تصویر اسلام و مسلمانان در مدلاین : تجزیه و تحلیل محتوا

The growing number and diversity of Muslims in the United States and Western Europe challenge clinicians and researchers to understand this population's perspectives and experiences regarding health and biomedicine. For information about Muslim patient populations, clinicians and researchers routinely consult medical literature. To examine how this literature portrays Muslims, we conducted an ethnographic content analysis of 2342 OVID MEDLINE-indexed abstracts from 1966 through August 2005, derived from a Boolean search for “islam or muslim or muslims.” Manifest (explicitly stated) themes included Muslim religious practices, Islamic law and ethics, history of Islamic medicine, public health, social medicine, and cultural competence. Latent (underlying) themes implied that being an observant Muslim poses health risks; Muslims are negatively affected by tradition, and should adopt modernity; and that “Islam” is a problem for biomedical healthcare delivery. A countervailing latent theme implies that being Muslim may promote good health. We discuss ambiguities in uses of the term “Muslim;” implications of Muslim practices for health management and healthcare delivery; and ways in which MEDLINE-indexed literature intersects with orientalist and colonialist discourse about religious Others. Such intersections highlight connections with potential structural inequalities in healthcare delivery to Muslim patients.

Popular media and political rhetoric devote growing attention to Muslims and Islam, while Muslim populations in the US and Western Europe continue to rise. The hostility and suspicion facing Muslims following September 11, 2001, and Western military interventions in Muslim-majority countries, challenge clinicians, researchers, and policymakers to better understand diverse Muslim perspectives, experiences, and ways of practicing Islam relative to health and biomedicine. Researchers seeking such information regularly consult medical literature. Yet this literature is not produced in a vacuum. Media reports, political rhetoric, and legislative action regularly promote negative stereotypes that characterize Muslims as an out-group (Runnymede Trust et al., 2004). Such portraits both reflect and filter into Western policy interests in the Middle East (Gerges, 2003; McAlister, 2005) and affect Muslims in Western societies (Shaheen, 2003). US polls indicate that from one-quarter (Council on American-Islamic Relations (2004) and Council on American-Islamic Relations (2006a)) to one-half (Dean & Fears, 2006) of Americans hold negative views of Islam and Muslims. Islamophobia and anti-Muslim hate crimes have increased significantly in the US (Council on American-Islamic Relations, 2006b) and in Europe (Allen & Nielsen, 2002; Runnymede Trust et al., 2004). Islamophobic discourse portrays Islam as monolithic and threatening, Muslims as using their religion to gain advantages, and Muslim cultures as significantly different from other cultures. Anti-immigrant attitudes frequently accompany such messages (Commission on British Muslims and Islamophobia, 1997), building on a history of orientalist representations of Muslim societies as deficient or deviant versions of a modern, rational, Europe (Said, 1978). Medical literature includes studies involving “Islam,” a religious tradition, and “Muslims,” the people who follow this tradition. We hypothesized that a systematic content analysis of MEDLINE-indexed abstracts might illuminate meanings assigned to both terms in health-related contexts and in scientific writing. To that end, we examined such abstracts from over a 40-year period, looking for recurring themes or “frames.” We asked, which themes are manifest (explicit), and which, latent (underlying, and perhaps unintended)? We wondered whether trends in Western media and popular culture about Muslims might enter biomedical discourse. If so, how, and what might be their implications for healthcare settings? Medical anthropologists argue that the “biomedical gaze” (Foucault, 1973; Lock & Gordon, 1988) pathologizes and Otherizes its objects. Yet does this tendency adequately explain possible negative representations of Muslims and Islam? One study of “Chinese people” in North American social work literature, for instance, suggests that professional service providers often replicate cultural biases that “otherize” and “essentialize” ethnic minorities (Tsang, 2001). When biomedical pathologizing tendencies intersect with discourses about marginalized minorities, they can reproduce cultural prejudices and reinforce disparities in health outcomes and healthcare access. We propose, therefore, not to demonstrate that Muslims are treated uniquely in medical literature, but to explicate how representations of Muslims and Islam in medical literature may intersect with broader cultural discourses within which readers of these texts are situated.

The role of religion and spirituality (Barnes, 2003; Sloan, 2005) in clinical settings is a subject of current debate. In biomedical literature, “religion” and “spirituality” often appear as generic input or outcome variables, “soft factors” among others, with little attention to the socio-economic and political contexts within which patients interact, and/or to how community and individual practices vary both temporally (within history and a lifetime) and geographically. The lack of nuanced portraits of Muslim lives in medical literature is the first issue. While growing numbers of Muslim clinicians and researchers work to correct misperceptions about their coreligionists, and to offer guidelines for care, publication and indexing structures may undercut significant change in accurately representing Islam and Muslims. A recent study of MEDLINE-indexed articles on death, dying and ethics in Judaism, Christianity, and Islam concluded that “although MEDLINE is an excellent source of the more objective reality of science … MEDLINE is an incomplete source of information for the complex interplay of death, dying and religion” (italics in original). The authors fault the narrow clinical focus, the lack of social and theological contexts, and the selection bias in favor of US-based authors and journals for serious under-representation, superficiality, and inaccuracy of information on religious perspectives (del Pozo & Fins, 2005). A similar analysis of Islamic biomedical ethics literature indexed in MEDLINE finds that the “expert voices” (often Muslim physicians) represent little of the actual process of Muslim legal–ethical decision-making, and tend to make over-generalized statements about what “Muslims believe” or “Islamic Law says” (Shanawani & Khalil, 2005). One cannot expect medical literature to provide deeply nuanced representations of religious beliefs, rituals, values, and concerns. One can expect, however, that the broad portrait of indexed abstracts, taken together, might better reflect intra- and inter-religious variation. The second issue is that the aggregate portrait available is skewed, through publication and research bias, toward representing the negative impact of Islam on health. Medical literature, by its nature, frames issues within a disease model, such that they can potentially be addressed by medical interventions. To legitimize health researchers attending to them, social problems are medicalized as social deficits or deficiencies. While much fruitful work has resulted from the careful articulation of problems and solutions, a deficiency discourse risks perpetuating unexamined biases. As social–psychological research into racial/ethnic health disparities demonstrates (van Ryn, 2002), the unexamined social cognition of physicians affects communication and practice in clinical settings. The portrayal of groups who live in or who emigrate from non-Western countries as poor, rural, uneducated, and refugees (from their own problems) desiring the freedom and prosperity of the West is a classic trope of colonialist discourse. Our analysis of MEDLINE coverage of Muslims suggests that poor, rural, and refugee populations for the most part “represent” Islam to the reader. When such bias merges with cultural scripts drawn from orientalist/colonialist discourse about “Others” (particularly less powerful Others), it portrays Muslims as endangering their health, creating unhealthy environments for women, clinging to tradition, and as posing anomalous problems for the biomedical system. Xenophobic political discourse in the popular press surrounding immigration and asylum policy fosters an environment in which “Muslim” becomes synonymous with demonized and threatening “asylum seekers,” “immigrants,” and unassimilated Others (Runnymede Trust et al., 2004). Does this discourse reproduce structural inequalities in healthcare for Muslims, particularly Muslim minorities? Initial evidence from the US and UK suggests that it does (Laird, Amer, Barnett, & Barnes, 2007; Weller, Feldman, & Purdam, 2001), and this issue demands further research. The solutions to these problems involve both critical reading and critical research across disciplines. The MEDLINE index could expand to include more material from the social sciences and humanities. Alternatively, clinicians could be trained to use multiple disciplinary databases in their search for insight into cultural and religious dimensions of their patients’ lives. In either case, however, health professionals must read available literature with a critical eye to uncover potential biases vis-à-vis out-groups in our societies. The present study has employed ethnographic content analysis to examine the intersections of biomedical and popular discourse about Islam and Muslims in medical research literature. The sub-analysis of field-related discourses has allowed more nuanced discussion. Ranked classification has enabled us to notice multiple approaches and to address overlaps between themes and styles. Both the content and analytical method in this study should enable researchers to rethink how they examine the influence of Muslim identity on healthcare knowledge, attitudes, and practices, and relationships between clinician perceptions of and care for Muslim patients. Health science researchers must exercise greater critical rigor in the portrayal of the relationships between religion and health. Critical research requires us to portray our subjects with accuracy and balance, to check for bias, allow for nuance, and avoid broad generalizations about whole religious traditions. When we use the term “Islam” or “Muslim” to describe subjects, we need to specify the meanings of these terms in the contexts within which we work. Growing awareness of how transnational population movements are transforming European and American societies increasingly emerges in the medical literature. In Public health abstracts, an older argument that immigrants should simply acculturate to host cultures now shares space with calls for providers to adapt health promotion literature, sites, and office procedures to accommodate other practices and cultural values. Some health professionals are increasingly willing to collaborate with the value orientations of Muslim religious authorities or individuals. The restrictions and prohibitions of Islamic law and ethics, for example, interest some epidemiologists as protective factors and some policy makers who are designing public health education programs. Of course, such cooperation can also be functionally utilitarian, using subordinate discourses to bypass “traditional” perspectives and “introduce” “modern” techniques and structures of healthcare delivery. Cultural competence literature, while often well intentioned, may likewise co-opt religious language and values as a “negotiating tool” to ensure that provider instructions will be “understood” (i.e., obeyed). Further research into the variability of reception and design of organ transplantation, family planning, or HIV prevention programs in predominantly Muslim countries could help to broaden and granulate this picture. It is unclear whether we would find portrayals of adherents to other traditions in MEDLINE-indexed literature analogous to the portrayal of Muslims. The reproductive and other health practices of minority religious groups, such as Catholics, Mormons, Jehovah's Witnesses, Christian Scientists, and Jews, have received medical attention for their resistance to certain standard public health advisories and medical procedures. Notably, each of these groups has also been the target of broader social prejudice and discrimination in Western societies at particular historical moments. Even so, contemporary mainstream (Western) media portrayals of these religious traditions differ from images of Islam and Muslims. It is the intersection and overlap between these two circles of discourse that magnifies their potential health effects. Future studies should also analyze comparatively the portrayal of other religious traditions and their adherents, with particular attention to issues of internal diversity, political and social contexts, and the reproduction of cultural scripts of superiority and inferiority. The portraits of groups and religious traditions one finds in medical literature actively appropriate from and contribute to the processes of cultural exchange outside the clinical encounter. These portraits, in turn, shape that encounter in ways that matter for health and healthcare.