On the History and Future of Medical Anthropology in Germany – and the Close Relationship between Medicine, Technology and Society in a Globalizing World: Interview with Arthur Kleinman

In June 2011, Professor Arthur Kleinman (Harvard University) visited the Freie Universität Berlin and the Ruprecht-Karls-Universität Heidelberg. It was one of Arthur Kleinman’s first visits to Germany since 1988, the year he attended an international workshop on the “Anthropologies of Medicine” at the University of Hamburg. This workshop in 1988 was organized by Professor Beatrix Pfleiderer[1] and could have become a major step on the way to establishing medical anthropology as an academic discipline in Germany. However, it was strongly determined by a conflict between the participants that evolved, among others, around the role of medicine and anthropology during the Nazi regime and the Holocaust.

In this interview, Professor Kleinman remembers the discussions at the workshop and provides his view of the reasons why medical anthropology evolved so slowly within German academia. He also speaks about the different historical background of anthropology in the USA where medical anthropology has established itself at the center of the discipline today, as well as about the future role of social and cultural anthropology in the context of globalization. He also comments on the ongoing transformations of universities in the USA and the role of the humanities therein; the potential of exploring science, technology and health institutions from an anthropological perspective; and finally on some of the theoretical challenges for contemporary medical anthropology.

The interview was conducted, and subsequently shortened and edited for the blog, by Hansjörg Dilger and Angelika Wolf.[2] Both Wolf and Dilger are founding members of the Work Group Medical Anthropology in the German Anthropological Association. Since its founding in 1997, the Work Group has been seminal for the establishing of medical anthropology as an academic discipline in Germany.

Interview with Arthur Kleinman (June 30, 2011)

Hansjörg Dilger: As you are aware, medical anthropology had a difficult start in Germany. We are interested to learn what your view of this history is. Especially with regard to the conference in 1978 and what happened afterwards. But we are also interested in your views of the future possibilities for medical anthropology in Germany – and where the field is evolving towards. So about the history of medical anthropology in Germany first: you said you participated in this conference in 1978 and we, the younger generation of German medical anthropologists, felt that this would have been an opportunity to build medical anthropology as an academic discipline. The field would have looked differed in the 1990s when we studied – but something happened at that point …

Arthur Kleinman: Well, you know, it was an ambitious conference that had many participants. It had a number of young German anthropologists, who looked like they would be the first generation of real medical anthropologists. Like Beatrix Pfleiderer was one of the leading ones, but she was not the only one at that time. And I guess the disappointment was that the conference generally was quite… I think quite good, but not much happened that came out of it. So the follow-through was not good. That’s one thing. And indeed I’d say from my perspective one sad thing was that I had expected Beatrix to really lead the way in medical anthropology. And she – I think from my perspective – more or less dropped out and so I think that was unfortunate.

Hansjörg Dilger: And the discussions at the conference itself, was it mostly about medical anthropology in Germany or…?

Arthur Kleinman: The discussions at the conference. Yeah, it was broad, it was very broad. But I think one of the things that derailed the meeting, that made the agreeing less focused; with less of a specific agenda afterward was that at that time we knew we were going to have to address the issue of the role of medicine in anthropology in Germany before the war – in racialist science and in the Holocaust. But I didn’t expect it to play such a large role as it did. And I felt at that time that it was very important to address these issues, but that they became obstacles rather than a starting point. And I think that that was unfortunate. And actually the way that happened was the worst surprising way, which is that we had invited a group of doctors who represented what I thought was a very unusual tradition in medicine, a sort of a moral medicine. And in the middle of a presentation of one of these doctors, a medical sociologist from the university of Hamburg stood up and criticized him and pointed to the fact that the Romantic medicine had been part of the Nazi program. And you know then – what shall I say – it “derailed” is a good American term.

We were on a train line going forward and all of a sudden we got off on things. And that wasn’t that what we got off on was unimportant. It was important. It was important to understand that Josef Mengele, a horrible horrible example of the worst in medicine, was getting his Ph.D. in a field – quote unquote – that he at least thought it was medical anthropology. You know that’s very problematic and we had to discuss that. But that should not have been where the discussions ended, but really it should have been the starting point for building things. And when I came out of the meeting at the end I did expect there to be certain developments. And I learned a great deal. I learned that, you know, that there was some difficulty in using the term “medical anthropology”; at that time rehabilitating it. I understood that anthropology itself – social and cultural anthropology – was carrying the burden of the past… of a different past sort of the Völkerkunde-burden, sort of freeing itself from folkloric studies et cetera. And, you know, I reckon that we learned a lot of those things we heard. And we also saw some terrific people – I should go back to a list of participants – who represent the history of medicine and medical sociology. And so, you know, there was a real sense of talking about the relationship of the social sciences to medicine. But of course given my particular interest I was concerned with how medical anthropology would develop out of this. And my disappointment came from the lack of development.

Now, I also learned that there were certain kinds of obstacles that you’ve had that we haven’t had in the United States. So, one was the burden of the racialist science past. We have plenty of racialist science in America, but it had very little to do with medical anthropology. Secondly, we have no ethnomedical tradition. And although it would seem that ethnomedicine within medicine would be one of the building blocks for medical anthropology, I was very suspicious at that time and remain suspicious now that that is a building block in medical anthropology. Because I think that what’s meant by “ethnomedicine” in Europe is not necessarily anthropology, but something closer to a sort of medicine of ethnic minorities, you know. And focusing particularly on non-western medical traditions and also doing it in a way that reminds me of the historians’ crisis in medical history. In medical history about 40 years ago, 30 years ago there was a historians’ crisis between the antiquarian tradition of physicians and actual social-historians doing medicine. And until they sorted that out they were not able to build a really strong medical history. And I saw ethnomedicine in Germany in this relationship to medical anthropology in that same kind of conflicted tradition as antiquarianism in medicine and medical history. And so I think that’s been another difficulty you’ve had.

But surprisingly, I mean, if you put all those things to the side and you look at the development of medical anthropology in Europe it is surprising that a country as vibrant as Germany with such an outstanding intellectual tradition and so strong an academy has not developed further in medical anthropology. Just contrast Germany with Holland: So Germany has around 80 million people? Holland has 15 million people? Germany probably has three times the universities or four times the universities that you have in Holland and much more research funding and the like. And yet, look at Amsterdam and Leiden and other medical anthropology programs in Holland. I don’t think there really is an equivalent to that in Germany today and so something obviously has been delayed in happening. And now, my own opinion is that medical anthropology is advancing as part of a wave what we might call “medical humanism” in which there is a recognition both outside of medicine and inside of medicine that values, history, culture, moral experience are all being overwhelmed by a flood of technology, enormous change in institutional structures, the priorities of political economy. And that, in response to this, it is necessary to get back to very fundamental questions about the relationship of the social world to sickness and caregiving and to understand the role of social institutions in the development of the health sector and medical education. And also to project a vision from ethnic minorities through diasporas to an understanding of global health today. And medical anthropology grows because it is in the perfect place to mediate and play a role with all those developments.

Angelika Wolf: I have a question that is related to that. When I look to the Netherlands, France, Great Britain, United States I can see that they started quite early to define themselves as immigration countries whereas Germany had no immigration policy. German public defined people coming here as “guestworkers”, thereby implicating that they should go back to their home country. This has changed in the last few years and I wonder whether this change in policy also supports the development of medical anthropology.

Arthur Kleinman: Great! I hope so, hope so. Hope that’s the case. But you know, medical anthropology in the United States in the 1950s and 60s was concerned with ethnic minorities what you would call immigrants, but ever since the 1970s its principle interest had been global. And so, yes there is a concern with ethnicity, but there’s even a greater concern with health, sickness and medicine around the world. And maybe part of the issue was that coming out of the Second World War the United States was a global power and had global responsibilities and it was natural for anthropologists to get engaged on a global level. Germany was more inward looking plus the fact after the First World War you had given up your colonies. So even the colonial tradition, which stimulated anthropology in the UK and in France, was limited and so you didn’t have that stimulus. But I think it’s inappropriate to look too far in the past. Germany is a global power today; its economy alone is one of the great examples of globalization. Therefore it’s bizarre to me that anthropology has not developed along with those connections. And so it’s not just medical anthropology, it’s social and cultural anthropology generally. And I think you need support for this. You need the university support, you need the financial research support in this regard. You need cognate fields like medicine that are not hostile, but see themselves as neighborly, as helpful.

Arthur Kleinman with Angelika Wolf and Hansjörg Dilger. Photo: Caroline Meier zu Biesen, June 2011.

Hansjörg Dilger: My question is then: with globalization the whole field of anthropology in a way is changing and trying to find its role. How is medical anthropology relevant here? And how could medicine become relevant for the existence of social sciences and the liberal arts, as you mentioned in your talk two days ago?[3]

Arthur Kleinman: I take three very different things here. First of all, that globalization means that each of the societies around the world that has the knowledge capacity, institutional capacity and financial resources is developing their own anthropology. And so one of the exciting things here is to see medical anthropology in China and in India is not the same as medical anthropology in the United States, Great Britain or continental Europe. And so I’m very excited about what the future will be there. I think we gonna see different kinds of anthropologies and just like in the area of history, subaltern studies in India had an enormous effect on social history worldwide. Who knows what effect may come out the different forms of medical anthropology in the non-western world for the rest of us?

Secondly, I think that globalization means that we’re looking at connections between diasporas and homelands in a way we never did before. So, take for example Mexican-Americans. Mexican-Americans are part of the largest ethnogroup in America, who we call “Latinos” or “Spanish speakers”. There are Puerto Ricans, there are Cubans, but the largest group is Mexican-Americans. And for Mexican-Americans since they are right next door to Mexico the old ideas we had about immigrants are totally wrong. The idea that somehow immigrants became an enclave in a larger society and then had to struggle to maintain their cultural roots – this is a model that may have held in the 19^th century, but not now. First of all, Mexicans go back and forth. They even go back to rural Mexico and then to the United States. And they’re bicultural, they’re binational. They live in two different places. And their roots in the United States are as vibrant as their roots in Mexico. And they’re not acculturating in the classical sense. Acculturation is an irrelevant term for them! They are relating to an America, which itself no longer has a kind of a homogenous mainstream, but is a very divided society with many different sectors to it. You take California today: what Latinos call “Englands” or “white Californians” are in a minority! So what is the culture of California that Mexicans are relating to? It’s very broad, an ethnically broad culture. So, there’s a whole side of the American experience that has had to deal for a long period of time with multiculturalism and how you engage that. And I think your country now is seriously beginning to do that, but – in my view, if you’ll accept a polite criticism – you’re way behind us in this regard.

Now, the third thing is the development of medicine itself as a powerful social institution. Not just medicine, but health care systems as a powerful part of the economy, of the political structure and the like. And here anthropology has been part of the social sciences’ attempt to make sense of this world. Now, what surprises is that, if you look at origins of the social sciences’ attempts to understand institutions the greatest theoretical contribution came from a German: Max Weber. Someone I hold in deep respect. And yet, we’re not seeing today the kinds of social studies of health institutions in Germany that one would expect to see coming out of that tradition. And so, I think also that fields like science, technology and society will help to advance medical anthropology, both in terms of the anthropology of science, the anthropology of health institutions and the anthropology of health systems. So those three things coming together speak to a more robust place for medical anthropology.

But I also want to be very very clear about another point. Here I don’t know whether Germany is in the same place as the United States, but I suspect it may be, because the United States and England are in a very interesting place. And that is that it used to be really a candidate maybe – I don’t want to sound presumptionist or anyway. It used to be that the model of universities in the United States was based on Harvard, Yale, Princeton. It was the model of the broad liberal arts institutions that supported social science, humanities, applied science, basic science at the same level. Now, in the United States that model has weakened and the dominant model for research universities in the United States is the Massachusetts Institute of Technology model, the MIT model. It’s to grow the applied sciences, to continue to support the basic sciences, but not at the same level as the applied sciences, and it’s to shrink the humanities and the social sciences. And I think that this is an incredibly dangerous thing for the humanities and social sciences. The great threat here is that we’ll become much smaller enterprises in the United States and we will not have the same – what shall I say – we will not have the same expectation for aspiring to excellence that we see in the applied sciences. We’ll be expected to have a much smaller agenda, a much more limited set of aspirations. And I think that in this regard one of the arguments for a robust social science and humanities in the future is the importance of looking at the social roots of health and the social consequences of technology and science and the like. And that medical anthropology is perfectly positioned to benefit from that concern – as are fields like sociology of science and the history of science etcetera. And I think that will be one of the things that will be in the future a support. But I think it’s important to recognize that we’re not going to enter an era like the 1950s or 60s where there was a major thrust to build the social sciences and support to humanities. We’re gonna rather be at a time of limited growth, of constraint and also of focused priorities where the priorities of knowledge for knowledge’s sake is going to be restricted and the priority of knowledge for application in the world is going to be expanded greatly. Ok?

Angelika Wolf: I’d like to come back to the beginning when you got your position at Harvard. My question is, if you look at the situation of Germany today, what possible ways are there to promote the institutionalization of medical anthropology as an academic discipline? Did you have a strategy for that?

Arthur Kleinman: Yeah. Well, let me say first of all that I started teaching medical anthropology at Harvard in 1973. And at that time the most established program in medical anthropology was at Berkeley, was George Foster’s program at Berkeley. And George did excellent things and produced many outstanding students. And the programs at the University of California Berkeley and the University of California San Francisco were very important. In 1982 I started our PhD program with medical anthropology within social and cultural anthropology. I started a small MA program and I started big courses to undergraduates. And I also began – with my colleague Byron Good – a postdoctoral fellowship program. And we benefit from a number of things. First of all, because I was joint-appointed between a medical school, the Harvard Medical School, and the Faculty of Arts and Sciences, I was able to bridge fields in a way that – I recognize – was absolutely critically. And actually I’m gonna say something that you’ll think is silly, but it was very important: When I took my job I asked for two parking places; one at the Medical School and one at the Faculty of Arts and Sciences. And that turned out to be actually very important, because I had to go back and forth. And if I had to constantly either use the buses or constantly look for where I was gonna park my car I would have been deterred from trying to go frequently back and forth. And it was very important to go back and forth. So, I think that was part of our success. Secondly, I had a mentor and later colleague, Leon Eisenberg, who was thoroughly committed to me building medical anthropology on the Medical School side. And I had a group of colleagues on the anthropology side, who were equally committed to me building medical anthropology. So, rather than running into obstacles I had nothing but support in doing this. There were a number of other things that helped us. One was that social and cultural anthropology in the United States did not have many postdoctoral programs; very few. And hence our postdoctoral program attracted some outstanding social and cultural anthropologists, who might not have considered themselves medical anthropologists until they took part in that program. And I can tell you I had some wonderful postdoctoral fellows. And I think a number of them probably would not have necessarily fully identified with medical anthropology, except for being in a program that was intellectually exciting and that provided a postdoctoral space. So I think having a postdoctoral fellowship program – if you can develop it in Germany – is a very good idea…

Angelika Wolf: …but needs finance…

Arthur Kleinman: Yeah finance! So we were financed for almost 25 years, 24 years by the federal government with that program, but we don’t have that any longer, unfortunately. Similarly on the MD-PhD side Leon Eisenberg and I had a grant from the MacArthur Foundation to begin with. And then the US Government in more recent years, which funds MD-PhD programs usually for biological sciences, decided at Harvard to include medical anthropology as part of that; not just medical anthropology, but also medical history and health policy. And so those two things funded about 20 MD-PhD students. Now, we’re not the only place that has had MD-PhD students, but I think if you look across America we’ve had the largest number. And – again – we’ve attracted just some remarkable people. So, if you look at some of my former students they’ve taken three different tracks. Some of them have emphasized staying in anthropology or going the direction of the university as a whole. A good example of that would be Jim Kim[4] who is now the president of Dartmouth or Lawrence Cohen who runs the medical anthropology program at Berkeley, but solely within the anthropology department. Another group has emphasized medicine, hospital work, and global health. And one of the figures there would be Paul Farmer. And in more recent years I’ve seen students go into both directions. So, students like Clara Han, an MD-PhD, have sort of followed in the track of Lawrence Cohen. Others of my MD-PhD students have gone more in the track of medicine or even public health. And I have a current group – the very very exciting group of MD-PhD students that we’ll see what they decide to do. I would like to see some do what I’ve done. That is divide their time between the two. Surprisingly very few of my students have ended up like this. And yet, I think that’s a good model. I don’t think if I was either fully on the medicine school side or fully on the anthropology side I could have built the kind of program. So I’d like to see some of my students do the same thing that I’ve done. There are a couple of other things that have helped us a great deal, I think. One is that the university agreed to letting an NGO that Paul Farmer, Jim Kim, Ophelia Dahl had started, called “Partners in Health” come into the social medicine department. And this NGO “Partners in Health” has been very important. That is the arm that is out in the world doing things in medical anthropology. And I think that this has become one of the more important global health NGOs worldwide. It’s done some remarkable things and I think it’s attracted all kinds of students to the global health area. The second thing is that there is a kind of moral movement today for global health in the United States that is attracting a huge number of undergraduates, medical students, anthropology students, and students of many many different fields. And I think medical anthropology has benefitted greatly from that and hopefully has contributed to that area as well. A last thing is that – as I mentioned earlier – I think the anthropology of science has significantly strengthened medical anthropology and has tied medical anthropology to the history of science, to the sociology of science, to the broader sort of concerns about science and technology and their consequences.

Now, let me just say a couple of other things. When I’ve started in medical anthropology it was principally a very small field with some medical applications that were very narrow; almost no theory and very little in the way of ethnography. And what I’m most proud of my generation – not of me or my program, but of my whole generation, of people like Margaret Lock, Nancy Scheper–Hughes, Allan Young, Mark Nichter and many many others – is that we changed that world completely. And we made the field much more theoretically important and we built ethnography into it in a strong way. So if you look at American anthropology today, medical anthropology is in the center of the discipline, not on the margins of the discipline. And I would hope that that would be what would happen in Germany; that medical anthropology would be part of the center of what the discipline is about.

Angelika Wolf: We hope so as well.

Hansjörg Dilger: I have one final question in terms of theory. I think you mentioned it in our conversation yesterday that you see a future in the intersection of medical anthropology with the anthropology of emotions and cultural psychiatry or cultural psychology. You said that here is something where theoretical innovations can come from or a future might be.

Arthur Kleinman: Yes. First of all let me say that I don’t wanna restrict the theoretical contributions to this area, but it happens to be an area of very concerned worth. And so my feeling is medical anthropology’s theoretical contributions are occurring in its intersections with many different subjects, but I do think that the issue of subjectivity – what I would call “subjectivity” – with its concern with emotions and values is a crucial part of theory building in medical anthropology. And I think here you see medical anthropology, the anthropology of emotions, or what’s called in the United States psychological anthropology, cultural psychiatry, but also a broader range of psychology and psychiatry; and a broad concern with how the self is changing, how emotions and values can act, or the building of sensibility in different societies. I think this is producing a very rich set of theories about persons that is important, because it is so thoroughly intersubjective. It suggests that the self is part of a field much as Bourdieu saw it; a field that I would call “local moral worlds”. Those local moral worlds are no longer the classical village or the classical neighborhood, they may be transcontinental networks. And they’re very permeable and they may be multiple ones. But there’s no question that the self is embedded in worlds. And as those worlds change in their political-economic structure, in their moral conditions so, too, does the self change. And I think that this is one of the interesting areas for theory development in medical anthropology. Not the only one by any means!

So, there are a number of other areas that I find very exciting in medical anthropology. One of them is the study of institutional structures and how institutions come to define practices in important ways. Another one is providing the theory for whole fields of medicine that have been without theory. So for example global health has no theory guiding it. It’s simply a series of problems, not even a series of problems, an assortment of different kinds of problems. And I think one of the exciting things that’s happening out of medical anthropology’s involvement with global health is the development of theory; of new theories for understanding how the colonial past and the postcolonial era influence health practices today; new theories about the effect of political economy on structural violence and many different areas. I think that’s another exciting area. I think ideas like Margaret Lock’s idea of “local biology” is an enormously significant contribution that lets us see bio-cultural, bio-social interactions in a much more anthropological framing. To put in the word for my own ideas, I see my idea of local worlds of being moral worlds, of social suffering as an organizing category, as important ideas in the development of not just medical anthropology, but social and cultural anthropology more generally. Indeed, it’s important to have recognized: I regard myself as a physician and social and cultural anthropologist. My focus is medical anthropology and that’s the field I have committed myself to. But I think of myself as an anthropologist and a physician and I’m thinking about both fields developing.

Angelika Wolf and Hansjörg Dilger: Thank you for the interview, Professor Kleinman.

Footnotes

[1] Beatrix Pfleiderer held the first professorship in Germany (appointed at the University of Hamburg in 1982) that was dedicated specifically to medical anthropology. While she was immensely productive during her tenure in Hamburg, she resigned from the position in 1989 (Ethnoscripts 14/2 2012).

[2] We would like to thank Max Schnepf for the transcription of the interview.

[3] Professor Kleinman gave a lecture at Freie Universität Berlin on June 28, 2011, titled “Anthropology and Cross-Cultural Mental Health”. The lecture was organized by the Research Area “Medical Anthropology” at the FU Institute of Social and Cultural Anthropology in collaboration with the International Research Project on Mental Health and Migration at Charité Universitätsmedizin Berlin and the FU Center for Area Studies. A video of the lecture is available here.

[4] Jim Yong Kim was President of Darthmouth College between 2009 and 2012 until he became President of the World Bank.