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MEDICAL ANTHROPOLOGY, VAN DER GEEST ANTH 168: Anthropology of Health 3 BS HS | PROF Luisa Dela Cruz | SEM 1 2024 Ethnography focused on indigenous beliefs and pra...

MEDICAL ANTHROPOLOGY, VAN DER GEEST ANTH 168: Anthropology of Health 3 BS HS | PROF Luisa Dela Cruz | SEM 1 2024 Ethnography focused on indigenous beliefs and practices related to MEDICAL ANTHROPOLOGY health, illness, and healing MEDICAL ANTHROPOLOGY Indigenous = non-western cultures Study of medical phenomena as social and cultural phenomena Excluded ideas within biomedicine Medical Looked at medical ideas as religious and magical beliefs ; therapeutic ○ Imperious adjective → implies that MA is interested in medical sciences or branch of practices as rituals anthropology in service of medicine → IT IS NOT ○ Culture and personality studies ○ Anything related to health, well-being, sickness, and treatment of ill-health Focused on differing personality traits and psychological disorders in Anthropology various cultures → Accounted for these differences by linking them to ○ Equipped w/ all methodological, epistemological, and theoretical tools and ideas different patterns of socialization and values Emic viewpoint Cultural productions of psychic identities and mental health Intersubjectivity ○ International public health Reflexivity Advised policymakers and health professionals on local ideas and Explorative customs and other factors that might conflict w/ biomedical principles Informal Interpretive VIRCHOW, GRODDECK, WEIZACKER Participatory Virchow ○ Pointed out links between social and economic conditions and ill-health POPULARITY OF MA Groddeck Offers wide and fascinating field for ethnography ○ Student of Virchow ○ Wide: There is virtually nothing that can’t be related to health and sickness ○ Argues for distinction between disease and falling ill before meanings of disease, ○ Fascinating: Teases out social and cultural constructions from experiences that illness, and sickness appear to be naturally given Weizacker Offers possibility of practicing “useful” anthropology ○ Argued against dominance of biomedicine and its physicalist concept of disease ○ Insights can be applied in practical work → Enhance health and well-being ○ Saw disease as a meaningful sign of human distress Fertile field for anthropological theorizing Expression of unsolved conflicts ○ Focus on boundaries of what can be called “cultural” demands new ways of thinking ○ Also emphasized the importance of total context of ill-health about what constitutes human life Illness takes place in the pathology of family, marriage, upbringing, ○ Boundaries → emotion, subjectivity, intersubjectivity, empathy, morality, suffering, etc. and work HISTORY OF MA HISTORY OF MA (Cont.) Predecessors First predecessors of MA were often medical professionals ○ Physical anthropology ○ Doctors who worked outside their own society that stumbled on cultural practices Practice within biomedical research and study relations between that clashed w/ their biomedical concepts → Forced them to pay attention to these bodily processes and sociocultural practices “other” medical ideas and practices Sought to find evidence for different stages of physical and psychic Cultural anthropologists evolution among “primitive” populations → Very racist, justified ○ Overlooked health and medicine as suitable topics for cultural study colonialism ○ Studied diseases and way people tried to treat these but never explored these as Now known for forensic work in hospitals/labs both cultural and medical Overlap w/ MA is most present in ecological perspective Ethnocentrism ○ Ethnomedicine ○ Indigenous medical practices were not taken seriously BS Health Sciences ‘24 - ‘25 | Rafa Diaz |1  MEDICAL ANTHROPOLOGY, VAN DER GEEST ANTH 168: Anthropology of Health 3 BS HS | PROF Luisa Dela Cruz | SEM 1 2024 ○ Anthropologists rarely studied their own society and not institutions/practices from and in social function; the field of science → Science was science, not culture Diseases, in the scientific paradigm of modern medicines, are ○ Paradoxical consequence: Critical medical professionals started to reflect on social, abnormalities in the structure and function of body organs and cultural, and political implications of biomedicine before anthropologists (e.g. systems. Virchow, Groddeck, Weizacker) ○ As a tool for tracing other, subtler differences in perceiving and defining sickness, this distinction has proven very useful. ECOLOGICAL PERSPECTIVE ○ Now it is gradually being discarded. It has served a purpose, but also caused View culture as human adaptation to environment confusion. ○ Health = result of successful adaptation to environmental challenges Source of confusion: ○ Sickness = outcome of failure to adapt ○ Ethnocentric use of the term “disease,” which seemed to presume to be “the real Human body consistently exposed to environmental inputs thing”, that is the professional and Western scientific definition, ○ Because the organism is slow to adapt to environmental changes → people devise ○ Whereas “illness” was relegated to a label for somewhat naive lay beliefs, where cultural means to protect their body (wearing clothes, building houses); “lay” apparently = the thinking of both patients and non-Western practitioners. ○ Cultural adaptation is also believed to affect genetic adaptation in the long run However, for the study of the practitioner–patient relationship, the distinction between Ecological orientation in MA operates in collaboration with demography, epidemiology, illness and disease has been of great importance. biology, and other natural sciences ○ It has enabled researchers to perceive vast communication gaps between patients Rarely uses the conventional anthropological tools of participant observation, informal and doctors. conversation, and empathy. Prefers measurement to qualitative insight, objectivity to intersubjectivity, population to Explanatory model individual. ○ Suggested by Kleinman (1980) ○ Therefore, it has contributed little to a deeper understanding of experiences of ○ Assumed that different actors in medical encounters develop their own explanations sickness, suffering, and care in accordance with their own ideas and concerns. Ecology-oriented medical anthropologists have shown how diseases are related to ○ Symptoms of sickness were seen as “symbolic” = they referred to problems and pathogenic factors in the environment. distress that were not directly expressed. ○ Classic example: solving the mystery of kuru, a neurological disease in Papua New Guinea, found to be related to the practice of cannibalism during funeral Narratives became a favored tool to get nearer to the existential experience of sickness, ceremonies. pain, and medical treatment ○ They provide the patient (but also those involved in cure and care) maximum INTERPRETIVE/ SEMIOTIC PERSPECTIVE freedom to tell and illustrate their point of view and experience Very different from the ecological perspective ○ They are typically performances and “accounts”: that is, they not only present but Practiced by a majority of medical anthropologists from the 1980s until today also “defend” and justify the speaker’s interests in the matter Medical anthropologists began to look at health, illness, care, and cure as meaningful “Public accounts”→ comply with and confirm the accepted social experiences. norms ○ Inspired by phenomenology, hermeneutics, and Geertz’s plea for a semiotic “Private accounts” → reveal the personal experiences and further the anthropology interests of the speaker. Attention shifted back to the “native’s point of view.” ○ Narratives do not always “exist” in a crystallized form ready for performance but may Important interpretive contribution by MA: the distinction between “illness” and “disease,” also be created and improvised in concrete situations. first proposed by Fabrega. ○ Eisenberg’s description was: “Patients suffer ‘illnesses’; physicians diagnose and Body as “the existential ground of culture” (Thomas Csordas) treat ‘diseases’” ○ Inspired by the phenomenological work of the French philosopher Merleau-Ponty on Illnesses are experiences of disregarded changes in states of being the body as a subject (corps sujet) and Bourdieu’s concept of “habitus” as the BS Health Sciences ‘24 - ‘25 | Rafa Diaz |2  MEDICAL ANTHROPOLOGY, VAN DER GEEST ANTH 168: Anthropology of Health 3 BS HS | PROF Luisa Dela Cruz | SEM 1 2024 “socially informed body” ○ This concept has been particularly fruitful in studies that challenge reports of ○ Embodiment → Csordas coined this term for the biological incorporation into the “victimization” of vulnerable groups. body of the social and material world. Example: James Scott’s study of “everyday resistance” by Malaysian ○ There is no other way to be in the world and to perceive and sense the world than peasants through our bodies. Summary: ○ The body is the nexus of the multiple strings that attach us to the world. ○ The early transactionalist studies focused on the agency of the strong who ○ It is the “book” that can be read to explore our lives. successfully pursue their interests and by doing so transform society, The body and embodiment are now central concepts in medical anthropology and ○ In the later phase attention was more directed to the weak who manage to eke out a cultural anthropology at large. measly existence without changing the “objective” conditions of their life. Two outstanding monographs in which the body is presented as a locus of suffering, dependency, and control: CRITICAL/ POLITICAL-ECONOMIC 1. Autobiographic “ethnography” of Robert Murphy (1987) about a progressive tumor The origins and spread of disease have been shown in many instances to be closely in his spinal cord which led to disability and ultimately to his death related to the working of a capitalist economy. 2. Emily Martin’s (1987) feminist critique of the medicalization of the female body as a Morbidity and mortality patterns reveal statistical associations with socioeconomic children-producing machine. parameters Qualitative case studies demonstrate how poverty and exploitation constitute enormous AGENCY barriers for healthy living. The present interest in agency, as social maneuvering or navigating to secure one’s Modern Western health care interests, was preceded by “transactionalism.” ○ a product as well as a producer and reproducer in a capitalist tradition. ○ Transactionalist theory was originally formulated as an explicit critique of structural ○ It is part of a system in which profit is a primary aim. functionalism. On the global and the local scale, health services are a commodity mainly available for People were seen as self-interested manipulators defying rules, as those who can afford to buy them = higher social classes. individuals fighting for their own private or family interests, as Paul Farmer’s Infections and Inequalities (2001) “entrepreneurs.” ○ Exposed the disparities in health and health care Key concepts: patronage and clientelism, brokerage, network, and the ○ Question: why do certain people “die of infections such as tuberculosis, AIDS and “strong man” malaria while others are spared this risk”? ○ Functionalists emphasized continuity in culture and looked at the community, ○ Answer: social inequality, poverty, structural violence, gender inequality, and racism transactionalists change and at the individual. Local and global inequalities in health The penetration of a capitalist economy brought with it more freedom for individuals ○ Increasingly addressed and analyzed in Foucauldian rather than in Marxist terms ○ New opportunities for the individual included: ○ The focus shifted from what accounts for health in equality to the political force that private wages, property, and career, free(er) partner choice, increased health and medicine possess personal mobility, and a more individual-oriented ideology. ○ Foucault: medicine, together with criminal justice, → political instrument to exercise Healthcare proceeded accordingly, modulating from largely kinship- or community-based control (“biopower”). therapy to more private practices. Body politic (Scheper-Hughes and Lock, 1987) ○ Medical practitioners were seen as entrepreneurs and patients as clients. ○ Reveals the vulnerability of people in their bodily existence, which needs the care ○ It was essentially individual oriented (defining disease as an individual problem, and and cure that the state can provide or withhold, or can use to exclude individuals preferring to treat patients in isolation from their community). from society ○ It was “commodified”: everything was for sale. Agency ○ Used to demonstrate that people are able to manage their affairs and defend their interests in spite of repression and apparent loss of autonomy. BS Health Sciences ‘24 - ‘25 | Rafa Diaz |3  MEDICAL ANTHROPOLOGY, VAN DER GEEST ANTH 168: Anthropology of Health 3 BS HS | PROF Luisa Dela Cruz | SEM 1 2024 APPLIED MEDICAL ANTHROPOLOGY The number of journals that accommodate the work of medical anthropologists has Regarded as superficial and divested of theoretical reflection. increased at least fivefold since the 1980s. It is “thin” to please the non-anthropological parties that are responsible for policy and Next to these are journals for specific themes within medical anthropology such as practical interventions. children, aging, sexuality, care, science and technology, methodology, and HIV/ AIDS. Critical medical anthropology is only credible if it leads to action Teaching courses in medical anthropology can now be found across the globe, including Craig Janes and Kitty Corbett: “the ultimate goal of anthropological work in and of global in a growing number of “developing countries.” health is to reduce global health inequities and contribute to the development of Job opportunities for medical anthropologists are relatively favorable thanks to the sustainable and salutogenic sociocultural, political, and economic systems” perceived relevance of their specialization for the improvement of human life conditions Four areas where anthropologists are well equipped to contribute to this objective: and the political importance attached to health and health care. ○ In-depth ethnography which shows how health inequalities work and are maintained Two remarkable shifts in the development of medical anthropology: in concrete social settings; 1. The “homecoming” or de-exoticization of medical anthropology: ○ Analysis of the impact of “global technoscience” on local worlds; For a long time (medical) anthropologists were preoccupied with “others” ○ Critical examination of the role of international health programs and policies; and their health related beliefs and practices and overlooked the social ○ Study of the social and health effects of the proliferation of local private and cultural dimension of medicine in their own society. organizations and NGOs. ○ The old divide between “developed” and “developing” societies seems slowly to be losing its significance. MEDICAL ANTHROPOLOGY TODAY 2. Medical anthropologists who used to be mainly concerned about social and cultural Remarkable development: the growing interest and involvement of medical impacts on health and medical practice have now turned about and are exploring anthropologists in biomedical science and technology. how medicine shapes culture and society. Recent work addresses topics like: Health and medicine — key values that constitute the quality of life. ○ Genetics (Sarah Gibbon, Margaret Lock, Gísli Pálsson), In studying health in its many ramifications, anthropologists are able to grasp crucial ○ New epidemics (Paul Farmer, João Biehl, Didier Fassin), meanings that people attach to their lives ○ “Biopolitics” (Vinh-Kim Nguyen, Nikolas Rose), ○ “Biosociality” (Paul Rabinow), ○ “Biological citizenship” (Adriana Petryna), ○ Organ transplantation and the organ trade (Lawrence Cohen, Nancy Scheper-Hughes, Aslihan Sanal), ○ Clinical trials (Adriana Petryna), ○ Pharmaceuticals (Anita Hardon, Sylvie Fainzang, Mark Nichter), ○ Reproductive technologies (Marcia Inhorn, Rayna Rapp, Viola Hörbst, Sarah Franklin), ○ Aging (Lawrence Cohen, Mike Featherstone), ○ Disability (Benedicte Ingstad, Susan Whyte), ○ HIV/AIDS (Alice Desclaux, Hansjörg Dilger, Fred Le Marcis), ○ Death and dying (Sharon Kaufman, Margaret Lock) – and so on. Research sites are moving to laboratories, hospitals, offices of health organizations and ministries, and pharmaceutical companies. Biological variation ○ Its importance emphasized in a recent work by Margaret Lock and Vinh-Kim Nguyen) ○ The result of the ceaseless entanglement of human biology with evolutionary and environmental forces in addition to historical, political, economic, social, and cultural variables. BS Health Sciences ‘24 - ‘25 | Rafa Diaz |4  HEALTH: HOW SHOULD WE DEFINE IT? MACHTELD HUBER (2011) The current WHO definition of health, formulated ○ WHO has developed several in 1948, describes health as “a state of complete systems to classify diseases and physical, mental, and social well-being and not describe aspects of health, merely the absence of disease or infirmity.” disability, functioning, and quality of life. LIMITATIONS OF WHO DEFINITION ○ Yet because of the reference to a Most criticism of the WHO definition concerns the complete state, the definition absoluteness of the word “complete” in relation to remains “impracticable, because well-being. ‘complete’ is neither operational 1. The first problem is that it unintentionally nor measurable.” contributes to the medicalization of society. NEED FOR REFORMULATION ○ The requirement for complete Various proposals have been made for health “would leave most of us adapting the definition of health. The best unhealthy most of the time.” known is the Ottawa Charter, which emphasizes social and personal resources Analysis: The limitations of the current definition as well as physical capacity. are increasingly affecting health policy. ○ However, WHO has taken up none of these proposals. *The persistent emphasis on complete physical Nevertheless, the limitations of the current well-being could lead to large groups of people definition are increasingly affecting health becoming eligible for screening or for expensive policy. interventions even when only one person might ○ For example, in prevention benefit, and it might result in higher levels of programs and healthcare, the medical dependency. definition of health determines the outcome measures: health gain in 2. The second problem is that since 1948, survival years may be less relevant the demography of populations and the than societal participation, and an nature of disease have changed increase in coping capacity may be considerably. more relevant and realistic than ○ Disease patterns have changed, complete recovery. with public health measures such Redefining health is an ambitious and as improved nutrition, hygiene, and complex goal; many aspects need to be sanitation and more powerful considered, many stakeholders consulted, healthcare interventions. and many cultures reflected, and it must also take into account future scientific and *Aging with chronic illnesses has become the technological advances. norm, and chronic diseases account for most of The preferred view on health was “the the expenditures of the healthcare system, putting ability to adapt and to self-manage.” pressure on its sustainability. The definition should be replaced by a In this context, the WHO definition concept or conceptual framework of becomes counterproductive as it declares health. people with chronic diseases and ○ A general concept, according to disabilities definitively ill. sociologist Blumer, represents a characterization of a generally 3. The third problem is the agreed direction in which to look, operationalization of the definition. as reference.  ○ But operational definitions are also affected by external conditions such as needed for practical life such as social and environmental challenges. measurement purposes. ○ By successfully adapting to an illness, people are able to work or The first step towards using the concept of to participate in social activities “health, as the ability to adapt and to and feel healthy despite limitations. self-manage” is to identify and characterize it If people are able to develop successful for the three domains of health: strategies for coping, (aged-related) impaired functioning does not strongly Physical Health change the perceived quality of life, a In the physical domain, a healthy phenomenon known as the disability organism is capable of “allostasis”—the paradox. maintenance of physiological homeostasis through changing circumstances. MEASURING HEALTH ○ When confronted with The general concept of health is useful for physiological stress, a healthy management and policies, and it can also organism is able to mount a support doctors in their daily protective response, to reduce the communication with patients because it potential for harm, and restore an focuses on empowerment of the patient (adapted) equilibrium. (for example, by changing a lifestyle), which the doctor can explain instead of Mental Health just removing symptoms by a drug. In the mental domain, Antonovsky ○ However, operational definitions describes the “sense of coherence” as a are needed for measurement factor that contributes to a successful purposes, research, and evaluating capacity to cope, recover from interventions. psychological stress, and prevent Measurement might be helped by post-traumatic stress disorders. constructing health frames that ○ The sense of coherence includes systematize different operational the subjective faculties enhancing needs—for example, differentiating the comprehensibility, between the health status of individuals manageability, and meaningfulness and populations and between objective of a difficult situation. and subjective indicators of health. ○ A strengthened capability to adapt The measurement instruments should and to manage yourself often relate to health as the ability to adapt and improves subjective well-being and to self-manage. may result in a positive interaction Good first operational tools include the between mind and body. existing methods for assessing functional status and measuring quality of life and Social Health sense of well-being. Several dimensions of health can be identified in the social domain, including: CONCLUSION ○ People’s capacity to fulfill their Just as environmental scientists describe potential and obligations the health of the earth as the capacity of a ○ The ability to manage their life with complex system to maintain a stable some degree of independence environment within a relatively narrow despite a medical condition range, we propose the formulation of ○ The ability to participate in social health as the ability to adapt and to activities, including work self-manage. Health in this domain can be regarded as a dynamic balance between opportunities and limitations, shifting through life and  Medical Anthropology and Epidemiology: ○ Until it became an elective in medical Diverges or Converges? schools in US (Inhorn, 1995) ○ Physicians interested in public health take further studies/specializations in this field as Main Idea: With the lack of interdisciplinary it is not offered in undergrad and med anthropological-epidemiological research due to the schools perceptions among medical anthropologists that MA and Problem encountered by both MA and EPI: hard to epidemiology diverge, there is a greater call for collaboration translate epistemological assumptions to clinical through identifying five of these perceived areas of divergence medicine as epidemiology is population and and attempting to reconceptualize them as areas of public-health-based without clinical intervention convergence. ○ This similar structural positions vis a vis biomedicine should unite the two fields Introduction CONCLUSION: epidemiology and medical anthropology tackle Trostle: noted that despite historical efforts of collaborating the different perceptions of disease but converge in the problem two fields, it has been one of “benign neglect,” many “missed of translating these into clinical interventions opportunities” and active “schism.” 2. Epidemiology is reductionistic and positivistic; FIVE MAJOR AREAS OF DIVERGENCE anthropology is holistic and humanistic as perceived by medical anthropologists Epidemiology is seen as a highly scientific, - These areas may have prevented interdisciplinary computer-laboratory-based from of connections from flourishing number-crunching, devoid of human interactions - Hence, reconceptualized as areas of convergence to ○ Not a monolithic enterprise, not all produce studies that are greater than the sum of epidemiologists are reductionists (narrowly their individual anthropological or epidemiological focused on limited conceptions of diseases) contributions. ○ Neither lacking in breadth, interdisciplinary Disclaimer: Article is not about RRL but on sparking vigor and critical reflexivity conversation and discussions, with existing schisms to be ○ Some epidemiologists are broad and bridged. holistic, even anthropological ○ 19th Century epidemiological studies 1. Epidemiologists study biomedically defined attended to both behavioral and social diseases; anthropologists study illness experiences factors Epidemiology: the study of the distribution and ○ Positivistic discipline: inherently apolotical, determinants of diseases and injuries in human ahistorical and acultural, decontextualized populations perspective ○ Disease-oriented and disease as a Western ○ BUT epidemiology has considered the biomedical construct political-economic nature of numerous ○ Disease: abnormalities in the sturcture health problems and/or function of organs and organ MA is seen as highly interactive and interpretive, systems; pathological states whether or not intensive encounter with real people they are culturally recognized CONCLUSION: Epidemiology is not solely scientific, but it also Misconceptions: disease is objective takes into account culture relative to people’s lived and culture-free experiences, similar to MA. BUT disease itself is a cultural construction as evidenced by: 3. Epidemiology and Anthropology employ different 1. Rapidly changing state of affairs in biomedical methods definitions of disease states Epidemiology 2. Degree to which ‘folk models’ permeate ○ Said to use narrow “scientism” through biomedical physician’s notions of disease scientific methodology (aka methodolatry) definition and causation (technical terms vs ○ HOWEVER, vast epi studies are not folk language) experimental but are observational 3. Degree to which biomedical definitions of ○ MA studies are participant observational; disease and disease causation differ from one with a similar method of EPI through talking cultural context to another with people (interview, FGDs) Paradigm Shift: when both fields combine their Difference in methods: scope rather than kind definitions of multiple causes of illness (research designs and data analysis methods) Epidemiology & MA is not necessarily uncritical in ○ MA has greater variety of methods and less accepting biomedical notions of disease normative methodological standards ○ ex. Social epidemiology (study of the social ○ EPI deals with larger sample sizes and work relations of poor health rather than narrowly with people who do not view themselves defined disease outcomes) connected in any way Epidemiology is a mere ‘handmaiden’ of biomedicine Some (ex. Genetic epidemiology) ○ Rather, it is a statistical discipline of work with small sample sizes of biomedicine where epidemiology is a public individuals who are often related health specialty  ○ Similar in data collection: interviewing, archival research, and record view Many MA are attracted to epidemiology due to ‘methodological fit’ Given the increasing number of dually (both working on the convergence of the two fields) trained individuals, synthetic studies are expected to increase CONCLUSION: there are no fixed rules dividing the two on a methodological basis; they have greater similarities than differences. 4. Epidemiology ‘blames victims’ for their ‘risky’ behaviors; anthropology examines the macro-level conditions giving rise to those behaviors Cause of this perception: EPI is concerned with the relationship between human behavior and disease leading to victim blaming BUT epidemiology is population-based ○ Identifying population-based behavior is not the same as ‘blaming individuals’ or their cultures ○ It’s only failure is that it never went beyond mere identification of the behavior and attempting to explain these in the cultural context of a population ○ It asks who, what, when, where, how, but NOT why MA resolves this gap by attempting to explain but not blame CONCLUSION: epidemiology identifies (not blames) the risk factors from the population-based behavior and culture, and MA tries to comprehensively and contextually explain these to the people 5. Epidemiology generates ‘risk’ and medicalizes life; anthropology critiques ‘risk’ and attempts to alleviate human suffering EPI may overmedicalize life by identifying and providing definitions of risky behavior, at-risk groups and risk-reduction strategies ○ Can be taken advantage of by the biomedical community (pharmacies, laboratories, etc.) HOWEVER, both EPI and MA share the major goal of producing knowledge to alleviate human suffering ○ Useful in prevention Need for an alternative discourse on risk, one that is concerned with disease, debility, and death (not just one aspect but all and its overlaps) of the many less privileged areas in the world CONCLUSION: Both EPI and MA share the goal of producing knowledge to alleviate human suffering ARTICLE CONCLUSION Synthetic, interdisciplinary anthropological-epidemiological research is relatively rare because of the predominant areas of divergence. However, the convergence of the two must be understood to obtain a valuable opportunity to move the discipline in exciting new directions.  Anthropology in the Clinic: The Problem of Cultural Anthropologists and Clinicians Competency and How to Fix It ○ Common belief: primacy of experience (Kleinman & Benson, 2006) Empathizing with the lived experiences of the patient to INTRODUCTION: The lack of evidence on the value of cultural understand the illness competence for professional care-giving is a failure of outcome research to take culture seriously enough to routinely assess THE EXPLANATORY MODELS APPROACH the cost-effectiveness of culturally informed therapeutic An interview technique that tries to understand how practices, NOT a lack of effort to introduce culturally informed the social world affects and is affected by illness strategies into clinical settings. Used to start a conversation and not to end one When human illness is recast to a technical disease PROBLEMS WITH CULTURAL COMPETENCY categories, experience is lost 1. It suggests that culture can be reduced to a technical Explanatory models open physicians to human skills for which clinicians can be trained to develop communication and set their expert knowledge aside expertise a. Culture is often made synonymous with “Mini-Ethnography” ethnicity, nationality and language 1. Ethnic identity b. Cultural competency becomes a set of “do’s ○ Talk about ethnic identity and determine and don’ts” that define how to treat a what matters to the patient patient given their ethnic background ○ Acknowledge and affirm a person’s 2. The idea of isolated societies with shared cultural experience of ethnicity and illness meanings would be rejected by anthropologists ○ Ethnicity is not an abstract identity but a today, since it leads to dangerous stereotyping. vital aspect of how life is lived a. Generalizing culture to the whole population ○ Rather than assuming (which can lead to (Japanese believe that.. Chinese believe dangerous stereotyping), ask the patient. that..) 2. What is at stake? 3. Cultural factors may hinder a practical understanding ○ Close relationships, material resources, a. Historically, culture is defined in the domain religious commitments of patient and family 3. The illness narrative 4. Culture of biomedicine ○ A series of questions aimed at acquiring an a. Source of stigma and racial bias across understanding of the meaning of illness minority groups ○ Clinician should be open to cultural differences in local world, and the patient CULTURE IS NOT STATIC should recognize that doctors do not fit a Culture is not homogenous or static, having multiple certain stereotype variables 4. Psychosocial stress ○ Inseparable from economic, political, ○ Ongoing stresses and social supports that religious, psychological and biological characterize people’s lives conditions Ex. family tensions, work problems, financial ○ It is a process through which ordinary difficulties activities and conditions take on an ○ Propose interventions to improve patient’s emotional tone and moral meaning for life participants 5. Influence of culture on clinical relationships ○ Cultural processes include the embodiment ○ One critical tool in ethnography is the critical of meaning BUT it frequently differ within self-reflection that comes from the the same ethnic group due to individual unsettling but enlightening experience of differences (age, class, gender, personality) being between social worlds. ○ Unpack the formative effect including bias, THE IMPORTANCE OF ETHNOGRAPHY inappropriate technology interventions and Ethnography is the technical term used in stereotyping anthropology for its core methodology 6. The problems of cultural competency approach ○ An anthropologist’ description of what life is ○ Every intervention has potential unwanted like in a “local world” effects ○ Understanding the native’s point of view ○ Most serious side-effect of cultural through intensive and imaginative empathy competency is that the attention to cultural for their experiences difference can be interpreted by patients as Ethnography VS Cultural Competency intrusive and might cause feelings of being ○ Ethnography eschews the “trait list singled out and stigmatized approach” –culture as a set of already-known ○ Overemphasis on cultural difference can factors lead to identifying the cultural root of the ○ It emphasizes engagement with others and problem solves the issue the practices they do ○ It also emphasizes the ambivalence of being DETERMINING WHAT IS AT STAKE FOR THE PATIENT in both worlds Using culturally appropriate terms to explain people’s life stories helps health professionals restore a broken relationship and allows treatment to continue 1. Healthcare providers do not stigmatize or stereotype patients ○ It is a case study of an individual, and not as a representative of the whole population; hence, should not be generalized ○ Not all Chinese people eat specific food 2. Culture is not just for the patients, but also for health professionals ○ A physician too rigidly oriented around the classification system of biomedicine may find it unacceptable to use lay classifications for the treatment ○ The first ethical task in face of a person’s suffering is ACKNOWLEDGEMENT ○ Moral meaning of suffering is more important than cultural competency Know what is at stake for the patient on a deeper level CONCLUSION What clinicians need to understand through the mini-ethnography is what really matters for the patient and what is at stake. We should routinely ask the patients what matters for them in the experience of illness and treatment to arrive at thorough treatment decisions and negotiate with patients. Finding out what matters for a person is not a technical skill, but an elective affinity. As Franz Kafka said, a born doctor has a hunger for people. And its main thrust is to focus on the patient as an individual, not a stereotype; as a human being facing danger and uncertainty, not merely a case; as an opportunity for the doctor to engage in an essential moral task, not an issue in cost- accounting  WHAT COVID-19 MAY TEACH US ABOUT INTERDISCIPLINARITY ANNEMARIE MOL, ANITA HARDON (2020) Interdisciplinarity Good interdisciplinarity is not simply a matter of achieving Often cast as a matter of different disciplines looking at a shared completeness. Rather, it requires paying attention to the object from different perspectives such that each discipline diverse concerns of different disciplines and incorporating highlights a different aspect of that object. responsive negotiation of their collaborative possibilities and However, when different disciplines congregate, the sum total is the tensions between them. often not an easily assembled coherent picture. ○ It is crucial to achieve lucid insight into the ways in which On the contrary, the various conclusions reached by different different disciplines (or, for that matter, sub-disciplines and disciplines may well point in different directions. sub-sub-disciplines) operationalise their object of inquiry Different disciplines handle reality in different ways. and, each in their own way, respond to the concerns they ○ They draw on different techniques, address different share. concerns and operationalise their object of inquiry in different ways. They foster different paradigms. Quite like the proverbial apples and oranges, the various entities that researchers working in different disciplines study cannot simply be added together to create a meaningful whole. Thus, interdisciplinarity does not accord with the metaphor of the jigsaw puzzle in which each discipline adds a piece until ‘the whole picture’ is laid out on the table. Different disciplines engage with reality each in their own way. ○ These ways are not closed off to one another. Different disciplines readily draw on each other’s work and their prac titioners may collaborate. ○ However, it also happens that they pull and push in different directions. Hence, the tensions and clashes.  VERSIONS OF COVID-19 Virologists Clinicians Study all kinds of viruses, and their objects of inquiry include viruses’ genes, The starting point for clinicians is not the SARS-CoV-2 virus, but the ways it history, hosts, levels of virulence and transmission routes. affects its human hosts. ‘COVID-19 is a contagious disease due to an infection by a specific type of COVID-19 is a disease that causes havoc in the bodies of unfortunate coronavirus: SARS-CoV-2’. patients. The disciplines of virology and clinical medicine collaborate closely. For instance, the diagnostic tests that allow clinicians to ascertain if a patient is indeed infected with SARS-CoV-2 were crafted by virologists, while virologists learn from clinicians how the virus impacts its human hosts. Hence, while there are marked crossovers between pursuing a virus and treating a patient’s body, the precise objects that these two disciplines operationalise are not the same. Context: While clinicians were trying to save their patients’ lives, outside hospitals, preventive measures were implemented. These were oriented around blocking the most probable routes the virus might take from one host to another. People were warned to wash their hands, cough into their elbows and avoid handshakes. They were asked to maintain a significant distance between their bodies. Physicists Biomedical Researchers/Biomedodical Experts Started to wonder what distance might be significant enough, given the Wanted to know the probability of this transmission route resulting in people behaviour of fluids. becoming infected with SARS-CoV-2. They did not envision individuals, but They operationalised COVID-19 as a disease caused by a virus hitchhiking populations. from one body to the next, dissolved in bodily fluids, and set up laboratory Hence, they turned to infectious disease epidemiology, the discipline for experiments to discover how far bodily fluids travel. which COVID-19 is a contagious viral disease spreading in its own specific Might have shown that, under experimental conditions, aerosols may ways through human populations. possibly travel from one body to another. Epidemiologists Immunologists The transmission of the virus is not experimentally orchestrated but Researchers taking their cues from immunology do not invest in painstakingly counted and traced in real-life situations. transmission routes, but foreground the hosts. Then, there is the tracing, which requires detective work. COVID-19 is an infectious disease that stimulates immune systems in ○ Example: Is the outbreak among the members of a choir due to intriguingly diverse ways. their singing, or does a thorough investigation reveal that all those They underline that some people, once infected, are affected far less than infected gathered together in a small corridor for coffee after others, and wonder to which extent this the preparedness of their immune rehearsal? system may be involved in this. Note: Possible, probable and actual transmission routes are different phenomena and hence different objects to research. Even so, they share something in common: they are all transmission routes. ○ Studying them helps to shape the hygienic measures that seek to prevent the virus from reaching its human hosts.  The complexity becomes apparent in evaluations of the population-wide use of face masks. Within the logic of hygiene, face masks are meant to prevent the Within an immunological logic, the most significant characteristic of face transmission of virus. masks is not necessarily that they block the transmission of the virus, but Accordingly, evaluating their efficacy is a matter of comparing the number of that they might lower the transmitted dose. positive tests between regions where face masks are worn and regions The parameter of success for this particular use of face masks would not be where they are not. fewer positive tests; there might even be more positive tests than in populations not wearing face masks. ○ The parameter of success, in this case, would be the elicitation of a protective immune response, resulting in fewer cases of severe disease and fewer deaths. Economics The clash that so far has gained most public attention is that between the hygienic blocking of viral flows by means of lockdowns and the hampering of economic flows that results from them. Blocking economic flows, by contrast, is not similarly reversible, as it creates a downward spiral. Once businesses have gone bankrupt and jobs are lost, it is not obvious how to revitalise economies. For economics, COVID-19 is a threat to the economy as measures to block flows of the virus also block monetary flows. ○ This discipline does not disaggregate biological events from societal responses to it, as these jointly affect the economy. Moreover, the threat COVID-19 poses is worse in societies without a properly functioning welfare state, for when people without jobs have no money to spend, they cannot, once a lockdown ends, pay for the goods and services that might allow others to resume working and once more earn their keep. Hygiene and economics have different unities of calculation, which are graphed along different x-axes and y-axes, with recommendations that point in different directions—however, instead of simply clashing, they are also interdependent. Hence, just as successful lockdowns depend on people having sufficient food and appropriate housing, a vigorous economy depends on a sufficiently healthy population. Epidemiologists Anthropologists/Social Scientists Attempt to comprehend the pandemic by developing explanatory models. Social Scientists: COVID-19 is a multifaceted problem faced by particular Using as their input all kinds of data that impress them as suitable, they people, living under specific social and material conditions. hope to model the most likely routes according to which COVID-19 spreads ○ This means that, even if, thanks to WHO coordination, COVID-19 through human populations. has the same name across the globe, it is not the same reality everywhere. Social scientists share this investment in specificity with clinicians, who likewise take heed of the specificities of this singular patient in the here and now.  Similarly to research by physicists, epidemiological models aim for But while clinicians in intensive care units prioritise such variables as generality. oxygen saturation and blood levels of bradykinin, social scientists ○ These models are abstracted from single instances, so that they investigate such issues as overburdening due to double duties, suffering may travel unhindered around the globe. from loneliness, increases in domestic violence and deepening inequalities This approach conflicts with the investment in specificities current in due to lack of schooling. anthropology and other social sciences, where ‘human populations’ stand out as an undue abstraction. SUMMARY ANTH 168 Nasa dugo (‘It’s in the blood’): lay conceptions of hypertension in the Philippines (Lasco G, Mendoza J, Renedo A, et al., 2020) ○ -> contribute to the scholarly literature that focuses on lay conceptions of illness as forms of social knowledge in their own Key Terms/Concepts right that play a key role in framing illness and treatment experiences—many of which do not fit biomedical understandings Cultural beliefs of ‘disease’. - structure how people make sense of health and illness, forming Objective: Identify ways that Filipino patients with hypertension, ‘explanatory models’ which ‘offer explanations of sickness and particularly in low-income families, conceptualize their condition. treatment to guide choices among available therapies and therapists and to cast personal and social meaning on the experience of sickness.’ Folk physiology Methods - an explanatory model that can explain people’s perceptions of causes of hypertension, drawing from qualitative data We draw on qualitative data gathered in the mixed-method longitudinal Responsive and Equitable Health Systems—Partnership on Non-Communicable Blood Diseases (RESPOND) project which examines patient pathways and barriers to - the bodily element through which ‘high blood’ (which is how patients hypertension care in the Philippines and Malaysia. refer to hypertension) is experienced and made a reality for patients - changes in the blood were seen as the mechanism through which 71 semi-structured interviews (40 initial and 31 follow-up) and four focus hypertension is understood to operate in the body. group discussions with patients diagnosed with hypertension. The setting was urban and rural low-income communities in the Philippines. Background The usage of grounded theory enabled us to avoid being limited by preconceptions about hypertension, given that many of the research team Recognising the growing burden of non-communicable diseases, now have medical backgrounds and have experienced patients’ knowledge and affecting one in four Filipinos, with higher rates in urban areas, the understanding in clinical settings. Department of Health (DOH) is promoting health education and provision of antihypertensive medications. However, despite health promotion campaigns that have focused on modifiable risk factors such as tobacco and alcohol use, diet and exercise, hypertension prevention and control Findings remain a challenge, especially among low income patients with intention, knowledge and healthcare system factors serving as barriers to care. Blood is central to the ‘folk physiology’ of hypertension for many of our Most scholarly attention to hypertension in the Philippines has focused on participants. biomedical aspects of treatment, epidemiology and clinical outcomes, Aside from the term ‘high blood’, its literal Tagalog translation ‘mataas ang largely ignoring its social and cultural dimensions. dugo’ or ‘malakas ang dugo’ (strong blood’) were also used to refer to Understanding sociocultural factors that inform people’s attitudes to their hypertension. hypertension and treatment behavior: Hypertension exists for many of the participants because of changes in the ○ -> guide clinicians’ interactions with patients along different stages blood, particularly, in its perceived: of the care pathway and help policymakers craft communications 1. Viscosity strategies for health promotion. Blood can either be… ANTH 168 Nasa dugo (‘It’s in the blood’): lay conceptions of hypertension in the Philippines (Lasco G, Mendoza J, Renedo A, et al., 2020) ○ malabnaw (thin or watery) - associated with ‘low Views of heat as a trigger of hypertension can shape people’s blood’; behavior, including self-management, with participants using fans ○ malapot (thick or viscous) - associated with ‘high or avoiding heat to try to ‘lower’ their hypertension or maintain blood’; lead to various symptoms, like headache health. and a thickening of the neck. ○ Ex. Multiple electric fans were commonly used during 2. Temperature interviews ○ mainit (hot) or kumukulo (boiling) - linked to high As a way of addressing changes in hypertension blood pressure status, in addition to their immediate function of alleviating discomfort, particularly in urban areas 4 main overlapping causes for hypertension identified by the participants: where the humidity and daytime highs of 1. Namamana (‘Inherited’): folk genetics - The predisposition for having 32°C–35°C can be become overbearing in their hypertension is inherited, and that this genetic component is ‘nasa dugo’ small, tightly packed and poorly ventilated (in the blood). houses. Many study participants viewed hypertension as ‘namamana’ or These temperature-related ‘care’ practices were adapted to work inherited through blood. within the constraints of people’s livelihood and everyday Some viewed deaths among family members due to stroke or work. ‘atake sa puso’ (heart attack) as meaning that they could suffer ○ Ex. Cora, 62, a female farmer from Quezon Province the same fate. This notion of genetic risk is evidenced by shared: “Lucia, my friend, told me not to stay long under discourses around adherence to treatment and self management. the sun because my (blood) pressure might go up. My job There is also an underlying notion of this susceptibility being is farming so I’m always under the sun. If I cannot bear mediated by the blood. the heat, I go under a shade. I also wear a hat as a ○ Ex. As Kristina, a housewife from Quezon, mentioned: protection from heat.” “high blood that is inherited is natural to the body, it’s unavoidable, it just arrives.” Aside from signifying discomfort with high temperatures and This points to an understanding of people having humidity, heat also serves as a metaphor for anger and similar different types of blood depending in part with emotional states, as will be discussed in the following section. their family -> influence the seriousness they 3. ‘Stress’ - Physical and emotional stressors can lead to hypertension attach to hypertension prevention, diagnosis, likewise by causing blood to heat up. treatment and self-care. ○ Ex. Ernesto said: irritated, especially when it’s hot -> head 2. Init (Heat) - Hot weather or init (heat) can trigger episodes of hypertension will heat up -> body will be affected -> your blood will boil by causing blood to heat up or boil. -> BP is high. Heat is seen as a risk factor, taken seriously to a point that it ○ Ex. Phsyical stress: you had trip, you travel, you walk, informs certain practices. then you work again -> your blood pressure will increase. ○ Ex. Rosita’s BP sometimes goes down but because of However, not all strenuous activity is associated with stress fatigue and the heat, and it goes up again, so when they leading to ‘high blood’; physical exercise was recognised as sleep at night, all their windows are open. I: That’s why beneficial when done as a recreational activity—as opposed to you have a lot of electric fans here due to the heat. R: work-related physical effort, further highlighting the role of Very much. It can kill you. emotions in this explanation. ANTH 168 Nasa dugo (‘It’s in the blood’): lay conceptions of hypertension in the Philippines (Lasco G, Mendoza J, Renedo A, et al., 2020) 4. Pagkain (Diet) - Particular foods (and beverages) cause hypertension by Our study illustrates how these blood-based mechanisms create a making blood thicker and more malambot (viscous). dynamic non-chronic view of hypertension that draws from both local intake of foods they consider ‘unhealthy’ such as those that are knowledge and biomedical ideas. maalat (salty) and mataba (fatty). Michael Tan affirmed the role of blood in ‘folk genetics, reinforcing the Blood, once again, figures as the medium through which food ‘nasa dugo’ (in the blood) explanation from our participants. Tan also exerts its effects on hypertension: draws a link between heat and blood that bears striking parallels with the ○ Participants speak of eating too much food, particularly accounts we elicited. those perceived to be high in cholesterol, as causing The broader explanatory models that underline these attitudes need to be blood to be more malapot (viscous) -> bara (clogs) in the explored further: as others have documented, there are similar concepts in blood -> ‘high blood’ and the complications they attribute folk medicine in the region and elsewhere in the world. to it: stroke and heart attack. ○ For instance, humoural theory and the related ‘hot–cold The local notion of ‘cholesterol’—understood simply as a syndrome’, elements of which have been documented in the substance that comes from taba (fat)—is NOT the same as its use Philippines, may inform the emphasis on blood, heat and balance in biomedicine. that figure prominently in our participants’ narratives—and ○ Cheap foods - seen by the participants as having higher underwrite notions of balance and flow that are inherent in them cholesterol while expensive ones are seen as healthier and could inform their overall approach to health. ○ Specific foods are particularly high in cholesterol—like ○ ‘Grand’ explanatory models are rooted in long-running beliefs crab and pork skin. but explanatory models are iterative, incorporating biomedical Ex. In a coastal community with affordable crabs concepts and semantics. The challenge, then, is to document not for low-income households, one participant just explanatory models but how they evolve over time and explains that despite their accessibility, consuming across sociocultural contexts. too much can cause discomfort, so self-discipline and moderation are essential. Implications for policy and changes We see the immediacy of the food’s relationship to ‘high blood’; the fattiness or the perceived ‘cholesterol’ translates to These findings can inform the design of interventions that are tailored to symptomatology; it is perceived to have an immediate effect on local circumstances. However, by incorporating the lessons into clinical the body. Conversely, the inability to eat adequately is linked to practice, this knowledge can promote a shared understanding between ‘low blood’. health professionals, who may come from quite different sociocultural backgrounds, and their patients. Blood-based folk physiology - help explain the ‘dynamic’ or ‘non-chronic’ view of hypertension Discussion and high blood pressure, as a condition that comes and goes, or, in the words of one participant, as an ‘on and off’ illness. Explanatory Models - help explain how people experience and make sense of symptoms. Rueda-Baclig and Florencio mentioned ‘viscosity of the blood’, and Because our participants think that they can feel their blood, they also recognised the centrality of blood ‘flow’ in conceptions of hypertension. think that they can feel ‘high blood’; for them, a sphygmomanometer often Notably, they also reported how some respondents viewed hypertension serves to confirm—NOT detect—hypertension. This legibility of and anemia as opposite conditions, of ‘high blood’ and ‘low blood’. ANTH 168 Nasa dugo (‘It’s in the blood’): lay conceptions of hypertension in the Philippines (Lasco G, Mendoza J, Renedo A, et al., 2020) hypertension in terms of ‘folk physiology’ can explain the sporadic nature Summary not just of medication-taking but also of BP monitoring. These findings also reinforce the rationale for health promotion campaigns What is already known? to: ► Cultural knowledge and local perceptions about particular illnesses can affect ○ work with communities in a participatory way, health seeking behaviour and clinical encounters. ○ recognising (and anticipating) their local conceptions rather than simply seeking to displace them by the transfer of biomedical What are the new findings? knowledge ► We present an explanatory model for how the causes of hypertension are ○ acknowledging how some of their self-care practices can be understood in the Philippines, with ideas—(1) genetics, (2) heat, (3) stress and (4) mobilized for shared therapeutic goals diet—all drawn from notions of blood. Importantly, this participatory health promotion work must also enable communities to critically reflect and act on the ways in which What do the new findings imply? biomedicine ‘constructs’ the body and marginalizes local ► Our findings can explain Filipino patients’ self-care practices, as well as their vocabularies with which to articulate illness and suffering. view of hypertension as a dynamic, non-chronic state, both of which have consequences for hypertension management. ► They also illustrate how broader cultural theories can influence the way a specific medical condition is conceptualised and experienced. Conclusion This paper identified perceived causes of hypertension among these poor communities in the Philippines, related to genetics, heat, stress and diet. These are perceived, in a cultural explanatory model, as acting by changing the characteristics and behavior of blood. Collectively, they contribute to a folk physiology of hypertension that those in these communities use to explain the aetiology of the condition and influence non-medical forms of self-care. This folk physiology also accounts for a view of hypertension as a dynamic, non-chronic condition. The study shows how local knowledge, shared by rural and urban communities, shapes the way a specific medical condition is understood and acted on, and how these notions and practices can then inform preventive and care practices. The way that hypertension is frequently seen NOT as a chronic constant condition but rather as an episodic one triggered by external influences is particularly relevant for efforts to address adherence to treatment.