The locus of care: families, communities, institutions and the provision of welfare since antiquity

seventeenth-century introduction of Jesuit's bark as "mere" placebos, Shapiro does attempt to provide some historical context for modem concerns. He considers therapy from ancient times to the present and he recounts the history of blind trials in detail. Interestingly, he is not entirely dismissive of religious cures, precisely because he is aware of the potential strength of the placebo effect. By contrast, the essayists have a view that extends no further into the past than a few classic research papers and that does not cross cultures, except in the case of David B Morris's proposal of a biocultural model of pain and belief. Despite its limitations, this may be the essay that is most thought-provoking for practitioners of the social studies of medicine. A terminological problem that will need to be resolved is the confusion between "placebos", inert substances sometimes prescribed for a variety of reasons, and "the placebo effect", which is present to some extent in all healing practices everywhere. Several authors, including Shapiro, express a hope that placebos will disappear from medical practice or describe some drugs as "non-placebos", although it is clear that non-specific healing is an indispensable part of therapeutic efficacy. Unfortunately, simply referring to a lack of specificity appears not to cover the case either, since the effects of placebo drugs are often very specific indeed, as Irving Kirsch points out. As far as historians are concerned, it is the placebo effect in general that is more significant. Howard Brody insists, quoting a classic paper of 1938, that it is necessary to examine "the doctor as therapeutic agent". Although neither of these books devotes much space to the issue, this places a new emphasis on the centrality of the rhetorical engagement between healer and patient. Trust, meaning, desire, and expectation are clearly crucial elements in successful healing. Cultural differences, changing explanations, and the symbolic reconfigurations involved in ritual healing can all have material effects. As a handful of medical anthropologists have long argued, modem medicine has more in common with healing in other cultures than is generally acknowledged, so that a serious consideration of the placebo effect obliges historians, sociologists and anthropologists of medicine to rethink many of their accustomed positions. I liked this book. It attempts to expose the variety of settings in which care has been provided, inside and outside the family, and to challenge orthodoxies on the relative merits of various forms …