Fluent Essays

Many cultures have ethno-etiologies that provide explanations for illness that are not based in science. From a biomedical perspective, the non-scientific medical treatments provided in these cultures have a low likelihood of success. Despite this, people tend to believe that the treatments are working. Why do you think people tend to be satisfied with the effectiveness of the treatments they receive that are based on the ethno-etiologies?  In transcultural nursing practice, why would it be important for nurses to understand such ethno-etiologies when nurses interact with patients of different cultures? PERSPECTIVES: AN OPEN INTRODUCTION TO CULTURAL ANTHROPOLOGY Nina Brown, Thomas McIlwraith, Laura Tubelle de González 2020 American Anthropological Association 2300 Clarendon Blvd, Suite 1301 Arlington, VA 22201 ISBN Print: 978-1-931303-67-5 ISBN Digital: 978-1-931303-66-8 http://perspectives.americananthro.org/ This book is a project of the Society for Anthropology in Community Colleges (SACC) http://sacc.americananthro.org/ and our parent organization, the American Anthropological Association (AAA). Please refer to the website for a complete table of contents and more information about the book. SECOND EDITION 17 17 HEALTH AND MEDICINE HEALTH AND MEDICINE Sashur Henninger-Rener, Pasadena City College [email protected] Learning Objectives Learning Objectives • Define the biocultural perspective and provide examples of how interactions between biology and culture have affected human biology. • Identify four ethno-etiologies (personalistic, naturalistic, emotionalistic, and biomedical) and describe how each differs in explain- ing the root cause of illness. • Explain the significance of faith in healing. • Examine the relationship between mental health and cultural factors, including stigma, that affect the way people with mental health conditions are perceived. • Discuss examples of culture-bound syndromes. • Evaluate the positive and negative effects of biomedical technologies. What does it mean to be “healthy”? It may seem odd to ask the question, but health is not a universal concept and each culture values different aspects of well-being. At the most basic level, health may be perceived as surviving each day with enough food and water, while other definitions of health may be based on being free of diseases or emotional troubles. Complicating things further is the fact that that each culture has a different causal explanation for disease. For instance, in ancient Greece health was considered to be the product of unbalanced humors or bodily fluids. The four humors included black bile, phlegm, yellow bile, and blood. The ancient Greeks believed that interactions among these humors explained differences not only in health, but in age, gender, and general disposition. Various 425 things could influence the balance of the humors in a person’s body including substances believed to be present in the air, changes in diet, or even temperature and weather. An imbalance in the humors was believed to cause diseases, mood problems, and mental illness.1 The World Health Organization (WHO) recognizes that the health of individuals and communities is affected by many factors: “where we live, the state of our environment, genetics, our income and edu- cation level, and our relationships with friends and family.” 2 Research conducted by the WHO suggests that these characteristics play a more significant role in affecting our health than any others, includ- ing having access to health care. For this reason, anthropologists who are interested in issues related to health and illness must use a broad holistic perspective that considers the influence of both biology and culture. Medical anthropology, a distinct sub-specialty within the discipline of anthropology, investi- gates human health and health care systems in comparative perspective, considering a wide range of bio-cultural dynamics that affect the well-being of human populations. Medical anthropologists study the perceived causes of illness as well as the techniques and treatments developed in a society to address health concerns. Using cultural relativism and a comparative approach, medical anthropologists seek to understand how ideas about health, illness, and the body are products of particular social and cultural contexts. ANTHROPOLOGY AND THE BIOCULTURAL PERSPECTIVE Evolutionary biology is a field of study that investigates the ways that natural processes have shaped the development of life on Earth, producing measurable changes in populations over time. Humans, Homo sapiens, are a special case in the discussion of evolution. We are a relatively young species that has been on Earth for only about 195,000 years.3 Although this may sound like a long time, com- pared with other animals, humans are newcomers and we have been subject to processes of natural selection and adaptation for less time than many other living things. In that short time period, human lifestyles have changed dramatically. The first humans evolved in Africa and had a foraging lifestyle, living in small, kin-based groups. Today, millions of people live in crowded, fast-paced, and technolog- ically advanced agricultural societies. In evolutionary terms, this change has happened rapidly. The fact that these rapid changes were even possible reveals that human lifestyles are biocultural, products of interactions between biology and culture. This has many implications for understanding human health. The theory of natural selection suggests that in any species there are certain physical or behavioral traits that are adaptive and increase the capacity of individuals to survive and reproduce. These adap- tive traits will be passed on through generations. Many human traits contributed to the survival of early human communities. A capacity for efficient walking and running, for instance, was important to human survival for thousands of years. However, as cultural change led to new lifestyles, some human characteristics became maladaptive. One example is the obesity epidemic that has emerged all over the world. According to the Center for Disease Control and Prevention, more than one-third of the population of the United States is obese.4 Obesity is considered to be a “disease of civilization,” meaning that it did not exist in early human popu- lations. Taking a biocultural evolutionary approach to human health, we can ask what traits character- istic of early human foraging populations might have encouraged an accumulation of fat in the human body. The answer comes from the evidence of food shortages among foraging populations. In fact, 47 percent of societies that forage experience food shortages at least once per year. Another 24 percent experience a shortage at least every two years.5 When taking this into account, the ability to retain body fat would have been advantageous for humans in the past. Women with more body fat could give birth to healthy babies and breastfeed them, even in periods of food scarcity. It is also possible that women 426 PERSPECTIVES: AN OPEN INTRODUCTION TO CULTURAL ANTHROPOLOGY and men would have viewed body fat as a sign of health and access to resources, choosing sexual part- ners based on this characteristic. If so, powerful biological and cultural forces would have contributed to genetic traits that led to efficient metabolism and higher body fat. With the development of agriculture, calories became more easily available while many people in the population became more sedentary. Traits that were once adaptive became maladaptive. The develop- ment of cultural preferences for foods high in fat and sugar, such as the “standard American diet” (SAD) is directly associated with obesity. These cultural changes have had a negative impact on health in many places. In Polynesia, for instance, obesity rates were around 15 percent in traditional farming commu- nities, but climbed to over 35 percent as people moved to cities.6 This is an example of the biocultural nature of many human health challenges. Another example of this biocultural dynamic is sickle cell anemia, an inherited disease that can be fatal. A person who inherits the sickle cell gene from both parents will have red blood cells with an usual sickle (crescent) shape. These cells cannot carry oxygen as efficiently as normal red blood cells and they are also more likely to form painful and dangerous blood clots. Ordinarily, genetic conditions that make it more difficult for individuals to survive or have children, will become less common in populations over time due to the effects of natural selection. From an evolutionary perspective, one might ask why a deadly genetic condition has remained so common in human populations. The cultural context is important for answering this question. The sickle cell gene is found most often in human populations in Africa and Southeast Asia where malaria is widespread. Malaria is a mosquito- borne illness that can be deadly to humans. People who have inherited one copy of the sickle cell anemia trait (instead of the two copies that cause sickle cell disease) have resistance to malaria. This is a sig- nificant adaptive trait in parts of the world where malaria is widespread. There is some evidence that malaria became a significant threat to human health only after the invention of agriculture. The defor- ested areas and collections of standing water that characterize agricultural communities also attract the mosquitos that carry disease. 7 In this case, we can see biocultural dynamics in action. Because resistance to malaria is an adaptive trait, the sickle cell gene remained common in populations where malaria is present. In parts of West and Central Africa, up to 25 percent of the population has the sickle cell gene. While sickle cell anemia is still a deadly disease, those who inherit a single copy of the gene have some protection from malaria, itself a deadly threat in many places. This example illustrates the biocultural interaction between genes, pathogens, and culture. Infectious diseases generally do not have an adaptive function for humans like the examples above, but many infectious diseases are influenced by human cultural systems. Because early human commu- nities consisted of small groups with a foraging lifestyle, viruses and bacteria transmitted from per- son to person were unlikely to result in large-scale epidemics. Healthy individuals from neighboring groups could simply avoid coming into contact with anyone who was suffering from illness and out- breaks would be naturally contained.8 The rapid increase in the size of human communities following the invention of agriculture changed this pattern. Agriculture can support more people per unit of land and, at the same time, agriculturalists need to live in permanent urban settlements in order to care for their crops. In a cyclical way, agri- culture provides more food while also requiring that people have sizeable families to do the necessary farm work. Over the course of several thousand years, agricultural communities became increasingly densely populated. This had many implications for local ecology: problems disposing of waste and diffi- culty accessing clean water. A prime example of the health effects of the transition to urban settlements is cholera, a water-borne illness that spreads through water that has been polluted with human feces. Cholera, which was first detected in urban populations in India, has killed tens of thousands of people 427 Figure 1: Traditional Tibetan Medicine Poster. throughout history and continues to threaten populations today, particularly in developing countries, where access to clean water is limited, and in places that have experienced natural disasters.9 From an adaptive perspective, human beings die from infectious diseases because they do not have immunity to them. Immunity can be built up over time for some diseases, but unfortunately only after the illness or death of many members of a population.10 When a new infectious disease reaches a pop- ulation, it can wreak havoc on many people. Historically, several new infectious diseases are known to have been introduced to human populations through contact with livestock. Tuberculosis and smallpox were linked to cattle and influenza to chickens. When humans domesticated animal species, and began to live in close proximity to them, new routes for the transmission of zoonotic disease, illnesses that can be passed between humans and animals, were established.11 Living in cities accelerates the spread of infectious diseases and the scale of outbreaks, but may also contribute to the natural selection of genetic traits that confer resistance to disease. This biocultural evolutionary process has been documented in urban populations where there are genes providing some resistance to leprosy and tuberculosis.12 ETHNOMEDICINE Ethnomedicine is the comparative study of cultural ideas about wellness, illness, and healing. For the major- ity of our existence, human beings have depended on the resources of the natural environment and on health and healing techniques closely associated with spiritual beliefs. Many such practices, including some herbal remedies and techniques like acupuncture, have been studied scientifically and found to be effective.13 Others have not necessarily been proven medically effective by external scientific evidence, but continue to be embraced by communities that perceive them to be use- ful. When considering cultural ideas about health, an important place to start is with ethno-etiology: cultural explanations about the underlying causes of health problems. In the United States the dominant approach to think- ing about health is biomedical. Illnesses are thought to be the result of specific, identifiable agents. This can include pathogens (viruses or bacteria), malfunction of the body’s biochemical processes (conditions such as cancer), or physiological disorders (such as organ failure). In biomedicine as it is practiced in the United States (Western biomedicine), health is defined as the absence of disease or dysfunction, a perspective that notably excludes consideration of social or spiritual well-being. In non-Western contexts biomedical explanations are often viewed as unsatisfac- tory. In his analysis of ideas about health and illness in non-Western cultures, George Foster (1976) concluded that these ideas could be categorizes into two main types of ethno-etiology: personalistic and naturalistic.14 428 PERSPECTIVES: AN OPEN INTRODUCTION TO CULTURAL ANTHROPOLOGY https://pressbooks.com/app/uploads/sites/47044/2019/02/health_figure_1.jpg https://pressbooks.com/app/uploads/sites/47044/2019/02/health_figure_1.jpg Ethno-Etiologies: Personalistic and Naturalistic Personalistic ethno-etiologies view disease as the result of the “active, purposeful intervention of an agent, who may be human (a witch or sorcerer), nonhuman (a ghost, an ancestor, an evil spirit), or supernatural (a deity or other very powerful being).”15 Illness in this kind of ethno-etiology is viewed as the result of aggression or punishment directed purposefully toward an individual; there is no acci- dent or random chance involved. Practitioners who are consulted to provide treatment are interested in discovering who is responsible for the illness—a ghost, an ancestor? No one is particularly interested in discovering how the medical condition arose in terms of the anatomy or biology involved. This is because treating the illness will require neutralizing or satisfying a person, or a supernatural entity, and correctly identifying the being who is the root cause of the problem is essential for achieving a cure. The Heiban Nuba people of southern Sudan provide an interesting example of a personalistic etiol- ogy. As described by, S.F. Nadel in the 1940s, the members of this society had a strong belief that illness and other misfortune was the result of witchcraft. A certain magic, mysteriously appearing in individuals, causes the death or illness of anyone who eats their grain or spills their beer. Even spectacular success, wealth too quickly won, is suspect; for it is the work of a spirit-double, who steals grain or livestock for his human twin. This universe full of malig- nant forces is reflected in a bewildering array of rituals, fixed and occasional, which mark almost every activity of tribal life.16 Because sickness is thought to be caused by spiritual attacks from others in the community, people who become sick seek supernatural solutions. The person consulted is often a shaman, a person who specializes in contacting the world of the spirits. In Heiban Nuba culture, as well as in other societies where shamans exist, the shaman is believed to be capable of entering a trance-like state in order to cross between the ordinary and supernatural realms. While in this state, the shaman can identify the individual responsible for causing the illness and sometimes the spirits can be convinced to cure the disease itself. Shamans are common all around the world and despite the proverbial saying that “prostitution is the oldest profession,” shamanism proba- bly is! Shamans are religious and medical practitioners who play important social roles in their com- munities as healers with a transcendent ability to navigate the spirit world for answers. In addition, the often have a comprehensive knowledge of the local ecology and how to use plants medicinally. They can address illnesses using both natural and supernatural tools. In naturalistic ethno-etiologies, diseases are thought to be the result of natural forces such as “cold, heat, winds, dampness, and above all, by an upset in the balance of the basic body elements.”17 The ancient Greek idea that health results from a balance between the four humors is an example of a nat- uralistic explanation. The concept of the yin and yang, which represent opposite but complementary energies, is a similar idea from traditional Chinese medicine. Achieving balance or harmony between these two forces is viewed as essential to physical and emotional health. Unlike personalistic expla- nations, practitioners who treat illness in societies with naturalistic ethno-etiologies are interested in understanding how the medical condition arose so that they can choose therapeutic remedies viewed as most appropriate. Emotional difficulties can be viewed as the cause of illness in a naturalistic ethno-etiology (an emo- tionalistic explanation). One example of a medical problem associated with emotion is susto, an illness recognized by the Mixe, an indigenous group who live in Oaxaca, Mexico, as well as others through- out central America. The symptoms of susto include difficulty sleeping, lack of energy, loss of appetite and sometimes nausea/vomiting and fever. The condition is believed to be a result of a “fright” or shock and, in some cases at least, it is believed to begin with a shock so strong that it disengages the soul from 429 the body.18 The condition is usually treated with herbal remedies and barrida (sweeping) ceremonies designed to repair the harm caused by the shock itself.19 Although physicians operating within a bio- medical ethno-etiology have suggested that susto is a psychiatric illness that in other cultural contexts could be labeled anxiety or depression, in fact susto is does not fit easily into any one Western biomed- ical category. Those suffering from susto see their condition as a malady that is emotional, spiritual, and physical.20 In practice, people assess medical problems using a variety of explanations and in any given society personalistic, naturalistic, or even biomedical explanations may all apply in different situations. It is also important to keep in mind that the line between a medical concern and other kinds of life chal- lenges can be blurry. An illness may be viewed as just one more instance of general misfortune such as crop failure or disappointment in love. Among the Azande in Central Africa, witchcraft is thought to be responsible for almost all misfortune, including illness. E.E. Evans-Pritchard, an anthropologist who studied the Azande of north-central Africa in the 1930s, famously described this logic be describing a situation in which a granary, a building used to store grain collapsed. In Zandeland sometimes an old granary collapses. There is nothing remarkable in this. Every Zande knows that termites eat the supports in course of time and that even the hardest woods decay after years of service. Now a granary is the summerhouse of a Zande homestead and people sit beneath it in the heat of the day and chat or play the African hole-game or work at some craft. Consequently it may hap- pen that there are people sitting beneath the granary when it collapses and they are injured…Now why should these particular people have been sitting under this particular granary at the particular moment when it collapsed? That it should collapse is easily intelligible, but why should it have collapsed at the particular moment when these particular people were sitting beneath it…The Zande knows that the supports were undermined by termites and that people were sitting beneath the granary in order to escape the heat of the sun. But he knows besides why these two events occurred at a precisely similar moment in time and space. It was due to the action of witchcraft. If there had been no witchcraft peo- ple would have been sitting under the granary and it would not have fallen on them, or it would have collapsed but the people would not have been sheltering under it at the time. Witchcraft explains the coincidence of these two happenings.21 According to this logic, an illness of the body is ultimately caused by the same force as the collapse of the granary: witchcraft. In this case, an appropriate treatment may not even be focused on the body itself. Ideas about health are often inseparable from religious beliefs and general cultural assumptions about misfortune.22 Is Western Biomedicine An Ethno-Etiology? The biomedical approach to health strikes many people, particularly residents of the United States, as the best or at least the most “fact based” approach to medicine. This is largely because Western bio- medicine is based on the application of insights from science, particularly biology and chemistry, to the diagnosis and treatment of medical conditions. The effectiveness of biomedical treatments is assessed through rigorous testing using the scientific method and indeed Western biomedicine has produced successful treatments for many dangerous and complex conditions: everything from antibiotics and cures for cancer to organ transplantation. However, it is important to remember that the biomedical approach is itself embedded in a distinct cultural tradition, just like other ethno-etiologies. Biomedicine, and the scientific disciplines on which it is based, are products of Western history. The earliest Greek physicians Hippocrates (c. 406-370 BC) and Galen (c. 129-c. 200 AD) shaped the development of the biomedical perspective by providing early 430 PERSPECTIVES: AN OPEN INTRODUCTION TO CULTURAL ANTHROPOLOGY Figure 2: The Taiyang bladder meridian, one of several meridians recognized in Traditional Chinese medicine. From Shou Hua’s Jushikei Hakki, 1716, Tokyo insights into anatomy, physiology, and the relationship between environment and health. From its ori- gins in ancient Greece and Rome, the knowledge base that matured into contemporary Western bio- medicine developed as part of the Scientific Revolution in Europe, slowly maturing into the medical profession recognized today. While the scientific method used in Western biomedicine represents a dis- tinct and powerful “way of knowing” compared to other etiologies, the methods, procedures, and forms of reasoning used in biomedicine are products of Western culture. 23 In matters of health, as in other aspects of life, ethnocentrism predisposes people to believe that their own culture’s traditions are the most effective. People from non-Western cultures do not necessarily agree that Western biomedicine is superior to their own ethno-etiologies. Western culture does not even have a monopoly on the concept of “science.” Other cultures recognize their own forms of science separate from the Western tradition and these sciences have histories dating back hundreds or even thousands of years. One example is Traditional Chinese Medi- cine (TCM), a set of practices developed over more than 2,500 years to address physical complaints holistically through acupuncture, exercise, and herbal remedies. The tenets of Tradi- tional Chinese Medicine are not based on science as it is defined in Western culture, but millions of people, including a growing number of people in the United States and Europe, regard TCM as credible and effective. Ultimately, all ethno-etiologies are rooted in shared cultural perceptions about the way the world works. Western biomedi- cine practitioners would correctly observe that the strength of Western biomedicine is derived from use of a scientific method that emphasizes objectively observable facts. However, this this would not be particularly persuasive to someone whose culture uses a different ethno-etiology or whose understanding of the world derives from a different tradition of “science.” From a comparative perspective, Western biomedicine may be viewed as one ethno-etiology in a world of many alternatives. Techniques for Healing Western biomedicine tends to conceive of the human body as a kind of biological machine. When parts of the machine are damaged, defective, or out of balance, chemical or surgical interventions are the preferred therapeutic responses. Biomedical practitioners, who can be identified by their white coats and stethoscopes, are trained to detect observable or quantifiable symptoms of disease, often through the use of advanced imaging technologies or tests of bodily fluids like blood and urine. Prob- lems detected through these means will be addressed. Other factors known to contribute to wellness, such as the patient’s social relationships or emotional state of mind, are considered less relevant for both diagnosis and treatment. Other forms of healing, which derive from non-biomedical ethno-etiologies, reverse this formulation, giving priority to the social and spiritual. In Traditional Chinese Medicine, the body is thought to be governed by the same forces that animate the universe itself. One of these is chi (qi), a vital life force that flows through the body and energizes the body and its organs. Disruptions in the flow or balance of chi can lead to a lack of internal harmony and ultimately to health problems so TCM practitioners use treatments designed to unblock or redirect chi, 431 https://pressbooks.com/app/uploads/sites/47044/2019/02/health_figure_2.jpg https://pressbooks.com/app/uploads/sites/47044/2019/02/health_figure_2.jpg including acupuncture, dietary changes, and herbal remedies. This is an example of humoral healing, an approach to healing that seeks to treat medical ailments by achieving a balance between the forces or elements of the body. Communal healing, a second category of medical treatment, directs the combined efforts of the community toward treating illness. In this approach, medical care is a collaboration between multiple people. Among the !Kung ( Ju/’hoansi) of the Kalahari Desert in southern Africa, energy known as num can be channeled by members of the community during a healing ritual and directed toward individu- als suffering from illness. Richard Katz, Megan Bisele, and Verna St. Davis (1982) described an example of this kind of ceremony: The central event in this tradition is the all-night healing dance. Four times a month on the average, night signals the start of a healing dance. The women sit around the fire, singing and rhythmically clap- ping. The men, sometimes joined by the women, dance around the singers. As the dance intensifies, num, or spiritual energy, is activated by the healers, both men and women, but mostly among the danc- ing men. As num is activated in them, they begin to kia, or experience an enhancement of their con- sciousness. While experiencing kia, they heal all those at the dance.24 While communal healing techniques often involve harnessing supernatural forces such as the num, it is also true that these rituals help strengthen social bonds between people. Having a strong social and emotional support system is an important element of health in all human cultures. Faith and the Placebo Effect Humoral and communal approaches to healing, which from a scientific perspective would seem to have little potential to address the root causes of an illness, present an important question for medical anthropologists. What role does faith play in healing? Sir William Osler, a Canadian physician who was one of the founders of Johns Hopkins Hospital, believed that much of a physician’s healing ability derived from his or her ability to inspire patients with a faith that they could be cured.25 Osler wrote: Faith in the Gods or in the Saints cures one, faith in little pills another, suggestion a third, faith in a plain common doctor a fourth…If a poor lass, paralyzed apparently, helpless, bed-ridden for years, comes to me having worn out in mind, body, and estate a devoted family; if she in a few weeks or less by faith in me, and faith alone, takes up her bed and walks, the Saints of old could not have done more.26 In fact, there is a considerable …