familiarize yourself with the overall structure of the
argument. “Prereading” for the main ideas is not a
substitute for the real reading, but it can prepare you
to understand the article when you do read it.
In the introductions we have provided orientations
to the general context and framework of the material.
Section introductions provide important “conceptual
tools”; put these concepts and vocabulary tools into
your own personal intellectual toolbox and “own”
them. Each selection introduction also includes ques-
tions to ponder. These questions will help you to place
a particular selection into the larger scheme of things,
to get you to think about the broader (and sometimes
unanswerable) questions involved. At the end of each
introduction, you will find a “context box” that will
tell you something about the selection’s author and
why the article was written.
Because medical anthropology is such a diverse
field, we have divided this book into two main parts.
Part I introduces you to the multiple approaches used
by medical anthropologists in their research and other
work. Part II is about applying medical anthropology.
This part covers a variety of different problem areas—
from doctor-patient communication to global health
programs—and presents selections that illustrate how
anthropological analysis can be relevant to under-
standing and solving those real problems.
10 To the Student
Note that there is an important field called “applied
anthropology” in which people, including medical
anthropologists, do research, program implementa-
tion, and program evaluation for particular clients who
hire them to work on particular problems. The writings
of these applied anthropologists are often in reports for
their clients. The selections in Part II do not all fit neatly
within the domain of applied anthropology. Although
many discuss particular solutions to a problem—
such as the AIDS epidemic or social stigma related
to disease—the main purpose of other selections is
to get readers to rethink the problem in a new way.
This rethinking is what is meant by “applying” medi-
cal anthropology (Podolefsky, Brown, and Lacy 2011).
If you are interested in learning more about
medical anthropology, you may want to consult one
of its handbooks. They include the classic collection
by Sargent and Johnson, Medical Anthropology: Con-
temporary Theory and Method (1996), the two-volume
Encyclopedia of Medical Anthropology by Ember and
Ember (2004), and A Companion to Medical Anthropol-
ogy by Singer and Erickson (2011). If you are thinking
about graduate study, you may want to consult the
website of the Society for Medical Anthropology
(www.medanthro.net). The major academic journals
in the field include Medical Anthropology Quarterly;
Medical Anthropology; Social Science and Medicine;
Culture, Medicine, and Psychiatry; and Medicine and
Anthropology.
We hope you enjoy the selections here and that
you learn a lot from your study of medical anthro-
pology. What you learn in this course will encourage
you to think more broadly about disease, healing,
illness experiences, and medical systems at home and
around the world.
Peter J. Brown and Svea Closser
September 2015
Part I
UNDERSTANDING MEDICAL ANTHROPOLOGY
Biosocial and Cultural Approaches
Page Intentionally Left Blank
 1
Medical Anthropology: An Introduction
Peter J. Brown
Svea Closser

Chances are you just started taking this course in medi- paradigm or model. For example, medical anthropology is
cal anthropology, and you are not sure what exactly it not limited to the study of exotic, non-Western medical sys-
is going to be about. Chances are also that one of your tems, even though the description of religion and healing
friends—or your roommate or even your parents—will systems is as old as anthropology itself. The field now also
ask: “Sounds interesting, but what is medical anthropol- has other areas of research, such as the cultural analysis of
ogy?” The purpose of this selection is to help you to be pre- biomedicine and the understanding of the globalization of
pared to answer that question. As you will see, it is not an biomedical technologies.
easy one to answer. Many medical anthropologists have As you read this selection, consider these questions:
this problem, for example, at cocktail parties. Part of the
problem is that many people—even well-educated ones— n What do anthropologists mean by culture, and
do not really know what anthropology is. Therefore, when how is it related to health and healing?
some people ask the question, they have a preconception n Why is the distinction between disease and ill-
that anthropology means only archaeology. In this situa- ness important in medical anthropology? Why
tion, your challenge is to gently help them out by saying might this difference not be very important to
something like this: “Although some medical anthropolo- physicians and other health care providers?
gists do study the health of prehistoric populations, most
n Which of the different approaches in medical
medical anthropologists use a cultural orientation to study
anthropology seems most interesting to you?
health and medicine in contemporary populations, espe-
Why?
cially multiethnic ones like our own.” But long definitions
are not always useful. Therefore, to keep the conversation
interesting, have a few examples of medical anthropologi-
cal research at hand. Chapter 1’s selection provides some
Context: The following article, updated by Peter
interesting ones.
Brown and Svea Closser, was originally provided
Medical anthropology studies human health prob-
for this reader by Ron Barrett, Mark Padilla, and
lems and healing systems in their broad social and cul-
Erin Finley. Peter Brown is a professor of anthro-
tural contexts. Medical anthropologists engage in both
pology and global health at Emory University;
basic research on issues of health and healing systems
Svea Closser is an associate professor of anthropol-
and applied research aimed at improving therapeutic care
ogy and global health at Middlebury College. In
in clinical settings or improving public health programs
the years since the first (much different!) version of
in community settings. Drawing from biological, social,
this article was written, medical anthropology has
and clinical sciences, medical anthropologists engage in
grown exponentially, developing into a rich and
academic and applied research, contributing to the under-
varied field. It is a measure of the field’s diversity
standing and improvement of human health and health
and ongoing evolution that not all medical anthro-
services worldwide.
pologists will agree with the structure of the disci-
Medical anthropology is inherently interdisciplinary—
pline as it is presented here.
meaning that it is not characterized by a single theoretical

Understanding and Applying Medical Anthropology: Biosocial and Cultural Approaches (3rd ed.) by Peter J. Brown and Svea Closser, 13–24 © 2016
Taylor & Francis. All rights reserved. Chapter 1 original article source: P. J. Brown and S. Closser. 2015. Medical Anthropology: An Intro-
duction to the Fields. In P. J. Brown and S. Closser (Eds.), Understanding and Applying Medical Anthropology (3rd ed.).

13
14 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches
WHAT IS MEDICAL ANTHROPOLOGY?
M
edical anthropology is the application of anthropo-
logical theories and methods to questions of health,
illness, medicine, and healing.
The Society for Medical Anthropology uses a
more lengthy definition:
Medical Anthropology is a subfield of anthropology
that draws upon social, cultural, biological, and lin-
guistic anthropology to better understand those fac-
tors which influence health and well-being (broadly
defined), the experience and distribution of illness,
the prevention and treatment of sickness, healing pro-
cesses, the social relations of therapy management, and
the cultural importance and utilization of pluralistic
medical systems. The discipline of medical anthropol-
ogy draws upon many different theoretical approaches.
It is as attentive to popular health culture as bioscientific
epidemiology, and the social construction of knowl-
edge and politics of science as scientific discovery and
hypothesis testing. Medical anthropologists examine
how the health of individuals, larger social formations,
and the environment are affected by interrelationships
between humans and other species; cultural norms and
social institutions; micro and macro politics; and forces
of globalization as each of these affects local worlds.
(Society for Medical Anthropology 2015)
This definition can be daunting to someone coming
to anthropology for the first time, but its essential
point is as we stated: Medical anthropology is the
anthropological study of health and healing. Medi-
cal anthropology takes the tools of anthropology and
applies them to human illness, suffering, disease,
and well-being.
To understand what medical anthropology is,
then, one must understand anthropology as a whole.
Introductory anthropology courses usually begin
with some variation of the short and classic definition:
“Anthropology is the study of humankind.” Although
a bit vague, this definition underscores that anthro-
pology is a holistic and interdisciplinary enterprise
that uses many different approaches to understand
important human issues. In the broadest sense, these
approaches are usually categorized into four major
subfields: cultural anthropology, physical or biologi-
cal anthropology, anthropological archaeology, and
anthropological linguistics.
These days, however, introductory courses are
often the first and last places where anyone gives much
thought to the relationships among these four sub-
fields of anthropology. In recent decades anthropol-
ogy has gone the way of many academic disciplines.
Its subfields have become increasingly specialized,
each with its own dictionaries and theoretical orien-
tations. As a result of these increasingly specialized
differences, the academic discussions between the
subfields of anthropology have gotten scarce. Such
trends are unfortunate, because the compartmentali-
zation of anthropology often undermines the disci-
pline’s greatest strengths: its holistic approach and
interdisciplinary nature.
Culture is, of course, a central concept in
anthropology—although its definition is contested.
One definition of culture is “the learned patterns
of thought and behavior shared by a social group.”
Culture includes not only belief systems but also the
economic systems and social structures that affect
how people live. Many selections in this book show
how culture has profound influences on health.
But because health is influenced not only by cul-
ture and social structure but also by evolution and
biology (and in fact we argue in this book that biol-
ogy and culture are inseparable), medical anthropolo-
gists often draw on more than one subdiscipline. For
example, some selections in this reader show how the
biology, growth, and development of human beings
are historically and currently shaped by cultural
influences. Human biology and culture are intimately
related, and so we should adopt a holistic perspective
when we are studying human health and sickness.
In regard to the four traditional subfields of
American anthropology (cultural anthropology,
physical or biological anthropology, anthropologi-
cal archaeology, and anthropological linguistics), the
most common type of anthropologist is a cultural
anthropologist. And most practicing medical anthro-
pologists were trained in cultural anthropology. But
medical anthropology, a relatively new area of spe-
cialization, is not really a subfield, partly because, as
we mentioned, subfields of anthropology generally
have a central theoretical paradigm. In contrast, medi-
cal anthropologists use a wide variety of theoretical
perspectives—and they often do not agree on which
ones are best. As you will see, medical anthropolo-
gists apply a range of theories and methods to issues
of human health, sickness, and healing.
BASIC CONCEPTS
As is the concept of culture, the notion of health is
difficult to define. According to the charter of the
World Health Organization, health is “a state of com-
plete physical, mental and social well-being, and not
merely the absence of disease or infirmity” (World
Health Organization 2015a).
What constitutes well-being in one society, how-
ever, may be quite different from another. The ideal
of a lean-figured body—a sign of health in the West—
may indicate sickness and malnutrition in sub-Saharan

Africa (Brown 1981). In the fishing villages that line
Lake Victoria, the parasitic disease schistosomiasis is
so prevalent that the bloody urine of young males is
considered a healthy sign of approaching manhood
(Desowitz 1987). In the United States, the “elegant pal-
lor” and “hectic flush” of consumption (tuberculosis)
were often imitated by healthy people at the turn of
the 20th century because of the disease’s association
with famous writers and artists (Sontag 1983). Any
conceptualization of health must therefore depend
on an understanding of how so-called normal states
of well-being are constructed within particular social,
cultural, and environmental contexts.
Core Concepts
Medical anthropologists use two terms to talk about
states of ill health: illness and disease. Disease refers to
the clinical manifestations of altered physical function
or infection. It is a clinical phenomenon, defined by
pathophysiology. Illness, in contrast, encompasses the
human experience and perceptions of alterations in
health, as informed by its broader social and cultural
dimensions.
This distinction helps in understanding many
important phenomena, such as interactions between
patients and healers. For example, a doctor using a
disease model may see the patient’s symptoms as
the expression of clinical pathology, a mechanical
alteration in bodily processes that can be “fixed” by a
prescribed biomedical treatment. From the patient’s
perspective, however, an illness experience may
include social as well as physiological processes. The
physician’s diagnosis may not make sense in terms
of the patient’s understanding of her illness, and the
doctor’s “cure” may not take into consideration the
patient’s family dynamics, the potential for social
stigma in the community, or lack of money to follow
through with treatment.
Healing practices that humans use range from
cardiac bypass surgery, to amulets worn for protec-
tion against the evil eye, to conflict resolution between
kin groups. Shamans, priests, university-trained phy-
sicians, and members of one’s family may assume a
healing role at any given time in a person’s life. All of
these, including biomedicine, are aspects of ethnomedi-
cines, medical systems firmly tied to cultural systems.
A Critical Perspective
In the last part of the 20th century, medical anthropol-
ogy experienced a significant break from its past. Dur-
ing this period, there were intense intellectual debates
1 Medical Anthropology: An Introduction 15
about the approaches sometimes called critical theories,
including postmodernism and Marxism. In general,
these approaches require people to critically exam-
ine their own intellectual assumptions about how the
world works; the basic idea is that our ideas of reality
are shaped by our culture and that sometimes these
ideologies conceal complex political relationships.
These debates influenced cultural anthropology
in general and medical anthropology specifically. An
important outcome was the development of critical
medical anthropology, a perspective that coalesced in
the 1980s and 1990s (Singer 1989). These days, the per-
spectives of critical medical anthropology are main-
stream within medical anthropology. Most medical
anthropologists agree with two broad critiques that
critical medical anthropology made of earlier work.
The first critique was that many medical anthro-
pologists had incorrectly attributed health disparities
to cultural differences without examining the influ-
ence of global political-economic inequality on dis-
ease distribution. In the past, medical anthropologists
had tended to view illness as existing within local
cultural systems, and they neglected the larger politi-
cal and economic context within which these cultures
are found. Critical medical anthropologists described
how large-scale political, economic, and cognitive
structures constrain individuals’ decisions, shape
their social behavior, and affect their risk for disease.
Readings in this book that exemplify this approach
are in Chapter 11 by Paul Farmer and Chapter 14 by
Merrill Singer.
One example of this kind of thinking was
Meredeth Turshen’s analysis of the political-economic
dimensions of disease in Tanzania. Turshen described
how a history of colonialism drastically affected
the country’s nutritional base, altered its kinship
structure, and imposed constraints on its health
care system. She questioned previous studies’ focus
on local culture and emphasized an alternative she
called the “unnatural history of disease” (Turshen
1984). Critical medical anthropologists made similar
arguments concerning health disparities in wealthier
countries like the United States.
Because of their interest in macro-level forces
(such as world capitalism), critical medical anthro-
pologists were generally skeptical of health policies
that proposed local solutions. Thus critical medical
anthropologists not only challenged the local focus of
traditional medical anthropology but also criticized
the narrow focus of health interventions that did not
address the large-scale factors influencing disease
(Morsy 1990).
The second critique made by critical medical
anthropology centered on the questioning of underly-
ing epistemologies (ways of knowing) and conceptual
16 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches
categories of medicine and Western culture in general.
For example, the 16th-century French mathematician,
scientist, and philosopher René Descartes articulated
a fundamental cultural model of the separation of
mind and body. This is a “culturally constructed”
idea that many people take for granted in everyday
thought and talk. But your own experiences of emo-
tional states—not to mention recent discoveries in
neuroscience—make it clear that the body/mind dis-
tinction is not quite true. Similarly, there are many
notions embedded in everyday clinical medicine that
are culturally constructed and often based on meta-
phors. For example, low blood pressure is consid-
ered a dangerous sign of heart problems in Germany,
while in the United States it is considered a marker of
excellent health (Payer 1988). The ideas and practice of
medicine cannot be separated from culture.
From our perspective, the mainstreaming of the
critical perspective within medical anthropology has
led to many important developments, including an
energetic engagement with social justice and health
disparities. Paul Farmer, a physician and anthropolo-
gist who also directs the nonprofit organization Part-
ners in Health, has been highly influential in this area.
Farmer’s most famous work highlights the impact of
global inequality on the emergence of such infectious
diseases as HIV/AIDS and multidrug resistant tuber-
culosis (Farmer 1999, 2004). In providing a critical
perspective on global inequalities in health, Farmer
and many others have effectively highlighted how
socioeconomic and political factors cause profound
inequalities in health and disease.
A Practice Orientation
Medical anthropologists engage in research on issues
of health and healing systems, as well as research
aimed at the improvement of therapeutic care and
public health programs. Sometimes these types of
research are labeled as “basic” or “applied,” respec-
tively, but because medical anthropologists study
human health, most “basic” research has obvious
practical relevance, and many of the field’s core the-
oretical concepts were developed by people actively
engaged in clinical and public health work. There is
a great deal that we do not know about the causes of
sickness and the processes of healing; anthropologists
can contribute to the growth of human knowledge in
these important areas. At the same time, anthropolo-
gists contribute to the design and implementation of
programs alleviating complex health problems. This
back-and-forth between engagement and reflection
energizes the discipline.
Many medical anthropologists, then, have a
practice orientation (Inhorn and Wentzell 2012), even
as they think theoretically. Unlike other social scien-
tists, medical anthropologists generally think they
have an obligation to act to improve human health
(Fassin 2012). This belief, however, doesn’t mean
that they agree on what action is appropriate. Medi-
cal anthropologists’ critical perspectives indicate that
they are very aware that the institutional structures
of biomedicine and public health sometimes entrench
inequalities rather than alleviate them. Most medical
anthropologists are constantly reflecting on whose
interests their involvement in these structures serves
(Singer 1995).
Some medical anthropologists are very actively
engaged within biomedical and public health institu-
tions. For a significant period of its history, medical
anthropology dealt with the health beliefs and prac-
tices of ethnic minorities. Margaret Clark’s Health in
the Mexican-American Culture (1959) is a good exam-
ple of such work. Her analysis emphasizes, for exam-
ple, that it is insufficient simply to translate medical
instructions when the patient population has limited
literacy and biomedical language (in any language)
is unfamiliar to them. Medical anthropologists have
often been called to assist in improving communi-
cation across both language and cultural barriers
between patients and their health care providers. Such
problems in communication have been described
in Anne Fadiman’s book The Spirit Catches You and
You Fall Down (1998), which deals with the conflicts
between the family of a Hmong child and her Ameri-
can doctors. Some perspectives on “cultural compe-
tency” training programs in medical schools can be
found in Part II in the section titled “Working with the
Culture of Biomedicine.”
Not all anthropologists agree that these training
programs are a good thing. Several medical anthropol-
ogists have argued that such programs reinforce racial
stereotypes rather than dealing with power inequities
that are at the root of poor health outcomes (Carpenter-
Song, Schwallie, and Longhofer 2007; Gregg and Saha
2006). Such active debate and reflection—both engaged
with and critical of practice—is a hallmark of medi-
cal anthropology. A critical analysis of such a cultural
competency course at Harvard Medical School can be
found in the selection in Chapter 35.
Anthropologists working within clinical settings,
however, do much more than talk about culture and
communication. Anthropologists within the Veterans’
Administration (VA), for example, work on a variety
of issues, including the root causes of substance abuse
and homelessness in female veterans (Cheny et al.
2013; Hamilton, Washington, and Zuchowski 2013)

and the improvement of mental health services for
veterans with posttraumatic stress disorder (PTSD)
(Besterman-Dahan, Lind, and Crocker 2013; Finley
2013).
In addition to clinical settings, many anthropolo-
gists work in public health policymaking, program
development, and intervention. Anthropological per-
spectives are relevant at all levels of the public health
process, from the interpretation of disease trends to
the design, implementation, and evaluation of pro-
grams. For example, medical anthropologists working
on the Ebola response did research on topics from the
role of informal health workers in the Ebola response
to the long-term investments needed for stronger
health systems and the reasons why some people
might resist interventions aimed at stopping Ebola
(Ebola Response Anthropology Platform 2015). They
also argued compellingly in international venues that
public health agencies should stop conceptualizing
culture as a barrier and a source of misinformation
and should instead focus on designing responses the
desires and needs of recipient populations in mind
(Chandler et al. 2015).
Yet other medical anthropologists think that ana-
lyzing and writing, often from within the academy, is
the best way to create positive change. These medi-
cal anthropologists believe that it’s hard to think and
write critically about health institutions if one is too
close to them (or working for them), so they advocate
speaking truth to power from outside such structures,
often from academic positions.
Through work both practical and theoretical,
medical anthropologists contribute to our under-
standing of issues with life-and-death consequences.
They approach these issues from a wide variety of
theoretical perspectives, all rooted in anthropology.
FIVE BASIC APPROACHES TO
MEDICAL ANTHROPOLOGY
The scope of anthropological inquiry into issues of
human health, sickness, and healing is very diverse—
so diverse in 2015 that writing this introduction,
which characterizes the field, is intimidating. None-
theless, we’ve identified five basic approaches to med-
ical anthropology:
1. biological
2. ecological
3. ethnomedical
4. experience-near
5. studies in and of biomedicine.
1 Medical Anthropology: An Introduction 17
The first two of these approaches emphasize the inter-
action of humans and their environment in a way
that we consider biosocial—that is, with a focus on
the interaction between biological/health questions
and socioeconomic and demographic factors. The last
three of these approaches to medical anthropology are
cultural—they emphasize the concept of culture (the
patterns of thought and behavior characteristic of a
group) and how people experience life.
For all the diversity of the field, nearly all medical
anthropologists share four essential premises: (1) that
illness and healing are best understood in the com-
plex and varied interactions between human biology
and culture; (2) that disease is influenced by culture,
economics, and politics; (3) that the human body and
symptoms are interpreted through cultural filters;
and (4) that the insights of medical anthropology have
important pragmatic consequences for the improve-
ment of health and health care in human societies.
1. Biological Approaches in Medical
Anthropology
Much research in biological anthropology concerns
important issues of human health and illness. Many
of the contributions of biological anthropologists help
to explain the relationships between evolutionary
processes, human genetic variation, and the differ-
ent ways that humans are sometimes susceptible, and
other times resistant, to disease.
The evolution of disease in ancient human popu-
lations helps us to better understand current health
trends, a concept described in more detail in Chapter
8’s selection by George Armelagos, Peter Brown, and
Beth Turner. For example, the recent global trend of
emerging and reemerging infectious diseases, such
as tuberculosis and AIDS, is influenced by forces of
natural and cultural selection that have been pre-
sent throughout modern human evolution. During
the time of the Paleolithic (about 2,500,000 to 200,000
years ago), early human populations lived in small
bands as nomadic hunters and gatherers. The low
population densities during this period would not
have supported the acute infectious diseases found
today; instead, chronic parasitic and insect-transmitted
diseases were more prevalent.
The shift toward sedentary living patterns and
subsistence based on plant and animal domestication,
sometimes called the Neolithic Revolution (about
10,000 b.c.e.), had a profound effect on human health.
Skeletal evidence from populations undergoing this
transition shows an overall deterioration in health con-
sistent with the known relationship between infectious
18 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches
disease and malnutrition. New infectious diseases
emerged, a result of increasing population density,
social stratification, decreased nutritional variety, prob-
lems of clean water and sanitation, and close contact
with domesticated animals (Armelagos, Goodman,
and Jacobs 1991; Cockburn 1964). These changes had
a disproportionate effect on women, young children,
the elderly, and the emerging underclass, who were
most susceptible to infections in socially stratified
societies (Armelagos and Cohen 1984).
Currently, great threats to human health come
from chronic degenerative conditions. These so-
called diseases of civilization, such as heart disease,
diabetes, and cancer, are the leading causes of adult
mortality throughout the world today. Many of these
diseases share common etiological (causative) fac-
tors related to human adaptation over the last 100,000
years. For example, obesity and high consumption of
refined carbohydrates and fats are related to increased
incidences of heart disease and diabetes. Human sus-
ceptibility to excess amounts of these substances can
be explained by the evolution of human metabolism
over millions of years in contexts of relatively large
amounts of exercise, seasonal food shortages, and
diets low in fat (Konner and Eaton 2010; Weil 2008).
A related theory of “thrifty genes” was pro-
posed to explain relatively shorter-term evolution-
ary changes that account for genetic variation in the
susceptibility to chronic diseases between different
contemporary populations (Neel 1982). Some popula-
tions have significantly higher prevalences of adult-
onset diabetes and hypertension than others. The
thrifty-gene hypothesis proposes that genes affecting
insulin physiology were selected for, allowing people
to adapt to an irregular food supply. This adapta-
tion arose during times of “feast or famine” for cer-
tain populations, including some Native Americans,
oceangoing Pacific Islanders, and African Americans
descended from slaves. In the context of modern diets,
however, these genes add to the burden of chronic
disease (Lieberman 2008).
But variation in human susceptibility to chronic
diseases cannot be accounted for by genetic explana-
tions. Environmental and sociocultural factors play
a primary role. Health disparities between ethnic
groups in the United States are a result of discrimi-
nation leading to poorer living environments and
increased stress, among other causes of poor health
(Dressler 1996; Williams 1999).
Some biological contributions to medical anthro-
pology critique the misapplication of biological con-
cepts. During the late 19th century, measurements
of cranial size were taken of Jewish and Southern
European immigrants to the United States and com-
pared with those of Anglo-American residents. The
differences in cranial size between these populations
were used to support a theory of racial hierarchy based
on hereditary differences in brain size. By careful com-
parisons between first- and second- generation groups
from these immigrant populations, Franz Boas (the
founder of American Anthropology) was able to dem-
onstrate that these differences were attributable to
environmental influences on body size (Boas 1940).
Subsequent analyses have discredited previous stud-
ies relating measurements of intelligence to those
of cranial capacity (Gould 1981), and categories of
human races have been shown to have little validity
in the study of human variation (Goodman, Moses,
and Jones 2012).
Some biological anthropologists also contribute
to the field of ethnopharmacology. Anthropologists
in this field consider not only the physiological prop-
erties of plant substances but also issues related to
their selection, preparation, and intended uses within
particular social settings and broader cultural frame-
works (Etkin 1996).
Biological anthropology plays a central role in
the field of evolutionary medicine, which considers
how survival pressures over the course of evolution
may have shaped human biology. Health research-
ers who incorporate an appreciation of the ongoing
effects of natural selection on the physiology of peo-
ple and other organisms may be equipped to develop
more sophisticated approaches in their efforts to
treat or prevent disease (Nesse and Williams 1996).
For example, research on SIDS (sudden infant death
syndrome) and children’s sleeping arrangements has
shown that despite statements by many officials in the
United States that infants should always sleep alone,
mother-infant cosleeping (the evolutionary norm)
may be the safest choice for babies in particular social
and economic contexts (McKenna and McDade 2005).
Biological anthropology’s appreciation for the inter-
connectedness between genes and environment has
led to many developments in the field of evolution-
ary medicine and holds promise for many more. The
reading selection in Chapter 3 deals with this topic.
2. Ecological Approaches
Ecology refers to the relationships between organisms
and their total environment. Within medical anthro-
pology, the ecological perspective focuses on the inter-
actions between environmental contexts and human
health. An ecological approach to medical anthro-
pology emphasizes that the total environment of the
human species includes the products of large-scale
human activity, as well as “natural” phenomena, and
that health is affected by all aspects of human ecology.

It includes attention to how people survive in varying
environments, how they find food, how they distrib-
ute resources, how they deal with disease, and how
the demographics of their population are changing
over time (McElroy and Townsend 2014). Pathogens
that cause infectious disease, such as the malaria par-
asite, and factors that affect risk for chronic disease,
for example, diet, are closely tied to humans’ relation-
ships with their environments. The term medical ecol-
ogy has been used to describe this approach.
Two broad levels of analysis inform this approach.
At the micro level, cultural ecology examines how cul-
tural beliefs and practices shape human behavior,
such as sexuality and residence patterns, which in
turn alter ecological relationships between host and
pathogen. At a broader level, political ecology exam-
ines the historical interactions of human groups and
the effects of political conflict, migration, and global
resource inequality on disease ecology (Brown, Smith,
and Inhorn 1996). Many ecological approaches to
medical anthropology include some aspects of both
cultural and political ecology. Malaria and schistoso-
miasis provide two useful examples.
Malaria is a disease caused by a microscopic
Plasmodium parasite that is transmitted to human
hosts through contact with mosquitoes of the genus
Anopheles. These mosquitoes breed and multiply in
stagnant pools of water in warm climatic regions of
the world. Malaria has a long and sordid history in
many societies, and it continues to be a major cause of
human morbidity and mortality today (Brown 1997).
At a cultural ecological level, adaptations to malaria
include highland Vietnamese building practices, in
which stilted houses allowed people to live above the
10-feet mosquito flight ceiling (May 1958). In another
ecological context, although malaria had been eradi-
cated in the southern Italian island of Sardinia, Brown
discovered that many cultural practices functioned
to reduce contact with malaria-carrying mosquitoes
(Brown 1981;) see the selection in Chapter 7). These
included settlement and land-use patterns, whereby
nucleated villages are located in highland areas and
flocks of sheep are taken to the lowlands in the winter,
thus minimizing contact with the mosquitoes during
peak malaria seasons.
At a political ecological level, however, these
adaptive cultural practices were probably motivated
by historical threats of military raids and expropria-
tion of land by foreigners. Furthermore, wealthy
Sardinians had less contact with mosquitoes because
they did not have to leave the safety of the village to
work in the fields as did the laborers, nor did they
have to stay in the village during peak malaria sea-
son when they could afford to take summer vacations
abroad. Thus, the example of malaria demonstrates
1 Medical Anthropology: An Introduction 19
that multiple ecological variables—biological, cul-
tural, political, and economic—interact to influence
the prevalence of particular diseases in a given envi-
ronmental context. In recent years—marked by the
advent of climate change—more areas of the world
have become vulnerable to malaria; this is a political
ecological phenomenon.
Schistosomiasis, a parasitic disease spread by
snails, provides a dramatic example of the relation-
ship between political ecology and disease. For dec-
ades, economic development programs throughout the
world have often focused on the building of dams to
prevent seasonal flooding, improve irrigation, and pro-
vide hydroelectric power (Heyneman 1979). Enormous
dams, such as the Aswan High Dam on the Nile River,
have dramatically altered the ecology of surrounding
areas by preventing seasonal flooding and creating one
of the largest man-made bodies of water in the world.
A byproduct of such changes, however, is an altered
relationship between human populations and certain
water-borne parasitic infections, such as schistosomia-
sis. The small snails that carry schistosomiasis thrive
in the numerous irrigation canals emanating from the
dams, increasing human exposure to the parasites. This
exposure has led to an increased risk of contracting
schistosomiasis, an infection that primarily affects chil-
dren, in people that live close to some kinds of dams
and irrigation systems. But the way this relationship
plays out depends on the larger ecological context of
the dam, as well as the socioeconomic status of people
at risk (Steinmann et al. 2006).
The story of schistosomiasis demonstrates that
political-economic forces, such as dam development
programs, can dramatically shape the relationship
between host and disease in human populations.
Thus, medical ecology’s definition of “environment”
includes the political-economic consequences of col-
lective human activity. In this globalizing world
characterized by out-of-control carbon emissions and
climate change that will have serious health effects
(Chapter 10), there is no doubt that political-economic
policies directly influence local disease ecologies.
3. Ethnomedical Approaches
All societies have medical systems that provide a
theory of disease etiology (causation), methods for the
diagnosis of illness, and prescriptions and practices for
curative or palliative (calming, soothing) treatment. The
initial development of medical anthropology derived
from anthropological interest in the healing beliefs and
practices of different cultures (Wellin 1978). These
beliefs and practices related to healing are often referred
to as ethnomedicine. Anthropological approaches to the
20 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches
study of ethnomedicine have always included not
only understanding how people think about health
and disease but also studying the social organization
of healing practices (Fabrega 1975). In the simplest
sense, all ethnomedical systems have three interre-
lated parts:
1. a theory of the etiology of sickness
2. a method of diagnosis based on the etiological
theory
3. the prescription of appropriate therapies based on
the diagnosis.
Health systems, from a cross-cultural perspective,
generally fall into two categories:
1. personalistic systems that explain sickness as the
result of supernatural forces directed at a patient,
by either a sorcerer or an angry spirit
2. naturalistic systems that explain sickness in terms
of natural forces, such as the germ theory of con-
tagion in Western biomedicine and the imbalance
of humours in many forms of Chinese, Indian,
and Mediterranean systems (see the selection in
Chapter 16).
At the beginning of the 20th century, anthropo-
logical studies of medical systems were confined to
ethnographic descriptions of “exotic” practices within
non-Western societies. Many of the observations
about sickness and therapeutic rituals were analyzed
as a window on underlying cosmological beliefs and
cultural values within comparative studies of myth
and religion. Some aspects of these works have been
criticized for a tendency to sensationalize the differ-
ences of “primitive” people in comparison to their
readership in Western industrialized societies (Rubel
and Hass 1996).
The term ethnomedicine was first defined as
“beliefs and practices related to disease which are the
products of indigenous cultural development and are
not explicitly derived from the conceptual framework
of modern medicine” (Rubel and Hass 1996). In recent
decades this arbitrary distinction supposedly “indig-
enous,” “traditional,” and “nonscientific” medical
systems and supposedly “Western,” “modern,” and
“scientific” medical systems has been abandoned by
nearly all medical anthropologists. Medical anthro-
pologists challenge the idea that biomedicine is an
empirical, law-governed science unbiased by cultural
premises. They understand that all medical systems
are constantly changing, and all are closely tied to
their cultural contexts.
In India, for example, many Ayurvedic practition-
ers receive university training, practice in commercial
institutions, and supplement their ancient therapies
with antibiotics, X-rays, and other tools of biomedi-
cine (Nichter and Nichter 1996). Likewise, many
Indian physicians trained in biomedicine use Indian
categories to explain health issues to their patients.
As another example, in her comparison of biomedi-
cal systems in Europe and North America, Lynn Payer
found considerable variability in the health beliefs
and practices that constitute biomedicine (Payer
1988). Because of these issues of cultural diversity
even within biomedicine, it is more useful to consider
ethnomedicine as the study of any form of medicine
as a cultural system. In other words, biomedicine is
one of many ethnomedical systems.
Patients often draw on the ideas of one or more
ethnomedical systems in their own understanding of
illness. They develop an explanatory model (EM), a
personal interpretation of the etiology, treatment, and
outcome of sickness by which a person gives meaning
to his or her condition. Although EMs are personal,
they are also learned cultural models, so that an EM
shared by a group might be considered a folk model of
disease. There is often disparity between the explana-
tory models of patients and healers, which may lead
to problems of communication and nonadherence to
prescribed therapies (Brown, Gregg, and Ballard 1997;
see the selection in Chapter 34).
While stated health beliefs may influence treat-
ment decisions, explanatory models alone are not
good predictors of people’s observed patterns of health
seeking—because significant differences often exist
between cultural “ideals” (what people say they do)
and “real” behavior of observable action. For example,
a study of Nepalese patients found that people often
sought multiple medical resources for a single illness
despite verbal claims to the contrary (Durkin-Longley
1984). Many different factors may weigh on decisions
concerning when and where to seek treatment, such as
the influence of family members (Janzen and Arkinstall
1982), social networks, and geographic access to health
resources (Kunitz 1989; Mumtaz et al. 2013). In many
cases, economic resources can severely limit treatment
options. Even with great strides made in lowering the
cost of antiretroviral therapy, for example, nearly two
thirds of HIV-positive people in low- and middle-
income countries do not have access to these lifesaving
drugs (World Health Organization 2015b).
4. Anthropology in and of Biomedicine
In recent years there has been an increased focus
on studying biomedicine as an ethnomedical sys-
tem of knowledge and social practice. Although this
approach has a lot in common with the study of other

ethnomedicines, it has become such a large part of the
subfield of medical anthropology that we are giving it
its own section here.
One classic example of this approach is an article
by Nancy Scheper-Hughes and Margaret Lock (1987).
They critically examined the idea that the mind and
body are separate entities, a fundamental premise of
biomedicine. They suggested that the dominance
of biomedicine had made the concept of separation
of mind and body so pervasive that people lacked a
precise vocabulary to express the complex interac-
tions between mind, body, and society.
The excellent text An Anthropology of Biomedicine
(Lock and Nguyen 2011) examines the “technologies
of the body in context,” including the human transfor-
mations (through transplants, and so on) that stretch
our moral boundaries. This focus includes an empha-
sis on biotechnologies such as genetic testing, the
use of pharmaceuticals, assisted reproduction, organ
transplants, genomics, plastic surgery, and other sci-
entifically derived treatments. In viewing how such
new technologies are taken up (or rejected) within
existing biomedical systems, we can observe how
they come to be associated with different social cir-
cumstances across different cultural settings. Repro-
ductive technologies such as in vitro fertilization, for
example, may come to epitomize one set of concerns
among women in the United States and a very differ-
ent set among men in Egypt and Lebanon. Chapter 27’s
article by Monir Moniruzzaman provides an example
of this kind of anthropological work.
The study of biomedicine sheds light on the epis-
temology of scientific and medical knowledge. Medi-
cal anthropologists study the processes by which
these forms of knowledge acquire their status as
“authoritative knowledge” rather than as “beliefs,”
the word often used to describe the knowledge sys-
tems of other ethnomedicines. As such, the distinction
between knowledge and belief can be seen as arbitrar-
ily reflecting differences in social power and therefore
as being highly questionable (Good 1994).
Studying the processes of knowledge creation in
biomedicine has provided important insight into how
“gold standards” of care and evidence come to be.
Medical anthropologist Allan Young, for example, has
shown how PTSD became accepted in the late 1970s
as a distinct mental illness (Young 1997). It was not a
process of psychiatrists suddenly discovering a new
disorder. Instead, PTSD came to be included in the
Diagnostic and Statistical Manual for Mental Disorders
(DSM), psychiatry’s official list of accepted diagnoses,
when a group of psychiatrists came together and—
urged by a vocal lobby of Vietnam veterans and their
advocates—agreed that PTSD should be recognized
despite a lack of medical and epidemiological research
1 Medical Anthropology: An Introduction 21
available to describe it. Chapter 31’s selection by Erin
Finley provides an excellent case study of PTSD in the
contemporary VA system.
Increasingly, medical anthropologists have exam-
ined the cultural and political dimensions of public
health and global health bureaucracies. Like scholars
who frame studies of biomedicine as a cultural sys-
tem, anthropologists are increasingly turning their
attention to the cultural beliefs, norms, and implicit
premises on which public health funding and admin-
istration are based (Biehl and Petryna 2013; Chandler
et al. 2015; Justice 1986). These medical anthropolo-
gists study a variety of public health agencies, from
UN agencies to NGOs to governments, and they pay
attention to the complex power relations between
these entities. Examples of this approach are in the
selections in Chapters 44 and 45, which explore the
contexts and complex effects of public health pro-
grams in Pakistan and Mozambique.
5. Experience-Near Approaches
In 1988, renowned anthropologist and psychiatrist
Arthur Kleinman published a book titled The Illness
Narratives, in which he advocated paying close atten-
tion to how people make sense of their illness experi-
ences through narrative (Kleinman 1988). He pointed
out that the stories people tell about their illnesses
can provide great insight into how they cope with
disease and suffering. Since then, what can broadly
be called an experiential approach in medical anthro-
pology has become increasingly resonant through-
out the other subfields. Anthropologists using this
approach frequently put illness-related suffering—
whether due to pain, disability, or the awareness of
one’s own mortality—at the center of their analysis.
They focus on three aspects of illness, in particular:
(1) narrative—the stories that people tell about their
illness; (2) experience—the way that people feel, per-
ceive, and live with illness; and (3) meaning—the
ways that people make sense of their illness, often
linking their experience to larger moral questions. For
example, in Chapter 23’s selection Linda Hunt con-
siders narratives from two individuals with cancer in
southern Mexico; although these two have different
cancers and face different life situations, both explain
their illness in relation to the disappointments and
obligations they have borne in their social lives.
Experiential (experience-near) approaches often
explore the links between sickness and problems in
the social world. Illness narratives in particular may
demonstrate how a symptom is experienced as trou-
bling because of its impact on relationships with oth-
ers, as when pain or fatigue interferes with a mother’s
22 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches
ability to care for her children. Narratives may also
provide a venue for negotiating the meaning of an
illness, particularly in the social space between fam-
ily members, patients, healers, and so forth. Kohn
writes of how care providers treating children with
facial disfigurements in Northern California create
“therapeutic emplotments”—essentially, complex
narratives—that are intended to help the children to
feel more comfortable with their appearance. In try-
ing to transform the children’s narratives of them-
selves and their appearance, the care providers are
in fact trying to shift the children’s experience of
their disfigurement from one of embarrassment and
shame to one of acceptance and confidence (Kohn
2000). Narrative, then, is not just a story of what has
happened, or is happening, or might happen. It can
also represent an active attempt to negotiate or con-
struct both individual selfhood and social relations
amid sickness and suffering.
A central theme in ethnographic descriptions
of illness and suffering is stigma. People who are
different—either physically, mentally, or in social
skills—are often subjected to negative judgments and
discrimination from so-called normal people; that
is, they are stigmatized. The originator of this idea
in medical social science, Erving Goffman (1963),
referred to this type of social disapproval as creating
a “spoiled identity.” The archetype of a stigmatized
disease is leprosy (Hansen’s disease), which despite
its terrible reputation is not very contagious at all.
There are both visible and invisible conditions
that are stigmatized. With visible conditions, such as
being extremely short-statured, people end up being
stared at and ostracized; this situation is described
in Chapter 36’s selection by Joan Ablon. Invisible
conditions—for example, having depression or herpes,
or having had an abortion—are usually conditions
that people prefer to keep secret; disclosing such a
condition is difficult and often socially dangerous.
A great deal of medical anthropological research
has been done on HIV/AIDS since the beginning of
the pandemic. In some ways HIV/AIDS has been an
epidemic of discrimination and stigma; however, the
availability and antiretroviral drugs has changed this
slightly (see Chapter 45).
The experiential approach has been applied most
often in the exploration of illnesses that are highly
subjective, such as chronic pain and mental illness.
These experiences, internal as they are, may be dif-
ficult to share or explain. Medical anthropologists
attempt to understand conditions such as psychosis
from within, interacting closely with and listening to
those who might otherwise be ignored because of their
difficulties in behaving and expressing themselves in
normative ways (Desjarlais 1997; Jenkins and Barrett
2003). In addition to helping social scientists rethink
the cultural boundaries between what is considered
normal verses pathological, these studies have the
potential to explore the relationship between body
and mind in a more holistic way.
Anthropologist Joao Biehl, for instance, has traced
the paths by which ongoing socioeconomic changes
in Brazil, accompanied by an increasing medicaliza-
tion of illness and infirmity, have resulted in families
leaving their mentally and physically disabled mem-
bers to live in ragged communities on the margins of
society (Biehl 2013). Following this social progression
to its outcome at the level of individual experience, he
describes how mentally ill individuals in Brazil per-
ceive and make sense of this social abandonment.
The experience of illness is something that evolves
in the space between body and mind, and between
individuals and those in their social environment; it
may change over time as the disease progresses or
resolves. In understanding how illness is experienced,
medical anthropologists gain insight into how peo-
ple endure and make meaning in some of the most
vulnerable moments of their lives, and thus they can
better appreciate how these processes play out in peo-
ple’s explanatory models, care-seeking behaviors, and
coping strategies.
CONCLUSION
Medical anthropology, like its parent discipline, is a
holistic and interdisciplinary enterprise. We began this
chapter quoting the definition of this subfield offered
by the Society for Medical Anthropology. This defini-
tion includes so many topics covering such a diverse
set of questions that some readers may think that it
was written by a committee. In the simplest sense,
medical anthropology refers to studies of health and
healing from biosocial and cross-culturally compara-
tive perspectives. In this regard, healing refers to all
medical systems, including modern biomedicine and
its sophisticated technologies, as cultural products.
Because there is such a remarkable diversity of
theories and methods used in medical anthropology,
we can appropriately talk about it as having subdisci-
plines of its own. In this article, we have outlined five
major approaches that medical anthropologists use
to better understand issues of human health, healing,
and sickness: biological and ecological (biosocial), and
ethnomedical, experience-near, and studies in and of
biomedicine (cultural). When we explore the specific
examples, however, it becomes clear that the five cat-
egories overlap.

Part I of this book—the part devoted to under-
standing medical anthropology—contrasts biosocial
approaches and cultural approaches; this seems to
be a fundamental distinction. Yet on closer examina-
tion, even this simple distinction is artificial, because
the culturally oriented analyses focus on biological/
medical processes, and the biological approaches
almost always emphasize the role of human (cultural)
behavior. Within all this theoretical and methodologi-
cal diversity, there are essential commonalities in an
anthropological study of health, illness, and healing.
These commonalities all stem from an anthropologi-
cal view of the world.
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Biosocial Approaches in Medical Anthropology
Evolution and Human Biological Variation: Chapters 2–7
CONCEPTUAL TOOLS
n Evolution is the central theoretical concept in the
biological sciences, including anthropology. Evolu-
tionary theory is able to explain literally millions of
biological observations of the natural world. The fact
that scientists argue about specific cases or that there
are parts of the evolutionary record that we know lit-
tle about should not detract from our appreciation of
this important concept.
n A driving force determining the direction, char-
acter, and speed of evolutionary change is natural
selection. Evolutionary change depends on the inter-
action of organisms and their environment. That
interaction results in differential rates of morbid-
ity (sickness), mortality, and fertility for individuals
with different traits. Genetic evolution works when
there is variation in a population based on inherited
characteristics. In the process of natural selection
some inherited traits affect the ability of individuals
to survive and reproduce; thus, over generations of
individuals living and dying in a particular ecological
context, traits that enhance reproductive fitness tend
to increase. And genetic traits that make it more likely
that individuals or their offspring will have fewer off-
spring tend to decrease. Evolutionary change includes
the possibility that, over generations, a species can
change into another species. Geographic isolation can
accelerate this process.
n There are other forces in evolution besides natu-
ral selection. These include mutation, gene flow or
migration, and genetic drift.
n Variation can be genetic (in the genes) or pheno-
typic (in observable characteristics). Some biologi-
cal variation among contemporary humans is related
to health—either phenotypic variation is the result
of different health and nutritional experiences or
genotypic variation affects patterns of morbidity (the
state of being diseased) and mortality (the number
of people who died). Differences in stature (height),
for example, may reflect the adequacy of childhood
diet, whereas genetic differences are involved with
predispositions to a wide variety of diseases (Frisancho
1993).
In 2003, because of advances in molecular biol-
ogy, scientists sequenced the entire human genome.
This was an amazing feat, but it also highlighted how
much we do not know. Gene frequency differences
usually reflect historical forces of natural selection
or migration. Comparative studies of anthropologi-
cal genetics can help in reconstructing prehistoric
patterns of population movement—for example, the
movement of Siberian people to North America. Dif-
ference in gene frequencies among populations can
also reflect historical exposure to particular factors
in natural selection—including diseases and food
shortages.
Phenotype refers to expressed biological features
resulting from the interaction of genes and environ-
ment. People living for a long period at high eleva-
tions, for example, can physiologically adapt to the
shortage of oxygen by developing greater hemo-
globin density as well as greater lung capacity. Babies
born in higher altitudes tend to be smaller than babies
born at sea level. Probably the most important mech-
anism for phenotypic variation involves nutrition.
Biological anthropologists studying human growth
and development have shown that poor growth—
stunting and wasting—is a sensitive measure of lack
of adequate food in childhood. Other kinds of mal-
nutrition, such as deficiencies in the micronutrients
iodine and vitamin A, may have permanent effects
on mental capacity. Therefore, observed biological
variations among groups often reflect environmental
rather than genetic difference.
25
Another random document with
no related content on Scribd:
creuse faconde, fléau dont tous nos écrivains et surtout nos orateurs
sont encore loin d’être indemnes.
Mais, au-dessus des romantiques et des positivistes, saluons, de
toute la vénération de notre amour, les grands apologistes, les
romanciers et les poètes catholiques sans qui nous ne serions pas
ce que nous sommes. Nommons-les ici, quand même ils sont dans
la mémoire de tous, comme on lit les noms des morts tombés au
champ d’honneur : de Maistre, Bonald, Lamennais avant son
apostasie, Balzac, en dépit de ses confusions philosophiques, Blanc
de Saint-Bonnet, Lacordaire, Barbey d’Aurevilly, Veuillot, Villiers de
l’Isle-Adam, Hello, Huysmans, Verlaine, Léon Bloy. Ces grands
aînés marchent devant nous, non pour nous imposer d’être leurs
disciples, mais pour nous exciter à faire mieux qu’ils n’ont fait.
Pour nous qui voyons de loin déjà ces luminaires d’un autre
siècle, la concordance de leurs mouvements espacés nous est un
haut signe d’espoir. Ils eurent mission de réintégrer le Christ au
centre de la pensée et du vouloir humain, et, dans cette œuvre
essentielle, ils se sont continués, comme s’échelonnent des astres
sur les routes éternelles. Entre Joseph de Maistre établissant la
suprématie du dogme et Barbey d’Aurevilly déclarant dans la
préface de l’Ensorcelée que l’art catholique, avec sa « grande
largeur », ne craint pas de toucher aux passions lorsqu’il s’agit de
faire trembler sur leurs suites, nous percevons cette commune
certitude : dans tous les domaines, aussi bien dans celui de
l’imagination que dans celui de l’intelligence, le catholicisme doit être
souverain.
Il doit l’être avant tout, au fond de l’écrivain lui-même. Si nos
aînés nous laissent des modèles imparfaits, ce n’est point seulement
que tout génie reste « court par quelque endroit ». C’est qu’ils furent
incomplètement des catholiques et des chrétiens. Supposez Balzac
prenant la peine de s’assimiler une bonne philosophie scholastique ;
il n’eût point confondu la nature et le surnaturel, comme il l’a fait
dans le galimatias de Louis Lambert et de Seraphita. Supposez
Verlaine s’évadant sans retour du cloaque où il avait expérimenté
l’immondice des instincts ; il nous eût donné mieux que la dolence
de ses faiblesses ; il se fût dépouillé d’un je ne sais quoi d’indécis et
d’artificiel qui s’insère en ses plus suaves élévations.
Car, s’il est souverain dans l’être intérieur du poète, le
catholicisme exclut de son œuvre les cabotinages littéraires, les
sournoises habiletés comme les molles négligences. Toute poésie
où une certaine forme de rythme et d’expression devient tyrannique,
calculée, porte un germe de mort, n’est pas vraiment chrétienne.
L’art chrétien, toujours difficile, est plein de pièges pour quiconque,
guetté par le démon du factice, s’y engage sans la candeur d’une foi
absolue. Et cette candeur même est plus aisée à perdre qu’à obtenir.
Il serait odieux d’en faire une attitude. Vous vous rappelez ce héros
d’un roman de Chesterton qui « voyait des anges agenouillés dans
l’herbe, avant d’avoir vu l’herbe ». Il serait beau de voir le monde
ainsi ; très peu d’entre nous — et très peu, c’est beaucoup dire —
ont ce degré d’ingénuité. Contentons-nous donc d’être sincères,
vrais devant les hommes comme devant nous-mêmes.
Le propre d’un écrivain catholique est d’aimer éperdument ce qui
est vrai. Pour atteindre le supra-sensible, nous avons à refouler le
brouillard, dense comme des ténèbres, d’un naturalisme athée. Il ne
s’agit point de fermer les yeux en le traversant, mais d’élever en
notre main la lampe ardente qui le percera. Projetons-en la flamme
hardie sur tout ce qui peut être éclairé. Quand on tient ces deux
vérités, la chute et la rédemption, il n’est aucun gouffre où l’on ne
puisse envoyer une flamme de justice, un signal de compassion, un
appel d’espérance.
Pour un artiste d’une foi vigoureuse, l’attitude en face de la
nature est aisée à définir : il regarde, il sent la vie telle que sa vue de
réaliste la lui fait voir et aimer ; et il l’interprète selon l’optique
chrétienne qui ne déforme pas les objets, qui les rejoint entre eux et
les explique en les illuminant.
Notre unanime désir est que cet ensemble d’idées aboutisse à
susciter, dans la littérature prochaine, plus d’ardeur créatrice, plus de
beauté. Durant la guerre et surtout au moment de la victoire, j’avais
espéré des temps cornéliens, un épanouissement d’enthousiasme,
d’allégresse, de force exubérante, des cris de clairons ailés dans un
soleil de gloire, puis le chœur austère des héroïsmes pacifiques
tendus vers la patrie et le monde à rénover. Ni l’esprit public, ni la
multitude des livres surgis depuis quatre ans n’ont correspondu à
cette illusion. Les Hymnes de Joachim Gasquet, symphonie
délirante, splendide par intervalles, ne chantent que le péan du
triomphe d’un jour.
Au lendemain du triomphe, le poids immense des deuils,
l’énormité de la tâche à reprendre, les déceptions du présent et les
anxiétés de l’avenir ont déterminé chez beaucoup une sorte
d’affaissement sur eux-mêmes, une dissolution des forces viriles. Il
est grand temps, pour les volontés en désarroi, de se reprendre. Aux
écrivains catholiques plus qu’à personne, il incombe de sonner le
ralliement des énergies. Je voudrais que leur voix, par-dessus la
lourde rumeur des incertitudes, ressemblât à ces cloches de balises
dont la vibration, large et douce comme celle d’un cor lointain,
domine les chocs des vents et les hurlements de la mer.
Je voudrais que les plus puissantes et les plus pures d’entre elles
fussent des cloches de cathédrale, des cloches de Te Deum, des
cloches de Fête-Dieu, des cloches de deuil aussi, de pitié ou
d’alarme, mais, plus encore, des cloches nuptiales, des cloches de
résurrection. Les âmes ont besoin de savoir qu’elles ne vont pas
mourir. D’où leur viendra, sinon du poète chrétien, en forme de libre
cantique, le message de la paix, le message de l’éternité ? Nulle
conception ne saurait être vaste et forte à l’égal du surnaturalisme
catholique. Lorsque j’en cherche l’idéale figure, je me souviens d’un
vieux mystique comparant l’amour parfait « à un anneau d’or qui
serait plus ample que le ciel, la terre et toutes les choses créées ».
Quand je m’en représente la réalité plus modeste, je pense à une
parole de l’admirable Mistral dans une lettre à Lamartine : « Si
humble et si petit que soit le grain de blé, lorsqu’il monte en épis
sous la rosée du ciel, il peut encore faire honneur à la main qui l’a
semé. »
Voilà le grand point : que le champ où nous voulons remplir notre
journée de bons ouvriers soit étroit ou large, avare ou plantureux, ne
disons jamais comme les hommes sans foi : Ce champ est à nous ; il
y a nous et rien que nous ; ne cherchons pas notre gloire, mais
rendons-la toute à la Main qui a tout donné.
 LES POSSIBILITÉS DU ROMAN CATHOLIQUE

Il ne sera jamais superflu de le redire : de toutes les formes

littéraires, la plus ardue, c’est le roman. Nulle autre ne requiert la
mise en jeu d’éléments si complexes ni une telle constance de vérité
créatrice. L’œuvre romanesque, parfaite comme est parfait, au
théâtre, Œdipe-Roi, semble un prodige encore à naître. Un bref
roman d’analyse, une idylle, un récit fantaisiste peuvent donner
l’illusion d’un ouvrage sans défaut. Mais, lorsqu’un vaste sujet
entrelace des caractères et des milieux, fait surgir, au-dessus de
figures multiples et d’une masse d’épisodes, une grande idée vitale,
cette entreprise équivaut à vouloir introduire dans le plan du réel un
système de forces, presque un monde incréé.
Pareille audace reste forcément inférieure à son objet. Elle a plus
de chances encore de ne point l’atteindre, si l’artiste veut faire tenir
en une synthèse les relations du visible avec l’invisible, s’il est un
romancier catholique et mystique.
Nous vivons dans la sphère des apparences. Elles retiennent
l’imagination par tout le poids de leurs attraits ; ou bien elles
l’oppriment par la terreur et le dégoût. Pour les dominer, il faut les
avoir scrutées sous la lumière des régions divines ; il faut aussi les
avoir bien vues d’un regard qui observe afin de représenter
fidèlement.
Le romancier catholique doit être tout ensemble un réaliste et un
surnaturaliste. Je dis réaliste, non point naturaliste. Catholique et
naturaliste, ces deux mots hurlent de se voir ensemble. Le
naturaliste s’attache au fait pour le fait ; il se pose devant la création
comme un clerc de notaire inventoriant un mobilier ; ou, s’il la
considère en philosophe, c’est, asservi à un dur système ; il saisit
dans l’homme l’animalité ; il constate les tares ataviques, la
mesquinerie des habitudes, la hideur des vices. Quand il note les
caractères d’un milieu, il n’a souci que d’ajouter quelques fiches au
dossier humain ; il se donne la volupté stérile de construire une
figuration. S’il se penche avec sympathie sur la misère de ses
personnages, s’il y reconnaît la sienne, il peut vivifier d’un souffle
douloureux ces ombres qui s’agitent dans le vide. La Sapho
d’Alphonse Daudet, la Germinie Lacerteux des Goncourt sont des
témoignages probants, comme une confession, sur la déchéance où
peut glisser une pauvre âme dans l’abandon. La vie lui paraît le plus
ennuyeux des non-sens. Le monde se dresse contre elle, comme
une machine stupidement implacable, pour l’écraser. La mort lui
reste, seule fenêtre entre-bâillée sur le libre espace. C’est pourquoi
tant de romans naturalistes, depuis Madame Bovary, finissent, d’une
manière inévitable, par un suicide. Les casiers de l’observation
naturaliste ressemblent à ces geôles suffocantes où Sainte Thérèse,
dans sa vision de l’Enfer, se sentit bloquée, sous un plafond si bas,
entre des parois si étroites qu’elle ne pouvait se tenir debout ni
s’asseoir ; et, naïvement, elle s’étonnait qu’au sein de ténèbres
opaques on pût distinguer toutes les choses affreuses pour la vue.
Image de damnation qui n’est pas un mensonge, quand le romancier
considère la société moderne, en son désordre et son athéisme. Les
âmes ne peuvent plus même jeter le cri de leur détresse :

Le silence est au fond de tout le bruit qu’on fait.

Si, par intervalles, le naturaliste et le réaliste catholique ont l’air

de se rejoindre, c’est dans la nausée des laideurs. Mais le premier
n’y reconnaît que le jeu accidentel de forces inconscientes ; l’autre y
découvre les suites du péché ; au bout des drames les plus atroces il
voit entreluire la Rédemption. L’art du naturaliste est un miroir qui
réfléchit de mornes surfaces ; celui du réaliste chrétien pénètre
jusqu’à la substance et aux racines des événements.
Le naturalisme est tellement inhumain que ses fanatiques eux-
mêmes n’ont guère pu s’y confiner. Flaubert s’abîma dans une sorte
de nihilisme idéaliste, celui que le Diable, au plus aigu de la
tentation, souffle à l’oreille de Saint Antoine : Peut-être qu’il n’y a
rien. Zola devait aboutir au songe millénariste, puéril et grossier,
d’une humanité innocente, heureuse par la satisfaction de ses
appétits.
La notion de substance, seul, le catholique en possède la ferme
plénitude. Il révère en toutes les choses de ce monde la main divine
qui les crée et les sauve. Il admire « les lys des champs », comme
Jésus les admirait, vêtus plus splendidement que Salomon sur son
trône.
Jésus n’apportait pas aux hommes une chimère de perfection. Il
voulait réellement souffrir et mourir. Vere passum, immolatum.
La foi en la Présence réelle demeure le fondement du réalisme
catholique.
C’était l’amour du Christ uni à la terre dans le pain et le vin de
l’Hostie qui jetait Saint François en contemplation devant les plus
infimes créatures et lui faisait parfois embrasser avec des pleurs de
joie les arbres ou les rocs dont le Seigneur a dit que, si les hommes
se taisaient, leurs pierres crieraient sa gloire.
L’homme étant conçu comme l’image de Dieu, l’artiste s’appliqua
plus exactement à la vérité de la ressemblance [107] .
[107] Il serait facile de montrer que tout réalisme
profond part d’une intention religieuse. Ainsi, dans l’art
égyptien.

De là, chez l’artiste chrétien, un sens de la beauté céleste, un

sens de la laideur aussi que le paganisme n’avait point soupçonné.
Car le péché déforme la ressemblance divine ; le Démon y
superpose son affreuse empreinte.
Et nous ne songeons pas seulement à la vérité des contrastes, à
l’exactitude plastique. Le plus important, c’est l’intérieur de l’homme,
l’éternel conflit dont il est le champ de bataille, le mystère des
perspectives surnaturelles où se prépare le dénouement.
Réalisme et surnaturalisme ne font qu’un.
 Appliquées au roman dont les formes ont une autre souplesse
que le théâtre ou le poème lyrique, les possibilités de l’art chrétien
sont immenses. Il semble étrange qu’on les ait si peu explorées.
Certains romans du moyen âge — ainsi Perceval le Gallois —
proposaient des fictions taillées, si l’on peut dire, en plein drap, dans
le dogme, et pleines de symboles mystiques. Raymond Lulle, dans
son Blanquerna, inspiré, croit-on, d’un roman hindou, suivit l’histoire
d’un homme jeune qui s’aventure à travers le monde, en quête de
bonheur et de sagesse ; il se marie, puis entre dans un monastère ; il
devient ensuite un prélat, un cardinal ; il est élu Pape ; après quoi il
se retire loin du monde ; ermite au fond d’un bois, il goûte enfin la
béatitude. Les Espagnols ont souvent imité ce type de roman qui
peut esquisser toutes les conditions sociales, peindre des milieux,
des sentiments multiples, se faire varié comme la vie même.
Cependant le genre, dès le moyen âge, fléchissait vers une
frivolité mondaine. On y cherchait ce qu’on y cherche trop encore, un
éphémère amusement. La plupart des sujets tournaient, comme des
écureuils dans leur cage, à l’intérieur de cette monotone intrigue : un
tel sera-t-il l’amant d’une telle ? Ils allaient de l’amour héroïque à
l’amour idyllique, laissant aux récits des contes les licences de
l’amour grivois.
Nous ne demanderons pas un modèle de roman catholique à
l’Amadis ni à l’Astrée, ni au Grand Cyrus, ni même à Don Quichotte,
encore moins au Décaméron ou à Pantagruel, bien que les plus
idéalistes de ces livres impliquent la civilisation chrétienne avec ses
délicatesses, et que Boccace, Rabelais, là même où ils travaillent à
corrompre le catholicisme, en restent nourris.
Le seul beau roman qui ait surnagé au XVIIe siècle fut, il est vrai,
un roman chrétien ; la Princesse de Clèves repose sur l’idée du
renoncement. Mme de Clèves sacrifie un bonheur possible ; elle
s’obstine à le repousser, quand la mort de son mari l’a rendue libre.
Mais, chez elle, l’amour humain ne s’immole pas à l’amour céleste ;
elle assure, avant tout, le repos de sa conscience ; elle a peur de
s’engager en de nouveaux liens. Deviendra-t-elle jamais un grand
cœur mystique ? Elle est bien plutôt une femme raisonnable qui
pèse des risques et se range au parti de l’entière sécurité.
Il eût été prodigieux que le XVIIIe siècle libertin vît surgir un roman
chrétien d’esprit. Manon Lescaut aurait pu l’être. Le conflit d’un
sentiment profane et d’une vocation pieuse, la rédemption après la
chute, le relèvement de la brebis perdue enfermaient la donnée
d’épisodes admirables. L’abbé Prévost n’en tira qu’un roman
d’aventures trop mollement bâti, où serpente le perfide lieu commun
de la courtisane réhabilitée.
Les romans de Voltaire visaient à exterminer toute conception
chrétienne de la vie. Candide est le ricanement satanique du
désespoir, devant l’énigme du péché. Néanmoins, le blasphème
atteste Dieu ; l’homme qui descend jusqu’au fond de sa misère
impuissante réveille, même contre son gré, le besoin d’un appel au
Rédempteur. Candide est plus près d’une apologétique à rebours
que la nouvelle Héloïse ou Paul et Virginie.
Avec sa thèse : La nature est bonne, Jean-Jacques semblait
ruiner, dans l’art, les chances d’un renouveau chrétien. La Terreur se
chargea de le démentir. Et Chateaubriand, converti, osa prendre le
contre-pied de Rousseau ; Atala rétablit au-dessus de la nature la
sainte loi du sacrifice. Très imparfaitement, d’ailleurs. Si la mère
d’Atala n’avait lié par un vœu imprudent l’avenir de sa fille, les
amants s’uniraient en liberté ; nous aurions, avec des horizons plus
vastes, une reprise de Paul et Virginie. La contrainte catholique
intervient comme un trouble-fête. Un disciple de Rousseau eût
estimé qu’elle a tort ; Chateaubriand devait être un peu de son avis.
Les parties chrétiennes du roman sont pauvres et sèches
d’expression.
De même, ses Martyrs restent une œuvre indécise entre le
christianisme et le mensonge païen.
En dépit de ses insuffisances, Chateaubriand ouvrait au roman
chrétien d’étonnantes perspectives. Atala et les Martyrs, après le
Génie du Christianisme, déterminèrent puissamment cette
préoccupation religieuse qui ne sera presque jamais absente de la
littérature, au XIXe siècle. Mais, pour trouver ce qui s’appelle un
roman catholique, il faut dépasser les temps lamartiniens, Hugo et
Balzac lui-même ; il faut aller jusqu’à Barbey d’Aurevilly.
Le romantisme eut, d’abord, cette néfaste action de dissoudre en
vague sentimentalité l’élan spirituel. Le sujet de Jocelyn, qui est un
roman versifié, offrait la matière d’une profonde étude sur la vie
intérieure d’un prêtre. Or le livre se réduit à de verbeuses
descriptions, à des effusions lyriques. Sauf en deux ou trois
épisodes où se dessine le drame, la pensée du poète ne se
concentre pas vers le dedans des êtres. Les rapports d’une âme
sacerdotale avec le dogme et la discipline ecclésiastique sont à
peine indiqués. L’indigence de mysticisme est navrante dans cette
histoire d’un sublime renoncement.
N’en soyons point surpris ; l’écrivain jette en son œuvre ce qu’il
porte au fond de sa vie réelle. Comment exprimer l’ascétisme si l’on
n’a l’intelligence et le désir d’une règle ascétique ? Le prêtre de
Jocelyn, comme l’évêque des Misérables, est construit sur le modèle
du Vicaire Savoyard ; la seule excuse de Lamartine et de Hugo, c’est
qu’on rencontrait alors des prêtres et des évêques formés sur un tel
patron.
Balzac, avec sa pénétration réaliste du catholicisme en tant
qu’ordre social, a magnifiquement exprimé l’action de la foi sur les
mœurs, les générosités qu’elle suscite, le drame des antagonismes
qu’elle approfondit. Rappelez-vous simplement Mme de Mortsauf du
Lys dans la vallée, Mme Grandet et sa fille. Il a peint toute la
gradation des milieux ecclésiastiques, depuis le curé du village
jusqu’au prélat raffiné. On a pu extraire de la Comédie humaine un
ensemble de maximes que ne désavouerait pas le plus orthodoxe
apologiste ; c’est lui, dans La Cousine Bette, qui a dit de la Vierge
Marie : « Elle efface par sa grandeur tous les types hindous,
égyptiens, grecs. La Virginité, mère des grandes choses, tient dans
ses belles mains blanches la clef des mondes supérieurs. Enfin,
cette grandiose et terrible exception mérite tous les honneurs que lui
décerne l’Église. »
 Pourquoi cependant Balzac n’a-t-il pas donné un seul roman
qu’on puisse qualifier d’exclusivement catholique ? C’est qu’il mêlait
au dogme une philosophie confuse, idéaliste, panthéiste, avec un
amalgame de mysticisme svedenborgien. Un seul axiome soutient
l’énormité de son œuvre : « La nature est une et compacte. » Ce
qu’on nomme attractions et répulsions des choses, réalisé dans les
intelligences, devient l’amour et l’antipathie. Ce qui est, en nous, la
volonté est, dans la plante, odeur ou sève. Matière et pensée, à l’en
croire, seraient les deux modes d’une Puissance unique. Sa vision
du monde spirituel, des sphères angéliques, çà et là prodigieuse
dans Seraphita, est troublée par les baroques extravagances qui lui
viennent du protestant Svedenborg.
D’autre part, il brouillait la notion précise du surnaturel et le
surnaturalisme tel que l’entendra, d’après lui, Baudelaire, une
transposition, exaltée jusqu’au vertige, des sensations où les mots
se crispent impuissants à rendre l’ineffable :
« Il m’a souvent semblé, déclare Emilio, dans Massimilla Doni, au
sujet de la femme qu’il aime, que le tissu de sa peau empreignît des
fleurs sur la mienne quand sa main se pose sur ma main… L’air
devient alors rouge et pétille ; des parfums inconnus et d’une force
inexprimable détendent mes nerfs, des roses me tapissent les parois
de la tête, et il me semble que mon sang s’écoule par toutes mes
artères ouvertes, tant ma langueur est complète. »
Autrement exacte et sévère fut la conception de Barbey
d’Aurevilly. L’Ensorcelée, Un prêtre marié, les Diaboliques nous
offrent les premiers exemplaires de romans ou de nouvelles qui
procèdent du dogme, de la morale, de la tradition catholique et qui,
hors d’elle, seraient impossibles [108] .
[108] Il faudrait y ajouter L’Honnête femme, de Louis
Veuillot. Voir ce que j’en ai dit dans les Lettres de février
1927.

Un réalisme théologique soutient ici le jeu des passions.

 Supposons, dans l’Ensorcelée, la fiction dépouillée de l’élément
surnaturel. Il lui resterait un tragique de folie amoureuse, mêlé aux
réminiscences de la Chouannerie. Mais son aspect légendaire, son
grandiose s’évanouiraient. Le grandiose tient au souffle satanique
qu’on y respire ; et le satanisme fait la vérité profonde du récit.
L’Église, avec ses dogmes, amplifie au reste tout ce qu’elle
touche. Parce qu’elle est, comme le Christ, un signe de
contradiction, en dressant contre les appétits humains une digue,
elle les force à rebondir, torrent orageux, ou les sublimise par la
soumission imposée.
C’est ainsi que d’Aurevilly, dans Un prêtre marié, entoure d’une
grandeur inouïe la tendresse de Sombreval pour sa fille. Sombreval,
avant de se marier et d’avoir une fille, était un prêtre. Il a beau vivre
en mécréant ; le signe de l’onction demeure sur lui. Il ne peut dire :
Ma fille ! sans répéter un sacrilège ineffaçable devant Dieu et devant
les hommes. Dans le plus naturel et le plus noble des sentiments il
mange, il boit à toute heure sa réprobation.
On reprochera au romancier, sans doute, de se complaire dans
l’anormal. Cette critique ne serait point vaine. Le surnaturel, pour se
révéler, a-t-il besoin de péripéties et d’âmes extraordinaires ? Il
semble plus probant s’il s’insère dans la trame des faits quotidiens.
Mais d’Aurevilly aurait pu répondre que l’anormal est incessant.
Nous croisons des humains que des yeux superficiels déclarent
« quelconques » ; rien d’étrange au dehors ne signale leur vie. Si
nous en connaissions le fond, nous serions terrifiés de ce qu’elle
cache, ou parfois éblouis de leurs vertus ignorées.
D’Aurevilly sentait ce qui manquait, dans son œuvre, à une
synthèse du visible et de l’invisible. Des âmes existent, ailées,
radieuses, qu’un vent pur enlève, comme la colombe de l’arche, au-
dessus des cloaques ténébreux. Le conteur des Diaboliques rêvait
de leur donner un pendant : les Célestes. Faute de temps ou
d’inspiration il ne les a jamais esquissées. C’est qu’il est plus
accessible d’exprimer les passions mauvaises que la vertu. Celle-ci
paraît trop aisément conventionnelle, hors du possible.
 Au temps de Barbey d’Aurevilly, une mode pessimiste portait les
écrivains à faire leur pâture de l’horrible, du monstrueux, de tout ce
qui révolte une sensibilité moyenne.
Huysmans, avant sa conversion, par un sadisme morbide, se
divertira en évoquant les atrocités d’un Gilles de Rais. Là-bas
s’achève sur l’effroyable récit d’une Messe noire. Léon Bloy
transposera, dans le Désespéré, les souffrances de sa jeunesse,
exagérant au delà du vraisemblable les calamités qu’un artiste peut
appeler sur lui.
Le Désespéré n’est pas un roman, pas plus qu’En route de
Huysmans. Un roman, disait d’Aurevilly, c’est de l’histoire possible.
Quand les faits réels débordent sur la fiction ou paraissent l’exclure,
nous n’avons plus un roman, mais des confessions, des mémoires,
une autobiographie, avec ce que Bloy appelait « l’arrangement
littéraire », la liberté de modifier ou même de déformer l’histoire, en
vue d’un certain effet. Bloy, d’ailleurs, était trop lyrique, et, comme
Huysmans, trop préoccupé de lui-même, pour se mettre dans l’état
d’esprit propre au romancier.
S’il eut sur le roman quelque influence, ce fut par ricochet, en
tant qu’il secouait d’âpres invectives l’illusion païenne où
s’engourdissait, chez certains, la ferveur de la foi.
Au contraire, les livres de Ferdinand Fabre sont de vrais romans,
et catholiques de pensée, bien qu’il n’y ménage guère les milieux
cléricaux. Une scène comme les obsèques nocturnes de Mgr de
Roquebrun, dans l’Abbé Tigrane, exigeait, pour être conçue, un sens
rare du dramatique inhérent aux liturgies. On peut blâmer comme
outrée la fureur ambitieuse d’un Rufin Capdepont. Mais n’oublions
pas que ce roman se passe en un diocèse montagneux, dans un
vieux pays proche de l’Espagne, où les antagonismes devaient
s’exaspérer sans merci. L’auteur a moins cherché la stricte
vraisemblance que la vérité symbolique. Le Démon, au surplus,
quand il rôde autour d’une âme insensible aux convoitises
charnelles, n’a prise sur elle que par l’ambition, l’orgueil ou le
désespoir ; c’est lui qui trouble le terrible et grand Capdepont.
 Nulle intention d’apologiste ne s’ajoute à la peinture des mœurs ;
et pourtant une apologétique indirecte s’en dégage ; la force divine
de l’Église est avérée même dans les faiblesses de ceux qui la
représentent.
Avec Barbey d’Aurevilly et Ferdinand Fabre se définissait déjà ce
que j’appellerais le roman catholique intégral : regarder la vie d’aussi
près qu’on peut l’atteindre, mais en éclairer tous les aspects par
cette flamme mystérieuse qui vient des gouffres d’en haut ou d’en
bas.
Beaucoup d’œuvres modernes — et des plus importantes — sont
nées, d’autre part, dans un rythme catholique ; elles seraient
impossibles si l’auteur ne pensait en croyant. Paul Bourget,
confrontant avec son expérience les doctrines de l’Église, fut amené
à ce témoignage que ses livres, depuis le disciple, réitèrent
obstinément : l’ordre catholique est principe de vie ; tout ce qui lui est
contraire engendre le chaos, la mort. René Bazin a posé, dans la
Barrière, un duel de consciences autour de l’orthodoxie, parce que
lui-même attachait à sa foi un prix pathétique. Henry Bordeaux, dans
la Maison morte, aurait-il rendu avec une simple émotion la mort
pieuse d’une paysanne, s’il n’avait trouvé au fond de son cœur la
piété d’un tel spectacle ?
François Mauriac a beau déclarer : « Je ne suis pas un romancier
catholique ; je suis un catholique qui écrit des romans », sa
sensibilité, ses fictions, son goût même de l’amer péché, tout
suppose chez lui une vie intérieure catholique dont son art est
pénétré jusqu’aux fibres.
Mais, ce que je veux attester, c’est l’élargissement des horizons
romanesques par le surnaturalisme. Il me conviendrait mal d’aller
prendre dans mon œuvre des arguments. J’aime mieux évoquer
l’admirable scène du Sanguis martyrum de Louis Bertrand où les
mineurs chrétiens voient surgir près d’eux un prêtre inconnu qui leur
apporte sous terre le Pain céleste. Ici, le miraculeux se mêle comme
naturellement à l’humain de la vie ; il s’impose parce qu’il est désiré,
attendu ; il n’affirme pourtant pas : C’est moi. Qu’on se rappelle
aussi, dans le Vin de ta vigne (de Louis Artus) la très suave et
prophétique nouvelle : L’enfant qui n’allait pas à l’école.
Un roman paru l’an dernier, Un pénitent de Furnes, d’Henri
Davignon, peut expliquer d’une façon probante quel imprévu
poignant le symbole chrétien ajoute à une situation peu neuve en
soi. La femme de Réginald Camerlinghe l’a quitté ; il veut expier pour
elle son erreur ; d’autant plus qu’il n’est pas lui-même sans reproche.
Il suit, comme pénitent, la lourde croix sur l’épaule, à travers les rues
de Furnes, le cortège de la Kermesse qui représente la Passion.
Chaque épisode de la Kermesse, au lieu d’être devant ses yeux un
jeu pictural, retentit en son cœur ; il sent le poids de la Croix qu’il
soutient et sa vertu expiatrice. Quelle beauté, par exemple, en ce
détail très simple, agrandi jusqu’au symbole :
« Jésus se relève, réaccepte le fardeau, et repart de son pas
rapide, court et cadencé. Sa silhouette projetée sur le mur semble
vouloir emplir l’horizon. De la foule, une petite vieille se détache et
tend vers l’homme en sueur un verre d’eau claire. Il a fait non de la
tête, tout à sa tâche infinie ! »
Plus récemment encore qu’Henri Davignon, Georges Bernanos,
dans son roman étrange : Sous le Soleil de Satan, explore avec une
audace de visionnaire les profondeurs de l’invasion démoniaque.
Cette œuvre synthétise des qualités superbes : un réalisme fort et
condensé, n’ayant peur ni du laid, ni du cynique, parce que le laid et
le cynique, c’est le rire du Démon, sa revanche sur l’œuvre divine ;
une pénétration des âmes tranchante, subtile, amère ; l’intensité
continue, même excessive de l’hallucination ; une façon de peindre
où le dedans projette sur le dehors des lueurs transcendantes ; des
dialogues dont chaque mot enferme du silence.
La couleur de l’ensemble est, comme le fond de certaines toiles
espagnoles, furieusement sombre ; car le soleil de Satan, c’est la
nuit. L’histoire de la malheureuse fille que le démon pousse du
désordre au suicide est liée à celle de l’abbé Donissan par une
relation toute mystique. Le drame se concentre dans le cœur de ce
prêtre ascète, tourmenté par l’Esprit du mal. Le Démon lui apparaît
même — c’est l’épisode capital du roman, — et cette vision doit,
pour une haute part, sa puissance au réalisme qui en soutient la
terreur surnaturaliste. Le curé de Lumbres reçoit, plus tard, le don
des miracles ; un fermier, dont l’enfant vient de mourir, l’adjure de
ressusciter son enfant. Le prêtre croit entendre un ordre mystérieux
qui le contraint d’opérer cette résurrection. Il l’essaie, il voit le petit
mort soulever ses deux paupières ; mais le cadavre retombe. Un
éclat de rire retentit, celui de la mère qui l’a suivi à son insu ; l’abbé
reconnaît le rire de Satan ; il s’enfuit épouvanté. Après un tel
désastre, il n’a plus qu’à mourir.
Le point contestable du livre semble cette outrance de faits
désespérants. Certaines âmes saintes vivent, il est vrai, dans la plus
noire désolation, et cet état peut se prolonger des années. Elles ne
sont point tentées, malgré tout, au delà des forces humaines. Dieu
les soulage par d’inexprimables joies. Un prêtre, chaque matin,
quand il offre le Corps de son Dieu, est comblé d’une Présence où il
reçoit un avant-goût du Paradis. Mais l’abbé Donissan se méfie
même de ces consolations :
« J’ai haï le péché, se dit-il, puis la vie même, et ce que je sentais
d’ineffable dans les délices de l’oraison, c’était peut-être ce
désespoir qui me fondait dans le cœur. »
Satan, craint-il, « est dans le regard qui le brave, il est dans la
bouche qui le nie. Il est dans l’angoisse mystique, il est dans
l’assurance et la sérénité du sot… Prince du monde ! Prince du
monde ! »
Et il en vient à cette conclusion terrible :
« Nous sommes vaincus ! Vaincus ! Vaincus ! »
Assurément, il ne faudrait pas confondre une telle torture
mystique avec l’idée fixe, l’obsession maladive du Diable, qui va
souvent jusqu’à la folie (j’ai rencontré, à Sainte-Anne, une vieille
dame folle, convaincue qu’elle était Satan en personne). Mais l’abbé
Donissan me paraît un janséniste effréné, presque un manichéen.
Avouer le triomphe de Satan équivaut à désespérer de la
Miséricorde, et nous ne sommes pas très loin du péché contre
l’Esprit.
 Je crains que Georges Bernanos, soit par une violence
systématique de tempérament, soit par une recherche de l’effet, n’ait
dépassé toute mesure dans l’expression de la tristesse
spirituelle [109] .
[109] Il reconnaît lui-même que la douceur et la
confiance font défaut à l’abbé Donissan ; ce prêtre est un
saint manqué. Mais la grandeur anormale dont il l’investit
abuse le lecteur sur les limites du personnage.

Et nous touchons ici une des graves difficultés du roman

catholique. Il représente l’homme pécheur, il doit le représenter. Un
roman catholique ne doit jamais être un fade mensonge d’idylle.
Cette expression du désordre, si forte qu’elle soit, va-t-elle
néanmoins infliger aux âmes un accablement ? Je l’ai dit à propos
des passions amoureuses :
« La grande règle, pour l’artiste chrétien, est de ne rien peindre
qui laisse aux lecteurs l’impression dominante d’un trouble
séduisant, de restreindre les épisodes charnels, d’en faire sentir les
suites douloureuses, de présenter le péché comme le péché, la
honte comme la honte. »
Mais, quand le romancier approfondit un drame spirituel, la limite
est plus délicate à franchir, et le danger plus subtil. Il faut une nette
fermeté de sens théologique, la justesse prudente de l’analyse, par-
dessus tout, la bonhomie et la droiture de l’intuition.
Les possibilités du roman catholique sont immenses ; ses
difficultés les égalent. Qu’elles ne rebutent pas les jeunes écrivains.
Qu’ils expriment, dans son ampleur, le mystère joyeux comme le
mystère douloureux de la vie intérieure. Qu’ils gardent, devant elle,
une précieuse humilité. Seul la rendrait, avec sa plénitude, celui qui
en aurait toute l’expérience, c’est-à-dire un Saint. Mais les Saints ont
mieux à faire que des romans.
 LE SIÈCLE EUCHARISTIQUE

Dans quelques jours ; toutes les routes de la chrétienté

s’empliront des pèlerins qui vont au Congrès de Lourdes. Une année
de plus dresse les reposoirs de la procession universelle où sera
glorifié le Christ-Hostie. Aucun fait, depuis le commencement du
nouveau siècle, n’est plus imposant que ces vastes assemblées de
catholiques venus de pays sans nombre pour articuler ensemble un
acte d’adoration. Le moyen âge lui-même n’a jamais connu de telles
assises mystiques : on se rendait alors à Saint-Jacques de
Compostelle comme en un lieu qui détenait les restes corporels d’un
apôtre et la vertu sanctifiante de ses os. Ici, les attraits tangibles
deviennent secondaires : l’Eucharistie peut s’adorer dans un pauvre
ostensoir de village aussi bien que sous un dais escorté par cent
évêques. Ce serait puéril, pour expliquer l’affluence des fidèles, d’en
admettre seulement les causes extérieures, la force d’impulsion qui
sollicite les hommes vers tout point où de longues foules se dirigent,
l’attente de magnificences extraordinaires et d’unanimes émotions. Il
faut atteindre au fond des âmes et, plus encore, dans les volontés
conductrices de l’Esprit Saint, les raisons durables de ce
mouvement.
A mesure que la fin des temps approche, une partie du genre
humain s’endurcit davantage à nier sa Rédemption ; mais celle qui
reste croyante veut plus énergiquement proclamer sa foi. Le soir
tombe sur le monde ; la nuit commençante sera la nuit du dernier
exode. C’est l’heure où les fils d’Israël immolaient l’Agneau sans
tache. Nous aussi, nous savons qu’il faut marquer de son sang le
linteau de notre porte afin que l’archange justicier, s’il passe, ne
touche point nos têtes de son glaive. Comme eux, nous devons
manger la pâque, « tenant à la main le bâton » de l’imminent voyage
et « en hâte », avec la faim d’un grand désir.
 Plus l’Église voit sa mission terrestre près d’être achevée, plus
elle se retrempe en ses origines. Aux premiers siècles, la
communion quotidienne était si bien admise que les chrétiens se
communiaient eux-mêmes dans leurs maisons. Mais, bientôt [110] ,
un scrupule dont le moyen âge ne sut se libérer et qui opprime
toujours les schismatiques grecs, retint les laïques à une distance
respectueuse du Sacrement ; plus tard, en France du moins, les
controverses protestantes et le jansénisme attiédirent, chez la
masse de ceux qui communiaient à Pâques et aux fêtes solennelles,
toute fervente familiarité. L’expression traditionnelle, « s’approcher
des Sacrements », correspondait à cet état de méfiance rationaliste ;
on s’en approchait, on ne les mêlait pas à son être intime.
Aujourd’hui encore, les hommes de la génération antérieure à la
nôtre sont imbus d’un préjugé contre la communion fréquente.
Pourtant, sur ce point comme sur tant d’autres, le pontificat de Pie X
marque un retour à la profonde vie primitive. Si beaucoup de
catholiques ont suivi docilement ses inspirations, c’est qu’ils
comprennent le principe très simple jadis exposé par saint
Ambroise :
[110] Dès le IVe siècle et même avant, par une
répercussion de l’arianisme (d’après le rapport de dom J.
Chapman, de l’Ordre de Saint-Benoît, au Congrès
eucharistique de Westminster, en 1908).

« Puisque chaque fois que le Sang est versé, il est versé pour la
rémission des péchés, je dois le recevoir toujours, afin que mes
péchés soient toujours remis. Je pèche constamment ; je dois donc
constamment prendre le remède contre le péché… Si c’est notre
pain quotidien, pourquoi attendez-vous une année pour le recevoir,
comme le font les Grecs en Orient ? Recevez tous les jours ce qui
tous les jours vous est profitable. Celui qui ne mérite pas de
communier chaque jour ne mérite pas de communier une fois l’an. »
Il n’est point d’âme pour qui ne résonne incessamment le
précepte d’amour : Prenez et mangez. Mais, tandis que la multitude
des mécréants rejette en hochant la tête et souvent avec
d’immondes opprobres le Dieu qui ne se lasse pas de s’offrir à tous,
le reste du troupeau demeuré fidèle s’élance d’autant plus avide vers
la nourriture délectable. « Dilate ta bouche et je l’emplirai », disait le
Seigneur à son peuple par la voix du Psalmiste ; cette parole, d’une
insondable munificence, est entrée dans nos oreilles plus clairement
qu’en celles de nos ancêtres. Ce n’est pas que nous méritions mieux
les largesses divines ; mais elles se multiplient à la mesure de notre
indigence. Le viatique est pour les fragiles, les infirmes et les
moribonds. Or, le monde ressemble à un grand malade qui ne sait
plus de quel côté se retourner sur son lit. De quoi peut-il avoir
encore faim, sinon du Pain vital, promesse d’éternité ? « Il a donné
aux tristes la coupe de son Sang », chante une hymne de la Fête-
Dieu. Plus que jamais il faut aux chrétiens, pour n’être pas tristes,
« l’esprit de triomphe » qui les fait marcher avec sécurité, comme les
jeunes hommes dans la fournaise, au milieu des tentations et des
haines. D’où recevraient-ils cette allégresse, sinon en mêlant à leur
sang toute la substance du Fort des forts, du Dominateur dont le
royaume n’aura pas de fin ?
Tel est le sens des Congrès eucharistiques et surtout des
Congrès internationaux. Les pèlerins appartenant aux patries les
plus distantes et les plus hostiles ne s’y donnent point rendez-vous à
seule fin de démontrer que le catholicisme restaure la famille
humaine en son harmonie plénière par l’unanimité d’une foi supra-
terrestre. Leur concorde jubilante figure pour quelques jours la
communion des élus, l’état de gloire et d’adoration perpétuelle qui se
nomme le paradis. On dirait qu’alors, du Levant jusqu’au Ponant, les
blasphèmes se sont tus, les hérésies et les schismes sont morts,
que le puits de l’abîme est clos sur le dragon lié à jamais ; là, tous
sont en tous, étant tous en Dieu. C’est comme un après-midi d’été
vêtu d’une splendeur et d’une paix où rien ne semble plus pouvoir
changer. Si quelque chose peut donner une image des béatitudes,
n’est-ce pas l’instant d’une bénédiction solennelle, quand le prêtre
élève au-dessus de la foule le Saint Sacrement ?
Et même, les bienheureux qui voient la Face de Jésus-Christ ne
peuvent plus mériter comme nous, prosternés devant l’ostensoir.