The defining characteristic of clinically applied anthropology is that it is anthropology practiced in health care settings: hospitals, clinics, health professional schools, and health care delivery systems of all kinds. The health care arena is so wide ranging and complex that it almost requires the kind of complete immersion that comes from working within the system itself and with its practitioners in order to do relevant research, theory building, teaching, and consulting. Anthropologists working within this branch of anthropology apply data, theory, and methods that clarify specific clinical issues and suggest changes in patient care, health maintenance, and health care delivery.
Alternative names have been suggested for the sub-discipline: “clinical anthropology,” “clinically applied anthropology,” “clinically applied medical anthropology,” and “applied medical anthropology.” The critical issue in the choice of a name turns on the roles the anthropologist necessarily must assume in the health care setting. Early on, concerns were expressed about the title “clinical anthropologist,” a title that was thought indirectly to imply that the anthropologist could perform patient interventions. With the exception of those anthropologists who have additional licensure in medicine, nursing, or therapy, there are legal/liability issues in their involvement in direct patient care beyond that of a consultant to licensed health care providers. This concept of a restricted role vis-à-vis patients is not shared by all: clinical anthropologist and naturopathic doctor John Rush argues for a hands-on therapeutic role for clinical anthropologists. However, the roles assumed by anthropologists who apply their skills within clinical settings are, by and large, those of teacher, consultant, and researcher. Usually, the clinically applied anthropologist combines all three. The term “clinically applied anthropology” will be used in this entry.
The field began to be distinguished as a separate subdiscipline of medical anthropology in the late 1970s and early 1980s with the appearance of the writings and research activities of the following individuals: Arthur Kleinman, Leon Eisenberg, Byron Good, Noel Chrisman, Thomas Maretzki, Dimetri Shimkin, and Peggy Golde. The activities of these anthropologists and their colleagues announced a trend that was to run through the subdiscipline from that time to the current day: the close, interdisciplinary collaboration between health care professionals and anthropologists. Three early writings are illustrative of this collaboration, with the first being a seminal article, “Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research,” by physician anthropologist Kleinman, psychiatrist Eisenberg, and anthropologist Good. Both the edited books by Chrisman and Maretzki, Clinically Applied Anthropology, and Shimkin and Golde, Clinical Anthropology, are comprised of chapters written by anthropologists, physicians, psychologists, psychiatrists, and others working in direct patient care. At about this same time, anthropologist-nurses began to make their influence known in the work of Pamela Brink and Madeleine Leininger.
Biomedical Culture as a Focus of Research and Analysis in Clinically Applied Anthropology
Anthropologists who have centered their work in health care settings have, in a very real sense, entered a well-defined and pervasive culture, that of biomedicine, that is very different, sometimes antithetical to, the culture of the social sciences. In terms of time management, behavioral norms, vocabulary, values, and, especially epistemological perspective, biomedicine and anthropology are worlds apart. The tension between the positivist, empiricist worldview that suffuses biomedicine and its allied fields and the mostly interpretive, constructivist approaches to human sickness and suffering that characterize much of anthropological thought is broadly discussed in the writings of Fabrega, Kleinman, Hahn, and Good.
What constitutes knowledge and knowledge claims in anthropological understandings of illness are often not considered central to the diagnosis and treatment of disease in biomedicine. This contrast has created obstacles, difficult but not at all insurmountable, for anthropologists who work in health care settings. In some degree, anthropologists have found significant subject matter for theoretical formulations and research about human sickness in the contrast between the traditional perspectives of anthropology and biomedicine.
For example, a major focus of research for anthropologists in clinical settings has been that of examining and describing the characteristics of the culture of biomedicine itself and the role of physicians as central actors in this hierarchical universe. The socialization into that culture of students as they become clinicians and acquire what Good has called the “medical gaze” has been another closely examined subject for anthropologists. This unique way of seeing the body and the world of disease permeates the world of health care as a particular and distilled expression of Western rational and object-centered thought. Clinically applied anthropologists generally see this narrowness of focus in biomedicine as a failure to treat suffering patients as whole persons within sociocultural contexts of meaning. They have taken the opportunity to build contrasting models of human suffering through mental and physical disorder that emphasize illness as experienced by patients within a wider experiential and symbolic world as described by Kleinman and Hahn.
Taking a somewhat different perspective in his examination of biomedical culture, critical medical anthropologist Merrill Singer, from his vantage as researcher at the Hartford Health Clinic, mounted a critique of medical anthropology in general and the role of anthropologists in health settings in particular. He and other anthropologist colleagues such as Hans Baer and Nancy Scheper-Hughes saw many clinically applied anthropologists as having “bought in” to the power structure that constitutes the biomedical system. The critical medical anthropologists pointed out that the distribution of illnesses suffered by patient populations, their access and response to care, and differential treatment outcomes were the result of macrolevel socioeconomic and political forces that were replicated and perpetuated in the biomedical system. Another allegation made by this critique was that anthropologists who do research and other work in the health care system perpetuate the inequities within it by ignoring the structural and political factors that cause these disparities. Many clinical anthropologists disputed this allegation, calling attention to a long tradition in medical and clinically applied anthropology of examining these factors in the social production of disease and expressing an unwillingness to reduce illness and the interactions between patients and health care systems solely to the paradigm of class struggle.
Clinical Anthropologists as Educators
Despite the differences in perspective between bio-medicine and anthropology, or perhaps, ironically, because of them, clinically applied anthropologists have found important niches in medical and health care settings as teachers and consultants. Clinicians and others who design health care delivery systems are ultimately concerned with successful patient outcomes, and such outcomes are very inconsistently obtained despite the ongoing development of new diagnostic methods, medicines, and treatment modalities. The last two decades have seen a growing emphasis on patient-centered care and the importance for clinicians of building workable therapeutic alliances with their patients. Within this context, the “anthropological gaze” has come to be valued, particularly in medical and nursing schools.
In many schools, clinical anthropologists have made a contribution through teaching health care professionals anthropological techniques and concepts useful to their everyday practices. Teachers and trainers have concentrated their efforts most successfully in two areas: enhancing patient/provider communication and integrating patients’ sociocultural context into diagnosis and treatment planning. For example, one of the most enduring and clinically useful techniques taught was Kleinman’s method for eliciting a patient’s explanatory model (EM) of his or her sickness through a set of several questions that might be used in taking a history or making a differential diagnosis. The questions served to help the clinician grasp the patient’s understandings of the causes and characteristics of the illness problem and its effect on his or her life. Providing this context allowed the clinician to move from the narrow perspective of disease, which considered only the physical pathology, to a broader view that encompassed the patient’s illness, the lived experience of the sickness from the patient’s point of view. Based on this wider understanding, the clinician’s communication with the patient was greatly improved, and negotiating a treatment plan that ensured acceptance was more probable. The concept of a patient’s explanatory model or emic paradigm has been widely used in educational and training programs since Kleinman and his colleagues introduced it.
Early on, according to the writings of Noel Chrisman and Robert Ness, medical, dental, pharmacy, and nursing students, as well as other budding health professionals, were found to be initially resistant to the teachings of clinical anthropologists and questioned the relevance of this “soft” subject matter in the curriculum. This resistance persists to this day, though to a lesser degree, and is based on the strong scientific focus of clinical students and their lack of formal training or previous exposure to the social and behavioral sciences. Teaching clinically applied anthropologists has successfully overcome such resistance by concentrating on integrating anthropological materials into the teaching of specific skills required of clinicians: healing, educating, and planning. This is done by consistently integrating social and cultural factors surrounding disease processes alongside discussion of physiological processes, connecting the dots in the relationship of one to the other. The utility of understanding patients’ perspectives and life circumstances is made essential to effective information transfer and treatment planning. Cultural elements are woven into case studies that students then analyze. In the study of epidemiology, concepts of social epidemiology, that is, the social and cultural factors involved in the distribution, symptom expression, onset, course, treatment, and outcome of illnesses, are made clear. Clinically applied anthropologists often serve alongside physicians and nurses as preceptors in community-based clinical rotations. Students are exposed to clinically applied anthropologists when they participate in hospital rounds and as consultants in case management discussions.
In the last 10 years, as a result of the drive for cultural competence/cultural responsiveness in health care, teaching of anthropological concepts to practicing clinicians working in health management organizations, community clinics, hospitals, and mental health facilities has been ongoing. Instead of classes and preceptorships, clinically applied anthropologists organize workshops and staff seminars as well as participate in grand rounds and resident training.
Innovative strategies geared to adult learning are used. Geri-Ann Galenti, for example, has written a very well-accepted book of cultural case studies organized around clinical themes that she uses as a basis for on-site workshops in hospitals and clinics. Jean Gilbert, in collaboration with physicians, nurses, and health educators at Kaiser Permanente, has created video vignettes that are case studies of clinical issues relating to pediatrics, obstetrics, internal medicine, geriatrics, and behavioral health. Chrisman has developed programs in community-based care and cultural medicine for hospital nurses, hospices, and community health practitioners. Other anthropologists have organized national conferences bringing together clinicians, anthropologists, and health care providers and managers from many fields to present and discuss issues in cultural medicine. In all of these endeavors, clinically applied anthropologists work closely with persons from many health care disciplines. This collaborative approach gives validity to and underscores the importance of anthropological data and approaches to quality patient care.
Dual Roles: The Clinically Applied Anthropologist Clinician
Doctors, nurses, and behavioral health therapists who are also anthropologists have been a part of this subdiscipline since its inception. Many do their work as faculty in medical and nursing schools and as practicing physicians. Anthropologist-physicians following in the footsteps of Kleinman and Eisenberg include Robert C. Like and Kathleen Culhane-Pera. Like, a family medicine physician, in collaboration with other physicians and fellow anthropologist Arthur Rubel, created a cultural curriculum for family practice medical students that has served as a model for numerous medical programs. Culhane-Pera, a family physician at Ramsey Family and Community Medicine Residency in Minnesota, has done extensive research among the Hmong community. Healing by Heart, written by Culhane-Pera in collaboration with other health care professionals and anthropologists (Peter Kundstadter, anthropologist epidemiologist, and Joseph Westermeyer, anthropologist psychiatrist), is an in-depth study of the Hmong culture’s interactions with health care providers and the health care system. It includes a well-detailed model for providing culturally responsive care useful for curriculum design and practitioner training.
Persons exemplifying the dual roles of anthropologist/mental health professional include practicing psychiatrists Horatio Fabrega and Joseph Westermeyer and psychologist Richard Castillo. Fabrega has written extensively on the interaction of biological and symbolic and cultural factors in mental health as well as the role of culture in psychiatric diagnosis. Joseph Westermeyer has studied alcohol and drug use and substance-related disorders across several populations. Castillo has focused on cross-cultural psychopathology and psychotherapy. Both he and Fabrega were part of the Group on Culture and Diagnosis who served as cultural advisers on the cultural formulation in the fourth version of the Diagnostic and Statistical Manuel (DSM-IV) used in diagnosing patients throughout the mental health care field.
Nurses were among the first health care professionals to combine clinical and anthropology degrees, and they form a special unit within the American Anthropological Association. They have their own journal, the Journal of Transcultural Nursing. Examples of nurse anthropologists include Margie Kagawa-Singer, who is a professor in the School of Public Health, University of California, Los Angeles, with a research focus in oncology. Another is Fred Bloom, researching in the area of HIV/AIDs and community health care utilization at the Centers for Disease Control. Margarita Kay, well known for her research on folk and indigenous medical medicines and practices, is a clinical anthropologist working in Tucson, Arizona, clinics and at the University of Arizona. The list of clinically applied anthropologists in nursing is extensive, and it includes nurses specializing in every aspect of clinical medicine and health care from nutrition to chronic diseases, geriatrics and end-of-life care, genetics, and childbirth.
Clinically Applied Anthropologists as Policymakers, Advocates, and Consultants
In the three or so decades since medical anthropology began to be clinically applied, the structure of health care settings, the demographic characteristics of the patient population, and the politics of health care, all of which form the environment in which clinically applied anthropologists work, have undergone very significant changes. Due to immigration, refugee resettlement, and globalization, many patients entering the health care systems are linguistically and culturally different from members of the clinical professions. While the latter have certainly become more diverse as to race, ethnicity, and gender, this has only increased the probability that clinicians and their patients will not share basic cultural understandings about sickness and health. Furthermore, research begun in the 1980s and continuing into the present has demonstrated persistent inequalities in health status, treatment, and access to care across racial and ethnic populations. In an effort to address these issues, the cultural competency in the health care movement and field was born, a movement that was originally informed by the work of clinically applied anthropologists but that now has extended to a much wider health care base. As active participants, clinically applied anthropologists have increasingly become advocates, specialists in health care delivery to diverse populations, and designers of curricula and diverse forms of training for health care professionals, students, and practicing clinicians. As with most other work of clinically applied anthropologists, they have collaborated in multidisciplinary teams with health care providers and community advocates of many types. Following are some examples of this kind of involvement.
The creation of the National Standards for Culturally and Linguistically Appropriate Services in Healthcare (CLAS Standards) was begun in an advocacy group that included physician anthropologist Like and clinically applied anthropologist Gilbert, working with other health care providers and government officials. These standards, after national input from all health care sectors, were endorsed and published by the Department of Health and Human Services, Office of Minority Health. They provide guidance to health care organizations for enhancing the quality of care to diverse patient populations. These standards are now being used as benchmarks and guidelines by health care accreditation bodies as well as state and federal auditors of health-care-providing organizations.
In 2002, clinically applied anthropologists, including nurse and physician anthropologists, gathered with physicians, nurses, health educators, and health care and accreditation administrators from across the United States to formulate The Principles and Recommended Standards for the Cultural Competence Education of HealthCare Professionals. This document, the creation of which was underwritten by The California Endowment, sets out recommended con-tent, skills development, pedagogical strategies, and evaluation techniques for ensuring that clinicians are educated to treat diverse patient populations in a culturally responsive manner. The principles and recommendations are being used in designing curricula by undergraduate and graduate programs of clinical education and in the accreditation of professional schools. It is anticipated that these materials will continue to be used in many ways as other states, following the lead of New Jersey, require training in cultural approaches to patient care as a condition of licensure for physicians, and cultural medicine is required in the curricula of medical schools.
Recently, clinically applied anthropologists such as Mary-Jo DelVecchio Good have turned their attention to determining the reasons behind differential treatment of minority patients, as studies, such as those summarized in the Institute of Medicine report Unequal Treatment, have indicated that at least some of these patients receive less than adequate care as a probable result of clinician behavior and poor patient-clinician interaction. Both physician-patient communication and the structuring of health care delivery and access are being examined to determine how these statistically significant variations in treatment arise.
Anthropologists with research in clinical settings often provide consultation to private foundations. For example, Susan Scrimshaw has been involved as an advisory board member on the Robert Wood Johnson Foundation initiative, Hablamos Juntos, an effort to seek effective ways of providing language interpretation in health care to meet the needs of the now vast number of limited-English speakers in the patient population. Under grants on this initiative, other clinically applied anthropologists are studying methods of interpretation and translation in health care settings to determine the most effective methods of providing these language services in health care settings that provide care to linguistically diverse patients.
Clinical anthropologists consult in a number of capacities in the public and private sectors. For example, they are asked to provide information and advice to the National Institutes of Health on the direction of future research and to give help on developing requests for applications (RFAs), Many also sit on research review study panels. Clinically applied anthropologists are working with the Department of Health and Human Services Health Resources and Services Administration in designing curriculum guidance for the Centers of Excellence medical, nursing, pharmacy, and dental schools.
Anthropologists working in corporate health delivery organizations help set policy and advocate for and direct research and development programs and care delivery strategies to meet the needs of diverse patient populations. They consult to health care management and often develop ongoing staff and provider education programs in cultural medicine. In California, for example, Medicaid contracts specify that all contracting health care organizations, public and private, must provide for the cultural competence education of practitioners and support staff, as well as manage their health care delivery practices and linguistic services so as to meet the needs of diverse patients.
Clinically applied anthropologists’ strong ethno-graphic research backgrounds in many areas of health care as well as their close familiarity with the clinical and care delivery environments equip them well for serving in a wide variety of research, teaching, consultant, and policymaking positions. Equally helpful is their experience in collaborating across health care disciplines and their flexibility in moving from clinical to teaching settings. As a result, the field of clinically applied anthropology is continuing to expand in the United States as the nation focuses more and more on the issues of health care in its diverse and aging population.
- Brink, P. (1976). Transcultural nursing: A book of readings. Englewood Cliffs, NJ: Prentice Hall.
- Chrisman, N. J., & Maretzki, T. W. (Eds.). (1982). Clinically applied anthropology: Anthropologists in health science settings. Dordrecht, Holland: D. Reidel.
- Culhane-Pera, K., Vawter, D. E., Xiong, P., Babbitt, B., & Solberg, M. M. (Eds.). (2003). Clinical and ethical case stories of Hmong families and Western providers. Nashville, TN: Vanderbilt Press.
- DelVecchio Good, C., James, M-J., Good, B., & Becker, A. E. (2002). The culture of medicine and racial, ethnic, and class disparities in health care. Supplement to Brian D. Smedley, Adriennne Y. Stith, & Alan Nelson (Eds.), Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.
- DeSantis, L. (2001). Culture reorientation of registered nurse students. Journal ofTranscultural Nursing, 12(4), 310-318.
- Galanti, G.-A. (2004). Caring for patients from different cultures (3rd ed.). Philadelphia: University of Pennsylvania Press.
- Gilbert, M. J. (2002). Principles and recommended standards for cultural competence education of health care professionals. Los Angeles: California Endowment.
- Hahn, R. A. (1995). Sickness and healing. An anthropological perspective. New Haven, CT: Yale University Press.
- Mezzich, J. E., Kleinman, A., Fabrega, H., Jr., & Parron, D. L. (Eds.). (1996). Culture & psychiatric diagnosis: A DSM-IV perspective. Washington, DC: American Psychiatric Press.
- Rush, J. A. (1996). Clinical anthropology: An application of anthropological concepts within clinical settings. Westport, CT: Prager.