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Cecil Helman, who died of motor neurone disease in 2009, was one of the foremost experts on the clinical applications of medical anthropology. He focused on the cross-cultural study of health, illness and medical care and was instrumental in introducing this subject to mainstream medical education. His experience as a GP was informed by his training as an anthropologist. He encouraged doctors to look beyond the symptoms presented by the patient and to try to understand how these related to their belief systems and cultural backgrounds.
Helman’s seminal book Culture, Health and Illness was first published in 1984 and it remains the standard text on medical anthropology. The fifth edition was published in 2007 and runs to 500 A4 sized pages. It’s supported by a website (www.culturehealthandillness.com). There’s a whole chapter on Ritual and the management of misfortune, which provides a very accessible introduction to the subject together with lots of references for the curious. Helman is particularly interested in considering ritual as it applies to health, illness and the management of misfortune.
I have summarised some key passages from the chapter.
What is Ritual?
Helman notes that “Rituals are a feature of all human societies, large and small. They are an important part of the way that any social group celebrates, maintains and renews the world in which it lives, and the way it deals with the uncertainties that threaten that world”. But what is ritual? He proposes a number of definitions, all of which have a key characteristic of being “a form of repetitive behaviour that does not have a direct overt technical effect”. Quoting Loudon he says that rituals are symbolic actions, i.e. “the behaviour or actions say something about the state of affairs, particularly about the social conditions of those taking part in the ritual”. For Turner “Ritual is a periodic restatement of the terms in which men of a particular culture must interact if there is to be any kind of coherent social life”. Two functions of ritual according to Turner are a) an “expressive” function and b) a “creative” function. Values are expressed in dramatic form and communicated to those taking part in the ritual and those observing it. For Leach the “expressive” aspect of ritual has the properties of a language which can only be understood within a specific cultural context and by those who can decode its meaning. We need therefore to understand this context before we can decode the message. Through its “creative” aspect, according to Turner, ritual defines the ways in which people perceive reality, reinforcing a society’s values and principles.
The Symbols of Ritual
The use of symbols is central to the expressive and creative functions of ritual. Turner studied the forms and meanings of the symbols used by the Ndembu tribe in Zambia for their healing rituals. He concluded that each symbol had a whole range of associations and meanings relating to the values of the society and its relationships with the natural and supernatural worlds. There’s always more to a symbol than meets the eye – a range of associations for those taking part in the ritual. There’s information about values, organisation and how the world is seen. This is especially important when the world is threatened.
Turner concentrates on physical objects when considering ritual symbolism but Helman suggests that there are many other components of ritual that can have a strong symbolic value. These include: clothing, colours, body decorations, smells, tastes, foods, sounds, words, silences, rhythms, movements and gestures. He further notes that important rituals take place at a specific, designated time and at a place set aside for the purpose. The components of ritual usually occur in a particular order at specified parts of the ritual and in a specified way.
Helman goes on to consider ritualistic aspects of medical practice and symbols and to deconstruct the meaning of the white coat. The context in which it is worn is important, he argues. Professions allied to medicine may adopt the same uniform so additional symbols become important – the stethoscope, the pager, the nametag – to differentiate the doctor. “Thus doctors employ the potent symbols of medical science in the same way that non-Western healers employ certain religious symbols or artefacts”.
Helman lists some of the multiple associations that the “ritually symbolic” hospital doctor’s white coat carries with it:
- A training in medicine
- A licence to practise medicine
- Membership of the medical profession
- Being answerable to a professional organisation
- A repository of specialised and inaccessible knowledge
- Power to take a medical history
- Licence to examine bodies
- Power to prescribe drugs
- Power over others lower in the medical hierarchy
- Orientation towards caring and the relief of suffering
- A scientific orientation
- Emotional and sexual detachment
- Respectability, high status, high income
- Familiarity with illness, suffering and death
He cites evidence that the way that doctors dress remains important to patients despite recent trends towards less formality in medical practice.
Turner suggests that ritual symbols have another attribute, “polarization of meaning”. At one pole the association is with “social and moral facts”, at the other “physiological facts”. This is especially true at times of transition – birth, menarche, puberty, marriage, death. These events have a profound social importance but in the West many of the rituals associated with these times of change have disappeared, with the effect that these events are stripped of any meaning other than the merely physiological.
Types of Ritual
Anthropologists have described three main types of public ritual.
- Cosmic cycle or calendrical rituals.
- Rituals of social transitions (rites of passage).
- Rituals of misfortune.
Calendrical rituals are associated with changes of the seasons, holy days or commemorative days for instance. The other two types of ritual have more relevance to medical practice.
Rituals of social transition or rites of passage are present in every society, signalling the transition from one status to another. Leach suggests that they have their origin in the human tendency to divide things or actions into categories. In using symbols to differentiate classes we are creating artificial boundaries in a field that is naturally continuous. These are characterised by a sense of ambiguity or danger. There is a sense of unease when things lie in the no man’s land between definitions or categories. In Leach’s view most ritual occasions are concerned with the movement across social boundaries from one social status to another. The ritual proclaims the change but also “magically brings it about”.
According to Van Gennep there are three stages to rites of passage: separation, transition, incorporation.
Helman considers various social rituals or rites of passage:
- Rituals of pregnancy and childbirth
- Rituals of death and mourning
He considers both in terms of their social significance and the ways in which they mark changes in status. He suggests that modern obstetric practice involves practices and beliefs that have an important ritual component and that the ritual symbols are those of medical science and technology. The pregnant woman is regarded as being particularly vulnerable and is monitored in a ritual fashion until she is felt to be “safe”, after the six week post-natal check – about 40 days after the birth. (Interestingly the number 40 has symbolic power in many rituals of transition). The periodic medical interventions help to provide reassurance at a time of profound physiological change and to reduce anxiety.
Helman considers the medicalization of death and dying, with death (especially in the USA) being considered a socio-medical failure. Elsewhere Mary Douglas observes that rituals are plastic – they change with time and circumstance. Changing rituals around death and the mourning period may have the effect of making these events more difficult to deal with.
Helman goes on to consider healing rituals, describing them as rituals of social transition. The “ill person” is transformed into a “healthy person”. The process often involves the patient’s withdrawal from everyday life while treatment is undertaken and taboos observed. On recovery the patient is ritually reincorporated into society. He describes the patient’s admission to and discharge from hospital in these terms.
Rituals of misfortune come into play at times of unexpected crisis or misfortune. Loudon postulates that this type of ritual has a manifest function – the solution of a specific problem, and a latent function, the re-establishment of disturbed relationships. Illness is seen as a social event. The illness of an individual threatens the cohesion of the group.
Rituals of misfortune have two phases: diagnosis or divination and treatment of the effects of the misfortune. In the case of illness, diagnosis includes giving it a name or identity within a cultural frame of reference, explaining how it was caused and what is likely to happen. In many societies there is a public ritual associated with this and explanations may have a mystical element to them. In the West diagnosis is a private affair and is couched in terms of disordered bodily or mental functions. But both activities involve the transition of the sufferer’s social identity, from “ill” to “cured”.
Technical aspects of ritual
Helman encourages us to look at healing rituals in terms of their coexisting technical aspects as well. He suggests that the two overlap; no matter how “sacred” a healing ritual may be it can have practical effects. Similarly, the practical elements of Western medical practice are interwoven with ritual. Administering medicines or carrying out surgical procedures may be viewed in these terms. In addition, diagnosis and treatment in the West takes place in ritual time and space – in places designated for the purpose and at clearly delineated times. The environment has an effect on the process, as does the personality of the doctor (see Balint). Helman notes that Byrne and Long’s research (Doctors talking to Patients) revealed that GP consultations in the UK tended to follow a recognisable pattern, with ritual exchange of information: symptoms and complaints in one direction, diagnoses and advice in the other.
Functions of Ritual
These can be classified as psychological, social and protective.
Psychological functions include making sense of the problem, providing a culturally appropriate explanation for it and a prognosis. This in itself is a form of treatment.
Social functions overlap with the psychological. Illness threatens the cohesion of the group and can create a temporary caring community around the victim.
Rituals can protect the ill in psychological or physical ways. We have already considered this in respect of antenatal care. Secluding an ill person as part of the ritual of social transition may limit the spread of infection (“quarantine” – 40 again) as may cleansing rituals.
Mary Douglas observes that the industrialised world is moving away from ritual and “there is a lack of commitment to common symbols”. She suggests that this may make it more difficult to deal with misfortune, disease and death and the various stages of the the life cycle. Interestingly a recent paper in the Annals of Internal Medicine supports this. The authors note that American hospital physicians are less and less likely to take a history from a patient or carry out a physical examination, relying instead on tests and investigations. The patient still expects this ritual to be carried out and is left feeling let down.
This paper is a selective summary of the main points of Chapter 9 of Helman’s Culture Health and Illness (Fifth edition). I hope it encourages you to read the original!
 Van Gennep 1873-1957, German born ethnographer brought up and educated in France. His most famous book was Rites of Passage (1909). He coined the term “liminaire” (liminality).
 Verghese A, et al. The Bedside Evaluation: Ritual and Reason. Annals of Internal Medicine. 155:6;550-553 (Oct 18 2011)