Chapter 8 Outline

Introduction

• In 2014, the media declared an American outbreak of Ebola, a virus with a 50% mortality rate. Thousands of people had already died of Ebola in West Africa.
• There were a variety of cases and responses to the presence of Ebola in the United States, all of which fueled the panic displayed across the media.
• The first person diagnosed with Ebola, Thomas Eric Duncan, was treated by two nurses at a Dallas hospital. One of those nurses had flown to Ohio and back before being diagnosed with the disease herself, sending the public into panic that the disease might be travelling via domestic air travel.
• A volunteer health worker, Dr. Craig Spencer, contracted the disease in Guinea and returned to his home in New York City before being diagnosed. Driven by media pressure, the three governors in the tristate area around New York implemented mandatory quarantine orders for anyone arriving from West Africa with a fever.
• A volunteer nurse, Kaci Hickox, returned from West Africa to the Newark airport with a slightly elevated temperature. New Jersey governor Chris Christie insisted that she be quarantined for three weeks in a makeshift facility, a tent in the parking lot of the airport. She was released only a few days later when she showed no symptoms.
• The Ebola outbreak was devastating in West Africa, compounded by extreme poverty, war, broken public healthcare systems, dangerous burial practices, and inadequate understanding of how the virus could be spread. But it was never a serious risk in America, where there are fewer of these aggravating factors.

Understanding the American reaction to the virus is not a biomedical problem; it is a cultural one. Accordingly, this chapter focuses on the question, How does culture influence our experience of health and illness? To address this focal question, the chapter is organized around the following problems:

• How do biological and cultural factors shape our bodily experiences?
• What do we mean by health and illness?
• How and why do doctors and other health practitioners gain social authority?
• How does healing happen?
• How can anthropology help us address global health problems?

• Anthropologists apply their knowledge of culture, biology, and disease to address real-world health crises.

How do Biological and Cultural Factors Shape Our Bodily Experiences?

• Since the 1920s, anthropologists have struggled with questions about the relationship between human biology and culture.
• 19^th century anthropologists including Edward Burnett Tylor and Lewis Henry Morgan thought that biology explained why indigenous people in Africa, Australia, and the Americas had more modest tools and technologies than those of Europeans and white Americans—they were simply less developed.
• The idea that biology determines who we are waned in the decades after 920, but has seen a resurgence in the age of genetic and DNA research.
• Anthropologists are skeptical of grand claims about biological destiny and see this logic as a cultural idiom specific to our society.
• We are biocultural beings in which biological, psychological, and cultural processes interact in complex ways.
• The human mind, the emergent qualities of consciousness and intellect that manifest themselves through thought, emotion, perception, will, and imagination, is one place where biology and culture merge. Cognitive processes do not happen separately from our bodies. So human biology sets limits that all humans share, but culture shapes cognitive processes for each individual.
• Cultural differenced affect perception and mental development and social pressures, such as rapid political-economic change, can have physical and bodily consequences.
• The mind is not a fixed thing and it manifests itself through the whole person, throughout a person’s lifetime.
• Through studies of people with psychological problems across the globe, it has become clear that psychological dynamics observed in Western countries are not universal.
• Culture affects how humans think about their psychology and display mental disorders. Therefore, we have to approach mental illness is a culturally relative way.
• A culture-bound syndrome is a mental illness unique to a culture. For example, koro is a condition unique to Chinese and Southeast Asian cultures in which an individual believes his external genitalia—or, in a female, nipples—are shrinking and even disappearing.
• Societies also change what they consider a disorder, as in the case of homosexuality in the United States, which was seen as abnormal until very recent history.
• Just as experiences of mental illness diverge cross-culturally, treatments differ as well. For example, in Bali, the village healer or “balian” treats people with madness or “buduh” by resolving the social disruption or family conflict that is seen to have caused the illness.
• Globalization has spread Western psychological terms, notions, and illnesses across the world via global flows of Western media, psychiatric practices, and the expansion of pharmaceutical companies. These influences have destabilized indigenous ways of understanding and treating mental illness.
• The most basic matters of human cognition and psychology are not simply the function of our biological hardwiring, they are a complex interplay between biological, psychological, and cultural factors.

What Do We Mean by Health and Illness?

• We all have a subjective sense of what “health” and “illness” mean. Health is “soundness of body and mind” or as “freedom from disease.” Illness is being “unhealthy,” or having a “disease,” “malady,” or “sickness.” But how optimally functioning does a person have to be to consider himself or herself healthy rather than ill? Are everyday aches and pains illness? Or can one remain “healthy” despite these things?
• It helps to employ the relativistic concept of sick role: the culturally defined agreement between patients and family members to acknowledge that the patient is legitimately sick.
• Medical anthropology is the subfield of anthropology that tries to understand how social, cultural, biological, and linguistic factors shape the health of human beings.
• While doctors focus on treating sickness and disease and public health officials focus on preventing outbreaks, medical anthropologists look at cultural constructions of illness, prevention, and treatment.
• The individual acknowledgment of illness is both subjective and incredibly variable. People without adequate health care in the United States literally “can’t afford” to be sick. Earl Koos’s 1940s study of American illness demonstrated this.
• One respondent wanted a very specific definition of “sick.” She described sometimes feeling so bad that she could “curl up and die” but was not “sick” because her family lacked money to visit a doctor and the kids needed care, concluding “most of us can’t be sick—even when we need to be.”
• By almost any objective measure, someone who could “curl up and die” is ill. But this objective measure doesn’t necessarily translate into a personal perception of illness. Social expectations related to illness vary with class, gender, age, employment, and lifestyle.
• People in poverty usually work more physically demanding jobs, eat less healthy food, and are less likely to seek medical care.
• Environment and cultural expectations affect the perception of illness.
• For example, in parts of Mali, infection rates of schistosomiasis, a liver and bladder infection caused by a parasitic worm that lives in water, are so high that it is not locally recognized as “illness.” Blood in the urine is a symptom experienced so frequently by adolescent males that they associate it with the transition to adulthood, not parasites.
• Most Americans would run, not walk, to a doctor if they saw blood in their urine. The key point here is that people rarely worry about symptoms that are common in their community.
• At the beginning of the Ebola outbreak in West Africa, it took weeks for people to understand what was happening and how dangerous it was because they had never dealth with an epidemic before.
• In the United States, we also had never dealt with an Ebola outbreak, but the media and popular representations of virus-driven apocalypses shaped our responses to the virus, which were very different than those seen in West Africa.
• When we explore cultural expressions of the “sick role,” it’s clear that different societies have different expectations of the sick person and people who interact with that person. Our “natural” behavior of staying home from work or school, in bed, with chicken soup is a very specific social response to illness.
• Anthropologist Robert Welsch contracted malaria while conducting fieldwork among the Ningerum people of Papua New Guinea. He then followed the American norm of medicine, fluids, seclusion, and rest.
• Ningerum villagers had a very different perception of their sick role. Believing the illness to be caused by sorcery, they expressed concern and spent long hours with Welsch to comfort him and remove any suspicion that they were involved with the sorcery. The more he tried to be by himself, the more they interpreted his behavior to mean that he was about to die.
• Contrary to the “stiff upper lip” mentality of many Westerners, the Ningerum are expected to demonstrate the severity of their symptoms as a call to action. Americans would probably react more negatively than sympathetically to exaggerated fainting, bleeding, vomiting, shrieking, and smearing oneself with mud.

How and Why Do Doctors and Other Health Care Practitioners Gain Social Authority?

• The cliché is that American parents want their kids to grow up to be doctors and lawyers. The prestige and social authority associated with the medical profession are relatively new. In the eighteenth and nineteenth centuries doctors had a limited ability to effectively heal patients and a lower social status.
• What social processes privileged the doctor’s perceptions over the patient’s throughout the twentieth century?
• According to Paul Starr (1982), twentieth-century physicians in the United States used their status as professionals to increase their incomes, respect, and the exclusive right to determine medical treatments. Organizations like the American Medical Association gave doctors greater control over training doctors of the future.
• But the wealth and respect of American doctors are not evident in most other countries’ medical communities.
• In many countries around the world, doctors and patients have very different views, with patients focusing on illness and doctors on disease.
• Disease: the purely physiological condition of being sick, usually determined by a physician.
• Illness: the psychological and social experience the patient has of a disease.
• We explain the authority gap between doctors and patients in the following way:
• The doctor’s view is the officially sanctioned one. Hospitals, governments, insurance providers, and courts recognize the diagnosis of the physician as legitimate.
• The patient who actually has to live with the symptoms generally lacks any ability to authorize a prescription or treatment, or even offer an official diagnosis.
• Understanding the different perspectives of doctors and patients and the difference between disease and illness is a focus of medical anthropology.
• In the 1950s and 1960s, anthropologists heavily favored Western medicine and assumed that interpretations of illness in the developing world were a result of ignorance. (For example, in Mali, schistosomiasis is correlated with adolescence but caused by a parasite.)
• Medical anthropologist Arthur Kleinman explained that healers and patients often have different explanatory models of illness: explanations of what is happening to the patient’s body by the patient, by the patient’s family, or by a healthcare practitioner, each of whom may have a different model of what is happening.
• See “Classic Connections: Arthur Kleinman and the New Medical Anthropological Methodology”
• Kleinman’s research demonstrates that considering both patient’s and doctor’s explanatory models of illness will likely result in the most effective medical solutions.
• How illness is defined depends on individual, cultural context and also on time. Conditions that aren’t recognized as illness can become so through medicalization: the process of viewing or treating as a medical concern conditions that were not previously understood as medical problems.
• So how does a non-problem become a problem or vice versa? For example, alcoholism:
• Between the founding of the United States and the early twentieth century excessive alcohol consumption was viewed as a sin or sign of weak character. By the 1980s, American society, especially health insurance companies and health care providers, had begun to view it as a disease. (Consider the vast difference in social meaning between a “drunk” and a “person who suffers from alcoholism.”)
• Three reasons have been suggested for increasing medicalization in the United States:
• Financial: Everyone, from pharmaceutical companies to health insurers, is better situated to profit from treating disease than from treating “moral failings.”
• Medical: Medicalization increases the social standing and authority of doctors.
• Scientific: Given the unparalleled success of the scientific method, Americans are more comfortable seeking scientific solutions to social problems.

How Does Healing Happen?

• Our physical bodies heal, but healing itself is a complex biocultural process. Medical anthropologists recognize four distinct therapeutic processes: clinical processes, symbolic processes, social processes, and persuasion.
• Clinical therapeutic process: the healing process in which medicines have some active ingredient that is assumed to address either the cause or the symptom of a disorder.
• Symbolic therapeutic process: a healing process that restructures the meanings of the symbols surrounding the illness, particularly during a ritual.
• Social support therapeutic process: a healing process that involves a patient’s social networks, especially close family members and friends, who typically surround the patient during an illness.
• Placebo effect (persuasion): a healing process that works on persuading a patient that he or she has been given a powerful medicine, even though the “medicine” has no active chemical ingredient.

What Can Anthropology Contribute to Addressing Global Health Concerns?

• Anthropologists have always sought to understand cultural approaches to illness and health care systems. In recent years, they have increasingly made proactive efforts to improve health care in their research communities. These themes, understanding and actively addressing global problems, are focuses of modern medical anthropology.
• In the 1950s, medical anthropologists assisted with an early attempt to reduce infant mortality in Latin America through public health programs. Their goal was to encourage rural peasants to receive vaccinations and other medical interventions at these clinics.
• By the 1970s, the idea that global diseases could be eradicated by the year 2000 seemed justified. However, the emergence of new diseases like HIV and the reemergence of older ones created a continued need for medical anthropology.
• Non-Western civilizations like India, China, and the Arab world have had sophisticated medical systems for centuries. As these nations began to industrialize, they adopted many aspects of Western medicine. However, it supplemented local systems, rather than replacing them.
• Most societies draw on multiple medical traditions simultaneously, a concept called medical pluralism: the co-existence and interpenetration of distinct medical traditions with different cultural roots in the same cultural community.
• For example, Indian Ayurvedic practitioners diagnose health problems by reading the pulse and mixing the specific herbs together. Practitioners also use Sinhalese (referring to the people of Sri Lanka) medical ideas in a mediation of Ayurveda and local Sinhala medicine. More recently, these practitioners have begun to include thermometers and standard Western medicines along with their herbal preparations.
• In an increasingly globalized world, medical anthropologists emphasize that all medical systems are plural systems. These plural systems can be part of the solution to global health problems.
• See “Anthropologist as Problem Solver: Nancy Scheper-Hughes on an Engaged Anthropology of Health”
• Medical anthropologists play a role in understanding and preventing the spread of disease, including viral epidemics like HIV and Ebola.
• For example, condom use has been relatively effective at preventing the spread of HIV in the United States and Europe but less so in sub-Saharan Africa, Haiti, and Southeast Asia. In Africa, specifically, epidemiologists did not immediately recognize the patterns of transmission along trucking routes.
• Anthropologists recorded people’s ideas about HIV, their explanatory models, and specific information about the sexual practices of women and men that helped reveal these patterns.
• Anthropologist and physician Paul Farmer (1992) and Jim Yong Kim founded Partners in Health to holistically address social, economic, political, and health problems in Cange, Haiti. Twenty years later, Cange has nearly returned to its original lush environment, combined with major improvements in local health.
• Anthropology’s holistic and cross-cultural approach can lead to innovative solutions in global health.
• See “The Anthropological Life: Zak Kaufman, Grassroots Soccer, and the Fight to Slow the Spread of HIV/AIDS”

Conclusion

• Many medical anthropology projects are among the most useful applied anthropology projects being conducted by anthropologists today.
• Although our bodies and what goes wrong with them are unquestionably tangible and real, people everywhere around the globe construct the meaning of particular sets of symptoms that we have called illness. We do not just respond naturally to impairments in our bodies but in culturally constructed ways as well.