So What's So Cultural About Disease?

Medical Anthropology: The study of human disease in a cross-cultural, historical and evolutionary perspective. It marks the intersection between biology, culture and applied research.

Important TENENTS that will be covered over the course of this semester:

• Biology and culture matter equally in the human experience of disease
• every aspect of the illness experience from the individual's recognition of the symptoms to assessments of treatment outcomes is shaped by the cultural frameworks of the sufferer and of those to who he/she turns for help. (A "bio-cultural perspective" avoids the REDUCTIONISM of models which neglect cultural factors)
• The political economy is the primary epidemiological factor
• People's health risks and the treatment resources which are available are directly related to the economic and political structures in a society
• Ethnography is an essential tool to understand human suffering due to disease
• allows for a holistic understanding of health and illness
• Medical anthropology can help alleviate human suffering
• Can lead to health interventions by providing cultural information on the community as well as the medical practitioners and healthcare institutions that undertake the interventions. Culture is relevant.

CULTURE IN MEDICINE

"Outside the significance that man voluntarily attaches to certain conditions, there are no illnesses or diseases in nature" (Peter Sedgwick, 1981)

• "natural events" do not prior to the human social meaning attached to them constitute illness, sickness or disease.
• disease is an imposition of human meanings on naturally occurring processes...this seems less controversial when we look at other cultures
• dano-Peruvian Shaman (illnesses result from injurious actions of sorcerers -HUMAN AGENCY), dano means "harm'. The Shaman's job is to reverse the effects of these poisons and in some cases punish them
• onanism-18th century Europe-masturbation=the cause of many illnesses
• draptomania-USA 1851 (Runaway Slave Syndrome)
• Ovarian diseases- Victorian Era USA-HRT today???
• ADHD-today, USA

IMPACT OF CULTURE ON CONTEMPORARY BIO-MEDICINE

• The rise of the MECHANICAL METAPHOR for the functioning of the human anatomy (THE BODY AS MACHINE), can be traced to the shift from a rural, farm economy to an industrial economic base. This has been argued to have contributed to the DEHUMANIZING OF CLINICAL PRACTICE.
• DISEASE AS COMBAT (warfare metaphor) resonated with the priorities and concerns of the Cold War in which it arose. (Sontag, Martin, Jaret)
• expensive high tech approaches to curing disease find the same compelling justifications as Pentagon budgets- no cost is too high when it comes to conquering the enemy, surrender is unacceptable
• Doctors will not give up, patients are "forced" into extreme therapies
• influence the way that funds are allocated and limits the ways that we might deal with disease otherwise when we go at things full throttle
• mastectomy, chemotherapy and radiation
• "the medical enterprise is from its conception value-loaded, it is not simply an applied biology, but a biology applied in accordance with the dictates of social interest" (Sedgwick)

These connections shape the knowledge and the practice of the surgeon and the shaman alike-CULTURAL ASSUMPTIONS and SOCIAL STRUCTURES have an impact on the way that both healers and patients think about and respond to disease.

DEVELOPMENT OF MEDICAL ANTHROPOLOGY

The history of the development of medical anthropology out of joint concerns of physical (biological) and cultural anthropology is recent in the discipline.

• FUNCTIONALISM and Medical Anthropology

"What a disease is in the last instance is, not a biological fact, but a decision of society"

• Ideas about the causes of disease can reflect lines of social tension in a society
• The very threat of causing a disease can serve as a powerful social sanction supporting the status quo against those who are inclined to deviate from social norms
• witchcraft
• homosexuality
• prostitutes
• argued for the interconnection of all aspects of society (functionalism) and the cultural construction of disease

WELL-BEING is an important concern in medical anthropology and it refers to the goodness of a person’s life, or of some aspect of it like health, happiness, relationships or spirituality. 

• Unlike virtue or status, well-being refers only to how well things are going for the person being judged. 
• This goodness can be judged ‘objectively’ through some commonly agreed criteria. 

Well-being can be usefully seen has having three kinds of meaning:

• a hedonic sense of enjoyment,
• a subjective-evaluative sense of life satisfaction (in relation to some personally salient criteria and aspirations), and
• an objective-evaluative sense of goodness according to some agreed normative criteria.
• The ‘being’ part is interestingly complex too: it doesn’t necessarily refer to an individual human body and psyche in the here and now.

The ancient Greek term for well-being, eudaimo-nia (which literally means ‘having a good spirit’) and the South Asian concept of karma (the cumulative effects of actions on well-being over several lifetimes), remind us that the person whose well-being is assessed may have porous boundaries and be distributed through other people, other species, and other lives.

Well-being is individually and culturally variable in significant and interesting ways. The salient contents of well-being vary:

• health
• relationships
• activities
• capabilities
• spiritual encounters, and so on...
• and so do people’s views on how to achieve it. The values underpinning ‘well’ vary, as do existential concepts of ‘being’ and ontological concepts of ‘self’.

Abstract concepts of well-being may or may not feature in moral discourse. The wellness emphasized may be of:

• individuals or collectivities,
• this-wordly or other-wordly,
• bodily or mental,
• human or spiritual.

The core challenge in the anthropology of well-being is about balancing relativism and universalism. People’s enjoyment of life is relative to:

• their cultural contexts,
• their age and gender,
• the expectations they have grown up with,
• their individual capabilities and characters.

METHODOLOGY

Fieldwork in medical anthropology is a dynamic process that is NOT well suited to the structured, HYPOTHESIS TESTING RESEARCH PARADIGM of the laboratory sciences.

SOLUTION: Participant Observation

• learn the local language (way of communicating)
• live in the community and participate in public life as is appropriate
• develop rapport with local patients and healers that would allow you to participate in local healing session or learn about other healing practices.
• once rapport develops you may be able to move to more structured interviews and surveys

PROBLEMS:

• those you work with have the right to set LIMITS to your research (human subjects). Ethically your first duty is to protect the rights and lives of the people that you study.

Models for Promoting Culturally Competent Patient-Provider Communication: Kleinman's Nine Questions

Kleinman developed "EXPLANATORY MODELS" to understand how people relate to their illnesses, that we will be borrowing to understand experiences with HIV this semester.

..."notions that patients, families, and practitioners have about a specific illness episode.These informal descriptions of what an illness is about have enormous clinical significance: to ignore them may be fatal. They respond to such questions as, What is the nature of this problem? Why has it affected me? What course will it follow? How does it most affect my body? What treatments do I desire? What do I most fear about the illness and its treatments? Explanatory models are responses to urgent circumstances ...[that} contain contradictions and a shift in content. They are our representations of the cultural flow of life experience:consequently...they congeal and unravel as that flow and our understanding of it firms up in one situation only to dissolve in another. (Kleinman 1988, 120-122).

The questions are*:

• What do you call your problem?
• What name does it have?
• What do you think caused your problem?
• Why do you think it started when it did?
• What does your sickness do to you?
• How does it work? How severe is it?
• Will it have a short or long course?
• What do you fear most about your disorder?
• What are the chief problems that your sickness has caused for you?
• What kind of treatment do you think you should receive?
• What are the most important results you hope to receive from the treatment?

*Harvard physician and anthropologist Arthur Kleinman studied how cultural beliefs impact an individual's understanding of health and illness. Kleinman's work offers an approach to understand the patient's "illness narrative." The wording of questions should vary with characteristics of the patient, the problem and the setting. Patients may hesitate to disclose their beliefs, so patience and a genuine interest are important. The goal of the question is to elicit a patient's understanding of their health. (Reference: Kleinman, A. (1980). Patients and healers in the context of culture. Berkley, CA: University of California Press).