Ethno-etiology

Anthro Connections

Traditional medicine in India includes such elements as herbs, pills, oil massages, dietary regimens, meditation, and exercise. Two major branches include Ayurvedic (eye-yur-vay-dik) healing, related to Hinduism, and Unani (oo-nah-nee) healing, related to Islam. They share many elements, and each requires a trained expert to diagnose problems and prescribe a treatment plan. In the past decade, Ayurvedic healing has gained global attention. Many five-star spas in India, especially in the southern state of Kerala, provide Ayurvedic treatments. Health tourism there is on the rise, drawing people from within India as well as from Europe and the Middle East. Aspects of Ayurvedic healing enjoy a large following around the world among Hindus and non-Hindus alike, and Ayurvedic techniques appear to be effective in addressing a variety of health problems. For example, a recent study in Norway indicates that women with fibromyalgia, which is considered a treatment-resistant condition, experienced significant, long-term reduction in symptoms, including pain and depression (Rasmussen et al. 2012).

Medical anthropology is one of the most rapidly growing areas in anthropology, probably because of its relevance to a major global challenge: people’s health. This chapter first describes how people in different cultures think and behave regarding health, illness, and healing. The second section considers three theoretical approaches in medical anthropology. The chapter concludes by discussing how globalization is affecting health.

Since the early days of anthropology, the topic of ethnomedicine, or the study of cross-cultural health systems, has been a focus of research. A health system encompasses many areas: perceptions and classifications of health problems, prevention measures, diagnosis, healing (magical, religious, scientific, healing substances), and Melissa Gurgel is a Brazilian model and beauty pageant titleholder who was crowned Miss Brasil 2014 and represented her country at Miss Universe 2014. Her looks exemplify the global norm of female beauty and health. Many models and beauty queens, however, suffer from a range of health and behavioral problems.

In the 1960s, when the term ethnomedicine first came into use, it referred only to non-Western health systems and was synonymous with the now abandoned term primitive medicine. The early use of the term was ethnocentric. Contemporary Western biomedicine (WBM) , a healing approach based on modern Western science that emphasizes technology in diagnosing and treating health problems related to the human body, is an ethnomedical system, too. Medical anthropologists now study WBM as a cultural system intimately bound to Western values. Thus, the current meaning of the term ethnomedicine encompasses health systems everywhere.

healers. Defining and Classifying Health Problems

Emic diversity in labeling health problems presents a challenge for medical anthropologists and health-care specialists. Western labels, which biomedically trained experts accept as true, accurate, and universal, often do not correspond to the labels in other cultures. One set of concepts that medical anthropologists use to sort out the many cross-cultural labels and perceptions is the disease–illness dichotomy. In this model, disease refers to a biological health problem that is objective and universal, such as a bacterial or viral infection or a broken arm. Illness refers to culturally specific perceptions and experiences of a health problem. Medical anthropologists study both disease and illness, and they show how each must be understood within their cultural contexts.

A first step in ethnomedical research is to learn how people label, categorize, and classify health problems. Depending on the culture, the following may be bases for labeling and classifying health problems: cause, vector (the means of transmission, such as mosquitoes), affected body part, symptoms, or combinations of these.

Often, knowledgeable elders are the keepers of ethnomedical knowledge, and they pass it down through oral traditions. Among groups of American Indians of the Washington–Oregon region, many popular stories refer to health (Thompson and Sloat 2004). The stories convey messages about how to prevent health problems, avoid bodily harm, relieve afflictions, and deal with old age. For example, here is the story of Boil, a story for young children:

· Boil was getting bigger.

· Her husband told her to bathe.

· She got into the water.

· She disappeared. (2004:5)

Other longer stories about Boil add complexities about the location of the boil and how to deal with particular boils, revealing indigenous patterns of classification.

A classic study among the Subanun (soo-BAH-nun) people focused on their categories of health problems (Frake 1961). In the 1950s, the Subanun were horticulturalists living in the highlands of Mindanao, in the Philippines (Map 5.1). Being egalitarian people, all Subanun, even young children, had substantial knowledge about health problems and how to deal with them. Of their 186 labels for health problems, some are a single term, such as “itch,” which can be expanded on by using two words, such as “splotchy itch.” Skin diseases are common afflictions among the Subanun and have several degrees of specificity (Figure 5.1).

The Republic of the Philippines comprises an archipelago of over 7,000 islands, of which around 700 are populated. The population is 104 million, with two-thirds living on Luzon. The economy is based on agriculture, light industry, and a growing business-processing outsourcing (BPO) industry. Over 8 million Filipinos work overseas and remit more than $12 billion per year, a large part of the country’s economy. Although Filipino and English are the official languages, more than 170 languages are spoken. Literacy rates are high for both males and females. Many different ethnic groups live in the country, with Tagalog people constituting the largest proportion of 30 percent. The Philippines has the world’s third largest Christian population, among which Roman Catholicism is predominant. In WBM, panels of medical experts have to agree about how to label and classify health problems according to scientific criteria. Classifications and descriptions of thousands of afflictions are published in thick manuals, and online, that physicians consult before they give a diagnosis. In countries where medical care is privatized, the code selected may determine whether the patient’s costs are covered by insurance or not.

Further, Western medical guidelines are biased toward diseases that WBM recognizes, and they ignore health problems that other cultures recognize. Anthropologists have discovered health problems around the world referred to as culture-specific syndromes or folk illnesses. A culture-specific syndrome is a health problem with a set of symptoms associated with a particular culture (Figure 5.2). Social factors such as stress, fear, or shock often are the underlying causes of culture-specific syndromes. Biophysical symptoms may be involved, and culture-specific syndromes can be fatal. Somatization , or embodiment, refers to the process through which the body absorbs social stress and manifests symptoms of suffering.

For example, susto, or “fright/shock disease,” is found in Spain and Portugal and among Latino people wherever they live. People afflicted with susto attribute it to events such as losing a loved one or having a terrible accident (Rubel, O’Nell, and Collado-Ardon 1984). For example, in Oaxaca, southern Mexico (see Map 4.3), a woman said her susto was brought on by an accident in which pottery she had made was broken on its way to market, whereas a man said that his susto came on after he saw a dangerous snake. Susto symptoms include loss of appetite, lack of motivation, breathing problems, generalized pain, and nightmares. The researchers analyzed many cases of susto in three villages. They found that the people most likely to be afflicted were those who were socially marginal or experiencing a sense of role failure. For example, the woman with the broken pots had also suffered two spontaneous abortions and was worried that she would never have children. In Oaxaca, people with susto have higher mortality rates than other people. Thus, social marginality, or a deep sense of social failure, can place a person at a higher risk of dying. It is important to look at the deeper causes of susto.

Medical anthropologists first studied culture-specific syndromes in non-Western cultures. This focus created a bias in thinking that they exist only in “other” cultures. Now, anthropologists recognize that Western cultures also have culture-specific syndromes. Anorexia nervosa and a related condition, bulimia, are culture-specific syndromes found mainly among White middle-class adolescent girls of the United States, although some cases have been documented among African American girls in the United States and among young males (Fabrega and Miller 1995). Since the 1990s, and perhaps as a result of Western globalization, cases have been documented in Hong Kong and in cities in Japan and India. Anorexia nervosa’s cluster of symptoms includes self-perception of fatness, aversion to food, hyperactivity, and, as the condition progresses, continued wasting of the body and often death.

No one has found a clear biological cause for anorexia nervosa, although some researchers claim that it has a genetic basis. Cultural anthropologists say that much evidence suggests a strong role for cultural construction. One logical result of the role of culture is that medical and psychiatric treatments are notably unsuccessful in curing anorexia nervosa (Gremillion 1992). Extreme food deprivation can become addictive and entrapping, and the affliction becomes intertwined with the body’s biological functions. Extended fasting makes the body unable to deal with ingested food. Thus, medical treatment may involve intravenous feeding to override the biological block.

Pinpointing the cultural causes of anorexia nervosa, however, is also difficult. Some experts cite societal pressures on girls that lead to excessive concern with looks, especially body weight. Others feel that anorexia is related to girls’ unconscious resistance to controlling parents. For such girls, food intake may be one thing over which they have power.

Ethno-Etiologies

People in all cultures, everywhere, attempt to make sense of health problems and try to understand their cause or etiology. The term ethno-etiology refers to a cross-culturally specific causal explanation for health problems and suffering.

Among the urban poor of northeastern Brazil, people consider several reasons when they are sick (Ngokwey 1988). In Feira de Santana, the second largest city in the state of Bahia in the northeast (see Map 3.3), ethno-etiologies include natural, socioeconomic, psychological, or supernatural factors. Natural causes include exposure to the environment. For example, people say that humidity and rain cause rheumatism, excessive heat causes dehydration, and some types of winds cause migraines. Other natural explanations for illness take into account the effects of aging, heredity, personality, and gender. Contagion is another natural explanation, as are the effects of certain foods and eating habits. In the psychosocial domain, emotions such as anger and hostility cause certain health problems. In the supernatural domain, spirits and magic can cause health problems. The African–Brazilian religions of the Bahia region encompass many spirits who can inflict illness. They include spirits of the unhappy dead and devil-like spirits. Some spirits cause specific illnesses; others bring general misfortune. In addition, envious people with the evil eye cast spells on people and cause much illness. People also recognize the lack of economic resources, proper sanitation, and health services as structural causes of health problems. In the words of one person, “There are many illnesses because there are many poor” (1988:796).

The people of Feira de Santana also recognize several levels of causality. In the case of stomachache, they might blame a quarrel (underlying cause), which prompted the aggrieved party to seek the intervention of a sorcerer (intermediate cause), who cast a spell (immediate cause), which led to the resulting illness. The multilayered causal understanding opens the way for many possible avenues of treatment.

The multiple understandings of etiology in Bahia contrast with the scientific understandings of causality in WBM. The most striking difference is the tendency for biomedical etiologies to exclude structural issues and social inequality as causing illness. Medical anthropologists use the term structural suffering , or social suffering, to refer to health problems caused by powerful forces such as poverty, war, famine, and forced migration. Such structural factors affect health in many ways, with effects ranging from anxiety and depression to death.

An example of a culture-specific syndrome that clearly implicates structural factors as causal is sufriendo del agua, or “suffering from water” (Ennis-McMillan 2001). Research in a low-income community in the Valley of Mexico, located in the central part of the country (see Map 4.3), reveals that sufriendo del agua is a common health problem, especially among women. The immediate cause is the lack of water for drinking, cooking, and washing. Women, who are responsible for cooking and doing the washing, cannot count on water coming from their taps on a regular basis. This insecurity makes the women feel constantly anxious and in a state of nervous tension. The lack of access to water also means that the people are at higher risk for cholera, skin and eye infections, and other biophysical problems. A deeper structural cause of sufriendo del agua is unequal development. The construction of piped water systems in the Valley of Mexico bypassed low-income communities in favor of servicing wealthier urban neighborhoods and supplying water for irrigation projects and the industrial sector. In Mexico, as a whole, nearly one-third of the population has inadequate access to clean drinking water and to a dependable supply of water for bathing, laundry, and cooking.

The following material describes two healing modalities or approaches to healing that are likely unfamiliar to most readers. It then discusses cross-cultural examples of healers and healing substances.

Community Healing

A general distinction can be drawn between private healing and community healing . The former addresses bodily ailments in social isolation, whereas the latter encompasses the social context as crucial to healing. Compared with WBM, many non-Western systems use community healing. An example of community healing comes from the Ju/wasi foragers of the Kalahari Desert in southern Africa (review Culturama, Chapter 1). Ju/wasi healing emphasizes the mobilization of community “energy” as a key element in the cure:

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 clapping. 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 dancing men. As num is activated in them, they begin to kia or experience an enhancement of their consciousness. While experiencing kia, they heal all those at the dance. (Katz 1982:34)

A Ju/wasi healer in a trance, in the Kalahari desert, southern Africa. Most Ju/wasi healers are men, but some are women.

1. In your microculture, what are the patterns of gender, ethnicity, and class among various kinds of healers?

The dance is a community event in which the entire camp participates. The people’s belief in the healing power of num brings meaning and efficacy to the dance through kia.

Does community healing “work”? In both ethnic and Western terms, the answer is yes. It “works” on several levels. People’s solidarity and group sessions may support mental and physical health, acting as a health protection system. When people fall ill, the drama and energy of the all-night dances may act to strengthen the afflicted in ways that Western science would have difficulty measuring. In a small, close-knit group, the dances support members who may be ill or grieving.

An important aspect of the Ju/wasi healing system is its openness. Everyone has access to it. The role of healer is also open. There is no special class of healers with special privileges. More than half of all adult men and about 10 percent of adult women are healers.

Humoral Healing

Humoral healing is based on a philosophy of balance among certain elements within the body and within the person’s environment (McElroy and Townsend 2008). In this system, food and drugs have different effects on the body and are classified as either “heating” or “cooling”—the quotation marks indicate that these properties are not the same as thermal measurements. Diseases are the result of bodily imbalances—too much heat or coolness—that must be counteracted through dietary and behavioral changes or medicines that will restore balance.

Umbanda is a popular religion in Brazil and, increasingly, worldwide. Its ceremonies are devoted to healing through spiritual means. In this session, tourists at the back of the room watch as Umbanda followers perform a dance related to a particular deity.

1. What is your opinion on the role of spirituality in health and healing, and on what do you base your view?

Humoral healing systems have been practiced for thousands of years in the Middle East, the Mediterranean, and much of Asia. In the New World, indigenous humoral systems exist and sometimes blend with those that Spanish colonialists brought with them. Humoralism has shown substantial resilience in the face of WBM as a source of healing for many people. Local people also reframe WBM in classifying biomedical treatments as either heating or cooling.

In Malaysia (see Map 1.1), several humoral traditions coexist, reflecting the region’s history of contact with outside cultures. Malaysia has been influenced by trade and contact between its indigenous culture and that of India, China, and the Arab-Islamic world for around 2,000 years. Indian, Chinese, and Arabic health systems all define health as the balance of opposing elements within the body, although each has its own variations (Laderman 1988). Indigenous belief systems may have been compatible with these imported models because they also were based on concepts of heat and coolness.

Insights into these indigenous systems before outsiders arrived come from accounts about the Orang Asli, indigenous peoples of the interior of the Malaysian peninsula who are relatively unaffected by contact. A conceptual system of hot–cold opposition dominates Orang Asli cosmological, medical, and social theories. The properties and meanings of heat and coolness differ from their counterparts in Islamic, Indian, and Chinese humoralism in several ways. In the Islamic, Indian, and Chinese systems, for example, death is the result of too much coolness. Among the Orang Asli, excessive heat is the primary cause of mortality. In their view, heat emanates from the sun and is associated with excrement, blood, misfortune, disease, and death. Humanity’s hot blood makes people mortal, and their consumption of meat speeds the process. Heat causes menstruation, violent emotions, aggression, and drunkenness.

Coolness, in contrast, is vital for health among the Orang Asli. Staying in the forest protects against the harmful effects of the sun. Following this logic, the treatment of illness aims to reduce or remove heat. If someone were to fall ill in a clearing, the entire group would relocate to the coolness of the forest. The forest is also a source of cooling leaves and herbs. Healers are cool and retain their coolness by bathing in cold water and sleeping far from the fire. Extreme cold, however, can be harmful. Dangerous levels of coolness are associated with the time right after birth, because the mother is believed to have lost substantial heat. The new mother should not drink cold water or bathe in cold water. She increases her body heat by tying sashes around her waist that contain warmed leaves or ashes, and she lies near a fire.

Healers

In an informal sense, everyone is a “healer,” because self-diagnosis and treatment are likely the first steps when anyone feels ill. Yet, in all cultures, some people become recognized as having special abilities to diagnose and treat health problems. Cross-cultural evidence indicates some common features of healers (Figure 5.3).

In various cultures, specialists include midwives, bonesetters (those who reset broken bones), shamans or shamankas (male or female healers, respectively, who mediate between humans and the spirit world), herbalists, general practitioners, psychiatrists, nurses, acupuncturists, chiropractors, dentists, and hospice care providers. Some healing roles may have higher status and more power and may receive higher pay than others.

Midwifery is an example of a healing role that is endangered in many parts of the world because birth has become increasingly medicalized and brought into the institutional realm of the hospital rather than the home. The term midwife refers to a person, usually female, who has formal or informal training in assisting a woman to give birth. In Costa Rica, a government campaign to promote hospital births with a biomedical doctor in attendance achieved a rate of 98 percent of all births taking place in hospitals by the end of the twentieth century (Jenkins 2003). This achievement means that midwives, especially in rural areas, can no longer support themselves, and they are abandoning their profession. The promotion of hospital births has destroyed the positive elements of community-based midwifery and its provision of social support and techniques such as massage for the mother-to-be.

Healing Substances

Around the world, thousands of natural or manufactured substances are used as medicines for preventing or curing health problems. Anthropologists have spent more time studying the use of medicines in non-Western cultures than in the West, although a more fully cross-cultural approach is emerging that also examines the use and meaning of Western pharmaceuticals (Petryna, Lakoff, and Kleinman 2007).

These boys are selling hyssop, a medicinal herb, in Syria. In Unani (Islamic) traditional medicine, hyssop is used to alleviate health problems such as asthma.

1. Do research to learn more about hyssop and its medicinal uses.

Phytotherapy is healing through the use of plants. Cross-culturally, people use many different plants for a wide range of health problems, including gastrointestinal disorders, skin problems, wounds and sores, pain relief, infertility, fatigue, altitude sickness, and more (see Eye on the Environment). Increasing awareness of the range of potentially useful plants worldwide provides a strong incentive for protecting the world’s cultural diversity, because it is people, especially indigenous people, who know about botanical resources (Posey 1990).

Leaves of the coca plant have for centuries been a key part of the health system of the Andean region of South America (Allen 2002). Coca is important in rituals, in masking hunger pains, and in combating the cold. In terms of health, Andean people use coca to treat gastrointestinal problems, sprains, swellings, and colds. The leaf may be chewed or combined with herbs or roots and water to make a maté (MAH-tay), a medicinal beverage. Trained herbalists have specialized knowledge about preparing matés. One maté, for example, is for treating asthma. The patient drinks the beverage, made of a ground root and coca leaves, three to four times a day until cured.

Minerals are also widely used for prevention and healing. For example, many people worldwide believe that bathing in water that contains high levels of sulfur or other minerals promotes health and cures ailments such as arthritis and rheumatism. Thousands of people every year go to the Dead Sea, which lies beneath sea level between Israel and Jordan, for treating skin diseases. Bathing in the sulfur springs near the Dead Sea and plastering oneself with mud from the shore provide relief from skin ailments such as psoriasis. Throughout East Asia, including Japan, bathing in mineral waters is popular as a health-promotion practice.

In a more unusual practice, thousands of people worldwide visit “radon spas” every year, seeking the therapeutic effects of low doses of radon gas to alleviate the symptoms of arthritis and other afflictions. In the United States, many radon spas are located in mines in the mountains of Montana (Erickson 2007). At one such spa, the Free Enterprise Mine, the recommended treatment is to go into the mine for one-hour sessions, two or three times daily, for up to a total of about 30 sessions. The mine contains benches and chairs, and clients read, play cards, chat, or take a nap. Some “regulars” come back every year and make plans to meet up with friends from previous visits.

Guests are undergoing radon treatment at the Kyongsong Sand Spa in Haonpho-ri, North Korea. The spa, and its hot spring, has a 500-year history as a healing center. The treatment shown here is a “sand bath” used for chronic diseases such as arthritis, postoperative problems, and some female problems.

Pharmaceutical medicines are increasingly popular worldwide. Although these medicines have many benefits, negative effects include overprescription and frequent use without a prescription. The sale of patent medicines is often unregulated, and self-treating individuals can buy them in a local pharmacy. The popularity and overuse of capsules and injections has led to a growing health crisis related to the emergence of drug-resistant disease strains.

Guests are undergoing radon treatment at the Kyongsong Sand Spa in Haonpho-ri, North Korea. The spa, and its hot spring, has a 500-year history as a healing center. The treatment shown here is a “sand bath” used for chronic diseases such as arthritis, postoperative problems, and some female problems.

Pharmaceutical medicines are increasingly popular worldwide. Although these medicines have many benefits, negative effects include overprescription and frequent use without a prescription. The sale of patent medicines is often unregulated, and self-treating individuals can buy them in a local pharmacy. The popularity and overuse of capsules and injections has led to a growing health crisis related to the emergence of drug-resistant disease strains.

Situated in the Andes Mountains, Bolivia is the lowest-income country in South America, although it is rich in natural resources, including the second largest oil field in South America after Venezuela. The population of 10 million includes a majority of indigenous people of nearly 40 different groups. The largest are the Aymara-speaking (2 million) and Quechua-speaking groups (1.5 million). Thirty percent of the population is mestizo, of mixed descent, and 15 percent is of European descent. Two-thirds of the people are low-income farmers. The official religion is Roman Catholicism, but Protestantism is growing. Religious syncretism is prominent. Most people speak Spanish as their first language, although Aymara and Quechua are also common. Bolivia’s popular fiesta known as El carnival de Oruro is on UNESCO’s list of Intangible Cultural Heritage. In 2014, the government started building a mass-transit aerial cable system linking the capital city, La Paz, with its neighbor city, El Alto, the highest city in the world and the city in Latin America with the largest Indian population.

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