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 tenets 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. 

• Physician and experimental psychologist William HR Rivers was interested in non-Western medicines as a member of the scientific expedition organized by AC Haddon to the Torres Straits of Australia. 
• Based on DIFFUSIONIST MODELS, he created a classification system for disease causation beliefs and an analysis of the geographic centers for each type.
• Diseases are believed to be caused by either human agency (magical beliefs), spiritual or supernatural agency (eg taboo), and/or natural agency (virus, bacteria, genetics).
• he concluded that Australian Aboriginal society must have been a wellspring for the idea that human agency is at the root cause of disease based on the intense clustering there of such belief. (through FIELDWORK)
  
• "the practice of medicine is a social process, subject to the same laws , and to be studied by the same methods as other social processes" and the the "practices of primitive people were logical and systematic and in some respects more rational [than Western medicine at that time]." (Western science did not have monopoly on rationality).
• Erwin Akerknecht: FUNCTIONALISM and Medical Anthropology
• 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
• "What a disease is in the last instance is, not a biological fact, but a decision of society"
• 1950's Consulting :International Health Care Projects 
• final catalyst to the creation of a separate field of medical anthropology
• APPLIED ROOTS of Medical Anthropology
• The Marshall Plan, the development of agencies like WHO (world health organization), AID (agency for international development), and INCAP (institute of Nutrition of Central America and Panama), sought to eradicate epidemic diseases and improve basic sanitation in poor countries.
• anthropologists were hired to identify and remove cultural impediments blocking the success of the project and overcoming these "cultural obstacles".
• research inside, and soon after arose the concept of applied anthropology in medicine
• Modern Medical Anthropology
• Founded in 1971

Expanding Views of "Health" in Medical Anthropology

Showing an interest in the well-being of the people we write about is the primary way of showing that we care about them. Anthropology must do better in this regard; the patchiness and cultural idiosyncrasies of anthropology are embarrassingly evident in our weak engagement in the study of well-being. Although we all know that it is a paramount concern of all humans, the main anthropological disposition towards well-being has been to say nothing directly about it, and certainly not to develop it as an analytical or normative theme. Explicit anthropological attention to well-being has tended to polarize into either naive anti-modernist celebrations of non-Western well-being on the one hand, or gloomy and perhaps voyeuristic immersion into ill-being on the other.

Each of these three kinds of disposition (ignoring it, uncritically celebrating it, or exploring only its absence) is a distinctive kind of empathy failure. Without explicit, balanced, and plausible scrutiny of well-being the anthropological ‘other’ is, by default, unfeeling, and their life is unevaluated. When feelings or values are discussed, anthropologists have tended to describe people as either exceptionally well (in ‘lost paradise’ accounts) or exceptionally ill (in the now much more common explorations of suffering, poverty, and powerlessness). Balanced and careful enquiry into well-being has yet to emerge in anthropology, although three unprecedented anthropological collections on well-being begin to point the way (Corsin Jimenez 2007; Gough and McGregor 2007; and Mathews and Izquierdo 2008).

Well-being 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 prudential value, to how well things are going for the person being judged. This goodness can be judged ‘objectively’ through some commonly agreed criteria. Someone who has a ‘good life’ doesn’t necessarily enjoy it. 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 respective importance of inner feelings and outward displays varies, and such a distinction may or may not be made. Enhancement of well-being may or may not be seen as a valid personal pursuit, or as the collectively valued criterion for judging the goodness or fairness of institutions and policies.

Anthropological literature whose titles announce interest in ‘well-being’, ‘health’, ‘mental health’, ‘experience’ and ‘subjectivity’ tends mainly to be about ill-being and suffering, and perhaps about therapy and damage limitation, but not about understanding and promoting really good lives. Anthropologies of morality, social inequality, social development, therapy and post-trauma rehabilitation all habitually ignore the implicit well-being themes that ought to provide their rationales. There have of course been important contributions to the understanding of well-being, but these have come indirectly (and hence inefficiently and partially), via writing about ill-being, suffering, and therapy, and via incidental, under-analyzed ethnographic snippets that tell us something about how people how people conceptualize well-being.

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. 

But relativism can distract us from evaluating cultural practices and institutions, as Edgerton so tellingly exposed in his book Sick Societies (1992). Consideration of well-being also reminds us of our anthropological duty to say something about human nature (Bloch 2005). 

By discussing well-being we can learn a lot about what people (professional evolutionary scientists or otherwise) believe concerning how humanity evolved and how that knowledge relates to well-being and morality. 

• Do people perceive ‘mismatches’ between current situations and those we evolved in, which they believe we need to resolve (Grinde 2002; Gluckman and Hanson 2006)? 
• Is it good (morally, or for our pleasure or dignity) to live according to human ‘nature’ and in a ‘natural’ setting? 
• Do people imagine some primordial well-being that we have lost through some original sin or bad development, and do they anticipate more well-being in some this-worldly or heavenly future?

Unless we strengthen our analysis of how people conceptualize, debate, promote, expect, and experience well-being: 

• too much of our anthropological writing will remain inconsiderate (appearing not to care about other people’s well-being), 
• non-evaluative (implicitly or explicitly refusing to discuss the goodness or badness of institutions and practices in terms of their fairness or their effects on well-being), 
• anesthetic (ignoring people’s feelings), and 
• unimportant (failing to spell out implications for practices and policies that might improve well-being). 

http://www.internationaljournalofwellbeing.org/index.php/ijow/article/viewFile/89/238?origin=publication_detail

http://www.cdc.gov/hrqol/wellbeing.htm

https://www.authentichappiness.sas.upenn.edu/learn/wellbeing

Questions and Methods in the Study of Sickness and Healing

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

• Because of the nature of working in different cultures, the direction of your research, and your research technique may shift in response as you become more sophisticated in the knowledge of the culture, or in response to ongoing debates in the profession at home.

The Research Experience:

• How do we balance the demands of scientific research methods 
• testable hypotheses
• replicable experiments
• representative samples
• experimental controls

         with the constraints and opportunities of research carried out in "natural settings" outside of the laboratory?

• SOLUTION: Participant Observation
• learn the local language
• 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 (Peru) or learn about other healing practices.
• once rapport develops you may be able to move to more structured interviews and surveys
• PROBLEMS: 
• How to minimize your effect on these local practices due to your presence and observation, while you document it
• 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.