345
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French cultural ideas and greater experience with infectious disease, especially tuberculosis, lead to a conceptualization of AIDS that is different frmm that encountered In North America
Cross-cultural Medicine A Decade Later The French Are Different French and American Medicine in the Context of AIDS JAMIE FELDMAN, MA, Urbana, Illinois
Medicine has often been approached as a thing apart from culture, as a uniform Western science. Within the past 10 years, we have begun to recognize that medicine is a system of beliefs and practices intrinsically linked to its larger sociocultural context. Still, it is generally perceived as uniform across North America and Western Europe. My recent research on French and American medical perspectives on the acquired immunodeficiency syndrome (AIDS) challenges this view by exploring differences in the structure of health care, the physician-patient relationship, and the conceptualizations of disease, particularly AIDS. These differences are not specific to AIDS, but the disease serves to exemplify them and to act as a medium for expressing what makes French and American medicine distinct. Global epidemics such as AIDS require both international response and cross-cultural understanding. (Feldman J: The French are different-French and American medicine in the context of AIDS, Issue]. West J Med 1992 Sep; 157:345-349)
Biomedicine has been defined as an objective Western science of the chemical and physiologic functions, and malfunctions, of the human body. This is contrasted with "ethnomedicine," the healing systems of other societies, based not in biology but in culture. Within the past ten years, however, this focus has changed. Westerners have begun to recognize biomedicine, too, as a system of beliefs and practices intrinsically linked to its larger sociocultural context and as a legitimate focus of anthropologic research."2 Although it is now well accepted to study differences in the biomedical practices of culturally distinct places such as Japan3'4 or to study the differences between lay and professional health concepts,5'6 medicine is generally perceived as uniform across the Western world, particularly North America and Western Europe. A notable exception is the research compiled by Hahn and Gaines demonstrating the heterogeneity of biomedicine, particularly across medical specialties.' Such direct qualitative research into medical practices is rare in France due to the resistance of physicians toward the involvement of social scientists either in clinics or in medical schools.8 On both sides of the Atlantic, few researchers outside of Payer9 and, more recently, Gaines'0 have explored possible medical differences between Western nations such as France and the United States. This has perpetuated the assumption of uniformity. My recent research on French and American medical perspectives on the acquired immunodeficiency syndrome (AIDS) challenges this view. Epidemics in general, and AIDS in particular, give social scientists an unparalleled opportunity to examine the interaction of institutional practices, social values, and cultural assumptions." -14 Highly publicized medical research and treatment of AIDS took place in the United States and France from the beginning of the epi-
In
Cross-cultural Medicine-A Decade Later [Special
demic, providing an excellent opportunity for examining differences between the two countries. During a portion of 1987 and from fall 1990 to 1991, I was a participant-observer in AIDS clinics in Paris, France, and Chicago, Illinois. As a fourth-year medical student and an anthropologist, I was able to participate fully in the activities of the clinics, including treating patients under supervision. In addition, in both countries I conducted 86 interviews with clinicians and researchers working with patients with AIDS and the human immunodeficiency virus (HIV). I discovered a wide variety of differences in the structure, values, and practices between French and US medical care. Many of these differences are not specific to AIDS. Rather, AIDS serves to exemplify them and to act as a medium for expressing what makes French medicine distinct. If American physicians were to enter a Paris clinic, they, like myself, would initially feel comfortable. All the tools of the trade would be present-thermometers, blood pressure cuffs, and the view box for reading x-ray films. Their French colleagues would be speaking in recognizable terms of pneumonia, blood counts, and brisk reflexes. Little by little, however, a certain unease would develop. Americans would notice that temperatures are taken rectally or under the arm but never orally. Drugs are almost never called by the generic name but by an entirely distinct set of trade names, including a vast number of antibiotics that American physicians never encounter. Powders and suppositories are popular drug forms, and it is the patients, not the physicians, who carry prescription pads. A routine checkup does not usually include a urinalysis. The French physicians rarely inquire about smoking habits or alcohol use. One may well brush off these differences as "local color"-interesting but unimportant in the presence of over-
From the Medical Scholar's Program, Department of Anthropology, University of Illinois, Urbana-Champaign, Urbana. Reprint requests to Jamie Feldman, MA, 2017 Philo Rd #15, Urbana, IL 61801.
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ABBREVIATIONS USED IN TEXT AIDS = acquired immunodeficiency syndrome AZT = zidovudine HIV = human immunodeficiency virus
arching common ideas. It is through these differences in what people do and say that culture is expressed, however. 'I The expression of culture in French medicine can be found in how health care is structured, in the relationship between physicians and patients, and even in conceptualizations of health and disease, as in the case of AIDS. As our hypothetic visiting Americans would discover, nothing can be taken for granted.
Structure of the Health Care System One of the first differences that confronted me in Paris was nationalized health care, where patients are reimbursed by Securite Sociale for 75% to 100% of the costs of care, including medication. On my second day at the clinic, a nurse-administrator asked me, "Is it true that you have people in America going without care because they don't have money?" This question was repeated many times by many people during my stay, accompanied by looks of either indignation or complete bafflement. The fact that everyone isprise en charge, literally "taken in charge," by the French health care system is an expression of social values, a belief in basic health care as a right, and that the state, rather than corporate groups or individual persons, is the appropriate guarantor of this right.'6 This fundamental structural difference immediately affects the interaction between physician and patient. In sharp contrast to everyday practice in the United States, patients in France, except for foreign visitors, are never asked how they are paying for their care, and patients themselves almost never request a different medication because of concern over cost. When I asked a resident at the Paris clinic about differences between the United States and France, she replied: Well, I would say the first point is maybe a social point, because patients here, as soon as they get AZT (the main antiviral drug used in treating That AIDS), they are 100% taken in charge by the Social Security. changes, I think, completely the relationship between the doctors .and the patients.
The role of money changes the fundamental physicianpatient relationship in a critical way. Carroll suggests that French attitudes toward talk of money are similar in character to American responses to talk of sexuality. Americans express repugnance toward public discussions of sexual experiences, whereas those of financial conquests are acceptable. In France, people may openly vaunt their sexual exploits, but bragging about one's wealth is considered to be in "bad taste." '7PPl28l131) By developing a nationalized system of health care, the French are able to remove talk about money, an ambivalent and distasteful topic, from the medical encounter. What on the surface appears a mere difference in health care policy is, on a much deeper level, an essential difference in culture.
Generalists and Specialists Another structural difference, that of the roles of generalist and specialist, is also highlighted by the approach to AIDS. Most clinicians in France are general practitioners, medecins de ville, who do not have hospital privileges. They
have generally little power or prestige in the French medical community."8 Specialists, including those in internal medicine, are employed by hospitals to admit patients and oversee their care and to run outpatient clinics in various specialties. Most patients with HIV infection are referred to these hospital-based specialists. Although some generalists do manage to care for their AIDS patients, they are not allowed to prescribe zidovudine (AZT). In addition, only hospital pharmacies are allowed to fill prescriptions for AZT and other AIDS-related medications. The rules governing the distribution of AZT are set by multihospital committees made up of hospital clinicians and pharmacists. At one such meeting, a physician brought up the idea of expanding AZT-prescribing privileges to generalists. The pharmacists expressed skepticism that generalists would know how to manage the drug appropriately and concern that patients would go from physician to physician and pharmacy to pharmacy, stockpiling prescriptions for AZT. The committee finally agreed that certain generalists who "were known" to the hospital would be allowed to prescribe the drug, but patients could only obtain the medication at that hospital's pharmacy. In this instance, AIDS serves as a vehicle for reshaping the role of the generalist physician in France while maintaining the power and high status of the specialist. It also underlines the power of pharmacists in dictating access to medications and the importance of personal ties-that is, of "being known" in the French medical community. The AIDS epidemic has reconstructed the role of the generalist. There simply are not enough specialists in France to handle the volume of cases, which in turn creates potential for expansion of the generalist role, first in AIDS care and then perhaps in other areas as well. As one general practitioner put it: The town doctors had always been kept apart, the general practitioner had always been someone who has not been well-seen in France. He is someone who is there to prescribe for sore throats, do certificates, but he has not . had a sufficient impact.. AIDS has come to transform somewhat this way of seeing the town doctor.
Boundaries Between Disciplines In French medical practice, strong boundaries exist not only between generalists and specialists but also between specialties. Physicians in the Paris clinic, for example, rarely did funduscopic examinations on patients, a routine part of any physical examination in the United States. When I asked the reason, I was told that funduscopic examinations are the province of ophthalmologists and that few physicians outside that specialty were comfortable doing such an examination. When I explained that this was not the case in the United States, I was informally designated the funduscopic examination specialist for the clinic and was encouraged to help the residents practice this skill. As in so many areas of medicine, this strong differentiation, too, is changing in response to the AIDS epidemic. Given the high incidence of ocular infections in patients with AIDS, such as cytomegaloviral retinitis, the director of the clinic often encouraged his staff to do funduscopic examinations, to go beyond the boundaries of their own specialty, which was usually in infectious disease or general internal medicine. In France, there seems to be less resistance to incorporating knowledge and procedures from internal medicine subspecialties, such as dermatology and oncology. Unlike any
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US clinic I visited, for instance, nononcologist physicians at the Paris clinic supervised chemotherapy for Kaposi's sarcoma. This difference may stem from different conceptualizations of AIDS, discussed later, formed at the beginning of the epidemic.
Physician-Patient Relationships As Americans who have had contact with French medicine invariably describe, the physician-patient relationship is paternalistic, with the physician assuming most ofthe control over decision making. On the surface this description appears to be accurate. The important question, however, is, "What playing out of sociocultural values is involved in the French doctor-patient relationship?" As might be guessed, it goes beyond a simple question of physicians maintaining control over patients. The treatment of patients with AIDS provides an excellent setting in which to analyze this relationship. For example, American physicians almost invariably tell an HIV-positive patient of the diagnosis of full-blown AIDS, whereas French clinicians often choose not to do so. This was especially the case nearer the beginning of the epidemic, when few therapies existed. In 1987 a French informant explained: I never use the word "AIDS." I say, "You don't have AIDS," and that's the only reference I'm using for AIDS. I never say to a person, "You have AIDS." I say, "You have Pneumocystis." I let them do their own connections, I don't give it to them.
Another clinician remarked: Sometimes we may say to a patient, "You are an AIDS patient," OK? Sometimes we cannot because we feel it, I feel it, they know what it means, hear the word, you know, because they want to but they don't want to hear, for example, "Kaposi's sarcoma," they want to hear "toxoplasmosis," "Pneumocystis," you know, but they don't want to know AIDS, OK? The word "AIDS." .
.
.
The value expressed in this discourse is not one of maintaining control, or of saying "I know best," but rather of caring for the patient, of trying to ascertain what the patient may or may not wish to know. Although the issue of power is certainly involved in the control of information, it is not the sole factor. Rather, I would suggest that French physicians and patients both are tending to value the social tie over the imparting of information as the predominant feature of the physician-patient relationship, reinforced by the lack of commercial overtones seen in the American health care system. Although exploring the physician-patient relationship specifically, Carroll notes that French people seek information on any topic differently from Americans, prizing the information gained from trusted people in a face-to-face encounter."7 In fact, French patients often change physicians until they can establish this sense of trust with a provider. 19 In this regard, the physician-patient relationship in France takes on some aspects of friendship. A friend in an emergency such as illness is expected to take burdens off the ill person to the point of temporarily taking charge of the person's life. French physicians, by not fully informing patients of the diagnosis, are perhaps doing as a trusted friend might do.l2(pp7S,76) In the United States, the stereotypic person with AIDS, especially as perceived by physicians, is well informed about the disease and takes an active role in the treatment, often suggesting or refusing specific therapies in accordance with his or her knowledge and desires. The French patient, in contrast, rarely questions the prescribed treatments and vir-
3
3
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347
tually never suggests alternatives. French physicians, unlike their American counterparts, rarely lay out several options for a patient's decision but rather recommend a path of therapy and explain the reasons for that recommendation. In one such observed interaction, a French clinician discovered the rapid spread of a patient's Kaposi's sarcoma. The physician told the patient, "Because they are nodular lesions, you can't treat them locally [with radiation], you must use general [systemic] treatment." The physician then outlined the chemotherapy agents he favored. The patient's questions were procedural-how often must he come in; will he be able to work during this time-rather than questioning the proposed therapy itself. This example serves as an interesting contrast to an encounter between another French clinician and an American patient. When the physician informed the patient that he needed to be admitted to hospital to treat an infection, the American quickly suggested that he could receive the intravenous antibiotic therapy at home. The suggestion was not based on financial considerations, as the patient was covered by the French health care system, but as a therapeutic alternative in keeping with the patient's own desires. This sparked an uncomfortable negotiation between the two, a result of differences not only between the physician's and the patient's explanations of illness but also between French and American expectations of the respective roles of physicians and patients. As with many aspects of medicine, the AIDS epidemic is changing the physician-patient relationship in France. Several French physicians told me that AIDS patients were more active and questioning about their treatment than other patients and that, because of AIDS, they have changed their approach to informing patients about their disease. The central issue, however, remains maintaining a relationship of trust, here underscored by a general practitioner: It's not like in cancer when, especially in France, people used to lie to patients, to say, "It's nothing, it's not a cancer." But with AIDS, I think it's impossible because most people that come here with AIDS have seen AIDS before .. So it's something new, too, because. people are aware. And I think . . it's important not to lie because when you lie to people, they will never accept treatment and so on if they don't trust you. So you have to be very honest.
Differences between French and American medicine are found not only in how medical care is structured or how physicians relate to patients but in how the body and its ills are constituted. These differences are subtle but telling, and the context of AIDS provides us again with a remarkable example.
Conceptualizations of AIDS Earlier I noted that, unlike any of the American physicians, the French clinicians I met administered some types of chemotherapy themselves. This difference appears to be rooted in the history of AIDS in both countries. At the beginning of the epidemic, the vast majority of French clinicians who became involved with patients with AIDS were general internists or infectious disease specialists. Research on AIDS followed this pattern, coming out of hospital-based laboratories or basic biologic research centers such as the Pasteur Institute. In the United States, however, a considerable number of research and clinical investigators began their careers in oncology. Many well-known cancer centers have included AIDS research and treatment in their mission, such as Memorial Sloan-Kettering Cancer Center in New York City and
348
the Dana Farber Cancer Institute in Boston, Massachusetts. These origins have a profound effect on how AIDS is viewed and treated in each country. One American clinician described a "turf battle" over AIDS between infectious disease specialists and oncologists. In his view the infectious disease specialists won but have ended up employing an oncologic model of the disease. Indeed, the attempts to develop a staging system for AIDS, as used in many cancers, have come mainly from the United States. Clinical trial protocols, too, are often structured like cancer treatment trials. Even AZT was first used as a cancer therapy. In both French and American clinics, courses of treatment would be influenced by patients' symptoms, if any, and the number of CD4+ lymphocytes (the cell initially targeted by HIV upon infection). In American clinics, clinicians would distinguish whether or not a patient has had an "AIDSdefining illness" according to the 1987 Centers for Disease Control criteria. In contrast, when epidemiologists asked a Paris clinic for a count of patients with AIDS as defined by the Centers for Disease Control criteria, the staff had to spend several minutes reviewing each patient's chart before deciding whether that patient indeed had AIDS. In France AIDS is consistently addressed as a continuous spectrum of disease rather than in the discrete stages of many American cancer models. Although cancer remains a powerful point of reference for clinicians treating AIDS in France, their models of AIDS retain elements of an infectious disease paradigm. Themes of toxicity and the development of resistance to drugs, both important concepts in treating infectious diseases, are common when French clinicians speak of AIDS, especially in reference to the use of AZT. French physicians prescribe AZT for patients with CD4+ lymphocyte counts of less than 200 x 101 per liter, whereas Americans begin such treatment much earlier, at 500 x 106 per liter. A medical panel convened by the French government to make recommendations about early treatment in HIV infection, commented thus on the results of US studies on AZT: It is advisable to remark that the mean length of follow-up in this study is only one year, that the long-term effects of treatment are unknown, and that the data on in vitro and in vivo resistance to zidovudine are also very fragmentary.20(pS)
Why the French emphasis on the problem of resistance? As cancer is a primary model for AIDS in America, so tuberculosis may be an unspoken model for AIDS in France. Historically the two countries have had extremely divergent experiences with and approaches to this chronic infectious disease that, like cancer, is common in AIDS patients. The American approach is to screen the population for tuberculosis by using skin tests and then to provide prophylaxis with isoniazid to those known to have had exposure. In contrast, the French have long had a high prevalence of tuberculosis12,000 cases annually-and now vaccinate most of their population. In addition, resistance to isoniazid (nearly 5% of cases) and other therapies is not uncommon.2' Thus, the French experience with tuberculosis seems to inform their approach to AIDS, itself a chronic, difficult-totreat infection. Concerned over the development of resistant strains of HIV in the population, the French intervene later in the course of the illness. Another factor besides epidemiologic experience may be driving this difference in the treatment of both diseases-the French concept of terrain. Loosely defined, terrain is the
FRENCH AND AMERICAN MEDICINE AND AIDS
body's overall ability to ward off disease and appears to be conceptually integral to French medicine as a whole. As Payer notes, It makes the French leaders in fields that concentrate on shoring up the terrain, such as immunotherapy for cancer. And it results in a decidedly more casual attitude toward the elimination of dirt and germs than that seen in many other countries.9(P62)
The concept of terrain appears fundamental to French medicine and perhaps fundamental to French conceptualizations of AIDS. For example, during a staff meeting at a French clinic, the director pointed out how some people become sick quickly with HIV infection while others stay healthy a long time, expressing it as a compatibility between each person's immune system and the virus. He concluded, "And there must be an immune response, because it [AIDS] is a slow disease. Otherwise, it would be like in infants, who don't have developed immune systems." Working from the concept of terrain, it would thus be reasonable to emphasize the use of vaccines for both tuberculosis and, experimentally, AIDS, exposing the body to the disease agent and enabling the terrain to defend against subsequent infection. In this model it would make sense to let a relatively healthy terrain do its work as long as possible before damaging both it and the disease agent with relatively toxic drugs-as seen in the French approach to the use of AZT. Finally, immune modulators, such as diethyldithiocarbamate (DTC [Imuthiol]) and interferon, would be considered an important form of therapy, as reflected in their use early in the AIDS epidemic and continuing to a lesser extent today. 22 Thus, French biomedical models and treatment practices regarding AIDS arise out of culturally distinct conceptualizations of how the body works in response to disease.
Conclusion Despite their differences, there is no doubt that French and American medicine share many commonalities, both being fundamentally based on a cellular-biochemical definition of disease. Although their approaches to AIDS vary, they remain for the most part mutually comprehensible, using similar therapies (such as AZT) and extrapolating from overlapping diseases of reference (such as cancer and tuberculosis). Yet, the two systems are dissimilar-in structure, social relations, and physiologic concepts. The context of AIDS not only reveals these differences but is transforming them. Gaines concludes that the two medical systems are not units of a universal empiric system but are distinct, locally influenced symbolic systems, continually being reinterpreted. (Atwood Gaines, PhD, Case-Western Reserve University, written communication, 1987). Western medicine, in turn, is not a single uniform medical system but a multiplicity of related systems, each arising out of its own cultural and historical context. Several important clinical implications emerge from this conclusion. First, clinical practice is also cultural practice, whether in Japan, France, or the United States. Physicians across hospitals or across regions may differ in their practice precisely because they practice in different sociohistorical contexts. Second, AIDS is a global epidemic and as such requires international efforts from a variety of health care systems, including biomedicine. The nature of the disease may be defined differently among physicians from different countries, entailing extra effort on their part to reach common understanding. -Treatment approaches that are both suc-
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cessful and acceptable in one medical system may not be either in another system, as seen with the tuberculosis vaccine. Finally, the American physician-patient relationship, based on the cultural values of empowerment and information sharing, may not operate in other medical systems, resulting in differences in the protocols for clinical trials and in ethical issues such as informed consent. For cross-cultural understanding to occur, however, one must first recognize that difference exists. American and French physicians may speak to one another, but true translation requires not just a dictionary but an anthropologic perspective. REFERENCES 1. Wright P, Treacher A (Eds): The Problem of Medical Knowledge: Examining the Social Construction of Medicine. Edinburgh, Scotland, University of Edinburgh Press, 1982 2. Fleck L: Genesis and Development of a Scientific Fact. Chicago, III, University of Chicago Press, 1979 3. Ohnuki-Tierney E: Illness and Culture in Contemporary Japan: An Anthropological View. Cambridge, Great Britain, Cambridge University Press, 1984 4. Lock M: A nation at risk: Interpretations of school refusal in Japan, In Lock M, Gordon D (Eds): Biomedicine Examined. Dordrecht, The Netherlands, Kluwer Academic Publishers, 1988, pp 377-414 5. Kleinman A: Patients and Healers in the Context of Culture. Berkeley, Calif, University of California Press, 1980 6. Low S: Medical practice in response to a folk illness: The treatment of nervios in Costa Rica, In Lock M, Gordon D (Eds): Biomedicine Examined. Dordrecht, The Netherlands, Kluwer Academic Publishers, 1988, pp 415-438
349 7. Hahn R, Gaines A (Eds): Physicians of Western Medicine: Anthropological Approaches to Theory and Practice. Dordrecht, The Netherlands, D Reidel Publishing, 1985 8. Herzlich C: Sociology of health and illness in France, retrospectively and prospectively. Soc Sci Med 1985; 20:121-122 9. Payer L: Medicine and Culture: Varieties of Treatment in the United States, England, West Germany, and France. New York, NY, Henry Holt, 1988 10. Gaines A: Medical/psychiatric knowledge in France and America: Culture and sickness in history and biology, chap 6, In Gaines A (Ed): Ethnopsychiatry: The Cultural Construction of Professional and Folk Psychiatries. Albany, NY, State University of New York Press, 1992, pp 171-202 11. Rosenberg C: What is an epidemic? AIDS in historical perspective. Daedalus 1989; 118:1-18 12. Herlizch C, Pierret J: Une Maladie Mediatisee: Le SIDA dans Six Quotidiens Francais. Paris, France, CERMES-CNRS/INSERM/EHESS, 1988 13. Fox D, Fee E (Eds): AIDS: The Burdens of History. Berkeley, Calif, University of California Press, 1988 14. Treichler P: AIDS, homophobia and biomedical discourse: An epidemic of signification. Cult Stud 1987; 1:263-305 15. Geertz C: The Interpretation of Cultures. New York, NY, Basic Books, 1973 16. Wilsford D: Doctors and the State: The Politics of Health Care in France and the United States. Durham, SC, Duke University Press, 1991 17. Carroll R: Cultural Misunderstandings: The French-American Experience. Chicago, III, University of Chicago Press, 1988 18. Baszanger I: Professional socialization and social control: From medical students to general practitioners. Soc Sci Med 1985; 20:133-143 19. Escande JP: Les Medecins. Paris, France, Grasset, 1975 20. Recommendations du Groupe d'Experts sur la Prise en Charge et le Traitement Precoce de l'Infection a VIH. Paris, France, Ministry of Health, 1990 21. Le Guide de Poche de Conduite Therapeutique en Pathologie Infectieuse. Paris, France, Association des Professeurs de Pathologie Infectieuse, 1990 22. Grmek M: History of AIDS. Princeton, NJ, Princeton University Press, 1990
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French cultural ideas and greater experience with infectious disease, especially tuberculosis, lead to a conceptualization of AIDS that is different frmm that encountered In North America
Cross-cultural Medicine A Decade Later The French Are Different French and American Medicine in the Context of AIDS JAMIE FELDMAN, MA, Urbana, Illinois
Medicine has often been approached as a thing apart from culture, as a uniform Western science. Within the past 10 years, we have begun to recognize that medicine is a system of beliefs and practices intrinsically linked to its larger sociocultural context. Still, it is generally perceived as uniform across North America and Western Europe. My recent research on French and American medical perspectives on the acquired immunodeficiency syndrome (AIDS) challenges this view by exploring differences in the structure of health care, the physician-patient relationship, and the conceptualizations of disease, particularly AIDS. These differences are not specific to AIDS, but the disease serves to exemplify them and to act as a medium for expressing what makes French and American medicine distinct. Global epidemics such as AIDS require both international response and cross-cultural understanding. (Feldman J: The French are different-French and American medicine in the context of AIDS, Issue]. West J Med 1992 Sep; 157:345-349)
Biomedicine has been defined as an objective Western science of the chemical and physiologic functions, and malfunctions, of the human body. This is contrasted with "ethnomedicine," the healing systems of other societies, based not in biology but in culture. Within the past ten years, however, this focus has changed. Westerners have begun to recognize biomedicine, too, as a system of beliefs and practices intrinsically linked to its larger sociocultural context and as a legitimate focus of anthropologic research."2 Although it is now well accepted to study differences in the biomedical practices of culturally distinct places such as Japan3'4 or to study the differences between lay and professional health concepts,5'6 medicine is generally perceived as uniform across the Western world, particularly North America and Western Europe. A notable exception is the research compiled by Hahn and Gaines demonstrating the heterogeneity of biomedicine, particularly across medical specialties.' Such direct qualitative research into medical practices is rare in France due to the resistance of physicians toward the involvement of social scientists either in clinics or in medical schools.8 On both sides of the Atlantic, few researchers outside of Payer9 and, more recently, Gaines'0 have explored possible medical differences between Western nations such as France and the United States. This has perpetuated the assumption of uniformity. My recent research on French and American medical perspectives on the acquired immunodeficiency syndrome (AIDS) challenges this view. Epidemics in general, and AIDS in particular, give social scientists an unparalleled opportunity to examine the interaction of institutional practices, social values, and cultural assumptions." -14 Highly publicized medical research and treatment of AIDS took place in the United States and France from the beginning of the epi-
In
Cross-cultural Medicine-A Decade Later [Special
demic, providing an excellent opportunity for examining differences between the two countries. During a portion of 1987 and from fall 1990 to 1991, I was a participant-observer in AIDS clinics in Paris, France, and Chicago, Illinois. As a fourth-year medical student and an anthropologist, I was able to participate fully in the activities of the clinics, including treating patients under supervision. In addition, in both countries I conducted 86 interviews with clinicians and researchers working with patients with AIDS and the human immunodeficiency virus (HIV). I discovered a wide variety of differences in the structure, values, and practices between French and US medical care. Many of these differences are not specific to AIDS. Rather, AIDS serves to exemplify them and to act as a medium for expressing what makes French medicine distinct. If American physicians were to enter a Paris clinic, they, like myself, would initially feel comfortable. All the tools of the trade would be present-thermometers, blood pressure cuffs, and the view box for reading x-ray films. Their French colleagues would be speaking in recognizable terms of pneumonia, blood counts, and brisk reflexes. Little by little, however, a certain unease would develop. Americans would notice that temperatures are taken rectally or under the arm but never orally. Drugs are almost never called by the generic name but by an entirely distinct set of trade names, including a vast number of antibiotics that American physicians never encounter. Powders and suppositories are popular drug forms, and it is the patients, not the physicians, who carry prescription pads. A routine checkup does not usually include a urinalysis. The French physicians rarely inquire about smoking habits or alcohol use. One may well brush off these differences as "local color"-interesting but unimportant in the presence of over-
From the Medical Scholar's Program, Department of Anthropology, University of Illinois, Urbana-Champaign, Urbana. Reprint requests to Jamie Feldman, MA, 2017 Philo Rd #15, Urbana, IL 61801.
FRENCH AND AMERICAN MEDICINE AND AIDS
346
ABBREVIATIONS USED IN TEXT AIDS = acquired immunodeficiency syndrome AZT = zidovudine HIV = human immunodeficiency virus
arching common ideas. It is through these differences in what people do and say that culture is expressed, however. 'I The expression of culture in French medicine can be found in how health care is structured, in the relationship between physicians and patients, and even in conceptualizations of health and disease, as in the case of AIDS. As our hypothetic visiting Americans would discover, nothing can be taken for granted.
Structure of the Health Care System One of the first differences that confronted me in Paris was nationalized health care, where patients are reimbursed by Securite Sociale for 75% to 100% of the costs of care, including medication. On my second day at the clinic, a nurse-administrator asked me, "Is it true that you have people in America going without care because they don't have money?" This question was repeated many times by many people during my stay, accompanied by looks of either indignation or complete bafflement. The fact that everyone isprise en charge, literally "taken in charge," by the French health care system is an expression of social values, a belief in basic health care as a right, and that the state, rather than corporate groups or individual persons, is the appropriate guarantor of this right.'6 This fundamental structural difference immediately affects the interaction between physician and patient. In sharp contrast to everyday practice in the United States, patients in France, except for foreign visitors, are never asked how they are paying for their care, and patients themselves almost never request a different medication because of concern over cost. When I asked a resident at the Paris clinic about differences between the United States and France, she replied: Well, I would say the first point is maybe a social point, because patients here, as soon as they get AZT (the main antiviral drug used in treating That AIDS), they are 100% taken in charge by the Social Security. changes, I think, completely the relationship between the doctors .and the patients.
The role of money changes the fundamental physicianpatient relationship in a critical way. Carroll suggests that French attitudes toward talk of money are similar in character to American responses to talk of sexuality. Americans express repugnance toward public discussions of sexual experiences, whereas those of financial conquests are acceptable. In France, people may openly vaunt their sexual exploits, but bragging about one's wealth is considered to be in "bad taste." '7PPl28l131) By developing a nationalized system of health care, the French are able to remove talk about money, an ambivalent and distasteful topic, from the medical encounter. What on the surface appears a mere difference in health care policy is, on a much deeper level, an essential difference in culture.
Generalists and Specialists Another structural difference, that of the roles of generalist and specialist, is also highlighted by the approach to AIDS. Most clinicians in France are general practitioners, medecins de ville, who do not have hospital privileges. They
have generally little power or prestige in the French medical community."8 Specialists, including those in internal medicine, are employed by hospitals to admit patients and oversee their care and to run outpatient clinics in various specialties. Most patients with HIV infection are referred to these hospital-based specialists. Although some generalists do manage to care for their AIDS patients, they are not allowed to prescribe zidovudine (AZT). In addition, only hospital pharmacies are allowed to fill prescriptions for AZT and other AIDS-related medications. The rules governing the distribution of AZT are set by multihospital committees made up of hospital clinicians and pharmacists. At one such meeting, a physician brought up the idea of expanding AZT-prescribing privileges to generalists. The pharmacists expressed skepticism that generalists would know how to manage the drug appropriately and concern that patients would go from physician to physician and pharmacy to pharmacy, stockpiling prescriptions for AZT. The committee finally agreed that certain generalists who "were known" to the hospital would be allowed to prescribe the drug, but patients could only obtain the medication at that hospital's pharmacy. In this instance, AIDS serves as a vehicle for reshaping the role of the generalist physician in France while maintaining the power and high status of the specialist. It also underlines the power of pharmacists in dictating access to medications and the importance of personal ties-that is, of "being known" in the French medical community. The AIDS epidemic has reconstructed the role of the generalist. There simply are not enough specialists in France to handle the volume of cases, which in turn creates potential for expansion of the generalist role, first in AIDS care and then perhaps in other areas as well. As one general practitioner put it: The town doctors had always been kept apart, the general practitioner had always been someone who has not been well-seen in France. He is someone who is there to prescribe for sore throats, do certificates, but he has not . had a sufficient impact.. AIDS has come to transform somewhat this way of seeing the town doctor.
Boundaries Between Disciplines In French medical practice, strong boundaries exist not only between generalists and specialists but also between specialties. Physicians in the Paris clinic, for example, rarely did funduscopic examinations on patients, a routine part of any physical examination in the United States. When I asked the reason, I was told that funduscopic examinations are the province of ophthalmologists and that few physicians outside that specialty were comfortable doing such an examination. When I explained that this was not the case in the United States, I was informally designated the funduscopic examination specialist for the clinic and was encouraged to help the residents practice this skill. As in so many areas of medicine, this strong differentiation, too, is changing in response to the AIDS epidemic. Given the high incidence of ocular infections in patients with AIDS, such as cytomegaloviral retinitis, the director of the clinic often encouraged his staff to do funduscopic examinations, to go beyond the boundaries of their own specialty, which was usually in infectious disease or general internal medicine. In France, there seems to be less resistance to incorporating knowledge and procedures from internal medicine subspecialties, such as dermatology and oncology. Unlike any
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US clinic I visited, for instance, nononcologist physicians at the Paris clinic supervised chemotherapy for Kaposi's sarcoma. This difference may stem from different conceptualizations of AIDS, discussed later, formed at the beginning of the epidemic.
Physician-Patient Relationships As Americans who have had contact with French medicine invariably describe, the physician-patient relationship is paternalistic, with the physician assuming most ofthe control over decision making. On the surface this description appears to be accurate. The important question, however, is, "What playing out of sociocultural values is involved in the French doctor-patient relationship?" As might be guessed, it goes beyond a simple question of physicians maintaining control over patients. The treatment of patients with AIDS provides an excellent setting in which to analyze this relationship. For example, American physicians almost invariably tell an HIV-positive patient of the diagnosis of full-blown AIDS, whereas French clinicians often choose not to do so. This was especially the case nearer the beginning of the epidemic, when few therapies existed. In 1987 a French informant explained: I never use the word "AIDS." I say, "You don't have AIDS," and that's the only reference I'm using for AIDS. I never say to a person, "You have AIDS." I say, "You have Pneumocystis." I let them do their own connections, I don't give it to them.
Another clinician remarked: Sometimes we may say to a patient, "You are an AIDS patient," OK? Sometimes we cannot because we feel it, I feel it, they know what it means, hear the word, you know, because they want to but they don't want to hear, for example, "Kaposi's sarcoma," they want to hear "toxoplasmosis," "Pneumocystis," you know, but they don't want to know AIDS, OK? The word "AIDS." .
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The value expressed in this discourse is not one of maintaining control, or of saying "I know best," but rather of caring for the patient, of trying to ascertain what the patient may or may not wish to know. Although the issue of power is certainly involved in the control of information, it is not the sole factor. Rather, I would suggest that French physicians and patients both are tending to value the social tie over the imparting of information as the predominant feature of the physician-patient relationship, reinforced by the lack of commercial overtones seen in the American health care system. Although exploring the physician-patient relationship specifically, Carroll notes that French people seek information on any topic differently from Americans, prizing the information gained from trusted people in a face-to-face encounter."7 In fact, French patients often change physicians until they can establish this sense of trust with a provider. 19 In this regard, the physician-patient relationship in France takes on some aspects of friendship. A friend in an emergency such as illness is expected to take burdens off the ill person to the point of temporarily taking charge of the person's life. French physicians, by not fully informing patients of the diagnosis, are perhaps doing as a trusted friend might do.l2(pp7S,76) In the United States, the stereotypic person with AIDS, especially as perceived by physicians, is well informed about the disease and takes an active role in the treatment, often suggesting or refusing specific therapies in accordance with his or her knowledge and desires. The French patient, in contrast, rarely questions the prescribed treatments and vir-
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tually never suggests alternatives. French physicians, unlike their American counterparts, rarely lay out several options for a patient's decision but rather recommend a path of therapy and explain the reasons for that recommendation. In one such observed interaction, a French clinician discovered the rapid spread of a patient's Kaposi's sarcoma. The physician told the patient, "Because they are nodular lesions, you can't treat them locally [with radiation], you must use general [systemic] treatment." The physician then outlined the chemotherapy agents he favored. The patient's questions were procedural-how often must he come in; will he be able to work during this time-rather than questioning the proposed therapy itself. This example serves as an interesting contrast to an encounter between another French clinician and an American patient. When the physician informed the patient that he needed to be admitted to hospital to treat an infection, the American quickly suggested that he could receive the intravenous antibiotic therapy at home. The suggestion was not based on financial considerations, as the patient was covered by the French health care system, but as a therapeutic alternative in keeping with the patient's own desires. This sparked an uncomfortable negotiation between the two, a result of differences not only between the physician's and the patient's explanations of illness but also between French and American expectations of the respective roles of physicians and patients. As with many aspects of medicine, the AIDS epidemic is changing the physician-patient relationship in France. Several French physicians told me that AIDS patients were more active and questioning about their treatment than other patients and that, because of AIDS, they have changed their approach to informing patients about their disease. The central issue, however, remains maintaining a relationship of trust, here underscored by a general practitioner: It's not like in cancer when, especially in France, people used to lie to patients, to say, "It's nothing, it's not a cancer." But with AIDS, I think it's impossible because most people that come here with AIDS have seen AIDS before .. So it's something new, too, because. people are aware. And I think . . it's important not to lie because when you lie to people, they will never accept treatment and so on if they don't trust you. So you have to be very honest.
Differences between French and American medicine are found not only in how medical care is structured or how physicians relate to patients but in how the body and its ills are constituted. These differences are subtle but telling, and the context of AIDS provides us again with a remarkable example.
Conceptualizations of AIDS Earlier I noted that, unlike any of the American physicians, the French clinicians I met administered some types of chemotherapy themselves. This difference appears to be rooted in the history of AIDS in both countries. At the beginning of the epidemic, the vast majority of French clinicians who became involved with patients with AIDS were general internists or infectious disease specialists. Research on AIDS followed this pattern, coming out of hospital-based laboratories or basic biologic research centers such as the Pasteur Institute. In the United States, however, a considerable number of research and clinical investigators began their careers in oncology. Many well-known cancer centers have included AIDS research and treatment in their mission, such as Memorial Sloan-Kettering Cancer Center in New York City and
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the Dana Farber Cancer Institute in Boston, Massachusetts. These origins have a profound effect on how AIDS is viewed and treated in each country. One American clinician described a "turf battle" over AIDS between infectious disease specialists and oncologists. In his view the infectious disease specialists won but have ended up employing an oncologic model of the disease. Indeed, the attempts to develop a staging system for AIDS, as used in many cancers, have come mainly from the United States. Clinical trial protocols, too, are often structured like cancer treatment trials. Even AZT was first used as a cancer therapy. In both French and American clinics, courses of treatment would be influenced by patients' symptoms, if any, and the number of CD4+ lymphocytes (the cell initially targeted by HIV upon infection). In American clinics, clinicians would distinguish whether or not a patient has had an "AIDSdefining illness" according to the 1987 Centers for Disease Control criteria. In contrast, when epidemiologists asked a Paris clinic for a count of patients with AIDS as defined by the Centers for Disease Control criteria, the staff had to spend several minutes reviewing each patient's chart before deciding whether that patient indeed had AIDS. In France AIDS is consistently addressed as a continuous spectrum of disease rather than in the discrete stages of many American cancer models. Although cancer remains a powerful point of reference for clinicians treating AIDS in France, their models of AIDS retain elements of an infectious disease paradigm. Themes of toxicity and the development of resistance to drugs, both important concepts in treating infectious diseases, are common when French clinicians speak of AIDS, especially in reference to the use of AZT. French physicians prescribe AZT for patients with CD4+ lymphocyte counts of less than 200 x 101 per liter, whereas Americans begin such treatment much earlier, at 500 x 106 per liter. A medical panel convened by the French government to make recommendations about early treatment in HIV infection, commented thus on the results of US studies on AZT: It is advisable to remark that the mean length of follow-up in this study is only one year, that the long-term effects of treatment are unknown, and that the data on in vitro and in vivo resistance to zidovudine are also very fragmentary.20(pS)
Why the French emphasis on the problem of resistance? As cancer is a primary model for AIDS in America, so tuberculosis may be an unspoken model for AIDS in France. Historically the two countries have had extremely divergent experiences with and approaches to this chronic infectious disease that, like cancer, is common in AIDS patients. The American approach is to screen the population for tuberculosis by using skin tests and then to provide prophylaxis with isoniazid to those known to have had exposure. In contrast, the French have long had a high prevalence of tuberculosis12,000 cases annually-and now vaccinate most of their population. In addition, resistance to isoniazid (nearly 5% of cases) and other therapies is not uncommon.2' Thus, the French experience with tuberculosis seems to inform their approach to AIDS, itself a chronic, difficult-totreat infection. Concerned over the development of resistant strains of HIV in the population, the French intervene later in the course of the illness. Another factor besides epidemiologic experience may be driving this difference in the treatment of both diseases-the French concept of terrain. Loosely defined, terrain is the
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body's overall ability to ward off disease and appears to be conceptually integral to French medicine as a whole. As Payer notes, It makes the French leaders in fields that concentrate on shoring up the terrain, such as immunotherapy for cancer. And it results in a decidedly more casual attitude toward the elimination of dirt and germs than that seen in many other countries.9(P62)
The concept of terrain appears fundamental to French medicine and perhaps fundamental to French conceptualizations of AIDS. For example, during a staff meeting at a French clinic, the director pointed out how some people become sick quickly with HIV infection while others stay healthy a long time, expressing it as a compatibility between each person's immune system and the virus. He concluded, "And there must be an immune response, because it [AIDS] is a slow disease. Otherwise, it would be like in infants, who don't have developed immune systems." Working from the concept of terrain, it would thus be reasonable to emphasize the use of vaccines for both tuberculosis and, experimentally, AIDS, exposing the body to the disease agent and enabling the terrain to defend against subsequent infection. In this model it would make sense to let a relatively healthy terrain do its work as long as possible before damaging both it and the disease agent with relatively toxic drugs-as seen in the French approach to the use of AZT. Finally, immune modulators, such as diethyldithiocarbamate (DTC [Imuthiol]) and interferon, would be considered an important form of therapy, as reflected in their use early in the AIDS epidemic and continuing to a lesser extent today. 22 Thus, French biomedical models and treatment practices regarding AIDS arise out of culturally distinct conceptualizations of how the body works in response to disease.
Conclusion Despite their differences, there is no doubt that French and American medicine share many commonalities, both being fundamentally based on a cellular-biochemical definition of disease. Although their approaches to AIDS vary, they remain for the most part mutually comprehensible, using similar therapies (such as AZT) and extrapolating from overlapping diseases of reference (such as cancer and tuberculosis). Yet, the two systems are dissimilar-in structure, social relations, and physiologic concepts. The context of AIDS not only reveals these differences but is transforming them. Gaines concludes that the two medical systems are not units of a universal empiric system but are distinct, locally influenced symbolic systems, continually being reinterpreted. (Atwood Gaines, PhD, Case-Western Reserve University, written communication, 1987). Western medicine, in turn, is not a single uniform medical system but a multiplicity of related systems, each arising out of its own cultural and historical context. Several important clinical implications emerge from this conclusion. First, clinical practice is also cultural practice, whether in Japan, France, or the United States. Physicians across hospitals or across regions may differ in their practice precisely because they practice in different sociohistorical contexts. Second, AIDS is a global epidemic and as such requires international efforts from a variety of health care systems, including biomedicine. The nature of the disease may be defined differently among physicians from different countries, entailing extra effort on their part to reach common understanding. -Treatment approaches that are both suc-
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cessful and acceptable in one medical system may not be either in another system, as seen with the tuberculosis vaccine. Finally, the American physician-patient relationship, based on the cultural values of empowerment and information sharing, may not operate in other medical systems, resulting in differences in the protocols for clinical trials and in ethical issues such as informed consent. For cross-cultural understanding to occur, however, one must first recognize that difference exists. American and French physicians may speak to one another, but true translation requires not just a dictionary but an anthropologic perspective. REFERENCES 1. Wright P, Treacher A (Eds): The Problem of Medical Knowledge: Examining the Social Construction of Medicine. Edinburgh, Scotland, University of Edinburgh Press, 1982 2. Fleck L: Genesis and Development of a Scientific Fact. Chicago, III, University of Chicago Press, 1979 3. Ohnuki-Tierney E: Illness and Culture in Contemporary Japan: An Anthropological View. Cambridge, Great Britain, Cambridge University Press, 1984 4. Lock M: A nation at risk: Interpretations of school refusal in Japan, In Lock M, Gordon D (Eds): Biomedicine Examined. Dordrecht, The Netherlands, Kluwer Academic Publishers, 1988, pp 377-414 5. Kleinman A: Patients and Healers in the Context of Culture. Berkeley, Calif, University of California Press, 1980 6. Low S: Medical practice in response to a folk illness: The treatment of nervios in Costa Rica, In Lock M, Gordon D (Eds): Biomedicine Examined. Dordrecht, The Netherlands, Kluwer Academic Publishers, 1988, pp 415-438
349 7. Hahn R, Gaines A (Eds): Physicians of Western Medicine: Anthropological Approaches to Theory and Practice. Dordrecht, The Netherlands, D Reidel Publishing, 1985 8. Herzlich C: Sociology of health and illness in France, retrospectively and prospectively. Soc Sci Med 1985; 20:121-122 9. Payer L: Medicine and Culture: Varieties of Treatment in the United States, England, West Germany, and France. New York, NY, Henry Holt, 1988 10. Gaines A: Medical/psychiatric knowledge in France and America: Culture and sickness in history and biology, chap 6, In Gaines A (Ed): Ethnopsychiatry: The Cultural Construction of Professional and Folk Psychiatries. Albany, NY, State University of New York Press, 1992, pp 171-202 11. Rosenberg C: What is an epidemic? AIDS in historical perspective. Daedalus 1989; 118:1-18 12. Herlizch C, Pierret J: Une Maladie Mediatisee: Le SIDA dans Six Quotidiens Francais. Paris, France, CERMES-CNRS/INSERM/EHESS, 1988 13. Fox D, Fee E (Eds): AIDS: The Burdens of History. Berkeley, Calif, University of California Press, 1988 14. Treichler P: AIDS, homophobia and biomedical discourse: An epidemic of signification. Cult Stud 1987; 1:263-305 15. Geertz C: The Interpretation of Cultures. New York, NY, Basic Books, 1973 16. Wilsford D: Doctors and the State: The Politics of Health Care in France and the United States. Durham, SC, Duke University Press, 1991 17. Carroll R: Cultural Misunderstandings: The French-American Experience. Chicago, III, University of Chicago Press, 1988 18. Baszanger I: Professional socialization and social control: From medical students to general practitioners. Soc Sci Med 1985; 20:133-143 19. Escande JP: Les Medecins. Paris, France, Grasset, 1975 20. Recommendations du Groupe d'Experts sur la Prise en Charge et le Traitement Precoce de l'Infection a VIH. Paris, France, Ministry of Health, 1990 21. Le Guide de Poche de Conduite Therapeutique en Pathologie Infectieuse. Paris, France, Association des Professeurs de Pathologie Infectieuse, 1990 22. Grmek M: History of AIDS. Princeton, NJ, Princeton University Press, 1990
