At Work in the Fields of Public Health: The Abuse of Rationality

Author(s): Gilles Bibeau

Source: Medical Anthropology Quarterly, New Series, Vol. 11, No. 2, Knowledge and
Practice in International Health (Jun., 1997), pp. 246-252
Published by: Wiley on behalf of the American Anthropological Association
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COMMENTARIES

GILLES BIBEAU
Departement d'anthropologie
Universite de Montreal, Quebec

At Work in the Fields of Public Health: The

Abuse of Rationality
his special issue presents anthropological involvement in public health both
as a vehicle for enhancing the participation of anthropologists in preventive
and curative health programs, and as an intellectual activity of theorizing
around the "rationality" of human beings. As a theorizing activity, anthropolog
provides its own critical insights about the connections assumed to exist betwee
beliefs and behaviors, knowledge, attitudes, and practices, and about relate
problems such as the differential exposure to messages, the conditions in which
behavioral changes are produced, and the decision-making process regarding the
use of health services. Wherever anthropologists in public health work (developin
or more developed countries), whatever they do in health promotion, prevention
care, and rehabilitation (for example, education for safe sex, promotion of needl
exchange programs among intravenous drug users, studies of therapeutic itinerar
ies, formulating culturally appropriate measures for controlling tuberculosis or
malaria), and whoever their colleagues may be (health educators, experts i
communication, demographers, epidemiologists, social psychologists, nutrition
ists, health administrators, social workers, etc.), anthropologists tend to use a
disciplinary framework organized around three key parameters: a focus on loca
knowledge, cultural sensitivity, and a grounding in community.
These articles abundantly echo the idea that the bottom-up approach allows
the use of indigenous knowledge and community resources, and also makes loca
persons and community groups coresponsible for developing policies, programs,
and activities for improving health. The articles have identified with great clarit
weaknesses that severely limit the effectiveness of many preventive and curativ
activities that still rely too exclusively on conventional schemes-the mere trans
position of Western models to quite different societies-largely unconnected t
the ways local communities identify, explain, and manage health problems. Case
studies such as Lane's evaluation of television soap operas for health education in

Medical Anthropology Quarterly 11(2):246-255. Copyright ? 1997 American Anthropological Ass

ciation.

246

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COMMENTARIES 247

Egypt, Vecchiato's of the utilization of ethnomedical knowledge of tuberculosis

by health educators among the Sidamo of Ethiopia, and the quantitative and for-
malized study by Weller et al. of treatment-seeking in a rural population of the Pa-
cific coast of Guatemala, open the door rather nicely (particularly Lane and Vec-
chiato) to innovative interventions and to the exploration of a new conceptual
framework to better understand peoples' behavior.
The article by Weller and colleagues, however, typifies anthropologists' at-
traction and fascination for epidemiological and managerial models for the study
of health problems. In this latter case, the authors' theorization of the "decisional
approach" did not convince me that we learn more about individual behavior with
this type of model than with the more classical studies of the health-seeking pro-
cess such as those of Janzen, Igun, Zempleni, and many others.
Despite their declared intention to break with the dominant public health
models, most anthropologists are not really willing to distance themselves from the
methodology and theorizing of what is perceived as "real" science in public health:
survey questionnaires; focused studies of specific health problems such as tubercu-
losis, diarrhea, malaria, and so on; quantitative analyses and probability statements
of causality; and theories represented as models. The original intent of this MAQ
issue was to discuss prevalent anthropological notions about the relationship be-
tween collective beliefs and knowledge and individual behavior and practices, and
to critically examine these associations with reference to new research and a theo-
retical agenda for international health. But we end up with theoretical contributions
that go only halfway in their criticism and that deliberately refuse to question the
foundations of the public health enterprise as it exists in developing countries. In
their article, the Peltos limit themselves to arguing, in quite conventional fashion,
that anthropologists should contribute to public health by conducting "focused eth-
nographic studies." Yoder's introductory article on "negotiating relevance" is the
only one that really takes intellectual risks by critically examining the political
powers invested in the "normalizing discourse" of public health. I find productive
insights in this text: a resistance to the loss of imagination in creating new public
health models, a critique of the knowledge and production theory largely domi-
nated by epidemiology and management, and suggestions for the exploration of
new territory.
In the following pages, I raise a series of concerns and criticisms relevant to
anthropologists engaged in the field of public health who seem to survive in that
world by alienating themselves to the point that they either become reluctant to in-
voke their own anthropological training or they trivialize its theories and methods.
The failure of so many preventive and educational activities in North America and
abroad have been so widely documented that anthropologists should not hesitate to
work toward a substantive reorientation of public health activities and, hopefully,
to a more solid anchoring of these activities in local cultures and communities. I
understand that colleagues outside academia who contract with agencies for serv-
ices performed must compromise with these agencies, but I am not sure that their
cooperation-often with uncritical dedication-will really serve anthropology and
its practitioners in the long run. Violence in many forms, rising rates of suicide, ur-
banization and forced migration, political repression, resurgence of conservative
movements, and increase of poverty all point to basic changes in the cultural, so-
cial, political, and economic situations in most countries. In this increasingly

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248 MEDICAL ANTHROPOLOGY QUARTERLY

complex context, anthropologists appear well equipped, both conceptually and

methodologically, to provide highly original expertise for the study of these phe-
nomena and their impact on public health. The time has come to adopt more radical
positions, to end sterile partnerships, and to rediscover our own disciplinary iden-
tity. Such a strategy will not produce a withdrawal from the public health scene but
rather will promote anthropology to the forefront of debate and intervention.

A Return to the Basic Social Paradox

We know from experience that individuals have different lifestyles, make

their own choices, and build their lives on particular values. Some people seek reli-
gious consolation and actively participate in a church, while others display no such
interest. Some people pay great attention to personal and community identity,
spending time and resources for their neighborhood, while others seem content to
live privately. Some individuals pursue innovative ideas and explore new territory
while others prefer the well-traveled roads and crowded public spaces. Who can
say which is the true path to fulfillment? Why do private preferences vary so much
from one person to another?
Anthropologists maintain that human nature is thoroughly historical, that in-
dividuals and societies are shaped through particular histories, worldviews, and
sets of values and creeds that inform our unique existence. We assume that rules,
patterns, and commonalities exist beyond interindividual variations and that hu-
man groups, whatever their size or degree of social cohesion, can be identified by
their common actions, a shared system of meaning, and a sense of belonging to that
group. If they hope to contribute to a better understanding of culture(s) and social
life, anthropologists must drop the idea that the peoples of the world live on village
squares in small cohesive communities.
In the face of the dominant North American culturalism and its most recent
resurgence in interpretive anthropology, which places the notion of "collective
meaning" at the very core of its concerns, it seems urgent that we concentrate on
studies of the distribution of meaning in social space, and on searching social
sources of diversity and heterogeneity rather than focusing exclusively on cultural
sharing, uniformity, and homogeneity. This perspective can return our attention to
the actual behavior of individuals as well as to the social contexts in which catego-
ries of people take action. Classical anthropology has amply demonstrated that
meanings, values, and beliefs circulate in all societies through complex flows and
processes that cross the frontiers of various social spaces (households, neighbor-
hoods, workplaces, commercial centers, educational institutions, government
agencies, etc.), and that the dominant meanings often conflict with new ideas pro-
moted by social movements or microcultures, which fight to transform the collec-
tive system of values.
By placing the actions and practices of individuals once again into their social
settings, anthropologists will discover the real world as seen by individuals, a
meaningful world that is usually fragmented and where contrastive norms and
competitive values are put into action. It is precisely this fragmentation and diver-
sity, this resistance and submission, that emerges from the clash between the val-
ues of the centralizing agencies (churches, schools, media, markets, states) and the
decentralizing values of subcultures and social movements that anthropologists in-

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COMMENTARIES 249

creasingly examine. These contrasting values do not lead to a parallel, coexisting

sociocultural world, but rather to a mosaic, a dynamic movement and flow of ideas,
an interplay between central values and new beliefs.
Most anthropologists subscribe to the idea that the behaviors and practices of
individuals encapsulate their values and their meaningful world, making them ac-
cessible for study. Therefore, the key ethnographic unit of investigation should be
neither individual acts or events (as is current in social psychology) nor the domi-
nant cultural meanings (a dogma for anthropologists), but rather the actual net-
works through which actors exact and transform unique values and meanings into
practices. An intravenous drug addict may share the subculture of shooting galler-
ies, but most addicts are also engaged in many other social scenes (work, educa-
tion, management, unemployment), each with its specific value system. People to-
day routinely participate in multiple and contradictory scenes. Thus we cannot
separate the discovery of the logic that connects beliefs and behavior from the
study of the multiple stages on which these persons live out their lives.

Increasing Unpredictability and Loss of Control

Anthropologists currently recognize that people in most societies around the

world are confronted with more and more ambiguity, with multiple referential
models, and with enlarging zones of unpredictability on the edges of their social
and cultural world. Individuals and societies seem to have entered a permanent
transitional state, with fuzzy boundaries that make human groups and individuals
fragile as new possibilities emerge, and with worldviews that have multiple refer-
ents that make individual behavior less self-reproducing and less predictable. The
tribes, ethnic groups, and nations that anthropologists used to see as a juxtaposition
of autonomous entities with their own distinctive features may still exist, but the
boundaries that once protected them from the influx of neighboring peoples and
new ideas appear far more porous than they once were.
The quality of life in most countries has deteriorated in recent decades follow-
ing economic disintegration, violence, social disruptions, forced migration, wars,
and rapid urbanization. The structural adjustment programs of the International
Monetary Fund and the World Bank in developing countries have increased unem-
ployment and generated psychosocial problems for many. An increasing number
of marginalized and excluded people have lost the power to control their own lives
and decide about their future. Family networks and community support systems
have been eroded, and people are weakened in the face of the major institutions
that exert direct control over the lives of ordinary people.
This new world of shifting power and multiple allegiances, in which people
have fundamentally revised their cognitive space, invites anthropologists to break
from the behavioral assumptions derived from social psychology and from empha-
sizing cognition. The insights of the behavioral models for predicting behavior dis-
cussed in this issue (health belief model and others) are most applicable to mono-
lithic cultures. As the age of monolithic cultures disappears, and individuals refer
constantly to cultural forms that are hybrid and creolized, the operational value of
these models disappears.
For medical anthropology to interact productively with public health, it must
find ways to reconnect the patterns of social relations with the cultural order. While

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250 MEDICAL ANTHROPOLOGY QUARTERLY

individuals can be seen as bearers of culture, they are also social agents who are
members of specific social groups, who occupy precise positions in a social hierar-
chy, and who hold more or less power to reach their personal goals. Values and be-
liefs do not exist outside of the social context in which individuals operate, trans-
forming these "collective representations" into actions, interactions, and practices.
A radical shift toward the social grounding of meaning points toward the recogni-
tion that behavior precedes belief, that cultural beliefs are revealed by actions, and
that the belief/behavior relation must be inverted. It is through the study of social
actions, whether cast as behaviors or practices, that anthropologists will discover
beliefs and values. When this is applied in public health, researchers will be led in-
evitably to take more seriously daily living conditions and their impact on the
health of individuals.

The Normative Nature of Public Health Education

We live in societies in which normative behaviors are defined by panels of ex-

perts and professionals (social workers, lawyers, career consultants, psychologists)
invested with moral authority to declare what is good for people. Social scientists,
health educators, and experts in marketing and advertising have combined their
skills to convince people to behave according to certain ethical standards. Anthro-
pologists are often asked to assist communication specialists to dispel erroneous
beliefs, to combat inadequate behaviors, and to tailor messages to better fit with the
values of target populations. Anthropologists who collaborate in this enterprise
also remind their colleagues that people already have a wealth of local knowledge
and that the recommended behaviors must compete with a vast array of repre-
sentations of what is good health. In our societies, anthropologists have played the
role of cultural experts who assist communicators to break down resistance to new
health messages. Anthropologists may derive pleasure in the power of the role of
expert while at the same time being disappointed in the responses to their social
criticisms. Although ethnographers continue to maintain that there are no natural
laws that impose a normative order on all populations, that ethical norms vary tre-
mendously from one society to another, and that collective values are not the result
of a democratic process nor the decision of professionals, this relativistic message
is not often heard by those convinced of the value of their messages about the
maintenance of good health.
It is commonly held that there are moral and legal limits to the rights of indi-
viduals to behave according to their own personal system of values. The rights of
groups and of the state to oppose individual choice is also limited. Ethicists have
historically used the notion of social responsibility and the principle of solidarity
with others as guidelines for balancing a respect for individual choice and the need
for collective codes and norms. In some countries cigarettes have been banned in
all public spaces, and some health educators have even suggested that smoking
may one day be banned on the street as well. Such efforts at controlling individual
behavior suggest there may be a contradiction between the desire for individual
freedom and the principles of social solidarity and good health.
Paradoxically, the individualistic bias of our North American ideology of
rights and obligations deprives individuals of their uniqueness even as it treats
them as equivalent social entities. Normative homogenization appears as the ulti-

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COMMENTARIES 251

mate outcome of a social equality expressed in an individualistic idiom: public

health is simply a sanitary version of the republican revolution. Certain researchers
think that, with hope, The Republic of Virtue of Rousseau will materialize in our
postmodern times. To achieve this goal, the state will have to legislate against all
sorts of excesses (food, fatness, laziness, self-indulgence) and will promote, with
the help of public health specialists, a common asceticism for all citizens. The soli-
darity of all is reaffirmed through behavioral control, with the new citizens becom-
ing tax payers who care about safe behaviors.
The need for a better marketing of good behavior is expressed increasingly on
many stages, both conservative and liberal, as we move toward a society with in-
creasing control over individual lives. In this context, will anthropology remain a
purely ancillary discipline at the service of health education and communication?
We must discover that public health always incorporates a definition of the res
publica, and that greater control in the domain of health brings with it a slipping to-
ward a more authoritarian society. The relativistic discourse of anthropology
should be used to combat this drift.

The Commodification of Behavioral Models

Within the social sciences, anthropologists should seek to counteract wh

seems to be the dominant mechanistic view about how we think about ourselves
and how we behave, a view introduced by the recent cognitivist shift in the human
sciences. In this view, human beings are predominately shaped by "cognitive blue-
prints" stored in the brain in the form of mental maps, scripts, frames, and scenar-
ios that shape actions of individuals along predetermined lines. These mental con-
structions are generally seen as ready-made schemes that scientists can learn to
"read" in order to predict actual behaviors of individuals, and more globally, as a
space where the logical relationships among actions can be deciphered. Exponents
of the predictive function of mental blueprints support recent trends in cognitive
psychology and models of the brain that have grown out of the cognitivist empha-
sis of the human sciences in the 1980s.
The notion of mental maps has relied heavily on linguistic analogies: the rela-
tionship of behavior to mental maps corresponds to that of "parole" (spoken lan-
guage) to "langue" (syntactic rules). This linguistic analogy is either misleading or
only partially valid, for beliefs and representations cannot be equated to syntactic
rules of grammar, and individuals are far less constrained in their behavior than by
the rules of grammar. Reality is far more complex; behavior should be seen as dis-
courses and narratives acted out in specific contexts derived from personal histo-
ries. The personal mental constructions (beliefs, ideas, representations) serve to
produce a tremendous variety of actions and discourses that are made meaningful
within specific contexts in the lives of individuals.
The linguistic analogy is useful in that individuals generally act with refer-
ence to norms and values, but it must be complemented by the attention to the daily
condition in which persons live. Individual experience is a personal text, a daily
narrative that is dialectical rather than linear, and that is constantly shaped by one's
personal history and context of life. There may be some sort of mental blueprint in
the mind or body, but this blueprint does not allow us to predict personal decisions
that people make about love, money, friendship, or health.

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252 MEDICAL ANTHROPOLOGY QUARTERLY

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JEANNINE COREIL
Department of Community and Family Health
College of Public Health
University of South Florida

More Thoughts on Negotiating Relevance

In his introductory paper, Stanley Yoder raises some very important issues for
anthropology within the international health arena. He hits the mark squarely
by defining the core problem as that of "negotiating relevance" in collaborative
situations, a task we often undermine through weakly articulated theoretical ap-
proaches. Yoder rightly faults our atheoretical and noncritical research stances as
contributing to the limited impact of anthropology on the theoretical bases of public

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