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Biomedicine defines the therapeutic efficacy of a treatment or of a drug by looking at the individual body, that of the patient. Collateral aspects of cure, which could include other people in addition to the patient, are usually omitted from the studies on therapeutic efficacy. However, during the Biennial Conference ‘Pluralizing Global Mental Health’ (9-10 June 2022) at the Edinburgh Centre for Medical Anthropology, it emerged that patients’ socio-economic status, ethnicity, lack of formal education and qualifications intersect and shape clinical outcomes within the context of mental illness. The reductionist approach of biomedicine, which considers only clinical and biological aspects of the patient, neglecting the cultural and socio-economic ones, has negatively affected biomedicine’s therapeutic efficacy. 

 

Biological reductionism establishes the identity of biomedicine affirming its scientific status. At the same time, it restricts its capacity to understand the etiology of the pathology (Kleinman & Good, 1985). We need to overtake this biological reductionism through new ways of considering the relationship between culture and the medical system. Theoretical reflections conveyed by the conference 'Pluralizing Global Mental Health' spoke directly to the idea of pluralizing the concept of therapeutic efficacy.As Dr Stefan Ecks pointed out in his contribution to the EdCMA Conference, it is impossible to treat and heal mental health conditions without also considering an improvement in patients' socio-economic conditions. This insight reflects my ethnographic studies on migrant survivors of gender-based violence in Italy.  They experienced devaluation of their social status, accepting jobs in the low-income and informal segments of the labour market. Migration and gender-based violence increase the social isolation of survivors, disrupting, or drastically changing, their social network. This condition has a negative impact on everyday social and interpersonal interactions. It leads to forms of self-isolation, depression, and mental illness that cannot be cured without an improvement of their socio-economic conditions. The healing idea should be analysed in its appropriate economical, political, and cultural context. To grasp the significance of efficacy, for both patients and medical doctors, broader parameters should be adopted which include patients' socio-economic positioning within society. 

 

A vast body of anthropological literature (Kleinman, Good 1985; Lévi-Strauss 1966; Lock 1980; Low 1981; Turner 1984) shows the existence of different patterns of efficacy dependent on social and cultural factors that intersect the medical domain. One of the most famous reflections on the existence of multiple forms of efficacy is Lévi-Strauss’ essay L’efficacitè symbolique (1985), which shows how the efficacy of care depends on the ability to construct a network of meanings linked to symbols, with the aim of making illness and physical pain acceptable. Lévi-Strauss also highlights the social component of symbolic efficacy. In fact, for the treatment to take effect, it is necessary that the power of the healer is socially recognized. 

 

Social and political power are connected to the therapeutic processes within both traditional and biomedical contexts. For instance, these dynamics emerge in the construction of Traditional Chinese Medicine, a medical system that Margaret Lock (1980) defines as orchestrated medical pluralism in which biomedicine and traditional medicine interact with each other in a way that reconfirms the hierarchies of the dominant medical system. 

 

Different parameters needed to evaluate efficacy come into play in a medical consultation. The comparison among different ways of understanding and evaluating efficacy emerges from Setha Low’s studies on nervios in Costa Rica (1981). Medical consultation shows that the meaning attributed to nervios is constituted by the interaction between the sociocultural and the biomedical systems.  Three different domains emerge from this interaction: the etiological one where doctors tend to adopt popular explanations in a context of illness during a meeting with the patient; a diagnostic one, where doctors adopt popular models when interacting with patients and biomedical models when speaking with colleagues; and finally, the domain of the cure as it is structured by doctors according to both models. In the latter domain, doctors prescribe treatments to resolve physical symptoms and then try to understand patient’s problems by attributing a cultural meaning to them (Low, 1981). 

 

Understanding nervios implies, according to Setha Low, the use of models that she defines as a set of interactive knowledge. The plan is that of integrating language and behaviour in the doctor-patient interaction. This set includes models that the doctor takes from both psychosomatic medicine and the understanding of the relation between social stress and disease’s expressions, abilities that she has developed through practice and experience. The phenomenon of nervios is seen by doctors as a sign of social and personal discomfort (Low, 1981). The efficacy itself must be also approved and evaluated by the social group the patient and medical doctor belongs to. As my participants’ life trajectories show, mental illness and related treatments involve a vast range of dynamics and social actors surrounding patients/survivors of gender-based violence. 

 

My findings highlight that precarious economic conditions, post-traumatic stress disorder, migration-related stress, financial and/or emotional dependency on their abusers, and pressing maternal duties prevent female survivors from recovering their mental health. The intersection between strategies for socio-economic integration and strategies implemented to deal with mental health issues generates a variety of specific outcomes as survivors’ subjectivity plays a key role in navigating the recovery. I contend that the subjective embodiment of both trauma of sexual violence and socio-economic strategies shapes survivors’ trajectories to fully recover their psycho-physical well-being.  Understanding mental health issues requires considering a broader network of social actors related to patients/survivors as well as a broader concept of efficacy, capable of incorporating dynamics that transcend biomedical treatments.

 

Emanuela Nadia Borghi (@n_borghi) is a PhD candidate at the University of St Andrews in the Department of Social Anthropology and School of Medicine. She started her fieldwork in Italy among forcibly displaced people and migrant women in 2018, during her Masters in Cultural Anthropology at the University of Milan-Bicocca. Her doctoral research focuses on the practices and strategies of resistance to discrimination, gender-based violence and socio-economic marginalization within Italian society from a subjective and bodily perspective. Taking into account humanitarian systems and government policies,  she is interested in survivors’ mental health and the impact of the intersection between trauma and socio-economic strategies on female survivors’ life trajectories. 

 

References

Arthur Kleinman, Byron J. Good, Culture and depression : studies in the anthropology and cross-cultural psychiatry of affect and disorder, Oakland: University of California Press, 1985.

 

Claude Lévi-Strauss,  L’efficacité symbolique, in Anthropologie structurale, Parigi: Plon, 1958, tr. ita. Antropologia strutturale, Milano: Il saggiatore, 1966. 

 

Margaret Lock, East Asian Medicine in Urban Japan: Varieties of Medical Experience. Berkeley: University of California Press, 1980. 

 

Setha Low, The Meaning of Nervios. A sociocultural Analysis of Symptom Presentation in San José, Costa Rica, «Culture, Medicine and Psychiatry», n.3, vol.25, 1981.