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The limitations of medical ecology:

The concept of adaptation in the

context of social stratification and

social transformationMerrill Singer

a

aAssistant Clinical Professor, Department of Community

Medicine, University of Connecticut Health Center, Storrs, CT,

06268

Available online: 12 May 2010

To cite this article: Merrill Singer (1989): The limitations of medical ecology: The concept of

adaptation in the context of social stratification and social transformation, Medical Anthropology,10:4, 223-234

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Medical Anthropology, 1989, Vol. 10, pp. 223-234Reprint Available directly from the publisherPhotocopying permitted by license onlyGordon and Breach, Science Publishers, Inc. 1989Printed in the United States of America

The Limitations of Medical Ecology: TheConcept of Adaptation in the Context of SocialStratification and Social TransformationMerrill Singer

Medical anthropology has long suffered under acloak of insecurity.1 Since Scotch's (1963) reviewof its literature over twenty years ago , the secret hasbeen out that medical anthropology lacks theoreticalunity or what later reviewers called "a shared andconceptually based view" of itself and its subjectmatter (Colson and Selby 1974:246). Now , it wouldseem, all of that is changing. Over the last severalyears, medical anthropologists in growing numbershave embraced the theoretical approach of medicalecology (McElroy and Townsend 1979; Wood1979; Moore et al. 1980), a perspective that Landy(1983:187) concludes has achieved "a broad tacitconsensus" within the field.While the development of an overarching theo-retical approach in medical anthropology is to beapplauded, this paper challenges the capacity of

medical ecology to adequately and productively fillsuch a role. This point is made by identifying andcritically examining several interrelated and funda-mental shortcomings of the medical ecological per-spective. Although the soundness of medical ecol-ogy can be questioned on a number of levels (e.g.,Polunin 1976; Trotter 1985), this paper is concernedprimarily with the arenas of social stratification andsocial transformation; phenomena, it is argued, thatare understood poorly within the narrow confines ofthis theoretical framework. The flaws in medicalecology that are of concern here arise ultimatelyfrom the failure to consider fully or accurately therole of social relations in the origins of health andillness. In this, medical ecology shares ground withbiomedicine. Both approaches participate in the re-production of the reigning consciousness of West-ern society through a mystification of the social

world (Singer et al. 1984; Baer, Singer, and John-sen 1986). Because it adopts a holistic systems ap-proach to etiology, medical ecology purports to gobeyond the traditional clinical understanding ofhealth and disease. In fact, both the medical modeland medical ecology are limited by their tendency todiminish society while they reify disease.

The Background of Medical Ecology: TheChanging Anthropological Attitude Toward

the EnvironmentThe term ecology first appeared in print over onehundred years ago (Vayda and Rappaport 1968). Ithas been defined by Allee and his co-workers(1949:1) as "the science of the interrelation be-tween living organisms and their environment, in-cluding both the physical and the biotic environ-ment, and emphasizing interspecies as well asintraspecies relations." The roots of the ecologicalperspective run deep in the anthropological tradi-tion, extending at least as far back as the intellectualera that gave rise to Darwin's Origin of Species(1859). As Meggers (1954:801) notes, " [e]arly stu-dents, impressed with the ways in which cultureswere adjusted to the unique features of their localenvironments, developed the concept of environ-mental determinism." Thus, on the basis of soilfertility alone did Montesquieu explain the contrast-ing governmental forms of Athens and Sparta. Inhis classic study, The Mind of PrimitiveMan, Boascriticized this approach by identifying a weak linkin the environmentalist armor.

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geographic conditions have only the power tomodify culture. By themselves they are notcreative . . . We can understand that a fertilesoil will induce an agricultural people whosenumbers are increasing rapidly to improve itstechnique of agriculture, but not, how it couldbe the cause of the invention of agriculture.However rich in ore a country may be , it doesnot create techniques of handling metals; how-ever rich in animals that might be domesti-cated, it will not lead to the development ofherding if the people are entirely unfamiliarwith the uses of domesticated animals. [Boas1938:190]Boas' differentiation of positive and negativecausality (determinism vs . possibilism) proved to bean important lesson for the ecological perspective inanthropology (Kaplan and Manners 1972:78; Al-land 1970). It is now widely recognized that "[en-vironmental deterministic theories served as ration-ales for political dominance in many guises"(Moran 1979:24). However, it may not be the case,as Meggers' (1954:801) believed, that with the ac-cumulation of ethnographic studies "the variability

in cultural patterns became more evident and theidea of determinism was rejected," at least not byeveryone. Thus, some have seen Harris' (1968:4)argument that "similar technologies applied to sim-ilar environments tend to produce similar arrange-ments of labour in production and distribution, and. . . these in turn call forth similar kinds of socialgroupings which justify and coordinate their activ-ities by means of similar systems of values andbeliefs" as but a complex rephrasing of environ-mental determinist thinking.Harris notwithstanding, vulgar determinism failedto win paradigmatic status in anthropology. None-theless, the discip line's interest in the relationship ofculture to environment never flagged. Typically,while attacking the determinist position in Habitat,Economy and Society, Forde (1934:464) insisted"the study of the relations between cultural patternsand physical conditions is one of greatest importancefor an understanding of human society . . . " O n eexpression of this continued interest is found inWissler's attempt to formulate a law of culture/nature correspondence. Based on his studies of thedistribution of cultural traits among Native Ameri-cans, Wissler (1926:214) claimed that "when twosections of a continent differ in climate, florae, andfaunae, or in their ecological complexes, the culture

of the tribal group in one section w ill differ from thatin the other." Yet Wissler was cautious about as-signing positive causality to the environment. "T heinfluence of the env iro nm en t... appears as a passivelimiting agency rather than a causal factor in triballife," he maintained (Wissler 1926:339).As these remarks suggest, aspects of the ecolog-ical perspective were woven into the core of theanthropological fabric. In Kroeber's (1939:205)words, it came to be the received wisdom of an-thropology that "no culture is wholly intelligiblewithout reference to the noncultural or so-called en-vironmental factors with which it is in relation andwhich condition it." Serious effort to investigatethe nature/culture relationship, however, awaitedKroeber's student Julian Steward, the founder ofmodern cultural ecology. In Harris' (1968:666)evaluation, Steward's work "constitutes the firstcoherent statement on how the interaction betweenculture and environment could be studied . . . "

The starting point for cultural ecology, accordingto Steward (1955:32), is a recognition that "[h]u-man beings do not react to the web of life solelythrough their genetically-derived organic equip-ment. Culture, rather than genetic potential for ad-aptation, accommodation, and survival, explainsthe nature of human societies." In stressing thispoint, Steward was attempting to differentiate cul-tural ecology, which has as its primary goal theexplanation of culture, from general ecology,which, when it takes up the issue of human behav-ior, is especially concerned with demographicrather than cultural variables. On this foundation,Steward investigated the origin of certain culturalfeatures in a variety of societies in terms of adap-tation to local environmental conditions. It was hisposition, however, that "[e]ach case must bejudged on its own m erits, and broad generalizationswill be possible only when an adequate taxonomy ofsociocultural types has been developed and whenthe cultural ecology of each has been analyzed"(Steward 1955:173).

While most of Steward's research focused onNew World indigenous populations, some of hislater work was concerned with contemporary com-plex society, particularly Puerto Rico. It is signifi-cant that not only did Steward become interested inthe nature of this type of social entity, but in hisanalysis of it he recognized the importance of classrelations and the existence of cultural non-sharingamong the various social classes, and, in addition,called attention to transformations in Puerto Rican

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SINGER / Limitations of Medical Ecology 225society "brought about by a set of institutionswhich have been imposed . . . from the outside"(Steward 1955:222). Out of these concerns, itwould seem, came the powerful studies of socialrelationship, social stratification, and social trans-formation written by several of Steward's students(e.g., Wolf 1982; Mintz 1985).

Although most ecological interest in cultural an-thropology since Steward directly or indirectly fol-lows his lead, and thus takes as its objective theexplanation of culture, an alternative trend began toemerge in the 1960s. Researchers who adopted thisapproach were attempting to build a unified ecolog-ical analysis concerned with explaining human de-mographics rather than human culture. Vayda andRappaport, leading proponents of this orientation,have written:

Consistent with usage in ecology, the focus ofanthropologists engaged in ecological studiescan be upon human populations and upon eco-systems and biotic communities in which hu-man populations are included. To have unitsfitting into the ecologist's frame of reference isa procedure with clear advantages. Humanpopulations as units are commensurable withthe other units with which they interact to formfood webs, biotic communities, and ecosys-tems. Their capture of energy from and ex-changes of material with these other units canbe measured and then described in quantitativeterms. No such advantage of commensurabilityobtains if cultures are made the units, for cul-tures, unlike human populations, are not fedupon by predators, limited by food supplies, ordebilitated by disease, (emphasis added)[Vayda and Rappaport 1968:494]

The Perspective of Medical EcologyIn spite of a clear influence from cultural ecology,medical ecology most directly emerges from thegeneral ecological rather than the cultural ecologicaltrend in anthropological concern with the environ-ment. This influence is both conceptual, as seen inmedical ecology's selection of the human popula-tion as its unit of analysis, and historical, as seen inthe acknowledged influence of Vayda on the ideasof Alland (1970:viii), a founding father of medicalecology.

If one considers human populations as the sub-ject matter for research rather than "Cul-tures," then these units may be treated equallywell as behavior or physical entities. If the bi-ological model is adhered to, we shall beforced to recognize the connections whichmust exist between genetic and extrageneticevents. We shall also come to see that the thor-ough study of human adaptation is essentially abiological problem involving, in part, a veryimportant series of nongenetic processes. [Al-land 1970:47]Because of its avowed concern with both biolog-ical and cultural variables, the formulators of med-

ical ecology see it as holistic, comprehensive, sys-tematic, and synthesizing. Its adoption, affirmsAlland (1966), will enable medical anthropology tobridge the yawning chasm that divides the biologi-cal and sociocultural arms of the parent discipline.Indeed, the breadth of medical ecology's reportedgaze is phenomenal.the scope of the ecological model includes so-cieties and populations, the behavior of humangroups and microbiota, perceptions of the en-vironment and primary environmental fea-tures, definitions of disease and disease itself,ethnomedicine (and traditional medical sys-tems) and modern medicine, (emphasis inoriginal) [Wellin 1977:58]

Moreover, the ecological approach is said to be"valuable for delineating elements of a dynamicsystem, determining how the various elements worktogether, identifying hazards or potential stress ar-eas, predicting types and direction of change, andassessing adaptive and deleterious responses to bothplanned and unplanned change" (Jerome, Pelto,and Kandel 1980:15). Finally, medical ecologyclaims to emerge from and incorporate the majorideas and insights of the founding ancestors of med-ical anthropology (Wellin 1977).At heart, medical ecology adopts the view thathealth and disease are "reflections of ecologicalrelationships within a population, between neigh-boring populations, and among the life forms andphysical components of a habitat. Medical ecologyconsiders health to be a measure of how well apopulation has adapted to its environment"(McElroy and Townsend 1979:2).As this description suggests, the central pillar in

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226 MEDICAL ANTHROPOLOGY / Volume 10 / Number 4the medical ecological model, as with ecology gen-erally, is the concept of adaptation. While the ideaof adaptation to the environment has become anarticle of faith within anthropology, as Burnham(1973) reminds us, there is seldom serious consid-eration of what is actually meant by this phrase andconsiderable ambiguity in its usage (Brown 1986).Indeed, in recent years, there has been mountingconcern about the explanatory value of the adapta-tionist perspective in all of the behavioral fields(Bargatzky 1984). Even in biology, several promi-nent researchers conclude that the concept of adap-tation is "fraught with difficulties" (Lewontin1978:228; Gould and Lewontin 1979).

So too is the program of medical ecology, which,it is argued in the remainder of this paper, is lessbalanced, less comprehensive, and theoretically.lessimpressive than the claims of some of its adherentsmight suggest.

Shortcomings of Medical EcologyThe first problem of medical ecology arises in itsattempt to specify the environment to which a pop-ulation is purportly adapting. While Bargatsky(1984) recently identified a number of pitfalls in thisendeavor, his discussion omits a full treatment ofthe role of social relations in creating the humanenvironment. For example, in their account of theevolving patterns of birth, disease, and death,McElroy and Townsend (1978) present the case ofKepone poisoning among industrial workers inHopewell, Virginia in 1975. While these authors(1979:13) maintain that "health is a measure of en-vironmental adaptation," their example is an unam-biguous case in which the determinant relationshipis social and not environmental. Although they(1979:164) note that "workers in a given industryusually bear the brunt of damage from a hazardoussubstance," McElroy and Townsend avoid any ex-amination of social relational factors, such as class,ownership of productive forces, and the extractionof profit, that would add insight to their profile (cf.,Nash and Kirsch 1986). By abstaining from a dis-cussion of these issues , the adaptationist perspectiveappears to assign inequities in social relationships tothe environment, thereby not only legitimizingthose inequities as natural, but implying that thenoxious consequences of exploitation are indicatorsof the maladaptation of politically and economicallysubordinate groups.

In most settings examined by medical anthropol-ogists, cannot the reading of disease rates as mea-sures of environmental fitness serve as a fancifullyphrased agenda for victim-blaming? Consider N ew-man's effort to geographically map malnutrition.On a gross world basis the American Geo-graphical Society (1953) maps show that theareas of undernutrition and malnutritionclosely coincide with the tropical and warmertemperate regions of backward food producingtechnologies. . . . To a considerable extent thenutritional deficiency diseases are distributedby climate zones, are often worse at certainseasons, and are sometimes related to specificfood crops. When these deficiency diseasesreach epidemic p roportions, they appear to rep-resent the worst lags in man's adaptation to hisnutritional environment. [Newman 1977:322-323]

But history tells a different story. "The notion that'the tropics' lie under some kind of primordial cursemakes it difficult to explain, however, why thegreat civilizations of the ancient worldEgypt,Mesopotamia, the Indus Valleyor the laterMayan and Chinese Empires, all flourished inmainly tropical regions which are now the most un-derdeveloped parts of the glob e" (Worsely 1984:1).Indeed, the answer to 'tropical underdevelopment'lies outside the tropics (and hence outside the do-main of ecology). In commenting on Newm an's ob-servations Landy appropriately notes:

the missing factor in the ecology-nutri-tion-disease calculus could well be not so muchthe consequences of tropical or warm temper-ate climate directly but their combination withan exploitative situation where the foods pro-duced by a people are consumed by others [soas to make a profit for someone else]. In otherwords, there may be a correlation betweenthese climates and imperialist domination, sothat the amount and nutritional quality of foodproduced is not a measure of the amount andquality of food consumed by the food-producers, since they are drained off by eco-nomically more powerful forces. [Landy1977:320]As Davison (1983) argues for Haiti, efforts toaccount for malnutrition there in terms of maladap-

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SINGER / Limitations of Medical Ecology 227tive social patterns obfuscates the disastrous impactof several hundred years of colonial and neo-colo-nial extraction from the island. In Davison's esti-mation (personal communication), what is mostneeded, in light of the expansionary character of theworld capitalist system and the inherently exploit-ative nature of class relations globally and nation-ally, is social and not geographic mapping of hun-ger and disease. In this light, so-called "diseases ofmodernization" and "diseases of poverty" can beunderstood as the consequence of location in par-ticular regions of the world economy with their as-sociated social, productional and habitational fea-tures, rather than as the consequence of adaptationor even maladaptation to particular environments.Indeed, the whole notion of adaptation is suspect inthe discussion of what some would describe as in-herently antagonistic global class relations.

While some medical ecologists seek to avoid thedilemma discussed above by simply avoiding orpaying scant attention to phenomena that have anobvious social determinant, others attempt tosqueeze accounts of oppressive social relations intothe conceptual categories of ecologic theory. Thus,Moore et al. (1980) describe the devastating historyof interactions between European colonialists andNative Americans, in which indigenous peopleswere militarily crushed, subjected to periodic mas-sacre, expropriated of their land, robbed intermit-tently of their children, concentrated on unproduc-tive lands, and deprived of their culture, in thefollowing fashion:

Emergent colonialist policies, all in the nameof progress, thus focused on reducing the'threat from below,' while at the same timemaximizing resource (including land) avail-ability. This can be conceptualized as a situa-tion in which initially different systems inter-lock through time, as a result of occupying thesame territory and competing for the samescarce resources. [Moore et al. 1980:85]Another approach to the social conundrum in

medical ecology is to maintain that human popula-tions adapt to both physical and social environ-ments. McElroy and Townsend (1979:13), for ex-ample, state that life in human groups involves thecreation of "survival-promoting relationships with-in an environmental system. T hese are relationshipswithin the group, with neighboring groups, andwith the plants and animals of the habitat." There

are several confusions created in conceiving of so-cial relations as environmental relations. First, un-like the physical environment, which, as indicated,most medical ecologists accept as "an inert config-uration of possibilities and limits to development''(Sahlins 1967:367), social relations are anything butinert. As the case of European/Native American re-lations cited above or any one of an endless numberof similar examples suggests, social relations arecausal. Secondly, as such cases reveal, social rela-tions can be imposed suddenly from without onto aseemingly stable community. It seems curious thatrepercussions from such imposition (e.g., increasedmorbidity) should be labeled a failure to adapt. Fi-nally, it is analytically important to keep social re-lations distinct from relations w ith the physical en-vironment, because of the powerful ideologicaltendency to disguise social relations as natural re-lations. As Taussig reminds us:

Time, space, matter, cause, relation, humannature, and society itself are social productscreated by man jus t as are the different types oftools, farming systems, clothes, houses, mon-uments, languages, myths, and so on, thatmankind has produced since the dawn of hu-man life. But to their participants, all culturestend to present these categories as if they werenot social products but elementary and immu-table things. As soon as such categories aredefined as natural, rather than social products,epistemology itself acts to conceal understand-ing of the social order. Our experience, ourunderstanding, our explanationsall servemerely to ratify the conventions that sustainour sense of reality unless we appreciate theextent to which the basic 'building blocks' ofour experienced and sensed reality are not nat-ural but social constructions. [Taussig 1980:4]

It is thus vital that the entrancing lure of naturalisticlanguage and the greater stature of the physical sci-ences not deceive us into a phantom objectivity thatdisguises more than it reveals.A second problem with medical ecology is thetendency to smuggle in an intrinsically conservativeslant by assigning value to the maintenance of theexisting social configuration on the assumption thathomeostasis is the teleological goal of all systems.According to the logic of ecological theory, if aconfiguration exists, especially if it endures, it mustbe adapted, and m oreover, in the medical ecological



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lexicon, it must be healthy. Yet, as Sahlins(1968:370) realized some time ago, we "must notpresume that whatever is there is good, rational,useful or advantageous." Sahlins (1968:369) illus-trates this point by reference to the adoption of tim-ber and galvanized iron houses in Fiji, despite their"obvious cost in personal comfort, and possibly inhealth too." Adoption of new housing styles in Fijiwas linked to the island's incorporation into theworld market as a copra-producing center ratherthan a product of ecological adaptation.

The key question commonly ignored by the eco-logical approach is: adaptive for whom? Simplyput, "what is good for the elite is not a function ofthe survival needs of dominated p opu lations" (Fried-man 1980:254). Thus, when Foster and Anderson(1978:v) tell us that "health-related behavior, inWestern and Third World countries al ik e, . . . tendsto be adaptive; consciously and subconsciously it isdesigned to promote the survival and increase themembers of soc iety ," do they include health-relatedbehavior such as commerciogenic malnutrition re-sulting from infant formula promotions, the dump-ing of harmful, banned or outmoded drugs on ThirdWorld markets by pharmaceutical corporations,government-sponsored sterilization campaignsamong Native Americans and Puerto Ricans, drugexperimentation on indigenous peoples and prisoninmates, intentional exposure to nuclear testingamong military personnel, or even the scheduling ofsurgeries to meet physician rather than patientneeds? The adaptationist program founders becauseit adopts an organismic view of society as a seam-less whole with uniform interests and power amongits members, while confounding social relations asecological relations.

In this regard, the often repeated assertion that"health and disease are measures of the effective-ness with which human groups . . . adapt to theirenvironments" (Lieban 1970:1031), ignores notonly the social origins of disease as suggestedabove, but also the degree to which diagnosis is asocial process, disease a medically constructed cat-egory, and illness a socially regulated role (Mishler1981: Singer 1986a,b). As Waitzkin and Watermanpoint out:

[t]he sick role provides a controllable form ofdeviance which mitigates potentially disruptiveconflicts between personality needs and the so-cial system's role demands. . . . The latentfunctions of the sick role depend on the exis-

tence within a social system of professionalswho control access to the role. These profes-sionals permit adoption of the sick role by cer-tifying illness under certain circumstances.However, partly because of the potentially dis-ruptive effects of widespread adoption of thesick role, they restrict access according tounique criteria within each institutionalsetting. . . . [Thus,]. . . physicians may permitaccess to the sick role, encourage stoicism, ordenounce malingeringin the latter case, de-nying access to the sick role. [Waiztkin andWaterman 1974:38-39]Similarly, Alland's (1970:180) assertion that

"the proper measure of adaptation is populationincrease" would misguidedly provide ecologicalrather than social understanding for demographicgrowth (Mamdani 1972), unless, of course, we arewilling to turn Social Darwinism on its head andconclude that the best adapted are the least pow erfulwithin and between contemporary nations becausethey are the most numerous and fastest growingpopulations. As Brown (1986) asserts, "a commit-ment to use the Darwinian measure of adaptation,reproductive success, results in a conclusion whichdefies common sensethat the lower class popula-tion is better adapted to [t]he environment than theupper class." Because of the determinant role ofsocial relations in population-growth, such rates area poor measure of environmental adaptation(Friedman 1980). Moreover, the claim that popula-tion increase is the "proper measure" of adaptationblurs fundamental differences in the nature of cul-tural and biological responses to environmental con-tingencies (Brown 1986).Third, while it is certainly the case that all socialsystems must respond to the material conditionsthey face, in what sense can we say that they areadapted to them? Indeed, there are several problemswith the way in which the concept of adaptation isused in medical ecology. For exam ple, adaptationistaccounts of folk medical systems commonly haveconcluded that such systems play a significant part

"in solving certain problems of adaptation," suchas enabling rural migrants to adjust to urban life(Press 1978:12). While folk medical systems can nodoubt be credited w ith providing social and psycho-logical support to displaced peasants and labor mi-grants in the city (Singer and Borrero 1984), assist-ing people to survive at the bottom of anexploitative socio-economic structure is a rather



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SINGER / Limitations of Medical Ecology 229

narrow achievement to be labeled adaptation. AsFriedman (1974:460) indicates, "[i]t is practicallyapologetic to assume that an institution is adaptivebecause it functions to keep a variable above a cer-tain lower limit when, in fact, by treating that so-ciety as a whole we find that the present organiza-tion establishes an upper limit which, if the societywere reorganized, would itself appear in the lowerrange of adaptiveness" (emphasis in original). Inother words, it is the existing set of social relationswithin and between classes and categories of per-sons in society that ultimately determines the adap-tive function of medical or any other behavior, andthus it is within the context of these relations thatquestions of adaptation must be raised. When raisedseparate from this context, as is commonly the casein explanations of the adaptive function of this orthat institution or customary behavior, ecologicalquestions only serve to mystify social life.

Moreover, because of their self-regulatory, ho-meostatic view of behavior, ecologists tend to in-corporate a passive view of the relationship betweenhuman groups and their environments. This prob-lem stems, in part, from the traditional biologicalconception of adaptation. As Lewontin (1978:215)notes, "[a] . . . difficulty with the specification ofempty niches to which organisms adapt is that itleaves out of account the role of the organism itselfin creating the niche. Organisms do not experienceenvironments passively; they create and define theenvironments in which they live." This is, ofcourse, especially true of humans who are capableof and regularly involved in radically altering theirphysical environment. In Wolf's (1982) apt phrase,humans do not adapt to nature so much as we en-gage it and transform it; that is to say, we adaptnature to fit socially constructed designs. This iswhy, of course, the emergence of culture markssuch a fundamental turning point in human evolu-tion. Culture transformed not only the evolutionarypath of our species but the very character of thespecies/environment relationship (Woolfson 1982).Importantly, this new relationship with nature is notjust a consequence of the powerful technologies as-sociated with industrial society. As Kabo notes inthe following account of Tasmanian foraging soci-ety, environmental transformation through social la-bor has long been a defining feature of the culture/environment relationship.

The Tasmanians' burning of grass was thecause of periodic fires that covered enormous

areas, replacing humid forests with bushes andopen savannas and altering the climate and thecharacter of the soils. Fire freed whole regionsof impenetrable forest (which was a great ad-vantage for the Tasmanian hunters), destroyedthe vegetation cover in significant areas, andincreased erosion. All this indicates that, evenin this early stage of socioeconomic and cul-tural development, people did not just pas-sively adapt to the natural environment but alsoactively influenced it. In pursuit of their owninterest, and often quite consciously, they ef-fected far-reaching changes in it the conse-quences of which could not, of course, be fore-seen. [Kabo 1985:603]In proposing an ecological perspective for medi-cal anthropology, Alland was quite aware of thisproblem.Man changes his environment, often drasti-cally, through the adaptive mechanism of cul-ture, and this changed environment then acts asa selective agent on man's physical structure aswell as his behavior. [Alland 1970:34]

If this be so, it must again be asked just what ad-aptation really means and whether this is the mostuseful terminology for restating what Marx recog-nized long ago in the first volume of Capital,namely thatIn production people oppose themselves to na-ture by acting on the external world and chang-ing it; but at the same time they are dialecti-cally one with nature, for in changing it theychange themselves as well. [O'Laughlin1975:346]As Marx emphasized, involvement with the en-vironment is socially determined. There is, there-fore, tremendous plasticity in human response to agiven set of ecological (or social) circumstances.Consequently, the key questions to be asked are: on

what basis are environmental restructuring deci-sions made? who makes such decisions? and withwhat consequences, intended or unintended? Con-sider an example cited by McElroy and Townsend,the case of sugar plantation workers in Jamaica. Asthey explain (1979:206), these cash-crop workerswere able to maintain an adequate diet becausesome lands considered too wet for sugar cultivation

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230 MEDICAL ANTHROPOLOGY / Volume 10 / Number 4were used for subsistence rice growing by the work-ers. But, "[w]hen the landowners drained the wetlands to increase the area under sugar cultivation,the workers suffered because they no longer wereable to supplement their diet of store-boughtfoods." Analyzing the consequent malnutritionamong workers and their families in terms of mal-adaptation to the local environment would not onlytotally distort the nature of the human/environmentrelationship, but, as with previous examples, dis-guise the determinant role of stratified social rela-tions and the encompassing political economy inshaping local interactions with and manipulation ofthe physical environment.

It also can be seen that, like their brethren inother sectors of the discipline, medical ecologistsuse the term adaptation in a multitude of ways, somany, in fact, that the term is left without a clearcutmeaning. As Smith (1979:55) has remarked, "ad-aptation has become an almost m agical word, a con-cept that is either protean in meaning or else isreally several different concepts traveling under thesame semantic label." The two most common us-ages, as has been noted, make reference to therather different relationships that rise between pop-ulations and their physical and social "environ-ments" (Gordon 1966). But sometimes, the term isemployed to discuss patterns at the individual levelas well. According to Moore et al. (1980:22),"[a]daptive capacity . . . is the capability of thewhole person to adjust to changes in the environ-ment, to cope with internal and external stress, andgenerally to maintain an equilibrium in all internalphysiological and psychological systems." As wesee, here adaptation describes not only the individ-ual's relationship with his external (physical andsocial) environments, but his internal environmentas well. As the following passage from McElroyand Townsend reveals, the concept of adaptationeven is stretched to cover cultural changes designedto meet human psychobiological needs.

Adaptation . . . extends beyond ecological sys-tems. It also involves adjustments and changesthat increase the group's competence and se-curity, maintain the community's physical andemotional health, and protect the individualand defend the ego. [McElroy and Townsend1979:103-104)

Conversely, the concept of adaptation is pressedinto service as a way to characterize a g roup 's (or an

individual's) psychobiological response to culture.Eaton (1977:41), for instance, reports that "dia-betes mellitus may be a disordered physiologicaland psychological adaptation to rapid culturechange." In his discussion of medical systems asadaptive systems, Dunn (1976:143) completes theadaptationist circle by asserting that in addition tobiological needs, such systems are adapted to"human ideas of comfort, ease, satisfaction, andjoy in life; " in short, culture (the medical system) isadapted to culture (culturally defined beliefs aboutquality of life). As this discussion suggests, there isconsiderable confusion in the medical ecology lit-erature concerning "what is adapting to what." Isculture an adaptive mechanism or an environment towhich humans must adapt? Is culture adapted to thenatural environment or to psychobiological needs orto culture itself? Is it the individual or the popula-tion that adapts?

This brings us to the final weakness of adapta-tionism, the problem of social transformation. Be-cause the restructuring of social relationships canhave a radical impact on the health status and healthcare system of a society, understanding the natureand determinants of social transformation should beissues of central concern to medical anthropology.Additionally, this is true because a medical system,as a mechanism of social control, can play a signif-icant role in the maintenance of an existing structureof social relations (Singer 1981) or, conversely,contribute to a thorough-going transformation of so-ciety. Witness the role of Vodun (voodoo) in theHaitian revolution (Metraux 1972) or the activitiesof folk healers in El Salvador who provide much ofthe treatment to the revolutionary forces (SilviaSandoval, personal communication).

In terms of the argument being developed here,three points relating to the adaptationist approach tosocial transformation are relevant. First, the overalldirection of the "ecological transition" (Bennett1976) under the impact of social systems has beentoward deliberately simplified and fragile ecosys-tems based on monocrop cultivation. As Bargatzky(1984:403) asserts, "[i]t is hard to understand how. . . this might be subsumed under the heading of'adaptation of culture to the natural environment'without getting entangled in sheer absurdities."Second, as Friedman (1980:254) points out, the di-rection of social evolution "has been dominated bypower structures whose accumulative tendencies areanything but adaptive." Finally, several writershave questioned the very basis of an adaptationist



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SINGER / Limitations of Medical Ecology 231approach to social transformation. "W ha t, " Fried-man (1979:259) asks, "is an entity that preservesitself by its own self-transformation. Where is the'sel f in all this, if it is not just an empty subjec t?"Whyte (1978:74-75) raises a parallel point, arguingthat when a social system "h as radically altered itsstructure, it becomes a matter of opinion whether itis the same system that has survived through adap-tive response, or has perished through maladapta-tion and been replaced by a new system."

As this discussion reveals, w ithout a rigorousway to differentiate adaptation from maladaptationand survival from nonsurvival, social transforma-tion remains an anomaly for the ecological para-digm. Again, this shortcoming stems from inatten-tion to the alignment of social relations that bothshapes perception of and interaction with the envi-ronment. Social transformations, after all, are con-ditioned by the emergence of new social groups andnew ways in which groups are related to each othervis-a-vis the process of social production.

ConclusionWhile this paper is intended as a critique of medicalecology's inattention to the fundamental importanceof asymmetrical social relationships in determininghuman environmental relations and social dynam-ics, it is certainly not the case that all who subscribeto medical ecology are either ignorant of or uncon-cerned with the issues raised here. Rather, it ap-pears that many medical ecologists will either paylip service to the importance of relational, political-econom ic, and macro-level forces and then m ove onswiftly to a narrowed focus on ecological variables,or they will pay considerable attention to determi-nant social phenomena without seeming to recog-nize that they have moved far beyond, and in facthave violated, basic assumptions of their ecologicalframework.

Moreover, it is not the intention of this paper tosuggest the need for a synthesis of political-economy of health and medical ecology, especiallynot if, as some might interpret such a synthesis,sociopolitical and socioeconomic variables aretacked on as supplementary components to alreadycomplex ecological models in which the environ-ment and adaptation to it are embraced as the mostpowerful concepts. Rather, the objective has beento assert the need for a critical rethinking of thepresuppositions and concepts of medical ecology.

Such a rethinking is difficult for cultural reasons asTaussig explains:Faced with unsatisfactory and indeed politi-cally motivated paradigms of explanation thathave been insinuated into the mental fiber ofmodern capitalist societyits mechanical ma-terialism as well as its alienated forms in reli-gions and nostalgiawhat counterstrategy isavailable for the illumination of reality thatdoes not in some subtle way replicate its rulingideas, its dominant passions, and its enchant-ment of itself. As I see it, this question is bothnecessary and Utopian. It is essential to posethe challenge, but it is Utopian to believe thatwe can imagine our way out of our culturewithout acting on it in practical ways that alterits social infrastructure. [Taussig 1980:7]An approach for confronting this dilemmaonethat will forever remain tentative and incompletewithout the practical social alterations to whichTaussig alludesbegins with the rigorous critiqueof ruling ideas and the active exploration of theirorigins, functions, and distribution in social science

and popular discourse. On this foundation, alterna-tivebut still culturally encumberedconceptionscan be erected and subjected to further critique. Be-cause it is "difficult to socially change what is notsocially seen" (McMurtry 1978:140), this task hasdirect practical implications. First steps in the de-velopment of a critical approach to medical anthro-pology are now being taken by a number of workersin the field.2With reference to the issues addressed in this pa-per, if, as Bargatzky (1984:402) maintains, "socio-cultural institutions are adapted to human physio-logical needs but not to the natural environment,"then a critical rethinking of adaptation might, forexample, suggest that its appropriate measure is thedegree to which social systems meet human needs.While there is, no doubt, considerable room fordebate about the content and variability of humanneeds and a required discussion of who decides and

on what basis what human needs are and how theyare best satisfied, this orientation, at least, directsour attention to the reasons the needs of individualsin particular social categories (e.g., defined byclass, sex, race, etc.) are or are not met. Thereby,perhaps, medical anthropology can avoid perceiv-ing social relations as products of environmentalrelations, when, in fact, the reverse is true. More-



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over, the discipline can avoid the biomedical errorof assuming that health and disease are natural andnot social entities.

NOTES1. This paper is an "offspring" of "Why Not Havea Critical Medical Anthropology?", co-presentedwith Hans Baer at the 1983 annual meeting of theAmerican Anthropological Association. An earlierversion of this paper was presented at the 1985meeting of the Association. In its various drafts,this paper has benefited from discussions with ordirect comments from Lani Davison, Hans Baer,Fuat Yalin, Shiela Cosminsky, and Peter Brown,and encouragement to write it from Robert TrotterII.2 . See especially the Special Issue: Toward a Crit-ical Medical Anthropology of Social Science andMedicine 23(2) 1986 and the special issue: GRAM-SCI, MARXISM, and Phenomenology: essays forthe Development of Critical Medical Anthropologyof Medical Anthropology Quarterly 2(4) 1988. Re-lated concerns are addressed in a forthcoming spe-cial collection in Medical Anthropology entitledSocialist Health/Capitalist Health: Is There a Dif-ference? and in a symposion on critical approachesin medical anthropology and medical sociology inthe November 1986 issue of Medical AnthropologyQuarterly.

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