Anthropology meets medicine
Margaret Lock's life work has helped reveal how people's experience of sickness and health is tied to the culture they belong to
Photo: Owen Egan
You walk down the hospital hall, passing by doctors in loose scrubs, nurses carrying folders, confused visitors, orderlies pushing elaborate machines that go ping. Clinicians order tests, aides soothe patients. You may also pass by, without knowing it, an anthropologist.
No longer concerned solely with understanding customs in developing countries, anthropologists are also busy making the familiar strange and the strange familiar in developed-world settings. Their qualitative research can be vital to better understanding the Western approach to health and the body.
A career of exposing culture's impact on medical matters earned anthropologist Margaret Lock the 2007 Gold Medal for Achievement in Research from the Social Sciences and Humanities Research Council. The council holds that the McGill University professor of the departments of anthropology and social studies of medicine is "internationally regarded as one of the most distinguished and productive medical anthropologists of her generation."
By training her comparative gaze on life cycles from adolescence to menopause to death, Dr. Lock has exploded preconceptions of the body and seemingly immutable biological events. Her fieldwork has taken place in hospitals, medical offices, universities and homes of participants in Europe, North America and Japan, where she lived on and off for eight years.
Her impromptu relationship with the East began in San Francisco, where the English-born Margaret met Richard Lock, captain of the Cambridge University Judo team, as he was en route to attend the 1964 Tokyo Olympics.
"His version is I ran after him to Japan. My version is that he begged me to join him," she says. The Locks soon switched from their universities in England to study at University of California, Berkeley, he in comparative literature, while she made the move from biochemistry to anthropology, specializing in the body in health and illness and in Japanese culture.
Dr. Lock's worldview changed profoundly once she immersed herself into the daily life of a country where the language and history were so different from her own. She also saw the cultural differences through the eyes of her two children, who spent their first years in Japan and California.
In Japan, the easily accessible daycare emphasizes consideration of others and awareness of one's role in the family. Older siblings help babies, children look out for each other, and activities are done in groups. Teachers repeatedly emphasize simple courtesies, such as where to put one's shoes or how to greet newcomers.
"Kids get used to having an ordered life, so they are sensitive to the impact on other people," Dr. Lock says. In comparison, her kids found American habits more individualizing, less calm.
After a move to McGill University in 1977 and decades of highly regarded work in medical anthropology, Dr. Lock shot into the public realm with her 1993 book, Encounters with Aging: Mythologies of Menopause in Japan and North America, which compared North American and Japanese views on menopause.
Dr. Lock had expected to find cultural differences, but the biological differences took her by surprise, "Proportionately fewer Japanese women seemed to be suffering from hot flashes and night sweats," she says.
Where North Americans and Europeans pathologize menopause into a crisis event fixable by medical intervention, the Japanese see the end of menarche as just "part of the aging phenomenon, an event in all the others that go along with changing eyesight, beginning to get aches and pains, greying hair and so on," says Dr. Lock. Other researchers have shown since that symptom reporting varies around the world, reinforcing her findings in Japan, and have shown similarities in other parts of Asia, too. Conversely, Middle Eastern women may report more symptoms than Americans.
Though diet may have an impact on menopause, it's far from the simplistic way most media breathlessly reported. "You can't just say 'drink soy milk'," Dr. Lock says. "It isn't really appropriate to think of the human body as a 'black box' as something universal for which a standard medication, such as a powerful hormone replacement therapy medication, is appropriate."
When Dr. Lock tackled her next big topic, organ transplantation, she saw that death is a cultural construct, like menopause. Her book Twice Dead: Organ Transplants and the Reinvention of Death (2002) surprised medical professionals everywhere.
Although American and Japanese neurologists agree on the diagnosis of brain death, that doesn't automatically decree the end of human life, Dr. Lock explains. With a ventilator, the body is demonstrably alive through breath, skin colour and organ viability, and Japanese culture is wary of accepting this state as the end of life, and families are reluctant to consent to organ donation. (In North America, as long as the individual has made explicit his or her wishes to donate organs, doctors are free to do so upon pronouncement of brain death.)
"At what point are you going to agree socially that death has come about?" Dr. Lock asks. "Is it when the body is putrefying as it was in mediaeval times? Or is it when the heart stops beating as throughout modern medical times, or when the brain stops functioning as with a massive brain injury?"
Over her career, Dr. Lock has seen a growing appreciation of social studies among medical professionals. Medical students today are a different breed than 30 years ago, when many wondered why an anthropologist would waste their time in the classroom. McGill, like most Canadian medical schools, now has more women than men students. It also has a higher proportion of francophones and a larger number of students from minority populations than it used to.
Today's students "have grown up in an environment in which we all think of medical knowledge in a different way," she says. "We've all read in newspapers and magazines about health and illness and research and what we're supposed to do to stop getting sick,"
Some years ago, Franco Carnevale took a graduate seminar with Dr. Lock when he was head nurse of the Montreal Children's Hospital's pediatric intensive care unit and helped her gain access to the hospital for research for her book Twice Dead. He says he found her "especially skilled" in relating her complex work to clinicians.
"She completely changed my whole understanding of how culture relates to medicine," says Dr. Carnevale, now director of McGill's master's of nursing program. "Clinicians are used to thinking of culture in terms of a barrier, such as language, for which you need an interpreter, or the eating habits of patients that may harm their health. She helped me see culture as a framework for understanding health, illness and the body, and that Western medicine is rooted in its cultural beliefs."
Currently, Dr. Lock is delving into a complex and subtle question. At first glance, it looks as though she's exploring late-onset Alzheimer's, but really she's investigating the relationship that at-risk people have with emerging genetic knowledge, such as how people handle information on genetic testing that might mean an increased chance of disease later in life.
Dr. Lock chose late-onset Alzheimer's partly because its susceptibility gene was one of the first to be mapped, and she wanted to steer clear of the more predictive single-gene disorders like Tay-Sachs or cystic fibrosis.
"People thought this mapping was an enormous breakthrough, and that they would have the key to solving this dreadful disease," she says.
But, as the genetic role's complexity emerged over the following years, and as the impact of diet, social or environmental factors on the gene's expression became obvious, molecular biologists began to appreciate the subtlety of the gene's influence - for example, among some hunter-gatherer populations, the susceptibility gene even protects against Alzheimer's.
Dr. Lock drew on interviews with two groups of people with a family history of the disease, in Montreal and in the United States. Their knowledge about Alzheimer's came from doctors, support groups and the media. The American group received genetic counseling and up-to-the-minute education on Alzheimer's, and that group was further divided into those who were offered gene testing and those who were given a risk assessment based on family history.
Despite the Americans' more precise genetic understanding, Dr. Lock was surprised to find few differences between them and the Canadians. All preferred to look to their family histories of the disease, and all held many ideas about Alzheimer's and its causes. (Interestingly, most of the American participants who undertook genetic testing either misremembered or entirely forgot their genetic risk status.)
Dr. Lock says that, unlike the public discourse about breast cancer with its hyped-up genetic fear-mongering, the media haven't been inflammatory about Alzheimer's, and it looks like public perception has followed suit. Dr. Lock believes that systematic genetic testing won't be encouraged (except perhaps by opportunistic private companies), and she even sees an eventual "dethroning of the gene." Molecular biology is going through a paradigm shift; "genes are to be put in their place, and not picked out as determining forces of life itself and various diseases," she says.
"Now the new genetics is reinforcing this kind of thinking, and people are now talking about individualized and personalized medicine - which I think is sort of a pipe dream - but there is powerful recognition today that human bodies show a lot of significant biological variation as far as disease vulnerability is concerned."
The revelation that there are many influences on the body has led to a boom in the field of epigenetics, which looks at how social and environmental factors can override simplistic genetic determinism. This ensures that anthropologists will play an ever-increasing role in our medical care, and be encountered even more often in our hospital corridors.
Photo: Martin Lipman
A winning field
by Gary May
The paradox is clear to Vinh-Kim Nguyen: Foreign relief dollars are flowing into Africa for HIV/AIDS treatment in record amounts, but it is creating jealousy and resentment among the local populations.
"People with HIV get drugs, they get food aid, and their kids get their school fees paid for," says the Université de Montréal physician and medical anthropologist, who won the Social Sciences and Humanities Research Council 2007 Aurora Prize. It's awarded to an outstanding new researcher doing exciting and original work in the social sciences or humanities.
His research showed that "having a disease, a fatal illness, was becoming a survival strategy. Having HIV is better than not having it. The perversity of that really struck me. It was very disturbing because it [AIDS relief] was something we had all fought for."
The British-born Nguyen, who was a child when his family moved to Canada, has always felt a connection to Africa through relatives in the French-speaking western region. The 44-year-old first visited Africa at age 18. That was before the world had heard of AIDS, but when he decided to dedicate his life's work to its treatment, his Africa connections served him well.
Dr. Nguyen began in 1994 to help community-based organizations set up treatment programs in Burkina Faso, Mali and the Ivory Coast. That's when he became interested in the social dynamics of humanitarian aid and how recipients reacted to it.
This "humanitarian invasion" has created an unequal power dynamic in the region, he found. By framing the issue, he hopes people will look at humanitarian relief in a new way, one that will further benefit the nations it's designed to help.
Among his many scholarly connections, Dr. Nguyen is a professor and research fellow with Germany's Max-Planck Institute for Social Anthropology, a researcher at the Centre hospitalier de l'U de M, consultant for the International HIV/AIDS Alliance and a member of the board of directors for Médecins du Monde Canada.
Suzanne Bruneau, a program officer with SSHRC, says the fact the winners of its two most important prizes - Drs. Nguyen and Gold Prize winner Margaret Lock - are both medical anthropologists was coincidence.