No abstract

Major health care problems such as patient dissatisfaction, inequity of access to care, and spiraling costs no longer seem amenable to traditional biomedical solutions. Concepts derived from anthropologic and cross-cultural research may provide an alternative framework for identifying issues that require resolution. A limited set of such concepts is described as illustrated, including a fundamental distinction between disease and illness, and the notion of the cultural construction of clinical reality. These social science concepts can be developed into clinical strategies with direct application in practice and teaching. One such strategy is outlined as an example of a clinical social science capable of translating concepts from cultural anthropology into clinical language for practical application. The implementation of this approach in medical teaching and practice requires more support, both curricular and financial.

The dysfunctional consequences of the Cartesian dichotomy have been enhanced by the power of biomedical technology. Technical virtuosity reifies the mechanical model and widens the gap between what patients seek and doctors provide. Patients suffer "illnesses"; doctors diagnose and treat "diseases". Illnesses are experiences of discontinuities in states of being and perceived role performances. Diseases, in the scientific paradigm of modern medicine, are abnormalities in the function and/or structure of body organs and systems. Traditional healers also redefine illness as disease: because they share symbols and metaphors consonant with lay beliefs, their healing rituals are more responsive to the psychosocial context of illness. Psychiatric disorders offer an illuminating perspective on the basic medical dilemma. The paradigms for psychiatric practice include multiple and ostensibly contradictory models: organic, psychodynamic, behavioural and social. This mélange of concepts stems from the fact that the fundamental manifestations of psychosis are disordered behaviours. The psychotic patient remains a person; his self-concept and relationships with others are central to the therapeutic encounter, whatever pharmacological adjuncts are employed. The same truths hold for all patients. The social matrix determines when and how the patient seeks what kind of help, his "compliance" with the recommended regimen and, to a significant extent, the functional outcome. When physicians dismiss illness because ascertainable "disease" is absent, they fail to meet their socially assigned responsibility. It is essential to reintegrate "scientific" and "social" concepts of disease and illness as a basis for a functional system of medical research and care.

The theme of this address—that brain and mind are as warp and woof in the fabric of psychiatry—may seem so much a truism as to be a banal choice. I think not. Despite the lip service paid to brain-mind integration, its implications are daily contravened in both theory and practice. At least, this is so in the country where I reside. If the problem is more extreme in the States, as most everything seems to be, recall the words Sir Aubrey Lewis (1953) wrote in commenting on Anglo-American contrasts, some 30 years ago: “the chief differences between your psychiatric scene and ours are differences only of quantity and tempo.” Think of me, then, as an anthropologist describing an exotic foreign culture and reporting on the strange customs of the natives, in hope of shedding light on your own.

Contemporary psychiatric research conclusively demonstrates that mind/brain responds to biological and social vectors and is jointly constructed by both. Major brain pathways are specified in the genome; detailed connections are fashioned by, and consequently reflect, socially mediated experience in the world. Just at the time when integration at the level of theory is coming into sight, comprehensive patient care is endangered by for-profit corporate managed care, which is transforming medical visits into commodities on a production line. Physicians and patients must join in a coalition to protect quality, ensure access, and build continuity into all of medical care.