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Medical Encounters: Interdiscourse Communication

in the Context of Biomedical Hegemony

Ashley Thompson

Mount Royal University

ANTH 4452

Advanced Topics in Linguistic Anthropology

April 23, 2014

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The dominant beliefs and assumptions about health, illness, and healing practices, both

physical and emotional, are rooted in the discourse system of Western biomedicine. This

particular medical discourse system is very powerful in today’s highly scientific, technological,

and globalized world and so, this paper will explore this medical discourse system and how

meaning gets constructed in interactions between individuals who take part primarily in

“traditional” or ethnomedical discourse systems and those who participate exclusively in the

discourse system of biomedicine. These explorations will be undertaken using an interdiscourse

approach that examines discourse systems or cultural toolkits. This paper will explore and

analyze the discourse system of biomedicine and the power relations it reflects and produces

through interactions. To gain a deeper understanding of these discourse systems and power

relations, this paper will explore ethnographic data on biomedical and ethnomedical discourses.

Before exploring different medical discourse systems, we should first define them. First

and foremost, a discourse system is basically a cultural toolkit that is constructed and

reinforced by complementary cultural tools and ideologies (Scollon et al. 2011:9). To participate

in a discourse system one must master a variety of tools that are connected to the social

practices and relationships that one wants to participate in and re-affirm (Scollon et al.

2011:136). A widely disseminated discourse system is that of Western biomedicine. As a way of

understanding and dealing with matters of human health and illness, biomedicine is often

considered to be a logical and universal truth (Hahn and Kleinman 1986:306). It is typically

believed to be an objective and value-free system for understanding and treating human

suffering that occupies a realm free of politics, religion, or culture (1989:306). Biomedicine,

however, is one of many meaningful discourse systems for understanding, talking about, and

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experiencing wellness, sickness, and healing. After all, biomedicine, like all medical discourse

systems, is a socially-constructed “artifact of human society” (Hahn and Kleinman 1986:306).

Nevertheless, there are several significant factors related to power and hegemony, both

institutional and symbolic, which distinguish biomedicine from ethnomedical or “traditional

medicine” discourse systems.

Judgements of what constitutes illness, suffering, or wellness vary across and within

cultures or what Keck calls “groups of belonging” (Keck 1993:297). The discourse system of

biomedicine, while one of many, wields significant political and economic power around the

world. Through the mechanisms of neo-liberal capitalism and rapid advancements in

technology, biomedical ways of understanding human health and healing practices have

become privileged and institutionalized around the globe (Hahn and Kleinman 1986:320). As a

discourse system, biomedicine is rooted in contexts involving particular values, assumptions,

and ambiguities which are explicitly and implicitly taught through social interactions and

processes of socialization. These values, assumptions, and ambiguities are then re-enacted and

re-reproduced in institutional settings where there is a distinct social division of labour and

power (Hahn and Kleinman 1986:306). Thus, the discourse system of biomedicine must be

understood as existing within the context of neo-liberal capitalism and power relations.

As one of James Paul Gee’s big “D” Discourses, the Discourse of biomedicine involves

particular ways of saying, doing, and being that construct identities and power relations in

various interactions and contexts (Gee 2010:11). For example, the language of biomedicine

simultaneously communicates a message and constructs and enacts identities and practices in

situated medical interactions. For these interactions to be successful, it is important that

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participants have shared knowledge of the rules and norms for how to say, do, and be in ways

that are recognizable to other people participating in the Discourse of biomedicine (Gee

2010:11–12). Along with particular ways of saying, doing, and being in this discourse system,

there are also particular ways of perceiving, constructing, and treating illness that sets it apart

from ethnomedical or “traditional medicine” discourse systems; ways that often individualize

and internalize human suffering (Keck 1993:295).

In theory and in practice, biomedicine places a strong emphasis on human biology, more

specifically, on physiology and pathophysiology (Hahn and Kleinman 1986:307). This approach

to health and illness thus, commonly conceptualizes illness and suffering as biological problems

that exist “inside” individuals (Garro 2000:308). This conceptualization, however, is grounded in

biomedicine’s reliance on “internalizing systems” which are contingent upon body-based,

physiological explanations and interpretations of health and illness (Garro 2000:308).

Conversely, many ethnomedical discourse systems externalize illness and distress rather than

understanding the problem as something that exists within the sick person’s body. In these

externalizing systems, according to Linda Garro (2000), an illness is not universally perceived to

be something “inside” an individual, but rather, a symptom of disturbed social relations or

other external forces (2000:308). In these systems, the primary concern for healers and

patients is determining what events or agents might have led to the illness (Garro 2000:308).

In the framework of biomedicine, illness and disease are concieved as disruptions and

malfunctions in the human body or brain, as it relies heavily on the Cartesian dualism that

views the brain as separate from the body (Wilce 2009:208). To heal within the biomedical

discourse system then, is to restore a “physiological homeostasis” in the bodies and brains of

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individual patients (Hahn and Kleinman 1986:313). This emphasis on isolating a biological cause

of a particular illness or affliction is embedded in biomedicine’s reductionist approach that

tends to focus on smaller parts and processes within the body. For instance, according to

Robbins (1976), the prevailing view in biomedicine is that “behind every organic illness there

are malfunctioning cells” (Hahn and Kleinman 1986:313). Biomedical assumptions about health

and illness thus immediately establish unequal power relations where the doctor possesses and

conveys specialized and objective knowledge about the patient’s wellbeing and bodily

processes. Recognizing and understanding the power relations between patients and doctors is

crucial to examining and analysing communication across medical discourse systems.

The patient-doctor relationship is one that commonly involves a certain degree of

paternalism as well as an asymmetrical distribution of power and knowledge (Hahn and

Kleinman 1986:316). Power and control in these medical interactions, however, are not

perpetuated through coercion. In fact, they are generally accepted and agreed upon by both

patients and doctors, assuming that both parties are familiar with the acceptable ways of

saying, doing, and being in medical encounters (Lupton 2003:120). For instance, patients allow

for their bodies to be gazed upon, prodded, and measured by doctors and nurses because this

is what people involved in the biomedical discourse system are socialized to expect and enact in

medical encounters. The key to biomedical hegemony lies in its ability to rule by consent and

routinize hierarchal relationships and interactions in clinical settings (Lupton 2003:120).

However, hierarchal relationships and unequal power dynamics are also produced and

maintained through talk itself.

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The talk that takes place between patients and doctors plays a significant role in

creating and maintaining their hierarchal relationship. For example, James Wilce (2009) found

that doctors tended to interrupt patients more often than the reverse (1995:929). Candace

West (1984) also found that doctors interrupted patients more often if they were female or

people of colour (Kuipers 1989:108). Interestingly, West’s research (1984) also found that

patients were more likely to interrupt their doctors if they were female (Kuipers 1989:108).

Interruptions are important, Wilce (1995) argues, because they signify a breakdown of

communicative cooperation through dismissal of the other participants’ topic and imposition of

a new one (1995:929).

The expected and exclusive use of directives by doctors also constructs their

relationships with patients as well as their identities as doctors, as individuals who possess

specialized biomedical knowledge and expertise. Through the normalized process of

questioning a patient, the doctor controls turn-taking as well as the emerging talk (Ainsworth-

Vaughn et al. 2001:454). From the onset, this routine interaction establishes a hierarchal

relationship wherein the patient is not given the same rights to question the doctor (Ainsworth-

Vaughn et al. 462). Furthermore, doctors tend to be the ones to maintain control over the topic

of discussion. One way that they do this is by taking what Joel C. Kuipers (1989) calls an

“optional third turn,” which evaluates the initial information given to the doctor by the patient.

It is clear from these rules for speaking, doing, and being in a biomedical context that both

doctors and patients construct identities and power relations through communicating. While

there are a variety anticipated and socially-recognizable ways of doing, saying, and being in

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biomedical contexts, there are similarly socially-recognizable ways of saying, doing, and being in

ethnomedical discourse systems which primarily externalize illness and distress.

There are many ethnomedical discourse systems that often co-exist with biomedicine.

Many of these discourse systems tend to view illness not as something that exists exclusively

“inside” an individual but rather, something caused external phenomena such as disturbed

social relations and supernatural forces (Garro 2000:308). If ethnomedical discourse systems do

place focus onto individuals, however, it is usually to restore balance in their bodies (Garro

2000:307). Nevertheless, since biomedicine dominates the global public discourse on health,

there continues to be an invisibilization and repudiation of ethnomedical discourse systems.

Linda Garro (2000) emphasises the importance of recognizing that health and illness are

conceptualized differently by different discourse systems and that they are equally valid and

meaningful (2000:308). In her research, Garro (2000) highlights the work of both Foster (1976)

and Young (1976) who focused on “disease etiologies in non-Western medical systems” (Garro

2000:307). Young (1976) offers two primary types of etiologies in ethnomedical or “traditional”

medical discourse systems that are useful for investigating interdiscourse communication:

naturalistic systems and personalistic systems (Garro 2000:307).

Within naturalistic medical systems, illness is explained in systemic and impersonal

terms, with sickness being believed to be caused primarily by natural forces and conditions such

as cold, heat, and dampness and above-all, by a disturbance in the balance of basic bodily

elements (Garro 2000:307). Treatment is thus oriented towards re-establishing balance in the

body. Healers in these discourse systems may advise patients that they can ward off illness by

avoiding certain conditions, situations, or behaviours (Garro 2000:307). This approach of re-

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establishing balance and avoiding external causes of illness is in contrast with Young’s

personalistic system (1976). The personalistic system typically perceives illness to be caused by

the actions of an agent who may be a human, such as a sorcerer or a witch, a non-human, like

a ghost, evil spirit, or ancestor, or a supernatural being such as a deity (Garro 2000:307).

Treating the sick in personalistic systems, then, centers on uncovering what type of agent is

responsible. Therefore, in personalistic systems, what may be called magic, religion, and

medicine often overlap substantially (2000:307).

While Young’s (1976) idea of naturalistic and personalistic ethnomedical systems is

intriguing and useful for this paper, it was formulated nearly 40 years ago. This is significant

because Young did his work during a time that preceded the global dissemination of biomedical

discourses and treatments through neo-liberal capitalism. Today, ethnomedical and biomedical

discourse systems and treatments often intersect and interact with one another within the

framework of biomedical hegemony. An ethnographic study undertaken by Storck et al. (2000)

explores these intersections and interactions through examining traditional Navajo healing

practices and discourses.

In their research, Storck et al. (2000) examine three primary traditional Navajo healing

discourses and rituals. These include Traditional Healing Practices, The Native American Church

or NAC Healing practices, and Christian Healing Practices. Traditional Navajo healing rituals are

often provided by a medicine woman or medicine man who determines the underlying cause of

illness by employing techniques like conversation, hand-trembling, and crystal-gazing (Storck et

al. 2000:576). The healer then refers the individual to a hataali or chanter, to perform

ceremonial chants, dances, prayers, and sand-paintings to address their illness and

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accompanying stress (Storck et al. 2000:576). The healing practices of the Native American

Church, however, are rooted in the spirituality of the Plains people and are centered on a

ceremony that involves the consumption of sacred peyote and participation in night-long

singing and prayer sessions. These spiritual ceremonies are coordinated by a healer referred to

as the Road Man (2000:576). In contrast, Christian healing practices tend to be centered on

communal prayer groups, regular church services, and seasonal revitalization meetings led by

Navajo Pentecostal ministers (Storck et al. 2000:576). These three healing practices and

discourse systems continue to be fundamental parts of Navajo society but are now, more than

ever, regularly coming into contact with the discourse system of biomedicine.

One informant, a highly-respected Navajo woman and grandmother named Eleanor,

discusses her healing preferences with Storck et al. (2000) through a Navajo translator

(2000:579). Eleanor talks about how she and her family are longstanding members of the NAC

but that this particular healing system often overlaps with both the Traditional Navajo and

biomedical systems (Storck et al. 2000:579). While Eleanor states that she has accessed

biomedical services throughout her life and will, along with her family, continue to access clinics

and hospitas if necessary, she affirms that her current medical issues are best dealt with NAC

and Traditional healing practices. A particularly positive healing experience for Eleanor, she

recounts, was a nine-day long ceremony known as a Traditional Shootingway Ceremony that

her healer advised her to participate in (Storck et al. 2000:508).

A Traditional Shootingway Ceremony commonly involves sand-painting, healer-led

singing, and herb-induced sweating and vomiting in order to treat various illnesses and

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ailments. Eleanor expresses to Storck et al. (2000) how her participation in the ceremony

healed her numb feet, knee pain, stomach issues, arthritis, sleep problems, and difficulty

concentrating (2000:580). Her healing began when she became aware of the causes of her

conditions, she adds. For instance, she describes how she learned that her symptoms were

caused by disharmony and distress related to several past events in her life (2000:580). This

cause became known to her during her participation in the Traditional Shootingway Ceremony.

These past events, she recalls, included being put at risk in-utero by being too close to her

father as he conducted a healing ceremony and by eating corn that had been struck by lightning

as well as by consuming a sheep that had been bitten by a venomous snake (Storck et al.

2000:580). Moreover, the Ceremony revealed to Eleanor that she was once “hit by a rainbow”

and that her family had witnessed her being engulfed by the end of that rainbow (2000:580).

Eleanor regards this rainbow experience as being positive but still desires to have it

appropriately addressed in order restore the healing benefits that she believes rainbows can

invoke (Storck et al. 2000:580).

Nevertheless, Eleanor also references the significance of her family’s knowledge of

medicinal herbs which have helped her cope with various conditions including high blood

pressure, arthritis, and diabetes (Storck et al. 2000:580). In fact, as for the cause of diabetes,

Eleanor believes the disease is caused by social and political factors as none of the Navajo

Elders have developed diabetes. Specifically, Eleanor asserts that the disease is caused by

“contract with Anglos” and with “Anglo lifestyle and dietary influences” (Storck et al. 2000:579–

580). Using Young’s (1976) concept of internal and external systems, it may be argued that

Eleanor’s conceptions and experiences with her various conditions rely on the belief that

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sickness has an external cause; something that exists outside of an individual and has

community-wide impacts (Garro 2000:308). Colonialism has negatively impacted the health of

the entire community and Eleanor seems to perceive her illness not as something that impacts

her alone, but rather, an affliction she shares with members of her community. Thus, while

Eleanor experiences these conditions as an individual, her experiences also reflect the larger

collective consequences of colonialism. Therefore, Eleanor’s medical discourse system provides

important insight into how different medical discourse systems influence people’s

understanding of health, illness, and healing in ways that can have a significant impact on

communication in medical interactions.

The medical discourse systems that individuals and communities participate in

significantly influence how they talk about, interpret, and embody health, illness, and healing.

When different medical discourse systems come into contact in the context of biomedical

power and hegemony, there is a risk of miscommunication. Biomedical discourses, therapies,

drugs, and technologies are more widespread than ever and there are few regions of the world,

if any, that have not come into contact with Western biomedicine (Wilce 2009:207). However,

it is important to stress that issues with communication in biomedical settings are not due to

differences in “culture,” but rather, differences in discourse systems. This will be demonstrated

through the exploration of various ethnographic studies conducted in medical settings,

between individuals involved in a variety of medical discourse systems.

In her research in the Lin Mai District of Northeast Thailand, an area primarily populated

by the Isan people, an often marginalized ethnic Lao community, Jen Pylypa (2007) explores the

ethnomedical category of illness identified by village communities as khai mak mai or Fruit

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Fever; a sickness that is believed to be untreatable by biomedicine (2007:349). Its symptoms

have been understood by biomedical doctors as being caused by diseases and conditions

ranging from heart infections, diarrheal disease, and dengue fever, to malaria and cancer.

However, local community members affirm that khai mak mai is characterized by a distinctive

rash that can only be correctly diagnosed by a traditional healer (Pylypa 2007:359). Thus,

traditional healing practices are widely perceived as being respected and authoritative

alternatives to the biomedical system in circumstances that may involve khai mak mai

(2007:352).

The belief that biomedicine is unable to treat khai mak mai, Pylypa (2007) asserts, stems

from the view that the illness is incompatible with certain biomedical substances, particularly

intravenous saline as well as with certain types of fruit (2007:349). Families of individuals who

have died from khai mak mai believe that these incompatible substances were the reason for

their loved ones’ demise (2007:358). These substances are typically referred to by the Isan as

phit substances (Pylya 2007:357). Many of the local people tell Pylypa (2007) that they are

often dismissed by their doctors when they express concerns about phit substances. This

dismissive response by doctors, however, leads to miscommunication and frustration, causing

many people to avoid biomedical advice and treatment entirely. Many of the community

members in Pylypa’s study (2007) attest that communication problems are mainly caused by a

tension between the local knowledge of khai mak mai and biomedical knowledge (2007:358).

Ek, a local informant, describes how some family members of deceased patients were berated

by doctors for delaying medical treatment despite the fact that the family believed the deaths

were primarily caused by the hospital’s inability to correctly manage khai mak mai (Pylypa

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2007:358). It may be suggested then, that the communication problems between patients with

the symptoms of khai mak mai, their families, and biomedical doctors are directly related to

their differing medical discourse systems and forms of knowledge.

Suphap, another informant in Pylyla’s research (2007), discusses her 12-year old son and

their most recent visit to the local hospital. She recalls that when she arrived there with her sick

son, she inquired about intravenous saline, asking the doctor if it was incompatible with her

son’s illness (2007:357). The doctor tried to respond to Suphap’s concerns by telling her that

saline was not “incompatible with anything.” Nevertheless, shortly after her son received the IV

of saline, he died. Suphap attributes his death to the hospitals’ mismanagement of his khai mak

mai (Pylya 2007:358). Duean, another woman who spoke with Pylya (2007), recalls when her

son was taken to the district hospital and given intravenous saline upon gaining confirmation

from a local healer that her son was not sick with khai mak mai. She admits, however, that

when the nurses were not looking she would pinch the IV tube closed to prevent saline from

entering her son’s body (2007:358). Duean also managed slip in medicinal herbs to give her son

while he was in the hospital. Nevertheless, after four days in the hospital, the boy died. While

the doctor attributed the boy’s death to a heart infection, Duean attributed it to the

intravenous saline solution that her son received. She reflects to Pylya (2007), “If I hadn’t taken

my son to the doctor, he wouldn’t have died” (2007:358–359). Clearly, these

miscommunications and misunderstandings are frustrating for patients and biomedical

practitioners alike. Nevertheless, many of the local informants did refer to one nurse in

particular, Mo Kham, who they believe is the only local biomedical worker who understands

khai mak mai and addresses their concerns.

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Mo Kham, while not a participant in her patients’ discourses or explanatory models of

khai mak mai, has been able to address their concerns about phit substances in a way that both

respects and validates them (Pylypa 2007:364). When patients express concerns about

intravenous saline and its safety, Mo Kham responds not by giving a generalized statement but

rather, by explaining under what circumstances intravenous saline may be dangerous, like in

situations where needles and other instruments are not properly sterilized. Mo Kham also

reassures patients by letting them know that with proper care such dangers can be easily

avoided (Pylypa 2007:364–365). Mo Kham also responds to patients’ concerns about

incompatible fruits by providing suggestions about what fruits they should eat, like oranges,

rather than simply saying that “no fruits are harmful” (2007:365).

Mo Khams’ detailed responses and her indirect acknowledgement of shared knowledge

left patients feeling respected and validated (Pylypa 2007:364). Unlike the other biomedical

practitioners encountered by informants, Mo Kham was able to engage with her patients’

medical discourse system and their local understandings of khai mak mai. She was thus able to

communicate effectively with patients while simultaneously respecting their knowledge. Mo

Kham, instead of being an outsider, became a socially-recognizable participant in the patients’

discourse of khai mak mai. Similar to the findings in Pylypa’s (2007) study, Burghart’s (1996)

research also explores how local knowledge and traditional medical discourse systems

interacts with biomedicine by focusing on local, ethnomedical perceptions of water purity and

decontamination in Janakpur, Nepal (Burghart 1996).

Burghart’s study (1996) of water purity in Janakpur, Nepal, focuses on interactions

between Maithili-speaking peasant women and Maithili-speaking biomedical doctors. The

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research primarily focuses on the misinterpretations that arise in interactions where doctors

are instructing women on purifying water for their infants and why these misinterpretations

arise (Burghart 1996:65). These medical encounters are significant because many people in the

Janakpur region of Nepal, particularly socially-marginalized individuals like peasant women,

have their own ideas and beliefs about water purity that often differ greatly from those of

biomedicine (1996:65). The intrigue, then, lies in exploring how these medically-situated

misunderstandings can occur in contexts where both participants speak the same language, live

in the same region, and believe that they are being clear and easily understood. A culturalist

approach thus cannot and should not be employed when investigating these misinterpretations

as they arise not through “cultural differences” but rather, through differences in medical

discourse systems and forms of knowledge.

In Janakpur, water is widely believed to be something that is naturally pure or suddh,

and so, there is often difficulty in linguistically expressing and interpreting the notion that water

can be made pure (Burghart 1996:65). Water is also considered to be naturally suddh because it

is one of the five fundamental elements of the universe (1996:65). Indeed, the term “pure

water” is ambiguous in both English and Maithili as there are a variety of water “types,” such as

distilled, sterilized, natural, and so forth (1996:65). It is also believed that water is pure if it is

obtained from its original source and that water gathered from hand pumps, which travels

through iron pipes driven into the Earth, is always pure (Burghart 1996:66). However, this water

is not interpreted as “pure” as in sterilized and free of bacteria but as something that is “light”

and easy to digest (Burghart 1996:66). These local understandings of water purity are

significant because hospital doctors and nurses in Janakpur regularly instruct peasant women to

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boil their water and continue boiling it for 15 minutes before preparing formula and many of

these women, if they boil the water at all, tend not to follow these instructions but believe that

they are (Burghart 1996:63).

Through undertaking a large-scale survey of Maithili women given medical instructions

on how to “correctly” boil water, Burghart (1996) and his researchers were able to gain more

insight into the miscommunication between patients and biomedical practitioners. One woman

in particular insisted that she fully understood the boiling instructions and boiled her water for

“some time,” but yet, contradicted the advice when she returned home from the hospital and

allowed the researchers to observe her water boiling method (Burghart 1996:66). In her

kitchen, the woman brought her fresh hand-pump water to a boil and then swiftly removed it

from the stove to cool off (1996:67). The researchers were surprised by the woman’s actions as

well as by the fact that she did not appear to notice their reaction or believe that she had

contradicted the advice in any way (1996:67). While it is possible that this misunderstanding

was due to semantic confusion, as the instruction “to boil” could be interpreted as the entire

action of bringing water to boil, which takes around 15 minutes, but it is unlikely (Burghart

1996:66). The question remains then, how is it that this woman and many others in the study

continued to go against their doctors’ advice but believed that they were following it?

In order to understand the misinterpretations in these medical interactions, there must

be an examination of all that is “beyond” speech, such as discourse systems and forms of

knowledge. It is clear that the patients and doctors in these medical encounters studied by

Burghart (1996) unconsciously appeal to their own discourse systems and forms of knowledge

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and in doing so, misunderstand each other (Scollon et al. 2011:6). In the previous example

involving a Maithili-speaking woman and her Maithili-speaking doctor, the doctor unconsciously

appealed to their biomedical discourse system and its many routinized practices in order to

enact their powerful identity as well as provide the patient with specific instructions for boiling

water. Correspondingly, the woman appealed to her discourse system regarding water purity

and the routinized practices for preparing liquids to give to infants. For example, the

researchers found that the woman’s method of boiling water was identical to her and many of

the other women’s method of scalding animal milk (Burghart 1996:67).

This milk scalding practice is rooted in traditional knowledge and discourses and is

utilized to temporarily destroy the taints that cause milk to sour (Burghart 1996:67). Thus, the

local women’s methods for boiling water make sense to them because their interpretations of

the doctor’s advice are based on their knowledge of milk scalding, not on biomedical

knowledge about purifying water which they believe is already suddh (Burghart 1996:67).

However, just as the peasant women are not fully aware of how they misinterpreted the

doctor’s advice; the doctors are equally unaware of why they advised their patients to boil

water for a lengthy 15 minutes (Burghart 1996:71).

The doctors involved in Burghart’s (1996) study all affirm that their instructions to boil

water for 15 minutes were appropriate. The research team, however, discovered that the

doctors insisted on the 15 minute duration based on their own biomedical discourse system

(Burghart 1996:71). The doctors gave their patients these particular instructions not because

they are necessarily factual but because they are the official institutionalized instructions for

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sterilizing medical syringes and other instruments within biomedicine. While the

decontamination of drinking water does require boiling, it is does not require boiling for a

duration of 15 minutes. Thus, the doctors applied their biomedical knowledge of proper

sterilization methods for medical instruments when giving instructions to local women on

purifying water The doctors were, in fact, unaware that they advised one thing while doing

another (Burghart 1996:71). That is, while the doctors were advising women on the proper

methods for purifying water they were actually outlining the procedures for sterilizing medical

equipment. Similarly, the women in the study believed that they understood the doctors’

procedures for boiling water because they already understood the procedures for scalding

animal milk and “lightening” water to aid digestion (Burghart 1996:70). The women made

meaning of the biomedical instructions by appealing to their cultural toolkits or discourse

systems; like the doctors, they believed they were doing one thing but were actually doing

another. Burghart’s study in Nepal, therefore, clearly demonstrates the need for taking an

interdiscourse approach when examining miscommunication between people, particularly

miscommunication that takes place within institutionalized settings that are embedded in

power relations. Moreover, Burghart’s study (1996) highlights how an interdiscourse approach

provides a greater depth of analysis than those which rely on notions of “cultural differences”

being the main obstacles to successful communication.

Most people are not aware of how they draw inferences or make meaning in a

multitude of situated interactions that often involve a variety of people. As social beings with

our own discourse systems and multiple social identities, we tend to rely on assumptions

formulated from past interactions we have had with various people in various contexts (Gee

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2010:42). We have expectations of how communication will commence based on past

interactions and this is particularly true in biomedical encounters where there is a distinct

hierarchal relationship and a series of expected speech acts and practices. While the “language

of biomedicine” may be difficult for even those participating in the biomedical discourse system

to understand, the likelihood of miscommunication is even higher when the patient and doctor

primarily access different cultural toolkits or discourse systems regarding health, illness, and

healing. While proponents of culturalism maintain that these communication issues are due

primarily to “cultural differences,” they are, in fact, caused by differences in discourse systems.

As demonstrated in Burghart’s study (1996), patients and doctors may share a common

location, group of belonging, or language but may not participate in the same medical discourse

systems. It is difficult and problematic, then, to argue that “cultural differences” are to blame

for communication problems in biomedical settings as there is significant diversity within

cultural groups of belonging. An interdiscourse approach to communication in biomedical

settings is also useful for revealing the power relations which are constructed and re-affirmed

in these situated interactions as well as for exploring how such interactions reinforce and

reproduce the hegemonic authority of biomedicine.

Overall, this paper attempted to the explore and analyze the biomedical discourse

system, how miscommunication can take place in situated medical interactions between people

participating in the biomedical discourse system and those primarily involved in “traditional” or

ethnomedical discourse systems. While not seeking to undermine the many advantages and

positive aspects of biomedicine, this paper sought to provide a glimpse into its power as a

discourse system and how it interacts with a variety of other medical discourse systems that are

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often invisibilized and devalued. As mentioned previously, it is not cultural difference that leads

to miscommunication between participants but rather, differences in cultural toolkits or

discourse systems. These different tool-kits, when making contact, can both exemplify and

produce contrasting meanings and interpretations which may lead to communication problems.

The issues stem not from a person’s language, groups of belonging or cultures, their country of

origin or their ethnicity but rather, their discourse systems – the cultural tools for saying, doing,

and being in a variety of contexts. Approaching medical interactions from an interdiscourse

perspective allows for biomedical doctors and institutions to provide better care and

communicate more effectively with patients who may or may not participate in the discourse

system of biomedicine.

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References Cited

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2001 “The Discourse of Medical Encounters.” In the Handbook of Discourse Analysis.

Deborah Schiffrin, Deborah Tannen, and Heidi E. Hamilton, eds. Pp. 453–469.

Oxford:Blackwell.

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