3/19 TOPIC: Crazy Like Us: Globalization of American Psyche

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The Americanization of Mental Illness

Published: January 8, 2010

NYTIMES.COM

Alex Trochut

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By ETHAN WATTERS

Published: January 8, 2010

AMERICANS, particularly if they are of a certain leftward-leaning, college-educated type, worry about our country’s blunders into other cultures. In some circles, it is easy to make friends with a rousing rant about the McDonald’s near Tiananmen Square, the Nike factory in Malaysia or the latest blowback from our political or military interventions abroad. For all our self-recrimination, however, we may have yet to face one of the most remarkable effects of American-led globalization. We have for many years been busily engaged in a grand project of Americanizing the world’s understanding of mental health and illness. We may indeed be far along in homogenizing the way the world goes mad.

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This unnerving possibility springs from recent research by a loose group of anthropologists and cross-cultural psychiatrists. Swimming against the biomedical currents of the time, they have argued that mental illnesses are not discrete entities like the polio virus with their own natural histories. These researchers have amassed an impressive body of evidence suggesting that mental illnesses have never been the same the world over (either in preval‎ence or in form) but are inevitably sparked and shaped by the ethos of particular times and places. In some Southeast Asian cultures, men have been known to experience what is called amok, an episode of murderous rage followed by amnesia; men in the region also suffer from koro, which is characterized by the debilitating certainty that their genitals are retracting into their bodies. Across the fertile crescent of the Middle East there is zar, a condition related to spirit-possession beliefs that brings forth dissociative episodes of laughing, shouting and singing.

The diversity that can be found across cultures can be seen across time as well. In his book “Mad Travelers,” the philosopher Ian Hacking documents the fleeting appearance in the 1890s of a fugue state in which European men would walk in a trance for hundreds of miles with no knowledge of their identities. The hysterical-leg paralysis that afflicted thousands of middle-class women in the late 19th century not only gives us a visceral understanding of the restrictions set on women’s social roles at the time but can also be seen from this distance as a social role itself — the troubled unconscious minds of a certain class of women speaking the idiom of distress of their time.

“We might think of the culture as possessing a ‘symptom repertoire’ — a range of physical symptoms available to the unconscious mind for the physical expression‎ of psychological conflict,” Edward Shorter, a medical historian at the University of Toronto, wrote in his book “Paralysis: The Rise and Fall of a ‘Hysterical’ Symptom.” “In some epochs, convulsions, the sudden inability to speak or terrible leg pain may loom prominently in the repertoire. In other epochs patients may draw chiefly upon such symptoms as abdominal pain, false estimates of body weight and enervating weakness as metaphors for conveying psychic stress.”

In any given era, those who minister to the mentally ill — doctors or shamans or priests — inadvertently help to select which symptoms will be recognized as legitimate. Because the troubled mind has been influenced by healers of diverse religious and scientific persuasions, the forms of madness from one place and time often look remarkably different from the forms of madness in another.

That is until recently.

For more than a generation now, we in the West have aggressively spread our modern knowledge of mental illness around the world. We have done this in the name of science, believing that our approaches reveal the biological basis of psychic suffering and dispel prescientific myths and harmful stigma. There is now good evidence to suggest that in the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression‎ of mental illness in other cultures. Indeed, a handful of mental-health disorders — depression, post-traumatic stress disorder and anorexia among them — now appear to be spreading across cultures with the speed of contagious diseases. These symptom clusters are becoming the lingua franca of human suffering, replacing indigenous forms of mental illness.

As he was in the midst of publishing his finding that food refusal had a particular expression‎ and meaning in Hong Kong, the public’s understanding of anorexia suddenly shifted. On Nov. 24, 1994, a teenage anorexic girl named Charlene Hsu Chi-Ying collapsed and died on a busy downtown street in Hong Kong. The death caught the attention of the media and was featured prominently in local papers. “Anorexia Made Her All Skin and Bones: Schoolgirl Falls on Ground Dead,” read one headline in a Chinese-language newspaper. “Thinner Than a Yellow Flower, Weight-Loss Book Found in School Bag, Schoolgirl Falls Dead on Street,” reported another Chinese-language paper.

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In trying to explain what happened to Charlene, local reporters often simply copied out of American diagnostic manuals. The mental-health experts quoted in the Hong Kong papers and magazines confidently reported that anorexia in Hong Kong was the same disorder that appeared in the United States and Europe. In the wake of Charlene’s death, the transfer of knowledge about the nature of anorexia (including how and why it was manifested and who was at risk) went only one way: from West to East.

Western ideas did not simply obscure the understanding of anorexia in Hong Kong; they also may have changed the expression‎ of the illness itself. As the general public and the region’s mental-health professionals came to understand the American diagnosis of anorexia, the presentation of the illness in Lee’s patient population appeared to transform into the more virulent American standard. Lee once saw two or three anorexic patients a year; by the end of the 1990s he was seeing that many new cases each month. That increase sparked another series of media reports. “Children as Young as 10 Starving Themselves as Eating Ailments Rise,” announced a headline in one daily newspaper. By the late 1990s, Lee’s studies reported that between 3 and 10 percent of young women in Hong Kong showed disordered eating behavior. In contrast to Lee’s earlier patients, these women most often cited fat phobia as the single most important reason for their self-starvation. By 2007 about 90 percent of the anorexics Lee treated reported fat phobia. New patients appeared to be increasingly conforming their experience of anorexia to the Western version of the disease.

What is being missed, Lee and others have suggested, is a deep understanding of how the expectations and beliefs of the sufferer shape their suffering. “Culture shapes the way general psychopathology is going to be translated partially or completely into specific psychopathology,” Lee says. “When there is a cultural atmosphere in which professionals, the media, schools, doctors, psychologists all recognize and endorse and talk about and publicize eating disorders, then people can be triggered to consciously or unconsciously pick eating-disorder pathology as a way to express that conflict.”

The problem becomes especially worrisome in a time of globalization, when symptom repertoires can cross borders with ease. Having been trained in England and the United States, Lee knows better than most the locomotive force behind Western ideas about mental health and illness. Mental-health professionals in the West, and in the United States in particular, create official categories of mental diseases and promote them in a diagnostic manual that has become the worldwide standard. American researchers and institutions run most of the premier scholarly journals and host top conferences in the fields of psychology and psychiatry. Western drug companies dole out large sums for research and spend billions marketing medications for mental illnesses. In addition, Western-trained traumatologists often rush in where war or natural disasters strike to deliver “psychological first aid,” bringing with them their assumptions about how the mind becomes broken by horrible events and how it is best healed. Taken together this is a juggernaut that Lee sees little chance of stopping.

“As Western categories for diseases have gained dominance, micro-cultures that shape the illness experiences of individual patients are being discarded,” Lee says. “The current has become too strong.”

Would anorexia have so quickly become part of Hong Kong’s symptom repertoire without the importation of the Western template for the disease? It seems unlikely. Beginning with scattered European cases in the early 19th century, it took more than 50 years for Western mental-health professionals to name, codify and popularize anorexia as a manifestation of hysteria. By contrast, after Charlene fell onto the sidewalk on Wan Chai Road on that late November day in 1994, it was just a matter of hours before the Hong Kong population learned the name of the disease, who was at risk and what it meant.

THE IDEA THAT our Western conception of mental health and illness might be shaping the expression‎ of illnesses in other cultures is rarely discussed in the professional literature. Many modern mental-health practitioners and researchers believe that the scientific standing of our drugs, our illness categories and our theories of the mind have put the field beyond the influence of endlessly shifting cultural trends and beliefs. After all, we now have machines that can literally watch the mind at work. We can change the chemistry of the brain in a variety of interesting ways and we can examine DNA sequences for abnormalities. The assumption is that these remarkable scientific advances have allowed modern-day practitioners to avoid the blind spots and cultural biases of their predecessors.

Modern-day mental-health practitioners often look back at previous generations of psychiatrists and psychologists with a thinly veiled pity, wondering how they could have been so swept away by the cultural currents of their time. The confident pronouncements of Victorian-era doctors regarding the epidemic of hysterical women are now dismissed as cultural artifacts. Similarly, illnesses found only in other cultures are often treated like carnival sideshows. Koro, amok and the like can be found far back in the American diagnostic manual (DSM-IV, Pages 845-849) under the heading “culture-bound syndromes.” Given the attention they get, they might as well be labeled “Psychiatric Exotica: Two Bits a Gander.”

Western mental-health practitioners often prefer to believe that the 844 pages of the DSM-IV prior to the inclusion of culture-bound syndromes describe real disorders of the mind, illnesses with symptomatology and outcomes relatively unaffected by shifting cultural beliefs. And, it logically follows, if these disorders are unaffected by culture, then they are surely universal to humans everywhere. In this view, the DSM is a field guide to the world’s psyche, and applying it around the world represents simply the brave march of scientific knowledge.

Of course, we can become psychologically unhinged for many reasons that are common to all, like personal traumas, social upheavals or biochemical imbalances in our brains. Modern science has begun to reveal these causes. Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening. Those stories, whether they tell of spirit possession, semen loss or serotonin depletion, predict and shape the course of the illness in dramatic and often counterintuitive ways. In the end, what cross-cultural psychiatrists and anthropologists have to tell us is that all mental illnesses, including depression, P.T.S.D. and even schizophrenia, can be every bit as influenced by cultural beliefs and expectations today as hysterical-leg paralysis or the vapors or zar or any other mental illness ever experienced in the history of human madness. This does not mean that these illnesses and the pain associated with them are not real, or that sufferers deliberately shape their symptoms to fit a certain cultural niche. It means that a mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.

EVEN WHEN THE underlying science is sound and the intentions altruistic, the export of Western biomedical ideas can have frustrating and unexpected consequences. For the last 50-odd years, Western mental-health professionals have been pushing what they call “mental-health literacy” on the rest of the world. Cultures became more “literate” as they adopted Western biomedical conceptions of diseases like depression and schizophrenia. One study published in The International Journal of Mental Health, for instance, portrayed those who endorsed the statement that “mental illness is an illness like any other” as having a “knowledgeable, benevolent, supportive orientation toward the mentally ill.”

Mental illnesses, it was suggested, should be treated like “brain diseases” over which the patient has little choice or responsibility. This was promoted both as a scientific fact and as a social narrative that would reap great benefits. The logic seemed unassailable: Once people believed that the onset of mental illnesses did not spring from supernatural forces, character flaws, semen loss or some other prescientific notion, the sufferer would be protected from blame and stigma. This idea has been promoted by mental-health providers, drug companies and patient-advocacy groups like the National Alliance on Mental Illness in the United States and SANE in Britain. In a sometimes fractious field, everyone seemed to agree that this modern way of thinking about mental illness would reduce the social isolation and stigma often experienced by those with mental illness. Trampling on indigenous prescientific superstitions about the cause of mental illness seemed a small price to pay to relieve some of the social suffering of the mentally ill.

But does the “brain disease” belief actually reduce stigma?

In 1997, Prof. Sheila Mehta from Auburn University Montgomery in Alabama decided to find out if the “brain disease” narrative had the intended effect. She suspected that the biomedical explanation for mental illness might be influencing our attitudes toward the mentally ill in ways we weren’t conscious of, so she thought up a clever experiment.

In her study, test subjects were led to believe that they were participating in a simple learning task with a partner who was, unbeknownst to them, a confederate in the study. Before the experiment started, the partners exchanged some biographical data, and the confederate informed the test subject that he suffered from a mental illness.

The confederate then stated either that the illness occurred because of “the kind of things that happened to me when I was a kid” or that he had “a disease just like any other, which affected my biochemistry.” (These were termed the “psychosocial” explanation and the “disease” explanation respectively.) The experiment then called for the test subject to teach the confederate a pattern of button presses. When the confederate pushed the wrong button, the only feedback the test subject could give was a “barely discernible” to “somewhat painful” electrical shock.

Analyzing the data, Mehta found a difference between the group of subjects given the psychosocial explanation for their partner’s mental-illness history and those given the brain-disease explanation. Those who believed that their partner suffered a biochemical “disease like any other” increased the severity of the shocks at a faster rate than those who believed they were paired with someone who had a mental disorder caused by an event in the past.

“The results of the current study suggest that we may actually treat people more harshly when their problem is described in disease terms,” Mehta wrote. “We say we are being kind, but our actions suggest otherwise.” The problem, it appears, is that the biomedical narrative about an illness like schizophrenia carries with it the subtle assumption that a brain made ill through biomedical or genetic abnormalities is more thoroughly broken and permanently abnormal than one made ill though life events. “Viewing those with mental disorders as diseased sets them apart and may lead to our perceiving them as physically distinct. Biochemical aberrations make them almost a different species.”

In other words, the belief that was assumed to decrease stigma actually increased it. Was the same true outside the lab in the real world?

The question is important because the Western push for “mental-health literacy” has gained ground. Studies show that much of the world has steadily adopted this medical model of mental illness. Although these changes are most extensive in the United States and Europe, similar shifts have been documented elsewhere. When asked to name the sources of mental illness, people from a variety of cultures are increasingly likely to mention “chemical imbalance” or “brain disease” or “genetic/inherited” factors.

Unfortunately, at the same time that Western mental-health professionals have been convincing the world to think and talk about mental illnesses in biomedical terms, we have been simultaneously losing the war against stigma at home and abroad. Studies of attitudes in the United States from 1950 to 1996 have shown that the perception of dangerousness surrounding people with schizophrenia has steadily increased over this time. Similarly, a study in Germany found that the public’s desire to maintain distance from those with a diagnosis of schizophrenia increased from 1990 to 2001.

Researchers hoping to learn what was causing this rise in stigma found the same surprising connection that Mehta discovered in her lab. It turns out that those who adopted biomedical/genetic beliefs about mental disorders were the same people who wanted less contact with the mentally ill and thought of them as more dangerous and unpredictable. This unfortunate relationship has popped up in numerous studies around the world. In a study conducted in Turkey, for example, those who labeled schizophrenic behavior as akil hastaligi (illness of the brain or reasoning abilities) were more inclined to assert that schizophrenics were aggressive and should not live freely in the community than those who saw the disorder as ruhsal hastagi (a disorder of the spiritual or inner self). Another study, which looked at populations in Germany, Russia and Mongolia, found that “irrespective of place . . . endorsing biological factors as the cause of schizophrenia was associated with a greater desire for social distance.”

Even as we have congratulated ourselves for becoming more “benevolent and supportive” of the mentally ill, we have steadily backed away from the sufferers themselves. It appears, in short, that the impact of our worldwide antistigma campaign may have been the exact opposite of what we intended.

NOWHERE ARE THE limitations of Western ideas and treatments more evident than in the case of schizophrenia. Researchers have long sought to understand what may be the most perplexing finding in the cross-cultural study of mental illness: people with schizophrenia in developing countries appear to fare better over time than those living in industrialized nations.

This was the startling result of three large international studies carried out by the World Health Organization over the course of 30 years, starting in the early 1970s. The research showed that patients outside the United States and Europe had significantly lower relapse rates — as much as two-thirds lower in one follow-up study. These findings have been widely discussed and debated in part because of their obvious incongruity: the regions of the world with the most resources to devote to the illness — the best technology, the cutting-edge medicines and the best-financed academic and private-research institutions — had the most troubled and socially marginalized patients.

Trying to unravel this mystery, the anthropologist Juli McGruder from the University of Puget Sound spent years in Zanzibar studying families of schizophrenics. Though the population is predominantly Muslim, Swahili spirit-possession beliefs are still preval‎ent in the archipelago and commonly evoked to explain the actions of anyone violating social norms — from a sister lashing out at her brother to someone beset by psychotic delusions.

McGruder found that far from being stigmatizing, these beliefs served certain useful functions. The beliefs prescribed a variety of socially accepted interventions and ministrations that kept the ill person bound to the family and kinship group. “Muslim and Swahili spirits are not exorcised in the Christian sense of casting out demons,” McGruder determined. “Rather they are coaxed with food and goods, feted with song and dance. They are placated, settled, reduced in malfeasance.” McGruder saw this approach in many small acts of kindness. She watched family members use saffron paste to write phrases from the Koran on the rims of drinking bowls so the ill person could literally imbibe the holy words. The spirit-possession beliefs had other unexpected benefits. Critically, the story allowed the person with schizophrenia a cleaner bill of health when the illness went into remission. An ill individual enjoying a time of relative mental health could, at least temporarily, retake his or her responsibilities in the kinship group. Since the illness was seen as the work of outside forces, it was understood as an affliction for the sufferer but not as an identity.

For McGruder, the point was not that these practices or beliefs were effective in curing schizophrenia. Rather, she said she believed that they indirectly helped control the course of the illness. Besides keeping the sick individual in the social group, the religious beliefs in Zanzibar also allowed for a type of calmness and acquiescence in the face of the illness that she had rarely witnessed in the West.

The course of a metastasizing cancer is unlikely to be changed by how we talk about it. With schizophrenia, however, symptoms are inevitably entangled in a person’s complex interactions with those around him or her. In fact, researchers have long documented how certain emotional reactions from family members correlate with higher relapse rates for people who have a diagnosis of schizophrenia. Collectively referred to as “high expressed emotion,” these reactions include criticism, hostility and emotional overinvolvement (like overprotectiveness or constant intrusiveness in the patient’s life). In one study, 67 percent of white American families with a schizophrenic family member were rated as “high EE.” (Among British families, 48 percent were high EE; among Mexican families the figure was 41 percent and for Indian families 23 percent.)

Does this high level of “expressed emotion” in the United States mean that we lack sympathy or the desire to care for our mentally ill? Quite the opposite. Relatives who were “high EE” were simply expressing a particularly American view of the self. They tended to believe that individuals are the captains of their own destiny and should be able to overcome their problems by force of personal will. Their critical comments to the mentally ill person didn’t mean that these family members were cruel or uncaring; they were simply applying the same assumptions about human nature that they applied to themselves. They were reflecting an “approach to the world that is active, resourceful and that emphasizes personal accountability,” Prof. Jill M. Hooley of Harvard University concluded. “Far from high criticism reflecting something negative about the family members of patients with schizophrenia, high criticism (and hence high EE) was associated with a characteristic that is widely regarded as positive.”

Widely regarded as positive, that is, in the United States. Many traditional cultures regard the self in different terms — as inseparable from your role in your kinship group, intertwined with the story of your ancestry and permeable to the spirit world. What McGruder found in Zanzibar was that families often drew strength from this more connected and less isolating idea of human nature. Their ability to maintain a low level of expressed emotion relied on these beliefs. And that level of expressed emotion in turn may be key to improving the fortunes of the schizophrenia sufferer.

Of course, to the extent that our modern psychopharmacological drugs can relieve suffering, they should not be denied to the rest of the world. The problem is that our biomedical advances are hard to separate from our particular cultural beliefs. It is difficult to distinguish, for example, the biomedical conception of schizophrenia — the idea that the disease exists within the biochemistry of the brain — from the more inchoate Western assumption that the self resides there as well. “Mental illness is feared and has such a stigma because it represents a reversal of what Western humans . . . have come to value as the essence of human nature,” McGruder concludes. “Because our culture so highly values . . . an illusion of self-control and control of circumstance, we become abject when contemplating mentation that seems more changeable, less restrained and less controllable, more open to outside influence, than we imagine our own to be.”

CROSS-CULTURAL psychiatrists have pointed out that the mental-health ideas we export to the world are rarely unadulterated scientific facts and never culturally neutral. “Western mental-health discourse introduces core components of Western culture, including a theory of human nature, a definition of personhood, a sense of time and memory and a source of moral authority. None of this is universal,” Derek Summerfield of the Institute of Psychiatry in London observes. He has also written: “The problem is the overall thrust that comes from being at the heart of the one globalizing culture. It is as if one version of human nature is being presented as definitive, and one set of ideas about pain and suffering. . . . There is no one definitive psychology.”

Behind the promotion of Western ideas of mental health and healing lie a variety of cultural assumptions about human nature. Westerners share, for instance, evolving beliefs about what type of life event is likely to make one psychologically traumatized, and we agree that venting emotions by talking is more healthy than stoic silence. We’ve come to agree that the human mind is rather fragile and that it is best to consider many emotional experiences and mental states as illnesses that require professional intervention. (The National Institute of Mental Health reports that a quarter of Americans have diagnosable mental illnesses each year.) The ideas we export often have at their heart a particularly American brand of hyperintrospection — a penchant for “psychologizing” daily existence. These ideas remain deeply influenced by the Cartesian split between the mind and the body, the Freudian duality between the conscious and unconscious, as well as the many self-help philosophies and schools of therapy that have encouraged Americans to separate the health of the individual from the health of the group. These Western ideas of the mind are proving as seductive to the rest of the world as fast food and rap music, and we are spreading them with speed and vigor.

No one would suggest that we withhold our medical advances from other countries, but it’s perhaps past time to admit that even our most remarkable scientific leaps in understanding the brain haven’t yet created the sorts of cultural stories from which humans take comfort and meaning. When these scientific advances are translated into popular belief and cultural stories, they are often stripped of the complexity of the science and become comically insubstantial narratives. Take for instance this Web site text advertising the antidepressant Paxil: “Just as a cake recipe requires you to use flour, sugar and baking powder in the right amounts, your brain needs a fine chemical balance in order to perform at its best.” The Western mind, endlessly analyzed by generations of theorists and researchers, has now been reduced to a batter of chemicals we carry around in the mixing bowl of our skulls.

All cultures struggle with intractable mental illnesses with varying degrees of compassion and cruelty, equanimity and fear. Looking at ourselves through the eyes of those living in places where madness and psychological trauma are still embedded in complex religious and cultural narratives, however, we get a glimpse of ourselves as an increasingly insecure and fearful people. Some philosophers and psychiatrists have suggested that we are investing our great wealth in researching and treating mental illness — medicalizing ever larger swaths of human experience — because we have rather suddenly lost older belief systems that once gave meaning and context to mental suffering.

If our rising need for mental-health services does indeed spring from a breakdown of meaning, our insistence that the rest of the world think like us may be all the more problematic. Offering the latest Western mental-health theories, treatments and categories in an attempt to ameliorate the psychological stress sparked by modernization and globalization is not a solution; it may be part of the problem. When we undermine local conceptions of the self and modes of healing, we may be speeding along the disorienting changes that are at the very heart of much of the world’s mental distress.

DR. SING LEE, a psychiatrist and researcher at the Chinese University of Hong Kong, watched the Westernization of a mental illness firsthand. In the late 1980s and early 1990s, he was busy documenting a rare and culturally specific form of anorexia nervosa in Hong Kong. Unlike American anorexics, most of his patients did not intentionally diet nor did they express a fear of becoming fat. The complaints of Lee’s patients were typically somatic — they complained most frequently of having bloated stomachs. Lee was trying to understand this indigenous form of anorexia and, at the same time, figure out why the disease remained so rare.

거식증·우울증…미국산 정신병 세계를 덮다!

[프레시안 books] 에단 와터스의 <미국처럼 미쳐가는 세계>

기사입력 2011-03-04 오후 4:35:32

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에단 와터스의 <미국처럼 미쳐가는 세계>(김한영 옮김, 아카이브 펴냄)는, 현대 정신 의학이 다양한 문화의 자생적 문제 해결 능력을 무시하고 미국 문화의 잣대로 인간의 몸과 마음을 재단함으로써 발생하는 사태들에 대한 보고서다.

저자는 거식증, 외상 후 스트레스 장애(PTSD), 정신 분열병, 우울증 등 서구에서 발견되고 분류되고 관리돼 온 대표적 정신 질환이 홍콩, 스리랑카, 아프리카의 잔지바르, 일본에서 퍼져나가는 양상을 세심히 관찰해서 보여준다. 그리고 서양 의학은 토착 문화의 자생력을 파괴하는 폭력을 행사하고 있다고 주장한다. 이 중 홍콩과 일본은 우리와 같은 동아시아 문화권에 속하는 지역이어서 특히 관심이 간다.

아마 현대 의학이 인류를 참혹한 질병의 고통에서 구해준 은인이라고 믿는 독자라면 무척 당혹스러울 것이다. <질병 판매학>(알마 펴냄), <더러운 손의 의사들>(양문 펴냄), <제약 회사들은 어떻게 우리의 주머니를 털었나>(청년의사 펴냄) 등 현대 의료의 어두운 면을 보여주는 많은 책들이 출판되기는 했어도 의학이 인류 구원의 보루라는 믿음은 우리 사회에 아직 굳건하다.

이 책들은 제약 회사가 처방권을 가진 의사를 합법적으로 또는 탈법적으로 매수해서 꼭 필요하지도 않은 처방들을 남발하도록 조장한다고 폭로한다. 실제로 한국에서도 약을 처방하는 대가로 제약 회사가 의사나 의료 기관에 지불하는 리베이트 문제가 여러 차례 언론의 주목을 받기도 했다.

2000년에 있었던 의사들의 파업은 의약 분업을 통해 약품의 유통 마진을 줄이려는 정부와 의사 집단의 이해가 충돌한 사건이었다. 문제를 이런 측면에서만 보면 이해 당사자들 사이의 조정과 합의가 해결책이다. 실제로 의사들의 파업은 힘에 따라 이해관계를 재분배하는 걸로 마무리되었다.

▲ <미국처럼 미쳐가는 세계>(에단 와터스 지음, 김한영 옮김, 아카이브 펴냄). ⓒ아카이브

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하지만 이 책은 문제를 좀 더 근원적인 곳에서 찾아낸다. 우리가 세상을 살아가면서 축적해가는 삶의 지혜, 즉 공동체의 문화에서다. 그런데 미국의 의사들이 중심이 돼서 만들어낸 '정신 질환 진단 분류 체계(DSM)'에는 서양과 다른 세계관의 삶을 담을 공간이 없다. 따라서 서양의 정신 의학은 서양인의 삶에서 형성된 정서와 문제를 기준으로 다른 문화권의 삶을 재단할 수밖에 없다.

홍콩의 거식증 사례에서 보는 바와 같이 날씬한 외모에 대한 무의식적인 동경이 이 병의 원인이라는 서양식 설명은 실제 사례와 거의 들어맞지 않는데도 말이다. DSM은 특정 문화권에서만 발견되는 증상을 포함하기도 한다. 한국인에게만 있는 '화병'이 그중 하나다. 하지만 서양의 교향악에 국악 가락 한 소절을 집어넣는다고 그 음악이 국악이 되지는 않는다. 이 책은 그런 문화적 불협화음에 관한 것이다.

문제를 이해관계보다 더 큰 문화의 틀 속에서 찾아낸 것이 이 책의 큰 장점이다. 이로써 우리는 의료를 보는 새로운 관점을 갖게 된다. 이것은 20세기 중반 이후 현대 의학을 비판적으로 보기 시작하면서 대두된 여러 학문 중 하나인 의료 인류학의 접근법이기도 하다. 책에서 언급되는 하버드대학교의 아서 클라인만은 타이완에서의 정신병 연구를 통해 정신 질환에 대한 문화적 연구의 길을 열었다.

이 책은 한 걸음 더 나아가 현지 문화에 대한 깊은 이해 없이 서구의 잣대를 들이대는 것은 문화적 폭력일 뿐 아니라 현지 주민을 새로운 의료 상품의 소비자로 만들어 사회·경제적으로 수탈하는 것이라고 주장한다. 거식증과 정신 분열병의 사례가 주로 문화적 폭력에 대한 것이라면, 외상 후 스트레스 장애와 우울증의 사례는 주로 문화적 폭력이 경제적 수탈의 수단이 되고 있음을 지적하는 것이다. 외상 후 스트레스 장애와 우울증은 각각 서구식 훈련을 받은 심리 상담사와 거대 다국적 제약 기업의 큰 시장을 만들어내는 동시에 현지인들을 서양인처럼 앓게(미쳐가게) 만든다는 것이다.

세계가 미국처럼 미쳐가는 이유 중 하나가 현지 문화에 대한 무지와 무시라면, 다른 하나는 미국인들의 몸과 마음이 되어버린 그들 자신의 문화에 대한 반성의 부재다. 이 책의 초점은 전자에 있지만 후자에 대해서도 마땅히 주의를 기울여야만 한다. 이것은 의료 인류학이 갔던 경로이기도 하다.

최초의 의료 인류학자들은 과학에 바탕을 둔 서양 의학의 객관성과 보편성을 의심하지 않았다. 그런데 식민지와 후진국에서는 건강에 관한 각종 미신과 토착 신앙 때문에 서양 의학이 잘 수용되지 않았다. 이 문제를 극복하기 위해서는 그들의 신앙과 문화를 연구해야만 했다. 이후 후진국의 신앙과 거기에 바탕을 둔 토착 의학을 연구하다 보니 비교 분석을 위해 같은 방법으로 서양 의학을 들여다보지 않을 수 없었다.

그러자 문화적 장막에 가려 보이지 않던 서양 의학의 전제들을 볼 수 있게 되었다. 서양 의학을 보급하기 위해 시작된 연구가 이제는 오히려 서양 의학의 문제점들을 반성하는 계기가 된 것이다. "다른 문화의 믿음들을 깊이 탐구하면 우리 자신의 문화적 편향들이 깜짝 놀랄 정도로 적나라하게 드러날 수 있다."

이 책은 서양의 정신 의학이 다른 문화권에서 만들어내는 문제들에 관한 것이지만, 거꾸로 다른 문화의 시선으로 서양 의학을 비판적으로 바라볼 필요도 있다는 교훈을 주기도 한다. 이런 점에서 이 책은 일상에 대한 지나친 의료화가 다양한 맥락 속에서 자동적으로 습득된 문제 해결 능력을 무력화시켜 오히려 병을 만든다고 주장하는 이반 일리치의 <병원이 병을 만든다>(미토 펴냄), 그리고 프랑스의 정신 의학이 식민지 알제리인의 정신을 파괴하고 지배하는 양상을 비판한 프란츠 파농의 <대지의 저주받은 사람들>(그린비 펴냄)과 일맥상통한다.

우리나라도 이 책 <미국처럼 미쳐가는 세계>에서 예외는 아니다. 이제는 더 이상 그런 진단명을 쓰지 않지만 50대 이상의 세대라면 히스테리와 신경 쇠약이라는, 서양에서 발명되고 수입된 증세에 익숙할 것이다. 실제로 그런 증상을 앓았던 경험이 있는 사람도 적지 않다. 유명 연예인들의 잇따른 자살은 우울증에 대한 우려를 증폭시켰고, 아마 그 발병을 더 촉진시켰을지도 모른다. 또 천안함 사건에서 살아남은 승조원에게 실시했다는 외상 후 스트레스 장애 치료는 과연 어떤 문화적 전제에서 출발한 것인지, 거기에 대한 반성도 필요하다. 혹시 치료를 빌미로 틀에 박힌 가치를 주입하지는 않았는지 생각해볼 일이다.

이 책은 이러한 현실적 반성 외에 우리들 자신의 본성을 어떻게 보아야 하는지에 대한 성찰의 계기가 되기도 한다. 우리는 우리가 생물학적 존재인 동시에 무의식적으로 문화에 길들여진 존재라는 사실을 너무 쉽게 잊어버린다. 이 책은 이 점을 상기시켜준다. 대중은 문화적 권위의 지지를 받는 틀 속에서 질병을 이해하고 경험한다. 중세 유럽에서는 그 문화적 권위가 교회였지만, 근대 이후 급속히 과학으로 이동한다. 그리고 20세기 이후에는 자본과 소비가 그 자리를 차지한다.

19세기 유럽에서 크게 유행했던 히스테리 환자들은 이 분야의 문화적 권위였던 의사 샤르코가 진단하고 분류하고 기술한 그대로의 증상을 겪었다. 오늘날의 소년 소녀들은 TV에 등장하는 연예인의 외모와 행동과 소비 패턴을 규범으로 삼고 닮으려 한다. 그래서 성형과 미용과 다이어트의 열풍이 분다. 이것은 "무의식이 감정의 고통을 당대에 이해될 수 있는 언어로 표현하는 시도"의 결과다. 이렇게 문화적 기대와 개인적 경험이 상호작용하고, 우리의 생물학적인 몸은 문화적 경험과 기대를 무의식적으로 내면화한다. 몸과 문화는 분리되지 않는 하나의 생물-문화적(Bio-Cultural) 현실이다.

21세기의 문화적 권위인 자본은 바로 그 생물-문화적 현실을 파고들어 자신들에게 유리한 새로운 생물-문화적 현실을 만들어낸다. 이것은 자율적인 문제 해결 노력이 아닌 약품의 소비가 규범인 현실이다. 이런 현실이 확대되면 모든 사람이 그 새로운 생물-문화적 현실의 구성요소가 된다. 책 속에 인용된 애플바움의 말처럼 "완벽한 건강이라는 유토피아적 가능성을 추구하는 과정에서 우리는 부지중에 기업의 마케팅 담당자들에게 우리가 가진 자유의 도구들을 마음대로 통제할 고삐를 넘겨주고 말았다. 과학의 객관성, 의료의 윤리와 공정성, 환자의 이익을 위해 일하겠다는 맹세를 스스로 지키는 한에서 의학에 자율성을 부여할 특권은 이제 그들 손에 있다."

의료인이 전문가로서의 자율성과 대중의 의료인에 대한 신뢰를 되찾고, 환자가 의약품의 소비자가 아닌 자기 건강의 주체로 바로 설 수 있을지의 여부는 바로 이와 같은 사회·문화적 메커니즘을 바꿀 수 있을지의 여부에 달려 있다. 이 책이 의료와 관련된 모든 논쟁을 시작하기 전에 반드시 읽어야 할 필독서가 되어야 하는 이유다.

 

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