Medical Cultures, Therapeutic Properties, and Laws in Global History

Previous articleNext article FreeMedical Cultures, Therapeutic Properties, and Laws in Global HistoryHelen TilleyHelen Tilley*History Department, Northwestern University, 1881 Sheridan Road, Evanston, IL 60208, USA; [email protected].For their astute feedback and comments on earlier drafts, my heartfelt thanks to Projit Mukharji, Suman Seth, Ronald Numbers, Paul Ramírez, David Schoenbrun, W. Patrick McCray, Justin Stearns, Sheila Ann Dean, and two anonymous reviewers. Search for more articles by this author Full TextPDF Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinked InRedditEmailQR Code SectionsMoreThis volume of Osiris takes as its central goal the need to bridge studies of medical cultures, past and present, with studies of the law and legal cultures, encouraging a sustained and historically informed dialogue across all these fields.1 It deliberately concentrates most attention on the nineteenth and twentieth centuries when medical and legal connections intensified, institutional structures proliferated, and a diverse set of laws and regulations arguably achieved global impact. The field of medical history, for all its accomplishments, still lacks clear and persuasive grand narratives that take all these dynamics into account or that explain their consequences. At the same time, disciplines focused on (bio)medical phenomena today-such as critical global health studies, medical humanities, and science and technology studies-are still insufficiently engaged with the voluminous literature produced by historians, including those focused on science, medicine, and technology. The blind spots this produces matter. Indeed, anyone who ignores the multifaceted and entangled roots of medical and legal phenomena, or believes that the past is irrelevant because recent bioscientific and institutional changes have been so radical and rapid, tends to analyze current trends in ways that are themselves misleading.2 Put simply, disciplinary and professional silos continue to prevent scholars from developing empirically robust and historically nuanced studies of medicine and law on a global scale. This volume offers one path forward.Therapeutic Properties is premised on the idea that boundary work in medical activities has always been mediated and constituted by laws and legal thinking. It recognizes that when people have acted to sort and classify what would and would not count as medical or therapeutic, they did so across many geographical scales and within myriad legal jurisdictions, making these processes inextricably linked. Just as important, the articles in this volume parse legal issues in terms of both hard and soft laws. Where the concept of "hard law" captures such things as legislation, treaties, court rulings, judicial orders, legal customs, constitutions, and the like-all backed up in principle by tools to entice and force compliance-"soft law" gestures to rules, regulations, plans, norms, resolutions, guidelines, and protocols that come with no such tools of "enforcement" because they are by definition nonbinding (i.e., voluntary and aspirational); yet they still leave their mark on the world.3 Only by considering legal and medical histories in tandem is it possible to tease out the interrelations and effects of these different kinds of law.The articles in Therapeutic Properties build upon four historical insights relating to (1) the global ascendency of biomedical cultures and their counterparts, (2) the persistence of unofficial and unorthodox forms of care, (3) the production of quotidian and clandestine therapeutics, and (4) the synergistic role of laws and legal processes in setting boundaries across all medical domains. This introduction walks readers through these four insights-with a section for each one-in order to explain the wider historical context that frames the volume. They should also help anyone taking up these issues for the first time to see more clearly how and why they are important. The concluding section discusses each article's themes and arguments, tying several of the threads together.Biomedical Cultures and Counterparts Across the PlanetOver the last two centuries, biomedicine-defined broadly to include public health and primary care-has achieved unparalleled authority at the global level.4 No one should be that surprised by this statement because it is now part of a shared and dominant reality. Medical historian Roy Porter came to a similar conclusion more than two decades ago, giving it a provocative twist: "What began as the medicine of Europe is becoming the medicine of humanity."5 In spite of his confident claim, historians who trace these patterns continue to debate just how European all of Europe's medicine really has been, while anthropologists and sociologists, and anyone focused on people's health, rightly question whether it has indeed become humanity's medicine.6 A more precise, though less pithy, statement of fact would be this: biomedical approaches are now the norm for governments the world over. This means that there is no single or archetypal biomedicine, but rather a mosaic of biomedical cultures, each with different kinds of official backing. For Porter, and so many others, biomedicine is one of history's "winners." Just why and how it won, he left to others to explain, surmising only that it resulted from some combination of "western political and economic domination" and the fact that "it is perceived, by societies and the sick, to 'work' uniquely well, at least for many major classes of disorders."7 The forces that helped biomedical methods and ideas predominate picked up in pace and intensity in the middle of the nineteenth century when states, empires, and international organizations began to systematize and standardize their work on an ever-growing scale. Legal instruments and institutions were integral throughout, yet their exact roles in so many different places still remain opaque.As biomedical approaches coalesced and began to achieve different degrees of official power, this process produced side effects of its own, generating an array of therapeutic cultures that were themselves novel and often without precedent.8 These patterns tend to be less well understood, certainly at a popular level, but even among historians of science and medicine (and specialists in area studies) because they require comparative and transnational methods to bring them fully to light. To put this in Porter's terms, it forces scholars to pay attention to the other medalists, the runners-up, the also-rans, the dropouts, and even those who are still trying to come from behind. More to the point, it means looking at the referees, the umpires, the coaches, the rule books, the funders, the fans, the playing fields, and the pickup games. Porter thought about this himself and even had a cast of characters in mind: "It is conceivable that in a hundred years' time traditional Chinese medicine, shamanistic medicine, or Ayurvedic medicine will have swept the globe ... but there is no real indication of that happening, while there is every reason to expect the medicine of the future to be an outgrowth of present western medicine-or at least a reaction against it."9 True, and yet ... in certain respects Chinese medicine has swept the globe, while Islamic-, Asian-, and African-influenced forms of therapeutics have held onto and even expanded their continental coverage, and "shamans" (or unorthodox practitioners of all kinds, including those metaphysically inspired) have not gone away.10 What should we make of these patterns, and how do we explain them in historical terms at the same time that we explain biomedicine's ascendency?Scholars, of course, have long recognized the frictions and fusions of cross-cultural exchanges, including their inequalities, and have noted the many epistemic and real-world phenomena they generated in their wake. Medical anthropologist Margaret Lock tried to put her finger on this dynamism in the following way: "In no case, not even in Europe and North America, has biomedicine entirely usurped other forms of healing practices already present. Pluralism [has been] the norm and, paradoxically, with globalization, diverse forms of medical practice have actually proliferated both in countries that modernized early and in those where the process commenced much later."11 Given that Lock is right-medical practices have multiplied-why has it also been so easy for powerful figures to render invisible different cultures of care and approaches to health in so many places over time? The answer lies, in part, in the way political entities have given certain professionals (and their institutions and practices) an official stamp of approval, otherwise known as legal recognition, while pushing to the margins so many other players. But it also rests in increasingly popular ideas of progress and the loaded term "modern" itself, both of which led people to cast whatever they viewed as the concepts' opposites to be no longer important, useful, or relevant.Even the history of medicine has fallen prey to this tendency, framing its origin stories and grand narratives in ways that deliberately winnow down definitions of who and what are most significant, because the field understandably wishes to contextualize prevailing and powerful patterns.12 Whatever gets left to one side, scholars suggest, was insufficiently important anyway, because it failed to have enough of a lasting impact or secure the support of influential arbiters, or perhaps both. While most medical historians avoid telling Whiggish stories about an inevitable path toward more effective remedies, it is harder to sidestep methods and lexicons that inadvertently naturalize this kind of narrative arc. Certain concepts, in other words, are embedded in epistemic cultures of their own, and using them can lock scholars into genres of medical storytelling that create blinkered views.Histories of infectious diseases-both specific and composite-offer a perfect illustration of this challenge because they tend to be premised on understandings of reality that make it tough to do justice to the sheer array of time-specific, place-specific, and language-specific ideas about illnesses, therapies, and cosmologies that have been coterminous.13 So, scholars must pick and choose, featuring some places and languages over others, all while moving in their stories toward the arrival of microscopes, the proliferation of laboratories, the creation of vaccines and new drug therapies, the hygienic triumph (or failure) over parasites, and, perhaps most important, a kind of secular disenchantment of the world.14 Such stories and their demographic "lessons"-about lives lost and saved, experts investigating and intervening, and people contesting and benefiting-make it hard to remember that "germ theories" and their accompanying tools arose within specific political and racial economies that shut down other conceptual and therapeutic possibilities.15 The people who wielded these new tools often insisted that they made medicine "modern," which created an explicit trade-off; any diagnostic categories, definitions of health, or healing practices that did not fit within their epistemic cultures had to be rejected in order for these new epidemiological and bodily "facts" to take their place.This dialectic-and circular-logic has created its own kinds of real-world effects and helps to explain why in some regions of the world, new or recently assembled medical cultures were labeled "traditions" and often placed in an explicit ethnonational lineage, eventually becoming something pervasively called "traditional" or "indigenous" medicine (e.g., traditional Chinese medicine or Maori medicine).16 Some scholars have taken to referring to these things as "neotraditional" to signal just such novelty.17 These synergies also explain why certain specialists were rejected outright, precisely because they failed to conform to the needs and moral requirements of states and empires that were aspiring to be modern (consider "voodoo," "obeah," or any number of other stereotypical terms).18 Such practitioners can be considered the "losers" in the global game; they were thrown out because they were considered unfit for the task. Those in positions of authority often chose labels for these players (and their expertise) that reflected a sense of danger, calling their work witchcraft, superstition, magic, or sorcery, and alleging their unreasonable and unreal natures, even as they responded to them in real and visceral ways.19Over the last two centuries, different parts of the world experienced similar conditions as empires expanded (and contracted), as nation-states multiplied in successive waves, and as medical missionaries worked to spread their "gospel." Leaders and laypeople alike struggled to distinguish between old and new forms of medicine-and between orthodox and unorthodox health practices-in the process.20 To put these dynamics in stark relief, the globalization of biomedicine and the codification of "traditional medicine" were two sides of the same historical coin. Both also generated their own illicit shadows, including such phenomena as medical negligence and malpractice, activities around which robust legal cultures have arisen. Over time, modern medicine-and its cognates, Western medicine, biomedicine, and scientific medicine-became catchall categories for ideas about effective medicine (whether true or not). In turn, whatever was thought to have come before or to exist outside its remit was, by definition, less effective (risky even) and largely benched or suspended from official play.As anyone familiar with biomedical cultures and their counterparts knows, the story does not end here. These dualisms-modern/traditional, effective/ineffective, Western/non-Western, reasonable/unreasonable, official/unofficial, real/unreal-rest upon myths and illusions of their own. It is just these partial perspectives that history's winners have tried to insist upon, and that policy makers (and their enforcers) often echo, even when they criticize the status quo. To switch from a sports analogy to a judicial analogy, by paying too little attention to the long history of dissenting opinions (in medical practice), dominant approaches in global health studies manage to double down on just those blind spots, suggesting far more historical consensus about definitions-including what works, what does not, and why-than has ever existed in practice.21 If only the world were so simple.Unofficial and Unorthodox Therapeutics: Competing Jurisdictions and Sovereign PublicsUntil fairly recently, these legal distinctions and official policies have not really mattered for most people, which leads to a second historical insight on which this volume rests. Myriad forms of healing and state-sanctioned medicine, public and private, have coexisted and intermingled for centuries, and these patterns persist into the present.22 States and municipalities have never had a monopoly over cultures of care. This has been true both in places where there have been few (or poorly enforced) laws and in places where many laws exist, because people find ways to maneuver in pursuit of health on their own terms. Just as important, as laws proliferated, they created intersecting and competing jurisdictions, meaning that rules could operate at different scales and contradict, cancel out, or dampen each other's authority. Antivaccination and faith-healing movements are just two of the more recent examples of this phenomenon.23 Scholars may find it easy to acknowledge these juridical complexities, but it is also easy, especially for those focused on more recent biomedical or state-centric histories, to misconstrue or simply ignore them.There are several reasons for such confusion and neglect. To start with, the very idea that each state would have its own sovereign "health system" is actually relatively new at the global level, and rests on shaky ground.24 Even so, boosters have been especially effective in creating the impression that state-sanctioned systems are the best, if not the only, game in town. Metrics and rankings only reinforce this message. With these, many health care models count only those people the state designates as official, ensuring that anyone who does not fit the bill is either ignored or is sorted into religious, mutual aid, or "informal" economic categories.25 The blind spots here have to do with cultures of care that are illegible to state techniques of counting. Going further, certain boosters of official models of health care have also been good at distorting the historical record by failing to acknowledge different polities' past medical norms and practices, while they also exalt-even as they may misunderstand-the genealogies of others.26 The blind spots here have to do with influential arbiters' refusal to accept-or their need to deny outright-other models of care. This insight applies just as much to places where text-based understandings of health prevailed-within Eurasian and Islamic spheres where you might find influential "classical" texts-as to places where oral, but no less literary or learned, approaches were the norm, such as parts of Africa, the Americas, and various islands and archipelagos. And in truth, textual and oral approaches have coexisted almost everywhere.Finally, unofficial and unsanctioned therapeutic practices have been easy to misunderstand, because they have involved types of agency that operated outside or alongside political hierarchies and elite activities. To follow their impact means studying forms of bottom-up and horizontal social power. Here we might think of the many ways people enslaved or subjected to colonial rule ended up playing crucial roles and leaving lasting traces within different domains of health care (and much else besides). These latter patterns are admittedly harder to pin down, especially as geopolitical units have changed (altering what counts as official) and as certain nation-states have come to exercise an outsized influence over the way the "public" in "public health" gets defined and imagined globally.27 The Ottoman empire offers a good example of this. As British and French officials encroached on its sovereign controls in North Africa in the second half of the nineteenth century, the empire's longstanding techniques of care and social welfare went from being authorized to unauthorized. Nonetheless, residents continued to look to Ottoman precedents, Islamic law, and enduring precepts about public health to guide them, even as French and British representatives built upon some of these practices, discarded others, and insisted that their "civilizing mission" would lead to improved health conditions for all.28Given that histories of "public health" tend to take the "modern (European) state" as the defining model, it has been easy to overlook that other ideas about sovereignty and health persisted.29 This matters for many reasons, not least because it affects the kinds of stories scholars tell about the origins and lived realities of "rights to health" thinking. Without comparative and genuinely global perspectives, these histories usually write much of the world out of the picture, giving more credit, once again, to elite actors, powerful institutions, and imperial states. Such players have indeed been influential, but they are hardly responsible for every innovation. The fact that so many histories suggest otherwise does not just distort the historical record, it also impoverishes our imaginations.Quotidian and Clandestine Therapeutics: Body Politics, Public Healing, and Medical MarketsUnofficial approaches to health have actually run the gamut from domestic forms of care, including palliative work surrounding debility and death, to institutions of "public healing."30 This introduces a third historical insight central to this volume. Studies of certain kinds of quotidian and collective healing have shifted the analytical frame away from doctor-patient dyads to explore intergenerational "quests for therapy."31 Such a wide-angle lens has allowed scholars focused on African medical history, for instance, to reveal how different groups have linked forms of political and social power to therapeutic power. Their analyses have shown that different healing acts were not so much about individual bodies as they were about the body politic (and nonhuman nature too). These scholars have made it clear that people at the mercy of certain social structures-including (transatlantic) slavery, capitalist modes of production, and colonial rule-have viewed them as forms of misfortune and affliction in their own right, requiring an organized response to restore "public" health precisely because the effects were felt on a collective level.32Trying to draw neat and tidy lines around what has and has not constituted "illness" (or health) and who was and was not a "healer"-also expecting that people have held such rigid distinctions in their own minds-is often belied by historical evidence. David Schoenbrun explains: "Healing in African history implicates other histories too.... The powers of kings, court ritualists, chiefs, certain mediums, and rainmakers-common actors in the domain of public health-are often understood to work in this expansive scope. Spirit possession activities cross these boundaries."33 This point helps to clarify why many historians who have explored the "social basis of health in Africa" have also foregrounded relationships between healing and harming; not unlike biomedical approaches, efforts to secure collective or public health have made use of tools and practices that can also inflict harm.34 Unless this point is made explicit, it becomes too easy to sanitize health histories and erase different kinds of conflict, and even violence.Because the rules of the game have always been contentious, unofficial or unsanctioned healing has tended to develop simultaneously in quotidian and clandestine forms, allowing its adherents and practitioners to avoid detection or even appear to be ineffectual or inconsequential. This has also meant that (colonial and national) state actors-some of the more powerful "umpires"-have mistaken or simply missed these unauthorized forms because they were not themselves well versed in such specialties. Official "verdicts" on this front have nonetheless had enduring ripple effects for both those caught in the crosshairs and those watching on the sidelines. Whatever "umpires" deemed irrelevant or silly or dangerous or simply having no existence tended to be taken as true (or at least potentially true). Their judgments raised the stakes for anyone wishing to defend things labeled unorthodox or (dangerously) different. Efforts to regulate these individual and social dangers have been pertinent for both collective healing and for certain types of intimate care, such as menses and puberty, sexual relations and fertility, childbirth and infant survival, which have constituted so many people's early encounters with "medicine" for much of human history.Early modern and imperial historians have addressed at least some of these different modes of social power by describing them in terms of a medical marketplace, arguing that people of all backgrounds have played a driving role in shaping which therapeutic cultures flourished and which languished the world over. Even as biomedical practitioners (and their allied disciplines) consolidated their own authority over the last two centuries, their rules were still unevenly applied, their geographical reach could be limited, and their social status was not always superior to that of other professed experts.35 As Porter himself understood only too well, it turned out that paying attention to the game's audience-patients and their social networks-revealed a lot about therapeutics that a narrow focus on players-medical experts-did not. Interestingly, ethnographers and area studies scholars had taken this insight to heart decades earlier, often in the midst of empire building.36A focus on medical markets and people's choices has helped generate a much better understanding of medical cultures "from below." It has also produced clearer pictures of the importance of different kinds of (medical) supply and (popular) demand, the role of profits and fees, forms of professional competition, and even underlying assumptions about health, charity, suffering, and welfare. "Patients," as Mark Jenner and Patrick Wallis have pointed out for England and its early modern empire, "'had the relative freedom to choose the practitioners they liked'; they were 'medically promiscuous,' selecting therapies and therapists according to their estimation of the practitioner's effectiveness or manners, not to mention cost."37 Before the rules of the game became more stable at state and global levels, experts and laypeople alike not only improvised (and borrowed), but also assumed that their own rules-including how they viewed the world and cycles of life and death within it-gave them the right "tools" for the job.38Markets, of course, operated on a variety of scales simultaneously and ensured polycentric and multidirectional influences. They also generated their own legal and governing cultures that deserve more careful scrutiny.39 As Mark Harrison points out, it was not just the existence of varied medical markets, but also the emergence of global commerce that accelerated interactions among different forms of healing and ensured that biomedical approaches reached wider audiences. As cities and industries grew in different parts of the world during the nineteenth and twentieth centuries, and as centers of agricultural production expanded, transnational trade brought "more people in contact with Western medicine and its products." Harrison elaborates: "Medicines and medical services were widely advertised and available in shops and in the workplace through numerous vendors and practitioners. This encouraged many people to experiment with a range of therapeutic alternatives to traditional remedies."40 Markets and trade networks served as powerful vectors for transmission; as they did, they also codified rules and laws about legitimate and illegitimate practices, safe and unsafe goods, productive and unproductive bodies, fake and real therapies, profitable and unprofitable exchanges, and so on.41 As novel ideas, tools, texts, and techniques circulated, they were often given some kind of vernacular spin. In this way, they came to do different kinds of work and generated different kinds of meaning (and therapeutic effects), depending on who deployed them.Yet, even when biomedical institutions and professions began to achieve more state power than others (that is to say, when the umpires started to call the shots more consistently in their favor), this did not always translate into similar levels of trust or popularity. The question is, why not? One set of answers has focused on unpacking biomedical cultures' many imbrications with political power-as handmaidens of empire, as means of reifying inequalities and "colonizing" bodies, as dubious (even dangerous) inspectors and experimenters, and as gatekeepers for professions and forms of care-which made sufficient numbers of people everywhere both ambivalent and critical. There is certainly much validity to these arguments, but they overlook another set of patterns: as commercial forces increasingly shaped the world, certain classes of specialists simultaneously took advantage of other laws to become more market oriented and developed their own strategies to maintain and even expand their geographical horizons.42 Their clientele actively supported them in their efforts, not least because what they did seemed to work. In other words, just because the umpires and rule books declared certain players out of the game (or benched them for breaking the rules), this did not mean they or their "patients" complied, nor did it mean that others' assessments of efficacy were accurate. Cosmopolitan trading zones on a variety of scales (including continental and oceanic) allowed many specialists and constituents room to shape the kinds of therapeutic cultures that made most sense for their needs, even if they lived in contexts such as colonial and racial states, or slave and settler societies that constrained liberties and possibilities. This insight, it is worth stressing, applies no less to nation-states and (neo)liberal regimes in the Global North than in the Global South.43Constitutive Powers of Laws and Legal ThinkingA fourth and final insight on which this volume rests, and that by now should be self-evident, is that none of these dynamics can be explained fully without exploring their imbrications with laws and legal thinking. Taking such steps with care allows scholars to historicize more fully a variety of ongoing debates-within states and intergovernmental institutions, and also among people themselves-over who has the right to heal, what constitutes a right to health, and why and how therapeutic properties so often become entangled with intellectual properties. Such analyses also get at the juridical dimensions of people's "search for security," including the restorative powers of justice and the pathological effects of injustice and social conflict.44 Given the recent focus in global health on biosecurity, which often sees the world from the vantage point of (powerful) states and officialdom, it seems important to also gesture to unofficial understandings of security.45 Adopting a vantage point of less powerful groups can remind us that collective harms to members of a body politic have had to be addressed and mended, no less than individual harms.A phrase like "racism kills" has proven to be true in more ways than o

Epistemology · Political science · Sociology · Historical Psychiatry and Medical Practices · History of Science and Medicine · Race, Genetics, and Society · History · Law · Philosophy

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