Beruflich Dokumente
Kultur Dokumente
Medical Anthropology
Encyclopedia of
Medical Anthropology
Edited by
Carol R. Ember
Human Relations Area Files at Yale University
New Haven, Connecticut
and
Melvin Ember
Human Relations Area Files at Yale University
New Haven, Connecticut
Published in conjunction with the Human Relations Area Files at Yale University
Advisory Board
GEORGE ARMELAGOS
ELOIS ANN BERLIN
GAY BECKER
PETER J. BROWN
C. H. BROWNER
JAMES W. CAREY
ALEX COHEN
WILLIAM W. DRESSLER
ROBERT EDGERTON
RUTHBETH FINERMAN
LINDA C. GARRO
PAUL HOCKINGS
LESLIE SUE LIEBERMAN
MARGARET LOCK
LENORE MANDERSON
MAC MARSHALL
JAMES J. MCKENNA
CARMELLA C. MOORE
ARTHUR J. RUBEL (deceased)
SUSAN C. WELLER
Emory University
University of Georgia
University of California at San Francisco
Emory University
University of California, Los Angeles
Centers for Disease Control and Prevention
Harvard University
University of Alabama
University of California, Los Angeles
University of Memphis
University of California, Los Angeles
University of Illinois at Chicago
University of Central Florida
McGill University
University of Melbourne
University of Iowa
University of Notre Dame
University of California, Irvine
University of California, Irvine
University of Texas Medical Branch, Galveston
Managing Editor
Jo-Ann Teadtke
The Encyclopedia of Medical Anthropology was prepared under the auspices and with the support of the Human
Relations Area Files, Inc. (HRAF) at Yale University. The foremost international research organization in the field of
cultural anthropology, HRAF is a not-for-profit consortium of 19 Sponsoring Member institutions and more than
400 active and inactive Associate Member institutions in nearly 40 countries. The mission of HRAF is to provide
information that facilitates the worldwide comparative study of human behavior, society, and culture. The HRAF
Collection of Ethnography, which has been building since 1949, contains nearly one million pages of information,
organized by culture and indexed according to more than 700 subject categories, on the cultures of the world. An
increasing portion of the Collection of Ethnography, which now covers more than 380 cultures, is accessible via the
World Wide Web to member institutions. The HRAF Collection of Archaeology, the first installment of which
appeared in 1999, is also accessible on the Web to member institutions. HRAF also prepares multivolume reference
works with the help of nearly 2,000 scholars around the world, and sponsors Cross-Cultural Research: The Journal
of Comparative Social Science.
Contributors
Thomas S. Abler, Department of Anthropology, University of Waterloo, Waterloo, Ontario
Rogaia Mustafa Abusharaf, Carr Center for Human Rights Policy, Kennedy School of Government, Harvard
University, Cambridge, Massachusetts
Steven Acheson, Archaeology Branch, Government of British Columbia, Victoria, British Columbia
Naomi Adelson, Department of Anthropology, York University, Toronto, Ontario
Pascale A. Allotey, Department of Public Health, University of Melbourne, Victoria, Australia
Hans A. Baer, Department of Anthropology, The George Washington University, Washington, D.C.
Eric J. Bailey, U.S. Department of Health & Human Services, National Institutes of Health, Bethesda, Maryland
Gay Becker, Department of Anthropology, History, and Social Medicine, University of California San Francisco, San
Francisco, California
Brent Berlin, Department of Anthropology, University of Georgia, Athens, Georgia
Elois Ann Berlin, Department of Anthropology, University of Georgia, Athens, Georgia
James R. Bindon, Department of Anthropology, University of Alabama, Tuscaloosa, Alabama
Astrid Blystad, Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
Barry Bogin, Department of Behavioral Sciences, University of Michigan-Dearborn, Dearborn, Michigan
Erika Bourguignon, Professor Emerita, the Ohio State University, Columbus, Ohio
David J. Boyd, Department of Anthropology, University of California, Davis, Davis, California
George Brandon, Department of Behavioral Medicine, City University of New York, New York, New York
Rae Bridgman, Department of City Planning, University of Manitoba, Winnipeg, Manitoba
Leslie Butt, Department of Pacific and Asian Studies, University of Victoria, Victoria, British Columbia
James W. Carey, Prevention Research Branch, Division of HIV/AIDS Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
Gloria Castillo, Universidad de San Carlos, San Carlos, Guatemala
Arachu Castro, Department of Social Medicine, Harvard Medical School, Boston, Massachusetts
Dia Cha, Anthropology and Ethnic Studies, St. Cloud State University, St. Cloud, Minnesota
Alex Cohen, Department of Social Medicine, Harvard Medical School, Boston, Massachusetts
Jeannine Coreil, Department of Community and Family Health, University of South Florida, Tampa, Florida
Jay Bouton Crain, Department of Anthropology, California State University, Sacramento, California
Kathleen A. Culhane-Pera, Department of Family Practice and Community Medicine, University of Minneapolis,
Minneapolis, Minnesota
Allan Clifford Darrah, Department of Anthropology, California State University, Sacramento, California
Nancy Romero-Daza, Department of Anthropology, University of South Florida, Tampa, Florida
Erin Picone-DeCaro, Prevention Research Branch, Division of HIV/AIDS Prevention, Centers for Disease Control
and Prevention, Atlanta, Georgia
Linus S. DigimRina, Department of Anthropology and Sociology, University of Papua New Guinea, Papua, New
Guinea
vii
viii
Contributors
Contributors
ix
Sharon R. Kaufman, Department of Anthropology, History, and Social Medicine, University of California San
Francisco, San Francisco, California
Satish Kedia, Department of Anthropology, The University of Memphis, Memphis, Tennessee
Sunil K. Khanna, Department of Anthropology, Oregon State University, Corvallis, Oregon
Jill E. Korbin, Department of Anthropology, Case Western Reserve University, Cleveland, Ohio
Brandon A. Kohrt, Department of Anthropology, Emory University, Atlanta, Georgia
Waud H. Kracke, Department of Anthropology, University of Illinois at Chicago, Chicago, Illinois
Peter Kunstadter, Department of Medical Anthropology, History, and Social Medicine, University of California San
Francisco, San Francisco, California
Robin Shrestha-Kuwahara, Division of Tuberculosis Elimination, National Center for HIV, STD, and TB
Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
Jennifer Kuzara, Anthropology Department, Emory University, Atlanta, Georgia
Michelle Lampl, Department of Anthropology, Emory University, Atlanta, Georgia
Murray Last, Department of Anthropology, University College London, London, England
Robert Lawless, Department of Anthropology, Wichita State University, Wichita, Kansas
Barbara W. Lex, Former Professor of Anthropology, Harvard Medical School, Boston, Massachusetts
Leslie Sue Lieberman, Department of Sociology and Anthropology, University of Central Florida, Orlando, Florida
Xingwu Liu, Department of Anthropology, DePaul University, Chicago, Illinois
Margaret Lock, Department of Social Studies of Medicine and Department of Anthropology, McGill University,
Montreal, Quebec
Ron Loewe, Department of Sociology, Anthropology, and Social Work, Mississippi State University, Mississippi
State, Mississippi
Chris Lyttleton, Department of Anthropology, Macquarie University, Sydney, Australia
Larry Leon Mai, Departments of Anthropology and Biological Sciences, California State University at Long Beach,
Long Beach, California
Frank Marlowe, Department of Anthropology, Harvard University, Cambridge, Massachusetts
Gregory G. Maskarinec, Department of Family Practice and Community Health, University of Hawaii, Mililani,
Hawaii
Joanne McCloskey, Department of Family and Community Medicine, University of New Mexico Health Sciences
Center, Albuquerque, New Mexico
Ann McElroy, Department of Anthropology, State University of New York at Buffalo, Buffalo, New York
Barbara Burns McGrath, Departments of Anthropology and Epidemiology, University of Washington, Seattle,
Washington
James J. McKenna, Professor of Anthropology, University of Notre Dame, Notre Dame, Indiana
F. John Meaney, Department of Pediatrics, University of Arizona, Tucson, Arizona
Robert J. Meier, Chancellors Professor Emeritus, Department of Anthropology, Indiana University, Bloomington,
Indiana
William E. Mitchell, Department of Anthropology, University of Vermont, Burlington, Vermont
Mary Spink Neumann, Prevention Research Branch, Division of HIV/AIDS Prevention, Centers for Disease Control
and Prevention, Atlanta, Georgia
Vinh-Kim Nguyen, Department of Social Studies of Medicine, McGill University, Montreal, Quebec
Kathleen A. OConnor, Department of Anthropology, University of Washington, Seattle, Washington
Contributors
Contributors
xi
Maureen Wilce, Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, Centers
for Disease Control and Prevention, Atlanta, Georgia
Michael Winkelman, Department of Anthropology, Arizona State University, Tempe, Arizona
Norma H. Wolff, Department of Anthropology, Iowa State University, Ames, Iowa
Louise Woodward, Nottinghamshire Healthcare NHS Trust, Nottingham, England
Michael R. Zimmerman, Department of Anthropology, University of Pennsylvania, Philadelphia, Pennsylvania
Preface
Illness and death are significant events for people everywhere. No one is spared. But medical beliefs and practices are
not the same everywhere. How people understand the causes of illness and death and how they cope with these events
vary from culture to culture. It is not surprising therefore that medical practitioners and others are becoming increasingly aware of the need to understand the influence of society and culture on medical belief and practice. Culture
the customary ways of thinking and acting in a societyoften affects the outcome of illness, and even which illnesses
occur. So those who are actively engaged in studying health and illness are coming to realize that biological and
cultural factors need to be considered if we are to reduce human suffering.
The professional medicine of Western cultures has been called biomedicine, because it mostly deals with the
biology of the human body. But biomedicine, like the medicine of other cultures, is also influenced by conditions and
beliefs in the culture, and therefore reflects the value and norms of its creators. So, if biomedicine is socially
constructed and not just based on science, its beliefs and practices may partly derive from assumptions and biases in
the culture. For example, it used to be thought that some people refrained from drinking milk because they were ignorant. Now, biomedicine realizes that the avoidance of milk is a rational response to the likelihood that drinking milk
results in diarrhea and other discomforts in people who lack an enzyme (lactase) that allows easy digestion of the
sugar in milk (lactose). Anthropologists were the first to realize that drinking milk would cause serious problems for
many people. The anthropologists fieldwork in other cultures around the world revealed that people in many places
that have milking animals must sour the milk before they can drink it, to reduce or eliminate the sugar in it that would
otherwise make them sick.
Severe diarrhea may also be an effect of the cultures system of social stratification. The direct causes of the
diarrhea may be biological, in the sense that the deaths are caused by bacterial or other infection. But why are so
many infants exposed to those infectious agents? Usually, the main reason is social or cultural. The affected infants
may mostly be poor. Because they are poor, they are likely to live with infected drinking water. Similarly, malnutrition may be the biological result of a diet poor in protein. But such a diet is usually also a cultural phenomenon, reflecting a society that has different classes of people, with very unequal access to the necessities of life, and unequal access
to decent medical care. For this and other reasons, medical anthropology is developing what has been called
a biocultural synthesis in its studies of health and illness.
Medical anthropology may even be in the forefront of the movement that is returning the entire field of anthropology to its biocultural roots. In any case, the growth of jobs in medical anthropology is one of the more striking
developments in contemporary anthropology. Medical anthropology has developed into a very popular specialty, and
the Society for Medical Anthropology is now the second largest unit in the American Anthropological Association.
ORGANIZATION
OF THIS
ENCYCLOPEDIA
A total of 53 thematic and comparative essays begin these volumes. These essays are grouped into five sections: general concepts and perspectives; medical systems; political, economic, and social issues; sexuality, reproduction, and the
life cycle; and health conditions and diseases. Then there are 52 cultural portraits of health and illness, articles that
describe the state of health and illness in 52 particular cultures around the world. Every cultural region of the world is
represented, as are cultures at all levels of social complexity. The Encyclopedia of Medical Anthropology is unique. In
addition to providing a large range of thematic essays, representing the various perspectives in medical anthropology,
these volumes are unique in focusing on so many particular cultures. No other single reference work comes close to
matching the depth and breadth of information on the varying cultural background of health and illness around the world.
We are able to provide the information contained here through the efforts of more than 100 contributorsgenerally
xiii
xiv
Preface
anthropologists but also other social scientistswho usually have firsthand experience with how medical cultures vary
around the world. Focusing on comparative topics and how health and illness are viewed and treated in the worlds
cultures is consistent with HRAFs mission to encourage and facilitate comparative worldwide studies of human society, culture, and behavior. Our aim is to leave the reader with a real sense of how different cultures deal with health and
illness, and what anthropology has contributed to understanding health and illness.
ORGANIZATION
OF THE
ARTICLES
The thematic and comparative essays vary in how they are organized, not just in their topics. The authors were encouraged by the editors to structure their discussions as they saw fit. On the other hand, the articles on health and illness
in particular cultures generally follow the same format to provide maximum comparability. That is, most of the culture articles cover the same topics, the list of which we developed with the help of our Advisory Board (see the headings in boldface below). If there is substantial variation within the culture (e.g., by class or gender), the author was
instructed to note it where appropriate, either in a particular section or at the end. A heading may be omitted if information on it is lacking or not applicable. The headings that follow are found in the vast majority of the articles to facilitate search and retrieval of information. Thus, the reader may easily compare how the cultures of the world differ and
are similar in the ways they deal with health and illness.
The outline for the culture articles includes the following topics.
Medical Practitioners
Types of full-time and part-time practitioners in the society, and descriptions of their roles and the people they serve.
Preface
xv
section. Discussions of age-related conditions (e.g., cardiovascular disease) will be reserved for the section on Health
Through the Life Cycle (see below).
Status and treatment of the aged. Discussion of the major medical problems of this age group.
Dying and Death. Treatment of the dying, concepts about death, reactions to it, and treatment of the body. Risks
to surviving spouses, if related to cultural practice (e.g., required suicide).
References
References to sources in the text are included to allow the reader to explore topics and cultures further.
OF
MEDICAL ANTHROPOLOGY
This reference work can be used by a variety of people for a variety of purposes. It can be used both to gain a general
understanding of medical anthropology and to find out about particular cultures and topics. A bibliography is provided
at the end of each entry to facilitate further investigation.
xvi
Preface
Beyond serving as a basic reference resource, the Encyclopedia of Medical Anthropology also serves readers with
more focused needs. For researchers interested in comparing cultures, this work provides information that can guide
the selection of particular cultures for further study. For those interested in international studies, the bibliographies in
each entry can lead one quickly to the relevant social science literature as well as provide a state-of-the-art assessment of knowledge about medical cultures around the world. For curriculum developers and teachers seeking to internationalize the curriculum, this work is a basic reference and educational resource as well as a directory to other
materials. For government officials, it is a repository of information not likely to be available in any other single
publication; in many cases, the information provided here is not available at all elsewhere. For students, from high
school through graduate school, it provides background and bibliographic information for term papers and class
projects. And for travelers, it provides an introduction to the medical cultures of places they may be visiting.
ACKNOWLEDGMENTS
There are many people to thank for their contributions. Eliot Werner, formerly at Plenum, played an important role in
the planning of the project. The Advisory Board made valuable suggestions about the outline for the culture entries
and possible topics to be covered in the thematic essays, and suggested potential authors. The editors were responsible for the final selections of authors and for reviewing the manuscripts. For managing the project at HRAF, we are
indebted to Jo-Ann Teadtke. We thank Teresa Krauss for overseeing the production process at Kluwer/Plenum and
Tracy van Staalduinen for her efficient handling of the production of this Encyclopedia. Finally, and most of all, we
thank the contributors for their entries. Without their knowledge and commitment, this work would not have been possible.
Carol R. Ember, Executive Director
Melvin Ember, President
Human Relations Area Files at Yale University
Contents
VOLUME I: TOPICS
3
12
23
31
37
42
49
58
MEDICAL SYSTEMS
Bioethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Elisa J. Gordon
Biomedical Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Margaret Lock
Biomedicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Atwood D. Gaines and Robbie Davis-Floyd
Medical Pluralism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hans A. Baer
Medicalization and the Naturalization of Social Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Margaret Lock
Phenomenology of Health and Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gay Becker
Possession and Trance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Erika Bourguignon
Shamanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Michael Winkelman
xvii
73
86
95
109
116
125
137
145
xviii
Contents
157
164
170
178
184
191
198
207
217
224
230
235
244
252
262
269
280
Contents
xix
311
319
328
335
353
360
374
383
391
407
462
479
486
493
506
518
528
545
557
564
572
579
xx
Contents
591
599
607
614
622
629
638
646
656
664
672
681
689
696
703
718
729
743
754
765
777
783
794
804
815
Contents
xxi
Matsigenka . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Carolina Izquierdo and Glenn H. Shepard Jr.
Maya of Highland Mexico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Elois Ann Berlin, Brent Berlin, and John R. Stepp
Mongolia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Daniel J. Hruschka and Brandon A. Kohrt
Nahua . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Brad R. Huber
Navajo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Joanne McCloskey
Nepal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gregory G. Maskarinec
Northwest Coast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Peter H. Stephenson and Steven Acheson
Ojibwa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Linda C. Garro
Oklahoma Choctaw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Joseph Neil Henderson and Linda Carson Henderson
Roma of the United States and Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Anne Hartley Sutherland
Samoa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
James R. Bindon
Saraguros . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ruthbeth Finerman
Shipibo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Warren M. Hern
Sotho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nancy Romero-Daza and David Himmelgreen
Sudanese . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Rogaia Mustafa Abusharaf
Thai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chris Lyttleton
Tongans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Barbara Burns McGrath
Trobriand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Jay Bouton Crain, Allan Clifford Darrah, and Linus S. DigimRina
Tuareg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Susan J. Rasmussen
Wape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
William E. Mitchell
Yanomam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Jennifer Kuzara and Raymond Hames
Yoruba . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Norma H. Wolff
823
838
850
863
873
883
890
903
915
923
929
937
947
957
964
971
980
990
1001
1009
1017
1029
Glossary
abortifacient. Any drug or compound that induces the expulsion of an embryo or fetus.
abortion. A spontaneous (usually called miscarriage) or induced expulsion of an embryo or fetus.
acculturation. The process of extensive borrowing of aspects of culture in the context of superordinate-subordinate
relations between societies; usually occurs as the result of external pressure.
acupuncture. A Chinese medical technique that consists of the insertion of one or several small metal needles into
the skin and underlying tissues at precise points on the body.
adaptation. Refers to genetic changes that allow an organism to survive and reproduce in a specific environment.
adaptive. A trait that enhances survival and reproductive success in a particular environment. Usually applied to
biological evolution, the term is also often used by cultural anthropologists to refer to cultural traits that enhance
reproductive success.
affinal kin. Ones relatives by marriage.
agency. Having the capacity or authority to act; also can refer to an establishment or organization that can act for
another or can carry out a function.
agricultural societies. Societies that depend primarily on domesticated plants for subsistence; see Horticulture and
Intensive Agriculture for the major type of agriculture.
agropastoralism. A type of subsistence economy based largely on agriculture with the raising of domesticated
animals playing an important part.
AIDS (Acquired Immune Deficiency Syndrome). A recent fatal disease caused by the HIV virus. A positive HIV
(see HIV) test result does not mean that a person has AIDS. A diagnosis of AIDS is made using certain clinical
criteria (e.g., AIDS indicator illnesses such as Pneumocystis carinii pneumonia, malignancies such as Kaposis
sarcoma and lymphoma).
albinism. A hereditary condition where melanin and other pigments are absent; such pigments normally provide
protection against ultraviolent radiation from the sun.
alcoholism. A disorder characterized by an individuals excessive consumption of alcoholic beverages that is causing harm to the individual and/or to others.
alimentary. Having to do with nutrition; in humans, the beginning of the digestive process begins in the mouth and
proceeds through the alimentary canal or tract through connected organs (esophagus, stomach, small and large
intestines; waste products are excreted through the end of the canal at the anus.
allele. One member of a pair of genes.
allopathic medicine. An alternative word for biomedicine. The term allopathic designates the biomedical tradition of working against pathology, wherein the treatment is meant to oppose or attack the disease as directly
as possible. Contrast with homeopathic medicine.
altered states of consciousness (trance). A range of states that generally share properties of inducing a slow wave
pattern (alpha and theta) in the brain. This slow wave pattern reflects enhanced activation of lower brain structures, particularly the paleomammalian (or limbic) brain. ASC are found universally and are institutionalized in
most societies in religion and healing rituals. ASC are induced through many ritual activities, such as drumming,
dancing, fasting, arduous activities, and drugs. ASC provide access to basic structures of consciousness and
unconscious complexes or structures that are generally interpreted as spiritual entities.
Alzheimers disease. A disability characterized by memory loss that affects the middle-aged and elderly. Manifests
in the fifth or later decades of life. Only 510% of Alzheimers cases are inherited. Brain tissue contains unusual
amounts of two gummy proteins, the beta- and tau-amyloids.
ambilineal Descent. The rule of descent that affiliates an individual with groups of kin related to him or her through
men or women.
xxiii
xxiv
Glossary
amniocentesis. A surgical procedure inserting a hollow needle through the abdominal wall to extract a sample of
amniotic fluid from the amniotic sac of the uterus of a pregnant woman for the purpose of diagnosing genetic
defects in the fetus.
amok. see amuk.
amuk (amuck). A temporary state of physically aggressive insanity relatively common in Malay populations.
In a suicidal attack, the amuk person attempts to maim or kill virtually everyone present. Often thought of as a
culture-bound syndrome.
amulet. A charm (often an ornament) believed to have powers to help the possessor or ward off evil.
ancestor spirits. Supernatural beings who are the ghosts of dead relatives.
androgynous. Refers to having both male and female characteristics or suitable for either sex, or having traditional
female and male roles eliminated or reversed.
ancestor worship. Veneration or reverence of ancestor spirits; ancestor spirits may be called upon for help or may
be given sacrifices to have them refrain from harming the living.
Angelman syndrome. Uncommon condition characterized by seizures, mental impairment and growth retardation,
protruding tongue, floppy muscle tone, large jaw, an inability to talk, and excessive and inappropriate laughter.
AS is caused by a small deletion in chromosome 15, inherited maternally.
anemia. A condition of too few red blood cells in the bloodstream which results in not enough oxygen to the
tissues and organs of the body.
animism. A term used by Edward Tylor to describe a belief in a dual existence for all thingsa physical, visible
body and a psychic, invisible soul.
anthropology. A discipline that studies humans, focusing on the study of differences and similarities, both
biological and cultural, in human populations. Anthropology is concerned with typical biological and cultural
characteristics of human populations in all periods and in all parts of the world.
anthropology of food. Focuses on the cultural and social significance of food and eating. Food is studied as a way
of understanding social and cultural processes and to reveal symbolic structures.
anthropometrics. The systematic collection and correlation of measurements relating to the human body.
antimicrobial. A drug for killing or suppressing the growth or proliferation of microorganisms.
anticipation. A phenomenon whereby a genetic disorder becomes increasingly severe from one generation to the
next (the age of onset usually gets lower, as well).
antisepsis. Processes, procedures, or treatments for killing microorganisms.
applied anthropology. The branch of anthropology that concerns itself with applying anthropological knowledge
to achieve practical goals, usually in the service of an agency outside the traditional academic setting. Also called
practicing anthropology.
association. An organized group not based exclusively on kinship or territory.
atherosclerosis. Progressive narrowing and hardening of the blood vessels over time.
asthma. Disorder of airways and lungs characterized by reversible inflammatory obstruction, breathing difficulties,
wheezing, and hypersensitivity.
autosomal recessive inheritance. The key feature of the recessive mode is that a new mutation does not result in a
new phenotype, so that only two phenotypes exist, one containing at least one dominant allele, and the other
containing two copies of the recessive allele. An autosomal chromosome is a non-sex chromosome.
avunculocal residence. A pattern of residence in which a married couple settles with or near the husbands mothers
brother.
Ayurveda. A medical system whose practice (in North India, Pakistan, Bangledesh, Sri Lanka, and the Arab world)
dates back thousands of years; Ayurveda emphasizes the concept of balance. There are three important biological modes and people are believed to differ in their natures as to the importance of various modes in their systems. Professionally trained Ayurvedic practitioners assess a patients nature and try to correct imbalances
primarily through diet. Different treatments are given to different patients depending upon their natures.
balanced reciprocity. Giving with the expectation of a straightforward immediate or limited-time trade.
band. A fairly small, usually nomadic local group that is politically autonomous.
Glossary
xxv
xxvi
Glossary
Glossary
xxvii
xxviii
Glossary
death. Concepts vary across cultures and relate to how a culture defines the end of an individuals personhood; such
concepts have varied over time and may even vary within cultures. (In the U.S. laws regarding definitions of
death are established by individual states which define death as an event marked by the cessation of either
respiratory, cardiac, or brain functioning.)
demographic transition. See epidemiological transition.
demography. The study of human populations, mostly using methods of quantitative analysis. Demographers may
study such characteristics as the age-composition of populations, fertility, fecundity, and mortality.
dengue fever. Like malaria, dengue causes fever, headache and chills, as well as body pain and skin rash. Unlike
malaria it is not recurrent, although persons who have had dengue are at elevated risk for the more serious forms
of dengue hemorrhagic fever and dengue toxic shock syndrome.
dependency theory. Views underdeveloped or developing nations which have not yet had substantial economic
growth as being the integral result of the processes by which other nations became developed; in other words,
relations of dependency arose because of colonial, usually Western, powers.
depression. A mood state including feelings of sadness, hopelessness, and other negative feelings. Short-lived
depression is normal. See clinical depression.
descriptive term. Kinship term used to refer to a genealogically distinct relative; a different term is used for each
relative.
descent rules. See rules of descent.
diabetes mellitus. A group of metabolic diseases characterized by high blood sugar or hyperglycemia. A form of
diabetes with onset in childhood is often called Type 1 diabetes; genetic factors play a major role and insulin
deficiency is almost total. Type 2 or adult-onset diabetes is related to obesity.
dialect. A variety of a language spoken in a particular area or by a particular social group.
diarrheal. Disease characterized by a high number and frequent bowel movements with watery stool.
disability. From a relativist perspective, impairment-disability is a mapping of what a particular culture or subculture perceives as anomalous physical or behavioral differences. A more etic definition from the World Health
Organization defines disabilities as any restriction or lack resulting from an impairment of ability to perform an
activity in the manner or within the range considered normal for a human being.
disease. A biomedically measurable lesion or anatomical or physiological irregularity. Compare with
illness.
divination. Getting the supernatural to provide guidance, usually through the use of magic.
diviners. Practitioners of divination.
division of labor. Rules and customary patterns specifying which kinds of work different kinds of people (e.g., by
age, gender, caste) perform.
DNA. Deoxyribonucleic acid; a long two-stranded molecule in the genes that directs the makeup of an organism
according to the instructions in its genetic code.
dolichocephaly. Having a disproportionately long head.
domestic violence. Physical aggression, often repetitive, by one or more members of the household against another
member or members.
dominant. The allele of a gene pair that is always phenotypically expressed in the heterozygous
form.
Downs syndrome. A congenital disorder caused by an extra chromosome on the chromosome 21 pair. Often
associated with congenital heart defects, mental retardation; individuals usually have a broad, short skull, broad
fingers with short digits and up-slanted eyes.
double descent. A system that affiliates an individual with a group of matrilineal kin for some purposes and with
a group of patrilineal kin for other purposes. Also called double unilineal descent.
dowry. A substantial transfer of goods or money from the brides family to the bride.
drug. Generally is a substance that affects the functioning of living things; with regard to medicine it refers to any
substance used as a medicine; in lay parlance drugs are often thought of as substances (sometimes illegal) that
Glossary
xxix
lead to addiction or altered states of consciousness. Although drugs are usually thought of as not foods, certain
foods (drug foods) can have pharmacological properties.
dysentery. Any of a number of disorders that involves inflammation of the intestines, often accompanied by pain
in the abdomen and frequent bowel movements.
ecology. The field of study concerned with the inter-relationships between organisms and their environments which
together constitute the ecosystem.
ecosystems. All the interrelationships between the organisms and the physical environment in a particular geographical space.
egalitarian society. A society in which all persons of a given age-sex category have equal access to economic
resources, power, and prestige.
ego. In the reckoning of kinship, the reference point or focal person.
emetic. A substance that causes vomiting.
emic. From the perspective of the insider; often referring to the point of view of the society studied; contrast with
etic.
enculturation. See socialization.
endemic disease. A disease that has been prevalent in an area over long periods of time.
endogamy. The rule specifying marriage to a person within ones own group (kin, caste, community).
enteric. Relates to the intestines.
endocannibalism. Cannibalism practiced with deceased members of ones own group.
epidemic disease. A disease that currently has very high prevalence. (Implies large fluctuation over time.) Compare
with endemic disease.
epidemiological transition. Can refer to a number of demographic transitions (such as when humans became food
producers) but usually refers to the more recent transition which includes lowering of infant mortality, longer
birth spacing, and the lengthening of life expectancy in recent times. Also called demographic transition.
epidemiology. Involves the use of population-based statistical methods of data collection and analysis to elucidate
and predict the patterns of development and distribution (including associated causal factors) and potential control of disease across and within populations.
epilepsy. A chronic neurological disorder that is characterized by sudden and recurrent seizures and convulsions
due to disturbance of the electrical activity in the brain.
episiotomy. A surgical incision of the vagina to widen the birth outlet.
ethnicity. The process of defining ethnicity usually involves a group of people emphasizing common origins and
language, shared history, and selected aspects of cultural difference such as a difference in religion. Since
different groups are doing the perceiving, ethnic identities often vary with whether one is inside or outside the group.
ethnic group. A social group perceived by insiders or outsiders to share a culture or a group that emphasizes its
cultural or social separateness.
ethnocentric. Refers to judgment of other cultures solely in terms of ones own culture.
ethnocentrism. The attitude that other societies customs and ideas can be judged in the context of ones own
culture.
ethnographer. A person who spends some time living with, interviewing, and observing a group of people so that
he or she can describe their customs.
ethnography. A description of a societys customary behaviors, beliefs, and attitudes.
ethnology. The study of how and why recent cultures differ and are similar.
ethnomedicine. The health-related beliefs, knowledge, and practices of a cultural group.
evil eye. The belief prevalent in many cultures that a person can cause harm to another by a look. To ward off the
evil eye, many people try not to make the person suspected of having the evil eye jealous.
ethnonym. An alternative name for a culture or ethnic group.
ethnopharmacology. The system of knowledge of medicines (their preparation, uses, and therapeutic effects) in a
cultural system.
xxx
Glossary
ethnopharmacopoeia. The medicines (often plant-based) and their known effects (therapeutic effects, appropriate
situations for use, etc.) of a culture.
ethnophysiology. The systems of knowledge in a culture relating to how organisms function.
ethos. The dominant assumptions or sentiments of a culture.
etic. From the perspective of the outsider; often refers to the way a researcher will classify something in the culture
studied based on her or his own scholarly perspective; allows comparison since etic categories are presumably
applicable to all cultures.
etiology. The causes of a disease or illness.
eugenics. The belief or practice that seeks to improve a human population by discouraging or forcing those with
perceived undesirable heritable traits to reproduce less or not at all (negative eugenics) and/or by encouraging or
forcing those with perceived desireable heritable traits to reproduce more (positive eugenics).
evolutionary medicine. See Darwinian medicine.
exogamy. The rule specifying marriage to a person from outside ones own group (kin or community).
exorcist. A person who expels spirits (usually demons) from possessed people.
explanation. An answer to a why question. In science, there are two kinds of explanation that researchers try to
achieve: associations and theories.
extended family. A family consisting of two or more single-parent, monogamous, polygynous, or polyandrous families linked by a blood tie.
extensive cultivation. A type of horticulture in which the land is worked for short periods and then left to regenerate for some years before being used again. Also called shifting cultivation.
family. A social and economic unit consisting minimally of a parent and a child.
fecundity. The biological capacity to have offspring; fecundity varies by individual and also by population. May be
affected by breastfeeding, caloric intake, strenuous exercise, among other factors.
filariasis. A disease caused by a parasitic nematode worm that blocks the lymphatic system resulting in the swelling
and thickening of the skin and tissues below the skin, particularly the leg, arm, or genitals.
female genital cutting (female genital mutilation). Usually refers to a societally mandated genital operation that
removes some part of the female genitalia or alters the genitalia. See circumcision and infibulation.
fertility rate. Provides an indication, usually for comparative purposes, of the number of live births per standard
unit of population; the total fertility rate is the average total number of live births a woman in a particular population is expected to have within her reproductive years.
feuding. A state of recurring hostility between families or groups of kin, usually motivated by a desire to avenge an
offense against a member of the group.
fieldwork. Firsthand experience with the people being studied and the usual means by which anthropological information is obtained. Regardless of other methods (e.g., censuses, surveys) that anthropologists may use, fieldwork
usually involves participant-observation for an extended period of time, often a year or more. See participantobservation.
folklore. Includes all the myths, legends, folktales, ballads, riddles, proverbs, and superstitions of a cultural group.
Generally, folklore is transmitted orally, but it may also be written.
food collection. All forms of subsistence technology in which food-getting is dependent on naturally occurring
resourceswild plants and animals.
food production. The form of subsistence technology in which food-getting is dependent on the cultivation and
domestication of plants and animals.
foragers. People who subsist on the collection of naturally occurring plants and animals. Also referred to as huntergatherers.
forensic anthropology. The use of anthropology to help solve crimes.
fossils. The hardened remains or impressions of plants and animals that lived in the past.
founder effect. A variety of genetic drift that occurs when a small group migrates to a relatively isolated location.
A gene that is either present or absent in that small group by chance is likely to become characteristic of the
future population.
Glossary
xxxi
fraternal polyandry. The marriage of a woman to two or more brothers at the same time.
G6PD deficiency. A red blood cell deficiency that can result in acute hemolytic crisis, often provoked by eating
fava beans.
gastrointestinal diseases. Any disease involving the stomach and/or intestines.
gender. Two or more classes of persons who are believed to be different from each other; society has different roles
and expectations for different genders (most societies have two gendersmale and femalebut others have
more than two).
gender differences. Differences between females and males that reflect cultural expectations and experiences.
gender division of labor. Rules and customary patterns specifying which kinds of work the respective genders
perform.
gender roles. Roles that are culturally assigned to genders.
gender status. The importance, rights, power, and authority of a particular gender.
gender stratification. The degree of unequal access by the different genders to prestige, authority, power, rights,
and economic resources.
gene. Chemical unit of heredity.
genetic disease. Any condition caused or influenced by a malfunctioning gene or cytogenetic (chromosome) error
that affects an organisms capacity for adaptation. Excepting lethal defects and sterility, genetic diseases display
certain familial modes of inheritance and exhibit morbidity and mortality patterns that may compromise direct
fitness.
genetic isolate. A population that hardly ever interbreeds with others; usually has distinctive genetic features.
genetics. The study of heredity and genes.
genitor. The biological father.
genome. The total set of genes carried by an individual or cell.
genomic imprinting. Also known as parental imprinting in which the expression of genes depends on whether the
chromosome of concern is maternal or paternal in origin.
genotype. The total complement of inherited traits or genes of an organism.
gestational diabetes. A form of diabetes that occurs in pregnancy and is usually temporary.
geophagy. The practice of eating earth (e.g., clay).
ghosts. Supernatural beings who were once human; the souls of dead people.
globalization. The massive flow of goods, people, information and capital across huge areas of the earths surface.
gods. Supernatural beings of nonhuman origin who are named personalities; often anthropomorphic.
goiter. Enlargement of the thyroid gland.
gonorrhea. A mostly sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae; it is marked by
pain in the male urethra.
Greek medical system. A professional medical system that originated in Greece and spread throughout Europe and
to parts of the Islamic world. Stemmed from Hippocrates and assumed that there were four humors (blood,
yellow and black bile, and phlegm) that must be kept in balance. These humors have hot and cold and wet and
dry properties.
group marriage. Marriage in which more than one man is married to more than one woman at the same time; not
customary in any known human society.
group selection. Natural selection of group characteristics.
guardian spirit. A supernatural spirit that guides a person in important activities or decisions; the spirit may come
to a person in a dream or the person may undertake a vision quest to find his or her guardian spirit.
hallucination. A perception of objects or events that does not come from an external source.
headman. A person who holds a powerless but symbolically unifying position in a community within an egalitarian
society; may exercise influence but has no power to impose sanctions.
healing. A complex process that starts with a patients experience of something being wrong and proceeds to some
form of diagnosis and then possibly treatment. Cultural ideas and practices are fundamental in the healing process
and societies vary enormously in the ways that the healing process proceeds.
xxxii
Glossary
health. A broad construct, consisting of physical, psychological, and social well being, including role functionality.
hegemony. The political and economic dominance one entity or group (e.g., state, nation, ruling class) has over
others.
hemoglobin. A complex oxygen-carrying protein in red blood cells.
hepatitis. Inflammation of the liver. An infectious or viral form of hepatitis can be spread through contact.
Symptoms are similar to influenza.
herbalist. A specialist skilled in the knowledge of medicinal plants.
hermeneutics. In contemporary anthropology involves the study of symbol systems to try to understand how
people construct and interpret reality; emphasizes the subjective nature of the ethnographic enterprise.
hernia. The protrusion of tissue or organ through an abnormal opening.
heterozygous. If the two genes, or alleles, for a trait differ, the organism is heterozygous for that trait.
historical archaeology. A specialty within archaeology that studies the material remains of recent peoples who left
written records.
HIV. Human immunodeficiency virus believed to cause AIDS. HIV destroys or impairs cells of the immune system, notably CD4 T cells. HIV infection is usually acquired through sexual contact with an infected partner
and also by contaminated injection equipment. Persons with HIV may not show any clinical symptoms for a long
time and may not know they are infected. See AIDS.
homeopathic medicine. Homeopathic derives from the Greek homoiossimilar or like treatment and pathos (suffering, disease). In this model, medicines produce symptoms similar to the illnesses that they are intended to treat.
Homo sapiens. All living people belong to one biological species, Homo sapiens, which means that all human
populations on earth can successfully interbreed. The first Homo sapiens may have emerged 100,000 years ago.
homosexuality. Defined broadly as sexual relationships between people of the same sex; however, cultures differ
widely in the ways they define and treat these relationships and the people who engage in them.
homozygous. If two genes or alleles for a trait are the same, the organism is homozygous for that trait.
hookworm. An intestinal infection commonly caused by the parasite Necator americanus; can cause diarrhea, anemia and anorexia.
horticulture. Plant cultivation carried out with relatively simple tools and methods; nature is allowed to replace
nutrients in the soil, in the absence of permanently cultivated fields.
hot/cold health systems. See humoral medicine.
human paleontology. See paleoanthropology.
human genome project. A worldwide project to determine the DNA sequences in all human DNA.
human variation. The study of how and why contemporary human populations vary biologically.
humoral medicine. A variety of medical systems based on the belief that a balanced state assures health, while an
excess or deficiency yields illness. The balance needs to be maintained between various humors
(see humors) and/or between elements such as heat and cold. Deducing the etiology of an illness points the
way to appropriate therapy through the application of the principle of opposites: for example, illness caused
by cold is treated with hot therapies, and vice versa.
humors (humours). One of a number of vital elements in the body (usually fluids). The various humoral medical
systems had different numbers of basic humors.
hunter-gatherers. People who collect food from naturally occurring resources, that is, wild plants, animals, and fish.
The phrase hunter-gatherers minimizes sometimes heavy dependence on fishing. Also referred to as foragers.
hydropathy. The treatment of diseases with the copious and frequent use of pure water.
hypotheses. Predictions, which may be derived from theories, about how variables are related.
hypercholesterolemia. One of the genetic forms of coronary heart disease that manifests in the 4th or 5th decade of
life. Genetically deficient low-density lipoprotein (LDL) protein receptors (LDLRs) in the liver cause LDL cholesterol to accumulate in the blood, resulting in high blood cholesterol, atherosclerosis and heart disease.
hyperglycemia. Too high a level of glucose in the blood.
hypoglycemia. An abnormally diminished concentration of glucose in the blood.
Glossary
xxxiii
hypertension. Persistent high blood pressure (the force that the blood moving through the arteries exerts on the arterial walls).
hypertriglyceridemia. Elevation of triglycerides in the bloodstream.
hypoxia. A condition of oxygen deficiency that often occurs at high altitudes.
hysteria. A condition (often considered a neurosis) marked by excitability and other emotional outbursts with disturbances of sensory and motor functions.
iatrogenic. Introduced inadvertently by medical treatment or medical procedures.
illness. The culturally structured, personal experience of being unwell which entails the experience of suffering.
Illness can refer to a variety of conditions cross-culturally. In some cultures, it is limited to somatic experiences; in others it includes mental dysfunction; in others it includes suffering due to misfortune, too.
immunization. The process by which disease resistance is acquired. It may occur in an organism naturally when
the organism produces its own antibodies in response to a pathogen or it may occur artificially with a vaccine.
incest taboo. Prohibition of sexual intercourse or marriage between mother and son, father and daughter, and
brother and sister. May be extended to other relatives.
incidence. Most commonly a ratio of new cases of a disease or condition for a standard population size (e.g., per
100,000 in a given year) in a particular population. Compare with Prevalence.
incomplete dominance (co-dominance). The key features of this dominant mode are that a new mutation results
in a new phenotype in the heterozygote, and its phenotype is intermediate between the two homozygotes. A familiar human example is the wavy-haired heterozygous offspring of straight- and curly-haired homozygous parents.
The A and B alleles in the ABO blood groups interact in a codominant fashion.
individual selection. Natural selection of individual characteristics.
infant mortality. See mortality.
infanticide. The practice of killing newborn babies; in many cultures it is not considered a crime and is generally
practiced when the parents say that they do not have the resources to rear the baby.
infectious disease. Any of a number of diseases that results from a microorganism.
infibulation. Female genital surgery that involves stitching together the vulva leaving only a small opening for the
passage of urine and menstrual blood. Usually done following circumcision. See circumcision.
influenza (flu). An acute viral infection involving the respiratory tract. It is also characterized by headache, aches,
and fever.
initiation ceremony (or rite). A ceremony which marks the passage of an individual from one status to another. Male
initiation ceremonies are often required of all boys in a society and mark the transition from boyhood to manhood.
In societies with age-sets, initiation ceremonies may mark a series of transitions to different stages of life. Male
initiation ceremonies often involve trauma such as hazing, genital operations, or tests of manliness. Female initiation ceremonies, which commonly occur after the onset of menstruation, are usually for one individual at a time.
intensive agriculture. Food production characterized by the permanent cultivation of fields and made possible
by the use of the plow, draft animals or machines, fertilizers, irrigation, water-storage techniques, and other
complex agricultural techniques.
in vitro fertilization. Fertilization that occurs in a laboratory.
IQ. An abbreviation for intelligence quotient. An intelligence quotient is a numerical measure based on a standardized
test designed to measure intelligence. Among the many criticisms of IQ tests are that they are generally culture
bound and therefore not good measures of intelligence for people of cultures and subcultures other than for which
the test was designed.
IUD. Abbreviation for intra-uterine device. A contraceptive that is placed within the uterus for the purpose of
preventing conception.
jaundice. Yellowing of the skin and eyes by bilirubin, a bile pigment, often because of a liver problem. Neonatal
jaundice sometimes occurs in newborns.
joint family. A type of extended family with at least two married siblings in the same generation; can also contain
parents.
xxxiv
Glossary
karma. The doctrine that life is but one in a chain of lives and that it is determined by actions in a previous life.
Past acts in previous lives can influence not only the future life but also the time in between lives.
kindred. A bilateral set of close relatives.
kula ring. A ceremonial exchange of valued shell ornaments in the Trobriand Islands, in which white shell armbands are traded around the islands in a counterclockwise direction and red shell necklaces are traded clockwise.
kuru. A chronic, progressive, uniformly fatal transmissible neurodegenerative disease now known to be caused by
a prion. It is named from the Fore word meaning to shiver, shake, or tremble.
kwashiorkor. An extreme form of protein-energy malnutrition.
language family. A group of related languages that are presumed to descend from the same ancestral language.
latah. An emotional disorder fairly common, especially among low ranking women, in Malay populations. The
affected person seems to satirize traditional manners and to mimic the words and gestures of others with whom
they are interacting.
leprosy. A disease caused by the Mycobacterium leprae; it is characterized by lesions of the skin and superficial
nerves. The extremities may become deformed and eroded.
levirate. A custom whereby a man is obliged to marry his brothers widow.
libidinal. Erotic in the broad sense defined by Freud, including pleasure.
life expectancy. The average number of years people might be expected to live in a particular population. It is based
on the ages of death over a period of time. Populations with high infant mortality may have low life expectancies
because of a large number of deaths at young ages; such populations might still have many people living to older
ages.
liminality. Can refer to any transitional or in-between state, but usually refers to the transitional state in a rite of
passage where an individual lacks status and prescribed codes of conduct.
lineage. A set of kin whose members trace descent from a common ancestor through known links.
longhouse. A multifamily dwelling with a rectilinear floorplan.
maidenhood. Refers to the customary period of time from the onset of puberty to marriage.
mal de ojo. See evil eye.
magic. The performance of certain rituals that are believed to compel the supernatural powers to act in particular ways.
maladaptive customs. Customs that diminish the chances of survival and reproduction in a particular environment.
Usually applied to biological evolution, the term is often used by cultural anthropologists to refer to behavioral
or cultural traits that are likely to disappear because they diminish reproductive success.
malaria. A set of diseases caused by various species of Plasmodium protozoans that are transmitted to humans from
the bite of the Anopheles mosquito.
malnutrition. Deficient levels of intakes of specific nutrients.
mana. A supernatural, impersonal force that inhabits certain objects or people and is believed to confer success
and/or strength.
manumission. The granting of freedom to a slave.
market or commercial exchange. Transactions in which the prices are subject to supply and demand, whether
or not the transactions occur in a marketplace.
marriage. A socially approved sexual and economic union usually between a man and a woman that is presumed
by both the couple and others to be more or less permanent, and that subsumes reciprocal rights and obligations
between the two spouses and between spouses and their future children.
matriarchy. An old general term for the disproportionate holding of power or authority by females; since there are
many domains of authority and power, anthropologists now generally identify more specific institutions or
customs such as the presence of matrilineal descent, matrilocal residence, the proportion of leaders or heads of
household that are female, inheritance by females, etc.
matriclan. A clan tracing descent through the female line.
matrilateral. Pertaining to the mothers side of the family, as in matrilateral cross-cousins or matrilateral parallel
cousins.
Glossary
xxxv
matrilineage. A kin group whose members trace descent through known links in the female line from a common
female ancestor.
matrilineal descent. The rule of descent that affiliates an individual with kin of both sexes related to him or her
through women only.
matrilocal residence. A pattern of residence in which a married couple lives with or near the wifes parents. Often
referred to as uxorilocal residence in the absence of matrilineal descent.
measles. An acute viral infection caused by a Morbillivirus in the paramyoxovirus family. Later symptoms involve
a red rash that spreads from the face.
mediation. The process by which a third party tries to bring about a settlement in the absence of formal authority
to force a settlement.
medical anthropology. A branch of anthropology that studies all aspects of health-related phenomena (health,
illness, and health care); considers cultural systems as well as the effects of local and worldwide social and political environments.
medical ecology. Studies health and disease in environmental context. Central to the model is the concept of ecosystem.
See ecosystem.
medical hegemony. The process by which the assumptions, concepts, and values of ruling classes or powers come
to permeate medical diagnosis and treatment.
medicalization. The process of making something medical. In other words, the extension of biomedicine into
non-biomedical realms (e.g., pregnancy, birth, menopause, exercising).
medical pluralism. In contrast to indigenous societies, which tend to exhibit a more-or-less coherent medical
system, state or complex societies have an array of medical systemsa phenomenon generally referred to
by medical anthropologists, as well as medical sociologists and medical geographers, as medical pluralism.
medium. Part-time religious practitioner who is asked to heal and divine while in a trance.
meiosis. The process by which reproductive cells are formed. In this process of division, the number of chromosomes in the newly formed cells is reduced by half, so that when fertilization occurs the resulting organism has
the normal number of chromosomes appropriate to its species.
menarche. The onset of menstruation.
menstrual seclusion. A mandated time that women must avoid all or some others (e.g., men) during their menstruation. Seclusion is often in a special menstrual hut or house.
menstrual taboos. Proscriptions about what women may or may not do during menstruation (e.g., must stay in a
menstrual hut or avoid cooking for others); rules may also apply to men (e.g., they may not have sex with their
wives during menstruation).
mental disorder. The Diagnostic and Statistical Manual of Mental Disorders definition is a clinically significant
syndrome or pattern in which an individual exhibits behavioral or psychological patterns that are associated with
distress, disability, or increased risk of pain or death; anthropologists have pointed out a number of problems
applying this definition cross-culturally. For example, many cultures do not clearly distinguish between mental and
physical disorders.
mental illness. See mental disorder.
mental retardation. Definitions of mental retardation need to consider the context of the individuals culture and
their peers in that culture. In the United States, mental retardation is often defined as a disability characterized
by significant limitations both in intellectual functioning and in adaptive behavior.
mesaticephalic. Having a medium-length head.
mestizo. A person of mixed European and Native American heritage; this term is usually used in Latin America.
microevolution. Small scale evolutionary change within populations or species.
midwife. A specialist to assist at birth.
mitochondrial DNA. See mtDNA.
mitochondrial inheritance. The inheritance of a trait encoded in the mtDNA.
mitosis. Cellular reproduction or growth involving the duplication of chromosomal pairs.
xxxvi
Glossary
moiety. A unilineal descent group in a society that is divided into two such maximal groups; there may be smaller
unilineal descent groups as well.
monogamy. Marriage between only one man and only one woman at a time.
monogenic. Controlled by only one gene.
monolingual. Using or knowing only one language.
monotheistic. Believing that there is only one high god and that all other supernatural beings are subordinate to, or
are alternative manifestations of, this supreme being.
morbidity. The proportion of sickness or a specific disease in a population.
mortality rate. Provides an indication, usually for comparative purposes, of the death rate in a population; may be
expressed as the number of deaths per 100,000 population in a given year; may be more specifically addressed
to specific age ranges such as the infant mortality rate (e.g., number of infant deaths/1000 live births).
moxibustion. A medical practice that originated in China. Traditionally, small cones of dried leaves are burned on
certain designated points of the body, generally the same points as those used in acupuncture. The term comes
from the name of the wormwood plant most frequently used, Artemisia moxa. It is believed that burning or heating certain points on the body increased circulation full-bloodedness and relieved pain. Nowadays the heated
material tends to be held above, not on, the body.
mtDNA (mitochondrial DNA). Extranuclear DNA found in the mitochondria. Mitochondria are responsible for
certain oxidative metabolic functions that store and release energy. Children (both males and females) inherit
mtDNA from their mothers only.
mumps. An acute infectious virus affecting the parotid glands, salivary glands in front and below the ear.
multidimensional scaling. Provides a visual representation in which items responded to in similar ways are placed
closer together in the scaling plot.
mutation. A change in the DNA sequence, producing an altered gene.
natal home. Where a person was born and (usually) grew up.
nationalism. A sense of consciousness that exalts one nation-state and seeks to promote that nations values, culture, and interests above those of others.
natural fertility. Populations whose fertility patterns are not influenced to any great extent by deliberate limitation
of family size are referred to as natural fertility populations; their family size and spacing is a function of the
biological capacities of individuals to reproduce (fecundity).
natural selection. The outcome of processes that affect the frequencies of traits in a particular environment. Traits
that enhance survival and reproductive success increase in frequency over time.
naturalistic medical systems. Sickness is explained by impersonal forces or conditions, including cold, heat, and
other forces that upset the bodys balance.
naturopathy. A treatment system that avoids drugs and surgery and emphasizes natural means (e.g., air, sunshine,
water) and physical manipulation and exercise to invigorate the body and improve health.
negotiation. The process by which the parties to a dispute try to resolve it themselves.
neolocal residence. A pattern of residence whereby a married couple lives separately, and usually at some distance,
from the kin of both spouses.
nephritis. Inflammation of the kidneys.
nerves (nervios, nervos, nevra, worriation). A widespread label for similar experiences in various cultures in
which patients complain of headache, dizziness, fatigue, weakness, and abdominal pain and attribute their symptoms to sadness, anger, fear, or worry.
nervios. The Spanish for nerves. See nerves.
neurasthenia. A disorder that is characterized by fatigue, lack of motivation, feelings of inadequacy, and psychosomatic symptoms.
neurofibromatosis. Genetic disorders of two types: the first is characterized by pale brown spots on the skin and
soft benign, but sometimes disfiguring, tumors usually at nerve endings in the skin; the second is marked by
tumors of the central nervous system and the acoustic nerve which can result in deafness.
Glossary
xxxvii
neurological disease. A disease pertaining to the nerve tissue in the body (including the brain, brain stem, spinal
cord, and ganglia).
neurosis. A form of mental distress which causes moderate to severe perturbation to relationships and ability to
adapt, but not to the extent of being subject to delusions. Compare with psychosis.
New World syndrome. A collection of metabolic disorders characterized by diabetes, obesity, high blood lipids,
gallstones and gallbladder cancer, resulted from a combination of founder effect and selective pressures encountered in harsh arctic environments by the first New World immigrant populations.
norms. Standards or rules about acceptable behavior in a society. The importance of a norm usually can be judged
by how members of a society respond when the norm is violated.
nuclear family. A family consisting of a married couple and their young children.
nosology. The knowledge of and the classification of diseases.
nutritional anthropology. A subfield of medical anthropology in which nutritional implications of food intake,
food as carrier of nutrients, nutritional status, human growth and health are the focus. Studies in nutritional
anthropology draw on theories and methods from both biological and social sciences.
oath. The act of calling upon a deity to bear witness to the truth of what one says.
obesity. A state of excess accumulation of fat on the body. Cultures differ in the degree to which fat is valued; most
biomedical practitioners have standardized measures for assessing degree of fat.
obsessive-compulsive disorder (OCD). A neurotic disorder in which a person becomes trapped in a pattern of
repetitive thoughts and behaviors that are senseless and distressing but extremely difficult for the person to
ignore. Usually accompanied by compulsions to repeat repetitive acts (e.g., washing hands). May if untreated
interfere seriously with daily functioning.
oedipal period. The time, according to Freudian theory, when a child develops an Oedipal complex, which refers
to sexual attraction to the opposite sex parent and feelings of rivalry with the parent of the same sex. Such feelings are normally repressed when the child fears the anger of the opposite sex parent. May commonly occur
between 3 to 6 years of age.
onchocerciasis. Although the common name for onchocerciasis is river blindness, this form of the disease is less
common than onchocercal skin disease, a disorder characterized by lesions and depigmentation.
ontology. The study of being or existence.
opportunistic infections. Infection with HIV is an example of an opportunistic infection because it weakens the
immune system to the point that it has difficulty fighting off certain infections. These types of infections are called
opportunistic infections because they take the opportunity a weakened immune system gives to cause illness.
ordeal. A means of determining guilt or innocence by submitting the accused to dangerous or painful tests believed
to be under supernatural control.
paleoanthropology. The study of the emergence of humans and their later physical evolution. Also called human
paleontology.
osteopathy. A profession that emphasizes the relationship between the muscle/skeletal structure of the body and
organ function. Osteopathic physicians are skilled in recognizing and correcting structural problems through
manipulation and other treatments.
pandemics. Epidemics that occur over a wide geographic area.
paradigm. A general concept or model accepted by an intellectual community as a effective way of explaining phenomena.
participant-observation. Living among the people being studiedobserving, questioning, and (when possible)
taking part in the important events of the group. Writing or otherwise recording notes on observations, questions
asked and answered, and things to check out later are parts of participant-observation.
pastoralism. A form of subsistence technology in which food-getting is based directly or indirectly on the maintenance of domesticated animals.
pater. The socially defined father. Compare with genitor.
pathogen. Any disease-producing agent.
xxxviii
Glossary
Glossary
xxxix
xl
Glossary
psychosis. A distressed state in which a person is subject to delusions and often hears voices; in crisis it incapacitates a person from usual activities and disrupts relationships.
psychosomatic. Referring to a physical disorder or symptom that is influenced by the mind or emotional factors.
pulmonary fibrosis. Chronic inflammation with progressive formation of fibrous tissue in the alveolar walls of the
lung; results in progressively increasing shortness of breath.
purdah. (Lit. veil or curtain), the practice, including the seclusion of women from public observation, of wearing
concealing clothing, and use of screens or curtains to hide women.
race. In biology, race refers to a subpopulation or variety of a species that differs somewhat in gene frequencies
from other varieties of the species. All members of a species can interbreed and produce viable offspring. Many
anthropologists do not think that the concept of race is usefully applied to humans because humans do not fall
into geographic populations that can be easily distinguished in terms of different sets of biological or physical
traits. Thus, race in humans is largely a culturally assigned category.
racism. The belief that some races are inferior to others.
raiding. A short-term use of force, generally planned and organized, to realize a limited objective.
random sample. A sample in which all cases selected have had an equal chance to be included.
rank society. A society that does not have any unequal access to economic resources or power, but with social
groups that have unequal access to status positions and prestige.
recessive. An allele phenotypically suppressed in the heterozygous form and expressed only in the homozygous form.
reciprocity. Giving and taking (not politically arranged) without the use of money.
recombinant DNA. Formed by the splicing of DNA from more than one source.
rectal prolapse. Protrusion of the rectal mucous membrane through the anus.
redistribution. The accumulation of goods (or labor) by a particular person or in a particular place and their
subsequent distribution.
reflexology. Uses massage and pressure techniques to relax and loosen muscles in the feet and hands. The feet and
hands are viewed as maps of the body; putting pressure on and massaging specific points on the feet or hands is
said to have an effect on the corresponding area of the body.
religion. Any set of attitudes, beliefs, and practices pertaining to supernatural power, whether that power rests in
forces, gods, spirits, ghosts, or demons.
renal. Pertaining to the kidney.
reproductive ecology. The study of how human reproduction is affected by ecological factors such as seasonal variability in food, environmental carrying capacity, and the production roles and spatial distribution in work.
respiratory disease. A disease that affects the organs involved in breathing (nose, throat, larynx, trachea, bronchi,
and lungs).
revitalization movement. A religious movement intended to save a culture by infusing it with a new purpose and life.
rheumatoid arthritis. A chronic inflammatory disease that destroys joints. May be an auto-immune disorder.
rickets. A condition caused by deficiency of vitamin D which disturbs normal hardening of the bones.
rite. A ceremonial act or series of actions.
rite of passage. A ritual associated with a change of status; see initiation rite.
ritual. A ceremony, usually formal, with a prescribed or customary form.
Sahel. The transitional semi-arid zone in Africa between the arid Sahara to the north and the humid savannas to the
south. It stretches from Senegal to the Sudan. It has become increasingly desertified.
scabies. A contagious inflammation of the skin caused by the itch mite.
scarification. The practice of producing raised scars on the body, usually for marking status (e.g., a tribal marking,
achievement of manhood) or for decorative purposes.
scarpie. A neurological degenerative disease of sheep and goats that may be a prion disease.
section. A group of kin related to one another by both matrilineal and patrilineal principles; excluded are those
related by only one principle as well as those not related by either principle. Associated with moieties and moiety exogamy.
Glossary
xli
schizophrenia. A severe mental disorder that most frequently begins in late adolescence or early adulthood and is
characterized by delusions (fixed, false ideas), hallucinations (either auditory or visual), and behavior that is
deemed socially inappropriate (e.g., going without clothes, lack of attention to personal hygiene).
scientific medicine. See biomedicine.
sedentarization. The process of become sedentary or settling into permanent communities.
segmentary lineage system. A hierarchy of more and more inclusive lineages; usually functions only in conflict
situations.
senescence. The state or process of becoming old.
septicemia. Blood poisoning by microorganisms or their toxins.
SES. Socioeconomic status.
sex differences. The typical differences between females and males that are most likely due to biological differences.
sexual division of labor. See gender division of labor.
sexually dimorphic. Refers to a species in which males differ markedly from females in size and appearance.
shaman. A religious intermediary, usually part time, whose primary function is to cure people through sacred songs,
pantomime, and other means; sometimes called witch doctor by Westerners.
shamanism. A religion characterized by the importance of the shaman as the intermediary between people and their
gods and spirits.
shifting cultivation. See extensive cultivation.
sib. See clan.
siblings. A persons brothers and sisters.
sickle cell anemia (sicklemia). A condition in which red blood cells assume a crescent (sickle) shape when deprived
of oxygen, instead of the normal (disk) shape. The sickle-shaped red blood cells do not move through the body
as readily as normal cells, and thus cause damage to the heart, lungs, brain, and other vital organs.
sickness. For some, sickness is defined primarily as a social category describing the sick role in society and the way
a person who is ill is expected to behave; sickness may also be used to describe illness and/or disease when the
distinction is not important. See illness and disease.
SIDS. See sudden infant death syndrome.
slash-and-burn. A form of shifting cultivation in which the natural vegetation is cut down and burned off. The
cleared ground is used for a short time and then left to regenerate.
slaves. A class of persons who do not own their own labor or the products thereof.
sleep architecture. Refers to the time, duration and order by which sleep stages or awakenings and arousals are
expressed throughout an organisms sleep behavior.
sleeping sickness. See trypanosomiasis.
smallpox. An acute viral disease characterized by a widespread rash with pustules. Considered to be eradicated but
previously caused high mortality.
socialization. A term used to describe the development, through the direct and indirect influence of parents and
others, of childrens patterns of behavior (and attitudes and values) that conform to cultural expectations.
social stratification. The presence of unequal access to important advantages depending on the social group one
belongs to. See class and caste.
society. A group of people who occupy a particular territory and speak a common language not generally understood by neighboring peoples. By this definition, societies do not necessarily correspond to nations.
sociobiology. See behavioral ecology.
sociology. A discipline that focuses on understanding social relations, social groups, and social institutions. Usually
focuses on complex societies.
sorcery. The use of certain materials to invoke supernatural powers to harm people.
sororal polygyny. The marriage of a man to two or more sisters at the same time.
sororate. A custom whereby a woman is obliged to marry her deceased sisters husband.
xlii
Glossary
soul flight (or soul journey). A trance state in which some aspect of the experient (soul, spirit, an animal familiar)
interacts with spirits in a non-ordinary reality. The soul journey or flight is a universal feature of shamanism.
soul loss. An injury to the core or essence of ones being or personal identity. The loss may be characterized by
despair, disharmony, and feelings of loss of meaning in life and connection with others. Soul constitutes a vital
essence of self-emotions. Soul loss occurs from trauma that causes an aspect of ones self to dissociate.
Reintegration of these dissociated aspects of self is central to healing. Soul recovery usually involves the help of
a shaman.
species. A population that consists of organisms able to interbreed and produce viable and fertile offspring.
spirits. Unnamed supernatural beings of nonhuman origin who are beneath the gods in prestige and often closer to
the people; may be helpful, mischievous, or evil.
state. A political unit with centralized decision making affecting a large population. Most states have cities with
public buildings; full-time craft and religious specialists; an official art style; a hierarchical social structure
topped by an elite class; and a governmental monopoly on the legitimate use of force to implement policies.
statistical association. A relationship or correlation between two or more variables that is unlikely to be due to
chance.
statistically significant. Refers to a result that would occur very rarely by chance. The result (and stronger ones)
would occur fewer than 5 times out of 100 by chance.
stereotype. A mental picture or attitude that is an oversimplified opinion or a prejudiced attitude.
STDs. Sexually transmitted diseases.
structural violence. The set of large-scale social forces, such as racism, sexism, political violence, poverty and
other social inequalities, which are rooted in historical and economic process.
stunting. Process which substantially reduces size or vigor. With reference to child growth often assumed to occur
if a child is more than 2 or 3 standard deviations below normal height and weight for its age. (The term wasting
may be used to refer to weight and the term stunting with regard to height.)
subculture. The shared customs of a subgroup within a society.
subsistence patterns. The methods humans use to procure food.
sudden infant death syndrome (SIDS, cot or crib death). The sudden death of a young infant or child which is unexpected by history and in which a thorough post-mortem examination fails to demonstrate an adequate cause of death.
supernatural. Believed to be not human or not subject to the laws of nature.
supine. Lying with back downward.
susto. The Spanish word susto means fright or fear. The basic idea in susto is that either a sudden shock as
in being startled, or an emotional shock, or a series of traumatic events, or a frightening encounter with a ghost
have damaged a person, often by startling their soul out of their body. Susto patients are described as restless
during sleep, listless, depressed, debilitated and indifferent to food and hygience.
swidden. The name used for a plot under extensive cultivation; see extensive cultivation.
syphilis. A sexually transmitted disease caused by the spirochete Treponema pallidum.
syncretism. The combination of different forms of belief or practice; usually refers to the blending of elements from
different religions as a result of contact.
syndemics. Refers to two or more epidemics (i.e., notable increases in the rate of specific diseases in a population),
interacting synergistically with each other inside human bodies and contributing, as a result of their interaction,
to excess burden of disease in a population; in other words health-related problems cluster by person, place or
time. Also refers to the health consequences of the biological interactions among co-present diseases. Also points
to the determinant importance of social conditions in disease interactions and consequences.
systemic lupus erythematosis. An autoimmune disorder that causes chronic inflammation of different organs of
the body.
taboo (tabu, tapu, kapu). A prohibition or restriction that, if violated, is often believed to bring supernatural
punishment.
tapu. See taboo.
Glossary
xliii
xliv
Glossary
Volume I: Topics
INTRODUCTION
From its earliest days, anthropology has included
research regarding health. However, it is only within the
past quarter-century that inquiry in this area has been systematized and synthesized into the area of specialization
known (but not unequivocally so) as medical anthropology. After discussing the concept health, we review
the history of medical anthropologys emergence. The
historical divide between applied and theoretical
medical anthropology is discussed. Our focus then turns
specifically to cross-cultural or ethnological health
research. Key conceptual models for understanding
health-seeking and health systems cross-culturally will
be described. We then contrast the explicitly comparative
cross-cultural perspective with contemporary ethnography, where single cultures are generally the focus of
inquiry, and we discuss the related debate over comparative research. Finally, popular research topic areas are
reviewed.
A BRIEF HISTORY OF
ANTHROPOLOGICAL HEALTH RESEARCH
While paradigms from all four fields of anthropology
inform the work of medical anthropologists today, the
roots of medical anthropology (a term that we later discuss) extend back in basically two directions, reflecting
two kinds of anthropological orientations. If we looked
back about 100 years, which is about as long as anthropology has existed in an organized fashion within the
United States, then we would see a group of biological or
physical anthropologists studying human growth and
development, evolution and adaptation, and forensic
issues. Secondly, we would see a group of social or cultural anthropologists interested in traditional or local
healing practices (often linked with religion and magic).
If we looked back about 70 years, the social-cultural
group would also contain anthropologists interested in
psychological issues related to cultural norms (this school
of inquiry is often referred to as the culture and personality school).
With the end of World War II, medical anthropology
(still at that time an unnamed specialization) received
impetus and support from foundation- and governmentfunded applied work in the arena of international public
health. The data collected by anthropologists in earlier
times for non-medical purposes proved invaluable;
anthropologists helped ensure that social and cultural
aspects of health and healing were taken into account in
ways that promoted international health program success
(Foster & Anderson, 1978, pp. 78).
generally refers to the extension of biomedicines authority into non-biomedical realms and the resulting regulation of everyday life.)
Once committed to the medical anthropology specialization, academically oriented scholars pushed theory
into a more central role. They called their colleagues to
task for forgetting that there can be neither data nor facts
without theories as to what constitutes each. They promoted the notion that theory must be used or applied:
through use, it is tested, revised, and strengthened
(Singer, 1992). Thereby, the somewhat spurious distinction between applied and theoretical (or basic) research
has become less salient.
Whats in a Name?
There are still those anthropologists who prefer to
self-identify as cultural or social anthropologists
interested in health, rather than as medical anthropologists. In some cases they cling to the old-fashioned
academic belief that applied work is infra dig.1 In other
cases, their concern relates to their narrow definition of
the term medical.
Technically speaking, the term medical refers
only to those curative practices engaged in by Westerntrained, allopathic, biomedical physicians (and when
hairs are split, surgeons are not included here). As effective as this type of curing may be, it is asocial and highly
technologized, bureaucratized, and industrialized. It deals
with body parts and systems rather than individuals. It
values quantitative over qualitative data.
Naming the anthropological health specialty medical
anthropology thus may be seen to suggest that the standard against which all other healing or curing practices
should be measured is the medical model (as defined
above). Such labeling may be understood to imply that an
anthropology concerned with non-medical healing or
based on the interpretive ethnographic method is unimportant or tangential.
On the other hand, many medical anthropologists
work has nothing to do with medicine as it is technically defined (i.e., as biomedicine; see above). For them,
and even for many anthropologists working in biomedical
settings, the term medical is used in a more generic,
universalistic sense. It is understood to refer to any system of curing or healingno matter what specific techniques are involved. The label medical anthropology is
thus not problematic for them.
HEALTH-SEEKING AND
PATTERNS OF RESORT
Much medical anthropology focuses on what people do
when they fall ill. In all cultures the household is the key
unit in therapy-seeking; members influence each others
care either directly through resource allocation and care
provision, or indirectly through examples set and modalities recommended. Individual problems are linked (in
various ways in various cultures) to the well-being of the
group and the group may therefore actually organize individual care. The less individualistic a culture is and the
more it promotes a socially linked self, the more whole
groups may be seen as being in need of therapy. In some
cultures, an entire group (e.g., the extended family) may
be seen as the patient and healing intra-group conflicts
may be part of the treatment regime (Janzen, 1978).
Although for some conditions only one treatment
modality will be necessary, this is not always the case.
There exists a hierarchy of resort (Romanucci-Ross,
1969/1977) in which people first try one thing and then
try another until their condition is fixed to their satisfaction. While the concept, as first used, related patterns of
resort to acculturation issues, the phrase is often used
today to mean that people try the most familiar or simplest and cheapest treatments first and seek more expensive, complex, or unfamiliar treatments later, if necessary.
Treatment choice can follow a hierarchical sequence,
but patterns of resort often involve many treatment
modalities at once. Further, people do not necessarily
adhere to all the official rules related to each type of treatment. People often combine recommendations creatively,
creating a regimen that they feel is right for them. Health
seeking is a dynamic process; people constantly reevaluate their symptoms and revise their healthcare plans
(Chrisman, 1978).
The recognition of symptoms is generally the first
step in what Noel Chrisman (1978) long ago termed the
health-seeking process. Symptom recognition depends
on cultural definitions of normal well-being, and understandings about the causes and contexts of sickness.
Owing to cross-cultural differences, symptoms are not
always grouped together in the same way cross-culturally.
However they may be grouped, some of the important factors that people in all cultures consider when evaluating
symptoms include how dangerous to life they are suspected to be, and the degree to which they interfere with
lifestyle or function. Also considered is the visibility and
frequency of the symptoms in others, and the way this
compares with their visibility and frequency in the ill individual.
Another important aspect of health-seeking is preventive behavior, and much thinking in relation to this has
come from anthropologists engaged in public and international health efforts. Again, symptom recognition is
Within-System Distinctions
One common typology describing complex medical
systems is the tripartite scheme of popular, folk, and professional medicine (Kleinman, 1978). The key variables
are: who provides care and in what context. In the popular sector, non-specialists, such as ones self, mother,
friends, or other kin and relations, provide treatment.
Treatment is based on shared cultural understandings,
and generally occurs in a family or household context.
Folk sector healers are specialists; their practice is based
on cultural traditions and philosophies. Legally sanctioned official systems make up the professional sector.
This three-part scheme is an advance on simple
publicprivate dichotomizing, in which private or household care is separated from care provided within the
formal health care system, and discounted. But the typology does have an unanticipated shortcoming in relation to
CROSS-CULTURAL (ETHNOLOGICAL)
VERSUS MONO-CULTURAL
(ETHNOGRAPHIC) RESEARCH
In the preceding sections we reviewed some of the key
concepts and models used in medical anthropology.
In doing so we concentrated on cross-cultural research,
in which numerous groups are compared in order to generate insights that will apply across all cultures. However,
not all anthropologists work with multiple cultures
concurrently. Some choose to scrutinize one group intensively, either staying with that group for the duration of
their career, or moving slowly and serially between
groups. The choice between cross-cultural (ethnological) and mono-cultural (ethnographic) research
depends on many things, including where one stands on
the controversial question of epistemologywhat kind of
knowledge is possible.
Cross-cultural research assumes that comparison is
possible. Those who conduct cross-cultural research
believe that fruitful comparisons can be made because the
culturally constructed, health-related categories that they
would study are universally, or at least regionally, meaningful (e.g., flow and blockage; see Sobo, 2003);
or because historical connections justify comparisons
Research Interests
RESEARCH INTERESTS
Applied or theoretical, comparativist or not, todays
medical anthropologists remain very interested in issues
relating to health education and promotion. Medical
and popular social representations of the body and of
diseasefor example, the differing ways in which
medical and scientific rhetoric has, across time, anchored
popular theories of gender in the body (e.g., Lacquer,
1990; Martin, 1987)have also received a good deal of
attention. The ways in which people come to experience
their bodies, according to how they are brought up to
believe that their bodies work and should feel or function,
has been another very productive topic for exploration,
and has generated theories of embodiment and lived
experience which sometimes even posit the body and its
physiological and anatomical reality as a crucial foundation for the creation of culture itself (e.g., Csordas, 1990;
Lakoff, 1987; Sobo, 1996).
Issues related to the therapeutic alliance between
patient and practitioner have been perennially popular
topics of inquiry for ethnographers, who have long been
interested in the psychological aspects of health and in
the social and cultural context of medical knowledge and
practice. More and more recent works have examined
how professionally dominated knowledge and practice
patterns are socially established, maintained, expressed, or
negotiatedor subvertedduring patientpractitioner
interaction (e.g., Lindenbaum & Lock, 1993). Other
aspects of the therapeutic alliance that have garnered
attention include the role of narrative employment and
interlocutionary storytelling in healing (e.g., Delvecchio
Good & Good, 2000; Mattingly & Garro, 1994), the
impact of illness on identity (e.g., Green & Sobo, 2000),
and the moral and ethical dimensions of the alliance,
especially in relation to new biomedical technology
(e.g., Brodwin, 2000; Lock, Young, & Cambrosio, 2000).
10
larger anthropological discipline. This move was underwritten by an overt acceptance of the importance of not
only pragmatic action but also the theory that inevitably
drives it, and a growing agreement that the relationship
between theory and action is neither oppositional nor
simply complementary; it is circular, dialogical, and
coherent. Just as mind and body only exist as a duality
theoretically, so too are theory and action only hypothetically divided. Experientially, and in good anthropology,
they are a unity. Advances made within the field of medical anthropology once the false dichotomy was exposed
have helped to ensure its continued growth and development as well as its value to those outside of the academic
arena.
NOTES
1. Literally, beneath ones dignity.
2. These are: the Society for Cultural Anthropology, the General
Anthropology Division, and the American Ethnological Society
(Carlo Simpao, personal communication, March 28, 2002).
CONCLUSION
Anthropologists have always been interested in health.
This interest has recently been systematized and synthesized into the area of specialization called medical
anthropology, and key concepts have been developed.
Controversies in this growing specialization have
concerned, among other things, the label medical,
cross-cultural versus ethnographic orientations, and
applied versus theoretical approaches.
Much of the cross-cultural research in this field has
concentrated on categorizing medical systems, understanding patterns of health-seeking, and, more recently,
comparing cultural responses to universal physiological
processes as well as comparing variations on universal
(or at least regionally or historically common) cultural
constructions related to health. Much of the in-depth
ethnographic research on health has focused on questions
relating to suffering, and its link to the relationship
between individual and society, as mediated by culture.
Patientpractitioner communication and relations as well
as the role of the body have also been salient concerns
of late.
After several decades of marginalization on the basis
of its practical (i.e., applied) orientation, medical anthropologists have begun to move toward the center of the
ACKNOWLEDGMENT
Great thanks are due to Carole Browner and Elisa Gordon for providing
invaluable comments and suggestions.
REFERENCES
Baer, H. A., Singer, M., & Johnson, J. H. (1986). Toward a critical medical anthropology. Social Science and Medicine, 23(2), 9598.
Brodwin, P. (Ed.). (2000). Biotechnology and culture: Bodies, anxieties,
ethics. Bloomington: Indiana University Press.
Browner, C. H., Ortiz de Montellano, B. R., & Rubel, A. J. (1988).
A methodology for cross-cultural ethnomedical research. Current
Anthropology, 29(5), 681689.
Chrisman, N. J. (1978). The health-seeking process: An approach to the
natural history of illness. Culture, Medicine and Psychiatry, 1(4),
351377.
Clements, F. (1932). Primitive concepts of disease. University of
California Publications in American Archaeology and Ethnology,
32, 185252.
Csordas, T. J. (1990). Embodiment as a paradigm for anthropology.
Ethos, 18(1), 547.
Delvecchio Good, M. J., & Good, B. J. (2000). Clinical narratives and
the study of contemporary doctorpatient relationships. In
G. L. Albrecht, R. Fitzpatrick, & S. C. Scrimshaw (Eds.),
Handbook of social studies in health and medicine (pp. 243258).
Thousand Oaks, CA: Sage.
References
Farmer, P. (1999). Infections and inequalities: The modern plagues.
Los Angeles: University of California Press.
Foster, G. M. (1976). Disease etiologies in non-Western medical
systems. American Anthropologist, 78(4), 773781.
Foster, G. M. (1994). Hippocrates Latin American legacy: Humoral
medicine in the new world. Amsterdam: Gordon and Breach.
Foster, G. M., & Anderson, B. G. (1978). Medical anthropology.
New York: Wiley.
Frankenberg, R., & Leeson, J. (1976). Disease, illness and sickness:
Social aspects of the choice of healer in a Lusaka suburb.
In J. Leeson (Ed.), Social anthropology and medicine, No. 13
(pp. 223258). San Diego, CA: Academic Press.
Good, B. J. (1994). Medicine, rationality, and experience: An anthropological perspective. Cambridge, UK: Cambridge University
Press.
Green, G., & Sobo, E. J. (2000). The endangered self: Managing the
social risk of HIV. London: Routledge.
Hahn, R. A. (1984). Rethinking illness and disease. Contributions
to Asian Studies: Special Volume on Southasian Systems of
Healing, 18, 123.
Janzen, J. M. (with Arkinstall, W.) (1978). The quest for therapy:
Medical pluralism in Lower Zaire. Los Angeles: University of
California Press.
Johnson, T. M., & Sargent, C. F. (1990). Introduction. In T. M. Johnson &
C. F. Sargent (Eds.), Medical anthropology: Contemporary
theory and method (pp. 19). New York: Praeger.
Jordan, B. (1993). Birth in four cultures: A crosscultural investigation
of childbirth in Yucatan, Holland, Sweden, and the United States
(4th ed., revised and expanded by R. Davis-Floyd). Prospect
Heights, IL: Waveland Press.
Justice, J. (1989). Policies, plans, and people: Foreign aid and health
development. Los Angeles: University of California Press.
Kleinman, A. (1978). Concepts and a model for the comparison of
medical systems as cultural systems. Social Science and Medicine,
12, 8593.
Lacquer, T. (1990). Making sex: Body and gender, from the Greeks to
Freud. Cambridge, MA: Harvard University Press.
Lakoff, G. (1987). Women, fire, and dangerous things. Chicago:
University of Chicago Press.
Leslie, C. (2001). Backing into the future. Medical Anthropology
Quarterly [Special issue, P. J. Guarnaccia (Ed.), The contributions
of medical anthropology to anthropology and beyond], 15(4),
428439.
Lindenbaum, S., & Lock, M. (Eds.). (1993). Knowledge, power, and
practice: The anthropology of medicine and everyday life.
Los Angeles: University of California Press.
Lock, M., Young, A., & Cambrosio, A. (2000). Living and working
with the new medical technologies: Intersections of inquiry.
Cambridge, UK: Cambridge University Press.
Loustaunau, M. O., & Sobo, E. J. (1997). The cultural context of health,
illness, and medicine. Westport, CT: Bergin & Garvey.
Martin, E. (1987). The woman in the body: A cultural analysis of
reproduction. Boston, MA: Beacon Press.
Mattingly, C., & Garro, L. C. (1994). Narrative representations of
illness and healing: Introduction. Social Science and Medicine,
38(6), 771774.
11
Mechanic, D. (1962). The concept of illness behavior. Journal of
Chronic Diseases, 15, 189194.
Nichter, M., & Nichter, M. (Eds.). (1996). Anthropology and international health: Asian case studies. Amsterdam: Gordon and Breach.
OConnor, B. B. (1995). Healing traditions: Alternative medicine and
the health professions. Philadelphia: University of Pennsylvania
Press.
Pelto, P. J., & Pelto, G. H. (1997). Studying knowledge, culture, and
behavior in applied medical anthropology. Medical Anthropology
Quarterly, 11(2), 147163.
Rapp, R. (2001). Gender, body, biomedicine: How some feminist concerns dragged reproduction to the center of social theory. Medical
Anthropology Quarterly [Special issue, P. J. Guarnaccia (Ed.), The
contributions of medical anthropology to anthropology and
beyond], 15(4), 466477.
Romanucci-Ross, L. (1969/1977). The hierarchy of resort in curative
practices: The Admiralty Islands, Melanesia. In D. Landy (Ed.),
Culture, disease and healing: Studies in medical anthropology
(pp. 481487). New York: Macmillan.
Rubel, A. J., & Moore, C. C. (2001). The contribution of medical
anthropology to a comparative study of culture: Susto and
tuberculosis. Medical Anthropology Quarterly [Special issue,
P. J. Guarnaccia (Ed.), The contributions of medical anthropology
to anthropology and beyond], 15(4), 440454.
Singer, M. (1992). Theory in medical anthropology. Medical
Anthropology [Special issue, M. Singer (Ed.), The application of
theory in medical anthropology], 14(1), 18.
Sobo, E. J. (1995). Choosing unsafe sex: AIDS-risk denial among
disadvantaged women. Philadelphia: University of Pennsylvania
Press.
Sobo, E. J. (1996). The Jamaican bodys role in emotional experience
and sense perception. Culture, Medicine and Psychiatry, 20,
313342.
Sobo, E. J. (2003). Prevention and healing in the household: The importance of socio-cultural context. In E. J. Sobo & P. S. Kurtin (Eds.),
Child health services research: Applications, innovations, and
insights (pp. 67119). San Francisco: Jossey-Bass.
Todd, H. F., & Ruffini, J. L. (1979). Teaching medical anthropology:
Model courses for graduate and undergraduate instruction
(Society for Medical Anthropology Special Publication No. 1).
Washington, DC: Society for Medical Anthropology.
Vuckovic, N. (2000). Self-care among the uninsured: You do what you
can do. Health Affairs, 19(4), 197199.
Waitzkin, H. (2000). The second sickness (2nd ed.). New York: Rowman
and Littlefield.
Young, A. (1982). The anthropologies of illness and sickness. Annual
Reviews in Anthropology, 11, 257285.
Young, A. (1983). The relevance of traditional medical cultures to
modern primary health care. Social Science and Medicine, 17(16),
12051211.
Young, A. (1986). Internalising and externalising medical belief
systems: An Ethiopian example. In C. Currer & M. Stacey (Eds.),
Concepts of health, illness, and disease (pp. 139160). [Original:
1976, Social Science & Medicine, 16, 4352.] Oxford: Berg.
12
INTRODUCTION
The term cognitive medical anthropology does not refer
to a recognized and clearly demarcated field of study but
rather to a body of work that addresses topics of relevance
to medical anthropologists while also reflecting cognitive
anthropological interest in the relation between human
society and human thought (DAndrade, 1995, p. 1,
italics removed).
Initially labeled as the new ethnography, ethnoscience, ethnosemantics, or ethnographic semantics
(Casson, 1994), the emergence of cognitive anthropology
dates to the beginning of what has been called the cognitive revolution in the late 1950s (DAndrade, 1995).
After a long cold winter of objectivism and the domination of behavioristic theories, the cognitive revolution
was intended to bring mind back into the human sciences (Bruner, 1990, p. 1). A recurring commitment
expressed in much of the cognitive anthropological literature is to describe and represent cultural knowledge in a
manner compatible with what is known about human cognition. For many, another longstanding orientation is to
the insiders view: the society members perspective on what things
mean and what is going on in his or her social world. The principal
aim of cognitive anthropology is to understand and describe people
in other societies in their own terms, as they conceive and experience it.
A further aim is to avoid the biases induced by ethnocentrism, distortions that result when an investigator imposes an outsiders view on life
in another society and describes it from this external perspective.
(Casson, 1994, p. 61)
a step toward the formulation of an operationallyexplicit methodology for discerning how people construe
their world of experience from the way they talk about it
(Frake, 1969, pp. 2829). During his fieldwork, Frake
found that: Their continual exposure to discussions of
sickness facilitates the learning of disease concepts by all
Subanun. Characterizing the meaning of a disease concept as the information necessary to arrive at a specific
answer or diagnosis (Frake, 1961, p. 114), Frake limited
the terms elicited to the perceptual realm of skin diseases
and the culturally specific (emic) diagnostic criteria
which serve to define and differentiate them. Noting the
conceptual exhaustiveness of Subanun classification of
natural phenomena (Frake, 1961, p. 131), Frake portrayed the underlying conceptual organization as taking
taxonomic form with different diagnostic criteria operative at different levels of contrast and with increasing
specificity at lower levels of the hierarchy. While
informants rarely disagree in their verbal descriptions of
what makes one disease different from another, the
real world of disease presents a continuum of symptomatic variation which does not fit neatly into conceptual
pigeonholes (Frake, 1961, p. 130). As a social activity
that involves negotiating the relevance of culturally
shared categories to specific instances, the diagnosis of
a particular disease may evoke considerable debate
(Frake, 1961, pp. 129 & 130131). Thus, while the
analysis of a cultures terminological systems will not,
of course, exhaustively reveal the cognitive world of its
members . . . it will certainly tap a central portion of it
(Frake, 1969, p. 30).
Aiming for a more comprehensive understanding of
the conceptual domain of illness, subsequent researchers
(DAndrade, Quinn, Nerlove, & Romney, 1972; Young,
1978; Young & Garro, 1994) report unsatisfactory results
from efforts to elicit taxonomies or to carry out standard
feature analysis (DAndrade, 1995, p. 70). Researchers
turned to methods, such as the termframe substitution
task, which allowed for directly comparable responses
across informants. Constructing a termframe interview
requires a list of illness terms as well as a set of statements about illness. Each illness term is systematically
inserted into each question frame and informants are
asked whether the resulting sentence is correct or not
(see Weller & Romney, 1988, for further details on
this and other systematic data collection techniques).
From Categories of Disease in American-English
and Mexican-Spanish (DAndrade et al., 1972), an
13
14
this (Romney, 1999, p. S103). A reanalysis of the contagion and hotcold rankings from the urban Guatemalan
women (Weller, 1984a) was presented in the article introducing the cultural consensus model (Romney et al.,
1986, pp. 327329) and reinforced the earlier findings
cultural consensus characterized the contagion rankings
but not the hotcold rankingsleading the authors to
conclude that informants do not share a coherent set of
cultural beliefs concerning what diseases require hot or
cold medicines (Romney et al., 1986, p. 328).
Another study exploring variation in cultural knowledge about illness and its treatment compared curers
and non-curers (all women) in Pichtaro using responses
from a termframe interview (Garro, 1986). The
Quadratic Assignment Program (Hubert & Schultz, 1976)
was used to test three alternative hypotheses of interinformant agreement. Although not originally analyzed
using the cultural consensus approach, a reanalysis
illustrated both sharing and variability within cultural
consensus theory (Garro, 2000a, pp. 281283). The
cultural consensus findings were consistent with a high
level of sharing in cultural knowledge across both the
curers and non-curers. Yet, there was variability in the
extent to which individuals could be said to represent this
shared knowledge. A specific prediction was that curers,
by virtue of their greater experience in dealing with
illness and differential opportunities to learn about it,
would better represent shared cultural knowledge as evidenced by higher overall levels of agreement (consensus)
within this group. This hypothesis was supported but it
was also discovered that there was a confounding with
age such that older individuals, irrespective of curer status (and curers tended to be older), also agreed more
among each other. Like curers, older individuals were
socially positioned to have learned more, and hence share
more knowledge about illness. Both of these findings
were consistent with cultural consensus theorys conceptualization of variation across informants as indicating
measurable differences in the amount of knowledge about
a cultural domain, with some knowing more than others.
15
a closer look at what can be learned through a comparative approach. Three different approaches are examined
here. The most ambitious of these is a collaborative,
multisite study using a shared methodology to study
intra- and inter-cultural variation in beliefs (Weller,
Pachter, Trotter, & Baer, 1993, p. 109) for four geographically separated and distinctive Latin American
samples. The illnesses are considered to be either biomedical or folk conditions. Weller and Baer (2001) present findings for five of the eight illnesses studied (AIDS,
diabetes, the common cold, empacho, and mal de ojo;
with asthma, nervios, and susto also included in the larger
design) and some detailed studies, comparing beliefs
for individual illness conditions have been published
(Weller et al., 1993, 1999). Noting that it is usually
impossible to know if reported differences between cultures are due to cultural differences or due to a difference
in methods used to study the cultures, the researchers
constructed a series of 100150 yes/no questions for
each of the illnesses which allowed them to collect comparable data at each site. The questions asked about
potential causes, susceptibility, signs and symptoms,
treatments, healers, and sequelae and were constructed
on the basis of informal interviews at each of four sites
and some additional sources (Weller & Baer, 2001). With
cultural consensus analysis supporting high agreement
within samples (Weller et al., 1993), the results of a binomial test indicating a strong majority response (66%)
in each sample for each illness was used to estimate
group beliefs about the presence/absence of features that
best described each illness (Weller & Baer, 2001,
p. 201). Features determined to be of high concordance
within each setting were then directly compared as a way
of assessing what was distinctive or unique across the
four groups. The finding of a high degree of sharing with
little unique variation across the groups led Weller and
Baer (2001, p. 222) to reflect on the underlying cognitive
representation and suggest that the illnesses and features
that define them may compose a systemic culture pattern
or high concordance code in the sense that they may form
a structured set of related items with high agreement and
stability across culture members. These comments about
feature sets brought to mind DAndrades (1976) somewhat different assessment, based on work involving the
termframe substitution interview, that it was cognitively
plausible to expect that knowledge about illness or any
other cultural domain is stored in terms of propositions,
or in other ways of representing conceptual relationships,
16
discussed the challenges in working toward the construction of a comparative framework that captures the range
of known variability across cultural settings while still
remaining open to ethnographic possibilities.
COGNITIVEETHNOGRAPHIC STUDIES
ILLNESS TREATMENT DECISIONS
OF
17
18
CULTURAL MODELS
NARRATIVES
AND ILLNESS
19
20
References
21
REFERENCES
Bauer, M. C., & Wright, A. L. (1996). Integrating qualitative and quantitative methods to model infant feeding behavior among Navajo
mothers. Human Organization, 55, 183192.
Boster, J. S. (1980). How the exceptions prove the rule: Aguaruna plant
classification (Doctoral dissertation, University of California,
Berkeley, 1980).
Bruner, J. (1986). Actual minds, possible worlds. Cambridge, MA:
Harvard University Press.
Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard
University Press.
Cain, C. (1991). Personal stories: Identity acquisition and selfunderstanding in Alcoholics Anonymous. Ethos, 19, 210253.
Capps, L., & Ochs, E. (1995). Constructing panic: The discourse of
agoraphobia. Cambridge, MA: Harvard University Press.
Casson, R. W. (1994). Cognitive anthropology. In P. K. Bock (Ed.),
Psychological anthropology (pp. 6196). Westport, CT: Praeger.
Clement, D. C. (1982). Samoan folk knowledge of mental disorders. In
A. J. Marsella & G. M. White (Eds.), Cultural conceptions of mental health and therapy (pp. 193213). Dordrecht, Netherlands:
Reidel.
DAndrade, R. (1976). A propositional analysis of U.S. American
beliefs about illness. In K. H. Basso & H. A. Selby (Eds.), Meaning
in anthropology (pp. 155180). Albuquerque: University of
New Mexico Press.
DAndrade, R. (1995). The development of cognitive anthropology.
Cambridge, UK: Cambridge University Press.
DAndrade, R. G., Quinn, N. R., Nerlove, S. B., & Romney, A. K.
(1972). Categories of disease in American-English and MexicanSpanish. In A. K. Romney, R. N. Shepard, & S. B. Nerlove (Eds.),
Multidimensional scaling: Theory and applications in the behavioral sciences, Vol. II (pp. 954). New York: Seminar Press.
Fabrega, H., Jr. (1970). On the specificity of folk illnesses.
Southwestern Journal of Anthropology, 26, 305314.
Fabrega, H., Jr., & Silver, D. B. (1973). Illness and shamanistic curing
in Zinacantan: An ethnomedical analysis. Stanford, CA: Stanford
University Press.
22
Farmer, P. (1994). AIDS-talk and the constitution of cultural models.
Social Science & Medicine, 38, 801810.
Frake, C. O. (1961). The diagnosis of disease among the Subanun of
Mindanao. American Anthropologist, 63, 113132.
Frake, C. O. (1969 [1962]). The ethnographic study of cognitive systems. In S. A. Tyler (Ed.), Cognitive anthropology (pp. 2841).
New York: Holt, Rinehart & Winston.
Garro, L. C. (1983). Variation and consistency in a Mexican folk illness
belief system (Doctoral dissertation, University of California,
Irvine, 1983).
Garro, L. C. (1986). Intracultural variation in folk medical knowledge:
A comparison between curers and non-curers. American
Anthropologist, 88, 351370.
Garro, L. C. (1988). Explaining high blood pressure: Variation in
knowledge about illness. American Ethnologist, 15, 98119.
Garro, L. C. (1994). Narrative representations of chronic illness
experience: Cultural models of illness, mind and body in stories
concerning the temporomandibular joint (TMJ). Social Science
and Medicine, 38, 775788.
Garro, L. C. (1996). Intracultural variation in causal accounts of
diabetes: A comparison of three Canadian Anishinaabe (Ojibway)
communities. Culture, Medicine and Psychiatry, 20, 381420.
Garro, L. C. (1998a). On the rationality of decision making studies:
Part 1: Decision models of treatment choice. Medical Anthropology
Quarterly, 12, 319340.
Garro, L. C. (1998b). On the rationality of decision making studies:
Part 2: Divergent rationalities. Medical Anthropology Quarterly,
12, 341355.
Garro, L. C. (2000a). Remembering what one knows and the construction of the past: A comparison of cultural consensus theory and
cultural schema theory. Ethos, 28, 275319.
Garro, L. C. (2000b). Cultural meaning, explanations of illness, and the
development of comparative frameworks. Ethnology, 39, 305334.
Garro, L. C. (2000c). Cultural knowledge as resource in illness narratives: Remembering through accounts of illness. In C. Mattingly &
L. Garro (Eds.), Narrative and the cultural construction of illness
and healing (pp. 7087). Berkeley & Los Angeles: University of
California Press.
Garro, L. C. (2001). The remembered past in a culturally meaningful
life: Remembering as cultural, social and cognitive process. In
H. Mathews & C. Moore (Eds.), The psychology of cultural
experience (pp. 105147). Cambridge, UK: Cambridge University
Press.
Garro, L. C. (2002). Hallowells challenge: Explanations of illness and
cross-cultural research. Anthropological Theory, 2, 7797.
Garro, L. C. (2003). Narrating troubling experiences. Transcultural
Psychiatry, 40, 543.
Garro, L. C., & Mattingly, C. (2000). Narrative as construct and construction. In C. Mattingly & L. C. Garro (Eds.), Narrative and the
cultural construction of illness and healing (pp. 149). Berkeley &
Los Angeles: University of California Press.
Good, B. (1994). Medicine, rationality, and experience: An anthropological perspective. Cambridge, UK: Cambridge University Press.
Goodenough, W. H. (1957). Cultural anthropology and linguistics. In
P. Garvin (Ed.), Report of the seventh annual round table meeting in
linguistics and language study (Monograph Series on Language and
Linguistics, No. 9 (pp. 167173) ). Washington, DC: Georgetown
University.
Background
23
BACKGROUND
Since its inception, medical anthropology has had an
applied orientation; much of the work done by medical
anthropologists is concerned with understanding and
responding to pressing health issues and problems around
the world as they are influenced and shaped by human
social organization, culture, and context. Despite its
strong emphasis on addressing practical health issues,
initiatives within the discipline have tended to be guided
by one or another of several alternative theoretical perspectives. While the boundaries between these frameworks for explaining health in a socio-cultural context
have not been always sharply defined, and, although there
have been disagreements about which are the leading theoretical approaches at any point in time, most medical
anthropologists are influenced in their work by the dominant theories within the field.
Several efforts have been made to describe and contrast the most influential theories within medical anthropology. In his book Sickness and healing: An
anthropological perspective, Robert Hahn (1995) identified three dominant theoretical frameworks within medical anthropology, including environmental/evolutionary
theories, cultural theories, and political/economic theories. In his book, Medicine, rationality, and experience:
An anthropological perspective, Byron J. Good (1994)
identified four theoretical orientations found in medical
anthropology: the empiricist paradigm, the cognitive paradigm, the meaning-centered paradigm, and the critical
paradigm. Finally, in Medical anthropology in ecological
perspective, Ann McElroy and Patricia Townsend (1996)
also discussed four approaches, namely medical ecological theories, interpretive theories, political economy or
critical theories, and political ecological theories. Despite
these varying ways of grouping and ordering conceptual
24
IN THE
25
26
Disease
Even under the best of circumstances, human beings
inevitably find themselves confronted with disease or illness. As it is for biomedicine, a central question for medical anthropology must be: What is disease? It is clear
why this question is important to biomedicine. Medical
anthropologists, however, have tended to avoid the question altogether by defining disease (i.e., clinical manifestations of ill health) as the domain of medicine and
illness (i.e., the sufferers experience of those manifestations) as the appropriate arena of anthropological investigation. From the perspective of CMA, however,
defining disease as beyond the concern or expertise of
anthropologists is a retreat from ground that is as much
social as it is biological in nature. Disease varies from
society to society in significant ways because of organic,
climatic, or geographical conditions, but also because of
the ways productive activities, resources, and reproduction are organized and carried out, and because of the
living and working conditions that flow from the social
distribution of resources. From the CMA perspective,
discussion of specific health problems, apart from their
social contexts, only serves to downplay social relationships underlying environmental, occupational, nutritional, residential, and experiential conditions. Disease
is not just the straightforward result of a pathogen or
physiological disturbance. Instead, a variety of social
problems such as malnutrition, economic insecurity,
occupational risks, industrial pollution, substandard
housing, and political powerlessness contribute to susceptibility to disease (Baer, Singer, & Johnson, 1986). In
short, disease is as much social as it is biological. In this
light, the tendency, be it in medicine or in medical anthropology, to treat disease as a given, as part of an immutable
physical reality, contributes to the tendency to neglect its
social origins. CMA strives, in McNeils (1976) terms, to
understand the nature of the relationship between
microparasitism (the tiny organisms, malfunctions, and
individual behaviors that are the proximate causes of
much sickness) and macroparasitism (the social relations
of exploitation that are the ultimate causes of much disease). For example, an insulin reaction in a diabetic postal
worker might be seen in a very reductionist mode as an
excessive dose of insulin that causes an outpouring of
adrenaline, a failure of the pancreas to respond with
appropriate glucagon secretion, etc. However, a critical
perspective would tend to lead a researcher to investigate
whether the postal work skipped breakfast because of
being late for work, the psychobiological effects of the
derisive demands of a supervisor, or the inability to break
for a snack because of pressure from above to increase
productivity, or, more broadly, the health consequences of
the structure of class forces in U.S. society that ensures
capitalist domination of production and the moment to
moment working lives of working people like postal
employees (Woolhandler & Himmelstein, 1989).
Syndemics
As part of its effort to identify and understand health
within the intersecting frameworks of political economy
and bio-social causality, the CMA approach to the study
of disease is characterized by the investigation of a set of
factors including biology, epidemiology, sufferer and
community understandings of the disease(s) of concern,
27
Sufferer Experience
Medical social scientists have become increasingly concerned about sufferer experiencethe manner in which
an ill person manifests his or her disease or distress.
Writing from a critical perspective, Margaret Lock and
Nancy Scheper-Hughes have criticized the Cartesian
duality of body and mind that pervades biomedical theory (Lock & Scheper-Hughes, 1996). In this effort, they
have made a significant contribution to an understanding
of sufferer experience by developing the concept of the
mindful body (Scheper-Hughes & Lock, 1987). Lock
and Scheper-Hughes delineate three relevant bodies in
health: the individual body, the social body, and the body
politic. An individuals image of his/her body, whether in
a state of health and well-being or in a state of distress or
28
countries that pride themselves on undergoing modernization, has been distorted into a pathological event rather
than a natural physiological one for childbearing women
and their families. Aspects of the medicalization of
birthing, for example, include (1) the withholding of
information on the disadvantages of obstetric medication,
(2) the expectation that women give birth in a hospital,
(3) the elective induction of labor, (4) the separation of
the mother from familial support during labor and birth,
(5) the confinement of the laboring woman to bed,
(6) professional dependence on technology and pharmacological methods of pain relief, (7) routine electronic
fetal monitoring, (8) the chemical stimulation of labor,
(9) the delay of birth until the physicians arrival, (10) the
requirement that the mother assume a prone position
rather than a squatting one, (11) the routine use of
regional or general anesthesia for delivery, and (12) routine episiotomy (Haire, 1978, pp. 188194). Beginning in
the 1970s, the feminist health movement, an expression
of resistance and advocacy in the health arena, has
prompted many women and men to challenge many of
these practices and has contributed to a heavier reliance
on home births conducted by a now significant cadre of
lay midwives in industrialized societies. One factor driving medicalization is the profit to be made from discovering new diseases in need of treatment. Medicalization
also contributes to increasing social control on the part
of physicians and health institutions over behavior. It
serves to mystify and depoliticize the social origins of
personal distress. Medicalization transforms problems at
the level of social structuresuch as stressful work
demands, unsafe working conditions, and povertyinto
individual-level problems subject to medical control
(Waitzkin, 1983).
Medical Hegemony
Medicalization
This process entails the absorption of ever-widening
social arenas and behaviors into the jurisdiction of biomedical treatment through a constant extension of pathological terminology to cover new conditions and
behaviors. Health clinics, health maintenance organizations, and other medical provider organizations now offer
classes on managing stress, controlling obesity, overcoming sexual impotence, alcoholism, and drug addiction,
and promoting smoking cessation. Even the birth
experience, not just in the United States but also in many
Medical Pluralism
Regardless of their degree of complexity, all health care
systems are based upon a dyadic core consisting of a
healer and a patient in interaction. The healer role may be
occupied by a generalist, such as the shaman in preindustrial societies or the family physician in modern societies. It may also be occupied by a complex array of
specialists from herbalists to oncologists even within a
single society. Rather than a single medical system, contemporary societies can sport a pluralistic set of healing
traditions, some of indigenous origin within particular
29
30
REFERENCES
Baer, H. A. (1982). On the political economy of health. Medical
Anthropology Newsletter, 14(1), 12, 1317.
Baer, H. A. (1989). The American dominative medical system as a
reflection of social relations in the larger society. Social Science
and Medicine, 28, 11031112.
Baer, H. A. (Ed.). (1996). Critical biocultural approaches in medical
anthropology: A dialogue [Special Issue]. Medical Anthropology
Quarterly (n.s.), 10(4).
Baer, H. A., Singer, M., & Johnsen, J. (eds.). (1986). Towards a critical
medical anthropology [Special issue]. Social Science and
Medicine, 23(2).
Baer, H., Singer, M., & Susser, I. (2002). Medical anthropology and
the world system: A critical approach (2nd ed.). Westport, CT:
Bergin & Garvey.
Crandon-Malamud, L. (1991). From the fat of our souls: Social change,
political process, and medical pluralism in Bolivia. Berkeley:
University of California Press.
Farmer, P. (1999). Infections and inequalities: The modern plagues.
Berkeley: University of California Press.
Femia, J. (1975). Hegemony and consciousness in the thought of
Antonio Gramsci. Political Studies, 23, 2948.
Frankenberg, R. (1980). Medical anthropology and development: A theoretical perspective. Social Science and Medicine, 14B, 197207.
Frankenberg, R. (1981). Allopathic medicine, profession, and capitalist
ideology in India. Social Science and Medicine, 15A, 115125.
Good, B. (1994). Medicine, rationality, and experience. Cambridge,
UK: Cambridge University Press.
Hahn, R. (1995). Sickness and healing: An anthropological perspective.
Ann Arbor: University of Michigan Press.
Haire, D. (1978). The cultural warping of childbirth. In J. Ehrenreich
(Ed.), The cultural crisis of modern medicine (pp. 185200).
New York: Monthly Review Press.
Ho, D. (1996). Viral counts count in HIV infection. Science, 272(24),
11671170.
Ingman, S. R., & Thomas, A. E. (eds.). (1975). Topias and Utopias in
health: Policy studies. The Hague: Mouton.
Lock, M., & Scheper-Hughes, N. (1996). A critical-interpretive
approach in medical anthropology: Rituals and routines of discipline and dissent. In C. F. Sargent & T. M. Johnson (Eds.), Medical
anthropology: Contemporary theory and method (pp. 4170).
Westport, CT: Praeger.
McElroy, A., & Townsend, P. K. (1996). Medical anthropology in ecological perspective (3rd ed.). Boulder, CO: Westview Press.
McNeill, W. H. (1976). Plagues and peoples. New York: Anchor Books.
Mering, O. von (1970). Medicine and psychiatry. In O. von Mering &
L. Kasdan (Eds.), Anthropology and the behavioral and health
31
History
Field research in the mid-20th century on disease distribution and human adaptation in various habitats formed
a solid foundation for foraging theoretical links among
medicine, ecology, and evolution. In The Ecology of
Human Disease (May, 1958), physician and geographer
Jacques May applied spatial analysis to regional and
cultural differences in malaria prevalence in Vietnam.
Livingstone (1958) correlated hemoglobin frequencies
with the histories of migration and ecological change in
West Africa. Research on the microevolution of indigenous South American populations (Neel, 1971) generated
profiles of genetic differences and disease resistance in
relatively isolated foragers and cultivators. Research
among high-altitude peoples by Baker and Little (1976)
and colleagues revealed the physiological plasticity of
humans and the limits to adaptability in rigorous environments. Field studies in subarctic regions (Steegmann,
1983) and in the Arctic (Laughlin, 1964) explored the
Methods
Medical ecology is a theoretical orientation rather than
a formal theory (Wellin, 1977), encompassing a broad
systems approach in research. Hence the choice of
research methods is eclectic, ranging from clinical measures (anthropometrics, fecal analysis for parasites, blood
32
ECOLOGY
AND
DISEASE
Medical ecology studies health and disease in an environmental context. Central to the model is the concept of
ecosystem: a set of relationships among organisms within
a given environment that provides both opportunities and
constraints (Moran, 2000). The environment has three
major components: biotic elements (sources of food,
building materials, predators and vectors), abiotic (climate, solar energy, inorganic materials), and cultural elements (human systems). Each of these components play
a central role in human well-being and survival.
Reproductive Ecology
Human reproduction is affected by ecological factors
such as seasonal variability in food, environmental carrying capacity, the production roles and spatial distribution
in work of men and women, and diseases causing infertility or subfecundity (Townsend & McElroy, 1992).
Studies of reproductive ecology have been carried out in
isolated populations by Konner and Worthman (1980),
Ellison (1990), and Binford and Chasko (1976).
MacCormack (1994) was among the first anthropologists
to focus on women as energy producers, with trade-offs
between subsistence and reproductive roles. The idea of
trade-offs, or reproductive compromises, is also fundamental in the work of Trevathan (1987), not only in a
socio-cultural sense, but also in terms of the evolution of
human fetal development and gestational parameters.
33
EVOLUTIONARY PERSPECTIVES
DISEASE
ON
34
35
36
SUMMARY
Medical anthropologists trained in many specialties are
developing models of evolution and ecology to explain
and predict factors affecting the well-being of individual
organisms, growth or decline of various populations, and
the survival of the human species. As the human genome
is mapped and analyzed by biologists and biocultural
anthropologists, evidence of the connections between
environmental adaptation and genetic change will
become increasingly clear.
At present we have relatively few strong cases linking evolutionary change to historically documented ecological change. A classic case involves cultural shifts to
agriculture in West Africa some 4,000 years ago, leading
to increased prevalence of particularly lethal forms of
malaria. In this case, natural selection for alleles providing resistance to malaria (e.g., hemoglobin variants such
as S, C, and E and enzyme deficiencies such as G6PD)
provides a clear example of genetic adaptation to environmental perturbations (Greene & Danubio, 1997).
Medical geographers and physical anthropologists continue to look for equally strong evidence for population
resistance to plague, tuberculosis, smallpox, syphilis, and
other diseases that have changed the course of human
history. With suitable models of disease ecology and
evolutionary mechanisms, medical anthropologists may
contribute to future understanding and prevention of
disease, disability, and environmental disequilibrium.
REFERENCES
Alland, A., Jr. (1970). Adaptation in cultural evolution: An approach to
medical anthropology. New York: Columbia University Press.
Baker, P. T., & Little, M. A. (Eds.). (1976). Man in the Andes: A multidisciplinary study of high altitude quechua. Stroudsburg, PA:
Dowden, Hutchinson and Ross.
Barr, R. G. (1999). Infant crying behavior and colic: An interpretation
in evolutionary perspective. In W. R. Trevathan, E. O. Smith, &
J. J. McKenna (Eds.), Evolutionary medicine (pp. 2752).
New York: Oxford University Press.
Binford, L. R., & Chasko, W. J., Jr. (1976). Nunamiut demographic history: A provocative case. In E. B. W. Zubrow (Ed.), Demographic
anthropology: Quantitative approaches (pp. 63143). Albuquerque:
University of New Mexico Press.
Black, F. L. (1975). Infectious diseases in primitive societies. Science,
187, 515518.
Brett, J., & Niermeyer, S. (1999). Is neonatal jaundice a disease
or an adaptive process? In W. R. Trevathan, E. O. Smith, &
History
37
Forensic Anthropology
Douglas H. Ubelaker
DEFINITIONS
Forensic anthropology represents the application of our
knowledge and techniques of physical anthropology to
medico-legal problems. Historically, such applications
have focused on skeletal remains, although issues involving soft tissue are at times included. With skeletal remains
forensic anthropologists are asked to offer opinions if the
evidence represents human, non-human animals, or other
materials. If the remains are thought to be human, then
analysis is directed toward such problems as determining
the age at death, sex, ancestry, living stature, postmortem
interval (time since death), anatomical parts represented,
the presence of disease or injury and if so, any treatment
of the conditions, any unusual features that might facilitate identification, any evidence of injury that might have
can &
contributed to death and postmortem change ( Is
HISTORY
The roots of forensic anthropology extend back to
19th-century interests in the biological basis of abnormal
38
behavior (Lombroso, 1887), Bertillonage (human identification using anthropometric measurements), and early
anatomists and physicians called upon to examine human
remains. Stewart (1979) has suggested that Thomas
Dwight (18431911) deserves the title of Father of
Forensic Anthropology in the United States for his
1878 essay on medicallegal identification of the human
skeleton and other works (Dwight, 1878). Other notable
early contributors were Jeffries Wyman (18141874),
George Dorsey (18691931) and Harris Hawthorne
Wilder (18641928) (Stewart, 1979; Ubelaker, 1999b).
Although the early pioneers of physical anthropology Ales Hrdlic ka (18691943) and Earnest A. Hooton
(18871954) were involved in casework (Stewart, 1979;
Ubelaker, 1999c), publication and professionalization of
the field came later, largely through the work of Wilton
M. Krogman (19031988) and T. Dale Stewart
(19011997) (Ubelaker, 2000a, 2000b). Key factors in
the development of forensic anthropology were the
growth of skeletal collections supporting forensic
research, routine consultation of Smithsonian anthropologists with the FBI, anthropological involvement with the
military to assist in identification issues, formation of the
Physical Anthropology Section of the American
Academy of Forensic Sciences in 1972, and the formation of the American Board of Forensic Anthropology in
1977 (Snow, 1982; Ubelaker, 1997). By the year 2001,
membership had grown to 252 in the Physical
Anthropology Section and to 50 Diplomates recognized
by the ABFA.
TRAINING
Certification in the ABFA requires a Doctoral degree in
Anthropology with an emphasis on Physical Anthropology and evidence of advanced study of human osteology,
human anatomy, and dental anthropology. Such a
requirement strongly suggests that forensic anthropologists receive their formal training in a PhD granting
Department of Anthropology with an emphasis on the
specialized areas mentioned. Training is also useful in
archeological recovery techniques, appropriate legal
issues, related areas of forensic science, and evidence
handling. Experience with actual forensic cases is
extremely important and usually is obtained by working
with a practicing forensic anthropologist. Courses, workshops, fellowships, and internships are also available to
Forensic Anthropology
PRIMARY GOALS
Usually, analysis in forensic anthropology is oriented
toward two major goals: (1) establishing a profile of the
individual represented that will assist in positive identification, and (2) the recognition and interpretation of
evidence of foul play.
As mentioned above, the identification profile can
involve determining that the remains are of human origin,
estimation of age at death, sex, ancestry, living stature,
general robusticity, the presence and treatment of medical
conditions, and noting any unusual biological features
that might be known about the once-living individual.
The accumulation of such information helps narrow the
search for the missing person and excludes individuals
who do not fit the profile.
In cases of recent origin in which identification has
remained elusive, a facial reproduction may be called for
(Taylor, 2001; Ubelaker, 2000c). This involves generating
an image of the head of the individual to be presented to
the public through the media. Such a technique is used to
reach out to the public for information about possible
missing persons. Different techniques can be employed
to generate such an image but most begin with
markers placed on the skull to document the depth of the
soft tissue at various places (Manhein et al., 2000). The
anthropologist and/or artist then produces either a twodimensional or three-dimensional image of the person
using various combinations of sculpture and/or computer
techniques.
If a photograph of a suspected missing person is
available, then it can be compared directly with a recovered skull through a process usually referred to as photographic superimposition. Using video and computer
equipment, specialists can directly compare the images
and assess the extent to which they are consistent
(Ubelaker, 2000d). This technique is used primarily for
exclusion (to indicate that the skull and photograph represent different individuals), but its use has diminished
(Ubelaker, 2000e) as more powerful molecular techniques for identification have become available.
Positive identification results when unique features
are found on recovered remains that are known to
have existed in a missing person. To establish positive
New Techniques
METHODOLOGY
Like other experts in forensic science, forensic anthropologists need to present objective, factual, and interpretative opinions on the evidence presented to them.
Although a case may be brought to the anthropologist by
a particular law enforcement group or others, it is important to retain objectivity and focus on the scientific issues
concerning the evidence presented.
The forensic anthropologist also must be flexible
and thoughtful in the selection of procedures and methodology. Many techniques are available to assist analysis,
but proper selection of those employed must be dictated
by the particular problem presented and the individual
39
NEW TECHNIQUES
Recent years have witnessed accelerated research in
forensic anthropology resulting in many new techniques
to support all areas of analysis. These are too numerous
and complex to be discussed in detail here, but the
following represent a few highlights.
Recovery efforts continue to rely primarily on
careful archeological-type techniques with extensive documentation. These efforts are supported by the use of aerial photography, surface topography study, ground
penetrating radar, cadaver dogs (dogs trained to detect the
odor of decomposing human tissue), and other technological advances.
The differentiation of human tissue from other
materials continues to rely extensively upon macroscopic
morphological indicators, but in fragmentary and other
difficult cases these techniques can be supplemented with
microscopic histological examination and/or elemental
analysis using a scanning electron microscope (SEM)
with associated energy dispersive spectrometer (EDS).
SEM/EDS analysis allows bones and teeth to be distinguished from most other materials. Microscopic analysis
of histological structure (Mulhern & Ubelaker, 2001)
allows human bone to be distinguished from some other
animals.
New techniques in the estimation of age at death,
sex, and stature have become available for more parts of
the skeleton and with a greater appreciation for the population variation involved.
In 1984, the physical anthropology section of the
American Academy of Forensic Sciences initiated a data
bank managed at the University of Tennessee, Knoxville.
This data bank maintains measurements and observations
on identified forensic cases and documented museum
collections which has been used to generate new methodology for analysis. Since these data were largely derived
from forensic cases, they are of obvious utility in developing new methods to use in individual cases. New
methodology stemming from this effort includes the
computer program FORDISC 2.0 (Ousley & Jantz,
40
APPLICATIONS
Most forensic anthropologists routinely work on individual cases presented to them by law enforcement, forensic
pathologists, or other parties. The military employs a
group of anthropologists to assist with the recovery and
identification effort of decedents associated with military
operations, especially those in southeast Asia.
Anthropologists also have become increasingly involved
in the investigations of mass disasters and suspected
international human rights violations.
In 1996 Diplomates of the American Board of
Forensic Anthropology reported that they had worked on
1,439 individual cases that year. Of these, 81% had been
presented to them by such agencies as local law enforcement, state police, military, coroners, medical examiners,
or sheriffs departments. The remaining 19% represented
civil cases; the majority of these were requested by the
plaintiff. Of the agency submissions, most originated
from medical examiners or coroners offices with the
military representing an additional major contributor.
Also in that year, Diplomates most commonly reported
on skeletons, but also on decomposed and relatively fresh
remains (Ubelaker, 2000f).
Forensic Anthropology
References
41
SUMMARY
Forensic anthropology has evolved into an important subfield of physical anthropology and forensic science
(Ubelaker, 1996). Forensic anthropologists routinely contribute to casework involving human remains and through
research and experience have increased their collective
ability to learn a great deal about an individual from their
remains.
REFERENCES
Dwight, T. (1878). The identification of the human skeleton. A medicolegal study. Boston, MA.
Fenger, S. M., Ubelaker, D. H., & Rubinstein, D. (1996). Identification
of workers compensation fraud through radiographic comparison.
Journal of Forensic Identification, 46(4), 418431.
42
Illness Narratives
IIlness Narratives
Ron Loewe
43
44
ILLNESS NARRATIVES IN
ANTHROPOLOGY AND BEYOND
The use of narrative to describe other peoples experiences of acute or chronic illness is also something of a
growth industry. In the last few years, analyses of patient
narratives have been used to explore everything from
autism (Gray, 2001) to temporomandibular joint syndrome (Garro, 1994). In between one finds studies of
breast cancer (Langellier & Sullivan, 1998), depression
(Kangas, 2001), diabetes (Hunt, Valenzuela, & Pugh,
1998; Loewe & Freeman, 2000), HIV (Bloom, 2001;
Ezzy, 2000), mental illness (Goodman, 2001), and schizophrenia (Lovell, 1997), to mention just a few of the more
recent ones. Ironically, though, as Byron Good notes,
there are relatively few studies that take an explicitly
cross-cultural perspective (Good, 1994), or venture
beyond the borders of the authors native land. Some that
do, include: Evelyn Earlys study of the informal stories
Baladi (Egyptian) women tell to clarify illness episodes
and garner emotional support (Early, 1985), Laurie
Prices use of illness narratives to understand gender
relations surrounding care-giving in Ecuador (Price,
1987); Sam Migliones study of nerves among Sicilians
living in Canada (Miglione, 2001), Byron Good and
Mary Del Vecchio Goods study of epilepsy, and the
possibility of healing through narrative, in Turkey
(Good & Del Vecchio Good, 1994); and Paul Farmers
discussion of how a model of AIDs was gradually developed through stories about afflicted individuals in rural
Haiti (Farmer, 1994).
In the latter, AIDSTalk and the Constitution of
Cultural Models, Farmer is in the unique position of
studying a disease which is in the process of emerging,
and is able to follow the evolution of thinking about AIDs
from the early 1980s, when many Haitians had not heard
of the disease, and there was nothing that could reasonably be called a story, through 1989 when local conceptions of the disease began to stabilize. In particular,
Farmer is able to trace changing concepts of AIDS from
a variant of tuberculosis in 198384, to an ill-defined
blood disease in 1986, to a Duvalier conspiracy in 1987,
and, finally, to a type of sent disease (e.g., voodoo).
As a type of disease that can be sent through microbes,
AIDS was new wine in old bottles; however, according to
Farmer, it was not simply the insertion of a new disease
into an old paradigm which lent stability to the publics
Illness Narratives
ILLNESS NARRATIVES
CLINICAL MEDICINE
IN
Because symptoms are by definition the patients interpretation of a malady, illness narratives have always been
considered a part of clinical medicine. As Greenhalgh and
Hurwitz note in Narrative Based Medicine: Dialogue and
Discourse in Clinical Practice (1998), even in the most
autocratic, doctor-centered redoubts of clinical medicine
the patient retains a special status as an information
bearer, and the most effete professors will exhort their
students to listen to the patient; shes telling you the
diagnosis (p. 6). What role the patient narrative plays in
medicine, of course, varies greatly from subspeciality to
subspeciality as well as across space and time. While the
practice of medicine by epistle in the 18th century obviously required a detailed written narrative (and a welleducated patient), the development of new technologies,
such as MRI and CAT scans, which allow physicians to
visualize the deepest recesses of the human body, and the
emphasis on medical testing, make patient narratives
seem almost dispensable. Ironically, as Kay and Purvis
note (1998), the development of electronic medical
records may contribute to a similar decline in doctor narratives, depending on whether, or to what extent, they
allow physicians to enter unstructured comments or free
text (pp. 192193).
45
46
Illness Narratives
NARRATIVE
AND THE
NARRATOLOGIST
While the word narrative now appears with notable regularity in the titles of anthropological studies of illness or
disease, there are relatively few studies that explore the
philosophical or ontological basis of narrative, or that
avail themselves of the large body of writing on narrative
in literary criticism, philosophy, or linguistics. Indeed,
like the social science interview analyzed by Briggs in
Learning How to Ask (1986), narrative is often conceived of as a more or less transparent medium for obtaining or revealing information about disease X from the
perspective of ethnic group Y or interest group Z. In other
words, what linguistic anthropologists like Briggs
describe as the referential function of language (e.g., the
world of objects) is privileged over the pragmatic or
metacommunicative functions of language. Nevertheless,
as Good notes in Medicine Rationality and Experience
(1994), anthropologists, and social scientists more generally, are becoming increasingly concerned with questions
like: To what extent do the stories report or depict events
or experiences as they occurred? Does a good history
mirror events and experience, or does it select events and
organize them culturally? To what extent is social life
itself organized in narrative terms? (p. 139).
Using the work of William Labov as a baseline, it is
also possible to detect a shift in the way these questions
are answered, although there is clearly no consensus, and,
undoubtedly, never will be, about what a narrative is.
References
47
NOTE
1. American and Chinese medical systems in several works (Kleinman,
1980; Kleinman, Kunstadter, Russell, & Gate, 1978).
REFERENCES
Ansay, A. M. (2001). Limbo: A memoir. New York: William Morrow.
Becker, G. (1994). Metaphors of disrupted lives: Infertility and Cultural
Constructions of Continuity, Medical Anthropological Quarterly
8, 383410.
Bloom, F. (2001). New beginnings: A case study in gay mens
changing perceptions of quality of life during the course of
HIV Infection. Medical Anthropology Quarterly, 15(1), 3857.
Briggs, C. (1986). Learning how to ask: A sociolinguistic appraisal of
the role of the interview in social science research. Cambridge,
UK: Cambridge University Press.
Broyard, A. (1993). Intoxicated by my illness and other writings on life
and death. New York: Fawcett Columbine.
Comaroff, J. (1976). A bitter pill to swallow; Placebo therapy in general
practice. Sociological Review, 24(1), 79.
Cousins, N. (1979). Anatomy of an illness as perceived by the patient:
Reflections on healing and regeneration. New York: Bantam Books.
Cousins, N. (1983). The healing heart: Antidotes to panic and
helplessness. New York: Norton.
Csordas, T. (1983). The rhetoric of transformation in ritual healing.
Culture, Medicine and Psychiatry, 7, 333376.
Csordas, T. (1988). Elements of charismatic persuasion and healing.
Medical Anthropology Quarterly, 2, 102120.
Dorris, M. (1990). The broken cord. New York: Harper Collins.
Dubos, R. (1965). Man adapting. New Haven, CT: Yale University Press.
48
Dubos, R. (1968). Men, medicine and environment. New York: Praeger.
Early, E. (1985). Catharsis and creation: The everyday narratives of
Baladi women of Cairo. Anthropological Quarterly, 58, 172181.
Ezzy, D. (2000). Illness narratives: Time, hope and HIV. Social Science
and Medicine, 50(5), 605617.
Fabrega, H., Jr. et al. (1976). Culture, language and the shaping of illness: An illustration based on pain. Journal of Psychosomatic
Research, 20(4), 323337.
Farmer, P. (1994). AIDS-talk and the constitution of cultural models.
Social Science and Medicine, 38(6), 801809.
Finkler, K. (1983). Spiritist healers in Mexico. South Hadley, MA:
Bergin & Garvey.
Frank, A. (1995). At the will of the body: Reflections on illness. Boston:
Houghton Mifflin.
Garcia-Marquez, G., & Rabasa, G. (1996). Chronicles of a death foretold. London: Penguin.
Garro, L. (1994). Narrative representations of chronic illness experience: Cultural models of illness, mind, and body in stories concerning the temporomandibular joint (TMJ). Social Science and
Medicine, 38(6), 775788.
Good, B. J., (1994). Medicine, rationality and experience: An anthropological perspective. London: Cambridge University Press.
Good, B. J., & DelVecchio Good, M.-J. (1994). In the subjunctive
mode: Epilepsy narratives in Turkey. Social Science and Medicine,
38(6), 835842.
Goodman, Y. (2001). Dynamics of inclusion and exclusion: Comparing
illness narratives of Haredi male patients and their Rabbis. Culture,
Medicine and Psychiatry, 25(2), 169194.
Gould, S. J. (1998). The median isnt the message. In T. Greenhalgh &
B. Hurwitz (Eds.), Narrative based medicine: Dialogue and
discourse in clinical practice. London: BMJ Books.
Gray, D. E. (2001). Accomodation, resistance and transcendence: Three
narratives of autism. Social Science and Medicine, 53(9), 12471257.
Greenhalgh, T., & Hurwitz, B. (1998). Narrative-based medicine:
Dialogue and discourse in clinical practice. London: BMJ Books.
Holmes, J. (1998). Narrative in psychotherapy. In T. Greenhalgh &
B. Hurwitz (Eds.), Narrative based medicine: Dialogue and
discourse in clinical practice. London: BMJ Books.
Hunt, L., Valenzuela, M., & Pugh, J. (1998). Porque Me Toca a Mi:
Mexican American diabetes patients causal stories and their relationship to treatment behaviors. Social Science and Medicine,
46(8), 959969.
Hunter, K. (1991). Doctors stories: The narrative structure of medical
knowledge. Princeton, NJ: Princeton University Press.
Jamison, K. R. (1995). An Unquiet Mind. New York: Knopf.
Jefferson, G. (1978). Sequential aspects of storytelling in conversation.
In J. Schenkein (Ed.), Studies in the organization of conversational
interaction. New York: Academic Press.
Kangas, I. (2001). Making sense of depression: Perceptions of melancholia in lay narratives. An Interdisciplinary Journal for the Social
Study of Health, Illness and Medicine, 5(1), 7692.
Kapferer, B. (1983). A celebration of demons: Exorcism and the aesthetics of healing in Sri Lanka. Bloomington: Indiana University
Press.
Kay, S., & Purvis, I. (1998). The electronic medical record and the
story stuff: A narrativistic model. In T. Greenhalgh & B. Hurwitz
(Eds.), Narrative based medicine: Dialogue and discourse in
clinical practice. BMJ Books.
Illness Narratives
Kleinman, A. (1980). Patients and healers in the context of culture: An
exploration of the borderland between anthropology, medicine and
psychiatry. Berkeley: University of California Press.
Kleinman, A. (1988). The illness narratives: Suffering, healing and the
human condition. New York: Basic Books.
Kleinman, A., Kunstadter, A., Russell, E., & Gate, J. (Eds.). (1978).
Culture and healing in Asian societies: Anthropological, psychiatric and public health studies. Cambridge, MA: Shenkman.
Labov, W., & Waletsky, J. (1967). Narrative analysis: Oral versions of
personal experience. In J. Helms (Ed.), Essays in the verbal and
visual arts. Seattle: University of Washington.
Laderman, C. (1991). Taming the wind of desire: Psychology, medicine
and aesthetics in Malay Shamanistic performance. Berkeley:
University of California Press.
Langellier, K. (1989). Personal narratives: Perspectives on theory and
research. Text and Performance Quarterly, 9, 243276.
Langellier, K., & Sullivan, C. (1998). Breast talk in cancer illness.
Qualitative Health Research, 8(1), 7694.
Launer, J. (1998). Narrative and mental health in primary care. In
T. Greenhalgh & B. Hurwitz (Eds.), Narrative based medicine:
Dialogue and discourse in clinical practice. BMJ Books.
Levi-Strauss, C. (1963a). The effectiveness of symbols. In Structural
anthropology. New York: Basic Books. pp. 186205.
Levi-Strauss, C. (1963b). The sorcerer and his magic. In Structural
anthropology. New York: Basic Books. pp. 167185.
Loewe, R., & Freeman, J. (2000). Interpreting diabetes mellitus:
Differences between patient and provider models of disease and
their implications for clinical practice. Culture, Medicine and
Psychiatry, 24, 379401.
Loewe, R., Freeman, J., Schwartzman, J., Quinn, L., & Zukerman, S.
(1998). Doctor talk and diabetes: Towards an analysis of the clinical construction of chronic illness. Social Science and Medicine,
47(9), 12671276.
Lovell, A. (1997). The city is my mother: Narratives of schizophrenia
and homelessness. American Anthropologist, 99, 355368.
Mattingly, C. (1998). Healing dramas and clinical plots: The narrative
structure of experience. Cambridge, UK: Cambridge University
Press.
Miglione, S. (2001). From illness narratives to social commentary: A
Pirandellian approach to nerves. Medical Anthropological
Quarterly, 15(1), 100125.
Mishler, E. (1995). Narrative accounts in clinical and research
interviews. In B. L. Gunderson, P. Linell, & B. Nordberg (Eds.),
The Construction of Professional Discourse. London: Longman.
Morrison, M. (1991). White rabbit: A doctors story of her addiction
and recovery. New York: Berkley Books.
Murphy, R. (1987). The body silent. New York: Norton.
Polanyi, L. (1985). Conversational storytelling: Discourse and dialogue.
In T. Van Dijk (Ed.), Handbook of discourse analysis (Vol. 3,
pp. 98115). London: Academic Press.
Price, L. (1987). Ecuadorian illness stories: Cultural knowledge in
natural discourse. In D. Holland & N. Quinn (Eds.), Cultural
models in language and thought. Cambridge, UK: Cambridge
University Press.
Reissman, K. (1993). Narrative analysis [Qualitative research methods
series, No. 30]. Newbury Park, CA: Sage.
Roney, L. (1999). Sweet invisible body: Reflections on life with
diabetes. New York: Henry Holt.
Introduction
49
INTRODUCTION
Paleopathology, the study of disease in ancient remains,
is aimed at improving our understanding of the evolution
of diseases and their interaction with human biologic and
social history (Aufderheide & Rodriguez-Martin, 1998;
Brothwell & Sandison, 1967; Ortner & Aufderheide,
1991). Pathogenic organisms, environmental factors, and
patterns of disease evolve just as do larger organisms,
including hosts and vectors of disease. There is evidence,
however, for considerable stability in some hostparasite
relationships. Similar parasitic worms have been found in
Egyptian mummies and modern Egyptians. Such historical perspectives are necessary to prepare us for changes
in disease incidence and for new diseases, such as
Legionnaires disease and AIDS (Zimmerman, 2001).
Evidence of ancient disease is obtained from historic
records, works of art such as paintings, pottery effigies,
and figurines, religious statuary, figures and faces on
coins, skeletons, and mummies. Many diseases leave little or no direct mark on the bones and pseudopathologic
changes can be produced by erosive forces or animals
chewing on bones. Although lesions in archeological
specimens represent only a small proportion of the total
morbidity, the incidence of disease of a population, there
are valid reasons for such studies. Certain characteristics
or anomalies are useful as genetic markers. Evidence of
traumatic injuries can give information on the occupational or military orientation of the group under study.
Infectious diseases provide inferences on the general
health status of the population.
A major consideration in dealing with ancient material is that modern patients with skeletal pathology present one with symptoms and signs, whereas archeological
material presents one with a bone that has either a hole or
a bump. The diagnosis of skeletal lesions is properly
based on history, radiological findings, and pathology,
but we rarely have adequate history in dealing with
ancient skeletal material, and pathology is generally confined to the gross appearance, as microscopy is highly
technical (Schultz, 2001). One other caution is the paradox that skeletons showing pathology are usually those
of relatively healthy individuals. Unhealthy individuals
die very quickly, before they have time to develop
skeletal lesions.
Mummies are bodies preserved either artificially or
naturally. The Egyptian practice of artificial mummification developed from the natural preservation of bodies
buried in the desert in pre-Dynastic times, which may
have had a role in the development of the belief in life after
death. When it became customary to provide the deceased
with food and funerary furniture, larger graves and aboveground tombs allowed decomposition, necessitating the
development of artificial techniques of mummification.
All deceased Egyptians were mummified until the
Christian era, ca. 200400 AD, with a gradual refinement
of technique over the millennia, although in all periods the
poor were less carefully mummified (Zimmerman &
Angel, 1986). Artificially preserved mummies are found
in many other areas of the world as well.
Natural mummies, due to freezing or drying,
have been found in bogs and in arctic and arid areas.
50
THE HISTORY
OF
PALEOPATHOLOGY
After an early 19th-century period focusing on the examination of native American skulls, interest shifted to evidence of disease, dominated by activities at the
Smithsonian Institution, the Army Medical Museum, and
the Peabody Museum at Harvard. In Europe a controversy arose when Rudolf Virchow, the German pathologist, anthropologist, and politician questioned the
authenticity of the Neander Valley specimen, suggesting
that the Neanderthal remains were those of an abnormal
modern man suffering from rickets or syphilis.
The next period, from 1900 to 1970, began with the
Smithsonian appointment of Ales Hrdlicka. Describing
lesions that he called symmetrical osteoporosis, he
noted that they were probably representative of a systemic
disorder. He built one of the worlds great collections and
contributed to the training of many anthropologists.
Flinders Petrie examined prehistoric Egyptian bones by
X-ray in 1897, but the technique was little used until the
work of Roy Moodie in the 1930s, and is only now beginning to be fully utilized.
The first of the truly modern paleopathologists was
Sir Marc Armand Ruffer. Ruffer was an English
experimental pathologist and bacteriologist of some
note when an illness forced him to Egypt for recuperation. He developed the rehydration technique that is
still in use for preparing microscopic sections of mummies and made a number of important diagnostic contributions before being lost at sea in World War I (Ruffer,
1921).
The first full-length book on paleopathology was
written by Roy L. Moodie (1923), an American
TECHNICAL CONSIDERATIONS
The preservation of buried bone varies with soil type.
Bones from acidic soil areas, such as Mesoamerica, will
be softened and often in poor condition. Careful excavation of skeletons, with complete clearing of the soil, is
essential. Most bones can be cleaned with warm water.
Skulls should be examined first for remnants of brain
tissue and for ear ossicles.
Hot paraffin wax, formerly used for conservation of
bone, can be damaging. Shellac preserves the surface but
tends to peel off in a few years, taking bone with it.
Soluble plastics are the best preservatives. Plaster of Paris
Paleopathologic Findings
51
THE CLASSIFICATION
OF
DISEASE
PALEOPATHOLOGIC FINDINGS
Congenital Defects
These defects, which are present at birth, may be hereditary or acquired before birth. Many are minimal and
do not cause any functional disability. There can be
abnormal fusions of bones, or failure of bone components
to fuse. Skull sutures may vary in their relationship.
Statistical analysis of skeletal variations can reveal significant associations and inferences as to the biological affinities of the individuals under study. Examples of acquired
congenital disorders are infections such as German
measles and syphilis, and chemically induced abnormalities such as the thalidomide babies born in the 1950s.
Congenital dwarfism is a generalized condition that
is easily recognized. Achrondoplasia, the most common
form, is due to a hereditary defect in the formation of
52
Traumatic Injury
Fracture constitutes the most common bone pathology
in both ancient and modern material (excluding arthritis).
If there is adequate immobilization of the bone, then
healing can be almost perfect, while poor immobilization
can lead to imperfect healing or nonunion. However,
many wild animals have well healed fractures. Medical
intervention may not be as necessary as we think; a well
healed fracture in an archeological specimen need not
imply the presence of an ancient orthopedic surgeon.
The recognition of traumatic injury in ancient
material can be difficult. Fractures or wounds, such as
sword cuts, if incurred shortly before death, will show no
evidence of healing and may be impossible to differentiate from postmortem injury. If there has been time for
healing, then rounding of the edges of wounds or callus
Paleopathologic Findings
53
Infectious Disease
These disorders are caused by microorganisms, including
bacteria, viruses, rickettsia, fungi, and single-celled
protozoan parasites. Invasion by macroorganisms, those
visible to the eye, such as worms and insects, constitutes
infestation. Modern treatment has altered many diseases and comparison between ancient and modern
diseases must keep this fact in mind.
Most infections do not affect the skeleton directly,
but the skeleton can be involved indirectly. Childhood
infections can result in the production of growth arrest
lines or Harris lines in the long bones, resulting in a very
rough index of morbidity. Infections that result in anemia
cause a secondary hyperplasia of the bone marrow, particularly in the skulls of children. X-rays show a characteristic hair-on-end appearance and the external surface
of the bone shows osteoporotic pitting, called porotic
hyperostosis. The geographic distribution of this lesion
has been shown to overlap that of malaria and these
conditions have been linked to sickle cell anemia and
thallessemia.
Bone infections, osteomyelitis, mostly bacterial
infections, reach the bone by a penetrating injury such as
a laceration or open fracture, by the bloodstream from a
distant site, or by direct extension from an infection such
as a soft tissue or dental abscess or a sinus infection.
Mastoiditis has been found in Neanderthal, Nubian,
54
Egyptian, and American Indian skulls, secondary to middle ear infection. The infected bone becomes necrotic and
is surrounded by pus, which may drain to the surface
through sinus tracts. Such infections can still be very difficult to treat and may persist for years. Pyogenic
osteomyelitis is an ancient disease, having been described
in dinosaur skeletons.
An infection with extensive historical documentation is bubonic plague, caused by Yersinia pestis. The
black death killed more than a quarter of the population
of Europe in the 14th century. Infection is transmitted to
humans by the bite of an infected rat flea. The lymph
nodes become greatly swollen (bubos), or, under conditions of crowding, transmission is by inhalation, causing
a rapidly fatal pneumonia. Sporadic infections still occur,
traceable to wild rodents.
A spirochetal disease of significance in human
history is syphilis. Advanced acquired disease results
in damage to many organs, including the cardiovascular
system, skeleton, skin, and upper respiratory tract. Congenital syphilis is passed across the placenta and is
characterized by deformities of the teeth, legs, and face.
The periostitis of syphilis is quite distinctive, but in
archeological material can be impossible to distinguish
from yaws.
The origin of syphilis, New World or Old, has long
been a point of controversy. One school holds that the
varying spirochetal diseases are different manifestations
of the same disease in different populations. Some feel
that yaws originated in the Pacific, spread to the New
World and manifested itself as syphilis when contracted
by adult European explorers, while others believe that
syphilis was present in the pre-Columbian Old World.
Tuberculosis, caused by an acid-fast bacillus, affects
the bone in a certain percentage of cases with destruction
of joints as well as bone. Involvement of the vertebral
bodies causes collapse and hunchback (kyphosis or Potts
disease). There are good examples from Dynastic Egypt,
but not pre-Dynastic, suggesting a possible evolution
from the bovine form of the disease, cattle having been
domesticated at the beginning of the Dynastic period.
Tuberculosis has been found in Europe at about 2000 BC
and in a mummy from pre-Columbian America, where
pottery figurines with kyphosis are also found.
Leprosy, caused by another acid-fast bacillus, is a
disease of considerable historical interest, because of
Biblical references and the fact that the characteristic
bone changes in the disease were first delineated in
Paleopathologic Findings
55
56
Immunologic Diseases
Although these are serious problems in the modern world
(AIDS, lupus erythematosis, etc.), these diseases have not
been identified in the paleopathologic record.
Degenerative Disease
Osteoarthritis (OA) is probably the best documented
disease in paleopathology. It has been described in
Neanderthals and in Cro-Magnon and Paleolithic
humans. Many Egyptian skeletons show characteristic
lesions, indicating that this is truly a wear and tear disorder, rather than being due, as was once thought, to cold
damp climates. The disease has also been described in
more recent skeletons from Britain and Europe. OA is
seen in joints that are used excessively. Examples of this
are OA of the temporomandibular joint in populations
that employ vigorous mastication of a rough diet, and
atlatl elbow seen in native American populations using
a throwing stick.
Rheumatoid arthritis is a disease of the smaller
bones of the hands and feet and the changes are sometimes only radiological, so the diagnosis is difficult in the
usual archeological material. An Egyptian mummy has
been diagnosed as having gout, with uric acid deposits in
the joints.
Circulatory Abnormalities
Changes in the delivery to the tissues of a normal amount
of blood containing the proper amount of electrolytes,
nutrients, and oxygen at the proper pressure can result in
damage. Infarction is necrosis of tissue due to interruption of the blood supply, usually due to atherosclerosis.
Myocardial (heart) and pulmonary (lung) infarcts are
often immediately fatal, but they may heal, often with
scarring and impaired function. There is considerable
paleopathologic evidence of atherosclerosis and Egyptian
tomb paintings give evidence of acute myocardial infarction, but experimental studies show that the necrosis of
an acute infarct is indistinguishable from postmortem
autolysis and thus probably undiagnosable.
Cancer
This class of diseases is among the most important in
industrialized societies. Benign tumors grow slowly,
remain localized, and cause only cosmetic or, occasionally, pressure effects. Malignant tumors, or cancers, grow
rapidly and have the ability to invade locally and to
spread throughout the body, metastasize, causing the
death of the individual. The progression of such tumors
can be erratic, but, if unchecked by medical or surgical
intervention, cancers will metastasize to vital organs via
lymphatics or blood vessels, destroying the function of
organs such as the liver, lung, or brain and causing death.
There have been a number of studies indicating that
cancer is a relatively modern disease. Comparative evidence shows that tumors are rare in nonhuman primates.
One very early tumor is most likely not a cancer but a
benign proliferation of bone of the femur of Homo
erectus, the immediate predecessor of Homo sapiens, discovered in Java in the early 20th century. This lesion has
been diagnosed as either myositis ossificans, a reaction to
trauma, or an example of fluorosis. Identical lesions have
been seen in modern patients suffering from excess ingestion of fluorine and similar lesions are noted in sheep
grazing in volcanic areas, such as Java. Tumors are
mentioned in the Egyptian medical papyri but have been
interpreted by modern readers as simply swellings or perhaps varicose veins. Cancers crab-like nature was noted
by the Greeks about 200 AD, but the first reports in the
scientific literature of a number of distinctive tumors have
only been over the past 200 years. Examples include scrotal cancer in chimney sweeps in 1775, nasal cancer in
snuff-users in 1761, and Hodgkins disease in 1832. Only
one diagnosis of a soft tissue tumor has been reported
in a mummyrectal carcinoma in an Egyptian of the
3rd century AD.
Tens of thousands of skeletons have been examined
and only a few tumor diagnoses made. Osteomas of the
skull have been described in several different skeletal
populations. Osteochondromas have been diagnosed in
skeletons from Scandinavia, Egypt, and in the New
World. A medieval skeleton from the Swedish island of
Gotland showed multiple exostoses, some of which
occluded the pelvic outlet, with death in labor. The
unborn fetus showed evidence of the same disease.
Tumors described by Elliot-Smith and Ruffer in Egyptian
skeletons as osteosarcoma, primary malignancy of bone,
are unlikely to be so, based on the gross morphology.
Some more likely cases have been reported from Europe
and Peru, although these could be reactive processes,
secondary to infection. Osteosarcoma is not an exceptionally rare tumor now and, as it usually produces bone,
Conclusion
Dental Paleopathology
Caries (cavities) is very much a disease of civilization but
has probably always been associated with humans and is
found in wild apes as well. Caries have been noted in
Australopithecines, Homo erectus, and Neanderthals.
Neolithic populations show caries in 210% of all teeth.
For the Roman period and the middle ages the figure is
slightly higher, 514%, but with the increase in the use of
more refined sugars and flours in the diet over the past
1,000 years the incidence has risen to the modern figure
of 5090%.
Caries has an inverse relationship with dental attrition, tooth wear, which has decreased since antiquity. The
diet in ancient times contained much grit, as flour or meal
was made by grinding wheat or corn on stone slabs.
57
CONCLUSION
The paleopathologic examination of ancient human
remains is useful for archeologists, anthropologists, and
physicians. Paleopathologic techniques can also be
applied to any desiccated tissues, including recent
remains, as in forensic settings.
For the archeologist there is information on living
conditions and social organization. In this context infectious and traumatic conditions are probably of the most
interest. Infectious diseases require a certain minimal
population living in close contact for their propagation
and are thus associated with at least village living, if not
urbanization. Disabling diseases, such as arthritis, which
take some time to develop, imply a degree of social
organization adequate to assume the burden of a cripple.
The congenital disorders, such as achondroplasia, have a
similar implication. Traumatic injuries tell us about the
military or industrial status of a population. Tumors,
while of interest to the pathologist studying the evolution
of disease, are sporadic and probably of little interest to
58
REFERENCES
Allison, M. J., Pezzia, A., Gerszten, E., Giffler, R. F., & Mendoza, D.
(1974). Aspiration pneumonia due to teeth950 AD and 1973 AD.
Southern Medical Journal, 67, 479483.
Aufderheide, A. C., & Rodriguez-Martin, C. (1998). The Cambridge
encyclopedia of paleopathology. Cambridge, UK and New York:
Cambridge University Press.
Brothwell, D. R. (1972). Digging up bones: The excavation, treatment
and study of human skeletal remains (2nd ed.). London: Trustees
of the British Museum (Natural History).
Brothwell, D. R., & Sandison, A. T. (1967). Diseases in antiquity.
Springfield, IL: C.C. Hall.
Cockburn, A., Cockburn, E. & Reyman, T. A. (Eds). (1998). Mummies,
diseases and ancient cultures. Cambridge, UK: Cambridge
University Press.
El-Najjar, M. Y., Ryan, D. J., Turner, C. G. II, & Lozoff, B. (1976). The
etiology of porotic hyperostosis among the prehistoric and historic
Anasazi Indians of Southwestern United States. American Journal
of Physical Anthropology, 44, 477487.
Hart Hansen, J. P. (1998). Bodies from Cold Regions. In Cockburn,
Cockburn & Reyman, op. cit., (pp. 336350).
PSYCHOANALYTIC UNDERSTANDING
RITUAL CURE AND PROPHYLAXIS
59
OF
60
Personal Symbols
61
PERSONAL SYMBOLS
In a study of Sri Lankan Sinhalese ascetic mystics,
Gananath Obeyesekere has focused on one symbol of
their ascetic condition: matted locks of hair, which are
regarded as the lingam (phallus) of the god. In a series of
in-depth interviews with several of these women, he discovers how they use this collective religious symbol to
resolve personal, emotional problems in their lives
(Obeyesekere, 1981). Such symbolspublicly recognized symbols which, however, retain a deep and unique
personal significancehe terms personal symbols. He
develops an argument in his book, based on interviews
with a number of these ascetic mystics, that such personal symbols may express problematic emotions, forbidden wishes, and guilt over them. The public symbols
are appropriated by each individual as a kind of collectively provided personal symptom. In a subsequent book
(Obeyesekere, 1990), he generalizes this line of thinking,
in an analogy with the dream work (Freud, 1900/1955),
62
ANTHROPOLOGICAL CONTRIBUTIONS TO
THE TREATMENT OF PSYCHOSIS
The treatment of mental illness is a subject of considerable interest for psychoanalytic anthropology, in
nonwestern societies and closer to home. Treatment
programs of psychosis that integrate native healers into
the treatment process have had striking results. A wellknown example is the program started by T. Adeoye
Lambo at Naro in Nigeria, in which patients were taken
into families in the village of Naro and, as part of the
treatment, worked and participated in village and family
life. Native healers were used alongside psychiatrists as
part of the treatment (Lambo, 1964).
The psychoanalytic treatment of psychosis in North
America was pioneered by two psychoanalysts who are
also anthropologists. Bryce Boyer, who, together with his
anthropologist wife Ruth, has lived among the Apache
and done extensive field work with them (to the extent of
being initiated as an Apache shaman: Boyer, 1964), was
one of the first analysts in the United States to undertake
psychoanalytic treatment of psycotic patients. His successful practice stimulated others, and led to the formation of the Boyer Institute in San Francisco. An
extraordinarily successful treatment program for psychosis has been developed and run by Willy Apollon, a
psychoanalyst from Haiti with anthropological training,
with his colleagues, Danielle Bergeron and Lucie Cantin.
Apollon, who did anthoropological study of Vaudou for
CULTURAL EXPRESSION
AND PSYCHOSES
OF
NEUROSES
63
ANTHROPOLOGICAL INTERVIEWING
PSYCHOANALYTIC PROCESS:
COMPARISON
AND
64
65
66
References
REFERENCES
Antokoletz, J. (1987). A psychoanalytic view of acculturation:
Analyzing I am Joaquin. Texas Psychologist, 39(2), 37.
Apollon, W. (1996). Postcolonialism and psychoanalysis: The example
of Haiti. Journal for the Psychoanalysis of Culture and Society,
1(1), 4351.
Apollon, W. (1998). Lespace vaudou et la mtaphore phallique.
Luniversel, perspectives psychanalytiques (pp. 181198).
Qubec, Canada: GIFRIC, Collection le savoir analytique.
Apollon, W. (1999). Psychoses: loffre de lanalyste. Qubec, Canada:
GIFRIC, Collection le savoir analytique.
Apollon, W., Bergeron, D., & Cantin, L. (1990). Traiter la psychose.
Qubec, Canada:GIFRIC.
Apollon, W., Bergeron, D., & Cantin, L. (2000). The treatment of psychosis. In K. Malone & S. Friedlander, (Eds.) The subject of Lacan.
Albany: State University of New York.
Bateson, M. C. (1968). Insight in a bicultural context. Philippine
Studies, 16, 267301.
Bettelheim, B. (1975). The uses of enchantment. New York: Knopf.
Bilu, Y. (1979). Sigmund Freud and Rabbi Yehudah: On a Jewish
mystical tradition of psychoanalytic dream interpretation.
Journal of Psychological Anthropology, 2, 443463.
Bilu, Y. (1985). The Taming of the deviants and beyond: An analysis of
Dybbuk possession and exorcism in Judaism. The Psychoanalytic
Study of Society, 11, 132.
67
Boyer, L. B. (1964). Folk psychiatry of the Apaches of the Mescalero
Indian reservation. In A. Kiev (Ed). Magic, Faith and Healing.
Glencoe, IL: The Free Press.
Boyer, L. B. (1983). The regressed patient. New York: Jason Aronson.
Boyer, L. B. & R. Boyer (1985). Crisis and continuity in the personality of an Apache shaman. Psychoanalytic Study of Society
11(63104). Hillside, N. J.: The Analytic Press.
Boyer, L., & Simon A. Grolnick (Eds.) The Analytic Press.
Birman, J. (1988). Percursos na histria da psicanlise. Rio de Janeiro,
Brazil:Livraria Taurus Editora.
Briggs, J. (1970). Never in anger. Cambridge, MA: Harvard University
Press.
Casagrande, J. B. (Ed.). (1959). In the company of man. New York:
Harper.
Caudill, W. (1959). Observations on the cultural context of Japanese
psychiatry. In M. K. Opler (Ed.), Culture and mental health
(Chap. 8).
Cerqueira, G. (Ed.). (1982). Crise na psicanlise. Rio de Janeiro,
Brazil: Edies Graal.
Conklin, B. (2001). Consuming grief: Compassionate cannibalism in
an Amazonian society. Austin: University of Texas Press.
Crapanzano, V. (1975). Saints, Jnun and dreams. Psychiatry, 38,
145159.
Crapanzano, V. (1980). Tuhami: Portrait of a Moroccan. Chicago IL:
Univerisity of Chicago.
Crapanzano, V. (1981). Text, transference and indexicality. Ethos, 9,
122148. [Reprinted in Hermes dilemma and Hamlets desire: On
the epistemology of intepretation (pp. 115135). Cambridge, MA:
Harvard University Press.]
Crapanzano, V. (1994). Rethinking psychological anthropology: A critical view. In M. Surez-Orozco & George and Louise Spindler
(Eds.), The making of psychological antoropology (pp. 223243).
New York: Harcourt Brace.
DaMatta, R. (1978, Maio). O ofcio de etnologo, ou como ter anthropological blues. Boletim do Museu Nacional: Antropologia (27).
Danneberg, E. (1995). Psychoanalysis against the grain: Argentina, Chile,
Nicaragua, Cuba. In Kutter, P. (1995). Psychoanalysis International:
Vol 2. America, Asia, Australia, further European Countries
(pp. 241256). Stuttgart, Germany: Frommann-Holzborg.
Desai, P., & Coelho, G. (1980). Indian immigrants in America:
Some cultural aspects of psychological adaptation. In P. Saran &
E. Eames (Eds.) The new ethnics: Asian Indians in the United
States. New York: Praeger.
Devereux, G. (1956). Normal and abnormal: The key problem of
psychiatric anthropology. In J. B. C. & T. Gladwin (Eds.) Some uses
of anthropology: Theoretical and applied (pp. 2348). Washington,
DC:Anthropological Society of Washington. [Reprinted in Basic
problems of ethno-psychiatry Chapter 1, pp. 371, by G. Devereux
(B. Gulati & G. Devereux, Trans.), 1980. Chicago IL:University of
Chicago Press.]
Doi, T. (1973). The anatomy of dependence. Tokyo, Japan: Kodansha
International Press.
Erikson, E. (1969). Ghandis truth. New York: Norton.
Erikson, E. (1975). In search of Gandhi. In Life history and the historical moment (pp. 111189). New York: Norton.
Etkind, A. (1995). Russia (until 1989). In Kutter, P. (1995).
Psychoanalysis International: Vol 2. America, Asia, Australia,
68
further European countries (pp. 333344). Stuttgart, Germany:
Frommann-Holzborg.
Ewing, K. (1987). Clinical psychoanalysis as an ethnographic tool.
Ethos, 15, 1639.
Ewing, K. (1992). Is psychoanalysis relevant for anthropology? In
T. Schwartz, G. White, & C. Lutz (Eds.). New directions in
psychological anthropology (pp. 251268). Cambridge, UK:
Cambridge University Press.
Foulks, E. (1972). The Arctic hysterias (Anthropological Studies,
No. 10). Washington, DC: American Anthropological Association.
Freeman, D. M. A. Foulks, E. & Freeman, P. A. (1976). Ghost sickness
and superego development in the Apache Indian male.
Psychoanalytic Study of Society, 7, 123171.
Freeman, D. (1967). Shaman and incubus. Psychoanalytic Study of
Society, 4, 315343.
[Werner Muensterberger and Sidney Axelrad. New York:IUP]
Freire Costa, J. (1986). Violncia e psicanlise. Rio de Janeiro, Brazil:
Edies Graal.
Freire Costa, J. (1989). Psicanlise e contexto cultural. Rio de Janeiro,
Brazil: Editora Campus.
Freire Costa, J. (1994). Pragmtica e processo psicanaltico. In J. Freire
Costa (Ed.), Redescries da psicanlise, Rio de Janeiro, Brazil:
Relume/Dumar.
Freud, S. (1955) The intepretation of dreams (Standard ed., 4 & 5).
London: Hogarth. (Original work published 1900.)
Freud, S. (1957) Mourning and melancholia (Standard ed., 14
pp. 243258). London: Hogarth. (Original work published 1917.)
Freud, S. (1961). A 17th century demonological neurosis (Standard
ed., 19 pp. 72105). London: Hogarth. (Original work published
1923.)
Garza-Guerrero, A. C. (1974). Culture shock: Its mourning and the
vicissitudes of identity. Journal of the American Psychoanalytic
Association, 22, 408429.
Guthrie, G. & D. Szanton. (1976). Folk diagnosis and treatment of
schizophrenia: Bargaining with the Spirits. In W. Lebra (Ed.)
Culture Bound Syndromes, Ethnopsychiatry, and alternative
Therapies. Honolulu: University Press of Hawaii.
Hay, T. (1971). The Windigo psychosis: Psychodynamic, cultural and
social factors in aberrant behavior. American Anthropologist, 73,
119.
Herdt, G. (1981). Guardians of the Flute. New York: McGraw Hill.
Herdt, G. (1982). Fetish and fantasy in Sambia initiation. In G. Herdt
(Ed.) Rituals of Manhood. Berkeley: University of California
Press, pp. 4498.
Herdt, G. and R. J. Stoller. (1987). The effect of supervision on the practice of ethnography. In H. P. Duerr (Ed.) Die wilde Seele zur
Ethnopsychanalyse von Georges Devereux. Frankfurt, Germany:
Suhrkamp.
Herdt, G. & R. J. Stoller. (1990). Intimate Communications. New York:
Columbia University Press.
Hollan, D. (1994a). Suffering and the work of culture: A case of magical poisoning in Toraja. American Ethnologist, 20.
Hollan, D. (1994b). Contentment and suffering: Culture and experience
in Toraja. New York: Columbia University Press.
Kakar, S. (1978). The inner world: A psychoanalytic study of childhood
and society in Delhi. Delhi: Oxford University Press.
Kakar, S. (1979). A case of depression. Samiksa, 33(3), 6171.
References
Obeyesekere, G. (1981). Medusas hair: An essay on personal symbols
and religious experience. Chicago, IL: University of Chicago Press.
Obeyesekere, G. (1990). The work of culture: Symbolic transformation
in psychoanalysis and anthropology. Chicago, IL: University of
Chicago Press.
Okonogi, K. (197879) The Ajase complex of the Japanese. Japan
Echo, 5(4, pt.1), 88105; 6(1, pt. 2), 104118.
Opler, M. K. (1959). Culture and mental health. New York: Macmillan.
Parsons, A. (1969). Belief, magic and anomie. New York: The Free
Press.
Paul, R. (1990). Recruitment to monasticism among the Sherpas. In
D. K. Jordan & M. J. Swartz (Eds.), Personality and the cultural
construction of society (pp. 254274). Tuscaloosa: University of
Alabama Press.
Pollock, G. (1972). On mourning and anniversaries: The relationship of
culturally constituted defensive systems to intrapsychic adaptive
process. Israel Annals of Psychiatry, 10, 940.
Ramanujam, B. K. (1986). Social change and personal crisis: A view
from an Indian practice. In The cultural transition (pp. 6586).
M. White & S. Pollak (Eds.), London: Routledge.
Ramanujam, B. K. (1992). Implications of some psychoanalytic concepts in the Indian context. In D. Spain (Ed.) Psychoanalytic
anthropology after Freud. New York: Psyche Press, pp. 121135.
Reid, J. (1979). A time to live, a Time to grieve: Mourning among the
Yolngu of Australia. Culture, Medicine and Psychiatry, 3,
319346.
Ribeiro, D. (1980). Uir sai ao encontro de Mara: as experincias de
um ndio que saiu procura de deus. In Uir sai procura de deus:
ensaios de etnologia e indigenismo (pp. 1329). Rio de Janeiro:
Editora Paz e Terra. (Original work published in Anhembi, 26(76),
1957.)
Rivers, W. H. R. (19171918). Dreams and primitive culture.
Manchester, UK: Manchester University Press.
Rivers, W. H. R. (1923). Conflict and dream. London: Kegan Paul.
Sagawa, R. Y. (1985). A psicanlise pioneira e os pioneiros da psicanlise. In S. Figueira (Ed.), Cultura da psicanlise (pp. 1534).
So Paulo, Brazil: Editora Casa do Psiclogo.
Sagawa, R. Y. (1994). A histria da sociedade Brasileira de psicanlise
de So Paulo. In Album de famlia. So Paulo, Brazil: Editora Casa
do Psiclogo.
Sapir, E. (1963a). The emergence of the concept of personality in a
study of cultures. In D. Mandelbaum (Ed.), Selected writings of
Edward Sapir (pp. 590597). Berkeley: University of California
Press. (Original work published 1934.)
Sapir, E. (1963b) Why cultural anthropology needs the psychiatrist.
In D. Mandelbaum (Ed.), Selected writings of Edward Sapir
(pp. 569577). Berkeley: University of California Press. (Original
work published 1938.)
Sebe Bom Meihy (1991). Canto de morte Kaiow: Histria oral de
vida. So Paulo, Brazil: Edies Loyola.
Shalvey, T. (1979). Claude Lvi-Strauss: Social psychotherapy and the
collective unconscious. Amherst: University of Massachusetts
Press.
Slobodin, R. (1978). W.H.R.Rivers: Pioneer anthropologist, psychiatrist
of The Ghost Road.: Gloustershire, U.K. Sutton.
Spiro, M. (1950). A psychotic personality in the South Seas. Psychiatry,
13, 189204.
69
Spiro, M. (1959). Cultural heritage, personal tensions and mental illness
in a South Sea culture. In: M. K. Opler (Ed.), Culture and mental
health (pp. 141171). New York: Macmillan.
Spiro, M. (1961). An overview and a suggested reorientation. In F. L.
K. Hsu (Ed.) Psychological anthropology. Homewood, IL: Dorsey
Press.
Spiro, M. (1965). Religious systems as culturally constituted defense
mechanisms. In Context and meaning in cultural anthropology:
Essays in honor of A.I. Hallowell (pp. 100113). Glencoe, IL: The
Free Press.
Spiro, M. (2003). The anthropological import of blocked access to
dream associations. In J. Mageo (Ed.) Dreaming and the self: New
perspectives on subjectivity, identity and emotion. Albany, N.Y.:
SUNY Press.
Talayesva, D., & Simmons O. (1942). Sun Chief: The autobiography of
a Hopi Indian. New Haven: Yale University Press.
Ticho, G. (1971). Cultural aspects of transference and countertransference (Discussion by Charles Chediak (Cuban analyst) and
Tetsuya Iwasaki). Bulletin of the Menninger Clinic, 35(5),
303334.
Toffelmeier, G., & K. Luomala (1936). Dreams and dream interpretation of the Diegueo Indians of Southern California.
Psychoanalytic Quarterly, 5, 195225.
Turner, V. (1967a). Muchona the hornet. In The forest of symbols
(chap. 6, pp. 131150). Ithaca NY: Cornell University Press.
(Original work published in In the company of man by
J. B. Casagrande (Ed.), 1959. New York: Harper).
Turner, V. (1961). Ndembu divination: Its symbolism and techniques.
Lusaka, Zambia: RhodesLivingston Institute. [Reprinted in
Revelation and divination in Ndembu ritual (pt. 2), 1972, Ithaca,
NY: Cornell University Press.]
Turner, Victor (1967b). The forest of symbols. Ithaca, NY: Cornell
University Press.
Villareal, I. (1997). Ad hoc commission of inquiry for the sociedade psicanaltica de Rio de Janeiro (Report). (Distributed to members by
the IPA Trust, Broomhills, Woodside Lane, London.) London:
International Psychoanalytic Association.
Vianna, H. B. (1994). No conte a ninguem. Rio de Janeiro, Brazil:
Imago Editora Ltda.
Vianna, H. B. (1997). La psychanalise face la dictature et la
torture: Nen parlez personne.
Villela, L. J. (1998). Cale-se, the Chalice of Silence: The return of the
repressed in Brazil. Journal for the Psychoanalysis of Culture and
Society, 3(2), 167173.
Vitebsky, P. (1993). Dialogues with the dead: The discussion of mortality among the Sora of Eastern India. Cambridge, UK: Cambridge
University Press.
Wallace, A. (1958) Dreams and wishes of the soul: A type of psychoanalytic theory among the seventeenth century Iroquois. American
Anthropologist, 60, 234248.
Wallace, A. (1959). The institutionalization of cathartic and controlstrategies in Iroquois religious psychotherapy. In M. K. Opler
(Ed.), Culture and mental health (pp. 6396), New York:
Macmillan.
Medical Systems
Bioethics
Contemporary Anthropological Approaches
Elisa J. Gordon
OF
HISTORICAL DEVELOPMENT OF
BIOETHICS AS A CULTURAL
DOMAIN OF INQUIRY
Bioethics emerged in the 1960s in response to myriad
factors including: biotechnological developments, namely
hemodialysis, organ transplantation, and mechanical
ventilation; the civil rights movement; the backlash
against physician paternalism; and revelations about
abuses in human subjects research (Beecher, 1966; Fox,
1990; Rothman, 1990). Technological developments, for
instance, raised questions about allocation of scarce
73
74
Bioethics
OF
75
76
Bioethics
77
78
Bioethics
ETHNOETHNIC TRADITIONS
Another body of work presents various religious, ethnic,
or cultural perspectives on bioethics (e.g., Ellerby,
McKenzie, McKay, Gariepy, & Kaufert, 2000). This
work is less empirical and more theoretical in orientation.
While one may find entire books devoted to Jewish
bioethics or Muslim bioethics, for instance, these do not
necessarily problematize the value systems of a religion
or present the religious systems within a broader cultural
context. Both A Cross-Cultural Dialogue on Health Care
Ethics (Coward & Ratanakul, 1999), and Transcultural
Dimensions in Medical Ethics (Pellegrino, Mazzarella, &
Corsi, 1992) provide excellent collections of papers
comparing religious (e.g., Jewish, Islam, Buddhist) and
cultural (e.g., Thai, Indian) developing world views about
health care ethics and health policy issues from a crosscultural perspective. These texts fall within a larger
group of handbooks written by non-anthropologists and
designed to guide health professionals in providing
IDENTITY
OF
BIOETHICISTS
79
IN
80
Bioethics
References
81
CONCLUSION
Anthropological research in bioethics has flourished in its
first decade. We can see that the relationship between
anthropology and bioethics is twofold: some do research
of bioethics as a cultural domain while others do
research in bioethics, often collaborating with others
outside the field to better address more applied concerns.
The field of bioethics as well as its methods, theories, and
practices are all rich areas for anthropological inquiry
given the diverse range of topics and issues that call for a
contextualized exploration of what it means to be a moral
human being. The continued development of biotechnological advances, health care challenges, and greater concern for the moral life or suffering experienced by
patients, families, and clinicians in a global world context
generates new questions about the definition of life and
death, self, other, personhood, power dynamics, and right
and wrong in the context of illness, health, and healing.
To answer these questions and to better inform health
policies, anthropologists are increasingly participating in
interdisciplinary collaborative bioethics research. Such
participation enables anthropological concerns to be
given greater voice in ensuring that taken-for-granted cultural assumptions are not accepted prima facie but are
instead contextually considered when analyzing theory
and practice within the bioethics enterprise.
REFERENCES
Advisory Committee on Human Radiation Experiments (1996). The
human radiation experiments: Final report of the Presidents
Advisory Committee. New York: Oxford University Press.
Anspach, R. R. (1993). Deciding who lives: Fateful choices in the
intensive-care nursery. Berkeley: University of California Press.
Barnes, D. M., Davis, A. J., Moran, T., Portillo, C. J., & Koenig, B. A.
(1998). Informed consent in a multicultural cancer patient
population: Implications for nursing practice. Nursing Ethics, 5,
412423.
Beauchamp, T. L., & Childress, J. F. (1994). Principles of biomedical
ethics (4th ed.). New York: Oxford University Press.
Beecher, H. K. (1966). Consent in clinical experimentation: Myth
and reality. Journal of the American Medical Association, 195,
3435.
Beeson, D., & Doksum, T. (2001). Family values and resistance to
genetic testing. In B. Hoffmaster (Ed.), Bioethics in social context
(pp. 153179). Philadelphia, PA: Temple University Press.
Blackhall, L. J., Murphy, S. T., Frank, G., Michel, V., & Azen, S. (1995).
Ethnicity and attitudes toward patient autonomy. Journal of the
American Medical Association, 274, 820825.
82
Blackhall, L. J., Gelya F., Murphy, S. T., Michel, V., Palmer, J. M., &
Azen, A. (1999). Ethnicity and attitudes toward life sustaining
technology. Social Science and Medicine, 48, 17791789.
Bogdan-Lovis, L. (2001, October). Evidence-based medicine: The
promise and the tyranny. Paper presented at the American Society
for Bioethics and Humanities Annual Meeting, Nashville, TN.
Bosk, C. (1979). Forgive and remember: Managing medical failure.
Chicago, IL: University of Chicago Press.
Bosk, C. (1992). All Gods mistakes: Genetic counseling in a pediatric
hospital. Chicago, IL: University of Chicago Press.
Bosk, C., & Frader, J. (1998). Institutional ethics committees:
Sociological oxymoron, empirical black box. In R. DeVries &
J. Subedi (Eds.), Bioethics and society: Constructing the ethical
enterprise (pp. 94116). Upper Saddle River, NJ: Prentice Hall.
Brodwin, P. (Ed.). (2000). Biotechnology and culture: Bodies, anxieties,
ethics. Bloomington: Indiana University Press.
Brodwin, P. (2001). Pluralism and politics in global bioethics education.
Annals of Behavioral Science and Medical Education, 7, 8086.
Brodwin, P. (2002). Genetics, identity, and the anthropology of
essentialism. Anthropological Quarterly, 75, 323330.
Brown, K. H. (1994). Outside the Garden of Eden: Rural values and
healthcare reform. Cambridge Quarterly of Healthcare Ethics, 3,
329337.
Browner, C. H., Preloran, H. M., & Cox, S. J. (1999). Ethnicity,
bioethics, and prenatal diagnosis: The amniocentesis decisions of
Mexican-origin women and their partners. American Journal of
Public Health, 89, 16581666.
Burgess, M., Rodney, P., Coward, H., Ratanakul, R., & Suwonnakote, K.
(1999). Pediatric care: Judgments about best interests at the onset
of life. In H. Coward & P. Ratanakul (Eds.), A cross-cultural
dialogue on health care ethics (pp. 160175). Waterloo, Ontario,
Canada: Wilfrid Laurier University Press.
Callahan, D., & Jennings, B. (2002). Ethics and public health: Forging
a strong relationship. American Journal of Public Health, 92,
169176.
Carrese, J. A., & Rhodes, L. A. (1995). Western bioethics on the Navajo
reservation. Journal of the American Medical Association, 274,
826829.
Carter, M., & Klugman, C. (2001). Cultural engagement in clinical
ethics: A model for ethics consultation. Cambridge Quarterly of
Healthcare Ethics, 10, 1633.
Christakis, N. (1999). Death foretold: Prophecy and prognosis in
medical care. Chicago, IL: University of Chicago Press.
Churchill, L. (1999). Are we professionals? A critical look at the social
role of bioethicists. Daedalus, 128, 253274.
Cohen, L. (1999). Where it hurts: Indian material for an ethics of organ
transplantation. Daedalus, 128, 135165.
Council for International Organizations of Medical Sciences (COIMS)
in collaboration with the World Health Organization (WHO)
(1993). International ethical guidelines for biomedical research
involving human subjects. Geneva, Switzerland.
Coward, H., & Ratanakul, P. (Eds.). (1999). A cross-cultural dialogue
on health care ethics. Waterloo, Ontario, Canada: Wilfrid Laurier
University Press.
Crawley, L. M., Marshall, P. A., & Koenig, B. A. (2001). Respecting cultural differences at the end of life. In L. Snyder & T. E. Quill (Eds.),
Physicians guide to end-of-life care (pp. 3555). Philadelphia, PA:
American College of Physicians.
Bioethics
Crigger, B. (1995). Negotiating the moral order: Paradoxes of ethics
consultation. Kennedy Institute of Ethics Journal, 5, 89112.
Crigger, B. (1998). As time goes by: An intellectual ethnography of
bioethics. In R. DeVries & J. Subedi (Eds.), Bioethics and society:
Constructing the ethical enterprise (pp. 192215). Upper Saddle
River, NJ: Prentice Hall.
Daniels, N., Kennedy, B., & Kawachi, I. (1999). Why justice is good for
our health: The social determinants of health inequalities.
Daedalus, 128, 215251.
Das, V. (1999). Public good, ethics, and everyday life: Beyond the
boundaries of bioethics. Daedalus, 128, 99133.
Das, V. (2000). The practice of organ transplants: Networks, documents,
translations. In M. Lock, A. Young, & A. Cambrosio (Eds.),
Living and working with the new medical technologies:
Intersections of inquiry (pp. 263287). New York: Cambridge
University Press.
DelVecchio Good, M.-J., Good, B. J., Schaffer, C., & Lind, S. E. (1990).
American oncology and the discourse on hope. Culture, Medicine
and Psychiatry, 14, 5979.
DelVecchio Good, M.-J., Munakata, T., Kobayashi, Y., Mattingly, C., &
Good, B.J. (1994). Oncology and narrative time. Social Science
and Medicine, 38, 855862.
DeVries, R., & Conrad, P. (1998). Why bioethics needs sociology. In
R. DeVries & J. Subedi (Eds.), Bioethics and society: Constructing
the ethical enterprise (pp. 233257). Upper Saddle River, NJ:
Prentice Hall.
Ellerby, J. H., McKenzie, J., Mckay, S., Gariepy, G. J., & Kaufert, J. M.
(2000). Bioethics for Clinicians: 18. Aboriginal cultures. Canadian
Medical Association Journal, 163, 845850.
Fabrega, H. (1990). An ethnomedical perspective of medical ethics. The
Journal of Medicine and Philosophy, 15, 593625.
Farmer, P. (1999). Infections and inequalities: The modern plagues.
Berkeley: University of California Press.
Fletcher, J. C., & Siegler, M. (1996). What are the goals of ethics
consultation? A consensus statement. Journal of Clinical Ethics,
7, 122126.
Flynn, P. A. (1992). Moral ordering and the social construction of
bioethics. (Doctoral Dissertation, University of California, San
Francisco, 1992). Dissertation Abstracts International, 52(07), 2706.
Fox, R. C. (1990). The evolution of American bioethics: A sociological
perspective. In G. Weisz (Ed.), Social science perspectives on medical ethics. Philadelphia: University of Pennsylvania Press.
Fox, R. C., & Swazey, J. (1978). The courage to fail: A social view of
organ transplants and dialysis. Chicago, IL: University of Chicago
Press.
Fox, R. C., & Swazey, J. (1984). Medical morality is not bioethics
medical ethics in China and the United States. Perspectives in
Biology Medicine, 27, 336360.
Fox, R. C., & Swazey, J. (1992). Spare parts: Organ replacement in
American society. New York: Oxford University Press.
Fox, R. C., Swazey, J., & Cameron, E. M. (1984). Social and ethical
problems in the treatment of end-stage renal disease patients. In
R.G. Narins (Ed.), Controversies in nephrology and hypertension
(pp. 4570). New York: Churchill Livingstone.
Frank, G., Blackhall, L. J., Michel, V., Murphy, S. T., Azen, S. P., &
Park, K. (1998). A discourse of relationships in bioethics: Patient
autonomy and end-of-life decision making among elderly Korean
Americans. Medical Anthropology Quarterly, 12, 403423.
References
Franklin, S. (1998). Making miracles: Scientific progress and the facts
of life. In S. Franklin & H. Ragon (Eds.), Reproducing reproduction: Kinship, power, and technological innovation (pp. 102117).
Philadelphia: University of Pennsylvania Press.
Gaines, A. D. (1982). Cultural definitions, behavior and the person in
American psychiatry. In A. Marsella & G. White (Eds.), Cultural
conceptions of mental health and therapy (pp. 167192).
Dordrecht, The Netherlands: Reidel.
Gaines, A. D. (1992). From DSM-I to III-R: Voices of self, mastery
and the other: A cultural constructivist reading of United States
psychiatric classification. Social Science and Medicine, 35,
324.
Gaines, A. D. (1998). Culture and values at the intersection of science
and suffering: Encountering ethics, genetics, and Alzheimer
disease. In S. Post & P. Whitehouse (Eds.), Genetic testing for
Alzheimer disease (pp. 256274). Baltimore, MD: Johns Hopkins
University Press.
Gilligan, C. (1982). In a different voice: Psychological theory and
womens development. Cambridge, MA: Harvard University Press.
Gordon, D. R. (1991). Female circumcision and genital operations in
Egypt and the Sudan: A dilemma for medical anthropology.
Medical Anthropology Quarterly, 5, 314.
Gordon, D. R. (1988). Tenacious assumptions in Western medicine.
In M. Lock & D. R. Gordon (Eds.), Biomedicine examined
(pp. 1956). Dordrecht, The Netherlands: Kluwer Academic.
Gordon, D. R. (1990). Embodying illness, embodying cancer. Culture,
Medicine and Psychiatry, 14, 273295.
Gordon, D. R. (1994). The ethics of ambiguity and concealment around
cancer: Interpretations through a local Italian world. In P. Benner
(Ed.), Interpretive phenomenology: Embodiment, caring and ethics
in health and illness (pp. 279322). Thousand Oaks, CA: Sage.
Gordon, D. R., & Paci, E. (1997). Disclosure practices and cultural
narratives: Understanding concealment and silence around cancer
in Tuscany, Italy. Social Science and Medicine, 44, 14331452.
Gordon, E. J. (2000). Preventing waste: A ritual analysis of candidate
selection for kidney transplantation. Anthropology and Medicine,
7, 351372.
Gordon, E. J. (2001a). Patients decisions for treatment of end-stage
renal disease and their implications for access to transplantation.
Social Science and Medicine, 53, 971987.
Gordon, E. J. (2001b). They dont have to suffer for me: Why dialysis patients refuse offers of living donor kidneys. Medical
Anthropology Quarterly, 5, 122.
Gordon, E. J. (2002). What race cannot tell us about access to
kidney transplantation. Cambridge Quarterly for Healthcare
Ethics, 11, 134141.
Gordon, E. J., & Daugherty C. K. (2003a). Hitting you over the head:
Oncologists disclosure of prognosis to advanced cancer patients.
Bioethics, 17, 142168.
Gordon, E. J. (2003b). Policy-making for daily hemodialysis: The uses
and abuses of evidence-based medicine. Paper presented at the
102nd annual meeting of the American Anthropological
Association. Chicago, IL.
Guillemin, J. H., & Holmstrum, L. L. (1986). Mixed blessings: Intensive
care for newborns. New York: Oxford University Press.
Hahn, R. A., & Gaines, A. D. (Eds.). (1985). Physicians of western
medicine: Anthropological approaches to theory and practice.
Dordrecht, The Netherlands: D. Reidel.
83
Haimes, E. (2002). What can the social sciences contribute to the study
of ethics?: Theoretical, empirical and substantive considerations.
Bioethics, 16, 89113.
Heimer, C. A., & Staffen, L. R. (1998). For the sake of the children: The
social organization of responsibility in the hospital and the home.
Chicago, IL: University of Chicago Press.
Hern, H. E., Koenig, B. A., Moore, L. J., & Marshall, P. A. (1998). The
difference that culture can make in end-of-life decision making.
Cambridge Quarterly of Healthcare Ethics, 7, 2740.
Hoffmaster, B. (1990). Morality and the social sciences. In
G. Weisz (Ed.), Social science perspectives on medical ethics
(pp. 241260). Philadelphia: University of Pennsylvania Press.
Hoffmaster, B. (1992). Can ethnography save the life of medical ethics?
Social Science and Medicine, 35, 14211431.
Hogle, L. F. (1999). Recovering the nations body: Cultural memory,
medicine and the politics of redemption. New Brunswick, NJ:
Rutgers University Press.
Hope, T. (1995). Evidence based medicine and ethics. Journal of
Medical Ethics, 21, 259260.
Ikels, C. (1997). Kidney failure and transplantation in China. Social
Science and Medicine, 44, 12711283.
Jecker, N. S., & Berg, A. O. (1992). Allocating medical resources in
rural America: Alternative perceptions of justice. Social Science
and Medicine, 34, 467474.
Jecker, N. S., Carrese, J. A., & Pearlman, R. A. (1995). Caring for patients
in cross-cultural settings. Hastings Center Report, 25, 614.
Jennings, B. (1990). Ethics and ethnography in neonatal intensive care.
In G. Weisz (Ed.), Social science perspectives on medical ethics
(pp. 261272). Philadelphia: University of Pennsylvania Press.
Joint Commission on Accreditation of Healthcare Organizations (1992).
Patients rights. 1992 accreditation manual for hospitals
(R.I. 1.1.6.1, pp. 103105). Chicago, IL: JCAHO.
Jones, J. H. (1993). Bad Blood. New York: Free Press.
Joralemon, D. (1995). Organ wars: The battle for body parts. Medical
Anthropology Quarterly, 9, 335356.
Joralemon, D. (2000). The ethics of the organ market: Lloyd Cohen and
the free marketeers. In P. Brodwin (Ed.), Biotechnology, culture,
and the body (pp. 224237). Urbana: University of Indiana Press.
Joralemon, D. (2002). Reading futility: Anthropological reflections on
a bioethical concept. Cambridge Quarterly of Health Care Ethics,
11, 112114.
Kass, N. E. (2001). An ethics framework for public health. American
Journal of Public Health, 91, 17761782.
Kaufert, J. (1999). Cultural mediation in cancer diagnosis and end of
life decision-making: The experience of Aboriginal patients in
Canada. Anthropology and Medicine, 6, 405421.
Kaufert, J., & ONeil, J. (1990). Biomedical rituals and informed
consent: Native Canadians and the negotiation of clinical trust. In
G. Weisz (Ed.), Social science perspectives on medical ethics
(pp. 4164). Philadelphia: University of Pennsylvania Press.
Kaufert, J., & Putsch, R. W. (1997). Communication through interpreters
in healthcare: Ethical dilemmas arising from differences in class, culture, language, and power. The Journal of Clinical Ethics, 8, 7187.
Kaufert, P., & ONeil, J. (1993). Analysis of a dialogue on risks in
childbirth: Clinicians, epidemiologists, and Inuit women. In
S. Lindenbaum & M. Lock (Eds.), Knowledge, power and practice: The anthropology of medicine and everyday life (pp. 3254).
Berkeley: University of California Press.
84
Kelly, S. E., Marshall, P. A., Sanders, L. M., Raffin, T. A., &
Koenig, B. A. (1997). Understanding the practice of ethics
consultation: Results of an ethnographic multi-site study. Journal
of Clinical Ethics, 8, 136149.
Kleinman, A. (1995a). Anthropology of bioethics. In Writing at the
margin: Discourse between anthropology and medicine (pp. 4167).
Berkeley: University of California Press.
Kleinman, A. (1995b). Anthropology of medicine. In W. Reich (Ed.),
Encyclopedia of bioethics, (2nd ed., pp. 16671674). New York:
Macmillan.
Koenig, B. A., & Gates-Williams, J. (1995). Understanding cultural
differences in caring for dying patients. Western Journal of
Medicine, 163, 244249.
Koenig, B. A., Greely, H. T., McConnell, L. M., Silverberg, H. L.,
Raffin, T. A., & The Members of the Breast Cancer Working Group
of The Stanford Program in Genomics, Ethics, and Society (1998).
Genetic testing for BRCA1 and BRCA2: Recommendations of the
Stanford program in genomics, ethics, and society. Journal of
Womens Health, 7, 531545.
Koenig, B. A., & Silverberg, H. L. (1999). Understanding probabilistic
risk in predisposition genetic testing for Alzheimer disease.
Genetic Testing, 3, 5563.
Kohn, T., & McKechnie, R. (Eds.). (1999). Extending the boundaries of
care: Medical ethics & caring practices. New York: Oxford
University Press.
Kuczewski, M., & Marshall, P. A. (2002). Decision dynamics in clinical research: The context and process of informed consent.
Medical Care, 40, V45V54.
Kunstadter, P. (1980). Medical ethics in cross-cultural and multicultural perspective. Social Science and Medicine, 14B, 289296.
Lane, S. D. (1994). Research bioethics in Egypt. In R. Gillon (Ed.),
Principles of health care ethics (pp. 885894). Chichester, UK:
Wiley.
Lane, S. D., & Rubinstein, R. A. (1996). Judging the other: Responding
to traditional female genital surgeries. Hastings Center Report,
26, 3140.
Lee, S. S. J., Mountain, J., & Koenig, B. A. (2001). The meanings of
race in the new genomics: Implications for health disparities
research. Yale Journal of Health Policy, Law, and Ethics, 1, 3375.
Levin, B. W. (1985). Consensus and controversy in the treatment of catastrophically ill newborns: Report of a survey. In T. H. Murray &
A. L. Caplan (Eds.), Which babies shall live? Humanistic dimensions of the care of imperiled newborns (pp. 169205). Clifton, NJ:
Humana Press.
Levin, B. W. (1988). The cultural context of decision making for
catastrophically ill newborns: The case of baby Jane Doe. In
K. L. Michaelson (Ed.), Childbirth in America: Anthropological
perspectives (pp. 178193). South Hadley, MA: Bergin & Garvey.
Levin, B. W. (1989). Decision making about care of catastrophically ill
newborns: The use of technological criteria. In L. M. Whiteford &
M. L. Poland (Eds.), New approaches to human reproduction: Social
and ethical dimensions (pp. 8497). Boulder, CO: Westview Press.
Levin, B. W. (1990). International perspectives on treatment choice
in neonatal intensive care units. Social Science and Medicine,
30, 901912.
Levin, B. W., & Fleischman, A. R. (2002). Public health and bioethics:
The benefits of collaboration. American Journal of Public Health,
92, 165167.
Bioethics
Levin, B. W., & Schiller, N. G. (1998). Social class and medical
decisionmaking: A neglected topic in bioethics. Cambridge
Quarterly of Healthcare Ethics, 7, 4156.
Lieban, R. W. (1990). Medical anthropology and the comparative study
of medical ethics. In G. Weisz (Ed.), Social science perspectives
on medical ethics (pp. 221240). Philadelphia: University of
Pennsylvania Press.
Lock, M. (1995). Contesting the natural in Japan: Moral dilemmas and
technologies of dying. Culture, Medicine and Psychiatry, 19, 138.
Lock, M. (1996). Deadly disputes: Ideologies and brain death in Japan.
In S. Youngner, R. Fox, & L. OConnell (Eds.), Organ transplantation: Meanings and realities (pp. 142167). Madison: University
of Wisconsin Press.
Lock, M. (2002). Twice dead: Organ transplants and the reinvention of
death. Berkeley: University of California Press.
Lock, M., & Honde, C. (1990). Reaching consensus about death: Heart
transplants and cultural identity in Japan. In G. Weisz (Ed.), Social
science perspectives on medical ethics (pp. 99120). Philadelphia:
University of Pennsylvania Press.
Lock, M., Young, A., & Cambrosio, A. (Eds.). (2000). Living and
working with the new medical technologies: Intersections of
inquiry. New York: Cambridge University Press.
Long, S. O. (1999). Family surrogacy and cancer disclosure: Physicianfamily negotiation of an ethical dilemma in Japan. Journal of
Palliative Care, 15, 3142.
Long, S. O. (2000a). Living poorly or dying well: Decisions about life
support and treatment termination for American and Japanese
patients. Journal of Clinical Ethics, 11, 236250.
Long, S. O. (2000b). Public passages, personal passages, and reluctant
passages: Notes on investigating cancer disclosure practices in
Japan. Journal of Medical Humanities, 21, 313.
Long, S. O. (2001). Ancestors, computers, and other mixed messages:
Ambiguity and euthanasia in Japan. Cambridge Quarterly for
Healthcare Ethics, 10, 6271.
Long, S. O., & Chihara, S. (2000). Difficult choices: Policy and
meaning in Japanese hospice practice. In S. O. Long (Ed.), Caring
for the elderly in Japan and the US: Practices and policies
(pp. 146171). New York: Routledge.
Marshall, P. A. (1992). Anthropology and bioethics. Medical
Anthropology Quarterly, 6, 4973.
Marshall, P. A. (1996). Boundary crossings: Gender and power in
clinical ethics consultations. In C. F. Sargent & C. B. Brettell
(Eds.), Gender and health: An international perspective
(pp. 205226). Upper Saddle River, NJ: Prentice Hall.
Marshall, P. A. (2001). The relevance of culture for informed consent in
U.S.-funded international health research. In National Bioethics
Advisory Commission, Ethical and policy issues in international
research: Clinical trials in developing countries, Vol. 2. Bethesda,
MD: National Bioethics Advisory Commission.
Marshall, P. A., & Daar, A. (2000). Ethical issues in human organ
replacement: A case study from India. In L. M. Whiteford &
L. Manderson (Eds.), Global health policy, local realities: The fallacy of the level playing field (pp. 205230). Boulder, CO: Lynne.
Marshall P. A., & Koenig, B. (1996). Bioethics and anthropology:
Perspectives on culture, medicine, and morality. In C. F. Sargent &
T. F. Johnson (Eds.), Medical anthropology: Contemporary theory
and method (Rev. ed., pp. 349373). Westport, CT: Praeger.
References
Marshall, P. A., & Koenig, B. (2001). Ethnographic methods. In
J. Sugarman & D. Sulmasy (Eds.), Method in medical ethics
(pp. 169191). Washington, DC: Georgetown University Press.
Marshall, P. A., Koenig, B. A., Barnes, D. M., & Davis, A. J. (1998).
Multiculturalism, bioethics, and end-of-life care: Case narratives
of Latino cancer patients. In J. F. Monagle & D. C. Thomasma
(Eds.), Health care ethics: Critical issues for the 21st century
(pp. 421431). Gaithersburg, MD: Aspen.
Marshall, P. A., & Rotimi C. (2001). Ethical challenges in community
based research. American Journal of the Medical Sciences, 322,
259263.
Marshall, P. A., Thomasma, D. C., & Bergsma, J. (1994). Intercultural
reasoning: The challenge for international bioethics. Cambridge
Quarterly of Healthcare Ethics, 3, 321328.
McBurney, C. (2001). A contextual approach to clinical ethics consultation: Plus a change? In B. Hoffmaster (Ed.), Bioethics in social
context (pp. 180198). Philadelphia, PA: Temple University Press.
Muller, J. H. (1992). Shades of blue: The negotiation of limited codes
by medical residents. Social Science and Medicine, 34, 885898.
Muller, J. H. (1994). Anthropology, bioethics, and medicine: A provocative trilogy. Medical Anthropology Quarterly, 8, 448467.
Muller, J. H., & Desmond, B. (1992). Ethical dilemmas in a crosscultural context: A Chinese example. Western Journal of Medicine,
157, 323327.
Muller, J. H., & Koenig, B. A. (1988). On the boundary of life and
death: The definition of dying by medical residents. In M. Lock &
D. Gordon (Eds.), Biomedicine examined (pp. 351374).
Dordrecht, The Netherlands: Kluwer Academic.
Myser, C. (2003). Differences from somewhere: The normality of
whiteness in bioethics in the United States. American Journal of
Bioethics, 3, 111.
Nelson, R. M. (2000). The ventilator/baby as cyborg: A case study in
technology and medical ethics. In P. Browdin (Ed.), Biotechnology,
culture, and the body (pp. 209223). Urbana: University of Indiana.
Ohnuki-Tierney, E. (1994). Brain death and organ transplantation.
Current Anthropology, 35, 233254.
Orfali, K. (2001). tude comparative sur le rle de la famille en
ranimation nonatale en France et aux Etats-Unis. Rapport
pour la Mission Interministerielle de Recherche et dtudes
[Comparative study on familys role in NICUs in France and in the
US. Report for the French Ministry of Research].
Orfali, K. (2002, September). Lingrence profane dans la dcision
mdicale: le malade, la famille et lthique clinique [The lay
intrusion in medical decision making: The patient, the family
and clinical ethics]. Revue Franaise des Affaires Sociales,
La Documentation Franaise.
Orfali, K. (In press). Parental role in medical decision making: Fact or fiction. A comparitive study of ethical dilemmas in French and
American neonatal intensive care units. Social science and Medicine.
Orona, C. J., Koenig, B. A., & Davis, A. J. (1994). Cultural aspects
of nondisclosure. Cambridge Quarterly of Healthcare Ethics,
3, 338346.
Orr, R., Marshall, P. A., & Osborn, J. (1995). Cross-cultural considerations in clinical ethics consultations. Archives of Family Medicine,
4, 159164.
Pellegrino, E., Mazzarella, P., & Corsi, P. (Eds.). (1992). Transcultural
dimensions in medical ethics. Frederick, MD: University
Publishing Group, Inc.
85
Press, N., Browner, C. H., Tran, D., Morton, C., & Le Master, B. (1998).
Provisional normalcy and perfect babies: Pregnant womens
attitudes toward disability in the context of prenatal testing. In
S. Franklin & H. Ragon (Eds.), Reproducing reproduction:
Kinship, power, and technological innovation (pp. 4665).
Philadelphia: University of Pennsylvania Press.
Price, F. (1999). Triplets: Who cares? In T. Kohn & R. McKechnie
(Eds.), Extending the boundaries of care: Medical ethics & caring
practices (pp. 4960). New York: Berg.
Rapp, R. (1999). Testing women, testing the fetus: The social impact of
amniocentesis in America. New York: Routledge.
Reverby, S. M. (Ed.). (2000). Tuskegees truths: Rethinking the
Tuskegee syphilis study. Chapel Hill: University of North Carolina
Press.
Rothman, D. J. (1990). Human experimentation and the origins of
bioethics in the United States. In G. Weisz (Ed.), Social science
perspectives on medical ethics (pp. 185200). Philadelphia:
University of Pennsylvania Press.
Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., &
Haynes, R. B. (2000). Evidence-based medicine: How to practice
and teach EBM, (2nd ed.). New York: Churchill Livingston.
Satel, S. L. (2000). PC, M.D.: How political correctness is corrupting
medicine. New York: Basic Books.
Scheper-Hughes, N. (2000). The global traffic in human organs. Current
Anthropology, 41, 191224.
Sharp, L. A. (1995). Organ transplantation as a transformative
experience: Anthropological insights into the restructuring of the
self. Medical Anthropology Quarterly, 9, 357389.
Sharp, L. A. (2001). Commodified kin: Death, mourning, and competing claims on the bodies of organ donors in the United States.
American Anthropologist, 103, 112133.
Sharp, L. A. (2002). Denying culture in the transplant arena:
Technocratic medicines myth of democratization. Cambridge
Quarterly of Healthcare Ethics, 11, 142150.
Shweder, R. A., & Bourne, E. J. (1982). Does the concept of person vary
cross-culturally? In A. J. Marsella & G. M. White (Eds.), Cultural
conceptions of mental health and therapy (pp. 97137). Boston,
MA: D. Reidel.
Siminoff, L. A., & Arnold, R. M. (1999). Increasing organ donation in
the African-American community: Altruism in the face of an
untrustworthy system. Annals of Internal Medicine, 130, 607609.
Siminoff, L. A., Arnold, R. M., Caplan, A. L., Virnig, B. A., & Seltzer, D.
L. (1995). Public policy governing organ and tissue procurement in
the United States. Annals of Internal Medicine, 123, 1017.
Siminoff, L. A., & Chillag, K. (1999). The fallacy of the gift of life.
Hastings Center Report, 29, 3441.
Slomka, J. (1992). The negotiation of death: Clinical decision making
at the end of life. Social Science and Medicine, 35, 251259.
Slomka, J. (1995). What do apple pie and motherhood have to do with
feeding tubes and caring for the patient? Archives of Internal
Medicine, 155, 12581263.
Smith, W. J. (2000). Culture of death: The assault on medical ethics in
America. San Francisco, CA: Encounter Books.
Tonelli, M. R. (1998). The philosophical limits of evidence-based
medicine. Academic Medicine, 73, 12341240.
US National Commission for the Protection of Human Subjects of
Biomedical and Behavioral Research (1978). The Belmont report:
Ethical principles and guidelines for the protection of human
86
Biomedical Technologies
Biomedical Technologies
Anthropological Approaches
Margaret Lock
INTRODUCTION
The history of technology1 has usually been transmitted
in Europe and North America as an heroic tale about the
conquest of the enemy, whether this be aspects of the
human or natural worldsa narrative of progress, and of
the betterment of social life in general. This has been
characterized as the Standard View of technology
(Pfaffenbergger, 1992), one which assumes that necessity
is the mother of invention, causing humans to produce
tools, devices, and artifacts that permit us, we believe,
increasingly rational, autonomous, and prosperous lives,
liberated from the constraints imposed by individual
biology, oppressive human enemies, and the environment.
It has been suggested that inherent to the Standard
View are two sets of tacit meanings that at first glance
appear to be contradictory. The first assumes that the
relationship of humans to technology is too obvious to
need examination. Organizations, industries, technicians,
craftspeople, and so on simply make things that are in
themselves neither good nor bad. The second approach,
one of technological determinism, conceives of technology as a powerful and autonomous agent, inherent to
progress, and therefore by definition an unquestionable
good, but that inevitably dictates the form to be followed
by human social life (see, for example, Heilbroner, 1967).
Marshall Sahlins (1976) takes a very different
approach. For him neither technologies nor the human
needs they are devised to alleviate should be conceptualized as autonomous, but must inevitably be understood
as embedded in cultures and histories. Cultural analyses
of technology are concerned with the attribution of meaning to technologies and their application, and hence with
entrenched moral imperatives (Pfaffenberger, 1992,
p. 506). The politics of national, community, and individual identity making is intimately associated with the
development, global transfer, and implementation of
socio-technical artifacts and systems. Pfaffenberger
concludes that when we examine the impact of technology on society, we are talking today about the impact
of one kind of social behavior on another (Pfaffenberger,
1988). For him technology is humanized nature, and
inseparable from both political relationships and the
culturally informed meanings associated with it.
It has been shown repeatedly that artifacts, including
biomedical technologies, can be introduced successfully
to new cultural settings without a simultaneous adoption
of the logical use originally associated with them
(Lock & Kaufert, 1998; Van Der Geest & Reynolds
Whyte, 1988). New meanings and social relations coalesce around transported artifacts, whatever the direction
of their travel.2 This is not an argument for the autonomy
of artifacts (or for that matter for the autonomy of culture), but rather for their inherent heterogeneity as social
objects. Alternatively, some artifacts and technologies,
notably when they threaten entrenched values, are
87
BIOGRAPHIES OF PHARMACEUTICALS
AND CONTRACEPTIVES
Numerous scholars, among whom Charles Leslie was
perhaps the first, have shown how medical pluralism is
the rule in virtually all societies today, so that competition among medical sectors is common (Leslie, 1980),
often with major repercussions on the health of populations. This tendency is well illustrated by examining the
availability and use of medicinal technologies. Beginning
in the 1950s anthropologists showed concern about the
effects of imported pharmaceuticals, notably antibiotics,
on the health of people in developing countries, when it
became clear that these powerful medications were being
misapplied. Anthropologists also were interested in the
impact of the availability of pharmaceuticals on the use
of indigenous medicines.
It was quickly recognized that politics are inevitably
implicated in the global transfer of drugs, but in addition
that pharmaceuticals have not only biochemical properties but are also associated with culturally defined
meanings. We can speak of the biography of a drug: its
production, distribution, marketing, interpretation and
use, argue Van Der Geest and Reynolds Whyte (1988).
Etkin (1988), in a similar vein, discusses the cultural
construction of efficacy with respect to pharmaceuticals
and suggests that healing should be understood as processual in order to grasp the way in which a series of
outcomes are usually considered important to efficacy,
not all of them physical.
It has been shown repeatedly that the introduction of
pharmaceuticals has had major impacts, many of
them negative, in societies without a health sector that
has a well-functioning and well-funded infrastructure.
In El Salvador, for example, when the use of locally
produced indigenous medicinals was largely replaced,
due to the introduction of a commercial pharmaceutical
sector, community breakdown was evident as well as
individual dependence on brand name prescription
medications (Ferguson, 1981). Van Der Geest and
88
Biomedical Technologies
CONTRACEPTIVES
AND
ABORTION
89
90
Biomedical Technologies
Boundary Crossings: Organ Transplants and the Mixing of Self and Other
91
92
Biomedical Technologies
References
93
NOTES
1. By technology I mean tools, machines, artifacts, prostheses, and
other devices that have been created through human effort for the
purpose of changing, manipulating, or controlling the natural and
human worlds. Included are the technologies of the survey as
discussed by Foucault (1979).
2. This is as equally true for acupuncture and herbal medicines being
imported and adopted for use in Europe and North America, as it is,
for example, for vaccinations being administered throughout Africa.
REFERENCES
Adams, V. (in press). Establishing proof: Translating science and the
state in Tibetan medicine. In M. Nichter & M. Lock (Eds.), New
horizons in medical anthropology: Essays in honour of Charles
Leslie. London: Routledge, pp. 200220.
Ali, K. A. (1996). The politics of family planning in Egypt.
Anthropology Today, 12, 1419.
Anagnost, A. (1995). A surfeit of bodies: Population and the rationality
of the state in post-Mao China. In F. D. Ginsburg & R. Rapp,
(Eds.), Conceiving the New World Order (pp. 2241). Berkeley:
University of California Press.
Becker, G. (2000). The elusive embryo: How women and men approach
new reproductive technologies. Berkeley: University of California
Press.
Berg, M. (1997). Rationalizing medical work: Decision-support
techniques and medical practices. Cambridge, MA: The MIT Press.
Berg, M., & Mol, A. (1998). Differences in medicine: Unraveling
practices, techniques and bodies. London: Duke University Press.
Cambrosio, A., & Keating, P. (1995). Exquisite specificity: The monoclonal antibody revolution. Oxford, UK: Oxford University Press.
Coleman, S. (1983). Family planning in Japanese society. Princeton,
NJ: Princeton University Press.
Crowley, M. (2001). Organ donation and receiving in Mexico. PhD thesis, University of California, Los Angeles.
Csordas, T. J. (2000). Computerized cadavers: Shades of being and
representation in virtual reality. In P. E. Brodwin (Ed.), Biotechnology
and culture: Bodies, anxieties, ethics (pp. 173192). Bloomington:
Indiana University Press.
Cussins, C. (1996). Anthological chorography: Agency through
objectification in infertility clinics. Social Studies of Science, 26,
475610.
94
Das, V. (2000). The practice of organ transplants: Networks, documents,
translations. In M. Lock, A. Young, & A. Cambrosio (Eds.), Living
and working with the new medical technologies: Intersections of
inquiry (pp. 263287). Cambridge, UK: Cambridge University Press.
Edwards, J., Franklin, S., Hirsch, E., Price, F., & Strathern, M. (1993).
Technologies of procreation: Kinship in the age of assisted
conception. Manchester, UK: Manchester University Press.
Etkin, N. L. (1988). Cultural constructions of efficacy. In S. Van der
Geest & S. W. Reynolds (Eds.), The context of medicines in
developing countries: Studies in pharmaceutical anthropology
(pp. 299326). London: Kluwer Academic.
Farmer, P. (1999). Cruel and unusual: Drug resistant tuberculosis
as punishment. In V. Stern (Ed.), Sentenced to die? The problem
of TB in prisons in Eastern Europe and Central Africa (pp. 7088).
London: Kings College, International Center for Prison Studies.
Farquhar, J. (1995). Re-writing traditional medicine in post-Maoist
China. In D. Bates, (Ed.), Knowledge and the scholarly medical tradition (pp. 251276). Cambridge, UK: Cambridge University Press.
Ferguson, A. (1981). Commercial pharmaceutical medicine and
medicalization: A case study from El Salvador. In Culture,
Medicine and Psychiatry, 5(2), 105134.
Foucault, M. (1979). Discipline and Punish: The Birth of the Prison.
New York: Vintage Books.
Franklin, S. (1995). Science as culture, cultures of science. Annual
Review of Anthropology, 24, 163184.
Franklin, S. (1997). Embodied progress: A cultural account of assisted
conception. London: Routledge.
Franklin, S., & Ragone, H. (1998). Reproducing reproduction: Kinship,
power and technological innovation. Philadelphia: University of
Pennsylvania Press.
Ginsberg, F., & Rapp, R. (l995). Conceiving the New World Order:
The global politics of reproduction. Berkeley: University of
California Press.
Good, M. J. (1980). Of blood and babies: The relationship of popular
Islamic physiology to fertility. Social Science and Medicine, 14B,
147156.
Grunfest-Schoepf, B. (1998). Inscribing the body politic: Women and
AIDS in Africa. In M. Lock & P. Kaufert (Eds.), Pragmatic women
and body politics (pp. 98126). Cambridge, UK: Cambridge
University Press.
Handwerker, L. (1998). The consequences of modernity for childless
women in China: Medicalization and resistance. In M. Lock &
P. Kaufert (Eds.), Pragmatic women and body politics
(pp. 178205). Cambridge, UK: Cambridge University Press.
Heilbroner, R. L. (1967). Do machines make history? Technology and
Culture, 8, 335345.
Hogle, L. (1995). Standardization across non-standard domains: The
case of organ procurement. Science, Technology, and Human
Values, 20, 482500.
Hogle, L. (1999). Recovering the nations body: Cultural memory,
medicine, and the politics of redemption. London: Rutgers
University Press.
Inhorn, M. C. (1994). Quest for conception: Gender, infertility,
and Egyptian medical traditions. Philadelphia: University of
Pennsylvania Press.
Joralemon, D. (1995). Organ wars: The battle for body parts. Medical
Anthropology Quarterly, 9(3), 335356.
Biomedical Technologies
Kaufert, P. (1998). Women, resistance, and the breast cancer movement.
In M. Lock & P. Kaufert (Eds.), Pragmatic women and body politics (pp. 287309). Cambridge, UK: Cambridge University Press.
Kaufman, S. R. (2000). In the shadow of death with dignity: Medicine
and cultural quandaries of the vegetative state. American
Anthropologist, 102(1), 6983.
Kielmann, K. (1998). Barren ground: Contesting identities of infertile
women in Pemba, Tanzania. In M. Lock & P. Kaufert (Eds.),
Pragmatic women and body politics (pp. 127163). Cambridge,
UK: Cambridge University Press.
Latour, B. (1999). Pandoras hope: Essays on the reality of science
studies. Cambridge, MA: Harvard University Press.
Layne, L. (1996). Hows the baby doing? Struggling with narratives of
progress in a neonatal intensive care unit. Medical Anthropology
Quarterly, 10, 624656.
Leslie, C. (1980). Medical pluralism in world perspective. In C. Leslie
(Ed.), Medical pluralism [Special issue] Social Science and
Medicine, 14B(4), 190196.
Leslie, C. (1989). Indigenous pharmaceuticals, the capitalist world
system, and civilization (pp. 2331). Kroeber Anthropological
Society Papers, Nos. 6979.
Lewin, E. (1998). Wives, mothers, and lesbians: Rethinking resistance
in the US. In M. Lock & P. Kaufert (Eds.), Pragmatic women and
body politics (pp. 164177). Cambridge, UK: Cambridge
University Press.
Lock, M. (1993). Encounters with aging: Mythologies of menopause in
Japan and North America. Berkeley: University of California
Press.
Lock, M. (1997). Displacing suffering: The reconstruction of death in
North America and Japan. In A. Kleinman, V. Das, & M. Lock
(Eds.), Social suffering (pp. 207244). Berkeley: University of
California Press.
Lock, M. (1998). Perfecting society: Reproductive technologies,
genetic testing, and the planned family in Japan. In M. Lock &
P. Kaufert (Eds.), Pragmatic women and body politics
(pp. 206239). Cambridge, UK: Cambridge University Press.
Lock, M. (2000). On dying twice: Culture, technology and the determination of death. In M. Lock, A. Young, & A. Cambrosio (Eds.),
Living and working with the new medical technologies: Intersections
of injury. Cambridge, UK: Cambridge University Press.
Lock, M. (2002). Twice dead: Organ transplants and the reinvention of
death. Berkeley: University of California Press.
Lock, M., & Kaufert, P. (1998). Pragmatic women and body politics.
Cambridge, UK: Cambridge University Press.
Lopez, I. (1998). An ethnography of the medicalization of Puerto Rican
womens reproduction. In M. Lock & P. Kaufert (Eds.), Pragmatic
women and body politics (pp. 240259). Cambridge, UK:
Cambridge University Press
MacCormack, C., & Draper, A. (l988). Cultural meanings of oral
rehydration salts in Jamaica. In S. Van der Geest & S. W. Reynolds
(Eds.), The context of medicines in developing Countries: Studies
in pharmaceutical anthropology (pp. 277288). London: Kluwer
Academic.
Morsy, S. (1998). Not only women: Science as resistance in open door
Egypt. In M. Lock & P. Kaufert (Eds.), Pragmatic women and
body politics (pp. 7797). Cambridge, UK: Cambridge University
Press.
95
Biomedicine
Atwood D. Gaines and Robbie Davis-Floyd
EARLY STUDIES
OF
BIOMEDICINE
96
Biomedicine
ANTHROPOLOGY
AND
BIOMEDICINE
97
98
Biomedicine
99
100
Biomedicine
101
NEW TRENDS
BIOMEDICINE
IN THE
STUDY
OF
102
Biomedicine
THE STANCE
OF
PRACTICE
103
104
TRANSLATING BIOMEDICINE
Throughout the late 19th and 20th centuries, Biomedicine
was massively exported into Third World countries.
Sometimes it was borrowed and at others it was exported
as a result of its colonialist imposition (Kleinman, 1980;
Lock, 1993; Reynolds, 1976; Weisberg & Long, 1984).
Still later, it was actively sought by developing countries
as a feature of modernization. The modernizing process
acts as an homogenizing funnel that channels development toward univariate points: in economics, capitalism;
in production, industrialization; in health care, Biomedicine. The three work in tandem, as the importation
of Biomedicine means the investment of huge sums of
money in the construction of large hospitals (the factories
of health care), the training of staff, and the incorporation
of expensive medical technologies. Such modern
biomedical facilities usually serve the colonizers and the
middle and upper classes of colonized populations and
are largely inaccessible to the majority of the population.
As in the West, major improvements in health for
these biomedically underserved majorities have primarily
resulted not from Biomedicine but from public health
initiatives to clean water and improve waste disposal and
nutrition (McKeown, 1979)improvements that many
Third World communities still sorely lack.
When Biomedicine is transplanted, it is altered in
significant ways in terms of clinical practices, nosologies,
medical theory, concepts of self, and therapeutics
(Farmer, 1992; Feldman, 1995; Gaines & Farmer, 1986;
Hershel, 1992; Kleinman, 1980; Lock, 1980; Reynolds,
1976; Weisberg & Long, 1984). For example, pharmaceutical agents only available by physician prescription in
the First World often take on a life of their own in Third
World countries: traditional healers and midwives incorporate allopathic injections into their pharmacological
repertoires; drugs are sold in pharmacies and on the
streets without prescription. In a sense, people become
their own diagnosticians and self-prescribe, without the
biomedical establishment but also without a systematic
way of dealing with the biological implications of their
use of allopathic medicines (Nichter, 1989; Van Der
Geest & Whyte, 1988).
Biomedicines inaccessibilty and lack of cultural
fit often ensure that practitioners in the developing world
do not enjoy a monopoly on medical care; indigenous
and professional healers from non-biomedical systems
continue to serve large clienteles. In some areas,
Biomedicine
References
REFERENCES
Alexander, L. (1981). Double-bind between dialysis patients and
the health practitioners. In L. Eisenberg & A. Kleinman (Eds.),
The relevance of social science for medicine. Dordrecht, The
Netherlands: Reidel.
Alexander, L. (1982). Illness maintenance and the new American sick
role. In N. Chrisman & T. Maretzki (Eds.), Clinically applied
anthropology: Anthropologists in health science settings. Dordrecht,
The Netherlands: Reidel.
Baer, H. A. (1989). The American dominative medical system as a
reflection of social relations in the larger society. Social Science
and Medicine, 28(11), 11031112.
Baer, H. A. (2001). Biomedicine and alternative healing systems in
America: Issues of class, race, ethnicity, and gender. Madison:
University of Wisconsin Press.
Barkan, E. (1992). The retreat of scientific racism: Changing concepts
of race in Britain and the United States between the world wars.
Cambridge, UK: Cambridge University Press.
Blue, A. V., & Atwood, D. G. (1992). The ethnopsychiatric repertoire: A review and overview of ethnopsychiatric studies. In
D. G. Atwood (Ed.), Ethnopsychiatry: The cultural construction of
professional and folk psychiatries. Albany, NY: State University of
New York Press.
Bosk, C. (1979). Forgive and remember: Managing medical failure.
Chicago, IL: University of Chicago Press.
Buckley, T. J., & Gottlieb, A. (1987). Blood magic. Berkeley: University
of California Press.
Carrese, J. A., & Rhodes, L. A. (1995). Western bioethics on the Navajo
Reservation: Benefit or harm? Journal of the American Medical
Association, 274(10), 826829.
Cartwright, E. (1998). The logic of heartbeats: Electronic fetal
monitoring and biomedically constructed birth. In R. Davis-Floyd &
105
J. Dumit (Eds.), Cyborg babies: From techno-sex to techno-tots.
New York: Routledge.
Casper, M. (1998). The making of the unborn patient: A social anatomy
of fetal surgery. New Brunswick, NJ: Rutgers University Press.
Colen, S. (1986). With respect and feelings: Voices of West Indian
childcare and domestic workers in New York City. In J. B. Cole
(Ed.), All American women: Lines that divide, ties that bind.
New York: Free Press.
Coulehan, J. (1985). Chiropractic and the clinical art. Social Science
and Medicine, 21, 383390.
Cussins, C. (1998). Quit snivelling, cryo-baby. Well work out which
ones your mama! In R. Davis-Floyd & J. Dumit (Eds.), Cyborg
babies: From techno-sex to techno-tots. New York: Routledge.
Davis-Floyd, R. (1987). Obstetric Training as a Rite of Passage.
Medical Anthropology Quarterly, 1(3): 288318.
Davis-Floyd, R. (1992). Birth as an American rite of passage. Berkeley:
University of California Press.
Davis-Floyd, R. (1994). The technocratic body: American childbirth as
cultural expression. Social Science and Medicine. 38(8): 11251140.
Davis-Floyd, R. (2001). The technocratic, humanistic, and holistic
models of birth. International Journal of Obstetrics and
Gynecology, 75(Suppl. 1), S5S23.
Davis-Floyd, R., & Dumit, J. (1998). Cyborg babies: From techno-sex
to techno-tots. New York: Routledge.
Davis-Floyd, R., & Sargent, C. (Eds.). (1997). Childbirth and authoritative knowledge: Cross-cultural perspectives. Berkeley: University
of California Press.
Davis-Floyd, R., & St John, G. (1998). From doctor to healer: The
transformative journey. New Brunswick, NJ: University of
California Press.
Davis-Floyd, R., Cosminsky, S., & Pigg, S. L. (Eds.). (2001). Daughters
of time: The shifting identities of contemporary midwives [Special
triple issue] Medical Anthropology, 20, 23/4.
DelVecchio Good, M.-J. (1985). Discourses on physician competence.
In R. Hahn & A. D. Gaines (Eds.), Physicians of western medicine:
Anthropological approaches to theory and practice. Dordrecht,
The Netherlands: Reidel.
DelVecchio Good, M.-J. (1991). The practice of biomedicine and the
discourse on hope: A Preliminary investigation into the culture of
American oncology. In B. Pfleiderer & G. Bibeau (Eds.),
Anthropologies of medicine: A colloquium on West European and
North American perspectives. Wiesbaden, Germany: Vieweg und
Sohn Verlag.
DelVecchio Good, M.-J. (1995). American medicine: The quest for
competence. Berkeley: University of California Press.
DelVcecchio Good, M.-J., Brodwin, P. E., Good, B. J., & Kleinman, A.
(Eds.). (1992). Pain as human experience: An anthropological
perspective. Berkeley: University of California Press.
Desai, P. N. (1989). Health and medicine in the Hindu tradition.
New York: Crossroad.
Devereux, G. (1944). The social structure of a schizophrenic ward and
its therapeutic fitness. Journal of Clinical Psychotherapy, 6(2),
231265.
Devereux, G. (1949). The social structure of the hospital as a factor in
total therapy. American Journal of Orthopsychiatry, 19(3), 492500.
Devereux, G. (1953). Cultural factors in psychoanalytic theory. Journal
of the American Psychoanalytic Association, 1, 629655.
106
Devereux, G. (1961). Mohave Ethnopsychiatry. Washington, D.C.:
Smithsonian Institution Press.
Devereux, G. (1963). Primitive psychiatric diagnosis: A general
theory of the diagnostic process. In mans image in medicine and
anthropology. New York: University Press.
Devereux, G. (1980). Schizophrenia: An ethnic psychosis. Basic problems of ethnopsychiatry. Chicago: University of Chicago Press.
Devries, R., Benoit, C., van Tiejlingen, E., & Wrede, S. (Eds.). (2001).
Birth by design: Pregnancy, maternity care, and midwifery in
North America and Europe. New York: Routledge.
DiGiacomo, S. M. (1987). Biomedicine as a cultural system: An
anthropologist in the kingdom of the sick. In H. A. Baer (Ed.),
Encounters with biomedicine: Case studies in medical anthropology. New York: Gordon & Breach.
Downey, G. L., & Dumit, J. (1997). Cyborgs and citadels: Anthropological interventions in emerging sciences and technologies.
Santa Fe, NM: School of American Research Press.
Dumit, J., & Davis-Floyd, R. (2001). Cyborg anthropology. In
T. Montgomery (Ed.), Routledge International Encyclopedia of
Womens Studies. New York: Routledge.
Duster, T. (1990). Backdoor to eugenics. New York: Routledge.
Early, E. (1982). The logic of well-being: Therapeutic narratives in
Cairo, Egypt. Social Science and Medicine, 16, 14911497.
Edgerton, R. (1966). Conceptions of psychosis in four African societies.
American Anthropologist, 2, 408425.
Edgerton, R. (1971). The cloak of competence: Stigma in the lives of the
mentally retarded. Berkeley: University of California Press.
Ehrenreich, B., & English, D. (1973). Complaints and disorders: The
sexual politics of sickness. New York: CUNY, the Feminist Press.
Engel, G. (1977). The need for a new medical model: A challenge for
biomedicine. Science, 196, 129136.
Engel, G. (1980). The clinical application of the biopsychosocial model.
American Journal of Psychiatry, 137(5), 535544.
Evans-Pritchard, E. E. (1937). Witchcraft, oracles, and magic among
the Azande. Oxford, UK: Clarendon Press.
Farmer, P. E. (1992). The birth of the klinik: A culture history of Haitian
professional psychiatry. In A. D. Gaines (Ed.), Ethnopsychiatry:
The cultural construction of professional and folk psychiatries.
Albany: State University of New York Press.
Fausto-Sterling, A. (1992). Myths of gender: Biological theories about
women and men (2nd ed.). New York: Basic Books.
Fausto-Sterling, A. (2000). Sexing the body: Gender politics and the
construction of sexuality. New York: Basic Books.
Feldman, J. (1995). Plague doctors: Responding to AIDS in France and
America. Westport, CT: Bergin & Garvey.
Foster, G., & Anderson, B. (1978). Medical anthropology. New York:
Wiley.
Foucault, M. (1975). The birth of the clinic: An archaeology of medical
perception. New York: Vintage.
Foucault, M. (1977). Discipline and punish: Birth of the prison
(A. Sheridan, Trans.). New York: Pantheon.
Foucault, M. (1978). The history of sexuality: An introduction (Vol. 1,
R. Hurley, Trans.). New York: Random House.
Fox, R. (1979). Essays in medical sociology. New York: Wiley.
Fox, R. (1990). The evolution of American bioethics: A sociological
perspective. In G. Weisz (Ed.), Social science perspectives on
medical ethics. Dordrecht, The Netherlands: Kluwer Academic.
Frank, G. (2000). Venus on Wheels. Berkeley: University of California
Press.
Biomedicine
Franklin, S., & Davis-Floyd, R. (2001). Reproductive technology. In
T. Montgomery (Ed.), Routledge International Encyclopedia of
Womens Studies. New York: Routledge.
Gaines, A. D. (1979). Definitions and diagnoses: Cultural implications
of psychiatric help-seeking and psychiatrists definitions of the
situation in psychiatric emergencies. Culture, Medicine and
Psychiatry, 3(4), 381418.
Gaines, A. D. (1982a). Cultural definitions, behavior and the person in
American psychiatry. In A. Marsella & G. White (Eds.), Cultural
conceptions of mental health and therapy. Dordrecht, The
Netherlands: D. Reidel.
Gaines, A. D. (1982b). Knowledge and practice: Anthropological ideas
and psychiatric practice. In N. Chrisman & T. Maretzki (Eds.),
Clinically applied anthropology: Anthropologists in health science
settings. Dordrecht, The Netherlands: Reidel.
Gaines, A. D. (1986). Disease, communalism and medicine. Culture,
Medicine and Psychiatry, 10(3), 397403.
Gaines, A. D. (1987). Cultures, biologies and dysphorias. Transcultural
Psychiatric Research Review, 24(1), 3157.
Gaines, A. D. (1991). Cultural constructivism: Sickness histories
and the understanding of ethnomedicines beyond critical
medical anthropologies. In B. Pfleiderer & G. Bibeau (Eds.),
Anthropologies of medicine: A colloquium on West European and
North American perspectives. Wiesbaden, Germany: Vieweg und
Sohn Verlag.
Gaines, A. D. (Ed.). (1992a). Ethnopsychiatry: The cultural construction of professional and folk psychiatries. Albany: State University
of New York Press.
Gaines, A. D. (1992b). Ethnopsychiatry: The cultural construction of
psychiatries. In A. D. Gaines (Ed.), Ethnopsychiatry: The cultural
construction of professional and folk psychiatries. Albany: State
University of New York Press.
Gaines, A. D. (1992c). Medical/psychiatric knowledge in France and
the United States: Culture and sickness in history and biology. In
A. D. Gaines (Ed.), Ethnopsychiatry: The cultural construction of
professional and folk psychiatries. Albany: State University of
New York Press.
Gaines, A. D. (1992d). From DSM I to III-R; Voices of self,
mastery and the other: A cultural constructivist reading of
U.S. psychiatric classification. Social Science and Medicine,
35(1), 324.
Gaines, A. D. (1995). Race and racism. In W. T. Reich (Ed.),
Encyclopedia of Bioethics. New York: Macmillan.
Gaines, A. D. (1998a). Culture and values at the intersection of science
and suffering: Encountering ethics, genetics and Alzheimer
disease. In S. G. Post & P. J. Whitehouse (Eds.), Genetic testing for
Alzheimer disease: Clinical and ethical issues. Baltimore, MD:
Johns Hopkins University Press.
Gaines, A. D. (1998b). From margin to center: From medical anthropology to cultural studies of science: A review essay. American
Anthropologist, 100(1), 191194.
Gaines, A. D. (n.d., a). From subject to object: Psychiatry in the anthropological gaze. In A. D. Gaines & P. J. Whitehouse (Eds.) Ideas into
realities: Essays in the Cultural Studies of Science and Medicine
(in review). Berkeley: University of Calfornia Press.
Gaines, A. D. (n.d., b). Figures of speech: Local biology, race and
science in a millennial medical anthropology (in review).
Berkeley: University of California Press.
References
Gaines, A. D., & Farmer, P. A. (1986). Visible saints: Social cynosures
and dysphoria in the Mediterranean tradition. Culture, Medicine
and Psychiatry, 10(3), 295330.
Gaines, A. D., & Hahn, R. A. (Eds.). (1982). Physicians of western
medicine: Five cultural studies [Special Issue]. Culture, Medicine
and Psychiatry, 6(3): 215384.
Gaines, A. D., & Hahn, R. A. (1985). Among the physicians: Encounter,
exchange and transformation. In R. A. Hahn & A. D. Gaines (Eds.),
Physicians of western medicine: Anthropological approaches to
theory and practice. Dordrecht, The Netherlands: Reidel.
Gaines, A. D., & Jeungst, E. (n.d.). Myths of bioethics. Manuscript in
review.
Gaines, A. D., & Whitehouse, P. J. (1998). Harmony and consensus:
Cultural aspects of organization in international science. Alzheimer
Disease and Associated Disorders, 12(4), 17.
Geertz, C. (1973). The interpretation of cultures. New York: Basic
Books.
Gevitz, N. (1982). The D.O.s: Osteopathic medicine in America.
Baltimore, MD: Johns Hopkins University Press.
Ginsburg, F., & Rapp, R. (1991). The politics of reproduction. Annual
Review of Anthropology, 20, 311343.
Ginsburg, F., & Rapp, R. (Eds.). (1995). Conceiving the New World
Order: The global politics of reproduction. Berkeley: University of
California Press.
Goffman, E. (1961). Asylums. New York: Doubleday/Anchor.
Good, B. J. (1977). The heart of whats the matter: The semantics of
illness in Iran. Culture, Medicine and Psychiatry, 1(1), 2558.
Good, B. J. (1993). Culture, diagnosis and comorbidity. Culture,
Medicine and Psychiatry, 16(4), 427446.
Good, B. J. (1994). Medicine, rationality and experience: An anthropological perspective. Cambridge, UK: Cambridge University Press.
Good, B. J., & DelVecchio Good, M.-J. (1981). The semantics of
medical discourse. In E. Mendelsohn & Y. Elkana (Eds.), Science
and Cultures. Dordrecht, The Netherlands: Reidel.
Good, B. J., & DelVecchio Good, M.-J. (1993). Learning medicine:
The construction of medical knowledge at Harvard Medical
School. In S. Lindenbaum & M. Lock (Eds.), Knowledge, power
and practice. Berkeley: University of California Press.
Good, B. J., & DelVecchio Good, M.-J. (2000). Parallel Sisters:
Medical anthropology and medical sociology. In C. Bird,
P. Conrad, & A. Fremont (Eds.), Handbook of medical sociology
(5th ed.). Englewood Cliffs, NJ: Prentice Hall.
Gordon, D. (1988). Tenacious assumptions in western medicine. In
M. Lock & D. Gordon (Eds.), Biomedicine examined. Dordrecht,
The Netherlands: Kluwer Academic.
Gordon, D., & Paci, E. (1997). Disclosure practices and cultural narratives: Understanding concealment and silence around cancer in
Tuscany, Italy. Social Science and Medicine, 44(10), 14331452.
Gordon, E. J. (1999). If its not broke, dont fix it: Patients and clinicians decision making for treatment of end-stage renal disease
in the United States. Unpublished dissertation. Case Western
Reserve University, Department of Anthropology, Cleveland, OH.
Gray, C. H. (Ed.). (1995). The Cyborg handbook. New York: Routledge.
Groce, N. (1985). Everybody here spoke sign language. Cambridge,
MA: Harvard University Press.
Hacking, I. (1983). Representing and intervening. Cambridge, UK:
Cambridge University Press.
107
Hahn, R. A. (1985). A world of internal medicine: Portrait of an
internist. In R. A. Hahn & A. D. Gaines (Eds.), Physicians of
western medicine: Anthropological approaches to theory and
practice. Dordrecht, The Netherlands: Reidel.
Hahn, R. A. (1992). The state of Federal health statistics on racial and
ethnic groups. Journal of the American Medical Association,
267(2), 268273.
Hahn, R. A., & Gaines, A. D. (Eds.). (1982). Physicians of western
medicine: An introduction. Physicians of western medicine: Five
cultural studies [Special issue]. Culture, Medicine and Psychiatry,
6(3), 215218.
Hahn, R. A., & Gaines, A. D. (Eds.). (1985). Physicians of western
medicine: Anthropological approaches to theory and practice.
Dordrecht, The Netherlands: Reidel.
Haraway, D. (1991). Simians, Cyborgs and women: The reinvention of
nature. New York: Routledge.
Haraway, D. (1997). Modest_Witness@Second_Millennium. Female
Man_Meets_OncoMouse.:Feminism and technoscience.
New York: Routledge.
Helman, C. (1985). Psyche, soma and society: The social construction
of psychosomatic disease. Culture, Medicine and Psychiatry, 9(1),
126.
Hershel, H. J. (1992). Psychiatric institutions: Rules and the accommodation of structure and autonomy in France and the United States.
In A. D. Gaines (Ed.), Ethnopsychiatry: The cultural construction
of professional and folk psychiatries. Albany: State University of
New York Press.
Hinze, S. W. (1999). Gender and the body of medicine or at least some
body parts: (Re)constructing the prestige hierarchy of medical
specialties. The Sociological Quarterly, 40(2), 217239.
Hughes, C. (1968). Medical care: Ethnomedicine. In D. L. Sills (Ed.),
International Encyclopedia of the Social Sciences. New York: Free
Press.
Ingstad, B., & Reynolds Whyte, S. (Eds.). (1995). Disability and
culture. Berkeley: University of California Press.
Jenkins, J. H. (1988). Ethnopsychiatric interpretations of schizophrenic
illness: The problem of nervios within Mexican-American
families. Culture, Medicine and Psychiatry, 12(3), 303331.
Johnson, T. (1985). Consultationliaison psychiatry: Medicine as
patient, marginality as practice. In R. A. Hahn & A. D. Gaines
(Eds.), Physicians of western medicine: Anthropological
approaches to theory and practice. Dordrecht, The Netherlands:
Reidel.
Jordan, B. (1993). Birth in four cultures (4th ed., revised and updated
by R. Davis-Floyd). Prospect Heights, OH: Waveland Press.
Jordan, B. (1997). Authoritative knowledge and its construction. In
R. Davis-Floyd & C. Sargent (Eds.), Childbirth and authoritative
knowledge: Cross-Cultural Perspectives. Berkeley: University of
California Press.
Katz, P. (1981). Rituals in the operating room. Ethnology, 20(4),
335350.
Katz, P. (1985). How surgeons make decisions. In R. A. Hahn &
A. D. Gaines (Eds.), Physicians of western medicine:
Anthropological approaches to theory and practice. Dordrecht,
The Netherlands: Reidel.
Katz, P. (1998). The scalpels edge: The culture of surgeons. Boston, MA:
Allyn & Bacon.
108
Keller, E. F. (1992). Secrets of life; Secrets of death: Essays on language,
gender and science. New York: Routledge.
Kleinman, A. (1980). Patients and healers in the context of culture.
Berkeley: University of California Press.
Kleinman, A. (1988a). The illness narratives. New York: Basic Books.
Kleinman, A. (1988b). Rethinking psychiatry: From cultural category to
personal experience. New York: Free Press.
Kleinman, A., & Good, B. J. (Eds.). (1985). Culture and depression:
Studies in the anthropology and cross-cultural psychiatry of affect
and disorder. Berkeley: University of California Press.
Kleinman, A., Kunstadter, P., Alexander, E., & Gale, J. (Eds.). (1975).
Medicine in Chinese cultures. Washington, DC: National Institutes of
Health, US Government Printing Office for the Fogerty International
Center.
Konner, M. (1987). Becoming a doctor: A journey of initiation in medical
school. New York: Viking.
Kuhn, T. S. (1962). The structure of scientific revolutions. Chicago:
University of Chicago Press.
Kuriyama, S. (1992). Between mind and eye: Japanese anatomy in the
eighteenth century. In C. Leslie & A. Young (Eds.), Paths to Asian
medical knowledge. Berkeley: University of California Press.
Labov, W., & Fanshel, D. (1977). Therapeutic Discourse. New York:
Academic Press.
Langess, L. L., & Levine, H. G. (Eds.). (1986). Culture and retardation:
Life histories of mildly mentally retarded persons in American
society. Dordrecht, The Netherlands: Reidel.
Latour, B., & Woolgar, S. (1979). Laboratory life: The construction of
scientific facts. Princeton, NJ: Princeton University Press.
Leslie, C. (Ed.). (1976). Asian medical systems. Berkeley: University of
California Press.
Leslie, C., & Young, A. (Eds.). (1992). Paths to Asian medical knowledge.
Berkeley: University of California Press.
Lvi-Strauss, C. (1963a). The sorcerer and his magic. Structural anthropology (pp. 167185). New York: Basic Books.
Lvi-Strauss, C. (1963b). The effectiveness of symbols. Structural anthropology (pp. 206231). New York: Basic Books.
Lieban, R. W. (1990). Medical anthropology and the comparative study of
medical ethics. In G. Weisz (Ed.), Social science perspectives on
medical ethics. Dordrecht, The Netherlands: Kluwer Academic.
Lindenbaum, S., & Lock, M. (Ed.). (1993). Knowledge, power and
practice. Berkeley: University of California Press.
Lock, M. (1980). East Asian medicine in urban Japan. Berkeley:
University of California Press.
Lock, M. (1993). Encounters with aging. Berkeley: University of
California Press.
Lock, M. (2002). Twice dead: Organ transplants and the reinvention of
death. Berkeley: University of California Press.
Lock, M., & Gordon, D. (Eds.). (1988). Biomedicine examined. Dordrecht,
The Netherlands: Kluwer Academic.
Lock, M., Young, A., & Cambrosio, A. (Eds.). (2000). Living and working
with the new medical technologies. Cambridge, UK: Cambridge
University Press.
Lostaunau, M. O., & Sobo, E. J. (1997). The cultural context of health,
illness, and medicine. Westport, CT: Bergin & Garvey.
Luhrmann, T. M. (2000). Of two minds: The growing disorder in American
psychiatry. New York: Knopf.
Maretzki, T. (1989). Cultural variation in biomedicine: The Kur in West
Germany. Medical Anthropology Quarterly, 3(1), 2235.
Biomedicine
Maretzki, T., & Seidler, E. (1985). Biomedicine and naturopathic healing
in West Germany: A history of a stormy relationship. Culture,
Medicine and Psychiatry, 9(4), 383427.
Marsella, A. (1980). Depressive experience and disorder across cultures.
In J. Draguns & H. Triandis (Eds.), Handbook of cross-cultural
psychology: Vol. 6. Psychopathology. New York: Allyn & Bacon.
Marshall, P. (1992). Anthropology and bioethics. Medical Anthropology
Quarterly (n.s.), 6(1), 4973.
Martin, E. (1987). The woman in the body. Boston, MA: Beacon Press.
Martin, E. (1990). The egg and the sperm: How science has constructed a
romance based on stereotypical malefemale roles. Signs, 16(3),
485501.
Martin, E. (1994). Flexible bodies: Tracking immunity in America from the
days of polio to the age of AIDS. Boston, MA: Beacon Press.
Mattingly, C. (1999). Healing dramas and clinical plots. Cambridge, UK:
Cambridge University Press.
McKeown, T. (1979). The role of medicine: Dream, mirage, or nemesis?
Princeton, NJ: Princeton University Press.
Merton, R., Reader, G., Kendall, P. et al. (1957). The student physician.
Cambridge, MA: Harvard University Press.
Middleton, J. (1967). Magic, witchcraft, and curing. Garden City, NJ:
Natural History Press.
Mishler, E. (1981). Viewpoint: Critical perspectives on the biomedical
model. In E. Mishler, L. A. Rhodes, S. Hauser, R. Liem, S. Osherson,
& N. Waxler (Eds.), Social contexts of health, illness, and patient
care. Cambridge, UK: Cambridge University Press.
Mitchell, L. M. (2001). Babys first picture. Toronto, Canada: University
of Toronto Press.
Moore, S. F., & Myerhoff, B. (Eds.). (1977). Secular ritual. Assen, The
Netherlands: Van Gorcum.
Nichter, M. (1989). Anthropology and international health: South Asian
case studies. Dordrecht, The Netherlands: Kluwer Academic.
Nuckolls, C. W. (1998). Culture: A problem that cannot be solved.
Madison: University of Wisconsin Press.
Ohnuki-Tierney, E. (1984). Illness and culture in contemporary Japan: An
anthropological view. Cambridge, UK: Cambridge University Press.
Oths, K. S. (1992). Unintended therapy: Psychotherapeutic aspects of
chiropractic. In A. D. Gaines (Ed.), Ethnopsychiatry: The cultural
construction of professional and folk psychiatries. Albany: State
University of New York Press.
Paget, M. A. (1982). Your son is cured now; You may take him home.
In A. D. Gaines & R. A. Hahn (Eds.), Physicians of western medicine: Five cultural studies [Special issue]. Culture, Medicine and
Psychiatry, 6(3), 237259.
Payer, L. (1989). Medicine and culture. New York: Penguin.
Pfifferling, J. H. (1976). Medical anthropology: Mirror for medicine. In
F. X. Grollig & H. Haley (Eds.), Medical anthropology. The Hague:
Mouton.
Prince, R. (1964). Indigenous Yoruba psychiatry. In A. Kiev (Ed.), Magic,
faith and healing. New York: Free Press.
Rabinow, P. (1996). Making PCR: A story of biotechnology. Chicago, IL:
University of Chicago Press.
Rapp, R. (2001). Testing women, testing the fetus: The social impact of
amniocentesis in America. New York: Routledge.
Reynolds, D. K. (1976). Morita psychotherapy. Berkeley: University of
California Press.
Rothman, B. K. (1982). In labor: Women and power in the birthplace.
New York: Norton.
Introduction
109
Rothman, B. K. (1989). Recreating motherhood: Ideology and technology in patriarchal society. New York: Norton.
Rubinstein, R. A., Laughlin, C. D. Jr., & McManus, J. (1984). Science
as cognitive process: Toward an empirical philosophy of science.
Philadelphia: University of Pennsylvania Press.
Scheper-Hughes, N., & Lock, M. (1987). The mindful body: A prologomenon to future work in medical anthropology. Medical
Anthropology Quarterly, 1(1), 641.
Schiebinger, L. (1993). Natures body. Boston: Beacon Press.
Simons, R. C., & Hughes, C. (Eds.). (1985). The culture-bound
syndromes: Folk illnesses of psychiatric and anthropological
interest. Dordrecht, The Netherlands: Reidel.
Singer, M., Valentn, F., Baer, H., & Jia, Z. (1998). Why does Juan
Garca have a drinking problem? The perspective of critical
medical anthropology. In P. J. Brown (Ed.), Understanding and
applying medical anthropology (pp. 286302). London: Mayfield.
Stein, H. (1967). The doctornurse game. Archives of General
Psychiatry, 16, 699703. (Reprinted in Conformity and conflict,
4th ed., pp. 167176, by J. P. Spradley & D. W. McCurdy (Eds.),
1980.) Boston, MA: Little, Brown.
Stein, H. (1990). American medicine as culture. Boulder, CO: Westview
Press.
Strauss, A., Schatzman, L., Bucher, R., Ehrlich, D., & Sabzhin, M.
(1964). Psychiatric ideologies and institutions. New York: Free
Press.
Medical Pluralism
Hans A. Baer
INTRODUCTION
Medical systems in all human societies, regardless of
whether they are indigenous or state-based, consist of a
dyadic core consisting of a healer and a patient. Healers
range from generalists, such as the shaman in indigenous
societies or the proverbial family physician in modern
societies, to specialists, such as the herbalist, bonesetter,
midwife, or medium in preindustrial societies or the
urologist, internist, or psychiatrist in modern societies. In
contrast to indigenous societies, which tend to exhibit a
more-or-less coherent medical system, state or complex
societies exhibit the conflation of an array of medical
systemsa phenomenon generally referred to by medical anthropologists, as well as medical sociologists and
medical geographers, as medical pluralism. The medical
110
Medical Pluralism
CONCEPTIONS
OF
MEDICAL PLURALISM
societies. Regional medical systems are systems distributed over a relatively large area, such as Ayurveda and
Unani medicine in India and Sri Lanka and traditional
Chinese medicine. Cosmopolitan medicine refers to
the world-wide system commonly referred to as
Western medicine, regular medicine, allopathic medicine,
scientific medicine, or biomedicine. Complex societies
generally contain all three of these systems. In modern
industrial or post-industrial societies, biomedicine
the dominant systemtends to exist in a competitive
relationship with other systems such as chiropractic,
naturopathy, Christian Science, evangelical faith healing,
and various folk medical systems. It often seeks either to
annihilate these systems or to restrict their scope of practice. In some instance, biomedicine seeks to absorb or
co-opt them, particularly if the latter achieve increasing
legitimacy.
Chrisman and Kleinman (1983) created a widely
used model that delineates three overlapping sectors in
health care systems. The popular sector consists of health
care performed by patients themselves, their families,
social networks, and communities. It includes a wide array
of therapies, such as special diets, herbs, exercise, rest,
baths, and massage, and, in the case of modern societies,
articles such as over-the-counter drugs, vitamin supplements, humidifiers, and hot water bottles. Based on
research in Taiwan, Kleinman estimates that 7090% of
the treatment episodes on the island occur in the popular
sector. The folk sector encompasses various healers
who function informally and often on a quasi-legal or even
illegal basis. These include shamans, mediums, magicians,
herbalists, bonesetters, and midwives. The professional
subsector includes the practitioners and bureaucratic structures, such as clinics, hospitals, and associations, which
are associated with both biomedicine and professionalized
heterodox medical systems, such as Ayurvedic and Unani
medicine in South Asia, herbalism and acupuncture in the
Peoples Republic of China, and homeopathy, osteopathy,
chiropractic, and naturopathy in Britain.
In keeping with Navarros (1986, p. 1) assertion that
classes as well as races, ethnic groups, and genders within
capitalist societies have different ideologies which
appear in different forms of cultures, it may be argued
that these social categories also construct different
medical systems to coincide with their respective views
of reality. In contrast to many medical anthropologists
who observe that complex societies exhibit a pattern of
medical pluralism, many neo-Marxian medical social
scientists confine their attention to the dominant capitalintensive system of medicine and ignore or at best give
fleeting attention to alternative medical systems. Critical
medical anthropology (CMA), which builds on the work
of the political economy of health, attempts to overcome
these shortcomings (Singer & Baer, 1995). It asserts that
patterns of medical pluralism tend to reflect hierarchical
relations in the larger society. Patterns of hierarchy
may be based upon class, caste, racial, ethnic, regional,
religious, and gender distinctions. Medical pluralism
flourishes in all socially stratified or state societies and
tends to mirror the wide sphere of class and social relationships. National medical systems in the modern world
tend to be plural, rather than pluralistic, in that biomedicine enjoys a dominant status over heterodox and/or
folk medical practices. In reality, plural medical systems
may be described as dominative in that one medical
system generally enjoys a preeminent status vis--vis
other medical systems. While within the context of a
dominative medical system one system attempts to exert,
with the support of social elites, dominance over other
medical systems, people are quite capable of dual use
of distinct medical systems (Romanucci-Ross, 1977).
Medical pluralism in the modern world is characterized by a pattern in which biomedicine exerts dominance
over alternative medical systems, whether they are professionalized or not. The dominant status of biomedicine is
legitimized by laws that grant it a monopoly over certain
medical practices, and limit or prohibit the practice of
other types of healers. Nevertheless, biomedicines dominance over rival medical systems has never been absolute.
The state, which primarily serves the interests of the
corporate class, must periodically make concessions to
subordinate social groups in the interests of maintaining
social order and the capitalist mode of production. As a
result, certain heterodox practitioners, with the backing of
clients and particularly influential patrons, have been able
to obtain legitimation in the form of full practice rights
(e.g., homeopathic physicians in Britain, osteopathic
physicians in the United States, and Ayurvedic and Unani
physicians in India) or limited practice rights (e.g.,
chiropractors, naturopaths, and chiropractors in North
American societies, many European societies, as well as
Australia and New Zealand). Lower social classes, racial
and ethnic minorities, and women have utilized alternative
medicine as a forum for challenging not only biomedical
dominance but also, to a degree, the hegemony of the
corporate class and its political allies.
111
CASE STUDIES
OF
MEDICAL PLURALISM
India
Leslie (1977) has conducted historical and ethnographic
research on medical pluralism in India. He delineates
five levels in the Indian dominative medical system:
(1) biomedicine, which relies upon physicians with M.D.
and Ph.D. degrees from prestigious institutions;
(2) indigenous medical systems, which include practitioners who have obtained degrees from Ayurvedic,
Unani, and Siddha medical colleges; (3) homeopathy,
whose physicians have completed correspondence
courses; (4) religious scholars or learned priests with
unusual healing abilities; and (5) local folk healers, bonesetters, and midwives. In contrast to some 150,000 biomedical physicians, there were an estimated 400,000
practitioners of Ayurveda, Unani, and Siddha in the early
1970s. Ayurveda is based upon Sanskrit texts, Unani on
Galenic and Islamic medicine, and Siddha on South
Indian humoralism. In addition to 95 biomedical schools,
India has 92 Ayurvedic colleges, 15 Yunani colleges, and
a college of Siddha medicine. Although homeopathy
entered India as a European import, the opposition to it
by the British-dominated biomedical profession spared it
association with colonialism. Homeopathic practices
have become a standard component of Ayurveda.
Although the Indian state continued to support biomedicine after independence, in 1970 it established the Central
Council of Indian Medicine as a branch of the Ministry
of Health in an effort to legitimize the traditional professionalized medical systems and for the purposes of registering traditional physicians, regulating education and
practice, and fostering research (Leslie, 1974). According
to Leslie (1992, p. 205), [Traditional] physicians are
sometimes painfully aware that cosmopolitan medicine
[or biomedicine] dominates the Indian medical system,
yet a substantial market exists for commercial Ayurvedic
products and for consultation with practitioners.
Zaire
Janzen (1978) presents an account of how patients in a
region of Lower Zaire engage in therapy management
and how they resort to various medical systems in addressing illness. The therapy management group, consisting
of kinspeople, friends, and colleagues, serves to broker the
relationship between physicians, nurses, indigenous and
112
Medical Pluralism
Haiti
Like Crandon-Malamud, Brodwin (1996) conducted
ethnographic research on medical pluralism at the
village level, namely in the Haitian village of Jeanty
(pseudonym). In addition to access to biomedicine or
metropolitan medicine, the villagers turn to various
other practitioners and healing systems in their search for
better health. These include herbalists, bonesetters, midwives, the cult of Roman Catholic saints, Voodou priests,
and Pentecostal ministers. Morality and medicine are
intricately intertwined in rural Haiti and pose questions of
innocence or guilt. People in Jeanty debate among themselves as to which healing system they should resort to in
an effort to achieve moral balance in their lives. While
recognizing its value in treating certain diseases, they
regard the biomedical dispensary in their village as yet
another site where local representatives of powerful outside forces provide valued resources and techniques for
ordering life (Brodwin, 1996, p. 67). For the problems
of everyday life, the villagers can turn to the houngan and
mambo (male and female Vodou religious healer),
Catholic lay exorcists, or Pentecostal healers. Whereas
Vodou and Catholicism coexist in a complementary and
somewhat tense relationship, Pentecostalists tend to
regard them systems as diabolic. Regardless of
the healing system that the villagers employ, as
Brodwin argues, each of them to address pressing moral
dilemmas.
Kyoto, Japan
In 197374, Margaret Lock (1984) conducted ethnographic research on medical pluralism in Kyoto, Japan.
113
114
Medical Pluralism
References
115
REFERENCES
Baer, H. A. (2001). Biomedicine and alternative healing systems in
America: Issues of class, race, ethnicity, and gender. Madison:
University of Wisconsin Press.
Brodwin, P. (1996). Medicine and morality in Haiti. Cambridge, UK:
Cambridge University Press.
Chrisman, N. J., & Kleinman, A. (1983). Popular health care, social
networks, and cultural meanings: The orientation of medical anthropology. In D. Mechanic (Ed.), Handbook of health, health care, and
the health professions (pp. 569580). New York: Free Press.
Crandon-Malamud, L. (1991). From the fat of our souls: Social change,
political process, and medical pluralism in Bolivia. Berkeley:
University of California Press.
Dunn, F. (1976). Traditional Asian medicine and cosmopolitan
medicine as adaptive systems. In C. Leslie (Ed.), Asian medical
systems: A comparative study (pp. 133158). Berkeley: University
of California Press.
Elling, R. H. (1981). Political economy, cultural hegemony, and mixes
of traditional and modern medicine. Social Science and Medicine,
15A, 8999.
English-Lueck, J. A. (1990). Health in the New Age: A study in
California health practices. Albuquerque: University of New
Mexico Press.
Fabrega, Jr., H. (1997). Evolution of healing and sickness. Berkeley:
University of California Press.
Frankenberg, R. (1980). Medical anthropology and development:
A theoretical perspective. Social Science and Medicine, 14B,
197207.
Janzen, J. (1978). The quest for therapy in lower Zaire. Berkeley:
University of California Press.
116
MODERNIZATION
AND
MEDICALIZATION
117
118
119
120
MEDICALIZED IDENTITIES
CONDITIONS
AND
Social science critiques of medicalization, whether associated more closely with labeling theory and the social
control of deviance, or with Foucaldian theory and the
relationship of power to knowledge, have documented the
way in which identities and subjectivity are shaped
through this process. When individuals are publicly
labeled as schizophrenic, anorexic, infertile, menopausal,
a heart transplant, a trauma victim, and so on, transformations of subjectivity are readily apparent (Ablon,
1984; Becker, 2000; Estroff, 1993; Kaufman, 1988).
At times medicalization may function to exculpate
individuals from responsibility for being sick, and individuals may then actively participate in this process
(Lock, 1990; Nichter, 1998).
Medicalization of Wellness
121
MEDICALIZATION
OF
WELLNESS
122
RISK
AS
SELF-GOVERNANCE
References
123
REFERENCES
Ablon, J. (1984). Little people in America: The social dimensions of
dwarfism. New York: Praeger.
Adams, V. (2001). Particularizing modernity: Tibetan medical theorizing of womens health in Lhasa, Tibet. In L. Connor & G. Samuels
(Eds.), Healing powers and modernity (pp. 222246). Westport,
CT: Bergin & Garvey.
Adams, V. (2002). Establishing proof: Translating science and the
state in Tibetan medicine. In M. Nichter & M. Lock (Eds.), New
horizons in medical anthropology: Essays in honour of Charles
Leslie (pp. 200220). Reading, UK: Harwood Academic.
Anagnost, A. (1995). A Surfeit of bodies: Populations and the rationality of the state in post-Mao China. In F. D. Ginsburg & R. Rapp
(Eds.), Conceiving the New World Order (pp. 2241). Berkeley:
University of California Press.
Arnold, R. (1993). Colonizing the body: State medicine and epidemic
disease in nineteenth century America. Berkeley: University of
California Press.
Barrett, R. J. (1988). Interpretations of schizophrenia. Culture,
Medicine and Psychiatry, 12, 357388.
124
Barroso, C., & Corra, S. (1995). Public servants, professionals, and
feminists: The politics of contraceptive research in Brazil. In
F. D. Ginsburg & R. Rapp (Eds.), Conceiving the New World Order
(pp. 292306). Berkeley: University of California Press.
Becker, G. (2000). The elusive embryo: How women and men approach
new reproductive technologies. Berkeley: University of California
Press.
Brodwin, P. (1996). Medicine and morality in Haiti: The contest for
healing power. Cambridge, UK: Cambridge University Press.
Browner, C., & Press, N. (1995). The normalization of prenatal diagnostic screening. In F. D. Ginsburg & R. Rapp (Eds.), Conceiving
the New World Order: The global politics of reproduction
(pp. 307322). Berkeley: University of California Press.
Browner, C., & Press, N. (1996). The production of authoritative knowledge in American prenatal care. Medical Anthropology Quarterly,
10, 141156.
Clarke, A. E., Mamo, L., Shim, J. K., Fishman, J. R., & Fosket, J. R.
(2000). Technoscience and the new biomedicalization: Western
roots, global rhizomes. Sciences Sociales et Sant, 18(2), 1142.
Comaroff, J. (1993). The diseased heart of Africa: Medicine, colonialism,
and the black body. In S. Lindenbaum & M. Lock (Eds.), Knowledge
power and practice: The anthropology of medicine and everyday life
(pp. 305329). Berkeley: University of California Press.
Conrad, P. (1992). Medicalization and social control. Annual Review of
Sociology, 18, 209232.
Crawford, R. (1984). A cultural account of health: Control, release and
the social body. In J. B. McKinlay (Ed.), Issues in the political
economy of health (pp. 60106). New York: MethuenTavistock.
Davis-Floyd, R. E. (1988). Birth as an American rite of passage. In
K. Michaelson (Ed.), Childbirth in America: Anthropological
perspectives (pp. 153172). Beacon Hill, MA.: Bergin & Garvey.
Davis-Floyd, R. E. (1996). The technocratic body and the organic body:
Hegemony and heresy in womens birth choices. In C. F. Sargent
& C. B. Brettell (Eds.), Gender and health: An international
perspective (pp. 123166). Englewood Cliffs, NJ: Prentice Hall.
Estroff, S. E. (1993). Identity, disability, and schizophrenia: The problem
of chronicity. In S. Lindenbaum & M. Lock (Eds.), Knowledge,
power and practice: The anthropology of medicine and everyday
life (pp. 247286). Berkeley: University of California Press.
Farquhar, J. (1995). Re-writing traditional medicine in post-Maoist
China, In D. Bates (Ed.), Knowledge and the scholarly medical tradition (pp. 251276). Cambridge, UK: Cambridge University Press.
Ferzacca, S. (2002). Governing bodies in new order Indonesia. In
M. Nichter & M. Lock (Eds.), New horizons in medical anthropology: Essays in honour of Charles Leslie (pp. 3557). Reading,
UK: Harwood Academic.
Fiedler, D. C. (1997). Authoritative knowledge and birth territories in
contemporary Japan. In R. E. Davis-Floyd & C. F. Sargent (Eds.),
Childbirth and authoritative knowledge: Cross-cultural perspectives (pp. 159179). Berkeley: University of California Press.
Foucault, M. (1979). Discipline and punish: The birth of the prison.
New York: Vintage.
Fraser, G. (1992). Afro-American midwives, biomedicine, and the state.
Cambridge, MA: Harvard University Press.
Handwerker, L. (1998). The consequences of modernity for childless
women in China: Medicalization and resistance. In M. Lock &
P. Kaufert (Eds.), Pragmatic women and body politics
(pp. 178205). Cambridge, UK: Cambridge University Press.
Introduction
125
INTRODUCTION
The last quarter of the 20th century has seen a shift in the
social sciences, especially in anthropology, from objectified descriptions of the body in health and illness to
126
127
PHENOMENOLOGY
OF THE
BODY
128
ETHNOGRAPHIC USES
LIVED BODY
OF THE
129
THE BODY
IN
DISTRESS
130
THE BODY
OF
DIFFERENCE
Since its inception in medical anthropology, a phenomenological approach has been applied to the study of
OF
The temporal dimension of peoples lives plays an important part in understanding embodied health and illness.
Phenomenology is less concerned with establishing what
actually happened in the past than in exploring the past as
a mode of present experience (M. Jackson, 1996, p. 38).
Peoples historical experiences of their bodies is expressed
through embodiment (Connerton, 1989). Memory not
only reflects personal, subjective experience, it is socially
constructed and present oriented, reshaping experience
(Halbwachs, 1992). Lambek (1996, p. 235) suggests that
memory be viewed as a cultural practice. Memories are
powerful symbols of the self (Csordas, 1994b), permeated
by peoples views of how life has been and should be
(G. Becker, 1997). Memories can be seen as incomplete,
reshaped interpretations made in an effort to create a
world that makes sense (Becker, Beyene, & Ken, 2000b).
Memory is thus a critical aspect of embodiment.
131
132
ACKNOWLEDGMENTS
Preparation of this chapter was supported by grants R37 AG1114 4 and
RO1 AG14152 from the National Institutes of Health, National Institute
on Aging.
REFERENCES
Ablon, J. (1984). Little people in America. New York: Praeger.
Ablon, J. (1996). Gender response to neurofibromatosis 1. Social
Science & Medicine, 42, 99109.
Ablon, J. (1999). Living with genetic disorder: The impact of neurofibromatosis 1. Westport, CT: Auburn House.
Abu-Lughod, L. (1991). Writing against culture. In R. G. Fox (Ed.),
Recapturing anthropology: Working in the present. Santa Fe, NM:
School of American Research.
Adams, V. (1998). Suffering the winds of Lhasa: Politicized bodies,
human rights, cultural difference, and humanism in Tibet. Medical
Anthropology Quarterly, 12, 74102.
Ainlay, S. (1989). Day brought back my night: Aging and new vision
loss. London: Routledge.
Becker, A. E. (1994). Nurturing and negligence: Working on others
bodies in Fiji. In T. J. Csordas (Ed.), Embodiment and experience:
The existential ground of culture and self. (pp. 100115).
Cambridge, UK: Cambridge University Press.
Becker, A. E. (1995). Body, self, and society: The view from Fiji.
Philadelphia: University of Pennsylvania Press.
Becker, G. (1980). Growing old in silence. Berkeley: University of
California Press.
Becker, G. (1994). The oldest old: Autonomy in the face of frailty.
Journal of Aging Studies, 8, 5976.
Becker, G. (1997). Disrupted lives: How people create meaning in a
chaotic world. Berkeley: University of California Press.
Becker, G. (2000). The elusive embryo: How women and men approach
new reproductive technologies. Berkeley: University of California
Press.
Becker, G. (2002). Dying away from home: Quandaries of migration in
two ethnic groups. Journal of Gerontology: Social Sciences, 57B,
S79S95.
Becker, G., Beyene, Y., & Canalita, L. (2000). Immigrating for status in
late life: Effects of globalization on Filipino American veterans.
Journal of Aging Studies, 14, 273291.
References
Becker, G., Beyene, Y., & Ken, P. (2000a). Health, welfare reform, and
narratives of uncertainty among Cambodian refugees. Culture,
Medicine, and Psychiatry, 24, 139163.
Becker, G., Beyene, Y., & Ken, P. (2000b). Memory, trauma, and
embodied distress: The management of disruption in the stories of
Cambodians in exile. Ethos 28, 320345.
Becker, G., & Kaufman, S. R. (1995). Managing an uncertain illness
trajectory in old age: Patients and physicians views of stroke.
Medical Anthropology Quarterly, 9, 165187.
Behar, R. (1993). Translated woman: Crossing the border with
Esperanzas story. New York: Beacon.
Behar, R., & Gordon, D. A. (Eds.). (1995). Women writing culture.
Berkeley: University of California Press.
Benner, P. (Ed.). (1994). Interpretive phenomenology: Embodiment,
caring, and ethics in health and illness. Thousand Oaks,
CA: Sage.
Bidney, D. (1973). Phenomenological method and the anthropological
science of the cultural life-world. In M. Natanson (Ed.),
Phenomenology and the social sciences, v. 1 (pp. 109140).
Evanston, IL: Northwestern University Press.
Bigwood, C. (1991). Renaturalizing the body (with the help of MerleauPonty). Hypatia 6.
Bluebond-Langner, M. (1996). In the shadow of illness: Parents and
siblings of the chronically ill child. Princeton: Princeton University
Press.
Boddy, J. (1988). Spirits and selves in Northern Sudan: The cultural therapeutics of possession and trance. American Ethnologist, 15, 427.
Bourdieu, P. (1977). Outline of a theory of practice (R. Nice, Trans.).
Cambridge, UK: Cambridge University Press.
Bourdieu, P. (1984). Distinction: A social critique of the judgment of
taste (R. Nice, Trans.). Cambridge, MA: Harvard University Press.
Bourdieu, P. (1990). The logic of practice (R. Nice, Trans.). Stanford,
CA: Stanford University Press.
Bourgois, P. (1995). In search of respect: Selling crack in El Barrio.
Cambridge, UK: Cambridge University Press.
Bourgois, P. (1998). The moral economies of homeless heroin addicts:
Confronting ethnography, HIV risk, and everyday violence in San
Francisco shooting encampments. Substance Use and Misuse, 33,
23232351.
Bourgois, P., & Schonberg, J. (2000). Explaining drug preferences:
Heroin, crack, and fortified wine in a social network of homeless
African-American and white injectors. Proceedings of the
Community Epidemiology Working Group (NIH Publication No.
01-4916, pp. 411418). Washington, DC: National Institute on
Drug Abuse.
Briggs, C. L. (1996). The meaning of nonsense, the poetics of embodiment, and the production of power in Warao healing. In
C. Laderman & M. Roseman (Eds.), The performance of healing
(pp. 185232). New York: Routledge.
Bruner, E. M. (1986). Experience and its expressions. In V. W. Turner &
E. M. Bruner (Eds.), The anthropology of experience (pp. 332).
Bloomington: Indiana University Press.
Butler, J. (1989). Sexual ideology and phenomenological description:
A feminist critique of Merleau-Pontys Phenomenology of perception. In J. Allen & I. M. Young (Eds.), The thinking muse: Feminism
and modern French philosophy (pp. 85100). Bloomington:
Indiana University Press.
133
Butler, J. (1993). Bodies that matter: On the discursive limits of sex.
New York: Routledge.
Butler, J. (1997). Performative acts and gender constitution: An essay in
phenomenology and feminist theory. In K. Conboy, N. Medina, &
S. Stanbury (Eds.), Writing on the body: Female embodiment and
feminist theory (pp. 401417). New York: Columbia University
Press.
Castro, R., & Eroza, E. (1998). Research notes on social order and
subjectivity: Individuals experience of susto and fallen fontanelle
in a rural community in Central Mexico. Culture, Medicine, and
Psychiatry, 22, 203230.
Chatterji, R. (1998). An ethnography of dementia: A case study of an
Alzheimers disease patient in the Netherlands. Culture, Medicine,
and Psychiatry, 22, 355382.
Chuengsatiansup, K. (1999). Sense, symbol, and soma: Illness experience in the soundscape of everyday life. Culture, Medicine, and
Psychiatry, 23, 273301.
Connerton, P. (1989). How societies remember. New York: Cambridge
University Press.
Crossley, M. L. & Crossley, N. (2001). Patient voices, social movements and the habitus: How psychiatric survivors speak out.
Social Science & Medicine, 52, 14771489.
Csordas, T. J. (1990). Embodiment as a paradigm for anthropology.
Ethos, 18, 547.
Csordas, T. J. (1993). Somatic modes of attention. Cultural Anthropology,
8, 135156.
Csordas, T. J. (1994a). Introduction: The body as representation and
being-in-the-world. In T. J. Csordas (Ed.), Embodiment and experience: The existential ground of culture and self (pp. 126).
Cambridge, UK: Cambridge University Press.
Csordas, T. J. (1994b). The sacred self: A cultural phenomenology of
charismatic healing. Berkeley: University of California Press.
Csordas, T. J. (1996). Imaginal performance and memory in ritual
healing. In C. Laderman & M. Roseman (Eds.), The performance
of healing (pp. 91114). New York: Routledge.
Csordas, T. J. (1997). Language, charisma, and creativity: The ritual
life of a religious movement. Berkeley: University of California
Press.
Csordas, T. J. (1999). The bodys career in anthropology. In H. L. Moore
(Ed.), Anthropological theory today (pp. 172205). Cambridge,
UK: Polity Press.
Csordas, T. J. (2000). Computerized cadavers: Shades of being and representation in virtual reality. In P. E. Brodwin (Ed.), Biotechnology
and culture: Bodies, anxieties, ethics (pp. 173192). Bloomington:
Indiana University Press.
Daniel, E. V. (1991). The pulse as an icon in Siddha medicine. In
D. Howes (Ed.), The varieties of sensory experience: A sourcebook
on the anthropology of the senses (pp. 100110). Toronto, Canada:
University of Toronto Press.
Daniel, E. V. (1994). The individual in terror. In T. J. Csordas (Ed.),
Embodiment and experience: The existential ground of culture and
self (pp. 229247). Cambridge, UK: Cambridge University Press.
Daniel. E. V. (1996). Charred lullabies: Chapters in an anthropography
of violence. Princeton, NJ: Princeton University Press.
Daniel, E. V., & Knudsen, J. C. (1995). Introduction. In E. V. Daniel &
J. C. Knudsen (Eds.), Mistrusting refugees (pp. 112). Berkeley:
University of California Press.
134
Das, V., Kleinman, A., Lock, M., Ramphele, M., & Reynolds, P. (Eds.).
(2001). Remaking a world: Violence, social suffering, and
recovery. Berkeley: University of California Press.
Das, V., Kleinman, A., Ramphele, M., & Reynolds, P. (Eds.). (2000).
Violence and subjectivity. Berkeley: University of California
Press.
Davis, K. (1997). Embody-ing theory: Beyond modernist and
postmodernist readings of the body. In K. Davis (Ed.), Embodied
practices: Feminist perspectives on the body (pp. 126). London:
Sage.
Desjarlais, R. R. (1992a). Body and emotion: The aesthetics of illness
and healing in the Nepal Himalayas. Philadelphia: University of
Pennsylvania Press.
Desjarlais, R. R. (1992b). Yolmo aesthetics of body, health and soul
loss. Social Science & Medicine, 10, 11051117.
Desjarlais, R. R. (1996). Struggling along. In M. Jackson (Ed.), Things
as they are: New directions in phenomenological anthropology
(pp. 7093). Bloomington: Indiana University Press.
Devisch, R. (1993). Weaving the threads of life: The Khita gyneco-logical healing cult among the Yaka. Chicago, IL: University
of Chicago Press.
Devisch, R. (1996). The cosmology of life transmission. In M. Jackson
(Ed.), Things as they are: New directions in phenomenological
anthropology (pp. 94114). Bloomington: Indiana University
Press.
Dillon, M. C. (1991). Preface: Merleau-Ponty and postmodernity. In
M. C. Dillon (Ed.), Merleau-Ponty Vivant (pp. ixxxxv). Albany:
State University of New York Press.
Elias, N. (1978). The history of manners. Oxford: Basil Blackwell.
(Original work published 1939)
Estroff, S. (with Lachicotte, W. S., Illingworth, L C., & Johnston, A.)
(1991). Everybodys got a little mental illness: Accounts of illness
and self among people with severe, persistent mental illness.
Medical Anthropology Quarterly, 5, 331369.
Farmer, P. (1988). Bad blood, spoiled milk: Bodily fluids as moral
barometers in rural Haiti. American Ethnologist, 15(1), 6283.
Farmer, P. (1996). Infections and inequalities. Berkeley: University of
California Press.
Fernandez, J. (1974). The mission of metaphor in expressive culture.
Current Anthropology, 115, 119145.
Frank, A. W. (1990). Bringing bodies back in: A decade review. Theory,
Culture, and Society, 7, 131162.
Frank, A. W. (1995). The wounded storyteller: Body, illness, and ethics.
Chicago, IL: University of Chicago Press.
Frank, G. (1979). Finding the common denominator: A phenomenological critique of life history method. Ethos, 7, 6894.
Frank, G. (1986). On embodiment: A case study of congenital limb
deficiency in American culture. Culture, Medicine, and Psychiatry,
10, 189219.
Frank, G. (2000). Venus on wheels: Two decades of dialogue on
disability, biography, and being female in America. Berkeley:
University of California Press.
Gadow, S. (1986). Frailty and strength: The dialectic of aging. In
T. R. Cole and S. A. Gadow (Eds.), What does it mean to grow old?
(pp. 237243). Durham, NC: Duke University Press.
Garro, L. (1992). Chronic illness and the construction of narratives. In
M.-J. Good, P. Brodwin, B. Good, & A. Kleinman (Eds.), Pain as
References
Jackson, M. (1989). Paths toward a clearing: Radical empiricism and
ethnographic inquiry. Bloomington: Indiana University Press.
Jackson, M. (1996). Introduction: Phenomenology, radical empiricism,
and anthropological critique. In M. Jackson (Ed.), Things as they
are: New directions in phenomenological anthropology (pp. 150).
Bloomington: Indiana University Press.
Jackson, M. (1998). Minima ethnographica: Intersubjectivity and the
anthropological project. Chicago, IL: University of Chicago Press.
Jenkins, J. H., & Valiente, M. (1994). Bodily transactions of the
passions: El calor among Salvadoran women refugees. In
T. J. Csordas (Ed.), Embodiment and experience: The existential
ground of culture and self (pp. 163182). Cambridge, UK:
Cambridge University Press.
Kaufert, J., & Locker, D. (1990). Rehabilitation ideology and respiratory support technology. Social Science & Medicine, 30, 867877.
Kaufman, S. R. (1986). The ageless self: Sources of meaning in late life.
Madison: University of Wisconsin Press.
Kaufman, S. R. (1988a). Illness, biography, and the interpretation of self
following a stroke. Journal of Aging Studies, 2, 217227.
Kaufman, S. R. (1988b). Toward a phenomenology of boundaries in
medicine: Chronic illness experience in the case of stroke. Medical
Anthropology Quarterly, 2, 338354.
Kirmayer, L. (1992). The bodys insistence on meaning: Metaphor as
presentation and representation in illness experience. Medical
Anthropology Quarterly, 6, 323346.
Kleinman, A. (1988). The illness narratives. New York: Basic Books.
Kleinman, A. (1992). Pain and resistance: The delegitimation and
relegitimation of local worlds. In M.-J. Good, P. E. Brodwin,
B. J. Good, & A. Kleinman (Eds.), Pain as human experience: An
anthropological perspective. Berkeley: University of California
Press.
Kleinman, A. (1995). Writing at the margin: Discourse between
anthropology and medicine. Berkeley: University of California
Press.
Kleinman, A., Das, V., & Lock, M. (Eds.). (1997). Social suffering.
Berkeley: University of California Press.
Kleinman, A., & Kleinman, J. (1991). Suffering and its professional
transformation: Toward an ethnography of interpersonal experience. Culture, Medicine, and Psychiatry, 15, 275301.
Kleinman, A., & Kleinman, J. (1994). How bodies remember: Social
memory and bodily experience of criticism, resistance, and delegitimation following Chinas Cultural Revolution. New Literary
History, 25, 707723.
Laderman, C., & Roseman, M. (Eds.). (1996). The performance of
healing. New York: Routledge.
Lamb, S. (2000). White saris and sweet mangoes: Aging, gender, and
body in North India. Berkeley: University of California Press.
Lambek, M. (1996). The past imperfect: Remembering as moral
practice. In P. Antze & M. Lambek (Eds.), Tense past: Cultural
essays in trauma and memory (pp. 235254). New York: Routledge.
Langness, L. L., & Frank, G. (1981). Lives: An anthropological
approach to biography. Novato, CA: Chandler and Sharp.
Leder, D. (1990). The absent body. Chicago, IL: University of Chicago
Press.
Lee, S. (1999). Fat, fatigue, and the feminine: The changing cultural
experience of women in Hong Kong. Culture, Medicine, and
Psychiatry, 23, 5173.
135
Leenhardt, M. (1979). Do kamo: Person and myth in the Melanesian
world. (B. M. Gulati, Trans.). Chicago, IL: University of Chicago
Press.
Levy-Bruhl, L. (1979) How natives think. (L. A. Clare, Trans.).
New York: Arno Press.
Lock, M. (1993). Cultivating the body: Anthropology and epistemologies
of bodily practice and knowledge. Annual Review of Anthropology
22, 133155.
Lock, M., & Scheper-Hughes (1996). A critical-interpretive approach in
medical anthropology: Rituals and routines of discipline and
dissent. In C. F. Sargent & T. M. Johnson (Eds.), Medical anthropology: Contemporary theory and method (2nd ed., pp. 4170).
New York: Praeger.
Low, S. (1994). Embodied metaphors: Nerves as lived experience. In
T. J. Csordas (Ed.), Embodiment and experience: The existential
ground of culture and self (pp. 139162). Cambridge, UK:
Cambridge University Press.
Luborsky, M. R. (1994). The cultural adversity of physical disability:
Erosion of full adult personhood. Journal of Aging Studies, 8,
239253.
Luborsky, M. R. (1995). The process of self-report of impairment in
clinical research. Social Science and Medicine, 40, 14471459.
Mattingly, C. (1998). Healing dramas and clinical plots: The narrative
structure of experience. Cambridge, UK: Cambridge University
Press.
Mattingly, C., & Garro, L. C. (Eds.). (2000). Narrative and the cultural
construction of illness and healing. Berkeley: University of
California Press.
Mattingly, C., & Lawlor, M. (2001). The fragility of healing. Ethos, 29,
3057.
Mauss, M. (1950). Les techniques du corps. Sociologie et anthropologie.
Paris: Presses Universitaires de France.
McCallum, C. (1996). The body that knows: From Cashinahua epistemology to a medical anthropology of lowland South America.
Medical Anthropology Quarterly, 10, 347372.
Merleau-Ponty, M. (1962). Phenomenology of perception. (C. Smith,
Trans.). New York: Routledge.
Mimica, J. (1996). On dying and suffering in Iqwaye existence. In
M. Jackson (Ed.), Things as they are: New directions in phenomenological anthropology (pp. 213237). Bloomington: Indiana
University Press.
Murphy, R. (1987). The body silent. New York: Henry Holt.
Myerhoff, B. (1978). Number our days. New York: Dutton.
Nordstrom, C. (1998). Terror warfare and the medicine of peace.
Medical Anthropology Quarterly, 12, 103121.
Olujic, M. B. (1998). Embodiment of terror: Gendered violence in
peacetime and wartime in Croatia and Bosnia-Herzegovina.
Medical Anthropology Quarterly, 12, 3150.
Ong, A. (1995). Making the biopolitical subject: Cambodian immigrants, refugee medicine, and cultural citizenship in California.
Social Science & Medicine, 40, 12431257.
Ots, T. (1990). The angry liver, the anxious heart, and the melancholy
spleen: The phenomenology of perceptions in Chinese culture.
Culture, Medicine, and Psychiatry, 14, 2158.
Ots, T. (1994). The silenced bodythe expressive leib: On the
dialectic of mind and life in Chinese cathartic healing. In
T. J. Csordas (Ed.), Embodiment and experience: The existential
136
ground of culture and self (pp. 116138). Cambridge, UK:
Cambridge University Press.
Palmer, G. B., & Jankowiak, W. R. (1996). Performance and imagination: Toward an anthropology of the spectacular and the mundane.
Cultural Anthropology, 11, 225258.
Pandolfi, M. (1990). Boundaries inside the body: Womens sufferings in
southern peasant Italy. Culture, Medicine, and Psychiatry, 14,
255273.
Pitcher, L. M. (1998). The divine impatience: Ritual, narrative, and
symbolization in the practice of martyrdom in Palestine. Medical
Anthropology Quarterly, 12, 830.
Preston, P. (1994). Mother father deaf: Living between sound and
silence. Cambridge, MA: Harvard University Press.
Quesada, J. (1998). Suffering child: An embodiment of war and its
aftermath in Post-Sandinista Nicaragua. Medical Anthropology
Quarterly, 12, 5173.
Rhodes, L. A., McPhilips-Tangum, C. A., Markham, C., & Klenk,
R. (1999). The power of the visible: The meaning of diagnostic
tests in chronic back pain. Social Science & Medicine, 48,
11891203.
Root, R., & Browner, C. H. (2001). Practices of the pregnant self:
Compliance with and resistance to prenatal norms. Culture,
Medicine, and Psychiatry, 25, 195223.
Roseman, M. (1990). Head, heart, odor, and shadow: The structure of
the self, the emotional world, and ritual performance among Senoi
Temiar. Ethos, 18, 227250.
Roseman, M. (1991). Healing sounds from the Malaysian rainforest:
Temiar music and medicine. Berkeley: University of California
Press.
Rubinstein, R. (1989). The home environments of older
people: A description of the psychosocial processes linking
person to place. Journal of Gerontology: Social Sciences, 44,
S45S53.
Rubinstein, R. (1990). Personal identity and environmental meaning in
later life. Journal of Aging Studies, 4, 131147.
Sacks, O. (1984). A leg to stand on. New York: Harper & Row.
Scheer, J., & Luborsky, M. (1991). The cultural context of polio
biographies. Orthopedics, 14, 11731184.
Scheper-Hughes, N. (1992). Death without weeping: The violence
of everyday life in Brazil. Berkeley: University of California
Press.
Scheper-Hughes, N., & Lock, M. (1987). The mindful body: A prolegomenon to future work in medical anthropology. Medical
Anthropology Quarterly, 1, 641.
Schutz, A. (1967). Collected papers, 1: The problem of social reality
(M. Natanson, Ed.). The Hague: Martinus Nijhoff.
Shuttleworth, R. P. (2000). The search for sexual intimacy for men with
cerebral palsy. Sexuality and Disability, 18, 263282.
Shuttleworth, R. P. (2002). Defusing the adverse context of disability
and desirability as a practice of the self for men with cerebral palsy.
In M. Corker & T. Shakespeare (Eds.), Disability and postmodernity. New York: Cassell, pp. 112126.
Shuttleworth, R. P. (in press). Disabled men: Expanding the masculine
repertoire. In B. Smith & B. Hutchinson (Eds.), Gendering
Disability. New Brunswick, NJ: Rutgers University Press.
Behavioral Manifestations
137
INTRODUCTION
The English term possession includes both the concept
of ownership and of control and domination. Belief in
possession by spirits, that is, the possibility that an
individuals actions and behavior may be controlled by
spirits or demons, is attested in English usage from the
16th century. These beliefs have left their traces in everyday language. Belief in spirit possession is both ancient
and very widespread as seen in the historical and ethnographic record. One of the remarkable features of this
system of beliefs and associated ritual practices is its very
great flexibility and innovative potential. This is demonstrated by its expansion and diffusion, where decline and
indeed disappearance might have been expected. In a
large-scale, cross-cultural study, some form of such
beliefs was found to be present in 77% of 488 sample
societies (Bourguignon, 1973). Given the terminological
confusion at the time of this research and a great deal of
ad hoc generalization in the literature on the basis of
single ethnographic cases, such systems of belief needed
to be studied in the larger context of their behavioral and
sociocultural correlates. Once the geographic distributions and the cultural linkages had been identified, the
special features of specific ethnographic instances could
be studied in depth. A distinction between beliefs and
behaviors revealed that certain types of behaviors reflect
general human physiological and psychological features
and that these are not necessarily associated with possession beliefs. A broad sampling of human societies made
it clear that what may be considered pathological in
Western bio-medicine is often conceptualized in radically
different ways in other cultures.
SOURCES
AND
TYPES
OF
BELIEFS
BEHAVIORAL MANIFESTATIONS
The behavioral manifestations of such possessions, or
displacement of a persons soul or other key element by
another entity, vary widely but fall into two main groups:
(1) negative changes in physical health or behavior or, on
the other hand, enhanced powers, and (2) alterations in
state of consciousness and behavior. Bourguignon (1973)
refers to the second type as Possession Trance and to the
former simply as Possession (or non-Trance Possession).
These two types have different geographic distributions
and are linked to different sociocultural and economic
variables. Also, where they occur in the same society,
they are likely to have different distributions within the
population. The second type, Possession Trance, is
significantly linked to female participation.
Trance (or dissociation), not linked to possession
belief (non-Possession Trance), may be sought intentionally, as in the vision quest of North American Indians.
138
139
POSSESSION BELIEFS
WESTERN THOUGHT
IN
140
POSSESSION
AND
HEALING
141
142
THE RETURN
OF
EXORCISM
searches for alternatives) and partly due to crises in identity. Examples include the presence of Caribbean religions in the United States and in the United Kingdom.
These were syncretic religions developed in the areas
from which the migrants have come. In Trinidad, for
example, we find both South Indian Kali religion and
Afro-Protestant groups, both of which are at this time represented in Britain. In a different vein, the development of
and interest in Channeling in the United States speaks to
a concern with identity and self help (M. Brown, 1997).
This pattern of mediumistic behavior is distinct from earlier Spiritualism of the 19th and early 20th century, where
the spirits called up through mediums were those of the
recently dead. The spirits called on by channelers address
more distant, impersonal spirit guides. There is also a
belief in reincarnation and previous lives. Most channelers are women; most spirits male.
Although Spiritualism was first developed in the
United States, it rapidly spread to Europe. A French
variety, as developed by Alain Kardec (pseudonym of
H. L. D. Rivail), has been most influential in Latin
America. Spiritistic religions and Protestant Evangelical
religions which encourage ecstatic experiences are the
most rapidly spreading forms of religion worldwide.
POSSESSION RELIGIONS
AND TRADITION
AS
WORSHIP
143
SUMMARY
AND
SOME CONCLUSIONS
144
REFERENCES
Bilu, Y. (1996). Dybbuk and Maggid: Two cultural patterned altered
states of consciousness in Judaism. AJS Review, 21, 123.
Boddy, J. (1989). Wombs and alien spirits: Women, men and the zar cult
in northern Sudan. Madison: University of Wisconsin Press.
Bourguignon, E. (1973). Introduction: A framework for the comparative
study of altered states of consciousness. In E. Bourguignon (Ed.),
Religion, altered states of consciousness and social change
(pp. 338). Columbus: Ohio State University Press.
Bourguignon, E. (1976). Spirit possession belief and social structure.
In Bharati (Ed.), The realm of the extra-human, ideas and actions
(pp. 1726). The Hague: Mouton.
Bourguignon, E. (1989a). Trance and Shamanism: Whats in a name?
Journal of Psychoactive Drugs, 21, 916.
Bourguignon, E. (1989b). Multiple personality, possession trance and
the psychic unity of mankind. Ethos, 17, 371384.
Brown, M. F. (1997). The channeling zone: American spirituality in an
anxious age. Cambridge, MA: Harvard University Press.
Brown, K. M. (1991). Mama Lola: A vodou priestess in Brooklyn.
San Francisco: University of California Press.
Certeau, M. de (2000). The possession at Loudon (M. B. Smith, Trans,
with a Foreword by S. Greenblatt). Chicago, IL: University of
Chicago Press.
Chlyeh, A. (1999). Les Gnaoua du Maroc:Itineraires initiatiques,
transe et possession. Paris: editions la Pense Sauvage.
Corin, E. (1998). Refiguring the person: Dynamics of affect and
symbols in an African spirit possession cult. In: M. Lambeck &
A. Strathern (eds.), Bodies and persons: Comparative perspectives
from Africa and Melanesia (pp. 80102). Cambridge, UK:
Cambridge University Press.
Crossan, J. D. (1994). Jesus: A revolutionary biography. New York:
Harper Collins.
Cuneo, M. (2001). American exorcism. Garden City, NY: Doubleday.
DAndrade, R. (1961). The anthropological study of dreams.
In F. L. K. Hsu (Ed.), Psychological anthropology: approaches to
culture and personality. Homewood, IL: Dorsey.
Danforth, L. M. (1989). Firewalking and religious healing: The
Anastenaria of Greece and the American firewalking movement.
Princeton, NJ: Princeton University Press.
de Heusch, L. (1981). Why marry her? Society and symbolic structures.
London: Cambridge University Press.
Dodds, E. R. (1957). The Greeks and the irrational. Berkeley:
University of California Press.
Evans-Pritchard, E. E. (1937). Oracles, witchcraft, and magic among
the Azande. Oxford, UK: Clarendon Press.
Evans-Pritchard, E. E. (1962). Zande theology, social anthropology, and
other essays. New York: Free Press of Glencoe.
Goldish, Matt, ed. (2003). Spirit Possession in Judaism; Cases and
Contexts from the Middle Ages to the Present. Madison: U.
Wisconsin P.
Goodman, F. D. (1981). The exorcism of Anneliese Michel. Garden City,
NY: Doubleday.
Greenbaum, L. (1973). Societal Correlates of Possession Trance in
sub-Saharan Africa, In: E. Bourguignon, (ed.) Religion, Altered
States of Consciousness and Social Change. Columbus: Ohio State
University Press.
Introduction
145
Guinebert, C. (1959). The Jewish world at the time of Jesus. New York:
University Books.
Hensley, D. (1993). Hells Gate: Terror at Bobby McKays Music World.
Jacksonville, FL.: Audio Books Plus.
Herskovits, M. J. (1937). Life in a Haitian valley. New York: Knopf.
Hollan, D. (2000). Culture and dissociation in Toradja. Transcultural
Psychiatry, 37, 545559.
Jeanmaire, H. (1951). Dionysus: Histoire du culte de Bacchus. Paris: Payot.
Johnston, S. I. (2001). Charming children: The use of the child in
ancient divination. Arethusa, 34, 97117.
Kahn, M. S., & Kelly, K. J. (2001). Cultural tensions in psychiatric
nursing: Managing the interface between western mental health
care and Xhosa traditional healing in South Africa. Transcultural
Psychiatry, 38, 3540.
Kehoe, A. B. (2000). Shamanism and religion: An anthropological exploration in critical thinking. Prospect Heights, IL: Waveland Press.
Kendall, L. (1985). Shamans, housewives, and other restless spirits:
Women in Korean ritual life. Honolulu: University of Hawaii Press.
Kenyon, S. (ed.). (1995). Possession and social change in eastern Africa.
Anthropological Quarterly, 68(2), 71132.
Kiev, Ari (ed.). (1964). Magic, faith and healing: Studies in primitive
psychiatry today. New York: Free Press of Glencoe.
Kleinman, A. (1980). Patients and Healers in the Context of Culture.
Berkeley: University of California Press.
Lambeck, M. (1989). From disease to discourse: Remarks on the
conceptualization of trance and spirit possession. In C. A. Ward
(Ed.), Altered states of consciousness and mental health: A crosscultural perspective. Newbury Park, CA: Sage.
Lewis, I. M. (1989). Ecstatic religions (Rev. ed.). Baltimore, MD: Penguin.
Maurizio, L. (1995). Anthropology and spirit possession: A reconsideration of the Phythias role at Delphi. Journal of Hellenic Studies,
115, 6986.
Moore, J. G. (1982). Music and dance as expressions of religious
worship in Jamaica. In S. Ottenberg (Ed.), African religious groups
Shamanism
Michael Winkelman
INTRODUCTION
The term shaman entered English from other cultures
(Flaherty, 1992) and has been attributed to practices
around the world (Vitebsky, 2001). Shamanism received
widespread academic attention following Eliades (1964)
Shamanism: Archaic techniques of ecstasy, which considered shamanism a worldwide healing practice involving
ecstatic communication with the spirit world on behalf of
the community (cf. Halifax, 1979; Hultkrantz, 1973).
Whether shamanism is cross-cultural or regionally
specific, and consequently an etic or emic phenomenon, is
146
CROSS-CULTURAL PERSPECTIVES
ON SHAMANS
The problems of a definitional approach to shamanism
(e.g., see Jakobsen, 1999; Townsend, 1997) are overcome
by a cross-cultural approach that provides an empirical
basis for characterizing shamans. Cross-cultural research
reveals an etic shamanism world-wide in huntergatherer
societies and universal practices using ASC for healing
(Winkelman, 1986a, 1990, 1992; see Winkelman &
White, 1987 for data and methods). Shamanism was
an ecologicalpsychobiological adaptation of hunter
gatherer societies to biological structures, psychosocial
processes, and therapeutic needs (Winkelman, 2000).
This psychobiological foundation for the huntergatherer
shaman also provided the basis for the persistence of
similar ASC-based healing practices in more complex
societies; these have been referred to as shamanistic
healers (Winkelman, 1990), recognizing their continuity
with shamanism.
The foundations of shamanism are derived from:
(1) ASC induction activities that elicit the relaxation
response and produce theta wave synchronization across
levels of the brain; (2) analogic and visual symbolic
systems involving a presentational symbolism and other
innate representational modules for self, others, mind,
and nature; and (3) socioemotional and psychodynamic
ritual processes and their physiological, social, psychological, and cognitive effects. Shamanistic ASC involve a
biological mode of consciousness with many adaptive
physiological consequences directly related to healing
(e.g., relaxation, psychological integration, opioid, and
serotonin-mediated effects). Shamanism uses presentational symbolic systems (Hunt, 1995) and analogical
thought processes produced through integration of innate
representational systems of the brain, specialized adaptations for processing perceptions of social relations
(self/others), their intentionalities (mind reading),
and animal knowledge (natural history representations)
Shamanism
UNIVERSALS
OF
SHAMANS
Universals of Shamans
Shamanic ASC
Ecstasy, trance, or ASC are central to selection, training,
and practice, and induced through many procedures that
have physiological effects (Winkelman, 1986b, 1992,
2000; cf. below). Shamanic ASC occur in a dramatic
ritual encounter within the spirit world. After extensive
singing, chanting, drumming, and dancing, shamans
collapse into apparent unconsciousness, but have an
intact memory of the ensuing visionary experience upon
returning to ordinary reality. Shamans experience flying
to other worlds with spirit allies, or encountering spiritual
or supernatural entities. Sometimes shamans ASC
involve an internal focus of attention without extensive
induction procedures. The typical procedures used by
shamans to induce an ASC involve extreme activation of
the sympathetic nervous system through drumming and
dancing until exhaustion of the sympathetic system from
extreme exertion leads to collapse into a parasympathetic
dominant state characterized by intense visual activity.
Shamans also induce ASC through fasting, other forms of
auditory stimulation (e.g., clapping, singing, and chanting), prolonged periods of sleeplessness, temperature
extremes, and painful austerities. Hallucinogens are used
in some traditions (see Furst, 1976; Harner, 1973;
Winkelman, 1996). Deliberate periods of sleep and dream
incubation may also be used for inducing ASC.
Soul Journey
The soul journey or flight is a universal feature of
shamanism, although not characteristic of all of the
shamansASC. The shamans interaction with spirits may
take the form of a journey into the spirit worlds, a visit
from the spirit world, or a transformation into an animal.
Shamans ASC are typically referred to as flights or journeys, and share visual experiences in which some aspect
of the practitioner (i.e., soul, spirit, or animal familiar)
147
interacts with spirits in a non-ordinary reality. The crosscultural distribution of experiences similar to shamanic
flight has an innate basis in psychophysiological structures that reflect homologies across symbolic, somatic,
and physiological systems (Hunt, 1995; Laughlin, 1997;
Winkelman, 2000). The visionary experiences of the soul
journey reflect a natural phenomenon of the human nervous system and occur as a consequence of the dysinhibition of the visual centers of the brain. Soul journey
involves taking the role of the other in the visual spatial modality involving a presentational symbolism
(Hunt, 1995). These externalized self-representations
provide new forms of self-awareness and subjective experience, maximizing the symbolic self-referential capacity
in the imageticintuitive mode. The shamanic soul flight
is a representation of the shamans transcendence.
ShamansASC normally do not involve possession (spirit
takes over and dominates consciousness), but rather the
control of spirits, particularly animal spirits.
148
Soul Loss
A central shamanic illness is soul loss, which Achterberg
(1985) characterizes as an injury to the core or essence of
ones being. Soul loss reflects concerns with the essence
of crucial aspects of the self (Ingerman, 1991), involving
the loss of, or injury to, fundamental aspects of personal
identity. This injury to ones essence is manifested as
despair, disharmony, and loss of meaning in life and feelings of belonging and connection with others. Soul
constitutes a vital essence of self-emotions. Soul loss
occurs from trauma that causes an aspect of ones self to
dissociate. This separated aspect of the self carries with it
the impact of the traumatic experiences that are unavailable to the rest of the self, arresting ego and emotional
development. Reintegration of these dissociated aspects
of self is central to healing. Soul recovery involves the
shamans dramatic enactment of battles with terrifying
and threatening spirit images that symbolize disowned
and repressed aspects of the self (Walsh, 1990). Through
their recovery one regains a sense of a social self alienated
by trauma and feelings of disharmony and disconnectedness (Ingerman, 1991). Community is significant in soul
retrieval, with social support vital to the healing processes
and re-integration of self. Community participation facilitates social bonding and release of the bodys opioids,
producing a sense of well-being. The shamans dramatic
struggles with the spirit world to realize soul recovery
and power animal recovery produce powerful experiences, transforming self and altering social relationships.
Therapeutic Processes
The psychodramatic ritual encounter with the spirits is
a foundation of shamanic therapeutics. Therapeutic
effects derive from physiological and psychological effects
of ASC, manipulation of spirit world constructs, and
community relations discussed below. Shamanic therapeutics are mediated through song, chants, music, and percussion, eliciting the ancient audiovocal systems of the brain
(Oubr, 1997). Music has a number of different therapeutic effects through physiological and psychological actions,
Shamanism
SHAMANISTIC HEALERS
All societies have healers who use ASC in community
rituals to interact with the spirit world (Winkelman,
1986b, 1992). These shamanistic healers share core
characteristics of shamansecstasy (ASC), community,
and spiritsreflecting psychobiological principles of the
brain that are manifested universally (Winkelman, 1992,
2000). The biologically based ASC central to shamanism
is also the foundation of shamanistic healers training and
practices. ASC enhance integration of lower brain
processes with frontal processes through induction of
synchronized theta wave patterns that entrain the brain
with common patterns across the neuraxis (nerve bundle
running from the base of the brain to the frontal cortex).
Community has a variety of psychosocial functions and
psychobiological effects in healing, including eliciting
opioid-mediated immune system enhancement. The spirit
world is a symbol system for social identification
and self-development and differentiation. Shamanistic
healers share other characteristics, including: beliefs
that spirits and humans cause illness; using spirits in
therapeutic processes; and ritual manipulations for the
restoration of health (Winkelman & Winkelman, 1991).
Other types of shamanistic healers (e.g., mediums and
healers) differ from shamans because of the effects of
their respective societies (agricultural, politically integrated) (Winkelman, 1986a, 1990, 1992).
Psychobiological Structures of
Shamanistic ASC
All cultures have procedures for accessing ASC but differ
in their attitudes toward these states and the means
for controlled access (Laughlin et al., 1992). These
universals of shamanistic practices reflect underlying
149
SHAMANISTIC THERAPEUTIC
PROCESSES
Therapeutic mechanisms of shamanistic healing derive
from ASC, community relations, and ritual spirit-world
interactions. ASC have physiological effects, including
the relaxation response, the elicitation of opioid release,
and enhanced serotonergic action. The spirit world plays
a role as sacred others, representing personal and
community identity models and aspects of the psyche. The
spirit world and communitys therapeutic roles include
models for development, social support, and community
bonding. Ritual processes manipulate physiology,
psychology, and social relationships for therapeutic
processes.
150
conflicts that affect emotions, behavior, and physiological responses. ASC enhance expression of repressed
aspects of self by reducing habitual screening processes
and giving expression to non-verbal information.
ASC evoke paleomammalian brain or limbic system
functions that manage autonomic nervous system balance, emotional mentation, self and social identity
processes, bonding and attachment, and the integration of
information. These contribute to healing, producing an
integration of personal and social consciousness. The
theta wave entrainment characteristic of ASC produces
integration across hierarchical brain levels, an integration
of pre- or unconscious functions into conscious awareness. ASC and ritual enhance integration of cognitive and
emotional processes and information from different functional systems of the brain, providing optimal conditions
for learning, attention, memory, and adaptation to novel
situations (Mandell, 1980).
Therapeutic Aspects of
Community Relations
Shamanistic healing typically occurs in a community
context. Community participation facilitates therapeutic
effects derived from psychosocial influences (positive
expectation and social support). These collective rituals
strengthen group identity and commitment, enhancing
community cohesion by reintegrating patients into the
group. Communal healing practices reinforce attachment
needs in the mammalian biosocial system (Kirkpatrick,
1997). Attachments and affectional bonds that evolved
to maintain proximity between infants and care-givers
provide a secure basis for the self, feelings of comfort,
and protection from powerful figures (e.g., shamans,
spirit allies).
Shamanistic practices enhancing social cohesion
elicit psychosociophysiological mechanisms that release
endogenous opiates. Frecska and Kulcsar (1989) review
evidence that shamanistic practices elicit psychobiologically mediated attachment based in opioid mechanisms.
Opioid release is produced through cultural symbols that
have been cross-conditioned with patterns of attachment
and their physiological and emotional responses.
Emotionally charged cultural symbols associated with
physiological systems during attachment socialization
link mythological and somatic spheres, providing a basis
for elicitation of the opioid system in shamanistic ritual.
Endogenous opioids are also stimulated by a variety of
physical aspects of shamanic ritual (Prince, 1982;
Shamanism
however, in addressing emotional distress through the provision of explanations and mechanisms for obtaining
relief, and in eliciting community support systems that
meet fundamental human needs for belonging, comfort,
and bonding with others. Shamanistic healing effects emotions through: elicitation of repressed memories, restructuring painful memories, confession and forgiveness,
resolving intrapsychic conflict, alleviating repressions, and
giving expression to unconscious concerns. Explanations
provided in shamanistic healing processes typically minimize personal guilt, negative emotional process, intrapsychic conflict, and internal discrepancies through attributing
responsibility to external agents (i.e., spirits). Ritual controls attitudes through metaphoric and affective processes
operating independently of higher cognitive processing,
providing mechanisms for manipulating affective
responses independent of habitual resistances. Emotions
and unconscious structures are typically addressed by
attributing these to external forces (spirits). Shamanic ritual also provides psychoemotional and mental reprogramming of lower brain processes in the material embodied in
the chants, songs, and psychodramatic enactments that
change perception of self, social relations, and emotions.
Shamanism produces meaning through universal
aspects of symbolic healing (Dow, 1986), particularizing
the patients circumstances within a cultural mythology,
and manipulating that system to emotionally transform the
self-system of the patient. Ritual manipulation of the spirit
world enables shamans to symbolically transform individual psychophysiological processes through emotions
related to well-being and attachment. Shamanistic ritual
activities access innate drives toward self-differentiation
and identification with other, promoting reorganization
at higher levels of integration. Through ritual manipulation
of psychophysiological structures not directly accessible to
the conscious ego, shamans evoke cognitive and emotional
responses that cause physiological changes. These are
achieved by the manipulation of cultural symbols associated with autonomic responses and through activities that
cause physiological changes (e.g., drumming, fasting).
151
152
Shamanism
References
of shamanism found worldwide. It acts upon the assumption that there is a non-ordinary reality that involves spirits
and souls, and that compassionate spirits can be elicited to
assist in human healing. Shamanic therapies are eclectic,
taking a holistic approach in which they complement other
approaches. They address soul loss, guardian spirit and
power loss, spirit and object intrusion, and possesion
(Harner & Harner, 2000); shamanic treatments are also
considered particularly effective for the treatment of the
consequences of trauma, drug dependence, and mental
and emotional illness. Shamanic therapies involve restoring and maintaining personal power through an alliance
between the shaman and client that requires the latters
self-discipline and dedication. Relationships with the
spirit world, particularly animal powers, are central to
maintaining personal well-being.
Central aspects of the classic shamanic vision quest
involved processes for self-empowerment. A similar
approach underlies contemporary shamanic counseling
and the training of the client to make a shamanic journey
on his own to acquire or restore his personal power.
This active aspect of shamanic journeying induces a
sense of mastery and control. Harner (1988) characterizes
shamanic counseling as a method of personal empowerment wherein one comes to acquire respect for ones own
ability to obtain spiritual wisdom without relying on
external mediators (p. 181). The shamanic healing
approaches encompass virtually all spiritual healing practices (Harner & Harner, 2001); their emphases include
using soul journey to treat spiritual aspects of illness
through the assistance of spirit allies while in an ASC.
Shamanisms biopsychosocial approach to healing integrates emotional, mental, spiritual, and social dimensions
within a physiological framework.
SUMMARY
Shamanistic practices reflect ancient human traditions of
healing through altering consciousness, manipulating
identity and psychosocial dynamics through constructs
represented in the spirit world, and eliciting the biopsychosocial dynamics of community support. These
traditions are rooted in human psychobiology and brain
dynamics, giving them a continued relevance in the
contemporary world. The widespread persistence of these
practices and their resurgence in the modern world is
vibrant testimony to the continued relevance of shamanic
153
REFERENCES
Achterberg, J. (1985). Imagery in healing: Shamanism and modern
medicine. Boston, MA: New Science Library: Shambhala.
Bird-David, N. (1999). Animism revisited: Personhood, environment
and relational epistemology. Current Anthropology, 40, 6791.
Boddy, J. (1994). Spirit possession revisited: Beyond instrumentality.
Annual Review of Anthropology, 23, 407434.
Bourguignon, E. (1976). Possession. San Francisco, CA: Chandler and
Sharpe.
Castillo, R. (1991). Divided consciousness and enlightenment in Hindu
Yogis. Anthropology of Consciousness, 2(304), 16.
Clottes, J., & Lewis-Williams, D. (1998). The shamans of prehistory:
Trance and magic in the painted caves. New York: Harry Abrams.
Dow, J. (1986). Universal aspects of symbolic healing: A theoretical
synthesis. American Anthropologist, 88, 5669.
Eliade, M. (1964). Shamanism: Archaic techniques of ecstasy.
New York: Pantheon Books.
Flaherty, G. (1992). Shamanism and the eighteenth century. Princeton,
NJ: Princeton University Press.
Frecska, E., & Kulcsar, Z. (1989). Social bonding in the modulation of
the physiology of ritual trance. Ethos, 17(1), 7087.
Furst, P. (Ed.). (1976). Hallucinogens and culture. San Francisco, CA:
Chandler and Sharp.
Goodman, F. (1988). How about demons? Possession and exorcism in
the modern world. Bloomington: Indiana University Press.
Guthrie, S. (1993). Faces in the clouds. Oxford, UK: Oxford University
Press.
Halifax, J. (1979). Shamanic voices. New York: E.P. Dutton.
Harner, M. (Ed.). (1973). Hallucinogens and shamanism. New York:
Oxford University Press.
Harner, M. (1988). What is a shaman? In G. Doore (Ed.), Shamans path:
Healing, personal growth and empowerment (pp. 715). Boston,
MA: Shambhala.
Harner, M. (1990). The way of the shaman. San Francisco, CA:
Harper & Row.
Harner, M., & Harner, S. (2000). Core practices in the shamanic treatment of illness. Shamanism. 13(12), 1930.
Hultkrantz, A. (1973). A definition of shamanism. Temenos, 9, 2537.
Hunt, H. (1995). On the nature of consciousness. New Haven, CT: Yale
University Press.
Ingerman, S. (1991). Soul retrival. San Francisco, CA: Harper Collins.
Jakobsen, M. (1999). Shamanism: Traditional and contemporary
approaches to the mastery of spirits and healing. New York:
Berghahn Books.
Kirkpatrick, L. (1997). An attachment-theory approach to psychology
of religion. In B. Spilka & D. McIntosh (Eds.), The psychology of
religion. Boulder, CO: Westview Press.
154
Krippner, S. & Welch, P. (1992). Spiritual dimensions of healing: From
native shamanism to contemporary health care. New York:
Irvington.
Laughlin, C. (1997). Body, brain, and behavior: The neuroanthropology
of the body image. Anthropology of Consciousness, 8(23), 4968.
Laughlin, C., McManus, J., & dAquili, E. (1992). Brain, symbol and
experience: Toward a neurophenomenology of consciousness.
New York: Columbia University Press.
Lewis, I. (1988). Ecstatic religion: An anthropological study of spirit
possession and shamanism. London: Routledge.
Mandell, A. (1980). Toward a psychobiology of transcendence: God in
the brain. In D. Davidson & R. Davidson (Eds.), The psychobiology
of consciousness (pp. 379464). New York: Plenum.
Mithen, S. (1996). The prehistory of the mind: A search for the origins
of art, religion and science. London: Thames and Hudson
Noll, R. (1983). Shamanism and schizophrenia: A state-specific
approach to the schizophrenia metaphor of shamanic states.
American Ethnologist, 10(3), 443459.
Noll, R. (1985). Mental imagery cultivation as a cultural phenomenon:
The role of visions in shamanism. Current Anthropology, 26,
443451.
Oubr, A. (1997). Instinct and revelation: Reflections on the origins of
numinous perception. Amsterdam: Gordon and Breach.
Pandian, J. (1997). The sacred integration of the cultural self: An
anthropological approach to the study of religion. In S. Glazier
(Ed.), The anthropology of religion, (pp. 505516). Westport, CT:
Greenwood Press.
Peters, L., & Price-Williams, D. (1981). Towards an experiential
analysis of shamanism. American Ethnologist, 7, 398418.
Prince, R. (1982). The endorphins: A review for psychological anthropologists. Ethos, 10(4), 299302.
Ryan, R. (1999). The strong eye of shamanism: A journey into the caves
of consciousness. Rochester, NY: Inner Traditions.
Shekar, C. (1989). Possession syndrome in India. In C. Ward (Ed.),
Altered states of consciousness and mental health (pp. 7995).
Newbury Park, CA: Sage.
Siikala, A. (1978). The rite technique of the Siberian shaman (Folklore
Fellows communication 220). Helsinki, Finland: Soumalainen
Tiedeskaremia Academia.
Spilka, B., Shaver, P., & Kirkpatrick, L. (1997). A general attribution
theory for the psychology of religion. In B. Spilka & D. McIntosh
(Eds.), The psychology of religion (pp. 153170). Boulder, CO:
Westview Press.
Stark, R. (1997). A taxonomy of religious experience. In B. Spilka &
D. McIntosh (Eds.), The psychology of religion: Theoretical
approaches (pp. 209221). Boulder, CO: Westview Press.
Swanson, G. (1973). The search for a guardian spirit: The process of
empowerment in simpler societies. Ethnology, 12, 359378.
Shamanism
Townsend, J. (1997). Shamanism. In S. Glazier (Ed.), Anthropology of
religion: A handbook of method and theory (pp. 429469).
Westport, CT: Greenwood Press.
Valle, J., & Prince, R. (1989). Religious experiences as self-healing
mechanisms. In C. Ward (Ed.), Altered states of consciousness and
mental health: A cross-cultural perspective (pp. 149166).
Newbury Park, CA: Sage.
Vitebsky, P. (2001). Shamanism. Norman: University of Oklahoma
Press.
Walsh, R. (1990). The spirit of shamanism. Los Angeles: Tarcher.
Walton, K., & Levitsky, D. (1994). A neuroendocrine mechanism for the
reduction of drug use and addictions by transcendental meditation.
Alcoholism Treatment Quarterly, 11(1/2), 89117.
Winkelman, M. (1986a). Magico-religious practitioner types and
socioeconomic analysis. Behavior Science Research, 20(14),
1746.
Winkelman, M. (1986b). Trance states: A theoretical model and crosscultural analysis. Ethos 14, 76105.
Winkelman, M. (1990). Shaman and other magico-religious healers:
A cross-cultural study of their origins, nature and social transformation. Ethos, 18(3), 308352.
Winkelman, M. (1992). Shamans, priests and witches. A cross-cultural
study of magico-religious practitioners (Anthropological Research
Papers No. 44). Tempe: Arizona State University.
Winkelman, M. (1996). Psychointegrator plants: Their roles in human
culture and health. In M. Winkelman & W. Andritzky (Eds.),
Yearbook of cross-cultural medicine and psychotherapy, Vol. 6
(pp. 953). Berlin: Verlag und Vertrieb.
Winkelman, M. (1997). Altered states of consciousness and religious
behavior. In S. Glazier (Ed.), Anthropology of religion: A handbook
of method and theory (pp. 393428). Westport, CT: Greenwood
Press.
Winkelman, M. (1999). Altered states of consciousness. In D. Levinson,
J. Ponzetti, & P. Jorgensen (Eds.), Encyclopedia of human
emotions (pp. 3238). New York: Macmillan.
Winkelman, M. (2000). Shamanism: The neural ecology of consciousness and healing. Westport, CT: Bergin & Garvey.
Winkelman, M., & White, D. (1987). A cross-cultural study of magicoreligious practitioners and trance states: Data base. In D. Levinson &
R. Wagner (Eds.), Human relations area files research series in
quantitative cross-cultural data: Vol. 3D. New Haven, CT: HRAF
Press.
Winkelman, M., & Winkelman, C. (1991). Shamanistic healers and their
therapies. In W. Andritzky (Ed.), Yearbook of cross-cultural
medicine and psychotherapy, 1990 (pp. 163182). Berlin: Verlag
und Vertrieb.
Winn, T., Crowe, B., & Moreno, J. (1989). Shamanism and music
therapy. Music Therapy Perspectives, 7, 6171.
Disasters
Jody Glittenberg
IMPORTANCE
DISASTERS
OF
UNDERSTANDING
HISTORY
OF
RESEARCH
ON
DISASTERS
157
158
Disasters
DEFINITION
OF
DISASTER
PERSPECTIVES
FROM
ANTHROPOLOGY
159
METHODOLOGIES USED IN
ANTHROPOLOGICAL DISASTER
RESEARCH
Archeology, an anthropological method, provides an
in-depth historical account by rebuilding the event
through scientific reconstruction of the material culture.
Through such material, social structure, political economic vulnerabilities, terrain, habitat, mortuary, and
belief systems can be reconstructed through evidence left
by the people. Material evidence sheds much light on
how the group coped or met their demise. Chronicles and
archives also bring to light how segments of the society
compromised, coped, and evolved. These documents may
reveal in minute detail how societies interpreted the
meaning of these disruptive events.
160
Disasters
161
162
Disasters
CONCLUSION
A disaster occurs when the sociocultural structure of a
group is vulnerable and an event overwhelms the limits
References
REFERENCES
Annis, R. (1987). God and production in a Guatemalan town. Austin:
University of Texas Press.
Aptekar, L. (1994). Environmental disasters in global perspective.
New York: G. K. Hall/Macmillan.
Baker, G. W., & Chapman, D. W. (Eds.). (1964). Man and society in
disaster. New York: Basic Books.
Bates, F. L., & Pelanda, C. (1994). An ecological approach to disasters.
In R. R. Dynes & K. J. Tierney (Eds.), Disasters, collective behavior, and social organization (pp. 145162). Newark: University of
Delaware Press.
Brydon, L., & Grant, S. (1989). Women in the Third World: Gender
issues in rural and urban areas. New Brunswick, NJ: Rutgers
University Press.
Carr, L. J. (1932). Disaster and the sequence pattern concept of social
change. American Journal of Sociology, 8, 207218.
Doughty, P. L. (1971). From disaster to development. Americas, 23(5),
2535.
Doughty, P. L. (1999). Plan and pattern in reaction to earthquake: Peru,
19701998. In A. Oliver-Smith & S. Hoffman (Eds.), The angry
earth (pp. 234256). New York: Routledge.
Doughty, P. L., & Doughty, M. (1968). Huaylas, an Andean district in
search of progress. Ithaca, NY: Cornell University Press.
Drabek, T. E. (1970). Methodology of studying disasters: Past patterns and
future possibilities. American Behavioral Scientists, 13(3), 331343.
Dynes, R. (1974). Organizational behavior in disaster. Newark:
University of Delaware, Disaster Research Center.
Fritz, C. E., & Williams, R. B. (1957). The human being in disasters:
A research perspective. Annals of American Academy of Political
and Social Science, 309, 4251.
Glittenberg, J. (1976). A comparative study of fertility in highland
Guatemala: An Indian and a Ladino town. Unpublished dissertation, University of Colorado.
Glittenberg, J. (1981). Variations in migrant settlements. Image, 13,
4347.
Glittenberg, J. (1987). The human ecosystem and human adaptation
a contemporary view. In L. Moore, P. Van Arsdale, J. Glittenberg, &
R. Aldrich (Eds.), The biocultural basis of health (pp. 1553).
Prospect Heights, IL: Waveland Press.
Glittenberg, J. (1989, July/September). Socioeconomic and psychological, impact of disaster recovery. Prehospital and Disaster
Medicine, 4, 2130.
Glittenberg, J. (1994). To the mountain and back. Prospect Heights, IL:
Waveland Press.
163
Glittenberg, J. (2001). Community as slayer, community as healer:
A study of alcohol, drugs, and violence in a Mexican American
town (Final unpublished report). Tucson, University of Arizona,
National Institute on Drug Abuse.
Green, L. (1999). Fear as a way of life: Mayan widows in rural
Guatemala. New York: Columbia University Press.
Hewitt, K. (1983). Interpretations of calamity from the viewpoint of
human ecology. London: Allen & Unwin.
Hoffman, S. M. (1999a). Anthropology and the angry earth: An
overview. In A. Oliver-Smith & S. Hoffman (Eds.), The angry
earth (pp. 116). New York: Routledge.
Hoffman, S. M. (1999b). The worst of times, the best of times: Toward
a model of cultural response to disaster. In A. Oliver-Smith &
S. Hoffman (Eds.), The angry earth (pp. 132155). New York:
Routledge.
Menchu, R. (1992). I, Rigoberta Menchu: An Indian woman in
Guatemala (A. Wright, Trans.). London: Verso.
Moore, L., Van Arsdale, P., Glittenberg, J., & Aldrich, R. (1987). The
biocultural basis of health. Prospect Heights, IL: Waveland Press.
Oliver-Smith, A. (1986). The Martyred City: death and rebirth in the
Andes. Albuquerque: University of New Mexico Press.
Oliver-Smith, A. (1998a). Global changes and the definition of disaster.
In E. L. Quarantelli (Ed.), What is a disaster?: Perspectives on the
question (pp. 195198). New York: Routledge.
Oliver-Smith, A. (1998b). Disasters, social change, and adaptive systems. In E. L. Quarantelli (Ed.), What is a disaster?: Perspectives
on the question (pp. 231233.) New York: Routledge.
Petersen, K. (1992). The maquiladora revolution in Guatemala (Orville
H. Schell, Jr., Ed.). Occasional Paper Series, 2. Center for
International Human Rights, Yale Law School Publications.
Prince, S. H. (1920). Catastrophe and social change: Based upon a
sociological study of the Halifax disaster. New York: Columbia
University Press.
Quarantelli, E. L. (1957). The behavior of panic participants. Sociology
and Social Research, 41, 187194.
Quarantelli, E. L. (Ed.). (1978). Disasters, theory, and research.
London: Sage.
Quarantelli, E. L. (1998). Introduction: The basic question, its importance, and how it is addressed in this volume. In E. L. Quarantelli
(Ed.), What is a disaster?: Perspectives on the question (pp. 18).
New York: Routledge.
Sheets, P. (1979). Environmental and cultural effects of the Ilopango
eruption in Central America. In P. Sheets & D. Grayson (Eds.),
Volcanic activity and human ecology (pp. 525564). New York:
Academic Press.
Sheets, P. (1987). Possible repercussions in western Honduras in the
third-century eruption of Ilopango volcano. In G. Pahl (Ed)., The
periphery of the southeastern classic Maya realm (pp. 4152).
Los Angeles: University of California at Los Angeles, Latin
American Center.
Sheets, P. (1992). The Ceren site: A prehistoric village buried by
volcanic ash in Central America. Fort Worth, TX: Harcourt
Brace.
Turner, R. H. (1981). Collective behavior and resource mobilization as
approaches to social movements: Issues and continuities. Research
in Social Movements, Conflict and Change, 4, 124.
164
WHAT
IS
ECONOMIC DEVELOPMENT?
Development
A bridge with no river.
A tall facade with no building.
A sprinkler on a plastic lawn.
An escalator to nowhere.
A highway to the places
the highway destroyed.
An image on TV of a TV
showing another TV
on which there is yet another TV.
Eduardo Galeano
165
166
ANTHROPOLOGISTS IN HEALTH
ECONOMIC DEVELOPMENT
AND
167
168
WHERE TO GO
FROM
HERE?
Many models of economic development rest on unexamined colonial and neocolonial assumptions and should be
REFERENCES
Asad, T. (Ed.). (1973). Anthropology and the colonial encounter.
London and New York: Ithaca Press and Humanities Press.
Baer, H. A., Singer, M., & Susser, I. (1997). Medical anthropology and
the world system. Westport, CT: Bergin & Garvey.
Bennett, J. W. (1996). Applied and action anthropology: Ideological and
conceptual aspects. Current Anthropology, 36, S23S53.
Boserup, E. (1986). Womans role in economic development. Brookfield,
VT: Gower.
Cardoso, F. H., & Faletto, E. (1969). Dependencia y Desarrollo en
Amrica Latina. Mexico: Siglo XXI; First English translation,
1978, Dependency and development in Latin America.
Los Angeles: University of California Press.
Castro, A., Farmer, P., Gusmo, R., Guzmn, M. G., Kour, G.,
Levcovitz, E. et al. (2003). Infectious Diseases in Latin America
and the Caribbean: The Impact of Health Systems Reform on its
Control and Prevention. Washington, DC: Pan American Health
Organization.
Cernea, M. M. (1985). Putting people first: Sociological variables in
rural development. New York: Oxford University Press.
Comte, A. (1830). [1998]. Cours de philosophie positive. Paris: Hermann.
Cueto, M. (1994). Missionaries of science: The Rockefeller Foundation
and Latin America. Bloomington: Indiana University Press.
Darwin, C. (1964). On the origin of species. Cambridge, MA: Harvard
University Press. (Original work published 1859.)
Donahue, J. M. (1989). Rural health efforts in the urban dominated
political economy: Three Third World examples. Medical
Anthropology, 11, 109125.
Donahue, J. M. (1990). The role of anthropologists in primary health
care: Reconciling advocacy and research. In J. Coriel & J. D. Mull
(Eds.), Anthropology and health care (pp. 7997). Boulder, CO:
Westview.
References
Dos Santos, T. (1970). The structure of dependence. In K. Wilber (Ed.),
The political economy of development and underdevelopment.
New York: Random House.
Economic Social Council (1945). Charter of the Economic and Social
Council. New York: United Nations.
Engels, F. (1902). The Origin of the family, private property and the
state. Chicago, IL: Kerr. (Original work published 1884.)
Escobar, A. (1995). Encountering development: The making and
unmaking of the Third World. Princeton, NJ: Princeton University.
Farmer, P. (1992). AIDS and accusation: Haiti and the geography of
blame. Berkeley: University of California Press.
Farmer, P. (1994). The uses of Haiti. Monroe, ME: Common Courage
Press.
Farmer, P. (1999). Infections and inequalities: The modern plagues.
Berkeley: University of California.
Farmer, P. (2003). Pathologies of Power: Health, Human Rights, and
the New War on the Poor. Berkeley: University of California
Press.
Farmer, P., & Castro, A. (2002). Un pilote en Hati: De lefficacit de la
distribution dantiviraux dans des pays pauvres, et des objections
qui lui sont faites. Vacarme, 19, 1722.
Farmer, P., Connors, M., & Simmons, J. (Eds.). (1996). Women, poverty,
and AIDS: Sex, drugs, and structural violence. Monroe, ME:
Common Courage.
Farmer, P., & Good, B. J. (1991). Illness representations in medical
anthropology: A critical review and a case study of the representation of AIDS in Haiti. In J. A. Skelton & R. T. Croyle (Eds.),
Mental representation in health and illness (pp. 132162).
New York: Springer-Verlag.
Farmer, P., Landre, F., Mukherjee, J. S., Claude, M. S., Nevil, P.,
Smith-Fawzi, M. C. et al. (2001). Community-based approaches
to HIV treatment in resource-poor settings. Lancet, 358,
404409.
Foster, G. (1962). Traditional cultures and the impact of technological
change. New York: Harper & Row.
Foster, G. (1977). Medical anthropology and international health
planning. Social Science & Medicine, 11, 527534.
Foster, G. (1982). Applied anthropology and international
health: Retrospect and prospect. Human Organization, 41(3),
189197.
Iriart, C., Merhy, E. E., & Waitzkin, H. (2001). Managed care in Latin
America: The new common sense in health policy reform. Social
Science & Medicine, 52, 12431253.
Justice, J. (1989). Policies, plans and people: Foreign aid and health
development. Berkeley: University of California Press.
Kim, J. Y., Millen, J. V., Irwin, A., & Gershman, J. (Eds.). (2000). Dying
for growth: Global inequality and the health of the poor. Monroe,
ME: Common Courage.
Laurell, A. C. (2001). Health reform in Mexico: The promotion of
inequality. International Journal of Health Services, 31(2),
291321.
Marx, K. (1964). Pre-capitalist economic formations. London:
Lawrence & Wishart. (Original work published 1857.)
Montgomery, E., & Bennett, J. W. (1979). Anthropological studies of
food and nutrition: The 1940s and the 1970s. In W. Goldschmidt
(Ed.), The uses of anthropology. Washington, DC: American
Anthropological Association.
169
Moore, L. G., Van Arsdale, P. W., Glittenberg, J. E., & Aldrich, R. A.
(1987). The biocultural basis of health: Expanding views of
medical anthropology. Prospect Heights, IL: Waveland Press.
Morgan, L. H. (1965). Ancient society. Cambridge: Harvard University
Press. (Original work published 1864.)
Morgan, L. M. (1993). Community participation in health: The politics
of primary care in Costa Rica. Cambridge, UK: Cambridge
University. (Published in Spanish as Participacin Comunitaria en
Salud. La Poltica de Atencin Primaria en Costa Rica, 1997.
San Jos, Costa Rica: Editorial Nacional de Salud y Seguro Social,
Caja Costarricense de Seguro Social.)
Morgan, L. M. (1998). Latin American social medicine and the politics
of theory. In G. Alan & T. Leatherman (Eds.), Building a new biocultural synthesis: Political-economic perspectives in biological
anthropology. Ann Arbor: University of Michigan.
Murray, C. J. L., & Frenk, J. (2000). A framework for assessing the
performance of health systems. Bulletin of the World Health
Organization, 78(6), 717731.
New, P. K.-M., & Donahue, J. M. (Eds.). (1986). Strategies for primary
health care by the year 2000: A political economic perspective.
Introduction. Human Organization, 45(2), 9596.
Organization for Economic Co-operation and Development (2000).
Recent trends in official development assistance to health (14 pp.).
Paris: OECD.
Paul, B. (Ed.). (1955). Health, culture, and community: Case studies of
public reactions to health programs. New York: Russell Sage
Foundation.
Pillsbury, B. (1986). Making a difference: Anthropologists in international development. In W. Goldschmidt (Ed.), Anthropology and
public policy: A dialogue. Washington, DC: American
Anthropological Association.
Pillsbury, B. (1991). International health: Overview and opportunities.
In C. E. Hill (Ed.), Training manual in applied medical
anthropology. Washington, DC: American Anthropological
Association.
Prebisch, R. (1949). El Desarrollo Econmico de la Amrica Latina y
alguno de sus principales problemas. El Trimestre Econmico,
35(1), 137.
Rostow, W. W. (1960). The stages of economic growth: A non-communist
manifesto. Cambridge, UK: Cambridge University Press.
Rylko-Bauer, B., & Farmer, P. (2002). Managed care or managed
inequality? A call for critiques of market-based medicine. Medical
Anthropology Quarterly, 16(4), 476502.
Sen, A. (1975). Employment, technology and development. Oxford, UK:
Clarendon Press.
Sen, A. (1981). Poverty and famines: An essay on entitlement and
deprivation. Oxford, UK: Clarendon Press.
Sen, A. (1984). Resources, values and development. Cambridge, MA:
Harvard University Press.
Sen, A. (1985). Commodities and capabilities. Amsterdam: NorthHolland.
Singer, M. (Ed.). (1997). The political economy of AIDS. New York:
Baywood.
Spencer, H., (1852[1863]). Essays: Scientific, Political and Speculative.
London: Williams and Norgate.
Stebbins, K. (1993). Constraints upon successful public health
programs: A view from a Mexican community. In P. Conrad &
170
Homelessness
Whiteford, L. M. (1992). Caribbean colonial history and its contemporary health care consequences: The case of the Dominican
Republic. Social Science & Medicine, 35(10), 12151225.
Whiteford, L. M. (1993). International economic policies and child
health [Special issue on women in development, R. Gallin, Ed.].
Social Science & Medicine, 37(11), 13911400.
Whiteford, L. M. (1998). Childrens health as accumulated capital:
Structural adjustment in the Dominican Republic and Cuba. In
N. Scheper-Hughes & C. Sargent (Eds.), Small wars: The cultural
politics of childhood. Berkeley: University of California Press.
Whiteford, L. M., & Manderson, L. (Eds.). (2000). Global health policy,
local realities: The fallacy of the level playing field. Boulder, CO:
Lynne Rienner.
World Health Organization (2001). Macroeconomics and health:
Investing in health for economic development (200 pp.). Geneva,
Switzerland: Author, Commission on Macroeconomics and
Health.
Homelessness
Irene Glasser and Rae Bridgman
The field of anthropology has contributed much to
documenting the condition of homelessness, with the
goals of easing the lives of those who are homeless, and
pointing to ways of preventing and eradicating homelessness. Anthropologys theories, methodologies, and
modes of analysis make it especially suited to unearthing
the subtleties of homelessness. As one of the most visible
indicators of poverty, homelessness confronts communities with their inability to offer everyone the most basic
conditions for a healthy and productive life.
OF
171
METHODOLOGIES
HOMELESSNESS
FOR THE
STUDY
OF
172
Panhandling
A common method of survival on the street is
panhandling, or begging for money. There are few
anthropological studies on begging, which is perhaps
surprising given the attention of anthropologists to life on
Homelessness
Getting Food
By the 1980s, soup kitchens and food banks, once called
emergency feeding programs, had dropped the word
emergency from their titles and become a part of the contemporary landscape in North America. Soup kitchens,
serving a hot noontime meal or evening dinner, and sometimes serving breakfast as well, have come to be relied
upon by people who live on the streets and in shelters
(shelters typically do not serve meals during the day).
Soup kitchens and food banks have become so
institutionalized that levels of government now depend on
them to supplement meager social assistance, people in
need of doing community service and charity work
depend upon their existence to fulfill their commitments,
and poor people (most of whom are not homeless) depend
on them for a hot meal and food supplies. Glasser (1988)
described a soup kitchen that served a daily hot meal to
Squatting
In the developing world, millions of people live in
squatter settlements, which are self-made housing units,
often at the edge of a city, inhabited by poor people who
have invaded the land, often at night, and built structures. From the pueblos jvenes (young towns) of Lima,
Peru, to the bidonvilles (tin cities) of Africa, these examples of self-help are seen as incipient communities that
could, with the assistance of clean water, security of
tenure, and some basic services, become stable communities of productive citizens (see Turner, 1976, for a full
discussion of the potential of squatter settlements). In the
industrialized world, squatting usually refers to homeless
people taking over a vacant building or creating an
encampment on a vacant lot.
Shelter Life
When anthropologists have focused their attention on
shelter living, they have, for the most part, been struck by
the corrosive effects of shelter life on the homeless
person. Desjarlais (1997) spent time in a mid-size
(52 beds) shelter for the homeless mentally ill. Although
the staff regarded the shelter as the Rolls Royce of
shelters, the place was in fact noisy and distracting. The
clients just struggling along, as they put it, can be seen as
173
a shelter-induced adaptation, and may not be due primarily to the mental illness suffered by most of the residents.
According to Desjarlais, struggling along contrasts to
experiencing life, which implies active engagement with
the world, including the ability to perceive, reflect, and
act. Residents of the shelter spent much of the day pacing,
bumming and smoking cigarettes, and drinking coffee.
The description is reminiscent of Murrays (1984)
contrast between linear time, where people make longterm plans, and cyclical time, associated with survival
goals. Life on the streets is often associated with immediate, daily, weekly, and monthly cycles of time: the
hours of opening and closing of the soup kitchens and
shelters, the weekly appointments with social workers
and doctors, and monthly check days.
In a study of a large (600 beds) New York City
shelter (Franklin Avenue shelter in the South Bronx),
Gounis (1992) hypothesized that the institutionalized
atmosphere of the shelter eventually resulted in the shelterization or dependency of the occupants. For example,
rules governing time and space kept the men on the move
(to leave during the day, to be in by early afternoon) or
kept them waiting in line (e.g., the ubiquitous lines for
food, the shower, seeing the caseworker). The men were
not allowed to sleep in a bed or on the floor during the
day and so resorted to sleeping on top of pool tables and
ping-pong tables, a sight reminiscent of the large mental
hospitals before the era of deinstitutionalization.
Observers of shelter life have noticed the great
variability among shelters. Liebow (1993), in a richly
descriptive ethnographic account of his 10 years of
participant observation in two womens shelters in the
Washington, DC, area, notes major differences. One
shelter, he calls The Refuge, was staffed mostly by volunteers, and was housed in the fellowship hall of a
church. It was a low-demand (for the shelter users)
albeit bare-bones shelter. Liebow found that women
appeared to be comfortable there, despite the physical
limitations of the space. On the other hand, The Bridge
was conceptualized as a therapeutic house, providing
shelter for women, but with the understanding that the
women would be actively working on a case plan to
return to permanent housing. The staff were paid and well
educated, and, according to Liebows observations, were
more burned out than the volunteer staff of The Refuge.
The book, Tell Them Who I Am, was written in part
in collaboration with the homeless women and staff of
the two shelters, who read and commented on the
174
Homelessness
Doubling-Up
Probably the least researched type of adaptation to homelessness is that of living with another family, usually
another poor family, on a very temporary basis. This is
referred to as doubling-up and is often a precursor to
life on the streets, or in encampments and shelters.
In Janet Fitchens pioneering work on rural homelessness in New York state (Fitchen, 1991), she found that
the most frequent form of lack of adequate shelter among
the rural poor was to squeeze two families into a trailer or
apartment that was already too small for one. These
arrangements were often short-lived, as the strain of the
situation made life unbearable. Fitchen found that
doubling-up was associated not with mental illness or
substance abuse, but a worsening economy in rural areas
due in part to the great loss of manufacturing jobs.
Another factor that led to doubling-up was the rise of
single motherhood in which income (through work or
welfare) was not adequate to pay rent.
If a realistic portrayal of homelessness is to be
achieved, it is incumbent upon the researcher to capture the
dynamic quality of life on the streets as people cycle
through the various alternative places to sleep (the street,
shelters, hotels, and rehabilitation programs). For example,
interview someone after a long hotel stay and they may
discuss the loneliness and danger of their life. Interview
the same person after a stint in a rehabilitation program
(e.g., detoxification, or alcohol, or drug treatment), and
they may bitterly complain about the regimentation and
lack of privacy. It is important to know where in the cycle
we are meeting the person (Koegel, 1992). Cycles of living
on the streets may be seasonal, as has been observed
among some groups of aboriginal people in Canadian
cities who spend several months living on the streets,
interspersed with several months up North on a reserve.
HEALTH
AND
HOMELESSNESS
Physical Health
In a study of men using homeless shelters in Toronto,
homeless mens mortality rate was 8.3 times the mortality rate of the general male population in the same city in
the 1824 year old age group, 3.7 in the 2544 year old
group, and 2.3 times the 4564 year old group (Hwang,
2000). The rates of traumatic disorders, skin and blood
vessel disorders, respiratory diseases, and chronic diseases such as hypertension, diabetes, and chronic
obstructive pulmonary disease are higher in the homeless
population than in the general population (Institute for
Medicine, 1988). Of great concern are homeless individuals with infectious tuberculosis who sleep in crowded
shelters and are not able to adhere to their medication
regimen.
Mental Illness
For many people in North America the issue of homelessness is closely tied to the phenomenon of deinstitutionalization, which refers to the process of having
people who were hospitalized with psychiatric problems
leave the hospital in order to live in the community. In the
United States and Canada, the movement away from
long-term hospital stays in favor of short-term, crisisoriented hospitalizations and then community placements
occurred in force during the 1960s and 1970s. Life in the
community was considered more humane than life in
the large psychiatric institutions. However, approximately 10 years after the community placements began,
there appeared to be a visible segment of former patients
Ending Homelessness
Substance Abuse
The relationship of alcohol and drug use to homelessness
is interactive, in that it is very difficult for an individual
with limited financial resources to remain in housing when
much of his/her money is spent on substances, and it is difficult for an individual to focus on substance abuse treatment when his/her basic survival needs for shelter, food,
and warmth are only precariously met. A recurring question is whether substance use disorders precede homelessness or are precipitated by it (Glasser & Zywiak, 2003).
There is substantial evidence that alcoholism is the
most pervasive health problem of the homeless in the
United States (Fischer & Breakey, 1991). The rate of
alcohol abuse has been estimated to be 5868% for
homeless men; 30% for homeless single women; and
10% for mothers in homeless families. In the general
population, the rates for alcohol abuse are estimated to be
10% for men and between 3% and 5% for women.
Determining the rate of drug use among the homeless
has been especially fraught with problems, since many
studies do not distinguish between drug and alcohol use or
between occasional use and a regular drug habit. An estimated rate of between 25% and 50% of the homeless
175
population use illicit drugs, and this exceeds the rate of the
general population in the United States. Intravenous drug
use is one of the primary transmitters of the HIV virus.
In their study of homeless youth in Hollywood,
California, Robertson, Koegel, and Ferguson (1989)
found that almost half (48.4%) of their respondents could
be diagnosed as being either alcohol users or being alcohol dependent at some point in their lives, and that even
the nonabusers drank and were at high risk of becoming
problem drinkers. The authors found that being on the
street exacerbated the amount of drinking. Interestingly,
very few of the total sample (6.5%) said that their drinking was a contributing factor to their homelessness,
although almost one quarter (23.7%) said that alcoholrelated problems (including alcohol-induced violence)
had led to their leaving home. Very few of the youth had
had any kind of alcohol treatment.
In an excellent study examining the overlap of mental health and substance abuse problems among the
homeless, 1,260 shelter residents in New York City were
surveyed (Struening & Padgett, 1990). How, the
researchers asked, is health status related to the individuals involvement with alcohol, drugs, mental disorder,
and a combination of all three? It is not surprising that the
coexistence of heavy substance use with symptoms (or a
history) of mental disorder resulted in very high rates of
poor health, disability, and worsening health conditions.
The often-cited health problems were hypertension,
stomach and liver problems, and respiratory disease. The
implication of this study is again that medical and mental
health care (including substance-abuse treatment) need to
be integrated with services for the homeless. Especially
important is early and effective intervention with substance abusers in order to circumvent a lifetime of health
consequences of alcohol and/or drug abuse.
Beyond the epidemiology of substance use among
the alcohol- and drug-using homeless population, advocates for the homeless argue that providing housing is a
first step in rehabilitation. Given the episodic nature of
much of the homelessness of the population, it is also
important to consider providing adequate support to individuals during their housed periods.
ENDING HOMELESSNESS
What do we know about ending homelessness? If many
of the homeless shelters in North America have not been
176
Daytime Respites
While on the street, there is an intermediate step of
service between outreach efforts and permanent shelter
which may be termed a daytime respite, or a place of
rest and refuge for the homeless person. One successful
daytime respite is Chez Doris, a multilingual (French,
English, and, increasingly, Inuktitut, the language of the
Inuit) daytime shelter for women in Montreal. The center
was named after Doris, a destitute young woman murdered on the street in 1974. Chez Doris is the gathering
spot for over 60 women a day; they come for food, clothing, baths, laundry facilities and, most of all, the companionship of the other women and the staff. The center
is funded by a combination of government and private
donations, and the women who utilize Chez Doris also
provide much of the labor needed to run the place. It is a
low demand, no-questions-asked service that accepts
women who are poor, on the street, and may have
psychiatric and/or substance-abuse problems.
Homelessness
CONCLUSION
Anthropologists have been able to offer the thick
description of homeless communities that are so often
References
REFERENCES
Baxter, E., & Hopper, K. (1981). Private lives/public spaces: Homeless
adults on the streets of New York City. New York: Community
Service Society.
Burt, M. R. (1992). Over the edge: the growth of homelessness in the
1980s. New York: Russell Sage Foundation.
Canada Mortgage and Housing Corporation (CMHC) (1999). Best
practices for alleviating homelessness. (Rep. Distinct Housing
Needs Series). Ottawa, Canada.
Cohen, C. I., & Sokolovsky, J. (1989). Old men of the Bowery:
Strategies for survival among the homeless. New York: Guildford
Press.
Curtis, K. (1996, April). Urban poverty and the social provision of
food assistance. Paper delivered at the Urban Affairs Association
meeting, New York City.
Desjarlais, R. (1997). Shelter blues: Sanity and selfhood among the
homeless. Philadelphia: University of Pennsylvania Press.
Fabrega, H., Jr. (1971). Begging in a Southeastern Mexican City.
Human Organization, 303, 277287.
Fischer, P. J., & Breakey, W. R. (1991). The epidemiology of alcohol,
drug, and mental disorders among homeless persons. American
Psychologist, 46, 11151128.
Fitchen, J. M. (1991). Endangered space, enduring places: Change,
identity, and survival in rural America. Boulder, Co.: Westview
Press.
Glasser, I. (1988). More than bread: Ethnography of a soup kitchen.
Tuscaloosa: University of Alabama Press.
Glasser, I. (1994). Homelessness in global perspective. New York:
G. K. Hall.
Glasser, I., & Bridgman, R. (1999). Braving the street: The anthropology of homelessness. New York: Berghahn Books.
177
Glasser, I., & Zywiak, W. (2003). Homelessness and substance use: A
tale of two cities. Substance Use and Misuse, 38(36): 553578.
Gounis, K. (1992). Temporality and the domestication of homelessness.
In H. I. Rutz (Ed.), The politics of time (pp. 127149). Washington,
DC: American Anthropology Association.
Hopper, K. (1991). Symptoms, survival, and the redefinition of public
space: A feasibility study of homeless people at a metropolitan
airport. Urban Anthropology, 20(2), 155175.
Hwang, S. W. (2000). Mortality among men using homeless shelters in
Toronto, Ontario. Journal of the American Medical Association,
83(16), 21522157.
Institute of Medicine (1988). Homelessness, health, and human needs.
Washington, DC: National Academy Press.
Koegel, P. (1992). Through a different lens: an anthropological
perspective on the homeless mentally ill. Culture, Medicine, and
Psychiatry, 16(1), 122.
Liebow, E. (1993). Tell them who I am: the lives of homeless women.
New York: Penguin Books.
Marshall, M., Nehring, J., & Gath, D. (1994). Characteristics of homeless mentally ill people who lose contact with caring agencies.
Journal of Psychological Medicine, 11(4), 160163.
Murray, H. (1984). Time in the streets. Human Organization, 43(2),
154161.
Robertson, M. J., Koegel, P., & Ferguson, L. (1989). Alcohol use and
abuse among homeless adolescents in Hollywood. Contemporary
Drug Problems, 16(3), 415452.
Rossi, P. H., Wright, J. D., Fisher, G. A., & Willis, G. (1987, March).
The urban homeless: Estimating composition and size. Science,
13361341.
Shapiro, J. (1969). Dominant leaders among slum hotel residents.
American Journal of Orthopsychiatry, 39, 644650.
Spradley, J. (1970). You owe yourself a drunk: An ethnography of urban
nomads. Boston, MA: Little, Brown.
Struening, E. L., & Padgett, D. K. (1990). Physical health status,
substance use and abuse, and mental disorders among homeless
adults. Journal of Social Sciences, 46(4), 6581.
Turner, J. (1976). Housing by the people: Towards autonomy in building environments. London: Marion Boyars.
Turner, B. (1988). Building Community: A Third World Case Book. A
Summary of the Habitat International Coalition NonGovernmental Organizations Project for the International Year of
Shelter for the Homeless, 1987, in association with Habitat Forum
Berlin. (Monograph.)
Williams, B. F. (1995). The public I/eye: Conducting fieldwork to do
homework on homelessness and begging in two U.S. cities.
Current Anthropology, 36(1), 2551.
Wolch, J., & Rowe, S. (1992). On the streets: Mobility paths of the
urban homeless. City and Society, 6(2), 115140.
178
INTRODUCTION
Patterns of diet and activity, and nutritional and health
status vary across cultures and historical periods. For
example, currently there are populations living as
huntergatherers and also groups subsisting on diets high
in fat and refined carbohydrates. The nutrition and health
situations in developing countries have been exemplified
by nutrient deficiencies, such as protein-energy malnutrition, iron deficiency anemia, vitamin A deficiency, and
iodine deficiency, in addition to periodic famine and high
prevalence of infectious diseases. In contrast, over the
past 100 years nutrition-related non-communicable diseases (obesity, cardiovascular disease, diabetes, some
types of cancer) have mainly been a challenge in Western
industrialized countries. However, today changes in work
patterns, lifestyles, and food systems (e.g., global availability of cheap vegetable oils and fats) are contributing
to an increase in non-communicable diseases also in
developing countries, particularly countries in rapid
economic transition. As a result these countries are facing
a growing risk of a double burden: the persisting problem
of undernutrition plus the rising prevalence of obesity
(Drewnowski & Popkin, 1997; Popkin, 2002).
The relationships of food, nutrition, society, and
culture are highly relevant for population health and
welfare. Food is integrated into all aspects of life, and is,
therefore, also studied in a wide range of disciplines. In
nutritional sciences food is mainly viewed in terms of its
nutrient composition and effects upon the bodys metabolic processes and health status. There has been a special interest in developing methods for measuring nutrient
intake and defining essential, adequate, and optimal
intakes of nutrients. Anthropological perspectives, which
are broad and holistic, tend to look at food and nutrition
in populations as complex systems influenced by many
factors, including the environment, genetic inheritance,
culture, and socioeconomic circumstances. Anthropological research on food and nutrition examines the
origin, development, and diversity of the human diet and
tries to understand how and what people in different
HISTORY OF NUTRITIONAL
ANTHROPOLOGY
The early history of nutritional anthropology dates back to
studies of food and social organization in non-industrial
societies in the 1930s. The British anthropologist Audrey
Richards (1939) is often described as the first one who
explicitly focused on food. She studied economic and
social factors affecting food among the Bemba in central
Africa. Her work was part of the British applied anthropology movement, which was associated with colonial
governance and welfare.
In the 1940s, studies of nutrition and the culture of
eating were stimulated by the circumstances related to
World War II. Committees that included anthropologists
and nutritionists were set up in the United States and the
United Kingdom to plan food rationing and to ensure
adequate nutrition for the troops and support personnel.
The U.S. Committee on Food Habits was directed by a
well-known anthropologist, Margaret Mead (Wilson,
2002). Between 1950 and 1970 food- and nutritionrelated themes were included in some anthropological
studies, but nutrition was not in generally a central focus
of anthropological study.
In the 1970s food and nutrition within anthropology
was revived as nutritional anthropology in the United
States. Pelto (1986) traces the development of the field to
four social forces: the world energy and food crisis in the
early 1970s; growing interest in the role of nutrition in
health and diseases; the emergence of ethnicity as a social
and political phenomenon; and an interest in gourmet food
and cooking in affluent societies. The rise of cultural ecology as a theoretical perspective in anthropology was also
central to the development of nutritional anthropology.
The American Anthropological Association organized
sessions on the biocultural perspective of nutrition in
response to the increased interest in the 1970s and this
resulted in a widely used publication (Jerome, Kandel, &
Pelto, 1980). The Committee on Nutritional Anthropology
179
THEORETICAL ORIENTATIONS
METHODS IN NUTRITIONAL
ANTHROPOLOGY
AND
180
Pelto (1996) has provided a framework for organizing nutritional anthropology research. She has grouped
research questions in nutritional anthropology into the
following main headings: (1) sociocultural processes and
nutrition; (2) social epidemiology of nutrition; (3) belief
structures and nutrition; and (4) physiological adaptation,
population genetics, and nutrition. Nutritional anthropological research on sociocultural processes and nutrition
examines the nutritional consequences of social and
cultural forces. The basic question is: What is the impact
of sociocultural processes on nutrition? Sociocultural
processes refer to both long-term and short-term evolutionary changes, such as transformation of subsistence
from huntinggathering to agriculture, the introduction of
new technologies, modernization, or migration from rural
to urban areas. In studies classified as the social epidemiology of nutrition the central issue is the identification of
the determinants of, or the factors associated with, food
intake and nutritional status. The emphasis is on the nutritional condition, and anthropologists aim to recognize the
role of social factors in the etiology of that condition. For
example, they have studied the factors that determine malnutrition or deficient levels of intakes of specific nutrients.
Some of the nutritional anthropology research focuses on
the relationships between cultural beliefs and nutritional
outcomes. By examining the links between cultural idea
systems (e.g., the humoral medicine system of hot/cold
beliefs or modern rational models of diet) and nutrient
intake, the strengths and weaknesses of dietary systems
can be assessed and sociocultural barriers to change and
potential avenues for facilitating improvement in dietary
practices can be revealed. The group of studies labeled
physiological adaptation, population genetics, and nutrition include research that addresses how the nutritional
history of a population has formed or affected its physiological or genetic characteristics (e.g., low birth weight,
growth, obesity). For example, nutritional anthropologists
have studied the differences in the capacity to maintain
production of lactase, an enzyme required for the digestion of milk, beyond early childhood from one population
to another.
A considerable part of the work in nutritional
anthropology is applied in nature; anthropological theories and methods are used to understand and improve specific nutritional problems and alleviate malnutrition. In
the 1940s, work focused on solving the nutritional problems of feeding the army and populations during war.
Since the 1970s a growing number of anthropologists
THEMES IN NUTRITIONAL
ANTHROPOLOGY
The anthropological literature on nutrition- and healthrelated issues has become vast over the last decades and
it also has a broad geographic spread. Nutritional anthropologists have covered a wide variety of topics, ranging
from nutritional adequacy in prehistoric populations to
various forms of malnutrition in late modernity. The
different types of malnutrition studies include proteincalorie malnutrition, micronutrient malnutrition, and
overnutrition. Next, two themes have been selected to
illustrate some of the variation in nutritional anthropology research and the contribution of anthropology to
advancing our understanding of nutrition and health:
(1) hunger and malnutrition in low-income countries, and
(2) the possible effects of our nutritious past on human
health and well-being today.
181
182
References
183
REFERENCES
Baer, R. D. (1998). Cookingand copingamong the Cacti: Diet,
nutrition and available income in northwestern Mexico.
Amsterdam: Gordon and Breach.
Beardsworth, A., & Keil, T. (1997). Sociology on the menu: An invitation to the study of food and society. London & New York:
Routledge.
Brown, P. J., & Konner, M. (1998). An anthropological perspective on
obesity. In P.J. Brown (Ed.), Understanding and applying medical
anthropology (pp. 401413). Mountain View, CA: Mayfield.
Caplan, P. (1994). Feasts, fasts, famine: Food for thought (Berg
Occasional Papers in Anthropology, No. 2). Berg Publishers Ltd:
Oxford, UK.
Counihan, C., & Van Esterik, P. (Eds.). (1997). Food and culture:
A reader. New York & London: Routledge.
Dettwyler, K. A. (1994). Dancing skeletons: Life and death in West
Africa. Prospect Heights, IL: Waveland Press.
Dettwyler, K. A. (1998). The biocultural approach in nutritional anthropology: Case studies of malnutrition in Mali. In P. J. Brown (Ed.),
Understanding and applying medical anthropology (pp. 389401).
Mountain View, CA: Mayfield.
DeWalt, K. M. (1993). Nutrition and the commercialization of agriculture: Ten years later. Social Science & Medicine, 36, 14071416.
Drewnowski, A., & Popkin, B. M. (1997). The nutrition transition: New
trends in the global diet. Nutrition Reviews, 55, 3143.
Eaton, S. B., & Konner, M. (1985). Paleolithic nutrition: A consideration
of its nature and current implications. New England Journal of
Medicine, 312, 283289.
Eaton, S. B., Shostak, M., & Konner, M. (1998). Stone agers in the fast
lane: Chronic degenerative diseases in evolutionary perspective.
In P. J. Brown (Ed.), Understanding and applying medical anthropology (pp. 2133). Mountain View, CA: Mayfield.
Goodman, A. H., Dufour, D. L., & Pelto, G. H. (Eds.). (2000). Nutritional
anthropology: Biocultural perspectives on food and nutrition.
Mountain View, CA: Mayfield.
Haas, J. D., & Harrison, G. G. (1977). Nutritional anthropology and
biological adaptation. Annual Review of Anthropology, 6, 69101.
Himmelgreen, D. A. (2002). You are what you eat and you eat what
you are: The role of nutritional anthropology in public health
nutrition and health education. Nutritional Anthropology, 25, 212.
184
INTRODUCTION
The post-World War II era marked the rise of new nationstates. Released from the shackles of European colonialism, the former colonies as newly emerging nations
began to chart their own courses toward becoming modern global partners with and for their former colonizers.
Manifestos of various political persuasions and economic
strategies became blueprints for transforming colonialist
architectures of rule into nationalist administrations. One
important manifesto that spoke a common language
across the globe was development ideology. For newly
emerging nation-states in search of an international
language to legitimate their status as democratic nations
among democracies, development ideology, based on the
COLONIALISM, EARLY
POST-COLONIALISM, AND HEALTH
The health consequences of colonialism immediately
faced by post-colonial regimes cannot be characterized
by any one set of health problems, health practices, and
perceptions. Rather, differences in health and health care
reflect regional, class, ethnic, gender, age, rural and/or
urban circumstances, posing a myriad of challenges for
post-colonial development efforts. The withdrawal of
colonial powers left behind a mixed legacy of health
conditions and health care provisions. Where one lived in
terms of geography, and where one stood in terms of
colonial social structure were significant determinants of
health for emerging post-colonial societies. Janzen
(1978) in his groundbreaking ethnography on medical
pluralism among the BaKongo in Lower Zaire (todays
Democratic Republic of the Congo), describes the social
and geographic distributions of various health problems
faced by available medicine at the time of his study
(1969). The Belgian colonial government played a central
role in the increasing prevalence of post-colonial
endemic killers among populations in the Lower Zaire
river region. Colonial expansion into the region disrupted
an ecological balance among settlement patterns, subsistence strategies, and economic arrangements. Colonial
infrastructure projects, for example the building of the
railroad, required a local labor force. Colonial recruitment activities resulted in the displacement of people and
settlements. Before the intrusion of colonial expansion,
185
186
187
188
POST-COLONIAL DEVELOPMENTS
AND HEALTH
Post-colonial development met and continues to meet the
challenges of high fertility and mortality rates, health
environmental issues, poverty and its impact on segments
of post-colonial populations, acute respiratory infections,
diarrheal diseases, vaccine-preventable infectious diseases, malaria, and other tropical vector-borne diseases.
In fact, the persistence of these health issues is considered
the bio-historical facts of under-development that are also
the targets of development. Any positive changes in these
and other health measures of progress brought about by
development signal successful movement toward takeoff. Post-colonial governments, along with a wide variety
of other governments, international aid agencies, and
non-governmental organizations have targeted the health
and demographic measures of progress for which Europe
and the United States provide the gold standards in terms
of achieving their pinnacle stage of development.
The health profiles of developing countries bore out
in demographic profiles are based on national census data
collected by post-colonial state bureaucracies. This important activity of the state provided the targets toward which
development projects could be applied. The demographic
profiles of non-Western industrialized countries were
and continue to be the comparative measures used to
track a developing countrys movement toward becoming
a developed country. Returning to the Congo, relying on
statistics collected in 1959, Janzen reveals a demographic
profile for the Lower Zaire in which life expectancy at
birth only reached 37.64 years for males and 40 years for
females. The infant mortality rate stood at 180 deaths
per 1,000, half of what it had been 20 years earlier, but
nevertheless still a high rate of death. He noted constant
but high fertility rates, and a declining mortality rate overall. Similarly, Indonesia just after Independence (1950)
experienced life expectancy rates at birth of 3540 years.
Infant mortality rates at this time stood at 200 deaths per
1,000 (Ananta & Arifin, 1990). As in the case of central
Africa, Indonesia also continued to exhibit high fertility
rates as well as high rates of maternal mortality.
Post-Colonial Medicine
POST-COLONIAL MEDICINE
Post-colonial health provisions are an admixture of
medical practices and perceptions that reflect the colonial
experience. These local health care systems continue to
include a combination of hospitals, clinics, health posts,
pharmacies, nurse paramedical practitioners, and health
cadres as well as a multitude of government-sponsored
health programs, for example family planning programs,
family nutrition improvement programs, village community health development programs, advanced age programs, and programs that train local level health
promoters, to name just a few. Mention should also be
made of the increasing number of magazines on health,
or articles and newspaper columns, television and radio
programs, and advertisements that all promote health
from the perspective of scientific medicine.
In addition, indigenous medicine, often referred to
as traditional medicine, is vibrantly apparent as well.
Anthropologist Charles Leslie (1974), in his work on
Asian medical systems, noted that in the context of
modernization medical revivalisms of traditional medicine constituted a looking forwardlooking backward
for many nations in their quest to become modern
developed countries. Particularly in China and India,
medical revivalism was a significant aspect of cultural
189
190
REFERENCES
Ananta, A., & Arifin, E. N. (1990, November). Demographic transition
in Indonesia: A projection into the year 2020 (Population
Projection Series No. 1). Jakarta Indonesia: Demographic Institute.
Arnold, D. (Ed.). (1988). Imperial medicine and indigenous societies.
Oxford, UK: Oxford University Press.
Bhabha, H. K. (1994). The location of culture. London and New York:
Routledge.
Boomgaard, P. (1993). The development of colonial health care in Java:
An exploratory introduction. Bijdragen Tot De Taal-, Land- En
Volkenkunde, 149, 7793.
Brown, C. (1987). The influenza pandemic of 1918 in Indonesia. In
N. G. Owen (Ed.), Death and disease in Southeast Asia:
Explorations in social, medical, and demographic history
(pp. 235256). Oxford, New York: Oxford University Press.
Comaroff, J., & Comaroff, J. (1992). Ethnography and the historical
imagination. Boulder, CO: Westview Press.
Escobar, A. (1994). Encountering development: The making and
unmaking of the Third World. Princeton, NJ: Princeton University
Press.
Ferzacca, S. (1996). In this pocket of the Universe: Healing the modern
in a central Javanese city. Ph.D. dissertation, University of
Wisconsin-Madison, Department of Anthropology.
Ferzacca, S. (2001). Healing the modern in a central Javanese city
Carolina Academic Press.
Ferzacca, S. (2002). Governing bodies in New Order Indonesia. In
M. Lock & M. Nichter (Eds.), New Horizons in Medical
Anthropology, Essays in honor of Charles Leslie (pp. 3557).
London and New York: Routledge.
Gardiner, P., & Oey, M. (1987). Morbidity and mortality in Java
18801940: The evidence of colonial reports. In N. G. Owen (Ed.),
Death and disease in Southeast Asia: Explorations in social,
medical, and demographic history (pp. 7090). Oxford and
New York: Oxford University Press.
Grinker, R. R. (1994). Houses in the rainforest: Ethnicity and inequality among farmers and foragers in central Africa. Berkeley:
University of California Press.
Gupta, A. (1998). Post-colonial developments: Agriculture in the
making of modern India. Durham and London: Duke University
Press.
Janzen, J. M. (1978). The quest for therapy: Medical pluralism in Lower
Zaire. Berkeley: University of California Press.
Janzen, J. M. (2001). The Social fabric of health: An introduction to
medical anthropology. New York: McGraw-Hill.
Background
191
Refugee Health
Pascale A. Allotey
INTRODUCTION
The study of refugees as a population invites a multidisciplinary approach because their very existence often
is a result of history, politics, economics, conflict and,
more recently, globalization; their protection is a matter
of international, refugee, humanitarian, and human rights
law; their settlement involves immigration, citizenship,
and national sovereignty; and their long-term outcomes
involve multi-sectoral collaboration between providers of
education, health, and welfare. As a population, refugees
are influenced directly by the culture of the countries of
origin, the culture of conflict and instability, and the
culture of the countries in which they resettle. This entry
provides a brief overview of the health of the worlds
refugees. It covers the cultural issues affecting health and
the provision of health care from conflict through to
settlement. It also examines a range of cross-cultural
approaches to the health of refugees in a number of
countries.
BACKGROUND
The international community, initially through the
League of Nations, and subsequently the United Nations
(UN), recognized that priority needed to be given to
addressing the vulnerability of the many displaced individuals living within a context where governments were
unwilling or unable to enforce laws and protect their
192
Refugee Health
193
IMPLICATIONS OF CONFLICT
DISPLACEMENT
AND
194
Refugee Health
195
PROVISION
OF
HEALTH CARE
196
community, cultural differences, poverty, and marginalization combined with pre-migration and settlement
stressors all contribute to social and health disadvantage
identified in many refugee groups. These factors are also
the main barriers to accessing health services (Jones &
Gill, 1998; Palmer & Short, 2000).
The provision of health care to resettling refugees in
a third country depends to a large extent on the policy
environment towards migrants. Over time and in various
contexts, governments have adopted policies broadly
based on philosophies of assimilation, integration, or
multi-culturalism (Palmer & Short, 2000). Assimilation,
which reflects current trends in Europe, is based on an
expectation that migrants and refugees will blend in with
the dominant culture with no significant change expected
from the host community. There is little recognition of or
tolerance for diversity under policies of assimilation.
Integration recognizes and respects differences in culture
and provision is made for language and cultural differences. Integration policies provide assistance to refugees
to function within the dominant culture. Multi-culturalism
or cultural pluralism is based on total participation of all
cultural and ethnic groups in the political process in recognition of their contribution to the development of a
dynamic, evolving culture of diversity.
In reality, there is a broad variation in the implementation of these policies into service provision. In
broad terms, the policy environment dictates the allocation of resources that enable health services to respond in
one way or another. However, services also need to some
degree to reflect the needs of their client group. Within
health service provision for refugees, service delivery
models have ranged from specialized ethno-specific
services to mainstream services with no clear agreement
of the advantages of either. The debate is ongoing in part
because of the differences in outcome indicators, which
may be based on efficiency in health service provision or
on specific outcomes for the patient. The most desirable
would achieve both.
Ethno-specific models provide targeted services to
ethnic groups, ensuring that the providers of the service
are either from the same ethnic backgrounds or are
culturally sensitive to the needs of the specific groups.
Other refugee-targeted services include dedicated clinics
that recognize the special health needs of this group such
as particular parasitic conditions that are not endemic
within the host population and, more commonly, specialized trauma counseling services for survivors of torture
and trauma (Palmer & Short, 2000). It has been argued,
Refugee Health
CONCLUSION
It would be unduly optimistic to make projections about
the elimination of conflict, particularly under current
global circumstances. Anthropologists have an important
role to play in the exploration and analysis of situations
that create refugees, enable them to survive and maintain
resilience in spite of significant trauma, and rebuild their
lives post conflict both through repatriation and resettlement. There is a particular dearth of knowledge on the
health of refugees within protracted conflict situations
where there is long-term uncertainty, a lack of cultural
and social infrastructure which we generally understand
to be necessary for human societies, and the application
of that information to build structures to support and
maintain health.
NOTE
1. Article 31 of the convention states that The Contracting States shall
not impose penalties, on account of their illegal entry or presence, on
refugees who, coming directly form a territory where their life or freedom was threatened in the sense of article 1, enter or are present in their
territory without authorization, provided they present themselves without delay to the authorities and show good cause for their illegal entry
or presence (UNHCR, 1951).
2. The screening process for the resettlement of refugees for many
countries gives priority to the well educated, healthy applicants; a further occasion for the disadvantaged to be further marginalized.
References
REFERENCES
Allotey, P. (1998). Travelling with excess baggage: A study of refugee
women in Western Australia. Women and Health, 28(2), 6381.
Allotey, P. Manderson, L., Nikles, J. Reidpath, D. & Sauvarin, J. (1998).
Cultural diversity. A guide for health professionals. Brisbane: The
University of Queensland for Queensland Health.
Benjamin, J. A. (2001). Conflict, post conflict and HIV AIDS the gender connections. Women, War and HIV/AIDS: West Africa and the
Great Lakes, Paper Presented at the International Womens Day
World Bank, Washington, DC March 8 2001.
Bhagwati, P. N. (2002). Detention centres in Australia. Geneva,
Switzerland: United Nations High Commissioner for Human Rights.
Brooks, G. (1995). Nine parts of desire: The hidden world of Islamic
women. Sydney, Australia: Anchor Books.
Christianson, S. A., & Safer, M. A. (1996). Emotional events and
emotions in autobiographical memories. In D. Rubin (Ed.),
(pp. 218241). Remembering our past: Studies in autobiographical memory. Cambridge, UK: Cambridge University Press.
Copelon, R. (2000). Gender crimes as war crimes: Integrating crimes
against women into International Criminal Law. McGill Law
Journal, 46, 217240.
Csordas, T. J. (1994). Embodiment and experience: The existential
ground of culture and self. Cambridge, UK: Cambridge University
Press.
de Bousingen, D. D. (2002). Health issues and the rise of Le Pen in
France. The Lancet, 359, 1673.
Dean, M. (1998). UK government announces first health action zones.
The Lancet, 351, 111.
Eckersley, R. (2001). Culture, health and well-being. In R. Eckersley,
J. Dixon, & R. Douglas (Eds.), The social origins of health and
well-being. Melbourne, Australia: Cambridge University Press.
Geissler, E. M. (1998). Cultural assessment. St. Louis: Mosby.
Goldstein, J. A. (2001). Conquests: Sex, rape and exploitation in
wartime. In War and gender (pp. 332402). Cambridge, UK:
Cambridge University Press.
Grnseth, A. S. (2001). In search of community: A quest for well-being
among Tamil refugees in Northern Norway. Medical Anthropology
Quarterly, 15(4), 493514.
Harrell-Bond, B., & Wilson, K. (1990). Dealing with dying: Some
anthropological reflections on the need for assistance by refugee
relief programmes for bereavement and burial. Journal of Refugee
Studies, 3, 228243.
Herlihy, J., Scragg, P., & Turner, S. (2002). Discrepancies in autobiographical memoriesimplications for the assessment of asylum
seekers: Repeated interviews study. British Medical Journal, 324,
324327.
International Catholic Migration Commission (2001). Futures of
refugees and refugee resettlement. International Journal of
Refugee Law, 13(4), 569583.
Jones, D., & Gill, P. S. (1998). Refugees and primary care: Tackling the
inequalities. British Medical Journal, 317, 14441446.
Kelaher, M., & Manderson, L. (2000). Migration and mainstreaming:
Matching health services to immigrants needs in Australia. Health
Policy, 54, 111.
Kelley, N. (2001). The conventional refugee definition and gender based
persecution: A decades progress. International Journal of Refugee
Law, 13(4), 559568.
197
Kirkwood, N. A. (1993). A hospital handbook on multiculturalism and
religion. Newtown, CT: Millennium Books.
Kleinman, A., Das, V., & Lock, M. (1997a). Introduction. In A. Kleinman,
V. Das, & M. Lock (Eds.), Social suffering pp. ixxxvii. Berkeley:
University of California Press.
Kleinman, A., Das, V., & Lock, M. (Eds.). (1997b). Social suffering.
Berkeley: University of Calfornia Press.
Kleinman, A., & Kleinman, J. (1997). The appeal of experience, the
dismay of images: Cultural appropriations of suffering in our
times. In A. Kleinman, V. Das, & M. Lock (Eds.), Social suffering
pp. 123. Berkeley: University of California Press.
Lambert, H. (2001). The conceptualisation of persecution by the House
of Lords: Horvath v. Secretary of State for the Home Department.
International Journal of Refugee Law, 13(1,2), 1631.
Levenson, R., & Coker, N. (1999). The health of refugees: A guide for
GPs. London: Kings Fund.
Lipson, J. G., Dibble, S. L., & Minarik, P. A. (1996). Culture and
nursing care: A pocket guide. San Francisco: UCSF Nursing Press.
Makiya, K. (1993). Cruelty and silence: War, tyranny, uprising and the
Arab world. London: Jonathan Cape.
Manderson, L., & Allotey, P. (2003a). Cultural politics and clinical
competence in Australian health services. Anthropology in
Medicine, 10(1), 7085.
Manderson, L., & Allotey, P. (2003b). Story telling, marginality and community in Australia: How immigrants position their differences in
health care settings. Medical Anthropology, 22(1), 121.
Mares, P. (2001). Borderline. Sydney: UNSW Press.
Mateen, F., & Titemore, B. (1999). The right to seek asylum: A dwindling right? (Brief No. 2(2) ). Centre for Human Rights and
Humanitarian Law.: American University. Washington, D.C.
McMaster, D. (2001a). Asylum seekers. Australias response to
refugees. Melbourne, Australia: Melbourne University Press.
McMaster, D. (2001b). Australian immigration and its other. In
D. McMaster (Ed.), Asylum seekers. Australias response to refugees
(pp. 3865). Melbourne, Australia: Melbourne University Press.
McMaster, D. (2001c). The wretched of the earth. In D. McMaster
(Ed.), Asylum seekers. Australias response to refugees. (pp. 937).
Melbourne, Australia: Melbourne University Press.
Middle East Watch and Physicians for Human Rights. (1993). The
Anaful Campaign in Iraqi Kurdistan: The destruction of Koreme.
New York: Human Rights Watch.
Morris, A. (1998). Our fellow Africans make our lives hellthe lives of
Congolese and Nigerians living in Johannesburg. Ethnic and
Racial Studies, 21(6), 11161136.
Palmer, G. R., & Short, S. D. (2000). Health services for disadvantaged
groups. In G. R. Palmer & S. D. Short (Eds.). Health care and public policy. An Australian analysis (pp. 252302). Melbourne,
Australia: Macmillan.
Shacknove, A. (1993). From asylum to containment. International
Journal of Refugee Law, 5(4), 516533.
Shalev, A. Y., Cohen, J. Ellis, S. J. Litva, A. Devilly, G. J., Clark, T.,
Cabrera-Abreu, C., Hargrave, A. & Summerfield, D. (2001). Posttraumatic stress disorder. BMJ, 322(7297): 1301.
Shrestha, N., et al. (1998). Impact of torture on refugees displaced
within the developing world. Journal of the American Medical
Association, 280, 443448.
Silove, D., & Kinzie, J. D. (2001). Survivors of war trauma, mass
violence, and civilian terror. In E. Gerrity, T. M. Keane, & F. Tuma
198
Social Stratification
INTRODUCTION
DEFINITIONS
AND
199
200
Social Stratification
HEALTH
AND
SOCIAL STRATIFICATION
BIOMEDICINE
AND
MEDICALIZATION
In the Western context, and in the United States specifically, biomedicine has assumed the role of the dominant
health system (Singer & Baer, 1995). By focusing on the
modes of biomedical production, anthropologists can
look at the ways in which capitalism has been resisted or
transformed by the individual participants (Morgan,
1987). Foster and Anderson (1978) define biomedicine as
an ethno-medical system which has both its genesis and
its sustenance within Western political, economic, and
ideological institution. It is variously called cosmopolitan
medicine, capitalist medicine, Western medicine, and
urban medicine. Importantly, Foster and Anderson (1978)
point out that biomedicine is an ethno-medical system,
just like curanderismo in Latin America, Ayurveda in
India, and Qi-based systems in China. Biomedically
informed health providers blame the victim. Indeed, in
capitalist medicine (Navarro, 1986) the system is rarely
implicated, while the worker is further burdened. Among
Constructing Hierarchy
201
NEGOTIATING HEALTH
STRATIFICATION
AND
SOCIAL
CONSTRUCTING HIERARCHY
Structural forces are implicated in the production of
illness as well as with the provision of health care and
treatment. There is a variety of socioeconomic and structural parameters on which health care is not only defined
but also delivered. These parameters may be ethnicity
(including racial classification), sexual orientation,
class, and gender.
Ethnicity
Though issues of discrimination based on skin color were
the foundations of political activism in the 1960s and
202
1970s, race did not constitute a central focus of anthropological study until much more recently (Harrison,
1999). It is only within the last two decades or so that
anthropologists have taken the position that race is a
social category, not a meaningful biological category as
applied to humans. By focusing attention on the perceived ethnic differences, the physician defers attention
from clinical shortcomings (Stein, 1985). For example,
the African American experience has been well studied
(e.g., Powdermaker, 1939; Stack, 1974). Among the medical community, the importance of ethnicity and race as a
basis for the provision of health care are only now becoming apparent. In the case of cardiovascular disease, recent
studies document that African Americans are less likely
to receive the same types of preventive screening measures as European Americans, resulting in a higher morbidity and mortality rates, with African American women
being the most disadvantaged group. As Brown (2002)
states, Overall, the general pattern of care suggests that
African-American women may receive high-technology
cardiac treatment significantly less often than all other
race and sex categories. Racial disparities in the provision of health care are corroborated by other researchers
(e.g., Funk et al., 2002) and represent the tip of the
iceberg into the inquiry of ethnicity and race and as a
determinant of health care status.
By demonstrating the different socialization patterns
of European American and African American youth,
anthropology has provided a context for understanding
variances in health behavior and practice based on racial
categories (Boone, 1989; Heurtin-Roberts & Reisin, 1993;
Wilson, 1985). For instance, young African American
women have a less stereotypical body image, and they are
more comfortable with their own bodies (Parker et al.,
1995). In addition, among African American women condom use is motivated not by economic considerations but
by affective ties and notions of self-esteem (Sobo, 1995).
Self-supporting women with strong kinship ties demonstrate a higher incidence of condom use, while those
women who depended upon their male partners for
both affection and/or income are less likely to insist
upon condom use. Variation in such behavior has definite
implications for health status.
Another more recent example is an analysis of the
pushpull factors influencing alcoholism among Native
Americans (Spicer, 1997). Among members of this
group, alcohol is considered a communal commodity and
is thus shared freely; drinkers must be willing to provide
Social Stratification
Sexual Orientation
While pre-Boasian anthropology was interested in
maintaining Victorian morality, contemporary research
has little use for such prudery, and actively lobbies
against it (e.g., Deacon, 1997; Hare, 1985; Jacobus, 1990;
Mead, 1928; Roscoe, 1995). AIDS was and continues to
be a controversial issue, not just because of the politics of
identification and prevention, but also of treatment, such
as in the case of needle exchange programs. In activist
gay communities, alternative therapies for AIDSthat is,
those that do not conform to the standards of the medical
communitybecame normal and no longer alternative
(Eisenberg et al., 1993). AIDS has the highest percentage
of alternative therapy use of any chronic ailments.
Estimates of alternative therapy use among AIDS patients
range from 36% to 73%, compared with 7% for cancer
patients, and 5% among the general population (Furin,
1997). The disease came to be identified as a punishment
for unacceptable lifestyles, and disease as caused by sin
re-entered mainstream discourse about the disease.
Because of the AIDS epidemic, anthropological research
focused upon and found encouragement for studying the
drug subculture and the subculture of the homosexual
community within the United States (Furin, 1997; Singer
& Baer, 1995; Whitehead, 1997). Since AIDS was initially categorized as a gay disease, and because some men
who engaged in homosexual activity did not necessarily
think of themselves as gay, they did not think the warnings about AIDS applied to them. This has resulted in the
high frequency of AIDS among men who are members of
racial minorities. In the American context, African
American men who engage in homosexual behavior use
the term gay only in reference to homosexual European
American men (Whitehead, 1997). In the Washington,
DC, area, 66% of the new AIDS cases are African
American men who have low survival rates after diagnosis (Whitehead, 1997, p. 412). Whitehead (1997)
Constructing Hierarchy
Class
Strickland and Shetty (1998, pp. 2526) posit that
measures of health status, a relatively long-term property
of the individualtend to show more marked social class
differences. In the American context, the medical marketplace is the primary mode of health care delivery. As a
consequence, Heurtin-Roberts and Reisin (1993, p. 223)
point out that just as American affluence is not equitably
distributed, neither are our basic health care services.
In the American context, Appalachia is often
described as enamored of folk remedies. Cavendar and
Beck (1995, p. 140) argue that in fact, members of this
community are pragmatic, and though pious, are not
overly given to superstition or faith healing. Traditional
remedies, such as turpentine or onion poultices to treat
upper respiratory ailments, have slowly been replaced
with commodities available in todays health market,
namely pharmaceuticals and professional services.
Younger generations may express disdain for the backward ways of their parents and grandparents because they
have internalized the primitive characterization of this
type of healing as it has been expressed to them by outsiders (Cavendar & Beck, 1995, p. 140). The changing
health practices, namely a preference for health commodities, are reflective of the changing subsistence base
of this area.
As a class structure, incarcerated criminals constitute
the lowest social order in society. They are deprived of
rights, privileges, and often personhood itself (Foucault,
1975). Prisons are a particularly intriguing area of study,
especially from an anthropological perspective. Coupled
with the legal mandate of 1976 which required prisons to
provide adequate and timely medical care to inmates,
correctional systems have been searching for ways to
203
Gender
Perhaps one of the foremost determinants of social status
in the cross-cultural record is gender. The contemporary
feminist movement in anthropology dates to the 1970s
when Rosaldo and Lamphere (1974) published their
revolutionary work, and Ehrenreich and English (1978)
realized the feminist agenda through a meticulous
critique of the biomedical establishment. Their work
added to the existing literature on the health of minority
groups, but underscored the notion of biomedicine as a
means to enforce an amassed set of Euro-American
values (Jacobus, 1990). After examining the historical
relationship between women and biomedicine, they
proposed that the goal of medicine was to legitimate a
masculinist society, dressed up as objective truth
(Ehrenreich & English, 1978, p. 5; also Keller, 1985;
Martin, 1991). As patients, women are subordinate to
physicians and also to medical technology (e.g., Frank
et al., 1998). With respect to pharmaceuticals, women are
more likely to be prescribed psychotropic drugs than men,
owing to a higher incidence of what Estroff (1993) terms
I am diseases, such as anorexia. Thus, women not only
suffer from such diseases, but also from complete identification with them (see also Davis-Floyd, 1992). In the
genetic counseling industry, Rapp (1988) describes the
process from the points of view of the patient and
provider. The people who work in this industry tend to be
young women. However, because the job requires a fair bit
of emotional involvement with parents and helping them
to understand the meaning of genetic assay in their unborn
child, the rate of employee turnover tends to be fairly high.
204
Social Stratification
CONCLUSIONS
In taking a structural approach to the production of health
and disease, medical anthropology brings together
socioeconomic determinants and clinical practice in the
analysis of biomedicine. The result of this approach
demonstrates that definitions of health and health care
have a correlation with ethnicity, class, sexual orientation, and gender that serve as lenses through which the
biomedical establishment may be viewed. If good health
is a scarce commodity in a complex society such as the
United States, its distribution is necessarily dependent
upon social status. Anthropological contributions to discussions of health and disease demonstrate that the
administration of health care is a means of social control.
Despite new health technologies and methods of health
care delivery, their patterns of use are largely informed by
entrenched social and political mores (e.g., Sinha, 2000).
The advantage to the anthropological approach is that
issues of power and agency are inserted into the dialogue
of clinical biomedicine that otherwise narrowly focuses
on pathogens and individual biological processes. By
using the tools of social analysis, medical anthropology
References
REFERENCES
Anagnost, A. (1995). A surfeit of bodies: Population and the rationality
of the state in post-Maoist China. In F. D. Ginsburg & R. Rapp
(Eds.), Conceiving the new world order (pp. 2241). Berkeley:
University of California Press.
Banerji, D. (1982). Poverty, class and health culture in India. New
Delhi: Prachi Prakashan.
Boone, M. (1989). Capital crime: Black infant mortality in America.
Newbury Park, CA: Sage.
Brearley, P. et al. (1978). The social context of health care. London:
Martin Robertson.
Brown, S. L. (2002). Race and sex differences in the use of cardiac
procedures for patients with ischemic heart disease in Maryland.
Journal of Health Care for the Poor and Underserved, 4, 526537.
Cassell, J. (1996). The woman in the surgeons body: Understanding
difference. American Anthropologist, 1, 4153.
Cavendar, A. P., & Beck, S. H. (1995). Generational change, folk medicine, and medical self-care in a rural Appalachian community.
Human Organization, 2, 129142.
Comaroff, J., & Comaroff, J. (1992). Ethnography and the historical
imagination: Studies in the ethnographic imagination. Boulder,
CO: Westview Press.
Coplan, D. B. (1992). Fictions that save: Migrants performance and
Basotho national culture. In G. E. Marcus (Ed.), Rereading cultural
anthropology (pp. 267295). Durham, NC: Duke University Press.
Csordas, T. (1988) The conceptual status of hegemony and critique in
medical anthropology. Medical Anthropology Quarterly, 2,
416421.
Davis-Floyd, R. (1992). Birth as an American rite of passage. Austin:
University of Texas Press.
Deacon, D. (1997). Elsie Clews Parsons. Chicago: University of
Chicago Press.
Douglas, M. (1966). Purity and danger: An analysis of the concepts of
pollution and taboo. New York: Pantheon Books.
Ehrenreich, B., & English, D. (1978). For her own good: 150 Years of
the experts advice to women. New York: Doubleday.
Eisenberg, D. M., Kessler, R. C., Foster, C., Norlock, F. E., Calkins,
D. R., & Delbanco, T. L. (1993) Unconventional medicine in the
United States. The New England Journal of Medicine, 4, 252256.
Estroff, S. (1993). Identity, disability, and schizophrenia. In
S. Lindenbaum & M. Lock (Eds.), Knowledge, practice, and
power (pp. 247286). Berkeley: University of California Press.
Finerman, R. (1989). The burden of responsibility: Duty, depression,
and nervios in Andean Ecuador. In D. Davis & S. Low (Eds.),
Gender, health, and illness (pp. 141157). New York: Hemisphere.
Foster, G., & Anderson, B. G. (1978). Medical anthropology. New York:
Knopf.
Foucault, M. (1963). The birth of the clinic: An archaeology of medical
perception (A. M. Sheridan Smith, Trans.). New York: Vintage
Books.
205
Foucault, M. (1975). Discipline and punish: The birth of the prison
(A. Sheridan, Trans.). New York: Vintage Books.
Frank, A. G. (1966). The development of underdevelopment. In Wilber
and Jacobsen (Eds.), The political economy of development and
underdevelopment (pp. 107118).
Frank, G., Blackhall, L. J., Michel, V., Murphy, S. T., Azen, S. P., &
Part, K. (1998). A discourse of relationships in bioethics: Patient
autonomy and end-of-life decision making among elderly Korean
Americans. Medical Anthropology Quarterly, 4, 403423.
Funk, M. et al. (2002). Racial differences in the use of cardiac
procedures in patients with acute myocardial infarction. Nursing
Research, 3, 148157.
Furin, J. J. (1997). You have to be your own doctor: Sociocultural
influences on alternative therapy use among gay men with AIDS
in West Hollywood. Medical Anthropology Quarterly, 4, 498504.
Gilman, C. P. (1993). In T. Erskine & C. Richards (Eds.), The yellow
wallpaper. (Reprint of edition) New Brunswick, NJ: Rutgers
University Press.
Gramsci, A. (1971). Selections from the prison notebooks. London:
Lawrence & Wisheart.
Habermas, J. (1970). Towards a theory of communicative competence.
Inquiry, 4, 360375.
Hare, P. (1985). A womans quest for science: Portrait of anthropologist
Elsie Clews Parsons. Buffalo, NY: Prometheus Books.
Harrison, F. V. (1999). Introduction: Expanding the discourse on race.
American Anthropologist, 3, 609631.
Heurtin-Roberts, S., & Reisin, E. (1993). Folk models of hypertension
among black women: Problems in illness management. In
J. Coreil & J. D. Mull (Eds.), Anthropology and primary health
care (pp. 222250). Boulder, CO: Westview Press.
Hipkins, J. H. (1997). Telemedicine in correctional systems. In
R. Bashshur, J. H. Sanders, & G. Shannon (Eds.), Telemedicine:
Theory and practice (pp. 375390). Springfield, IL: Charles
C. Thomas.
Jacobus, M. (1990). In parenthesis: Immaculate conceptions and
feminine desire. In M. Jacobus, E. F. Keller, & S. Shuttleworth
(Eds.), Body/politics: Women and the discourses of science
(pp. 1128). New York: Routledge.
Jones, R. (1994). Songs from the village: An ethnography of gender,
reproduction, and sexuality in St. Lucia, West Indies (Doctoral
dissertation, Southern Methodist University, 1994).
Keller, E. F. (1985). Reflections on gender and science. New Haven, CT:
Yale University Press.
Kleinman, A. (1980). Patients and healers in the context of culture : An
exploration of the borderland between anthropology, medicine,
and psychiatry. Berkeley: University of California.
Krauss, I. (1976). Stratification, class, and conflict. New York: Free Press.
Lantz, P., Dupuis, L., Reding, D., Kerauska, M., & Lappe, K. (1994).
Peer discussions of cancer among migrant farm workers. Public
Health Reports, 4, 512520.
Laurence, L., & Weinhouse, B. (1994). Outrageous practices: The
alarming truth about how medicine mistreats women. New York:
Fawcett Columbine.
Levy, M. (1987). A piece of my mind: Dr Mom. Journal of the
American Medical Association, 4, 536.
Lock, M. (1993). The politics of mid-life and menopause: Ideologies for
the second sex in North America and Japan. In S. Lindenbaum &
206
M. Lock (Eds.), Knowledge, practice, and power (pp. 330363).
Berkeley: University of California Press.
Low, S. (1989). Gender, emotion, and nervios in Urban Guatemala.
In D. Davis & S. Low (Eds.), Gender, health, and illness
(pp. 116140). New York: Hemisphere.
Mascie-Taylor, G. G. N. (1995). The anthropology of disease.
New York: Oxford Science.
Martin, E. (1991). The egg and the sperm: How science has constructed
a romance Based on stereotypical male and female roles. Signs, 31,
485501.
Mead, M. (1928). Coming of age in Samoa. New York: William
Morrow.
Morgan, L. (1987). Dependency theory in the political economy of
health: An anthropological critique. Medical Anthropology
Quarterly, 2, 131154.
Morsy, S. (1990). Political economy in medical anthropology. In
T. Johnson & C. Sargent (Eds.), Medical anthropology:
Contemporary theory and method (pp. 2646). New York: Praeger.
Morsy, S. (1993). Bodies of choice: Norplant experimental trials on
Egyptian women. In B. Mintzes, A. Hardon, & J. Hanhart (Eds.),
Norplant under her skin. Amsterdam: Womens Health Action
Foundation.
Morsy, S. (1995). Deadly reproduction among Egyptian women:
Maternal mortality and the medicalization of population control.
In F. D. Ginsburg & R. Rapp (Eds.), Conceiving the New World
Order (pp. 162176). Berkeley: University of California Press.
Navarro, V. (1981). The underdevelopment of health or the health of
underdevelopment: An analysis of the distribution of human health
resources in Latin America. In V. Navarro (Ed.), Imperialism,
health, and medicine (pp. 1536). Farmingdale, NY: Baywood.
Navarro, V. (1986). U.S. Marxist Scholarship in the analysis of health
and medicine. International Journal of Health Services, 15,
525545.
Parker, S. et al. (1995). Body image and weight concerns among
African American and white adolescent females: Differences that
make a difference. Human Organization, 2, 103114.
Pearce, T. O. (1993). Lay medical knowledge in an African context. In
S. Lindenbaum & M. Lock (Eds.), Knowledge, practice, and
power (pp. 150165). Berkeley: University of California Press.
Pearce, T. O. (1995). Womens reproductive practices and biomedicine.
In F. D. Ginsburg & R. Rapp (Eds.), Conceiving the New World
Order (pp. 195208). Berkeley: University of California Press.
Pickett, J. et al. (Eds.). (2000). The American Heritage Dictionary of the
English Language. Boston: Houghton Mifflin.
Powdermaker, H. (1939). After freedom: A cultural study in the Deep
South. New York: Viking Press.
Rapp, R. (1988). Chromosomes and communication: The discourse
of genetic counseling. Medical Anthropology Quarterly, 2,
143157.
Social Stratification
Rebhun, L. A. (1993). Nerves and emotional play in Northeast Brazil.
Medical Anthropology Quarterly, 2, 131152.
Rosaldo, M. Z., & Lamphere, L. (1974). Woman, culture, and society.
Stanford, CA: Stanford University Press.
Roscoe, P. B. (1995). The perils of positivism. American Anthropologist,
3, 492504.
Shils, E. (1970). Deference. In E. O. Laumann P. M. Seigel, & R. W.
Hodge. (Eds.), The logic of social hierachies. Chicago: Markham.
Singer, M. (1990). Reinventing medical anthropology: Toward a critical
realignment. Social Science and Medicine, 2, 179187.
Singer, M. (1996). The evolution of AIDS work in a Puerto Rican
community organization. Human Organization, 1, 6775.
Singer, M., & Baer, H. (1995). Critical medical anthropology. Amityville,
NY: Baywood.
Singer, M., & Marxuach-Rodriguez, L. (1996). Applying anthropology
to the prevention of AIDS: The Latino Mens Health Project.
Human Organization, 2, 141148.
Sinha, A. (2000). An overview of telemedicine: The virtual gaze of
healthcare in the next century. Medical Anthropology Quarterly, 3,
291309.
Sobo, E. J. (1995). Finance, romance, social support, and condom use
among impoverished inner-city women. Human Organization, 2,
115128.
Sowell, T. (1983, November). Second thoughts about the Third World.
Harpers Magazine, 2442.
Spicer, P. (1997). Toward a (dys)functional anthropology of drinking:
Ambivalence and the American Indian experience with alcohol.
Medical Anthropology Quarterly, 3, 306323.
Stack, C. (1974). All our kin: Strategies for survival in a black community. New York: Basic Books.
Stein, H. (1985). The culture of the patient as a red herring in clinical decision making: A case study. Medical Anthropology Quarterly, 1, 24.
Strickland, S. S., & Shetty, P. S. (1998). Nimah biology and social
inequality. Cambridge, UK: Cambridge University Press.
Tumin, M. (1994). Some principles of stratification: A critical analysis.
In D. Grusby (Ed.), Social stratification: Class, race & gender.
Boulder, CO: Westview Press.
Waitzkin, H. (1979). Medicine superstructure and micropolitics. Social
Science and Medicine, 13a, 601609.
Whiteford, L. M., & Poland, M. L. (Eds.). (1989). New approaches to
human reproduction. Boulder, CO: Westview Press.
Whitehead, T. (1997). Urban low income African American men,
HIV/AIDS, and gender identity. Medical Anthropology Quarterly,
4, 411447.
Wilson, R. P. (1985). An ethnomedical analysis of health beliefs, health
behavior, and hypertension among low income black Americans
(Doctoral dissertation, Stanford University, 1985).
Wilkerson, R. (1996). Unhealthy societies: The afflictions of inequality.
New York: Routledge.
207
INTRODUCTION
Health outcomes are inextricably linked to poverty
(Farmer, Conners, & Simmons, 1996), and as a result
anthropologists studying urban populations have devoted
considerable attention to understanding and representing
the health conditions of the urban poor. Anthropological
portrayals of the poor have altered over time. Despite
earlier social science research documenting the disturbing health outcomes among the urban poor (e.g., Engels,
1892; Liebow, 1967; Spradley, 1970), there was relatively
little ethnographic research that integrated theory from
both urban and medical anthropology prior to the 1980s
(Foster & Kemper, 1996). Even then, wary of misrepresenting the poor through reductionist stereotypes, anthropologists have often evaded focused analysis of urban
poverty (Bourgois, 1995). The intent of this entry is to
both summarize the health challenges faced by people
living in urban poverty and briefly trace theoretical
approaches to the urban poor.
Anthropologists have variously referred to poor
urban areas as ghettos (e.g., Hannerz, 1969) urban
slums (Whyte, 1943), squatter settlements (Glasser,
1994), or inner-cities (Singer, 1994; Wallace et al.,
1994). The nuanced meaning of each of the above terms,
and the appropriateness of each to describe poor urban
populations, has been previously discussed and debated
(Hannerz, 1969, 1980), and will not be covered here. For
the purposes of this entry, I will use the term used to
describe the locale by the authors at the time of their
research, with the caveat that each term clearly reflects the
historical and political setting of the research. For lack of
a better general term, I will use urban poor to refer to
those most often vulnerable to disease in urban settings.1
The review will also look at what anthropology has
brought to the study of the health of the urban poor, and
what it can potentially contribute in the future. Physical,
cultural, and medical anthropologists have all contributed
THREATS TO HEALTH
URBAN POOR
AMONG THE
208
Homelessness
Homelessness is not a problem exclusive to urban areas,
but the poor living in cities are especially vulnerable to
being left without shelter. Overcrowding, inadequate housing, unemployment, policies directed against the poor and
working class, gentrification, and, in the United States, the
de-institutionalization of mental hospitals in the 1970s
have all been cited as factors contributing to urban homelessness (Baer, Singer, & Susser, 1997; Glasser, 1994;
Hopper, 1988). In particular, poor urban youth are at risk
for homelessness. Facing sexual or physical abuse, inadequate family resources, or rejection because of sexual identity, some youth may choose to or be forced to leave home
(Clatts, Davis, Sotheran, & Atillasoy, 1998; Glasser, 1994).
Violence
Exposure to violence is another widely acknowledged
problem for the poor living in urban settings, especially
the homeless (Glasser, 1994). Researchers have conceptualized the proliferation of violence in cities as the result
of: (1) clashes between ethnic and social boundaries
(Merry, 1981, 1996); (2) rapid social disintegration
(Wallace, 1990); (3) the result of familial stigma and the
misuse of state power (Glasser, 1994; Hecht, 1998);
(4) gender power differences and homophobia (Asencio,
1999); and (5) as the byproduct of the inherent danger of
operating in an underground economy (Bourgois, 1995,
1998). Violence is also closely associated with illicit substance use and alcoholism (Singer, 1994; Wallace, 1990),
both of which are linked to HIV risk directly through the
sharing of contaminated needles (Singer, 1996), trading
sex for drugs (Sterk, Elifson, & German, 2000), and indirectly through decreases in inhibition (Stall, HeurtinRoberts, McKusick, Hoff, & Wanner-Lang, 1990).
Malnutrition
Malnutrition is a threat for both rural and urban dwellers
worldwide (Schell, 1996). As already noted, malnutrition
is one of many issues in the web of health problems
facing the urban poor and homeless. Although the inability to purchase basic foodstuffs is a critical factor in
Anthropological Theory and Urban Poverty: Ways of Representing the Urban Poor
Infectious Disease
Infectious disease is a focal point of urban medical
anthropological literature in developing countries, and
international health research. The poor in urban areas of
developed countries and developing countries, often
malnourished or with compromised immune systems, are
vulnerable to infectious disease because of inadequate
shelter, sanitation, and inaccess to basic heath care or lack
of health insurance. For example, despite heightened
attention, education, and improvements in sanitation,
acute diarrhea remains a health threat, and a leading cause
of death for young children worldwide (Kendall, 1991).
Children with inadequate or no housing are especially at
risk for diarrheal disease because of the unavailability of
clean water and sanitation services (Glasser, 1994).
Describing her ethnographic work in Brazilian favelas,
Scheper-Hughes (1984, 1985) argues that rates of infant
mortality are so common, and resources so scarce, that
mothers have developed emotional strategies for coping
with the awareness that some of their children may die.
For example, mothers may not name their children immediately to prevent bonding to a child who may not survive,
or they may favor children perceived as hardier and thus
more likely to survive to the detriment of weaker more
vulnerable children. Nation and Rebhun (1988) argue that
mothers were far from inured to the death of children, but
simply did not have the economic means of obtaining
adequate health care for their children. The structural constraints influencing infant mortality are addressed in detail
by Scheper-Hughes (1992). Tuberculosis, medically manageable with access to adequate health care, is often fatal
to the poor in both rural and urban areas of the developing
world (Farmer, 1999).
209
210
Conclusion
211
ON
Structural Violence
Farmer and colleagues argue that the poor, through
their experience of social inequality, discrimination, and
limited choice endure a structural violence that concretely
manifests on a local level (Farmer, 1999; Farmer et al.,
1996). Central to the concept of structural violence is an
evaluation of how disease is linked to social inequality,
class, and ethnicity. Dresslers (1993) research, for
example, demonstrates that skin color is significantly
associated with hypertension mediated socially through
experiences of racism and not genetically. Singer argues
that the high rates of drug use among urban minorities
reflects an attempt to alleviate the depression and low
self-esteem engendered by the frustration of enduring
perpetual racism and poverty (Baer et al., 1997;
Singer, 1994).
Urban Syndemics
The idea of structural violence is premised, in part, on
Wallaces analysis of the multiple layers of societal and
structural factors that place individuals at risk for HIV
(Wallace, 1988, 1990). Capturing a wider trend in urban
areas with systemic implications for poverty and health,
Wallace recounts how urban deterioration in the Bronx,
loss of municipal and public health sector funds, in conjunction with widespread fires, combined to result in an
environment conducive to the rapid spread of HIV. Singer
(1994) first described what he termed syndemics of the
urban poor. Syndemics, fully explained by Baer, Singer,
and Susser (1997) below, are intertwined and mutually
reinforcing health issues and social conditions of the
urban poor:
Health in the inner-city is a product of a particular set of closely
interrelated endemic and epidemic diseases, all of which are strongly
influenced by a broader set of political-economic and social factors,
including high rates of unemployment, poverty, homelessness, and
residential overcrowding, substandard nutrition, environmental toxins,
and related health risks, infrastructural deterioration and loss of housing stock, forced geographic mobility, family breakup and disruption of
social support networks, youth gangs and drug-related violence, and
health care inequality. (Baer et al., 1997, p. 174)
CONCLUSION
Clearly, anthropology has much to bring to the task of
comprehending and effectively addressing health problems related to urban poverty. Anthropological research
has effectively represented and portrayed the sociocultural, biological, and structural components of health and
disease for the urban poor. Rich ethnographic descriptions illuminate the complexities of the daily struggles of
the urban poor, while capturing the historical processes
and political and economic roots of their vulnerability to
212
NOTE
1. Susser, however, cautions that a limitation of the term urban poor
is its implication that the poor are separate and not an integral
component of dynamic economic systems.
REFERENCES
Armelagos, G., Ryan, M., & Leatherman, T. (1990). Evolution of infectious diseasea biocultural analysis of AIDS. American Journal
of Human Biology, 2(4), 353363.
Asencio, M. (1999). Machos and sluts: Gender, sexuality, and violence
among a cohort of Puerto Rican adolescents. Medical
Anthropology Quarterly, 13(1), 107126.
Baer, H. A., Singer, M., & Susser, I. (1997). Medical anthropology and
the world system. Westport, CT: Bergin & Garvey.
Basham, R. (1978). Urban anthropology: The cross-cultural study of
complex societies. Palo Alto, CA: Mayfield.
Bourgois, P. (1995). In search of respect: Selling crack in El Barrio.
New York: Cambridge University Press.
Bourgois, P. (1996). Office work and the crack alternative among Puerto
Rican drug dealers in East Harlem. In G. Gmelch & W. P. Zenner
(Eds.), Urban life, readings in urban anthropology (pp. 418431).
Prospect Heights, IL: Waveland Press.
Bourgois, P. (1999). The moral economies of homeless heroin addicts:
Confronting ethnography, HIV risk, and everyday violence in
San Francisco shooting encampments. Substance Use and Misuse,
33(11), 23232351.
Clatts, M. C., Davis, W. R., Sotheran, J. L., & Atillasoy, A. (1998).
Correlates and distribution of HIV risk behaviors among homeless
youth in New York City: Implications for prevention and policy.
Child Welfare, 77(2), 195207.
Clatts, M. C., & Davis. W. R. (1999). A demographic and behavioral
profile of homeless youth in NYC: Implications for AIDS outreach
and prevention. Medical Anthropology Quarterly, 13(3), 365374.
Decosas, J., & Padian, N. (2002). The profile and context of the
epidemics of sexually transmitted infections including HIV in
Zimbabwe. Sexually Transmitted Infections, 78(1), 140146.
Dressler, W. (1990). Culture, stress and disease. In T. M. Johnson &
C. F. Sargent (Eds.), Medical anthropology: Contemporary theory
and method (pp. 248268). New York: Praeger.
Dressler, W. (1993). Health in the African-American community:
Accounting for health inequalities. Medical Anthropology
Quarterly, 7(4), 325345.
Eames, E., & Goode, J. (1996). Coping with poverty: A cross-cultural
view of the behavior of the poor. In G. Gmelch & W. P. Zenner
(Eds.), Urban life, readings in urban anthropology (pp. 378392).
Prospect Heights, IL: Waveland Press.
Engels, F. (1892). The condition of the working-class in England in
1844. London: Swan Sonnenschein & Co.
Farmer, P. (1995). Culture, poverty, and the dynamics of HIV transmission in rural Haiti. In: H. Brummelhuis and G. Herdt (Eds.):
Culture and Sexual Risk: Anthropological Perspectives on AIDS.
New York: Gordon: 328.
Farmer, P. (1999). Infections and inequalities: The modern plagues.
Berkeley: University of California Press.
Farmer, P. E., Conners, M., & Simmons, M. (Eds.). (1996). Women,
poverty, and AIDS: Sex, drugs, and structural violence. Monroe,
ME: Common Courage Press.
Farmer, P., Lindenbaum, S., & DelVeccio-Good, M. J. (1993). Women,
poverty and AIDS: An introduction. Culture, Medicine, and
Psychiatry, 17, 387397.
Foster, G. M., & Kemper, R. V. (1996). Fieldwork in cities. In
G. Gmelch & W. P. Zenner (Eds.), Urban life, readings in urban
anthropology (pp. 135150). Prospect Heights, IL: Waveland Press.
Fullilove, M., Green, L., & Fullilove, R. (1999a). Building momentum:
An ethnographic study of inner-city redevelopment. American
Journal of Public Health, 86(6), 840844.
Fullilove, R. E., Fullilove, M. T., Northridge, M. E., Ganz, M. L.,
Basset M. T., McLean D. E., et al. (1999b). Risk factors for excess
mortality in Harlem: Findings from the Harlem Household Survey.
American Journal of Preventive Medicine, 16(3S), 2228.
Glasser, I. (1994). Homelessness in global perspective. New York:
G.K. Hall.
Goode, J., & Eames, E. (1996). An anthropological critique of the
culture of poverty. In G. Gmelch & W. P. Zenner (Eds.), Urban life,
readings in urban anthropology (pp. 405417). Prospect Heights,
IL: Waveland Press.
Hannerz, U. (1969). Soulside. New York: Columbia University Press.
Hannerz, U. (1980). Exploring the city: Inquiries toward an urban
anthropology. New York: Columbia University Press.
Hecht, T. (1998). At home in the street: Street children of Northeast
Brazil. Cambridge, U.K.: Cambridge University Press.
Himmelgreen, D., Perez-Escamilla, R., Segura-Millan, S., Peng, Y.,
Gonzalez, A., Singer, M., et al. (2000). Food insecurity among low
income Hispanics in Hartford, CT: Implications for the public
health policy. Human Organization, 59(3), 334342.
Hopper, K. (1988). More than passing strange: homelessness and mental
illness in New York City. American Ethnologist, 15(1): 155167.
Jochelson, K., Mothibeli M., and J. P. Leger. (1991). Human immunodeficiency virus and migrant labor in South Africa. International
Journal of Health Services: Planning, Administration, Evaluation
2191: 157173.
References
Kendall, C., Hudelson, P., Leontsini, E., Winch, P., Lloyd, L., & Cruz, F.
(1991). Urbanization, Dengue, and the health transition:
Anthropological contributions to international health. Medical
Anthropology Quarterly, 5(3), 257268.
Liebow, E. (1967). Tallys corner. Boston: Little, Brown.
Low, S. (1999). Introduction. Theorizing the city. In S. M. Low (Ed.),
Theorizing the city: The new urban anthropology reader
(pp. 136). New Brunswick, NJ: Rutgers University Press.
Manderson, L. (1998). Applying medical anthropology in the control of
infectious disease. Tropical Medicine and International Health,
3(12), 10201027.
Marks, C. (1991). The urban underclass. Annual Review of Sociology,
17, 445466.
McDade, T. W., & Adair, L. S. (2001). Defining the urban in urbanizations and health: A factor analysis approach. Social Science and
Medicine, 53, 5570.
Merry, S. E. (1981). Urban danger: Life in a neighborhood of strangers.
Philadelphia, PA: Temple University Press.
Merry, S. E. (1996). Urban danger: Life in a neighborhood of strangers.
In G. Gmelch & W. P. Zenner (Eds.), Urban life, readings in urban
anthropology (pp. 4759). Prospect Heights, IL: Waveland Press.
Morsy, S. (1990). Political economy in medical anthropology. In
T. M. Johnson & C. F. Sargent (Eds.), Medical anthropology:
Contemporary theory and method (pp. 2646). New York: Praeger.
Nation, M., & Rebhun, L. (1988). Angels with wet wings wont fly.
Culture, Medicine and Psychiatry, 12(2), 141200.
Parker, R. (1995). The social and cultural construction of sexual risk, or
how to have (sex) research in an epidemic. In: H. Brummelhuis and
G. Herdt (Eds.): Culture and Sexual Risk: Anthropological
Perspectives on AIDS. New York: Gordon: 257269.
Parker, R., Easton, D., & Klein, C. (2000). Structural barriers and
facilitators in HIV prevention: A review of international research.
In E. Sumartojo & M. Laga (Eds.), AIDS: Structural factors in HIV
prevention, 14(Suppl. 1), S22S32.
Romero-Daza, N., & Himmelgreen, D. (1998). More than your money
for labor: Migration and the political economy of AIDS. In
M. Singer (Ed.), The political economy of AIDS (pp. 185204).
New York: Baywood.
Rubenstein, R. A., & Lane, S. D. (1990). International health and
development. In T. M. Johnson & C. F. Sargent (Eds.), Medical
anthropology: Contemporary theory and method (pp. 367390).
New York: Praeger.
Sabatier, R. (1996). Migrants and AIDS: Themes of vulnerability and
resistance. In M. Haour-Knipe & R. Rector (Eds.), Crossing
borders: Migration, ethnicity and AIDS (pp. 87101). London:
Taylor & Francis.
Sanjek, R. (1990). Urban anthropology in the 1980s: A worldview.
Annual Review of Anthropology, 19, 151186.
Schell, L. M. (1996). Cities and human health. In G. Gmelch &
W. P. Zenner (Eds.), Urban life, readings in urban anthropology
(pp. 135150). Prospect Heights, IL: Waveland Press.
Schensul, S. and M. Borrero. (1982). Introduction: The Hispanic Health
Council. Urban Anthropology, 11(1): 18
Scheper-Hughes, N. (1984). Infant mortality and infant care: cultural
and economic constraints on nurturing in Northeast Brazil. Social
Science and Medicine 1995: 535546.
Scheper-Hughes, N. (1985). Culture, scarcity, and maternal thinking:
maternal detachment and infant survival in a Brazilian shantytown.
Ethos 13(4): 291317.
213
Scheper-Hughes, N. (1992). Death without weeping: The violence of
everyday life in Brazil. Berkeley: University of California Press.
Schoepf, B. G. (1992). Gender relations and development: Political
economy and culture. In A. Seidman, & F. Anang (Eds.), TwentyFirst century Africa: Toward a new vision of self-sustaining development (pp. 203241). Trenton, NJ: Africa World Press.
Schoepf, B. G., Engundu, W., Wa Nkera, R., Ntsomo, R., & Schoepf, C.
(1991). Gender, power, and risk of AIDS in Zaire. In M. Turshen
(Ed.), Women and health in Africa. Trenton, NJ: Africa World Press.
Singer, M. (1994). AIDS and the health crisis of the U.S. urban poor:
The perspective of critical medical anthropology. Social Science
and Medicine, 39(7), 931948.
Singer, M. (1996). A dose of drugs, a touch of violence, a case of
AIDS: Conceptualizing the SAVA syndemic. Free Inquiry, 24(2),
99110.
Spradley, J. (1970). You Owe Yourself a Drunk: An Ethnography of
Urban Nomads. Boston: Little Brown.
Stack, C. B. (1974). All our kin: Strategies for survival in a black
community. New York: Harper & Row.
Stall, R., Heurtin-Roberts, S., McKusick, L., Hoff, C., & Wanner-Lang, S.
(1990). Sexual risk for HIV transmission among singles-bar patrons
in San Francisco. In R. Vlack & W. F. Skinner (Eds.), AIDS and the
social sciences: Common threads (pp. 100123). Lexington:
University of Kentucky Press.
Sterk, C. E., Elifson, K. W., & German, D. (2000). Female crack users
and their sexual relationships: The role of sex-for-crack exchanges.
The Journal of Sex Research, 37(4), 354360.
Susser, I. (1982). Norman street: Poverty and politics in an urban neighborhood. New York: Oxford University Press.
Susser, I. (1999). Creating family forms: The exclusion of men and
teenage boys from families in the New York City shelter system. In
S. M. Low (Ed.), Theorizing the city: The new urban anthropology
reader (pp. 6782). New Brunswick, NJ: Rutgers University Press.
Susser, I., & Kreniske, J. (1997). Community organizing around HIV
prevention in rural Puerto Rico. In G. C. Bond, J. Kreniske,
I. Susser, & J. Vincent (Eds.), AIDS in Africa and the Caribbean,
(pp. 5164). Boulder, CO: Westview Press.
Susser, I., & Stein, Z. (2000). Culture, sexuality, and womens agency
in the prevention of HIV/AIDS in Southern Africa. American
Journal of Public Health, 90(7), 10421048.
Voeten, H., Egesah, O., Ondiege, M., Varkevisser, C., & Habbema, J. D.
(2002). Clients of female sex workers in Nyanza Province, Kenya:
A core group in STD/HIV transmission. Sexually Transmitted
Infections, 29(8), 444452.
Wallace, R. (1988). A synergism of plagues: Planned shrinkage,
contagious housing destruction and AIDS in the Bronx.
Environmental Research, 47, 133.
Wallace, R. (1990). Urban desertification, public health and public
order: Planned shrinkage, violent death, substance abuse and AIDS
in the Bronx. Social Science and Medicine, 31(7), 801813.
Wallace, R., Fullilove, M, Fullilove, R., Gould P., and D. Wallace
(1994). Will AIDS be contained within U.S. minority populations?
Social Science and Medicine 39(8): 10511062.
Waterston, A. (1993). Street addicts in the political economy.
Philadelphia, PA: Temple University Press.
Whyte, W. F. (1943). Street corner society. Chicago: University of
Chicago Press.
Aging
Jay Sokolovsky
AN ANTHROPOLOGY
OF
AGING
217
218
Aging
OF
GENDER
AND
AGING
219
STATUS
OF THE
AGED
220
Aging
AGING POPULATIONS
GLOBAL CONTEXT
IN A
Notes
221
Table 1. Some Demographic Comparisons Between More and Less Developed Regions
Region
More developed
regions
Less developed
regions
Least developed
regions
Population aged
60 years or older.
Percentage of total
population
Percentage 80 years
or older
Potential Support
Ratio (number of
persons aged
1564 years per
aged 65 years
or older)
1999
2050
1999
2050
1999
2050
19
33
16
27
21
17
12
12
10
18
Source: United Nations (1999). Population Aging, 1999. United Nations, Population Division, Sales No. E.99.XIIII.11.
Reprinted with permission.
NOTES
1. There have also been a good number of recent special issues of
journals which have focused on the anthropology of aging. These
include: Positive Adaptations to Aging in Cross-Cultural
Perspective. Special Issue of Journal of Cross-Cultural Gerontology,
16(1), 2001; Aging and Eldercare, Journal of Family Issues, 21(6),
2000; Home Health Care and Elders: International Perspectives.
Special Issue of Journal of Cross-Cultural Gerontology, 8(4), 1993;
Cultural Contexts of Aging and Health, Special Issue of Medical
Anthropology Quarterly, 9(2), 1995.
222
2. The most comprehensive bibliography on the anthropology of aging
is Schweitzer (1991). However, new information about ongoing
ethnographic aging research and related publications can be
followed through the Cultural Context of Aging web site at
http://www.stpt.usf.edu/~jsokolov.
REFERENCES
Aguilar, M. (Ed.). (1998). The politics of age and gerontocracy in
Africa: Ethnographies of the past and memories of the present.
Lawrenceville, NJ: Africa World Press.
Albert, S., & Cattell, M. (1994). Old age in global perspective: Crosscultural and cross-national views. New York: G. K. Hall.
Amoss, P., & Harrell, S. (Eds.). (1981). Other ways of growing old:
Anthropological perspectives. Stanford, CA: Stanford University
Press.
Arnsberger, P., Fox, P., Xivlan, Z., & Shixun, G. (2000). Population
aging and the need for long-term care: A comparison of the United
States and the Peoples Republic of China. Journal of CrossCultural Gerontology, 15, 207227.
Barker, J. (1997). Between humans and ghosts: The decrepit elderly in
a Polynesian society. In J. Sokolovsky (Ed.), The cultural context
of aging: World-wide perspectives (2nd ed., pp. 407425).
Westport, CT: Bergin & Garvey.
Bateson, G. (1950). Cultural ideas about aging. In E. P. Jones (Ed.),
Research on aging. Berkeley: University of California Press.
Becker, G. (1980). Growing old in silence. Berkeley: University of
California Press.
Bever, E. (1982). Old age and witchcraft in early modern Europe. In
P. Sterns (Ed.), Old age in preindustrial society (pp. 150190).
New York: Holmes & Meier.
Beyene, Y. (1989). From menarche to menopause: Reproductive lives of
peasant women in two cultures. Albany: State University of
New York Press.
Bledsoe, C. (2002). Contingent lives: Fertility, time and aging in West
Africa. Chicago, IL: University of Chicago Press.
Bossen, L. (2002). Chinese older women and rural development.
Totowa, NJ: Rowan & Littlefield.
Brown, J., Subbaiah, P., & Therese, S. (1994). Being in charge: Older
women and their younger female kin. Journal of Cross-Cultural
Gerontology, 9, 231254.
Cattell, M. (1995). Gender, aging and health: A comparative approach.
In C. Sargent & C. Brettell (Eds.), Gender and health: An international perspective (pp. 87122). New York: Prentice Hall.
Clark, M. (1967). The anthropology of aging: A new area for studies of
culture and personality. Gerontologist, 7, 5564.
Clark, M., & Anderson, B. (1967). Culture and aging: An anthropological study of older Americans. Springfield, IL: Charles Thomas.
Cohen, L. (1998). No aging in India. Berkeley: University of California
Press.
Counts, D., & Counts, D. (Eds.). (1985). Aging and its transformations:
Moving toward death in Pacific societies. New York: University
Press of America.
Cool, L., & McCabe, J. (1987). The scheming hag and the dear old
thing: The anthropology of aging women. In J. Sokolovsky (Ed.),
Aging
Growing old in different societies: Cross-cultural perspectives
(pp. 5668). Acton, MA: Copley.
Cowgill, D. (1974). The aging of populations and society. The Annals of
the American Academy of Political and Social Sciences, 415, 118.
Cowgill, D. (1986). Aging around the world. Belmont, CA: Wadsworth.
Cowgill, D., & Holmes, L. D. (Eds.). (1972). Aging and modernization.
New York: AppletonCenturyCrofts.
Crews, D., & Garruto, R. (Eds.). (1994). Biological anthropology and
aging. New York: Oxford University Press.
Davis-Friedman, D. (1991). Long lives: Chinese elderly and the
communist revolution. Stanford, CA: Stanford University Press.
du Toit, B. (1990). Aging and menopause among Indian South African
women. Albany: State University of New York Press.
Flint, M., & Samil, R. (1990). Cultural and subcultural meanings of the
menopause. Annals of the New York Academy of Sciences, 592,
134148.
Foner, N. (1994). The caregiving dilemma. Berkeley: University of
California Press.
Freidenberg, J. (2000). Growing old in El Barrio. New York: New York
University Press.
Fry, C. (1981). Dimensions: Aging, culture and health. Brooklyn, NY:
J. F. Bergin.
Fry, C. (1980). Aging in culture and society, comparative viewpoints
and strategies. Brooklyn, NY: J. F. Bergin.
Fry, C. (2000). Culture, age, and subjective well-being: Health, functionality, and the infrastructure of eldercare in comparative
perspective. Journal of Family Issues, 21, 751756.
Fry, C., & Keith, J. (1986). New methods for old age research. Westport,
CT: Greenwood.
Glascock, A. (1997). When killing is acceptable: The moral dilemma
surrounding assisted suicide in America and other societies. In
J. Sokolovsky (Ed.), The cultural context of aging: World-wide
perspectives (2nd ed., pp. 5670). Westport, CT: Bergin & Garvey.
Glascock, A., & Feinman, S. (1981). Social asset or social burden:
Treatment of the aged in non-industrial societies. In C. Fry (Ed.),
Dimensions: Aging, culture, and health (pp. 1332). Hadley: MA:
Bergin & Garvey.
Guo, Z. (2000). Ginseng and aspirin: Health care alternatives for aging
Chinese in New York. Ithaca, NY: Cornell University Press.
Gutmann, D. (1987). Reclaimed powers: Toward a new psychology of
men and women in later life. New York: Basic Books.
Hawkes, K., OConnell, J. F., Blurton Jones, N. G., Alvarez, H., &
Charnov, E. L. (1998). Grandmothering, menopause, and the
evolution of human life histories. Proceedings of the National
Academy of Sciences, 95, 13361339.
Hazan, H. (1980). The limbo people. Boston, MA: Routledge &
Kegan Paul.
Henderson, N., & Vesperi, M. (1995). The culture of long term care.
Westport, CT: Bergin & Garvey.
Henry, J. (1963). Culture against man. New York: McGraw-Hill.
Ikels, C. (1997). Long-term care and the disabled elderly in
urban China. In J. Sokolovsky (Ed.), The cultural context of
aging: World-wide perspectives (2nd ed., pp. 452471). Westport,
CT: Bergin & Garvey.
Ikels, C., & Beall, C. (2000). Age, aging and anthropology. In R. Binstock
& L. George (Eds.), The handbook of aging and the social sciences
(5th ed., pp. 125139). San Diego, CA: Academic Press.
References
Kaufert, P., & Lock, M. (1992). What are women for?: Cultural
construction of menopausal women in Japan and Canada. In
V. Kerns & J. Brown (Eds.), In her prime: New views of middle-aged
women (pp. 201219). Urbana: University of Illinois Press.
Kaufman, S. (1986). The ageless self: Sources of meaning in late life.
Madison: The University of Wisconsin Press.
Keith, J., Fry, C., Glascock, A., Ikels, C., Dickerson-Putnam, J.,
Harpending, H., et al. (1994). The aging experience: Diversity and
commonality across cultures. Thousand Oaks, CA: Sage.
Kerns, V., & Brown, J. (Eds.). (1992). In her prime: New views of
middle-aged women (2nd ed.). Urbana: University of Illinois
Press.
Kertzer, D., & Keith, K. (Eds.). (1984). Age and anthropological theory.
Ithaca, NY: Cornell University Press.
Kertzer, D., & Laslett, P. (Eds.). (1994). Demography, society and old
age. Berkeley: University of California Press.
Kinoshita, Y., & Kiefer, C. W. (1992). Refuge of the honored. Berkeley:
University of California Press.
Kinsella, K., & Gist, Y. (1995). Older workers, retirement, and
pensions: A comparative international chartbook. Washington, DC:
Bureau of the Census.
Kinsella, K., & Velkoff, V. (2001). An aging world 2001. Washington, DC:
US Bureau of the Census.
Kopytoff, I. (1971). Ancestors as elders. Africa, 41, 129142.
Lamb, S. (2000). White saris and sweet mangoes: Aging, gender and
the body in North India. Berkeley: University of California Press.
Laslett, P. (1976). Societal development and aging. In R. Binstock &
E. Shanas (Eds.), Handbook of aging and the social sciences.
New York: Van Nostrand Reinhold.
Lloyd-Sherlock, P. (2000). Old age and poverty in developing countries:
New policy challenges. World Development, 18, 12.
Lock, M. (1993). Encounters with aging: Mythologies of menopause in
Japan and North America. Berkeley: University of California
Press.
Mead, M. (1967). Ethnological aspects of aging. Psychosomatics,
8, 3337.
Myerhoff, B. (1978). Number our days. New York: E. P. Dutton.
Myerhoff, B., & Simic, A. (Eds.). (1978). Lifes career-aging: Cultural
variations on growing old. Beverly Hills, CA: Sage.
Plakans, A. (1989). Stepping down in former times: A comparative
assessment of retirement in traditional Europe. In D. Kertzer &
K. W. Schaie (Eds.), Age structuring in comparative perspective
(pp. 7597). Hillsdale, NJ: Lawrence Erlbaum.
Putnam-Dickerson, J., & Brown, J. (Eds.). (1998). Women among
women: Anthropological perspectives on female age hierarchies.
Champaign: University of Illinois Press.
Rasmussen, S. (1987). Interpreting androgynous woman: Female
aging and personhood among the Kel Ewey Tuareg. Ethnology,
26, 1730.
Rasmussen, S. (1997). The poetics and politics of Tuareg aging: Life
course and personal destiny in Niger. Dekalb, IL: Northern Illinois
University Press, p. 223.
Rhoads, E., & Holmes, L. D. (1995). Other cultures, elder years.
(2nd ed.). Thousand Oaks, CA: Sage.
223
Rosenberg, H. (1997). Complaint discourse, aging and caregiving among
the Ju/hoansi of Botswana. In J. Sokolovsky (Ed.). The cultural
context of aging: World-wide perspectives (2nd ed., pp. 3355).
Westport, CT: Bergin & Garvey.
Rubinstein, R. (Ed.). (1990). Anthropology and aging: Comprehensive
reviews. Dordrecht, The Netherlands: Kluwer Academic.
Sankar, A., Luborsky, M., Rwabuhemba, T., & Songwathana, P. (1998).
Comparative perspectives on living with HIV/AIDS in middle life:
Cross cultural perspectives. Research on Aging, 20, 885911.
Savishinsky, J. (1991). The ends of time: Life and work in a nursing
home. New York: Bergin & Garvey.
Savishinsky, J. (2000). Breaking the watch: The meanings of retirement
in America. Ithaca, NY: Cornell University Press.
Schweitzer, M. M. (1991). Anthropology of aging: A partial annotated
bibliography. Westport, CT: Greenwood.
Shenk, D. (1998). Someone to lend a helping hand: Women growing old
in rural America. Newark, NJ: Gordon and Breach.
Silverman, P. (Ed.). (1987). Comparative studies. In P. Silverman (Ed.),
The elderly as modern pioneers (pp. 312344). Bloomington:
Indiana University Press.
Silverman, P., & Maxwell, R. J. (1987). The significance of information
and power in the comparative study of the aged.
In J. Sokolovsky (Ed.), Growing Old in Different Societies: CrossCultural Perspectives. Acton, MA: Copley.
Simmons, L. (1945). The role of the aged in primitive society.
New Haven, CT: Archon Books. (1970). North Haven, CT: Shoe
String Press.
Sokolovsky, J. (Ed.). (1997). The cultural context of aging: World-wide
perspectives (2nd ed.). Westport, CT: Bergin & Garvey.
Thang, L. L. (2001). Generations in touch: Linking the old and young
in a Tokyo neighborhood, Ithaca, NY: Cornell University Press.
Traphagan, J. (2003). Illness and Aging in Japan. Durham, NC:
Carolina Academic Press.
van Willigen, J., & Chadha, N. K. (1999). Social aging in a Delhi neighborhood. Westport, CT: Bergin & Garvey.
Vesperi, M. (1998). City of green benches: Growing old in a new downtown (2nd ed.). Ithaca, NY: Cornell University Press.
Vincentnathan, S. G., & Vincentnathan, L. (1994). Equality and hierarchy in untouchable intergenerational relations and conflict resolutions. Journal of Cross-Cultural Gerontology, 9, 119.
von Mering, O. (1957). A family of elders. In O. von Mering & S. King
(Eds.), Remotivating the mental patient. New York: Russell Sage
Foundation.
Warner, L. (1958). A black civilization: A social study of an Australian
tribe (Rev. ed.). New York: Harper.
Witchcrafta violent threat (2000). Ageing and Development, 6, 9.
Woolfson, P. (1997). Old age in transition: The geriatric ward.
Westport, CT: Greenwood Press.
World Bank (1999). Entering the 21st century: World development
report 19992000. Retrieved December 2, 1999, from http://
www.worldbank.org/wdr/2000/fullreport.html
224
Birth
Birth
Carolyn Sargent
INTRODUCTION
Birth, the physiological process of childbearing, is both a
biological and cultural event. In all societies, the universal
physiology of birth is culturally shaped and managed.
Jordans (1978, 1993) groundbreaking work Birth in Four
Cultures initiated the field of study now known as the
anthropology of birth, or more broadly, the anthropology
of reproduction. Following Jordan, anthropologists have
focused on the study of birthing systems rather than on the
comparison of individual and isolated birth practices
which characterized the earliest anthropological references on this topic. The cross-cultural analysis of birthing
systems has documented that birth is globally a culturally
marked life crisis event that is socially patterned as well
as being a biological phenomenon. The cultural patterning
of birth includes beliefs and practices surrounding pregnancy; expectations regarding the circumstances in which
pregnancy may occur and who may legitimately reproduce; prescriptions and proscriptions affecting expectant
mothers, their partners, and families; the management of
labor, including the circumstances under which interventions occur and the characteristics of such interventions;
and treatment during the postpartum period. Birthing systems range from low-technology systems exemplified by
the Maya of Central America (Jordan, 1978) or the Bariba
of West Africa (Sargent, 1982, 1989) to the high-technology
biomedical systems of most industrialized societies.
Generally, birth practices within a particular society are
consensually shaped, with a low level of variation within
any given system, but considerable variation across different societies. As Jordan (1978) observed, we find that
within any given system, birth practices appear packaged
into a relatively uniform, systematic, standardized, ritualized, even morally required routine (p. 2).
EARLY ETHNOGRAPHIES
AND
SURVEYS
225
TOWARD
AN
ANTHROPOLOGY
OF
BIRTH
226
Birth
227
228
AN ANTHROPOLOGY OF
WESTERN CHILDBIRTH
The anthropology of Western childbirth has represented a
core element in studies of birthing systems from Jordans
comparative research through the 1990s. A consistent
theme in this body of research emphasizes that the dominant cultural definition of birth in the United States is a
medical one, in which pregnancy is viewed as a pathological state, requiring specialist attention and hospital
delivery. Accordingly, the medicalization of childbirth,
characterized by use of technological interventions during birth, such as episiotomy (a surgical incision of the
vagina to widen the birth outlet), intravenous medication,
and the lithotomy (suppine) position for delivery, have
become standard procedures (Davis-Floyd, 1992; Jordan,
1978; Romalis, 1981). This widespread use of technology
has led Davis-Floyd to suggest the term technocratic
birth, in her classic study of birth as an American rite of
passage. Technocratic birth predominates in the United
States, where 98% of women give birth in hospitals. In
many hospitals more than 80% of women receive
epidural anesthesia, and at least 90% receive episiotomies
(Davis-Floyd & Sargent, 1997, p. 11). In some hospitals,
the cesarean, or surgical birth rate has reached 30% or
higher (Sargent & Stark, 1987). A minority of American
womenless than 2%rely on midwifery and home
birth. A revival of interest in midwifery in industrialized
societies has generated research on such topics as the history of midwifery, regional traditions of midwifery in the
United States, and the politics and professionalization of
midwifery (Fraser, 1995; see Davis-Floyd & Sargent,
1997 and Ginsburg & Rapp, 1991, for specific citations).
The impact of the medicalization of birth in the
United States is illuminated in Emily Martins (1987)
exploration of how women talk about their birth experiences. Martin examines scientific and medical representations of womens bodies and reproductive processes.
She analyses the medical treatment of birth in relation to
Birth
References
LOCAL/GLOBAL PERSPECTIVES
Three decades of ethnographic and theoretical work
on birthing systems have produced a substantial and
empirically grounded anthropological literature. Case
studies from North America, Europe, and societies of
Asia, Africa, and Latin America have generated the
material for anthropological analyses of multiple ways
of knowing about birth. Anthropologists have begun to
address not only the encounter between low- and hightechnology birth systems, but also the diverse paradigms
of maternity and birth held by different categories of
women within heterogeneous societies (Browner &
Sargent, 1996, p. 232). In addition, a scant but important
literature explores the topic of men in relation to
229
REFERENCES
Browner, C., & Sargent, C. (1996). Anthropological studies of human
reproduction. In C. Sargent & T. Johnson (Eds.), Medical anthropology: Contemporary theory and method (Rev. ed., pp. 219235).
Westport, CT: Praeger.
Cosminsky, S. (1976). Cross-cultural perspectives on midwifery. In
F. X. Grollig, S. J. Harold, & B. Haley (Eds.), Medical anthropology (pp. 229249). The Hague: Mouton.
Davis-Floyd, R. E. (1992). Birth as an American rite of passage.
Berkeley: University of California Press.
Davis-Floyd, R., & Sargent, C. (1997). Childbirth and authoritative
knowledge: Cross-cultural perspectives. Berkeley: University of
California Press.
Daviss, B.-A. (1997). Heeding warnings from the canary, the whale, and
the Inuit: A framework for analyzing competing types of knowledge
about childbirth. In R. Davis-Floyd & C. Sargent (Eds.), Childbirth
and authoritative knowledge: Cross-cultural perspectives
(pp. 441474). Berkeley: University of California Press.
Ebin, V. (1994). Interpretations of infertility: The Aowin people of southwest Ghana. In C. MacCormack (Ed.), Ethnography of fertility and
birth (2nd ed., pp. 131151). Prospect Heights, IL: Waveland Press.
Ford, C. S. (1964). A comparative study of human reproduction
(Yale University Publications in Anthropology, No. 32): New
Haven Human Relations Area Files Press.
Fraser, G. J. (1995). Modern bodies, modern minds: Midwifery
and reproductive change in an African American community.
In F. D. Ginsburg & R. Rapp (Eds.), Conceiving the New World
Order: The global politics of reproduction (pp. 4259). Berkeley:
University of California Press.
230
Breast-Feeding
Breast-Feeding
Wenda R. Trevathan
231
232
Breast-Feeding
OF
233
SUPPLEMENTATION
AND
WEANING
234
BREAST-FEEDING PRACTICES
IN THE WEST
In the United States, the number of mothers who chose to
breast-feed their infants had declined by the middle part
of the 20th century, with the decline being most rapid in
the middle and upper classes, in association with the
economic ability to purchase breast milk substitutes. By
the end of World War II, most American women bottlefed their babies (Raphael, 1973). One of the factors
behind the decrease in breast-feeding was active promotion of infant formula by food and drug manufacturing
companies. Initially, promotion efforts were aimed at
educated women in industrialized nations, but as the birth
rate began to fall in the early 1960s, manufacturers turned
to developing nations for their markets. Outraged at what
were viewed as unethical marketing practices resulting in
commerciogenic malnutrition in infants of developing
nations, advocacy groups in Europe and North America
began what has been called the most successful international boycott in history against Nestl and other manufacturers of milk substitutes (Van Esterik, 1989). As a
result of the boycott and publicity surrounding it, the
World Health Organization produced the WHO/
UNICEF Code of Marketing for Breastmilk Substitutes
in 1981. (The United States was the only member of
the 122-nation World Health Assembly to vote against
Breast-Feeding
235
REFERENCES
Anonymous (1997). Breastfeeding and the use of human milk.
Pediatrics, 100, 10351039.
Child Growth
Barry Bogin
236
Child Growth
237
Table 1. Life History Principal Traits and Trade-offs
Principles
Trade-offs
1. Size at birth
2. Growth patterns
AND
3. Age at maturity
From Bogin (2001). This is a partial list of the most important traits. The list is
based on the discussion in Cole (1954) and Stearns (1992), who provide
additional traits.
238
Child Growth
Prenatal Life
Fertilization
First trimester
Second trimester
Third trimester
Birth
Postnatal Life
Neonatal period
Infancy
Childhood
Juvenile
Adolescence
Adulthood
Prime and
transition
Old age and
senescence
a
20
200
18
180
16
160
14
12
140
10
120
100
6
80
4
60
2
0
Height, cm
Stage
10 12
14 16
18 20
22
40
AGE, years
Figure 1. Distance and velocity curves of growth for human
beings. Boysolid line, girlsbroken line. The stages of postnatal
growth are abbreviated as follows: I infancy, C childhood, J
juvenile, A adolescence, M mature adult (Bogin, 1999).
decelerates quickly. The infants growth curve is a continuation of the fetal pattern, in which the rate of growth
in length actually reaches a peak in the second trimester
of gestation, and then begins a deceleration that lasts until
childhood. The childhood stage encompasses the ages of
about three to seven years. The growth deceleration of
infancy ends at the beginning of childhood, and the rate
of growth levels off at about 6 cm per year. This levelingoff in growth rate is unusual for mammals, as virtually all
other species continue a pattern of deceleration after
infancy. This slower and steady rate of human growth
maintains a relatively small-sized body during the childhood years. About 60% of children have a small acceleration in growth rate, called the mid-growth spurt, at the
end of childhood.
The human juvenile stage begins at about age seven
years, and is characterized by the slowest rate of growth
since birth. In girls, the juvenile period ends, on average,
at about the age of 10, two years before it usually ends in
boys. The difference reflects the earlier onset of adolescence in girls. Human adolescence is the stage of life
when social and sexual maturation takes place. In terms
of growth, both boys and girls experience a rapid acceleration in the growth velocity of virtually all of the bones
of the body. This is called the adolescent growth spurt.
Adolescence ends when skeletal growth is complete. This
usually marks the achievement of full reproductive maturity, meaning both physical and psychosocial maturity.
In addition to changes in growth rate, each stage
may also be defined by characteristics of the dentition,
WHY GROW
AND
DEVELOP?
239
Slow and steady rate of growth and relatively small body size
A large, fast-growing brain
Higher resting metabolic rate than any other mammalian species
Immature dentition
Sensitive period for maturation of fundamental motor patterns
Sensitive period for cognitive and language development
Weaned, with dependence on older people for care and feeding
240
Child Growth
female, may provide care for children (Bogin, 1994a; Bogin &
Smith, 1996). This type of care-taking is rare in other primates,
even for apes. Adoptions of orphaned infants by females do
occur in chimpanzee social groups, but only infants older than
four years and able to forage for themselves survive more than a
few weeks (Goodall, 1983). It seems that the human infant can
more easily make new attachments to other caretakers than the
chimpanzee infant. The ability of a variety of human caretakers
to attach to one or several human infants may also be an important factor. The psychological and social roots of this difference
between human and non-human species in attachment behavior
are not known. However, this flexibility in attachment behavior
allowed, in part, for the evolution of childhood and the reproductive efficiency of the human species.
5. Childhood allows for developmental plasticity. The value of this
plasticity was discussed above. Cross-cultural examples of
plasticity in human growth are given below.
CROSS-CULTURAL EXAMPLES
CHILD GROWTH
OF
241
RISKS
FOR
CHILDREN
242
Child Growth
CONCLUSION
Childhood is a unique stage in the life history of human
beings. Prior to the late 1980s standard textbook explanations for the value of childhood held that it provides
extra time for brain development and learning. This is
true, but advances in life history theory and analysis of the
fossil record of human evolution are now used to associate the initial selective value of childhood more closely to
parental strategies to give birth to new offspring and
provide care for existing dependent young. Additionally,
the childhood stage allows for increased developmental
plasticity and fitness for the young. The dependency of
References
NOTE
1. This entry focuses on theoretical issues of interest to medical anthropology. Detailed treatments of the biology of child growth, techniques of measurement, behavioral and cognitive development, body
shape and composition, clinical issues, and the evolution of human
growth may be found in Ulijaszek et al. (1998) and Bogin (1999).
REFERENCES
Alley, T. R. (1983). Growth-produced changes in body shape and size
as determinants of perceived age and adult caregiving. Child
Development, 54, 241248.
Belsey, M. A. (1993). Child abuse: Measuring a global problem. World
Health Statistics Quarterly, 46, 6977.
Boas, F. (1892). The growth of children, II. Science, 19, 281282.
Boas, F. (1940). Race, language, and culture. New York: Free Press.
Bogin, B. (1999). Patterns of human growth (2nd ed.). Cambridge, UK:
Cambridge University Press.
Bogin, B. (2001). The growth of humanity. New York: WileyLiss.
Bogin, B., Smith, P., Orden, A. B., Varela Silva, M. I., & Loucky, J.
(2002). Rapid change in height and body proportions of MayaAmerican children. American Journal of Human Biology, 14, 19.
Cole, L. C. (1954). The population consequence of life history phenomena. Quarterly Review of Biology, 19, 103137.
Crooks, D. L. (1995). American children at risk: Poverty and its consequences for childrens health, growth, and school achievement.
Yearbook of Physical Anthropology, 38, 5786.
Dettwyler, K. A. (1995). A time to wean: The hominid blueprint for
the natural age of weaning in modern human populations. In
243
P. Stuart-Macadam & K. A. Detwyller (Eds.), Breastfeeding:
Biocultural perspectives (pp. 3974). New York: Aldine de Gruyter.
Dietz, W. H., Marino, B., Peacock, N. R., & Bailey, R. C. (1989).
Nutritional status of Efe pygmies and Lese horticulturalists.
American Journal of Physical Anthropology, 78, 509518.
Eveleth, P. B., & Tanner, J. M. (1976). World-wide variation in human
growth. Cambridge, UK: Cambridge University Press.
Eveleth, P. B., & Tanner, J. M. (1990). World-wide variation in
human growth (2nd ed.). Cambridge, UK: Cambridge University
Press.
Fingerhut, L. A., & Kleinman, J. C. (1989). Trends and current status in
childhood mortality, United States, 19801985 (Vital and Health
Statistics, Series 3, 26, DHHS Publication No. PHS 891410).
Washington, DC: US Government Printing Office.
Fox, J. (1977). Occupational mortality 197072. Population Trends,
9, 815.
Fredriks, A. M., van Buuren, S., Burgmeijer, R. J., Meulmeester, J. F.,
Beuker, R. J., Brugman, E. et al. (2000). Continuing positive
secular growth change in The Netherlands 19551997. Pediatric
Research, 47, 316323.
Garn, S. M., Pesick, S.D., & Pilkington, J. J. (1984). The interaction
between prenatal and socioeconomic effects on growth and development on childhood. In J. Borms, R. Hauspie, A. Sand,
C. Susanne, & M. Hebbelinck (Eds.), Human growth and development (pp. 5970). New York: Plenum.
Gray, J. P., & Wolfe, L. D. (1998). What accounts for population variation in height? In C. R. Ember, M. Ember, & P. N. Peregrine (Eds.),
Research frontiers in anthropology (pp. 149168). Englewood
Cliffs, NJ: Prentice Hall.
Huttley, S. R., Victoria, C. G., Barros, F. C., & Vaughn, J. P. (1992).
Birth spacing and child health in urban Brazilian children.
Pediatrics, 89, 10491054.
Kliegman, R. M. (1992). Perpetual poverty: Child health and the underclass. Pediatrics, 89, 710713.
Kliegman, R. M. (1995). Neonatal technology, perinatal survival, social
consequences, and the perinatal paradox. American Journal of
Public Health, 85, 909913.
Lancaster, J. B., & Lancaster, C. S. (1983). Parental investment:
The hominid adaptation. In D. J. Ortner (Ed.), How humans adapt
(pp. 3365). Washington, DC: Smithsonian Institution Press.
Landauer, T. K., & Whiting, J. W. M. (1981). Correlates and consequences of stress in infancy. In R. H. Munroe, R. L. Munroe, &
B. B. Whiting (Eds.), Handbook of cross-cultural human development. New York: Garland STPM Press.
Lorenz, K. (1971). Part and parcel in animal and human societies:
A methodological discussion. In K. Lorenz (Ed.) & R. Martin
(Trans.), Studies in animal and human behavior (Vol. 2,
pp. 115195). Cambridge, MA: Harvard University Press.
Mascie-Taylor, C. G. N., & Bogin, B. (Eds.). (1995). Human variability and plasticity. Cambridge Studies in Biological Anthropology.
Cambridge, UK: Cambridge University Press.
McCabe, V. (1988). Facial proportions, perceived age, and caregiving.
In T. R. Alley (Ed.), Social and applied aspects of perceiving faces
(pp. 8995). Hillsdale, NJ: Lawrence Earlbaum.
Morbeck, M. E., Galloway, A., & Zihlman, A. L. (Eds). (1997). The
evolving female: A life-history perspective. Princeton, NJ:
Princeton University Press.
244
Todd, J. T., Mark, L. S., Shaw, R. E., & Pittenger, J. B. (1980). The
perception of human growth. Scientific American, 242, 132144.
Ulijaszek, S., Johnston, F. E., & Preece, M. (Eds.). (1998). Cambridge
encyclopedia of human growth and development. Cambridge, UK:
Cambridge University Press.
Ulijaszek, S. J., & Strickland, S. S. (1993). Nutritional anthropology:
Prospects and perspectives. London: Smith Gordon.
United Nations International Childrens Emergency Fund (2001).
http://www.childinfo.org/eddb/malnutrition/
Walcher, G. (1905). Ueber die Entstehung von Brachy- und
Dolichocephalie durch willkrliche Beinflussung des kindlichen
Schadels. Zentralblatt fr Gynakologie, 29, 193196.
Worthman, C. (1993). Biocultural interactions in human development.
In M. E. Pereira & L. A. Fairbanks (Eds.), Juvenile primates
(pp. 339358). Oxford, UK: Oxford University Press.
INTRODUCTION
Dying and death are profound aspects of human experience whose definitions and meanings are fabricated
through cultural and historical lenses. Though death is
biologically inevitable, it is also a social fact; knowledge
about it is made. It is understood through frameworks of
religion and social structure, science and medicine, loss
and disruption that are available to individuals within
societies. There is no such thing as a natural death, that
is, a death that occurs beyond the boundaries of culture
and historical moment, social norms and expectations,
tradition and innovation.
The anthropology of dying and death itself,
considered from the early days of ethnographic practice,
illustrates a major shift in how those terms have been situated and employed. Late 19th and early 20th century
studies of death were conducted within the frameworks of
the anthropology and sociology of religion, ritual practice, and structuralfunctionalism. Recent critiques of
early studies note their attention to normative practices
surrounding the corpse, the funeral, and the bereaved to
the exclusion of acknowledgement of the dying person
and the intense emotions surrounding the dying transition. Late 20th century and contemporary studies focus
245
246
CRITIQUE
AND INNOVATION
247
248
DEATH AS A PROBLEM
BIOPOLITICS
OF
LIFE
AND
clinical medicine. Timmermans (1999, p. 53) ethnographic study of the history, politics, routinization, and
rationalization of resuscitation in Western Europe and the
United States shows that while resuscitation rarely saves
lives, it frames death as a socio-medical failure, a roadblock to be cleared by modern medicine. The disjunction
between the societal quest for death with dignitythat
is, a death without medical intervention to prolong dying
and the regular use of life-extending/death-prolonging
technologies in the acute-care hospital and emergency
room setting became a central preoccupation of American,
and to a lesser extent Western European, medicine by the
mid-1980s (Kaufman, 1998; Muller & Koenig, 1988).
The making of post-modern or late modern subjects,
described in ethnographies of reproductive, transplant,
and other biomedical technologies, is explored by
Kaufman (2000) in regard to persons/bodies who are
betwixt and between life and death, culture, and nature.
The permanent comatose condition and the institutions
and practices that enable that form of life to exist are
extreme manifestations of the life extension enterprise
and they create further cultural remappings of the notions
of life, person, and death. Shifting understandings of
natural death, life prolongation, and suffering, for
example, impact and are informed by cultural quandaries
(especially American) about approaching, negotiating,
and accepting death, the value of any form of life, and
what social practices constitute dignity.
A number of recent studies focus on relationships
among medical care, death, the enactment of dignity,
and notions of suffering in cross-cultural comparison
(see, e.g., Kleinman, Das, & Lock, 1997). Farmer and
Kleinman (1989) compare the stories of two persons
dying from AIDS, one at a Harvard teaching hospital and
the other in a poor, rural community in Haiti, to highlight
ways in which the powers of biomedicine are limited to
diagnosis and treatment and ignore the suffering of the
dying. Gordon and Paci (1997), in a juxtaposition of
the autonomycontrol narrative of North America with
the social embeddedness narrative of Tuscany, Italy,
show how cultural assumptions underlying visions of
the good guide medical practices surrounding the
disclosure or concealment of life-threatening illness.
Informed consent, self-determination, and autonomy,
guiding principles of biomedical ethics that are of
primary importance in the delivery of American medicine
and that are now circulating the globe and gaining ascendance, seem harsh, irresponsible, and naive from the
249
OF
DISEASE
250
References
CONCLUSION
In the context of medical technologies that simultaneously
extend life and prolong dying, the commodification of poor
bodies in a global economy of scarcity, debt, and demand,
and the proliferation of violent conflict into everyday life,
death and life enter a zone of indistinction in which biopolitics determines their precise definition (Agamben, 1998).
The ways in which law, medicine, the market, concepts of
the body, private life, and political existence come together
in new cultural formations will continue to be a rich ground
for anthropological investigation.
REFERENCES
Agamben, G. (1998). Homo sacer. Stanford, CA: Stanford University
Press.
Aries, P. (1974). Western attitudes toward death from the middle ages
to the present. Baltimore, MD: Johns Hopkins University Press.
Aries, P. (1981). The hour of our death. New York: Knopf.
Armstrong, D. (1987). Silence and truth in death and dying. Social
Science & Medicine, 24, 651657.
Arney, W. R., & Bergen, B. J. (1984). Medicine and the management of
living. Chicago, IL: University of Chicago Press.
Battaglia, D. (1990). On the bones of the serpent. Chicago, IL:
University of Chicago Press.
Becker, G. (2002). Dying away from home: Quandaries of migration for
elders in two ethnic groups. Journal of Gerontology. 57B, 579595.
Biehl, J. G. (1999). Other life: AIDS, biopolitics, and subjectivity in
Brazils zones of social abandonment. (Doctoral dissertation,
University of California, Berkeley, 1999.) Ann Arbor: UMI
Dissertation Services.
Block, M., & Parry, J. (Eds.). (1982). Death and the regeneration of life.
Cambridge, UK: Cambridge University Press.
Bosk, C. L. (1999). Professional ethicist available: Logical, secular,
friendly. Daedalus, 128, 4768.
251
Bourgois, P. (2001). The continuum of violence in war and peace: Postcold war lessons from El Salvador. Ethnography, 2, 537.
Cohen, L. (1998). No aging in India. Berkeley: University of California
Press.
Cohen, L. (1999). Where it hurts: Indian material for an ethics of organ
transplantation. Daedalus, 128, 135166.
Danforth, L. M. (1982). The death rituals of rural Greece. Princeton,
NJ: Princeton University Press.
Daniel, E. V. (1996). Charred lullabies. Princeton, NJ: Princeton
University Press.
Desjarlais, R. R. (1992). Body and emotion. Philadelphia: University of
Pennsylvania Press.
Desjarlais, R. R., & Kleinman, A. (1994). Violence and demoralization
in the new world disorder. Anthropology Today, 10, 912.
Douglass, W. A. (1969). Death in Murelaga: Funerary rituals in a
Spanish Basque village. Seattle: University of Washington Press.
Fabian, J. (1974). How others diereflections on the anthropology
of death. In A. Mack (Ed.), Death in American experience
(pp. 177201). New York: Schocken Books.
Farmer, P. (1992). AIDS and accusation. Berkeley: University of
California Press.
Farmer, P. (2001). Infections and inequalities (Updated ed. with new
preface). Berkeley: University of California Press.
Farmer, P., Connors, M., & Simmons, J. (Eds.). (1996). Women, poverty,
and AIDS. Monroe, ME: Common Courage Press.
Farmer, P., & Kleinman, A. (1989). AIDS as human suffering.
Daedalus, 118, 135160.
Finkel, M. (2001, May 27). Complications. The New York Times
Magazine, pp. 2633, 40, 52, 59.
Foucault, M. (1975). The birth of the clinic. New York: Vintage.
Fox, R. C. (1991). The evolution of American bioethics: A sociological
perspective. In G. Weisz (Ed.), Social science perspectives on medical ethics (pp. 201217). Philadelphia: University of Pennsylvania
Press.
Francis, D., Kellaher, L., & Neophytou, G. (2004). The secret cemetery.
Oxford and New York: Berg.
Glaser, B. G., & Strauss, A. L. (1965). Awareness of dying. New York:
Aldine.
Glaser, B. G., & Strauss, A. L. (1968). Time for dying. New York:
Aldine.
Goody, J. (1962). Death, property and the ancestors. London: Tavistock.
Gordon, D., & Paci, E. (1997). Disclosure practices and cultural narratives: Understanding concealment and silence around cancer in
Tuscany, Italy. Social Science & Medicine, 44, 14331452.
Gorer, G. (1965). Death, grief and mourning. New York: Doubleday.
Green, L. (Ed.). (1998). The embodiment of violence. Medical
Anthropology Quarterly, 12, 37.
Hertz, R. (1960). Death and the right hand. New York: Free Press.
(Original work published 1907.)
Huntington, R., & Metcalf, P. (1979). Celebrations of death: The
anthropology of mortuary ritual. Cambridge, UK: Cambridge
University Press.
Kaufman, S. (1998). Intensive care, old age, and the problem of death
in America. The Gerontologist, 38, 715725.
Kaufman, S. (2000). In the shadow of death with dignity: Medicine and
cultural quandaries of the vegetative state. American Anthropologist,
102, 6983.
252
Kim, J. Y., Millen, J. V., Irwin, A., & Gershaman, J. (Eds.). (2000).
Dying for growth: Global inequality and the health of the poor.
Monroe, ME: Common Courage Press.
Kleinman, A. (1999). Moral experience and ethical reflection: Can
ethnography reconcile them? A quandary for The new bioethics.
Daedalus, 128, 6998.
Kleinman, A., Das, V., & Lock, M. (Eds.). (1997). Social suffering.
Berkeley: University of California Press.
Klinenberg, E. (1999). Denaturalizing disaster: A social autopsy of the
1995 Chicago heat wave. Theory and Society, 28, 239295.
Klinenberg, E. (2002). Heat wave: A social autopsy of disaster in
Chicago: University of Chicago Press.
Kubler-Ross, E. (1969). On death and dying. New York: Macmillan.
LeVine, R. (1982). Gusii funerals: Meaning of life and death in an
African community. Ethos, 10, 2665.
Lock, M. (2000). On dying twice: Culture, technology and the
determination of death. In M. Lock, A. Young, & A. Cambrosio
(Eds.), Living and working with the new medical technologies
(pp. 233262). Cambridge, UK: Cambridge University Press.
Lock, M. (2002). Twice dead: Organ transplants and the reinvention of
death. Berkeley: University of Calfornia Press.
Metcalf, P. (1982). A Borneo journey into death. Philadelphia:
University of Pennsylvania Press.
Muller, J., & Koenig, B. (1988). On the boundary of life and death.
In M. Lock & D. Gordon (Eds.), Biomedicine examined
(pp. 351374). Boston, MA: Kluwer.
Myerhoff, B. (1978). Number our days. New York: Dutton.
Nagengast, C. (1994). Violence, terror, and the crisis of the state. Annual
Review of Anthropology, 23, 109136.
Palgi, P., & Abramovitch, H. (1984). Death: A cross-cultural perspective. Annual Review of Anthropology, 13, 385417.
Quesada, J. (1998). Suffering child: An embodiment of war and its
aftermath in post-Sandinista Nicaragua. Medical Anthropology
Quarterly, 12, 5173.
Robben, A., & Nordstrom, C. (1995). Introduction: The anthropology
and ethnography of violence and sociopolitical conflict.
INTRODUCTION
Having little parallel in its ability to arouse an emotional
response, the practice of female genital cutting (FGC)
has come under increasingly intense international
scrutiny from news media, feminist and human rights
253
THE TRIVIALIZATION
OF
CULTURE 2
254
255
256
257
258
259
260
IN LIEU
OF
CONCLUSIONS
NOTES
1. A longer version of this paper previously appeared as the introduction to Female Circumcision in Africa: Culture, controversy, and
change, edited by Shell-Duncan and Hernlund (2000).
2. The expression the trivialization of culture was coined by
Canadian anthropologist Claudie Gosselin (Gosselin, 2000).
3. For instance, Shell-Duncan et al. (2000) report that among Rendille
pastoralists in northern Kenya, excision was, in the past, performed
at the time of marriage, legitimizing reproduction. Within the past
20 years, it has become increasingly common for girls to attend
school, and a rising number of girls have eloped without being
excised. A solution to avoid illegitimate childbearing has been to
uncouple excision and marriage, circumcizing girls instead before
attending secondary school.
4. Accounts in the literature refer to ancient Egyptian beliefs about the
bisexuality of the gods, which possibly merged with pre-existing
African ideas that identify the feminine soul of a man as located
in the foreskin and the male soul of a woman in the clitoris
(Meinardus, 1967). Although such a discussion is beyond the scope
of this entry, interesting parallels can also be drawn to the welldocumented Western discomfort with gender ambiguity that has
resulted in routinely performing surgery on hermaphroditic infants.
5. For example, The Economist (February 13, 1999, p. 45) reported that
the U.S. State Departments Human Rights report lists those
African governments that have banned female circumcision, and is
used as a guide to allocating American aid.
REFERENCES
Abu-Sahlieh, S. A. A. (1994). To mutilate in the name of Allah and
Jehova: Legitimization of male and female circumcision. Medicine
and Law, 13,575622.
Abusharaf, R. M. (1995). Rethinking feminist discourses on female
genital mutilation: The case of Sudan. Canadian Woman Studies,
15(23),5254.
Abusharaf, R. M. (1996). Revisiting feminist discourses on female
circumcision: Responses from Sudanese indigenous feminists.
References
Paper presented at the American Anthropological Association 95th
Annual Conference, San Francisco.
Abusharaf, R. M. (2000). Revisiting feminist discourses on infibulation:
Responses from Sudanese feminists. In B. Shell-Duncan &
Y. Hernlund (Eds.), Female circumcision in Africa: Culture,
controversy, and change (pp. 151166). Boulder, CO: Lynne
Rienner.
Ahmadu, F. (1995, April/May). Rites and wrongs. Pride, 2123.
Ahmadu, F. (2000). Rites and wrongs: An insider/outsider reflects on
power and excision. In B. Shell-Duncan & Y. Hernlund (Eds.),
Female circumcision in Africa: Culture, controversy, and
change (pp. 283312). Boulder, CO: Lynne Rienner.
Assaad, M. B. (1980). Female circumcision in Egypt: Social implications, current research, and prospects for change. Studies in Family
Planning, 11(1), 316.
Bashir, L. M. (1996). Female genital mutilation in the United States: An
examination of criminal and asylum law. Journal of Gender and
the Law, 4(361), 415454.
Boddy, J. (1982). Womb as oasis: The symbolic content of pharaonic
circumcision in rural northern Sudan. American Ethnologist, 9(4),
682698.
Boddy, J. (1991). Body politics: Continuing the anti-circumcision
crusade. Medical Anthropology Quarterly, 5(1), 1517.
Boulware-Miller, K. (1985). Female circumcision: Challenges to the
practice as a human rights violation. Harvard Womens Law
Journal, 8, 155177.
Brennan, K. (1989). The influence of cultural relativism on international
human rights law: Female circumcision as a case study. Law and
Inequality, 7, 367398.
Caldwell, J. C., Orubuloye, O., & Caldwell, P. (1997). Male and female
circumcision in Africa: From a regional to a specific Nigerian
examination. Social Science & Medicine, 44(8), 11811193.
Carr, D. (1997). Female genital cutting: Findings from the demographic
and health surveys program. Calverton, MD: Macro International.
Coleman, D. L. (1998). The Seattle compromise: Multicultural sensitivity and Americanization. Duke Law Journal, 47, 717783.
Daly, M. (1978). African genital mutilation: The unspeakable atrocities.
In Gyn/ecology: The metaethics of radical feminism (pp. 153177).
Boston, MA: Beacon.
Eliah, E. (1996, May). Reaching for a healthier future. Populi, 1216.
Gordon, D. (1991). Female circumcision and genital operations in
Egypt and the Sudan: A dilemma for medical anthropology.
Medical Anthropology Quarterly, 5(1), 314.
Gosselin, C. (2000). Feminism, anthropology and the politics of
excision in Mali: Global and local debates in a post-colonial world.
Anthropologica, 42(1), 4360.
Griaule, M. (1965). Conversations with Ogotenmli: An introduction to
Dogon religious ideas. London: Oxford University Press.
Gruenbaum, E. (1982). The movement against clitoridectomy and
infibulation in Sudan: Public health policy and the womens movement. Medical Anthropology Newsletter, 13(2), 412.
Gruenbaum, E. (2000). Is female circumcision a maladaptive cultural
pattern? In B. Shell-Duncan & Y. Hernlund (Eds.), Female
circumcision in Africa: Culture, controversy, and change
(pp. 4154). Boulder, CO: Lynne Rienner.
Hansen, H. H. (197273). Clitoridectomy: Female circumcision in
Egypt. Folk, 14/15, 1526.
261
Hernlund, Y. (2000). Cutting without ritual and ritual without cutting:
Female circumcision and the re-ritualization of initiation in
the Gambia. In B. Shell-Duncan & Y. Hernlund (Eds.), Female
circumcision in Africa: Culture. controversy, and change
(pp. 235252). Boulder, CO: Lynne Rienner.
Hite, S. (1976). The Hite Report: A nationwide study of female sexuality. New York: Dell.
Hosken, F. P. (1978). The epidemiology of female genital mutilations.
Tropical Doctor, 8, 150156.
James, S. (1998). Shades of othering: Reflections on female circumcision/genital mutilation. Signs, 23(4), 10311048.
Johnson, M. (2000). Becoming a Muslim, becoming a person: Female
circumcision, religious identity, and personhood in GuineaBissau. In B. Shell-Duncan & Y. Hernlund (Eds.), Female
circumcision in Africa: Culture, controversy, and change
(pp. 215234). Boulder, CO: Lynne Reinner.
Leigh, J. (1997, January). The agony of Daphne Pratt. New African, 28,
Leonard, L. (2000). Adopting female circumcision in southern Chad:
The experience of the Myabe. In B. Shell-Duncan & Y. Hernlund
(Eds.), Female circumcision in Africa: Culture, controversy, and
change (pp. 167192). Boulder, CO: Lynne Rienner.
Lewis, H. (1995). Between Irua and female genital mutilation:
Feminist human rights discourse and the cultural divide. Harvard
Human Rights Journal, 8(Spring), 155.
Lightfoot-Klein, H. (1989). Prisoners of ritual: An odyssey into female
genital circumcision in Africa. New York: Harrington Park Press.
Lutkehaus, N. C., & Roscoe, P. B. (1995). Gender rituals: Female
initiation in Melanesia. New York: Routledge.
Mackie, G. (1996). Ending footbinding and infibulation: A convention
account. American Sociological Review, 61, 9991017.
Mackie, G. (2000). Female genital cutting: The beginning of the end. In
B. Shell-Duncan & Y. Hernlund (Eds.), Female circumcision in
Africa: Culture, controversy, and change (pp. 253283). Boulder,
CO: Lynne Rienner.
Marlatt, G. A. (1998). Harm reduction around the world: A brief history.
In G. A. Marlat (Ed.), Harm reduction: Pragmatic strategies for managing high-risk behaviors (pp. 3048). New York: Guilford Press.
Meinardus, O. (1967). Mythological, historical and sociological aspects
of the practice of female circumcision among the Egyptians. Acta
Ethnographica Academiae Scientiarum Hungaricae, 17(34),
387397.
Morsy, S. A. (1991). Safeguarding womens bodies: The white mans
burden medicalized. Medical Anthropology Quarterly, 5(1), 1923.
Nypan, A. (1991). Revival of female circumcision: A case of neotraditionalism. In K.A. Stolen & M. Vaa (Eds.), Gender and
change in developing countries (pp. 3965). Oslo: Norwegian
University Press.
Obermeyer, C. M. (1999). Female genital surgeries. Medical
Anthropology Quarterly, 13(1), 79106.
Obiora, L. A. (1997). Bridges and barricades: Rethinking polemics and
intransigence in the campaign against female circumcision. Case
Western Law Review, 47(2), 275378.
Sargent, C. (1989). Maternity, medicine, and power: Reproductive
decisions in urban Benin. Berkeley: University of California Press.
Sargent, C. (1995). Confronting patriarchy: The potential for advocacy
in medical anthropology. Medical Anthropology Quarterly, 5,
2425.
262
Immunization
Immunization
Global Programs, Local Acceptance and Resistance
Anita Hardon
INTRODUCTION
Until recently immunization as object of investigation
was limited to public health researchers and historians of
science and medicine (Basch, 1994; Greenough, 1980).
Immunization became a more popular topic for anthropological enquiry in the 1970s, when global immunization programs aimed at universal coverage were
launched. Anthropologists were invited by global health
agencies such as the World Health Organization (WHO)
to help identify structural and cultural barriers to achieving increased immunization coverage. More recently
there has been attention to broader issues, including
the processes through which immunization comes to
be institutionalized as a routine practice in public
health management, at the global, national, and local
levels; and there are wider issues pertaining to popular
conceptions of immunity, the role of global institutions,
THE HISTORY
OF IMMUNIZATION
263
264
Immunization
265
successful approach to increasing coverage. Gender issues may
affect the accessibility of vaccination sessions. In Bangladesh,
where the seclusion of women is widespread, mothers themselves did not like to be vaccinated with tetanus toxoid by male
vaccinators, but had no objections if their children were
(Chowdury, Aziz, & Bhuiya, 1998).
2. Staff attitudes: The sociocultural difference between staff and
recipient, and the general attitude of staff toward recipients
were found to be significant. A multi-country study (Streefland
et al., 1999) found that health workers often behave impolitely.
In Malawi, for example, health workers were reported to shout
at women who arrived late. They worked slowly and stopped at
midday even if there was still a long line of women waiting for
the services (Chilowa & Munthali, 1999). In the Philippines,
health workers reportedly were angry if mothers forgot to bring
their vaccination cards (Ramos-Jiminez, Rodrigues, Patino, &
Lim, 1999).
3. Social exclusion processes: Several studies have pointed to the
low immunization rates in marginalized population groups.
A study in Britain found that severely handicapped or disadvantaged groups were less frequently immunized (Berkeley,
1983). A study in India found that scheduled caste women and
their children were denied access to a community home where
vaccination sessions were held until the children of higher caste
women had been vaccinated. Scheduled castes are groups in
India with a very low position in the social hierarchy based on
their supposed ritual impurity (SSIM/India, 1998).
4. Communication on effects: An emphasis on coverage has meant
that immunization programs have emphasized the benefits of
immunization over risks. Anthropological studies have shown
that experiences with side-effects such as fever, abcesses, and
pain can limit future acceptability of vaccines. Mothers also do
not want to have immunizations given to their sick children.
Sick children are considered especially vulnerable. Health
workers know about the concern of their clients, and they know
that they will be blamed if side-effects occur. In practice,
they therefore do warn about side-effects, and are reluctant to
immunize sick children (Heggenhougen & Clements, 1987;
WHO, 1998).
266
pressure, if not prodding, of health workers and community leaders (Nichter, 1995, p.617). Others (Streefland
et al., 1999) have suggested that such a dichotomy is not
sensitive enough to variations in actual vaccination behavior. Acceptance, it is argued, can be more or less active.
Despite efforts to deliver vaccines virtually to every
childs doorstep worldwide, empirical studies suggest that
mothers have to overcome substantial barriers to get their
children vaccinated. As mentioned above, they have to
walk far, or wait for a long time before being attended to.
Is such acceptance passive? Or is it active demand?
Insight into vaccination acceptance and demand
requires an understanding of local notions of disease
etiology. Very few studies have explored these in relation
to interpretations of vaccine efficacy, reflecting perhaps a
neglect in medical anthropology for preventive medicine.
Many more studies have been done on indigenous notions
of therapeutic medicine (Van der Geest, Reynolds,
Whyte, & Hardon, 1996). In their study among the
Bambara of Mali, Imperato and Traore (1969) point out
that the Bambara perceived a vaccination to be an amulet
that works if Koranic charms and diviners incantations
have failed. Just as amulets need to be renewed, so vaccinations are seen to be timebound. In Indonesia mothers
who do not fully vaccinate their children were found to
believe that their children are healthy, and therefore not
in need of further vaccinations (Nichter, 1995). In the
view of the mothers it was the quantity, and not the quality of the distinct vaccinations that mattered. And, Mull,
Anderson, and Mull (1990) describe how in the Hindu
Kush region of Pakistan, tetanus-toxoid (TT) vaccines
given to mothers are seen to prevent or cure Khudakan,
an illness associated with neonatal tetanus. Khudakan,
according to their respondents, is caused by spirits passed
on from the mother to the child. One reason that TT vaccination was accepted is that it is congruent with local
beliefs. Others have reported that mothers do not have
faith in the power of the vaccine to prevent disease; rather
they expect the vaccine to reduce the severity of the
disorder (Odebiyi & Ekong, 1982).
Congruence with local notions of disease etiology
and vaccine efficacy clearly affects the extent to which
people accept and demand vaccines. When they believe
that the vaccines have a general protective effect, and serious illness still occurs, individual mothers may decide
against further vaccination of their children. Refusal to
vaccinate is then based on individual weighing of costs
and benefits. In the above cited case on the promotion of
Immunization
References
267
IN ANTICIPATION
RESISTANCE
OF
FUTURE
REFERENCES
Addlakha, R., & Grover, A. (2000). User configuration and perspective:
Hepatitis B introductory trial in East Delhi. Economic and Political
Weekly, 35(8/9), 736744.
Banerjea, N., & Coutinho, L. (2000). Social production of blame: Case
study of OPV-related deaths in West Bengal. Economic and
Political Weekly, 25(8/9), 709718.
Banjeri, D. (1990). Crash of the immunization program: Consequences
of a totalitarian approach. International Journal of Health
Services, 20(3), 501510.
Basch, P. F. (1994). Vaccines and world health: Science policy and
practice. Oxford, UK: Oxford University Press.
Berkeley, M. I. K. (1983). Measlesthe effect of attitudes on immunization. Health Bulletin, 41, 141147.
Chilowa, W., & Munthali, A. (1999). Immunization in Malawi.
Amsterdam: Spinhuis.
Chowdury, A. M. R., Aziz, K. M. A., & Bhuiya, A. (1998). The near
miracle revisited. Social science perspectives of the immunization
programme in Bangladesh. Amsterdam: Spinhuis.
Coreil, J., Losikoff, P., Pincu, R., Mayard, G., Ruff, A. J., Hausler, H.
P., Desormeau, J., Davis, H., & Boulos, R. (1998). Cultural feasibility studies in preparation for clinical trials to reduce maternalinfant HIV transmission in Haiti. AIDS Education and
Prevention, 10(1), 4662.
Childrens Vaccination Initiative (1997). The CVI strategic plan:
Managing opportunity and change. A vision of vaccination for the
21st century. Geneva, Switzerland: Author.
268
Das, V., Das, R. K., & Coutinho, L. (2000). Disease control and immunization: A sociological enquiry. Economic and Political Weekly,
15(8/9), 625632.
Dietz, V., & Cutts, F. (1997). The use of mass campaigns in the
expanded programme on immunization: A review of reported
advantages and disadvantages. International Journal of Health
Services, 27(4), 767790.
Foucault, M. (1979). Discipline and punish: The birth of the prison.
New York: Vintage.
Greenough, P. R. (1980). Variolation and vaccination in South Asia,
c. 17001865: A preliminary note. Social Science and Medicine,
14D, 345347.
Hardon, A. (1997). Contesting claims on the safety and acceptability
of anti-fertility vaccines. Reproductive Health Matters, 10,
6882.
Hardon, A. (2001, March). Immunization for all? A critical look at the
first GAVI partners meeting. HAI Lights, 6(1), 13.
Hardon, A., Streefland, P. H., Egers, E. M., & Gerrits, T. (1998).
Acceptatie van vaccinatie onder allochtonen in Amsterdam en
Arnhem. Amsterdam: Universiteit van Amsterdam, Sectie Medische
Antropologie.
Heggenhougen, K., & Clements, J. (1987). Acceptability of childhood
immunization: Social science perspectives. A review and annotated
bibliography. London: London School of Hygiene and Tropical
Medicine, Evaluation and Planning Center.
Imperato, P., & Traore, D. (1969). Traditional beliefs about measles
and its treatment among the Bambaro of Mali. Tropical Geography,
21, 62.
Justice, J. (1987). The bureaucratic context of international health:
A social scientists view. Social Science & Medicine, 25(12),
13011306.
Mull, D. S., Anderson, J. W., & Mull, J. D. (1990). Cow dung, rock salt,
and medical innovation in the Hindu Kush of Pakistan: The
cultural transformation of neonatal tetanus and iodine deficiency
disease. Social Science & Medicine, 30, 675.
Muraskin, W. (1990). Origins of the CVIpolitical foundations. Social
Science & Medicine, 42(12), 17201734.
Muraskin, W. (1998). The politics of international health: The
childrens vaccine initiative and the struggle to develop vaccines
for the third world. Albany: State University of New York
Press.
Nichter, M. (1990). Vaccinations in South Asia: False expectations and
commanding metaphors. In J. Correil & D. Mull (Eds.),
Anthropology and Primary Health Care (pp. 196221). Boulder,
CO: Westview Press.
Nichter, M. (1995). Vaccinations in the Third World: A consideration
of community demand. Social Science & Medicine, 41(5),
617632.
Odebiyi, A. I., & Ekong, S. C. (1982). Mothers concepts of measles and
attitudes toward measles vaccine in Ife Ife, Nigeria. Journal of
Epidemiology and Community Health, 36, 209.
Immunization
Onta, S. R., Sabroe, S., & Hansen, E. H. (1998). The quality of immunization data from routine primary health care reports: A case from
Nepal. Health Policy and Planning, 13(2), 131139.
Plochg, T., & van Staa, A. I. (2002). Vaccineren als dilemma. Chronisch
zieken begrepen, 80, 2734.
Ramos-Jiminez, P., Rodrigues, C. A., Patino, O. L., & Lim, B. L.
(1999). Immunization in the Philippines. Amsterdam: Spinhuis.
Salkever, D. S. (1976). Accessibility and demand for preventive care.
Social Science & Medicine, 10, 469575.
Shore, C., & Wright, S. (1997). Anthropology of policy: Critical
perspectives on governance and power. London: Routledge.
Social Science and Immunization/India (1998). Sustainability of vaccination programs and social demand for vaccinations. Country
study India. Delhi: University of New Delhi, Centre for
Development Economics.
Starling, M., Brugha, R., Walt, G., Heaton, A., & Keith, R. (2002). New
products into old systems. The Global Alliance for Vaccines and
Immunization (GAVI) from a country perspective. London: Save
the Children.
Streefland, P. (1999). Quality of vaccination services and social demand
for vaccinations in Africa and Asia. Bulletin of the World Health
Organization, 77(9), 722730.
Streefland, P. (2001). Public doubts about vaccination safety and resistance against vaccination. Health Policy, 55, 159172.
Streefland, P. (2002). Introduction of a HIV vaccine in developing
countries: Social and cultural dimensions. Vaccine, 21(1314),
13041309.
Streefland, P., Chowdury, A. M. R., & Ramos-Jiminez, P. (1999).
Patterns of vaccination acceptance. Social Science & Medicine, 49,
17051716.
United Nations International Childrens Emergency Fund (1996).
Evaluation research: Sustainability of achievements: Lessons
learned from universal child immunization: Report of a steering
committee. New York: Author.
Van der Geest, S., Reynolds-Whyte, S., & Hardon, A. (1996). The
anthropology of pharmaceuticals. Annual Review of Anthropology,
25, 153178.
Walsh, J. A., & Warren, K. S. (1980). Selective primary health care: An
interim strategy for disease control in developing countries. Social
Science & Medicine, 14C, 145163.
Walt, G. (1993). WHO under stress: Implications for health policy.
Health Policy, 24(2), 125144.
World Health Organization (1992). Programme report for 1992,
expanded programme on immunization. Geneva, Switzerland:
Author.
World Health Organization (1997). Polio: The beginning of the end.
Geneva, Switzerland: Author.
World Health Organization (1998). To what extent are vaccine adverse
events a deterrent to immunization? (GPV-CVI/SAGE.98/WP.08).
Geneva, Switzerland: Author.
Historical Background
269
Population Control
Robert J. Meier
HISTORICAL BACKGROUND
Evolutionary PerspectiveMalthus
and Darwin
Thomas Robert Malthus, in his major work originally
published in 1816, Essay on the Principle of Population
(1968), projected a gloom and doom scenario for the
human race in what he surmised to be a losing battle
between population growth and an adequate food supply.
Simply put, humans would multiply at a exponential rate
(2, 4, 8, 16, etc.) while increasing food production only
would occur at an arithmetic rate (1, 2, 3, 4, etc.). As a
dire consequence, the human species would far outstrip
its subsistence capacity, unless population growth was
checked by such agents as famine and disease. We will
have a closer look at the Malthusian doctrine later on, but
for now it is important to note that it was Malthus who
helped clarify for Charles Darwin a vexing problem he
had regarding evolution. Darwin was searching for an
understanding of how change would take place over time
in a population, and in 1838 it was the writing of Malthus
that led him to the notion of struggle for existence, possibly due to limited food resources. Given that the reproductive potential of a population exceeded what appeared
to him to be more or less stable population numbers,
Darwin theorized that a selection process was operating
to remove those individuals who were less able to successfully compete for restricted resources. He eventually
published his theory of Natural Selection in 1859
(Darwin, 1892).
Malthus and Darwin established what to this day
are considered to be natural checks that help to maintain or restore populations within the boundaries of
resource availability. Resources, of course, come in many
forms, not the least of which are an adequate food
supply, mates, and a measure of secure habitat, or safe
living environment. In terms of Darwinian evolution,
then, population control was part and parcel of a natural
process.
270
Population Control
THEORIES
AND
METHODS
Basics of Demography
Demography studies the size, composition, distribution,
and dynamics of populations. Size refers to the number of
persons, usually counted in a census, which can be more
or less accurate depending on the method and thoroughness of counting. Composition deals with a breakdown of
total population in terms of sex and age categories, and
can also include other categories such as race/ethnic
group and SES. Distribution primarily maps the placement and density of populations. Finally, and most
importantly for the topic of population control, dynamics
covers the changes that take place within and between
populations. In simple terms, population size change can
occur depending upon the number of births versus the
number of deaths, plus or minus the number of persons
who migrate into or away from a population. Birth,
fertility, reproductive, and death/mortality rates are more
formally defined than will be utilized here. A highly useful presentation of demographic rates can be found in
Gage (2000). Suffice it to say that this discussion on
population control will be oriented toward some rather
broad aspects of human endeavors to maintain, reduce, or
increase total population size, or to restrict/promote
271
Ecological Models
Imbedded within population ecology is the notion of
carrying capacity, which basically asserts that there is a
maximum population size for a particular set of environmental conditions. One population growth model, out of
several that have been postulated, asserts that exceeding
the maximum would result in degrees of environmental
degradation, ultimately leading to a collapse of the entire
ecosystem. This issue will be taken up in the next section.
It is generally assumed that during the period of
exclusive foraging/hunting economy of our past, human
groups could and did live in a state of harmony with
nature, that is, within the constraints of carrying capacity.
Whether this was intentional through a realized and
understood concept of conservation of resources, or
whether it was simply a matter of having a relatively low
level of exploitative technology, is not always clear.
Probably it was some of each. Certainly there was and
still is a recognition by a numerous cultures of the connectedness between people and the environment through
cosmology, subsistence, and even sophisticated understanding of ecological concepts. There is, of course, the
highly practical understanding that living too long in one
place can raise the risk of certain diseases and parasitic
infections due to accumulated wastes. Hence, it might be
argued that migrating to avoid pollution was one impetus
for human population expansion.
The shifting of subsistence patterns from hunting/
foraging to that of sedentary agriculture very likely
occurred during continuous periods of population
growth. Whether or not population growth was a key
stimulus to the development of agriculture, or whether
agriculture was the base from which rapid population
growth could take place, has been subject to theoretical
dispute (Bogin, 2001). On the one hand, the Boserup
theory of positive demographic pressure contends that
increasing population brought forth increasing demand
for food, followed by more intense efforts for food
procurement through evermore effective agricultural
technology (Livi-Bacci, 2001). The classic theory
272
Population Control
Developments in Medicine
Population growth, expressed as natural increase, is
dependent upon the differential rate of births and deaths,
more births than deaths results in a population increase,
and of course, a decrease occurs when deaths overtake
births. This section will summarize methods that have
been developed to control causes of human mortality and
factors that influence fertility.
Death Control. As noted above, causes of deaths
in pre-industrial peoples likely centered on periodic
episodes of starvation and repeated occurrences of serious injuries, from both man-made and natural events. The
question as to whether compassion and care was extended
to injured, physically disabled or aged persons has been
273
274
Population Control
ISSUES
AND
CONTROVERSIES
275
Overpopulation
Alarming demographic projections regarding ineffectively controlled human population growth and consequent environmental catastrophes have spawned several
literary warnings with ominous titles (e.g., Ehrlich,
The Population Bomb, 1968; Carson, Silent Spring
1962). Perhaps no sentinel in this camp is better known
276
Population Control
277
278
based on case studies as well as broader studies, of sterilization abuse among U.S. women, as does Hartmann
(1995) with respect to Native women. As will be discussed below, procreative rights stand in most peoples
eyes as a foundation of humanity. Hence, forced sterilization is seen to violate reproductive freedom, irrespective of the good intention as defined by those who carry
out the act.
A voiced concern in more recent times is whether
certain biomedical developments might constitute a new
form of eugenics. This issue centers on the growing capability of identifying genes that are in part responsible for
determining such behavorial traits as intelligence and personality, or desired physical attributes such as stature.
When this capability is realized there will be the potential
for abuse in either selecting prenatally for these traits, or
postnatally under the guise of gene therapy. Nonmedical
(in certain instances this could be termed cosmetic)
applications of the new genetics obviously fall within
the purview of quality control of humans, and they raise
the spector of earlier eugenics movements. Certainly the
stakes have been raised now that human cloning may
be added to the controversial mix. However, in spite of the
danger of potential abuse, it does seem that there is a place
for legitimate medical uses of gene therapy.
Population Control
improve household economy. While subsistence livelihoods are still prevalent throughout the world today, the
controversial nature of abortion as a population control
measure centers on particular countries, perhaps exemplified by the United States and China.
Abortion in the United States is legal and may
be used as part of family planning. In this application
it appears that parents mostly carry out their decision
to terminate a pregnancy at the personal or family
level, often dealing with unwanted pregnancies. Antiabortion groups have marshaled forces to thwart the practice of abortion, and have made attempts to overthrow the
Roe v. Wade decision. One highly visible group, the
Center for Bio-Ethical Reform, denounces abortion as an
act of genocide through its display of highly graphic
posters. This action is countered by Pro-Choice advocates, and organizations such as Planned Parenthood
maintain that safe, readily available abortions should be
contained within a broad framework of family planning.
Not surprisingly, there is little likelihood that the abortion
controversy in the United States will be resolved in the
near future.
The situation in China offers a different perspective
on the abortion controversy. China instituted a national
population policy in the 1970s that employed abortion
within its highly coercive family planning program that
established birth quotas. In the 1980s, both incentives
(in the form of wage and pension increases, medical and
educational benefits, etc.) as well as disincentives (such as
salary cuts and loss of benefits) were imposed on Chinese
couples (Livi-Bacci, 2001). Chinas population policy has
been viewed as an attack on basic human rights as well as
a targeted assault on womens rights, since forced
abortions often selected female fetuses (Hartmann,
1994). More recently the one-child policy has been
relaxed somewhat, and the coercive program is being
phased out as China has been able to realize some of
its demographic goals by sharply reducing fertility
(Livi-Bacci, 2001).
Another controversy concerning abortion has
arisen in its use to selectively abort female fetuses in
favor of son-preference (Hartmann, 1995). This practice
has been documented in India and other developing
countries (Miller, 1987; Segal, 2001), where initially
amniocentesis and now ultrasound are done to ascertain
sex. Selective abortion combined with neglect have
resulted in a low female to male sex ratio among children
in India (Segal, 2001).
References
279
REFERENCES
Adamson, D. M., Belden, N., DaVanzo, J., & Patterson, S. (2000).
How Americans view world population issues. A survey of public
opinion. Santa Monica, CA: RAND.
Bates, M. (1968). Role of war, famine, and disease in controlling
populations. In L.B. Young (Ed.), Population in perspective
(pp. 3060). New York: Oxford University Press.
Bledsoe, C., & Hill, A. G. (1998). Social norms, natural fertility, and the
resumption of postpartum contact in The Gambia. In A.M. Basu
& P. Aaby (Eds.), The methods and uses of anthropological demography (pp. 268297). Oxford: Clarendon Press.
Bogin, B. (2001). The growth of humanity. New York: WileyLiss.
Bok, S. (1994). Population and ethics: Expanding the moral space.
In G. Sen, A. Germain, & L. C. Chen (Eds.), Population policies
reconsidered. Health, empowerment, and rights (pp. 1526).
Boston, MA: Harvard University Press.
CBSHealthWatch (2001). Studying smallpox: A brief history of
the killer. Retrieved from http://www.cbshealthwatch.com/cx/
viewarticle/404956.
Carson, R. (1962). Silent spring. Boston: Houghton Mifflin.
Cassidy, C. M. (1980). Benign neglect and toddler malnutrition. In
L.S. Greene & F. Johnston (Eds.), Social and biological predictors
of nutritional status, physical growth, and neurological development (pp. 109139). New York: Academic Press.
Cassidy, C. M. (1987). World-view conflict and toddler malnutrition.
In N. Scheper-Hughes (Ed.), Child survival. Anthropological
perspectives on the treatment and maltreatment of children
(pp. 293324). Dordrecht, The Netherlands: D. Reidel.
Cavalli-Sforza, L. L., & Bodmer, W. F. (1999). The genetics of human
populations. Mineola, NY: Dover.
Cohen, M. (1977). The food crisis in prehistory, overpopulation and the
origins of agriculture. New Haven, CT: Yale University Press.
Darwin, C. (1892). The origin of species by means of natural selection.
New York: Appleton.
Dettwyler, K. A. (1991). Can paleopathology provide evidence for
compassion? American Journal of Physical Anthropology, 84,
375384.
Dettwyler, K. A. (1994). Dancing skeletons. Life and death in West
Africa. Prospect Heights, IL: Waveland Press.
Ehrlich, P. R. (1968). The population bomb. New York: Ballantine
Books.
Ellison, P. T. (2001). On fertile ground. A natural history of human
reproduction. Cambridge, MA: Harvard University Press.
Ellison, P. T., & ORourke, M. T. (2000). Population growth and
fertility regulation. In S. Stinson, B. Bogin, R. Huss-Ashmore, &
D. ORourke (Eds.), Human biology. An evolutionary and biocultural perspective (pp. 553586). New York: WileyLiss.
Fathalla, M. F. (1994). Fertility control technology: A women-centered
approach to research. In G. Sen, A. Germain, & L. C. Chen (Eds.),
280
Reproductive Health
Reproductive Health
Andrea Whittaker
INTRODUCTION
Research on reproductive health within medical anthropology encompasses peoples emic perspectives on all
matters related to sexuality and reproductive processes
281
282
Reproductive Health
FERTILITY REGULATION
Cultures differ in their understandings of fertility and the
process of conception. For example, work on Sri Lanka
(Nichter & Nichter, 1987) has found the first few days
immediately following the cessation of menstruation is
considered the most fertile, due to perceptions that the
womb is most open to conception before and immediately after menstruation. Likewise, women are considered fertile immediately following childbirth due to the
open state of the womb. Humoral notions of hot/cold and
wet/dry also affect fertility. Given that the safe period
is a common means of family planning in Sri Lanka, the
provision of fertility cycle education combined with the
use of condoms could result in a more effective usage of
the safe period both for those wishing to postpone or
space their children, or for those wishing to fall pregnant.
Many cultures have detailed knowledge of herbs,
foods, and medicines for fertility regulation. Newmans
edited work (1985) documents herbal medicines and
other techniques used for menstrual regulation, the management of pregnancy, and assistance with labor in seven
cultures, including ChineseMalay, Afghanistan, Egypt,
Colombia, Peru, Costa Rica, and Jamaica. Indigenous
means of fertility regulation remain popular even when
modern means of contraceptives are available, because
they coincide with local understandings of the body,
are controlled by women, are readily available and are
socially and culturally acceptable. Humoral rationales
underlie many cultures understanding of reproductive
processes and many of the indigenous medicines used in
fertility regulation involve manipulating the bodys
humoral balance to enhance fertility or to delay it. In Cali,
Colombia, one cause of menstrual delay is understood to
be impurities in the womb or menstrual blood, or the
accumulation of cold in the vagina. Remedies that purify
the womb and restore humoral balance or others defined
Fertility Regulation
283
284
PREGNANCY OUTCOMES
In parallel with public health interest in maternal and
child health during the 1960s and 1970s, ethnographic
studies drew attention to the diverse ways of managing
pregnancy, childbirth, and mothering (see the entry
Birth). The management of pregnancy, birth, and the
postpartum period has important consequences for
womens reproductive health. Long-term complications
of pregnancy and childbirth include uterine prolapse, fistulae (holes in the birth canal that allow leakage of urine
or feces from the bladder or rectum) incontinence, painful
intercourse, and infertility. Obstructed labor can cause
permanent nerve damage causing loss of sensation in
the feet and legs, and infections can cause pelvic inflammatory disease, damaging the reproductive system.
Although there is a large anthropological literature on
birth and maternity, there remains scant material on
womens experiences of such conditions.
In many cultures, the postpartum period is defined
as one of vulnerability for both mother and child and is
characterized by a reduction of household and work
responsibilities, minimal social interactions, and support
from female kin. Appropriate actions taken through the
postpartum period are also believed to ensure a womans
continued reproductive health, strength, and beauty in
many cultures. In a number of Southeast Asian cultures,
the practice of mother roasting following birth involves
a period during which the new mother rests close to a
constantly burning fire for a period that varies from several days to several weeks as part of a measure to restore
the humoral balance to a womans body. Childbirth
causes a cold state requiring the gradual restoration of
heat to her body (Manderson, 1981; Mougne, 1978;
Rice & Manderson, 1996; Sich, 1981; Whittaker, 1999).
Postpartum practices also involve dietary restrictions. Foods may be avoided due to their humoral status
as cold foods, or for metaphorical reasons, for example
some strong smelling foods are believed to affect the
quality of the breastmilk. Anthropological studies of
dietary practices and restrictions during pregnancy and in
the postpartum period have also helped clarify to what
extent such practices may negatively impact upon
womens health and the pregnancy outcome (Laderman,
Reproductive Health
285
286
Reproductive Health
SEXUALITY
AND
HIV/AIDS
In their review, Davis and Whitten note that anthropological approaches to the cross-cultural study of sexuality
typically reflect prevailing values in the West at the time
(Davis & Whitten, 1987). Sexuality remains a provocative
subject area with a range of ethical and methodological
difficulties. There remain few detailed ethnographic
studies on sexuality and sexual health (Vance, 1991), especially in relation to aging and sexuality, youth sexuality
(Burbank, 1988; Manderson & Rice, 2002), homosexual
practices (Taylor, 1985), sexual violence, transsexualism,
CONCLUSION
The meanings, beliefs, and practices surrounding
reproduction are structured historically and culturally
by local and global forces (Ginsburg & Rapp, 1991,
1995; Greenhalgh, 1995; Jolly & Ram, 2001; Ram &
Jolly, 1998). Reproductive experiences are structured by
References
REFERENCES
Barnett, T., & Blaikie, P. (1992). How households, families and communities cope with AIDS. In T. Barnett & P. Blaikie (Eds.), AIDS
in Africa: Its present and future impact (pp. 86109). London:
Belhaven Press.
Beyene, Y. (1989). From menarche to menopause: Reproductive lives of
peasant women in two cultures. Albany, NY: SUNY Press.
Birke, L., Himmelweit, S., & Vines, G. (1990). Tomorrows child:
Reproductive technologies in the 90s. London: Virago.
Boddy, J. (1982). Womb as oasis: The symbolic context of pharaonic
circumcision in rural Northern Sudan. American Ethnologist, 9(4),
682698.
Boonmongkon, P., Nichter, M., & Pylypa, J. (2001). Mot luuk problems
in northeast Thailand: Why womens own health concerns matter
as much as disease rates. Social Science & Medicine, 53,
10951112.
Brown, J. K. (1982). Cross-cultural perspectives on middle-aged
women. Current Anthropology, 23, 143156.
Brown, J. K., & Kerns, V. (Eds.). (1985). In her prime: A new view of
middle-aged women. South Hadley, MA: Bergin & Garvey.
Browner, C. H. (1983). Male pregnancy symptoms in urban Colombia.
American Ethnologist, 10(3), 494510.
Browner, C. H. (1985). Traditional techniques for diagnosis, treatment,
and control of pregnancy in Cali, Colombia. In L. F. Newman
(Ed.), Womens medicine. A cross-cultural study of indigenous
fertility regulation (pp. 99123). New Brunswick, NJ: Rutgers
University Press.
Buckley, T. (1988). Menstruation and the power of Yurok women. In
T. Buckley & A. Gottlieb (Eds.), Blood magic: The anthropology
of menstruation (pp. 187209). Berkeley: University of California
Press.
287
Buckley, T., & Gottlieb, A. (Eds.). (1988). Blood magic: The anthropology of menstruation. Berkeley: University of California Press.
Burbank, V. (1988). Aboriginal adolescence: Maidenhood in an
Australian community. New Brunswick, NJ: Rutgers University
Press.
Carter, A. T. (1995). Agency and fertility: For an ethnography of practice.
In S. Greenhalgh (Ed.), Situating fertility: Anthropology and demographic inquiry (pp. 5585). Cambridge, UK: Cambridge
University Press.
Cecil, R. (Ed.). (1996). The anthropology of pregnancy loss:
Comparative studies in miscarriage, stillbirth and neonatal death.
Oxford, UK: Berg.
Chavez, L. R., Hubbell, F. A., McMullin, J. Martinez, R. G., & Mishra,
S. I. (1995). Structure and meaning in models of breast cancer and
cervical cancer risk factors: A comparison of perceptions among
Latinas, Anglo women, and physicians. Medical Anthropology
Quarterly, 9(1), 4074.
Chirawatkul, S. (1996). Blood beliefs in a transitional culture in
Northeast Thailand. In P. Liamputtong Rice & L. Manderson
(Eds.), Maternity and reproductive health in Asian societies
(pp. 247260). Amsterdam: Harwood Academic.
Chirawatkul, S., & Manderson, L. (1994). Perceptions of menopause in
Northeast Thailand: Contested meaning and practice. Social
Science & Medicine, 39(11), 15451554.
Davis, D. L., & Whitten, R. G. (1987). The cross-cultural study of
human sexuality. Annual Review of Anthropology, 16, 6998.
Delaney, C. (1988). Mortal flow: Menstruation in Turkish village
society. In T. Buckley & A. Gottlieb (Eds.), Blood magic: The
anthropology of menstruation (pp. 7593). Berkeley: University of
California Press.
DeVecchio Good, M.-J. (1980). Of blood and babies: The relationship
of popular Islamic physiology to fertility. Social Science &
Medicine, 14B, 147156.
Ebin, V. (1994). Interpretations of infertility: The Aowin people of southwest Ghana. In C. MacCormack (Ed.), Ethnography of fertility and
birth (2nd ed., pp. 131151). Prospect Heights, IL: Waveland Press.
Farmer, P. (1992). AIDS and accusation: Haiti and the geography of
blame. Berkeley: University of California Press.
Farquhar, J. (1991). Objects, processes and female infertility in Chinese
medicine. Medical Anthropology Quarterly, 5, 370399.
Ford, C. S. (Ed.). (1964). A comparative study of human reproduction.
New Haven: Human Relations Area Files Press.
Franklin, S. (1990). Deconstructing desperateness: The social
construction of infertility in popular representations of new
reproductive technologies. In M. McNeil, I. Varcoe, & S. Yearley
(Eds.), The new reproductive technologies (pp. 200229).
New York: St. Martins Press.
Gammeltoft, T. (1999). Womens bodies, womens worries: Health and
family planning in a Vietnamese rural community. Richmond, UK:
Curzon Press.
Ginsburg, F. (1989). Contested lives: The abortion debate in an
American community. Berkeley: University of California Press.
Ginsburg, F., & Rapp, R. (1991). The politics of reproduction. Annual
Review of Anthropology, 20, 311343.
Ginsburg, F. D., & Rapp, R. (Eds.). (1995). Conceiving the new world
order: The global politics of reproduction. Berkeley: University of
California Press.
288
Githens, M., & Stetson, D. M. (Eds.). (1996). Abortion politics: Public
policy in cross-cultural perspective. London: Routledge.
Greenhalgh, S. (Ed.). (1995). Situating fertility: Anthropology and
demographic inquiry. Cambridge, UK: Cambridge University
Press.
Gregg, J. (2000). Mixed blessings: Cervical cancer screening in Recife,
Brazil. Medical Anthropology, 19(1), 4163.
Gruenbaum, E. (1996). The cultural debate over female circumcision:
The Sudanese are arguing this one for themselves. Medical
Anthropology Quarterly, 10(4), 455475.
Gruenbaum, E. (1999). The movement against clitoridectomy and
infibulation in Sudan: Public health policy and the womens
movement. Medical Anthropology Quarterly, 13(2), 412.
Gruenbaum, E. (2001). The female circumcision controversy: An anthropological perspective. Philadelphia: University of Pennsylvania
Press.
Handwerker, L. (1998). The consequences of modernity for childless
women in China: Medicalisation and resistance. In M. Lock &
P. A. Kaufert (Eds.), Pragmatic women and body politics
(pp. 178205). Cambridge, UK: Cambridge University Press.
Handwerker, W. P. (Ed.). (1990). Births and power: Social change and
the politics of reproduction. Boulder, CO: Westview Press.
Herdt, G. H. (Ed.). (1982). Rituals of manhood: Male initiation in
Papua New Guinea. Berkeley: University of California Press.
Hey, V., Itzin, C., Saunders, L., & Speakman, M. A. (Eds.). (1989).
Hidden loss: Miscarriage and ectopic pregnancy. London: The
Womens Press.
Indriso, C., & Fathalla, M. F. (1999). Introduction. In C. Indriso &
M. F. Fathalla (Eds.), Abortion in the developing world
(pp. 2353). London: World Health Organisation & Zed Books.
Ingstad, B. (1990). The cultural construction of AIDS and its consequences for prevention in Botswana. Medical Anthropology
Quarterly, 4(1), 2840.
Jolly, M., & Ram, K. (Eds.). (2001). Borders of being: Citizenship,
fertility, and sexuality in Asia and the Pacific. Michigan:
University of Michigan Press.
Kaplan, E. A. (1999). The politics of surrogacy narratives. In
E. A. Kaplan & S. Squier (Eds.), Playing dolly: Technocultural
formations, fantasies, and fictions of assisted reproduction
(pp. 116133). New Brunswick, NJ: Rutgers University Press.
Katz, M., & Konner, M. (1981). The role of the father: An anthropological perspective. In M. Lamb (Ed.), Child development (pp.
155185). New York: Wiley.
Kendall, L. (1987). Cold wombs in balmy Honolulu: Ethnomedicine
among Korean immigrants. Social Science & Medicine, 25(4),
367376.
Kerns, V. (1985). Sexuality and social control among the Garifuna. In
J. K. Brown & V. Kerns (Eds.), In her prime: A new view of middleaged women (pp. 87100). South Hadley, MA: Bergin & Garvey.
Kielmann, K. (1998). Barren ground: Contesting identities of infertile
women in Pemba, Tanzania. In M. Lock & P. A. Kaufert (Eds.),
Pragmatic women and body politics (pp. 127163). Cambridge,
UK: Cambridge University Press.
Laderman, C. (1983). Wives and midwives: Childbirth and nutrition in
rural Malaysia. Berkeley: University of California Press.
LaFleur, W. R. (1992). Liquid life. Abortion and Buddhism in Japan.
Princeton, NJ: Princeton University Press.
Reproductive Health
Lock, M. (1988). The selfish housewife and menopausal syndrome in
Japan (Women in International Development Publication Series).
East Lansing: Michigan State University.
Lock, M. (1998). Perfecting society: Reproductive technologies,
genetic testing, and the planned family in Japan. In M. Lock &
P. A. Kaufert (Eds.), Pragmatic women and body politics
(pp. 206239). Cambridge, UK: Cambridge University Press.
Lock, M., & Kaufert, P. A. (Eds.). (1998). Pragmatic women and body
politics. Cambridge, UK: Cambridge University Press.
Lovell, A. (1983). Some questions of identity: Late miscarriage,
stillbirth and perinatal loss. Social Science & Medicine, 17(11),
755761.
Luker, K. (1984). Abortion and the politics of motherhood. Berkeley:
University of California Press.
Lyttleton, C. (2000). Endangered relations: Negotiating sex and AIDS
in Thailand. Amsterdam: Harwood Academic.
MacCormack, C. (1985). Lay concepts affecting utilization of family
planning services in Jamaica. Journal of Tropical Medicine and
Hygiene, 88, 281285.
Malinowski, B. (1932). The sexual life of savages in northwestern
Melanesia. London: Routledge and Kegan Paul.
Manderson, L. (1981). Roasting, smoking and dieting in response to
birth: Malay confinement in cross-cultural perspective. Social
Science & Medicine, 15B, 509520.
Manderson, L. (1986). Food classification and restriction in peninsular
Malaysia: Nature, culture, hot and cold? In L. Manderson (Ed.),
Shared wealth and symbol: Food, culture, and society in Oceania
and Southeast Asia (pp. 127143). Cambridge, UK: Cambridge
University Press.
Manderson, L., & Rice, P. L. (Eds.). (2002). Coming of age:
Adolescence in South-east Asia. Richmond, UK: Curzon Press.
Martin, E. (1987). The woman in the body: Cultural analysis of
reproduction. Stoney Stratford, UK: Open University Press.
Maternowska, M. C. (2000). A clinic in conflict: A political economy
case study of family planning in Haiti. In A. Russell, E. J. Sobo, &
M. S. Thompson (Eds.), Contraception across cultures:
Technologies, choices, constraints (pp. 103126). Oxford, UK:
Berg.
Maynard Tucker, G. (1986). Barriers to modern contraceptive use in
rural Peru. Studies in Family Planning, 17(6), 308316.
Mead, M. (1928). Coming of age in Samoa. New York: William
Morrow.
Millar, M. I. (1987). Genital chlamydial infection: A role for social
scientists. Social Science & Medicine, 25(12), 12891299.
Modell, J. (1989). Last chance babies: Interpretations of parenthood in
an in vitro fertilization program. Medical Anthropology Quarterly,
3(2), 124138.
Montagu, M. F. A. (1949). Embryology from antiquity to the end of the
18th century. Ciba Symposia, 10(4), 9941008.
Morgan, L. M. (1990). When does life begin? A cross-cultural perspective on the personhood of fetuses and young children. In E. Doerr &
J. W. Prescott (Eds.), Abortion rights and fetal personhood
(2nd ed., pp. 89107). Long Beach, CA: Centerline Press.
Morsy, S. A. (1980). Body concepts and health care: Illustrations from
an Egyptian village. Human Organization, 39(1), 9297.
Mougne, C. (1978). An ethnography of reproduction. Changing patterns
of fertility in a Northern Thai village. In P. A. Stott (Ed.), Nature
References
and man in South East Asia (pp. 68106.). London: School of
Oriental & African Studeis, University of London.
Nag, M. (1972). Sex, culture, and human fertility: India and the
United States. Current Anthropology, 13, 231237.
Nanda, S. (1985). The Hijras of India. Journal of Homosexuality,
11(34), 3554.
Nanda, S., & Francher, J. S. (1980). Culture and homosexuality. The
Eastern Anthropologist, 33(2), 139152.
Newman, L. F. (Ed.). (1985). Womens medicine. A cross-cultural study
of indigenous fertility regulation. New Brunswick, NJ: Rutgers
University Press.
Nichter, M. (1996a). The ethnophysiology and folk dietetics of pregnancy: A case study from South India. In M. Nichter & M. Nichter
(Eds.), Anthropology and international health: Asian case studies
(pp. 3569). Amsterdam: Gordon & Breach.
Nichter, M. (1996b). Modern methods of fertility regulation: When and
for whom are they appropriate? In M. Nichter & M. Nichter (Eds.),
Anthropology and international health: Asian case studies
(pp. 71108). Amsterdam: Gordon & Breach.
Nichter, M. (1996c, September/October). Self-medication and STD
prevention. Sexually Transmitted Diseases, 353356.
Nichter, M., & Nichter, M. (1987). Cultural notions of fertility in South
Asia and their impact on Sri Lankan family planning practices.
Human Organization, 46(1), 1828.
Oakley, A., McPherson, A., & Roberts, H. (1984). Miscarriage.
London: Fontana.
Obermeyer, C. (1999). Female genital surgeries: The known, the
unknown, and the unknowable. Medical Anthropology Quarterly,
13(1), 79106.
Parker, R. (1987). Acquired Immunodeficiency Syndrome in urban
Brazil. Medical Anthropology Quarterly, 1(2), 155175.
Petchesky, R. P. (1990). Abortion and womans choice: The state,
sexuality and reproductive freedom (Rev. ed.). Boston, MA:
Northeastern University Press.
Petchesky, R. P., & Judd, K. (Eds.). (1998). Negotiating reproductive
rights: Womens perspectives across countries and cultures.
London and New York: Zed Books.
Polgar, S. (1972). Population history and population policies from an
anthropological perspective. Current Anthropology, 13, 203211.
Polgar, S., & Marshall, J. F. (1978). The search for culturally acceptable
fertility regulating methods. In M. H. Logan & E. E. Hunt (Eds.),
Health and the human condition: Perspectives in medical anthropology. Belmont, CA: Wadsworth.
Quam, M. (1990). The sick role, stigma and pollution: The case of
AIDS. In D. A. Feldman (Ed.), Culture and AIDS (pp. 2944).
New York: Praeger.
Ram, K., & Jolly, M. (Eds.). (1998). Maternities and modernities:
Colonial and postcolonial experiences in Asia and the Pacific.
Cambridge, UK: Cambridge University Press.
Rapp, R. (1990). Constructing amniocentesis: Maternal and medical
discourse. In F. Ginsburg & A. L. Tsing (Eds.), Uncertain terms:
Negotiating gender in American culture (pp. 2842). Boston, MA:
Beacon Press.
Rapp, R. (1991). Moral pioneers: Women, men, and fetuses on a frontier
of reproductive technology. In M. Di Leonardo (Ed.), Gender at
the crossroads of knowledge: Feminist anthropology in the postmodern era. Berkeley: University of California Press, 383395.
289
Rapp, R. (1999). Testing women, testing the fetus: The social impact of
amniocentesis in America. New York: Routledge.
Rasmussen, S. J. (1991). Lack of prayer: Ritual restrictions, social
experience, and the anthropology of menstruation among the
Tuareg. American Ethnologist, 18, 751769.
Rasmussen, S. J. (2000). From childbearers to culture-bearers:
Transition to postchildbearing among Tuareg women. Medical
Anthropology, 19(1), 91116.
Renaud, M. L. (1997). Women at the crossroads: A prostitute communitys response to AIDS in urban Senegal. Amsterdam: Gordon &
Breach.
Rice, P. L., & Manderson, L. (Eds.). (1996). Maternity and reproductive health in Asian societies. Amsterdam: Harwood Academic.
Richards, A. (1956). Chisungu: A girls initiation ceremony among the
Bemba of Northern Rhodesia. London: Faber & Faber.
Riviere, P. G. (1974). The couvade: A problem reborn. Man, 9, 423435.
Rosen, R. H., & Benson, T. (1982). The second class partner: The male
role in family-planning decisions. In G. L. Fox (Ed.), The childbearing decision: Fertility attitudes and behavior. Beverly Hills,
CA: Sage.
Russell, A., Sobo, E. J., & Thompson, M. S. (Eds.). (2000).
Contraception across cultures: Technologies, choices, constraints.
Oxford, UK: Berg.
Rylko-Bauer, B. (1996). Abortion from a cross-cultural perspective: An
introduction. Social Science & Medicine, 42(4), 479482.
Sandelowski, M. (1990). Fault lines: Infertility and imperiled sisterhood. Feminist Studies, 16(1), 3352.
Sandelowski, M. (1991). Compelled to try: The never-enough quality of
conceptive technology. Medical Anthropology Quarterly, 5(1),
2947.
Shah, A. M. (1961). A note of the Hijadas of Gujurat. American
Anthropologist, 63(6), 13251330.
Shell-Duncan, B., & Hernlund, Y. H. (2000). Female circumcision in
Africa: Culture, controversy, and change. Boulder, CO: Lynn
Rienner.
Sich, D. (1981). Traditional concepts and customs of pregnancy, birth
and post partum period in rural Korea. Social Science & Medicine,
15B, 6569.
Sobo, E. (1992). Unclean deeds: Menstrual taboos and binding ties
in rural Jamaica. In M. Nichter (Ed.), Anthropological approaches
to the study of ethnomedicine (pp. 101126). New York: Gordon &
Breach.
Sobo, E. (1993a). Bodies, kin and flow: Family planning in rural
Jamaica. Medical Anthropology Quarterly, 7, 5073.
Sobo, E. (1993b). One blood: The Jamaican body. Albany, NY: SUNY
Press.
Songwathana, P., & Manderson, L. (2001). Stigma and rejection: Living
with AIDS in villages in Southern Thailand. Medical
Anthropology, 20(1), 123.
Stark, N. (2000). My body, my problem: Contraceptive decision-making
among rural Bangladeshi women. In A. Russell, E. J. Sobo, &
M. S. Thompson (Eds.), Contraception across cultures: Technologies,
choices, constraints (pp. 179196). Oxford, UK: Berg.
Suggs, R. C., &. Marshall, D. S. (1971). Anthropological perspective on
human sexual behaviour. In D. S Marshall & R. C. Suggs (Eds.),
Human sexual behaviour: Variations in the ethnographic spectrum
(pp. 218244). New York: Basic Books.
290
Taylor, C. L. (1985). Mexican male homosexual interaction in public
contexts. Journal of Homosexuality, 11(34), 117136.
Thompson, M. S. (2000). Family planning or reproductive health?
Interpreting policy and providing family planning services
in Highland Chiapas, Mexico. In A. Russell, E. J. Sobo, &
M. S. Thompson (Eds.), Contraception across cultures:
Technologies, choices, constraints (pp. 221243). Oxford, UK:
Berg.
Vance, C. S. (1991). Anthropology rediscovers sexuality: A theoretical
comment. Social Science & Medicine, 33(8), 875884.
Vatuk, S. (1985). South Asian cultural conceptions of sexuality.
In J. K. Brown & V. Kerns (Eds.), In her prime: A new view of
middle-aged women (pp. 137154). South Hadley, MA: Bergin &
Garvey.
Whiteford, L., & Sharinus, M. (1988). Delayed accomplishments:
Family formation among older first-time parents. In K. Michaelson
(Ed.), Childbirth in America (pp. 239253). South Hadley, MA:
Bergin & Garvey.
Reproductive Health
Whittaker, A. (1996). Quality of care for women in Northeast Thailand:
Intersections of class, gender and ethnicity. Health Care for
Women International, 17(5), 435448.
Whittaker, A. (1999). Birth and the postpartum in Northeast Thailand:
Contesting modernity and tradition. Medical Anthropology: Crosscultural Studies in Health and Illness, 18, 215242.
Whittaker, A. (2000). Intimate knowledge: Women and their health in
Northeast Thailand. Sydney, Australia: Allen & Unwin.
Whittaker, A. (2002). Negotiating care: Reproductive tract infections in
Vietnam. In A. Whittaker (Ed.), Womens health in mainland
Southeast Asia. Binghamton, NY: Haworth Medical Press.
Wood, K., Jewkes, R., & Abrahams, N. (1997). Cleaning the womb,
constructions of cervical cancer screening and womb cancer
among rural Black women in South Africa. Social Science &
Medicine, 45(2), 283294.
Wright, P. (1982). Attitudes toward childbearing and menstruation
among the Navajo. In M. McKay (Ed.), The anthropology of
human birth (pp. 337394). Philadelphia, PA: F.A. Davis.
Alcohol Use
Dwight B. Heath and Irene Glasser
ALCOHOL
AND
ALCOHOL USE
293
294
Alcohol Use
ANTHROPOLOGY
STUDIES
AND
ALCOHOL
295
296
Alcohol Use
RECENT TRENDS
IMPLICATIONS
AND
PRACTICAL
Some Milestones
In one sense it is disappointing that anthropology has not
had more impact on how people use and think about
alcohol. In another sense, it is gratifying that so much has
been accomplished by so few in a field long dominated
by biomedical interests.
Openness to considering cultural differences with
respect to alcohol is often stated as a goal although many
in the field must be reminded of it when dealing with
specific issues. A bibliography, a periodic newsletter,
and a few anthologies and occasional review articles,
or special issues of journals on various topics, make it
easier now to keep abreast of the diverse and scattered
literature.
297
recommend policies. They continue to emphasize adoption of a bundle of measures intended to lessen such
problems. These include increasing taxes on beverage
alcohol, restricting advertising, mandating health-warning labels, increasing the minimum legal drinking age,
curtailing sales outlets and hours of business, and other
measures aimed at decreasing the overall consumption
of alcohol.
Many individuals abstain and even so-called moderate drinkers generally consume very little. It should not
be surprising that most control measures cut drinking
among non-abusers while hardly affecting those who
engage in heavy drinking. It is a concern that so little has
been achieved in the way of reducing harm or preventing
problems.
The inordinate emphasis on the consumption model
has resulted in an imbalance in research and writing about
alcohol by those who claim to have a primarily social or
cultural interest. By far the greatest portion of such work
is epidemiological, correlating the quantity and frequency of drinking with various alcohol-related problems
and compiling quantitative data on alcohol as used by
diverse demographic categories. Most such studies are
conducted by means of social surveys, with close attention to the exact wording of the instrument or questionnaire, and to the process of sampling within the large
population. Such studies can be conducted by unskilled
personnel using standard survey instruments, and they
yield quantitative data that can be tabulated and statistically manipulated, have the superficial appearance of
hard science, and are easily communicated in visual
format. Unfortunately, too often even the principal
investigator is at a loss to explain or to interpret findings
in terms that would have meaning to the subjects or to
colleagues.
By contrast, most ethnographic studies require close
and sustained work by skilled observers and yield qualitative data that do not easily lend themselves to tabulation
or visual presentation. Brief papers based on such qualitative studies too often are regarded as little more than
interesting anecdotes and few bother to read the expository style that is often judged to be soft in comparison
with numerical findings. Those who mistakenly confuse
numbers with science give credibility to quantification,
even while many methodological issues remain questionable among survey practitioners.
It is becoming commonplace to give lip service to
the ideal of combining qualitative with quantitative
298
Education as Prevention
It is primarily anthropologists who proposed the sociocultural model (as an alternative to the consumption
model discussed above) as a means of preventing or lessening alcohol-related problems. Centuries of experience
demonstrate that (contrary to what many believe) drinking at an early age, drinking every day, or drinking more
than two drinks at a sitting, are not major factors in identifying who will have alcohol-related problems (as
throughout southern Europe), suggesting instead that
familiarity with alcohol and its effects, an unglamorous
view of drinking, and learning to do so with food and in
the company of kin may be protective.
On the assumption that sociocultural integration of
alcohol is preventive, education about it seems to be
called for to remedy widespread ignorance and inaccurate
stereotypes about drinking and its outcomes. Numerous
experiments with brief educational efforts, often unrelated to other topics and taught by people who are not
knowledgeable, relying heavily on scare tactics, have
been discredited, but there have been few attempts at
long-term accurate teaching in ways that relate alcohol in
credible ways to other things people care about. Rather
than attempting to diminish drinking by everyone, such
an approach would probably help abstainers to understand their choice as well as help some of those who
might otherwise drink inappropriately, creating problems
for themselves and others.
Alcoholics Anonymous
Alcoholics Anonymous (AA) is a fellowship of individuals whose primary concern is to stop drinking.
Alcohol Use
299
300
Alcohol Use
BIBLIOGRAPHY
Baer, H. S., Singer, M., & Susser, I. (1997). Legal addictions, Part I,
Demon in a bottle. In H. S. Baer, M. Singer, & I. Susser (Eds.),
Medical anthropology and the world system: A critical perspective
(pp. 73101). Westport, CT: Bergin & Garvey.
Douglas, M. (Ed.). (1987). Constructive drinking: Perspectives on drink
from anthropology. Cambridge, UK: Cambridge University Press.
Heath, D. B. (Ed.). (1995). International handbook on alcohol and
culture. Westport, CT: Greenwood.
Heath, D. B. (2000). Drinking occasions: Comparative perspectives on
alcohol and culture. Philadelphia, PA: Brunner/Mazell.
Lowinson, J., Ruiz, P., Millman, R., & Langrod, J. (Eds.). (1997).
Substance abuse: A comprehensive textbook. Baltimore, MD:
Williams & Wilkins.
MacAndrew, C., & Edgerton, R. (1969). Drunken comportment:
A social explanation. Chicago: Aldine.
Definitions
301
INTRODUCTION
Child abuse and neglect violate some of our most
cherished views of human relationships. Parents are
expected to nurture and care for their offspring, providing
the foundation for families and societies. Nevertheless,
child abuse and neglect have occurred throughout history
and across cultures. Child maltreatment became a
concerted field of inquiry and a matter of public and
professional attention in the United States in the early
1960s (Kempe, Silverman, Droegmueller, & Silver, 1962).
Many nations had similar experiences of first denying the
existence of child maltreatment within their boundaries,
only to later discover its existence. This stimulated
interest in the broader cross-cultural record (Hrdy, 1999;
Korbin, 1981; Levinson, 1989; Scheper-Hughes, 1987;
Scheper-Hughes & Sargent, 1998).
DEFINITIONS
Definitional ambiguity has been a major stumbling block
in child abuse and neglect research and practice. There has
been considerable difficulty in formulating valid and reliable definitions of child maltreatment. Definitions are critical because they influence case identification and thereby
knowledge about child maltreatment. Identification of
child maltreatment relies on a complex interaction of (1)
harm to the child; (2) caretaker behaviors that produced or
contributed to that harm; and (3) societal or cultural
assignment of responsibility or culpability.
Child maltreatment was initially defined in the
medical and social welfare literature in the United States
302
from cultural standards and norms affords an intracultural view that highlights those individuals who violate the continuum of acceptable behavior. And third,
societal-level maltreatment of children is sometimes
confused with culturally acceptable behaviors. Societal
neglect refers to the level of harm or deprivation that a
larger political body (e.g., nation) is willing to tolerate for
its children (Korbin, 1981, 1997). Because child maltreatment has not always been labeled as such in other
cultures, some anthropological works have examined
physical punishment (Levinson, 1989) or emotional
climate as accepting or rejecting (Rohner, 1986).
INCIDENCE
AND
DEMOGRAPHICS
ETIOLOGY
The etiology of child abuse and neglect is poorly understood, even within those nations that have the longest
history of research and policy attention to the problem.
More sophisticated etiological models stress the importance of an ecological framework, with risk and protective
factors transacting across the ecological levels of individual factors, family factors, community factors, and factors
in the larger sociocultural environment. These complex
theoretical models, however, have rarely been adequately
subjected to empirical testing and research (Cicchetti &
Lynch, 1993; National Research Council, 1993).
A cross-cultural perspective has the potential to
enhance understanding of the complex interaction of risk
and protective factors that contribute to or prevent the
occurrence of child maltreatment. It is not currently
known whether common or divergent pathways lead to
child maltreatment across diverse populations. For example, does the interaction of poverty and an individual history of child maltreatment have different consequences in
different community contexts? Etiological factors should
have explanatory power both within and between cultures.
The cross-cultural record sheds some light on
categories of children at risk for maltreatment. Even in
303
OF
CHILD
304
CONSEQUENCES
NEGLECT
OF
CHILD ABUSE
AND
INTERVENTION
AND
PREVENTION
REFERENCES
Cicchetti, D., & Lynch, M. (1993). Toward an ecological/transactional
model of community violence and child maltreatment:
Consequences for childrens development. Psychiatry, 56, 96118.
Handwerker, H. P. (2001). Child abuse and the balance of power in
parental relationships: An evolved domain-independent mental
mechanism that accounts for behavioral variation. American
Journal of Human Biology, 13, 679689.
Hrdy, S. B. (1999). Mother nature. A history of mothers, infants, and
natural selection. New York: Pantheon Books.
Kempe, C. H., Silverman, F. N., Droegmueller, W., & Silver, H. K.
(1962). The battered child syndrome. Journal of the American
Medical Association, 181, 1724.
Korbin, J. (Ed.) (1981). Child abuse and neglect: Cross-cultural
perspectives. Berkeley and Los Angeles: University of California
Press.
Korbin, J. (1987a). Child maltreatment in cross-cultural perspective:
Vulnerable children and circumstances. In R. Gelles & J. Lancaster
(Eds.), Child abuse and neglect: Biosocial dimensions (pp. 3155).
Chicago: Aldine.
Introduction
305
INTRODUCTION
CholeraA Water-Borne Disease
The practically invisible bacterium Vibrio cholerae made
millions of people sick and die before it was first recognized in 1503 (Kiple, 1993). Easily transmitted through
water and food, sudden large outbreaks of cholera can
occur through fecal contamination of a water supply.
Cholera outbreaks are often associated with a breakdown
in sanitary conditions such as those following a hurricane
or flood where drinking water systems are contaminated
with fecal matter as pipes break and raw sewage spills
out. Political and economic forces are also implicated in
the spread of cholera; its spread is most often associated
with inadequate sanitation and hygiene conditions.
The World Health Organization (WHO, 2001)
estimates that every 8 seconds a child dies of a waterrelated disease and probably more than five million
people die from diseases associated with contaminated
water and poor sanitary conditions. Cholera and other
water-borne and water-washed illnesses are particularly
relevant for social science research because their control
depends on understanding the human decisions and
behaviors surrounding the continual transmission of the
bacterium. Medical anthropologists contributions to the
306
TYPOLOGY
DISEASES
OF
WATER-RELATED
ANTHROPOLOGICAL CONTRIBUTIONS
TO THE STUDY OF WATER-RELATED
DISEASES
Much of the anthropological research on cholera builds on
the extensive body of literature created between the 1980s
and 2000 by medical anthropologists studying diarrheal
disease (Bentley, 1988; Chen & Scrimshaw, 1983; Green,
1986; Kendall, Foote, & Martorell, 1983, 1984; Nitcher,
1988; Whiteford, 1999; Yoder, 1995). The world-wide
scale of Child Survival intervention programs, and in
307
308
Conclusion
309
CONCLUSION
Understanding the Determinants of
Water-Related Diseases
Understanding the cultural beliefs and behaviors related
to water use, as well as the underlying reasons for water
scarcity, are central to any attempt to reduce morbidity
and mortality due to cholera and other water-borne diseases. Untangling the complex set of relationships
between determinants of water supply, personal and
household hygiene behaviors, and exposures to waterborne diseases has benefited from the work of medical
anthropologists and their application of concepts, skills,
and techniques. The synergistic effect of expanding our
understanding of the underlying determinants of the
changing rates of water-borne and water-washed diseases
to include behaviors and beliefs associated with water
insecurity enhances our ability to facilitate the interruption of transmission of water-borne and water-washed
disease such as cholera, trachoma, schistosomiasis, amoebic dysentery, malaria, and hepatitis.
310
REFERENCES
Ahmed, S. A., Hoque B. A., & Mahmud A. (1998). Water management
practices in rural and urban homes: A case study from Bangladesh
on ingestion of polluted water. Public Health, 112, 317321.
Arar, N. H. (1998). Cultural responses to water shortage among
Palestinians in Jordan: The water crisis and its social impact on
child health. Human Organization, 57(3), 284291.
Baer, H., Singer, M., & Johnson, J. H. (1986). Introduction: Toward a critical medical anthropology. Social Science & Medicine, 23, 9598.
Bentley, M. D. (1988). The household management of childhood diarrhea in rural North India. Social Science & Medicine, 27, 7585.
Cairncross, S., & Cliff, J. L. (1987). Water use and health in Mueda,
Mozambique. Transactions of the Royal Society of Tropical
Medicine, 81(1), 5154.
Cairncross, S., & Kinnear, J. (1992). Elasticity of demand for water in
Khartoum, Sudan. Social Science & Medicine, 34(2), 183189.
Chen, L. C., & Scrimshaw, N. (1983). Diarrhea and malnutrition:
Urthactions, mechanisms and intervention. New York: Plenum
Press.
Diamond, J. (1992). The return of cholera. Discover, 13, 6066.
Esrey, S. A., & Habicht, J. (1986). Epidemiological evidence for health
benefits from improved water supplies and sanitation in developing countries. Epidemiology Review, 8, 117128.
Frankenberg, R. (1988). Gramsci, culture and medical anthropology:
Kundry and Parsifal? Or rats tail to sea serpent. Medical
Anthropology Quarterly, 2, 324337.
Good, B. J. (1977). The heart of whats the matter: The semantics of
illness in Iran. Culture, Medicine, & Psychiatry, 1, 2558.
Good, B. J., & DelVecchio Good, M. J. (1980). The meaning of symptoms: A cultural hermeneutic model for clinical practice. In
L. Eisenberg & A. Kleinman (Eds.), The relevance of social science
for medicine (pp. 165196). Dordrecht, The Netherlands: D. Reidel.
Good, B. J., & DelVecchio Good, M. J. (1981). The semantics of
medical discourse. In E. Mendelsohn & Y. Elkana (Eds.), Sciences
and cultures, sociology of the sciences (Vol. 5, pp. 177212).
Dordrecht, The Netherlands: D. Reidel.
Green, E. (1986). Diarrhea and the social marketing of oral rehydration
salts in Bangladesh. Social Science & Medicine, 23, 357366.
Guthman, J. P. (1995). Epidemic cholera in Latin America: Spread and
routes of transmission. Journal of Tropical Medicine and Hygiene,
98, 419427.
Joralemon, D. (1999). Exploring medical anthropology. Needham
Heights, MA: Allyn & Bacon
Kendall, C., Foote, D., & Martorell, R. (1983). Anthropology, communications, and health practices in Honduras. Human Organization,
42, 353360.
311
AND
DISEASE
ON
312
ANTHROPOLOGICAL PERSPECTIVES
CHRONIC DISEASES OF AGING
ON
313
314
with risk factors for osteoporosis, and treatment is indicated for those meeting the WHO criteria for osteoporosis
(Juby, 1999). The principal treatment for osteoporosis is
the use of agents that retard bone resorption, including calcium, estrogen, calcitonin, and biphosphonates. Hormone
replacement therapy (estrogen and estrogen/progestogen
combinations) has been shown to be effective for both
the prevention and treatment of osteoporosis with a
demonstrated decrease in the risk of fractures (Murray
et al., 1995).
Sociocultural Studies of Osteoporosis. Despite
the frequent disability and physical disfigurement associated with this condition, little attention has been given to
osteoporosis from a sociocultural viewpoint (Gold &
Drezner, 1995). Seanne (2000) has examined behavioral
and psychological strategies used by elderly women with
osteoporosis to negotiate and protect their sense of self in
the face of meanings associated with aging and with the
disease. Other qualitative research (Paier, 1996) has
documented the negative psychosocial impact of vertebral osteoporotic fractures on older womens selfperceived physical functioning, appearance, and social
connectedness.
Alzheimers Disease
Alzheimers disease (AD) is the most common adult
onset neurodegenerative disorder and accounts for up to
60% of all age-related cases of dementia in Western
societies (Woodruff-Pak & Papka, 1999). The disease is
characterized by a progressive decline in cognitive abilities, personality, and psychomotor functioning over a
period averaging from 8 to 10 years (Filley, 1995; Morris,
1994). Memory impairment is the principal feature of AD
and several distinct stages of the disease, often classified
as mild, moderate, and severe, are recognized (Morris,
1994). Early manifestations of the disease include the
inability to recall recent events, difficulties with wordfinding, and geographic or temporal disorientation. As
memory loss grows over the course of the disease, the
individuals ability to carry out even simple routine activities is affected, language output and comprehension
decline, and behavioral problems, such as wandering and
restlessness, aggression, and suspiciousness appear. In
advanced AD, the affected individual is totally functionally dependent due to severe dementia, and is typically
mute and incontinent.
Conclusion
315
CONCLUSION
With the global aging of populations, the worldwide
impact of age-related chronic diseases on quality of life
316
REFERENCES
Agerwal, S. C., & Grynpas, M. D. (1996). Bone quantity and quality in
past populations. Anatomical Record, 246, 423432.
Bovet, P. (1995). The epidemiologic transition to chronic diseases in
developing countries: Cardiovascular mortality, morbidity, and risk
factors in Seychelles (Indian Ocean). Sozial- und Preventivmedizin,
40, 3543.
Center, J., & Eisman, J. (1997). The epidemiology and pathogenesis of
osteoporosis. Baillieres Clinical Endocrinology and Metabolism,
11, 2362.
Chandra, V., Ganguli, M., Pandav, R., Johnston, J., Belle, S., &
DeKosky, S. T. (1998). Prevalence of Alzheimers disease and
other dementias in rural India: The Indo-U.S. study. Neurology, 51,
10001008.
Chandra, V., Ganguli, M., Ratcliff, G., Pandav, R., Sharma, S. et al.
(1998). Practical issues in cognitive screening of elderly illiterate
populations in developing countries. The Indo-U.S. Cross-National
Dementia Epidemiology Study. Aging (Milano), 10, 349357.
Chatterji, R. (1998). An ethnography of dementia: A case study of an
Alzheimers disease patient in the Netherlands. Culture, Medicine, &
Psychiatry, 22, 355382.
Consensus Development Conference (1993). Diagnosis, prophylaxis,
and treatment of osteoporosis. American Journal of Medicine, 94,
646650.
Cooper, C., Campion, C., & Melton, L. J., III (1992). Hip fractures in
the elderly: A world-wide projection. Osteoporosis International,
2, 285298.
Crews, D. (1990). Anthropological issues in biological gerontology. In
R. L. Rubinstein (Ed.), Anthropology and aging (pp. 1138).
Dordrecht, The Netherlands: Kluwer Academic.
Crews, D. E., & Gerber, L. M. (1994). Chronic degenerative diseases and
aging. In D. E. Crews & R. M. Garruto (Eds.), Biological anthropology and aging (pp. 154181). New York: Oxford University
Press.
Daniels, E. D., Pettifor, J. M., Schnitzler, C. M., Moodley, G. P., &
Zachen, D. (1997). Differences in mineral homeostasis, volumetric bone mass and femoral neck axis length in black and white
South African women. Osteoporosis International, 7, 105112.
DeRousseau, C. J. (1994). Primate gerontology: An emerging discipline.
In D. E. Crews & R. M. Garruto (Eds.), Biological anthropology
and aging (pp. 127153). New York: Oxford University Press.
Eisman, J. A. (1999). Genetic determinants of peak bone mass. In
J. Bonjour & R. C. Tsang (Eds.), Nutrition and bone development
References
Hendrie, H. C., Osuntokun, B. O., Hall, K. S., Ogunniyi, A. O., Hui, S. L.,
Unverzagt, F. W. et al. (1995). Prevalence of Alzheimers disease
and dementia in two communities: Nigerian Africans and African
Americans. American Journal of Psychiatry, 152, 14851492.
Hirai, S. (2000). Alzheimer disease: Current therapy and future therapeutic strategies. Alzheimer Disease and Associated Disorders, 14
(Suppl. 1), S3S10.
Juby, A. (1999). Managing elderly peoples osteoporosis: Why? who?
how? Canadian Family Physician, 45, 15261536.
Kalaria, R. N., Ogengo, J. A., Patel, N. B., Sayi, J. G., Kitinya, J. N.,
Chande, H. M. et al. (1997). Evaluation of risk factors for
Alzheimers disease in elderly east Africans. Brain Research
Bulletin, 44, 573577.
Kaufmann, S. (1988). Toward a phenomenology of boundaries in medicine: Chronic illness experience in the case of stroke. Medical
Anthropology Quarterly, 338354.
Khoury, M. J. (1998). Genetic and epidemiologic approaches to the
search for geneenvironment interaction: The case of osteoporosis.
American Journal of Epidemiology, 147, 12.
King, H., Aubert, R. E., & Herman, W. H. (1998). Global burden of
diabetes, 19952025: Prevalence, numerical estimates, and projections. Diabetes Care, 21, 14141431.
Kuh, D., & Ben-Shlomo, Y. (Eds.). (1997). A life course approach to
chronic disease epidemiology. New York: Oxford University Press.
Larson, E. B., & Imai, Y. (1996). An overview of dementia and ethnicity with special emphasis on the epidemiology of dementia. In
G. Yeo & D. Gallagher-Thompson (Eds.), Ethnicity and the dementias (pp. 920). Washington, DC: Taylor & Francis.
Lau, E. M. (1997). Epidemiology of osteoporosis in urbanized Asian
populations. Osteoporosis International, 7 (Suppl. 3), S91S95.
Lau, E. M., Young, R. P., Ho, S. C., Woo, J., Kwok, J. L., Birjandi, Z.
et al. (1999). Vitamin D receptor gene polymorphisms and bone
mineral density in elderly Chinese men and women in Hong Kong.
Osteoporosis International, 10, 226230.
LeBars, P. L., Kieser, M., & Itil, K. Z. (2000). A 26-week analysis of a
double-blind, placebo-controlled trial of the gingko biloba extract
EGb761 in dementia. Dementia and Geriatric Cognitive
Disorders, 11, 230237.
Leon, D., & Ben Shlomo, Y. (1997). Preadult influences on cardiovascular disease and cancer. In D. Kuh & Y. Ben Shlomo (Eds.), A life
course approach to chronic disease epidemiology (pp. 4577).
New York: Oxford University Press.
Levison, C. H., Hastings, D. W., & Harrison, J. N. (1981). The epidemiologic transition in a frontier townManti, Utah: 18491977.
American Journal of Physical Anthropology, 56, 8393.
Liu, H. C., Fuh, J. L., Wang, S. J., Liu, C. Y., Larson, E. B., Lin, K. N.
et al. (1998). Prevalence and subtypes of dementia in a rural
Chinese population. Alzheimer Disease and Associated Disorders,
12, 127134.
Liu, Z. H., Zhao, Y. L., Ding, G. Z., & Zhou, Y. (1997). Epidemiology
of primary osteoporosis in China. Osteoporosis International, 7
(Suppl. 3), S84S87.
MacLennan, W. J. (1999). History of arthritis and bone rarefaction evidence from paleopathology onwards. Scottish Medical Journal, 44,
1820.
Mautalen, C., & Pumarino, H. (1997). Epidemiology of osteoporosis in
South America. Osteoporosis International, 7(Suppl. 3), S73S77.
317
Melton, L. J. (1995). Epidemiology of fractures. In B. L. Riggs &
L. J. Melton, III (Eds.), Osteoporosis (pp. 225247). Philadephia,
PA: Lippincott-Raven.
Melton, L. J. (1997). The prevalence of osteoporosis. Journal of Bone
and Mineral Research, 12, 17691771.
Miles, T. P., & Brody, J. A. (1994). Aging as a worldwide phenomenon.
In D. E. Crews & R. M. Garruto (Eds.), Biological anthropology
and aging (pp. 315). New York: Oxford University Press.
Mitteness, L. S. (1987). The management of urinary incontinence by the
community-living elderly. The Gerontologist, 27, 185193.
Mix, J. A., & Crews, W. D., Jr. (2000). An examination of the efficacy
of Gingko biloba extract EGb761 on the neuropsychologic functioning of cognitively intact older adults. Journal of Alternative
and Complementary Medicine, 6, 219229.
Morris, J. C. (1994). Differential diagnosis of Alzheimers disease.
Clinics in Geriatric Medicine, 10, 257276.
Murray, C., Luckey, M., & Meier, D. (1996). Skeletal integrity. In
E. L. Schneider & J. W. Rowe (Eds.), Handbook of the biology of
aging (pp. 431444). San Diego, CA: Academic Press.
National Institute on Aging (1996). Global aging into the 21st century.
Bethesda, MD: Author.
Neel, J. V. (1962). Diabetes mellitus: A thrifty genotype rendered detrimental by progress? American Journal of Human Genetics, 14,
353362.
Neel, J. V. (1982). The thrifty genotype revisted. In J. Kobberling &
R. B. Tattersall (Eds.), The genetics of diabetes mellitus
(pp. 283293). New York: Academic Press.
Nelson, D. A., Feingold, M., Bolin, F., & Parfitt, S. (1991). Principal
components analysis of regional bone density in black and white
women: Relationship to body size and composition. American
Journal of Physical Anthropology, 86, 507514.
Nguyen, T. V., Howard, G. M., Kelly, P. J., & Eisman, J. A. (1998). Bone
mass, lean mass, and fat mass: Same genes or same environment?
American Journal of Epidemiology, 147, 316.
Olson, M. C. (1999). The heart still beats but the brain doesnt answer.
Perception and experience of old-age dementia in the Milwaukee
Hmong community. Theoretical Medicine and Bioethics, 20,
8595.
Omram, A. R. (1971). The epidemiologic transition: A theory of the
epidemiology of population change. Milbank Memorial Fund
Quarterly, 49, 509538.
Paier, G. S. (1996). Specter of the crone: The experience of vertebral
fracture. Advances in Nursing Science, 18, 2736.
Pearson, T. A. (1996). Cardiovascular diseases as a growing health
problem in developing countries: The role of nutrition in the
epidemiologic transition. Public Health Reviews, 24, 131146.
Pearson, T. A. (1999). Cardiovascular disease in developing countries:
Myths, realities, and opportunities. Cardiovascular Drugs and
Therapy, 13, 95104.
Pericek-Vance, M. A., Johnson, C. C., Rimmler, J. B., Saunders, A. M.,
Robinson, L. C., DHondt, E. G. et al. (1996). Alzheimers disease
and apolipoprotein E-4 allelle in an Amish population. Annals of
Neurology, 39, 700704.
Plato, C. C., Fox, K. M., & Tobin, J. D. (1994). Skeletal changes in
human aging. In D. E. Crews & R. M. Garruto (Eds.), Biological
anthropology and aging (pp. 272300). New York: Oxford
University Press.
318
Popkin, B. M. (1994). The nutrition transition in low-income countries:
An emerging crisis. Nutrition Reviews, 52, 285298.
Radebaugh, T. S., Buckholtz, N. S., & Khachaturian, Z. S. (1996).
Fisher Symposium: Strategies for the prevention of Alzheimer
diseaseOverview of planning meeting III. Alzheimer Disease
and Associated Disorders, 10, 15.
Roca, W. A. (1994). Frequency, distribution, and risk factors for
Alzheimers disease. Nursing Clinics of North America, 29,
101111.
Roca, W. A., & Amaducci, L. (1991). Epidemiology of Alzheimers
disease. In D. W. Anderson (Ed.), Neuroepidemiology: A tribute to
Bruce Schoenberg (p. 55). Boca Raton, FL: CRC Press.
Rogers, R. G., & Hackenberg, R. (1987). Extending epidemiologic
transition theory: A new stage. Social Biology, 34, 234243.
Rowe, S. M., Jung, S. T., & Lee, J. Y. (1997). Epidemiology of
osteoporosis in Korea. Osteoporosis International, 7 (Suppl. 3),
S88S90.
Salamone, L. M., Glynn, N. W., Black, D. M., Ferrell, R. E., Palermo, L.,
Epstein, R. S. et al. (1996). Determinants of premenopausal bone
mineral density: The interplay of genetic and lifestyle factors.
Journal of Bone and Mineral Research, 11, 15571565.
Samsioe, G. (1997). Osteoporosisan update. Acta Obstetrica
Gynecologica, 76, 189199.
Saunders, P. A. (1998). My brains on strike: The construction of
identity through memory accounts by dementia patients. Research
on Aging, 20, 6590.
Scott, J. C., & Hochberg, M. C. (1998). Arthritis and other musculoskeletal diseases. In R. C. Brownson, P. L. Remington, &
J. R. Davis (Eds.), Chronic disease epidemiology and control
(pp. 465489). Washington, DC: American Public Health
Association.
Seanne, M. W. (2000, May). Aging, illness, and self-concept: A study
of older women with osteoporosis. Dissertation Abstracts
International, A., 60 (10-A), 3753.
Silverman, M., Musa, D., Kirsch, B., & Siminoff, L. A. (1999). Selfcare for chronic illness: Older African Americans and whites.
Journal of Cross-Cultural Gerontology, 14, 169189.
Silverman, M., Smola, S., & Musa, D. (2000). The meaning of healthy
and not healthy: Older African Americans and whites with chronic
illness. Journal of Cross-Cultural Gerontology, 15, 139156.
Solomon, D. H. (1999). The role of aging processes in aging dependent
diseases. In V. L. Bengtston & K. W. Schaie (Eds.), Handbook of
theories of aging (pp. 133150). New York: Springer.
A Controversial Term
319
Culture-Bound Syndromes
L. A. Rebhun
A CONTROVERSIAL TERM
In 1994 the American Psychiatric Association decided
to include an appendix on culture-bound syndromes in
its Diagnostic and Statistical Manual, version Four
(DSM-IV). This marked a turning point in psychiatrys
treatment of culture, and together with revisions in other
parts of the DSM to use more culturally and ethnically
inclusive language (Good, 1996), constituted a major step
in attempts to reconcile the approaches of anthropology
and psychiatry to human psychological variation. This
reconciliation remains an on-going and controversial
process.
At the same time as anthropologists have increasingly attacked what they see as problems in the basic
concept of culture-boundedness, psychiatrists have
shown increasing interest in cultural variation and made
greater attempts to include awareness of cultural variation
within official diagnostic categories. The DSM-IV defines
culture-bound syndromes as follows:
Recurrent, locality-specific patterns of aberrant behavior and troubling
experience that may or may not be linked to a particular DSM-IV diagnostic category. Many of these patterns are indigenously considered
to be illnesses, or at least afflictions, and most have local names .
[C]ulture-bound syndromes are generally limited to specific societies or
culture areas, and are localized, folk, diagnostic categories that frame
coherent meanings for certain repetitive, patterned, and troubling sets
of experiences and observations (American Psychiatric Association,
2000).
320
represents a positive step toward greater cultural inclusiveness in otherwise ethnocentric diagnostic definitions.
One problem arises with the idea of cultures as bounded
entities: contemporary anthropology regards culture as
both internally differentiated and constantly changing,
and has a strong focus on how members of different cultures and subcultures interact with and adapt ideas and
practices from one another. Anthropologists have also
debated whether the various phenomena described in the
literature are properly conceived as syndromes.
Regarding the boundedness of cultures, some syndromes originally described as culture-bound in the literature turn out on further investigation to appear in a
variety of sometimes loosely related cultural settings,
but not to actually be confined to just one local area or
language group. For example, koro, in which men (and
sometimes women) believe their sexual organs are
shrinking or disappearing, was originally described as a
South Chinese culture-bound syndrome, but has also
been reported among other Asian groups. The term koro
itself is of Malayo-Indonesian origin and the syndrome
has been observed in Indonesia as well as Singapore,
Hong Kong, Thailand, and parts of India (Jilek & JilekAal, 1985). Similarly, nerves first described as a
Guatemalan syndrome has been described all over the
Mediterranean and the Americas as well as in the Middle
East (see below for more detail). Jilek and Jilek-Aal
(1985) reject attempts to classify human behavior as
either universal or culturally specific, arguing that what
get defined as culture-bound syndromes in the literature reflect reactions to geopolitical, and socio-economic
conditions in local areas in reaction to local ideologies,
and that groups in similar situations will manifest similar
reactions under different names.
Theorists have also disputed whether the concept of a
syndrome occurs in all cultural settings. Anthropologists
often use the word emic to describe phenomena as
viewed from within a particular cultural perspective and
etic to describe phenomena as viewed from an imposed
non-native perspective, especially when an imported definitional or interpretive category is used to describe some
local phenomenon. The very concept of a syndrome can be
seen as etic for it reflects the ways in which the psychiatry
of Western Europe, the United States, Canada, Australia,
and similar societies classify experience and behavior.
Some theorists dispute the possibility of direct translation from one cultural setting to another. Yap (1969)
saw the phenomena he discussed as local variations of
Culture-Bound Syndromes
Types of Syndromes
TYPES
OF
SYNDROMES
Simons and Hughes (1985) posit that startle matching (latah) and sleep paralysis have a neurophysiological
basis, whereas genital retraction (koro), sudden mass
assault (amok), and running (pibloktoq) do not, and
they further state that fright illness (susto) and cannibal
321
compulsion (windigo) probably ought not to be considered culture-bound syndromes, because they do not have
specific enough descriptions to be useful as psychiatric
terms and because they make the category culture-bound
syndrome too heterogeneous to be really useful. In addition, the theorists mark windigo as a problematic term
because of controversies over whether it ever actually
existed. This division of phenomena remains in line with
Yaps original idea (1962, 1969) that culture-bound
syndromes constitute local variations of universal phenomena, and adds a more critical appraisal of existing
literature by rejecting some terms as non-specific or
inaccurate.
In the case of windigo, Marano (1985), in Simons
and Hughes collected volume, claims that despite
an extensive literature on the phenomenon, in fact
there never has been such a syndrome among Northern
Algonquin peoples. Literary descriptions posit that some
Northern Algonquins suffer from fits in which they experience a compulsion to kill and eat human beings. Marano
claims that some Algonquin peoples believed that compulsive cannibals lived among them as part of their
understanding of witchcraft, and that some individuals
were accused of being windigo, and even executed on the
basis of that accusation.
But just in the same way that the majority of people
accused of witchcraft in Western and Southern Europe in
the 16th century actually were not casting spells, cavorting with demons, or holding black masses, and the majority of people accused of vampirism in Eastern Europe at
the time were not in fact undead blood suckers, the unfortunates accused of being windigo were not really cannibals. At the time that many Algonquins were fearing
windigos, and many anthropologists were collecting data,
Native Americans were undergoing severe hardships
from disease, conquest, and both political and economic
domination. Like other societies under stress, they
expressed their trauma through fear of attack by witches.
The Algonquin belief that witchcraft took the form of
cannibalism was mistaken by early researchers for the
presence of actual cannibalism (Marano, 1985).
Hall (2001) provides an even more critical typology
of how the term culture-bound syndrome is used. He
posits that theorists use the term to refer to:
1. apparent psychiatric illnesses not attributable to an identifiable
organic cause or corresponding to a Western disease category;
2. locally recognized and named psychiatric syndromes;
322
Culture-Bound Syndromes
3. discrete disease entities not or not yet recognized by Western
medicine;
4. named local illnesses which elaborate symptoms found in
Western populations but not named as syndromes in the West;
5. culturally accepted explanatory models of sickness not matching allopathic categories and which in Western settings might
indicate delusions;
6. states or sets of behaviors involving communing with spirits, or
possession by spirits, or loss of ones soul not necessarily seen
as pathological within their own cultural setting, but indicating
delusion, psychosis, or hallucination in Western nosology;
7. syndromes reported to anthropologists or other foreigners but
not directly observed, which may be used to justify punishment
or execution of an outcast.
NERVES
Although there are cross-cultural differences in the
description of nerves, there are also so many crosscultural similarities that it can no longer be considered so
much a culture-bound phenomenon as a widespread label
for similar experiences in cultures with sometimes tenuous historical links (Finkler, 1989; Low, 1985, 1989). The
syndrome appears in the literature in various languages:
nervios in Spanish, nervos in Portuguese, nevra in
Greek, etc. The African American worriation can also
be considered a variant of nerves (Camino, 1989). In
English, it is usually written within quotation marks to
distinguish it from the anatomical word.
Patients with nerves usually complain of
headache, dizziness, fatigue, weakness, and abdominal
pain and attribute their symptoms to sadness, anger, fear,
or worry (Davis & Guarnaccia, 1989), although symptoms and etiology vary. While some theorists discuss
nerves among men (Duarte, 1986; Koss-Chioino, 1989;
Low, 1985, 1989), others see it as either a specifically
feminine disorder (Barnett, 1989; Davis, 1983, 1989;
Finerman, 1989; Kay & Portillo, 1989; Low, 1989;
SUSTO
The Spanish word susto means fright or fear.
Although Simons and Hughes (1985) argue that susto
ought no longer be considered a culture-bound syndrome
because it is too non-specific in its description, nonetheless the DSM-IV lists it in its appendix. The basic idea in
susto is that either a sudden shock as in being startled, or
an emotional shock, or a series of traumatic events, or
a frightening encounter with a ghost have damaged a
person, often by startling their soul out of their body.
Koro
323
KORO
Like nerves, koro has been described in a variety of
locales mostly in Asia and among Asian immigrants to
other areas. A few individual cases of men panicked that
their genitals are shrinking have also been recorded in
other cultural settings, but here the phenomenon does not
seem to have become formalized as a widespread belief
(Chowdhury & Bera, 1994; Earleywine, 2001; Fishbain,
Barsky, & Goldberg, 1989). Koro sufferers are usually
male, and during episodes they become convinced that
their genitals are shrinking up inside their bodies. Koro
sufferers also manifest acute anxiety, and often believe
that full genital retraction will result in death. Cases of
women fearing breast and genital shrinkage have also
been recorded, but more rarely (Cheng, 1996; Jilek &
Jilek-Aal, 1985). Koro was first mentioned in Western
medical texts in 1895, although its mention did not
become widespread until the 1960s (Chowdhury, 1998).
Although often described as a Chinese culture-bound
syndrome, the word koro itself is of Malay origin, and
refers to the head of a turtle. The equivalent term in
Mandarin would be suoyang, but that is not the term commonly used in English language literature (Cheng, 1996).
In addition to reports of individuals manifesting
koro, some researchers have reported on widespread outbreaks or epidemics of koro (Bartholomew, 1994;
Cheng, 1996; Jilek & Jilek-Aal, 1985). Jilek and JilekAal posit that the epidemics of koro they analyze in
Thailand and India were related to the movement of ethnically distinct political refugees into new areas or anticipated military attacks from ethnic rivals, where local
people feared engulfment or destruction from their adversaries. They theorize that the belief in disappearing sexual organs is a metaphor for the fear of being unable to
reproduce and sustain families, to dying as a people due
to perceived aggression from ethnically distinct others,
and compare koro epidemics to the ghost dance religion
of the Coast Salish people under military attack from
colonists as a reaction to the stresses of conquest. Rather
than look at koro as an individual phenomenon related to
Oedipal castration fears, they argue for its comprehension
as an idiom of distress (Nichter, 1981), incomprehensible
outside its political setting (Jilek & Jilek-Aal, 1985).
Interestingly, some theorists have adopted the term
koro to refer to any case of believed genital shrinkage or
disappearance, no matter the cultural setting (Earleywine,
324
AMOK
British colonial officials in Malaysia were so impressed
with the idea that native Malays might suddenly grab a
weapon and embark on a frenzied homicidal attack, that
they adopted the Malay word amok into the English language to refer to any sudden, violent, chaotic behavior.
Such attacks, usually following a period of brooding,
may have their origin in forms of warfare in historical
Malaysia, although by the time they were described
by the British, they had become individual attacks (Carr,
1985). Historical accounts from Southern India,
Malaysia, and Indonesia describe elite warriors known by
a variety of names including amouco, amok, and amokos
and famous for their willingness to die in furious attacks.
However as early as the 15th century, historical accounts
describe civilian men who suddenly took on an apparently indiscriminate homicidal fury (Spores, 1988). John
Spores points out, however, that amoks often attack members of their immediate family (Spores, 1988) and is
among those theorists who question whether amok
attacks are in fact indiscriminate and whether amoks do
not actually remember their actions, as claimed (BurtonBradley, 1985; Carr, 1985; Hughes, 1985; Spores, 1988).
Although Carr (1985) argues that amok is properly
understood as a specifically Malay phenomenon, others
see similarities with sudden, homicidal attacks in other
parts of the world, as in mass shootings in schools and
workplaces in the United States, for example (ArboledaFlorez, 1985). Theorists who like to compare similar
events in disparate settings might also ask whether ostensibly politically motivated attacks such as suicide bombings in Israel, Palestine, and other world areas share
similarities with these other described assaults. Although
Simons and Hughes (1985) argue to retain amok within the
culture-bound syndromes, the frequency of mass homicidal and homicidal/suicidal attacks in a variety of world
Culture-Bound Syndromes
areas tends to indicate, once again, that the idea of culturebounding remains problematic. However, the proliferation
of sudden homicidal and homicidal/suicidal attacks in
many parts of the world indicates that understanding such
behavior, however classified, should remain a priority.
KURU
Unlike other culture-bound syndromes, kuru has been
identified with a biomedical condition. First appearing
among Fore tribal people in New Guinea in the late
1920s, kuru (meaning shaking with fear) manifested with
tremors and progressive dementia concluding in
inevitable early death and was most common among
women. The Fore at first attributed it to assault by ghosts,
but eventually concluded that it was caused by sorcery.
By the early 1960s, the Fore were a community in crisis
with increasing numbers of women dying from kuru, and
they responded with community meetings to denounce
sorcery and increasing attempts to identify the witches
they believed were killing their wives and mothers
(Lindenbaum, 1979, 2001). However, by the 1990s the
incidence of kuru had dropped to the point where it is
today a rare condition (Lindenbaum, 2001).
In 1979, physician D. Carleton Gadjusek won the
Nobel Prize in medicine for his discovery of an infectious
origin for kuru, which his research revealed to be caused
by what he called a slow virus but later researchers
call a prion similar to those that cause Creutzfeldt-Jakob
disease, scrapie, and, more recently, bovine spongiform
encephalitis (mad cow disease). In combination with
research by anthropologist Shirley Lindenbaum, his
work showed a possible transmission path through the
practice of consuming parts of the remains of deceased
relatives as an aspect of funerary practices, allegedly an
increasing practice in the early 20th century, but ceasing
by the 1960s (Lindenbaum, 1979). This contention
has attracted controversy because there has been no firsthand observation of endo-cannibalism among the Fore
(Lindenbaum, 2001).
Kuru fits two of Halls classifications of culturebound syndromes (Hall, 2001): culturally accepted
explanatory models of sickness not matching allopathic
categories and which in Western settings might indicate delusions (the attribution of witchcraft) and
discrete disease entities not or not yet recognized by
325
LATAH
CULTURE-BOUND SYNDROMES
SOCIAL CHANGE
AND
326
REFERENCES
American Psychiatric Association (2000). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington, DC: American
Psychiatric Association.
Arboleda-Flores, J. (1985). Amok. In R. C. Simons & C. C. Hughes
(Eds.), The culture-bound syndromes: Folk illnesses of psychiatric
and anthropological interest (pp. 251262). Dordrecht, The
Netherlands: D. Reidel/Kluwer Academic.
Baer, R. D., & Bustillo, M. (1993). Susto and mal de ojo among Florida
farmworkers: Emic and etic perspectives. Medical Anthropology
Quarterly, 7, 90100.
Barnett, E. A. (1989). Notes on nervios: A disorder of menopause. In
D. L. Davis & S. M. Low (Eds.), Gender, health, and illness: The
case of nerves (pp. 6778). New York: Hemisphere.
Bartholomew, R. E. (1994). The social psychology of epidemic koro.
International Journal of Social Psychiatry, 40, 4660.
Burton-Bradley, R. G. (1985). The amok syndrome in Papua and New
Guinea. In R. C. Simons & C. C. Hughes (Eds.), The culture-bound
syndromes: Folk illnesses of psychiatric and anthropological interest (pp. 237250). Dordrecht, The Netherlands: D. Reidel.
Camino, L. (1989). Nerves, worriation, and black women: A community study in the American south. In D. L. Davis & S. M. Low
(Eds.), Gender, health, and illness: The case of nerves
(pp. 203222). New York: Hemisphere.
Carr, J. E. (1985). Ethno-behaviorism and the culture-bound syndromes: The case of amok. In R. C. Simons & C. C. Hughes (Eds.),
The culture-bound syndromes: Folk illnesses of psychiatric
and anthropological interest (pp. 199223). Dordrecht, The
Netherlands: D. Reidel/Kluwer Academic.
Cayleff, S. (1988). Prisoners of their own feebleness: Women, nerves
and western medicinea historical overview. Social Science &
Medicine, 26, 11991207.
Cheng, S. (1996). A critical review of Chinese koro. Culture, Medicine, &
Psychiatry, 20, 6782.
Chowdhury, A. N. (1998). Hundred years of koro: The history of a
culture-bound syndrome. International Journal of Social
Psychiatry, 44, 181188.
Chowdhury, A. N., & Bera, N. (1994). Koro following cannabis smoking: Two case reports. Addiction, 89, 10171020.
Culture-Bound Syndromes
Clark, M. H. (1989). Nevra in a Greek village: Idiom, metaphor, symptom, or disorder? In D. L. Davis & S. M. Low (Eds.), Gender,
health, and illness: The case of nerves (pp.103126). New York:
Hemisphere.
Crandon, L. (1983). Why susto? Ethnology, 22, 153168.
Davis, D. L. (1983). Woman the worrier: Confronting feminist and
biomedical archetypes of stress. Womens Studies, 10: 135146.
Davis, D. L. (1989). The variable character of nerves in a Newfoundland
fishing village. Medical Anthropology, 2, 6378.
Davis, D. L., & Guarnaccia, P. J. (1989). Health, culture, and the nature
of nerves: Introduction. Medical Anthropology, 2, 113.
Davis, D. L., & Low, S. M. (Eds.). (1989). Gender, health, and illness:
The case of nerves. New York: Hemisphere.
Davis, D. L., & Whitten, R. G. (1988). Medical and popular traditions
of nerves. Social Science & Medicine, 26, 12091221.
Dobkin de Rios, M. (1985). Saladeraa culture-bound misfortune syndrome in the Peruvian Amazon. In R. C. Simons & C. C. Hughes
(Eds.), The culture-bound syndromes: Folk illnesses of psychiatric
and anthropological interest (pp. 351370). Dordrecht, The
Netherlands: D. Reidel/Kluwer Academic.
Duarte, L. F. D. (1986). Da Vida Nervosa Nas Classes Trabalhadores
Urbanas. Rio de Janeiro: Jorge Zahar.
Dunk, P. (1989) Greek women and broken nerves in Montreal. Medical
Anthropology, 2, 2945.
Earleywine, M. (2001). Cannabis-induced koro in Americans. Addiction,
96, 16631666.
Eguchi, S. (1991). Between folk concepts of illness and psychiatric
diagnosis: Kitsune-tsuki (Fox Possession) in a mountain village of
western Japan. Culture, Medicine, & Psychiatry, 15, 421451.
Etsuko, M. (1991). The interpretation of fox possession: Illness as
metaphor. Culture, Medicine, & Psychiatry, 15, 453477.
Finerman, R. (1989). The burden of responsibility: Duty, depression,
and nervios in Andean Ecuador. In D.L. Davis & S.M. Low (Eds.),
Gender, health, and illness: The case of nerves (pp. 4966). New
York: Hemisphere.
Finkler, K. (1989). The universality of nerves. In D.L. Davis &
S.M. Low (Eds.), Gender, health, and illness: The case of nerves
(pp. 7987). New York: Hemisphere.
Fishbain, D. A., Barsky, S., & Goldberg, M. (1989). Koro (Genital
Retraction Syndrome): Psychotherapeutic interventions. American
Journal of Psychotherapy, 43, 8791.
Geertz, H. (1968). Latah in Java: A theoretical paradox. Indonesia, 5,
93104.
Good, B. (1996). Culture and DSM-IV: Diagnosis, knowledge, and
power. Culture, Medicine, & Psychiatry, 20, 127132.
Guarnaccia, P., DeLaCancela, V., & Carrillo, E. (1989). The multiple
meanings of ataques de nervios in the Latino community. Medical
Anthropology, 2, 4762.
Hall, T. M. (2001). Culture-bound syndromes. (September 6, 2001).
Retrieved from http://weber.ucsd.edu/~thall/cbs_intro.html.
Hufford, D. (1982). The terror that comes in the night: An experiencecentered study of supernatural assault traditions. Philadelphia:
The University of Pennsylvania Press.
Hughes, C. C. (1985). Commentary: The sudden mass assault taxon. In
R.C. Simons & C.C. Hughes (Eds.), The culture-bound syndromes:
Folk illnesses of psychiatric and anthropological interest
(pp. 263266). Dordrecht, The Netherlands: D. Reidel/Kluwer
Academic.
References
Jilek, W., & Jilek-Aal, L. (1985). The metamorphosis of culturebound syndromes. Social Science & Medicine, 21, 205210.
Kay, M., & Portillo, C. (1989). Nervios and dysphoria in Mexican
American widows. In D. L. Davis & S. M. Low (Eds.), Gender,
health, and illness: The case of nerves (pp. 181202). New York:
Hemisphere.
Kenny, M. G. (1978). Latah: The symbolism of a putative mental
disorder. Culture, Medicine, & Psychiatry, 2, 209231.
Kenny, M. (1985). Paradox lost: The latah problem revisited. In
R. C. Simons & C. C. Hughes (Eds.), The culture-bound syndromes:
Folk illnesses of psychiatric and anthropological interest
(pp. 6376). Dordrecht, The Netherlands: D. Reidel/Kluwer
Academic.
Kleinman, A. (1977). Depression, somatization, and the new crosscultural psychiatry. Social Science & Medicine, 11, 310.
Kleinman, A. (1980). Patients and healers in the context of culture: An
exploration of the borderland between anthropology, medicine,
and psychiatry. Berkeley: University of California Press.
Koss-Chioino, J. D. (1989). Experience of nervousness and anxiety
disorders in Puerto Rican women: Psychiatric and ethnopsychological perspectives. In D. L. Davis & S. M. Low (Eds.), Gender,
health, and illness: The case of nerves (pp.153180). New York:
Hemisphere.
Krieger, L. (1989). Nerves and psychosomatic illness: The case of Um
Ramadan. In D. L. Davis & S. M. Low (Eds.), Gender, health, and
illness: The case of nerves (pp. 89102). New York: Hemisphere.
Lindenbaum, S. (1979). Kuru sorcery: Disease and danger in the New
Guinea highlands. Palo Alto, CA: Mayfield.
Lindenbaum, S. (2001). Kuru, prions, and human affairs: Thinking
about epidemics. Annual Review of Anthropology, 30, 363385.
Lock, M. (1990). On being ethnic: The politics of identity breaking and
making in Canada or nevra on Sunday. Culture, Medicine &
Psychiatry, 14, 237254.
Low, S. (1985). Culturally interpreted symptoms or culture-bound syndromes: A cross-cultural review of nerves. Social Science &
Medicine, 21, 187196.
Low, S. (1989). Health, culture, and the nature of nerves: A critique.
Medical Anthropology, 2, 9195.
Marano, L. (1985). Windigo psychosis: The anatomy of an emicetic
confusion. In R. C. Simons & C. C. Hughes (Eds.), The culturebound syndromes: Folk illnesses of psychiatric and anthropological interest (pp. 411448). Dordrecht, The Netherlands:
D. Reidel/Kluwer Academic.
Moodley, P. (1985). Koro in non-Chinese subjects. British Journal of
Psychiatry, 146, 102103.
Nichter, M. (1981). Idioms of distress: Alternatives in the expression of
psychosocial distress. A case study from South India. Culture,
Medicine, & Psychiatry, 5, 379408.
327
Rebhun, L. A. (1993). Nerves and emotional play in Northeast Brazil.
Medical Anthropology Quarterly, 7(2), 131151.
Rebhun, L. A. (1999). The heart is unknown country: Love in the
changing economy of Northeast Brazil. Palo Alto, CA: Stanford
University Press.
Rubel, A. J., ONell, C. W., & Collado, R. (1984). Susto: A folk illness.
Berkeley: University of California Press.
Rubel, A. J., ONell, C. W., & Collado, R. (1985). The folk illness called
susto. In R. C. Simons & C. C. Hughes (Eds.), The culture-bound
syndromes: Folk illnesses of psychiatric and anthropological
interest (pp.333350). Dordrecht, The Netherlands: D. Reidel/
Kluwer Academic.
Scheper-Hughes, N. (1988). The madness of hunger: Sickness,
delirium, and human needs. Culture, Medicine, & Psychiatry, 12,
429458.
Scheper-Hughes, N. (1992). Death without weeping: The violence of
everyday life in Brazil. Berkeley: University of California Press.
Simons, R. C. (1985). The resolution of the latah paradox. In
R. C. Simons & C. C. Hughes (Eds.), The culture-bound syndromes:
Folk illnesses of psychiatric and anthropological interest (pp. 4362).
Dordrecht, The Netherlands: D. Reidel/Kluwer Academic.
Simons, R. C. & Hughes, C. C. (1985). The culture-bound syndromes:
Folk illnesses of psychiatric and anthropological interest.
Dordrecht, The Netherlands: D. Reidel/Kluwer Academic.
Slutka, J. A. (1989). Living on their nerves: Nervous debility in
Northern Ireland. In D. L. Davis and S. M. Low (Eds.), Gender,
health, and illness: The case of nerves (pp. 127152). New York:
Hemisphere.
Spores, J. C. (1988). Running amok: An historical inquiry. Ohio
University Monographs in International Studies. Southeast Asia
Series (82).
Winzeler, R. L. (1995). Latah in Southeast Asia: The history and
ethnography of a culture-bound syndrome. Cambridge, U.K.:
Cambridge University Press.
World Health Organization (1992). The ICD-10 classification of mental
and behavioural disorders: Clinical description and diagnostic
guidelines. Geneva, Switzerland: World Health Organization.
Yap, P. M. (1962) Words and things in comparative psychiatry, with
special reference to the exotic psychoses. Acta Psychiatrica
Scandanavia, 38, 163169.
Yap, P. M. (1965). Koro in a Briton. British Journal of Psychiatry, 111,
4349.
Yap, P. M. (1969). The culture-bound reactive syndromes. In W. Caudill &
T.-Y. Lin (Eds.), Mental health research in Asia and the Pacific
(pp. 3353). Honolulu, HI: EastWest Center Press.
Zhang, A. Y., Yu, L. C., Zhang, J., Tang, D., & Draguns, J. G. (2001).
Anthrophobia: Its meaning and concomitant experiences.
International Journal of Social Psychiatry, 47, 5670.
328
INTRODUCTION
For the past half-century medical anthropology has been
guided by various theoretical orientations. These include
(but are not exhausted by) interpretive orientations,
politicaleconomic orientations, and biocultural orientations. The latter approach to research, which is allied with
ecological and adaptation perspectives, has been productive for the field through the explicit effort to link the
biological and the cultural. Research in some areas of
medical anthropology can proceed with scant reference to
human biology (e.g., interactions of patients and healers).
There are, however, some questions of cultural significance that require taking account of biological variation
within and between populations. A biocultural orientation
provides theory and method for approaching these
problems and for unpacking the complex interactions of
culture and biology.
Cardiovascular disease, as a general term, refers to
any pathology of the cardiovascular system, which would
include diseases of the heart as well as vascular disease
affecting other parts of the body (such as stroke). Medical
anthropologists have studied this broad category of diseases in a variety of ways, but this entry will focus primarily on a condition that is less disease per se but rather
a kind of barometer of the system as a whole: blood pressure. A regular cycle of pressure in the cardiovascular
system is necessary for basic tissue nutrition. Oxygen and
nutrients must be transported across cell membranes. A
relatively low level of blood pressure is required for this
tissue perfusion; yet, it is not unusual for a persons blood
pressure to be considerably higher than that required for
system maintenance. At even modest levels of blood pressure (e.g., those considered normal in biomedicine,
such as 130/80 mmHg, or millimeters of mercury) the
risk of serious cardiovascular events such as myocardial
infarction (or heart attack) increases significantly.
Cross-cultural research on blood pressure has been
carried out for over 30 years, sometimes by medical
anthropologists, sometimes by epidemiologists and other
researchers. One reason that much research on blood
blood pressure, and to link characteristics of the communities studied with data from the Human Relations Area
Files. A number of interesting results emerged from this
exercise. First, community mean blood pressures increase
along a continuum of sociocultural complexity, with societies arrayed according to the familiar sequence of foraging, pastoral, horticultural, agricultural, and industrial
modes of adaptation. Second, the increase of community
mean blood pressures is not smooth and linear along this
continuum; rather, there is a sharp increase in mean blood
pressure between horticultural and agricultural societies,
which then stays high in industrial societies. And third,
controlling for community average levels of obesity does
not alter the pattern, which is consistent by age and sex
as well. It is unlikely that these patterns are artifacts of
differences between observers in the measurement of
blood pressure, since such differences would be more
likely to obscure patterns rather than produce them.
Furthermore, these differences are not an artifact of
treated cases, since measurements were carried out on (at
least roughly) representative samples of the communities.
The work of Waldron and associates probably
represents the most convincing evidence for societal
differences in disease risk.
329
330
and saturated fats, both of which are thought to be associated with increasing blood pressure. But again, when
investigated closely, changing patterns of dietary intake
do not account entirely for increasing blood pressure
levels.
Attention therefore turned to social, psychological,
and cultural factors that might account for these differences. In the late 1950s and early 1960s there was a
remarkable burst of activity in thinking about this issue,
culminating in an article by Cassel, Patrick, and Jenkins
(1960). These investigators were particularly interested in
what happened to migrants from rural areas to urban
areas, although the same reasoning can be applied to culture change occurring within any community. They
offered the following hypothesis: the migrant to a novel
setting carries with her a particular understanding of how
the world works, in every sense (i.e., what it means to
work, how marriages are constituted, how families treat
themselves and their neighbors, how to worshipeverything). She is confronted, however, with a system for
which her understanding may not work. The novel and
dominant culture of the new setting must be learned for
everyone elses behavior to be understood, and indeed for
her to behave in ways that are understandable to others.
She must, in other words, culturally adapt to the new setting. Even if she is successful, such adaptation can be
costly. Indeed, this is precisely what Hans Selye meant by
the General Adaptation Syndrome when he gave the concept of stress its first scientific respectability in the 1930s.
Adaptation is costly, and the cost of adaptation is written
on the body in terms of what we call health. So, Cassel
et al. argued that the less successfully the migrant culturally adapts to the new setting, the higher her stress levels
and the higher her blood pressure.
This introduced the concept of stress, and the idea
of the stress of culture change, to the literature on
modernization and disease. There were, however, certain
theoretical and methodological difficulties that limited
this as an area of inquiry. First, there was increasing disenchantment within anthropology, especially cultural
anthropology, with the whole idea of modernization. The
theoretical orientation guiding this work came out of the
linear models of economic development that guided postWorld War II thinking. All societies were seen as moving
along a trajectory of development that would culminate
in an industrial mode of production, accompanied by a
predictable set of social and cultural changes. This
has turned out to be dramatically wrong; instead, a world
systems theory posits a continuing state of underdevelopment within some societies, as these occupy positions on
the periphery of that world system. Regardless of which
specific variant of this theory is used, some kind of world
systems view appears to describe more accurately what is
going on with respect to economic development (or continuing under-development) than does a modernization
perspective. Therefore, some other way of thinking about
the epidemiologic transition is needed.
Second, while Cassel et al. developed a very useful
theory of the health effects of culture change, it proved to
be very difficult to actually test. This research group was
extremely productive, but the logic of the tests of these
ideas remained an epidemiologic logic. In epidemiology,
the logic of making inferences about the operation of
disease processes generally involves the comparison of
population groups, one of which is thought to have been
exposed to a particular set of risk factors, while the other
has not. In the work of Cassel et al. this logic involved
comparing groups thought to have been exposed to a set
of sociocultural stressors (e.g., migrants to a novel cultural setting) versus those who have not been exposed to
this set of stressors (e.g., sedentes), with differences interpreted in terms of the contradictions of cultural systems
described by the theory. There never was, however, any
direct evidence that these cultural contradictions actually
occurred. In other words, methodological developments
for assessing in a precise and rigorous way the differences in shared culture between groups, and how these
differences may enter into individual behaviors, which in
turn are associated with higher blood pressure, were not
forthcoming. Therefore the theory remained essentially
untested.
Third, anthropologists increasingly turned their
attentions to advances occurring in cognate fields (psychology, sociology, and epidemiology, principally) with
respect to the stress model. The period of the 1960s and
1970s was an extremely fertile one in terms both of
theory and method in the evolution of the stress model.
Ethnographers drew on these developments and integrated these concepts and methods with anthropological
concerns to derive models of stress relevant in the context
of developing societies. This enabled these researchers to
avoid the pitfalls of the concept of modernization, while
at the same time employing measures that could be
directly linked to individual behaviors and health outcomes. This served as a major direction in research
throughout this period.
Models of Stress
MODELS
OF
STRESS
331
332
333
334
SUMMARY
The cross-cultural study of cardiovascular disease risk
has been remarkably productive for building theory
within medical anthropology and in anthropology writ
large. As Caudill (1958) pointed out many years ago, disease can be used to trace the fault lines within sociocultural systems. As such, the study of blood pressure
cross-culturally has provided insight into how culture and
social structure come together to generate obstacles and
barriers, and to create supports and resources, for persons
in their everyday lives. Furthermore, medical anthropologists studying cardiovascular disease have been sensitive to world systems and how macro-level change can
have measurable consequences at the level of the individual and her health status.
In one sense, research in this area has come full circle. Early researchers such as Scotch and Cassel interpreted their results in terms of a culture theory
emphasizing shared meaning, and how inconsistencies or
incongruities in meaning could lead to stress and disease.
Later researchers, applying the stress model, were able to
identify factors at the individual level and to more
directly test the importance of those factors. The importance of culture in the process was not lost, but continued
a role as defining context and an interpretive framework
for more specific findings.
More recent work, taking advantage of innovations
in culture theory and research methods, has been able to
empirically demonstrate how the cultural is linked to the
individual, which in turn is linked to the biological. This
direction in research is likely to be productive in terms
both of building culture theory, and in terms of uncovering new dimensions of human health.
335
REFERENCES
Bindon, J. R., Knight, A., Dressler, W. W., & Crews, D. E. (1997).
Social context and psychosocial influences on blood pressure
among American Samoans. American Journal of Physical
Anthropology, 103, 718.
Cassel, J. C., Patrick, R., & Jenkins, C. D. (1960). Epidemiological
analysis of the health implications of culture change. Annals of the
New York Academy of Sciences, 84, 938949.
Cassel, J. C. (1976). The contribution of the social environment to host
resistance. American Journal of Public Health, 104, 107123.
Caudill, W. (1958). Effects of social and cultural systems in reactions to
stress. New York: Social Science Research Council.
Dressler, W. W. (1982). Hypertension and culture change: Modernization and disease in the West Indies. South Salem, NY: Redgrave.
Dressler, W. W. (1993). Social and cultural dimensions of hypertension
in blacks: Underlying mechanisms. In J. G. Douglas & J. C. S. Fray
(Eds.), Pathophysiology of hypertension in blacks (pp. 6989).
New York: Oxford University Press.
Dressler, W. W. (1999). Modernization, stress and blood pressure: New
directions in research. Human Biology, 71, 583605.
Dressler, W. W., & Bindon, J. R. (2000). The health consequences of
cultural consonance: Cultural dimensions of lifestyle, social support and blood pressure in an African American community.
American Anthropologist, 102, 244260.
Dressler, W. W., & Santos, J. E. D. (2000). Social and cultural dimensions of hypertension in Brazil: A review. Cadernos de Sade
Pblica, 16, 303315.
Henry, J. P., & Cassel, J. C. (1969). Psychosocial factors in essential
hypertension. American Journal of Epidemiology, 90, 171200.
Janes, C. R. (1990). Migration, social change and health. Stanford, CA:
Stanford University Press.
McGarvey, S. T. (1999). Modernization, psychosocial factors, insulin
and cardiovascular health. In C. Panter-Brick & C. M. Worthman
(Eds.), Hormones, health and behavior (pp. 244280). Cambridge,
U.K.: Cambridge University Press.
Panter-Brick, C., & Worthman, C. M. (Eds.). (1999). Hormones, health
and behavior. Cambridge, UK: Cambridge University Press.
Romney, A. K., Weller, S. C., & Batchelder, W. H. (1986). Culture as
consensus: A theory of culture and informant accuracy. American
Anthropologist, 88, 313338.
Scotch, N. A. (1963). Sociocultural factors in the epidemiology of Zulu
hypertension. American Journal of Public Health, 53, 12051213.
Waldron, I., Nowotarski, M., Freimek, M., Henry, J. P., Post, N., &
Witten, C. (1982). Cross-cultural variation in blood pressure.
Social Science & Medicine, 16, 419430.
Worthman, C. (1999). Epidemiology of human development. In
C. Panter-Brick & C. M. Worthman (Eds.), Hormones, health and
behavior, (pp. 47104). Cambridge, U.K.: Cambridge University
Press.
production. Type 1 diabetes is designated as an autoimmune disease and accounts for approximately 5% of
the cases of diabetes worldwide. Individuals with type 1
diabetes require insulin.
Type 2 diabetes or adult-onset diabetes is characterized by hyperinsulinism in response to the resistance of
target tissues to the transport of glucose into cells.
Obesity is a significant risk factor for type 2 diabetes.
Type 2 diabetes accounts for approximately 90% of diabetes worldwide and is often considered a disease of
modernization since it occurs disproportionately among
populations adopting a Westernized lifestyle (Baschetti,
1998; Joe & Young, 1994; Popkin, 2001). It may be
controlled through diet, exercise, and medication.
Approximately 510% of diabetes is due to
other causes that are often transient rather than chronic.
336
DIAGNOSTIC CRITERIA
Symptoms of diabetes include: frequent urination
(polyuria), hunger, thirst (polydipsia), weight loss,
blurred vision, and skin itchiness. In children there may
be growth impairment. Among type 2 diabetics insulin
resistance may be present for a number of years prior to
the development of elevated blood glucose levels. When
insulin production can no longer compensate for peripheral tissue resistance, blood glucose levels rise, reaching
the criteria for a diagnosis of diabetes.
The World Health Organization (WHO) diagnostic
criteria for diabetes mellitus include a medical history of
diabetes or a fasting plasma glucose level 140 mg/dl
(7.8 mmol/L) or a plasma glucose level 2 hr after a meal
of 200 mg/dl (11.1 mmol/L). However, the National
Diabetes Data Group in the United States has a criterion
of a fasting plasma glucose level of 126 mg/dl
(7.0 mmol/L) (ADA, 2002a; WHO, 1985). An oral
glucose tolerance test is also used for diagnosis. If the
plasma glucose level is 200 mg/L (11.1 mmol/L) 2 hr
after consuming a standard 75 mg oral glucose load, then
a provisional diagnosis of diabetes is made. Normal
plasma glucose levels are 110 mg/L (6.1 mmol/L).
Individuals with pre-diabetes or impaired glucose
tolerance have fasting plasma glucose levels between
110 mg/dl and 126 mg/dl, or an oral glucose tolerance test
equal to or exceeding 140 mg/L (7.8 mmol/L).
The 2-hr plasma glucose levels have been set at a cut
point where the prevalence of eye disease (retinopathy)
and kidney disease (nephropathy) increase dramatically.
However, in certain populations (e.g., Pima Indians and
Pacific Islanders) with high a prevalence of type 2 diabetes the cut point at which there is a marked increase in
complications is lower ( 126 mg/dl). These include
the Pima Indians of Arizona and several Pacific Island
populations.
The American Diabetes Association (ADA) Expert
Committee on the Diagnosis and Classification of
Diabetes Mellitus (ADA, 2002a) recommend testing
DIABETES COMPLICATIONS
Diabetes is the sixth leading cause of death in the
United States. Among diabetics heart disease is the primary cause of diabetes-related deaths and is 24 times
higher in people with diabetes than those without the
disease (ADA, 2002a; Centers for Disease Control,
2001). A life-threatening consequence of type 1 diabetes
is diabetic coma due to ketoacidosis resulting from the
exclusive use of fat as an energy source.
The most frequent complications of long-term diabetes occur because of abnormalities in the blood vessels
and nerves caused by chronic hyperglycemia. Diabetes is
the leading cause of blindness, kidney failure, and amputations of the lower limb. There are also abnormalities
that occur in the immune, cardiovascular, and digestive
systems as well as periodontal disease, sexual dysfunction, and complications of pregnancy (ADA, 2002a;
Harris, 1995). Diabetes also is associated with psychological and social dysfunction. Because type 2 diabetes
often does not have an acute onset, it may go undiagnosed
for a number of years until a consequence of the disease
is treated and the underlying diabetes is diagnosed (ADA,
2002a; Centers for Disease Control, 2001).
In the United States, Native Americans exhibit the
highest mortality and complication rates of any ethnic
groups. The Native American populations age-adjusted
diabetes mortality rates for 199193 were 11.9/100,000
for the United States but 31.7/100,000 for all Indian
Health Service areas (Gohdes & Acton, 2000). Native
American diabetics are four times more likely than their
white counterparts to experience a lower limb amputation
and six times more likely experience end stage renal disease or kidney failure. In Oklahoma, a state with more
Diabetes Epidemiology
DIABETES EPIDEMIOLOGY
In 2000 the worldwide estimate by the International
Diabetes Federation (IDF) was 151 million adults (2079
years) with type 2 diabetes. This is an increase from
30 million in 1985 and 135 million in 1995. There is a projected global estimate of 300 million people in 2025 (IDF,
2001). Because higher energy intakes and lower energy
expenditures are having differential impacts on developed
and developing countries, the prevalence of type 2 diabetes in developing countries is expected to increase by
170% compared with a rise of 41% in developed countries
between 1995 and 2025 (IDF, 2001). Approximately half
this increase will be Asian and Pacific Islander populations. China is predicted to have a prevalence increase of
68%, followed by India (59%) and other Asian countries
and the Pacific Islands (41%) (Joslin Diabetes Center,
2002). By comparison, the worldwide estimate for type 1
diabetes was 4.9 million in 2000 and is not expected to
show a major increase in prevalence.
The Diabetes Atlas 2000 (IDF, 2001) contains estimates of diabetes prevalence in 130 countries including
more than 5.5 billion people within the seven regions of
the IDF. Lowest regional rates are in Sub-Sahara Africa
and the highest rates in the Western Pacific. Countries
with a prevalence of diabetes between 1.5% and 3.9%
include Chile, China, the Philippines, Ireland, Brazil,
Argentina, the United Kingdom, Peru, Thailand, Norway,
South Africa, Columbia, and Venezuela. Countries with
a prevalence of diabetes between 4% and 8% include
Turkey, Indonesia, Portugal, Finland, Poland, India,
Greece, Korea, Melanesia, Hungary, Israel, Japan, the
United States (6.2%), and New Zealand. Countries
between 8% and 12% include Egypt, Cuba, and
Singapore. A number of Caribbean and South Pacific
Island countries, Mexico, Papua New Guinea, Bahrain,
Hong Kong, Pakistan, and the Czech Republic range
from 12% to 15% (Table 1) (IDF, 2001).
The three tiers of prevalence represent countries
from all parts of the world demonstrating genetic and ethnic diversity. Because most of these countries are small,
the top 10 countries in terms of numbers of individuals
with diabetes is very different. In descending order theses
are: India, China, the United States, Pakistan, Japan,
337
Prevalence (%)
15.5
15.0
14.8
14.2
14.1
13.2
12.1
11.8
11.7
11.5
Country
India
China
United States
Pakistan
Japan
Indonesia
Mexico
Egypt
Brazil
Italy
Number of people
(millions)
32.7
22.6
15.3
8.8
7.1
5.7
4.4
3.4
3.3
3.1
338
POPULATIONS STUDIED
ANTHROPOLOGISTS
BY
MEDICAL
339
MEDICAL ANTHROPOLOGY
DIABETES
AND
340
resulted from a combination of founder effect and selective pressures encountered in harsh Arctic environments
by the first New World immigrant populations. Wendorf
(1989) has a slightly different scenario. He suggested
that selection for thrifty genotypes occurred when the
ancestors of Paleoindians migrated south of the northern
ice-free corridor and were confronted with unfamiliar
non-Arctic hunting conditions. These conditions, he
hypothesized, precipitated food shortages and selection
favoring those who are able to store calories efficiently.
These scenarios are confounded by evidence of multiple
migrations. For example, there are low rates of diabetes
among the more recent Canadian Athapascan speakers;
however, this is not the case for U.S. Athapascans.
These differences in prevalence suggest that gene
environmental interactions play important roles in
diabetes risk (Sievers & Fisher, 1981; Szathmary, 1986).
Most of the literature on genetic thriftiness has
focused on selective pressures operating in adulthood.
Kuzawa (1998) focuses on human infancy and early
childhood. He reviewed the literature supporting a strong
selective advantage of a quick insulin trigger with
enhanced fat storage as a hedge against infant morbidity
and mortality. Refeeding after starvation or respiratory
and diarrheal illnesses is accompanied by increases in
insulin production. Furthermore, infants who have suffered nutritional compromise in utero and are small
for their gestational age gain weight with appropriate
nutritional interventions but demonstrate reduced glucose
tolerance and are at high risk for insulin resistance metabolic syndrome, or Syndrome X, later in life (Barker,
1994, 1999; Phipps et al., 1993; Raven, 1988). The
Barker hypothesis of prenatal origins of later life diseases, including diabetes, compliments the thrifty gene
hypothesis (Kuzawa, 1998).
Szathmary (1986, 1990) and Ritenbaugh and
Goodby (1989) questioned the utility of the thrifty gene
model for explaining high rates of diabetes in indigenous
North American populations because the diets of the
founding New World populations were likely high in
protein and fats and low in carbohydrates. Therefore, they
hypothesized there would not be intense selection
pressure for rapid glucose uptake but instead enhanced
gluconeogenesis whereby glucose is produced from proteins. This thriftiness for metabolic conversion would
have been an adaptation rendered disadvantageous by
modern diets high in carbohydrate. Allen and Cheer
(1996) write of a non-thrifty genotype with a slow insulin
trigger that would have conferred protection against
341
342
343
344
African-American Traditional
Medicine
African Americans, the second largest minority in the
United States, have a diabetes rate 33% greater than
Whites (Tull & Roseman, 1995). The heterogeneous
traditional medical system combines African healing,
Civil War era medicine, West Indian Voodoo, fundamentalist Christianity, and European medical and anatomical
systems (Snow, 1974). A fundamental belief is the direct
connection between the forces of nature and health.
Seasonal (e.g., phases of the moon) and natural climatic
events as well as lucky numbers play a role in illness
prevention, etiology, treatment, and prognosis. Health is
considered to be good fortune and is part of Gods plan
but must include appropriate self-care of the mind, body,
and spirit (Lieberman et al., 1996, 1999). Traditionally,
the major causes of illness were: (1) exposure to cold
causing mucus and the clotting of blood that can lead
to headache, hypertension, and stroke; (2) dirt or
germs leading to heat, fever, rashes, and inflammation;
(3) improper diet resulting in high or low blood and
high sugar or diabetes; and (4) improper conduct or
parental transgressions causing disorders in children. The
author has encountered this in the explanatory model for
type 1 diabetes among children at an outpatient clinic in
the Southeast U.S.
Grannies, herbalists, herb doctors, root doctors, and
spiritual healers engaged to diagnose and treat conditions. Supernatural or magical illnesses caused by sorcery or voodoo, or rootwork that can hex an individual,
require healers with supernatural powers (www.diversity
resources.com/health2k/health/african2.html, accessed
8/2002). Today these healers rarely treat type 2 diabetes.
African Americans generally rely on biomedicine
although herbal home remedies and dietary precautions
are employed along with insulin and oral medication.
Worriation or stress has been stated as a cause of type
2 diabetes and its complications (Lieberman et al.,
1996).
345
346
Conclusion
347
population are not easily transferable to others. CarsonHenderson (2002) warns against trait listing of specific
characteristics of tribes and the use of trait lists in
over-generalizing homogeneity resulting in inappropriate
programs and educational materials.
The ADAs Diabetes Assistance and Resource (DAR)
Program is an innovative project designed to provide education and motivation to Latinos by working with government
agencies and Latino community-based organizations.
Recognizing that women are the gatekeepers of a familys
health and welfare in Latino communities, the DAR
Program developed a successful community-based outreach
activity called Diabetes Home Health Parties where peer
educators, Diabetes Lay Counselors, or Consejeras
De Diabetes are trained (Davidson et al. 1994). The ADA
has been active in developing educational materials and programs that target U.S. ethnic groups (www.diabetes.org).
CONCLUSION
Type 2 diabetes is rapidly becoming a worldwide epidemic as populations adopt modernized or Westernized
lifestyles. Evolutionary evidence for the selective advantage of diabetes thrifty genotypes and phenotypes predisposes humans to the deleterious and diabetogenic effects
of contemporary culture. Recent dietary changes are
characterized by an abundance of calorically dense, sugary and fatty foods with low fiber content. In addition,
labor-saving, energy-efficient daily activity patterns
reduce caloric needs and energy expenditure. The result
is a high prevalence of obesity, insulin resistance,
hyperglycemia, and other physiological abnormalities
comprising Syndrome X.
Medical anthropologists have investigated the medical, social, and cultural responses to diabetes among ethnic groups in the United States and Canada where diabetes
is in high prevalence. Less attention has been paid to other
parts of the world where diabetes is just now becoming a
chronic disease of epidemic proportions. The topics
reviewed in this entry include: diabetes diagnosis and epidemiology; descriptions of dietary beliefs, consumption
patterns, and subsistence activities; traditional medical system beliefs, attitudes, and healthcare patterns; problems of
diagnosis and treatment encountered within the biomedical
healthcare system; and the development of educational and
community-based diabetes intervention programs. The
research and publication trends documented by Weidman
(2001) clearly indicate that medical anthropologists will
348
continue to respond to the increasing prevalence and growing cultural disruption of type 2 diabetes with theoretical,
methodological, and applied research.
REFERENCES
Allen, J. S., & Cheer, S. M. (1996). The non-thrifty genotype. Current
Anthropology, 37, 831842.
American Diabetes Association (2002a). Expert committee on the diagnosis and classification of diabetes mellitus (Report to the expert
committee on the diagnosis and classification of diabetes mellitus).
Diabetes Care, 25 (Suppl. 1), S5S20.
American Diabetes Association (2002b). Diabetes among Native
Americans. Retrieved 2002 from the American Diabetes
Association Website:. www.diabetes.org
Baier, L. J., Bogardus, C., & Sacchettini, J. C. (1996). A polymorphism
in the human intestinal fatty acid binding protein alters fatty acid
transport across caco-2 cells. Journal of Biological Chemistry, 271,
1089210896.
Baker, P. T., Hanna, J. T., & Baker, T. S. (Eds.). (1986). The changing
Samoans: Behavior and health in transition. Oxford, UK: Oxford
University Press.
Barker, D. J. P. (1994). Non-insulin diabetes. In Mothers, babies and
diseases in later life (pp. 8093). London: British Medical Journal
Publishing Group.
Barker, D. J. P. (1999). Fetal origins of type 2 diabetes mellitus. Annals
of Internal Medicine, 130, 322324.
Baschetti, R. (1998). Diabetes epidemic in newly westernized populations: Is it due to thrifty genes or to genetically unknown foods?
Journal of the Royal Society of Medicine, 91, 22625.
Benyshek, D. C., Martin, J. F., & Johnston, C. S. (2001). A reconsideration of the origins of type 2 diabetes epidemic among Native
Americans and the implications for intervention policy. Medical
Anthropology, 20, 2564.
Bindon, J. R., & Baker, P. T. (1985). Modernization, migration and obesity among Samoan adults. Annals of Human Biology, 12, 6776.
Bindon, J. R., Crews, D. E., & Dressler, W. W. (1991). Lifestyle,
modernization and adaptation among Samoans. Collegium
Antropologicum, 15, 101110.
Broadhurst, C. L. (1997). Nutrition and non-insulin dependent diabetes
mellitus from an anthropological perspective. Alternative
Medicine Review, 2, 378399.
Brosseau, J. D. (1994). Diabetes and Indians: A clinicians perspective.
In J. R. Joe & R. S. Young (Eds.), Diabetes as a disease of
civilization: The impact of culture change on indigenous peoples
(pp. 4166). New York: Mouton de Gruyter.
Broussard, B. A. (1991). Innovative diabetes nutrition education in
American Indians and Alaska natives. In H. Rifkin, J. A. Colwell, &
S. I. Taylor (Eds.), Diabetes 1991: Proceedings of the 14th
International Diabetes Federation Congress (pp. 793796).
Washington, DC: Elsevier Science.
Bruce, S. G. (2000). Prevalence and determinants of diabetes mellitus
among the Metis of Western Canada. American Journal of Human
Biology, 12, 542551.
Caldwell, E. M., Baxter, J., Mitchell, C. M., Shetterly, S. M., & Hammon,
R. F. (1998). The association of non-insulin-dependent diabetes
mellitus with perceived quality of life in biethnic population:
References
disease of civilization: The impact of culture change on indigenous
peoples (pp. 357377). New York: Mouton de Gruyter.
Ferzacca, S. (2000). Actually I dont feel that bad: Managing diabetes and
the clinical encounter. Medical Anthropology Quarterly, 14, 2850.
Frate, D. A., Ginn, M., & Keys, L. (2000). A community based case
management model for hypertension and diabetes. Practicing
Anthropology, 22, 3436.
Fujimoto, W. Y., Leonetti, D. K., Kinyoun, J. L., Newell-Morris, L., &
Shuman, W. P. (1987). Prevalence of diabetes mellitus and
impaired glucose tolerance among second-generation JapaneseAmerican men. Diabetes, 36, 8692.
Gang, E. H. (1995). Polytherapeutic approaches to the control
of hyperglycemia in non-insulin dependent diabetics in Korea
(Dissertation, University of Florida, Gainesville, FL, 1995).
Garro, L. C. (1987). Cultural knowledge about diabetes. In T. K. Young
(Ed.), Diabetes in the Canadian Native population: Biocultural
perspectives. Toronto, Canada: Canadian Diabetes Association.
Garro, L. C. (1995). Individual or societal responsibility? Explanations
of diabetes in an Anishinaabe (Ojibway) community. Social
Science & Medicine, 40, 3746.
Garro, L. C., & Lang, G. C. (1994). Explanations of diabetes: Anishinaabe
and Dakota deliberate upon a new illness. In J. R. Joe & R. S. Young
(Eds.), Diabetes as a disease of civilization: The impact of culture
change on indigenous peoples (pp. 293328). New York: Mouton
de Gruyter.
Gibbs, T., Cargill, K., Lieberman, L. S., & Reitz, E. (1980). Nutrition in
a slave population: An anthropological examination. Medical
Anthropology, 4, 175262.
Gittelsohn, J., Harris, S. B., Burris, K. L., Kakegamic, L., Landman, L. T.,
Sharma, A. et al. (1996). Use of ethnographic methods for applied
research on diabetes among the Ojibway-Cree in Northern
Ontario. Health Education Quarterly, 23, 365382.
Gittelsohn, J., Harris, S. B., Whitehead, S., Wolever, T. M. S.,
Hanley, A. J. G., Barnie, A. et al. (1995). Developing diabetes
intervention in an Ojibwae-Cree community in Northern Ontario:
Linking qualitative and quantitative data. Chronic Disease
Canada, 16, 157164.
Glass, M. (1996). Diabetes in Navajo Indians. Federal Practitioner, 12,
4148.
Goforth-Parker, J. (1994). The lived experience of Native Americans
with diabetes within a transcultural nursing perspective. The
Journal of Transcultural Nursing, 6, 511.
Gohdes, D. (1988). Patterns of diabetes among elders from specific
ethnic groups. Albuquerque, NM: Indian Health Service.
Gohdes, D. M. (1996). Diabetes in American Indians: A growing
problem. Diabetes Care, 9, 609613.
Ghodes, D. M., Schraer, C. & Rith-Najarian, (1996). Diabetes prevention
in American Indians and Alaskan Natives. Where are we in 1994?
Diabetes Research and Clinical Practice, 34(suppl.), S95S100.
Gohdes, D. M., & Acton, K. (2000). Diabetes mellitus and its complications. In E. R. Rhoades (Ed.), American Indian health:
Innovations in health care, promotion, and policy (pp. 221243).
Baltimore: Johns Hopkins University Press.
Gohdes, D. M., Kaufman, S., & Valway, S. (1993). Diabetes in
American Indians: An overview. Diabetes Care, 16, 239243.
Gohdes, D. M., Rith-Najarian, S., & Acton, K. (1996). Improving
diabetes care in the primary health setting: The Indian health
experience. Annals of Internal Medicine, 124, 149152.
349
Goran, M. I. & Gower, B. A. (1999). Relationship between visceral fat
and disease risk in children and adolescents. American Journal of
Clinical Nutrition, 70, 149S156S.
Grover, J. K., Yadav, S., & Vats, V. (2002). Medicinal plants of India with
anti-diabetic potential, Journal of Ethno Pharmacology, 81, 81100.
Gulliford, M. C. (1996). Epidemiological transition in Trinidad and
Tobago, West Indies 19521992. International Journal of
Epidemiology, 25, 357365.
Hagey, R. (1984). The phenomenon, the explanations and the responses:
Metaphors surrounding diabetes in urban Canadian Indians. Social
Science & Medicine, 18, 265272.
Harris, M. I. (1991). Epidemiological correlates of NIDDM in
Hispanics, Whites and Blacks in the US population. Diabetes
Care, 14, 639648.
Hall, T. R., Hickey, M. E., & Young, T. B. (1991). The relationship of
body fat distribution to non-insulin-dependent diabetes mellitus in
a Navajo Community. American Journal of Human Biology, 126.
Hall, T. R., Hickey, M. E., & Young, T. B. (1992). Evidence for recent
increases in obesity and non-insulin-dependent diabetes mellitus in a
Navajo community. American Journal of Human Biology, 547553.
Hall, T. R., Hickey, M. E., & Young, T. B. (1994). Many farms revisited:
Evidence of increasing weight and non-insulin dependent diabetes
in a Navajo community. In J. R. Joe & R. S. Young (Eds.), Diabetes
as a disease of civilization: The impact of culture change on
indigenous peoples (pp. 129146). New York: Mouton de Gruyter.
Hanley, A. J., Harris, S. B., Gittelsohn, J., & Andres, F. F. (1995).
The Sandy Lake health and diabetes project: Design, methods and
lessons learned. Chronic Disease in Canada, 16, 149156.
Hanley, A. J., Harris, S. B., Gittelsohn, J., Wolever, T. M., Saksvig, B., &
Zinman, B. (2000). Overweight among children and adolescents
in a Native Canadian community: Prevalence and associated
factors. American Journal of Clinical Nutrition, 71, 693700.
Harris, M. (1995). Diabetes in America (2nd ed.) (National Institutes
of Health Publication No. 95-1468). Washington, DC: US
Government Printing Office.
Harris, S. B., Gittelsohn, J., Hanley, A., Barnie, A., Wolever, T. M.,
Gao, J. et al. (1997). The Prevalence of NIDDM and associated
risk factors in Native Canadians. Diabetes Care, 20, 185187.
Hickey, M. E., & Carter, J. S. (1994). Cultural barriers to delivering
health care: The non-Indian provider prospective. In J. Joe &
R. Young (Eds.) Diabetes as a Disease of Civilization: The Impact
of Culture Change on Indigenous Peoples (pp. 453470). New
York: Mouton de Gruyter.
Hoffman B. H., & Haskell, A. J. (1984). The Papago: Historical, social
and medical perspectives. Mount Sinai Journal of Medicine, 51, 707.
Hollow, W. B. (1999). Traditional Indian medicine. In J. M. Galloway,
B. W. Goldberg, J. S. Alpert, & M. H. Trujillo (Eds.), Primary
care of Native American patients: Diagnosis, therapy, and
epidemiology (pp. 3138). Boston: Butterworth-Heinemann.
Hood, V., Kelly, B., Martinez, C., Shuman, S., & Secer-Walker, R. H.
(1987). A Native American community initiative to prevent
diabetes. Ethnicity and Health, 2, 277285.
Hunt, L. M., Arar, N. H., & Akana, L. K. (2000). Herbs, prayer, and insulin.
Use of medical and alternative treatments by a group of Mexican
American diabetic patients. Journal of Family Practice, 49, 216223.
Hunt, L. M., Arar, N. H., & Larme, A. C. (1998). Contrasting patient
and practitioner perspectives in type 2 diabetes management.
Western Journal of Nursing Research, 20, 656676.
350
Hunt, L. M., Valenzuela, M. A., & Pugh, J. A. (1998). Porque me toco
a mi? Mexican American diabetes patients causal stories and their
relationship to treatment behaviors. Social Science & Medicine,
46, 959969.
Indian Health Service (1990). Diabetes nutrition teaching tools: A
resource guide for dietitians. Albuquerque, NM: Health Science
Diabetes Program.
Indian Health Service (2000). Trends in Indian health: 19981999.
Rockville, MD: US Department of Health and Human Services.
International Diabetes Federation (2001) Diabetes atlas 2000
(International Diabetes Federation, Eds.). Brussels, Belgium: Author.
Jenkins, D. J. A., Kendall, C. W. C., Agustin, L. A., Franceschi, S.,
Hamidi, M. et al. (2002). Glycemic index: overview of implications in health and disease. American Journal of Clinical Nutrition,
76(suppl.) 266S273S.
Joe, J. R., & Young, R. S. (1994). Diabetes as a disease of civilization:
The impact of culture change on indigenous peoples. Berlin:
Mouton de Gruyter.
Joos, S. K. (1984). Economic, social, and cultural factors in the
analysis of disease: Dietary change and diabetes mellitus among
the Florida Seminole Indians. In L. Brown & K. Mussels (Eds.),
Ethnic and regional foodways in the United States: The performance of group identity (pp. 217237). Knoxville: University of
Tennessee Press.
Joos, S. K., & Ewart, S. (1988). A health survey of Klamath Indian elders 30 years after the loss of tribal status. Public Health Reports,
103, 166173.
Joos, S. K., Mueller, W. H., Hanis, C. L., & Schull, W. J. (1984).
Diabetes alert study: Weight history and upper body obesity in diabetic and non-diabetic Mexican American adults. Annals of Human
Biology, 11, 167171.
Joslin Diabetes Center (2002). Why is diabetes more common in Asians
and Pacific Islanders? Available from http://www.joslin.harvard.
edu/api/why_common.
Judkins, R. A. (1975). Diet and diabetes among the Iroquois: An
integrative approach. Forty-first International Congress of
Americanists (pp. 313322), Mexico, 1972 (Actas Del Xli
Congreso Internacional De Americanistas, 41, 313322).
Knowler, W. C., Pettitt, D. J., Bennett, P. H., & Williams, R. C. (1983).
Diabetes mellitus in the Pima Indians: Genetic and evolutionary
considerations. American Journal of Physical Anthropology, 62,
107114.
Knowler, W. C., Pettitt, D. J., Saad, M. F., & Bennett, P. H. (1990).
Diabetes mellitus in the Pima Indians: Incidence, risk factors and
pathogenesis. Diabetes Metabolism Review, 6, 127.
Knowler, W. C., Williams, R. C., & Pettitt, D. J. (1988). Gm 3;5,13,14
and type II diabetes mellitus: An association in American Indians
with genetic admixture. American Journal of Human Genetics, 43,
520526.
Korean National Federation of Medical Insurance (1993). 1992 medical
insurance statistical year. South Korea: Seoul.
Kozak, D. (1996). Surrendering to diabetes: An embodied response
to perceptions of diabetes and death in the Gila River Indian
community. Journal of Death and Dying, 35, 347359.
Kuczmarski, R. J., Flegal, K. M., Campbell, S. M., & Johnson, C. L.
(1994). Increasing prevalence of overweight among US adults. The
National Health and Nutrition Examination Surveys, 19611991.
Journal of the American Medical Association, 272, 205211.
References
Loewe, R., Schwartzman, J., Freeman, J., Quinn, L., & Zuckerman, S.
(1998). Doctor talk and diabetes: Towards an analysis of the clinical construction of chronic illness. Social Science & Medicine, 47,
12671276.
McGarvey, S. T. (1994). The thrifty gene concept and adipose studies in
biological anthropology. Journal of the Polynesian Society, 103,
2942.
McGarvey, S. T., Bindon, J. R., Crews, D. E., & Schendel, D. E. (1989).
Modernization and adiposity: Causes and consequences. In
M. Little & J. Haas (Eds.), Human population biology (pp. 263280).
Oxford, UK: Oxford University Press.
McMurphy, M. P., Cesqueira, M. T., Connor, S. K., & Connor, W. E.
(1991). Changes in lipid and lipoprotein levels and body weight in
Tarahumara Indians after consumption of an affluent diet. New
England Journal of Medicine, 325, 17041708.
Miewald, C. E. (1997). Is awarenss enough? The contradictions of selfcare in a chronic disease clinic. Human Organization, 56, 353363.
Mueller, W. H., Joos, S. K., Hanis, C. L., Zavaleta, A. N., Eichner, J., &
Schull, W. J. (1984). The diabetes alert study: Growth, fatness, and
fat patterning, adolescence through adulthood in Mexican
Americans. American Journal of Physical Anthropology, 64,
389399.
National Diabetes Data Group (Eds.). (1985). Diabetes in America.
(National Institutes of Health Publication No. 85-1468).
Washington, DC: US Government Printing office.
Neel, J. V. (1962). Diabetes mellitus: A thrifty genotype rendered
detrimental by progress. American Journal of Human Genetics,
14, 353362.
Neel, J. V. (1982). The thrifty genotype revisited. In J. Kofferling (Ed.),
The genetics of diabetes mellitis (pp. 4960). New York: Academic
Press.
Neel, J. V., Weder, A. B., & Julius, S. (1998). Type II diabetes, essential
hypertension, and obesity as syndromes of impaired genetic
homeostasis: The thrifty genotype hypothesis enters the
21st century. Perspectives in Biology and Medicine, 42, 4474.
ODea, K. (1984). Marked improvement in carbohydrate and lipid
metabolism in diabetic Australian aborigines after temporary
reversion to traditional lifestyle. Diabetes, 33, 596603.
ODea, K., Spargo, R. M., & Akerman, K. (1980). Some studies on the
relationship between urban living and diabetes in a group of
Australian aborigines. Medical Anthropology, 4, 120.
Olson, B. (1999). Applying medical anthropology: Developing diabetes
education and prevention in American Indian cultures. American
Indian Culture and Research Journal, 23, 185203.
Pettitt, D. J., Aleck, K. A., & Bennett, P. H. (1983). Excessive obesity
in offspring of Pima Indian women with diabetes during pregnancy. New England Journal of Medicine, 308, 242245.
Pettitt, D. J., Moll, P. P., & Bennett, P. H. (1993). Insulinemia in
children at low and high risk of NIDDM. Diabetes Care, 16,
608615.
Phipps, K., Barker, D. J., Hales, C. N., Fall, C. H., Osmond, C., &
Clark, P. M. (1993). Fetal growth and impaired glucose tolerance
in men and women. Diabetologia, 36, 225228.
Popkin, B. M. (1998). The nutrition transition and its health implications in lower-income countries, Public Health Nutrition, 1,
521.
Popkin, B. M. (2001). The nutrition transition and obesity in the
developing world. Journal of Nutrition, 131, 871S873S.
351
Ramachandran, A., Snehalatha, C., Latha, E., & Manoharan, M. (1999).
Impacts of urbanization on the lifestyle and on the prevalence of
diabetes in native Asian Indian populations. Diabetes Research
and Clinical Practice, 44, 207213.
Raven, G. M. (1998). The role of insulin resistance in human disease.
Diabetes, 37, 15951607.
Ravussin, E., Valencia, M. E., Esparza, J., Bennett, P. H., & Schulz, L. O.
(1994). Effects of a traditional lifestyle on obesity in Pima Indians.
Diabetes Care, 17, 10671074.
Reid, J. M. (1989). The tao of health, sex and longevity. New York:
Fireside Books.
Reid, J. M., Fullmer, S. D., Pettigrew, K. D., Burch, T. A., Bennett, P. H.,
Miller, M. et al. (1971). Nutrient intake of Pima Indian women:
Relationships to diabetes mellitus and gallbladder disease.
American Journal of Clinical Nutrition, 24, 12821289.
Rhoades, E. R. (2000). American Indian Health: Innovations in health
care, promotion and policy. Baltimore: Johns Hopkins University
Press.
Ritenbaugh, C. (1981). A clinical view of diabetes. The perception of
evolution: Honoring Joseph B. Birdsell. Los Angeles: University
of California at Los Angeles, Anthropology Department.
Ritenbaugh, C., & Goodby, C. S. (1989). Beyond the thrifty gene:
Metabolic implications of prehistoric migration into the New
World. Medical Anthropology, 11, 227236.
Ritenbaugh, C., Szathmary, E. J., Goodby, C. S., & Feldman, C. (1996).
Dietary acculturation among the Dogrib Indians of the Canadian
Northwest Territories. Ecology of Food and Nutrition, 35, 8194.
Rokala, D. A., Bruce, S. G., & Meiklejohn, C. (1991). Diabetes
mellitus in native populations of North America: An annotated
bibliography (Monograph Series No. 4). Winnipeg: University of
Manitoba, Northern Health Research Unity.
Roseman, J. M. (1985). Diabetes in Black Americans. In National
Diabetes Data Group (Eds.), Diabetes in America (National
Institutes of Health Publication No. 85-1468). Washington, DC:
US Government Printing Office VIII: 124.
Russell, M. E., Weiss, K. M., Buchanan, A. V., Etherton, T. D., Moore,
J. H., & Kris-Etherton, P. M. (1994). Plasma lipids and diet of the
Mvskoke Indians. American Journal of Clinical Nutrition, 59,
847852.
Salbe, A. D., Weyer, C., Harper, I., Lindsay, R. S., Ravussin, E., &
Tataranni, P. A. (2002). Assessing risk factors for obesity between
childhood and adolescence: II: Energy metabolism and physical
activity. Pediatrics, 110, 307314.
Shepard, R. J., & Rode, A. (1996). Health consequences of
modernization: Evidence from circumpolar populations.
Cambridge, UK: Cambridge University Press.
Sievers, M. L., & Fisher, J. R. (1981). Diseases of North American
Indians. In H. Rothschild (Ed.), Biocultural aspects of disease
(pp. 191252). New York: Academic Press.
Smith, C. G. (1970). Cultures and diabetes among the Upland Yuma
Indians (Doctoral dissertation, University of Utah, Department of
Anthropology).
Smith. J., & Wiedman D. (2001). Fat content of South Florida Indian
frybread: Health implications for a pervasive Native-American
food. Journal of the American Dietetic Association, 101, 582585.
Snow, L. F. (1974). Folk medical beliefs and their implications for care
of patients: A review based on studies of Black Americans. Annals
of Internal Medicine, 81, 8296.
352
Stern, M. P., Gonzales, C., Mitchell, B. D., Villapando, E., Haffner, S.
M., & Hazuda, H. P. (1992). Genetic and environmental determinants of type II diabetes in Mexico City and San Antonio.
Diabetes, 41, 484492.
Stinson, S. (1992). Nutritional Anthropology. Annual Reviews in
Anthropology, 21, 143170.
Stolarczyk, L. M., Gilliland, S. S., Lium, D. J., & Owen, C. L. (1999).
Knowledge, attitudes and behaviors related to physical activity
among Native Americans with diabetes. Ethnicity and Health, 9,
5969.
Szathmary, E. J. (1986). Diabetes in arctic and subarctic populations
undergoing acculturation. Collegium Antropologium, 10, 145158.
Szathmary, E. J. (1990). Diabetes in Amerindian populations: The
Dogrib studies. In A. C. Swedlund & G. J. Armelagos (Eds.),
Disease in populations in transition (pp. 75103). New York:
Bergin & Garvey.
Szathmary, E. J. (1994a). Non-insulin dependent diabetes mellitus among
aboriginal North Americans. Annual Review of Anthropology, 23,
457482.
Szathmary, E. J. (1994b). Factors that influence the onset of diabetes
in Dogrib Indians of the Canadian Northwest Territories. In
J. R. Joe & R. S. Young (Eds.), Diabetes as a disease of
civilization (pp. 229268). Berlin: Mouton de Gruyter.
Szathmary, E. J., & Ferrell, R. E. (1990). Glucose level, acculturation,
and glycosylated hemoglobin: An example of biocultural
interaction. Medical Anthropology Quarterly, 4, 315341.
Szathmary, E. J., Ritenbaugh, C., & Goodby, C. S. (1987). Dietary change
and plasma glucose levels in an Amerindian population undergoing
cultural transition. Social Science & Medicine, 24, 791804.
Teufel, N. I. (1996). Nutrient characteristics of southwest Native
American pre-contact diets. Journal of Nutrition and Environmental Medicine, 6, 273284.
Teufel, N. I., & Ritenbaugh, C. K. (1998). Development of a primary
prevention program: Insight gained in the Zuni Diabetes
Prevention Program. Clinical Pediatrics, 37, 131141.
Thompson, S. J., & Gifford, S. M. (2000). Trying to keep a balance: The
meaning of health and diabetes in an urban Aboriginal community.
Social Science & Medicine, 51, 14571472.
Trowell, H. C., & Burkitt (1981). Western diseases and their emergence
and prevention. London: Edward Arnold.
Tull, E., & Roseman, J. (1995). Diabetes in African Americans.
In National Diabetes Data Group (Eds.), Diabetes in American
(2nd ed.) pp. 613629, NIH Publication No. 95-1468. Washington,
DC: US Government Printing Office.
Urdaneta, M. L., & Krehbiel, R. (1989). Cultural heterogeneity of
Mexican Americans and its implications for the treatment of
diabetes mellitus type II. Medical Anthropology, 11, 269282.
Valencia, M. E., Bennett, P. H., Ravussin, E., & Esparza, J. (1999). The
Pima Indians in Sonora, Mexico. Nutrition Reviews, 57, S55S58.
Narayan, M., Hoskin, M., Kozak, D., Kriska, A. M., Hanson,
R. L. et al. (1998). Randomized clinical trial of lifestyle interventions in Pima Indians: A pilot study. Diabetic Medicine, 15, 6672.
Weiss, K. M. (1990). Transitional diabetes and gallstones in Amerindians
peoples: Genes or environment? In A. C. Swedlund &
G. J. Armelagos (Eds.), Disease in populations in transition
(pp. 105123). New York: Bergin & Garvey.
Weiss, K. M., Cavanagh, P. R., Buchanan, A. V., & Ulbrecht, J. S.
(1989). Diabetes mellitus in American Indians: Characteristics,
Biomedical Perspectives
353
Diarrhea
Elois Ann Berlin
INTRODUCTION
BIOMEDICAL PERSPECTIVES
One natural defense of the body is to flush out the offending substances or organisms. This can be accomplished
by increasing the rate of peristalsis to rush the food bolus,
which has been liquified in the stomach and small intestine, through at such a rapid rate that there is no time for
absorption of the nutrient-containing liquids. Another
method of flushing is through increased secretion of
fluids across the intestinal mucosa into the intestine. Both
produce watery diarrhea. The alternative option to rid the
gastrointestinal tract of offending substances is to send it
back the way it came, as vomitus. Like any inflammatory
process, diarrheal disease may be accompanied by fever.
ETHNOMEDICAL PERSPECTIVES
354
Diarrhea
English
Distinguishing characteristics
Tsanel
General, watery
diarrhea
Bloody diarrhea
Mucoid diarrhea
Chich tsanel
Sim nakal tsanel
Bosbos tsanel
Tiltil tsanel
Xenel tsanel
Yaxal tsanel
Sakil tsanel
Distinguishing characteristics
Manyoka
Phiriganiso
Chinhamukaka
Chikamba
Nntsanganiko
Kuamwissira
Nyongo
Biomedical Perspectives
355
from the blood which tends to spill into the urine and stain
it a darker color. Absence of stool with a small amount of
bloody mucus (currant jelly effect) is suggestive of a
telescoping of the intestine (due to severe peristalsis) or
intestinal blockage (possibly by a worm mass).
Ethnomedical Transmission
and Cause
356
Diarrhea
Bacterial
Bacillus cereus
Campylobacter
Escherichia coli
(enterotoxigenic)
E. coli
(entreoinvasive)
E. coli 0157:H7
Salmonella
Shigella
Stool characteristics
Liquid
Blood
Mucus
Yes
Yes
Maybe
Yes
Fever
Vomit
Pain
Other
Maybe
Low grade
Yes
Mild
Abdomen
Head
Maybe
Low grade
Yes/nausea
colon
Later
Yes
Yes/nausea
Abdomen
severe
None/little
Yes
Yes
Possible
Initial
Later
Possible
Yes
Yes
Often
Yes
Maybe
Maybe
Often
severe
Stahylococcus
aureus
Vibrio cholera
Yes
Yersinia
Yes
Viral Agent
Cytomegalovirus
Norwalk virus
Rotavirus
Yes
Yes
Yes
Parasite
Ascaris spp.
Maybe
Worms
High
Cryptosporidium
Entamoeba
histolytica
Giardia lamblia
Yes
Trichuris
trichiura
Maybe
Colorectal
Maybe,
severe
Yes
Low grade
Abdomen
Malaise, toxemia
Kidney failure possible
May enter blood
Tenesmus, Maybe
rectal prolapse
Medium
Currant jelly
stools
Maybe
Yes
Maybe
Maybe
Often
Worms
Maybe
Maybe
Yes
Maybe,
severe
Abdomen
Abdomen
Possible
straining
Straining
at stool
Biomedical Perspectives
Environmental Relationships
As pragmatic observers in close contact with their
environment, members of small-scale societies usually
can give a good description of seasonal variation in
occurrence of diarrhea. Since manipulation of environmental factors is not an option of such societies, these
normally remain descriptive observational data such as
There is more diarrhea when the rains come or
Children get a lot of diarrhea in the summer from eating
unripe fruit.
Environmental Factors. There is seasonal variation
in the frequency of diarrheal diseases. This variation is
consistent with what we know of the reproductive
requirements of the organisms, namely bacteria flourish
in warmth and viruses grow best in cold conditions.
However, the importance of seasonality is significantly
influenced by the general sanitation level (see, e.g.,
Ackers, Quick, Drasbek, Hutwagner, & Tauxe, 1998). In
areas where there is plenty of potable water readily available and quality sewage disposal, the principal transmission routes are disrupted and seasonal variation, indeed
overall infection rates, are reduced.
Small children are the least likely to observe good
hygienic practices and are, predictably, the most often
affected with diarrhea. This likely does not reflect greater
susceptibility so much as greater exposure. When infants
and small children share a dirt floor or yard with creatures
such as dogs, poultry, and pigs, they tend to share
their parasites as well. Young children in child-care facilities exchange many infections, diarrheal pathogens
included.
357
358
Diarrhea
Biomedical Perspectives
359
Acacia
S. aureus,
Yes
E. coli
Ageratina
S. aureus
Yes
Baccharis
S. aureus
Yes
Byrsonima
S. aureus (mild)
Cissampelos S. aureus, E. coli,
Yes
Candida albicans
Crataegus
S. aureus
Helianthemum S. aureus, E. coli,
Candida albicans,
Pseudomonas aeruginosa
Verbena
S. aureus, E. coli,
Candida albicans
Psidium
S. aureus, E. coli,
Yes
Candida albicans,
Pseudomonas aeruginosa
Tagetes
S. aureus, E. coli,
Yes
Candida albicans
a
b
spas. spasmolytic
hemo. hemostatic
Yes
Cytotoxic
Cytotoxic
Antimalarial
Sedative
Acacia
Cassia
Chenopodium
Cornus
Croton
Equisetum
Gaultheria
Geranium
Lobelia
Myrica
Piper
Plantago
Ranunculus
Rumex
Senecio
Solanum
360
Disability/Difference
http://www.nbif.org/outbreak/procedures/campylo.html
Foodborne Diseases Active Surveillance Network (FoodNet).
http://www.fsis.usda.gov/OA/background/bfoodnet.htm
WHO (World Health Organization). Division of Diarrhoeal and Acute
Respiratory Disease Control 1211 Geneva 27, Switzerland.
http://www.who.int/chd/publications/cdd/pofact77.htm
NOTES
1. The term health problems is used here to avoid the illness and disease
dichotomy. (1) Although the dichotomy is useful in some discussions, it treats the physiological experience (sickness) in a way that
is not helpful in this discussion. (2) That dichotomy fails to recognize the difference between infection and disease. (3) Such a
dichotomy seems to assume that a systems approach (i.e., one that
incorporates the patients family, social, and physical environments)
does not exist in biomedicine. (4) Many conditions that are neither
illness nor disease are recognized health problems in ethnomedical
systems (such as deformities and dysfunction). Ethnomedical
systems also distinguish conditions that are health-related, but not
necessarily problems, and certainly neither illness nor disease (such
as menstruation).
2. This is intended neither as a representative sample nor as an exhaustive survey of the distribution of use. It is merely a demonstration of
the fact that many plant genera are widely and probably independently used for the same conditions.
REFERENCES
Ackers, M.-L., Quick, R. E., Drasbek, C. J., Hutwagner, L., Tauxe, R. V.
(1998). Are there national risk factors for epidemic cholera? The
correlation between socioeconomic and demographic indices and
cholera incidence in Latin America. International Journal of
Epidemiology, 27(2), 330334.
Bhan, M. K., & Bhandari, N. (1998). The role of zinc and vitamin A in
persistent diarrhea among infants and young children. Journal of
Pediatric Gastroenterology and Nutrition, 26(4), 446453.
Coriel, J., & Mull, J. D. (1988). Introduction. Anthropological studies
of diarrheal disease. Social Science & Medicine, 27(1), 13.
Green, E. C. (1999). Indigenous theories of contagious disease. Walnut
Creek, CA: AltaMira Press.
Hogel, J., Lwanga, J., Ksiamba-Mugerwa, C., & Musonge, S. L. (1991).
Indigenous knowledge and management of childhood diarrhoeal
diseases. Arlington, VA: Management Sciences for Health
(PRITECH Project).
Mead, P. S., Slutsker, L., Dietz, V. et al. (1999). Food-related illness and
death in the United States. Emerging Infectious Diseases, 5,
607625.
Weiss, M. (1988). Cutural models of diarrhea illness: Conceptual
framework and review. Social Science & Medicine, 27, 516.
Disability/Difference
Russell P. Shuttleworth
INTRODUCTION
This entry has three primary aims: (1) to provide a brief
overview of the kinds of bodily and behavioral differences perceived as anomalous in a range of societies and
the various social responses to these differences; (2) to
review and critique research and theory in the anthropology of impairmentdisability; and (3) to suggest several
conceptual advancements that would move this area of
study forward.
CROSS-CULTURAL REVIEW OF
RESPONSES TO BODILY AND
BEHAVIORAL DIFFERENCES
As a broad inclusive category, and from a strict constructionist perspective, disability exists only in locally specific
relation to Western European notions of medicalization,
employment, and welfare (Groce, 1999; Whyte & Ingstad,
1995). Yet, some range of physical and behavioral
361
362
Disability/Difference
societies, however, other ethnophysiological or ethnopsychological concepts or indices may be highlighted instead
of or in addition to function. For example, among the
Shona, dryness of the affected part (presumably) within
their humoral system, is the essential factor in determining disability (Burck, 1999, p. 203). In addition, in many
non-Western societies, interpreting fault often takes
precedence over assigning blame to the individual or
wanting to improve the individuals condition or situation
(Devlieger, 1995). As Devlieger notes, The idea of
rehabilitation as a continuous effort of improving and
accommodating the living conditions of persons with
disabilities is basically a Western idea that is foreign to
Songye thought (p. 95).
All societies recognize and respond to cognitive
differences and erratic behavior. However, Nicolaisen
(1995) says the Punan Bah do not hold the mentally
impaired responsible for their situation (see also
Marshall, 1996). Epilepsy and madness are caused by
non-human spirits who invade or partly take over the
body, relegating the soul of the body to a secondary position. Effort is made by families to cure madness by way
of spirit mediums. Persons so affected are regarded as
dangerous only if violent. For the most part, effort is
made to include them as part of regular social relationships. On the other hand, for the Hubeer stupidity and
madness are viewed as similar to infertility and death and
the mentally impaired are often treated with abuse outside
of their family (Helander, 1995, p. 89). Talle (1995) states
that among the Kenya Maasai mentally retarded or mad
persons are regarded not as disabled in a physical sense
but as abnormal (fool). Nicolaisen (1995) echoes an
observation made by many cross-cultural researchers that
some forms of severe cognitive difference such as severe
forms of mental retardation, among the Punan Bah.
I suspect that children born with such impairments
wither away or die at an early age (p. 44).
Examining a particular social context within a
society can further reveal that those with certain physical
and behavioral differences may encounter restricted
access. Anthropologists often note in their studies of
impairmentdisability in other societies that physical
and/or cognitive impairment does not necessarily determine status and exclusion, that family and kinship ties are
more important (see, e.g., Ingstad, 1999). What are we
then to make of the fact that in the context of sexual
and/or marriage negotiation and family formation, it has
also paradoxically been observed that people with bodily
363
OF
THEORY
364
Disability/Difference
phenomenological and existentialphenomenological perspectives further have been presented (see French, 1994;
Hughes, 1999; Hughes & Paterson, 1997; Paterson &
Hughes, 1999; Shuttleworth, 1998, 2000a, 2000b, 2001;
Shuttleworth & Kasnitz, n.d.). For example, Paterson and
Hughes (1999) outline a phenomenological perspective on
impairment that draws much from the work of Leder
(1990) and shows how embodied contexts of meaning are
structured by non-disabled embodiment.
The symbolic anthropological study of impairmentdisability has not moved much beyond a focus on
the ritual notion of liminality. In a much-cited article,
partially intended to move beyond what they perceived to
be the inadequacies of the stigma concept and the language of deviance, Murphy et al. (1988) propose that the
concept of liminality could also apply to the social
response to disabled people in American society (Goldin
& Scheer, 1995; Murphy et al., 1988; see also Willett &
Deegan, 2001)). Disabled people have indeed often been
isolated, made invisible, seen as contaminated, avoided,
without status, and economically marginalized. These and
other responses are reminiscent of the social responses to
initiates who undergo the liminal phase of many rites of
passage (Turner, 1967). Thus, Murphy et al. (1998) argue
that, disability is not a thing, it is a juncture within a
processan arrestment in life history that is dramatized in
a rite of passage frozen in its liminal stage (p. 241).
However, Murphy and his associates err by trying to
force the processual notion of liminality onto the lived
experience of disability in general. The problem is that
they draw almost entirely from the experience of persons
with late-onset impairments. Extrapolating from the
experience of this population, Murphy et al. (1988) suggest that the physical laws of the disabled are better seen
as losses, rather than as deficiencies, for most of the
sightless once saw and most of the crippled once ran
(p. 241). However, people with early-onset impairments
do not experience the first phase of the proposed liminal model, that is, separation from normal bodies.
Therefore, their physical laws cannot be considered
losses in any sense of the term (Kasnitz & Shuttleworth,
1999; Shuttleworth, 2000b).
As mentioned earlier in this entry, a more consistent
model, that would not only apply to disability in the U.S.
context but also cross-culturally, is that certain bodily and
behavioral differences are perceived as anomalous or as
matter out of place (Douglas, 1966). Matter out of
place falls in between cultural categories and is thus
365
366
Disability/Difference
367
368
Disability/Difference
References
CONCLUSION
The anthropological study of impairmentdisability is
becoming more cross-cultural and is beginning to
develop innovative theoretical perspectives. However,
the mapping of local meanings of anomalous physical/
behavioral differences in relation to etic distinctions
between illness meanings, therapeutic treatments, and
pain associations, across different societies totality of
contexts, is virtually non-existent. Additionally, the
anthropological study of impairmentdisability has not
much benefited from the critical work of the last 20 years
within anthropology and medical anthropology. In reference to the latter, there has not been much engagement
with the critical approaches of medical anthropologists
such as Hans Baer, Nancy Scheper-Hughes, Margaret
Lock, and Paul Farmer (however, see Kasnitz &
Shuttleworth, 1999, 2001a, 2001b; Peace, 1997, 2001).
While it is never wise to assume asymmetrical power
369
ACKNOWLEDGMENTS
I would like to acknowledge the critical feedback of
Devva Kasnitz in assisting me in formulating several
ideas in this entry. Additionally, I wish to thank the
members of our course, Anthropology and Disability, at
the University of California, Berkeley, for their spirited
discussion of some of the key issues, which also assisted
in clarification.
REFERENCES
Ablon, J. (1981). Stigmatized health conditions. Social Science &
Medicine, 15B, 59.
Ablon, J. (1984). Little people in America: The social dimensions of
dwarfism. New York: Praeger.
Ablon, J. (1988). Living with difference: Families with dwarf children.
New York: Praeger.
Ablon, J. (1995). The elephant man as self and other: The
psychosocial costs of a misdiagnosis. Social Science & Medicine,
40, 14811489.
Ablon, J. (1996). Gender response to neurofibromatosis 1. Social
Science & Medicine, 42, 99109.
Ablon, J. (1999). Living with genetic disorder: The impact of neurofibromatosis 1. Westport, CO: Auburn House.
Allan, J. (1996). Foucault and special educational needs: A box of tools
for analyzing childrens experiences of mainstreaming. Disability
and Society, 11(2), 219233.
Angrosino, M. (1992). Metaphors of stigma: How deinstitutionalized
mentally retarded adults see themselves. Journal of Contemporary
Ethnography, 21, 171199.
Angrosino, M. (1994). On the bus with Vonnie Lee: Explorations in life
history and metaphor. Journal of Contemporary Ethnography, 23,
1428.
Angrosino, M. (1998). Opportunity house: Ethnographic stories of
mental retardation. Walnut Creek, CA: Altimara.
Anspach, R. (1979). From stigma to identity: Political activism among
the physically disabled and former mental patients. Social Science &
Medicine, 13A, 765772.
Becker, G. (1980). Growing old in silence: Deaf people in old age.
Berkeley: University of California Press.
Becker, G., & Arnold, R. (1986). Stigma as a social and cultural
construct. In S. C. Ainlay, G. Becker, & L. M. Coleman (Eds.),
The dilemma of difference: A multidisciplinary view of stigma
(pp. 3958). New York: Plenum Press.
Block, P. (1997). Biology, culture, and cognitive disability: Twentieth
century professional discourse in Brazil and the United States.
Unpublished doctoral dissertation, Duke University, Durham, NC.
370
Block, P. (2000). Sexuality, fertility and danger: Twentieth century
images of women with cognitive disabilities. Sexuality and
Disability, 18(4), 239254.
Block, P. (n.d.). Cognitive disability in Brazil and the United States:
A social historical and ethnographic comparison. In D. Kasnitz &
R. Shuttleworth (Eds.), Engaging anthropology in disability
studies. Williamsport, CT: Praeger.
Bourdieu, P. (1984). Distinction: A social critique of the judgement of
taste. Cambridge, MA: Harvard University Press.
Bruun, F. J. (1995). Hero, beggar, or sports star: Negotiating the identity of the disabled person in Nicaragua. In B. Ingstad & S. Whyte
(Eds.), Disability and culture (pp. 196209). Berkeley: University
of California Press.
Bruun, F. J., & Ingstad, B. (Ed.). (1990). Disability in cross-cultural
perspective (Working paper No. 4). Oslo, Norway: University of
Oslo, Department of Social Anthropology.
Burck, D. (1999). Incorporation of knowledge of social and cultural
factors in the practice of rehabilitation projects. In B. Holzer,
A. Vreede, & G. Weigt (Eds.), Disability in different cultures:
Reflections on local concepts (pp. 199207). Transcript Verlag:
Bielefeld, Germany.
Colligan, S. (1994). The ethnographers body as text: When disability
becomes other-abling. In G. Gold & L. Duval (Eds.), Working
with disability: An anthropological perspective. Anthropology of
Work Review, 15(23), 59.
Colligan, S. (2001). The ethnographers body as text and context:
Revisiting and revisioning the body through anthropology and
disability studies (R. Shuttleworth & D. Kasnitz, Guest Eds.).
Disability Studies Quarterly, 21(3), 113124.
Corker, M. (1998a). Deaf disabled, or deafness disabled? Toward a
human rights perspective (disabilities, human rights, and society).
London: Open University Press.
Corker, M. (1998b). Disability discourse in a postmodern world. In
T. Shakespeare (Ed.), The disability reader: Social science
perspectives (pp. 221233). New York: Cassell.
Corker, M. (1999). Differences, conflations, and foundationsthe
limits to accurate theoretical representation of disabled peoples
experience? Disability and Society, 14(D), 627642.
Corker, M., & Davis, J. (n.d.). Shifting selves, shifting meanings, learning culture: Toward a reflexive dialogics in disability research. In
D. Kasnitz & R. Shuttleworth (Eds.), Engaging anthropology in
disability studies. Williamsport, CT: Praeger.
Corker, M., & Shakespeare, T. (Eds.). (2002). Disability/postmodernity:
Embodying disability theory. New York: Continuum.
Dasen, V. (1993). Dwarfs in ancient Egypt and Greece. Oxford, UK:
Oxford University Press.
Davis, J. (1998). Understanding the meanings of children: A reflexive
process. Children and Society, 12(5), 336348.
Davis, J. (2000). Disability studies as ethnographic research and text:
Research strategies and roles for promoting social change?
Disability and Society, 15(2), 191206.
Davis, L. (1995). Enforcing normalcy: Disability, deafness, and the
body. New York: Verso.
Deshen, S. (1992). Blind people: The private and public life of sightless
Israelis. Albany: State University of New York Press.
Devlieger, P. (1995). Why disabled? The cultural understanding of
physical disability in an African society. In B. Ingstad & S. Whyte
Disability/Difference
(Eds.), Disability and culture (pp. 94106). Berkeley: University
of California Press.
Devlieger, P. (1998). Representations of physical disability in colonial
Zimbabwe: The Cyrene Mission and Pitaniko, the film of Cyrene.
Disability and Society, 13(5), 709725.
Devlieger, P. (1999). Developing local concepts of disability: Cultural
theory and research prospects. In B. Holzer, A. Vreede, & G. Weigt
(Eds.), Disability in different cultures: Reflections on local
concepts (pp. 297302). Transcript Verlag: Bielefeld, Germany.
Devlieger, P. (2000). The logic of killing disabled children: Infanticide,
Songye cosmology, and the colonizer. In J. Hubert (Ed.), Madness,
disability and social exclusion: The archaeology and anthropology
of difference (pp. 159167). New York: Routledge.
Dirks, N., Eley, G., & Ortner, S. (1994). Introduction. In N. B. Dirks,
G. Eley, & S. B. Ortner (Eds.), Culture/power/history: A reader in
contemporary social theory (pp. 345). Princeton, NJ: Princeton
University Press.
Douglas, M. (1966). Purity and danger: An analysis of the concepts of
pollution and taboo. London: Routledge and Kegan Paul.
Duval, L. (1984). Psychosocial metaphors of physical distress among
M.S. patients. Social Science & Medicine, 19, 635638.
Duval, L. (1994). Anthropology revisited by a displaced traveler. In
G. Gold & L. Duval (Eds.), Working with disability: An anthropological perspective. Anthropology of Work Review, 15(23), 34.
Eames, E., & Eames, T. (1997). Partners in independence: A success
story of dogs and the disabled. New York: Howell Book House.
Edgerton, R. B. (1993). The cloak of competence: Stigma in the lives of
the mentally retarded (Rev. ed.). Berkeley: University of California
Press.
Estroff, S. E. (1981). Making it crazy: An ethnography of psychiatric
clients in an American community. Berkeley: University of
California Press.
Fassin, D. (1991). Physical handicaps, economic practices and matrimonial strategies in Senegal. Social Science & Medicine, 32(3),
267272.
Foucault, M. (1973). Madness and civilization: A history of insanity in
the age of reason R. Howard, Trans. New York: Vintage/Random
House.
Frank, G. (1984). Life history model of adaptation to disability: The
case of a congenital amputee. Social Science & Medicine, 19,
639645.
Frank, G. (1986). On embodiment: A case study of congenital limb
deficiency in American culture. Culture, Medicine, & Psychiatry,
10, 189219.
Frank, G. (1988). Beyond stigma: Visibility and self-empowerment of
persons with congenital limb deficiencies. Journal of Social Issues,
44(1), 95115.
Frank, G. (2000). Venus on wheels: Two decades of dialogue on
disability, biography, and being female in America. Berkeley:
University of California Press.
French, L. (1994). The political economy of injury and compassion:
Amputees on the ThaiCambodian border. In T. J. Csordas
(Ed.), Embodiment and experience: The existential ground of culture and self (pp. 6999). Cambridge, UK: Cambridge University
Press.
Ghai, A. (2002). Disability in the Indian context: Post-colonial
perspectives. In M. Corker & T. Shakespeare (Eds.), Disability/
References
postmodernity: Embodying disability theory (pp. 88100).
New York: Continuum.
Goerdt, A. (1984). Physical disability in Barbados: A cultural perspective. Ann Arbor, MI: University Microfilms.
Goffman, E. (1963). Stigma: Notes on management of spoiled identity.
Englewood Cliffs, NJ: Prentice Hall.
Gold, G. (1994). Caretakers in a miniaturized world: Encounters
between paratransit drivers and a disabled anthropologist.
In G. Gold & L. Duval (Eds.), Working with disability: An anthropological perspective. Anthropology of Work Review, 15(23),
1921.
Gold, G. (n.d). The social construction of access: Alternative views of
an architectural concept. In D. Kasnitz & R. Shuttleworth (Eds.),
Engaging anthropology in disability studies. Williamsport, CT:
Praeger.
Goldin, C. (1984). The community of the blind: Social organization,
advocacy, and cultural redefinition. Human Organization, 43,
121131.
Goldin, C., & Scheer, J. (1995). Murphys contribution to disability
studies: An inquiry into ourselves. Social Science & Medicine, 40,
14431445.
Groce, N. (1985). Everyone here spoke sign language: Hereditary deafness on Marthas Vineyard. Cambridge, MA: Harvard University
Press.
Groce, N. (1999). General issues in research on local concepts and
beliefs about disability. In B. Holzer, A. Vreede, & G. Weigt (Eds.),
Disability in different cultures: Reflections on local concepts
(pp. 285296). Transcript Verlag: Bielefeld, Germany.
Guldin, A. (1999). Claiming sexuality: Mobility-impaired people and
sexualities in American culture (Masters paper in Anthropology,
University of Iowa Ames, IA.
Guldin, A. (2000). Self-claiming sexuality: Mobility impaired people in
American culture. Sexuality and Disability, 18(4), 233238.
Gussow, Z., & Tracy, G. (1968). Status, ideology and adaptation to
stigmatized illness: A study of leprosy. Human Organization, 27,
316325.
Gussow, Z., & Tracy, G. (1970). Stigma and the leprosy phenomenon:
The social history of a disease in the nineteenth and twentieth
centuries. Bulletin of Historical Medicine, 44, 425 ff.
Gwaltney, J. (1975). The thrice shy: Cultural accommodation to blindness and other disasters in a Mexican community. New York:
Columbia University Press.
Hahn, H. (1985). Toward a politics of disability: Definitions,
disciplines, and politics. Social Science Journal, 22, 87105.
Hanks, J., & Hanks, L. (1948). The physically handicapped in certain
non-western societies. Journal of Social Issues, 4(4), 1119.
Helander, B. (1995). Disability as incurable illness: Health, process, and
personhood in Southern Somalia. In B. Ingstad & S. Whyte (Eds.),
Disability and culture (pp. 7393). Berkeley: University of
California Press.
Herskovits, E., & Mitteness, L. (1994). Transgressions and sickness in
old age. Journal of Aging Studies, 8, 327340.
Holzer, B. (1999). Everyone has something to give. Living with a
disability in Juchitan, Oaxaca, Mexico. In B. Holzer, A. Vreede, &
G. Weigt (Eds.), Disability in different cultures: Reflections on
local concepts (pp. 4457). Transcript Verlag: Bielefeld,
Germany.
371
Holzer, B., Vreede, A., & Weigt, G. (Eds.). (1999). Disability in
different cultures: Reflections on local concepts. Transcript Verlag:
Bielefeld, Germany.
Hubert, J. (2000a). The social, individual and moral consequences of
physical exclusion in long-stay institutions. In J. Hubert (Ed.),
Madness, disability and social exclusion (pp. 196207). New York:
Routledge.
Hubert, J. (2000b). Introduction: The complexity of boundedness
and exclusion. In J. Hubert (Ed.), Madness, disability and social
exclusion (pp. 18). New York: Routledge.
Hubert, J. (Ed.). (2000c). Madness, disability and social exclusion.
New York: Routledge.
Hughes, B. (1999). The constitution of impairment: Modernity and the
aesthetic of oppression. Disability and Society, 14(2), 155172.
Hughes, B. (2000). Medicine and the aesthetic invalidation of disabled
people. Disability and Society, 15(4), 555568.
Hughes, B., & Paterson, K. (1999). The social model of disability and
the disappearing body: Toward a sociology of impairment.
Disability and Society, 12, 325340.
Hyland, J. (2000). Leprosy and social exclusion in Nepal: The continuing conflict between medical and socio-cultural beliefs and practices. In J. Hubert (Ed.), Madness, disability and social exclusion
(pp. 168179). New York: Routledge.
Ingstad, B. (1995). Mpho ya modimoA gift from god: Perspectives on
attitudes toward disabled persons. In B. Ingstad & S. Whyte (Eds.),
Disability and culture. Berkeley: University of California Press.
Ingstad, B. (1999a). The myth of disability in developing nations. The
Lancet, 354, 757758.
Ingstad, B. (1999b, November) Seeing disability in context. Paper presented at the 98th annual meeting of the American Anthropological
Association, Chicago, IL.
Ingstad, B., & Whyte, S. (Eds.). (1995). Disability and culture.
Berkeley: University of California Press.
Kaplan-Myrth, N. (2001). Blindness prevention in Mali: Are improvements in sight? (R. Shuttleworth & D. Kasnitz, Guest Eds.).
Disability Studies Quarterly, 21(3).
Kasnitz, D. (1993). Outsider/insider: Theoretical and practical lessons
about fieldwork from the career course of an ethnologist with a
disability. Paper presented at the annual meeting of the American
Anthropological Association, Washington, DC.
Kasnitz, D. (1995). Age at onset and personal disability history as
variables in disability research, theory, and advocacy. 1990
Proceedings of the Society for Disability Studies, Willamette, OR.
Kasnitz, D., & Shuttleworth, R. (1999, May). Engaging anthropology
in disability studies (Position papers in disability studies, 1(1) ).
Oakland, CA: World Institute on Disability.
Kasnitz, D., & Shuttleworth, R. (2001a). Anthropology in disability
studies. In B. Swadener & L. Rogers (Eds.), Semiotics and
dis/ability: Interrogating categories of difference (pp. 1941).
New York: State University of New York Press.
Kasnitz, D., & Shuttleworth, R. (2001b). Introduction: Engaging
anthropology in disability studies (R. Shuttleworth & D. Kasnitz,
Guest Eds.). Disability Studies Quarterly, 21(3), 217.
Kaufert, J. (2001). Two accounts of decisions about life supporting
technologies: Ethicists case examples and ventilator users life
narratives (R. Shuttleworth & D. Kasnitz, Guest Eds.). Disability
Studies Quarterly, 21(3), 7690.
372
Kaufert, J., & Kaufert, P. (1984). Methodological and conceptual issues
in measuring the long term impact of disability: The experience of
poliomyelitis patients in Manitoba. Social Science & Medicine, 19,
609618.
Kleinman, A., Das, V., & Lock, M. (Eds.). (1997). Social suffering.
Berkeley: University of California Press.
Kleinman, A., & Kleinman, J. (1991). Suffering and its professional
transformation: Toward an ethnography of interpersonal experience. Culture, Medicine, & Psychiatry, 15, 275301.
Kohrman, M. (2000). Grooming Que Zi: Marriage exclusion and
identity formation among disabled men in contemporary China.
American Ethnologist, 26, 890909.
Kohrman, M. (n.d.). Bodies of difference: Experiences of disability and
institutional advocacy in modern China. Berkeley, CA: UC Press.
Kondo, D. (1990). Crafting selves: Power, gender, and discourses of
identity in a Japanese workplace. Chicago: University of Chicago
Press.
Landsman, G. (1997). Concepts of personhood and mothers of persons
with disabilities. Disability Studies Quarterly, 17, 157176.
Landsman, G. (n.d.). Mothers, others, and the critique of the social
model of disability. In D. Kasnitz & R. Shuttleworth (Eds.), Engaging
anthropology in disability studies. Williamsport, CT: Praeger.
Langness, L., & Levine, H. (1986). Culture and retardation: Life
histories of mildly mentally retarded persons in American society.
Dordrecht, The Netherlands: D. Reidel.
Leder, D. (1990). The absent body. Chicago: The University of Chicago
Press.
Linton, S. (1998). Claiming disability: Knowledge and identity.
New York: New York University Press.
Luborsky, M. (1994). The cultural adversity of physical disability:
Erosion of full adult personhood. Journal of Aging Studies, 8,
239253. Washington, DC: George Washington University.
Marshall, M. (1996). Problematizing impairment: Cultural competence
in the Carolines. Ethnology, 35(4), 249269.
Monks, J., & Frankenberg, R. (1995). Being ill and being me: Self, body
and time in multiple sclerosis narratives. In B. Ingstad & S. Whyte
(Eds.), Disability and culture (pp. 107134). Berkeley: University
of California Press.
Murphy, R. (1987). The body silent. New York: Henry Holt.
Murphy, R., Scheer, J., Murphy, Y., & Mack, R. (1988). Physical
disability and social liminality: A study in the rituals of adversity.
Social Science & Medicine, 26, 235242.
Nicolaisen, I. (1995). Persons and nonpersons: Disability and personhood among the Punan Bah of Central Borneo. In B. Ingstad &
S. R. Whyte (Eds.), Disability and culture (pp. 3855). Berkeley:
University of California Press.
Ortner, S. (1984). Theory in anthropology since the sixties.
Comparative Studies in Society and History, 26, 126166.
Paterson, K., & Hughes, B. (1999). Disability studies and phenomenology: The carnal politics of everyday life. Disability and Society,
14(5), 597610.
Pawlowski, D. (2001). Work of staff with disabilities in an urban
medical rehabilitation hospital (R. Shuttleworth & D. Kasnitz,
Guest Eds.). Disability Studies Quarterly, 21(3), 6775.
Peace, J. (1997). Review essay: Ethnography and disability. Journal of
Contemporary Ethnography, 25, 500508.
Disability/Difference
Peace, J. (2001). The artful stigma (R. Shuttleworth & D. Kasnitz, Guest
Eds.). Disability Studies Quarterly, 21(3).
Pengra, L., & Godfrey, J. (2001). Different boundaries, different
barriers: Disability studies and Lakota culture (R. Shuttleworth &
D. Kasnitz, Guest Eds.). Disability Studies Quarterly, 21(3),
3653.
Phillips, M. (1990). Damaged goods: Oral narratives of the experience
of disability in American culture. Social Science & Medicine, 30,
849857.
Predaswat, P. (1992). Khi Thut, The disease of social loathing: An
anthropology of the stigma of leprosy in rural northeast Thailand.
Unpublished doctoral dissertation, University of California,
San Francisco and Berkeley, CA.
Preston, P. (1994). Mother father deaf. Cambridge, MA: Harvard
University Press.
Preston, P. (1995). Mother father deaf: The heritage of difference. Social
Science & Medicine, 40, 14611467.
Raji, O., & Hollins, S. (2000). Exclusion from funerary rituals and
mourning: Implications for social and individual identity. In
J. Hubert (Ed.), Madness, disability and social exclusion
(pp. 196207). New York: Routledge.
Raphael, D., Salovesh, M., & Laclave, M. (2001). Journeying through
life without a map: dyslexia, dysgraphia, dysnumia and other such
(R. Shuttleworth & D. Kasnitz, Guest Eds.). Disability Studies
Quarterly, 21(3), 152159.
Rosing, I. (1999). Stigma or sacredness. Notes on dealing with disability in an Andean culture. In B. Holzer, A. Vreede, & G. Weigt
(Eds.), Disability in different cultures: Reflections on local
concepts (pp. 2743). Transcript Verlag: Bielefeld, Germany.
Schact, R. (2001). Engaging anthropology in disability studies:
American Indian issues. (R. Shuttleworth & D. Kasnitz, Guest
Eds.). Disability Studies Quarterly, 21(3), 1735.
Scheer, J. (1987). The social consequences of mobility impairment in a
New York City neighborhood. Unpublished doctoral dissertation,
Columbia University, New York, NY.
Scheer, J., & Groce, N. (1988). Impairment as a human constant: Crosscultural and historical perspectives on variation. Journal of Social
Issues, 44, 2337.
Scheer, J., & Luborsky, M. (1994). The cultural context of polio
biographies. Orthopedics, 14, 11731181.
Scheper-Hughes, N. (1979). Saints, scholars and schizophrenics: Mental
illness in rural Ireland. Berkeley: University of California Press.
Scheper-Hughes, N. (1990). Mother love and child death in northeast
Brazil. In J. Stigler, R. Schweder, & G. Herdt (Eds.), Cultural
psychology: Essays on comparative human development.
Cambridge, UK: Cambridge University Press.
Scheper-Hughes, N. (1992). Death without weeping: The violence of
everyday life in Brazil. Berkeley: University of California Press.
Sentumbwe, N. (1995). Sighted lovers and blind husbands: Experiences
of blind women in Uganda. In B. Ingstad & S. Whyte (Eds.),
Disability and culture (pp. 159173). Berkeley: University of
California Press.
Shakespeare, T. (1994). Cultural representation of disabled people:
Dustbins for disavowal? Disability and Society, 9, 283299.
Shakespeare, T., Gillespie-Sells, K., & Davies, D. (1996). The sexual
politics of disability: Untold desires. New York: Cassell.
References
Shuttleworth, R. (1998). Experience and meaning in the pursuit of sexual relationships for men with cerebral palsy. Paper presented at
the 11th Annual Meeting of the Society for Disability Studies.
Oakland, CA.
Shuttleworth, R. (2000a). The search for sexual intimacy for men with
cerebral palsy. Sexuality and Disability, 18(4), 263282.
Shuttleworth, R. (2000b). The pursuit of sexual intimacy for men with
cerebral palsy. Unpublished doctoral dissertation, University of
California, San Francisco and Berkeley, CA.
Shuttleworth, R. (2001a). Symbolic contexts, embodied sensitivities
and the lived experience of sexually relevant interpersonal encounters for a man with severe cerebral palsy. In B. Swadener &
L. Rogers (Eds.), Semiotics and dis/ability: Interrogating categories
of difference (pp. 7595). New York: State University of New York
Press.
Shuttleworth, R. (2001b). Exploring multiple roles and allegiances
in ethnographic process in disability culture (R. Shuttleworth &
D. Kasnitz, Guest Eds.). Disability Studies Quarterly, 21(3),
103113.
Shuttleworth, R. (2002). Defusing the adverse context of disability and
desirability as a practice of the self for men with cerebral palsy. In
M. Corker & T. Shakespeare (Eds.), Disability/postmodernity:
Embodying disability theory (pp. 112126). New York: Continuum.
Shuttleworth, R., & Kasnitz, D. (n.d.). Introduction: Critically engaging
disability studies and anthropological theory on impairmentdisability. In Engaging Anthropology in Disability Studies, Kasnitz
& Shuttleworth (Eds.) Williamsport, CT: Praeger.
Stiker, H. (1999a). A history of disability (W. Sayers, Trans.). Ann
Arbor: University of Michigan Press.
Stiker, H. (1999b). Using historical anthropology to think disability.
In B. Holzer, A. Vreede, & G. Weigt (Eds.), Disability in different
cultures: Reflections on local concepts (pp. 352380). Transcript
Verlag: Bielefeld, Germany.
Stone, E. (1997). From the research notes of a foreign devil: Disability
research in China. In C. Barnes & G. Mercer (Eds.), Doing
disability research. Leeds, UK: The Disability Press.
Stone, E. (Ed.). (1999). Disability and development: Learning from
action and research on disability in the majority world. Leeds, UK:
The Disability Press.
Susman, J. (1994). Disability, stigma and deviance. Social Science &
Medicine, 38, 1522.
Talle, A. (1995). A child is a child: Disability and equality among the
Kenya Maasai. In B. Ingstad & S. Whyte (Eds.), Disability and
culture (pp. 5672). Berkeley: University of California Press.
Thompson, R. G. (1997). Extraordinary bodies: Figuring disability in
American culture and literature. New York: Columbia University
Press.
373
Turmusani, M. (1999a). Some cultural representations of disability in
Jordan: Concepts and beliefs. In B. Holzer, A. Vreede, & G. Weigt
(Eds.), Disability in different cultures: Reflections on local
concepts (pp. 102113). Transcript Verlag: Bielefeld, Germany.
Turmasani, M. (1999b). The participatory rapid appraisal method of
research on cultural representations of disability in Jordan. In
B. Holzer, A. Vreede, & G. Weigt (Eds.), Disability in different
cultures: Reflections on local concepts (pp. 343351). Transcript
Verlag: Bielefeld, Germany.
Turner, V. (1967). The forest of symbols: Aspects of Ndembu ritual.
Ithaca, NY: Cornell University Press.
Valentine, J. (2002). Naming and narrating disability in Japan. In
M. Corker & T. Shakespeare (Eds.), Disability/postmodernity:
Embodying disability theory (pp. 213227). New York:
Continuum.
Verbrugge, L., & Jette, A. (1993). The disablement process. Social
Science & Medicine, 38, 114.
Vreede, A. (1999). Some thoughts on definitions and a methodology of
cross-cultural research pertaining to disability. In B. Holzer,
A. Vreede, & G. Weigt (Eds.), Disability in different cultures:
Reflections on local concepts (pp. 323331). Transcript Verlag:
Bielefeld, Germany.
Wendell, S. (1996). The rejected body: Feminist philosophical
reflections on disability. New York: Routledge.
Weston, K. (1991). Families we choose: Lesbians, gays, kinship.
New York: Columbia University Press.
Whyte, S. (1995a). Constructing epilepsy: Images and contexts in East
Africa. In B. Ingstad & S. Whyte (Eds.), Disability and culture
(pp. 226245). Berkeley: University of California Press.
Whyte, S. (1995b). Disability between discourse and experience. In
B. Ingstad & S. Whyte (Eds.), Disability and culture (pp. 267291).
Berkeley: University of California Press.
Whyte, S., & Ingstad, B. (1995). Disability and culture: An overview.
In B. Ingstad & S. Whyte (Eds.), Disability and culture (pp. 332).
Berkeley: University of California Press.
Willett, J., & Deegan, M. (2001). Liminality and disability: Rites of
passage and community in hypermodern society (R. Shuttleworth
& D. Kasnitz, Guest Eds.). Disability Studies Quarterly, 21(3),
137151.
Willis, P. (1977). Learning to labour: How working-class kids get
working class jobs. Westmead, UK: Saxon House.
Wolf, C., & Dukepoo, F. (1969). Hopi Indians, inbreeding, and
albinism. Science, 164(3875), 3037.
World Health Organization (WHO). (1980). International Classification
of Impairments, Disabilities and Handicaps. Geneva, Switzerland:
Author.
374
Drug Use
Drug Use
J. Bryan Page
INTRODUCTION
Among all the things that people do in the quest for health,
ingestion of materials thought to improve an individuals
state of mind and body appears to be universal. Human
beings have discovered and learned to consume myriad
preparations derived from plants and minerals, usually in
the course of seeking food, but human foragers must have
had some degree of receptivity to possible remedies or
ways of achieving altered states of mind. This entry will
point out that the discovery of altered consciousness and
of remedies for ills have been, and still are inextricably
interconnected. Anthropologists, using their holistic
perspective in examining how herbal remedies and mindaltering drugs fit into the lives of the people who use
them, have provided especially useful information and
perspective on human variability related to drug use.
The archeological record of humankinds Paleolithic
epoch holds little evidence of early consumption of plants
or plant products as drugs.1 Nevertheless, in the thousands of years that our ancestors spent foraging in shifting and changing ecologies, the search for the edible
likely led to the discovery of the pleasurable, or at least
the interesting effects of certain plants (Naranjo, 1995).
The first clear evidence of use of a drug plant in the
Western Hemisphere involves the discovery of mescal
beans in a cave site in Coahuila, Mexico (Adovasio &
Fry, 1976) about 8,500 years ago. Use of alcohol is
implied in materials found in Old World sites of about the
same antiquity, and use of other drug plants somewhat
later. As with most invention, accidental occurrences
probably shaped the process of discovering the first
medicines and other drugs. Biodiversity in the local
ecology, the numbers of different species per square
meter, probably also played a part in adding to the list of
novel plant preparations found by early humans.
If we assume that accident and biodiversity combined to lead to the identification of drug plants, then we
could anticipate the relative productivity of different parts
of the world, taking into account density of population.
Not surprisingly, zones known to be tropical, but not
375
BACKGROUND
AND
HISTORY
376
Drug Use
377
DEVELOPMENT
MODELS
OF
METHODS
AND
378
Drug Use
379
380
Drug Use
IMPACT
AND
CONTRIBUTIONS
References
NOTE
1. A word about nomenclature is in order. Many well-meaning publications, some quoted in this entry, refer to drugs as substances.
That term is too broad for purposes of discussing what people take
to make them feel better, or at least different. This entry will refer to
all preparations ingested by human beings to alter the state of the
bodymind continuum as drugs, including tobacco, alcohol,
antibiotics, and heroin, among many others. The term preparation
will refer to a specific form of a drug, as it usually takes some preparing to render naturally occurring material into a consumable drug.
The entry will also refer to misuse of these drugs, not abuse, except
when referring to NIDA.
REFERENCES
Adovasio, J. M., & Fry, G. F. (1976). Prehistoric psychotropic drug use
in northeast Mexico and Trans-Pecos Texas. Economic Botany, 30,
9496.
Agar, M. (1973). Ripping and running. New York: Knopf.
Agar, M. (1980). Professional strangers: An informational introduction
to ethnography. New York: Academic Press.
Ames, G. M. (1985). Middle-class Protestants: Alcohol and the family.
In L. A. Bennett & G. M. Ames (Eds.), The American experience
with alcohol: Contrasting cultural perspectives ( pp. 435460).
New York: Plenum Press.
Baer, H. A., Singer, M., & Johnson, J. (1986). Towards a critical medical
anthropology [Special issue]. Social Science & Medicine, 23(2).
Barth, G. (1964). Bitter strength: A history of the Chinese in the
United States 18501870. Cambridge, MA: Harvard University
Press.
381
Becker, H. (1963). Outsiders: Studies in the sociology of deviance.
London: Free Press of Glencoe.
Bennett, L. A. (1985). Alcohol writ accountable: The Episcopal Diocese
of Washington, DC. In L. A. Bennett & G. M. Ames (Eds.), The
American experience with alcohol: Contrasting cultural perspectives (pp. 411434). New York: Plenum Press.
Bourgois, P. (1995). In search of respect selling crack in El Barrio.
New York: Cambridge University Press.
Burton, R. F., Sir (n.d.). First footsteps in East Africa. London:
J. M. Dent.
Carlson, R. G. (1996). The political economy of AIDS among drug
users in the United States: Beyond blaming the victim or powerful
others. American Anthropologist, 98(2), 266278.
Carlson, R. G., Wang, J., Siegal, H. A., Falck, R. S., & Guo, J. (1994).
An ethnographic approach to targeted sampling: Problems and
solutions in AIDS prevention research among injection drug and
crack-cocaine users. Human Organization, 53(3), 279286.
Carter, W. E. (1977). Ritual, the Aymara, and the role of alcohol in
human society. In B. M. DuToit (Ed.), Drugs, rituals, and
altered states of consciousness (pp. 101110). Rotterdam,
The Netherlands: Balkema Press.
Carter, W. E., Coggins, W. J., & Doughty, P. L. (1980). Cannabis in
Costa Rica. Philadelphia: ISHI Press.
Carter, W. E., & Mamani, M. (1986). Coca en Bolivia. La Paz, Mexico:
Librera Editorial Juventud.
Castaneda, C. (1968). The teachings of Don Juan: A Yaqui way of
knowledge. New York: Ballantine Books.
Chambers, C., & Ball, J. (1970). The epidemiology of opiate addiction
in the United States. Springfield, IL: Charles C. Thomas.
De Mille, R. (1976). Castanedas journey: The power and the allegory.
Santa Barbara, CA: Capra Press.
De Mille, R. (1990). The Don Juan papers: Further Castaneda
controversies. New York: Wadsworth Press.
Dobkin de Rios, M. (1968). Folk curing with a psychedelic cactus in
northern Peru. International Journal of Social Psychiatry, 15,
2332.
Dobkin de Rios, M. (1970). Banisteriopsis used in witchcraft and folk
healing in Iquitos, Peru. Economic Botany, 22(2), 194199.
Dobkin de Rios, M. (1971). Ayahuasca, the healing vine. International
Journal of Social Psychiatry, 17(4), 256269.
Dobkin de Rios, M. (1977). Suggested hallucinogenic motifs in New
World massive earthworks. In B. M. DuToit (Ed.), Drugs, rituals,
and altered states of consciousness (pp. 237250). Rotterdam,
The Netherlands: Balkema Press.
Dreher, M. C. (1984). Working men and Ganja: Marijuana use in rural
Jamaica, Philadelphia: Institute for the Study of Human Issues.
Feldman, H. W., Agar, M. H., & Beschner, G. M. (1979). Angel dust, an
ethnographic study of PCP users. Lexington, MA: Lexington
Books.
Fletcher, J. M., Page, J. B., Francis, D. J., Copeland, K., Naus, M. J.,
Davis, C. M. et al. (1996). Cognitive correlates of chronic cannabis
use in Costa Rican men. Archives of General Psychiatry, 53,
10511057.
Frazer, J. G. (1915). The golden bough, a study in magic and religion.
New York: St. Martins Press.
Furst, P. T. (1970). The Tsit (Erythrina spp.) of the Popol Vuh and
other psychotropic plants in pre-Columbian art. Paper presented
382
at the annual meeting of the Society of American Archaeology,
April 29May 2, Mexico.
Furst, P. T. (1990). To find our life: Peyote among the Huichol Indians of
Mexico. In P. T. Furst (Ed.), Flesh of the Gods: The ritual use of hallucinogens (pp. 136184). Prospect Heights, IL: Waveland Press.
Furst, P. T. (1995). This little book of herbs: Psychoactive plants as
therapeutic agents in the Badanius manuscript. In R. E. Schultes &
S. von Reis (Eds.), Ethnobotany: Evolution of a discipline
(pp. 108130). Portland, OR: Dioscordes Press.
Gamella, J. (1990). La historia de Julin: Memorias de heroina y
delincuencia. Madrid: Editorial Popular.
Gamella, J. (1994). The spread of intravenous drug use and AIDS in a
neighborhood in Spain. Medical Anthropology Quarterly, 8(2),
131160.
Gamella, J. (1999). Las rutas del extasis. Barcelona, Spain: Editorial
Ariel, S.A.
Harner, M. J. (1974). Hallucinogens and shamanism. New York: Oxford
University Press.
Heath, D. (1958). Drinking patterns of the Bolivian Camba. Quarterly
Journal of Studies on Alcohol, 19, 491508.
Heath, D. (1994). Agricultural changes and drinking among the
Bolivian Camba: A longitudinal view of the aftermath of a revolution. Human Organization, 53, 357361.
Honigmann, J. J., & Honigmann, I. (1945). Drinking in an Indian-white
community. Quarterly Journal on Studies of Alcohol, 5, 575619.
Koester, S. (1994). Copping, running, and paraphernalia laws:
Contextual variables and needle risk behavior among injection
drug users. Human Organization, 53(3), 287295.
La Barre, W. (1938a). The peyote cult (Yale University Publications in
Anthropology, No. 19). New Haven, CT: Yale University.
La Barre, W. (1938b). Native American beers. American Anthropologist,
40, 224234.
La Barre, W. (1960). Twenty years of peyote studies. Current
Anthropology, I, 4560.
Lowie, R. H. (1919). The tobacco society of the Crow Indians.
New York: The Trustees.
Marshall, M. (1979). Beliefs, behaviors and alcoholic beverages.
Ann Arbor: University of Michigan Press.
Mangin, W. (1957). Drinking among Andean Indians. Quarterly
Journal on Studies of Alcohol, 18, 5566.
Morgan, H. W. (1981). Drugs in America: A social history 18001980.
Syracuse, NY: Syracuse University Press.
Musto, D. (1987). The American disease: Origins of narcotic control.
New York: Oxford University Press.
Naranjo, P. (1995). Archaeology and psychoactive plants. In
R. E. Schultes & S. von Reis (Eds.), Ethnobotany: Evolution of a
discipline (pp. 393399). Portland, OR: Dioscordes Press.
National Commission of Drug Abuse. (1973). Marijuana: A signal of
misunderstanding. New York: Ballantine.
Nichter, M., & Cartwright, E. (1991). Saving the children for the
tobacco industry. Medical Anthropology, 5, 236256.
Page, J. B. (1983). The amotivational syndrome hypothesis and the
Costa Rica study: Relationships between methods and results.
Journal of Psychoactive Drugs, 15(4), 261267.
Page, J. B. (1990). Shooting scenarios and risk of HIV-1 infection.
American Behavioral Scientist, 33(4), 478490.
Page, J. B., Chitwood, D. D., Smith, P. C., Kane, N., & McBride, D. C.
(1990). Intravenous drug abuse and HIV infection in Miami.
Medical Anthropology Quarterly, 4(1), 5671.
Drug Use
Page J. B., Fletcher, J. M., & True, W. R. (1988). Psychosociocultural
perspectives on chronic cannabis use: The Costa Rican follow-up.
Journal of Psychoactive Drugs, 20(1), 5765.
Page, J. B., & Salazar, J. M. (1999a). Use of needles and syringes in
Miami and Valencia: Observations of high and low availability.
Medical Anthropology Quarterly, 4(4), 413435.
Page, J. B., & Salazar, J. M. (1999b). Lemon juice as a solvent for
heroin. Drug Use and Misuse, 34(8), 11931197.
Page, J. B., & Salazar, J. M. (2001). Where you sleep and where you
shoot: Suggestive data from Valencia. Drug Use and Misuse, 36
(1&2), 113129.
Page, J. B., Smith, P. C., & Kane, N. (1991). Shooting galleries, their
proprietors, and implications for prevention of AIDS. Drugs and
Society, 5(1/2), 6985.
Partridge, W. (1973). Life in a Hippie Ghetto. New York: Holt, Rinehart,
and Winston.
Preble. E., & Casey, J. (1969). Taking care of business: The heroin
users life on the streets. International Journal of the Addictions,
15, 329337.
Pritchett, W. K. (1993). The Liar School of Herodotus. Amsterdam:
J. C. Gieberg.
Rubin, V., & Comitas, L. (1975). Ganja in Jamaica. The Hague:
Mouton.
Schultes, R. E. (1938). The appeal of peyote (Lophophora williamsii)
as a medicine. American Anthropologist, 40, 698715.
Schultes, R. E. (1940). Teonanacatlthe narcotic mushroom of the
Aztecs. American Anthropologist, 42, 429443.
Schultes, R. E. (1963). Hallucinogenic plants of the New World.
Harvard Review, I, 145166.
Schultes, R. E. (1977). The botanical and chemical distribution of hallucinogens. In B. M. DuToit (Ed.), Drugs, rituals, and altered
states of consciousness (pp. 2555). Rotterdam, the Netherlands:
Balkema Press.
Schultes, R. E., & von Reis, S. (1995). Ethnobotany: Evolution of a
Discipline. Portland, OR: Dioscordes Press.
Singer, M. (1986). Towards a political economy of alcoholism. Social
Science & Medicine, 23, 113130.
Singer, M., Baer, H. A., & Susser, I. (1999). Medical anthropology and
the world system. Westport, CT: Bergin & Garvey.
Spradley, J. (1970). You owe yourself a drunk. Boston: Little, Brown
and Company.
Spradley, J. (1980). Participant observation: An ethnography of urban
nomads. New York: Holt, Rinehart and Winston.
Sterk, C. E. (1999). Fast lives : Women who use Crack Cocaine.
Philadelphia: Temple University Press.
Trotter, R. T., II, Bowen, A. M., & Potter, J. M. (1995). Network models
for HIV outreach and prevention programs for drug users. In
R. H. Needle, S. L. Coyle, S. G. Genser, & R. T. Trotter, II (Eds.).
Social networks, drug abuse, and HIV transmission (pp. 135153)
(NIDA Research Monograph No. 151. NIH Publication
No. 95-3889). Washington, DC: US Government Printing Office,
Superintendent of Documents.
Waterston, A. (1993). Street addicts in the political economy.
Philadelphia: Temple University Press.
Weppner, R. (1977). Street ethnography. Los Angeles: Sage.
Wilbert, J. (1990). Tobacco and shamanistic ecstasy among the Warao
Indians of Venezuela. In P. T. Furst (Ed.), Flesh of the Gods: The
ritual use of hallucinogens (pp. 5583). Prospect Heights, IL:
Waveland Press.
Introduction
383
INTRODUCTION
Epidemics emerge from specific, local concatenations of
biological and social processes. Through the prism of
culture, medical anthropologists have sought to understand how social processes both constrain and shape
infectious diseases. In an era of self-conscious globalization, anthropologists have moved beyond the realm of
traditional culture to examine how the cultures of biomedicine and of transnational institutions interact with
local forms of knowledge, practice, and power. This
makes anthropologists well-placed to examine the cultural dynamics of the interface between global and local
social relations and, from this viewpoint, examine the
biosocial processes underlying emerging infectious diseases today. Advances in the application of molecular
biological techniques to the study of epidemics promise
to deepen understanding of these biosocial processes.
Coordinated mapping of biosocial processes through
ethnographic and molecular methods holds the potential
to make a substantial contribution to the emerging discipline of emerging infectious diseases.
Most commentators agree that the 1992 publication
of an expert committee report on emerging infections was
a seminal moment that set the stage for subsequent efforts
to address this issue. The committee defined emerging
infections as new, re-emerging, or drug-resistant infections whose incidence in humans has increased within
the past two decades or whose incidence threatens to
increase in the near future (Institute of Medicine, 1992,
p. 3; see also Woolhouse & Dye, 2001, p. 981). This definition sets out a distinction between three microbial
causes of new epidemics: new pathogens, old pathogens
that have resurged, and pathogens that have changed
through the acquisition of drug resistance. Research on
emerging epidemics has described an ever-expanding
array of pathogens and their effects, largely using epidemiological and laboratory methods (Krause, 1998;
Thompson, 2000; Woolhouse & Dye, 2001). Examples of
new pathogens include HIV, of course, but also prions
the cause of mad cow diseaseand Hepatitis C virus
384
undertakes to capture the full social complexity of epidemics as they emerge. Dealing with both causes, and
effects of emerging infections requires both an historical
and an ethnographic approach. Engagement with emerging infectious diseases, which highlight the unexpected
consequences of social inequality, the plight of the
worlds poor, and the shortcomings of global public
health in todays globalizing world, has made medical
anthropology an increasingly politicized discipline
(Farmer, 1999; Whitman, 2000).
THEORETICAL HERITAGE
Anthropological engagements with non-Western and
Western medical systems has left a rich theoretical
heritage that is drawn on studies of emerging epidemics.
Three theoretical frameworks for analyzing health and
illness phenomena in a cross-cultural perspective have
emerged from these engagements. A realist framework
explains local variations in disease phenomena as culturally driven deviations from a biological universal; this use
of biology as the ontological ground of disease phenomena is a resolutely modernist position. In contrast, a
relativist framework examines how scientific discourses,
practices, and institutions construct the biological
world as objective and manipulable phenomena; the use
of such social constructivist explanations for local variations has a postmodernist sensibility. Finally, a radical
constructivist framework focuses on how biological
and social processes are historically and geographically
contingent and intertwined; these processes are understood to co-produce disease phenomena in variable ways.
This is an a-modernist position that grants ontological
privilege neither to the biological nor the social world.
The significance of these three frameworks for consideration of emerging infectious diseases will now be
explored in order.
Although anthropology was not overtly concerned
with health issues in the tropical climates where it cut its
ethnographic teeth, the engagement with primitive
culture left a theoretical legacy that shapes anthropological approaches to emerging infections to this day.
Anthropologists examining indigenous medical systems
sought to understand how these achieved healing outside
of a Western, biomedical framework. To do this, two
options were available to anthropologists. The first was to
assume that non-Western medical traditions had biological
Theoretical Heritage
medical objects and therapeutic effects within a selfvindicating, cultural system. Sociologists of science
applied the skeptical stance of anthropological
approaches to non-Western medical systems to biomedicine. Not to do so, they argued, was to succumb to an
a-symmetrical and a-sociological program. Biological
claims of efficacy could no longer be privileged over
social explanations in a symmetrical program of investigation. These critical scholars of science, often referred
to as social constructivists, inspired anthropologists
attempts to examine biomedicineand the question of
therapeutic efficacyin social and cultural terms. If biomedicine works, then, a broad corpus of anthropological
studies of biomedicine argue, it is because biomedicine is
able to harness the symbolic and material means necessary to achieve healing. Therapeutic efficacy is neither a
matter of just herbs and trances, nor drugs and surgeries,
but requires power, access to economic resources, and the
ability to fashion meaning.
Drawing on this framework, these studies emphasize
that pathogens themselves are socially constructed.
Sociologists of science have argued convincingly that
pathogens are invisible outside of the plethora of laboratory techniques that visualize and represent them in scientific documents, making them into social actors that
act through social practices and speak through scientific discourses. In addition, scientific knowledge is
driven by political, economic, and institutional concerns
that frame the questions that get asked, researched, and
published. This is not to say that pathogens are to be dismissed as figments of a fertile social imagination.
Pathogens are real precisely because the effects they
engender in bodies and societies are mediated through
scientific practices. Without epidemiology and molecular
virology, for example, the HIV epidemic would be less
real precisely because we would not have the scientific
instruments that allow us to see it and to understand it
as the common denominator across multiple registers,
whether embodied or social.
More recently, a third theoretical framework has
emerged from critical consideration of the knowledge
garnered from advances in biotechnology, namely the
increasingly detailed epidemiological maps afforded by
global surveillance programs, and cross-cultural research
on disease entities (Diamond, 1997; Ruffi & Sournia,
1984). This view, which I call the radical constructivist
view, argues that social relations can change pathogens
themselves, as well as the representations we have of
385
386
in bodies, certainly, but also a diverse range of representations, practices, and technologies deployed to understand, prevent, and treat disease. Mass vaccinations,
public health campaigns, media stories, rumours, and
gossip are powerful social mechanisms through which
pathogens act on society. The rubric of culture allows
these phenomena to be grouped together as an object of
anthropological analysis. In this view, pathogens are like
onions, and anthropologists have sought to peel back the
cultural skins that envelop the biological pathogen and
charge it with its social valence.
In summary, anthropological approaches allow a
broader consideration of how epidemics, and pathogens
themselves, are deeply socialized. This tells us that
emerging infectious diseases cannot be taken for granted
as natural phenomenathey are part of larger biosocial
processes that play out both at the micro and macro
levels. The potential of these theoretical approaches
to deepen our insight into the emergence of infectious
diseases has been underutilized, as anthropologists
have largely served as cultural interpreters and
troubleshooters brought into projects to anticipate, or
to provide post-hoc explanations of, negative community
responses (Inhorn & Brown, 1997, p. 12).
387
388
programs were generating a multi-drug-resistant epidemic by treating individuals with already partially
resistant TB.
This hypothesis was borne out by molecular resistance
testing of bacteria isolated from patients. Development of
drug resistance was attributed to the breakdown in curative public health services and the partial availability of
antibiotics in the private sector. This is a product of social
inequalities increasingly visible throughout the developing world, where a lucky few turn to private health care,
creating a market for biomedicines. As a result, the poor
are able to gain access to antibiotics through the informal
economy; however, that access is partial and fragmented
and leads to improper use and, consequently, the risk of
drug resistance. The evolution of MDRTB is tied to growing social inequalities and the privatization of global
health care through policies elaborated far from the communities where they have their impact. Privatization
was due to economic structural adjustment programs
mandated by Washington-based Bretton Woods institutions. These required that cash-strapped Third World
governments slash social spendingand public health
programsin order to meet the conditions for further
loans. However, in a world where knowledge of the
efficacy of biomedicines is truly globalized, it is difficult
to scale back the expectations of the sick, even when they
are poor (Kim, Irwen, Millen, & Young et al., 2000).
The pathogenic potential of the conjugation of pathogenic socio-economic shifts with biomedical globalization is visible in the outbreak of MDRTB in the former
Soviet Union. There, in the aftermath of communism, social
insecurity, coupled with growing social inequality, has been
blamed for skyrocketing crime. Increased crime has led to
increased incarceration rates; the inability of the criminal
justice system to hear the cases means that thousands are
incarcerated while awaiting trial. Simultaneously, breakdown of the public health system has been implicated
through drug shortagesin the emergence of MDRTB
epidemics. The Russian prison system plays an important
role in amplifying the epidemic, as the cramped and overcrowded conditions favor the spread of already-resistant
TB from ill inmates. The pathogen is then spread back
into the community as prisoners are released (Farmer,
1999; Hous, 1999; Kimmerling, 2000; Shilova & Dye,
2001). The Peruvian experience has been used as a model
to develop an ambitious control program for Russia that
has garnered impressive international support, demonstrating the potential for medical anthropology to lead the
CULTURES
OF
BIOMEDICINE
Cultures of Biomedicine
389
390
FUTURE DIRECTIONS
Growing interest in the link between globalization and
health has stimulated anthropological research on how
large-scale social forces and transnational movements
produce local cultural forms. Local inadequacies in
public health infrastructure, local disease ecologies that
explain differences in exposure to pathogens, and local
variations in biology have all been identified by medical
anthropologists, and other researchers, as factors influencing the emergence of epidemics. Given the disproportionate impact of biomedical practices in influencing the
disease ecology, this has been a good place to start.
However, anthropological attention must be paid to
the impact on infectious diseases of global processes,
whether they be ecological (as in the case of global warming) or socioeconomic (as in changes in agricultural production or forms of social inequality). For instance, deadly
outbreaks of E. Coli O:157 epidemics have occurred, and
have been linked to inadequate treatment of water and
food. This underlines the potential of transformations in
the industrial production of food to play a role in generating and/or spreading epidemics. The most dramatic
example is the epidemic of new variant CreutzfeldJacob
disease (vCJD), the modern form of kuru. Mad cow
disease (Bovine Spongiform Encephalopathy, or BSE)
led to an epidemic of vCJD in humans, because sporadic
genetic events that produced disease-producing prions
were amplified though industrial food production
processes. Afflicted animals were recycled, their carcasses used in the production of feed for other cows, in
effect cannibalizing them. This introduced the pathogen
into the bovine food chain as animal flour, spreading the
disease to other cows and, eventually, to the humans
that ate them. Debate over genetically modified foods
(GM foods) has cited the BSE epidemic as a warning.
In the past, medical anthropologist have worked
alongside public health practitioners to promote healthy
dietary habits and encourage the adoption of hygienic
measures to reduce the risk of water-borne infectious diseases (Nichter, 1989). As cultural diagnosticians, anthropologists adapted public health interventions to be
congruent to local beliefs, and worked to ensure that public health interventions could be adopted to maximum
effectfor example, by designing interventions to sell
ORS as a treatment for childhood diarrhea. Morbidity and
mortality from such water-borne infections remains a
major health, challenge, increasingly because clean water
REFERENCES
Burke, D. (1998). Evolvability of emerging viruses. In A. M. Nelson &
C. R. Horsburgh, J. (Eds.), Pathology of emerging infections 2.
Washington, DC: American Society for Microbiology.
Crosby, A. W. (1986). Ecological imperialism: The biological expansion
of Europe, 9001900. Cambridge, UK: Cambridge University Press.
Diamond, J. (1997). Guns, germs and steel: The fates of human
societies. New York: Norton.
References
391
disease in this context include anomaly, condition, morbid effect or defect, deficiency, disorder, and syndrome.
Some sources restrict discussions of genetic disease
to defects of single genes; others include polygenic disorders and the cytogenetic defects as well (Habener &
Williams, 2001; King, Rotter, & Morulsky, 1992).1 This
entry touches on all three manifestations of mutation.
Worldwide, more than half of all conceptions, and
about 7% of all live-born children, are affected by some
form of genetic disease.
392
Genetic Disease I
A BRIEF HISTORY
OF
GENETIC DISEASE
Antiquity
Herodotus to Maupertuis. The Greek historian and
geographer Herodotus in the 4th century BCE became the
first scholar to produce an attributable description of a
genetic condition in humans: The goddess [Aphrodite]
afflicted the Scythians and all their descendants
forever with hermaphroditism3 (Historiae, book I:
105). According to myth, the original Hermaphroditus
was first a son of the Greek god Hermes and goddess
Aphrodite; Hermaphroditus later fused with the nymph
Salamacis to produce a single individual with both
female and male characters. Conversely, Mittwoch has
interpreted the Hebraic version of Eves creation to mean
that Adam was first a hermaphrodite who was then
393
394
Genetic Disease I
MECHANISMS
OF
GENETIC DISEASE
There are two major classes of genetic disease: cytogenetic conditions (caused by chromosomal mutations),
and molecular genetic conditions (caused by mutations
to DNA).
Cytogenetic Conditions
During the 20th century it became apparent to geneticists
that chromosomes (the structures that package the genes)
could be mutated independently of the genes themselves.
Any cytogenetic condition, that is, a genetic disease
caused solely by the rearrangement of whole or parts of
chromosomes, came to be called a major chromosome
anomaly (MCA). Among the better-known examples of
MCAs are Down syndrome (trisomy 21), Turner syndrome
(monosomy X), Klinefelter syndrome (XXY aneuploidy),
and Cri-du-chat syndrome (5del) (see Table 1 of the entry
Genetic Disease II).
Chromosomal Mutations. These include changes in
chromosomes that are either numerical (too many or too
few chromosomes, causing aneuploidy) or structural (the
translocation or repatterning of portions of chromosomes). A standard karyotype for each species, including
humans, is used for comparison. Among the more common modes of chromosome mutations are deletions,
fusions, dissociations (fissions), inversions, and translocations. Many MCAs can profoundly influence phenotypic
features. In the 1860s, Dr. John Langdon Haydon Down
identified a striking phenotype that he called Mongolism,
later renamed Down syndrome.4
The causal mechanism of Down syndrome was characterized in 1959 as a failure of homologous chromatids
to separate normally during meiosis (non-disjunction),
resulting in a fetus with three copies of a chromosome,
now termed trisomy (in this case, trisomy-21).
The probability of experiencing certain chromosome mutations such as Down syndrome can be a function of maternal age. This change in probability is known
in general as an advanced parental age effect, and is
significant for some chromosome mutations that cause
congenital genetic diseases after the mother reaches
395
MENDELIAN MODES
OR TRANSMISSION
OF INHERITANCE
Autosomal Inheritance
Autosomal Recessive Inheritance. The key
feature of the recessive mode is that a new mutation
does not result in a new phenotype, so that only two
AB
Aa
Both, equally
Oculocutaneous
albinism, cystic fibrosis,
hyperlipoproteinemia,
neurosensory deafness,
pseudohermaphroditism,
situs inversus
Direction
Sex affected
Pedigree
features
Example(s)
AA, AB, BB
AA, Aa, aa
Genotypes
Achondroplasia,
amyotrophic lateral
sclerosis, lactose
intolerance, long-QT
syndrome,
neurofibromatosis,
porphyries
Both, equally
Androgen
insensitivity
syndrome,
colorblindness,
G6PD deficiency,
hemophilia,
muscular
dystrophy, X-linked
mental retardation
Primarily males
Congenital
generalized
hypertrichosis, Rett
syndrome
Affected males
transmit the trait to all
daughters; female
carriers transmit the
trait to half of their
children, both males
and females; affected
females transmit the
trait to all children
Both: 2:1
Sex-determining
region of the Y, zinc
finger protein
Males only
N/A
Aa
aA
aA
XYa
aa, aA, AA
Y only
YL
X only
XD
Two phenotypes
(aa, aY) and (aAAA,
AY), the latter pair
often have lowered
fitness (or AA, AY are
inviable if A is lethal),
new mutation
exposed in female aA
and male AY
X only
XR
Two phenotypes
(AAAa, AY) and (aa,
aY), the latter pair
often have lowered
fitness, new mutation
hidden in female Aa
but exposed in male
aY
Pairs 122
AD
The major modes of monogenic inheritance in humans, also known as the Mendelian modes. Abbreviations used include AD for autosomal dominant, AR for autosomal recessive, AC/I for autosomal codominant (or
incomplete dominance), XR for X-linked recessive, XD for X-linked dominant, YL for Y-linked. The direction of mutation is shown in the row labeled Direction, with the normal or wild-type allele shown on the
left, and the new mutant allele to the right.
Familial
hypercholesterolemia,
alpha thalassemia
Both, equally
Attribute(s)
Pairs 122
Pairs 122
AC/I
Chromosomes
AR
397
Monogenic Factors
Incomplete Dominance (Co-dominance). The
key features of the dominant mode are that a new mutation results in a new phenotype in the heterozygote, and
its phenotype is intermediate between the two homozygotes. A familiar human example is the wavy-haired heterozygous offspring of straight- and curly-haired
homozygous parents. The A and B alleles in the ABO
blood groups interact in a co-dominant fashion.
Complete Dominance. The key feature of the dominant mode is that a new mutation results immediately in
a new phenotype in the heterozygote. In many cases the
subsequent homozygote (AA) is inviable.
Sex-linked Inheritance
X-linked Inheritance. The key feature of the
X-linked mode is that males and females are affected disproportionately. X-linked genes are transmitted in either
a monogenic dominant or recessive mode of inheritance.
Females can be either homozygous or heterozygous for
X-linked traits, whereas normal males are always hemizygous for loci located on the X chromosome.
Y-linked Inheritance. The key feature of the
Y-linked mode is that only males carry the gene. Y-linked
inheritance is displayed by genes located on the
non-recombinant region of the Y chromosome. Normal
females never possess a Y chromosome, and normal males
are always hemizygous for the Y chromosome. Absence
of the SRY gene on a Y chromosome, through either mutation or crossing-over (to an X chromosome), results in a
condition known as the XY female syndrome.
NON-MENDELIAN MODES
INHERITANCE
OF
Epigenetic Factors
Genomic Imprinting, Uniparental Disomy, and
Anticipation. Genomic imprinting, also known as
parental imprinting, is an epigenetic, non-Mendelian
398
Genetic Disease I
Polygenic Factors
Heritability and Risk of Inheritance in
Multifactorial Disorders. Heritability may be
defined as the additive proportion of total phenotypic
variance in a polygenic trait attributable to genetic variation in a population. The values of heritability estimates
can range from 0% to 100%. Heritability is a function of
genetic factors, environmental factors, and the interaction
of genetic and environmental factors. Simple Mendelian
traits have a heritability of 100%. Diseases with a heritability of less than 100% are inevitably controversial,
such as those listed in the previous paragraph.
Other non-Mendelian mechanisms of clinical significance have been recently re-evaluated in terms of new
BIOTECHNOLOGY
MEDICINE
Phenocopies
Kuru, New Variant CJD, and the Other Prion
Diseases. Phenocopies appear initially to be inherited
conditions, but upon closer inspection turn out to be,
either wholly or in part, due to an environmental agency.
The thalidomide babies of the 1960s, for example, were
teratogen-induced phenocopies of phocomelia.
Kuru is a chronic, progressive, uniformly fatal transmissible neurodegenerative disease now suspected to be
a phenocopy, and is caused by a prion. Several other
prion diseases also exist, such as new variant
CreutzfeldJakob disease (vCJD); because the prion diseases may not be wholly environmental, however, these
will be discussed in more detail below.
DISTRIBUTIONS
399
OF
GENETIC DISEASES
AND
DARWINIAN
400
Genetic Disease I
401
402
Genetic Disease I
Table 2. Summary of Genotypic Data for New Variant CreutzfeldtJakob Diseasea
Population
Sample size
Control
Control
109
300
Total Control
409
Total nvCJD
MV
VV
0.45
0.43
0.39
0.49
0.16
0.08
0.44
0.46
0.10
(0.43)
(0.45)
(0.12)
15
67
35
0.73
0.69
1.00
0.14
0.06
0.00
0.13
0.25
0.00
117
0.79
0.05
0.16
H-W equilibrium
nvCJD
nvCJD
nvCJD
MM
p, q
Ref.b
1
2
0.67, 0.33
1
3
4
Four studies have provided genotypic data on two control and three affected populations. The two control populations (top) total 409
individuals; allele frequencies for the pooled groups are methionine (M) 0.67, and valine (V) 0.33. The population appears to be
in HardyWeinberg equilibrium.
Pooled data for the three nvCJD study groups (N 117) indicates that a significant number of affected nvCJD individuals have prion
genotype MM (79% observed vs. 44% expected) or VV (16% observed vs. 10% expected); although 46% of MV heterozygotes were
expected to acquire nvCJD, only 5% of this group actually acquired the disease. These differences are highly significant ( p 0.0001),
and strongly suggest that MV heterozygotes are at a selective advantage relative to either of the homozygote classes.
b
References: (1) Bratosiewicz et al. (2001); (2) Zimmerman et al. (1999); (3) Windl et al. (1996); (4) Will et al. (2000).
massive amounts of sequence and gene interaction relationship data is the work of those who practice bioinformatics. The old dogma of one gene, one enzyme has
given way to a vision that a gene is an amalgam of fragments that can be used in several ways in many different
organisms, and the path from raw gene sequence to final
gene product may not be linear, or even determinate. The
study of gene expression and how proteins are assembled
and modified by both RNAs and other proteins (including
prions) is called proteomics. Many agencies have already
transferred resources from the HGP to this new effort;
with less fanfare than the HGP launch in 1989, the Human
Proteome Project (HPP) was funded by Congress in 2001.
Because many of these epigenetic processes are so similar in both higher and lower species, proteomics seeks to
understand both individual cases of dissimilarity and the
cause of massive similarity in these processes across so
many species, including the recently recognized domain
of the Archaea. This research has given rise to an entirely
new field of endeavor, Darwinian Medicine, the search for
evolutionary explanations of vulnerabilities to disease
(Nesse & Williams, 1996; Stearns, 1999; Trevathan,
McKenna, & Smith, 1999).
Biotechnology
Biotechnology is the industrial development of commercial products through the modification and extension of
403
404
Bioethical Concerns
Proximate
versus
Ultimate
Effects
of
Intervention. Anthropologists often point out that in
the PTC taste blindness polymorphism there are nil frequencies of non-tasters among many recent hunting peoples, but high non-taster frequencies in cosmopolitan
areas, where humans have been longer removed from a
foraging subsistence (Boyce et al., 1976; Pool, 1992) (see
PTC tasting in Table 1 of the entry Genetic Disease II).12
The classic explanation for this observation is that
modernization provides both enhanced tools and special
environments in which such a gene-based condition can
survive and perhaps thrivethat culture in some respects
buffers the harsh effects of natural selection, and that
the former tension due to natural selection has been
relaxed. As populations modernize, the argument goes,
the need to personally detect goitrogens and other toxic
alkaloids becomes less and less necessary, andlike an
Genetic Disease I
References
405
NOTES
1. Unless a specific work is cited, material contained in this work is
common knowledge to human geneticists, and may be found in
introductory genetics texts such as Mange and Mange (1999), Vogel
and Motulsky (1999), or Lewis (2001).
2. Nosology: knowledge of, and the systematic classification of diseases.
3. Genetic conditions italicized in the text are summarized in Table 1
of the companion entry Genetic Disease II.
4. There has been a trend in recent years to omit the possessive case
when an eponym is associated with a syndrome; Downs has
become Down syndrome. This convention is followed here. Names
for certain diseases, for example Alzheimers disease, still feature
the possessive case.
5. Leridon (1977, table 4.20, and pp. 7681), and Carr and Gedeon
(1977).
6. While some defects are life threatening, others, such as male
pattern baldness or colorblindness, are more benign.
7. Epigenetics: study of the causes and course of development,
especially those mechanisms that affect the timing and interaction
of gene expression and tissue induction (Mai et al., in press).
8. Several other, less frequent mutations, includung deletions and
insertions, also cause transformational folding of the prion protein,
and result in clinically similarbut not identicalphenotypes.
9. Whole organism cloning should not be confused with DNA
cloning, which is the amplification of a segment of DNA (the clone)
after in vitro insertion of the clone into a suitable DNA vector, such
as a modified virus.
10. This date and time has become an understandably famous landmark
among medical geneticists, because of the historical importance of
the treatment.
11. Other in vitro techniques, such as fetal cell sorting, offer this same
promise.
12. Similarly, the incidences of congenital hearing loss, congenital
blindness, and juvenile-onset myopia have markedly increased in
urban populations for presumed similar reasons (although myopia
has both a genetic and a large environmental component).
13. Iatrogenic: an effect, usually negative and unintended, introduced
directly through the treatment of a healer.
14. Directed evolution is also known by the labels anthropogenic
selection, directed selection and directed molecular evolution.
REFERENCES
Anonymous. (1997a). Molecular medicine: A primer for clinicians.
Part X: Clinical implications of the new geneticsI. South Dakota
Journal of Medicine, 50(11), 401404.
406
Anonymous. (1997b). Molecular medicine: A primer for clinicians
Part XI: Clinical implications of the new geneticsII. South
Dakota Journal of Medicine, 50(12), 445448.
Atran, S. (1998). Folk biology and the anthropology of science:
Cognitive universals and cultural particulars. Behavior and Brain
Sciences, 21(4), 547569; discussion 569609.
Bajema, C. J. (Ed.). (1971). Natural selection in human populations.
New York: Wiley.
Boyce, A. J. et al. (1976). Association between PTC-taster status and
goitre in a Papuan New Guinea population. Human Biology, 48(4),
769773.
Bratosiewicz, J., Liberski, P. P. et al. (2001). Codon 129 polymorphism
of the PRNP gene in normal Polish population and in
CreutzfeldtJakob disease, and the search for new mutations in
PRNP gene. Acta Neurobiologiae Experimentalis (Warsz), 61(3),
151156.
Carr, D. H., & Gedeon, M. (1977). Population cytogenetics of human
abortuses. In E. B. Hook & I. H. Porter (Eds.), Population cytogenetics: Studies in humans (pp. 110). New York: Academic Press.
Cavalli-Sforza, L. L., Menozzi, P., & Piazza, A. (1994). The history and
geography of human genes. Princeton, NJ: Princeton University
Press.
Childs, B., Moxon, E. R., & Winkelstein J. A. (1992). 5. Genetics and infectious diseases. In R. A. King, J. I. Rotter, & A. G. Morulsky (Eds.),
The genetic basis of common diseases (pp. 7191). New York &
Oxford, UK: Oxford University Press.
Collins, F. S., & Gelehrter, T. D. (1992). 2. Molecular genetics. In
R. A. King, J. I. Rotter, & A. G. Morulsky (Eds.), The genetic basis
of common diseases (pp. 1933). New York & Oxford, UK: Oxford
University Press.
Darwin, C. (1868). The variation of animals and plants under domestication. London: John Murray.
Dunn, L. C. (1965). A short history of genetics: The development of
some of the main lines of thought, 18641939. Ames: Iowa State
University Press.
Gajdusek, D. C., & Zigas, V. (1957). Degenerative disease of the central
nervous system in New Guinea: The epidemic occurrence
of kuru in the native populations. New England Journal of
Medicine, 257, 974978.
Glass, B. (1968). Maupertuis, pioneer of genetics and evolution. In
B. Glass, O. Temkin, & W. L. Straus, Jr. (Eds.), Forerunners of
Darwin, 17451859 (pp. 5183). Baltimore: Johns Hopkins
University Press.
Habener, J. F., & Williams, G. W. (2001). The metabolic basis of
common inherited diseases. Philadelphia: W. B. Saunders.
Haig, D. (2000). Genomic imprinting, sex-biased dispersal, and social
behavior. Annals of the New York Academy of Sciences, 907,
149163.
Joner, G., & Sovik, O. (1989). Increasing incidence of diabetes mellitus
in Norwegian children 014 years of age 19731982.
Diabetologia, 32(2), 7983.
King, R. A., Rotter, J. I., & Morulsky, A. G. (1992). 1. The approach to
genetic bases of common diseases. In R. A. King, J. I. Rotter, &
A. G. Morulsky (Eds.), The genetic basis of common diseases
(pp. 318). New York & Oxford, UK: Oxford University Press.
Konotey-Ahulu, F. I. D. (1991). The sickle cell disease patient.
Houndsmills, UK: Macmillan.
Genetic Disease I
Lenz, F. (1931). Morbid hereditary factors. In E. Bauer, E. Fischer, &
F. Lenz (Eds.), Human heredity (pp. 213492). New York:
Macmillan.
Leridon, H. (1977). Human fertility. Chicago: University of Chicago
Press.
Levy-Marchal, C. (1998). Evolution of the incidence of IDDM in
childhood in France. Revue Epidemiologie Sante Publique, 46(3),
157163.
Lewis, R. (2001). Human genetics (4th ed.). Boston: McGraw-Hill.
Mai, L. L., Young Owl, M., & Kersting. P. (2004). Dictionary of human
biology and evolution. Cambridge, UK: Cambridge University
Press.
Mange, E. J., & Mange, A. P. (1999). Basic human genetics (2nd ed.).
Sunderland, MA: Sinauer.
Marks, J. (2001). Scientific and folk ideas about heredity. In
R. A. Zilinskas & P. J. Balint, (Eds.), The human genome project
and minority communities: Ethical, social and political dilemmas
(pp. 5366). Westport, CO: Praeger.
Matthews, J. D. et al. (1968). Kuru and cannibalism. The Lancet,
2(7565), 449452.
McElroy, A., & Townsend, P. K. (1996). Medical anthropology in
ecological perspective (3rd ed.). Boulder, CO: Westview Press.
McKee, L. (1987). Ethnomedical treatment of childrens diarrheal illnesses in the highlands of Ecuador. Social Science & Medicine,
25(10), 11471155.
Mittwoch, U. (1986). Males, females, and hermaphrodites. Annals of
Human Genetics, 50, 103121.
Nesse, R. M., & Williams, G. C. (1996). Darwinian medicine. New York:
Random House.
North, A. F., Jr., Gorwitz, K. et al. (1977). A secular increase in the
incidence of juvenile diabetes mellitus. Journal of Pediatrics,
91(5), 706710.
Nzewi, E. (2001). Malevolent ogbanje: Recurrent reincarnation or
sickle cell disease? Social Science & Medicine, 52(9), 14031416.
Onwubalili, J. K. (1983). Sickle cell anaemia and reincarnation beliefs
in Nigeria. The Lancet, 2(8364), 1423.
Pool, R. (1992). Wrestling anticancer secrets from garlic and soy sauce.
Science, 257(5075), 1349.
Prusiner, S. B., & Scott, M. R. (1997). Genetics of prions. Annual
Review of Genetics, 31, 139175.
Rhodes, R. (1997). Deadly feasts: The prion controversy and the
publics health. New York: Touchstone/Simon & Schuster.
Richards, M. (1997). It runs in the family: Lay knowledge about
inheritance. In A. Clarke & E. Parsons (Eds.), Culture, kinship and
genes: Towards cross-cultural genetics (pp. 175194). New York:
St. Martins Press.
Russell, N. (1986). Like engendering like: Heredity and animal breeding
in early modern England. Cambridge, UK: Cambridge University
Press.
Scriver, C. R., Beaudet, A. L., Sly, W. S., & Valle, D. (Eds.). (1995). The
metabolic and molecular basis of inherited disease (7th ed.).
New York: McGraw-Hill.
Stearns, S. C. (Ed.). (1999). Evolution in health and disease. New York:
Oxford University Press.
Terleph, T. A. (2000). Resisting biology. The unpopularity of a
genes-eye view. Annuals of the New York Academy of Sciences,
907, 212217.
Genetic Epidemiology
407
Genetic Disease II
Genetic Epidemiology of 150 Common or Informative Diseases1
Larry Leon Mai
GENETIC EPIDEMIOLOGY2
In 1874, when Charles Darwins younger cousin Francis
Galton published English Men of Science: Their Nature
and Nurture, Galton was no doubt aware of Shakespeares
priority, for when Prospero spoke of Caliban in 1611, calling him A devil, a born devil, on whose nature nurture can
never stick; ,3 one of the most entrenched dialectics in
all of biology was born.
The impasse, widened in 1690 by John Lockes now
well-worn metaphor of the newborn mind as a tabula
rasa,4 a blank slate on which nature had scribbled nothing,
became contentious when Galton insisted, to the contrary,
that nature had ordained not language itself, but differential
capacities for language; not genius, but differential predispositions for the realization of genius. It was as if Galton
had supposed that nature had indeed written on Lockes
clean slate, but that she had written her messages in invisible ink, and that the slate had to be held over a flame
before the messages could be read.
Somewhere between these polarized philosophical
views, between the nature uber alles of Galton and the
environmental determinism of Locke, an empirical middle
ground is currently being excavated, a middle ground that
rejects neither view and that successfully incorporates components from each. Nowhere has this become clearer than in
the complex interactions of disease agents, disease vectors,
and the gene-based responses of their human hosts.
Genetic epidemiology is the study of genetic elements of disease, and is a growing methodology for
understanding how those elements function in complex
biological systems. Genetic epidemiologists seek to discover and understand the genetic basis of diseases, traits
with complex inheritance patterns, and risk factors
associated with gene-based diseases within specific
environmental contexts (Mai, Young Owl, & Kersting,
2004; Motulsky, 1984).
The conjunction of the terms genetic and epidemiology at first may seem a forced blend; an attempt
to meld two separate approaches that is doomed to chronic
marbling rather than complete synthesis. However, some
of the recent work of geneticists, epidemiologists, and,
indeed, genetic epidemiologists, has blurred the once distinct barrier between these approaches. Classical
Mendelian genetics has an increasingly limited utility in
terms of understanding the complexity of many diseases
and genetic predispositions to cytotoxic agents. The new
mechanisms that have only recently become understood
are for the most part epigenetic rather than genetic.
This review will address the possibility of an
epidemiological transition, and end with a discussion and
illustration of transmissible (in the epidemiological
sense) genetic disease.
The concept of an epidemiological transition as a
continuum that can be organized into stages similar to the
well-known demographic transition has existed for some
408
time (Corruccini & Kaul, 1983; Lappe, 1994). Such a continuum might extend well back into Miocene primate ecology, and from there forward into the Plio-Pleistocene
foraging, scavenging, and hunting behaviors of early
hominids. During these millennia, hominids continued to
adapt genetically. They brought forward with them not
only the genetic markers of prior adaptations, but also a
host of commensal and parasitic heirloom species
(Barnes, Armelagos, & Morreale, 1999). Humans cohabit
a parallel evolutionary universe with body lice and enterobacteria that evolve and speciate in synchrony with us
(Hafner & Nadler, 1988; Klassen, 1992). We possess
anticarcinogens against most plant-related agents (Ames,
1983; Steinkellner et al., 2001) but fewer against
meat-related agents, especially heterocyclic amines
(HCAs) in cooked meat (Adamson et al., 1996; Sugimura,
2000). These observations reflect the long, slow process of
this epidemiological transition.
The roots of the anatomically modern human epidemiological transition extend back at least 10 millennia, to
a time when humans began to exploit marine environments extensively, and adapted both immunologically
and digestively to the consumption of shellfish and other
marine organisms (Walter et al., 2000).
The beginning of the human epidemiological transition proper, however, occurred when some human groups
shifted from gathering and hunting to primary food production and the domestication of animals (Corruccini &
Kaul, 1983; Diamond, 1997, p. 207). A second transition
occurred when acute infectious diseases were controlled
and the prevalence of chronic, noninfectious, and degenerative diseases increased; a third transition, according to
some researchers, is defined by the re-emergence and
emergence of antibiotic-resistant diseases on a global
scale (Barnes et al., 1999; note 1, pp. 229230).
Genetic diseases such as sickle cell disease (SCD)5
could be considered classic stage one/two noninfectious
adaptations. Genetic epidemiology describes the distribution of gene-based adaptations when driven by an
environmental agent, in this case the distribution of
the infections agents of malaria, various species of
Plasmodium.
Genetic diseases are increasing in prevalence, and
perhaps in incidence as well. Some of this change may be
an artifact of expertise, as higher resolution diagnostic
tools are invented, and as diagnostic skills improve. A
substantial proportion, however, is a sequela of improved
Genetic Disease II
409
DISTRIBUTIONS
OF
GENETIC DISEASES
Genetic diseases currently fall into three epidemiological groups: (1) familial, (2) transmissible, and
(3) sporadic.
Simple cases of familial genetic disease exhibit
classic Mendelian patterns of disease with uniform,
unambiguous phenotypic presentations. These are cases
with a family history, even if generations are skipped,
or even if affected persons receive the condition through
progenitors of the opposite sex. TaySachs disease and
familial Down syndrome are examples of familial conditions. More complex genetic diseases are now known to
exist, as well. These are cases where non-Mendelian
mechanisms such as anticipation, genomic imprinting, or
mitochondrial inheritance, are a major factor (see
Genetic Disease I). In either case, familial genetic diseases exhibit genealogical clustering: there is often a clinical propositus or proposita, and other family members
with the condition are thereby discovered.
Transmissible cases of genetic disease are more
ambiguous but usually manifest as a well-defined clinical
entity, such as in the prion diseases. In some cases there
may be no known family history. The criterion that distinguishes this group from the others is that those affected
have a clear gene-based potential for disease acquisition,
but an environmental co-factor is required to precipitate
the condition. One of the difficulties of diagnosis inherent in these conditions is that, because both a common
predisposing genotype and an environmental co-factor
are involved, some diagnosticians will be disposed to
emphasize either one or the otherthe condition will be
perceived arbitrarily as either genetic (nature) or environmental (nurture)rather than as co-factorial. Both Kuru
and new variant CreutzfeldtJakob disease can now be
viewed as clear members of this category (see Genetic
Disease I). Transmissible genetic diseases exhibit spatial
clustering. Because the environmental agent will appear
to have a point of origin, and will appear to have spread
outward from that point, such cases usually will appear at
first glance to be epidemiological in nature. Affected individuals may be the first in their family, in recent memory,
to acquire the condition. Only upon close examination of
DNA will it become clear that affected individuals
also have in common a predisposing genotype, and without that genotype others areeven upon exposure or
410
Genetic Disease II
Description
See Turner syndrome.
Aneuploidy that is incompatible with full term development.
See XX male syndrome.
See XY female syndrome.
See Patau syndrome.
See Edward syndrome.
See Down syndrome.
See Triplo-X syndrome.
See Klinefelter syndrome.
See Double-Y syndrome.
Dwarfism is one of the oldest known familial conditions,
although an exact understanding of its etiology is recent.
There are several types of dwarfism. ACH is a congenital,
hereditary form of dwarfism that results from a failure of
cartilage to be converted into bone in the epiphyseal disks.
ACH affects mainly the long bones by causing rhizomelic
shortening, but may also cause trident hand, frontal
bossing, and mid-face hypoplasia; the cranial base may
distend, causing the cranium to become enlarged
(megalencephaly). The defective gene is fibroblast growth
factor receptor-3 (FGFR3), normally expressed in the
chondrocytes of developing bones. Mating between
affected individuals who are heterozygotes (aA aA)
produce 25% homozygous normal children (aa). The
homozygous AA genotype is usually lethal; (AKA
short-limbed dwarfism, nanism). A slightly rarer form,
thanatophoric dwarfism, causes neonatal death. Pygmies
have another condition known as human growth hormone
resistance. See HGH-resistant dwarfism and pituitary dwarfism.
See Color blindness.
A form of gigantism often confused with several similar
disorders of which acromegaly is a feature; it is genetically
heterogeneous. Familial acromegaly is characterized by
continued growth after a normal adolescent growth spurt
resulting in coarseness of features, and is due to
overproduction of human growth hormone (hGH)
secondary in the majority of cases to an hGH-secreting
pituitary adenoma. Onset is in the third or fourth decade
(mean age of presentation is 44), and sexes are affected
equally (AKA familial somatotrophinoma). In gigantism
proper, proportional overgrowth of all body tissues
Trait
45,X0 syndrome
45,Y0
46,XX male syndrome
46,XY female syndrome
47,X_,13 syndrome
47,X_,18 syndrome
47,X_,21 syndrome
47,XXX syndrome
47,XXY syndrome
47,XYY syndrome
Achondroplasia (ACH;
100800, AD, 4p16.3)
Achromatopsia
Acromegaly (10220, AD,-)
Regional variation
002
001
Ref.
Table 1. Human Genetic Disease Synopsis AA Selection of 150 Syndromes or Disease-Related Entities with a Known or Highly Probable Genetic Etiology
411
Adenosine deaminase
deficiency (ADA; 102700, AD,
20q13.11)
Adrenoleukodystrophy,
X-linked (ALD, 300100, XR,
Xq28)
Rare, 1:100,000.
Regional variation
Description
Adenomatous polyposis of
the colon, familial (FAP;
175100, AD, 5q21q22)
Trait
Table 1. (Contd.)
005
004
003
Ref.
Albinism, type I,
oculocutaneous, tyrosinase
negative (OCA1; 203100, AR,
11q14q21)
008
007
006
Description
Absence of the pigment, melanin. In OCA2, functional
tyrosinase is present; two phenotypes occur, those with
and those without freckles. Sequelae include skin cancer
and gross visual impairment. Some pigment is present at
birth but lost during childhood. Cause is a deletion in the
P protein, which encodes a melanosomal membrane protein.
Matings between OCA1 and OCA2 individuals produce
double heterozygotes that are unaffected (AKA P-gene
related OCA2, tyrosinase-positive albinism).
Trait
Table 1. (Contd.)
Regional variation
012
011
010
009
Ref.
Ambiguous genitalia
Amyotrophic lateral
sclerosis, familial (FALS
or ALS; 105400, AD,
21q12.2q22.1)
Androgen insensitivity
syndrome (AIS; 300068, XR,
Xq11q12)
015
014
013
Description
Uncommon heterogeneous condition characterized by
seizures, mental impairment and growth retardation,
protruding tongue, floppy muscle tone, large jaw, an
inability to talk, and excessive and inappropriate laughter.
Exhibits evidence for genomic imprinting; AS is caused by
a small deletion in chromosome 15, inherited maternally.
The ubiquitin ligase gene (UBE3A) has been implicated.
AKA happy puppet syndrome, PraderWilli/Angelman
syndrome.
The inability to detect by smell certain musk-like sexual
odors; a polymorphism which may be caused by deletions
due to unequal crossing-over; There are several modes of
anosmia; AKA smell blindness.
Disorder of airways and lungs characterized by reversible
inflammatory obstruction, breathing difficulties, wheezing,
and hypersensitivity. A potential susceptibility region has
been identified: cytokine genes on HSA 5 are known to
regulate IgE production resulting in various severities of
allergic diseases. An interaction between another one of
many candidate genes, CD14, and an environmental agent,
endotoxin, is also suspected. Yet another candidate gene
on HSA 11q13, the high affinity IgE beta (2)-adrenergic
receptor (beta(2)AR) gene, is strongly linked to maternal
smoking during pregnancy. The interleukin-4 gene has also
been studied. The CCR5 locus also apparently attenutates
the severity of asthma. The trait also exhibits evidence for
genomic imprinting. Asthma is an atopic condition, possibly
with incomplete penetrance, and is clearly a multifactorial
disorder.
Condition characterized by poor muscle coordination,
involuntary eye movements, capillary dilation in eyes and
skin; sensitivity to light (radiosensitivity), immune defects,
and susceptibility to infections and cancer (9 normal
controls); chromosome breakage is a feature. Onset in the
first decade of life. AT is a heterogeneous condition with at
least 2 distinct subtypes. The causal agent is believed to be
a gene (ATM) involved with DNA processing and repair;
ATM functions normally to signal several cellular responses
to DNA damage. Several hundred SNP mutants have been
reported. AKA LouisBarr syndrome.
Trait
Table 1. (Contd.)
Affects 7% of individuals of
European ancestry, 0% of African
ancestry.
Regional variation
019
018
017
016
Ref.
023
022
021
020
CFTR protein
CharcotMarieTooth disease
1A (CMT1; 118200, 118220;
AD, 17p11.2)
Description
Trait
Table 1. (Contd.)
025
026
024
Ref.
Regional variation
Chromosomal anomalies,
major (MCA)
030
029
028
027
CreutzfeldtJakob syndrome
(CJD; 123400, AD, 20pter-p12)
Cri-du-chat syndrome
(123450, MCA, 5del)
Description
Congenital adrenal
hyperplasia (CAH, 201750,
AR, 6p21.3)
Trait
Table 1. (Contd.)
032
033
031
Ref.
Regional variation
Crohn disease
Deafness, neurosensory 1
(nonsyndromic, 220290, AR,
13q11q12)
035
034
Depression, unipolar
Diabetes insipidus,
nephrogenic, type 1 (NDI1,
304800, XR, Xq28)
Description
Trait
Table 1. (Contd.)
Regional variation
038
037
036
Ref.
Disaccharide intolerance
type I (222900, AR, 3q25q26)
Disaccharide intolerance
type III (223100, AR, 2q21.3)
042
041
040
039
Regional variation
Description
Trait
Table 1. (Contd.)
044
043
Ref.
Dwarfism, pygmy
047
046
045
Description
Affected males have hypertrichosis, abnormal or missing
teeth, and absence of sweat glands (with hypohidrosis).
Heterozygous female carriers show milder symptoms.
Affects thermoregulation (AKA hypohidrotic type ED).
Trait
Ectodermal dysplasia,
anhidrotic type (EDA;
305100, [224900, 129490],
XR, Xp12q13.1)
Emphysema, congenital
(130710, AD, 14q)
Epilepsy, progressive
myoclonic 2 (EPM2A;
254780, AR, 6q24)
Erythroblastosis fetalis
Factor V Leiden
thrombophilia (227400, AR,
1q23)
Table 1. (Contd.)
Regional variation
054
053
052
051
050
049
048
Ref.
Fructose intolerance,
hereditary, type I (229600,
AR, 9q22.3)
057
056
055
Description
Inability to digest milk sugar; symptoms in classic
galactosemia (type I) include muscle weakness,
enlargement of liver; cataracts, palsy, seizures and mental
impairment; death if untreated. The defective enzyme is
galactose-1-phosphate uridyl transferase (GALT). GALT
catalyzes step 2 of galactose to glucose reduction. About
150 different mutations to the GALT enzyme have been
identified worldwide. AKA GALT deficiency. Cf.,
disaccharide intolerance type III.
Inability to digest milk sugar; symptoms in type II
galactosemia are similar to type I. The defective enzyme
is galactokinase (GALK1). GALK1 catalyzes step 1 of
galactose to glucose reduction. AKA GALK deficiency,
galactokinase deficiency.
The defective enzyme is UDP-galactose-4-epimerase
(GALE). AKA GALE deficiency.
Heritable lysosomal storage disease with variable
symptoms: pain, fatigue, enlarged liver and spleen, nervous
system impairment, bone degeneration with fractures,
arthritis, skin pigmentation defects; fatal if untreated. Of
several modes, type I is caused by defective
glucocerebrosidase. Substitutional gene therapy has been
available since 1991; the working enzyme is injected
intravenously every two weeks, similar to insulin therapy in
diabetes.
GSSD is a rare familial disease thought in the 1980s to
exhibit an autosomal dominant mode of inheritance. Onset
is typically in the 4th5th decades. It was noted in cases
such as a family of sheepherders who exhibited ataxia,
progressive dementia, and absence of lower limb reflexes.
Course of the disease is 210 years; amyloid plaques are
found on autopsy and GSSD was later reclassified as one
of the human transmissible spongiform encephalopathies
(TSEs) similar to kuru and new variant CJD. Like these
other diseases associated with the prion protein, GSSD is
characterized by certain predisposing genotypes, in this
case a proline to leucine substitutional mutation at
position 101, as well as valine at positions 117 and 129.
AKA GerstmannStraussler syndrome (GSS), subacute
spongiform encephalopathy, prion dementia.
Trait
Galactosemia, type I
(230400, AR, 9p13)
Galactosemia, type II
(230200, AR, 17q24)
GerstmannStraussler
Scheinker disease (GSSD.
137440, AD, 20pterp12)
Table 1. (Contd.)
Regional variation
062
061
060
059
058
Ref.
Gilles de la Tourette
syndrome (GTS, 137580, MF;
2p11, 8q22, 11q23)
Glucose-6-phosphate
dehydrogenase (G6PD)
deficiency (305900, XR,
Xq28)
Glucosegalactose
malabsorption (GGM;
182380, AD, 22q13.1)
067
066
065
064
063
Guevedoces
Hemochromatosis,
hereditary (HH or HFE1;
235200, AR, 6p21.3)
Description
Trait
Table 1. (Contd.)
068
069
Ref.
Regional variation
Hemophilia A (HEMA;
306700, XR, Xq28)
Hemophilia B (HEMB;
306900, XR, X)
Hereditary fructose
intolerance, type I
Hereditary nonpolyposis
colon cancer,
familial (HNPCC)
HermanskyPudlak
syndrome (HPS; 203300, AR,
10q24q25)
Hermaphroditism, true
(235600, AD, - )
HGH-resistant dwarfism
(Pygmy; 265850, AR, [12q])
075
074
073
072
071
070
Hurler syndrome
Hydrops fetalis
Hypercholesterolemia,
familial (FH or FHC; 143890,
IAD, 19p13.2p13.3)
Hyperlipoproteinemia,
type I[a] (238600, AR, 8p22)
Regional variation
Description
Hunter syndrome
Trait
Table 1. (Contd.)
078
077
076
Ref.
Hypertrichosis, congenital
generalized (CGH or HTC2;
307150, XD, Xq24q27.1)
Hypophosphatasia, familial
(307800, XD, Xp22p22.1)
Hypopituitary dwarfism
Rare.
081
080
079
Klinefelter syndrome
(-, MCA, XXY)
Regional variation
Description
Jacob syndrome
Trait
Table 1. (Contd.)
084
083
082
Ref.
LeschNyhan syndrome
(308000, XR, Xq)
087
086
085
Description
A suite of behaviors characterized by radical mood swings,
from euphoria to depression. Two major, distinct modes are
recognized: bipolar affective disorder (BPAD, AKA manic
depressive illness), and unipolar affective disorder
(depression without mania). Onset in the first case is
usually the 2nd decade, and in the 3rd decade for the latter.
Affected individuals with a family history apparently
respond better to lithium than sporadic cases. Differential
concordance MZ:DZ twin rates of 57%:14%, and
correlation studies of adoptees with biological parents both
suggest some contribution of genetic factors, but with
incomplete penetrance; MAFD is an ambiguous
multifactorial disorder. Families with affected individuals
tend to show co-morbidity with schizoaffective disorder,
alcoholism, and/or anorexia nervosa, as well. The
possibility of genetic anticipation as an additional
mechanism has been proposed. Early linkage studies
reporting genes on chromosomes 11 and X (MADF2) have
been retracted.
Affected individuals have sugary-smelling urine, lethargy,
breathing and swallowing problems, mental impairment,
coma, and inevitably, death. A genetic disease of faulty
amino acid metabolism. The defective protein is branched
chain keto-acid dehydrogenase that results in an inability to
metabolize leucine, isoleucine, and valine. AKA branched
chain ketoaciduria.
Degenerative disease of connective tissue caused by a
defect in fibrillin (FBN1), an elastic tissue protein found in
the eyes, aorta, limb, finger, and rib bones. Affected
individuals appear tall and loose-jointed with spindly
fingers, long and slender limbs, hands and feet. A concave
chest deformity is also a feature, as are a curved spine,
displaced lens, and cardiovascular problems. Manifests in
the 3rd decade of life. It is usually a rupture and dissection
of the aorta that causes death. MFS is an example of
pleiotrophy, in which a single gene affects many target
tissues in a body. Indications of a paternal age effect. The
fibrillin cistron is large (more than 110,000 base pairs
spread over 65 exons).
Rheumatic condition characterized by recurrent episodes of
fever and inflammation of the abdomen. The candidate
gene, pyrin (MEFV), functions normally in granulocytes to
Trait
Table 1. (Contd.)
Rare; informative.
Regional variation
091
090
089
088
Ref.
MELAS
Mitochondrial
encephalopathy lactic
acidosis syndrome (MELAS;
540000, MH, mtDNA)
Mitochondrial myopathies
(551000, MH, mtDNA)
096
095
094
093
092
Description
MAOA is an enzyme found in the outer membranes of
mitochondria, and that normally catalyzes reactions that
metabolize the neurotransmitters dopamine, serotonin, and
noradrenaline. Due to one of several mutations, affected
individuals process chemicals in wine, cheese, and certain
Chinese foods differently, increasing the risk of heart
attacks. This controversial syndrome has also been
described as borderline mental impairment and abnormal
behavior, with familial aggregations of exhibitionism,
voyeurism, and arson. Panic disorder has also been linked
to the MAOA polymorphism (AKA Brunner syndrome). A
second form of the enzyme, MOAB, also exists.
Normal females are mosaics for the expressed/inactivated
X chromosome, with some lines expressing the mothers,
and some lines expressing the fathers X-linked alleles,
such as G-6-PD. Mosaicism proper, however, refers to a
somatic mutation during development, so that an individual
is a mosaic for, say, Down syndrome in only some cell
lines. Another (very rare) form of mosaicism occurs when
two embryos fuse very early in development and express in
one organism the genotypes of two individuals.
One of 13 similar mucopolysaccharidoses with a genetic
basis. Type I features mental impairment, enlarged liver
and spleen, heart disease, bone defects, hearing loss,
large tongue, corneal clouding, and coarse facial features;
fatal. A lysosomal storage disease in which the defective
enzyme is -L-iduronidase (AKA Hurler syndrome).
Severe symptoms: deformed face, dwarfism, joint stiffness,
deafness, mental impairment, heart defects, enlarged liver
and spleen; diagnostic heparitin sulfate in urine, fatal in
adolesence. Defective gene is iduronate sulphate sulfatase
(AKA Hunter syndrome).
Multiple birthing in humans is considered clinically to be an
exceptional, teratogenic event. Polyembryony is the
production of multiple embryos from a single fertilized egg,
such as monozygous twins. Most higher-order births (more
than two) are mixed sets of identical and fraternal twins.
The predicted number of natural births (not induced by
hormone therapy) of each kind is the subject of Hellins rule
(or law) of multiple births, which states that if the observed
frequency of twins in a population is n, then the expected
Trait
Monoamine oxidase A
deficiency (MAOA; 309850,
XR, Xp11.23)
Mosaicism, chromosomal
(158250, MCA, -)
Mucopolysaccharidosis,
type I (MPS1, 252800, AR,
4p16.3)
Mucopolysaccharidosis,
type II (MPS2; 309900, XR,
Xq20)
Multiple births
Table 1. (Contd.)
Rare; 1:100,000.
Rare; 1:150,000.
Rare; informative.
Regional variation
100
099
098
097
Ref.
Muscular dystrophy
Duchenne type (DMD,
310200, XR, Xp21.2)
frequency of triplets is n2, of quadruplets is n3, etc. The socalled vanishing twin phenomenon has recently led to a
renewed interest in the twin events. See twins.
103
102
101
Description
Relatively benign inherited disease characterized by mild
tumors of muscular, skeletal, and nervous system tissues,
especially on nerve endings in the skin, often accompanied
by caf-au-lait spots and soft tumors. The usual cause is
one of several defects in a cytoplasmic protein
(neurofibromin, NF1), which normally suppresses the
activity of a second gene (p21, the Ras oncogene) that
causes tumor formation; the result is uncontrolled cell
proliferation (AKA von Recklinghausen disease, peripheral
neurofibromatosis). Although the Elephant Man has often
been suggested as a case of NF1, Proteus syndrome is
now a better candidate.
Heritable condition characterized by tumors of cranial
nerves, deafness. The NF2 gene, merlin, normally
functions to link cell membranes to cytoskeletal structures.
Many mutations to the NF2 gene have been documented
(AKA central neurofibromatosis).
A constellation of conditions including hypertension,
obesity, hyperlipidemia, hyperinsulinemia (diabetes). AKA
syndrome X, metabolic syndrome.
Condition characterized by chronic weight gain and
retention. Mutations in the LEP gene for the hormone leptin
(OB), which functions normally as a fat-regulating hormone;
a deficiency dramatically affects metabolism resulting in
obesity. OB has been strongly implicated in animal studies
and the gene has been identified in the human genome.
Obesity, however, is a complex disorder in humans, and
genetic factors play only a part. One of the other candidate
genes for genetic susceptibility to adiposity, rather than
morbid obesity, has been mapped to 3p26p25; this gene
codes for a hormone secreted by the stomach, ghrelin, a
circadian molecule that stimulates human growth hormone
release from the pituitary and seems to have an
antagonistic interaction with leptin in feeding regulation and
the perception of hunger. A third factor, lipoprotein lipase
(PLP, see Hypolipoproteinemia), has also been the
subject of recent research.
A prenatal developmental disease that results in skeletal
fragility, osteoporosis, brittle and easily broken bones, blue
sclera, poor teeth, and hearing loss. Caused by a defective
procollagen gene that affects embryonic collagen
formation. The embryonic (congenital) form is usually fatal;
Trait
Neurofibromatosis type I
(NF1; 162220, AD, 17q11.2)
Neurofibromatosis type II
(NF2, 101000, AD, 22q12.2)
Osteogenesis imperfecta
(166210, 166200, 166260;
AD & AR; 7, 17)
Table 1. (Contd.)
106
107
105
104
Ref.
Regional variation
Phenylketonuria (PKU1;
261600, AR, 12q)
112
111
110
109
108
Philadelphia chromosome
(Ph1, 151410, MCA, t9; 22;
9q34 and 22q11.21)
Rare; informative.
Regional variation
Description
Phenylketonuria, maternal
(261600)
Trait
Table 1. (Contd.)
114
113
Ref.
Polydactyly, postaxial
(174200, AD, 7p13)
118
117
116
115
Description
Trait
Table 1. (Contd.)
Regional variation
122
121
120
119
Ref.
Pseudohermaphroditism,
female, with skeletal
anomalies (264270, AR, -)
Pseudohermaphroditism,
male, with gynecomastia
and hirsutism (264300,
264600, 201910; AR, 9q22,
2p23)
126
125
124
123
Description
Retinoblastoma (RB1;
180200, AD, 13q13.1q14.2)
Trait
Table 1. (Contd.)
Regional variation
129
128
127
Ref.
Schizophrenia (SCZD;
181500, 603342, 605210, MF,
5, 11q, plus 12 other possible
loci)
Severe combined
immunodeficiency disease,
X-linked (XSCID, 300400, XL,
Xq13; AKA Swiss type
agammaglobulinemia)
131
130
Description
SRY is among the very few genes that have been
mapped specifically to the Y-chromosome. The SRY maps
to the middle of the short arm of the Y chromosome in both
humans and in mice. SRY binds to DNA, distorting its
shape, and alters gene expression at the binding site. The
SRY alone is not expected to be the only gene that
determines maleness; rather it is expected to start a
cascade of effects due to genes located on the autosomes;
these are then expressed either differently (or only) in
males than in females. All Theria (marsupials and placental
mammals) have the SRY gene. When transferred into
normal XX female mouse genomes using the new genetic
technology (creating transgenic species), SRY DNA
fragments induce testis differentiation in those females.
AKA TDF, or testis differentiating factor. See ambiguous
genitalia, pseudohermaphroditism, XX male, and XY
female.
Described in the Western literature by Herrick in 1910, SCD
is an autosomal recessive genetic condition caused by
homozygosity for the mutant hemoglobin S allele (HbS).
SCD is found in populations where malaria is endemic, and
is characterized by anemia due to a culling of red blood
cells with an altered morphology due to defective hemoglobin
in the RBC wall that crystallizes under conditions of
dehydration or low oxygen tension; the deformed
corpuscules block capillary blood flow (thrombosis),
deforming them into a characteristic sickle shape during
sicklemia. Symptoms of a sickling crisis include external
manifestations of thromboses and ulceration of limb
tissues, but internal lesions occur as well. Other clinical
consequences include bone and joint pain, infections and
anemia. A substitutional mutation of the amino acid
glutamic acid for the normal valine at position six in the
beta chain of the more common form (HbA) of the adult
hemoglobin molecule is the cause of clinical problems. The
marrow and spleen are stressed to produce more red blood
cells (RBCs); too few RBCs causes anemia and too few
white blood cells (WBCs) impairs immunity. Sickle cell
disease usually limits life to 10 years or less in countries
where incidence is high in the presence of malaria. Under
such conditions, SCD-affected individuals are homozygous
(SS), with an estimated direct fitness lowered to 10% or
less. Carriers of the allele (AS) enjoy the maximum relative
Trait
Sex-determining region of
the Y chromosome (SRY;
480000, YL, Yp11.3)
Table 1. (Contd.)
Regional variation
133
132
Ref.
SRY
Rare.
136
135
134
Tourette syndrome
Regional variation
Description
Trait
Table 1. (Contd.)
139
138
137
Ref.
Twins
Waardenburg syndrome,
type 1 (WS1; 193500, AD,
2q35)
Rare; informative.
Rare; informative.
Rare.
145
144
143
142
141
140
Xeroderma pigmentosum
(XP; 278700, AR, 9q22.3)
XY female syndrome
(306100, XR, X[X])
Zellweger syndrome
(600414, 214100, AR,
12p13.3, 7q)
Rare; informative.
Regional variation
150
149
148
147
146
Ref.
This is a very small sample of the more than 5,000 known gene-based entities. For additional information, see Mai et al. (2004) and McKusick et al. (2004). The OMIM was consulted for all 150 entities,
and a major portion of each digest was abstracted from that source. Most of the conditions listed here are well-documented one-locus anomalies with a straightforward mode of inheritance and complete
penetrance. A few are polygenic or multifactorial, and a few are indicated as controversial. Supplemental data can be found in recent references for each condition as noted in the final column.
Description
Trait
Table 1. (Contd.)
Table References
NOTES
1. Dedicated to Sir Archibald Garrod and William Bateson, who deduced
the Mendelian recessive pattern of inheritance of alkaptonuria, the first
inborn error of metabolism described a century ago, in 1902.
2. This work is a companion piece to the entry Genetic Disease I.
3. Shakespeare (1611), The Tempest, Act IV, Scene I.
4. Locke, John (1690). Essay Concerning Human Understanding.
London.
5. Italicized terms in the text refer to conditions found in Table 1.
6. Although conventional wisdom sets the prevalence of a common
disease at 1:1,000, less common conditions have been included here
for the reasons noted.
7. Among the diseases or entities that have been excluded from this
survey are allergy (but see asthma), many forms of cancer (gastrointestinal, lung, reproductive organ), chemical sensitivity (but see anosmia), chronic liver disease, clubfoot, congenital dislocation of the hip,
several other demyelinating diseases, gluten-sensitive enteropathy,
many gynaecological disorders, hairlip ( cleft palate ankyloglossia), handedness, congenital heart malformation, several hyperbilirunimenias, hyperlipidemia, essential hypertension, hyperuricemia
and gout, several causes of infertility and pregnancy loss, multiple
sclerosis, narcolepsy, involutional osteoporosis, otitis media susceptibility, panic disorder, peptic ulcer, premature X-linked ovarian failure,
precocious puberty, pyloric stenosis, renal tract malformations, reward
deficiency syndrome, rheumatoid arthritis susceptibility, many
common skeletal disorders, sudden infant death syndrome (but see
Long-QT interval), thyroid and parathyroid disease; andnot
insignificantlyvirtually all of the immunogenetic lines of evidence
linking infectious disease susceptibility to MHC/HLA haplotypes.
REFERENCES
Adamson, R. H., Thorgeirsson, U. P., & Sugimura, T. (1996).
Extrapolation of heterocyclic amine carcinogenesis data from
rodents and nonhuman primates to humans. Archives of Toxicology
(Suppl. 18), 303318.
Ames, B. N. (1983). Dietary carcinogens and anticarcinogens. Oxygen
radicals and degenerative diseases. Science, 221 (4617), 12561264.
Barnes, K. C., Armelagos, G. I., & Morreale, S. C. (1999). Darwinian
medicine and the emergence of allergy. In W. R. Trevathan,
E. O. Smith, & J. J. McKenna (Eds.), Evolutionary medicine
(pp. 209243). New York: Oxford University Press.
Bodmer, W. F., & Cavalli-Sforza, L. L. (1976). Genetics, evolution and
man. San Francisco: W. H. Freeman.
Brown, M. H. (1990). The search for Eve. New York: Harper & Low.
Cann, R. L. (2001). Genetic clues to dispersal in human populations:
Retracing the past from the present. Science, 291(5509),
17421748.
Cavalli-Sforza, L. L., & Cavalli-Sforza, F. (1995). The great human
diasporas: The history of diversity and evolution. Reading, MA:
Addison-Wesley.
Cavalli-Sforza, L. L., Menozzi, P., & Piazza, A. (1994). The history and
geography of human genes. Princeton, NJ: Princeton University
Press.
453
Corruccini, R. S., & Kaul, S. S. (1983). The epidemiological transition
and the anthropology of minor chronic non-infectious diseases.
Medicine and Anthropology, 7, 3650.
Diamond, J. (1997). Guns, germs and steel: The fates of human societies. New York: W. W. Norton.
Dillehay, T. D. (2000). The settlement of the Americas: A new prehistory. New York: Perseus/Basic Books.
Hafner, M. S., & Nadler, S. A. (1988). Phylogenetic trees support the
coevolution of parasites and their hosts. Nature, 332(6161), 258259.
Klassen, G. J. (1992). Coevolution: A history of the macroevolutionary
approach to studying hostparasite associations. Journal of
Parasitology, 78(4), 573587.
Lappe, M. (1994). Evolutionary medicine: Rethinking the origins of
disease. San Francisco: Sierra Club Books.
Layrisse, M., & Wilbert, J. (1999). The Diego blood group and the
Mongoloid realm. Caracas, Venezuela: Instituto Caribe de
Anthropologa y Sociologa, Fundacin La Salle de Ciencias
Naturales.
Lewis, R. (2001). Human genetics (4th Ed.). Boston: McGraw-Hill.
Mai, L. L., Young Owl, M., & Kersting, P. (2004). Dictionary of human
biology and evolution. Cambridge, U.K.: Cambridge University
Press.
McKusick, V. et al. (2003). Online Mendelian Inheritance in Man
(OMIM). Available from http://www.ncbi.nlm.nih.gov/omim/
Motulsky, A. G. (1984). Genetic epidemiology. Genetic Epidemiology,
1(2), 143144.
Owens, K., & King, M. C. (1999). Genomic views of human history.
Science, 285(5439), 451453.
Steinkellner, H., Rabot, S., Freywald, C., Nobis, E., Scharf, G.,
Chabicovsky, M., Knasmuller, S., & Kassie, F. (2001). Effects of
cruciferous vegetables and their constituents on drug metabolizing
enzymes involved in the bioactivation of DNA-reactive dietary carcinogens. Mutation Research, 480481: 285297.
Sugimura, T. (2000). Nutrition and dietary carcinogens. Carcinogenesis,
21(3), 387395
Walter, R. C., Buffler, R. T. et al. (2000). Early human occupation of the
Red Sea coast of Eritrea during the last interglacial. Nature,
405(6782), 6569.
TABLE REFERENCES
001. Oberklaid, F., Danks, D. M. et al. (1979). Achondroplasia and
hypochondroplasia. Comments on frequency, mutation rate, and
radiological features in skull and spine. J Med Genet, 16(2): 1406.
002. Kaplan, F. J., Levitt, N. S. et al. (2001). Acromegaly in the
developing worlda 20-year teaching hospital experience. Br J
Neurosurg, 15(1): 227.
003. Burt, R. W. & Lipkin, M. (1992). 31. Gastrointestinal cancer. In:
The genetic basis of common diseases (King, R. A., Rotter, J. I., &
Morulsky, A. G., eds.), pp. 65080. New York & Oxford: Oxford
University Press; Kadmon, M., Tandara, A. et al. (2001).
Duodenal adenomatosis in familial adenomatous polyposis coli. A
review of the literature and results from the Heidelberg Polyposis
Register. Int J Colorectal Dis, 16(2); 6375.
004. Ariga, T. (2001). Gene therapy for adenosine deaminase
(ADA) deficiency: Review of the past, the present and the future.
454
005.
006.
007.
008.
009.
010.
011.
012.
013.
014.
015.
Genetic Disease II
Nippon Rinsho, 59(1), 725; Hirschhorn, R. (1990). Adenosine
deaminase deficiency. Immunodefic Rev, 2(3): 17598; Misaki, Y.,
Ezaki, I. et al. (2001). Gene-transferred oligoclonal T cells predominantly persist in peripheral blood from an adenosine deaminase-deficient patient during gene therapy. Mol Ther, 3(1), 247.
Percy, A. K. & Rutledge, S. L. (2001). Adrenoleukodystrophy and
related disorders. Ment Retard Dev Disabil Res Rev, 7(3): 17989.
Fontan Casariego, G. (2001). Primary immunodeficiencies.
Clinical features and variant forms. Allergol Immunopathol
(Madr), 29(3): 1017.
Preising, M., Op de Laak, J. P. et al. (2001). Deletion in the OA1
gene in a family with congenital X linked nystagmus. Br J
Ophthalmol, 85(9), 1098103.
Jeambrun, P. (1998). Oculocutaneous albinism: Clinical, historical and anthropological aspects. Arch Pediatr, 5(8): 896907.
Manning, M., Lissens, W. et al. (2000). Study of DNAmethylation patterns at chromosome 15q11-q13 in children born
after ICSI reveals no imprinting defects. Mol Hum Reprod, 6(11),
104953; Puri, N., Durbam-Pierre, D. et al. (1997). Type 2 oculocutaneous albinism (OCA2) in Zimbabwe and Cameroon:
Distribution of the 2.7-kb deletion allele of the P gene. Hum
Genet, 100(56): 6516.
Toyofuku, K., Wada, I. et al. (2001). Oculocutaneous albinism
types 1 and 3 are ER retention diseases: Mutation of tyrosinase or
Tyrp1 can affect the processing of both mutant and wild-type proteins. Faseb J, 15(12): 214961.
Muller, C. R., Fregin, A. et al. (1999). Allelic heterogeneity of
alkaptonuria in Central Europe. Eur J Hum Genet, 7(6): 64551.
Heston, L. L. (1992). 39. Alzheimers disease. In: The genetic basis
of common diseases (King, R. A., Rotter, J. I., & Morulsky, A. G.,
eds.), pp. 792800. New York & Oxford: Oxford University Press;
Schroder, B., Franz, B. et al. (2001). Polymorphisms within the
prion-like protein gene (Prnd) and their implications in human
prion diseases, Alzheimers disease and other neurological
disorders. Hum Genet, 109(3): 31925; Tanzi, R. E. & Parsons,
A. E. (2000). Decoding darkness: The search for the genetic causes
of Alzheimers disease. Cambridge, MA: Perseus Publishing.
Abdullah, M. A., Katugampola, M. et al. (1991). Ambiguous genitalia: Medical, socio-cultural and religious factors affecting management in Saudi Arabia. Ann Trop Paediatr, 11(4): 3438;
Fausto-Sterling, A. (2000). Sexing the body: Gender politics and the
construction of sexuality. New York: Basic Books; Mittwoch, U.
(1992). Sex determination and sex reversal: Genotype, phenotype,
dogma and semantics. Hum Genet, 89(5): 46779; Sultan, C.,
Paris, F. et al. (2001). Disorders linked to insufficient androgen
action in male children. Hum Reprod Update, 7(3): 31422.
Traynor, B. J., Codd, M. B. et al. (2000). Clinical features of amyotrophic lateral sclerosis according to the El Escorial and Airlie
House diagnostic criteria: A population-based study. Arch Neurol,
57(8): 11716.
Boehmer, A. L., Bruggenwirth, H. et al. (2001). Genotype versus
phenotype in families with androgen insensitivity syndrome. J
Clin Endocrinol Metab, 86(9): 415160; Fausto-Sterling, A.
(2000). Sexing the body: Gender politics and the construction of
sexuality. New York: Basic Books; Manning, M., Lissens, W. et al.
(2000). Study of DNA-methylation patterns at chromosome
15q11q13 in children born after ICSI reveals no imprinting
defects. Mol Hum Reprod, 6(11): 104953.
Table References
024.
025.
026.
027.
028.
029.
455
030.
031.
032.
033.
034.
035.
036.
037.
456
038.
039.
040.
041.
042.
043.
Genetic Disease II
Predictive genetic testing in maturity-onset diabetes of the young
(MODY). Diabet Med, 18(5): 41721.
Gerber, L. M. & Crews, D. E. (1999). Evolutionary perspectives
on chronic degenerative diseases. In: Evolutionary medicine
(Trevathan, W. R., Smith, E. O., & McKenna, J. J., eds.),
pp. 44369. New York: Oxford University Press; Hegele, R. A.
(2001). Genes and environment in type 2 diabetes and atherosclerosis in aboriginal Canadians. Curr Atheroscler Rep, 3(3):
21621; Martinez-Frias, M. L. (2001). Heterotaxia as an outcome
of maternal diabetes: An epidemiological study. Am J Med Genet,
99(2): 1426; Neel, J. V. (1999). The thrifty genotype in 1998,
Nutrition Reviews (pt. II), 57(5): S2S9; Rolf, C. & Nieschlag, E.
(2001). Reproductive functions, fertility and genetic risks of ageing men. Exp Clin Endocrinol Diabetes, 109(2): 6874; Simon,
D., Bourgeon, M. et al. (2001). Insulin sensitivity and ethnic
groups. Diabetes Metab, 27(2 Pt 2): 21521; Stern, M. P., Bartley,
M. et al. (2000). Birth weight and the metabolic syndrome:
Thrifty phenotype or thrifty genotype? Diabetes Metab Res Rev,
16(2): 8893; Sunday, J., Eyles, J. et al. (2001). Applying
Aristotles doctrine of causation to Aboriginal and biomedical
understanding of diabetes. Cult Med Psychiatry, 25(1): 6385;
Wiltshire, S., Hattersley, A. T. et al. (2001). A genomewide scan
for loci predisposing to type 2 diabetes in a U.K. population (the
Diabetes UK Warren 2 Repository): Analysis of 573 pedigrees
provides independent replication of a susceptibility locus on
chromosome 1q. Am J Hum Genet, 69(3): 55369.
Layrisse, M. & Wilbert, J. (1999). The Diego blood group and the
Mongoloid realm. Caracas, Venezuela: Fundacin La Salle de
Ciencias Naturales, Instituto Caribe de Anthropologa y
Sociologa; Sankaranarayanan, K., Chakraborty, R. et al. (1999).
Ionizing radiation and genetic risks. VI. Chronic multifactorial
diseases: A review of epidemiological and genetical aspects of
coronary heart disease, essential hypertension and diabetes mellitus. Mutat Res, 436(1): 2157.
Fernhoff, P. M. (2000). The 22q11.2 deletion syndrome: More
answers but more questions. J Pediatr, 137(2): 1457; Yong, D. E.,
Booth, P. et al. (1999). Chromosome 22q11 microdeletion and
congenital heart diseasea survey in a paediatric population. Eur
J Pediatr, 158(7): 56670.
Naim, H. Y. (2001). Molecular and cellular aspects and regulation
of intestinal lactase-phlorizin hydrolase. Histol Histopathol,
16(2): 55361.
Damberg, M., Garpenstrand, H. et al. (2001). Genetic mechanisms of behaviordont forget about the transcription factors.
Mol Psychiatry, 6(5): 50310. Flatz, G. (1992). 15. Lactase
deficiency: Biologic and medical aspects of the adult human
lactase polymorphism. In: The genetic basis of common diseases
(King, R. A., Rotter, J. I. & Morulsky, A. G., eds.), pp. 30525.
New York & Oxford: Oxford University Press; Naim, H. Y. (2001).
Molecular and cellular aspects and regulation of intestinal lactasephlorizin hydrolase. Histol Histopathol, 16(2): 55361; ThongNgam, D., Suwangool, P. et al. (2001). Lactose intolerance and
intestinal villi morphology in Thai people. J Med Assoc Thai,
84(8): 10906.
Robinson, D. O. & Jacobs, P. A. (1999). The origin of the extra Y
chromosome in males with a 47,XYY karyotype. Hum Mol Genet,
8(12): 22059. Shanske, A., Sachmechi, I. et al. (1998). An adult
with 49,XYYYY karyotype: Case report and endocrine studies.
044.
045.
046.
047.
048.
049.
Table References
050. Canneto, B., Carretta, A. et al. (2000). Congenital lobar emphysema in adults. Minerva Chir, 55(5): 3536; Kueppers, F. (1992).
12. Chronic obstructive pulmonary disease. In: The genetic basis
of common diseases (King, R. A., Rotter, J. I., & Morulsky, A. G.,
eds.), pp. 22239. New York & Oxford: Oxford University Press;
Thakral, C. L., Maji, D. C. et al. (2001). Congenital lobar emphysema: Experience with 21 cases. Pediatr Surg Int, 17(23): 8891.
Thompson, A. J., Reid, A. J. et al. (2000). Congenital lobar
emphysema occurring in twins. J Perinat Med, 28(2): 1557.
051. Benlounis, A., Nabbout, R. et al. (2001). Genetic predisposition to
severe myoclonic epilepsy in infancy. Epilepsia, 42(2): 2049;
Bird, T. D. (1992). 36. Epilepsy. In: The genetic basis of common
diseases (King, R. A., Rotter, J. I., & Morulsky, A. G., eds.),
pp. 73252. New York & Oxford: Oxford University Press;
Doose, H. & Neubauer, B. A. (2001). Preponderance of female sex
in the transmission of seizure liability in idiopathic generalized
epilepsy. Epilepsy Res, 43(2): 10314; Kjeldsen, M. J., Kyvik, K. O.
et al. (2001). Genetic and environmental factors in epilepsy: A
population-based study of 11900 Danish twin pairs. Epilepsy Res,
44(23): 16778; Matuja, W. B., Kilonzo, G. et al. (2001). Risk
factors for epilepsy in a rural area in Tanzania. A communitybased case-control study. Neuroepidemiology, 20(4): 2427;
Sacks, O. W. (1970). The man who mistook his wife for a hat.
New York: Harper Collins, Inc.; Salas Puig, X., Calleja, S. et al.
(2001). Juvenile myoclonic epilepsy. Rev Neurol, 32(10): 95761;
Schinzel, A. & Niedrist, D. (2001). Chromosome imbalances
associated with epilepsy. Am J Med Genet, 106(2): 11924;
Schupf, N. & Ottman, R. (2001). Risk of epilepsy in offspring of
affected women: Association with maternal spontaneous abortion.
Neurology, 57(9): 16429; Zupanc, M. L. (2001). Infantile
Spasms. Curr Treat Options Neurol 3(3): 289300.
052. Tanner, C. M., Goldman, S. M. et al. (2001). Essential tremor in
twins: An assessment of genetic vs environmental determinants of
etiology. Neurology, 57(8): 138991.
053. Lucotte, G. & Mercier, G. (2001). Population genetics of factor V
Leiden in Europe. Blood Cells Mol Dis, 27(2): 3627.
054. Collins, S., McLean, C. A. et al. (2001). Gerstmann
StrausslerScheinker syndrome, fatal familial insomnia, and
kuru: A review of these less common human transmissible
spongiform encephalopathies. J Clin Neurosci, 8(5): 38797;
Harder, A., Jendroska, K. et al. (1999). Novel twelve-generation
kindred of fatal familial insomnia from Germany representing
the entire spectrum of disease expression. Am J Med Genet,
87(4): 3116.
055. Baliga, B. S., Pace, B. S. et al. (2000). Mechanism for fetal hemoglobin induction by hydroxyurea in sickle cell erythroid progenitors. Am J Hematol, 65(3): 22733; Goncalves, M. S., Fahel, S.
et al. (1995). Molecular identification of hereditary persistence of
fetal hemoglobin type 2 (HPFH type 2) in patients from Brazil.
Ann Hematol, 70(3): 15961.
056. Crawford, D. C., Acuna, J. M. et al. (2001). FMR1 and the fragile
X syndrome: Human genome epidemiology review. Genet Med,
3(5): 35971; Toledano-Alhadef, H., Basel-Vanagaite, L. et al.
(2001). Fragile-X carrier screening and the prevalence of premutation and full-mutation carriers in Israel. Am J Hum Genet, 69(2):
35160.
057. Ali, M., Rellos, P. et al. (1998). Hereditary fructose intolerance. J
Med Genet, 35(5): 35365.
457
058. Suzuki, M., West, C. et al. (2001). Large-scale molecular screening for galactosemia alleles in a pan-ethnic population. Hum
Genet, 109(2): 2105.
059. Verma, I. C. (2000). Burden of genetic disorders in India. Indian
J Pediatr, 67(12): 8938.
060. Lai, K. & Elsas, L. J., (2001). Structurefunction analyses of a
common mutation in blacks with transferase-deficiency galactosemia. Mol Genet Metab, 74(12): 26472.
061. Poorthuis, B. J., Wevers, R. A. et al. (1999). The frequency of
lysosomal storage diseases in The Netherlands. Hum Genet,
105(12): 1516; Wallerstein, R., Starkman, A. et al. (2001).
Carrier screening for Gaucher disease in couples of mixed ethnicity. Genet Test, 5(1): 614.
062. Collins, S., McLean, C. A. et al. (2001). GerstmannStraussler
Scheinker syndrome, fatal familial insomnia, and kuru: A review
of these less common human transmissible spongiform
encephalopathies. J Clin Neurosci, 8(5): 38797.
063. Mathews, C. A., Herrera Amighetti, L. D. et al. (2001). Cultural
influences on diagnosis and perception of Tourette syndrome in
Costa Rica. J Am Acad Child Adolesc Psychiatry, 40(4): 45663;
Sacks, O. W. (1970). The man who mistook his wife for a hat.
New York: Harper Collins, Inc.; Sacks, O. W. (1973). Awakenings.
New York: Harper Collins Publishers, Inc.; Singer, H. S. (2000).
Current issues in Tourette syndrome. Mov Disord., 15(6):
105163; Walkup, J. T. (2001). Epigenetic and environmental risk
factors in Tourette syndrome. Adv Neurol, 85: 2739.
064. Budde, W. M. (2000). Heredity in primary open-angle glaucoma.
Curr Opin Ophthalmol, 11(2): 1016; Weih, L. M., Mukesh, B. N.
et al. (2001). Association of demographic, familial, medical, and
ocular factors with intraocular pressure. Arch Ophthalmol, 119(6):
87580; Yang, Y. H., Ju, K. S. et al. (1999). The Korean collaborative study on 11,000 prenatal genetic amniocentesis. Yonsei Med
J, 40(5): 4606.
065. Kaplan, M., Algur, N. et al. (2001). Onset of jaundice in glucose6-phosphate dehydrogenase-deficient neonates. Pediatrics, 108(4):
9569; Tishkoff, S. A., Varkonyi, R. et al. (2001). Haplotype
diversity and linkage disequilibrium at human G6PD: Recent origin of alleles that confer malarial resistance. Science, 293(5529):
45562; Whitmer, D. L. (1992). 18. Common hyperbilirubinemias. In: The genetic basis of common diseases (King, R. A.,
Rotter, J. I., & Morulsky, A. G., eds.), pp. 37582. New York &
Oxford: Oxford University Press.
066. Lam, J. T., Martin, M. G. et al. (1999). Missense mutations in
SGLT1 cause glucose-galactose malabsorption by trafficking
defects. Biochim Biophys Acta, 1453(2): 297303.
067. Parvari, R., Lei, K. J. et al. (1997). Glycogen storage disease type
1a in Israel: Biochemical, clinical, and mutational studies. Am J
Med Genet, 72(3): 28690. Visser, G., Rake, J. P. et al. (2000).
Neutropenia, neutrophil dysfunction, and inflammatory bowel
disease in glycogen storage disease type Ib: Results of the
European Study on Glycogen Storage Disease type I. J Pediatr,
137(2): 18791.
068. Hanson, E. H., Imperatore, G. et al. (2001). HFE gene and hereditary hemochromatosis: A HuGE review. Human Genome
Epidemiology. Am J Epidemiol, 154(3): 193206; Motulsky, A. G.
& Beutler, E. (2000). Population screening in hereditary hemochromatosis. Annu Rev Public Health, 21: 6579; Trent, R. J., Le, H.
et al. (2000). DNA testing for haemochromatosis: Diagnostic,
458
predictive and screening implications. Pathology, 32(4): 2749;
Vautier, G., Murray, M. et al. (2001). Hereditary haemochromatosis: Detection and management. Med J Aust, 175(8): 41821.
069. Modiano, D., Luoni, G. et al. (2001). The lower susceptibility to
Plasmodium falciparum malaria of Fulani of Burkina Faso (west
Africa) is associated with low frequencies of classic malariaresistance genes. Trans R Soc Trop Med Hyg, 95(2): 14952.
070. Joseph, K. S. & Kramer, M. S. (1998). The decline in Rh
hemolytic disease: Should Rh prophylaxis get all the credit? Am J
Public Health, 88(2): 20915.
071. Potts, D. M. & W. T. Potts (1999). Queen Victorias Gene:
Hemophilia and the Royal Family. London: Sutton Publishing.
072. Astermark, J., Berntorp, E. et al. (2001). The Malmo International
Brother Study (MIBS): Further support for genetic predisposition
to inhibitor development in hemophilia patients. Haemophilia,
7(3): 26772.
073. Anikster, Y., Huizing, M. et al. (2001). Mutation of a new gene
causes a unique form of HermanskyPudlak syndrome in a
genetic isolate of central Puerto Rico. Nat Genet, 28(4): 37680.
074. Fausto-Sterling, A. (2000). Sexing the body: Gender politics and
the construction of sexuality. New York: Basic Books; Kaefer, M.,
Diamond, D. et al. (1999). The incidence of intersexuality in children with cryptorchidism and hypospadias: Stratification based on
gonadal palpability and meatal position. J Urol, 162(3 Pt 2):
10036, discussion 10067; Krob, G., Braun, A. et al. (1994). True
hermaphroditism: Geographical distribution, clinical findings,
chromosomes and gonadal histology. Eur J Pediatr, 153(1): 210.
075. Rosenbloom, A. L., Guevara Aguirre, J. et al. (1990). The little
women of Lojagrowth hormone-receptor deficiency in an inbred
population of southern Ecuador. N Engl J Med, 323(20): 136774;
Wang, Z. (1999). Growth hormone deficiency in adults and clinical use of recombinant human growth hormone. Chin Med J
(Engl), 112(3): 195201.
076. Vincent, J. B., Paterson, A. D. et al. (2000). The unstable trinucleotide repeat story of major psychosis. Am J Med Genet, 97(1):
7797.
077. Motulsky, A. G. & Brunzell, J. D. (1992). 9. The genetics of coronary atherosclerosis. In: The genetic basis of common diseases
(King, R. A., Rotter, J. I., & Morulsky, A. G., eds.), pp. 15069.
New York & Oxford: Oxford University Press; Scriver, C. R.
(2001). Human genetics: Lessons from Quebec populations. Annu
Rev Genomics Hum Genet, 2: 69101.
078. Feussner, G., Feussner, V. et al. (1998). Molecular basis of
type III hyperlipoproteinemia in Germany. Hum Mutat, 11(6):
41723; Lee, M., Kim, J. Q. et al. (2001). Studies on the plasma
lipid profiles, and LCAT and CETP activities according to hyperlipoproteinemia phenotypes (HLP). Atherosclerosis, 159(2):
3819; Mahley, R. W. & Rall, S. C., Jr. (2000). Apolipoprotein E:
Far more than a lipid transport protein. Annu Rev Genomics Hum
Genet, 1: 50737; Motulsky, A. G. & Brunzell, J. D. (1992). 9.
The genetics of coronary atherosclerosis. In: The genetic basis of
common diseases (King, R. A., Rotter, J. I., & Morulsky, A. G.,
eds.), pp. 15069. New York & Oxford: Oxford University Press;
Okubo, M., Horinishi, A. et al. (2002). Seven novel sequence
variants in the human low density lipoprotein receptor related
protein 5 (LRP5) gene. Hum Mutat, 19(2): 186; Smith, J. D.
(2000). Apolipoprotein E4: An allele associated with many
diseases. Ann Med, 32(2): 11827.
Genetic Disease II
079. Garcia-Cruz, D., Sanchez-Corona, J. et al. (1997). Congenital
hypertrichosis, osteochondrodysplasia, and cardiomegaly: Further
delineation of a new genetic syndrome. Am J Med Genet, 69(2):
13851; Verhulst, J. (1996). Atavisms in homo sapiens: A Bolkian
heterodoxy revisited. Acta Biotheor, 44(1): 5973.
080. Zargar, A. H., Laway, B. A. et al. (1999). Hereditary hypophosphataemic rickets: Report of a family from the Indian subcontinent. Postgrad Med J, 75(886): 4857.
081. Davis, M. K. (2001). Breastfeeding and chronic disease in childhood and adolescence. Pediatr Clin North Am, 48(1): 12541, ix;
McConnell, R. B. & Vadheim, C. M. (1992). 16. Inflammatory
bowel disease. In: The genetic basis of common diseases (King, R.
A., Rotter, J. I., & Morulsky, A. G., eds.), pp. 32648. New York
& Oxford: Oxford University Press; Visser, G., Rake, J. P. et al.
(2000). Neutropenia, neutrophil dysfunction, and inflammatory
bowel disease in glycogen storage disease type Ib: Results of the
European Study on Glycogen Storage Disease type I. J Pediatr,
137(2): 18791.
082. Meschede, D., Louwen, F. et al. (1998). Low rates of pregnancy
termination for prenatally diagnosed Klinefelter syndrome and
other sex chromosome polysomies. Am J Med Genet, 80(4):
3304; Paulsen, C. A. & Plymate, S. R. (1992). 44. Klinefelters
syndrome. In: The genetic basis of common diseases (King, R. A.,
Rotter, J. I., & Morulsky, A. G., eds.), pp. 876894. New York &
Oxford: Oxford University Press.
083. Collins, S., McLean, C. A. et al. (2001). GerstmannStraussler
Scheinker syndrome, fatal familial insomnia, and kuru: A review
of these less common human transmissible spongiform
encephalopathies. J Clin Neurosci, 8(5): 38797.
084. Yen, M. Y., Lee, H. C. et al. (1999). Exclusive homoplasmic
11778 mutation in mitochondrial DNA of Chinese patients with
Lebers hereditary optic neuropathy. Jpn J Ophthalmol, 43(3):
196200.
085. Schroeder, S. R., Oster-Granite, M. L. et al. (2001). Selfinjurious behavior: Genebrainbehavior relationships. Ment
Retard Dev Disabil Res Rev, 7(1): 312; Short, E. M. (1992). 22.
Hyperuricemia and gout. In: The genetic basis of common
diseases (King, R. A., Rotter, J. I., & Morulsky, A. G., eds.),
pp. 482506. New York & Oxford: Oxford University Press.
086. Brown, W. T. (1992). 46. Longevity and aging. In: The genetic
basis of common diseases (King, R. A., Rotter, J. I., &
Motulsky, A. G., eds.), pp. 91536. New York & Oxford: Oxford
University Press; Garry, P. J. (2001). Aging successfully: A genetic
perspective. Nutr Rev, 59(8 Pt 2): S93101; Gerber, L. M. &
D. E. Crews (1999). Evolutionary prespective on chronic degenerative diseases. In: Evolutionary Medicine (Trevathan, W. R.,
Smith E. O., & McKenna, J. J., eds.), pp. 44369. New York:
Oxford University Press; Riggs, J. E. (1992). The dynamics of
aging and mortality in the United States, 19001988. Mech
Aging Dev, 66(1): 4557; Slagboom, P. E., Heijmans, B. T. et al.
(2000). Genetics of human aging. The search for genes contributing to human longevity and diseases of the old. Ann N Y Acad Sci,
908: 5063; Tan, Q., Yashin, A. I. et al. (2001). Variations of
cardiovascular disease associated genes exhibit sex-dependent
influence on human longevity. Exp Gerontol, 36(8): 130315;
Wei, Y. H., Ma, Y. S. et al. (2001). Mitochondrial theory of aging
maturesroles of mtDNA mutation and oxidative stress in human
aging. Zhonghua Yi Xue Za Zhi (Taipei), 64(5): 25970.
Table References
087. Towbin, J. A. & Vatta, M. (2001). Molecular biology and the prolonged QT syndromes. Am J Med, 110(5): 38598.
088. Goldin, L. R., Gershon, E. S., Nurnberger, J. I., & Berrettini, W. H.
(1992). 40. The major affective disorders: Bipolar, unipolar, and
schizoaffective. In: The genetic basis of common diseases
(King, R. A., Rotter, J. I., & Morulsky, A. G., eds.), pp. 80115. New
York & Oxford: Oxford University Press; Souery, D., Rivelli, S. K.
et al. (2001). Molecular genetic and family studies in affective
disorders: State of the art. J Affect Disord, 62(12): 4555.
089. Chuang, D. T. (1998). Maple syrup urine disease: It has come a
long way. J Pediatr, 132(3 Pt 2): S1723; Velazquez, A.,
Vela-Amieva, M. et al. (2000). Diagnosis of inborn errors of
metabolism. Arch Med Res, 31(2): 14550.
090. Devereux, R. B. & Brown, W. T. (1992). 11. Structural heart disease. In: The genetic basis of common diseases (King, R. A.,
Rotter, J. I., & Morulsky, A. G., eds.), pp. 192221. New York &
Oxford: Oxford University Press; Robinson, P. N. & Booms, P.
(2001). The molecular pathogenesis of the Marfan syndrome. Cell
Mol Life Sci, 58(11): 1698707.
091. Gershoni-Baruch, R., Shinawi, M. et al. (2001). Familial
Mediterranean fever: Prevalence, penetrance and genetic drift. Eur
J Hum Genet, 9(8): 6347.
092. Schimke, R. N. (1992). 30. Cancer in families. In: The genetic
basis of common diseases (King, R. A., Rotter, J. I., &
Morulsky, A. G., eds.), pp. 6419. New York & Oxford: Oxford
University Press; Spatz, A., Giglia-Mari, G. et al. (2001).
Association between DNA repair-deficiency and high level of p53
mutations in melanoma of Xeroderma pigmentosum. Cancer Res,
61(6): 24806; Tomescu, D., Kavanagh, G. et al. (2001).
Nucleotide excision repair gene XPD polymorphisms and genetic
predisposition to melanoma. Carcinogenesis, 22(3): 4038;
Villa, R., Folini, M. et al. (2000). Telomerase activity and telomere
length in human ovarian cancer and melanoma cell lines:
Correlation with sensitivity to DNA damaging agents. Int J Oncol,
16(5): 9951002.
093. Moller, L. B., Tumer, Z. et al. (2000). Similar splice-site mutations
of the ATP7A gene lead to different phenotypes: Classical Menkes
disease or occipital horn syndrome. Am J Hum Genet, 66(4):
121120.
094. Toniolo, D. (2000). In search of the MRX genes. Am J Med Genet,
97(3): 2217.
095. Chinnery, P. F., Howell, N. et al. (1998). MELAS and MERRF.
The relationship between maternal mutation load and the
frequency of clinically affected offspring. Brain, 121 ( Pt 10):
188994; Yanagawa, T., Sakaguchi, H. et al. (1998). Mitochondrial
myopathy, encephalopathy, lactic acidosis, and stroke-like
episodes with deterioration during pregnancy. Intern Med,
37(9): 7803.
096. Singh, K. K. (Ed.). (1998). Mitochondrial DNA mutations in
aging, disease, and cancer. New York: Springer-Verlag; Uusimaa,
J., Remes, A. M. et al. (2000). Childhood encephalopathies and
myopathies: A prospective study in a defined population to assess
the frequency of mitochondrial disorders. Pediatrics, 105(3 Pt 1):
598603.
097. Camarena, B., Cruz, C. et al. (1998). A higher frequency of a low
activity-related allele of the MAO-A gene in females with
obsessivecompulsive disorder. Psychiatr Genet, 8(4): 2557;
Comings, D. E. & Blum, K. (2000). Reward deficiency syndrome:
459
098.
099.
100.
101.
102.
103.
104.
460
105.
106.
107.
108.
109.
110.
111.
112.
Genetic Disease II
19(4): 42939; Wei, F., Cheng, S. et al. (2001). A man who inherited his SRY gene and Leri-Weill dyschondrosteosis from his
mother and neurofibromatosis type 1 from his father. Am J Med
Genet, 102(4): 3538.
Evans, D. G. (1999). Neurofibromatosis type 2: Genetic and clinical features. Ear Nose Throat J, 78(2): 97100.
Boutin, P. & Froguel, P. (2001). Genetics of human obesity. Best
Pract Res Clin Endocrinol Metab, 15(3): 391404; Bray, G. A.
(1992). 23. Obesity. In: The genetic basis of common diseases
(King, R. A., Rotter, J. I., & Morulsky, A. G., eds.), pp. 50728.
New York & Oxford: Oxford University Press.
Bittar, Z. (1998). Major congenital malformations presenting in
the first 24 hours of life in 3865 consecutive births in south of
Beirut. Incidence and pattern. J Med Liban, 46(5): 25660;
Nakajima, T., Ota, N. et al. (1999). Ethnic difference in contribution of Sp1 site variation of COLIA1 gene in genetic predisposition to osteoporosis. Calcif Tissue Int, 65(5): 3523.
Birch, J. M., Alston, R. D. et al. (2001). Relative frequency and
morphology of cancers in carriers of germline TP53 mutations.
Oncogene, 20(34): 46218; Chen, P., Aldape, K. et al. (2001).
Ethnicity delineates different genetic pathways in malignant
glioma. Cancer Res, 61(10): 394954; Malmer, B., Gronberg, H.
et al. (2001). Microsatellite instability, PTEN and p53 germline
mutations in glioma families. Acta Oncol, 40(5): 6337;
Niklinska, W., Chyczewski, L. et al. (2001). New molecular
approaches to lung cancer: Biological and clinical implications of
P53, P16 and K-RAS studies. Folia Histochem Cytobiol, 39(2):
99103; Paschke, T. (2000). Analysis of different versions of
the IARC p53 database with respect to GT transversion mutation frequencies and mutation hotspots in lung cancer of smokers
and non-smokers. Mutagenesis, 15(6): 4578; Spatz, A., GigliaMari, G. et al. (2001). Association between DNA repairdeficiency and high level of p53 mutations in melanoma of
Xeroderma pigmentosum. Cancer Res, 61(6): 24806; Wu, X.,
Kemp, B. et al. (1999). Associations among telomerase activity,
p53 protein overexpression, and genetic instability in lung cancer.
Br J Cancer, 80(34): 4537; Ye, R., Bodero, A. et al. (2001). The
plant isoflavenoid genistein activates p53 and Chk2 in an ATMdependent manner. J Biol Chem, 276(7): 482833.
Eldredge, R. & Rocca, W. A. (1992). 38. Parkinsons disease. In:
The genetic basis of common diseases (King, R. A., Rotter, J. I., &
Morulsky, A. G., eds.), pp. 77591. New York & Oxford: Oxford
University Press; Sacks, O. W. (1973). Awakenings. New York:
HarperCollins Publishers, Inc.; Siderowf, A. (2001). Parkinsons
disease: Clinical features, epidemiology and genetics. Neurol
Clin, 19(3): 56578, vi.
Tunca, Y., Kadandale, J. S. et al. (2001). Long-term survival in
Patau syndrome. Clin Dysmorphol, 10(2): 14950.
Kopp, P. (1999). Pendreds syndrome: Identification of the genetic
defect a century after its recognition. Thyroid, 9(1): 659.
Gjetting, T., Romstad, A. et al. (2001). A phenylalanine
hydroxylase amino acid polymorphism with implications for
molecular diagnostics. Mol Genet Metab, 73(3): 2804; Jersild, C.
& Grunnett, N. (1992). 37. Demyelinating disease. In: The
genetic basis of common diseases (King, R. A., Rotter, J. I., &
Morulsky, A. G., eds.), pp. 75374. New York & Oxford: Oxford
University Press.
Table References
124.
125.
126.
127.
128.
129.
130.
131.
461
132.
133.
134.
135.
136.
137.
138.
462
INTRODUCTION
As of December 2002, 42 million adults and children
were estimated to be living with HIV/AIDS in the world
(UNAIDS/WHO, 2002). Approximately 29.4 million of
these are in Sub-Saharan Africa. More than 30% of the
Introduction
463
464
HIV Transmission
HIV Treatment
At present, there are three major classes of anti-HIV
drugs (NIAID, 2002a). These include protease inhibitors,
nucleoside analog reverse transcriptase inhibitors (NRTIs),
465
and non-nucleoside analog reverse transcriptase inhibitors (NNRTs). Protease inhibitors work by preventing
HIV from being successfully assembled by and released
from infected CD4 cells. NRTIs act by incorporating
themselves into the genetic material of the virus, thereby
halting the viral building process (Richman, 2001).
NNRTs stop HIV production by binding directly onto
reverse transcriptase and preventing the duplication of
viral genetic materials (NIAID, 2002a, 2002b; Williams
et al., 1993).
Treatment generally involves administration of complex combinations of these drugs. Many of these powerful
agents have an array of unpleasant side-effects and toxicities. Combination treatment using therapies from each
class is necessary to reduce the chance of the virus developing drug resistance (Richman, 2001). Unfortunately,
over 90% of HIV-infected persons live in impoverished
less-developed countries where most cannot afford the
high price of antiretroviral drugs or do not have access to
them (Rand Corporation, 2002; United Nations, 2001;
Yamey, 2000). This is the case despite reduction in the
treatment costs brought on by price competition and international political pressures on the pharmaceutical industry (Garrett, 2000; United Nations, 2001).
IN
466
467
468
condom was easy and partner did not object). The DIT further states that persons or groups vary in their willingness
to quickly adopt a new idea or innovation and fall along
a continuum of venturesome innovators and early
adopters to more conservative laggards. As greater
proportions of a social network adopt an innovation, the
innovation becomes normative and it spreads more
quickly. HIV interventions using the DIT seek to identify
sources of information (e.g., respected persons) trusted
by the population of interest (e.g., gay men) and to use
these sources to inform and persuade other members of
the population to adopt the new behavior, often through
endorsing or modeling the behavior to demonstrate its
value and social acceptability.
ANTHROPOLOGY IN HIV/AIDS
BEHAVIORAL RESEARCH
Anthropology in HIV Behavioral
Intervention Research
Despite early calls from within the field to translate their
work into risk reduction strategies and behavioral interventions (e.g., Gorman, 1986; Herdt, 1987), there continues to be a noticeably low amount of anthropological
influence in HIV behavioral intervention research. The
Centers for Disease Control and Prevention (CDC)
reviewed over 5,000 HIV reports in its Prevention
Research Synthesis project (CDC, 2001b; Sogolow et al.,
2002). Virtually none of the effective interventions
identified in the Prevention Research Synthesis projects
database were based on a theory growing primarily out
of anthropology. In reviewing additional literature for
this entry, we also found relatively few anthropologists
appearing as lead authors or co-authors on publications
describing intervention studies, accompanied by rigorous
scientific evaluations. To date, the HIV/AIDS behavioral
intervention research field appears to have been largely
dominated by theories, methods, and perspectives primarily growing out of psychology, social psychology, health
education, epidemiology, and medicine.
469
470
471
472
DISCUSSION
AND
FUTURE DIRECTIONS
HIV/AIDS has become one of the most important challenges facing the contemporary world. There is not likely
to be an effective vaccine in the near-term future. While
anti-viral drugs have greatly reduced AIDS deaths in
wealthy countries such as in Europe or North America,
HIV medical care is very expensive, complex, does not
eliminate the virus from the bodies of infected persons,
and is largely out of reach for many impoverished
subpopulations and countries. The epidemic has had catastrophic health and humanitarian impacts on the physical, social, cultural, economic, and political well-being of
millions of people. The disease strips households and
473
474
REFERENCES
AIDS Community Demonstration Projects Research Group. (1999).
Community-level HIV intervention in five cities: Final outcome
data from the CDC AIDS Community Demonstration Projects.
American Journal of Public Health, 89(3), 336345.
Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting
social behavior. Englewood Cliffs, NJ: Prentice Hall.
Andiman, W. A. (2002). Transmission of HIV-1 from mother to infant.
Current Opinion in Pediatrics, 14(1), 7885.
Annett, H., & Rifkin, S. B. (1995). Guidelines to rapid participatory
appraisal to assess community health needs. Division of
Strengthening of Health Services. Geneva, Switzerland: World
Health Organization.
Bandura, A. (1986). The explanatory and predictive scope of selfefficacy theory. Journal of Social & Clinical Psychology, 4(3),
359373.
Bandura, A. (1997). Self-efficacy: The exercise of control. New York:
W. H. Freeman.
Barnett, T., & Whiteside, A. (2002). Poverty and HIV/AIDS: Impact,
coping and mitigation policy. In G. A. Cornia (Ed.), AIDS, public
policy and child well-being: UNICEF Innocenti Research Centre.
Retrieved November 26, 2002, from http://www.uniceficdc.org/research/ESP/aids/aids_index.html
Batchelor, K., Rossman Beel, E., & Freeman, A. (2001). Community
based assessment: A guide for HIV prevention workers. Dallas,
TX: University of Texas Southwestern Medical Center. Retrieved
November 26, 2002 from http://www3.utsouthwestern.edu/
preventiontoolbox/assess/assess.htm
References
Beebe, J. (2001). Rapid assessment process: An introduction. Walnut
Creek, CA: Altamira.
Bennet, F. J. (1995). Qualitative and quantitative methods: In-depth or
rapid assessment? Social Science & Medicine, 40(12), 15891590.
Bollinger, L., & Stover, J. (1999). The economic impact of AIDS in
African nations. Glastonbury, CT: The Futures Group International.
Retrieved November 26, 2002 from http:// www.futuresgroup.com
Bourgois, P. (1998). The moral economics of homeless heroin addicts:
Confronting ethnography, HIV, risk, and everyday violence in San
Francisco shooting encampments. Substance Use and Misuse,
33(Suppl. 11), 23232351.
Bourgois, P., Lettiere, M., & Quesada, J. (1997). Social misery and the
sanctions of substance abuse: Confronting HIV risk among homeless heroin addicts in San Francisco. Social Problems, 44(2),
155173.
California Department of Health Services. (1998). Good questions better answers: A formative research handbook for California HIV
prevention programs (Prepared by the University of California at
San Francisco for the California Department of Health Services,
Northern California Grant Makers AIDS Task Force). Retrieved
November 26, 2002 from http://www.caps.ucsf.edu/capsweb/
goodquestions
Carey, J. W. (1994). Improving international HIV program planning:
Systematic interview methods in the context of programmatic needs
assessment. Unpublished masters thesis, Emory University,
Rollins School of Public Health, Atlanta, GA.
Carey, J. W., Morgan, M., & Oxtoby, M. J. (1996). Intercoder agreement
in analysis of responses to open-ended interview questions:
Examples from tuberculosis research. Cultural Anthropology
Methods, 8(3), 15.
Carey, J. W., Wenzel, P. H., Reilly, C., Sheridan, J., & Steinberg, J. M.
(1998). CDC EZ-Text: Software for management and analysis of
semistructured qualitative data sets. Cultural Anthropology
Methods, 10(1), 1420.
Cegielski, J., Chin, D., Espinal, M., Frieden, T., Cruz, R., Talbot, E.
et al. (2002). The global tuberculosis situation. Progress and problems in the 20th century, prospects for the 21st century. Infectious
Disease Clinics of North America, 16(1), 158.
Centers for Disease Control and Prevention. (1981). Kaposis sarcoma
and pneumocystis pneumonia among homosexual menNew
York City and California. Morbidity and Mortality Weekly Report,
30, 305308.
Centers for Disease Control and Prevention. (1995). Casecontrol study
of HIV seroconversion in healthcare workers after percutaneous
exposure to HIV infected blood. Morbidity and Mortality Weekly
Report, 44(50), 929933.
Centers for Disease Control and Prevention. (1997). 1997 USPHS/IDSA
guidelines for the prevention of opportunistic infections in
persons with human immunodeficiency virus. Morbidity and
Mortality Weekly Report, 46, (RR-12), 148. Available from http://
www.cdc.gov/mmwr/preview/mmwrhtml/00048226.htm
Centers for Disease Control and Prevention. (1999). USPHS/IDSA
guidelines for the prevention of opportunistic infections in persons
infected with human immunodeficiency virus: US Public Health
Service (USPHS) and Infectious Disease Society of America
(IDSA). Morbidity and Mortality Weekly Report, 48, (RR-10),
3234. Available from http:// www.cdc.gov/epo/mmwr/
preview/mmwrhtml/rr4810a1.htm
475
Centers for Disease Control and Prevention. (2000a). HIV and its
transmission. Report retrieved November 26, 2002, from http://
www.cdc.gov/hiv/pubs/facts/transmission.pdf
Centers for Disease Control and Prevention. (2000b). Preventing the
sexual transmission of HIV, the virus that causes AIDS: What you
should know about oral sex? Report retrieved November 26, 2002,
from ftp://ftp.cdcnpin.org/Updates/oralsex.pdf
Centers for Disease Control and Prevention. (2000c). Syndemics
prevention network homepage. Report retrieved November 26,
2002, from http://www.cdc.gov/syndemics
Centers for Disease Control and Prevention. (2000d). HIVrelated
knowledge and stigmaUnited States 2000. Morbidity and
Mortality Weekly Report, 49(47), 10621064.
Centers for Disease Control and Prevention. (2001a). Condoms and their
use in preventing HIV infection. Report retrieved on November 26,
2002 from http://www.cdc.gov/hiv/pubs/facts/condoms.htm
Centers for Disease Control and Prevention. (2001b). CDCNational
Centers for HIV, STD and TB preventiondivision of HIV/AIDS prevention: compendium of HIV prevention interventions with evidence
of effectiveness. Report retrieved November 26, 2002, from http://
www.ede.gov/hiv/pubs/hivcompendium/IIIV compendium.htm
Centers for Disease Control and Prevention. (2001c). HIV/AIDS
Surveillance Report, 2001, 13(2), 144. Report retrieved December
28, 2002, from http://www.ede.gov/hiv/stats/ hasr1302.pdf
Centers for Disease Control and Prevention. (2002a). Frequently
asked questions and answers about coinfection with HIV and
Hepatitis C virus. Report retrieved November 26, 2002, from
http:// www.ede.gov/hiv/pubs/facts/HIV-HCV_Coinfection.pdf
Centers for Disease Control and Prevention. (2002b). The deadly intersection between TB and HIV. Report retrieved November 26, 2002,
from http://www.ede.gov/hiv/pubs/facts/hivtb.pdf
Clatts, M. C., & Mutchler, M. (1989). AIDS and the dangerous other:
Metaphors of sex and deviance in the representation of disease.
Medical Anthropology, 10, 105114.
Cochran, S. (1989). Women and HIV infection: Issues in prevention and
behavior change. In V. M. Mays, G. W. Albee, & S. F. Schneider
(Eds.), Primary prevention of AIDS: Psychological approaches
(pp. 302320). Newbury Park, CA: Sage.
Davis, K. R., & Weller, S. C. (1999). The effectiveness of condoms in
reducing heterosexual transmission of HIV. Family Planning
Perspectives, 31(6), 272279.
Day, S. (1988). Prostitute women and AIDS: Anthropology. AIDS, 2(6),
421428.
Deschamps, M. M., Pape, J. W., Hafner, A., & Johnson, W. D., Jr.
(1996). Heterosexual transmission of HIV in Haiti. Annals of
Internal Medicine, 125(4), 324330.
de Vincenzi, I. (1994). A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. New England
Journal of Medicine, 331(6), 341346.
DiClemente, R. J., Boyer, C., & Morales, E. (1988). Minorities and
AIDS: Knowledge, attitudes, and misconceptions among Black
and Latino adolescents. American Journal of Public Health, 78(1),
5557.
Dushay, R. A., Singer, M., Weeks, M. R., Rohena, L., & Gruber, R.
(2001). Lowering HIV risk among ethnic minority drug users:
Comparing culturally targeted intervention to a standard intervention. American Journal of Drug and Alcohol Abuse, 27(3),
501524.
476
Farmer, P. (1992). AIDS and accusation: Haiti and the geography of
blame. Berkeley: University of California Press.
Feldman, D. A. (1990). Postscript: Anthropology and AIDS. In
D. A. Feldman (Ed.), Culture and AIDS (pp. 205208). New York:
Praeger.
Feldman, J. L. (1995). Plague doctors: Responding to the AIDS
epidemic in France and America. Westport, CT: Bergin & Garvey.
Fenton, K. A., Chinouya, M., Davidson, O., & Copas, A. (2002). HIV
testing and high risk sexual behavior among Londons migrant
African communities: A participatory research study. Sexually
Transmitted Diseases, 78(4), 241245.
Fishbein, M., Middlestadt, S. E., & Hitchcock, P. J. (1994). Using
information to change sexually transmitted disease-related
behaviors: An analysis based on the theory of reasoned action. In
R. J. DiClemente & J. L. Peterson (Eds.), Preventing AIDS:
Theories and methods of behavioral interventions (pp. 6178).
New York: Plenum Press.
Furin, J. J. (1997). You may have to be your own doctor: Sociocultural
influences on alternative therapy use among gay men with AIDS
in West Hollywood. Medical Anthropology Quarterly, 11,
498504.
Gallant, J. E., Moore, R., & Chaisson, R. E. (1994). Prophylaxis for
opportunistic infections in patients with HIV infection. Annals of
Internal Medicine, 120(11), 932944.
Garrett, L. (2000, July 9). Drugmakers aid in war on AIDS / Controversy
rages over distribution. Report retrieved November 26, 2002, from
http://www.aegis.com/news/newsday/2000/ND000706.html
Georgeson, J., & Filteau, S. (2002). Physiology, immunology, and
disease transmission in human breast milk. AIDS Patient Care &
STDs, 14(10), 533539.
Gorman, M. (1986). The AIDS epidemic in San Francisco. In C. Janes,
R. Stall, & S. M. Gifford (Eds.), Anthropology and epidemiology.
Dordrecht, The Netherlands: D. Reidel.
Hansen, H., & Groce, N. E. (2001). From quarantine to condoms:
Shifting policies and problems of HIV control in Cuba. Medical
Anthropology, 19(3), 259292.
Harris, K. J., Jerome N. J., & Fawcett, S. B. (1997). Commentary:
Rapid assessment procedures: A review and critique. Human
Organization, 56(3), 375378.
Heggenhougen, H. K., & Pedersen, D. (1997). The relevance of anthropology for tropical public health: A historical perspective. Tropical
Medicine and International Health, 2(11), 510.
Herdt, G. (1987). AIDS and anthropology. Anthropology Today,
3(2), 13.
Herdt, G., & Boxer, A. (1991). Ethnography issues in the study of AIDS.
The Journal of Sex Research, 28(2), 171188.
Herdt, G., Leap, W. L., & Sovine, M. (1991). Anthropology, sexuality,
and AIDS. The Journal of Sex Research, 28(2), 167169.
Higgins, D. L., OReilly, K., Tashima, N., Crain, C., Beeker, C.,
Goldbaum, G. et al., & the AIDS Community Demonstration
Projects. (1996). Using formative research to lay the foundation for
community-level HIV prevention efforts: An example from the
AIDS Community Demonstration Projects. Public Health Reports,
111(Suppl. 1), 2835.
Holtgrave, D. R., Doll, L. S., & Harrison, J. (1997). Influence of behavioral and social science on public health policymaking. American
Psychologist, 52(2), 167173.
References
McLellan, E., MacQueen, K. M., & Neidig, J. L. (2002). Beyond the
qualitative interview: Data preparation and transcription. Field
Methods, 14(4), 440461.
Meyers, Y., & Ellen, J. (2001). Framing social violence and sexually
transmitted diseases. International Journal of STD & AIDS,
12(Suppl. 2), 52.
Moss, W., Bentley, M., Maman, S., Ayuko, D., Egessah, O., Sweat, M.
et al. (1999). Foundations for effective strategies to control
sexually transmitted infections: Voices from rural Kenya. AIDS
Care, 11, 95113.
Murray, S. O., & Payne, K. W. (1989). The social classification of AIDS
in American epidemiology. Medical Anthropology, 10(23),
115128.
National Institutes of Allergy and Infectious Diseases. (2001). Scientific
evidence on condom effectiveness for Sexually Transmitted
Disease (STD) prevention. (Summary from workshop held June
1213, 2000, Herndon, Virginia). Retrieved December 6, 2002,
from http://www.niaid.nih.gov/dmid/stds/condomreport.pdf
National Institutes of Allergy and Infectious Diseases. (2002a) Classes
of anti-AIDS drugs and therapeutics. Report retrieved November
26, 2002, from http://www.niaid.nih.gov/daids/dtpdb/clasdrug.htm
National Institutes of Allergy and Infectious Diseases. (2002b).
Treatment of HIV infection fact sheet. Retrieved December 5,
2002, from http://www.niaid.nih.gov/factsheets/treat-hiv.htm
Nations, M. K., & de Souza M. A. (1997). Umbanda healers as effective AIDS educators: Casecontrol study in Brazilian urban slums.
Tropical Doctor, 27(Suppl. 1), 6066.
Needle, R. H., Trotter, R. T., Goosby, E., Bates, C., & Von Zinkernagel, D.
(2000). Methodologically sound rapid assessment and response:
Providing timely data for policy development on drug use interventions and HIV prevention. International Journal of Drug
Policy, 11(12), 1923.
Neumann, M. S., & Sogolow, E. D. (2000). Replicating effective
programs: HIV/AIDS prevention technology transfer. AIDS
Education and Prevention, 12(Suppl. A), 3548.
Nicoll, A., Laukamm, J. U., Mwizarubi, B., Mayala, C., Mkuye, M.,
Nyembela, G. et al. (1993). Lay health beliefs concerning HIV and
AIDSa barrier for control programmes. AIDS Care, 5(2), 231241.
Norris, A. E., & Ford, K. (1991). AIDS risk behaviors of minority youth
living in Detroit. American Journal of Preventive Medicine, 7,
416421.
Nova Research Company. (1998). AFTER: A Framework of Tools for
Ethnographic Research (Version 3.0). [Computer software].
Bethesda, MD: Nova Research Company.
Novello, A. C., Peterson, H. B., Arrowsmith-Lowe, J., Thomas, J.,
Kelaghan, J., & Perlman, J. A. (1993). Condom use for prevention
of sexual transmission of HIV infection. Journal of the American
Medical Association, 269(22), 2840.
Osmanov, S., Pattou, C., Walker, N., Schwardlander, B., Esparza, J., &
WHO-UNAIDS Network for HIV isolation and characterization.
(2002). Estimated global distribution and regional spread of HIV-1
genetic subtypes in the year 2000. Journal of AIDS, 29(2), 184190.
Page, B. J. (1997). Needle exchange and reduction of harm: An anthropological view. Medical Anthropology, 18(1), 1333.
Parker, R., Herdt, G., & Carballo, M. (1991). Sexual culture, HIV
transmission, and AIDS research. The Journal of Sex Research, 28,
7596.
477
Prochaska, J. O. (1994). Strong and weak principles for progressing
from precontemplation to action on the basis of twelve problem
behaviors. Health Psychology, 13(1), 4751.
Prochaska, J. O., & DiClemente, R. C. (1986). Towards a comprehensive
model of change. In W. R. Miller & N. Heather (Eds.), Treating
addictive behaviors (pp. 327). New York: Plenum Press.
Quintanilla, K. (1996). Can HIV be transmitted through breast milk?
Nursing Times, 92(31), 357.
Rand Corporation. (2002) HIV cost and utilization study policy brief:
Access to HIV care initial results from the HIV cost and services
utilization study. Report retrieved November 26, 2002, from
http://www.rand.org/publications/RB/RB4530
Richman, D. (2001). HIV chemotherapy. Nature, 410(6831), 9951001.
Rieder, H., Cauthen, G., Kelly, G., Bloch, A., & Snider, D., Jr. (1989).
Tuberculosis in the United States. Journal of the American
Medical Association, 262(3), 385389.
Roberts, G. W., Bansbach, S. W., & Peacock, N. (1997). Behavioral scientists at the Centers for Disease Control and Prevention: Evolving
and integrated roles. American Psychologist, 52(2), 143146.
Rogers, E. M. (1962). Diffusion of innovations. New York: Free Press.
Rosenstock, I. (1974). Historical origins of the Health Belief Model.
Health Education Monographs, 2(4), 328335.
Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1994). The Health
Belief Model and HIV risk behavior change. In R. J. DiClemente
and J. L. Peterson (Eds.), Preventing AIDS: Theories and methods
of behavioral intervention (pp. 524). New York: Plenum Press.
Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the Health Belief Model. Health Education
Quarterly, 15(2), 175183.
Rugalema, G. (2000). A journey into the impact of HIV/AIDS in
Southern Africa. Review of African Political Economy, 28(86),
537545.
Rugalema, G., Weigang, S., & Mbwika, J. (1999). HIV/AIDS and the
commercial agricultural sector of Kenya: Impact, vulnerability,
susceptibility and coping strategies. Retrieved November 26,
2002, from the Food and Agricultural Organization Web site:
http://www.fao.org/sd/exdirect/exre0026.htm
Rugg, D. L., Levinson, R., DiClemente, R., & Fishbein, M. (1997).
Centers for Disease Control and Prevention partnerships with
external behavioral and social scientists: Roles, extramural funding, and employment. American Psychologist, 52(2), 147153.
Saracco, A., Mussicco, M., Nicolosi, A., Angarano, G., Arici, C.,
Gavazzeni, G. et al. (1993). Man-to-woman sexual transmission of
HIV: Longitudinal study of 343 steady partners of infected men.
Journal of AIDS, 6(5), 497502.
Schensul, S., & Schensul, J. (1998). A cross-national analysis of female
adolescent sexual risk: Comparative results from Mauritius and
Sri Lanka [Abstract no. 14124] International Conference on AIDS,
12, 207.
Scrimshaw, N. S., & Gleason, G. R. E. (1992). Rapid assessment
procedures: Qualitative methodologies for planning and evaluation of health related programs. Boston: International Nutrition
Foundation for Developing Countries.
Scrimshaw, S. C. M., Carballo, M., Ramos, L., & Blair, B. A. (1991).
The AIDS rapid anthropological assessment procedures: A tool for
health education planning and evaluation. Health Education
Quarterly, 18(1), 111123.
478
Selwyn, B. J., Frerichs, R. R., Smith, G. S., & Olson, J. (1989).
Rapid epidemiological assessment: The evolution of a new
disciplineIntroduction. International Journal of Epidemiology,
18(Suppl. 2)(4), 1.
Singer, M. (1994). AIDS and the health crisis of the US urban poor: The
perspective of critical medical anthropology. Social Science &
Medicine, 39(7), 931948.
Singer, M. (1996). A dose of drugs, a touch of violence, a case of AIDS:
Conceptualizing the SAVA syndemic. Free Inquiry, 24(2), 99110.
Singer, M., & Marxuach-Rodriquez, L. (1996). Applying anthropology
to the prevention of AIDS: The Latino gay mens health project.
Human Organization, 55, 141148.
Singer, M., Stopka, T., Siano, C., Springer, K., Barton, G., Khoshnood, K.
et al. (2000). The social geography of AIDS and Hepatitis risk.
American Journal of Public Health, 90(7), 10491056.
Snider, D. E., Jr., & Satcher, D. (1997). Behavioral and social sciences
at the Centers for Disease Control and Prevention: Critical disciplines for public health. American Psychologist, 52(2), 140142.
Sogolow, E., Peersman, G., Semaan, S., Strouse, D., Lyles, C. M., & the
HIV/AIDS Prevention Research Synthesis Project. (2002). The
HIV/AIDS Prevention Research Synthesis Project: Scope, methods, and study classification results. Journal of AIDS, 30 (Suppl.),
S15S29.
Stall, R., Paul, J., Barrett, D. C., Crosby, G. M., & Bein, E. (1999). An
outcome evaluation to measure changes in sexual risk-taking
among gay men undergoing substance use disorder treatment.
Journal of Studies on Alcohol, 60(6), 837845.
Sterk, C. (1999). Fast lives: women who use crack cocaine. Philadelphia:
Temple University Press.
Stratford, D., Ellerbrock, T. V., Akins, J. K., & Hall, H. L. (2000).
Highway cowboys, old hands, and Christian truckers: Risk behavior for human immunodeficiency virus infection among long-haul
truckers in Florida. Social Science & Medicine, 50(5), 737749.
Strotman, R., McLellan, E., MacQueen, K. M., & Milstein, B. (2002).
AnSWR: Analysis Software for Word-based Records, (Version
6.2). [Computer software]. Atlanta, GA: Centers for Disease
Control and Prevention.
Sulkowski, M., Mast, E., Seeff, L., & Thomas, D. (2000). Hepatitis C
virus as an opportunistic disease in persons infected with human
immunodeficiency virus. Clinical Infectious Diseases, 30 (Suppl. 1),
S77S84.
Sumartojo, E. (2000). Structural factors in HIV prevention: Concepts,
examples, and implications for research. AIDS, 14(Suppl. 1),
S3S10.
Sumartojo, E., Carey, J. W., Doll, L. S., & Gayle, H. (1997). Targeted
and general population interventions for HIV prevention: Towards
a comprehensive approach. AIDS, 11(10), 12011209.
Terry, M., Liebman, J., Person, B., Bond, L., Dillard-Smith, C., &
Tunstall, C. (1999). The Women and Infants Demonstration
Project: An integrated approach to AIDS prevention and research.
AIDS Education and Prevention, 11(2), 107121.
Trotter, R. T. (1995). Drug use, AIDS, and ethnography: Advanced
ethnographic research methods exploring the HIV epidemic. NIDA
Research Monograph, 157, 3864).
Trotter, R. T., Bowen, A. M., Baldwin, J. A., & Price, L. J. (1996).
Efficacy of network-based HIV/AIDS risk reduction programs in
midsized towns in the United States. Journal of Drug Issues, 26(3),
591605.
Introduction
479
INTRODUCTION
Anthropological research on insect vector-borne disease
spans the full spectrum of theoretical and methodological
approaches in medical anthropology. Important contributions to both biological and cultural anthropology have
emerged in this field. Theoretical orientations reflected in
the literature include ecological, ethnomedical, politicaleconomic, feminist and applied/public health perspectives. Research designs include large-scale population
studies, community surveys and clinical case studies.
This review will focus on malaria, the most prevalent and
deadly of the tropical diseases,1 with selective coverage
of other diseases transmitted by insects.
Most of the work cited here was conducted in the past
two decades. In 1979, Dunn noted the paucity of any behavioral science research on parasitic diseases and outlined a
very general program of research, including anthropological
studies (Dunn, 1979). Two decades later, Kendall and
Zielinski, (1999) document substantial development of the
field, including a prominent contribution of anthropological
perspectives and methods. This review covers five major
insect vector diseases: malaria, dengue fever, lymphatic
filariasis, onchocerciasis, and Chagas disease. These were
selected on the basis of their importance as world health
problems and as foci for anthropological research.
480
Vector
Pathogen
Malaria
Mosquito
Protozoa
Tropics,
Subtropics
300500 million
Dengue
Mosquito
Virus
Africa, Tropical
South America
Lymphatic
filariasis
Mosquito
Nematode
Tropics,
Subtropics
120 million
Onchocerciasis
Blackfly
Nematode
Africa, Latin
America
17.5 million
Chagas disease
Triatomine bug
Protozoan
Central and
South America
18 million
ECOLOGICAL STUDIES
The prominence of biocultural approaches to the study of
vector-borne diseases is well illustrated by anthropological research on malaria. The most notable example of this
tradition is the frequently cited case of malaria and sickle
cell disease in Africa (Alland, 1970; Livingstone, 1958;
McElroy & Townsend, 1996; Wisenfeld, 1967). Many
introductory texts use this case to illustrate the impact of
culture change (introduction of agriculture) on disease
ecology (malaria prevalence) and human biological adaptation (genetic selection for the malaria-protective sickle
cell trait). The transition to food production in East Africa
about two millennia ago was accompanied by the clearing of land, removal of forest canopy, and the exposure
of wet areas to sunlight. These conditions offer ideal
breeding grounds for mosquitoes, including Anopheles
gambiae, the vector for a severe strain of malaria caused
by Plasmodium falciparum. Mortality from falciparum
malaria was high, often killing 25% of its victims.
The opportune presence of a genetic mutation in the
population led to selection of individuals with the
abnormal hemoglobin that causes red blood cells to
sickle and prevent reproduction of Plasmodium organisms, and accounts for the prevalence of this trait in
African and African origin populations. The social ecology
of malaria in Africa illustrates the interaction of biology
and culture in the production of disease patterns.
Understanding of the interaction of biology and
culture in relation to malaria was further elaborated in
studies of the coevolution of certain cuisines and other
malaria-protective hemoglobin variants in Mediterranean
populations (Greene & Danubio, 1997). Focusing primarily
on G6PD (glucose-6-phosphate-dehydrogenase) deficiency
Distribution
People infected
Ethnomedical Studies
ETHNOMEDICAL STUDIES
Ethnomedical studies, broadly defined, comprise a large
proportion of anthropological research on vector-borne
diseases. Numerous studies have investigated local
beliefs and practices regarding specific conditions,
including conceptions of etiology, pathophysiology,
severity, home management, and treatment. Often such
481
482
COMMUNITY PARTICIPATION
HEALTH PROGRAMS
IN
Conclusion
483
CONCLUSION
Anthropological research on insect vector diseases,
largely conducted over the past two decades, reflects a
broad range of perspectives. Biocultural approaches
have been applied primarily to malaria, with ecological,
ethnomedical, and public health perspectives found
across all the diseases reviewed. Much of the research
484
NOTE
1. The delineation of such a disease-focused topic reflects the influence of biomedical nosology in defining specializations within
medical anthropology. The continued relevance of the category
tropical diseases, largely composed of the vector-borne diseases,
is a legacy of colonial history as well as scientific interest in exotic
infections affecting poor countries. Also, while the review focuses
on the work of anthropologists, it is often not meaningful to differentiate the latter from similar research conducted by social scientists trained in other disciplines. Thus, some anthropologically
oriented work by non-anthropologists is included.
ACKNOWLEDGMENT
The author thanks Dorothea Larsen and Marianne Sarkis for bibliographic assistance.
REFERENCES
Agyepong, I. A. (1992). Malaria: Ethnomedical perceptions and
practice in an Adangbe farming community and implications for
control. Social Science & Medicine, 35, 131137.
Ahorlu, C. K., Dunyo, S. K., Afari, E. A., Koram, K. A., & Nkrumah, F. K.
(1997). Malaria related beliefs and behavior in southern Ghana:
Implications for treatment, prevention, and control. Tropical
Medicine and International Health, 2, 488499.
Alland, A. (1970). Adaptation in cultural evolution: An approach to
medical anthropology. New York: Columbia University Press.
Amazigo, U. O. (1994). Detrimental effects of onchocerciasis on marriage and breast-feeding. Tropical and Geographical Medicine, 46,
322325.
A/rahman, S. H., Mohamedani, A. A., Mirgani, E. M., & Ibrahim, A. M.
(1995). Gender aspects and womens participation in the control
and management of malaria in Central Sudan. Social Science &
Medicine, 42, 14331446.
Awolola, T. S., Manafa, O. U., Rotimi, O. O., & Ogunrinade, A. F. (2000).
Knowledge and beliefs about causes, transmission, treatment and
References
Gordon, A. J., Rojas, Z., & Todwell, M. (1990). Cultural factors in
Aedes aegypti and dengue control in Latin America: A case study
from the Dominican Republic. International Quarterly of
Community Health Education, 10, 193211.
Greene, L. S., & Danubio, M. E. (1997). Adaptation to malaria: The
interaction of biology and culture. Amsterdam: Gordon & Breach.
Gyapong, M., Gyapong, J. O., Adjei, S., Vlassoff, C., & Weiss, M.
(1996). Filariasis in Northern Ghana: Some cultural beliefs and
practices and their implications for disease control. Social Science
& Medicine, 43, 235242.
Kendall, C., Leontsini, E., Gil, E., Cruz, F., Hudelson, P., & Pelto, P.
(1990). Exploratory ethnoentomology: Using ANTHROPAC to
design a dengue fever control program. Cultural Anthropology
Methods Newsletter, 2, 1112.
Kendall, C., & Winch, P. (1988, October 2022). Dengue control: The
challenge to the social sciences. Report of a Workshop. The Johns
Hopkins University, School of Hygiene and Public Health,
Baltimore, MD.
Kendall, C., & Winch, P. (1989, April 11). Integrated community-based
Aedes aegypti control project. Report to the Rockefeller
Foundation, Health Sciences Division.
Kendall, C., Zielinski, E., & Farmer, P. (1999). Social and cultural
factors in tropical medicine: Reframing our understanding of
disease. In Guerrant et al. (Eds.), Tropical infectious diseases:
Principles, pathogens and practice (pp.). Churchill Livingstone.
Leontsini, E., Gil, E., Kendall, C., & Clark, G. (1993). Effect of a
community-based Aedes aegypti control programme on mosquito
larval production sites in El Progreso, Honduras. Transactions
of the Royal Society of Tropical Medicine and Hygiene, 87,
267271.
Lipowsky, R., Kroeger, A., & Vazquez, L. (1992). Sociomedical aspects
of malaria control in Colombia. Social Science & Medicine, 24,
625637.
Livingston, F. B. (1958). Anthropological implications of sickle-cell
gene distribution in West Africa. American Anthropologist, 60,
533562.
Lloyd, L. P., Winch, P., Ortega-Canto, J., & Kendall, C. (1992). Results
of a community-based Aedes aegypti control program in Merida,
Yucatan, Mexico. American Journal of Tropical Medicine and
Hygiene, 46, 635642.
Lloyd, L. P., Winch, Ortega-Canto, J., & Kendall, C. (1994). The design
of a community-based health education intervention for the control
of Aedes aegypti. American Journal of Tropical Medicine and
Hygiene, 50, 401411.
MacCormack, C. P., & Lwihula., G. (1983). Failure to participate in a
malaria chemosuppression programme: North Mara, Tanzania.
Journal of Tropical Medicine and Hygiene, 86, 99107.
485
Manderson, L. (1992a). Summary of Seameo-tropmed technical meeting on social and behavioral aspects of malaria control:
Community participation and the control of malaria. Southeast
Asian Journal of Tropical Medicine, 23, 35.
Manderson, L. (1992b). Community participation and malaria control
in Southeast Asia: Defining the principles of involvement.
Southeast Asian Journal of Tropical Medicine, 23, 917.
McCombie, S. C. (1996). Treatment seeking for malaria: A review of
recent research. Social Science & Medicine, 43, 933945.
McCombie, S. C. (2002). Self-treatment for malaria: The evidence and
methodological issues. Health Policy & Planning, 17, 333344.
McElroy, A., & Townsend, P. (1996). Medical anthropology in ecological perspective (2nd ed.). Boulder, CO: Westview Press.
Miguel, C. A., Tallo, V. L., Manderson, L., & Lansang, M. A. (1999).
Local knowledge and treatment of malaria in Agusan del Sur, The
Philippines. Social Science & Medicine, 48, 607618.
Oaks, S. C., Jr., Mitchell, V. S., Pearson, G. W., & Carpenter, C. C. J.
(1991). Malaria: Obstacles and opportunities. Washington, DC:
National Academy Press.
Pan-African Study Group on Onchocercal Skin Disease. (1995). The
importance of onchocercal skin disease (TDR/AFR/RP/95.1).
Geneva, Switzerland: World Health Organization.
Rathgeber, E., & Vlassof, C. (1993). Gender and tropical diseases: A
new research focus. Social Science & Medicine, 37, 513520.
Reubush, T. K., II, Weller, S., & Klein, R. E. (1992). Knowledge and
beliefs about malaria on the Pacific coastal plain of Guatemala.
American Journal of Tropical Medicine and Hygiene, 46, 451459.
Vlassoff, C., & Bonilla, E. (1994). Gender-related differences in the
impact of tropical diseases in women: What do we know? Journal
of Biosocial Science, 26, 3753.
Whiteford, L. M (1997). The ethnoecology of dengue fever. Medical
Anthropology Quarterly, 11, 202223.
Winch, P., Kendall, C., & Gubler, D. (1992). Effectiveness of community
participation in vector-borne disease control. Health Policy and
Planning, 7, 342351.
Winch, P., Lloyd, L., Godas, M. D., & Kendall, C. (1991). Beliefs about
the prevention of dengue and other febrile illnesses in Merida,
Mexico. Journal of Tropical Medicine and Hygiene, 94, 377387.
Wisenfeld, S. L. (1967). Sickle-cell trait in human biological and cultural evolution. Science, 157, 11341138.
World Health Organization. (1996, March). Workplan of the task force
on gender and tropical diseases (Special Programme for Research
and Training in Tropical Diseases (TDR) ). Geneva: World Health
Organization.
486
Mental Disorders
Mental Disorders
Alex Cohen
BACKGROUND
The Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition (or DSM-IV) defines mental disorder as a clinically significant syndrome or pattern in
which an individual exhibits behavioral or psychological
patterns that are associated with distress, disability, or
increased risk of pain or death (American Psychiatric
Association, 1994).
However, there are several problems with this definition. First, it covers a vast range of conditions. One
might reasonably ask whether it is valid for a single definition to encompass the entire spectrum of conditions:
from the relatively rare, severe and chronic psychoses to
the relatively common, often comparatively mild and
intermittent mood disorders. Even if it is valid to speak of
mental disorders in such an inclusive way, more precise
focusing may be obligatory when formulating and testing
hypotheses about the effect of sociocultural environments
on human mental well-being. For example, Vikram
Patels (1998) research in Zimbabwe focuses on the relationship of culture to the manifestation, course, and outcome of depression and anxiety, while Ezra Susser and
his colleagues focus on brief psychotic disorders in India
(Susser, Varma, Malhotra, Conover, & Amador, 1995;
Susser & Wanderling, 1994).
Second, the authors of DSM-IV point out that the use
of the term mental implies a clear differentiation between
mental and physical disorder, a distinction that does
not, in fact, exist. For example, tropical diseases such as
malaria and sleeping sickness may produce symptoms that
mimic those of the psychoses and depression (Weiss,
Cohen, & Eisenberg, 2000), and non-specific fevers have
been implicated in the etiology of acute brief psychosis in
Northern India (Collins et al., 1999). At the same time,
physical disorders such as myocardial infarction may be
precipitated by emotional states of fear or anger (Kendell,
2001). Low-back pain often occurs in the absence of a
distinct physical disorder (Kleinman, 1988). Finally, epidemiological research in 10 countries found that loss of
energy, a symptom that is clearly associated with a host of
UNIVERSALS
AND
CULTURE-SPECIFICS
487
488
Mental Disorders
KINDS
OF
DISORDERS
Depression
The symptoms of depression include feelings of sadness,
hopelessness, and thoughts of death, often accompanied by
somatic complaints of fatigue, sleep disruptions, and
weight loss, all of which result in functional and social disability. Worldwide, hundreds of millions of people suffer
from depression. According to the most recent data, depressive disorder accounts for 4.4% of the worlds total burden
of disease as measured by Disability Life Years (DALYs),
which makes it a public health problem whose magnitude
is only slightly less than lower respiratory infections
(6.4%), perinatal conditions (6.2), and HIV/AIDS (6.1)
(WHO, 2001). Among people aged 1544 years, depressive disorders account for fully 8.6% of global DALY, second only to HIV/AIDS (13.0%). Epidemiological surveys
have found wide variation in cross-national rates, as
well as rates among women that are consistently higher
than those found in men (Weissman et al., 1996).
Epidemiological research has also determined that,
worldwide, about one quarter of all attendees in primary
care settings are suffering from mental disorder, most
frequently depression or mixed depression/anxiety, but
Kinds of Disorders
Schizophrenia
Schizophrenia is a severe mental disorder that most frequently begins in late adolescence or early adulthood and
is characterized by delusions (fixed, false ideas), hallucinations (either auditory or visual), and behavior that
is deemed socially inappropriate (e.g., going without
clothes, lack of attention to personal hygiene). It is the
mental disorder most closely associated with the terms
madness or insanity and is, in all societies, a highly stigmatized condition, one that may lead to social isolation,
neglect, and abuse (Weiss et al., 2000). Schizophrenia
is relatively rare; depending on the diagnostic criteria
used, it has an incidence rate of fewer than 5 persons
per 10,000. But if the disorder is chronically disabling, its
prevalence is much higher, about 120 per 1,000
489
490
Mental Disorders
References
THE FUTURE
For most of the 20th century, the anthropological study of
mental disorders and related phenomena focused on
exotic healing rituals, the so-called culture-bound syndromes, and the search for universal features that were
hidden by the noise of culturally shaped symptomatology (Becker & Kleinman, 2000). With Arthur Kleinmans
(1977) call for a new cross-cultural psychiatry, the
focus shifted away from universals to the examination of
local idioms of distress and how the nature of human
suffering was shaped into a multitude of forms by cultural
processes. At the beginning of the 21st century, the focus
of cross-cultural psychiatry and psychiatric anthropology
is once again shifting. In a psychiatric textbook article on
anthropology and psychiatry, Anne Becker (a psychiatrist
and anthropologist) and Kleinman state that the crosscultural study of mental disorders provides evidence for
their syndromal significance and integrity in the absence
of biological markers (Becker & Kleinman, 2000). Is
this an anthropological version of the old comparative
psychiatry, a neo-Kraepelinism? Sing Lee (2002) challenges the field, stating that cultural psychiatry must
move away from debates over categories and repetitious
studies of reliability that may have become irrelevant in
an era of global change. Research is now questioning the
assumption that depression is distinguished in some societies by psychological symptoms and in others by
somatic symptoms (see also Kirmayer & Young, 1998).
Whether or not depression has distinct forms in different
cultural settings, and whether or not idioms of distress are
incommensurable, the apparent effectiveness of antidepressants to treat a wide range of disorders challenges
some of the foundations of the new cross-cultural psychiatry. That is, the dominance of Western psychiatry
and its biomedical model of mental disorders, along with
the international marketing of antidepressants to treat a
491
REFERENCES
Abas, M. A., & Broadhead, J. C. (1997). Depression and anxiety among
women in an urban setting in Zimbabwe. Psychological Medicine,
27, 5971.
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington, DC: American
Psychiatric Association.
Andreasen, N. C. (1997). Linking mind and brain in the study of mental illnesses: A project for a scientific psychopathology. Science,
275(5306), 15861593.
Becker, A. E., & Kleinman, A. (2000). Anthropology and psychiatry. In
B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of
psychiatry (Vol. 1, 7th ed., pp. 463476). Philadelphia: Lippincott
Williams & Wilkins.
Cabot, M. R. (1990). The incidence and prevalence of schizophrenia in
the Republic of Ireland. Social Psychiatry & Psychiatric
Epidemiology, 25, 210215.
Carothers, J. C. (1953). The African mind in health and disease: A study
in ethnopsychiatry. Geneva, Switzerland: World Health Organization.
Cohen, A. (1992). Prognosis for schizophrenia in the Third World: A
reevaluation of cross-cultural research. Culture, Medicine &
Psychiatry, 16, 5375, 101106.
Cohen, A. (1999). The mental health of indigenous people: An international overview. Geneva, Switzerland: World Health Organization.
Cohen, A. (2001). The effectiveness of mental health services in primary care: The view from the developing world. Geneva: World
Health Organizations.
Collins, P. Y., Varma, V. K., Wig, N. N., Mojtabai, R., Day, R., & Susser,
E. (1999). Fever and acute brief psychosis in urban and rural settings in north India. British Journal of Psychiatry, 174, 520524.
Craig, T. J., Siegel, C., Hopper, K., Lin, S., & Sartorius, N. (1997).
Outcome in schizophrenia and related disorders compared between
developing and developed countries: A recursive partitioning
re-analysis of the WHO DOSMD data. British Journal of
Psychiatry, 170, 229233.
Desjarlais, R., Eisenberg, L., Good, B., & Kleinman, A. (1995). World
mental health: Problems and priorities in low-income countries.
New York: Oxford University Press.
492
Devereux, G. (1980). Schizophrenia: An ethnic psychosis or
schizophrenia without tears. In G. Devereux (Ed.), Basic problems
of ethnopsychiatry (pp. 214236). Chicago: University of Chicago
Press. (Original work published 1965).
Dohrenwend, B. P., & Dohrenwend, B. S. (1974). Social and cultural
influences on psychopathology. Annual Review of Psychology, 25,
417452.
Edgerton, R. B. (1966). Conceptions of psychosis in four East African
societies. American Anthropologist, 68, 408425.
Edgerton, R. B. (1969). On the recognition of mental illness. In S. C.
Plog & R. B. Edgerton (Eds.), Changing perspectives in mental illness (pp. 4972). New York: Holt, Rinehart and Winston.
Edgerton, R. B. (1984). Anthropology and mental retardation: Research
approaches and opportunities. Culture, Medicine & Psychiatry,
8(1), 2548.
Edgerton, R. B., & Cohen, A. (1994). Culture and schizophrenia: The
DOSMD challenge. British Journal of Psychiatry, 164, 222231.
Good, B. J. (1977). The heart of whats the matter. The semantics of illness in Iran. Culture, Medicine & Psychiatry, 1, 2558.
Good, B. J. (1994). Medicine, rationality, and experience: An anthropological perspective. Cambridge, UK: Cambridge University
Press.
Harding, C. M., Zubin, J., & Strauss, J. S. (1987). Chronicity in schizophrenia: Fact, partial fact, or artifact? Hospital & Community
Psychiatry, 38, 477486.
Harding, C. M., Zubin, J., & Strauss, J. S. (1992). Chronicity in schizophrenia: Revisited. British Journal of Psychiatry, 161(Suppl. 18),
2737.
Harrison, G., Hopper, K., Craig, T., Laska, E., Siegel, C., Wanderling, J.
et al. (2001). Recovery from psychotic illness: A 15- and 25-year
international follow-up study. British Journal of Psychiatry, 178,
506517.
Hopper, K., & Wanderling, J. (2000). Revisiting the developed versus
developing country distinction in course and outcome in schizophrenia: Results from ISoS, the WHO collaborative followup project, International Study of Schizophrenia. Schizophrenia Bulletin,
26, 835846.
Jablensky, A., Sartorius, N., Ernberg, G., Anker, M., Korten, A.,
Cooper, J. E. et al. (1992). Schizophrenia: Manifestations, incidence and course in different cultures: A World Health Organization
ten-country study. Psychological Medicine Monograph, Supplement 20. Cambridge, UK: Cambridge University Press.
Kendell, R. E. (2001). The distinction between mental and physical illness. British Journal of Psychiatry, 178, 490490.
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M.,
Eshlerman, S. et al. (1994). Lifetime and 12-month prevalence of
DSM-III-R psychiatric disorders in the United States. Archives of
General Psychiatry, 51, 819.
Kirmayer, L. J., & Groleau, D. (2001). Affective disorders in cultural
context. Psychiatric Clinics of North America, 24, 465478.
Kirmayer, L. J., & Young, A. (1998). Culture and somatization: Clinical,
epidemiological, and ethnographic perspectives. Psychosomatic
Medicine, 60, 420430.
Kleinman, A. (1977). Depression, somatization and the new crosscultural psychiatry. Social Science & Medicine, 11, 310.
Kleinman, A. (1982). Neurasthenia and depression: A study of somatization and culture in China. Culture, Medicine & Psychiatry, 6,
117190.
Mental Disorders
Kleinman, A. (1986). Social origins of Distress and disease:
Depression, neurasthenia, and pain in modern China. New Haven,
CT: Yale University Press.
Kleinman, A. (1988). Rethinking psychiatry: Cultural category to personal experience. New York: Free Press.
Kleinman, A. (1996). China: The epidemiology of mental illness.
British Journal of Psychiatry, 169, 129130.
Kleinman, A., & Cohen, A. (2000). A global view of depression from
an anthropological perspective. In A. Dawson & A. Tylee (Eds.),
Depression: Social and economic timebomb (pp. 1115). London:
BMJ Books.
Kleinman, A., & Good, B. (1985). Culture and depression: Studies in
the anthropology and cross-cultural psychiatry of affect and disorder. Berkeley: University of California Press.
Koegel, P., & Edgerton, R. B. (1984). Black six-hour retarded
children as young adults. Monographs of the American
Association on Mental Deficiency, (6), 145171.
Kraepelin, E. (2000). Comparative psychiatry. In R. Littlewood &
S. Dein (Eds.), Cultural psychiatry & medical anthropology: An
introduction and reader (pp. 3842). London: Athlone Press.
(Original work published 1904).
Kroeber, A. L. (1940). Psychotic factors in shamanism. Character and
Personality, 8, 204215.
Kulhara, P., & Chakrabarti, S. (2001). Culture and schizophrenia and
other psychotic disorders. Psychiatric Clinics of North America,
24, 449464.
Lee, S. (1999). Diagnosis postponed: Shenjing shuairuo and the transformation of psychiatry in post-Mao China. Culture, Medicine &
Psychiatry, 23, 349380.
Lee, S. (2002). Socio-cultural and global health perspectives for the development of future psychiatric diagnostic systems. Psychopathology,
35, 152157.
Lin, K.-M., & Kleinman, A. M. (1988). Psychopathology and clinical
course of schizophrenia: A cross-cultural perspective.
Schizophrenia Bulletin, 14, 555567.
Lin, T. Y. (1953). A study of incidence of mental disorders in Chinese
and other cultures. Psychiatry, 16, 313336.
Lin, T.-Y., Tardiff, K., Donetz, G., & Goresky, W. (1978). Ethnicity and
patterns of help-seeking. Culture, Medicine & Psychiatry, 2, 313.
Littlewood, R., & Dein, S. (Eds.). (2000). Cultural psychiatry & medical anthropology: An introduction and reader. London: Athlone
Press.
Manson, S. M. (1995). Culture and major depression: Current challenges in the diagnosis of mood disorders. Psychiatric Clinics of
North America, 18, 487501.
Manson, S. M., Shore, J. H., & Bloom, J. D. (1985). The depressive
experience in American Indian communities: A challenge for psychiatric theory and diagnosis. In A. Kleinman & B. Good (Eds.),
Culture and depression: Studies in the anthropology and crosscultural psychiatry of affect and disorder (pp. 331368). Berkeley:
University of California Press.
Mead, M. (2001). Coming of age in Samoa: A psychological study of
primitive youth for western civilisation. New York: Perennial
Classics.
Murphy, H. B. M., & Raman, A. C. (1971). The chronicity of schizophrenia in indigenous tropical peoples: Results of a twelve-year
follow-up survey in Mauritius. British Journal of Psychiatry, 118,
489497.
Background
493
Mental Retardation
F. John Meaney
BACKGROUND
Perhaps no phrase in any language produces in sum more
anxiety, controversy, fear, hopelessness, and stigma, at
least in Western societies, as mental retardation or a
similar phrase for intellectual disability. We live in a world
that cultivates and sells perfection, and while this might be
494
Mental Retardation
OF
495
496
Mental Retardation
THE EPIDEMIOLOGY
OF
MR
It is critical at the onset of a discussion of the epidemiology of MR to remind ourselves again that we are dealing
with a concept that is culturally based. How we define
MR and the tools we use to determine if an individual is
considered to have MR are by and large determined by
the majority culture in any society. Therefore, when we
conduct surveillance and epidemiological research,
we are assessing an outcome that is administrative in
nature in the sense that we are usually bound by the measurement tools that we know have cultural biases. This is the
ultimate limiting factor in any population studies of MR.
Prevalence
Routine surveillance systems for the collection of
population-based data from which to estimate prevalence
rates for MR are still not abundant across the world.
However, advancing computer technology and new possibilities for record linkage and data handling by Internet
websites are likely to improve epidemiologic studies of
MR in the future (Leonard & Wen, 2002). In the United
The Epidemiology of MR
Etiology
Mental retardation has been described in some recent
epidemiological reviews as a heterogeneous group of
conditions or disorders (Murphy, Boyle, Schendel,
Decoufl, & Yeargin-Allsopp, 1998) or group of conditions (Leonard & Wen, 2002). Current thinking about
human diseases stresses the need to move away from the
old ways of viewing nature versus nurture or some disease entity as the result of genetics or environment
toward a view that emphasizes that all diseases are likely
to be both genetic and environmental (Khoury, 1998). This
way of thinking gets us away from the typological thinking that seems to beset categorization of MR into groups
of conditions of prenatal, perinatal, or postnatal origin as
used currently. Applying this current view, perhaps MR is
best defined as an outcome of variable causes that can be
assessed along multiple dimensions, but is typically evaluated through measures of cognitive or intellectual functioning. In this manner, we can consider MR in general as
a multifactorial outcome for which multiple genes and
gene complexes are involved and numerous environmental
exposures interact with the underlying genetic factors.
Mental retardation is associated with numerous syndromes
for which genetic causes have been identified and/or environmental exposures that at least theoretically are thought
to interact with genetic factors to produce the outcome.
Another aspect to this thinking about MR is that we
apply the concepts so eloquently presented by Richard
Lewontin and his colleagues several decades ago
(Feldman & Lewontin, 1975; Lewontin, 1974). In a series
of publications in which the heritability of IQ was considered, Lewontin reminded us that we cannot estimate
what percent of a persons phenotype, such as height, is
the result of genes and what percent is environmental.
Lewontin stressed that these traits are studied in populations when we are attempting to assess how much of the
variation in a trait is the result of variability among
genetic backgrounds, namely genotypes, and how much
is of environmental origin. Similarly, we cannot say that
497
Population Differences
Whenever population comparisons are made for the
prevalence of MR, the methods by which populations are
delineated must be carefully considered. Most studies of
population differences for MR represent attempts to use
existing categorizations of populations, for example
racial and ethnic groups, such as those by the U.S. Census
Bureau, to compare rates of occurrence. At best these
populations represent a mix of underlying genetic and
environmental-based factors that are difficult to decipher
as to their contributions to the group differences.
Recent studies in the U.S. populations have demonstrated higher prevalence rates of MR for children of
African American ancestry than for other groups (Croen,
Grether, & Selvin, 2001; Murphy, Yeargin-Allsopp,
Decoufl, & Drews, 1995; Yeargin-Allsopp, Drews,
Decoufl, & Murphy, 1995), even after taking into account
certain socioeconomic and demographic variables in one
study (Yeargin-Allsopp et al., 1995). Similar betweenpopulation variation in rates of MR have been seen
elsewhere (e.g., in AustraliaLeonard & Wen, 2002).
Explanations for population differences have been summarized by Leonard and Wen (2002) and include the possibility of confounding variables, community factors such as
segregation and social disadvantage, cultural differences
that result in variable behavior among groups and use of
assessments of intellectual function that are not appropriate,
and prenatal or postnatal factors such as maternal conditions that could increase the risk of MR in specific groups.
When making any cross comparisons among populations,
such as international comparisons, issues involving the
methods used among systems to obtain data also need to be
considered (Durkin, 2002; Leonard & Wen, 2002).
498
GENETIC FACTORS
Mental Retardation
IN
MR
ENVIRONMENTAL FACTORS
IN
MR
Epidemiological Data
When dealing with the etiologies or risk factors for MR,
epidemiologists will generally categorize them by the
Environmental Factors in MR
499
Cultural Factors
Culture is certainly an important factor in how families
cope with having a member with MR and eventually
adapt through modification of individual and familial
behaviors. A rich literature has developed during the last
15 years concerning the stress experienced by families in
multiple cultures when a family member has a developmental disability such as MR. Psychological stress and
depression, and their correlates, have been studied in
Hispanic families (Blacher, Shapiro, Lopez, Diaz, &
Fusco, 1997; Magaa, 1999), Chinese families of a child
with Down syndrome (Cheng & Tang, 1995), Malaysian
mothers of children with MR, including some of Chinese
ethnicity (Ong, Chandran, & Peng, 1999), and African
American, Hispanic, and European American mothers of
children with disabilities (Mary, 1990). These data
demonstrate substantial evidence of the influence of cultural values and behaviors in adjustments of families.
Mary (1990) reported more feelings of self-sacrifice
among Hispanic mothers and more instances of spouse
denial in this group. Magaa (1999) showed that some
aspects of familism, an array of family caregiving, social
support, and obligatory behaviors, were protective of the
emotional well-being of Puerto Rican mothers of an adult
with MR. Blacher et al. (1997) suggested that it was
problems in the functioning of families that were the
best predictors of depression among Latino mothers in
500
Mental Retardation
ISSUES IN INTERVENTION
SERVICES FOR MR
AND
Family Supports
The family supports movement has seen great progress in
the last 20 years and continues to be a major emphasis
in the activities and funding concerning services for families of individuals with developmental disabilities.
Evaluation studies of interventions with families have
appeared in the literature of the 1990s (e.g., Davis &
Rushton, 1991), including evaluation specifically for
early intervention programs (Guralnick, 1997). The
Davis and Rushton (1991) study is of interest in that it
was cross-cultural, including both English-speaking (presumably of British ancestry) and Bangladeshi families in
London and used randomly assigned controls. The study
demonstrated positive effects for both families and children of a home-based, family counseling intervention,
with more marked effects in the Bangladeshi families,
who presumably benefited greatly from the counseling by
same-culture parent advisors.
A number of studies have appeared that review the
experiences of different cultural groups with family support activities. Shapiro and Simonsen (1994) reviewed
Disparities in Services
It has become apparent that healthcare for individuals with
developmental disabilities, as well as other services, is not
on a par with services for the non-disabled population.
The U.S. Surgeon Generals recent report (U.S. Public
Health Service, 2001) highlights the multiple problems in
this regard in the United States. The disparities cover the
entire lifespan, including in the United States residential
care/assisted living and nursing homes (Howard, Sloane,
Zimmerman, Eckert, Walsh et al., 2002). The sense among
those who work in the developmental disabilities fields in
other nations, even those with national healthcare systems,
is that there are gaps in the delivery of healthcare services
for individuals with developmental disabilities. For example, Bollard (1999) has reviewed the situation in the
United Kingdom with respect to primary healthcare delivery and concludes that the community learning disability
teams in collaboration with practicing nurses could
address some of the gaps in services.
Increasingly there are studies being done regarding
the costs of services for individuals with developmental
disabilities. A recent analysis of the Hawaii Medicaid feefor-service program demonstrated that profound MR was
among the 10 leading diagnostic categories in terms of
payments for healthcare (dollar volume for FY1999),
ranking fourth (Loke, Kang-Kaulupali, & Honbo, 2001).
Studies like these underscore the sense of cultural dissonance between the developmental disabilities communities
501
International Data
There is a growing literature on key issues in developmental disabilities from an international and multicultural
perspective. These issues include such areas of concern as
transition to adulthood, social integration, quality of life
(QoL), and education, among others. There are many
signs of changing attitudes and perspectives on an international basis. New initiatives in the special education
system in China toward integrating children with developmental disabilities into mainstream classes in local
schools (Deng & Manset, 2000) are a prime example of
these changes. Transition from late adolescence to early
adulthood is probably an area in need of more research
from a multicultural perspective. Recently Blacher (2001)
has stressed the need for more research to evaluate successes in this difficult transition period and the variables
that provide the strongest prediction of success, including
cultural attitudes and beliefs. Social integration of
individuals with MR from a cultural perspective has been
assessed at both the community (Calvez, 1993) and
national levels (Pedlar, 1990). Both studies point to limitations in the achievement of full integration into society.
Finally, measures of QoL for individuals with developmental disabilities, including more subjective realms of
assessment, have received much attention during the
1990s. An international comparison of individuals with
MR from a northern Italian community with a sample
from an Australian community as well as samples from
the general populations of both communities (Verri,
Cummins, Petito, Vallero, Monteath et al., 1999) showed
that scores on a standard index of QoL were similar
among the groups. The data did confirm that individuals
with milder MR could report on subjective QoL quite adequately. More research is needed along these lines, as well
as increased international comparisons and multicultural
research on important issues in developmental disabilities.
502
Mental Retardation
SUMMARY
AND
FUTURE PERSPECTIVES
The need remains for more research from an anthropological perspective on disabilities such as MR. Current
research supports the concept of disability as a sociocultural construct. Progress has been made in recent years in
considering cultural variation as a key factor in how families react and cope when a member has MR and how to
implement effective interventions and services. Research
into the causes of MR continues to make tremendous
progress through both epidemiological and genetic
studies that promise to contribute to improvements in the
prevention and treatment of MR.
Parmenter (2001) has recently contributed an interesting overview of the contributions of scientific studies
to developments in community inclusion for individuals
with MR. From his assessment of the literature over the
last 25 years or so, he perceives a growth in multiparadigmatic thinking and a less rigid way of conceptualizing
the nature of reality (p. 191). In his view, the challenge
to the community of researchers for the next century is
for a greater collaboration between researchers, policy
planners, and the people most deeply affectedthe
persons with an intellectual disability, their families and
carers (p. 191). The call for researchers to collaborate
more intensively comes at a time when, if anything, subspecialization in the sciences has intensified and at least
within scientific communities the ease with which such
collaboration gets done has all but disappeared in some
university communities as competition and scarce
References
ACKNOWLEDGMENTS
This work was supported in part by grant # 90DD0532/01 from the
Administration on Developmental Disabilities. The author would also
like to acknowledge the assistance provided by Mary M. Meaney and
Carolyn Henley in tracking down references and commenting on earlier
drafts of the paper. The manuscript benefited immensely from the
503
critical eye of Chris Cunniff, M. D. Any errors in factual knowledge
despite the assistance are the sole responsibility of the author.
REFERENCES
American Association on Mental Retardation (2002a). Mental retardation: Definition, classification, and systems of supports. Washington,
DC: Author.
American Association on Mental Retardation (2002b). Definition of
mental retardation. http://www. aamr.org/Policies/faq_mental_
retardation.shtml
American Psychological Association (1990). Guidelines for providers
of psychological services to ethnic, linguistic, and culturally
diverse populations. Washington, DC: Author
Bailey, D. B., Jr., Skinner, D., Correa, V., Arcia, E., Reyes-Blanes, M. E.,
Rodriguez, P. et al. (1999). Needs and supports reported by Latino
families of young children with developmental disabilities.
American Journal on Mental Retardation, 104, 437451.
Baker, E., Hinton, L., Callen, D. F., Altree, M., Dobbie, A., Eyre, H. J.
et al. (2002). Study of 250 children with idiopathic mental retardation reveals nine cryptic and diverse subtelomeric chromosome
anomalies. American Journal of Medical Genetics, 107, 285293.
Benassi, G., Guarino, M., Cammarata, S., Cristoni, P., Fantini, M. P.,
Ancona, A. et al. (1990). An epidemiological study on severe mental retardation in Bologna, Italy. Developmental Medicine and
Child Neurology, 32, 895901.
Blacher, J. (2001). Transition to adulthood: Mental retardation, families,
and culture. American Journal on Mental Retardation, 106, 173188.
Blacher, J., Shapiro, J., Lopez, S., Diaz, L., & Fusco, J. (1997).
Depression in Latina mothers of children with mental retardation:
A neglected concern. American Journal on Mental Retardation,
101, 483496.
Bollard, M. (1999). Improving primary health care for people with
learning disabilities. British Journal of Nursing, 8, 12161221.
Bower, C., Leonard, H., & Petterson, B. (2000). Intellectual disability
in Western Australia. Journal of Paediatrics and Child Health, 36,
213215.
Boyle, C. A., Yeargin-Allsopp, M., Doernberg, N. S., Holmgreen, P.,
Murphy, C. C., & Schendel, D. E. (1996). Prevalence of selected
developmental disabilities in children 310 years of age: The
Metropolitan Atlanta Developmental Disabilities Surveillance
Program, 1991. Morbidity and Mortality Weekly Report, 45, 114.
Brockley, J. A. (1999). History of mental retardation: An essay review.
History of Psychology, 2, 2536.
Calvez, M. (1993). Social interactions in the neighborhood: Cultural
approach to social integration of individuals with mental retardation. Mental Retardation, 31, 418423.
Centers for Disease Control and Prevention. (1996). Postnatal causes of
developmental disabilities in children aged 310 yearsAtlanta,
Georgia 1991. Morbidity and Mortality Weekly Report, 45, 130136.
Centers for Disease Control and Prevention. (2002). How common is
mental retardation? http://www. cdc.gov/ncbddd/dd/ddmr.htm.
Cheng, P., & Tang, C. S. (1995). Coping and psychological distress of
Chinese parents of children with Down syndrome. Mental
Retardation, 33, 1020.
504
Croen, L. A., Grether, J. K., & Selvin, S. (2001). The epidemiology of
mental retardation of unknown cause. Pediatrics, 107:E86.
Davis, H., & Rushton, R. (1991). Counselling and supporting parents of
children with developmental delay: A research evaluation. Journal
of Mental Deficiency Research, 35, 89112.
Deng, M., & Manset, G. (2000). Analysis of the learning in regular classrooms movement in China. Mental Retardation, 38,
124130.
Devlieger, P. J. (1999). From handicap to disability: Language use and
cultural meaning in the United States. Disability and Rehabilitation,
21, 346354.
Drews, C. D., Murphy, C. C., Yeargin-Allsopp, M., & Decoufl, P.
(1996). The relationship between idiopathic mental retardation and
maternal smoking during pregnancy. Pediatrics, 97, 547553.
Durkin, M. (2002). The epidemiology of developmental disabilities in
low-income countries. Mental Retardation and Developmental
Disabilities Research Reviews, 8, 206211.
Dyer-Friedman, J., Glaser, B., Hessl, D., Johnston, C., Huffman, L. C.,
Taylor, A. et al. (2002). Genetic and environmental influences on
the cognitive outcomes of children with fragile X syndrome.
Journal of the Academy of Child and Adolescent Psychiatry, 41,
237244.
Dykens, E. M., & Hodapp, R. M. (2001). Research in mental retardation: Toward an etiologic approach. Journal of Child Psychology
and Psychiatry, 42, 4971.
Feldman, M. W., & Lewontin, R. C. (1975). The heritability hang-up.
Science, 190, 11631168.
Fernald, C. D. (1995). When in London : Differences in disability
language preference among English-speaking countries. Mental
Retardation, 33, 99103.
Flint, J., & Wilkie, A. O. M. (1996). The genetics of mental retardation.
British Medical Bulletin, 52, 453464.
Frison, S. L., Wallander, J. L., & Browne, D. (1998). Cultural factors
enhancing resilience and protecting against maladjustment in
African American adolescents with mild mental retardation.
American Journal on Mental Retardation, 102, 613626.
Gelb, S. A. (1997). The problem of typological thinking in mental retardation. Mental Retardation, 35, 448457.
Gonzalez-Gordon, R. G., Salvador-Carulla, L., Romero, C., GonzalezSaiz, F., & Romero, D. (2002). Feasibility, reliability and validity of
the Spanish version of the Psychiatric Assessment Schedule for
Adults with Developmental Disability: A structured psychiatric
interview for intellectual disability. Journal of Intellectual Disability
Research, 46, 209217.
Groce, N. (1999). Disability in cross-cultural perspective: Rethinking
disability. The Lancet, 354, 756757.
Groce, N., & Scheer, J. (1990). Introduction. Anthropology and
disability [Special issue]. Social Science & Medicine, 30, vvi.
Guralnick, M. J. (1997). The effectiveness of early intervention.
Baltimore: P.H. Brookes.
Halfon, N., & Newacheck, P. W. (1999). Prevalence and impact of
parent-reported disabling mental health conditions among U.S.
children. Journal of the American Academy of Child and
Adolescent Psychiatry, 38, 600609.
Heller, T., Markwardt, R., Rowitz, L., & Farber, B. (1994). Adaptation
of Hispanic families to a member with mental retardation.
American Journal on Mental Retardation, 99, 289300.
Mental Retardation
Hou, J. W., Wang, T. R., & Chuang, S. M. (1998). An epidemiological
and aetiological study of children with intellectual disability in
Taiwan. Journal of Intellectual Disability Research, 42, 137143.
Howard, D. L., Sloane, P. D., Zimmerman, S., Eckert, J. K.,
Walsh, J. F., Buie, V. C. et al. (2002). Distribution of African
Americans in residential care/assisted living and nursing homes:
More evidence of racial disparity? American Journal of Public
Health, 92, 12721277.
Institute on Community Integration, University of Minnesota. (2000).
Prevalence of mental retardation and/or developmental disabilities: Analysis of the 1994/1995 NHIS-D. MR/DD Data Brief,
2, 111.
Khoury, M. J. (1998). Genetic and epidemiologic approaches to the
search for geneenvironment interaction: The case of osteoporosis
[Comment]. American Journal of Epidemiology, 147, 12.
Khoury, M. J., Burke, W., & Thomson, E. J. (2000). Genetics and public health: A framework for the integration of human genetics into
public health practice. In M. J. Khoury, W. Burke, & E. J. Thomson
(Eds.), Genetics and public health in the 21st century: Using
genetic information to improve health and prevent disease
(pp. 323). New York: Oxford University Press.
Leonard, H., & Wen, X. (2002). The epidemiology of mental retardation: Challenges and opportunities in the new millennium. Mental
Retardation and Developmental Disabilities Research Reviews, 8,
117134.
Lewontin, R. C. (1974). Annotation: The analysis of variance and the analysis of causes. American Journal of Human Genetics, 26, 400411.
Loke, M., Kang-Kaulupali, K. T., & Honbo, L. (2001). A profile of
Hawaiians in the Medicaid fee-for-service program. Pacific Health
Dialogue, 8, 322326.
Longmore, P. K. (1987). Uncovering the hidden history of people with
disabilities. Reviews in American History, 15, 355364.
MacMillan, D. L., Gresham, F. M., & Siperstein, G. N. (1993).
Conceptual and psychometric concerns about the 1992 AAMR
definition of mental retardation. American Journal on Mental
Retardation, 98, 325335.
Magaa, S. M. (1999). Puerto Rican families caring for an adult with
mental retardation: Role of familism. American Journal on Mental
Retardation, 104, 466482.
Mallon, J. R., MacKay, D. N., McDonald, G., & Wilson, R. (1991). The
prevalence of severe mental handicap in Northern Ireland. Journal
of Mental Deficiency Research, 35, 6672.
Mary, N. L. (1990). Reactions of black, Hispanic, and white mothers to
having a child with handicaps. Mental Retardation, 28, 15.
McDermott, S., Daguise, V., Mann, H., Szwejbka, L., & Callaghan, W.
(2001). Perinatal risk for mortality and mental retardation associated with maternal urinary-tract infections. Journal of Family
Practice, 50, 433437.
McKusick-Nathans Institute for Genetic Medicine, Johns Hopkins
University (Baltimore, MD) and National Center for Biotechnology Information, National Library of Medicine (Bethesda,
MD) (2000). Online Mendelian Inheritance in Man, OMIM (TM).
Retrieved October 2000 from http://www.ncbi. nlm.nih.gov/omim/
Meaney, F. J. (2001). Introduction: Birth defects surveillance in the
United States. Teratology, 64 (Suppl. 1), S1S2.
Miller, L., Tolliver, R., Druschel, C., Fox, D., Schoellhorn, J.,
Podvin, D. et al. (2002). Fetal alcohol syndromeAlaska,
References
Arizona, Colorado, and New York, 19951997. Morbidity and
Mortality Weekly Report, 51, 433435.
Miltiades, H. B., & Pruchno, R. (2002). The effect of religious coping
on caregiving appraisals of mothers of adults with developmental
disabilities. The Gerontologist, 42, 8291.
Murphy, C. C., Boyle, C., Schendel, D., Decoufl, P., & YearginAllsopp, M. (1998). Epidemiology of mental retardation in
children. Mental Retardation and Developmental Disabilities
Research Reviews, 4, 613.
Murphy, C. C., Yeargin-Allsopp, M., Decoufl, P., & Drews, C. D.
(1995). The administrative prevalence of mental retardation in
10-year-old children in metropolitan Atlanta, 1985 through 1987.
American Journal of Public Health, 85, 310323.
Nygaard, E., Smith, L., & Torgerson, A. M. (2002). Temperament in
children with Down syndrome and in prematurely born children.
Scandinavian Journal of Psychology, 43, 6171.
Ong, L. C., Chandran V., & Peng, R. (1999). Stress experienced by
mothers of Malaysian children with mental retardation. Journal of
Paediatrics and Child Health, 35, 358362.
Oswald, D. P., Coutinho, M. J., Best, A. M., & Nguyen, N. (2001).
Impact of sociodemographic characteristics on the identification
rates of minority students as having mental retardation. Mental
Retardation, 39, 351367.
Parmenter, T. R. (2001). The contribution of science in facilitating the
inclusion of people with intellectual disability into the community.
Journal of Intellectual Disability Research, 45, 183193.
Pedlar, A. (1990). Normalization and integration: A look at the Swedish
experience. Mental Retardation, 28, 275282.
Plank, G. A. (2001). Application of the cross battery approach in the
assessment of American Indian children: A viable alternative.
American Indian and Alaska Native Mental Health Research, 10,
2133.
Plomin, R., & Petrill, S. A. (1997). Genetics and intelligence: Whats
new? Intelligence, 24, 5377.
Reiss, S. (1994). Issues in defining mental retardation. American
Journal on Mental Retardation, 99, 17.
Rio, M., Molinari, F., Heuertz, S., Ozilou, C., Gosset, P., Raoul, O.
et al. (2002). Automated fluorescent genotyping detects 10%
of cryptic subtelomeric rearrangements in idiopathic syndromic
mental retardation. Journal of Medical Genetics, 39, 266270.
Roeleverd, N., Zielhuis, G. A., & Gabreels, F. (1997). The prevalence
of mental retardation: A critical review of recent literature.
Developmental Medicine and Child Neurology, 39, 125132.
Rogers-Dulan, J. (1998). Religious connectedness among urban African
American families who have a child with disabilities. Mental
Retardation, 36, 91103.
Ryan, J. J., Dai, X., Paolo, A. M., & Harrington, R. G. (1992). Factor
analysis of the Chinese WAIS with persons who have mental retardation. American Journal on Mental Retardation, 97, 111114.
505
Schaefer, G. B., & Bodensteiner, J. B. (1992). Evaluation of the child
with idiopathic mental retardation. Pediatric Clinics of North
America, 39, 929943.
Shapiro, J., & Simonsen, D. (1994). Educational/support group for
Latino families of children with Down syndrome. Mental
Retardation, 32, 403415.
Shin, J. Y. (2002). Social support for families of children with mental
retardation: Comparison between Korea and the United States.
Mental Retardation, 40, 103118.
Simeonsson, R. J., Chen, J., & Hu, Y. (1995). Functional assessment of
Chinese children with the ABILITIES index. Disability and
Rehabilitation, 17, 400410.
Skinner, D. G., Correa, V., Skinner, M., & Bailey, D. B., Jr. (2001). Role
of religion in the lives of Latino families of young children with
developmental delays. American Journal on Mental Retardation,
106, 297313.
Slone, M., Durrheim, K., Lachman, P., & Kaminer, D. (1998).
Association between the diagnosis of mental retardation and
socioeconomic factors. American Journal on Mental Retardation,
102, 535546.
Tombokan-Runtukahu, J., & Nitko, A. J. (1992). Translation, cultural
adjustment, and validation of a measure of adaptive behavior.
Research in Developmental Disabilities, 13, 481501.
US Public Health Service (2001). Closing the gap: A national blueprint
for improving the health of individuals with mental retardation.
(Report of the US Surgeon Generals Conference on Health
Disparities and Mental Retardation). Washington, DC: Author.
Verri, A., Cummins, R. A., Petito, F., Vallero, E., Monteath, S.,
Gerosa, E. et al. (1999). An ItalianAustralian comparison of
quality of life among people with intellectual disability living in
the community. Journal of Intellectual Disability Research, 43,
513522.
Westbrook, M. T., Legge, V., & Pennay, M. (1993). Attitudes towards
disabilities in a multicultural society. Social Science & Medicine,
36, 615623.
Yeargin-Allsopp, M. Y., Drews, D. C., Decoufl, P., & Murphy, D. D.
(1995). Mild mental retardation in black and white children in metropolitan Atlanta: A case control study. American Journal of
Public Health, 85, 324328.
Yeargin-Allsopp, M. Y., Murphy, C. C., Oakley, G. P., Sikes, R. K., &
the Metropolitan Atlanta Developmental Disabilities Study Staff
(1992). A multiple-source method for studying the prevalence of
developmental disabilities in children: The Metropolitan Atlanta
Developmental Disabilities Study. Pediatrics, 89, 624630.
506
INTRODUCTION
The sudden death of an infant under one year of age which
remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death
scene, and a review of the clinical history.
Willinger, 1989, p. 73.
There is no such thing as a baby, there is a baby and someone.
D. Winnicott
For species such as primates, the mother is the environment.
Sarah Blaffer Hrdy, 1999.
In Western industrialized societies pediatric health professionals generally encourage child care practices
believed to foster social and biological independence in
their infants, as early in life as possible. Birth is commonly viewed as the moment in which the newborn
becomes an independent being from the mother, since the
mothers body is seen no longer to directly regulate the
infants physiology through the placenta. In these cultures
the establishment of early infant/child independence is
the developmental goal, autonomy the desired outcome
(McKenna, 2002; Trevathan & McKenna, 1994; Young &
Fleming, 1998).
An important question raised by anthropological
studies, however, is whether historically recent recommended child care patterns that emerge from this view
presume infants to be more physiologically independent
from their caregivers than they actually are. By ignoring
the infants evolutionary history, such as a human infants
innate need for frequent night-time breast feeds and
maternal contact, are critical aspects of the infants biology being mismatched with rapidly changing patterns of
infant care that ultimately deprive the infant of needed if
not critical external regulatory maternal stimuli and support (LeVine, Dixon, & LeVine, 1994; Lipsitt, 1981;
Lozoff, 1982; Lozoff & Brittenham, 1979; McKenna,
1992, 2001, 2002; Montago, 1978).
507
508
2.0
100
1.8
SIDS rate
% BS> 5hrs
80
1.6
1.4
60
1.0
0.8
40
0.6
0.4
20
0.2
Figure 1. SIDS rates (1995) and the prevalence of bedsharing 5 h per night across cultures.
(Source: Nelson et al. (2001). Early Human Development, 62, 4355.)
Istanbul
Buenos Aires
Dublin
Odessa
Scotland
Dunedin
Hannover
Graz
HK caucasian
Brisbane
Vienna
Manitoba
Hungary
Copenhagen
Naples
Tokyo
Hong Kong
Stockholm
Beijing
Santiago
0
Chongquing
0.0
SIDS rate
1.2
509
AND
510
511
SIDS RATES
ACROSS
CULTURES
512
the national SIDS rate in Japan is 0.3 per 1,000 live births
(see McKenna, 2002, for data). These data do not, of
course, prove that co-sleeping is protective against SIDS.
It may well be that SIDS is under-reported in Japan, or
that it is misdiagnosed as infantile suffocation. Japanese
medical scientists have not participated in international
SIDS research studies to the extent that American and
European scientists have, so the postmortem procedures
they employ to identify SIDS may not be appropriate.
Nevertheless, these low SIDS rates deserve explanation
and further research.
In 1985, Davies reported on the rarity of SIDS in
Hong Kong. He used postmortem diagnostic protocols
that, on review for a follow-up study by Lee et al. (1989),
were judged comparable with Western diagnostic standards by John Emery, a renowned SIDS researcher from
Great Britain. Davies found that even in a context of
poverty and overcrowded conditions, where the incidence
of SIDS should be high, the rates were 0.036 per 1,000 live
births, or approximately 5070 times less common than in
Western societies. This finding is even more surprising
because breast feeding is not common (of 175 infants at 2,
4, and 6 months of age, the percentage of infants nursing
was 9%, 4%, and 2%, respectively), although co-sleeping
and the supine sleep position for infants represent the
cultural norm.
Davies proposed that proximity to the parent while
the infant is asleep may be one reason why the rates are
so low, as well as the typical (supine) sleeping position of
Chinese infants. The author asked whether the possible
influences of life style and caretaking practices in cot
death are being underestimated in preference for more
exotic and esoteric explanations (Davies, 1985)a
viewpoint not unlike that of Azaz et al. (1992) and Emery
(1983), who also implicate, for some English infants, the
importance of caregiving environments and other behavioralsocioeconomic factors. A follow-up on Davies
work by Lee et al. (1989) confirms the relative rarity of
cot deaths in Hong Kong, finding a slightly higher rate of
deaths per 1,000 live births (0.3, compared with
0.04/1,000 reported by Davies).
A third study confirmed the rarity of SIDS in infants
of Asian origin living in England and Wales, particularly
infants of mothers born in India and Bangladesh, but also
infants of mothers with African origins. As the authors
point out, Asian women have few illegitimate births, few
births at younger ages, and few of them smoke (Balarajan
et al., 1989)all of which seem to reduce the risks of
infants dying of SIDS. No mention was made of any possible differences in sleeping patterns that could explain
the lower SIDS rate among the Asian subgroup, although
it is likely that these infants were sleeping in proximity to
their parents.
These low SIDS rates continue in Asian ethnic groups
even after they immigrate to Western (non-co-sleeping)
cultures, where most continue their traditional caregiving
practices which include co-sleeping (Gantley, Davies, &
Murcott, 1993). One study reports that among five Asian
American subgroups living in California, the incidence of
SIDS ranged from a low of 0.9 deaths per 1,000 live births
to a high of 1.5 per 1,000. The variability was related
directly to the duration of residence in the United States: the
longer the group lived in the United States, the higher the
SIDS rates (Grether, Schulman & Croen, 1990), leading us
to ask if the trend toward higher SIDS rates reflects the
adoption of more American patterns of infant sleep management (i.e., solitary infant sleep), among other things.
Data from other industrial societies, among which at
least some general comparisons of SIDS rates can be
made, also tend to support the general hypothesis that
increased nocturnal contact between the parent and infant
may reduce the chances of SIDS among some infants. For
example, in cultures in which infants are less likely to
have their own room or in which infants are more likely
to be in close proximity to a parent during the night, SIDS
rates tend to be lower (Blair et al., 1999).
Most recently, the International SIDS Child Care
Study reports that some of the cultures in which either no
SIDS are reportedor its citizens are unaware of SIDSlike deathsare those cultures that report the highest
bed-sharing rates and other forms of co-sleeping, such as
room-sharing with parents, are the norm. Moreover, in
that same study, it is clear that many cultures that report
the lowest bed-sharing or room-sharing have the highest
SIDS (Nelson et al., 2001) (See Figure 1).
Even under the best of circumstances, admittedly
SIDS is difficult to diagnose. Because it is relatively rare,
and because postmortem procedures for identifying SIDS
are not necessarily standardized internationally, it is difficult to interpret differences in SIDS rates across cultures. Since parentinfant co-sleeping is hypothesized to
be relevant only to some subclasses of potential SIDS victims, proving the hypothesis becomes even more difficult.
In a series of sleep laboratory studies of mother
infant bed-sharing our research team studied normal
infant sleep in a context that attempted to match the
513
514
References
CONCLUSION
The causes of SIDS are complex. There is no one type of
SIDS death and, hence, there will never likely be just one
way to prevent it. While all types of research on SIDS
must, of course, continue, I argue here that regardless of
whatever the primary causes of SIDS prove to be, they
will only be understood alongside and in relation to the
515
REFERENCES
Anderson, G. C. (1991). Current knowledge about skin-to-skin (kangaroo) care for pre-term infants. Journal of Perinatology, 11, 21626.
Ariagno, R. L., & Glotzbach, S. F. (1991). Sudden infant death syndrome. In A. M. Rudolph (Ed.), Pediatrics (19th ed., pp. 850858).
Norwalk, CT: Appleton & Lange.
Azaz, Y., Fleming, P. J., Levine, M., McCabe, R., Stewart, A., &
Johanson, P. (1992). The relationship between environmental temperature, metabolic rate, sleep state and evaporative water loss in
infants from birth to three months. Pediatric Research, 32(4),
417 423.
Balarajan, R., Raleigh, V. S., & Botting, B. (1989). Sudden infant death
syndrome and postneonatal morality in immigrants in England and
Wales. British Medical Journal, 298, 716720.
Barnett, H. (1980). Sudden infant death syndrome. Child Health and
Human Development, U.S. Department of Health and Human
Services Bull.
Barone, M. (2002) How bedsharing calms infants. In J. McKenna (Ed.),
Mothering: Sleeping with baby (pp. 7275). Santa Fe, NM:
Mothering Magazine Inc.
516
Barry, H., III, & Paxson, L. M. (1971). Infancy and early childhood:
Cross-cultural codes. Ethology 10, 466508.
Blackwell, C. C., Saadi, A. T., Raza, M. W., Weir, D. M., & Busuttil, A.
(1993). The potential of bacterial toxins in sudden infant death syndrome (SIDS). International Journal of Legal Medicine, 105,
333338.
Blair, P. S., Fleming, P. J., Bensley, D., Smith, I., Bacon, C. et al. (1999).
Where should babies sleepalone or with parents? Factors influencing the risk of SIDS in the CESDI Study. British Medical
Journal, 319, 14571462.
Byard, R., & Krous, H. (Eds.). (2001). Sudden Infant Death Syndrome:
problems, puzzles, possibilities. London: Arnold.
Fleming, P. J., Blair, P., Bacon, C. (1996). Environments of infants during sleep and the risk of the sudden infant death syndrome: Results
of 19931995 case control study for confidential inquiry into
stillbirths and deaths in infancy. British Medical Journal, 313,
191195.
Davies, D. P. (1985). Cot death in Hong Kong: A rare problem? The
Lancet, 2, 13461348.
Douglas, J. (1989). Behaviour problems in young children. London:
Tavistock/Routledge.
Einspieler, C., Widder, J., Holzer, A., & Kenner, T. (1988). The predictive value of behavioral risk factors for sudden infant death. Early
Human Development, 18, 101109
Emery, J. L. (1983). A way of looking at the causes of crib death. In
J. T. Tildon, L. M. Roeder, & A. Steinschneider (Eds.), Sudden
Infant Death Syndrome (pp. 123132). New York: Academic Press.
Farooqi, S., Perry, I. J., & Beevers, D. G. (1991). Ethnic differences in
sleeping position and in risk of cot death. The Lancet, 338, 1455.
Field, T. (1995). Touch in early development. (Lawrence Earlbaum:
New Jersey
Fredrickson, D. D., Sorenson, J. F., & Biddle, A. K. (1993). Relationship
of sudden infant death syndrome to breast-feeding duration and
intensity. American Journal of Diseases of Children, 147, 460.
Gantley, M., Davies, D. P., & Murcott, A. (1993). Sudden infant death
syndrome: Links with infant care practices. British Medical
Journal, 306, 1620.
Gartner, L. (1997). Breast feeding and human milk. (Policy Statement:
American Academy of Pediatrics.) Pediatrics, 100(6), 10351039.
Gilbert, R. E., Wigfield, R. E., & Fleming, P. J. (1995). Bottle feeding
and the sudden infant death syndrome. British Medical Journal,
310, 8890.
Grether, J. K., Schulman, J., & Croen, L. A. (1990). Sudden infant death
syndrome among Asians in California. Journal of Pediatrics,
116(4), 525528.
Guntheroth, W. G., & Spiers, P. S. (1992). Sleeping prone and the risk
of sudden infant death syndrome. Journal of the American Medical
Association, 267, 23592363.
Harper, R. M., Leake, B., Hoffman, H., Walter, D. O., &
Hoppenbrouwers, T. (1981). Periodicity of sleep states is altered in
infants at risk for the sudden infant death syndrome. Science, 213,
10301032.
Hoffman, H., Damus, K., Hillman, L., & Krongrad, E. (1988). Risk
factors for SIDS: Results of the Institutes of Child Health and
Human Development SIDS cooperative epidemiological study. In
P. Schwartz, D. Southall, & M. Valdes-Dapena (Eds.), Sudden
Infant Death Syndrome: Cardiac and Respiratory mechanisms.
Annals of the New York Academy of Sciences, 533, 1330
References
Ludington-Hoe, S. M., Hosseini, R. B., Hashemi, M. S., Argote, L. A.,
Medellin, G., & Rey, H. (1992). Selected physiologic measures
and behavior during paternal skin contact with Colombian preterm
infants. Journal of Developmental Physiology, 18, 223232.
McCulloch. K., Brouillette. R. T., Guzetta, A. J., & Hunt, C. E. (1982).
Arousal responses in near-miss sudden infant death syndrome and
in normal infants. Journal of Pediatrics, 101, 911917.
McKenna, J. J. (1986). An anthropological perspective on the sudden
infant death syndrome (SIDS): The role of parental breathing cues
and speech breathing adaptations. [Special issue]. Medical
Anthropology, 10(1), 953.
McKenna, J. J. (1991). Researching the Sudden Infant Death Syndrome
(SIDS): The role of ideology in biomedical science. Stony Brook,
NY: State University of New York Research Foundation, New
Liberal Arts Monograph Service.
McKenna, J. J. (1992). Co-sleeping. In M. Carskaden (Ed.), Encyclopedia
of sleep and dreaming (pp. 143148). New York: Macmillan.
McKenna, J. J. (1995). The potential benefits of infantparent
co-sleeping in relation to SIDS prevention: Overview and critique
of epidemiological bed sharing studies. In T. O. Rognum (Ed.),
Sudden infant death syndrome: New trends in the nineties
(pp. 256265). Oslo: Scandinavian University Press.
McKenna, J. J. (2001) Part 1: Why we never ask, Is it safe for infants
to sleep alone? Historical origins of scientific bias in the bedsharing SIDS/SUDI debate. Academy of Breast Feeding and
Medicine, 7, 4, 3238.
McKenna, J. J. (2002). Breastfeeding & bedsharing: Still useful and
important after all these years. In Mothering Magazine, No. 114.
Mothering Magazine Inc: Santa Fe.
McKenna, J. J., & Bernshaw, N. (1995). Breast-feeding and co-sleeping
as adaptive strategies: Are they protective against SIDS? In
P. Stuart-Macadem & K. Dettwyler (Eds.), Bio-cultural aspects of
breast feeding. New York: de Gruyter.
McKenna, J. J., Loughlin, J., Carroll, J., Marcus, C., & Dekker, M.
(2000). Cultural influences on infant and childhood sleep biology
and the science that studies it: Toward a more inclusive paradigm.
In Sleep in development and pediatrics. New York:
McKenna, J. J., & Mosko, S. (2001). Motherinfant co-sleeping as
adaptation: A new scientific beginning. In R. Byard, & H. Krous
(Eds.), Sudden Infant Death Syndrome: Problems, puzzles, possibilities (pp. 259272) London: Arnold.
McKenna, J. J. (2002).
McKenna, J. J., Mosko, S., Dungy, C., & McAnich, J. (1990). Sleep and
arousal patterns of co-sleeping human motherinfant pairs: A preliminary physiological study with implications for the study of
sudden infant death syndrome (SIDS). American Journal of
Physical Anthropology, 83, 331347
McKenna, J. J., Mosko, S., & Richard, C. (1996). Bedsharing promotes
breast-feeding among Latino motherinfant pairs. Pediatric
Pulmonology, 20, 339.
McKenna, J. J., Thoman, E., Anders, T., Sadeh, A., Schechtman, V., &
Glotzbach, S. (1993). Infantparent co-sleeping in evolutionary
perspective: Imperatives for understanding infant sleep development and SIDS. Sleep, 16, 263282.
Mitchell, E. A., Stewart, A. W., Scragg, R., Ford, R. P. K., & Taylor, B. J.,
(1992). Ethnic differences in mortality from sudden infant death
syndrome in New Zealand. British Medicine Journal 306, S13S16.
Montagu, A. (1978). Touching. New York: Harper & Row.
517
Mosko, S., McKenna, J. J., Dickel, M., & Hunt, L. (1993). Parentinfant
co-sleeping: The appropriate context for the study of infant sleep
and implications for SIDS research. Journal of Behavioral
Medicine, 16, 589 610.
Mosko, S. Richard, C., McKenna, J. J., & Drummond, S. (1996a). Infant
sleep architecture during bedsharing and possible implications for
SIDS. Sleep, 19, 677 684.
Mosko, S., Richard, C., McKenna, J., Drummond, S., & Mukai, D.
(1997a). Maternal proximity and infant C02 environment during
bedsharing and possible implications for SIDS research. American
Journal of Physical Anthropology, 103, 315328.
Mosko, S., Richard, C., & McKenna, J. J. (1997b). Maternal sleep and
arousals during bedsharing with infants. Sleep, 20(2), 142150.
Mosko, S., Richard, C., McKenna, J. J., & Drummond, S. (1996b).
Infant sleep and arousals during bedsharing. Pediatric
Pulmonology, 20, 349.
Nelson, E. A. S., & Taylor, B. J. (2001). International child care practice
study: Infant sleeping environment. Early Human Development, 62,
4355.
Reite, M., & Capitanio, J. (1985). On the nature of social separation and
social attachment. In The psychobiology of attachment and
separation (pp. 223258). New York: Academic Press.
Reite, M., & Field, T. (Eds). (1985). The psychobiology of attachment
and separation. New York: Academic Press.
Reite, M., Harbeck, R., & Hoffman, A. (1981). Altered cellular immune
response following peer separation. Life Sciences, 29, 11331136.
Reite, M., Seiler, C., & Short, R. (1978). Loss of your mother is more than
loss of a mother. American Journal of Psychiatry, 135, 370371.
Reite, M., & Snyder, D. (1982). Physiology of maternal separation in a
bonnet macaque infant. American Journal of Primatology, 2,
115120.
Richard, C., Mosko, S., & McKenna, J. (1996). Sleeping position, orientation, and proximity in bedsharing infants and mothers. Sleep,
19(9), 685690.
Rognum, T. O. (Ed.). (1995). SIDS in the 90s. Oslo: Scandinavian
University Press.
Schwartz, P. J., & Sagatini, A. (1988). Cardiac innervation, neonatal
electrocardiology, and SIDS: A key for a novel preventive strategy.
Annals of New York Academy of Sciences, 533, 210220.
Scragg, R., Stewart, A. W., Mitchell, E. A., Ford, R. P. K., &
Thompson, J. M. D. (1995). Public health policy on bed sharing
and smoking in the sudden infant death syndrome. New Zealand
Medical Journal, 108, 218222.
Shannon, D. C., Kelly, D. H., & OConnell, K. (1977). Abnormal
regulation of ventilation in infants at risk for sudden infant death
syndrome. New England Journal of Medicine, 297, 747750.
Stewart, M. W., & Stewart, L. A. (1991). Modification of sleep respiratory patterns by auditory stimulation: Indications of a technique for
preventing sudden infant death syndrome? Sleep, 14(3), 241248.
Super, C., & Harkness, S. (1982). The infants niche in rural Kenya and
metropolitan America. In L. L. Adler (Ed.), Cross-cultural research
at issue (pp. 4755). New York: Academic Press.
Takeda, K. A. (1987). A possible mechanism of sudden infant death
syndrome (SIDS). Journal of Kyoto Prefective University of
Medicine, 96, 965968.
Tasaki, H., Yamashita, M., & Miyazaki, S. (1988). The incidence of
SIDS in Saga Prefecture (19811985). Journal of the Pediatric
Association of Japan, 92, 364368.
518
Tobacco Use
INTRODUCTION
TOBACCO
AND
HEALTH
519
OF
TOBACCO
520
Tobacco Use
521
522
commodity critical to the emergence of a global economy. Additionally, as Mintz (1985) points out, tobacco,
like other colonial products, including coffee, tea, chocolate, and sugar, were the drug foods that came to serve
as low-cost food substitutes for the laboring classes of
Europe during the rise of colonialism and the subsequent
rise of the capitalist mode of production. Increasing
the workers energy output and productivity, such substitutes figured importantly in balancing the accounts of
capitalism (Mintz, 1985, p. 148) by lowering the cost
of supporting a manual labor force while increasing
production.
This argument is tied also to the recognition that
with the rise of factory production, the lives of laboring
people were significantly transformed. Work shifted from
personal involvement in craft production or production
for personal consumption into segmented, often boring,
mass production under conditions that were alienating for
most workers. Under these circumstances, tobacco, and
the other items that formed the complex of drug foods
were so welcomed by workers they were hard to effectively legislate against, a pattern repeated in contemporary times with the current array of illicit mood-altering
substances.
Drug food substitutes such as tobacco also were of
critical importance in the colonial control of labor and
wealth outside of Europe. As Jankowiak and Bradburd
(1996, p. 718) have argued, in the colonial encounter
between Europeans and other societies throughout the
world, colonialists (e.g., traders, merchants, settlers, and
administrators) sought to dominate and expand the labor
productivity of indigenous peoples for the economic benefit of Europe. While, if necessary, military force was
used to achieve this end, inducing chemical dependence
on a substance such as tobacco was more efficient,
economical, [and] easier to sustain.
While, various drug foods were used to extract both
trade items and labor throughout the colonial realm, the
particular substance of greatest importance in any setting
differed. Thus, while alcohol was the dominant drug food
used to enhance the flow of goods to Europe from the
Indians of North America, in the island societies of the
Pacific Ocean tobacco reigned. In a cross-cultural review
of 19 Pacific societies, Jankowiak and Bradburd (1996)
found that in all but four (where alcohol or opium were
used) tobacco was the dominant drug food traded to
indigenous people in exchange for local horticultural and
other products. Resulting chemical dependence on tobacco
fueled subsequent exchange with and subordination to
Tobacco Use
ANTHROPOLOGICAL STUDIES
TOBACCO USE
OF
523
adolescent peer groups. Several studies show that smoking among adolescents, for example, is associated with
perceived approval for smoking in a valued peer network
(Green, 1979; Mittlemark, 1987). In her ethnographic
study of smoking among Puerto Rican adolescents in
Boston, McGraw (1989) strongly emphasizes an important cultural dimension of this behavior. She found that,
in fact, the physical impact of cigarette use may be the
least rewarding factor motivating consumption. Rather,
the primary appeal lies in the use of smoking as a behavioral mechanism to create new friendships or affirm
existing social connections.
While these examples are noteworthy, smoking still
does not appear to be a behavior especially fraught with
complex cultural meanings, especially for adults. Rather,
its primary message in everyday life in Western culture
appears to be the symbolic marking of either a time-out in
the middle of a course of action or work, especially one
that may be stressful or demanding (i.e., an equivalent to
a coffee break or because of feeling uptight), or to mark
the completion of a task or segment of the day (e.g., to
mark transition into a period of relaxation). Consequently,
to follow Blacks argument, anthropologists working in
other cultures often have not thought to look at smoking
as a topic of interest or one that can be tapped to reveal
rich cultural information. Of course, in some settings
smoking may be quite loaded symbolically and a topic
worthy of interest on these grounds, but it does not appear
that many anthropologists yet have explored this possibility. This is not to say anthropologists have ignored smoking completely, but only that they rarely have made it their
primary focus of research.
524
Tobacco Use
time, the Trobrianders view tobacco as a powerful substance that sorcerers use to attack their victims. Indeed,
almost all deaths are believed to be the work of a sorcerer
who has managed to chant magic spells into the victims
betel nut or tobacco. Weiner (1988) has recorded an
account of tobacco-related sorcery in which a sorcerer
gave an unbelieving Christian convert a cigarette to
smoke to prove his rejection of pre-Christian belief. Later
that night, the individual fell ill and died, affirming to all
the power of indigenous practice. Not surprisingly, people
in the Trobriands are very cautious about accepting
tobacco from powerful individuals who have knowledge
of sorcery. Among friends and relatives, however, smoking
together is a common social activity.
Among the Sambia of New Guinea, the largest island
in Melanesia, Herdt (1987, p. 71) notes the psychosocial
role of tobacco at the end of a day of toil in the gardens:
Smoking and betel-chewing relax people, who turn to gossip, to local news, to storiesthe old men always ready to
spin tales of war and adventures of the past, the children
always ready to hear the ghost stories that make them wideeyed and giggly with excitement. Communal smoking is
not peculiar to the islands of the Pacific. Shostak (1983)
describes in some detail the strong desire for tobacco she
encountered among the !Kung San of southern Africa, the
frequent requests they made of her for the substance, and
the predominantly group method of consumption.
In an unpublished study in South India among subsistence farmers of the Sudra and Harijan castes, Mark
Nichter (cited in Nichter & Cartwright, 1991) found that
tobacco is consumed in almost every household in a variety of ways, including smoking and snuff, and in conjunction with the chewing of betel nut. Among males over
25 years of age, 65% reported smoking cigarettes. People
explained that smoking increased relaxation, contributed
to sociability, helped to reduce the pain of hunger and
toothache, enhanced digestion, and assisted with regular
defecation. He estimated that tobacco purchases consumed 710% of household income. In another unpublished study from the Middle East, Marcia Inhorn (cited in
Nichter & Cartwright, 1991) examined tobacco consumption in Alexandria, Egypt. She found that 151 of the 190
(79%) lower-class male heads of household in her sample
had smoked, and 53% of these were smoking at least one
pack of cigarettes a day. This expense consumed between
one third and one half of disposable family income and
was seen by many women as hurting the familys ability
to properly feed their children. Addicted to cigarettes,
525
526
Tobacco Use
References
527
REFERENCES
Barnet, R., & Cavanagh, J. (1994). Global reams: Imperial corporations and the New World Order. New York: Simon & Schuster.
Barnett, H. G. (1961). Being a Palauan. New York: Holt, Rinehart, and
Winston.
Best, J. (1983). Economic interests and the vindication of deviance:
Tobacco in Seventh Century Europe. In M. Kelleher,
B. MacMurray, & T. Shapiro (Eds.), Drugs and society (pp. 173183).
Dubuque, IA: Kendall/Hunt.
Black, P. (1984). The anthropology of tobacco use: Tobian data and
theoretical issues. Journal of Anthropological Research, 40,
475503.
Brooks, J. (1952). The mighty leaf. Boston: Little, Brown.
Chandler, W. (1986). Banishing tobacco (Worldwatch Paper No. 68).
Washington, DC: Worldwatch Institute.
Corbett, K. (1999). Intervention strategies to prevent adolescents from
smoking. Proceedings of the Asia Pacific Association for the
Control of Tobacco, 10th Annual Symposium, Taipei.
Douglas, O. (1955). A Solomon Island society. Boston: Beacon Press.
Driver, H. (1969). Indians of North America. Chicago: University of
Chicago Press.
Eckert, P. (1983). Beyond the statistics of adolescent smoking.
American Journal of Public Health, 73, 439 441.
Eckholm, E. (1978). Cutting tobaccos toll (Worldwatch Paper #18).
Washington, DC: Worldwatch Institute.
Gittlesohn, J., McCormick, L. K., Allen, P., Grieser, M., Crawford, M.,
Davis, S. (1999). Inter-Ethnic Differences in Youth Tobacco
Language and Cigarette Brand Preferences. Ethnicity and Health,
4(4), 285303.
Green, D. (1979). Teenage smoking: Immediate and long term patterns.
Washington, DC: National Institute of Education.
Haddon, A. C. (1947). Smoking and tobacco pipes in New Guinea.
Philosophical Transactions of the Royal Society of London,
Series B, 232, 1278.
Hays, T. (1991). No tobacco, No hallelujah: Missions and the
early history of tobacco in Eastern Papua. Pacific Studies, 14,
91112.
528
Peto, R. (1990). Future worldwide health effects of current smoking patterns. Paper presented at World Health Organization Workshop,
Perth, Australia.
Price, J. (1964). The economic growth of the Chesapeake and the
European market, 16971775. Journal of Economic History, 24,
496511.
Ran Nath, U. (1986). Smoking: Third World alert. Oxford, U.K.: Oxford
University Press.
Shostak, M. (1983). Nisa: The life and words of a !Kung Woman.
New York: Vintage.
Sobel, R. (1978). They satisfy: The cigarette in American life. Garden
City, NY: Doubleday.
Stebbins, K. (1990). Transnational tobacco companies and health in
underdeveloped countries: Recommendations for avoiding a
smoking epidemic. Social Science & Medicine, 30, 227235.
Stebbins, K. (1994, November). Clearing the air: Introducing smoking
restrictions in West Virginia, Americas leading consumer of cigarettes per capita. Paper presented at the annual meeting of the
American Anthropological Association, Atlanta, GA.
Stebbins, K. (1997). Clearing the air: Challenges to introducing smoking restrictions in West Virginia. Social Science & Medicine, 44,
13951401.
Stebbins, K. (2001). Going like gangbusters: Transnational tobacco
companies making a killing in South America. Medical
Anthropology Quarterly, 15, 147170.
Tennet, R. (1950). The American cigarette industry: A study in
economic analysis and public policy. New Haven, CT: Yale
University Press.
Weiner, A. (1988). The Trobrianders of Papua New Guinea. New York:
Holt, Rinehart, and Winston.
Wilbert, J. (1987). Tobacco and shamanism in South America. New
Haven, CT: Yale University Press.
Willims, D. (1991). A new state, a new life: Individual success in
quitting smoking. Social Science & Medicine, 33, 13651372.
Wolf, E. (1969). American anthropologists and American society. In S.
Tyler (Ed.), Concepts and assumptions in contemporary anthropology (pp. 311). Athens: University of Georgia Press.
Zinn, H. (1980). Peoples history of the United States. New York:
Harper and Row.
INTRODUCTION
Worldwide tuberculosis (TB) kills more young and middleaged adults than any other infectious disease (WHO,
1999). Though it is curable and preventable, more than
EPIDEMIOLOGICAL
FEATURES OF TB
AND
MEDICAL
Epidemiology of TB
The epidemiology of TB has an unequal global distribution. The highest numbers of active TB cases are found in
less developed countries, especially in Southeast Asia,
which has 41% of the worlds TB burden with over 3 million cases per year; in the African nations that are most
affected by HIV, there are 1.6 million new TB cases
each year, in contrast with nations having established
market economies, which report roughly 100,000 cases.
Moreover, one third of the worlds population is estimated to have latent TB infection (WHO, 2001). In industrialized nations, although the numbers of cases continue
to decline, TB disproportionately affects low-income
groups, substance users, persons from TB-endemic
regions, the elderly, and residents of congregate facilities,
such as nursing homes and prisons (ATS, 1992; CDC,
2000; Grange, 1999).
The HIV/AIDS pandemic has greatly contributed to
the continuing threat of TB, particularly in Africa and
Southeast Asia. In Africa, the estimated incidence of TB
closely correlates with the estimated HIV prevalence
(WHO, 2001); worldwide, in fact, one third of the
increase in new TB cases in the last 5 years can be attributed to HIV (WHO, 1999). TB is now the leading cause
529
Medical Features of TB
TB disease in humans is a communicable disease caused
by Mycobacterium tuberculosis. Although it can affect
any part of the body, generally only active pulmonary and
laryngeal TB pose a risk of transmission from one person
to another. Like influenza, M. tuberculosis is transmitted
when a susceptible individual inhales air containing
droplet nuclei carrying the tubercle bacilli. Once inhaled,
the droplet nuclei eventually reach the lungs and
frequently spread throughout the body. In most cases, a
competent immune system limits the multiplication of the
tubercle bacilli, although some bacilli remain dormant
but viable, rendering a condition known as latent TB
infection (LTBI) (CDC, 1995a, 2000).
A person with LTBI has an estimated 10% lifetime
risk of developing active TB disease. However, certain persons, including children under 4 years of age, persons who
have a weakened immune system due to conditions such as
malnutrition, HIV/AIDS, diabetes, or certain cancers, and
those recently infected with M. tuberculosis, have a much
greater risk of developing active TB. HIV coinfection is
the strongest known risk factor for developing active
TB disease. Studies suggest that being coinfected with
HIV and TB places people at a 710% per year risk of
developing active TB (CDC, 1995a, 2000).
530
HISTORY
OF
TB
531
IN
In reviewing the published anthropological and social science literature on TB, wide gaps in research are apparent.
Research into the meaning and social implications of TB
has been limited to a relatively small number of cultures.
In her recent literature review, Ogden (2000) notes that
the limited use of theoretical frameworks to examine
behaviors hinders full understanding of the social and
cultural factors surrounding TB.
Similarly, Jaramillo (1998) found that many studies
are narrow in scope and examine neither the context of
TB control programs nor other external factors that may
influence behavior. Jaramillo further notes that the use of
different study designs and methods sometimes results in
contradictory findings. Despite the lack of theoretical
grounding and of reliable comparison studies that allow
patterns to be identified across cultures, the published
social science research provides valuable information on
key issues affecting patient outcomes. Issues related to
care-seeking behaviors, adherence to treatment, stigma,
program structure, and patientprovider relationships are
particularly important to TB control. This section has
been organized to reflect this applied approach.
532
serious risks both for the individual patient and for the
community. The issue of non-adherence to TB medications
has frequently been examined through varied approaches
and methodologies, yielding a wide range of findings
having no single predominant pattern. Many social scientists have identified patient health beliefs or health cultures
as the main cause of non-adherence (Barnhoorn &
Adriaanse, 1992; DiMatteo & DiNicola, 1981). Thompson,
Snider, and Farer (1985), examining adherence rates in
seven European countries, attributed differences to the
extent to which cooperativeness as a community value
cut across national cultures. Cultural perceptions of medications, such as the classification of medications into hot
or cold according to humoral theory, may also influence
adherence (Ito, 1999; Manderson, 1998).
Taking a broader perspective, other social scientists
see the issue of non-adherence as stemming from complex factors both within and beyond the control of
patients. These factors include patients confusion about
the implications of symptoms, social stigma, perception
of services and providers, transportation costs, the high
cost of medications, and service access and delivery
problems (Ailinger & Dear, 1998; Liam, Lim, Wong, &
Tang, 1999; Rubel & Garro, 1992; Sumartojo, 1993;
Thomson & Myrdal, 1986). Nachmans (1993) work with
Haitian refugees also showed that, despite patients trust
in Western medicines efficacy, lack of information and
mistrust of service providers greatly reduced their adherence to care (1993). Researchers in India found a high
default rate despite high levels of patient knowledge and
care-seeking. This behavior was not determined by cultural factors, but by the operational dysfunction of the
local TB program (Juvekar et al., 1995).
Considering the vast socioeconomic inequities that
persist throughout the world, Farmer affirms that individuals who do not adhere to therapy are probably the ones
least able to adhere (Farmer, 1997). A study of Latinos
in California demonstrated that, while trust in TB control
practices and social connections facilitated patients
adherence to treatment, access issues most affected
behaviors (Poss, 1998, 2000). Similarly, in an investigation of factors affecting medication-taking behavior in
central India, Barnhoorn and Adriaanse (1992) found that
three socioeconomic variables, not cultural factors, were
the strongest predictors of adherence: a familys per
capita income, the type of house in which they lived, and
the familys monthly income.
Virtually all adherence studies note the difficulties
encountered in measuring adherence. Even well-designed
533
534
535
Program Structure
CURRENT TOOLS
AND
APPROACHES
536
originally designed to understand individuals willingness to seek screening for TB (Becker, 1974). Under this
model, it is believed that people need to perceive themselves as susceptible to TB and able to personally benefit
from early detection before seeking preventive health
screening (Glanz et al., 1997). Researchers have applied
this model, as well as others, in the design of educational
materials and appropriate interventions (Ailinger & Dear,
1997; Kitazawa, 1995; Kleinman, 1980, 1989; Rubel,
1993; Shrestha-Kuwahara et al., 2002; West, 1993).
Methodologies traditionally used in anthropological
research, such as participant observation and discourse
analysis, yield rich information regarding health beliefs
and behaviors (Ndeti, 1972). Recently, social network
methods, which systematically measure the complex
interconnections between and among persons, have been
theorized (CDC, 2001; Chin et al., 2000; Klovdahl, 1985;
Klovdahl et al., 2001; MacQueen, 2000) and adopted to
improve the effectiveness of TB contact investigations
(Fitzpatrick et al., 2001).
To facilitate and enhance analysis of data collected
from qualitative methods, social scientists have developed
new research methods and computer software programs,
including CDC EZ-text and AnSWR (AnSWR, 2001;
Carey, Morgan, & Oxtoby, 1996; Carey, Wenzel, Reilly,
Sheridan, & Steinberg, 1998; Carey et al.,1997; CDC,
2001; MacQueen, McLellan, Kay, & Milstein, 1998).
Furthermore, to assist decision-makers in integrating
social science research into policy planning, Ogden
(2000) has defined a framework that can be used at the
national and local levels. Recent exploration of TB and
gender issues has also contributed to the development of
models that enable decision-makers to integrate social and
cultural factors into policy planning (Uplekar, Rangan,
Weiss, Ogden, & Borgdorff, 2001).
AND
As this entry has shown, anthropology and other social sciences have brought new perspectives on an ancient disease.
While notable contributions have undoubtedly been made,
this review has identified wide gaps regarding the theoretical issues pertinent to TB control. Recognizing the broader
sociocultural dimensions of TB, many social scientists
stress the need to examine the structural barriers hindering
the development and sustainability of interventions
References
REFERENCES
Ailinger, R. L., & Dear, M. R. (1997). Latino immigrants explanatory
models of tuberculosis infection. Qualitative Health Research,
7(4), 521531.
Ailinger, R. L., & Dear, M. R. (1998). Adherence to tuberculosis preventive therapy among Latino immigrants. Public Health Nursing,
15(1), 1924.
American Thoracic Society (1992). Control of tuberculosis in the
United States. American Review of Respiratory Disease, 146(6),
16231633.
537
Analysis Software for Word-based Records (AnSWR) (2001). Centers
for Disease Control and Prevention, National Center for HIV, STD,
and TB Prevention, Division of HIV/AIDS Prevention.
Auer, C., Sarol, J., Jr., Tanner, M., & Weiss, M. (2000). Health seeking
and perceived causes of tuberculosis among patients in Manila,
Philippines. Tropical Medicine & International Health, 5(9),
648656.
Ayvazian, F. L. (1993). History of tuberculosis. In L. B. Reichman &
E. S. Hershfield (Eds.), Tuberculosis: A comprehensive international approach (pp. 120). New York: Marcel Dekker.
Banerjee, A., Harries, A. D., Nyirenda, T., & Salaniponi, F. M. (2000).
Local perceptions of tuberculosis in a rural district in Malawi.
International Journal of Tuberculosis & Lung Disease, 4(11),
10471051.
Barnes, D. S. (1995). The making of a social disease: Tuberculosis in
nineteenth-century France. Berkeley: University of California
Press.
Barnhoorn, F., & Adriaanse, H. (1992). In search of factors responsible
for noncompliance among tuberculosis patients in Wardha District,
India [Erratum appears in Social Science & Medicine, 1992 June,
34(11), II]. Social Science & Medicine, 34(3), 291306.
Bates, B. (1992). Bargaining for life: A social history of tuberculosis,
18761938. Philadelphia: University of Pennsylvania Press.
Becker, M. H. (1974). The health belief model and personal health
behavior. San Francisco: Society for Public Health Education.
Blankenship, K. M., Bray, S. J., & Merson, M. H. (2000). Structural
interventions in public health. In E. Sumartojo & M. Laga (Eds.),
AIDS: Structural factors in HIV prevention (pp. S11S21).
Lippincott Williams & Wilkins.
Boehm, S., Coleman-Burns, P., Christensen, M., & Schlenk, E. (1995).
Behavioral skill training for the patient and the health care provider.
Improving tuberculosis treatment and control: An agenda for
behavioral, social, and health services research. Proceedings of
Tuberculosis and Behavior: National Workshop on Research for the
21st Century, August 2830, 1994, Bethesda, MD (pp. 97109).
Atlanta, GA: US Department of Health and Human Services,
Center for Disease Control and Prevention.
Broekmans, J. F. (2000). Tuberculosis control in low-prevalence countries. In L. B. Reichman & E. S. Hershfield (Eds.), Tuberculosis:
A comprehensive international approach. (pp. 7593). New York:
Marcel Dekker.
Brouwer, J. A., Boeree, M. J., Kager, P., Varkevisser, C. M., &
Harries, A. D. (1998). Traditional healers and pulmonary tuberculosis in Malawi. International Journal of Tuberculosis & Lung
Disease, 2(3), 231234.
Brudney, K., & Dobkin, J. (1991). A tale of two cities: Tuberculosis
control in Nicaragua and New York City. Seminars in Respiratory
Infections, 6(4), 261272.
Carey, J. W., Morgan, M., & Oxtoby, M. J. (1996). Intercoder agreement
in analysis of responses to open-ended interview questions:
Examples from tuberculosis research. Cultural Anthropology
Methods Journal, 8(3),15.
Carey, J. W., Oxtoby, M. J., Nguyen, L. P., Huynh, V., Morgan, M., &
Jeffery, M. (1997). Tuberculosis beliefs among recent Vietnamese
refugees in New York State. Public Health Reports, 112(1), 6672.
Carey, J. W., Wenzel, P. H., Reilly, C., Sheridan, J., & Steinberg, J. M.
(1998). CDC EZ-Text: Software for management and analysis of
538
semi-structured qualitative data sets. Cultural Anthropology
Methods Journal, 10(1), 1420.
Centers for Disease Control and Prevention (1994). Improving patient
adherence to tuberculosis treatment. Atlanta, GA: US Department
of Health and Human Services, Author.
Centers for Disease Control and Prevention (1995a). Self-study modules
on tuberculosis. Atlanta, GA: US Department of Health and
Human Services, Author.
Centers for Disease Control and Prevention (1995b). Improving tuberculosis treatment and control: An agenda for behavioral, social,
and health services research. Proceedings of Tuberculosis and
Behavior: National Workshop on Research for the 21st Century,
August 2830, 1994, Bethesda, MD. Atlanta, GA: US Department
of Health and Human Services, Author.
Centers for Disease Control and Prevention (1998). Prevention and
treatment of tuberculosis among patients infected with human
immunodeficiency virus: Principles of therapy and revised recommendations. Morbidity Mortality Weekly Report 47(RR-20), 151.
Centers for Disease Control and Prevention (2000). Core curriculum on
tuberculosis: What the clinician should know (4th ed.). Atlanta,
GA: US Department of Health and Human Services, Author.
Centers for Disease Control and Prevention (2001). Cluster of tuberculosis cases among exotic dancers and their close contactsKansas,
19942000. Journal of the American Medical Association,
285(18), 2322.
Chakraborty, A. K., Rangan, S., & Uplekar, M. W. (Eds.). (1995). Urban
tuberculosis control: Problems and prospects. Bombay, India: The
Foundation for Research in Community Health.
Chaulk, C. P. M., & Kazandjian, V. A. (1998). Directly observed therapy
for treatment completion of pulmonary tuberculosis: Consensus
statement of the public health tuberculosis guidelines panel.
Journal of the American Medical Association, 279(12), 943948.
Chaulk, C. P., Moore-Rice, K., Rizzo, R., & Chaisson, R.E. (1995).
Eleven years of community-based directly observed therapy for
tuberculosis. Journal of the American Medical Association,
274(12), 945951.
Chemtob, D., Weiser, S., Yitzhak, I., & Weiler-Ravell, D. (2000).
Medical anthropology: An important adjunct to international TB
control. In L. B. Reichman & E. S. Hershfield (Eds.), Tuberculosis:
A comprehensive international approach (pp. 745770). New
York: Marcel Dekker.
Chin, D. P., Crane, C. M., Diul, M. Y., Sun, S. J., Agraz, R., Taylor, S. et
al. (2000). Spread of Mycobacterium tuberculosis in a community
implementing recommended elements of tuberculosis control.
Journal of the American Medical Association, 283(22), 29682974.
Connolly, M., & Nunn, P. (1996). Women and tuberculosis. World
Health Statistics Quarterly, 49(2), 115119.
Crubzy, E., Ludes, B., Poveda, J. D., Clayton, J., Crouau-Roy, B., &
Montagnon, D. (1998). Identification of Mycobacterium DNA in
an Egyptian Potts disease of 5,400 years old. Comptes Rendus de
l Academie des SciencesSerie Iii, Sciences de la Vie, 321(11),
941951.
Daniel, T. M. (1997). Captain of death: The story of tuberculosis.
Rochester, NY: University of Rochester Press.
Daniel, T. M. (2000). The origins and precolonial epidemiology of
tuberculosis in the Americas: Can we figure them out?
International Journal of Tuberculosis & Lung Disease, 4(5),
395 400.
References
Glanz, K., Lewis, F. M., & Rimer, B. K. (Eds.). (1997). Health behavior and health education: Theory, research, and practice (2nd ed.).
San Francisco: Jossey-Bass.
Gokce, C., Gokce, O., Erdogmus, Z., Arisoy, E., Arisoy, S., Koldas, O.
et al. (1991). Problems in running a tuberculosis dispensary in a
developing country: Turkey. Tubercle, 72(4), 268276.
Grange, J. M. (1999). The global burden of tuberculosis. In J. D. Porter &
J. M. Grange (Eds.), Tuberculosis: An interdisciplinary perspective
(pp. 331). Singapore, Malaya: Imperial College Press.
Grange, J. M., & Festenstein, F. (1993). The human dimension of tuberculosis control. Tubercle & Lung Disease, 74(4), 219222.
Grange, J. M., Gandy, M., Farmer, P., & Zumla, A. (2001). Historical
declines in tuberculosis: Nature, nurture and the biosocial model.
International Journal of Tuberculosis & Lung Disease, 5(3),
208212.
Grange, J. M., & Zumla, A. (1999). Paradox of the global emergency of
tuberculosis. The Lancet, 353(9157), 996.
Grygier, P. S. (1994). A long way from home: The tuberculosis epidemic
among the Inuit. Montreal, Canada: McGill-Queens university
Press.
Heymann, S. J., Sell, R., & Brewer, T. F. (1998). The influence of program acceptability on the effectiveness of public health policy: A
study of directly observed therapy for tuberculosis. American
Journal of Public Health, 88(3), 442445.
Holmes, C. B., Hausler, H., & Nunn, P. (1998). A review of sex differences in the epidemiology of tuberculosis. International Journal of
Tuberculosis & Lung Disease, 2(2), 96104.
Hudelson, P. (1996). Gender differentials in tuberculosis: The role of
socio-economic and cultural factors. Tubercle & Lung Disease,
77(5), 391400.
Hurtig, A. K., Porter, J. D., & Ogden, J. A. (1999). Tuberculosis control
and directly observed therapy from the public health / human
rights perspective. International Journal of Tuberculosis & Lung
Disease, 3(7), 553560.
Institute of Medicine (2000). Ending neglect: The elimination of tuberculosis in the United States. Washington, DC: National Academy
Press.
Ito, K. L. (1999). Health culture and the clinical encounter: Vietnamese
refugees responses to preventive drug treatment of inactive tuberculosis. Medical Anthropology Quarterly, 13(3), 338364.
Jaramillo, E. (1998). Tuberculosis control in less developed countries:
Can culture explain the whole picture? Tropical Doctor, 28(4),
196200.
Jaramillo, E. (1999a). Tuberculosis and stigma: Predictors of prejudice
against people with tuberculosis. Journal of Health Psychology,
4(1), 7179.
Jaramillo, E. (1999b). Encompassing treatment with prevention: The
path for a lasting control of tuberculosis. Social Science &
Medicine, 49, 393 404.
Johansson, E., Diwan, V. K., Huong, N. D., & Ahlberg, B. M. (1996).
Staff and patient attitudes to tuberculosis and compliance
with treatment: An exploratory study in a district in Vietnam.
Tubercle & Lung Disease, 77(2), 178183.
Johansson, E., Long, N. H., Diwan, V. K., & Winkvist, A. (1999).
Attitudes to compliance with tuberculosis treatment among women
and men in Vietnam. International Journal of Tuberculosis & Lung
Disease, 3(10), 862868.
539
Juvekar, S. K., Morankar, S. N., Dalal, D. B., Rangan, S. G.,
Khanvilkar, S. S., Vadair, A. S., et al. (1995). Social and operational determinants of patient behavior in lung tuberculosis. Indian
Journal of Tuberculosis, 42, 8794.
Kalihi-Palama Health Center (1997) Cross-cultural tuberculosis manual:
Cultural influences on TB-related beliefs and Practices of Filipinos,
Vietnamese, Chinese, and Koreans. Honolulu, HI: AAPCHO.
Khan, A., Walley, J., Newell, J., & Imdad, N. (2000). Tuberculosis in
Pakistan: Socio-cultural constraints and opportunities in treatment.
Social Science & Medicine, 50, 247254.
Kitazawa, S. (1995). Tuberculosis health education. Needs in homeless
shelters. Public Health Nursing, 12(6), 409416.
Kleinman, A. (1980). Patients and healers in the context of culture.
Berkeley: University of California Press.
Kleinman, A. (1989). The illness narratives: Suffering, healing and the
human condition. New York: Basic Books.
Klovdahl, A. S. (1985). Social networks and the spread of infectious diseases: The AIDS example. Social Science & Medicine, 21(11),
12031216.
Klovdahl, A. S., Graviss, E. A., Yaganehdoost, A., Ross, M. W., Wanger,
A., Adams, G. J. et al. (2001). Networks and tuberculosis: An
undetected community outbreak involving public places. Social
Science & Medicine, 52(5), 681694.
Lerner, B. H. (1997). From careless consumptives to recalcitrant
patients: The historical construction of noncompliance. Social
Science & Medicine, 45(9), 14231431.
Liam, C. K., Lim, K. H., Wong, C. M., & Tang, B. G. (1999). Attitudes
and knowledge of newly diagnosed tuberculosis patients regarding
the disease, and factors affecting treatment compliance. International
Journal of Tuberculosis & Lung Disease, 3(4), 300309.
Liefooghe, R., Baliddawa, J. B., Kipruto, E. M., Vermeire, C., &
Munynck, A. O. (1997). From their own perspective. A Kenyan
communitys perception of tuberculosis. Tropical Medicine &
International Health, 2(8), 809821.
Liefooghe, R., Michiels, N., Habib, S., Moran, M. B., & De Muynck, A.
(1995). Perception and social consequences of tuberculosis: A
focus group study of tuberculosis patients in Sialkot, Pakistan.
Social Science & Medicine, 41(12), 16851692.
Lienhardt, C., Rowley, J., Manneh, K., Lahai, G., Nedham, D.,
Milligan, P. et al. (2001). Factors affecting time delay to treatment
in a tuberculosis control programme in a sub-Saharan African
country: The experience of The Gambia. International Journal of
Tuberculosis & Lung Disease, 5(3), 233239.
Long, N. H., Johansson, E., Diwan, V. K., & Winkvist, A. (1999).
Different tuberculosis in men and women: Beliefs from focus
groups in Vietnam. Social Science & Medicine, 49, 815822.
Lnnroth, K., Thuong, L. M., Linh, P. D., & Diwan, V. K. (1999). Delay
and discontinuityA survey of TB patients search of a diagnosis
in a diversified health care system. International Journal of
Tuberculosis & Lung Disease, 3(11), 9921000.
MacQueen, K. M. (2000). Social networking techniques for contact
investigation. 2000 National TB Controllers Workshop: orchestrating better contact investigations. (pp. 5357). Atlanta, GA: US
Department of Health and Human Services, Center For Disease
Control and Prevention.
MacQueen, K. M., McLellan, E., Kay, K., & Milstein, B. (1998).
Codebook development for team-based qualitative analysis.
Cultural Anthropology Methods Journal, 10(2), 3136.
540
Malotte, C. K., Hollingshead, J. R., & Rhodes, F. (1999). Monetary versus nonmonetary incentives for TB skin test reading among drug
users. American Journal of Preventive Medicine, 16(3), 182188.
Manderson, L. (1998). Applying medical anthropology in the control of
infectious disease. Tropical Medicine & International Health,
3(12), 10201027.
Mann, J. M., & Tarantola, J. M. (Eds.). (1996). AIDS in the World II:
Global dimensions, social roots, and responses. New York: Oxford
University Press.
Marinac, J. S., Willsie, S. K., McBride, D., & Hamburger, S. C. (1998).
Knowledge of tuberculosis in high-risk populations: Survey of
inner city minorities. International Journal of Tuberculosis & Lung
Disease, 2(10), 804810.
Mata, J. I. (1985). Integrating the clients perspective in planning a
tuberculosis education and treatment program in Honduras.
Medical Anthropology, 9(1), 5764.
Melendez, D., & Smith, K. L. (2000). Culturally-specific barriers to
tuberculosis care in Santa Clara County. Santa Clara, CA: Santa
Clara County Public Health Tuberculosis Prevention & Control
Program.
Menegoni, L. (1996). Conceptions of tuberculosis and therapeutic
choices in Highland Chiapas, Mexico. Medical Anthropology
Quarterly, 10(3), 381401.
Mitnick, C., Furin, J., Henry, C., & Ross, J. (1998). Tuberculosis among
the foreign born in Massachusetts, 19821994: A reflection of
social and economic disadvantage. International Journal of
Tuberculosis & Lung Disease, 2(9, Suppl. 1), S32S40.
Morisky, D. E., Malotte, C. K., Choi, P., Davidson, P., Rigler, S.,
Sugland, B. et al. (1990). A patient education program to improve
adherence rates with antituberculosis drug regimens. Health
Education Quarterly, 17(3), 253267.
Murray, C. L. (1991). Social, economic, and operational research on
tuberculosis: Recent studies and some priority questions. Bulletin
of the International Union against Tuberculosis and Lung Disease,
66, 149156.
Nachman, S. R. (1993). Wasted lives: Tuberculosis and other health
risks of being Haitian in a U.S. detention camp. Medical
Anthropology, 7(3), 227259.
Nair, D. M., George, A., & Chacko, K. T. (1997). Tuberculosis in
Bombay: New insights from poor urban patients. Health Policy &
Planning, 12(1), 7785.
Ndeti, K. (1972). Sociocultural aspects of tuberculosis defaultation:
A case study. Social Science & Medicine, 6, 397412.
Needham, D. M., Godfrey-Faussett, P. D., & Foster, S. D. (1998).
Barriers to tuberculosis control in urban Zambia: The economic
impact and burden on patients prior to diagnosis. International
Journal of Tuberculosis & Lung Disease, 2(10), 811817.
Ngamvithayapong, J., Winkvist, A., & Diwan, V. (2000). High AIDS
awareness may cause tuberculosis patient delay: Results from an
HIV epidemic area, Thailand. AIDS, 14(10), 14131419.
Nguyen, L., Yamada, S., Matsunaga, D. S., & Caballero, J.
(2000). Attitudes toward tuberculosis in Vietnamese immigrants.
Asian American and Pacific Islander Journal of Health, 8(1),
6975.
Nichter, M. (1994). Illness semantics and international health: The weak
lungs/TB complex in the Philippines. Social Science & Medicine,
38(5), 649663.
References
GA: U.S. Department of Health and Human Services, Center for
Disease Control and Prevention.
Rubel, A. J., & Moore, C. C. (2001). The contribution of medical
anthropology to a comparative study of culture: Susto and tuberculosis. Medical Anthropology Quarterly, 15(4), 440454.
Ryan, F. (1993). The forgotten plague: How the battle against
tuberculosis was wonand lost. (1st ed.). Boston: Little, Brown.
Salomo, M. A. (1999). A critique of the global effort: Do tuberculosis
control programmes only exist on paper?A perspective from
a developing country. In J. D. Porter & J. M. Grange (Eds.),
Tuberculosis: An interdisciplinary perspective (pp. 4965).
Singapore, Malaya: Imperial College Press.
Sbarbaro, J. (1990). Patient compliance with preventive therapy.
Operational considerations. Bulletin of the International Union
Against Tuberculosis & Lung Disease, 66(Suppl.) 3739.
Shrestha-Kuwahara, R., Wilce, M., DeLuca, N., & Taylor, Z. (2002).
Factors associated with identifying tuberculosis contacts. Manuscripts submitted for publication.
Smith, G. (1996). Contagious subversion: Cultural constructions of
disease. Queens Quarterly, 103(2), 403413.
Snider, D. E., & Satcher, D. (1997). Behavioral and social sciences at
the Centers for Disease Control and Prevention: Critical disciplines
for public health. American Psychologist, 52(2), 140142.
Sontag, S. (1990). Illness as metaphor and AIDS and its metaphors.
New York: Doubleday.
Star, S. L., & Bowker, G. C. (1997). Of lungs and lungers: The classified
story of tuberculosis. In A. Strauss & J. Corbin (Eds.), Grounded
theory in practice (pp. 197227). Thousand Oaks, CA: Sage.
Steen, T. W., & Mazonde, G. N. (1999). Ngaka ya setswana, ngaka ya
sekgoa or both? Health seeking behaviour in Botswana with pulmonary tuberculosis. Social Science & Medicine, 48(2), 163172.
Stimson, G. V. (1974). Obeying doctors orders: A view from the other
side. Social Science & Medicine, 8(2), 97104.
Sumartojo, E. M. (1993). When tuberculosis treatment fails: A social
behavioral account of patient adherence. American Review of
Respiratory Disease, 147(5), 13111320.
Sumartojo, E. M. (1995). Adherence to the tuberculosis treatment plan.
In F. L. Cohen & J. D. Durham (Eds.), Tuberculosis: A sourcebook
for nursing practice (pp. 121136). New York: Springer.
Sumartojo, E. M. (2000). Structural factors in HIV prevention:
Concepts, examples, and implications for research. In
E. Sumartojo & M. Laga (Eds.), AIDS: Structural Factors in HIV
Prevention (pp. S3S10). Lippincott Williams & Wilkins.
Sumartojo, E. M., Geiter, L. J., Miller, B., & Hale, B. E. (1997). Can physicians treat tuberculosis? Report on a national survey of physician
practices. American Journal of Public Health, 87(12), 20082011.
Thompson, N. J., Snider, D. E., Jr., & Farer, L. S. (1985). Variations in
national health care practices and behaviours and their influence on
international research. International Journal of Epidemiology,
14(3), 457462.
Thomson, E. M., & Myrdal, S. (1986). Tuberculosisthe patients
perspective. South African Medical Journal, 70(5), 263264.
Thorson, A., Hoa, N. P., & Long, N. H. (2000). Health-seeking behaviour of individuals with a cough of more than 3 weeks. The Lancet,
356(9244), 18231824.
Tomes, N. (2000). The making of a germ panic, then and now. American
Journal of Public Health, 90(2), 191198.
541
Trostle, J. A. (1988). Medical compliance as an ideology. Social Science
& Medicine, 27(12), 12991308.
Tulsky, J. P., Pilote, L., Hahn, J. A., Zolopa, A., Burke, M., Chesney, M.
et al. (2000). Adherence to isoniazid prophylaxis in the homelessA randomized controlled trial. Archives of Internal
Medicine, 160(5), 697702.
Tulsky, J. P., White, M. C., Young, J. A., Meakin, R., & Moss, A. R.
(1999). Street talk: Knowledge and attitudes about tuberculosis
and tuberculosis control among homeless adults. International
Journal of Tuberculosis & Lung Disease, 3(6), 528533.
Uplekar, M. W., & Rangan, S. (1996). Tackling TB: The search for solutions. Bombay, India: Foundation for Research in Community
Health.
Uplekar, M. W., Rangan, S., Weiss, M., Ogden, J. A., Borgdorff, M. W., &
Hudelson, P. (2001). Attention to gender issues in tuberculosis
control. International Journal of Tuberculosis & Lung Disease,
5(3), 220224.
Uplekar, M. W., & Shepard, D. S. (1991). Treatment of tuberculosis by
private general practitioners in India. Tubercle, 72(4), 284290.
van der Werf, T. S., Dade, G. K., & van der Mark, T. W. (1990). Patient
compliance with tuberculosis treatment in Ghana: Factors
influencing adherence to therapy in a rural service programme.
Tubercle, 71, 247252.
Vecchiato, N. L. (1997). Sociocultural aspects of tuberculosis control in
Ethiopia. Medical Anthropology Quarterly, 11(2), 183201.
Volmink, J., Matchaba, P., & Garner, P. (2000a). Directly observed
therapy and treatment adherence. The Lancet, 355, 13451350.
Volmink, J., Matchaba, P., & Garner, P. (2000b). Directly observed
therapy and treatment adherence [Letter]. The Lancet, 356(9234),
1032.
Walt, G. (1999). The politics of tuberculosis: The role of process and
power. In J. D. Porter & J. M. Grange (Eds.), Tuberculosis: An
interdisciplinary perspective (pp. 6798). Singapore, Malaya:
Imperial College Press.
Walton, D., & Farmer, P. (2000). The new white plague. Journal of the
American Medical Association, 284(21), 27892791.
Wandwalo, E. R., & Morkve, O. (2000). Knowledge of disease and
treatment among tuberculosis patients in Mwanza, Tanzania.
International Journal of Tuberculosis & Lung Disease, 4(11),
10411046.
West, E. A. (1993). The cultural bridge model. Nursing Outlook, 41(5),
229234.
Wilkinson, D. Gcabashe, L., & Lurie, M. (1999). Traditional healers as
tuberculosis treatment supervisors: Precedent and potential. International Journal of Tuberculosis & Lung Disease, 3(9), 838842.
World Health Organization (2000). Anti-tuberculosis drug resistance in
the world: Report No. 2, Prevalence and trends. The WHO/
IUATLD Global Project on Anti-tuberculosis Drug Resistance
Surveillance. Geneva, Switzerland: Author.
World Health Organization (2001). Global tuberculosis control Author
Report 2001. Geneva, Switzerland: Author.
World Health Organization, Global Tuberculosis Programme (1999).
TB advocacy, a practical guide [Pamphlet]. Geneva, Switzerland:
Author.
Wyss., K., Kilima, P., & Lorenz, N. (2001). Costs of tuberculosis for
households and health care providers in Dar es Salaam, Tanzania.
Tropical Medicine & International Health, 6(1), 6068.
542
Yamada, S., Caballero, J., Matsunaga, D. S., Agustin, G., & Magana, M.
(1999). Attitudes regarding tuberculosis in immigrants from the
Philippines to the United States. Family Medicine, 31(7), 477 482.
Yamasaki-Nakagawa, M., Ozasa, K., Yamada, N., Osuga, K.,
Shimouchi, A., Ishikawa, N. et al. (2001). Gender difference in
African Americans1
Eric J. Bailey
ALTERNATIVE NAMES
Black Americans, Blacks, Afro-Americans and
Afro-Caribbeans.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
545
546
African Americans
547
Cultural History
Another component of the comprehensive, holistic
approach to health is cultural history. The cultural historical approach helps us to better understand issues such as
African Americans past health-seeking process; African
Americans current perceptions of the national and local
health care systems; African Americans lack of participation in clinical trials; and African Americans alternative medical practices.
The significance of the cultural historical approach
can best be illustrated in an article entitled, African
American Suspicion of the Healthcare System is
Justified: What Do We Do about It? Dula (1994) uses
historical and contemporary examples of health care
issues that contributed to the mistrust and suspicion that
many African Americans have for the U.S. health care
system. According to Dula (1994), real abuses in experimentation have contributed greatly to the high level of
distrust within the African American population for
decades.
Suspicion of the medical system in the United States
has its origin in slavery medical practices. Dula (1994)
states that slaves were sources for medical experimentation and research by doctors, instructional material for
medical students, and that enslaved albinos and Siamese
twins were displayed as freaks at medical society meetings. African Americans contributed to scientific
progress, usually without consent or benefit to themselves, and sometimes without benefit even to science
(Dula, 1994, p. 348).
Another cultural historical case is the Tuskegee
experiment. Dula (1994) states that the Tuskegee experiment (1932)in which 400 African American men
participated in a government-sponsored study to find the
effects of untreated syphiliswas the ultimate proof that
European American health policy-makers, indeed,
deserved mistrust. Jones (1981) and Dalton (1989)
548
African Americans
MEDICAL PRACTITIONERS
The types and sources of treatment actions among
African Americans are likely to vary according to gender,
class, region of the United States, and degree of assimilation into mainstream society. In the United States,
most ethnic groups have the option of selecting from a
variety of sources: (1) self; (2) alternative or native health
practitioners; and (3) formal health professionals.
If the illness is perceived as naturalistic (i.e., due
to inadequate rest, poor nutrition, or germs), African
Americans tend to use initially one and/or a combination
of the following treatment actions: self-care, alternative
(indigenous) health practitioner, and formal health
professionals (Jackson, 1981; Jacques, 1976; Leininger,
1985; Spector, 1985). A discussion of self-care will presented be later in this entry.
In addition to the variety of home remedies or patent
medicines practiced among African Americans, there are
primarily two types of alternative indigenous health
practitioners serving the African American community:
(1) independent practitioners and (2) cultic practitioners
(Baer, 1985, p. 327). These two types of alternative
indigenous health practitioners operate as individuals or
are affiliated with some sort of occult-supply store, either
as the owner, an employee, or someone who rents office
space. The cultic practitioner is affiliated with a religious
group and practices in both public and private settings.
The multiplicity of African American alternative
Medical Practitioners
549
550
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Health
African Americans perception of what constitutes
healthy encompasses a relatively high tolerance of
discomforts from symptoms (Jackson, 1981). Studies
African Americans
Illness
Illness is defined as sickness of body or mind; disease is
defined as a harmful departure from the normal state of
a person or other organism (Green & Ottoson, 1994,
p. 697). Illnesses are classified as either naturalistic or
personalistic (Snow, 1974). Naturalistic agents identify
what caused an illness, whereas personalistic agents
recognize who caused the illness (Chino & Vollweiller,
1986). Such impersonal agents as inadequate rest, poor
nutrition, and germs cause illnesses. The etiology of
illnesses falls into three general categories: environmental
hazards, divine punishment, and impaired sociocultural
relationships.
In some cases, serious and life-threatening illnesses
are perceived to be sent by God (personalistic agent) or
some other personalistic agent as punishment for sin
(Hill, 1976; Snow, 1974). For example, many African
Americans who suspect they have a terminal illness, may
delay medical diagnosis. During this delay and/or denial
period, many African Americans turn to powers considered greater than themselves to fathom the reason for the
disease, thereby accepting terminal illness as Gods
will and believing that nothing more can be done.
Examples of naturalistic and personalistic causative
agents are described in the following studies. First, a study
investigating the treatment patterns of hypertension among
285 African Americans in the Detroit metropolitan area
contended that African Americans beliefs about the etiology of hypertension were based on naturalistic agents
(Bailey, 1991b). Bailey reported that informants considered inadequate rest, poor nutrition, weather disturbances,
Self-Care
Self-care includes positive steps taken by individuals to
either prevent disease or promote general health status
551
552
Infancy
In 1991, the mortality rate for African American infants
(17.6 per 1,000 live births) was 2.4 times that for
European American infants (7.3 per 1,000 live births).
Between 1970 and 1991, the mortality rate decreased
more for European American infants (59%) than for
African American infants (46%), widening the gap in
infant mortality between the two populations.
African Americans
Childhood
In 1996, there were 8.1 million African American families, 46% of them married-couple families. The majority
of African American families (57%) had children.
Families with children averaged two children apiece
(U.S. Census Bureau, 1998).
Overall, African American children have benefited
from the impressive health gains for all American
children since 1950 (National Research Council, 1989,
p. 405). The rate of death from all causes for children
aged 14 was 139.4 per 1,000 live births in 1950 and 51.4
per 1,000 live births in 1985. For children aged 514, the
comparable rates were 60.1 per 1,000 live births in 1950
and 26.3 per 1,000 live births in 1985 (National Center
for Health Statistics, 1997, p. 80). However, African
American children have not shared equally in the overall
health gains, and their death rates are much higher than
those for European American children.
Interestingly, the leading cause of death among children is injury. Accidents cause three times as many deaths
than do either of the next two leading causes of childhood
death (cancer and congenital anomalies). For African
American children, the highest rates of injuries occur in
or near the home (National Research Council, 1989, p.
405). The National Research Council states
that injuries are related to socioeconomic status: poor
children are very likely to live in areas in which heavy
Adolescence
Females. Adolescence is a period of significant life
transition, during which children cross the bridge into
adulthood (Adams, Scholenborn, Moss, Warren, & Kann,
1995). Behaviors established during this period are often
carried into adult life. Adams et al. (1995) state that
health behaviors established prior to adulthood can significantly influence health and longevity, both in the short
term and later in life.
In 1992, the Centers for Disease Control and
Prevention conducted the National Health Interview
SurveyYouth Risk Behavior Survey (NHISYRBS).
The NHISYRBS was a collaborative effort of the
Division of Health Interview Statistics, the National
Center for Health Statistics, and the Division of
Adolescent and School Health of the National Center for
Chronic Disease Prevention and Health Promotion. Of the
13,789 youth identified as eligible for the NHISYRBS,
10,645 completed questionnaires, representing an estimated 77.2% of eligible respondents (Adams et al., 1995).
With regard to weight control, Adams et al. (1995)
found that African American adolescent females (36%)
were less likely than European American adolescent
females (46.1%) to perceive themselves as being overweight. In addition, African American female teens
(41.5%) were less likely than European American
females (59.5%) and Hispanic females (55.1%) to report
any attempt to lose or keep from gaining weight in the
past week. Overall, the data show that proportionately,
fewer African American female and male youths considered themselves overweight compared with European
American female and male youths.
The importance of these national health data on the
perceptions of weight control among African American
adolescent females relates to the issue of obesity and
its health consequences. Obesity rates among
African American women are significantly higher than
for European American women (Kumanyika, 1994).
553
Moreover, chronic disease profiles of minority populations indicate that African Americans have higher than
average cardiovascular disease-related mortality
(Kumanyika, 1991; Otten et al., 1990). These health
trends and mortality suggest an urgent need for obesity
prevention programs for African American adolescent
females.
Males. Much of what has been written and researched
about African American adolescent males health and
social behavioral outcomes has been negative and downright gloomy. The health and social data that are often
cited in the literature and reported in the media are the
rates of homicide and sexually transmitted diseases.
According to the National Center for Health
Statistics (1997), the homicide rate for African
American males (72.5 per 100,000) were eight times
higher than for European American males (9.4 per
100,000) and nearly five times higher than for African
American females (13.9 per 100,000) as for European
females (3.0 per 100,000). Among African American
youth, the homicide rate (77.9 per 100,000) is eight to
nine times that for European American (9.6) and Asian
American youths (8.8) (National Center for Health
Statistics, 1994, p. 29). The cause of this disparity in
homicide rates is multifacetedin other words, factors
such as personal situational issues, societal discrimination, cultural historical racism, persistent unemployment,
peer pressure, and lack of formal education all contribute
to the high rate of homicide among African American
adolescent males.
With regard to African American male sexual behavior and the risk for HIV infection, the cause for the high
prevalence rate of HIV infection is also multifaceted.
Whitehead (1997), for example, found that broader
historical and sociocultural issues associated with
African American adolescent males and middle-aged
men contributed to the disproportionately high rate of
HIV infection.
According to Whitehead, adolescent African
American males need a masculinity transformation
primarily because the existing constructs of ideal
masculinity transformation fragment masculinity. In
other words, the process of becoming a male in our
gender-based society is incorrect. Our society teaches
young males inappropriate ways of achieving adulthood.
The goal of masculinity transformation is to achieve
a sense of masculine gender identity as a whole
(Whitehead, 1977, p. 436). Masculine transformation is a
554
African Americans
Adulthood
According to the National Center for Health Statistics
(1997), the 10 leading causes of death (from highest
incidence to lowest) for African Americans in 1995 were
diseases of the heart; malignant neoplasms (cancers);
cerebrovascular diseases (stroke); human immunodeficiency virus infection (HIV); unintentional injuries;
homicide and legal intervention; diabetes mellitus;
pneumonia and influenza; chronic obstructive pulmonary
diseases; and certain conditions originating in the perinatal
period (National Center for Health Statistics, 1997,
p. 117). African American men and women, however,
differ in the order and rank of the leading causes of death.
For example, HIV infection ranked third among
leading causes of death for African American men. With
regard to African American women, cerebrovascular
disease and diabetes mellitus ranked third and fourth,
respectively, among leading causes of death. Moreover,
ranking ninth for leading causes of death among African
American women were nephritis, nephritic syndrome,
and nephrosis (lupus).
The Aged
African American elders are a
important to recognize this
(Brangman, 1995). No typical
exists. They can vary from an
References
555
NOTE
Through the legacy of slavery, segregation, and discrimination, African Americans have developed a perspective
on death that is unique to this ethnic group (Mouton,
2000). End-of-life decision-making practices draw on
religious characterizations of death. The majority of
African Americans adhere to a Christian belief system,
with 83% claiming a Protestant affiliation (the majority
being Baptist) and 14% claiming Catholic affiliation
(Ellison & Sherkat, 1990). These religious beliefs recognize a transcendent soul that rises to heaven upon death.
African Americans also have a strong belief in a heaven
not of this earth. Furthermore, most African Americans
subscribe to an African American theology, a religious
doctrine that views God as the fighting God of the Old
Testament. It is important to realize that not all African
Americans view death from a religious construct.
However, religion does seem to play a significant role in
African Americans view of death and dying (Mouton,
2000, pp. 7475).
As a whole, African Americans are less likely than
European Americans to approve of euthanasia. For example, in a study comparing attitudes toward life-prolonging
treatment among 139 patients from a general medicine
clinic, only 63% of African Americans approved of
1. Excerpts from this article are reprinted from Eric Baileys book,
Medical Anthropology and African American Health, with permission from Greenwood Publishing.
REFERENCES
Adams, P., Scholenborn, C., Moss, A., Warren, C., & Kann, L. (1995).
Health-risk behaviors among our nations youth: United States,
1992. Washington, DC: U.S. Department of Health and Human
Services.
Aschenbrenner, J. (1973). Extended families among Black Americans.
Journal of Comparative Family Studies, 4, 257268.
Baer, H. (1985). Toward a systematic typology of black folk healers.
Phylon, 43, 327343.
Bailey, E. (1991a). Urban African American health care. Lanham, MD:
University Press of America.
Bailey, E. (1991b). Hypertension: An analysis of Detroit African
American health care treatment patterns. Human Organization, 50,
287296.
Bailey, E. (2002a). Medical anthropology and African American health.
Westport, CT: Bergin & Garvey.
Bailey, E. (2002b). African American alternative medicine: Using alternative medicine to prevent and control chronic diseases. Westport,
CT: Praeger.
Berry, M., & Blassingame, J. (1982). Long memory: The black experience in America. New York: Oxford University Press.
556
Blendon, R., Aiken, L., Freeman, H., & Correy, C. (1989). Access to
medical care for black and white Americans. Journal of the
American Medical Association, 261, 278281.
Blumhagen, D. (1982). The meaning of hypertension. In N. Chrisman &
T. Maretzki (Eds.), Clinically applied anthropology (pp. 297324).
Boston: D. Reidel.
Braithwaite, R. & Taylor, S. (Eds.). (1992). Health issues in the black
community. San Francisco: Jossey-Bass.
Brangman, S. (1995). African American elders: Implications for health
care providers. Clinics in Geriatric Medicine, 11, 1523.
Caralis, P. V., Davis, B., Wright, K., & Marcial, E. (1993). The influence of ethnicity and race on attitudes toward advance directives,
life-prolonging treatments, and euthanasia. Journal of Clinical
Ethics, 4(2), 155165.
Chino, H., & Vollweiller, L. (1986). Etiological beliefs of middleincome anglo Americans seeking clinical help. Human
Organization, 45, 245254.
Chatters, L., Levin, J., & Ellison, C. (1998). Public health and health
education in Faith communities. Health Education and Behavior,
25, 689699.
Cockerham, W. (1986). Medical sociology. Englewood Cliffs, NJ:
Prentice Hall.
Dalton, H. (1989). AIDS in blackface. Daedalus: Journal of American
Academy Arts and Science, Summer 205228.
Davis, R. (1977). Understanding ethnic womens experiences with pharmacopeia. Health Care for Women International, 18, 425437.
Dressler, W. (1982). Hypertension and culture change: Acculturation
and disease in the West Indies. New York: Redgrave.
Dula, A. (1994). African American suspicion of the healthcare system
is justified: What do we do about it? Cambridge Quarterly of
Health Care Ethics, 3, 347357.
Ellison, C. G., & Sherkat, S. E. (1990). Patterns of religious mobility
among African Americans. Sociological Quarterly, 4, 551566.
Ewell, J. (1813). Planters and mariners medical companion.
Philadelphia, PA: Scholarly Press.
Ford, M., Tilley, B., & McDonald, P. (1988). Social support among
African American adults with diabetes, Part 2: A review. Journal
of the National Medical Association, 90, 425432.
Garro, L. (1986). Cultural models of high blood pressure. Paper
presented at the 85th American Anthropological Association,
Philadelphia, PA.
Goodson, M. (1987). Medicalbotanical contributions of African slave
women to American medicine. Western Journal of Black Studies,
2, 198203.
Gorelick, P. B., Freels, S., Harris, B. A., Dollear, T., Billingsley, M., &
Brown, N. (1994). Epidemiology of vascular and Alzheimers
dementia among African Americans in Chicago, IL. Neurology, 44,
13911396.
Green, L., & Ottoson, J. (1994). Community health (7th ed.). St. Louis,
MO: Mosby.
Gregg, J., & Curry, R. (1994). Explanatory models for cancer among
African American women at two Atlanta neighborhood health
centers: The implications for a cancer screening program. Social
Science & Medicine, 39, 519526.
Harvey, W. (1988). Voodoo and Santeria: Traditional healing techniques
in Haiti and Cuba. In C. Zeichner (Ed.), Modern and traditional
health care in developing societies (pp. 101114). New York:
University Press of America.
African Americans
Hill, C. (1976). Folk medical belief system in the American south: Some
practical considerations. Southern Medicine, 1117.
Jackson, J. (1981). Urban black Americans. In A. Harwood (Ed.),
Ethnicity and medical care (pp. 37129). Cambridge, MA:
Harvard University Press.
Jackson, J. (1985). Race, national origin, ethnicity, and aging. In
R. Binstock & E. Shanas (Eds.), Handbook of aging and the social
sciences (pp. 264303). New York: Van Nostrand.
Jackson, J., Jackson, O., & Nixon, W. (1970). Medicine in the black
community. California Medicine, 113, 5761.
Jacques, G. (1976). Cultural health traditions: A black perspective. In M.
Branch & P. Paxton (Eds.), Providing safe nursing care for ethnic
people of color (pp. 115123). New York: Appleton-Century Crofts.
Jones, J. H. (1981). Bad blood: The Tuskegee syphilis experiment:
A tragedy of race and medicine. New York: Free Press
Jordan, W. (1975). Voodoo medicine. In R. Williams (Ed.), Textbook of
black-related diseases (pp. 716738). New York: McGraw-Hill.
Jordan, W. (1979). The roots and practice of voodoo medicine in
America. Urban Health, 8, 3841.
Kumanyika, S. (1994). Racial and ethnic issues in diet and cancer epidemiology. Advanced Experimental Medical Biology, 354, 5970.
Kumanyika, S., & Adams-Campbell, L. (1991). Obesity, diet, and psychosocial factors contributing to cardiovascular disease in blacks.
Cardiovascular Clinics, 21, 4773.
Lannin, D., Mathews, H., Mitchell, J., Swanson, M., Swanson, F., &
Edwards, M. (1988). Influence of socioeconomic and cultural factors
on racial differences in late-stage presentation of breast cancer.
Journal of the American Medical Association, 279, 10811807.
Leininger, M. (1985). Southern rural black and white American lifeways with focus on care and health phenomena. In M. Leininger
(Ed.), Qualitative research methods in nursing (pp. 195216).
New York: Grune & Stratton.
Lust, J. (1974). The herb book. New York: Bantam Books.
Manuel, R. (1985). Demographics and the black elderly. Paper
presented at the Gerontological Meetings, Chicago, IL.
Martin, J., & Panicucci, C. (1996). Health-related practices and priorities: The health behaviors and beliefs of community-living black
older women. Journal of Gerontological Nursing, 22, 4148.
Mathews, H., Lannin, D., & Mitchell, J. (1994). Coming to terms with
advanced breast cancer: Black womens narratives from eastern
North Carolina. Social Science & Medicine, 38, 789800.
Mbiti, J. (1975). Introduction to African religion. Ibadan, Nigeria:
Institute for Urban Studies.
McRae, M. Carey, P., & Anderson-Scott, R. (1998). Black churches as
therapeutic systems: A group process perspective. Health
Education and Behavior, 25, 778789.
Mouton, C. (2000). Cultural and religious issues for African Americans.
In K. Braun, J. Pietsch, & P. Blanchette (Eds.), Cultural issues in
end-of-life decision making (pp. 7182). Thousand Oaks, CA: Sage.
Mouton, C., Johnson, M., & Cole, D. (1995). Ethical considerations
with African American elders. Ethnogeriatrics, 11, 113129.
National Center for Health Statistics. (1996). Mortality trends for
Alzheimers disease: Fact sheets. In Vital and Health Statistics
(Series 20, No. 28). Washington, DC: Centers for Disease Control
and Prevention.
National Center for Health Statistics. (1997). Health, United States
199697 and injury chartbook (DHHS publication No. PHS
97-1232). Hyattsville, MD: US Government Printing Office.
557
Amish
Lawrence P. Greksa and Jill E. Korbin
ALTERNATIVE NAMES
OVERVIEW
OF THE
CULTURE
558
Amish
559
560
MEDICAL PRACTITIONERS
Amish individuals rely on a variety of health care practitioners. The Amish obtain health care from biomedical
practitioners, from a variety of complementary and alternative medicine providers, and through the use of home
remedies. As long as core religious beliefs are not
violated, individual preferences for health care providers
are allowed and respected. Biomedical care is sought for
both mental and physical illness, though the level of
acceptance of biomedical care, particularly for mental
health, varies across church districts. Many individuals
simultaneously consider and utilize both biomedical and
one or more different complementary and alternative
(CAM) treatments for virtually all illnesses. There is also
a reported tendency for the Old Order Amish not to utilize
preventive health services to any great extent, although
there is some suggestion that this is changing with
increased access to insurance and recognition of the
benefits of some preventive care, for example, childhood
immunization.
CAM health care is sought either because it is
believed to be efficacious or because of its lower cost.
Practitioners ranging from reflexologists to chiropractors
to herbal and vitamin practitioners may be consulted for
health problems. A unique practitioner found in the past
Amish
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Health among the Amish is generally associated with an
ability to perform ones work and the ability to eat well.
Biomedical paradigms, classifications, and theories about
illness and treatment are widely accepted among the
Amish, keeping in mind that there is both individual variability and variability across church districts. Biological
causes generally predominate in etiological explanations
of physical illness. With respect to mental illness, most
Old Order Amish distinguish between mental disorders
that have a biological basis, and therefore can be treated
with medication, and those that are not rooted in biology,
and therefore require counseling. Amish families are very
likely to accept biomedical treatments, regardless of cost,
that restore normal functioning, but are likely to strongly
resist treatments primarily designed to extend life when
there is no hope of restoring normal functioning. The latter, but not the former, is seen as interfering with Gods
will by most Amish.
SEXUALITY
AND
REPRODUCTION
561
Infancy
Infants are both breast- and bottle-fed, with both types
of feeding usually occuring on demand. Breast-feeding
remains the ideal or preferred method of infant feeding,
though women who elect to bottle feed are not criticized
for this decision. There are no data on the length of breast
feeding, but exclusive breast feeding seldom lasts for
more than 3 or 4 months, at which time Amish families
begin to provide soft supplementary foods, such as
mashed potatoes, to infants from the dinner table. There
are some reports that Amish babies often sleep in the
same bed as their parents for the first few months but the
frequency of this behavior is not clear. However, most
Amish parents do move their babies cribs into their bedrooms for the first several months after birth, to facilitate
infant care and feeding.
Infants are viewed as not yet having the ability to
distinguish between right and wrong, and therefore, they
should never be punished in any way for any act. Crying
is a sign that an infant needs comfort and is never cause
for discipline. Amish infants are primarily cared for by
their parents, but older children, particularly older female
children, will generally play an important role in child
care, even in infancy.
There has been resistance in the past, particularly in
the more conservative Amish groups, to child vaccinations, in the belief that vaccinations are attempts to thwart
Gods will. This has occasionally resulted in outbreaks of
disease within Amish communities. There may still be
some resistance to vaccinations (as well as biomedical
health care in general) in the most conservative groups,
but the majority of Amish parents recognize the value of
vaccinations. Additionally, while the Amish have their
562
Amish
occur. They are not blamed for failing but rather are
praised for succeeding. The general attitude is that this is
what all children do, so you will too.
Since work is seen as central to both good health and
being a good Christian, Amish children are assigned ageappropriate chores from an early age. Children are thus
incorporated into the work ethic of the family and community, and are seen by others, as well as by themselves,
as contributing to the general family welfare. There was
never any difficulty assigning useful and meaningful
tasks when most Amish were family farmers. Some
Amish are concerned that one negative consequence
of the transition to wage labor has been the loss of meaningful chores for the young, leading to potentially
dangerous idle hands.
Adolescence
Childhood
Amish parents recognize that one of their most important
functions is to raise their children to accept adult baptism
and lead a good Amish life. Parents recognize that they
must provide a good model of behavior for their children
at all times and believe that they must be constantly
vigilant to correct the behavior of their children whenever
it deviates from the expected norms of the Amish community. Amish parents see the road to becoming Amish
(and thus to salvation) as being straight and narrow. It is
their responsibility to keep their children on this track.
In particular, children are taught to be obedient, to
respect authority, to work hard, and that the well-being
of the group always takes precedence over their own
well-being. The latter belief is summarized in a saying
found in many schools: JOY: Jesus first, Others second,
Yourself last.
Amish parents believe that it is their moral obligation to firmly and consistently correct their children. This
sometimes is viewed as requiring physical punishment
(spanking). Spanking is seen as a necessary (even if disagreeable to the parent) tool for teaching obedience and
raising good Christian children. However, any corrective
action, including spanking, must not be performed in
anger. Amish parents recognize that any corrective behavior performed in anger will not be an effective learning
event, which should be the only goal of such behavior.
Toilet training generally begins at about 2 years of
age and is approached like all other stages of life for
children. Children are gently and calmly told what should
Adulthood
There are no special health or medical issues that arise
during adulthood for most Amish. However, due to the
unique genetic history of the Amish, there is a high
Bibliography
The Aged
Elders are accorded respect by the Amish. Elder
individuals try to live as independently as possible, often
moving into a small but separate house connected to one
of their childrens homes (grossdawdy house). In the past,
this move would occur when the parents turned over their
farm to one of their children, often the youngest male.
Once the elderly person is no longer capable of living
independently, they will generally either move in with
one of their children or their children will take turns taking care of them. In very rare cases, the elderly are placed
into a health care facility. Such cases generally only occur
if the family is convinced that appropriate care can only
be obtained in a nursing home.
563
BIBLIOGRAPHY
Acheson, L. S. (1994). Perinatal, infant, and child death rates among
the Old Order Amish. American Journal of Epidemiology, 139,
173183.
Bryer, K. B. (1979). The Amish way of death: A study of family support
systems. American Psychologist, 34, 255261.
Campanella, K., Korbin, J. E., & Acheson, L. (1993). Pregnancy
and childbirth among the Amish. Social Science and Medicine, 36,
333342.
Fuchs, J. A., Levinson, R. M., Stoddard, R. R., Mullet, M. E., &
Jones, D. H. (1990). Health risk factors among the Amish: Results
of a survey. Health Education Quarterly, 17, 197211.
Greksa, L. P. (2002). Population growth and fertility patterns in an Old
Order Amish settlement. Annals of Human Biology, 29, 192201.
Greksa, L. P., & Korbin, J. E. (1997). Influence of changing occupational
patterns on the use of commercial health insurance by the Old Order
Amish. Journal of Multicultural Nursing and Health, 3, 1318.
Hamman, R. F., Barancik, J. I., & Lilienfeld, A. M. (1981). Patterns of
mortality in the Old Order Amish. I. Background and major causes
of death. American Journal of Epidemiology, 114, 845861.
Hewner, S. (1997). Biocultural approaches to health and mortality in an Old
Order Amish community. Collegium Anthropologicum, 2 (1), 6782.
Hostetler, J. A. (1963). Folk and scientific medicine in Amish society.
Human Organization, 22, 269275.
Hostetler, J. A. (1993). Amish society (4th ed.). Baltimore: Johns
Hopkins University Press.
Hostetler, J. A., & Huntington, G. E. (1971). Children in Amish Society:
Socialization and community education. New York: Holt, Rinehart
and Winston.
Huntington, G. E. (1988). The Amish family. In C. H. Mindel,
R. W. Habenstein, & R. Wright, Jr. (Eds.), Ethnic families in America:
Patterns and variations (3rd ed., pp. 367399). Englewood Cliffs,
NJ: Prentice Hall.
Kraybill, D. B. (1989). The riddle of Amish culture. Baltimore: Johns
Hopkins University Press.
Kreps, G. M., Donnermeyer, J. F., & Kreps, M. W. (1994). The changing
occupational structure of Amish males. Rural Sociology, 59(4),
708719.
564
Argentine Toba
Tripp-Reimer, T., Sorofman, B., Lauer, G., Martin, M., & Afifi, L.
(1988). To be different from the world: Patterns of elder care
among Iowa Old Order Amish. Journal of Cross-Cultural
Gerontology, 3, 185195.
Waltman, G. H. (1996). Amish health care beliefs and practices. In
M. C. Julia (Ed.), Multicultural awareness in the health care professions (pp. 2341). Boston: Allyn & Bacon.
Yoder, K. K. (1997). Nursing intervention considerations among Amish
older persons. Journal of Multicultural Nursing and Health, 3,
4852.
Argentine Toba
Claudia R. Valeggia and Florencia Tola
ALTERNATIVE NAMES
There are no current alternative names for the Toba,
although Spanish colonizers used the collective term
Guaycur to refer to many indigenous communities
inhabiting the Gran Chaco. The name frentones (large
foreheads in Spanish) was in widespread use for eastern
Toba bands in the early centuries of contact. The Toba
call themselves Qom or Qompi (people).
OVERVIEW
OF THE
CULTURE
565
566
Health Situation
There are no current demographic statistics on the Toba,
but the Institute of Aboriginal Communities of Formosa
estimates a total of 70,000 Toba people living in
Argentina. As recognized Argentine citizens, the Toba
have access to free medical services at public hospitals
and health centers. However, it is a common complaint
that indigenous people are constantly discriminated
against at these places. Complaints from Toba people
range from being ignored at hospitals to being abused and
mistreated. The provincial governments have acknowledged the lack of communication between indigenous
and non-indigenous sectors in the arena of public health.
In order to alleviate this situation they implemented a
plan that includes training health agents at the local communities. These agents are in charge of monitoring the
health of a given number of families in their own villages,
reporting illnesses and new pregnancies, administering
medicines, and promoting health education. The success
of this strategy remains to be evaluated, but preliminary
results seem very promising.
Epidemiological statistics for each life cycle stage
are given below. Briefly, the current health situation of
the Toba is that of poor communities in developing countries. Infant and child mortality are high and mainly a
consequence of preventable causes, such as diarrhea,
dehydration, and respiratory infections. Tuberculosis is
prevalent across all ages and its incidence is more pronounced in rural communities. Cardiovascular problems
and obesity-related diseases are becoming increasingly
common among sedentarized, urban Toba.
MEDICAL PRACTITIONERS
Among the Toba there are different specialists who are
in charge of restoring health (Karsten, 1932; Mtraux,
1946, 1967). The main figures associated with medical
therapy in the larger part of Toba communities are the
shaman (pioGonaq) and the curandero (ratanataGaq).
Argentine Toba
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Sources of illness include spells attributed to the will of
shamans, non-human entities, or sorcerers, as well as to
SEXUALITY
AND
REPRODUCTION
567
568
Argentine Toba
Infancy
Birth weight is within normal ranges in both urban and
rural villages. A study of infant growth found that only
3% of infants born in a peri-urban village weighed less
than 2,500g, while 85% weighed between 2,500 and
4,000g and 12% weighed more than 4,000g (Valeggia &
Ellison, n.d.). The mean birth weight for this population
was 3,380 498g (range 2,0254,400g). A summary of
vital statistics for the year 2000 showed that in the more
rural communities, 8% of infants were born weighing less
that 2,500g, 80% were born between 2,500 and 4,000g,
and 12% weighed more than 4,000g at birth (Programa
NacyDef, 2000).
There are no gender preferences among the Toba
and both girls and boys receive much attention during
their first year of life. The growth of infants is very good
during the first year of life. In fact, the mean weightfor-age falls above two reference curves until 11 months
of age, showing a peak around 4 months (Faulkner,
Valeggia, & Ellison, 2000; Valeggia, Faulkner, & Ellison,
2001). Growth slows down progressively during the
second year.
All infants are breastfed from birth until 23 years
of age or until the mother becomes pregnant again.
Breastfeeding can be defined as on demand. On average, babies are put to the breast three to four times per
hour, even during their second year (Valeggia & Ellison,
2001a). Supplements to breast milk are introduced
around the fifth month of life and typically consist of
broths, noodles, and rice. In urban settings, formula feeding is starting to replace semi-solid food as the first supplement of choice. The mother is the principal caretaker
during infancy (Cohn, Valeggia, & Ellison, 2001). On
occasion and for brief periods, the father and older
siblings can act as surrogates.
Infant mortality during the first year of life varies
from 18.6 per 1,000 in peri-urban villages to 61.8 per
1,000 in rural communities (Programa NacyDef, 2000;
Torres, Cabutti, & Palatnik, 1973). The most commonly
cited causes of infant death in peri-urban settings are
upper-respiratory infections and gastrointestinal infections (diarrhea and dehydration). In more isolated areas,
peri-natal deaths appear to be the main cause of infant
death (Costanz et al., 2001).
Childhood
The Toba do not have set ceremonies to mark the beginning and end of childhood. Once children are weaned
they are considered to be independent and they are no
longer in permanent physical contact with the mother.
Girls begin to perform some light household chores and
child caretaking when they are 3 years old. However,
most helping activities are performed when the girl is
between 7 and 15 years old. Girls helping behavior
includes involvement in domestic work (e.g., cooking,
cleaning, tending the fire, washing), economic work (e.g.,
weaving baskets, selling handicrafts), or child caretaking.
Young boys are not expected to help, neither in household
chores nor in childcare (Bove, Valeggia, & Ellison, 2002).
Toba parents have a very permissive attitude toward
children. Children are seldom reprimanded or scolded
and are encouraged to learn through experience. As soon
as they start walking confidently, they join mixed-age
peer groups. Play is unsupervised and children usually
play at different locations within the village.
Early childhood (13 years old) is the life stage in
which Toba children are most vulnerable to problems of
malnutrition. A survey carried out by a pediatric hospital
in the province of Santa Fe indicated a worsening in the
grade of malnutrition in Toba children in successive
hospitalizations for other pathologies (Gomez, Morales,
Aride, Balonchar, & Jofre, 1998). During the second year
of life the mean weight-for-age declines and it falls
significantly below Argentine growth reference curves
(Faulkner et al., 2000). According to Faulkner et al.s
study, a sharp increase in the percentage of malnourished
children occurs around 15 months of age. The authors
suggest that this dramatic weight loss may be due to a
delay in introducing supplements, coupled with the
unavailability of appropriate, nutrient-rich weaning
foods.
In 1994, the Department of Epidemiological
Surveillance of the Province of Formosa evaluated the
nutritional status of indigenous children in the province
(Ranaivoarisoa & Ventura, 1998). Compared with nonindigenous children and with national growth curves,
Toba children 69 years old showed considerable growth
faltering. Of the surveyed children, 11% were one standard deviation below the national average and 8.5% were
two standard deviations below that average. The authors
also pointed out that Toba children in rural communities
were in better nutritional status than their urban counterparts, suggesting better diet quality in rural settings.
569
Adolescence
Adolescent girls start their reproductive lives at approximately 15 years of age. Vital statistics reports show high
rates of adolescent pregnancy. In certain Formosan
villages, as many as 44% of the Toba women giving birth
in the year 2000 were 19 years old or younger (Programa
NacyDef, 2000), with 3% being younger than 15 years
old. These rates were similar regardless of the location
and mode of subsistence of the community. Usually, adolescent mothers and their infants remain in the maternal
home until the second or third child. The custom of
fostering away children born to young girls is fairly
common, particularly in urban settings.
Adolescent prostitution is common in peri-urban
and urban settings. As many as 20% of the adolescent
girls participating in a reproductive history survey
conducted in a peri-urban village indicated that they
worked as prostitutes in a nearby truck stop (Valeggia,
unpublished data). During this survey, the girls indicated
that they seldom used condoms during their sexual
encounters. Prostitution, although illegal in Argentina,
is not stigmatized among the Toba and it is taken as a
temporary job.
Health information on adolescent boys is very
scarce. With the traditional customs of hunting and
fishing severely curtailed, and integration into the nonindigenous society being difficult, many adolescents turn
to alcohol. Alcoholism, in turn, leads to violent accidents
and death. Violent deaths were, in fact, one of the main
causes of adolescent mortality in the last few years in the
province of Formosa (Departamento de Informacin y
Estadsticas, 1999). In some villages, adolescents and
young adult men find support in the Evangelic church,
where they participate actively in ceremonies. School
570
Adulthood
There are virtually no written reports on the health of
adult Toba before Spanish colonization. In general, they
were described as strong, robust people. Early writings by
physical anthropologists noted that the Toba, together
with the Patagonian Indians, were among the tallest
South American Indians, with an average height of
around 169 cm for men and 156 cm for women
(Lehmann-Nitsche, 1908; Paulotti, 1948). Interestingly,
current adult height is not significantly different from
these figures.
At present, very few hospitals discriminate health
reports based on ethnicity. The data presented here were
obtained from districts in which the indigenous population represents the majority of people (Departamento de
Informacin y Estadsticas, 1999). Still, the data should
be regarded as tentative.
Tuberculosis is widespread among Toba adults,
particularly those living in more isolated communities.
The incidence of Chagas disease increases east to west in
the Gran Chaco, favored by the dryer climate and the
prevalence of traditional mud and palm huts in rural areas.
Among the urban Toba, the main morbidity causes include
hypertension, urinary infections (mainly women), gall
bladder calculi, and gastrointestinal infections. As many
as 80% of adult members of a rural community in the
province of Chaco presented with pterygium and
hypervascularization of the ocular conjunctiva (Torres
et al., 1973).
Although the incidence of gonorrhea is known to be
high among Chaco indigenous groups, other sexually
transmitted diseases are dramatically underreported. In a
survey conducted in 1998, 75% of the adult women in a
Toba community of Formosa reported current or past
symptoms of vaginitis and other urogenital infections
(Valeggia, unpublished data). Records from city hospitals
in Formosa and Chaco show a very low incidence of HIV
infection among Gran Chaco indigenous people
(Cravero, personal communication), but HIV tests are
not performed routinely and underreporting might be
significant.
Argentine Toba
The Aged
Aged people had an important role in Toba society in the
past. They were the ones teaching traditions to the young
and all important community decisions, including
marriages, had to be approved by a council of elders. Postreproductive Toba women also contributed considerably
to the community economy, carrying most of the burden
of forest-gathering. Today, changes in lifestyle are also
accompanied by a change in the role of elders in the
community. It is a common complaint of old people that
the young no longer respect them and that that is the cause
of a gradual loss of their ethnic identity.
It is difficult to accurately assess the age of older
Toba people. Even though most have identification documents, these are not reliable sources of dates of birth. In
any event, demographic data from some villages show a
dramatic drop after age 55 for both men and women. The
main cause of hospitalization for older Toba is pneumonia
and other respiratory infections. Mortality records from
the Formosan Ministry of Human Development indicate
that the main causes of mortality among older Toba adults
are tuberculosis, pneumonia, and various types of tumors.
References
REFERENCES
Alegre, I., & Francia, T. (2001). Historias nunca contadas. Buenos
Aires, Argentina: Ediciones del Tat.
Boggiani, G. (1899). Cartografa lingstica del Chaco. Estudio crtico
sobre un artculo del Dr. D. G. Brinton.Rev. del Instituto Paraguayo 3
(Compendio de etnografa paraguaya moderna): Asuncin Paraguay.
Bove, R. M., Valeggia, C. R., & Ellison, P. T. (2002). Girl helpers and
time allocation of nursing women among the Toba of Argentina.
Human Nature, 13(4), 457472.
Braunstein, J. (1983). Algunos rasgos de la organizacin social de los
indgenas del Gran Chaco (Publication No. 2). Buenos Aires,
571
Argentina: Universidad de Buenos Aires, Instituto de Ciencias
Antropolgicas, Trabajos de Etnologa.
Braunstein, J., & Miller, E. (1999). Ethnohistorical introduction. In
E. Miller (Ed.), Peoples of the Gran Chaco. Westport, CT: Bergin
& Garvey.
Cohn, M., Valeggia, C., & Ellison, P. T. (2001). Child care-taking and
maternal activities in a Toba community, Formosa, Argentina.
American Journal of Physical Anthropology (Suppl. 32), 51.
Costanz, J., Villaroel, M., Kayser, A., Barrios Centurion, R.,
Mendoza, L., & Gimenez, M. (2001). Diagnstico de salud area
programtica Pozo de MazaAo 2000. Formosa, Residencia
de Medicina General, Ministerio de Desarrollo Humano, Provincia
de Formosa.
Delucchi, M., Fontan, M., Grichener, S., & Wassner, M. (1996).
Proyecto de saneamiento bsico integral: Barrio Namqom,
Formosa. Formosa, Argentina: Convenio SDS-UNICEF.
Departamento de Informacin y Estadsticas (1999). Principales causas
de morbilidad segn grupos etreos y sexo. Formosa, Argentina:
Ministerio de Desarrollo Humano.
Faulkner, K. M., Valeggia, C., & Ellison, P. T. (2000). Infant growth
status in a Toba community of Formosa, Argentina. Social Biology
and Human Affairs, 65(1), 819.
Gelles, R. J., & Lancaster, J. (Eds.) (1987). Child abuse and neglect:
Biosocial dimensions. New York: de Gruyter.
Gomez, T., Morales, L., Aride, I. G., Balonchar, S., & Jofre, C. S.
(1998). Cultura de la alimentacin Toba. Simposio, Los pueblos
indgenas y la salud, Academia Nacional de Medicina Sociedad
Argentina de Pediatra.
Gordillo, G. (1995). La subordinacin y sus mediaciones: Dinmica
cazadora-recolectora, relaciones de produccin, capital comercial y
estado entre los Tobas del oeste de Formosa. In H. Trinchero (Ed.),
Produccin domstica y capital: Estudios desde la antropologa
econmica. Buenos Aires, Argentina: Biblos.
Idoyaga Molina, A. (1976/1977). Aproximacin hermenutica a las
nociones de concepcin, gravidez y alumbramiento entre los pilag
del Chaco Central. Scripta Ethnolgica, 4(2), 7898.
Karsten, R. (1926). The civilization of the South American Indians.
London: Kegan Paul, Trench, Trubner and Co.
Karsten, R. (1932). Indian tribes of the Argentine and Bolivian Chaco:
Ethnological Studies. Societas Scientiarum Fennica, 4(1), 10236.
Karsten, R. (1967). The Toba Indians of the Bolivian Gran Chaco.
Oosterhout, NB: Anthropological Publications.
Lehmann-Nitsche, R. (1908). Estudios antropolgicos sobre los
Chiriguanos, Chorotes, Matacos y Tobas (Chaco Occidental).
Anales del Museo Nacional de La Plata.
Mason, J. A. (1963). The languages of South American Indians. In
J. Steward (Ed.), Handbook of South American Indians. New York:
Cooper Square.
Mendoza, M. (2002). Band mobility and leadership among the Western
Toba hunter-gatherers of the Gran Chaco in Argentina. New York:
Edwin Mellen Press.
Mendoza, M., & Wright, P. G. (1989). Sociocultural and economic
elements of the adaptation systems of the Argentine Toba: The
Nacilamolek and Taksek cases of Formosa Province. Archeological
Approaches to Cultural Identity, 243257.
Mtraux, A. (1937). Etudes dethnographie Toba-Pilag (Gran Chaco).
Anthropos, 32.
572
Badaga
Badaga
Paul Hockings
ALTERNATIVE NAME
Burgher (early 19th century only).
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
Medical Practitioners
573
MEDICAL PRACTITIONERS
Although today the only practitioners found in the Badaga
community are likely to be doctors and nurses trained in
biomedicine and working in the states health-care system,
until perhaps 25 years ago there were therapists still functioning in an indigenous, mainly herbal system. While
most of these were unschooled general practitioners, there
were also some specialists in many of the villages. The
commonest was the midwife, always an experienced older
woman; a big village might have several. In addition one
could encounter exorcists who were necessary in instances
of ghost possession; bone-setters; and some specialists
who only handled one type of illness, such as fevers.
Although by the end of the 20th century the therapists had
disappeared, some of the other specialized practitioners
remained, for their services might still be needed. These
574
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Since there are no Badaga medical colleges and no textbooks (this having been a non-literate society until the
late 19th century), there has been no formalization of
medical theory except by the present author.
Indigenous belief was based on a lack of knowledge
of the internal organs, especially in the vegetarian phratries where nobody had ever butchered an animal. As a
consequence, it was not known that the heart existed, and
other anatomical knowledge was similarly inadequate.
The following outline of human physiology was given to
me by an elderly male therapist who had never been to
school.
The chest contains one organ, the nenju (which
would in biomedical terms encompass both heart and
lungs), which is of no great importance in the Badaga
understanding. For them the central organ is the belly.
There are some 16 organs in the body and nearly all are
somehow connected with the belly: this is responsible not
only for digestion but for blood circulation, reproduction,
breathing, smell, even sights and speech. Food goes
through the mouth into a tube, and then passes down to a
stomach. As with cattle (!) there is a second stomach
adjoining it, where the body stores liquids, which reach it
from the mouth by a separate tube. A third tube links the
two stomachs. The mixing of food from these two stomachs occurs in the belly, which lies around and below the
navel. Here blood is prepared from the mixed food and liquid, and is sent to all parts of the body through arteries.
The actual digestion is assisted by worms about the thickness of a pencil, which live in the belly and eat the food
there. They are essential to keep a person alive. An important unit within the belly is the colon (karu), which must
remain erect, otherwise the person will die. When breathing occurs, the air passes through the nostrils, the mouth,
the eyes, and the ears, by a single tube to the nenju, and
then on to the belly, where it is needed by the worms for
digestion. The evidence for this state of affairs is in
Badaga
SEXUALITY
AND
REPRODUCTION
575
576
Badaga
Infancy
After the child has sucked the breast for the first time, he
or she is given a small piece of bezoar. After a few days
some burnt rhizome of the sweet flag is also fed to the
baby. After a year or two the infant might be taken on a
pilgrimage to a nearby temple, where during an annual
festival mendicants were given consecrated pieces of
banana mixed with crude sugar. This they chewed a little,
then spat into the hands or mouths of devotees, who either
ate it themselves or fed it to their children because it was
believed to cure all disease. The main food of the infant
is mothers milk, but the child will be weaned at about
one year. If the mother eats too many sweet things, she
may transmit small worms to her baby through the breast
milk. She avoids going near any corpse, or the smell of
another womans birth, or the odor of anyone other than
her husband in the early morning, or hearing any frightening story, for fear that any of these bad winds may
Childhood
At about the fifth month the child is made to sit up, surrounded by blankets. In the sixth or seventh month he will
start to crawl, and will then be allowed to sleep on the
floor. People encourage him to crawl, stand, and walk. At
around 1218 months children begin to talk. For common
things like sleep, mat, rice gruel, etc. there are baby
words that people use. It is primarily the old people in the
household who educate their grandchildren and greatgrandchildren. The parents may be out working in the
fields much of the day. Now that most children are going
to school, this interaction with the elderly mainly occurs
in the evenings.
Small children are given relative freedom in their
actions, and are usually disciplined with threats: the coming of sorcerers, ghosts, mendicants, demons, or vaccinators to take them away are common threats. Otherwise
kindness and outright bribery are lavished on small children. Now between the ages of 5 and 7 years they find
themselves being sent off to school. Virtually every village
larger than a hamlet has at least one; some have several,
577
Adolescence
Menarche usually comes at the age of 14 or 15, sometimes earlier. Girls at about puberty used to be tattooed
on the brow, shoulders, and forearms with distinctively
Badaga patterns. The tattooing was done, without any
ceremony, with a thorn from one of two local plants or,
more recently, with pins or needles, using soot scraped
from the bottom of a pot for color. Traditionally, a girls
initiation into adulthood was essentially her marriage
ceremony, which would occur at about menarche.
Nowadays, child marriages do not occur. There are no
maladies recognized as specific to the period of adolescence, and no bodily mutilations mark any male initiation
ceremony.
Adulthood
Adult women might add further tattoos to the shoulders,
forearms, or back of the hands while they were in the
menstrual hut. Each village of adequate size would have
its own hut, or several small hamlets would share one,
until the mid-20th century. There is no theory of why
menstruation occurs: it is simply Gods will. A woman
should be segregated from food preparation activities for
six days.
578
The Aged
Old people are shown respect, but Badaga proverbs suggest
that people are well aware of the infirmities that come
with advanced age: A man above sixty years is said to
have half-sense; If the lord speaks, the whole village
quakes; if an old man speaks there is a sound of babbling; The activity of a 20-year-old is pleasure-loving;
the activity of an 80-year-old is that of old age. Cynical
though all of these may sound, respect is enjoined: If a
person cannot see, hear or walk, as he is such an old man,
you must first ask his permission to do anything. It is
believed that if a man wears gold his lifetime will
lengthen; whereas if he sees two crows in sexual congress
then he will die within a year. If he feels he is too young
to die, then he can countermand the omen by going up a
hill near his home and shouting out to the villagers that
hementioning his nameis dead. (A woman might
also persuade a man to do this for her.) Making sure no
one sees him, this act will have the effect of persuading
some neighbors to go to his house to pay respects to the
corpse; and this process of misleading the mourners is
supposed to prolong life.
Badaga
BIBLIOGRAPHY
Note: There are only one book and one article on the Badaga medical
system:
Blasco, F., & Fauvel, M. T. (1977). Plantes mdicinales des Nilgiri.
Journal dAgriculture tropicale et de botanique applique;
Travaux dethnobotanique et dethnozoologie, 24, 2339.
Hockings, P. (1980). Sex and disease in a mountain community.
New Delhi: Vikas; Columbia, MO: South Asia Books.
Related texts:
Hockings, P. (1988). Counsel from the ancients, a study of Badaga
proverbs, prayers, omens and curses. Berlin and New York:
Mouton de Gruyter.
Hockings, P. (1989). The cultural ecology of the Nilgiris District. In
P. Hockings (Ed.), Blue Mountains: The ethnography and
biogeography of a South Indian region (pp. 360376). New Delhi
and New York: Oxford University Press.
Hockings, P. (1999). Kindreds of the earth: Badaga household structure
and demography. New Delhi and Thousand Oaks, CA: Sage.
Hockings, P. (2001). Mortuary ritual of the Badagas of Southern India.
(Fieldiana, Anthropology, n.s., 32.) Chicago: Field Museum of
Natural History.
579
Bangladeshis
Darryl J. Holman and Kathleen A. OConnor
ALTERNATIVE NAME
Bangladeshis are often called Bengalis.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
580
The degree of observance varies widely by region, education, and socioeconomic condition. The practice of purdah
is believed to protect women from evil and maintains family respectability. Some adherents see purdah as a symbol
of piety and purity, that provides religious fulfillment. On
the other hand, purdah can severely restrict womens
mobility, and limits access to education, occupational
opportunity, and health care (Maloney et al., 1981).
Bangladeshi Muslim society is not highly stratified,
in accordance with the egalitarian principles of Islam. The
Hindu caste system, while present, does not figure prominently in Hindu communities because most Bangladeshi
Hindus belong to lower castes or outcaste groups.
Additionally, the generally low socioeconomic conditions
in rural areas have led to a reduction in caste consciousness
(Maloney et al., 1981).
The country of Bangladesh ranks 73 out of 90 in the
United Nations Human Poverty Index (UNDP, 2001). The
population density of the region was 900 people per km2
in 2001, making it the most densely populated non-island
area of the world. Economic development over the last
50 years has been hampered by frequent natural disasters
and political turmoil (Begum, 2001). Roughly, 7% of the
urban population lives in slums; 79% of Bangladeshis live
in a rural setting (Bangladesh Bureau of Statistics, 2001),
where most households have small plots of land or are
landless (Turner & Ali, 1996).
People in rural areas typically are involved in agriculture through sharecropping or wage-labor on larger
farms. The primary crop is rice (77% of cultivated land),
wheat (6%), and jute (4%). Agriculture makes up about
one third of the employment; about 8% are employed in
manufacturing, 9% are employed in the business sales sector, and 20% are employed in other service industries.
Something over one third of Bangladeshis are unemployed. Children from ages 1014 make up 12% of the
total labor force. Government statistics indicate that
almost half of Bangladeshis were below the poverty line
in 1996 (Bangladesh Bureau of Statistics, 2001). Independent estimates suggest a figure closer to 87% (Turner &
Ali, 1996).
Six years of primary education is compulsory for
Bangladeshi children. Even so, economic need results
in many children dropping out of school early. Recent
government-sponsored Food for Education programs raised
primary school retention rates to 70% (Mputu, 2001).
Government statistics place literacy at 68% for males and
51% for females. Begum (2001) places literacy at 32%, and
Bangladeshis
Medical Practitioners
581
MEDICAL PRACTITIONERS
Medicine is practiced at many levels in Bangladesh,
including self-care, care from a non-practitioner who has
gained some medical knowledge, care from paid and
unpaid practitioners without licenses, and licensed professionals. A number of specialties exist, such as midwives,
bone-setters, and dental practitioners (Ashraf, Chowdhury, &
Streefland, 1982). Additionally, health advice and remedies are available at local chemists (pharmacists).
Practitioners of a number of medical traditions coexist in Bangladeshi society. Traditions are sometimes combined so that a practitioner may draw from elements of
indigenous traditions and particular religious practices.
Frequently, allopathic treatment is used simultaneously
with traditional cures (Stewart, Parker, Chakraborty, &
Begum, 1994).
A study of health practitioners in Matlab thana in
the late 1970s enumerated 1,300 nongovernmental health
practitioners, 1,500 traditional midwives, and three
physicians in a government hospital (Sarder & Chen,
1981). Kobiraj practitioners accounted for 15% of health
practitioners. These practitioners follow Ayurvedic medical tradition based on Sanskrit texts belonging to Hindu
scriptures dating to before the second century AD
(Basham, 1976; Gupta, 1976). Kobiraj are unlicensed and
trained by apprenticeship. Combinations of herbal medicines, minerals, and dietary restrictions are used to cure
disease and for such things as preventing conception
(Aziz & Maloney, 1985). Just over half of the practitioners are men; over half have no formal education. Only
10% practice full time (Sarder & Chen, 1981).
Allopathic practitioners made up about 15% of practitioners in the Sarder and Chen (1981) study. Only one in
ten allopathic practitioner was licensed after formal training in medical school. Unlicensed practitioners usually
582
Bangladeshis
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Nearly all Bangladeshis, regardless of religion, believe
that disease occurs according to the will of a God or gods
(Ashraf et al., 1982). Additional awareness of illness
involves elements of pathogenicity, evil supernatural
forces, environmental exposures, personal behavior, and,
to some extent, heredity.
Some diseases are thought to be caused by exposure
to cold in the environment. One source of respiratory
illnesses, for example, is exposure to cold temperatures,
prolonged exposure to cold water, or even cold mud
(Stewart et al., 1994). Bangladeshis classify food as being
intrinsically hot (e.g., meat, fish, eggs) or intrinsically cold
(e.g., rice, many vegetables) (Maloney et al., 1981; Sarkar,
1982). Additionally, foods can turn cold when they
become stale or are leftover. Some foods are believed to
play a role in disease promotion, particularly cold foods,
which are considered to cause respiratory disease (Stewart
et al., 1994). Hot foods are often associated with health,
vitality, and sexuality (Maloney et al., 1981).
SEXUALITY
AND
REPRODUCTION
583
584
Bangladeshis
585
Infancy
Bangladeshis recognize infancy as a life stage from birth
to roughly 5 years of age. Infancy is a dangerous phase
of life. In 1978, nearly 14% of Bangladeshi infants died
in infancy compared with 1.4% in the United States. By
1998, the proportion had dropped to 8% of Bangladeshi
infants dying in infancy, compared with 0.7% in the
United States (WHO, 1999). The most common causes of
death for infants (Matlab comparison area from 1995 to
1999, ICDDR, B 1996a, 1996b, 1998, 1999, 2000, 2001)
were neonatal complications (other than tetanus), respiratory infections, and diarrheal disease. Factors associated with elevated postneonatal mortality (deaths from
4 to 54 weeks of age) are households that do not use
a latrine and households with more than 10 individuals
(Rahman, Rahman, Wojtyniak, & Aziz, 1985). Infants
born to teenage mothers, mothers of low socioeconomic
status, mothers with low education, and first-born infants
experience higher neonatal and postneonatal mortality
(Alam, 2000). Mortality by age 5 is 11.2% (rural) and
6.2% (urban) (Bangladesh Bureau of Statistics, 2001).
Breastfeeding is almost universal in rural Bangladesh,
but following birth, an infant may not breastfeed for several
days. During this spell, the infant is given prelacteal foods
such as rice water and honey (Rizvi, 1993). In the past,
delayed initiation of breastfeeding came out of the belief,
found throughout South Asia, that colostrum is harmful to
the infant. Recent public health programs have promoted
early breastfeeding out of concern over disease transmission from contaminated prelacteal foods and to ensure
infants receive the health benefits of colostrum. These programs may be responsible for recent decreases in the time
to initiation of breastfeeding (Holman & Grimes, 2001).
Nearly all Bangladeshi infants are breastfed
(Holman & Grimes, 2001; Huffman, Chowdhury,
Chakraborty, & Simpson, 1980; Khan, 1980). The duration
of breastfeeding exceeds an average of two years (Ahmed,
1986; Huffman et al., 1980; Mannan & Islam, 1995;
Mulder-Sibanda & Sibanda-Mulder, 1999). Urban women,
586
Childhood
Childhood is recognized as a life stage that begins
about the time a child starts school (age 6) and continues
through about 10 years of age. Aside from a ceremony for
the childs first school attendance, there are few rituals
associated with the transition to childhood. Boys are usually circumcized during early childhood. The occasion is
marked by a feast; the boys status changes to that of a
senior child. Most girls have an ear pierced between the
ages of 1 and 9 (Aziz & Maloney, 1985).
The overall effects of poverty and malnutrition are
reflected in 1996 statistics on stunting showing that
56% (rural) and 39% (urban) of children are more than
two standard deviations below height-for-age standards.
Likewise, 58% (rural) and 42% (urban) of children are
more than two standard deviations below weight-for-age
standards (Bangladesh Bureau of Statistics, 2001).
Bangladeshis
Adulthood
Adolescence
Adolescence encompasses three Bengali stages of life:
pre-adolescence, early adolescence, and late adolescence. The pre-adolescence stage begins with the growth
spurt around age 911. The stage ends around menarche
in girls, but is less demarcated for boys. During this stage,
a girl begins to adopt the dress of adult women. Both boys
and girls start taking on gender-specific adult roles within
the family. Individuals are expected to take on more
responsibility for their behavior, especially in limiting
their contact with individuals of the opposite sex. Preadolescent individuals are expected to sleep with samesex kin (Aziz & Maloney, 1985).
The early adolescence stage begins around puberty
or near the peak of the growth spurt. Boys remain in this
stage until their facial hair begins to grow, and their voice
changes. Menarche is considered private; it entails no
587
The Aged
Old age is recognized as a stage of life that begins in the
mid to late 50s. Elderly parents are cared for by their
sons, usually the oldest, although in urban settings elderly
women may live with a daughter (Kabir et al., 1998).
Care for the elderly is considered a beneficial responsibility, rather than a burden. The elderly are respected for
their wisdom; they command a near religious reverence
(Aziz & Maloney, 1985).
In the late 1990s, there were about 7 million elderly
Bangladeshis; about 17.5 million elderly are projected for
the year 2025 (Kabir et al., 1998). Men tend to live longer
than women, but because of the age difference at marriage, women tend to outlive their husbands (Ellickson,
1988). Mortality risk for elderly men and women is lower
while their spouse is alive. Mortality risk is also reduced
while living with a son (Rahman, 1999, 2000). Older
women report significantly more limitations in their daily
activities, and have more physical performance limitations
than do their male counterparts (Rahman & Liu, 2000).
588
Bangladeshis
REFERENCES
CHANGING HEALTH PATTERNS
Efforts to reduce diarrheal disease by establishing widespread tube-well sources has had unintended health consequences. In the mid-1990s, high concentrations of
naturally occurring arsenic were discovered in the ground
water in many regions of Bangladesh and West Bengal.
Arsenic-related health conditions include skin lesions,
skin cancers, cancers of internal organs, and neurological
disorders, but the onset of many conditions has a 10-year
latency period, so it is still too early to evaluate the longterm health effects. Because of the enormity of the
problemareas with high-concentration wells may
include half of the population of Bangladesharsenic
poisoning is being treated as a public health emergency
(Smith, Lingas, & Rahman, 2000).
Another public health crisis is the re-emergence of
malaria in recent years. Malaria had been almost eliminated from the region in the mid-1960s, primarily
through heavy use of DDT. The practice was halted
during the war of independence from Pakistan. Since
the mid-1970s, cases of malaria have increased steadily,
and reached a peak of nearly a million cases by 1997.
Additionally, a higher fraction of cases involves the more
severe and deadly falciparum malaria. The most heavily
infected areas are difficult to access and lack surveillance
infrastructure (Bangali, Mahmood, & Rahman, 2000).
HIV has not been a serious problem for Bangladeshis,
although there is growing concern over the potential for a
serious epidemic. As of 1999, about 13,000 individuals are
believed to be HIV positive (UNAID, 2001); but only 17
cases of AIDS have been reported (Ministry of Health and
Family Welfare, 2002). The infection has only recently
made in-roads into vulnerable groups. Prevalence among
sex workers is under 1%, but there is a low frequency of
condom use among commercial sex workers. Female sex
workers have an average of two to five clients a day and the
number of clients is estimated to be half a million men
daily. The high rate of other sexually transmitted diseases
References
Chowdhury, M. K., & Bairagi, R. (1990). Son preference and fertility
in Bangladesh. Population and Development Review, 16, 749757.
Croley, H. T., Haider, S. Z., Begum, S., & Gustafson, H. C. (1966).
Characteristics and utilization of midwives in a selected rural area
of East Pakistan. Demography, 3, 578580.
Dixon-Mueller, R. (1988). Innovations in reproductive health care:
Menstrual regulation policies and programs in Bangladesh. Studies
in Family Planning, 19, 129140.
Ellickson, J. (1988). Never the twain shall meet: Aging men and women
in Bangladesh. Journal of Cross-Cultural Gerontology, 3, 5370.
Faga, A., Scevola, D., Mezzetti, M. G., & Scevola, S. (2001). Sulphuric
acid burned women in Bangladesh: A social and medical problem.
Burns, 26, 701709.
Frank, N. L., & Hussain, S. A. (1971). The deadliest tropical cyclone
in history. Bulletin of the American Meterological Society, 52,
444483.
Gatrad, A. R. (1994). Muslim customs surrounding death, bereavement,
postmortem examinations, and organ transplants. British Medical
Journal, 309, 521523.
Greaney, V., Khandker, S. R., & Alam, M. (1998). Bangladesh:
Assessing basic learning skills. Dhaka, Bangladesh: World Bank.
Greiner, T. (1997). Breastfeeding in Bangladesh: A review of the
literature. Bangladesh Journal of Nutrition, 10, 3750.
Gupta, B. (1976). Indigenous medicine in nineteenth- and twentiethcentury Bengal. In C. Leslie (Ed.), Asian Medical Systems
(pp. 368378). Berkeley: University of California Press.
Hadi, A. (2000). Prevalence and correlates of the risk of marital sexual
violence in Bangladesh. Journal of Interpersonal Violence, 15,
787805.
Haque, C. E. (1988). Human adjustments to river bank erosion hazard
in the Jamuna floodplain, Bangladesh. Human Ecology, 16,
421437.
Hartmann, B., & Boyce, J. (1979). Needless hunger. San Francisco:
Institute for Food and Development Policy.
Holman, D. J., & Grimes, M. A. (2001). Colostrum feeding behaviour
and initiation of breast-feeding in rural Bangladesh. Journal of
Biosocial Science, 33, 139154.
Huffman, S. L., Chowdhury, A. K. M. A., Chakraborty, J., &
Simpson, N. K. (1980). Breast-feeding patterns in rural
Bangladesh. American Journal of Clinical Nutrition, 33, 144154.
International Centre for Diarrhoeal Disease Research, Bangladesh.
(1996a). Demographic surveillance systemMatlab: Registration
of demographic events, 1994, Vol. 25. Dhaka: Author.
International Centre for Diarrhoeal Disease Research, Bangladesh.
(1996b). Demographic surveillance systemMatlab: Registration
of demographic events, 1995, Vol. 27. Dhaka: Author.
International Centre for Diarrhoeal Disease Research, Bangladesh.
(1998). Demographic surveillance systemMatlab: Registration
of demographic events, 1996, Vol. 28. Dhaka: Author.
International Centre for Diarrhoeal Disease Research, Bangladesh.
(1999). Demographic surveillance systemMatlab: Registration
of demographic events, 1997, Vol. 30. Dhaka: Author.
International Centre for Diarrhoeal Disease Research, Bangladesh.
(2000). Health and demographic surveillance systemMatlab:
Registration of demographic events and contraceptive use, 1998,
Vol. 31. Dhaka: Author.
589
International Centre for Diarrhoeal Disease Research, Bangladesh.
(2001). Health and demographic surveillance systemMatlab:
Registration of demographic events, 1999, Vol. 32. Dhaka: Author.
Islam, R. (1978). The Bengali language movement and emergence of
Bangladesh. In C. Maloney (Ed.), Contributions to Asian studies
(pp. 142152), Vol. 11, Language and civilization change in South
Asia. Leiden, The Netherlands: E. J. Brill.
Islam, S. (1982). Case studies of indigenous abortion practitioners in
rural Bangladesh. Studies in Family Planning, 13, 8693.
Kabir, M., Uddin, M. M., Chowdhury, S. R., & Ahmed, T. (1986).
Characteristics of users of traditional contraceptive methods in
Bangladesh. Journal of Biosocial Science, 18, 2333.
Kabir, Z. N., Szebehely, M., Tishelman, C., Chowdhury, A. M. R.,
Hjer, B., & Winblad, B. (1998). Aging trendsmaking an invisible population visible: The elderly in Bangladesh. Journal of
Cross-Cultural Gerontology, 13, 361378.
Khan, A. R., Jahan, F. A., & Begum, S. F. (1986). Maternal mortality in
rural Bangladesh: The Jamalpur District. Studies in Family
Planning, 17, 712.
Khan, M. (1980). Infant feeding practices in rural Meheran, Comilla,
Bangladesh. American Journal of Clinical Nutrition, 33, 23562364.
Khan, M. A., Smith, C., Akbar, J., & Koenig, M. A. (1989).
Contraceptive use patterns in Matlab, Bangladesh: Insights from a
1984 survey. Journal of Biosocial Science, 21, 4758.
Koenig, M. A., Fauveau, V., Chowdhury, A. I., Chakraborty, J., &
Khan, M. A. (1988). Maternal mortality in Bangladesh. Studies in
Family Planning, 19, 6980.
Leslie, C. (1978). Pluralism and integration in the Indian and Chinese
medical systems. In A. Kleinman (Ed.), Culture and healing in
Asian Societies: Anthropological, psychiatric, and public health
studies (pp. 235251). Boston: G. K. Hall.
Maloney, C. (1974). Peoples of South Asia. New York: Holt, Rinehart
and Winston.
Maloney, C. (1977). Bangladesh and its people in prehistory. Journal of
the Institute of Bangladesh Studies, 2, 136.
Maloney, C., Aziz, K. M. A., & Sarker, P. C. (1981). Beliefs and fertility in Bangladesh. Dhaka, Bangladesh: International Centre for
Diarrhoeal Disease Research.
Mannan, H. R., & Islam, M. N. (1995). Breast-feeding in Bangladesh:
Patterns and impact on fertility. Asia-Pacific Population Journal,
10, 2338.
Measham, A. R., Rosenberg, M. J., Khan, A. R., Obaidullah, M.,
Rochat, R. W., & Jabeen, S. (1981). Complications from induced
abortion in Bangladesh related to types of practitioner and methods, and impact on mortality. The Lancet, 24, 199202.
Ministry of Health and Family Welfare, Government of Bangladesh.
(2002). National AIDS/STD Programme. Retrieved March from
http://www.bangla-aids.org/document/organization.htm
Mostafa, G., Wojtyniak, B., Fauveau, V., & Bhuiyan, A. (1991). The relationship between sociodemographic variables and pregnancy loss in
a rural area of Bangladesh. Journal of Biosocial Science, 23, 5563.
Mputu, H. A. (2001). Literacy and non-formal education in the E-9
countries. Paris: United Nations Educational, Scientific, and
Cultural Organization.
Mulder-Sibanda, M., & Sibanda-Mulder, F. S. (1999). Prolonged breastfeeding in Bangladesh: Indicators of inadequate feeding practices
590
or mothers response to childrens poor health? Public Health, 113,
6568.
Mushtaque, A., Chowdhury, R., & Kabir, Z. N. (1991). Folk terminology for diarrhea in rural Bangladesh. Reviews of Infectious
Diseases, 13, S252S254.
Nichter, M. (1989). Anthropology and international health: South Asian
case studies. Dordrecht, The Netherlands: Kluwer Academic.
Pebley, A. R., Huffman, S. L., Chowdhury, A. K. M. A., & Stupp, P. W.
(1985). Intra-uterine mortality and maternal nutritional status in
rural Bangladesh. Population Studies, 39, 425440.
Rahman, M. O. (1999). Family matters: The impact of kin on the mortality of the elderly in rural Bangladesh. Population Studies, 53,
227235.
Rahman, M. O. (2000). The impact of co-resident spouses and sons on
elderly mortality in rural Bangladesh. Journal of Biosocial
Science, 32, 8998.
Rahman, M., Laz, T. H., & Fukui, T. (1999). Health related research in
Bangladesh: MEDLINE based analysis. Journal of Epidemiology,
9, 235239.
Rahman, M. O., & Liu, J.-H. (2000). Gender differences in functioning
for older adults in rural Bangladesh. The impact of differential
reporting? Journal of Gerontology, 55A, M28M33.
Rahman, M., Rahman, M. M., Wojtyniak, B., & Aziz, K. M. S. (1985).
Impact of environmental sanitation and crowding on infant mortality in rural Bangladesh. The Lancet, 8445, 2831.
Riley, A. P. (1990). Dynamic and static measures of growth among
pre- and postmenarcheal females in rural Bangladesh. American
Journal of Human Biology, 2, 255264.
Rizvi, N. (1993). Issues surrounding the promotion of colostrum feeding in rural Bangladesh. Ecology of Food and Nutrition, 30, 2738.
Rob, U., & Cernada, G. (1992). Fertility and family planning in
Bangladesh. The Journal of Family Planning, 38, 5364.
Rochat, R., Jabeen, S., Rosenberg, M. J., Measham, A. R., Khan, A. R.,
Obaidullah, M., & Gould, P. (1981). Maternal and abortion
related deaths in Bangladesh, 19781979. International Journal
of Gynaecology and Obstetrics, 19, 155164.
Roy, N. C., Kane, T. T., & Barkat-e-Khuda. (2001). Socioeconomic and
health implications of adult deaths in families of rural Bangladesh.
Journal of Health, Population and Nutrition, 19, 291300.
Rozario, S. (1995). Traditional birth attendants in Bangladeshi
villages: Cultural and sociologic factors. International Journal
of Gynecology and Obstetrics, 50(Suppl. 2), S145S152.
Ruzicka, L. T., & Bhatia, S. (1982). Coital frequency and sexual abstinence
in rural Bangladesh. Journal of Biosocial Science, 14, 397420.
Ruzicka, L. T., & Chowdhury, A. K. A. M. (1987). Demographic
surveillance systemMatlab: Vital events, migration and marriages1976, Vol. 5. Dhaka, Bangladesh: International Centre for
Diarrhoeal Research.
Sarder, A. M., & Chen, L. C. (1981). Distribution and characteristics of
non-government health practitioners in a rural area of Bangladesh.
Social Science & Medicine, 15a, 543550.
Sarkar, P. C. (1982). Customs and beliefs associated with sexual
behavior and human fertility in rural Bangladesh. Eastern
Anthropologist, 35, 135142.
Bangladeshis
Sarker, P. C., Rahman, A. P. M. S., Chowdhury, J. H., Nasrin, T., &
Tariq, T. (1996). Infertility and practice of traditional methods of
treatment in cross-cultural perspective in Bangladesh. South Asian
Anthropologist, 17, 2125.
Shahidullah, M. (1994). Breast-feeding and child survival in Matlab,
Bangladesh. Journal of Biosocial Science, 26, 143154.
Shaikh, K., Aziz, K. M. A., & Chowdhury, A. I. (1987). Differentials of
fertility between polygynous and monogamous marriages in rural
Bangladesh. Journal of Biosocial Science, 19, 4956.
Siddique, A. K., Baqui, A. H., Eusof, A., & Zaman, K. (1991). 1988
floods in Bangladesh: Pattern of illness and causes of death.
Journal of Diarrhoeal Disease Research, 9, 310314.
Siddique, A. K., Zaman, K., Baqui, A. H., Akram, K., Mutsuddy, P.,
Eusof, A. et al. (1992). Cholera epidemics in Bangladesh:
19851991. Journal of Diarrhoeal Disease Research, 10, 7986.
Sirageldin, I., Norris, D., & Ahmad, M. (1975). Fertility in Bangladesh:
Facts and fancies. Population Studies, 29, 207215.
Smith, A. H., Lingas, E. O., & Rahman, M. (2000). Contamination of
drinking-water by arsenic in Bangladesh: A public health emergency. Bulletin of the World Health Organization, 78, 10931103.
Stewart, M. K., Parker, B., Chakraborty, J., & Begum, H. (1994). Acute
respiratory infections (ARI) in rural Bangladesh: Perceptions and
practices. Medical Anthropology, 15, 377394.
Strong, M. A. (1992). The health of adults in the developing world: The
view from Bangladesh. Health Transition Review, 2, 215224.
Turner, B. L., & Ali, A. M. S. (1996). Induced intensification:
Agriculture change in Bangladesh with implications for Malthus
and Boserup. Proceedings of the National Academy of Sciences of
the United States of America, 93, 1498414991.
UNAID (2001). Retrieved December 2001 from http://www.usaid.gov/
pop_health/aids/Countries/ane/bangladesh.html
United Nations Development Program (2001). Human Development
Report 2001. New York: Author.
van Ginneken, J., Bairagi, R., de Francisco, A., Sarder, A. M., &
Vaughn, P. (1998). Health and demographic surveillance in
Matlab: Past, present and future (Special publication 72). Dhaka,
Bangladesh: International Centre for Diarrhoeal Disease Research.
Vaughan, P. J., Karim, E., & Buse, K. (2000). Health care systems in
transition III. Bangladesh, Part I. An overview of the health care
system in Bangladesh. Journal of Public Health Medicine, 22, 59.
World Bank. (2000). Bangladesh HIV/AIDS Prevention Project (Report
21299-BD). Washington, DC: The World Bank.
World Health Organization. (1999). The World Health Report 1999.
Geneva, Switzerland: Author.
World Health Organization. (2000). The World Health Report 2000:
Health systems: Improving performance. Geneva, Switzerland:
Author.
Yasmin, L. (2000). Law and order situation and gender-based violence:
Bangladeshi perspective (Policy Studies 16). Colombo, Sri Lanka:
Regional Centre for Strategic Studies. Retrieved May 26, 2002,
from http://www.rcss.org/publications/POLICY/ps-16.html
Zeitlyn, S., & Rowshan, R. (1997). Privileged knowledge and mothers
perceptions: The case of breast-feeding and insufficient milk in
Bangladesh. Medical Anthropology Quarterly, 11, 5668.
591
ALTERNATIVE NAMES
The Baliem valley Dani are also known as the Dani and
the Grand Valley Dani. The term Dani used here does not
include the neighboring Western Dani, the Lani, or the
Yali, who have been called Dani in the past.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
592
Medical Practitioners
593
MEDICAL PRACTITIONERS
There are three kinds of people with specific healing skills
who contribute to the well-being of the Dani: part-time
healers with specific practical skills, sometimes known as
hathale; ritual participants, who seek to control the sacred
realm; and trained health workers called mantri.
First, hathale, or part-time healers, span several
realms. Many hathale are women. Some women have
expertise in assisting with childbirth. Other women are
experts at performing abortions. Others know herbal
remedies or can perform small curing ceremonies. Certain
individuals, mostly women (Heider, 1979), are known to
be powerful practitioners of the arts of magic. They can
cast spells and can sometimes cure the sick. Overall, there
is no special status accorded to these healers.
An important healer role is played by participants in
rituals designed to control sickness, food, and the threat of
enemies. Political leaders have to be able to involve the
ancestral ghosts in the affairs of the group (Ploeg, 2001,
p. 34) and one way of demonstrating this is by bringing
about good health through successful ritual practice.
Most of these rituals involve killing a pig, cutting it up,
cooking it, and eating it in a systematic manner (see
Aso-Lokobal, n.d.; Lokobal, 1994; Peters, 1975). Pig
sacrifices are intended to placate ancestors, thus ensuring
594
fertile gardens, fecund women, and a healthy and prosperous population. Failure to carry out the rituals in their
correct time and order can explain misfortune, sickness,
and misery. The most important of these rituals is the
kaneke hakasin, but Aso-Lokobal (n.d.) tallies 94 distinct
rituals related to Dani health. In sum, political leaders
produce Dani well-being, not by directly healing the sick,
but by the successful execution of rituals.
Lastly, some Dani have undergone two years of
nursing training, and are called mantri. For a small fee,
mantri working in government clinics will dispense some
medicines, treat wounds, and promote government health
programs such as family planning. Mantri often find
themselves in a position of conflict. On the one hand, all
mantri believe in the power of Dani rituals to provide
physical well-being through mediating social and spiritual relationships. On the other hand, they also dispense
with confidence the medicines that they believe will heal
their sick patients. Discretion in mediating two often
competing belief systems is key to their success. One
mantri summarizes a common strategy: Never tell a
patient you know he believes in spirits. Never tell them
what disease they have. Just give them the medicine
(Butt, 1998, p. 199).
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Traditional beliefs about ancestor spirits or supernatural
powers are intricately interwoven into Dani imaginings
about why and how people become sick. The rich world
of Dani wesa (the supernatural) includes ancestor spirits,
magical powers, and forest and animal spirits. These
intersect with the natural world, contemporary medical
services, and individual illness in complex and often idiosyncratic ways. In the main, illness and death are always
considered to be more or less directly caused by ghosts
(Heider, 1970, p. 227).
One belief common to all Dani is the importance of
soul matter or etai-egen. Each person who is born
needs to grow an etai-egen over the course of his or her
lifetime. The etai-egen is an immaterial substance that
rests lodged just beneath the sternum. Throughout adult
life the etai-egen is continually subject to potential disturbance or weakening, particularly through the work of
SEXUALITY
AND
REPRODUCTION
Dani sexuality has been a topic of active debate in anthropology, beginning with Karl Heiders (1976) argument
that the Dani had a low energy sexual system. Heider
had observed a seeming disinterest on the part of Dani
men and women to engage in sexual relationships during
his 1960s fieldwork. Their willing adherence to a four- to
five-year post-partum taboo, low birth rates, and low rates
of extra-marital sex, were interpreted by Heider as evidence of a general disinterest in heterosexual intercourse.
There is some data to support Heiders hypothesis.
As with most other highland New Guinea societies, negative symbolic constructions about women and their
reproductive capacities can make sexual intercourse an
activity fraught with tension and uncertainty for men.
Menstrual blood can poison mens bodies, food, and pigs,
according to the Dani, and men consider vaginal sex toxic
and potentially debilitating. Metaphors of poison and
contagion continue to be employed to strengthen assumptions about male superiority. Women also fear mens bodily substances. Semen, in particular, can poison womens
inner organs if it is ingested orally. Semen must never be
scattered on the ground, for it can kill plants and poison
the earth. A recent survey (Butt et al., 2002) suggested
that Dani men and women continue to limit their location
and kind of sexual activities in order to protect bodies and
gardens from the debilitating effects of bodily fluids.
Another practice that lends support to Heiders argument is that Dani women continue to attempt to space
their children so they are born every four to five years.
One way they do this is by not having sexual relations
with their husband. Parents of a newborn child are
expected to refrain from having sex with each other until
the woman has stopped breastfeeding, typically around
the childs fourth year. Post-partum sexual abstinence is
rooted in the conviction that semen is a highly dangerous
fluid to an infant, whose body is weak and unfinished. If
a couple has sex while the woman breastfeeds, semen can
travel up through the womans internal organs and come
out in her breast milk; this can make the child sick or die.
However, other data substantially challenge
Heiders claim of Dani low sexual energy. Peters
(1975) describes intense flirting and a high level of sexual knowledge among adolescents. Pre-marital sex was
seen as commonplace in the 1960s (Hayward, 1980;
Heider, 1976). Courting parties were common, and
Hayward (1980) describes couples leaving parties
595
596
Infancy
Dani women are skilled at transforming small, healthy
newborns into large, plump infants. The newborn spends
the first 4 months of life in a soft, smooth, and cool netbag. Women surround the infant with soft banana leaves
or cloth bedding in the netbag, and carry the infant in the
bag slung across their lower backs. The infant comes out
of the bag only to change soiled bedding, or partially to
breastfeed. Once the mother starts garden work, she takes
special care to enclose her baby under 10 or 12 netbags to
protect the child from the sun, and from being startled.
The babys vulnerable body, which is still wet, with
closed eyes and soft skin, needs extensive protection
from the spirit world (Butt, 1998). Infants grow very fast
in these conditions. By 4 months, most babies have more
than doubled their birth weight, and at 5 or 6 months
almost all infants are plump and healthy.
Infant health deteriorates once mothers begin giving
supplementary foods at around 6 or 7 months. Bananas,
mashed sweet potatoes, and, increasingly, mashed noodles or crackers, are some of the first foods the baby eats.
The protein levels of these foods are adequate, but many
infants get sick because they are exposed to bacteria on
the spoons that women increasingly use to feed their children. At 78 months, many infants experience their first
bout of diarrhea. Growth rates slow over the first year,
and by the age of 18 months, many children show signs
of inadequate nutritional intake.
Infants and young children also suffer from numerous
chronic skin problems, including infected insect bites and
scabies. Scabies are endemic because many women have
begun to use pieces of cloth instead of the more sanitary
netbag to hold their babies. Intestinal worms plague
significant numbers of young children. However, upperrespiratory infections are the biggest concern (see Figure 1)
and many infants who get pneumonia die of it. The death
Childhood
Dani childhood is carefree and pleasant. Children roam
forests and fields, and do so in age sets distinguished
along the lines of gender. Complex gender distinctions
between boys and girls come into play as the child
achieves more independence at around age 6 or 7. Bodies
of boys are seen as more soft than those of girls, and as
less likely to grow fast and well. Girls, in contrast, grow
faster, mature faster, and are seen as hardier than boys.
Despite claims to the contrary, the Dani exhibit preferential gender behavior. Boys are more likely to receive formal education than girls. Boys are also more likely to be
recipients of medical care than girls. Boys under the age
of 5 were taken to clinic one-third more often than girls
(Butt, 1998). In ritual situations, boys over the age of 10
or so receive larger pieces of pork than do girls, and they
are also fed before girls. Women compensate in part by
slipping secret bits of food to their girl children.
Adolescence
There is little ritual importance attached to the transition
from child to adolescent. Only young boys whose fathers
are from the waya moiety undergo a ritual to be made
waya (Heider, 1972). At this ritual, which occurs during
the big pig feast and lasts about two weeks, boys have dangerous wesa, or sacred power, drawn from them. They are
then purified through a series of rituals that involve some
deprivation, hunting, eating ritual taro, and painting a ritual red stripe on their nose (Heider, 1972; Peters, 1975).
For girls, once a young woman has begun to menstruate, in most regions of the valley her clan holds a formal, public rite-of-passage event in which her reproductive
capacities are extolled. This ceremony is known as the
hotalimo (Peters, 1975). The girl cooks sweet potatoes and
distributes them, and women dance non-stop to protect the
young girl, for the spirits of the dead want to kill people
at moments of crisis, like menstruation or sickness
(Peters, 1975, p. 37). Young women also undergo a skirting ceremony, which usually happens during the big pig
feast. Changing a grass skirt to the low-slung thread yokal
worn by grown women signifies the girls maturity and
597
Figure 1. Waiting at the clinic for the mantri, the 9-month-old infant on the right has attained the
Dani ideal of plumpness. In contrast, the worried mother on the left holds her 2-year-old son, who
is little bigger than the other baby. He has suffered from a respiratory infection for several weeks
and is mildly malnourished. This was his first trip to the clinic to receive penicillin.
Adulthood
At the point where a girl begins to menstruate, she may
already be married. Early Indonesian officials and missionaries were horrified to see girls aged 9 or 10 married
off during the big pig festival, but they did not realize that
the time between public, ritual marriage and consummation of marriage ties is often delayed by several years
before the bridegrooms family fully pays off debts to the
brides family (Heider, 1972). Nonetheless, early age at
marriage is common, and most young women give birth
before the age of 20. This increases the chance of them
contracting sexually transmitted diseases early in their
reproductive years.
For men, adulthood is achieved later in life, at the
time when assiduous attention to social and exchange
relations with kin and alliance members begins to pay off.
598
REFERENCES
Aso-Lokobal, N. (n.d.). Keterangan singkat mengenai beberapa unsur
penting dalam kebudayaan masyarakat Balim. Unpublished
manuscript.
Butt, L. (1998). The social and political life of infants among the Baliem
Valley Dani, Irian Jaya. Doctoral dissertation, McGill University,
Montreal, Canada.
Butt, L. (1999). Measurements, morality, and the politics of normal
infant growth. Journal of Medical Humanities, 20(2), 8199.
Butt, L. (2001a). Women and the perils of reproductive choice in Irian
Jaya, Indonesia. In H. Lansdowne & M. Dobell (Eds.), Women,
culture and development in the Pacific (pp. 6573). British
Columbia: University of Victoria.
Butt, L. (2001b). KB kills: Political violence, birth control and the
Baliem Valley Dani. The Asia Pacific Journal of Anthropology,
2(1), 6386.
Butt, L. (2001c). An epidemic of runaway wives: Discourses of Dani
Men on Sex and Marriage in Highlands Irian Jaya, Indonesia.
Crossroads: An Interdisciplinary Journal of Southeast Asian
Studies, 15(1), 5587.
Butt, L., Numbery, G., & Morin, J. (2002). Papuan Sexuality Project
Research Report. Jakarta: Aksi STOP AIDS (USAID-F.H.I.)
Coomaraswamy, R. (1999). Integration of the human rights of women
and the gender perspective: Violence against women. United
Nations Economic and Social Council.
Gajdusek, D. C. (1961). West New Guinea Journal: May 6, 1960 to
July 10, 1960. Bethesda, MD: National Institute of Neurological
Diseases and Blindness and National Institutes of Health.
Gardner, R. (1963). Dead birds. Boston, MA: Harvard University,
Peabody Museum, Film Study Center.
Gardner, R., & Heider, K. (1968). Gardens of war: Life and death in the
New Guinea stone age. New York: Random House.
Gietzelt, D. (1989). The Indonesianization of West Papua. Oceania, 59,
201221.
Golson, J., & Gardner, D. (1990). Agricultural and sociopolitical organization in New Guinea highlands prehistory. Annual Review of
Anthropology, 19, 395417.
Hanevik, K. (2000). Prayers, chants and drugs. Medicins Sans
Frontieres.
Overview of Culture
599
British
Ian Shaw and Louise Woodward
ALTERNATIVE NAMES
Great Britain, United Kingdomcomponent countries:
England, Scotland, Wales, and Northern Ireland.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
600
British
Medical Practitioners
601
MEDICAL PRACTITIONERS
Medical practitioners in the United Kingdom are overwhelmingly employed and trained by the NHS. The service is organized into two sectors: primary and secondary
care. Primary care includes health professionals such as
GPs, who receive clients from within the community with
undifferentiated and undiagnosed problems. The GP will,
in many cases, be the first contact an individual has made
regarding his or her condition. GPs serve the entire local
community in their areas. Nurse practitioners serve the
local community in a similar way to GPs. Primary care
nurse practitioners decide upon the priority of patient
needs by performing a full assessment of healthcare
needs, thereby determining a patients health status.
Some patients may simply need to remain under the care
of the nurse for treatment, whereas others will require
consultation with the GP. Here, the patient has the opportunity to consult with either a GP, a nurse practitioner, or
both. The role of the nurse practitioner is set to be given
full consideration in extending his/her role to reflect that
of the GP. However, while the nurse practitioner has a
wide range of skills, knowledge base, and ability to
deliver specific aspects of care at present, they may need
602
British
SEXUALITY
CLASSIFICATION OF ILLNESS, THEORIES
OF ILLNESS, AND TREATMENT OF
ILLNESS
The biomedical paradigm and its classification of and
theories about illness and treatments is dominant.
However, this approach has been modernized with
increasing acceptance amongst health practitioners of the
more behaviorally oriented multiple-risk-factor model.
This emphasizes the interaction between behavioral risk
factors and biological/genetic factors in the causation of
disease. The importance of structural and environmental
factors is also becoming increasingly recognized in
etiology and classification (Butler & Calnan, 2000).
AND
REPRODUCTION
603
Infancy
Infancy is not a clearly defined category in Britain.
However, there is a general view that infants are those
between the ages of birth and 5, at which point they start
primary school. Infancy is generally broken down in the
public mind into three categories: baby, toddler (from
taking first steps to developing the ability to run, skip, and
jumpthe term is derived from the toddling walk of
the child), and childhood. Health Visitors monitor the
initial development of the baby. Health professionals
heavily promote breastfeeding, and most mothers will
breastfeed for the first 18 weeks (the period of paid maternity leave allowed from work, though many employers
offer additional unpaid leave, some up to a year).
Subsequent development is monitored by GPs, who carry
out immunization. Infants are immunized at the ages of 2,
3, and 4 months against tetanus, diphtheria, whooping
cough, hemophilus influenzae type B (HiB), and polio. At
1218 months they receive vaccination against measles,
mumps, and rubella (MMR), which they are also vaccinated against a second time at between 3 and 4 years when
they will also receive additional vaccinations against
diphtheria, tetanus, and polio. Vaccination take-up is
high, over 80%, although the MMR take-up has dropped
below this level in some areas in the last year over fears
of links between the combined vaccination and autism.
This has resulted in isolated outbreaks of measles during
2002. If taken ill, children will usually expect to receive
separate specialist secondary care services.
There is little government support or provision of day
care for children under the age of 3 in Britain. Childcare
facilities do, of course, exist, and are run by private individuals, companies, and by local authorities. Extended
families, where in existence locally, may also play a part.
The cost of day-care varies across Britain, but 25 per
day2002 prices(approximately US$36) is a good
guide. This means that the low-paid or those with more
than one child not living in an extended family relationship
604
where there is support from those retired, may be financially better off if one parent remains at home. Labor
mobility has reduced the number of available family
members locally who could take on a childcare role. The
main caretaker is usually the mother. The state does provide free preschool (during the school term only) for children aged 4 (or aged 3 if in an area defined as having poor
educational performance). Children start full-time education from age 5.
In post-modern Britain, many of the social contacts
that parents have may be other parents whose children
attend the same day care.
Childhood
Childhood in Britain is a period of both protection and
exclusion. Childrens lack of competence in the highly
specialized differentiated world of adult activity in this
country provides an explanation for childrens exclusion
and the protectiveness that accompanies it (Mayall, 1996).
It is true to say that the daily lives of children are structured through the organization of their parents time (particularly when both parents work), although childhood is
also a time when there is protection from the world by
social and economic provision. Schooling from the age of 5
has the dual role of providing the education to enable
them to function in the adult world and to protect them
during the day while their parents are at work. Childhood
is also seen as a time for developing interpersonal skills
and relationships as well as providing creative space of
their own. Particularly in early childhood, childrens imagination is actively fostered by adultsSanta Claus really
does come down the chimney and Mickey Mouse really
does live in Disneyland. There is a desire amongst parents
to extend this period of innocence as long as possible.
Adolescence
There is no legal definition of adolescence in Britain. The
Children Act of 1989 covers everyone from birth to age
18, the legal age of consent. Legally, children are deemed
to have the capacity to tell right from wrong from the age
of 14. However, this age of legal responsibility was
recently reviewed following concerns raised by the murder
of the toddler Jamie Bulger by two children who were 10
and 11, and by other cases (including a rape committed by
an 11 year old). There is still a presumption of incapacity
for children between the ages of 10 and 14 in Britain.
However, legally, children in this age bracket can be
British
Adulthood
Health-related issues in adulthood are varied, and in recent
years a shift in emphasis has taken place to a demand for
the right to be healthy. As society has become adept at
problem-solving within the medical realm, a discourse has
developed in which health is seen as a basic human need
and medical care is perceived as a basic human right.
Related to this is the notion of individual responsibility,
which is partly reflected nowadays in the attention given
to self-help and complementary therapies; aromatherapy,
massage, shiatsu, yoga and relaxation, and acupuncture,
for example, have all become popular alternative forms of
therapy. Within adult mental health creative therapies,
such as art and horticultural therapies, are a developing
area. In conjunction with this is the increasing number of
fitness centres within the United Kingdom and increasing
numbers of people attending them. Gender-related issues
include concern about menopause and hormone replacement therapy (HRT), which has received mounting attention. Concerns have also been raised regarding the over
medicalisation of this natural change within a womans
body, whereby women are seen more sexually and
socially obsolete, and medically and emotionally out of
control. Studies show that HRT prevents osteoporosis and
may significantly reduce the risk of coronary artery disease, but they also indicate that HRT may increase a
womans risk for breast cancer.
Domestic abuse in the United Kingdom, either physical or verbal, is becoming recognized as a health issue for
a significant minority of women and children. Most
women experiencing domestic violence are not identified
in medical records. Abusive relationships are still very
much seen as a private affair, one where intervention has
unclear boundaries. Womens services within mental
health is a developing area, concentrating upon a service
that identifies the unique needs and demands of women,
including safety within in-patient and residential settings.
In particular, motherhood and mental health is now a recognized area of need, including post-natal depression.
Mens health has, in recent years, been receiving attention
both in the media and in the academic literature. The
demarcation between the health of a man and that of a
woman, however, is that mens health is more closely
associated with culture (and work) and womens, with
nature (and health). Prostate cancer has become an area of
concern for men; 22,000 men in the United Kingdom are
newly diagnosed with this each year. The incidence of testicular cancer has doubled in the past 20 years. Depression
also is widespread but more often goes unrecognized as a
condition in men than it does in women. Furthermore, the
effects of alcohol on the body are becoming an increasing
medical concern within both genders; young women now
drink more frequently than ever. Unequal access to medical care within society tends to be the experience of those
individuals suffering from a mental health condition,
rather than being unequal in terms of gender. Inequalities
exist also in terms of social, economic, and environmental disadvantage. Despite overall improvements in health,
the gap between socially disadvantaged and affluent sections of the population has widened. A significant movement within healthcare taking place at present is the
recognition and need to involve users at all stages of their
care. This spans the whole NHS to ensure the needs of
clients are met, and a more pro-active role in their treatment is taken by clients.
605
The Aged
The aged are structurally defined in Britain with mandatory retirement at age 65, when the state retirement pension
is also payable. However, those aged 65 in Britain often
do not see themselves as elderly and generally reserve that
phrase for those aged 75 and over. Life expectancy and
general health have increased for all age groups and the
numbers aged over 80 is increasing every year. Because of
the good health of those in their late 60s, the government
is currently considering introducing flexibility on retirement age. This is important because a longer retirement
means that more resources are required to fund it. A more
flexible retirement age would also provide more scope for
individual choice in this respect.
Income in retirement is linked to income in working
life. Although there is a state pension, it provides a very
basic income and the expectation is that this will be used
to supplement a private or employment-based pension
scheme. The current focus on welfare to work itself
tends to exclude those who have retired. Quality of life in
retirement, and social status, is still linked strongly to
income.
The elderly are the major consumers of Britains
NHS. There is an association between incapacity and
increasing old age; those over 80 consume 27 times the
health and social care resources as those between the ages
of 14 and 44. Those over 75 are also heavy drug users, with
an average of 12 prescriptions per year (Glennerster,
1997). The major medical problems of the elderly are
related to their age: age-related healing and visual impairment, cognitive impairment, and cerebral vascular diseases
and associated dementia. There are also skeletal problems
resulting from arthritis and osteoporosis, which give rise to
mobility issues. Some of these diseases and problems can
be found in those younger than 65, but the incidence
increases with age and concerns with mobility are particularly focused upon those over the age of 75. Labor mobility has meant that there is less likelihood of the children of
the elderly living locally to them, and consequently, there
is only limited practical support that the elderly can expect
to receive from family members. This places increasing
reliance upon primary health and social care services.
606
British
REFERENCES
Bowen, K. (2001). Infant feeding: Maternal choice or social control?
Unpublished Master by research and thesis dissertation, University
of Nottingham, U.K.
Butler, J., & Calnan, M. (2000). Health and health policy. In J. Baldock,
N. Manning, S. Miller, & S. Vickerstaff (Eds.), Social policy.
Oxford: Oxford University Press.
Engel, G. L. (1977). The need for a new medical model: A challenge for
biomedicine. Science, 196(4286), 120135.
Fox, J., & Benzeval, M. (1995). Perspectives on social variations in health.
In M. Benzeval, K. Judge, & M. Whitehead (Eds.), Tackling inequalities in health: An agenda for action (Chap. 2). London: Kings Fund.
Glennerster, H. (1997). Paying for welfare. London: Harvester.
Lane, K. (1995). The medical model of the body as a site of risk: A case
study of childbirth. In J. Gabe (Ed.), Medicine health and risk.
Oxford: Blackwell.
Mayall, B. (1996). Children, health and the social order. Milton
Keynes, U.K.: Open University Press.
Parker, G. (1990). With due care and attention. London: Family Policy
Studies Centre.
Rimmer, L., & Wicks, M. (1985). The challenge of change:
Demographic trends, the family and social policy. In H. Glennerster
(Ed.), The future of the welfare state. Aldershot, U.K.: Gower.
Shaw, I. (2002). How lay are lay beliefs? Health, 6(3), 287299.
Shaw, I., & Middleton, H. (2001). Recognising depression in primary
care, Journal of Primary Care Mental Health, 5, 2, 2427.
Shaw, I., & Shaw, G. (1993). Demography, nursing and community
care: A review of the evidence. Journal of Advanced Nursing, 18,
12121218.
607
Burmese
Monique Skidmore
ALTERNATIVE NAMES
In 1989, Burma was renamed the Union of Myanmar by
the newly constituted State Law and Order Restoration
Council (SLORC). The Burmese were renamed the
Myanmarese or Myanmars, and the Burmese language was similarly changed to the Myanmarese language.
Minority groups in Burma were renamed National
Races, with Myanmars used to designate Burmese citizens of all ethnicities residing within Burma. The United
Nations recognized the name change but pro-democracy
groups use the older terms, especially Burma,
Burmans, and Burmese as a way of protesting at the
undemocratic nature of the name changes.
From 1885 until 1937, Burma was designated a
province of India as part of the British Raj, and literature
of the period regarding Burma is found in Indian manuscripts and journals.
Several armed groups have claimed independence
from the military government and insurgent-held areas
often publish literature referring to their territory as an
independent entity. The chief example is publications
from Manerplaw, Kawthoolei, a self-designated independent homeland of the Karen people (and the Karen
National Union rebel headquarters) from 1971 until its
capture by Burmese military forces in 1995 (Hail, 1995).
LOCATION
AND
LINGUISTIC AFFILIATION
Shaped like a kite, Burma is the largest country in mainland Southeast Asia. Burma covers 671,000 km2 and borders the Andaman Sea, the Bay of Bengal, Bangladesh,
China, India, Laos, Thailand, and Tibet. Most of these
borders are flanked by mountain ranges, including the
Himalayas in the north. The central riverland plains are
the agricultural heart of the nation with the major
northsouth river, the Ayeyarwady, flowing to the large
delta area that spills into the Gulf of Martaban. The
Thanlwin River forms much of the border with China, and
the Mekong likewise forms the border between Laos,
OVERVIEW
OF THE
CULTURE
608
Burmese
609
610
MEDICAL PRACTITIONERS
Medical and medico-religious practitioners are utilized in
Burma for a range of emotional, supernatural, mundane,
and psychiatric problems. Biomedical physicians are
trained at the government institutes of medicine, including
training in many biomedical specialities. Overseas
training is a common route to specialist training. Private
diagnostic services such as X-ray and ultrasound exist in
cities and large towns. Opticians and dentists are also
common. Specialized nursing institutes also exist and
Burmese
SEXUALITY
AND
REPRODUCTION
611
612
Infancy
Burmese midwives deliver babies and perform abortions,
primarily through abdominal massage. The postpartum
period, me-dwin, is marked by sequestration of young
mothers, dietary taboos, and attempts to stop the body
from losing heat. This means that the body is not bathed
in cool water (sometimes no bathing occurs for 6 weeks),
and cold foods are not eaten. Burmese women usually
breastfeed exclusively for at least 2 months, with the water
that rice has been cooked in usually given as the babys
first supplemental food. Infants are carried and cuddled by
mothers, and rocking cots, hammocks, and swings are used
by mothers, sisters, daughters, and grandmothers to continually keep the child in motion when awake (Skidmore,
2002a). In urban, peri-urban, and regional centers, many
mothers use antenatal care, but infant mortality remains
high, as does maternal mortality, primarily from incomplete abortions. Maternal mortality is as high as 500580
per 100,00 live births (WHO, 1997). Women present to
regional hospitals on a daily basis with hemorrhage from
incomplete abortions. Studies conducted throughout
Burma indicate somewhere between 33% and 60% of
maternal mortality is directly attributed to abortions (Ba
Thike, 1997; Khin Than Tin & Khin Saw Hla, 1990;
Ministry of Health & UNFPA, 1999). Two studies have
found abortion to be the leading cause of maternal mortality in Myanmar (Krasu, 1992; UNICEF, 2000).
Vasectomy is illegal but there is a thriving trade by
urban surgeons. Cesarian rates are very high in some
areas and many women opt for a hospital birth, especially
a cesarian birth so as to also have sterilization following
the birth of their second child. Cesarian births are very
expensive and there is no uniformity of charge across the
urban and peri-urban areas (Skidmore & World Vision
International, 1997a, 1997b). These difficult conditions
for childbirth mean that infant mortality rates are almost
400% higher in the 40% of the country where no basic
biomedical health services exist (IPPF, 2002).
Childhood
Twenty-nine percent of the population is aged 014 years
(CIA, 2002). Thirty-eight percent of children aged 611
had, in 1994, recognizable signs of goiter (WHO, 2002).
In 1994, 31% of children under three years of age had
unacceptable weight-for-age ratios (WHO, 2002).
Children are traditionally allowed to run free until
the age of 12, when they are sent to monastic centers for
Burmese
Adolescence
The shinbyu (for boys) and ear-boring ceremony for girls
traditionally mark, for Burmese Buddhists, the coming of
age of adolescents and bestows upon them responsibilities of family and personal welfare. For impoverished
families this means adolescents must earn money to contribute to family income. For wealthier families it means
following Buddhist precepts and being respectful of
monks, parents, and teachers, as well as trying to excel at
school. In these ways, adolescents prove that they are
worthy of the care that their parents have invested in their
childhood. Many adolescents feel a fierce sense of duty
toward their parents. As young adults, adolescents are
required to dress in culturally appropriate ways and to be
mindful of Burmese cultural norms and traditions, especially with regard to appropriate gender behavior. For
young girls this includes having a chaperone in public.
Adulthood
Domestic violence, sexual bartering, sexual torture, and
death from incomplete abortions are all facets of everyday
life in the poorest of Burmas townships, especially those
townships that have been forcibly relocated from central
urban areas to paddy fields on the outskirts of the major
cities. Alcohol use is very high in these areas as mens
powerlessness becomes apparent in their lack of employment and social status that has resulted from their forcible
removal from previous townships (Skidmore, 2002b).
Domestic violence, polygyny (due to the highly
mobile nature of the young male workforce), and other
forms of marital disharmony have led to a very high
divorce rate, paralleled by an almost equal rate of remarriage. This means that families in the relocated townships
frequently consist of many step-relations. Incest has been
reported by girls and young women when step-brothers,
step-fathers, and step-uncles take financial responsibility
for the household. Fear of incest and marital rape is
widely reported in these townships. Forcible relocation
613
The Aged
Life expectancy rates are low, there is no welfare system
in Burma, and aged people have always been cared for
within the extended family unit. Wealthier Buddhists may
purchase a small home within the grounds of a monastery
and so retire there. These Buddhist retirement communities are generally happy places with small garden patches,
devotional and volunteer activities that revolve around the
monastic cycle, and preparations for the next life. For destitute older people, cataracts and arthritis are major impediments to mobility and no help exists, outside of the
charity of monasteries and neighbors.
Within family units, aged people command great
respect and continue to wield power over the occupations
and living arrangements of their children and grandchildren.
They continue to control the family finances although they
may spend increasing lengths of time at monasteries.
Infrastructure for disabled people is non-existent and most
roads are unpaved, making mobility difficult for aged people. They tend to stay home and guard the house against
theft. When a family member becomes frail or incapacitated, other family members worry that they must stay on
their own during the working day, afraid that unscrupulous
people will take advantage of their aged relatives.
614
Cree
REFERENCES
Ba Thike, K. (1997). Abortion: A public health problem in Myanmar.
Reproductive Health Matters, 9, 94100.
Central Intelligence Agency (2002). CIA World Factbook: Burma.
Washington, DC: Central Intelligence Agency Government
Publications.
Hail, J. (1995). Burmese attack could doom independence struggle.
Bangkok, Thailand: UPI.
Henderson, J. W., Heimann, J. M., Martindale, K. W., Shinn, R. S., Weaver,
J. O., & White, E. T. (1971). Area handbook for Burma, foreign area
studies. Washington, DC: U.S. Government Printing Office.
International Planned Parenthood Foundation (IPPF) (2002). Country
profile: Myanmar. Available from http://www.ippf.org/regions/
countries/mmr/index.htm
Khin Than Tin & Khin Saw Hla (1990). Causes of maternal deaths in
affiliated teaching hospitals. Yangon: Myanmar Medical
Association.
Krasu, M. (1992). An Overview of Maternal Morbidity in Myanmar.
Proceedings of a Seminar on Maternal Morbidity Obstetric and
Gynecological Section. Yangon: Myanmar Medical Association.
Leach, E. R. (1970). Political systems of Highland Burma: A study of
Kachin social structure. London: Athlone Press.
Ministry of Health (2002, May 2026). Ministry of Health Statistics.
Unpublished report cited by Myanmar Times and Business Review,
Health and Medicine Supplement, 6(115).
Ministry of Health and United Nations Population Fund (1999).
A reproductive health needs assessment in Myanmar. Yangon:
Author.
Myanmar Times and Business Review (2002, May 2026). Health and
Medicine Supplement, 6(115).
Peoples Tribunal on Food Scarcity and Militarization in Burma (The)
(1999, October). Voice of the hungry nation. Asian Human Rights
Commission.
Sein Tu (2002, May 2026). New attitudes to mental health care.
Myanmar Times and Business Review, Health and Medicine
Supplement, 6(115).
Skidmore, M. (1998). Flying through a skyful of lies: Survival strategies and the politics of fear in urban Burma (Myanmar) UMI,
NQ50073. Doctoral dissertation, McGill University.
Skidmore, M. (2002a, June). Menstrual madness: Womens health and
wellbeing in urban Burma (Myanmar). In A. Whittaker (Ed.),
Women and health [Special ed.] 35(4), 85104.
Skidmore, M. (2002b). Behind bamboo fences: Domestic violence
against women and children in urban Burma (Myanmar). In
L. Manderson & L. Bennett (Eds.), Women and violence in Asia
(Chap. 5, pp. 90106): Curzon Press.
Skidmore, M., & World Vision International (1997a). A rapid assessment study of maternal and child health in Mandalay, Myanmar.
Yangon: World Vision.
Skidmore, M., & World Vision International (1997b). A rapid assessment study of maternal and child health in Hlaingthayar,
Myanmar. Yangon: World Vision International.
Smith, M. (1996). Fatal silence: Freedom of expression and the right to
health in Burma. London: Article 19.
United Nations Drug Control Programme (UNDCP) (2001). World drug
report. Available from http://www.undcp.org/world_drug_report.html
United Nations International Childrens Fund (UNICEF) (2000).
UNICEF Statistics. Available from http://www.childinfo.org
Womens Organizations from Burma and Womens Affairs Department,
NCGUB (WOB and NCGUB) (2000). Burma: The current state of
womenconflict area specific. An unpublished shadow report to
the 22nd Session of CEDAW.
World Health Organization (1997). An assessment of the contraceptive
mix in Myanmar. Geneva, Switzerland: World Health Organization.
World Health Organization (2002). Country health profile: Myanmar.
New Delhi, India: World Health Organization.
Cree
Naomi Adelson
ALTERNATIVE NAMES
LOCATION
AND
LINGUISTIC AFFILIATION
615
OVERVIEW
OF THE
CULTURE
616
Cree
Medical Practitioners
617
MEDICAL PRACTITIONERS
Historically, the Eeyouch traveled in small family groups
and, hence did not develop any large, formal medical
tradition. This does not mean, though, that there were no
established healing practices or practitioners. There were
those who had expert knowledge of the plant resources of
the region, while others were gifted spiritual practitioners, employing sweat lodges or other healing ceremonies
as required. As well, some women excelled as midwives,
a practice that has all but disappeared with the hospitalbased births now requisite in the north. See the next section
for a summary of treatment practices.
618
Cree
619
Infancy
Infancy begins at birth and ends with a formal walking
out ceremony held at about the time when the child takes
its first steps. From the time the child is born and right up
until this ceremony, the infant is swaddled for warmth,
protection, and comfort and is exceptionally wellbundled to protect it from the elements whenever outside.
An additional protection used in the past, but cautioned
against more recently, was a small necklace made of
netting string that was used to trap any cold before it
entered the infants body and hence to shield it both physically and spiritually from the cold.
Many parents will prevent their infants feet from
touching the earth or ground until he or she has walked
out. The walking out ceremony, traditionally held at the
break of dawn on a day soon after the child is just old
enough to walk, is a celebration of the symbolic and social
transformation of the infant into a future Eeyou man or
woman. Little boys hold a carved wooden gun, symbolizing their future roles as hunters; little girls hold a carved
axe, signifying their roles in maintaining the hunting camp.
The young future Eeyouch, beautifully and ornately
dressed, are assisted out of a ceremonial dwelling by a parent and, witnessed by family and community, can touch the
ground for the first time. Symbolizing entry into the communal and natural worlds, the walking out ceremony
remains an important part of contemporary cultural practice. The ceremony is complete only after a large feast is
held, honoring the child as well as the community elders.
Unfortunately, infant mortality rates remain high
almost three times that of the province of Quebec (14.9 vs.
5.3 per 1,000 live births)despite a significant reduction
in infant deaths with improved pre-natal health services
over the last 20 years (Schnarch, 2001). One infant
disease is worthy of particular note. Cree leukoencephalopathy is a neurological disorder that occurs exclusively, albeit rarely, in Cree infants from northern Quebec
(and Manitoba). This is a uniformly fatal disease of
620
Childhood
Children, and especially the youngest child in the family,
are doted upon and given a fair degree of freedom outside
of the age-appropriate tasks required of them. Children are
not strictly disciplined and, traditionally, are taught primarily by example and by observing and listening to their
parents and grandparents. This is especially so when
learning about hunting-related activities such as the proper
maintenance of firearms, hunting gear, and equipment, as
well as weather patterns and other vital bush and camp
skills. Children are always dressed warmly and their feet
properly protected in order to safeguard them from the
harsh sub-Arctic elements, as cold or a chill entering the
body is viewed as a precursor to future illness.
There is some disjuncture for some parents between
the more rigid processes of school-based learning and
investing the child with the proper knowledge base and
skills to live and work on the land. This is part and parcel
of the contemporary tension between development and
traditional practices that permeates so many aspects of
the lives of the Eeyouch. In an attempt to balance these
sometimes divergent objectives, the Cree School Board
has implemented a formal Cree language program
through to the high school years, instruction only in Cree
in the first years of school, and a cultural program that
ranges from craft production to land-based activities as
part of the general curriculum. With control over education, the Cree School Board continues to work toward a
reconciliation between the basic provincial educational
requirements and the cultural needs of the children, and
more and more children are not only completing high
school locally but are traveling out of their communities
to complete college and university degrees.
Adolescence
Adulthood symbolically begins for boys when they successfully kill their first large game animal. This has been
known to happen when boys are between 8 and 10 years
old. Thus there is, historically, no particular period of adolescence. And, given the number of pregnancies and young
relationships and marriages today, there remains, for many,
virtually no time between childhood and the responsibilities of adulthood (almost 25% of births in Eeyou astchee
Cree
Adulthood
This stage of life, as mentioned in the previous section,
often begins early as young men and women start having
children and take on full familial duties while still in
school or early on in their lives. The focus here, though, is
on the older adults who have experienced dramatic transformations in the course of their lives. Many of the older
adults today were born and raised to a young age on the
land, then moved into sometimes squalid and certainly
under-serviced settlement communities as children. They
are the first generation to have had access to a formal educational system (some in more southern communities
were placed in residential schools, which had profound
effects, both negative and positive, on their future lives)
complete with its formal structures and regimented classroom environment. This generation became, too, the first
to lead the Eeyouch into their new relationship with government, moving out from under a paternalistic system of
governance and into an historic, if uncharted, form of selfgovernment. This generation, too, moved from predominantly land-based labor and resources to a substantially
more sedentary and stable lifestyle as the village became
References
The Aged
Older Eeyouch, or the elders, are the most highly
respected members of the community. The elders were all
born and raised on the land and their generation is viewed
as the last ones who truly know the physical, spiritual,
and symbolic contours of Eeyou astchee. They are
referred to as grandparents to all of the children, which
means, too, that they have a certain degree of authority in
the social management of the communitys children. The
elders are provided with the most and the choicest parts
of any hunted foods, are respected authorities on most
issues, and are looked after as best as any community is
able (given the constraints of the relative availability of
adequate housing or other chronic care facility). The elders constitute a very small proportion of the total Eeyou
population and are now living into their seventies.
621
REFERENCES
Adelson, N. (2000). Being alive well: Health and the politics of Cree
well-being. Toronto, Canada: University of Toronto Press.
Black, D. N., Watters, G. V., Andermann, E., Dumont, C., Kabay, M. E.,
Kaplan, P. et al. (1988). Encephalitis among Cree children in
Northern Quebec. Annals of Neurology, 24(4), 483489.
Bobbish-Rondeau, E., Boston, P., Iserhoff, H., Jordan, S., Kozolanka,
K., & MacNamara, E. et al. (1996). The Cree experience of diabetes: A qualitative study of the impact of diabetes among the
James Bay Cree (Final report). Chisasibi, Canada: Cree Board of
Health and Social Services.
Dougherty, K. (2001, October 24). Cree get $3.5-billion deal. The
Gazette, A1.
Feit, H. (1986) Hunting and the quest for power: The James Bay
Cree and whitemen in the twentieth century. In R. B. Morrison &
C. R. Williams (Eds.), Native peoples: The Canadian experience
(pp. 171207). Toronto, Canada: McClelland and Stewart.
Grand Council of the Crees (GCC) (1996). Never without consent:
James Bay Crees stand against forcible inclusion into an independent Quebec. Toronto, Canada: ECW Press.
Macpherson, D. (2001, October 25). A new great peace. The Gazette,
B3.
Marvelle, N. (2001). Retaliation and reconstruction: The James Bay
Crees success in the aftermath of development. In Cultural survival. Available from (http://www.cs.org/internships/cree.htm)
Roslin, A. (1999). Health concerns pour out at Assembly. The Nation,
6(8).
Schnarch, B. (2001). Health and what affects it in the Cree communities of Eeyou Istchee. Montreal, Canada: Cree Board of Health and
Social Services of James Bay and the Public Health ModuleCree
Region of James Bay.
622
Czechs
Czechs
Zdenek Salzmann
ALTERNATIVE NAMES
The Czechs call their culture c esk kultura (Czech culture). To call it Bohemian culture would be misleading
because the term Bohemian has a historic and geographic rather than an ethnographic or linguistic refer
ence. Furthermore, Bohemia (Cechy)
is only the larger,
western part of the Czech Republic; the smaller, eastern
part is Moravia (Morava). In the north, Moravia includes
a part of Silesia (Slezsko), a historical region that lies for
the most part in southwestern Poland.
History
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
Population
The population of the Czech Republic as of December
31, 2000, was 10,266,546, with females exceeding males
623
Government
The Czech Republic is a parliamentary democracy with a
Chamber of Deputies and a Senate. The President appoints
certain high officials (for example, the prime minister)
and can veto other than constitutional bills. During the postcommunist times (from 1990 on), several dozen political
parties have emerged, and the country has been governed by
a coalition of some of those parties receiving the most votes.
The results have not always led to an efficient government.
Religion
The first half of the 15th century was marked by a breach
with the Roman Church as a consequence of the reform
movement led by the Czech Jan Hus (John Huss). His
death in 1415, when he was burned at the stake in
Constance (Konstanz in southern Germany), initiated the
ambivalent attitude of the Czechs toward Roman
Catholicism; this ambivalence was later reinforced by the
attempt at forcible re-Catholization begun during the 17th
century by the Hapsburg rulers. More recently, the 41
years of communist rule (194889) undermined the
observance of religious practices even further.
At present, about 40% of the population are Roman
Catholic, about 4% Protestant, and the remaining 56%
uncommitted, atheist, or agnostic. Compared with the
people of Moravia, the Czechs of Bohemia tend to be
lukewarm in their religious beliefs and practices.
624
Environmental Pollution
Before 1990, protection of the environment was subordinated to the fulfillment of economic five-year plans. Lack of
Czechs
Diet
By American standards, traditional Czech food would be
considered heavy and fat. Portions of meat served are not
large, but potatoes or dumplings and substantial amounts
of animal fats (lard, butter, and cream) are used both in
gravies and in general cooking. Eaten as often as bread
and butter is bread covered with lard rendered from pork
fat (with cracklings) or with goose grease (and goose
liver). Only since the 1990s have salad vegetables been
available on a year-round basis; when out of season
locally, fresh vegetables are now imported.
During 1999, consumption of the main types of food
was as follows (amounts given are per person): pork
44.7 kg, poultry 20.5 kg, beef 13.8 kg, fish 5.2 kg, fats
and oils 23.1 kg, lard and bacon 5 kg, butter 4 kg, fresh
vegetables 85.3 kg, fresh fruit 75.6 kg, and potatoes 75.9 kg
(1 kg 2.2046 1b). However, during the final two decades
of the last century vegetable shortenings, oils, and
margarine began to replace animal fats. Despite some of
the desirable changes in the basic diet, obesity is quite
Health Infrastructure
The physical resources required for health care stabilized
during the last three years of the 20th century. The network of establishments for inpatient care included 211
hospitals with 67,457 beds (including 2,304 cots for newborns), 160 specialized therapeutic centers with 22,667
beds, and 63 health-spa centers with 22,179 beds. The
total number of inpatient beds per 10,000 inhabitants was
109.4 and has been slowly decreasing despite the fact that
the number of hospitalized patients in 2000 showed a
0.5% increase over 1999.
The number of pharmaceutical service establishments
has been growing rapidly since 1990, replacing most of the
earlier dispensaries (for example, an additional 80 pharmacies were established during 2000). While in 1990 all of
the 917 pharmacies and 1,216 dispensaries were stateowned, in 2000 only slightly more than 4% of the 1,706
pharmacies and none of the 183 dispensaries was owned
by the state.
625
Domestic Abuse
According to currently valid laws, all persons who permanently reside in the Czech Republic, as well as persons who
are not permanent residents but whose employer is located
in the republic, have health insurance. The insurance is paid
either by the insured (one third) and the employer (two
thirds) or by the state. Self-employed persons (and others
who qualify as such) pay their own premiums. The state
pays for all those who for one reason or another do not
belong to either of the above two categoriesfor example,
women on maternity leave, physically or mentally disadvantaged people, soldiers, and others.
Health insurance pays for all legitimate care
extended to patients to maintain or improve their health.
These services include ambulance transportation, emergency service, preventive care, hospital stay, balneological
626
MEDICAL PRACTITIONERS
Training of Medical Personnel
The training and education of future members of occupations related to the practice of medicine, pharmacy, and
certain types of health services have been proceeding
without problems. During the 200001 academic year,
students of medicine numbered 8,251 (of whom 4,637
were women), of pharmacy 1,655 (1,280 women), and of
types of health services requiring university training
3,383 (3,039 women). The numbers of graduates at the
end of the 19992000 academic year were, respectively,
912, 254, and 665. At present, seven medical schools of
three universities train physicians, two pharmaceutical
schools at two universities train pharmacists, and two
schools of social health at two universities train personnel for work in health and social care positions.
Paramedical schools in the academic year 200001
enrolled 26,301 students, of whom 3,405 attended evening
courses.
Czechs
Alternative Medicine
Although the biomedical approach has been accepted and
employed throughout the 20th century in the region, until
World War II some individuals in villages and small
towns preferred to consult herbalists (folk healers) and
use the recommended infusions, decoctions, or ointments
made from various herbs. Consulting herbalists was not
approved of during the communist era (194889). During
the last 10 years (since the early 1990s) folk medicine has
again become popular. It is practiced nonprofessionally
and usually involves the use of plant-derived remedies on
an empirical basis. To prevent some illnesses or to cure
them, herbalists as well as many physicians recommend
carefully watching ones diet, exercising, and using herbs
and other natural remedies, both domestic and imported.
Many patients of physicians also consult herbalists.
Balneology
Balneological institutionsthat is, health spas making
use of thermal mineral waters and mud or peat bathsare
Diseases
Infectious diseases must be made known to the authorities. The most important infectious diseases reported during 2000 are listed in Table 1. Compared with 1990,
increases in incidence occurred only for salmonellosis
other than typhoid fever and paratyphoid fever B, whooping cough, viral encephalitis, syphilis, and AIDS.
627
Number of cases
40,233
38,665
2,965
1,979
1,244
967
888
743
719
548
395
227
198
148
120
9
1
Of the noninfectious diseases, diabetes is quite widespread and gaining. In 2000 about 650,000 diabetics were
under treatment, with females exceeding males by about
60,000. To put it differently, there were well over 12,000
diabetics under treatment for every 100,000 inhabitants of
the Czech Republicmore than one in every ten persons.
The incidence of malignant neoplasms (tumors) rose
steadily over the last 40 years of the 20th century while the
rate of mortality from this cause over the past thirty years
has remained virtually the same in men and has risen only
slightly in women. During 1999, the most common malignancies in men were (in descending order) those of the skin,
bronchi and lungs, prostate, colon, bladder, kidney, rectum,
and stomach; in women those of the skin, breast, colon,
uterus, bronchi and lungs, ovaries, and cervix. Compared
with 30 other European countries, the standardized mortality rate for malignant tumors in the Czech Republic was the
fourth highest for men and the third highest for women.
During 2000, the most common causes of death for
both males and females were (in descending order) diseases of the circulatory system, neoplasms, external
causes (injuries and poisoning), diseases of the respiratory system, and diseases of the digestive system.
Mental Illness
Over two million (2,057,952) psychiatric examinations
took place during 2000; they concerned 361,931 patients
628
Czechs
Preventive Measures
Infancy
SEXUALITY
AND
REPRODUCTION
Childhood
Special schools are available for children who are mentally handicapped, have impaired hearing, speech, or
vision, are physically handicapped, or have a combination
of such problems. Four types of schools serve these
children. The numbers of students in each type are given
parenthetically for the academic year 200001: nursery
schools (boys 6,309; the number for girls is not available);
basic schools (grades 110; 14,159); special education
and reform schools (49,494); and secondary, vocational,
References
629
The Aged
People in the republic seem to age faster and look older
sooner than those of the same age in the United States.
Because many have had a stressful life, they usually retire
as soon as they become eligible. Widows and widowers
sometimes live with one of their married children, but if
their health and finances permit, are more likely to live an
independent life in their own house or apartment, or in a
retirement home. During 2000, 148 nursing homes with
12,129 beds were available for those pensioners who
needed nursing services.
As for mortality age, in 2000 a full 7,118 men out of
a total of 54,845 males died at 85 years of age or older;
16,734 out of a total of 54,119 females died at that age or
older. The most common causes of death in 2000 were diseases of the circulatory system (53.39%), neoplasms
(26.33%), external causes (injuries, poisoning, etc.; 6.49%),
diseases of the respiratory system (4.55%), and diseases of
the digestive system (3.89%).
REFERENCES
The information for the Czech Republic was obtained during the
authors visit there during the spring of 2002 and from the following
sources:
Statistick rocenka Cesk republiky 2001 (2001). Praha: Scientia.
Vseobecn encyklopedie v osmi svazcch (1999). Praha: Encyklopedie
Diderot.
Zdravotnick rocenka Cesk republiky 2000 (2001). Praha: stav
zdravotnickych informac a statistiky C esk republiky.
Datoga
Astrid Blystad and Ole Bjrn Rekdal
ALTERNATIVE NAMES
Datoga, Tatog, Tatoga, Datoog, and Mangati.
LOCATION
OVERVIEW
AND
LINGUISTIC AFFILIATION
The core Datoga area has for several centuries been the
Hanang and Mbulu Districts of Arusha Region in northern Tanzania, but Datoga groups are spread over much of
Tanzania in small localized enclaves.
OF THE
CULTURE
630
Datoga
Religion
Aseeta, the Datoga deity, appears as an androgynous,
powerful, and inherently good deity, invested with
immense creative potential. Communication between
human beings and the deity takes place with female and
male spirits (meangga) as mediators. The spirits are more
closely involved in peoples lives than Aseeta. Aseeta and
the spirits are particularly powerfully addressed by married Datoga women or women who wear the leather
skirt during the frequently arranged ghadoweeda ritual
(people seeking blessing), a ritual located at the heart of
Datoga tradition.
MEDICAL PRACTITIONERS
The landscape of indigenous Datoga medical practitioners consists of primarily three categories: Daremgajeega,
Bajuta, and Gijoodiga. Most male Datoga healers are
Daremgajeega. Daremgajeega is the name of a particular
clan of healers as well as of a group of healing clans. The
other major group of male healers is called Bajuta (Bajuta
being both a healing clan and a Datoga subsection).
The practices of the Daremgajeega and the Bajuta
are often quite similar. A common healing session implies
that the healer spits on his clients body for extended
periods of time, usually on the back, breast, and belly.
Spitting, in the characteristic way of sending showers
of spit through the teeth, is always perceived to be a
blessing among Datoga, but gains in significance when
carried out by a healer. The spitting is usually combined
with the use of mixtures of herbs and animal fat which
are rubbed over the patients body with slow massaging
movements to soothing accompaniment of chanted
prayers for blessing. Patients say their healers make them
calm down.
Daremgajeega and Bajuta healers use a large number of techniques in addition to the somewhat standardized sessions of spitting, application of medicine, and
prayers in their attempts to cure their patients. Creative
use of product from domestic animals, particularly from
cows and bulls, goats, and sheep is essential for Datoga
healers. This particularly includes a practice linked to the
consumption of fatty soups served with or without meat,
the consumption or the smearing of milk, gee, butter, or
631
632
Fever
Malaria and tuberculosis (TB) are conditions typically categorized as illnesses of God. Living in a harsh and disease-ridden environment, malaria and TB are common
conditions among Datoga of Hanang and Mbulu, and with
relatively little variation, the theoretization and treatment
linked to these conditions are similar to those of a whole
range of common illnesses in the area. Normal fever conditions are distinguished from intermittent fever and fever in
combination with bloody cough and weight loss as in TB.
These conditions receive similar treatment consisting
of a combination of drinking of melted butter/gee, eating
fatty soups cooked on beef meat, and drinking of herbal
mixtures. The herbs utilized vary somewhat from one illness condition to the next. The aim of this treatment is to
cause diarrhea and vomiting in order to expel the harmful
substances from the body. For the pure fever conditions
the drinking cows, bulls, or goats urine is added to make
the expulsion more efficient. With worsening conditions
patients suffering from any of these conditions may eventually be sent to hospital, but many Datoga choose hospitals as a last option, and their health may have severely
declined by the time they arrive.
Datoga
Physical Handicaps
Conditions that are particularly feared among Datoga are
illnesses linked to burning, severe bleeding, acute diarrhea, and conditions affecting the bones, all conditions
which may be attributed to either the will of God or to
human agency. The last condition warrants a few remarks
owing to its particular elaboration among Datoga.
The birth of malformed babies, that is, babies lacking fingers or toes or entire limbs, or accidents causing
such losses, are particularly feared among Datoga. Such
handicaps have caused expulsion and fear of infants as
well as of adults throughout the known history of Datoga.
The fear of a person without a finger, without feet,
or without other bony parts of the body, must be understood with reference to the connection made between such
conditions and a clans poor semen. In Datoga semen is
thought to be the substance that builds the bony structures
of a body, and hence malformed bones imply poor contribution by the genitor and in extension by his clan. What
is important in this context is that such an incomplete
condition can be transmitted to others, particularly
through the sharing of meals.
The fear of incomplete bones make Datoga shun
amputations, which at times cause flights from hospitals.
Severe and lengthy ritual activity carried out by Datoga
healers is the only remedy that, to some extent, can
cleanse individuals with such handicaps. Other categories
of handicap, such as deafness, dumbness, or blindness are
not feared. Individuals with such handicaps are rather
often located at the heart of Datoga ritual life.
SEXUALITY
AND
REPRODUCTION
633
634
sounds, or odd sensations are also shunned during pregnancy. When severe illness occurs during pregnancy, a
sheep or a goat is commonly slaughtered in order to cook
nourishing soup for the woman, and in due course the
assistance of healers is sought.
Itself so vulnerable and dependant, the child in the
womb may also be demanding and a source of potential
peril. Indeed, a pregnant womens body is considered to
be inhabited by a tiny strong-willed human being who has
the ability to make her ill or even cause her death. Thus,
a pregnant woman may experience herself as being
vulnerable to both external and internal forces. Her
leather skirt is tied tightly around her womb in a manner
that pushes her growing belly downwards. We close the
womb with the leather skirt informants would say,
indicating the way they seek to prevent the unruly fetus
from engaging in unproductive wild play. In addition, this
technique prevents her condition from becoming visible
until the final stages of pregnancy, thereby reducing the
danger of evil eyes.
Stuck Pregnancy (Muldeaneeda). In Datoga
experience, a fetus may suddenly cease to develop, in
which case the child becomes stuck in the maternal womb
(muldeaneeda). In such instances the woman experiences
symptoms of pregnancy, but the fetus ceases to develop
due to bleeding which leads to insufficient nourishment
for the child. For years the child may hide in the back
of a womans womb feeding on her body, leaving her
thin and weak. Some women are bothered throughout
their entire lives by recurring muldeaneeda, some of
which are said to simply die off, while others are eventually born. Children that are born after years of muldeaneeda, are often given the names Gidamulda (male) or
Udamulda (female), and these children are particularly
adored, since their births relieve their mothers of years
with pain and anxiety. The immense admiration of these
children is moreover related to their alleged potency.
Miscarriage and Infant Death. Other dreaded outcomes of a pregnancy include miscarriages and the death
of nursing infants. Such deaths are considered to be frightful, and constitute severe breaches in what is perceived to
be the correct development: from conception through pregnancy and birth to convalescence and nursing. Such events
produce dirt and those who are going to eat the dirty
conditionusually the woman, her children, and sometimes her husbandare isolated in separate enclosures
Datoga
Infancy
The sensation of having calmed down after birth is soon
followed by another unsafe phase, post-natal convalescence (ghereega)the months during which the woman
is to regain her strength, and the infant is to face its initial
harsh encounter with the world. Ghereega is a new liminal
phase which is associated with almost total seclusion of
the mother and infant in the low, dark, private room of the
mother for a period of 2 months after the birth of a boy,
and 3 months after the birth of a girl.
During the months the woman remains inside, she
focuses on ensuring her own and her childs health. The
midwife commonly stays on with the mother until the
first peril is passed, and until a male goat has been
selected, strangled, and butchered, and the song of the
child initiated. A girl is then commonly selected to stay
with her and assist her. Some women will move outside
with care after the remnants of the umbilical cord have
fallen off, but they usually remain close to the compound.
In such cases she places her baby deep in a leather sling,
and if the child is a boy she carries an arrow and a ritual
stick for protection. If she meets a stranger she will commonly look at the ground or bend down to signal that she
does not want contact.
A woman will generally let her infant suckle whenever it cries. However, breastfeeding does not begin
635
636
Childhood
The custom of mutating the physical body for beauty,
socialization, or preventive health purposes takes place
throughout childhood. The most common practices
include the initiation of a process of extending the earlobes, the removal of the two lower incisors, and circumcision of both girls and boys.
The mandatory removal of the clitoris and labia
minora is commonly carried out when a girl is between 2
and 5 years of age. This painful operation is carried out
by a local elderly woman with only a handful of women
present in the homestead. The incident is not talked about
much and receives no cultural elaboration. This appears
in stark contrast to male circumcision, which is a grand
ritual occasion characterized by the brewing of large
quantities of honey mead, sung prayer, and dancing. The
operation takes place when boys are between 5 and 12
years old. Large numbers of boys, sometimes several
hundred, are circumcized at the same occasion. The operation itself is commonly carried out with a knife or razor
blade, and is followed by the feeding of milk and blood
for the boys to regain their strength.
Adolescence
Youth is a time when Datoga pay substantial attention to
their maturing bodies, and spend time on modifying it for
Datoga
Adulthood
Alcohol Consumption. Datoga elders have customarily consumed the sacred honey mead primarily on ritual occasions and on grand occasions of festivity. Women
and youth have according to Datoga custom not consumed alcohol. With the tremendous transformations taking place in Datoga communities, not the least with the
increase in contact with outside peoples who brew a large
variety of brews on which there is no customary restrictions, the consumption of alcohol has increased substantially. Youth and sometimes women may today be seen
consuming non-indigenous brew, particularly on market
days. The increase in alcohol consumption, the transformations of the people involved in the consumption, and of
the timing and settings where the consumption takes place
is readily addressed by the Datoga informant.
References
637
REFERENCES
Blystad, A. (2000). Precarious procreation: Datoga pastoralists at the
late 20th century. Doctoral thesis, University of Bergen, Norway.
638
Fore
Rekdal, O. B. (1999). Cross-cultural healing in East African ethnography. Medical Anthropology Quarterly, 13(4), 458482.
Spencer, P. (1988). The Maasai of Mataputo: A study of rituals of rebellion. Manchester, UK: Manchester University Press.
Fore
David J. Boyd
ALTERNATIVE NAMES
None. The name Fore (pronounced FO-rey) was created
by an Australian patrol officer during a patrol into the
region in the early 1950s. Standing on the northern border
of this different linguistic group, he asked local people for
the name of those who lived further to the south. The
answer was porekina (kina people), meaning people
living downhill. Pore was transcribed as Fore
(Lindenbaum, 1979, p. 39).
LOCATION
AND
LINGUISTIC AFFILIATION
Three distinct dialects that reflect the geographical division are recognized: Ibusa dialect is spoken by the North
Fore, and Atigina and Pamusa dialects are spoken by the
South Fore. This is a region of considerable linguistic
diversity and the Fore share common territorial boundaries with speakers of seven other mutually unintelligible
languages.
OVERVIEW
OF THE
CULTURE1
Until the mid-20th century, the Fore, who currently number approximately 20,000 people, existed in relative isolation and had scant knowledge of the larger world
beyond their territorial boundaries. They lived as subsistence horticulturalists practicing an extensive form of
shifting swidden cultivation to produce their staple crop,
sweet potato (Ipomoea batatas), and a variety of
subsidiary foods. New gardens regularly were cleared in
the surrounding forest and settlements were quite mobile
as people moved their living sites to stay close to their
gardens. They also tended domestic pigs, which were the
most important form of local wealth and also essential
objects of transaction in acquiring wives, settling disputes, rewarding allies, and compensating enemies.
Although the Fore did share a common language, they did
not consider themselves one people. They had no encompassing name for all speakers of Fore, no unifying political organization, and no collective ceremonies. In fact,
social relations between local groups were generally
antagonistic and intergroup warfare was common
(Berndt, 1962). Groups would form impermanent
639
Gender Relations
The relations between Fore men and women are
relatively egalitarian, but important differences do exist in
the social spaces men and women occupy. In the political
arena, men dominate the public domain and vie with each
other through oratory and subtle persuasion to influence
the course of group activities. Also, in earlier times, men
as warriors were responsible for defending their groups
and for prosecuting offenses against them. In the domestic sphere, the gender division of labor still assigns relatively few tasks to only men or women. Men fell the trees
for new food gardens and women assist in cutting the
undergrowth and burning the debris. Men then build the
garden fences and women prepare the soil and plant most
of the crops. However, the bulk of labor required to
cultivate, weed, harvest, and transport garden produce
continues to be provided by women, although men do
assist as they wish. The burden of pig rearing also falls
largely to women who transport food and fodder from the
gardens and feed the pigs each day. Most food for household members is prepared and cooked by women and
men help with the gathering of firewood. Childcare again
is largely the responsibility of women who enlist the willing aid of older siblings. Women, who once made all articles of clothing and net bags from pliable tree barks and
other forest products, now purchase most clothing items
or sew them on hand-crank sewing machines. Men, who
used to craft weapons (bows, arrows and spears), no
longer do so. In sum, although the division of labor
assigns complementary tasks to men and women, women
continue to provide a much larger portion of the labor
required for essential household activities.
Female Pollution
The separation of male and female spheres is underpinned by an ideology of female pollution. Fore men, as
do men in many other societies in New Guinea and elsewhere, fear contamination by wives and other actual or
potential sexual partners. Especially debilitating would
be any contact with vaginal blood associated with menstruation or childbirth. Should such contamination occur,
either accidentally or as a deliberate act of assault, the
male victim is expected to suffer severe respiratory symptoms and a gradual wasting away. Living arrangements in
the past reduced the contact that men had with their
wives. All adult men and older initiated boys lived
640
Male Initiation
This theme of malefemale separation also is an important aspect of the Fore male initiation ritual. At the onset
of male initiation, pre-pubescent boys about 10 years of
age are taken from their mothers and sent to live with men
in the mens houses. During the various stages of the
ritual, which earlier lasted for several years, boys were
initiated into manhood. In addition to being instructed in
the proper behavior and responsibilities of men, they also
were taught the techniques of nose bleeding, cane swallowing, and vomiting that were thought to promote their
physical growth and maturation and to protect them from
the polluting powers of women. Armed with these personal defenses, they eventually were deemed marriageable adult men capable of protecting themselves from the
inherent dangers of marital relations. Male initiation ceremonies were halted in the late 1970s, but were resumed
in the late 1980s in a truncated form. Fore boys now
become men in a single week-long ritual.
Cannibalism
At some point in the early 1900s, the Fore adopted cannibalism, or anthropophagia. The consumption of human
flesh was common among various neighboring groups to
the north and gradually passed first to the North Fore and
later to the South Fore. Among the South Fore, a selective form of endocannibalism was practiced: only the
bodies of deceased group members were considered
appropriate for consumption while those who had died of
dysentery or leprosy, or had contracted yaws were
avoided. Of the corpses selected for consumption, all
body parts except the bitter gall bladder were eaten. As in
the distribution of a cooked pig, specific body parts were
given to designated relatives. But, not all Fore participated.
Fore
Sorcery
Sorcery is an abiding concern in Fore society. All contacts
between members of different parish sections, and even
some contacts within ones own local group, are edged
with the fear of sorcery. This appears to be a longstanding concern among the Fore. Genealogical evidence from
c. 190062 for one South Fore parish attributes more than
half of all deaths to sorcery (Lindenbaum, 1979, p. 65).
In general, sorcery is thought to emanate from the intentional, malicious activities of political enemies and social
inferiors who seek to harm rivals and those of higher
social status or members of their families. Sorcery is
judged to be a political act, a silent aggression, and bigman leaders are thought to be common targets. Although
sorcery techniques are quite varied, most require some
contact between the sorcerer and the victim or with items
that have been in close contact with the victim. To protect
against such contact, Fore go to extraordinary lengths to
guard their hamlets and living spaces from unknown and
suspected sorcerers. Typically, the sorcerer acquires bodily exuvia (hair, fingernail clippings, spittle, feces, etc.),
personal items (clothing, tobacco, etc.), or food leavings
of the intended victim. These are then treated by physical
manipulation and verbal spells that transmit the sorcerers
evil intent to the victim. Alternatively, a sorcerer may cast
an evil spell on some common item (food, tobacco) and
place it in a location where the intended victim likely will
come into contact with it. Angered wives, too, are thought
to employ the latter technique against their husbands by
contaminating their food, water, or tobacco with debilitating menstrual discharge. If the sorcery assault is successful, the victim will sicken and, in some instances, die.
(See Lindenbaum, 1979, pp. 6064, for a list of Fore sorcery practices and likely disease diagnoses.) As might be
expected, Fore people carefully dispose of all excreta and
food leavings and closely monitor personal possessions.
With the arrival in Fore territory of Australian colonial authorities in the late 1940s and as the increasing
influence of various outsiders spread during the 1950s
and 1960s, many of the above aspects of Fore life began
to change. At the insistence of the colonial administration, warfare was quickly curtailed and cannibalism had
641
Pigbel
Another illness that afflicted the Fore people is enteritis
necroticans, called pigbel.2 It was associated with ceremonial feasts during which pigs were butchered and
cooked in earthovens, and large quantities of pig meat
typically were exchanged and consumed. During the
preparation of the carcasses for cooking, meat often was
contaminated with a strain of the Clostridia bacteria present
in the bowels and feces of the animals. This was transmitted by various means to people during and after the
feast. Importantly, children were given raw entrails to
play with and small pieces of raw meat to chew on. Also,
undercooked meat was not consumed for several days as
it passed from hand to hand in extensive exchange networks. Symptoms of severe abdominal pain, bloody diarrhea, and vomiting appeared within a day or two of
consuming the contaminated meat. Most cases were mild,
but if severe cases were left untreated, gangrene would
progressively affect the small intestine and could cause
death. Pigbel was endemic throughout the highlands
region, but was largely unknown in the lowland areas of
New Guinea. It appears that this restricted distribution of
pigbel to the highlands was related to a diet that relied
heavily on one staple, sweet potato, which commonly
provided some 75% of calories. This low-protein daily
diet resulted in low levels of protein-digesting enzymes.
642
Kuru3
The Fore are most well-known in the medical and medical
anthropology literature as the unfortunate subjects of the
neurological disease, called kuru, which is a Fore word
meaning to shiver, shake, or tremble. Kuru is a disease of
the central nervous system that is progressive and always
fatal. Major symptoms progress from a slight unsteadiness when standing and walking to severe tremors and the
inability to walk without total support. Eventually, as the
tremors become increasingly severe, the patient is unable
to sit up or swallow and loses control of all motor functions, including speech. Death typically occurs about one
year after the onset of symptoms.
Since kuru was initially noticed by outsiders in the
early 1950s, it has become one of the great medical mysteries of the 20th century. Early epidemiological evidence
showed that the epidemic was confined to the Fore and
their close relatives in neighboring groups. Also, certain
families and hamlets were more affected than others, and
women and children of both sexes comprised the vast
majority of cases. It initially was proposed that kuru
might be an inherited genetic disorder, but the high incidence and lethal nature of the disease made this seem
unlikely. Ethnographic investigations in the early 1960s
by Robert Glasse and Shirley Glasse Lindenbaum
(Glasse, 1967) found that kuru had first appeared during
the lifetimes of older informants. Also, the first cases had
occurred among the North Fore with subsequent outbreaks spreading south, the same spatial pattern reconstructed for the adoption of endocannibalism. This
indicated a potential infectious agent. Also, it was known
that in the distribution of body parts, the brain was consumed only by women and children. This conformed to
Fore
MEDICAL PRACTITIONERS
In the past, the Fore relied on local curers to treat their
various maladies. Curers were individuals, both men and
women, who possessed the knowledge, techniques, and
spiritual power to cure the afflicted. The Fore recognize
two categories of curers: Bark Men and Bark Women, and
Dream Men. Bark Men and Bark Women usually reside
in the same parish as their patients and use forest medicines to treat minor ailments. They also are capable of
intervening with ghosts and forest spirits on behalf of the
sick. In the 1950s, new, more powerful curers emerged
who were thought to be able to counter illnesses caused
by sorcery, including kuru. These Dream Men, or Smoke
Men, always lived in distant parishes and in many cases
were not Fore. Relying on dreams and trance states
induced by the rapid inhalation of tobacco smoke and the
ingestion of psychotropic plants, they were able to see
beyond the realm of ordinary reality. They also were
capable of identifying the offending sorcerers by using
various divination techniques. To counter the sorcerers
evil acts, they prepared curative meals of pork laced with
masticated ginger and special tree barks. They also would
attempt to relieve the suffering of their patients by shooting small arrows into the skin at locations where the pain
was most acute. In the context of the kuru epidemic,
Dream Men enjoyed much influence and acclaim and
many acquired substantial wealth. Today, the Fore still
643
SEXUALITY
AND
REPRODUCTION
Sexual relations among the Fore remain guarded encounters. Given the ideology of female pollution, partners rendezvous outside the residential living space and away
from food gardens to avoid subjecting others to potential
644
Fore
Infancy 4
Infants are highly valued and the subjects of constant
attention. They are nurtured most closely by their mothers and are rarely away from physical contact with their
mothers for more than a short period of time. Other
women and older siblings willingly assist when asked to
do so. Breastfeeding is on demand at all times, with
infants sleeping next to their mothers, and continues for
a minimum of two years. Supplementary feeding of
masticated sweet potato begins at about 6 months of age.
Weaning is a gradual process. Mothers may ignore nursing requests, divert their toddlers attention toward other
activities, or rub bitter leaves on their nipples. If a subsequent pregnancy occurs during this period, weaning will
be more abrupt. Toddlers are never scolded or disciplined
by anyone and their requests for attention and physical
contact with adults and older children invariably are met.
Childhood
Childhood is a time of relatively carefree play, but gradually children are given more responsibility. Girls are integrated into female work roles as soon as they are physically
able to imitate their mothers. Boys, on the other hand, are
allowed to roam hamlet territory with play groups, often
away from adult supervision, and rarely are asked to help
with household chores. However, this life of little responsibility comes to an abrupt end when they are taken to live
in the mens house and begin the initiation process.
Children gradually are expected to act responsibly and follow the requests of adults. They will be admonished for
unacceptable behavior, but physical punishment is rare.
Adolescence
Fore adolescents experience increasing expectations of
adopting adult work and social roles. Girls are instructed
in proper adult behavior and provide important assistance
to their mothers in gardening and household activities.
A young womans first menstruation is cause for a
References
645
Adulthood
In the past, adult men frequently succumbed to injuries
sustained in warfare. Adult women were most likely to die
during childbirth or from contracting kuru. More recently,
local health has been influenced by the movement of Fore
people as labor migrants to coastal work sites. Beginning in
the early 1960s, Fore men entered the labor flow and were
joined by wives and other family members in the late 1970s.
While this reallocation of labor to external cash-earning
activities brought money into the local Fore economy, it
also brought malaria and sexually transmitted illnesses.
Gonorrhea, syphilis, and trichomoniasis are now common,
and chlamydia and herpes also are present. HIV/AIDS has
just been recognized among the Fore, but the details of
incidence remain sketchy. Fore migrant workers did return
home with money, but also with new diseases.
The Aged
As Fore people age and infirmities accumulate, they gradually and reluctantly withdraw from normal adult activities.
They are respected by younger adults, but also acknowledged as a necessary burden. Close family relatives provide
them with the necessities of life, but the influence of elderly
men in the political arena and elderly women in the domestic sphere eventually is assumed by the next generation.
NOTES
1. This description of Fore culture relies on Lindenbaum (1979, and personal communication, 2002), and M. Alpers (personal communication, 2002).
2. Information on pigbel is taken from Lawrence (1992) with additions
from M. Alpers (personal communication, 2002).
3. This account of kuru relies on Lindenbaum (1979) and Alpers
(1992).
4. The sections on Infancy and Childhood draw on information in
Sorenson (1976).
REFERENCES
Alpers, M. P. (1992). Kuru. In R. D. Attenborough & M. P. Alpers
(Eds.), Human biology in Papua New Guinea: The small cosmos
(pp. 313334). Oxford, U.K.: Oxford University Press.
Berndt, R. M. (1962). Excess and restraint: Social control among a New
Guinea mountain people. Chicago: University of Chicago Press.
Gajdusek, D. C., Gibbs, C. J., Jr., & Alpers, M. (1966). Experimental
transmission of a kuru-like syndrome to chimpanzees. Nature, 209,
794796.
Glasse, R. M. (1967). Cannibalism in the kuru region of New Guinea.
Transactions of the New York Academy of Sciences, 29, 748754.
Lawrence, G. (1992). Pigbel. In R. D. Attenborough & M. P. Alpers
(Eds.), Human biology in Papua New Guinea: The small cosmos
(pp. 314344). Oxford, U.K.: Oxford University Press.
Lindenbaum, S. (1979). Kuru sorcery: Disease and danger in the New
Guinea Highlands. Palo Alto, CA: Mayfield.
Lindenbaum, S. (2001). Kuru, prions, and human affairs: Thinking
about epidemics. Annual Review of Anthropology, 30, 363385.
Prusiner, S. B. (1989). Scrapie prions. Annual Review of Microbiology,
43, 345374.
Sorenson, E. R. (1976). The edge of the forest: Land, childhood, and
change in a New Guinea protoagricultural society. Washington,
D.C.: Smithsonian Institution Press.
646
French
French
Michelle Lampl
ALTERNATIVE NAMES
France, French Republic, Republique Franaise.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
The HIV prevalence rate was 0.44% in 1999 and estimated at 130,000 individuals living with AIDS.
Literacy, defined as reading and writing over
15 years of age, is said to be 99%.
Having suffered extensive losses in terms of manpower and economic well-being during World Wars I and
II, France is one of the most modern countries in the world
and a leader among the European Union. Since 1958, it
has had a presidential democracy which has provided
greater stability than its previous parliamentary democracy. It is a republic, divided into 22 regions, including the
territorial collectivity of Corsica and is subdivided into
96 departments. France includes four overseas departments
(French Guyana, Guadeloupe, Martinique, and Reunion)
and three overseas territorial collectivities (Mayotte, Saint
Pierre, and Miquelon). In addition, there are approximately
12 dependent areas over which France has transnational
disputes of sovereignty. There are numerous political
parties in France of opposing values, with a president
elected by popular vote for a five-year term.
France is an ethnically heterogeneous population,
representing peoples from North Africa, Indo-China, the
Basque region, Celtic, Latin, and Teutonic populations,
and nomadic Gypsies. France is presently predominantly
Roman Catholic (85%), with Muslims comprising about
510% of the population and Protestant, Jewish, and
unaffiliated sects equally apportioned.
Frances economy is composed of historically extensive government ownership, much of which is presently
undergoing privatization. Unemployment has been high
over the past decade. Steps to improve this include
mandatory retirement with an extensive and expensive
pension system. Frances economy suffers from a 35hour work week, lengthy paid vacations, and national
medical care. These expectations incur high taxes. The
labor force is comprised of 70% in services, 25% industry, and 4% agriculture. Approximately 23% of the population are white-collar workers and 30% of the working
population are manual workers.
France was the worlds fourth largest economic
power in the mid-1990s and the worlds number one
Medical Practitioners
647
MEDICAL PRACTITIONERS
French medical practice focuses primarily on physicians
who undergo traditional biomedical training. In contrast
to the United States, where four years of medical school
follow four years of undergraduate work, in France, medical training is initiated immediately after secondary
school education is completed. Competition is intense for
positions in this field. Physicians may become either
648
French
649
650
French
Homeopathy
Homeopathic physicians are trained in the same way as
all other physicians in France and then undergo further
specialization. They learn the unique diagnostic and treatment approaches of homeopathy, first developed by
Hahnemann in 1810 (Hahnemann, 1991). It is necessary
for the homeopathic physician to get to know the patient,
for even the same symptoms of disease may require different treatment depending on the personality of the
patient. The diagnosis is fundamentally the treatment in
homeopathic medicine. By identifying an individuals
temperament, much can be ascertained about immune
function and, with time, the appropriate chemicals will
restore balance to an individual and, thus, ones sense of
well-being. Each individual is treated in accord with his
or her internal milieu. It is critical during the initial interview to identify the nature of this temperament. This
requires a long conversation with the patient, directed
toward the identification of his/her individual responses
to temperature, stress, foods, and daily life. The homeopathic physician develops a profile of the patient based on
a typological classification. While the reason for an individual seeking medical attention matters, it is not the core
of the homeopathic interview. This is at first glance a singularly culture-bound diagnostic approach, and contrasts
with the checklist approach posed by many doctors,
where diagnosis follows a rote pattern, and treatment is
focused on scientific prescription and crisis management.
Homeopathic approaches follow a style that works quite
well in France for a number of people.
The central tenet of homeopathic treatment is similarity, or like treats like: remedies are chosen to match the
distinctive features of plants or minerals with the characteristics of the individual patient and his/her disease/
discomfort. For example, herpes simplex virus of the lips
(HSV II), results in chronic cold sores that are notoriously
recalcitrant to treatments in biomedicine. This is treated
homeopathically with success by small doses of rhus
toxicodendruma derivative of poison ivya treatment
chosen because the effects of the plant mimic the disease
that is being treated. Additionally, several chemicals may
also be prescribed to an individual apart from anything
directed toward the presenting complaint. The goal of this
further treatment is to improve the patients mental and
651
652
French
SEXUALITY
AND
REPRODUCTION
Sexuality is a normal part of the life cycle and both advertising and social norms accept the body as a source of
enjoyment. On average, sexual activity begins in adolescence and while a responsible and healthy emotional state
of individuals is a stated concern, there is no requirement
that love and marriage either precede or accompany sexual activity. While marriage is the expected social domain
for child-bearing, a number of young French couples live
together and have children prior to marriage. While many
French would question women who never marry, but take
occupations in lieu of child-bearing, this status is quite
acceptable and the role of women in powerful positions
depends greatly on the work domain and socioeconomic
class.
The French have a strong sense of privacy in matters
of their personal life. They are also quite tolerant of the
right of individuals to choose a lifestyle that is best suited
for themselves. Extra-marital affairs are not uncommon,
although they are expected to be discretely managed.
The fundamental right to contraception was first
affirmed in a public campaign in 198182. In 1992, a second national campaign was launched as the result of AIDS
and focused on public education regarding condoms. In
recognition of the 25th anniversary of the law establishing
the fundamental right to contraception, a third national
campaign was launched in 2000. With the slogan, It is up
to you to choose your contraception appearing in advertisements on TV, radio, and in the press, the combined
efforts of the Department of Health and the minister of
education aimed to educate adolescents on sexuality. The
goal was designed to inform teenage girls and women of
the availability of state-funded contraception options,
653
Infancy
The birth rate in 1995 was about 12/1,000 individuals in
France. As a modern European country, most births occur
654
Childhood
French children are expected to adopt appropriate behavior and customs from an early age. Moderate physical and
negative verbal discipline are the norm as demands for
children to conform to behavioral rules are clarified. A
narrow range of individual liberties are tolerated as cultural values are inculcated.
Health problems of French children parallel industrial countries at the present time, with infectious diseases
leading the common cause for pediatric consult.
Childhood cancers of both tissue and blood are significant
French
Adolescence
By the age of 12, French adolescents are mature young
adults, with expectations of taking on fully adult roles in
a short time. They are in training for their future jobs with
a choice already being made in terms of the schools that
they attend. Adolescents take responsibility in the home
and family and are learning about the larger sociopolitical sphere in which they live. They are becoming
sexually active and part of the school curriculum is
designed to provide public health information about safe
sex practices. Adolescents are expected to behave like
adults, although parents are not surprised to find them
having difficulties at times in this role.
The Aged
Aging is culturally reinforced by mandatory retirement at
the age of 60. Seen as a socially responsible action to provide jobs for the younger generation, this practice moves
an active individual into a category of retiree and forces
them to adjust their lifestyle to new economic and social
circumstances. For some people, this is a new time of
life, a socially approved change of job and focus and an
opportunity to explore new experiences. For others, this
can be a serious economic hardship and the severing of
ties with work-related social contacts can be isolating.
While no formal epidemiological studies have been
undertaken nationally to investigate the health consequences of taking retirement, it would be interesting to
follow patterns of alcohol consumption and depression
amongst the aging population.
There are a number of retirement homes that accept
individuals as they become infirm. Many families, however, take care of their aging relatives themselves, with
References
primary responsibility falling on eldest daughters as caretakers. Respect and consideration of aging family members wishes is a priority in many families.
REFERENCES
Allain, J. (1986). Anatomie, physiologie et pathologie du Berrichon vu
par lui-meme. (pp. 1722, pp. 3035).
Bancarel, Y., Blanc, M. P., Charrin, G., Chastan, E., Coldefy, J. F.,
Cottes, L. et al. (1988). Study of drug consumption in a working environment in France. Fundamental Clinical Pharmacology, 2, 37 46.
Benzecri, J.-P., Maiti, D.-D., Belon, P., & Questel, R. (1991). Comparaison
entre quatre mthodes de sevrage aprs une thrapeutique anxiolytique. Les Cahiers de lAnalyse des Donnes, 16(4), 389402.
Bourdieu, P. (1990a). The logic of practice. Stanford, CA: Stanford
University Press.
Bourdieu, P. (1990b). Distinction: A social critique of the judgement of
taste. Cambridge, MA: Harvard University Press.
Bourdieu, P. (1999). A critical reader (R. Shusterman, Ed.). London,
UK: Blackwell.
Brockliss, L. S. (1987). Taking the waters in early modern France: Some
thoughts on a commercial racket. Soc Soc Hist Med Bull (Lond),
40, 7476.
Cals, M. J., Bories, P. N., Blonde-Cynober, F., Coudray-Lucas, C.,
Desveaus, N., Devanlay, M., et al. (1996). Reference intervals and
biological profile in a group of healthy elderly population in the
Paris region. Annales de Biologie Clinique (Paris), 54, 307315.
Chapuy, M. C., Preziosi, P., Maamer, M., Arnaud, S., Gala, P.,
Hercberg, S. et al. (1997). Prevalence of vitamin D insufficiency in
an adult normal population. Osteoporosis International, 7, 439443.
Chaufferin, G. (2000). Improving the evaluation of homeopathy:
Economic considerations and impact on health. British Homeopathic
Journal, 89(Suppl. 1), S27S30.
655
Colin, P. (2000). An epidemiological study of a homeopathic practice.
British Homeopathic Journal, 89, 116121.
Delvaux, M., Fontaine, P., Bartsch, P., & Fontaine, O. (1998). Tetany,
spasmophilia, hyperventilation syndrome: Theoretical and therapeutic synthesis. Revue Medicale de Liege, 53, 610618.
Durlach, J., Bac, P., Durlach, V., Bara, M., Guiet-Bara, A. (1997).
Neurotic, neuromuscular and autonomic nervous form of magnesium imbalance. Magnesium Research, 10, 169195.
Fabry, R., Pochon, P., Trolese, J. F., & Duchne-Marullaz, P. (1985).
Variations du primtre de marche et des index de pression avant
et aprs preuves de march mesurs un an dintervalle chez 140
artriopathes traits Royat. Cahiers dartriologie de Royat, 12,
7882.
Ferley, J. P., Zmirou, D., DAdhemar, D., Balducci, F. (1989). A controlled evaluation of a homeopathic preparation in the treatment of
influenza-like syndromes. British Journal of Clinical
Pharmacology, 27, 329335.
Hahnemann, S. (1991). Organon of Medicine (J. Knzli, A. Naud &
P. Pendleton, Trans.) London: Victor Gollancz.
Horvilleur, A. G. (1981). Guide Familial de lHomopathie. Paris:
Hachette.
Kleijnen, J., Knipschild, P., & Riet, G. (1989). Clinical trials of homeopathy. British Medical Journal, 302, 316323.
Lafont, O. (2002). Medicines for towns and medicines for countrysides.
Rev Hist Pharm (Paris), 50, 211220.
Laroche, M., & Masieres, B. (1998). Does the French general practitioner correctly investigate and treat osteoporosis? Clinical
Rheumatology, 17, 139143.
Maquet, D., Croisier, J. L., Crielaard, J. M. (2000). Fibromyalgia in the
year 2000. Revue Medicale de Liege, 55, 991997.
Perdue, L. (1992). The French paradox and beyond. Sonoma, CA:
Renaissance.
Poitevan, B. (1987). Le devenir de lhomopathie. Paris: DOIN Ed.
Reilly, D. T., Taylor, M. A., McSharry, C., & Aitchison, T. (1986). Is homeopathy a placebo response? Controlled trial of homeopathic potency,
with Pollens in hayfever as a model. The Lancet, 18, 881886.
Renaud, S. C., Gueguen, R., Schenker, J., & dHoutaud, A. (1998).
Alcohol and mortality in middle-aged men from eastern France.
Epidemiology, 9, 184188.
Saint-Clair, M. (1993). Vins medicinaux et elixirs de sant. Colmar:
S.A.E.P.
Schilliger, P., & Bardelay, G. (1990). La cure thermale. Paris: Editions
Frison-Roche.
Tilly, B., Guilhot, J., Salanave, B., Fender, P., & Allemand, H. (2002).
Management of severe hypertension in France in 1999 and 2000:
Intermediate results of a health insurance intervention program.
Archives des Maladies du Coeur et des Vaisseaux, 95, 687694.
Vannier, L. (1992). Typology in homeopathy (Marianne Harling,
Trans.). Beaconsfield, U.K.
Warolin, C. (2002). Secret remedies in France until abolition in 1926.
Rev Hist Pharm (Paris), 50, 229238.
Weisz, G. (2001). Spas, mineral waters, and hydrological science in
twentieth-century France. Isis, 92, 451483.
656
Fulani
Fulani
Kate R. Hampshire
ALTERNATIVE NAMES
Fulani is a Hausa term, which is also commonly used in
English to describe this ethnic category. With the exception of Nigeria, most Fulani live in Francophone West
Africa, where they are widely known by the French (and
Wolof ) terms Peul or Peulh. Fulani living in the westernmost parts of the Sahel (Senegal, Gambia, Sierra Leone,
and Guinea) are usually referred to by the Manding word,
Fula. The Fulfulde term FulBe (sing. Pullo) is often
equated with Fulani, although it actually refers only to
high status, pastoral Fulani.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
Social Organization
Fulani society is hierarchically organized into castes
associated with social status and occupation. The main categories are FulBe: free-born, pastoralist Fulani, and their
Religion
Most Fulani are Muslim, and a strong identification
between being Fulani and being Muslim has been noted
in many areas (Burnham, 1996). Islam has been used as
a vehicle of conquest, and Fulani became the rulers of
large stretches of the Sahel in the 18th and 19th centuries
through Holy War ( jihad). However, the versions of Islam
practiced by Fulani incorporate many aspects of preIslam cosmology. This is apparent in the way illnesses
are conceptualized and treated. A minority of Fulani (e.g.,
the WoDaaBe groups in Niger) are not Muslim, but
practice traditional religions.
657
Country
Infant mortality
rate (per 1,000
live births)
Life
expectancy at
birth (years)
Doctors
per 100,000
people
Burkina Faso
Chad
Mali
Niger
Sources
106
92
134
191
UNICEF 1998
46
47
47
48
UNDP 1997
3
3
5
2
UNDP 1997
658
Fulani
MEDICAL PRACTITIONERS
For many common ailments, and for prevention of illness, everyone becomes a medical practitioner. For example, Riesman (1992) describes how all Fulani mothers in
northern Burkina Faso prepare basi, an infusion of herbs
and tree barks, which they give young babies to protect
them from various ailments. Women learn the secrets of
basi preparation from their mothers and grandmothers;
these include both the ingredients and the method of
preparation. In Chad, many common ailments are selftreated by Fulani using remedies made from ingredients
found around the home, such as milk, butter, spices, and
animals urine (Hampshire, 2002a, in press).
For more serious conditions, the range of medical
practitioners used by the Fulani reflects the variation in
perceived cause of illnesses. Most illnesses are perceived
to have their origins in malevolent external powers: spirits or djinns, witches, or non-human animals (De Bruijn
& Van Dijk, 1995). Such illnesses can only be treated by
confronting and defeating those forces, and are thus
amenable only to intervention by those with power in the
supernatural realm. MooDiBaaBe (sing. mooDiBo),
Islamic learned men, are frequently called upon in these
cases. MooDiBaaBe may use herbal medicine or Koranic
texts in their practice, or a combination of both (De
Bruijn & Van Dijk, 1995; Hampshire, 2002a; Riesman,
1992). An example of the use of Koranic texts is given by
Riesman (1992, p. 92). As a cure for madness, a mooDiBo
wrote Koranic verses on a wooden tablet in ink. The ink
was then washed off, and the solution drunk by the
afflicted person.
Today, the healing of mooDiBaaBe often goes hand
in hand with the use of modern medicine. Because of
the remoteness and poverty of many areas inhabited by
Fulani, many of the modern health facilities to which
they have access are fairly limited and basic health posts.
SEXUALITY
AND
REPRODUCTION
659
660
Fulani
Infancy
Post-Partum Practices. From the day of the birth
until the naming ceremony 8 days later, the mother is confined to her hut or tent (Riesman, 1992). She leaves only to
urinate or defecate in the bush and, even for this, she is
always accompanied by someone. A fire is lit when the
baby is born, and this fire burns continuously for the first
week of the childs life, until the naming ceremony. The fire
is used to heat water for bathing and preparing infusions.
On the eighth day after birth, the naming ceremony
(indeeri) takes place (Riesman, 1977, 1992). The infant is
washed and its head is shaved. It is carried back and forth
between the hut and the outside three times for a boy, four
times for a girl. A goat is sacrificed and the name of the
661
Childhood
Between the ages of 5 and 7, children are thought to begin
to develop haYYillo (a social sense) and are given their
first responsibilities (De Bruijn & Van Dijk, 1995;
Riesman, 1992). These responsibilities may include helping mothers with food preparation, or beginning to look
after small animals. Until that time, children are not
expected to know how to behave socially, or indeed to
comply with the demands of their caretakers. From ages
57 onwards, children are thought to be more responsible
for their actions, and are thus more likely to be reprimanded and corrected for behaving in inappropriate ways.
A particular danger to the health of children is pooli
(described above), and mothers take precautions, such as
making a loud noise, to try to prevent this (De Bruijn &
Van Dijk, 1995). Other health risks to childhood include
the belief that it is dangerous for a child to have contact
with its mother, and particularly with her milk, for the
662
Adolescence
Childhood ends quite early, for Fulani girls in particular.
Marriage takes place typically at an early agemean age
at first marriage for Fulani women in Burkina Faso was
found to be around 16 years, with a high proportion of
marriages happening considerably earlier (Hampshire &
Randall, 2000). For some time prior to marriage, girls are
expected to take on roles appropriate to adult women, and
much of the freedom associated with early childhood is
lost. In Burkina Faso, some Fulani girls from the age of
about 12 are sent to live with their future mothers-in-law,
as part of preparation for married life (Hampshire, 1998).
Fulani men marry later than women: among the
Burkinab Fulani, mean age at first marriage for men was
2425 years (Hampshire & Randall, 2000). Fulani men,
therefore, enjoy a more extended period of adolescence
during which they are free from many of the responsibilities of having their own family and herd. Among some
Burkinab Fulani men, it is common to begin to travel during this period, in particular to cities for temporary work
(Hampshire, 2002b; Hampshire & Randall, 1999).
Fulani
Adulthood
Until old age, Fulani are married for most of their adult
lives. Marriage is effectively universal and re-marriage is
typically rapid following divorce or widowhood
(Hampshire & Randall, 2000). Polygamous marriage is
practiced, although most marriages are monogamous:
among the Burkinab Fulani, for example, 7.6% of
The Aged
Old people are generally treated with deference and respect
in Fulani society (De Bruijn & Van Dijk, 1995; Riesman,
1992). According to De Bruijn and Van Dijk (1995), there
are established ideas about help for old people in cases of
illness or hardship. An old, widowed woman may receive
663
664
Garhwali
REFERENCES
Barkey, N. L., Campbell, B. C., & Leslie, P. W. (2001). A comparison
of health complaints of settled and nomadic Turkana men. Medical
Anthropology Quarterly, 15(3), 391408.
Bonfiglioli, A. M. (1988) DuDal: Histoire de famille et historique de
troupeaux chez un groupe WoDaaBe du Niger. Cambridge, U.K.:
Cambridge University Press / Edition de la Maison des Sciences
de lHomme.
Burnham, P. (1996). The politics of cultural difference in Northern
Cameroon. Edinburgh, U.K.: Edinburgh University Press.
David. N., & Voas, D. (1981). Societal causes of infertility and population decline among the settled Fulani of north Cameroon. Man,
16(4), 644664.
De Bruijn, M., & Van Dijk, H. (1995). Arid ways. Amsterdam: Thesis.
Dupire, M. (1963). The position of women in a pastoral society. In
D. Paulme (Ed.), Women of tropical Africa (pp. 4792). London:
Routledge.
Dupire, M. (1970). Organisation sociale des Peul. Paris: Edition Plon.
Foggin, P. M., Farhas, O., Shiirev-Adiya, S., & Chinabat, B. (1997).
Health status and risk factors of seminomadic pastoralists in
Mongolia: A geographical approach. Social Science & Medicine,
44(11), 16231647.
Hampshire, K. R. (1998). Fulani mobility: Causes, constraints and consequences of population movements in northern Burkina Faso.
Unpublished PhD thesis, University College London.
Hampshire, K. R. (2001). The impact of male migration of fertility decisions and outcomes in northern burkina faso. In S. Tremayne (Ed.).
Managing Reproductive Life, pp: 107126. Oxford: Berghahn.
Hampshire, K. R. (2002a). Networks of nomads: negotiating access to
health services among pastoralist women in chad. Social Sciences
and Medicine, 54, 102537.
Hampshire, K. R. (2002b). Fulani on the move: Seasonal economic
migration in the Sahel as a social process. Journal of Development
Studies, 38(5), 1536.
Hampshire, K. R. (2003, in press). What is safe motherhood?
Insiders and outsiders preceptions of maternal health among chadian pastoralists. Genus.
Hampshire, K. R., & Randall, S. C. (1995). The single round demographic survey (Technical Report No.1, Land use, household viability and migration in the Sahel). Unpublished manuscript.
Hampshire, K. R., & Randall, S. C. (1999). Seasonal labour migration strategies in the Sahel: Coping with poverty or optimising
Garhwali
Satish Kedia
ALTERNATIVE NAMES
The current name of Garhwal is of relatively recent origin. Etymologically, Garhwal means a region formed by
665
LOCATION
AND
LINGUISTIC AFFILIATION
Garhwali live in the North Indian Himalayas in the western part of the State of Uttaranchal. Uttaranchal comprises 13 districts and was part of the State of Uttar
Pradesh until 2000, when it was given autonomous status.
The Garhwal region is in the middle zone of the
Himalayas, which have a varying width of about 6090 km
and an elevation ranging between 1,000 m and 3,000 m
above sea level. The region is full of peaks and valleys
and is marked by rivers flowing through the deep gorges.
Most Garhwali people speak Garhwali and some
Hindi, both in the Indo-Aryan linguistic group. Prior to
the 19th century, Persian with Arabic script was used for
administrative purposes, but Garhwali with Devanagari
script remained the language of the commoners. Many
inscriptions and state orders were written in Garhwali. In
some regions of Garhwal, such as Rawain, Jaunpur, and
Juansar-Bawar, dialects of Garhwali called Rawalti,
Jaunpuri, and Jaunsari respectively are spoken.
It would not be prudent to generalize this commentary
to all regions of Garhwal. This narrative is primarily based
on the authors fieldwork among a peasant community near
Tehri in the western part of Uttaranchal during the mid1990s. However, a concerted effort was made to incorporate pertinent information from the writings of other
researchers who have worked in various parts of Garhwal.
OVERVIEW
OF THE
CULTURE
Garhwali are predominantly peasants and have approximately 8.5 million people living in Uttaranchal. The initial archeological evidence in Garhwal includes inscriptions
and artifacts from the time of King Ashoka (269232 BC)
and suggests that the region was inhabited long before this
period. The mythical Hindu texts, Puranas, Mahabharata,
and Ramayana, contain numerous indications that a society existed in this region. At that time, the people were
variously known as Kedarkhand, Uttarkuru, Kurujangal,
and Uttarakhand. However, it remains a matter of debate
among historians as to who were the original inhabitants.
The economy in the Garhwal region is primarily
agrarian with approximately 85% of the adult population
666
MEDICAL PRACTITIONERS
Garhwali use an eclectic mix of medical healers; biomedical practitioners are just one of the available options.
Biomedical practitioners with a medical degree are rare
in the Garhwal hills; most have only an associates degree
with a couple of years of medical training or apprenticeship and are in private practice. The district headquarters
or towns have a local hospital with doctors that have a
medical degree and, in some cases, other specialists. The
fees and traveling distance to the biomedical healers
make them unavailable to much of the population. There
are health centers with a health worker and a nurse for
every five or six villages.
Herbalists (deshi vaidhya) are available and found
throughout the Garhwal region. They use herbs and
medicinal plants indigenous to the Himalayas and are
consulted for prolonged and serious illnesses. Along with
the herbalists are the Ayurvedic doctors (Ayurvedic vaidhya) who have formal training in practicing medicine. An
Ayurvedic doctor uses many natural substances and food
in addition to herbs and medicinal plants to cure illnesses.
In Garhwal villages, it is difficult to make distinctions
between a herbalist and an Ayurvedic doctor; they are
both synonymously called vaidhya.
A variety of religio-magical healers in this region
specialize in warding off the malign effects of supernatural
Garhwali
Natural Causes
Garhwali perceive factors in the surrounding environment
as potential causes of illness, such as poor drinking water,
air quality, and changes in the weather. Poor hygiene is an
issue in some places of Garhwal, particularly due to overcrowding and poor sanitation. Hygiene problems cause
and exacerbate the spread of diseases, especially those
carried by mosquitoes and parasitic worms (Rizvi, 1991).
While the lay Garhwali person has little knowledge of
specific pathogens, there is an awareness that mosquitoes
can spread malaria and that worms ( pillu) cause stomach
upsets and diarrhea. The balance of the body humors can
be disturbed by rain, cold, wind, heat, and changes in
weather conditions, such as from hot or cold. Garhwali
believe that hot weather can cause fever, malaria,
headache, joint pain, stomach ache, backache, and diarrhea, while cold weather can cause cold, cough, fever,
pneumonia, and body and joint pain. The rainy season is
said to cause fever and skin diseases, among other illnesses, while the cold east wind, called purvia, is believed
to cause fever and other minor illnesses.
Garhwali consider food to be a major factor in the
maintenance of good health. Most food has been classified according to its hot and cold properties. In the local
humoral classification, most spicy and oily foods are considered hot and can imbalance the body fluids, resulting
in indigestion and diarrhea. Heat-producing foods lead to
headache, joint pain, backache, stomach ache, indigestion, diarrhea, and high blood pressure. Smoking hukka
(a form of pipe tobacco) and cigarettes leads to coughing
and other respiratory illnesses.
Supernatural Causes
Garhwali divide supernatural causes into three categories: animistic, magical, and mystic. Spirit intrusion
(opra, chhaya lagna, bhuta-pret lagna) is the hostile or
punitive act of a malevolent supernatural spirit possessing a person and causing dramatic symptoms of illness in
the process. Garhwali believe that spirits and ghosts are
invisible, intangible, and free-floating divine forces.
However, they do make a distinction between spirits and
667
668
Garhwali
Treatment
Garhwali practice a pluralistic system of medicine with
an emphasis on herbal and religio-magical healing with
increasing use of biomedicine. In response to the onset
of an illness that does not appear to be serious or lifethreatening, Garhwali frequently opt for self-treatment
(gharelu ilaz) at home. A number of therapeutic subcultures exist in the realm of self-treatment, such as
herbal and food therapy, massage, and over-the-counter
Ayurvedic and biomedicine. The strategies used in selftreatment are passed down within a family and are sometimes shared by the whole community. Self-treatment is
less expensive and does not require consulting a biomedical practitioner or folk healer, saving time, money, and
energy. Self-treatment also means either self-care or care
provided by the family, who ensures that the patient gets
appropriate food and proper rest. Restrictions may be
imposed on the patient to avoid exposure to the wind or
consumption of certain kinds of food. Another form of
self-treatment involves doing simple rituals to ward off
the effects of the evil eye or worshiping deities or ancestors
for their blessings to cure an illness.
669
SEXUALITY
AND
REPRODUCTION
670
Garhwali
Infancy
The birth of a baby in the family brings mixed emotions
among people. While it is a time of celebration, the process
of the birth itself is considered unclean. Special care is taken
to ensure that all ancestral worship is performed, especially
on the patrilineal side. Spirits and other people can be a
threat to both mother and baby, who are vulnerable to spirit
intrusion and evil eye. Visitors are regulated and need to
wait outside before they can get in. Any kind of visible birth
defect is considered an act of a deity or spirit or an outcome
of sins previously committed by one of the parents. After
the babys birth, the mother is not brought into the sun for
five days and is not exposed to even an oil lamp lit in the
same room. On the fifth day, the village priest mixes cow
urine with cow milk, puts a copper coin in it, and
chants verses. This liquid is then given to the mother and all
family members to consume as ambrosia, which is
supposed to have purifying effects for the whole family.
Midwives or a sister-in-law usually takes over the
responsibility of maintaining the physical well-being of
the new mother. Sometimes women return to their natal
home for deliveries to be taken care of and to avoid daily
chores in their homes. Women are given a semi-solid diet
for 21 days after delivery. These 21 days, called sujan, are
considered polluting for the entire family; the family limits
their participation in community celebrations and exchange
of food with others. On the twenty-first day, the family performs rituals, prepares special food, and thereafter returns
Childhood
Childhood is considered to last until 12 years of age. Since
mothers are busy with household chores, children are
taken care of by grandparents or older siblings. Only about
69% of children get immunizations. The children in
Garhwal suffer from a variety of communicable diseases.
Common diseases among children are pneumonia, upper
respiratory infections, diarrhea, and fever. Approximately
4% of the children experience disability, with hearing loss
being the most common. Child mortality in Uttaranchal
is 56 per 1,000 (International Institute for Population
Sciences & ORC Macro, 2000, p. 6). Malnutrition is commonplace due to inadequate and imbalanced nutrition
because of a higher dependence on the carbohydratebased diet as opposed to the traditionally diverse diet.
According to NFHS-2, more than half of the children
under the age of three are underweight and, between 6 and
35 months, 77% are anemic.
Adolescence
When girls reach the age of puberty, they are expected to
take the role of adult womenincreasing participation in
the household chores, restricting lifestyle, and avoiding
mixing with boys. Menstruation for a teenage girl is a
traumatic event and is considered unclean and a matter of
shame. Menstruating girls are not allowed in the kitchen
671
Adulthood
Women in Garhwal have to work extraordinarily hard
compared with men. Many men work in the cities or are
in the military. Even those who are home do not assist the
women with the household work. Women complain of
general weakness, body aches, and anemia and are prone
to accidents in the fields and forests. Women report respiratory infections, chronic bronchitis, gall bladder and urinary stones, and gynecological problems. Many married
women have limited access to healthcare and suffer from
reproductive health problems. According to one survey,
67.7% women reported abnormal vaginal discharge but
87.6% had not received treatment for it. Many others suffer from urinary tract infections, pain, and bleeding.
Sometimes men bring sexually transmitted diseases. Adult
men suffer the health consequences of drinking country
liquor, which many Garhwali men do. As described in the
disease causation section, mental illnesses, presumably
caused by the animistic, magical, and mystical agents, are
common among Garhwali adults.
The Aged
The life stage of the elderly starts at roughly 60 years of age.
The elderly continue to live in joint family households and
contribute significantly by watching fields and taking care
of children. Women sometimes help prepare meals, and
both men and women help feed the animals. The elderly
hold considerable power within the family and community
and play important roles in village and regional politics.
With age and inadequate and imbalanced nutrition,
the majority of the elderly suffer from chronic diseases,
including body aches, stomach ailments, respiratory
672
Garifuna
REFERENCES
Berreman, G. D. (1997). Hindus of the Himalayas: Ethnography and
change. Delhi, India: Oxford India Paperbacks.
International Institute for Population Sciences & ORC Macro (2000).
National Family Health Survey (NFHS-2), 199899: India.
Mumbai: International Institute for Population Sciences (IIPS).
Kedia, S. K. (1997). Impacts of involuntary resettlement on ethnomedical systems: A case study from North India. Unpublished doctoral
dissertation, University of Kentucky.
Kumar, K. T. (1991). Health and culture in rural Garhwal. American
Journal of Preventive Medicine, 7(10), 6364.
Rao, B. (1995). Is she ill or is she not: Female sexuality, gender ideologies and womens health in Tehri Garhwal, North India.
Unpublished doctoral dissertation, Syracuse University.
Rawat, A. S. (1989). History of Garhwal, 13581947: An erstwhile
kingdom in the Himalayas. New Delhi: Indus.
Rizvi, S. N. H. (1991). Medical anthropology of the Jaunsaris. New
Delhi: Northern Book Centre.
Srivastava, S. K. (1997). Women and health, as reported from a community health need assessment survey in 1997. Retrieved August 4,
2002, from http://www.education.vsnl.com/phalguni/health.html
Garifuna
Nancie L. Gonzlez and Gloria Castillo
ALTERNATIVE NAMES
Garifuna, which is actually an adjective, is the term now
preferred by the people themselves, and most widely
used, but until the 1970s they were more often known in
anthropological and travel literature as Black Caribs, and
as Morenos (Dark Ones) to their compatriots of other ethnicities. When speaking their own language, however, the
673
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
674
Spiritual Life
Traditional Garifuna religion focused attention of the living on the deceasedboth ancestors and the spirits of the
many children who died young. The former were believed
to be either benevolent or malevolent, depending upon the
relations one had with them in life, and on how well they
are attended to ritually after death. Spiritual guides or
shamans, called buwiyes, are capable of communicating
with these spirits, often using as helpers the spirits of dead
children, many of whom seek to be born again to their
mothers. Although conversion to Roman Catholicism
occurred for many on St Vincent, and for most others during the early years in Central America, it is rare to find a
Garifuna today who does not harbor beliefs in the reality
and the power of the spirits of their own relatives (Foster,
1982; Howland, 1984). Rituals to honor and placate the
dead occur apart from, but in conjunction with Catholic
masses, and enlightened Catholic priests close their eyes
to what some might think of as blasphemy.
Garifuna
Environment
The Caribbean coastline of Central America is hot, humid,
and has long been considered unhealthy by Europeans,
primarily because of their susceptibility to the fevers that
were endemic in the area until the middle of the 20th century. The Garifuna flourished there, both because of their
resistance to malaria, and because they were pre-adapted
to the tropics. They knew how to build their houses so as
to catch the sea breeze, and to stay out of the sun during
the height of the day, and they knew how to harvest the
natural resources. Most importantly, they were excellent
seafarers (McKusick, 1960; Nicholson, 1976).
Wild palms and other fibrous plants provided raw
materials for their traditional baskets, fish traps, mats,
hammocks, cassava presses and sifters, and roof thatching. An abundance of hardwoods was available for manufacturing canoes and other wooden implements, such as
cassava-graters. Houses were made of reeds, wattle and
daub, or palm boards, although cement blocks and
lumber are increasingly used today.
Citrus, avocado, mango, and other tropical fruit trees
adorn every village and most home sites. The oil-bearing
milk extracted from the fruit of the coconut palm is a
major ingredient in their cuisine, a primary source of cholesterol. Fish and shellfish such as shrimps, lobsters, and
crabs, were easily caught using nets and traps. At one time
the men also did some hunting in the interior, but this was
never so important as the harvests of seafood. Chickens
675
Economic Factors
Garifuna society has long been characterized as matrifocal, meaning that women are prevalent and influential,
especially in household and village affairs, and in maintaining ritual and other traditions (Kerns, 1983). Households are consanguineally based, centered on a group of
related women and their children (Gonzlez, 1970). This
stems from two circumstances. First, there were only 496
men, 547 women, and 422 children upon arrival in
Trujillo, Honduras in 1797 (Gonzlez, 1988). None of the
children were under three years of age, which meant that
virtually every woman of childbearing age was at risk of
pregnancy. High fertility would have been expected and
desired under these demographic circumstances. Second,
as described above, the out-migration of men became
more frequent, and because their return and length of stay
were always uncertain, motherdaughter households
became the norm. Polygyny had been customary on
St Vincent (Helms, 1981), and in Central America this
developed into a system of serial monogamy for the
women as various men came and went in their lives, while
the men had temporary or lasting common-law wives in
more than one village. The resulting pattern, which condoned multiple partners for the men, brittle unions, and
the right of the woman to seek new partners as old ones
disappeared, was beneficial in increasing fertility and in
maximizing a womans ability to seek men who would be
economically successful and supportive of her household
(Brown, 1975; McCommon, 1982). It also contributed to
widespread venereal diseases, and to difficulties in gender
or psychological differentiation for the men (Gonzlez,
1979; Mertz, 1977).
The coastal location was also important for the opportunities it afforded the men to seek employment among the
increasing numbers of foreign explorers, casual travelers,
missionaries, and would-be settlers arriving in the area
after the 1821 independence. Even before that time they
earned a reputation for being skilled, valiant mercenary
soldiers, serving both government and rebel leaders.
Concomitantly, the women, who were the chief agricultural producers, found markets among the same people.
At first the men traveled only on occasion, providing transport for both people and goods in their large seaworthy canoes, and as stevedores loading and unloading
ships in the several ports. In Belize and Honduras they cut
mahogany and dyewood, and in Guatemala they helped
with the construction of buildings in the ill-fated colony
of Santo Toms (Blondeel Van Cuelebrouk, 1846). The
migration gradually became more intense, some men
traveling daily or weekly to and from their villages, others working seasonally, and still others virtually disappearing for months or years at a time. In the early
20th century they began working on ships carrying
fruitespecially bananasto the United States, and
many elected to stay on there, working first on the docks
in ports such as New Orleans, Mobile, and New York.
Later, many signed on as seamen, cooks, or waiters on
ocean liners (Sherar, 1973).
Women began to emigrate in large numbers in the
1960s. Small children were left with their grandmothers,
and the households, which formerly contained three
Social Factors
676
Political Factors
The Garifuna have until recently lived virtually outside
the framework of national politics in Central America,
although the circumstances have varied from country to
country. In part, this was because they lived in relatively
isolated villages on a sparsely settled coastline that others eschewed. They are readily identifiable by their color,
their accents when speaking the dominant language, and
by other cultural characteristics. Despite the fact that the
general populations of both Honduras and Belize include
a strong component of genes from Africa, the Garifuna
are looked down upon, even by others with similar racial
characteristics. In Guatemala, which has a much smaller
Black population, they are feared and despised by the
indigenous people, and either ignored by the others or
appreciated only for their singing, dancing, and sexual
prowess. Ladinos have nearly always held the important
local offices, and as a class, hold a higher social position
than Garifuna of comparable economic and educational
status.
The Garifuna did not participate actively in
Guatemalas civil violence (196498), but the peace
agreement of 1998, in promising to better the human and
civil rights of minority peoples, specifically mentions the
Garifuna as one of the beneficiary groups. This has
helped politicize those still living in the country, and
many have left the coast to attend university level courses
in the capital city. Formerly this had been a career path
open to and chosen by only a handful of others. Although
basic literacy and fluency in a second language are nearly
universal today, many cannot do advanced academic
work owing to poor preparationitself the result of poor
schools, inattention to studying at lower levels, lack of
discipline, and expectations of emigration.
Politicization of Garifuna in Belize and Honduras
began earlier, and although they do not vote as a minority block in either country, they are taking various actions
to make their concerns known and addressed by the
national governments. In this, they have been assisted by
the United Nations and other organizations that bring
together indigenous peoples of the world to share their
concerns, ideas, and agendas.
Above the level of the extended family women wield
considerable influence, but little political power. Only in
Belize have women achieved public office at the national
level, and that occurred more often a generation ago than
now. New organizations aimed at strengthening ethnic
Garifuna
MEDICAL PRACTITIONERS
In the villages now and previously, formal biomedical
assistance is rare. The elders, as always, are a source of
information on home cures, some of them based upon purchased remedies such as paregoric, aspirin, cough medicine, and even antibiotics, the latter, like most medicines,
being available without medical prescriptions. In choosing
these they may be advised by pharmacists, if there are
such. Some villages have government-run clinics, which
are consulted as a last resort. Traditional curers, who may
be either men or women, include herbalists and diviners,
as well as buwiyes. The latter are thought to have innate
abilities and to be called to their profession, after which
they undergo lengthy training with a practicing buwiye.
As discussed below, they are usually consulted after home
remedies are exhausted, or if the illness is suspected of
having a supernatural cause (Cohen, 1984; Staiano, 1981).
A few Garifuna, including the second author, have
taken university degrees in medicine, but they rarely practice in their home villages. Some have studied pharmacy,
medicine or nursing at different levels in the United
States, but they also have, in effect, left their traditional
culture and people, and practice in cities. It is not known
what percentage of their patients, if any, is Garifuna.
677
SEXUALITY
AND
REPRODUCTION
678
in the floor of the house, but the amniotic sac, after careful
examination for what it may reveal of the childs character,
is dried, then wrapped in a red or black cloth to protect it
and the child from evil spirits or living enemies (Idiquez,
1982). The stump of the cord is also dried, preserved, and
may be used for medicinal purposes during the childs
lifetime.
The couvade appears to be an ancient, probably
Arawakan, custom (Riviere, 1974), of which there are
only traces today (Coehlo, 1949; Kerns, 1976; Munroe &
Munroe, 1971; Munroe et al., 1973; Taylor, 1950).
Fathers are still said to suffer some of the symptoms of
pregnancy, such as nausea and labor pains, and they are
advised to refrain from certain activities and foods, as
well as sexual relations with other women, so as not to
endanger the fetus.
Abortions are usually termed miscarriages, and both
occur with some frequency. Many of them are never
reported to authorities, so there is little information concerning them, but recent observations by the second
author suggest they are now increasing, especially among
younger women. Most women will admit to having lost
children, either before or after birth. Stillbirths also occur
with some frequency, for unknown reasons.
Infancy
Children are breast-fed, supplemented almost from birth
with a pap made of manioc starch. Unfortunately,
although this is thought to be especially nourishing, it provides only calories and tends to suppress the amount of
breast-milk, leading to early weaningoften after only a
few months, although many continue up to 2 years. The
broths from boiling either meat or black beans, with bread,
are offered after about 6 months, and the mother will premasticate other foods before offering them to a child without many teeth (Gonzlez, 1963; Jenkins, 1984).
Respiratory and intestinal illnesses, exacerbated by
undernutrition, are two of the most common ailments of
childhood. Vaccinations against the common childhood
diseases are available through government clinics, and
most children are so protected. Still, infant mortality is
relatively high in the villages, where biomedical assistance is not always available. Sickle-cell disease may also
contribute to many early infant deaths. Protection against
the evil eye and other malevolent dangers includes painting blue crosses upon the forehead, and the wearing of
amulets containing various charms.
Garifuna
Childhood
Children are cared for primarily by womenthe mother,
grandmother, older sisters, and auntsbut men who may
be resident in the household (e.g., mothers brothers) will
be called upon to help discipline little boys when the others
fail to control their behavior.
From the time children are able to walk without
assistance and to understand directions, they will be given
chores, such as carrying small pails of water and other
burdens, running errands in the neighborhood, or selling
homemade candy in the streets.
Adolescence
In early adolescence, when they can be really useful in
household and productive activities, girls and boys
may be passed around within the larger kin group wherever help is needed. A child learns to feel comfortable
sleeping and eating in several different households
(Sanford, 1971).
Adulthood
Despite the relatively high status of women, many of
them suffer physical abuse by the men with whom they
consort, but since sexual dimorphism tends to be slight,
the women are not adverse to striking backbut usually
not enough to risk losing the man. Due to the migrant
labor customs, men are in short supply between late
teenage and retirement. Women often vie with one
another for a mans favor, sometimes coming to blows,
although shouting matches, including name-calling,
insults and denunciations, are more common.
Most people have several different mates during their
lifetimes, but as late middle age approaches, many of them
settle down into a monogamous relationship, that may or
may not include co-residence. It is not uncommon for
such couples to go through a legal marriage ceremony,
often just days or even hours before the death of one
of them.
The Aged
The elders are respected, but often neglected or ignored
by their adult offspring or grandchildren. In return, or in
order to secure a favor, an individual may threaten to
haunt their children after death.
679
The Garifuna have been in contact with Western civilization for some 300 years. Although some traditional
beliefs and practices remain, most people today are aware
of and respect biomedicine. Most communities have running water, electricity, government schools, television,
telephones, fax machines, and computers. Thus, everyone
knows something about bacterial and viral infections,
diabetes, intestinal parasites, cancer, high blood pressure,
and the like. They do not, however, always connect these
or their own symptoms with poor hygiene or nutrition, or
with potentially damaging behavior patterns involving
substance abuse or irresponsible sexual activity.
Many young Garifuna believe themselves to be
immune to AIDS, even when they prove to be positive for
HIV. Ironically, despite this belief, there is considerable
stigma attached to having the disease, so it is probably
under-reported. Once diagnosed, many believe it to have
been a punishment from God or from the ancestors.
Castillo (2002) believes it to be the major cause of death
among adult Garifuna in Livingston today. It is also ravaging the communities in Belize and Honduras. It is also
no doubt responsible for a good bit of morbidity among
adults, including probable psychological problems that
go undiagnosed.
Genetically related diseases such as diabetes, arthritis, and sickle cell anemia are similarly less well understood, and are sometimes not recognized for what they
are. Recent studies in both Honduras and in Guatemala
indicate that drug use and alcoholism are increasing, as is
obesity. All are undoubtedly related to aspects of the
modern lifestyle, including relative sedentariness,
transnationalism, migration, poverty, tourism, and a
general decline in the quality of life.
Those Garifuna who do make these connections in
general and in their own lives, live in the cities of both
Central America and the United States, and at the most
visit the villages only occasionally and for short periods.
In their effort to learn more of their own roots and traditions, in what anthropologists call a nativistic or
revivalistic movement (Sanford, 1974), they concentrate on the more romantic symbols of their past, and fail
to recognize the sometimes-serious problems that beset
the people left behind. Local leaders have become more
sophisticated in political matters, and in Honduras and
Belize there are efforts underway to improve economic
680
REFERENCES
Blondeel Van Cuelebrouk, M. (1846). Colonie de SantoTomas.
Brussels: Le Ministre des Affaires Etrangeres.
Brown, S. E. (1975). Low economic sector female mating patterns in the
Dominican Republic. In R. Rohrich-Leavitt (Ed.), Women cross culturally: Change and challenge (pp. 149152). The Hague: Mouton.
Castillo, G. (2002). Factores sociales y culturales asociados a la prevalencia de VIH/SIDA en la poblacin Garifuna de Guatemala.
Masters Thesis, Public Health, Universidad de San Carlos,
Guatemala.
Cayetano, E. R. (1977). Garifuna songs of mourning. Belizean Studies,
5, 1726.
Coehlo, R. (1949). The significance of the couvade among the Black
Caribs. Man (n.s.), 49, 6471.
Cohen, M. (1984). The ethnomedicine of the Garifuna (Black Caribs) of
Rio Tinto, Honduras. Anthropological Quarterly, 57, 1627.
Cosminsky, S. (1976). Medicinal plants of the Black Caribs. Actes of the
Forty-second International Congress of Americanists, 6, 535552.
Crawford, M. H., & Gonzlez, N. L. (1981). The Black Caribs
(Garifuna) of Livingston, Guatemala: Genetic markers and admixture estimates. Human Biology, 53, 87103.
Crawford, M. H. (Ed.). (1983). Population biology and culture history
of the Black Caribs (Garifuna) of Central America. New York:
Plenum Press.
Crawford, M. H. (Ed.). (1984). Current developments in anthropological genetics. Black Caribs: A case study in biocultural adaptation
(Vol. 3). New York: Plenum Publishing Corporation.
Davidson, W. V. (1979). Dispersal of the Garifuna in the Western
Caribbean. Actes of the Forty-second International Congress of
Americanists, 6, 467474.
Foster, B. (1982). An interpretation of spirit possession in southern
coastal Belize. Belizean Studies, 10, 1823.
Glazier, S. D. (1980). A note on shamanism in the Lesser Antilles.
Proceedings of the international congress for the study of preColumbian cultures in the Lesser Antilles, 8, 447455.
Gonzlez, N. L. (1961). Family organization in five types of migratory
wage labor. American Anthropologist, 63, 12641280.
Gonzlez, N. L. (1963). Patterns of diet, health and sickness in a Black
Carib community. Tropical and Geographical Medicine, 15,
422430.
Gonzlez, N. L. (1966). Health behavior in cross-cultural perspective.
Human Organization, 25, 122125.
Gonzlez, N. L. (1969). Black Carib household organization: A study
of migration and modernization. Seattle: University of Washington
Press.
Gonzlez, N. L. (1970). Toward a definition of matrifocality. In Norman
Whitten, Jr. & John Szwed (Eds.), Afro-American anthropology:
Problems in theory and method (pp. 231243). New York: Free Press.
Gonzalez, N. L. (1984). Rethinking the consanguineal household.
Ethnology, 23, 112
Garifuna
Gonzlez, N. L. (1988). Sojourners of the Caribbean: Ethnogenesis and
ethnohistory of the Garifuna. Urbana: University of Illinois Press.
Gonzlez, N. L. (1995). African-derived religious behavior in the
Caribbean and New York. In Michael W. Coy & Leonard Plotnicov
(Eds.), African and African-American sensibility (pp. 2134).
Pittsburgh: University of Pittsburgh Ethnology Monographs, 15.
Gonzlez, N. L. et al. (1965). El factor Diego y el gene de clulas falciformes entre los Caribes de raza negra de Livingston, Guatemala.
Revista del Colegio Mdico de Guatemala, 16, 8386.
Gonzlez, N. L., & Gonzlez, Ian. (1979). Five generations of Garifuna
migration. Migration Today, 7, 1820.
Goodman, F. D., Henney, Jeannette H., & Pressel, Esther. (1974).
Trance, healing, and hallucination. New York: Wiley and Sons.
Helms, M. W. (1981). Black Carib domestic organization in historical
perspective: Traditional origins of contemporary patterns,
Ethnology, 20, 7786.
Howland, L. G. (1984). Spirit communication at the Carib dugu.
Language and Communication, 4, 89103.
Idiquez, J. (1982). El culto a los ancestros en la cosmovisin religiosa
de los Garfuna de Nicaragua. Managua: Universidad
Centroamericana, Managua.
Jenkins, C. L. (1984). Nutrition and growth in early childhood among the
Garifuna and Creole of Belize. In Michael H. Crawford (Ed.),
Current developments in anthropological genetics. Black Caribs: A
case study in biocultural adaptation (Vol. 3). (pp. 135147).
Kerns, V. (1976). Black Carib (Garifuna) paternity rituals. Actes of the
Forty-second International Congress of Americanists, 6, 513524.
Kerns, V. (1983). Women and the ancestors: Black Carib kinship and
ritual. Urbana: University of Illinois Press.
McCauley, E. (1981). No me hables de muerte . . . sino de parranda.
Tegucigalpa: ASEPADE (Asociacin para el Desarrollo).
McCommon, C. S. (1982). Mating as a reproductive strategy: A Black
Carib example. Doctoral dissertation, Pennsylvania State
University.
McKusick, M. (1960). Aboriginal canoes in the West Indies. Yale
University Publications in Anthropology, 1, 159178.
Mertz, R. (1977). Psychological differentiation among Garifuna male
students. Belizean Studies, 5, 1722.
Munroe, R. L., & Munroe, Ruth H. (1971). Male pregnancy symptoms
and cross-sex identity in three societies. Journal of Social
Psychology, 84, 1125.
Munroe, R. L., Munroe, Ruth H., & Whiting, J. (1973). The couvade: A
psychological analysis. Ethos, 6, 3074.
Nicholson, D. V. (1976). Precolumbian seafaring capabilities in the Lesser
Antilles. Proceedings of the International Congress for the Study of
Pre-Columbian Cultures of the Lesser Antilles, 6, 98105.
Palacio, J. O. (1983). Food and body in Garifuna belief systems.
Cajanus, 16, 149160.
Rivire, P. G. (1974). The couvade: A problem reborn. Man (n.s.), 9,
423435.
Sanford, M. (1971). Disruption of the mother-child relationship in conjunction with matrifocality: A study of child-keeping among the
Carib and Creole of British Honduras (Doctoral dissertation,
Catholic University, 1971).
Sanford, M. (1974). Revitalization movements as indicators of completed acculturation. Comparative Studies in Society and History,
16, 504518.
References
681
Greeks
Eugenia Georges
ALTERNATIVE NAMES
None.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
682
Greeks
MEDICAL PRACTITIONERS
Over 90% of the Greek population are covered by some
form of health insurance to which both employers and
employees contribute. Of the approximately 35,000
physicians working in Greece, two thirds are employed
by the National Health System and one third work in fulltime or part-time private practices. There is an ongoing
oversupply of medical doctors in Greece, many of whom
may wait years for a job opening in the public sector
(Colombotos & Fakiolas, 1993).
Lay practitioners such as bonesetters, practical
midwives and herbalists were important providers of
health care in rural areas through the middle of the 20th
century. Today, however, they are completely extinct. In
recent years, complementary healing traditions such as
683
Demonic Forces
Up until the middle of the 20th century, many Greeks living in rural areas maintained belief in a variety of
demonic forces known collectively as the xotika, forces
existing outside (exo) the bounds of Greek Orthodox
Christianity. Haunting the woods, streams, and crossroads
beyond the protected enclosure of the community, these
forces were prone to attack people during liminal periods
in the life cycle, particularly pregnancy, birth, and the
postpartum, and at the time of ones wedding. Unless protected by symbols and objects associated with the Greek
Orthodox Church, such as crosses, icons, amulets, phylacteries, holy water, or olive oil, a person encountering
these demonic forces could fall seriously ill or become
paralyzed, lose their sanity, and eventually die. These
beliefs today are chiefly found among the oldest Greeks,
who only reluctantly divulge them to avoid the derision
of the younger generations (Stewart, 1991).
Humoral Pathology
Humoral understanding of health and illness underpinned
many of the everyday practices of Greeks until relatively
recently and still guides aspects of popular health
care. Humoral theory was premised on an essentially
Galeno-Hippocratic approach to the body that understood
health and illness prevention in terms of maintaining an
684
Evil Eye
Another common cause of illness is the evil eye, to kako
mati. The evil eye is the conscious or unconscious product
of human envy. Its vector is a psychic force that emanates
from the eyes. Ultimately, the evil eye derives from the
devil: it is the devils work if people are envious and covet
the good fortune or possessions of others (Campbell, 1964;
Herzfeld, 1986). Once struck by this malignant force, the
person who is the object of envy may take ill, or if the coveted object is inanimate, a car, for instance, it may begin to
malfunction (Stewart, 1991). The evil eye may also be
inadvertently caused by more benign admiration, even on
the part of those closest to a person and who otherwise sincerely wish them well. Whatever the origins and intentions,
the harmful consequences are the same: headaches, body
aches, depression, and severe illness (Blue, 1991). To forestall the undesirable effects of the evil eye, and to avoid
being blamed for causing anothers misfortune, one should
either avoid making compliments, especially of babies and
children, who are thought to be especially vulnerable to the
evil eye, or be thoughtful enough to bracket ones admiration with an apotropaic gesture: formulaic spitting, or making the sound of spitting (ftou) three times, or uttering a
ritual phrase.
Religious Healing
Religious healing in Greece encompasses a wide variety of
practices, ranging from supplications and promises in the
Greeks
Mental Health
Mental illness, popularly associated with violent behavior, is highly stigmatized and infused with strong sentiments of shame for both the patient and his or her family.
Severe mental illness is believed to be inherited through
the blood. Thus, the mental illness of one family member
may affect the chances of marriage of others in the family. For this reason, efforts may be made to conceal mental illness or to isolate the afflicted family member in a
mental asylum.
Mental illness is commonly expressed through
somatic complaints, such as headaches and chest pains, and
through culturally specific idioms of distress, such as
nerves nevra, and lack of kefi, roughly glossed as a positive mood that is associated with high spirits and zest for
life. To avoid the stigma associated with the profession of
psychiatry, sufferers usually seek care from internists, who
will often prescribe tranquilizers. They may also prefer to
visit a neurologist who will treat their nerves. Mental illness may also be attributed to the evil eye, possession by the
devil, or to black magic, in which case, religious and magical practitioners may be consulted in addition to internists
and psychiatrists. Pilgrimages may be undertaken to holy
sites to pray and make votive offerings to saints and to the
Panayia for the patients recovery (Blue, 1991).
Greek psychiatrists, aware of the intense stigma
attached to mental illness, often avoid precise diagnoses,
such as schizophrenia, in favor of more vague, but less
socially damaging labels (Blue, 1991).
SEXUALITY
AND
REPRODUCTION
685
686
Greeks
Infancy
In the past, infants were not immediately nursed after birth.
The colostrum, the clear, nutritious fluid that precedes the
first flow of milk, was always expressed and discarded. In
contrast to the colostrum, which, perhaps because of its
transitional status, had an ambiguous valence that led to its
avoidance, breast milk was regarded as a pure and even
quasi-sacred substance. It was used to cure eye ailments of
all sorts (Blum & Blum, 1965). Until its mothers milk
came in, the infant was spoon-fed chamomile tea.
Chamomile also helped the baby expel the meconium, its
first, dark sticky stools, and clear the phlegm from its
throat. Although the infant was a highly desirable, even
quasi-sacred presence, these effluvia were considered
dirty, and had to be eliminated from its body before nursing could begin. Chamomile tea was also occasionally fed
to the baby afterward as well, especially if it had a stomach problem. Mothers nursed their infants exclusively for
the first 5 or 6 months. At that time, weaning foods, often
made of toasted wheat flour, were introduced.
On the third, fifth or seventh day after birth, depending on the region of Greece, a salting ritual was performed. The infants body was rubbed with salt and then
bathed. Salt, which has positive connotations and protective powers in Greek culture, helped the baby develop
physical toughness, good sense and a logical mind, and
cured its skin, just as meats were cured for preservation,
to prevent rashes.
Infants were wrapped in three layers of inner cloths
and then swaddled from head to toe. Swaddling helped
the babys legs to grow straight (although more than one
woman I interviewed during my research observed that
her child had turned out bow-legged, nonetheless).
Swaddling also effectively immobilized the infant and
made it easier for women to mind as they went about their
chores. When mothers removed the swaddling cloth to
change or bathe their babies, they vigorously stretched
the infants limbs to help them develop properly.
Stretching was done according to a standard formula,
with each leg or arm first gently tugged and then crossed
over to touch the opposite leg or arm.
From its ears to its feet, the infants body was the
focus of intense attention and concern, and mothers followed a number of practices to encourage its proper physical and esthetic development. In the weeks following the
birth, the new mother was fed plenty of soup made from
roosters so that the babys neck would become strong. To
Adulthood
As in the past, marriage continues to mark the passage to
full adulthood for Greek men and women. Even in contemporary Greece, marriage is usually the first time that
individuals will establish an independent household.
Patterns of parenting have undergone massive
changes in the postwar period. Older gendered idioms of
maternal suffering and sacrifice have been largely
replaced by the discourse of stress and anxiety, as
likely to be heard from fathers as from mothers. Both
motherhood and fatherhood have been profoundly rewritten, each in their own ways, by the child-centered,
emotionally-intensified, financially taxing, consumerist
687
The Aged
Institutionalization of the infirm elderly is rare in Greece.
The aged are usually cared for by their families, and
increasingly, by immigrant home caretakers. Grandmothers
in particular often provide valuable household labor and
assistance with childcare and housework that enables their
daughters to work full-time.
688
24 hours, in a loosely made wooden coffin that will facilitate decomposition. After a period of 3, 5 or 7 years, a
rite of exhumation is performed, after which the bones of
the deceased will usually be deposited in the community
ossuary. The condition of the exhumed bones reflects the
moral and spiritual status of the dead: clean white bones
indicate that sins have been forgiven and that the soul of
the deceased has entered paradise (Danforth, 1982;
Panourgi, 1995).
REFERENCES
Amy Victoria. B. (1991). Culture, Nevra, and Institution: Greek
Professional Ethnopsychiatry. Doctoral Dissertation, Case Western
Reserve University.
Anastasios, P. (1999). The increase in height as a mirror of socio-economic change in Greece. Paidiatriki, 62, 100103 (in Greek).
Campbell, J. K. (1964). Honour, family and patronage: A study of institutions and moral values in a Greek mountain community. Oxford:
Clarendon Press.
Charles, S. (1991). Demons and the devil: Moral imagination in modern
Greek culture. Princeton: Princeton University Press.
Constantinos, T. (1977). Dependency and development. Athens:
Themelio (in Greek).
David, S. (1998). Hes too cold! Children and the limits of culture on
a Greek island. Anthropology and Humanism, 23(2), 127138.
Greeks
Deanna, T. (1981). Favism and G6PD deficiency in Rhodes, Greece.
Doctoral Dissertation, Michigan State University.
Dimosthenis, A., & Mandi, P. (1997). Greece. The international encyclopedia of sexuality. New York: Continuum Press.
Eugenia, G. (1996). Abortion policy and practice in Greece. Social
Science and Medicine 42, 509519.
Eugenia, G. (1997). Fetal ultrasound and the production of authoritative
knowledge in Greece. In R. Davis-Floyd & C. Sargent (Eds.),
Childbirth and authoritative knowledge (pp. 91112). Berkeley:
University of California Press.
Jill, D. (1995). In a different place: Pilgrimage, gender, and politics at
a Greek island shrine. Princeton: Princeton University Press.
John, C., & Fakiolas, N. (1993). The power of organized medicine in
Greece. In F. Hafferty & L. McKinlay (Eds.), The changing
medical professions: An international perspective (pp. 138149).
New York: Oxford University Press.
Loring, D. (1982). The death rituals of rural Greece. Princeton:
Princeton University Press.
Michael, H. (1982). Ours once more: Folklore, ideology and the making
of modern Greece. Austin: University of Texas Press.
Michael, H. (1986). Closure as cure: Tropes in the exploration of bodily
and social disorder. Current Anthropology, 27, 107120.
Neni, P. (1995). Fragments of death, fables of identity. Madison:
University of Wisconsin Press.
Peter, L., & Evthymios, P. (1991). Contested identities: Gender and kinship in modern Greece. Princeton: Princeton University Press.
Rene, H. (1989). Heirs of the Greek catastrophe. Oxford: Clarendon
Press.
Richard, B., & Eva., (1965). Health and Healing in Rural Greece.
Stanford: Stanford University Press.
Richard, C. (1979). A Short history of modern Greece. Cambridge:
Cambridge University Press.
Roger, J. (1989). Triumph of the ethnos. In Elizabeth Tonkin, Maryon
McDonald, & Malcolm Chapman (Eds.), History and
ethnicity (pp. 7188). London: Routledge.
Thomas, G. (2001). Modern Greece. London: Arnold Publishers.
United Nations Development Program. (2001). Human development
report. New York: Oxford University Press.
Vassiliki. C. (1984). An Analysis of rituals surrounding birth in modern
Greece. Masters Thesis, University of Oxford.
Yewoubdar, B. (1989). From menarche to menopause: Reproductive
lives of peasant women in two cultures. New York: State University
of New York Press.
Cultural Overview
689
The Hadza
Frank Marlowe
ALTERNATIVE NAMES
Hadzabe, Hadzapi, Hatsa, Tindiga, Watindiga, Kangeju,
Wakindiga.
CULTURAL OVERVIEW
The Hadza are nomadic huntergatherers who live in a
savannawoodland habitat around Lake Eyasi in northern
Tanzania (Woodburn, 1968). They number about 1,000
(Blurton-Jones, OConnell, Hawkes, Kamuzora, & Smith,
1992), of whom many are still full-time foragers and
almost none of whom practice any kind of agriculture.
Men collect honey and use bows and arrows to hunt
mammals and birds. Women dig wild tubers, gather
baobab fruit, and berries. Camps usually have about 30
people and move about every month or so in response to
the availability of water and berries and a variety of other
reasons, such as a death.
The Hadza are very egalitarian and have no political
structure, indeed they have no specialists of any sort
(Woodburn, 1979). There is a slightly greater respect
afforded to older people but not very marked compared to
that in other East African societies. One manifestation of
this respect is the fact that camps are usually referred to
by the name of some senior man, usually in his 50s or 60s.
The core of a camp, however, tends to be a group of sisters, one of whom the man has long been married to. There
is no higher level of organization than the camp and people move into and out of camps with ease. Post-marital
690
The Hadza
691
692
MEDICAL PRACTITIONERS
With the exception of the few older women who know
how to perform a clitoridectomy, there are no medical
specialists or specialists of any kind among the Hadza.
Every adult knows about the various medicinal plants and
practices that the Hadza use. Any adult present may treat
someone with an ailment. Women often sit and groom
children, removing lice, washing them, and blowing their
noses. When anyone is injured and cannot forage for a
while, their close kin usually attend to them and bring
food back for them until they recover.
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Illnesses and causes of death tend to be explained in four
ways. (1) If someone falls to their death, the Hadza say the
cause of death is simply an accident. (2) If someone is killed
by a lion or a snakebite, this is just part of the dangers of the
natural world. Likewise, malaria is understood to be caused
by mosquito bites and sleeping sickness (African trypanosomiasis) the bite of the tsetse fly. (3) When the cause
is less obvious however, and especially when death is sudden, a heart attack or poisoning, and the person had been
healthy before, then the witchcraft of their non-Hadza
neighbors is often said to be the cause of death. The Hadza
do not themselves practice witchcraft but fear that of their
neighbors. Even when a death is clearly caused by some
disease, the Hadza may say this was due to witchcraft if that
person had had some quarrel with someone earlier. The
percentage of deaths attributed to such witchcraft is on the
rise, and these days even a few Hadza are suspected of
having learned witchcraft from their neighbors. (4) Finally,
there is the supernatural cause not involving witchcraft.
There are few rules or taboos in Hadza society, but one such
taboo relates to the eating of the epeme meat. Only the adult
epeme men can eat these parts of larger game (heart, kidneys, genitals, and back). Sub-adult males and all females
cannot eat this meat nor can they even see the men eat it. If
they do, it is said they can get ill or die.
There are several types of medical treatment
(Woodburn, 1959). For example, there is a certain type of
plant that is boiled and then drunk to relieve the symptoms of malaria. Several plants are used to cause one to
The Hadza
SEXUALITY
AND
REPRODUCTION
693
Infancy
Infants are carried at almost all times during the first 6
months of life and nurse on demand. Women carry infants
Childhood
By age 3, children have small slits made on their cheeks
by their mother, uncle, or grandparent, which leaves them
with small scars to identify them as Hadza. Toddlers are
not easy to take foraging because they are too young to
walk very far and too old and heavy to carry. They are
therefore, usually left in camp and that means someone
must be in camp to watch them. This can be almost
anyone, but is often a grandmother, and during the dry
season when men hunt at night, it is often the father who
is dozing in camp all day. Men interact most with their
young children when they are 13 or 4 years of age
(Marlowe, 2002a).
There is very little disciplining among the Hadza.
When children are in their terrible twos and throw violent tantrums, they pick up sticks and beat adults, who
merely fend off the blows, rather than take the stick away.
Children tend to learn how to behave from older children
because when a 2-year-old hits a 4-year-old, the 4-year-old
does take revenge. The most disciplining adults do is to
simply make a noise of displeasure. Their leniency extends
to letting young children play with whatever they want.
A baby can often be seen with a sharp knife or other dangerous object in its mouth with adults not bothering to take
it away. Nor do they try to keep little ones out of the fire.
Children get burned or get cut and learn on their own. By
the standards of modern America therefore, Hadza adults
would appear to be guilty of child neglect, if not abuse.
Actually Hadza parents are very loving and very rarely hit
or abuse their children, and children never feel unloved.
They grow up to be extremely well-behaved by the age of
4, without parental disciplining. They do not disobey their
parents, nor argue with them, and by 4 or 5 will wait on
adults or run errands often without even being asked.
694
Boys usually get their first bow when they are about
4 and spend hours each day in target practice. By the time
they are 7 or 8 they are already very good and kill small
birds and rodents. Girls begin accompanying their mothers on foraging forays by around 810 and also look after
their younger siblings.
Adolescence
By age 1012, boys and girls may begin having some
sex but only begin courting when girls are about 15 or 16
and boys 17 or 18. There is no disapproval of premarital
sex but it is kept secret anyway. There is no public display of affection even between married couples. Age at
menarche is about 16 or 17. At this time, or close to it,
there is a puberty ritual for girls attended only by females,
called Mai-to-ko, during which the tip of the clitoris is cut
off with a knife by one of the few older women who know
how to perform this. The Hadza may have acquired this
practice from their neighbors, the Iraqw, Datoga, or
Maasai, since all clitoridectomize women, though several
Hadza claim it is not a borrowed custom. Males are not
circumcised and there is no puberty ritual for boys. There
is a ritual eating of the epeme meat when a teenager has
killed his first big animal.
By the age of 10, girls are not only supplying about
half their own food needs but bringing food back to share
with others. They also tend younger siblings and other
children much of the time. Boys by the age of 10 or 12
go hunting in groups of 2 or 3 and kill birds and small
mammals. There is also no generation gap. Teenagers
look up to adults and get along well with the elders. This
is at least partly due to the fact that adults do not try to
control them and rarely express a strong opinion about
whom they should marry. The fact that there is little
polygyny means the young males are not in such intense
competition for females as they are in many cultures. In
addition, since there is no wealth, men do not have the
same kind of leverage over their sons as they do in societies where inheritance is important (Marlowe, 2003).
The Hadza
The Aged
Adulthood
Age at first marriage for females is about 1718 and
median age at first reproduction is 19 (Nicholas BlurtonJones, personal communication). Age at first marriage for
men is around 20. Marriage is not arranged and there is
no ceremony, it consists of a couple that has been secretly
References
695
diet, means they grow faster and larger and more are
becoming literate. However, future development and a
more sedentary existence will probably prove deleterious.
While the consumption of tobacco might pose the greater
direct threat to health, the ramifications of drinking are
much more severe. Promiscuous sex near the village is
bound to result in sexually transmitted diseases and death
from AIDS. In the village, begging and money from
tourists (for whom they perform a song and dance) leads
to drunkenness and quasi-prostitution, injuries from
fights, and murder. Murder is becoming more common,
mainly as a result of increasing alcohol consumption.
Other Hadza do not approve of a man beating his wife
and will reluctantly intervene to stop it, but when drunk,
men may seriously injure or kill their wives with little or
no provocation before anyone can prevent it.
REFERENCES
Barnicot, N. A., Bennett, F. J., & Woodburn, J. C. (1972). Blood pressure and serum cholesterol in the Hadza of Tanzania. Human
Biology, 44.
Barnicot, N. A., & Woodburn, J. C. (1975). Colour-blindness and sensitivity to PTC in Hadza. Annals of Human Biology, 2.
Blurton-Jones, N., Hawkes, K., & OConnell, J. (2002). Antiquity of
postreproductive life: Are there modern impacts on hunter-gatherer
postreproductive life spans? American Journal of Human Biology,
14(2), 184205.
Blurton-Jones, N., Hawkes, K., & OConnell, J. (1989). Modelling and
measuring costs of children in two foraging societies. In V. Standen &
R. Foley (Eds.), Comparative socioecology: The behavioural
ecology of humans and other mammals (pp. 367390). London:
Basil Blackwell.
Blurton-Jones, N., Marlowe, F., Hawkes, K., & OConnell, J. (2000).
Paternal investment and hunter-gatherer divorce rates. In L. Cronk,
N. Chagnon, & W. Irons (Eds.), Adaptation and human behavior:
An anthropological perspective (pp. 6990). New York: Elsevier.
Blurton-Jones, N., OConnell, J., Hawkes, K., Kamuzora, C. L., &
Smith, L. C. (1992). Demography of the Hadza, an increasing and
high density population of savanna foragers. American Journal of
Physical Anthropology, 89, 159181.
Boyd Eaton, S., Pike, M. C., Short, R. V., Lee, N. C., Trussell, J.,
Hatcher, R. A., et al. (1994). Womens reproductive cancers in evolutionary context. Quarterly Review of Biology, 69, 353367.
Fosbrooke, H. A. (1956). A stone age tribe in Tanganyika. The South
African Archeological Bulletin, 11(41), 38.
Gray, P., & Marlowe, F. (2002). Fluctuating asymmetry of a foraging
population: The Hadza of Tanzania. Annals of Human Biology,
29(5), 495501.
Marlowe, F. (2001). Male contribution to diet and female reproductive
success among foragers. Current Anthropology, 42(5), 755760.
Marlowe, F. (n.d.). Who tends Hadza children? In B. Hewlett &
M. Lamb (Eds.), Culture and ecology of Hunter-Gatherer children.
696
Haitians
Haitians
Robert Lawless
ALTERNATIVE NAMES
The ethnonyms for Haitian include the Creole word
ayisyen and the French word hatien. In English language
sources the word is also sometimes spelled Haytian. Haiti
in Creole is Ayiti; and in French, Hati.
LOCATION
AND
LINGUISTIC AFFILIATION
of modern history, however, the official language of government, business, and education has been French,
though only about 3% of the population speaks French
with any recognizable fluency. Traditionally the educated
elites have used the requirement of French to exclude the
masses from competing for positions in government and
business. Creole has, nevertheless, come into its own in
recent years and is gaining prestige as the natural tongue
of Haitians and of Haiti. The current constitution states,
All Haitians are united through one common language:
Creole. Creole and French are the official language of the
Republic. Due to the recent flood of Haitian migrants to
Florida, the international decline of the French language,
and various economic and cultural trends in the
Caribbean, there has been a considerable expansion in the
use of English.
OVERVIEW
OF THE
CULTURE
Demography
Although demographic information is highly undependable, an estimation of the total population would be
8,500,000 million, and the capital of Port-au-Prince would
History
The Republic of Haiti is the second oldest independent
nation in the Western Hemisphere, and it is the only one
with an overwhelmingly African culture. The people who
occupied the island of Hispaniola at the beginning of the
16th century when Europeans first arrived in significant
numbers rapidly succumbed to imported diseases, died in
battle, or were killed off by slavery in the first 50 years of
Spanish occupation. The Europeans then brought slaves
from Africa.
These slaves primarily worked the sugar cane plantations that made the French colony of Saint Domingue an
economic success. This success, however, was based on
unimaginable brutality and cruelty, and in 1789 the slaves
began their 5-year struggle for freedom. On January 1,
1804, the ex-slaves of Saint Domingue renamed their
country Haiti and proclaimed its independence.
From 1915 until 1934 the United States occupied
Haiti and suppressed peasant movements, revamped
the army, and concentrated sociopolitical power in Portau-Prince. Until 1946 the Haitian administrations were
pale reflections of U.S. political interests in the Caribbean.
Then from 1946 to 1950 President Dumarsais Estim ushered in a progressive era that saw an interest in African
heritage, cooperation with other Caribbean nations, the
development of peasant economic cooperation, the introduction of progressive income tax, expanded education
and economic opportunities for the poor, and the rise of a
middle class.
In 1957 President Franois Duvalier emerged as the
proclaimed heir to Estim. The Duvalier regime was
marked by brutal oppression against opponents and isolation from the international community. Many professionals fled into exile, and the economy descended into a
serious slump. With the 1971 transition from Duvalier to
his 19-year-old son Jean-Claude, the United States guided
Haiti to a new economic program that featured private
investments from the United States featuring no custom
taxes, a very low minimum wage, the suppression of labor
697
698
International Relations
Internationally Haiti is closely tied to the United States
with a sizeable majority of its exports coming to North
America and a goodly portion of its economy dependent
on government and nongovernment aid from the United
States. Although twice-elected Aristide remains popular
among Haitians, his socialistic and anti-American rhetoric means that influential sectors in the U.S. government
will continue to oppose his administration.
Since May 2000 when the party of President
Aristide won approximately 80% of the seats in a parliamentary election and the U.S.-backed opposition front
Democratic Convergence alleged that the election was
Haitians
Religion
All religions have a close connection with health and
illness, and an understanding of the religions of Haitians
is essential for developing an appreciation of their health
care system. Although some of the population is nominally Christian, the major religion of Haiti is Voodoo.
Between 50 and 75% of the population of rural Haiti
actively practice Voodoo, and 90% believe in it to some
degree. Voodoo is also very popular among the urban
working class, and to some degree among people in all
classes, including the educated elite. Many important ceremonies revolve around celebrations of milestones in the
life cycle, such as birth, maturity, marriage, and death.
Other important ceremonies focus on agriculture, planting, harvesting, and insuring a sufficient crop yield. An
ancient, affirmative, and legitimate religion that focuses
Colonial Era
No reliable information exists on the conditions for slaves
during the colonial era. The treatment of the slaves was
most certainly deplorable, and their diet was no doubt
substandard. Various estimates suggest that the life
expectancy of slaves after their arrival in Saint Domingue
was 7 years. As inhuman as it sounds, the economies of
slavery dictated that it was cheaper to export labor and
quite literally work the slaves to death rather than waste
time and energy on reproducing and maintaining a
domestic work force.
Postcolonial Era
Currently tuberculosis is Haitis most serious disease. The
country is also infected with malaria, influenza, dysentery,
tetanus, whooping cough, and measles. Eye problems are
endemic, and blindness is not uncommon and is usually
caused by cataracts, scarring of the cornea, and glaucoma.
Many Haitians, especially the poorer masses, suffer
many health problems associated with malnutrition. The
daily per capita food consumption is estimated at 1600
699
Current Era
An obvious current difficulty is the U.S.-sponsored
embargo. In an electronic message sent in March 2002 to
the Haitian Discussion Group the anthropologist and
physician Paul Farmer spells out the health problems
resulting from this embargo (Farmer, 2002). Farmers 80bed charity hospital has delivered health services in the
central plateau for the last 18 years, and he writes that the
situation there has gravely deteriorated because of a serious lack of resources, medical personnel, and an increase
in diseases. He draws a direct connection between this
suffering and the aid embargo.
Farmer points out that while the brutality of the
19911994 de facto military regime is well known with
thousands killed outright and hundreds of thousands
made homeless, the current catastrophic decline in overall health is much less publicized. There have been
measles epidemics, outbreaks of dengue fever and polio,
as well as the appearance of other vaccine-preventable
diseases. Most of these diseases are related to the increasing prevalence of malnutrition. According to Farmer,
The nationwide network of public clinics and hospitals
was left to fend for itself, and many health professionals
left Haiti as this network foundered (2002).
Although democratic rule was restored in 1994, and
a coalition of international donors promised more than
700
Haitians
Health Infrastructure
Although Western medicine has been available to the
urban elite for several decades and is, indeed, available
from a few rural clinics, Voodoo healers are a major part
of the medical system of Haiti. Interestingly Haitians
place an enormous emphasis on physical cleanliness. It is
very important to be clean-looking and clean-smelling in
your body, your clothing, and your home. This value may
be important in helping Haitians to accept modern medical practices. Bathing is explicitly health-oriented.
According to Haitian folk model, regular morning baths
are necessary to maintain the balance of the body.
Irregular bathing causes heating up of the body and may
result in stomach boils. Incidentally bathing, which is
often done in a nearby river, is usually done with the
clothes on, and it is thought that keeping the clothes on
helps cool the body and prevents loose bowels. For the
most part, however, health and healing for most Haitians
are handled by herbal medicine, bonesetters, injectionists,
Voodoo rituals, and by a rich body of folk knowledge.
MEDICAL PRACTITIONERS
Voodoo is a particularly egalitarian religion with both men
and women serving as intermediaries, and this rule follows for most of the indigenous therapists. There are at
least four types of indigenous therapists who can treat
illnesses caused by natural phenomena and two who treat
illnesses caused by unnatural phenomena: (1) herbalists,
(2) bonesetters, (3) injectionists, (4) midwives, (5) Voodoo
priests and priestesses, and (6) sorcerers.
(1) Among the most common therapists are herbalists (leaf doctors, or in Creole dkt fy or medsin fy). As with the other
indigenous therapists, herbalists have no manuals or organized
701
and priestesses or physicians or other types of indigenous
therapists, according to varying criteria such as severity of
illness, customary local practices, availability of competent
practitioners, and ability to pay. Supra-natural illnesses are
attributed either to sorcery or to the supra-natural spirits and
can be treated only by priests and priestesses.
(5) The first step in diagnosis is to determine the complexion of the
disease and the natural humoral balance of the patient.
Following the principle of opposites, a disease thought to be hot
will be treated with cold herbal remedies and the patient will be
advised to eat mainly cold foods. A person complaining, for
example, of chal in the head will usually be treated with cold
water and with medicinal leaves on the head. In general, treatment consists of attempts to restore the normal humoral balance.
Actual methods of diagnosis and treatment vary from one priest
and priestess to the next, but the pattern is generally something
like this: After receiving the initial complaint, which is often
very generala headache or a stomachachethe priests and
priestess call for the aid of their spirit helper. They most likely
sit before a domestic altar, recite the rosary, light candles, and
purify the floor with holy water, often chanting in a language
that is supposed to be African. They then become possessed by
their spirit helper, who gives them advice about how to proceed.
Usually they then collect a detailed medical history from the
patient and the patients relatives. They may also try to get more
specific details through the use of various divination techniques.
SEXUALITY
AND
REPRODUCTION
702
REFERENCES
Alleyne G. A. O. (2001). Health in Haiti. Pan American Journal of
Public Health, 10(3), 149151.
Arthur, C. (2002). Haiti: A guide to the people, politics and culture.
New York: Interlink.
Barnes-Josiah, D. L., Myntti, C., & Augustin, A. (1998). The three
delays as a framework for examining maternal mortality in Haiti.
Social Science and Medicine, 46, 981993.
Bentivegna, J. F. (1991). The neglected and abused: A physicians year
in Haiti. Rocky Hill, Connecticut: Michele.
Bordes, A., & Couture, A. (1978). For the people, for a change:
Bringing health to the families of Haiti. Boston: Beacon.
Burgess, A. L., Fitzgerald, D. W., Severe, P., Joseph, P., Noel, E.,
Rastogi, N., et al. (2001). Integration of tuberculosis screening at
an HIV voluntary counselling and testing center in Haiti. AIDS, 15,
18751880.
Coreil, J. (1983). Parallel structures in professional and folk health care:
A model applied to rural Haiti. Culture, Medicine and Psychiatry,
7, 131151.
Daniels, J. (2000). U.S. funded AIDS research in Haiti: Does geography dictate how closely the United States government scrutinizes
human research testing? Albany Law Journal of Science and
Technology, 11, 203224.
Dash, J. M. (2001). Culture and customs of Haiti. Westport,
Connecticut: Greenwood.
Haitians
Deschamps, M.-M., Fitzgerald, D. W., Pape, J. W., & Johnson, W. D.
(2000). HIV infection in Haiti: Natural history and disease progression. AIDS, 14, 25152522.
Direksyon Edikasyon Sanite ak Direksyon Ijyen Familial ak Nitrisyon
(1986). An nou aprann byen manje pou nou an sante. [Port-auPrince]: Minist Sante Piblik ak Popilasyon.
Farmer, P. (1988). Bad Blood, spoiled milk: Bodily Fluids as moral
barometers in rural Haiti. American Ethnologist, 15, 6283.
Farmer, P. (1992). AIDS and accusation: Haiti and the geography of
blame. Berkeley, CA: University of California Press.
Farmer, P. (2002). Dr. Paul Farmer outlines connection between suffering and aid embargo. Haitian Discussion Group. Http://www.webster.edu/~corbetre/haiti-archive/msg11016.html.
Farmer, P., Walton, D., & Carter, L. (2000). Infections and inequalities.
Global Change and Human Health, 1(2), 94109.
Fitzgerald, D. W., Behets, F., Caliendo, A., Roberfroid, D., Lucet, C.,
Fitzgerald, J. W., et al. (2000). Economic hardship and sexually
transmitted diseases in Haitis rural Artibonite Valley. American
Journal of Tropical Medicine and Hygiene, 62, 496501.
Freeman, B. C. (1992). Medical dictionary: Haitian CreoleEnglish;
EnglishHaitian Creole. Port-au-Prince: Evanglique.
King, K. W., Fougere, W., Webb, R. E., Berggren, G., Berggren, W. L., &
Hilaire, A. (1978). Preventive and therapeutic benefits in relation
to cost: Performance over 10 years of Mothercraft Centers in Haiti.
American Journal of Clinical Nutrition, 31, 679690.
Laguerre, M. S. (1987). Afro-Caribbean folk medicine: The reproduction
and practice of healing. South Hadley, MA: Bergin and Garvey.
Lawless, R. (1990). Haiti: A research handbook. New York: Garland.
Lawless, R. (1991). Haitians, AIDS, anthropology, and the popular
media. Florida Journal of Anthropology, 16(7), 17.
Lawless, R. (1992). Haitis bad press: Origins, development, and consequences. Rochester, Vermont: Schenkman.
Lawless, R. (2002). Haiti: Voodoo, Christianity, and politics. In R. G.
Mainuddin (Ed.), Religion and politics in the developing world:
Explosive interactions (pp. 3949). Aldershot, Hampshire,
England: Ashgate.
Miller, N. L. (2000). Haitian ethnomedical systems and biomedical
practitioners: Directions for clinicians. Journal of Transcultural
Nursing, 11, 204211.
Minn, P. (2001). Water in their eyes, dust on their land: Heat and illness
in a Haitian town. Journal of Haitian Studies, 7(1), 425.
Staff (1992). Report. [Port-au-Prince]: CPAU.
Wiedeman, J. E., Zierold, D., & Klink, B. K. (2001). Machete injuries
in Haiti. Military Medicine, 166, 10231025.
Wiese, H. J. C. (1976). Maternal nutrition and traditional food behavior
in Haiti. Human Organization, 35, 193200.
Overview of Culture
703
Han
Xingwu Liu
ALTERNATIVE NAMES
Chinese, Zhongguo-ren, Han-ren, Hua-ren, Tang-ren.
Because of their predominant numbers in China, the Han
are commonly referred to as Chinese in the English language, though in China (including Taiwan) they have
always called themselves Han-ren (Han people).
Outside China they tend to call themselves Chinese
(Zhongguo-ren) and many overseas Han Chinese also use
their provincial names or other local origins in China
(such as Guangdong, Fujian, Hakha, Taishan, etc.) to
refer to themselves since their Han identity is virtually
unknown outside China.
The name Han was derived from the Han River, an
upper tributary of the Yangtze River. It was further
strengthened by the famous Han Empire (206 BC220 AD)
which lasted for several hundred years when the people
began active interactions with the outside world. It is
understood the Han are the result of amalgamation of
numerous ancient ethnic groups.
While the term Han-ren is used in China to differentiate the Han from other ethnic groups, Hua-ren
now mostly refers to Overseas Chinese, such as Mei-ji
Hua-ren (American Chinese), Yindunixiya Huaren
(Indonesian Chinese), etc. Hua is an ancient name for
China, and it is still used when referring to China in combination with the word Zhong (middle), such as Zhong
Hua Ren Min Gong He Guo (Peoples Republic of China)
and Zhong Hua Min Guo (Republic of China).
Chinatowns in other countries are referred to as Tang-renjie, meaning Town of the Tang People. Tang refers to
the ancient Tang dynasty (618907) in China.
LOCATION
AND
LINGUISTIC AFFILIATION
the Hahka dialect, the Min dialect, and the Yue dialect. The
modern common speech ( pu-tong-hua) is based upon the
Northern dialect with Beijing pronunciation.
These dialects are mutually intelligible in most
cases, especially between the Northern dialect and others.
However, since 221 BC, there has been an unified idiographic (actually it is an idiographic script with phonetic
elements) script which has survived the long history of
China and which has been one of the most important factors in holding the people and the country together.
OVERVIEW
OF
CULTURE
704
The Han family is patriarchal, patrilineal, and patrilocal in nature. The key link that binds everyone together in
the family is xiao, filial piety. It means obligations of
descendants to their progenitors, especially ones father
and mother. The family is an unending chronic continuum
linking the dead, the living, and the unborn. The principles
underlying the kinship system are lineage, generation, sex,
and seniority, and the most important relationship in the
family is between the father and the son (Hsu, 1948). In
this closely-knit network everyone is taken care of and
nobody is left alone. The family clan may exert enormous
influence over individual families and their members.
Extensive use of kinship terms outside the family
and family clan, and even with strangers is a strong indication that among the Han the ideal society is one constructed on the family model.
While Confucianism provides the guidelines for
interpersonal relations in this world, ancestor worship
provides the solution for the next. As a religion Daoism
plays an auxiliary role. Mahayana Buddhism which originated in India also has considerable influence.
Christianity, both Roman Catholic and Protestant, is present and the followers are a small minority.
Han
Major Diseases
The ten leading causes of death in rural areas in order of
incidence are; (1) respiratory disease, (2) malignant
tumors, (3) cerebral vascular disease, (4) heart disease,
(5) traumatic injuries and toxicosis, (6) digestive diseases,
(7) urinary and reproductive diseases, (8) new born baby
diseases, (9) TB, and (10) endocrine, nutritional, metabolic and immune diseases. In metropolitan areas they are
705
706
Infrastructure
Among the Han people there are two medical systems,
namely biomedicine that they call Western medicine,
and traditional medicine which they call Chinese medicine (Zhong Yao). In both Japan and Korea, Chinese
medicine is called the Han medicine. For clarity this
article will use the terms Western medicine and
Chinese medicine. Though Western medicine came to
China during the early 20th century, it has never been
able to replace Chinese medicine which has long become
part of daily life.
Today Chinese medicine and Western medicine
enjoy equal status. All medical doctors must be trained in
both Chinese medicine and Western medicine although
they may have either as their major area of training. All
hospitals provide both services and when a patient comes
to see a doctor, he or she may have a choice with the help
of the doctor.
Health care in China was notorious before the
1950s. Steady progress has been made in public health
since then. At the end of 2000, there were 325,000 health
institutions (including clinics) throughout the country,
with a total of 3.18 million beds, 2.21 million of which
were in hospitals and public health centers. There were
4.49 million health workers, including 2.08 million doctors and 1.27 million senior and junior nurses (China
Yearbook of Health, 2000).
By mid-1960s, an effective healthcare network was
established and the whole population was provided with
basic preventive and curative health care. Strict control by
the government on drug production and sales ensured low
Han
Medical Practitioners
MEDICAL PRACTITIONERS
Four Thousand Years of
Unbroken Tradition
The beginning of Chinese medicine was lost in antiquity.
Legend of the Han attributed it to Shennong, The Divine
Peasant, one of the earliest emperors who was said to
have tasted hundreds of herbs. Later Shennong Ben Cao
Jing (Shennongs Herbal) was compiled in his name. It is
perhaps the worlds first pharmacopoeia. Thereafter the
investigation of herbal medicine has never been interrupted. A great amount of information has been recorded.
Methods of preparing herbal formulas have been successfully refined, and the number and variety of clinical
applications of herbal medicine have grown in proportion
(Hsu, 1986).
In the 3rd century BC, Huangdi Nei Jing (The Yellow
Emperors Classics of Internal Medicine) was compiled
showing how advanced practical medical knowledge was
at that time. Many of the formulas described in it are still
being used today. Hua Tuo, a historically famous medical
specialist in the beginning of the 3rd century, was able to
perform major surgery including opening the stomach
cavity and repairing the intestines, under anesthesia.
As a tradition, Chinese medicine is shaped by the
influence of Confucianism in many ways. Its secular
nature came from the Confucian attitude to respect gods
and ghosts but hold them at a distance. In history, many
Confucian scholars were also famous doctors, and their
strong sense of history and responsibility to society made
them instrumental in making the medical system a strong
and unbroken tradition (Li, 1990). Landmark medical
writings including materia medica and treatment experiences are countless including such works as Zhang
Zhongjings Shang Han Lun (Discussion of Cold Diseases,
about 200 BC), Sun Shimiaos Invaluable Prescriptions for
Ready Reference (652 AD), Li Shizhens A Compendium of
Materia Medica of the Ming Dynasty (13681644), A Grand
Dictionary of Chinese Medicine (1979), Encyclopedia
Sinica, Volume of Traditional Chinese Medicine (Zhongguo
Dabaike Quanshu Zhongyi 2000) and the China
Pharmacopoeia (2001).
707
Shamanism
Shamanism may have been practiced since the beginning
of the Han civilization. The famous bone-shell script that
evolved into the present Han writing (Chinese script) and
was used to predict the future may also have been used to
diagnose diseases. Since people also believed in supernatural causes of diseases, including gods, spirits of both
dead people (ancestor or dead relatives) and some mysterious animals such as the fox and weasels, shamans were
much needed to solve the problems acting as a go-between
or a messenger between these supernatural beings and the
human world. These shamans played an important relieving role in the countryside. Even during the time after
1949 when the Chinese government waged extensive
campaigns against superstition and religion, shamanism
has never disappeared entirely. With softening of the
policy toward traditional beliefs, shamanism seems to
have come back to the countryside especially in economically poor areas and remote regions.
Religious Personnel
In cosmology, disease and destiny (in the Chinese language destiny and life share the same word) are closely
connected. Therefore it is understandable that religious
personnel played a part in Chinese medicine. Most of the
Daoist (Taoist) priests and Buddhist monks had very
good knowledge of traditional medicine and used them in
their congregations. People also looked to these religious
premises for ultimate cures, especially in case of tenacious diseases or in case of barrenness.
708
Han
709
Classification of Illness
Concept of Illness
In Chinese medicine disease is defined in terms of breaking up of the relative balance in the human body.
According to this theory, there is an endless process of
adaptation among all parts of the human body and
710
Methods of Diagnosis
Doctors of Chinese medicine diagnose in four major
ways including inquiry (asking questions concerning
body temperature and how the patient feels, perspiration,
general body feeling, urination and stool, diet, feelings of
the lung and stomach, monthly discharges in case of
woman, etc.), visual observation (patients mood, face
color, shape of body, and color, shape of the tongue, etc.),
smelling and listening (patients body odor and voice),
and pulsation. Generally the information collected and
the observed symptoms are enough to help the doctor
determine the nature of the disease. Today doctors of
Chinese medicine are also using modern equipment and
methods such as stereoscope, X-ray, CT, etc., to verify
conclusions.
Treatment Principles
Prevention as Priority. The overall guiding rule in
treating diseases in Chinese medicine is determining the
root cause. It includes two aspects: one is taking precautions before disease strikes; the other is prevention after
a disease strikes. There are many formulas and methods
to help enhance the immune system. As early as the 16th
century, the Han people invented inoculation for smallpox. After a disease strikes, medical practice tries to intercept possible pathological changes. For instance, when
the liver is out of order, it is important to protect and
strengthen the spleen.
Balance as the Ideal State of Health. Because
everything is connected to everything else in a relationship
of cooperation and coordination it is the mission of
Chinese medicine to redress any imbalance. What is more,
in reestablishing this balance, efforts must be taken to
avoid creating any new imbalance. That is why treatment
with Chinese medicine is expected to be slow and noninvasive (Liu, 2002).
Holistic Considerations and Individualized
Treatment. In prevention, diagnosis and treatment,
everything, including the season and local conditions,
physical and psychological environment, the patients
Han
Methods of Treatment
Since Chinese medicine is nutrition oriented, it treats various health problems in terms of excess syndromes, deficiency syndromes, and deficiency with excess syndromes.
Deficiency includes deficiency in Qi, in blood, in Yin and
Yang; excess includes excess in wind, cold, heat, damp,
dryness, fire, phlegm, and Qi.
There are numerous methods of treatment in Chinese
medicine, but basically there are eight approaches that are
used singularly or in combination as the situation calls for:
(1) The diaphoretic approach induces sweat to expel pathogenic factors. It is used for external problems such as
unripe pox, sores, and boils. It may be due to external cold
or external heat, and therefore there are two basic ways
which are resolution of exterior with coolness and acridity, or resolution of exterior with warmth and acridity;
(2) the emetic approach induces vomiting to expel pathogenic factors or toxins. It is used in case of thick phlegm
in the throat or stagnant or poisonous food in the stomach;
(3) the purgation approach is used in case of serious
constipation, bloating, stagnant phlegm and blood, or in
case of parasites. It is comprised of cold purgation, warm
purgation, expelling of water, dissolution of stagnation, or
expelling parasites; (4) the harmonization approach is
used to resolve poor co-ordination between internal
organs in their functions. Malaria and irregular menses are
also treated this way; (5) the warming approach is taken
711
Classification of Medicine
Sources of Chinese Medicine. Chinese medicine
is characterized by natural, low cost, and nutrition
oriented sources. So far there are 12,807 medicinal materials out of which 11,146 are herbs, 1,581 are from animal
sources, and 80 minerals (Encyclopedia Sinica, Volume
of Chinese Medicine, 2000 Edition). Because of the predominance of herbal sources, people refer to Chinese
materia medica as herbal medicine. Based upon principles of Chinese medicine in formulation, there are more
than one million patent formulas that can be adjusted with
addition or reduction of some ingredients to suit particular
needs of the patient. They represent a great rich treasure
house for health care and fitness.
Properties of Herbs. Herbs are said to have four
properties: cold, cool, warm, and hot, and five flavors:
sour, bitter, sweet, pungent, and salty. The four properties
have nothing to do with the temperature of the herbs.
They are the resulting effects produced by the herbs.
Coptis, phellodendron bark, gardenia fruit are classified
as cold medicine because they eliminate heat, dryness,
remove toxins, and they are normally used to tackle heat
patterns of diseases, while aconite and dry ginger are
classified as hot medicine because they are normally
employed to warm the center and dispel cold.
From the beginning, Chinese medical practitioners
found that herbs of certain taste possessed certain medical properties. With long historical development, the five
flavors actually come to represent the properties rather
than the actual flavor or taste. Herbs with sour flavor possess the ability of astriction and are used to treat seminal
emission, night sweating, enuresis, enduring diarrhea,
anal desertion, etc. Those with bitter flavor including
712
Han
Prescription Formulation Principles. After diagnosis and determination of the treatment principles, the
doctor of Chinese medicine decides the principal herb
and the auxiliary herbs in the formulation to achieve the
curative effects wanted. Sometimes a single herb is used,
but most often it is a compound preparation that may consist of anything from four to twenty herbs.
A compound prescription normally includes four
different component parts. They are called Monarch
(principal), Minister (adjuvant), Assistant (auxiliary), and
Guide (conductor) respectively.
The principal ingredient provides the main curative
action. The adjuvant helps strengthen the principal
action; the auxiliary is a corrector ingredient to relieve
secondary symptoms or to temper the action of the principal when it is too potent, and the conductor is to direct
the actions of the principal and adjuvant herbs to the
affected area or site or acts as a minor ingredient.
In a compound prescription, drug interactions must
be considered. According to Chinese medicine, herbs
may be either mutually reinforcing, mutually restraining
(to weaken or neutralize each others actions), mutually
counteracting (one ingredient reduces the potency or
toxicity of another), mutually neutralizing (one counteracts
the toxic reaction of another), or mutually incompatible.
Modern research has found that some of these relationships are valid and some are not. However a good herbal
doctor is one who knows really well the properties of the
herbs and uses them correctly and innovatively to treat his
patients.
Food Therapy
A very important medical tradition is what is called shi liao,
that is, food therapy. The origin of this can be traced back in
history to several thousand years. The Shennongs Herbal
(shen nong ben cao jing) carries 365 herbs classified into
three categories including superior, medium, and lower
grades. Most of those listed as superior are food grains,
vegetables, fruits, meats, and herbs with a friendly nature.
As herbal drugs are strong and taste awful, and long-term
use may hurt the stomach, the best way is to use food to do
the work. This is considered an ideal since foods may not
only cure in the long run, but may also be made into something enjoyable. Food therapy follows the same principle as
herbal treatment, that is, to warm up when cold is present,
cool off when heat is the problem, to supplement in case of
deficiency (vacuity) and discharge in case of excess. For
this, food items are classified into different categories
according to their properties and diet is planned in such a
way as to achieve therapeutic result in different situations.
Food therapy is often employed to supplement medical
treatments, especially for chronic diseases.
713
Tuina
Yangsheng (Life Preservation)
Shi liao and Shi Yang are included in another wider
approach called Yangsheng, that is, life preservation.
This includes a variety of ways to prolong life.
714
Han
SEXUALITY
AND
REPRODUCTION
Sexual Attitudes
As noted above, Chinese medicine holds that congenital
essence is responsible for reproduction. It is stored in the
kidney and serves as the origin of life. Congenital essence
can be transformed into acquired essence and vice versa.
Sexual over-indulgence is regarded as one of the major
causes of disease. Exhaustion of the reproductive essence
stored in the kidney impairs other organs and has serious
Seclusion of Women
Historically, seclusion of women was practiced and premarital sex was strictly forbidden. Marriages were
arranged by parents and often the nuptial night was the
first time the couple met. It was a great scandal if the bride
was found to not be a virgin. Even now it is still common
to have a relative or a friend to introduce a girl or a boy
since it may be considered improper to approach the opposite sex directly for purpose of marriage.
Traditionally, only men could initiate divorce and a
divorced woman carried stigma and little hope of a happy
remarriage.
Fertility
The average lifetime fertility rate of Chinese women was
reported to be 1.81 (1.98 in rural and 1.22 in urban areas)
in 2001 (National Family Planning & Reproductive
Health Survey, 2001). As the Han are a huge majority,
this may well represent the fertility of Han women.
Barren women are considered unlucky and for a long
time it was blamed on the woman if a couple failed to produce children or failed to produce a boy. It was generally
hoped that a married couple should have as many children
as possible and begin to have children as early as possible.
It was common to find a woman having eight or even ten
children. After 1949, there was a time when having more
children was encouraged by the Chinese government until
there was a population explosion. Since then there has
been a policy encouraging late marriage and fewer children. During the seventies and eighties, the policy was to
allow only one child per couple among the Han people
while minorities may have more. The policy was quite
successful in urban areas while in the countryside it was
Ideal Household
Large families comprising three or four generations are
generally considered ideal. Historical records often highlight large families, sometimes with a few hundred people
living under the same roof. But these are exceptions
rather than the rule. Statistics show that the average family
size through different times in history was 4.84 persons
(Qiao, 1990), though the clan, mostly under the same surname and therefore having the same ancestry, could be
quite strong organizationally. The 2000 census indicated
that the current average family size is 3.44 per family.
There are many joint families and extended families in the
countryside, but most of the families in the urban areas are
nuclear families.
715
716
Infancy
A newborn baby is taken care of by everybody in the family. A preferred caretaker both of the new mother and the
baby is the husbands mother. In some regions the baby is
tied with three cloth-made ropes, one just under the shoulders, the second around its waist with both hands on the
sides, and the third just above the ankles. From time to
time the grandmother would turn the baby to a different
direction and a well-cared baby would have a round head
and long limbs. Breast-feeding is generally the rule and
may continue for up to 3 or even 5 years; 9095% of
infants were reported nursed by their mothers (Simoons,
1992). Newborn babies are kept from people considered
unlucky, such as widows and those who have serious diseases. When traveling with young children, it was important to come back the same way so that their souls may not
get lost. When the child was thought to have lost its soul
the mother or grandmother would knock the door upper
lintel with a ladle to call it back. In some places children
are shaved with a pigtail behind called gui-jian-chou,
meaning devils fear to ward evils away. It is quite common to have a boy with a name of a girl to appear cheap
so he may be left alone by evil spirits. Children whom the
family considered vulnerable and had fear of losing may
even be given a name meaning, a dog, or a monk to ensure
their safety. A boy may be called ya-tou (girl) for the
same reason. To ensure safety of the child, the family
might also make clothes for it from oddments of cloth, or
a meal of rice collected from a hundred families.
Childhood
Children were taken care of by the elders, preferably the
grandmother on the fathers side, (though it is quite common, and even more preferably by the grandmother on
the mothers side in urban areas), and older siblings.
Corporal punishment is common and people believe it is
good for the child. Traditionally Han Chinese thought
children belonged to and were at disposal of their parents,
grandparents, etc., and theoretically these elders could do
Han
Adolescence
Children participate in adult activities early and learn life
skills by direct observation or by assisting adults in
chores. Anthropologists say that traditional Chinese
(Han) children did not have adolescence. Girls were
taught skills they would need after marriage. There was
virtually no sex education especially in the countryside
where young people had to pick up scraps of sexual
knowledge from older friends. Now children begin to go
to school at 6 or 7, mostly in their own neighborhoods in
urban areas and villages in the countryside. They are
encouraged to help their parents in their work, especially
during vacations.
Adulthood
Traditional Han society considered men and women adults
at marriage. The basic objective in life was to take care of
the mans parents and other elders in the family and to have
children to continue the family line. Marriage was arranged
by parents and other elders in the family with help from gobetweens. Ideal age of marriage was 16 for the bride and
18 for the bridegroom, but often a girl child was taken to
her husbands house to be raised by her parents-in-law first.
After 1950s, free choice has been encouraged though in
most cases people still use friends or relatives as gobetweens to introduce the couple to avoid embarrassment.
Menopause starts between 45 and 49.
The Aged
Age carried great respect and authority in traditional Han
society. The eldest male was generally the family head
References
717
REFERENCES
China Peoples Daily Online, April 4, 2002.
China Population Information and Research Center (COIRC), Available
online at www.cpirc.org.cn
China Yearbook of Chinese Medicine (Zhongguo Zhongyi Nianjian)
2000 (in Chinese). Beijing: China TCM.
China Yearbook of Health (Zhongguo Weisheng Nian Jian) 2000 (in
Chinese). Beijing: Peoples Medical.
Encyclopedia Sinica, Volume of Nationalities (Zhongguo Dabaike
Quanshu Minzu, 1986) (in Chinese). Encyclopedia Sinica.
Encyclopedia Sinica, Volume of Traditional Chinese Medicine
(Zhongguo Dabaike Quanshu Zhongyi 2000) (in Chinese).
Encyclopedia Sinica.
Fang, Thome. (1986). The Chinese view if life. Taipei, Taiwan: Linking.
Ge, Keyou. (1996). The dietary and nutritional status of Chinese population (1992 National Nutrition Survey). Peoples Medical.
He, Shaochu. (1998). An overview of Chinese medicine and culture
(Zhong Yi Yao Wen Hua Tong Lan) (in Chinese). World Books
Publishing Company: Beijing, Guangzhou, Shanghai & Xian.
Hsu, Francis L. K. (1948). Under the ancestorsshadow. New York, NY:
Columbia University Press.
Hsu, Hong-yen et al. (1986). Oriental Materia Medica: A concise guide
(pp. 342). Keats.
Li, Jingwei et al. (1990). Ancient Chinese Culture and Medical Science
(Zhongguo Gudai Wenhua Yu Yixue) (in Chinese). China: Hubei
Science and Technology.
Li, Xiangzhong. (1989). Elementary Traditional Chinese Medicine
(Zhongyixue Jichu) (in Chinese). Beijing, China: Peoples Health.
Liu, Xingwu. (2002). Good Health the Chinese Way. In Llewellyns
2003 Herbal Almanac (pp. 143164). Los Angeles, CA: Llewellyns.
National Family Planning & Reproductive Health Survey. (2001).
March 4, 2002.
Qiao, Jitang (1990) Chinese Life Rituals (Zhongguo Rensheng Liyi
Daquan). Tianjin Peoples Publishing.
Simoons, Frederick J. (1991). Food in China: A cultural and historical
inquiry, CRC Press, Boca Taton.
Wu, Gangzi et al. (1993). The treasure house of greater Chinese culture.
China: Hubei Peoples.
Xie, Zhu-Fan. (1995). Best of traditional Chinese medicine. Beijing,
China: New World.
Zhang, Benbo. (2002). Aging Population Requires New Action. China
Population Information and Research Center (CPIRC), Available
online at www.cpirc.org.cn
718
Hausa
Hausa
Murray Last
ALTERNATIVE NAMES
OVERVIEW
OF THE
CULTURE
719
720
Hausa
Wells have other uses, too. Deep wells are the most
common site for suicide and attempted suicide (the fire
brigade is called upon to rescue people from wells). They
are also places where the bodies of victims of violence
can be hidden. Contamination of wells and water supply
is a standard source of panic, and scare stories against a
pariah group may accuse them of this crime. Water, then,
is dangerous; only children swim for pleasureno one is
taught to swim. Bilharzia is common where children have
been tested for it. Defecation in rural areas is traditionally
done on waste ground or on fields close by the farmstead.
Only in towns are there pit latrines (salga) which are
emptied periodically by hand by specialists hired by the
residents. The night soil is taken to the edge of town
where it dries out and solidifies and is eventually sold to
farmers for use as manure. While the latrine is partly full,
ash from the cooking place is sprinkled on the surface to
reduce the smell. The hole, being infested with cockroaches, is often kept covered with a plate. A rising water
table (as in Kano city today) causes latrines to fill more
rapidly with water than was usual in the past. Where possible, the preferred direction to face when defecating is
south (one prays, in contrast, facing east). Most people
defecate very early in morning or at night; and if they are
defecating outside they often choose a high place or a
slope too steep for housing.
Houses are regularly swept clean by the women of
the house, though not in the middle of the day when spirits might be playing (you normally say excuse me as
you sweep, in case a spirit is about to be disturbed). Inside
a house the ground is kept very tidy; but outside the house,
rubbish tends to accumulate as the public authorities have
generally ceased to clean the streets even in relatively
wealthy parts of town. There is a good side to this: as spirits like rubbish to play in, heaps in the street keep them
occupied there rather than coming over the wall and inside
houses. Spirits are coming into towns, cities, and even villages in ever larger numbers from the bush because their
homes are disturbed by people and especially by motor
traffic; hence modernity brings mental illness.
MEDICAL PRACTITIONERS
Healers
There is a range of terms for healers. The most traditional
are maye (witch, implying he deals with spirits) and
Medical Practitioners
721
722
Hausa
Hospitals
Government hospitals, whether run by university medical
schools or by state ministries of health, exist in the major
cities, but in recent years their services have been marred
by lack of drugs and by basic equipment being out of operation. Electricity has also been intermittent. Shortages of
running water have made hygiene difficult for in-patients,
whose relations are expected to bring in food and drinking
water and do the washing of bed linen and patients clothes.
Private clinics have provided good services for the rich.
Mentally ill patients are treated in special units (Last,
1991c). In rural areas medical services vary enormously,
from a well-staffed and managed hospital to dispensaries
or cottage hospitals where the few staff can offer little or
nothing beyond advice; private clinics now compete for
patients too. Drugs may be out-of-date, dumped by firstworld suppliers; or they may even be fake, sold by
unscrupulous local manufacturers in plausible packaging. Where blood transfusions are possible, blood may be
supplied by a relative; if not, a person waiting by the hospital may be hired to supply blood. This is screened, and if
all right, added to the blood bank; if not, it is disposed of.
Ambulance services are almost non-existent, in
towns or in rural areas, so in an emergency adult patients
are carried to the roadside and put in a bus. But cases of
obstructed labor, for example, pose a real problem, as they
cannot be carried using a bed as a stretcher; that is taken
723
724
Hausa
SEXUALITY
AND
REPRODUCTION
725
Infancy
The baby is solely breast-fed until about 6 or 7 months old.
Weaning occurs after 2 years and some months, usually by
being sent away on a Friday to the mothers mother; sometimes a bitter substance has earlier been smeared on the
nipple to discourage the infant from suckling. A baby may
react badly to weaning. If an infant is weakening before it
is weaned, it may be a sign that the mothers husband has
started touching her, or even that she is pregnant with
another baby. Such a woman feels shame. Her infant, in its
distress, typically has flies hovering over its face. More
routine are the diarrheas associated with teething. A
mother watches the fontanel for signs of stress. Another
hazard is the fire within the mothers room; babies have
occasionally been known to fall into the fire as they sleep
with their mother. The baby by day is carried on her
mothers back (or by an elder sister), and is therefore very
early taught not to urinate or defecate except when told (the
baby is held between the mothers ankles, and a ssss
sound is made). The twinning rate in Hausaland is much
lower than among the Yoruba to the south; twins may be
unusually bad-tempered.
Childhood
Children work as well as attend school. Punishment is
given to those who fail to do their work properly; a child
absconding from school may find himself kept in shackles
(mari). But willingness to punish varies between Hausa
communities: Muslims are readier to punish the young
than are non-Muslim Hausa (Last, 2000b). Child sexual
abuse does occur, if rarely: there are stereotypical stories
about sadistic or sexually active teachers who abuse their
pupils. So, too, young girls may be sexually abused in
cities by adult men on weekends (and need urgent hospital
repairs the next day). But sometimes children use their
time on the street to experiment sexually with each other.
726
Adolescence
While menarche may mark the start of adolescence,
courtship may precede menarche, with the girl receiving
presents from older suitors. The period of courtship in
villages may start with girls having decorations (depicting, e.g., drums or even a boxer) incised on the neck and
upper chest; pot black darkens the drawings. Ideally in
the middle-class urban context, the would-be husband
should be 10 or more years older than his bride. In rural
areas, the age difference is less pronounced, and adolescents go courting in marketplaces and in the evenings
once the harvest is brought in (October to January).
Courting involves petting but not coition. The process
from betrothal to wedding takes some 3 months, and is a
Hausa
dry-season activity involving elders as well as the couples friends and kinswomen. Male adolescents may go to
a village brothel if they have the funds after the harvest,
but today, with AIDS and the reintroduction of Islamic
law, many brothels have been closed down and the
women dispersed.
Young men have to work hard to accumulate cash to
buy presents for their girlfriend. Many go on dry-season
migration (ci rani), to farms in the south of Nigeria and
even Ghana, or to cities where laboring jobs are to be
found. They gain experience by seeing the world and
experimenting with different foods, drinks, and social
habits; by being away, they also save their parents the
costs of feeding them from the familys granary (cf. Last,
1993a). Adolescent girls stay at home, possibly going to
school or trading on their mothers behalf. Stricter households, particularly in the towns, may insist on the girl
being in purdah by day, and only allowed out with an
escort after dark. Ideally, she will be betrothed or married
soon after menarche, thus transferring responsibility for
her well-being (and her further education) from her
parents to her new husband.
Adulthood
An adolescent male becomes an adult when he takes a
wife; he is responsible for another person. A woman
becomes an adult, not when she marries, but when she
has her first child, when she too is responsible for another
person. The couple are housed by the husbands parents,
with the bride having a room of her own, filled with her
bridal goods, and she has her own waterpot as well as
food bowls there; she cooks at her own fire in front of her
room (unless there is a single family kitchen). She is
likely to get pregnant within 2 years; if not, there may be
pressure on her to leave her husband, or on him to seek a
second wife (if he can afford one). If she does get pregnant and bears a child, it is not unusual for the first child
to die young. Although there is pressure on her to avoid
her baby (and not over-coddle it), in practice mothers are
very solicitous of their firstborn. If all goes well, she will
be pregnant again some 2 years after the first child is
born. And the process will continue for some six to ten
births. Women do seek means of restricting the number of
conceptions, but there are no formal means of contraception. Were she to divorce her husband, she would conventionally have to leave behind all her weaned children;
alternatively, she could declare herself menopausal, and
727
The Aged
A man starts becoming an elder (dattijo) around 40 years
old, but can cease to be regarded as an elder once he
becomes senile. An elderly woman too, after menopause,
acquires a special status, staying on with her grown-up
sons who have taken over the house and its land after the
death of her husband. Such old women are no longer subject to purdah, but they may have little reason to go out
except to the life cycle rituals of their childrens families
and other kin. Elders seldom leave the house and its environs, spending long hours in their dark room with enough
of a fire to keep them warm and may be fed by their sons
wives. Often toothless, they need to grind such luxuries
as kolanuts or groundnuts on a small tin grinder; other
foods require no chewing. Now they may have a radio
with its songs to listen to.
728
REFERENCES
Besmer, F. E. (1983). Horses, musicians & gods: The Hausa cult of possession-trance. South Hadley, MA: Bergin & Garvey.
Crampton, E. P. T. (1979). Christianity in Northern Nigeria (3rd ed.).
London: Geoffrey Chapman.
Erlman, V., & Magagi, H. (1989). Girka: Une crmonie
dinitiation au culte de possession boorii des Hausa de la rgion
de Maradi. Berlin: Dietrich Reimer Verlag.
Etkin, N. L. (1979). Indigenous medicine among the Hausa of Northern
Nigeria: Laboratory evaluation for potential therapeutic efficacy of
antimalarial plant medicinals. Medical Anthropology, 3.4,
401429.
Etkin, N. L. (1981). A Hausa herbal pharmacopoeia: Biomedical evaluation of commonly used plant medicines. Journal of
Ethnopharmacology, 4, 7598.
Etkin, N. L. (1996). Ethnopharmacologic perspectives on diet and medicine in northern Nigeria. In E. Schroder, G. Balansard,
P. Cabalion, J. Fleurentin, & G. Mazars, (Eds.), Mdicaments
Hausa
et aliments: Approche ethnopharmacologique (pp. 862). Metz:
Socit Franaise d Ethnopharmacologie.
Etkin, N. L., & Ross, P. (1991). Recasting malaria, medicine and meals:
A perspective on disease adaptation. In L. Romanucci-Ross, D. E.
Moerman, & L. R. Tancredi (Eds.), The anthropology of medicine:
From culture to method (2nd ed., pp. 130258). New York: Bergin
& Garvey.
Hill, P. (1972). Rural Hausa: A village and its setting. Cambridge:
Cambridge University Press.
Kleiner-Bosaller, A. (1993). Kwantacce, the sleeping pregnancy: A
Hausa concept. In Gudrun Ludwar-Ene, & Mechthild Reh (Eds.),
Gros-plan sur les femmes en Africa; Afrikanische Frauen im Blick;
Focus on women in Africa (pp. 1730). Bayreuth African Studies
Series 26. Bayreuth: Bayreuth University.
Koki, A. M. (1977). Alhaji Mahmudu Koki: Kano malam. (Neil Skinner,
Trans. Ed.). Zaria: Ahmadu Bello University Press.
Last, M. (1967). The Sokoto caliphate. London: Longmans Green.
Last, M. (1976). Presentation of sickness in a community of nonMuslim Hausa. In J. B. Loudon (Ed.), Social anthropology and
medicine (pp. 104149). ASA monographs 13. London: Academic
Press.
Last, M. (1979). Strategies against time. Sociology of Health and
Sickness, 1.3, 306317.
Last, M. (1981). The importance of knowing about not knowing. Social
Science and Medicine, 15B, 387392.
Last, M. (1988). Charisma and medicine in northern Nigeria. In
D. B. Cruise OBrien & C. Coulon (Eds.), Charisma and brotherhood in African Islam (pp. 176224). Oxford: Clarendon Press.
Last, M. (1991a). Spirit possession as therapy: Bori among nonMuslims in Nigeria. In I. M. Lewis (Ed.), Womens medicine: The
zar-bori cult in Africa & beyond (pp. 4963). Edinburgh:
Edinburgh University Press.
Last, M. (Ed.) (1991b). Adolescents in a Muslim city: The cultural context of danger and risk. In Youth & Health in Kano Today.
Kano Studies (special issue, pp. 317). Kano: Bayero University.
Last, M. (1991c). The presentation of mental illness at the Gorondutse
Psychiatric Hospital, Kano (pp. 3354) (with G. Ilyasu). In M. Last
(Ed.), Youth & Health in Kano Today. Kano Studies (special issue).
Kano: Bayero University.
Last, M. (1992). The importance of extremes: The social implications
of intra-household variation in child mortality. Social Science and
Medicine, 35.6, 799810.
Last, M. (1993a). The power of youth, youth of power: Notes on the
religions of the young in northern Nigeria. In H. dAlmeida-Topor,
C. Coquery-Vidrovitch, O. Goerg, & F. Guitart (Eds.), Les Jeunes
en Afrique (pp. 375399). Paris: LHarmattan.
Last, M. (1993b). History as religion: Deconstructing the Magians
(Maguzawa) of Nigerian Hausaland. In J-P. Chrtien (Ed.),
Linvention religieuse en Afrique: histoire et religion en Afrique
noire (pp. 267296). Paris: Karthala.
Last, M. (1999). Rubbish: Public health in northern Nigeria. In JeanPierre Olivier de Sardan (Ed.), Second rapport intermdiaire
(1999) (pp. 3743). Marseilles: CNRS/EHESS.
Last, M. (2000a). Social exclusion in northern Nigeria. In Jane Hubert
(Ed.), Madness, disability and social exclusion: The archaeology
and anthropology of difference (pp. 217239). London:
Routledge.
729
Paden, J. N. (1975). Religion and political culture in Kano. Berkeley:
University of California Press.
Ross, P. J., Etkin, N. L., & Muazzamu, I. (1991). The greater risk of
fewer deaths: An ethnodemographic approach to child mortality in
Hausaland. Africa, 61.iv, 502512.
Ross, P. J., Etkin, N. L., & Muazzamu, I. (1996). A changing Hausa
diet. Medical Anthropology, 17, 143163.
Schmaling, C. (2000). Maganar hannu: Language of the hands. A
descriptive analysis of Hausa sign language. Hamburg: Signum
Verlag.
Schram, R. (1971). A History of the Nigerian Health Services. Ibadan:
Ibadan University Press.
Wall, L. (1988). Hausa medicine: Illness and well-being in a West
African culture. Durham NC: Duke University Press.
ALTERNATIVE NAMES
Miao or Meo (considered derogatory by Hmong).
LOCATION
OVERVIEW
AND
LINGUISTIC AFFILIATION
Hmong are a distinct ethno-linguistic group who originated in China and who migrated into northern Southeast
Asia during the 19th century. After the end of the Secret
War in Laos in 1975, many Hmong fled to Thailand and
then were resettled around the world, including the United
States. Most Hmong in the United States speak two closely
related dialects of the MiaoYao language: White Hmong
(Hmoob Dawb or Moob Dlawb) and Green Hmong or Blue
Hmong (Hmoob Ntsuab or Moob Lees). These two groups
were traditionally distinguished by their dialect, dress,
housing style, and other cultural differences.
The Hmong diaspora is extensive, with over seven
million in China, one million in Southeast Asia (Schein,
2000), and almost 16,000 in France, Canada, French
Guyana, Australia, and Argentina (Rice, 2000). According
to the 2002 Census, 169,428 Hmong live in the United
States, with most in California, Minnesota, and Wisconsin
(Pfeifer, 2002). However, Hmong community leaders feel
OF THE
CULTURE
History
Hmong myths suggest Hmong lived in northern China
and migrated into southern China. Early Chinese historical records indicate that Hmong were lowland irrigated
rice farmers. Resisting the political control and population pressures of the Han Chinese, many ended up in the
mountainous areas of central and southern China. Some
Hmong migrated into the highlands of northern Southeast
Asia in the mid-1800s. In the first half of the 20th century,
French administrators in Laos granted opium-growing
concessions to some but not all of the Hmong in Xieng
Khouang province. This was one basis for the split
between Hmong who allied themselves with the French
and the Americans after 1954 and those who allied themselves with the Pathet Lao and northern Vietnamese.
From the 1960s through 1975, many Hmong were
recruited by the United States Central Intelligence Agency
730
Economy
The 20th century economy of Hmong in Laos was based
on subsistence swidden (slash and burn) cultivation of
upland dry rice, vegetables, and maize, with opium as a
medicine and as a cash crop in some areas. They also raised
pigs and chickens for food and horses for transport. Large
multi-generational patrilineal extended families cooperated economically in subsistence production. Other than
the activities of the CIA and the United States Agency for
International Development (USAID), there was no wage
labor and no Hmong village-based commerce. Very few
Hmong received any formal education or became fluent or
literate in Lao, French, or English (Yang D., 1991). Thus
few Hmong refugees had skills or basic knowledge that
was appropriate for employment in modern Western industrial, market, and service economies and only a small proportion of middle-aged and older adults have been
employed in wage work outside the house. In the 1980s to
1990s, some Hmong were self-employed farmers or gardeners, especially in California, but many have depended
on welfare programs for income and for health services.
Many adults work in menial jobs, such as janitorial and
factory work, often working two jobs or interchanging day
and night shifts so parents can care for their children.
However, many of the younger generation have become
educated and have entered the mainstream U.S. economy
(Lo, 2001; Mills & Yang, 1997; Yang & Murphy, 1994).
Religion
Traditional Hmong religion is animistic, with beliefs in
spirits (dab), ancestor worship (dab niam txiv pog yawg),
multiple souls (ntsuj plig), reincarnation, incantations for
blessing, curing, or cursing, and selection of spiritually
appropriate locations for houses and graves. The most
powerful spirits, including the Master of the Universe, are
believed to live in the sky; lesser spirits dwell on earth, or
underground (Lemoine, 1986; Morechand, 1968). In Laos,
Hmong learned about Buddhism from lowland ethnic
731
732
MEDICAL PRACTITIONERS
The Hmong have several traditional healers who continue
to influence the communitys health beliefs, values, and
practices in Southeast Asia and the United States (Cha,
2000; Culhane-Pera & Xiong, 2003; Kirton, 1985;
Lemoine, 1986; Spring, 1989; Thao X., 1986).
Shamans
Shamans (tus ua neeb) are generally men, but women
shamans are also known. There are two main types
of shamans: muag dub (covered face) and muag dawb
(uncovered face). The muag dub shamans are chosen by
the shamans helper spirits (dab neeb), go into trance
while wearing a black or red cloth over their face, and
enter the spirit world in order to battle the offending spirits, aided by their helping spirits. In contrast, the muag
dawb shamans are not chosen by spirits, and do not heal
while in a trance, so do not cover their faces with cloths
(Chindarsi, 1976; Cooper et al., 1996; Lemoine, 1986).
Tus ua neeb perform a wide range of ceremonies for
people in need of spiritual healing, as determined by
themselves, other healers, or family members. They perform preventive rituals such as soul calling (hu plig) at
New Year celebration and tying strings on wrists (khi tes);
diagnostic rituals and therapeutic ceremonies (Bliatout,
1986; Cha, 2000; Cooper, 1996). To ward off spirits in
Herbalists
The kws tshuaj are herbalists who diagnose illness and
dispense herbal medicines. They are usually women who
acquire their knowledge apprenticed to an older female
relative. The kws tshuaj are guided in diagnosing disease
and prescribing medicines by their helping spirits (dab
tshuaj) whose altar is beside the household altar to a main
house spirit (dab xwm kab). Sick people or their family
members bring spirit paper money and incense for the
dab tshuaj. Herbalists burn the offerings to inform the
spirits that people have come for assistance and to ask for
their spiritual guidance when gathering the appropriate
healing herbs (Cha, 2000; Cooper et al., 1996; Rice,
2000; Thao X., 1986).
In the United States, herbalists dispense dried herbs
(tshuaj qhuav) they receive from Southeast Asia or China,
fresh herbs (tshuaj ntsuab) they cultivate from Asian plants,
and medicines they collect in the wild or obtain from botanical gardens. Herbalists also distinguish between wild
herbs (tshuaj qus), which are forest plants and tame herbs
(tshuaj nyeg) which are domestic plants. Additionally, the
kws tshuaj may know other diagnostic or healing techniques, such as hu plig, zaws hno, kav, nqus, hno koob that
are described below. Some kws tshuaj specialize in specific
areas, such as fertility or childbirth (Cha, 2000; Cooper
et al., 1996; Rice, 2000; Spring, 1989; Thao X., 1986).
Magical Healers
The kws khawv koob are magical healers. They are usually men who learn their skills and obtain their connections with spirits (dab khawv koob) as an apprentice to an
experienced healer. There are various types of khawv
koob, each with specific rituals that use metal, water,
Other Healers
The tus hu plig are ordinary men and women (not necessarily healing specialists such as shamans) who have
gained the knowledge and skills to return peoples wayward souls. They can return souls that have left peoples
bodies when the person was frightened or when the souls
ware abducted by spirits and they can secure souls to bodies during preventive ceremonies, such as during New
Years celebrations or prior to a long journey. They help
people with soul loss as identified by themselves, other
traditional healers, or by a household diagnostician. They
have varying power and abilities. Some perform basic
ceremonies where they chant, entice the soul with eggs
and chickens, tie strings to wrists that secure the soul (khi
tes), and interpret the souls return. Others perform additional, more elaborate ceremonies (Cha, 2000; Chindarsi,
1976; Cooper et al., 1996).
Ordinary people have healing knowledge that is not
recognized as specialist knowledge. Many women know
about herbal medicines, without being an herbalist. Some
people know how to divine the presence of spiritual problems (tsawv qe and nchuav qe). Some people know how to
massage the abdomen and extremities, and then to gently
pierce the skin with a needle to release illness, built-up
wind, or bad blood (zaws hno). Others apply ointment on
the skin, then rub with a silver coin (coining or dermabrasion kav), or apply suction to the skin with a cup (cupping
or moxibustion nqus) to bring the illness to the skins surface in order to release toxins, wind, and stress. Some people massage specific neural pressure points to stimulate
blood flow and relieve muscle strain (xais ceeb) and others
pierce the skin with needles, akin to acupuncture (hno
koob) (Cha, 2000).
733
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Traditional Hmong classification of illness can be divided
into four classes: natural, supernatural, personal, and
social (Culhane-Pera & Xiong, 2003; Helman, 2000;
Thao, X., 1986).
734
life settled. The soul who guards the grave may make
family members ill if the grave is disturbed or if nondisintegrating elements are in the body, coffin, or grave.
Shamans helper spirits (dab neeg). People
become sick when shamans helper spirits (dab neeg)
chose them to become a shaman, and they recover when
they accept the responsibility of becoming a shaman.
Shamans must maintain good relationships with their
helping spirits; if they do not thank their helping spirits
or offend the spirits by performing rituals not consistent
with spirits wishes, they may get sick.
Tame and wild spirits (raug dab). Even though they
usually protect people, many types of tame or domestic
spirits (dab nyeg) and wild spirits (dab qus) cause illness.
Tame spirits include the ancestral spirits and the seven
household spirits that reside in houses. Families honor and
feed them with spirit money and food during special ceremonies. In turn, the spirits protect families from evil spirits
or warn them of impending doom. However, if families
neglect their responsibilities, or if spirits need something
from families, then spirits communicate their need by
making someone sick.
Wild spirits live outside the house. They can cause illness, seizures, or death by disturbing or stealing peoples
souls. People may inadvertently disturb the land or water
where spirits reside, thus inviting wrath. Evil spirits may
purposefully seek out people to cause death and destruction. Some spirits sit atop sleeping people and squeeze the
breath out of them. Also, souls of dead who were not properly buried and cannot find their ancestors in the afterworld
may cause illness, as a plea for assistance. Souls or ghosts
that have not achieved reincarnation because of the suicide
or violent death of their previous owners, may entice other
people to die in similar ways. In the United States, interactions with wild spirits seem to occur less frequently than
in Laos. People speculate that spirits are scared away by
electricity. Still, spirits in lakes cause drownings, roaming
ghosts cause car accidents, and evil spirits cause suffocation (diagnosed as Sudden Unexpected Nocturnal Death
Syndrome).
Sorcery (raug pob zeb, nyuj ciab). People who are
motivated by hate or revenge to harm others can hire
black magic specialists to send stones, bones, or other
objects to lodge in others. Sorcery was rare in Laos, and
seems to be even less common in the United States.
735
736
SEXUALITY
AND
REPRODUCTION
Sexual Identity
In traditional Hmong society, gender was interwoven with
the division of labor and considerations of social worth.
Both men and women worked in the fields and at home.
Women were responsible for child rearing, cooking,
weaving, embroidering, and animal husbandry. Men were
responsible for clearing land, creating tools, building
houses, making decisions, maintaining and overseeing
clan rituals, and supervising family matters. Men also took
an important part in child rearing. Generally, men had
higher social status and more power than women although
women gained power as they grew older and had larger
households to manage (Cooper, 1984; Donnelly, 1994;
Tapp, 1986; Thao C. T., 1986). Also, there was cultural
variation, such that some wives had more power than their
husbands, related to their recognized intelligence, ability
to manage money, treat illnesses, or make decisions.
Generally, at marriage, women left their natal family and
lived with their husbands family. Marriage had both
brideprice and bridewealth components. The grooms
family gave money (nqi mis nqi hno) to the brides family,
compensating for the familys economic loss and emotional hardship, and illustrating their promise to love and
take good care of the bride. The brides family sent a
dowry with the bride, consisting of clothes and silver, for
her contribution to her new household. Women were generally considered to be worth less than men (tsis muaj
nqis), as they were raised always knowing that they would
one day leave the family. Changing gender relations and
womens increasing power in the household is causing
social conflict (Her & Heu, 2003; Lyfoung, 2003).
Women were at a disadvantage with regard to
courtship and marriage. Traditionally, girls were expected
not to initiate courtship, and they were enjoined not to
openly express their preference for a husband. This is
changing in the United States, as some women and teenage
girls initiate courtship and express their desires about
737
Sexual Pleasure
Reproduction
In traditional society, the purpose of sex was for reproduction, and reproduction is for both economic reasons
and for continuation of the patrilineal links with ancestral
spirits. Hmong traditionally prefer large numbers of
children for economic and social reasons (Kunstadter,
2002). Additional hands in agricultural fields result in
enhanced family income and needed assistance in times
of trouble and old age. In Thailand, the total fertility rate
was 8 in 1987, which may have been similar to the
number in Laos. Fertility rates remained high in California
in the 1990s (Kunstadter et al., 1993).
Contraception
Traditionally, most couples did not use deliberate methods
of contraception but accepted children as fate (hmoov)
determined. It was believed that if a woman did not deliver
the pre-determined number of babies, she would be reborn
as a woman to deliver these infants. Birth spacing was
increased by near universal and prolonged breast-feeding.
If contraception was used, women secretly obtained
herbal medicines that could cause sterility from herbalists.
Herbalists were familiar with abortifacients, although the
extent of their use in Southeast Aia and the United States
is not known. It seems that abortifacients were used sparingly, given the danger of hemorrhage and death; women
and their husbands had to agree about taking the medicine.
In the United States, some people are choosing to
limit the number of children although many people are
concerned about side-effects of Western methods of contraception, from changing normal hormonal cycles to
increased weight to cancer. Most people prefer caiv, which
has multiple meanings: natural family planning, or withdrawal, or abstinence. Decision-making about contraception varies, influenced by peoples acculturation and
education levels; most men decide alone, many men and
women decide together, and some single or married
women make the decision alone (Kunstadter, 2003; Spring,
2001; Spring & Luchongvu, 2003). Over the past 25 years
in the United States, surgical abortions have increased, as
people have found the procedure more acceptable over
738
Infancy
Traditionally, at three days of life family members welcomed a newborn infant by calling the soul (hu plig) and
bestowing a name (tis npe) (Symonds, 2003). Today, animists continue these practices while Christian families
have altered or abandoned this ceremony, depending
upon their denomination. Traditionally, breast-feeding
mothers cared for their infants, with their families assistance. In the United States, the vast majority of infants
bottle-feed so family members can care for babies while
mothers return to school or work (Culhane-Pera, Naftali,
Jacobsen, & Xiong, 2002; Tuttle & Dewey, 1994, 1996).
Childhood
A general philosophical orientation toward childrearing
is characterized by hlub, a loving permissive attitude
739
Adolescence
Traditionally, teenagers had much work responsibility
and little freedom beyond the household and extended
family (Xiong Z. B., 2000). While there were no traditional
rites of passage, teenagers were encouraged to marry
when they had accomplished agricultural and domestic
life skills. The expectation to assume adult responsibilities was high, and discipline tended to be strict. While
premarital intercourse was tolerated, sexually active
teenagers were expected to marry. Conflicts in the United
States are resulting from tensions between parental
demands for conforming to traditional values and youths
desires for increased freedom. Parents feel their traditional values are being disrespected, and teenagers feel
parents are not realistic in U.S. society (Wheeler, 1998).
Parental concerns are compounded by the high rates of
740
Adulthood
In Laos and the United States, middle-aged adults have the
most responsibility for children, aging parents, and society
at large. Men are active in leading society, and increasingly
gain respect as they become elders. Women also have
increased status, with increased influence over family matters, and may have some community influence especially
if their husbands are clan leaders (Donnelly, 1994).
In Southeast Asia, adults suffered from infectious
diseases, accidents, and other ailments. In the United
States, the modern diseases of diabetes, hypertension,
strokes, heart attacks, and cancers are on the rise. Many
suffer from these ailments, and are challenged to respond
to these chronic and life-threatening conditions.
The Aged
Traditionally, elderspeople older than 50 years of age
were respected for their opinions and life experiences, and
enjoyed a reduced work load. Usually youngest sons and
their wives were responsible for the aged, including providing care as they became infirm. This continues in the
United States, although elders opinions and life experiences may be less relevant to their children and grandchildren than in Southeast Asia, and more elders live alone
or in nursing homes. Their health issues include the modern diseases, as well as degenerative diseases (arthritis,
osteoporosis, blindness, and deafness).
REFERENCES
Arax, M. (1994). Cancer case ignites culture clash: Hmong parents
refuse to agree to court-ordered chemotherapy for teen-age daughter. Los Angeles Times Nov. 21, v113, pA3, Col 1.
Arax, M. (1995). Hmongs sacrifice of puppy reopens cultural wounds:
Immigrant shamans act stirs outrage in Fresno, but he believes it was
only way to cure his ill wife. Los Angeles Times Dec. 16, v114, pA1.
Baker, P. T., Hanna, J. M., & Baker, T. S. (1986). The changing
Samoans: Behavior and health in transition. New York, Oxford:
Oxford University Press.
Barney, G. L. (1957). Christianity and innovation in Meo culture: A case
study in missionization. Unpublished MA thesis, University of MN.
Bliatout, B. T. (1986). Guidelines for mental health professionals to
help Hmong clients seek traditional healing treatment. In Glenn L.
Hendricks, et al. (Eds.), The Hmong in transition. New York:
Center for Migration Studies.
Bliatout, B. T. (1993). Hmong death customs: Traditional and acculturated. In D. P. Irish, K. F., Lundquist, & V. Jenkins-Nelson (Eds.),
Ethnic variations in dying, death and grief: Diversity in universality. Washington, DC: Taylor & Francis.
Bouvier, B. (1994). Hmong need more respect. (Letter). Bangkok Post,
August 19.
Bruce, H., & Xiong, C. (2003). Pregnancy complications. In
K. A. Culhane-Pera, D. E. Vawter, P. Xiong, B. Babbitt, &
M. Solberg (Eds.), Healing by heart. Nashville, TN: Vanderbilt
University Press.
Brunnquell, D., & Kuracheck, S. (2003). Children with high fevers. In
K. A. Culhane-Pera, D. E. Vawter, P. Xiong, B. Babbitt, &
M. Solberg (Eds.), Healing by heart. Nashville, TN: Vanderbilt
University Press.
Capps, L. L. (1994). Change and continuity in the medical culture of the
Hmong in Kansas City. Medical Anthropology Quarterly (new
series), 8(2), 161177.
References
Cha, Dia. (2000). Hmong American concepts of health, healing, and
illness and their experience with conventional medicine (Doctoral
Ph.D. dissertation). University of Colorado at Boulder: Boulder, CO.
Cha, Dia, & Chagnon, J. (1993). Farmer, war-wife, refugee, repatriate:
A needs assessment of women repatriating to Laos. Washington,
DC: Asia Resource Center.
Cha, Dia, & Small, C. A. (1994). Policy lessons from Lao and Hmong
women in Thai refugee camps. World Development, 22, 10451059.
Chindarsi, N. (1976). The religion of the Hmong Njua. Bangkok,
Thailand: The Siam Society.
Choy, J., Foote, D., Bojanowski, J., Yamashita R., & Vichinsky, E. (2000).
Outreach strategies for Southeast Asian communities: Experience,
practice, and suggestions for approaching Southeast Asian immigrant
and refugee communities to provide thalassemia education and trait
testing. Journal of Pediatric Hematology Oncology, 22(6), 588592.
Cooper, R. (1984). Resource scarcity and the Hmong response: Patterns
of settlement and economy in transition. National University of
Singapore: Singapore University Press.
Cooper, R., Tapp, N., Lee, G. Y., & Schworer-Kohl, G. (1996). The
Hmong. Bangkok, Thailand: Artasia Press.
Culhane-Pera, K. A. (1989). Analysis of cultural beliefs and power
dynamics in disagreements about health care of Hmong children.
Masters thesis. Mpls, MN: University of MN.
Culhane-Pera, K. A. (2003). Hospice patient with gallbladder cancer. In
K. A. Culhane-Pera, D. E. Vawter, P. Xiong, B. Babbitt, &
M. Solberg (Eds.), Healing by heart. Nashville, TN: Vanderbilt
University Press.
Culhane-Pera, K. A., Nafali, E. D., Jacobson, C., & Xiong, Z. B. (2002).
Cultural feeding practices and child-raising philosophy contribute
to iron deficiency anemia in refugee Hmong children. Ethnicity
and Disease, 12(2).
Culhane-Pera, K. A., & Thao, V. (2003). Children with high fevers. In
K. A. Culhane-Pera, D. E. Vawter, P. Xiong, B. Babbitt, &
M. Solberg (Eds.), Healing by heart, Nashville, TN: Vanderbilt
University Press.
Culhane-Pera, K. A., Vawter, D. E., Xiong, P., Babbitt B., & Solberg, M.
(Eds.), Healing by heart. Nashville, TN: Vanderbilt University
Press.
Culhane-Pera, K. A., & Xiong, Phua. (2003). Hmong culture: Tradition
and change. In K. A. Culhane-Pera, D. E. Vawter, P. Xiong,
B. Babbitt, & M. Solberg (Eds.), Healing by heart. Nashville, TN:
Vanderbilt University Press.
Donnelly, N. D. (1994). The changing lives of refugee Hmong women.
Seattle: University of Washington Press.
Fadiman, A. (1998). The spirit catches you and you fall down: A Hmong
child, her American doctors and the collision of two cultures.
New York: Farrar, Straus and Giroux.
Franks, A. L., Berg, C. J., Kane, M. A., Browne, B. B., Sikes, R. K.,
Elsea, W. R., & Burton, A. H. (1989). Hepatitis B virus infection
among children born in the United States to Southeast Asian
refugees. New England Journal of Medicine, 321(19), 13011305.
Gjerdingen, D. K., & Lor, V. (1997). Hepatitis B status of Hmong
patients. Journal of the American Board of Family Practice, 10(5),
322328.
Gjerdingen, D. K., Ireland, M., & Chaloner, K. M. (1996). Growth of
Hmong children. Archives of Pediatrics & Adolescent Medicine,
150(12), 12951298.
741
Haga, Chuck, & Her, Lucy, Y. (2001). At 18, she steps up to preserve a
family of 13. The Star Tribune, December 9, 2001.
Helman, C. G. (2000). Culture, health and illness: An introduction for
health professionals (4th ed.). Woburn, MA: Butterworth-Heinemann.
Henry, R. R. (1999). Measles, Hmong and metaphor: Culture change
and illness management under conditions of immigration. Medical
Anthropology Quarterly (new series), 13(1), 3250.
Her, Mymee, & Heu, C. P. (2002). Domestic violence. In K. A. CulhanePera, D. E. Vawter, P. Xiong, B. Babbitt, & M. Solberg (Eds.),
Healing by heart. In press.
Hmong National Development, Inc. (2001, Fall). HND Links:
A Quarterly Newsletter. Washington, DC.
Hmoob Thaj Yeeb. (1998). Taking a Public Stand: Completing the
journey from war to peace through the ending of violence.
Initiative for violence-free families and communities. St. Paul,
MN: Hmoob Thaj Yeeb.
Hones, D. F., & Cha, C. S. (1999). Educating New Americans:
Immigrant lives and learning. Mahwah, NJ: Lawrence Erlbaum
Associates.
Kirton, E. S. (1985). The locked medicine cabinet: Hmong health care in
America. Doctoral dissertation, University of Santa Barbara, CA.
Kunstadter, P. (2000). Hmong marriage patterns in relation to social
change. In G. Y. Lee, J. Michaud, C. Culas, & N. Tapp (Eds.), The
Hmong in Southeast Asia: Current issues. Chiang Mai: Silkworm.
Kunstadter, P. (2003). Controlling fertility. In K. A. Culhane-Pera,
D. E. Vawter, P. Xiong, B. Babbitt, & M. Solberg (Eds.), Healing
by heart. Paper presented at Am. Public Health Assoc. meeting,
Philadelphia, PA.
Kunstadter, P., & Kunstadter, S. L. (1990). Health transitions in
Thailand. In J. C. Caldwell, S. Findley, P. Caldwell, G. Santow,
W. Cosford, J. Braid, & D. Broers-Freeman (Eds.). What we know
about health transition (Vol. 1). Canberra: Health Transition
Centre, The Australian National University.
Kunstadter, P., Kunstadter, S. L., Podhisita, C., & Leepreecha, P. (1993).
Demographic variables in fetal and child mortality: Hmong in
Thailand. Social Science and Medicine, 36(9), 11091120.
Kunstadter, P., & Vang, VaKue. (2002). Mortality transition among
Hmong refugees in Fresno County, California, 19802001.
Unpublished manuscript.
Leepreecha, P. (2001). Kinship and identity among Hmong in Thailand.
Unpublished Doctoral dissertation. Seattle, WA: University of
Washington.
Lemoine, Jacques. (1986). Shamanism in the context of Hmong resettlement. In Glenn L. Hendricks et al. (Eds.), The Hmong In
transition. New York: Center for Migration Studies.
Lo, F. T. (2001). The promised land: Socioeconomic reality of the
Hmong people in urban America 19762000. Lima, Ohio:
Wyndham Hall Press
Long, Lynellyn D. (1993). Ban Vinai: The refugee camp. New York:
Columbia University Press.
Lyfoung, P. (2003). Domestic violence. In K. A. Culhane-Pera,
D. E. Vawter, P. Xiong, B. Babbitt, & M. Solberg (Eds.), Healing
by heart. Nashville, TN: Vanderbilt University Press.
Markides, K. S., & Coreil, J. (1986). The health of Hispanics in the
Southwestern United States: An epidemiological paradox. Public
Health Reports, 101, 253265.
742
Mills, P. K., & Yang, R. (1997). Cancer incidence in the Hmong of
Central California, United States, 198794. Cancer Causes
Control, 8(5), 70512.
Morbidity and Mortality Weekly Report. (1993). Lead poisoning associated with use of traditional ethnic remediesCalifornia
199192. 42(27), 521.
Morechand, G. (1968). Le Chamanisme des Hmong. Bulletin de
lEcole Francaise dExtreme Orient LXIV.
Mouacheuapo, S. (1999). Attitudes of Hmong patients to surgery. Paper
presented at Minnesota Academy of Family Physicians Annual
Spring Research Forum. Minneapolis, MN.
New York Times. (1994). Girl flees after clash of cultures on illness:
Should Hmong refugees have to accept Western medicine?
November 12, 1994, p. 6.
Ovesen, J. (1995). A minority enters the nation state: A case study of a
Hmong community in Vietiane Province, Laos. Sweden: Uppsala
University.
Pfeifer, M. E. (2002). U.S. census 2000: Trends in Hmong population
distribution across the regions of the United States. St. Paul, MN:
Hmong Cultural Center.
Plotnikoff, G. (2002). Child with Down syndrome and a heart defect.
In K. A. Culhane-Pera, D. E. Vawter, P. Xiong, B. Babbitt, &
M. Solberg (Eds.), Healing by heart. In press.
Poss, J. E. (1989). Hepatitis B virus infection in Southeast Asian children. Journal of Pediatric Health Care, 3(6),311315.
Quincy, K. (1995). Hmong: History of a people. Cheney, WA:
Washington University Press.
Rice, P. L. (1997). Giving birth in a new home: Childbirth traditions and
the experience of motherhood among Hmong women from Laos.
Asian Studies Review, 20(3), 133148.
Rice, Pranee L. (2000). The Hmong way: Hmong women and reproduction. Westport, CT: Bergin & Garvey.
Robinson, W. C. (1998). Terms of refuge: The Indochinese exodus and
the international response. New York, NY: United Nations High
Commissioner for Refugees.
Schein, L. (2000). Minority rules: The Miao and the feminine in Chinas
culture politics. Durham & London: Duke University Press.
Snyder, D. M., & Kunstadter, P. (2001). Providing health care in a multicultural community. In D. Wedding (Ed.), Behavior and Medicine
(3rd ed., pp. 4959). Seattle, Toronto, Gttingen, Bern: Hogrefe
and Huber.
Spring, M. A. (1989). Ethnopharmacologic analysis of medicinal plants
used by laotian Hmong refugees in Minnesota. Journal of
Ethnopharmacology, 26, 6591.
Spring, M. A. (2001). Reproductive health and fertility of Hmong immigrants in Minnesota. Doctoral dissertation. Minneapolis, MN:
University of Minnesota.
Spring, M. A., Ross, P. J., Etkin, N. L., & Deinard, A. S. (1995). Sociocultural factors in the use of prenatal care by Hmong women in
Minneapolis. American Journal of Public Health, 85(7), 10151017.
Spring, M. A., & Lochungvu, M. (2003). Family planning. In
K. A. Culhane-Pera, D. E. Vawter, P. Xiong, B. Babbitt, &
M. Solberg (Eds.), Healing by heart. Nashville, TN: Vanderbilt
University Press.
Strohl, L. (2000, May). Asian ascending. The Horizon Magazine.
Symonds, P. V. (2003). Calling in the soul: Gender and cycle of life in
a Hmong village. Seattle: University of Washington Press.
743
Iroquois
Barbara W. Lex and Thomas S. Abler
ALTERNATIVE NAMES
The Iroquois were and are a confederacy of several
Native North American nations. The original five members of the confederacy were the Mohawk, Oneida,
Onondaga, Cayuga, and Seneca. Accordingly, they were
known to English colonial officials as the Five Nations.
When the Tuscarora joined them early in the 18th century, they became the Six Nations. The Iroquois saw their
confederacy as a metaphorical longhouse, the multifamily dwelling which housed them in settlements at the
time of contact with Europeans. Hence they referred to
themselves as the Hodnosaunee, meaning, roughly,
People of the Longhouse. French colonists in Canada
used the term Iroquois, a name they probably learned
from a 16th century BasqueAlgonquian pidgin used in
the St. Lawrence valley (see Bakker, 1990; Goddard, 1978).
LOCATION
AND
LINGUISTIC AFFILIATION
744
Iroquois
Table 1. Contemporary Iroquois Reservations
and Reserves
Reservation or reserve
Enrolled
population
New York
Seneca Nation (Allegany and
Cattaraugus)
Tonawanda Band of the Senecas
Oneida
Onondaga
Tuscarora
Akwesasne (St. Regis)
Ontario
Akwesasne (St. Regis)
Tyendinaga
Six Nations
Wahta Mohawk (Gibson)
Oneida of the Thames
Quebec
Kahnawake (Caughnawaga)
Kanesatake (Oka)
Wisconsin
Oneida
6,241
1,050
1,100
1,600
1,200
5,638
9,500
7,046
20,876
659
4,776
8,888
1,943
11,000
Oklahoma
Seneca-Cayuga
2,460
OVERVIEW
OF THE
CULTURE
745
746
Iroquois
Table 2. Estimates of Numbers of Iroquois Warriors
Nation
Mohawk
Oneida
Onondaga
Cayuga
Seneca
1660
500
100
300
300
1,000
1665
300 to 400
140
300
300
1,200
1677
300
200
350
300
1,000
1689
270
180
500
300
1,300
1698
110
70
250
200
600
Total
2,200
2,240 to 2,340
2,150
2,550
1,230
MEDICAL PRACTITIONERS
Recent ethnographic studies of conservative portions of
Iroquois communities report that diagnosis of illness
occurs separate from its treatment. There are a small number of clairvoyants or traditional diagnosticians who are
regularly consulted about the cause of a patients problem.
These practitioners then direct patients to appropriate
cures. Advice may be to consult a herbalist for treatment,
to have a rite performed by one of the medicine societies,
or to consult specialists in western medicine (Blau, 1969,
p. 7; Shimony, 1994, pp. 270274; Isaacs, 1973, p. 77).
Herbalists are specialists who have acquired from
an earlier generation knowledge of local flora and the
747
748
Iroquois
SEXUALITY
AND
REPRODUCTION
Infancy
Public recognition of the place of an infant in a community
came at the Midwinter Ceremony or the Green Corn
Ceremony that followed its birth. Today the exact day on
which the names are announced as one element within
these lengthy ceremonies varies. A speaker announces the
name of each new member of the community. Each infant
receives a name held or owned by the matriclan into which
she or he was born (Sturtevant, 1984). Only one living person bears a specific name, and infants thought destined to
fulfill important ritual roles in adulthood are given names
of deceased ritualists (Blau, 1969, p. 27).
Infants are reported to have been nursed for lengthy
periods, 3 years being common with observations nearly
Childhood
Restraint on the actions of children was limited. The prefered form of punishment for bad behavior was to splash
the child with cold water. A thorough dousing or the threat
of a dunking in a cold stream were used on children who
do not reform. A red willow whip, to which tobacco had
been burned, was used to strike particularly disobedient
children. Traditional values disapproved slapping. Indeed,
severely punishing children was thought to bring disease,
hysteria, or the vomiting of worms upon the disciplinarian
(Shimony, 1994, pp. 209210). Parents also refrained
from disciplining children lest they commit suicide by eating the poisonous root, Cicuta, or that they might mature
to abuse their elderly parents (Fenton, 1941b, p. 125).
Field workers have noted considerable respect for the
rights of children to make their own decisions. Shimony
(1994, p. 269) records the case of parents accepting
the refusal of a 9-year-old to undergo a heart operation
deemed necessary by the local hospital.
749
Adolescence
Oral traditions suggest that vision quests by males at
puberty were once a significant element in Iroquois culture, but this does not appear to have been widely practiced in historic times. Similarly, oral tradition suggests
the isolation of a girl for up to a year at the time of her first
menses, but again this seems to have disappeared as a
practice by the time observers were recording Iroquois
culture and behavior. The girl did have to observe the
prohibitions of behavior observed by any menstruating
woman for the first three days of her period (Shimony,
1994, pp. 215216).
As a mark of maturity, the baby name previously
held was replaced, each person receiving an adult name
from the roster of names of his or her matriclan. As was
the case with the baby name, these names were publicly
announced at either the Green Corn Ceremony or the
Midwinter Ceremony. One of the boys who had received
a new name then led a Great Feather Dance as part of the
worship (Fenton, 1963).
Adulthood
Since the time of Morgan (1851, p. 83), clan exogamy has
been recognized among the Iroquois. However, this rule
has been frequently breached, even among conservative
Iroquois. Lineage exogamy is more frequently observed.
In addition to these matrilineal relatives, all persons related
to one through either parent are forbidden as a spouse or
sexual partner (see Shimony, 1994, pp. 3032).
Adult males, particularly those with ritual obligations,
undergo a regimen of purging for three days in the spring.
In the past this included baths in a sweat lodge. Various
herbal concoctions are used as emetics and laxatives to
cleanse the body. An 18th-century observer noted the use
for purging of very strong medicines which clear them out
to excess and might well kill a horse (Lafitau, 197477
(2), p. 206). One fasts during the purge but then takes
tonics to regain ones strength. Sassafras is thought to
restore the blood following the period of the purge. In addition to this period of spring cleaning, men may also
purge themselves in preparation for an important ritual
(Parker, 1913, p. 77; Shimony, 1994, pp. 265266).
A phobia apparently rare or absent among Iroquois males
is fear of heights (Wallace, 1951, p. 64).
Onset of menses was believed to occur at the new
moon. Shimony (1994, pp. 216218) reports that women
750
The Aged
Morgan (1851, p. 171) recorded the teaching of the
Longhouse religion speaker from Tonawanda, Jimmy
Johnson: It is the will of the Great Spirit that you reverence
the aged, even though they be as helpless as infants. The
prophet Handsome Lake preached that it was ordained
that people should live to an old age and that an old
woman should be as a child again and when she becomes
so the Creator wishes the grandchildren to help her
(Parker, 1913, p. 35). Despite this, Fenton (1941b, p. 125)
feels that the number of cases where Iroquois adults have
maltreated their aged parents is great enough to warrant
investigation and notes that two abused elderly Onondaga
males committed suicide. In one of these cases there were
factors involved other than simply abuse by adult children.
Randle (1951, p. 171) presents an idyllic view of the
role of the aged woman: Honored as heads of clans and
household, the old age of women could be rewarding,
surrounded by her offspring. Although unmarked by a
rite of passage, after menopause women can partake in
activities involving curing and medicines that previously
had been barred to them (Shimony, 1994, p. 218).
Wallace (1951, p. 64) notes that the absence of fear of
heights continues into old ageeven old men of 60
and 70 will take, and efficiently perform, such jobs as
pruning high trees, painting the roofs of buildings, and
carpentry work on scaffolds.
Iroquois
751
752
REFERENCES
Abler, T. S. (1970). Longhouse and palisade: Northern Iroquoian
villages of the seventeenth century. Ontario History, 52, 1740.
Abler, T. S. (1992). Beavers and muskets: Iroquois military fortunes in the
face of European colonization. In R. B. Ferguson & N. L. Whitehead
(Eds.), War in the tribal zone: Expanding states and indigenous warfare (pp. 151174). Santa Fe: School of American Research Press.
Abler, T. S. (1997). Iroquois: The tree of peace and the war kettle. In
M. Ember, C. R. Ember, & D. Levinson (Eds.), Portraits of culture:
Ethnographic originals, Vol. 1, North America (pp. 134).
Englewood Cliffs, New Jersey: Prentice Hall.
Abrams, G. H. J. (1994). Seneca. In M. B. Davis (Ed.), Native America
in the twentieth century: An encyclopedia (pp. 580582). New
York: Garland.
Bakker, P. (1990). A Basque etymology for the word Iroquois. Man
in the northeast, 40, 8993.
Blau, H. (1969). Calendric ceremonies of the New York Onondaga.
Doctoral dissertation, New School for Social Research, 1969.
Bonvillain, N. (1980). Iroquoian women. In N. Bonvillain (Ed.), Studies
in Iroquois culture (pp. 4758). Occasional publications in northeastern anthropology 6. Rindge, NH: Franklin Pierce College.
Bonvillain, N. (1984). Mohawk dialects: Akwesasne, Caughnawaga,
Oka. In M. K. Foster, J. Campisi, & M. Mithun (Eds.), Extending
the rafters: Interdisciplinary approaches to Iroquoian studies
(pp. 313323). Albany: State University of New York Press.
Buck, G. M., Mahoney, M. C., Michalek, A. M., Powell, E. J., &
Shelton, J. A. (1992). Comparison of Native American birth in
upstate New York with other race births, 198086. Public Health
Reports, 107, 569575.
Iroquois
Campisi, J. (1978). Oneida. In B. Trigger (Ed.), Handbook of North
American Indians, Vol. 15, Northeast (pp. 481490). Washington:
Smithsonian.
Campisi, J. (1994). Oneida. In M. B. Davis (Ed.), Native America in the
twentieth century: An encyclopedia (pp. 407408). New York:
Garland.
Canada Department of Indian Affairs and Northern Development (2001).
Registered Indian population by sex and residence 2000. Ottawa:
Minister of Public Works and Government Services Canada.
Dobyns, H. F. (1983). Their number become thinned. Knoxville:
University of Tennessee Press.
Engelbrecht, W. (1987). Factors maintaining low population density among
the prehistoric New York Iroquois. American Antiquity, 52, 1327.
Fenton, W. N. (1936). An outline of Seneca ceremonies at Coldspring
Longhouse. Publications in Anthropology 9. New Haven: Yale
University.
Fenton, W. N. (1940). An herbarium from the Allegany Senecas. In
W. J. Doty, C. E. Congdon, & L. H. Thorton (Eds.), The historic
annals of southwestern New York (pp. 787796). New York: Lewis
Historical Publishing.
Fenton, W. N. (1941a). Tonawanda longhouse ceremonies: Ninety years
after Lewis Henry Morgan. Smithsonian Institution. Bureau of
American Ethnology Bulletin, 128, 140156. Washington:
U.S. Government Printing Office.
Fenton, W. N. (1941b). Iroquois suicide: a study in the stability of a
culture pattern. Smithsonian Institution. Bureau of American
Ethnology Bulletin, 128, 79137. Washington: U.S. Government
Printing Office.
Fenton, W. N. (1941c). Masked medicine societies of the Iroquois.
Annual report of the Smithsonian Institution for 1940, pp. 397430.
Washington: U.S. Government Printing Office.
Fenton, W. N. (1942). Contacts between Iroquois herbalism and colonial medicine. Annual report of the Smithsonian Institution for
1941, pp. 503526. Washington: U.S. Government Printing Office.
Fenton, W. N. (1963). The Seneca Green Corn Ceremony. The New York
conservationist, 18 (OctoberNovember), 2022, 2728.
Fenton, W. N. (1978). Northern Iroquoian culture patterns. In B. Trigger
(Ed.), Handbook of North American Indians, Vol. 15, Northeast
(pp. 296321). Washington: Smithsonian.
Fenton, W. N. (1979). The great good medicine. New York State
Journal of Medicine, 79, 16031609.
Fenton, W. N. (1986). A further note on Iroquois suicide. Ethnohistory,
33, 448457.
Fenton, W. N. (1987). The False Faces of the Iroquois. Norman:
University of Oklahoma Press.
Fenton, W. N., & Kurath, G. P. (1951). The feast of the dead or ghost
dance at Six Nations Reserve, Canada. Smithsonian Institution.
Bureau of American Ethnology Bulletin, 149, 139166. Washington:
U.S. Government Printing Office.
Fenton, W. N., & Tooker, E. (1978). Mohawk. In B. Trigger (Ed.),
Handbook of North American Indians, Vol. 15, Northeast
(pp. 466480). Washington: Smithsonian.
Goddard, I. (1978). Synonymy. In B. Trigger (Ed.), Handbook of North
American Indians, Vol. 15, Northeast (pp. 319321). Washington:
Smithsonian.
Guldenzopf, D. (1984). Frontier demography and settlement patterns of
the Mohawk Iroquois. Man in the Northeast, 27, 7994.
References
Hauptman, L. M. (1994). Seneca-Cayuga. In M. B. Davis (Ed.), Native
America in the twentieth century: An encyclopedia (p. 582). New
York: Garland.
Henige, D. (1986). Primary source by primary source? On the role of
epidemics in New World depopulation. Ethnohistory, 33, 293313.
Herrick, J. W. (1995). Iroquois medical botany. Syracuse: Syracuse
University Press.
Horn, O. K., Paradis, G., Potvin, L., Macaulay, A. C., & Desrosiers, S.
(2001). Correlates and predictors of adiposity among Mohawk
children. Preventive medicine, 33, 274281.
Isaacs, H. L. (1973). Orenda: An ethnographic cognitive study of
Seneca medicine and politics Doctoral dissertation, State
University of New York at Buffalo, 1973.
Isaacs, H. L. (197677). Iroquois herbalism: The past 100 years.
International Journal of Social Psychiatry, 22, 272281.
Isaacs, H. L., & Lex, B. W. (1980). Handling fire: Treatment of illness
by the Iroquois false-face medicine society. In N. Bonvillain (Ed.),
Studies in Iroquois culture (pp. 513). Occasional publications in
northeastern anthropology 6. Rindge, NH: Franklin Pierce College.
Lafitau, J. F. (197477). Customs of the American Indians compared
with the customs of primitive times. W. N. Fenton & E. L. Moore
(Eds. and Trans). Toronto: Champlain Society.
Lex, B. W. (1977). Altered states of consciousness in Northern
Iroquoian rituals. In A. Bharati (Ed.), The realm of the extrahuman: Agents and audiences (pp. 277300). The Hague: Mouton.
Lex, B. W., & Norris, J. R. (1994). Health status of American Indian
and Alaska Native women. In A. C. Mastroianni, R. Faden, &
D. Federman (Eds.), Women and health research. Vol. II. Ethical
and legal issues relating to the inclusion of women in clinical studies (pp. 192215). Washington: Institute of Medicine.
Lounsbury, F. G. (1978). Iroquoian languages. In B. Trigger (Ed.),
Handbook of North American Indians, Vol. 15, Northeast
(pp. 334343). Washington: Smithsonian.
Lwebuga-Mukasa, J. S., & Dunn-Georgiou, E. ( 2000). The prevalence
of asthma in children of elementary school age in western New
York. Journal of Urban Health, 77, 745761.
Macaulay, A. C., Hanusaik, N., & Beauvais, J. E. (1989). Breastfeeding
in the Mohawk community of Kahnawake. Canadian Journal of
Public Health, 80(3), 177181.
Macaulay, A. C., Montour, L. T., & Adelson, N. (1988). Prevalence of
diabetic and atherosclerotic complications among Mohawk
Indians of Kahnawake, PQ. Canadian Medical Association
Journal, 139, 221224.
Macaulay, A. C., Paradis, G., Potvin, L., Cross, E. J., SaadHaddad, C., McComber, A., et al. (1997). The Kahnawake schools
diabetes prevention project: Intervention, evaluation, and baseline
results of a diabetes primary prevention program with a native
community in Canada. Preventive Medicine, 26, 779790.
Mahoney, M. C., Ellrott, M. A., & Michalek, A. M. (1989). A mortality
analysis of Native Americans in New York State, 19801986.
International Journal of Epidemiology, 18, 403412.
Mahoney, M. C., Michalek, A. M., Cummings, K. M., Nasca, P. C., &
Emrich, L. J. (1989). Mortality in a northeastern Native American
cohort, 19551984. Amerian Journal of Epidemiology, 129, 816826.
Michalek, A. M., Mahoney, M. C., Buck, G., & Snyder, R. (1993).
Mortality patterns among the youth of a northeastern American
Indian cohort. Public Health Reports, 108, 403407.
753
Montour, L. T., Macaulay, A. C., & Adelson, N. (1989). Diabetes
mellitus in Mohawks of Kahnawake, PQ: A clinical and epidemiologic
description. Canadian Medical Association Journal, 141, 549552.
Morgan, L. H. (1851). League of the Ho-d-no-sau-nee or Iroquois.
Rochester: Sage.
Oneida Indian Nation. (2000). Available online at, http://oneidanation.net/ Oneida, New York.
Parker, A. C. (1909). Secret medicine societies of the Seneca. American
Anthropologist, ns, 11, 161185.
Parker, A. C. (1913). The code of Handsome Lake, the Seneca prophet.
New York State Museum Bulletin 163. Albany: New York State
Museum.
Patterson, K. (1994). Tuscarora. In M. B. Davis (Ed.), Native America
in the twentieth century: An encyclopedia (pp. 663664).
New York: Garland.
Ramenofsky, A. (1987). Vectors of death: The archaeology of European
contact. Albuquerque: University of New Mexico Press.
Randle, M. C. (1951). Iroquois women, then and now. Smithsonian
Institution. Bureau of American Ethnology Bulletin, 149, 167180.
Washington: U.S. Government Printing Office.
Shimony, A. A. (1970). Iroquois witchcraft at Six Nations. In D. Walker,
(Ed.), Systems of North American witchcraft and sorcery
(pp. 239265). Moscow, Idaho: University of Idaho Press.
Shimony, A. A. (1994). Conservatism among the Iroquois at the Six
Nations Reserve. Syracuse: Syracuse University Press.
Snow, D. R. (1992). Disease and population decline in the northeast. In
J. W. Verano & D. H. Ubelaker (Eds.), Disease and demography in
the Americas (pp. 177186). Washington: Smithsonian Institution.
Snow, D. R. (1994). The Iroquois, Oxford: Blackwell.
Snow, D. R., & Lanphear, K. M. (1988). European contact and Indian
depopulation in the northeast: The timing of the first epidemics.
Ethnohistory, 35, 1533.
Snow, D. R., & Lanphear, K. M. (1989). More methodological perspectives: A rejoinder to Dobyns. Ethnohistory, 36, 299304.
Snow, D. R. & Starna, W. A. (1989). Sixteenth-century depopulation:
A view from the Mohawk valley. American Anthropologist, 91,
142149.
Speck, F. G. (1949). Midwinter rites of the Cayuga long house.
Philadelphia: University of Pennsylvania Press.
Starna, W. A. (1980). Mohawk Iroquois populations: A revision.
Ethnohistory, 27, 371382.
Starna, W. A. (1994). Onondaga. In M. B. Davis (Ed.), Native America
in the twentieth century: An encyclopedia (pp. 408409). New York:
Garland.
Sturtevant, W. C. (1978). Oklahoma Seneca-Cayuga. In B. Trigger
(Ed.), Handbook of North American Indians, Vol. 15, Northeast
(pp. 537543). Washington: Smithsonian.
Sturtevant, W. C. (1984). A structural sketch of Iroquois ritual. In
M. K. Foster, J. Campisi, & M. Mithun (Eds.), Extending the
rafters: Interdisciplinary approaches to Iroquoian studies
(pp. 133152). Albany: State University of New York Press.
Tooker, E. (1978a). Iroquois since 1820. In B. Trigger (Ed.), Handbook
of North American Indians, Vol. 15, Northeast (pp. 449465).
Washington: Smithsonian.
Tooker, E. (1978b). The league of the Iroquois: Its history, politics, and
ritual. In B. Trigger (Ed.), Handbook of North American Indians,
Vol. 15, Northeast (pp. 418441). Washington: Smithsonian.
754
Jamaican Maroons
Weaver, S. M. (1971). Smallpox or chickenpox: An Iroquoian communitys reaction to crisis. Ethnohistory, 18, 361378.
Weaver, S. M. (1972). Medicine and politics among the Grand River
Iroquois: A study of the non-conservatives. National Museum of
Man publications in ethnology 4. Ottawa: National Museums of
Canada.
Wells, R. N. (1994). Mohawk. In M. B. Davis (Ed.), Native America in
the twentieth century: An encyclopedia (pp. 353354). New York:
Garland.
Wray, C. F., Sempowski, M. L., & Saunders, L. P. (1991). Tram and
Cameron: Two early contact era Seneca sites. Rochester Museum &
Science Center research records, no. 21.
Wray, C. F., Sempowski, M. L., Saunders, L. P., & Cervone, G. C.
(1987). The Adams and Culbertson sites. Rochester Museum &
Science Center research records, no. 19.
Jamaican Maroons
George Brandon
ALTERNATIVE NAMES
Windward Maroons, Leeward Maroons. Also call themselves Nyankimpong Pickibo (children of the Creator
in Twi).
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
Context of Health
755
CONTEXT
OF
HEALTH
Maroons are politically, socially, and economically marginalized within Jamaica. The 1738/39 treaties gave the
colonial government the right to appoint Maroon chiefs
756
Jamaican Maroons
MEDICAL PRACTITIONERS
Dancers. The dancer was a distinctive ritual and religious figure that was last seen in Mooretown in the
1940s. Dancers specialized in ailments caused by spirits
and in severe cases that had not been resolved by other
medical means. They conducted public and private rituals
in which the dancer, assisted by prayers and drumming,
went into spirit possession and then healed from the
possessed state.
There are no full-time Maroon healers. Every healer practices their particular form of medicine part-time, alongside
diviners, and their use of European magic and occult sciences. Invocations, fashioning charms and talismans, and
using oils, candles, and holy water in their rituals are part
of their expertise. They may specialize in fortune telling,
sexual and love magic, magic related to farming or treating particular health problems with a combination of rituals and herbal medicine. Science men or scientists
are frequently associated or identified with obeah (the
Afro-Jamaican sorcery tradition) and herbalism, and may
or may not perform any of the other healer roles already
mentioned. They are often ambivalently valued figures
inspiring both fear and respect. A few science men occasionally have clients coming in from abroad or from
distant regions within Jamaica.
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Maroon Disease Theory: Etiology
Cold and Blood. Cold and blood are important
concepts in Maroon explanations of the causes of sickness. Cold is a fundamental element of Maroon etiology, an explanation for a general type of disease process
with wide ramifications. When Maroons speak of contracting a cold or contracting cold they are referring
not to the sickness itself as we might in speaking about a
head cold, but to cold as a causal factor underlying
the symptoms that have developed (Cohen, 1973, p. 69).
According to them, cold is responsible for the majority
of the sicknesses afflicting Maroons. Cold is a range on
a continuum of judgments that Maroons use in describing
bodily sensations related to temperature. While this
scheme of explanation tends to focus on the effect of cold,
the other extreme is not neglected and a few ailments are
traced to the effect of too much heat, the most prominent
of these being belly hot.
Cold is a pervasive generalized sensory quality or
force that emanates from certain objects or places in the
environment. The earth or ground is a source of cold; so
is immersion in cold water or getting soaked in the torrential downpours that mark the lives of both Leeward
and Windward Maroons day after day for weeks at a time.
But encounters with these cold-emanating elements of
the environment are common everyday occurrences.
757
758
Jamaican Maroons
759
Treatments
All of the healer types make use of a wide variety of
locally available plants in the forms of infusions of leaf
teas, decoctions made from the roots of plants to create
roots tonics or bitters, and tinctures using white rum,
wine or some other alcohol as a solvent medium. The
Maroon herbal pharmacy supplies them vermifuges,
cathartics, sedatives, diuretics, emmenagogues, antihypertensives, and medicines serving many other uses. The
uses often overlap and are emphasized variously in the
practices of the different healer types. For example, many
of the same herbs that are used to modulate menstruation,
ease, and speed up labor in childbirth, and perform purifying washouts of the body also induce abortion, so
midwifery requires a sophisticated knowledge of these
herbs and their dosage effects. Bush baths are another
means of using herbs medicinally. The healer ties up bundles of leaves and dips them in a tub or small basin of hot
bath water to steep. The patient either submerges himself
in the water or sits over the waters steam. Treatment with
poultices involves crushing the plants into a pulpy
mucilaginous mass, which is then positioned over and
wrapped around the affected area. Poultices can be made
760
Jamaican Maroons
SEXUALITY
AND
REPRODUCTION
761
762
Jamaican Maroons
Infancy
Depending on the number of other children a mother has
and the nature of her other responsibilities in the household, babies usually feed at the breast until their first teeth
appear. Sometimes women use a commercially prepared
formula along with breast-milk. Goat milk is available if
there is a problem with feeding but it is used only in
emergencies. When infants cease breast-feeding they are
weaned onto soft foods, often a preparation composed of
seasonal fruits and vegetables in a pulverized form.
Mothers may also spoon-feed infants a thick porridge,
fruit juice, and mashed fruits. It is not unusual to see a
3-year-old child receiving porridge from a bottle. Infants
diets may lack variety but malnutrition is uncommon.
Sometimes, though, there are problems: When infants
teeth come in: their gums hurt and they may develop diarrhea. A Maroon remedy for the gum pain is to rub the
gums with a young tomato. The diarrhea can be helped
with a rehydration salt of lime juice, sugar, and soda
given by the spoonful.
A not uncommon malady of infants is the mole
cold. According to Maroons, this infantile malady develops either because the mother takes her infant outside
while the rain is falling and the babys fontanel becomes
wet; or because the mother has not done a good job of drying the babys scalp after bathing it. Mole colds are fateful
for later life. If the mole cold takes root, Maroons predict
the child will become a sickly adult (Cohen, 1973, p. 75).
763
Adulthood
The two largest age groups in Mooretown and
Accompong are the youth and elders. Adults and young
adults, particularly the males, are highly mobile and are
often away from the villages for long periods. Working
away from home forces them to leave their children in the
care of grandparents or other relatives. Of the middle
aged as many have migrated as have remained in the
countryside, gone to England or the coastal cities.
Hypertension, back pain, insomnia, arthritis, and epigastric pain bedevil the adult men, as do the injuries and
wounds that result from farm work. The health problems
of Maroon women are very similar to the males except
that the women are more likely to suffer from headaches
and psychiatric disorders.
Adults use both traditional medicines and the nonprescription commercial medications available at small
local stores for self-treatment. Maroons treat themselves
for common mild problems or may seek assistance from
another adult or a relative. Mild problems that linger may
occasion a trip to a town where there is a biomedical practitioner or an older mature Maroon woman who has had
much experience with diagnosing or treating similar
problems. Severe, painful, or disturbing problems of long
duration call for either a biomedical doctor or a more
specialized Maroon healer. Sometimes a failure of biomedical diagnosis and treatment confirms the patients
own self-diagnosis and directs them back to the Maroon
folk system where herbal therapies predominate, sometimes supplemented by divination and other rituals.
Menopause is dealt with through dietary prescriptions (such as increase in eating green, leafy vegetables)
and a variety of herbs that are said to reduce the symptoms and strengthen the body. Domestic violence (men
beating women) flares up because of rumors of female
infidelity or men finding out that their women have been
with other men. If attacked by men, women are encouraged to fight back. Mens drunkenness is an important
cause of arguments and violence between men and
women. Alcohol use also figures prominently in fights
764
The Aged
Prominent health problems of Maroon elders include
chronic pain (hands, feet, stomach, and all over), high
blood pressure, arthritis, stomach problems, nerves, weakness, and fatigue, also diabetes. Quite a few elderly
Maroons continue doing light farm work into their sixties
and seventies. Subsistence requires it. With the old cooperative work, labor exchange, and barter arrangements
long laid low, elders must either farm or hire wage
workersnot a viable option for most elderly Maroons.
Instead the elders depend on their adult children who have
remained in the Maroon communities to assist and look
after them. Often, however, their children have left and
gone to the cities or overseas. These children may send
money back to elders but they are not there to look after
them. In these cases other relatives take care of them.
Jamaican Maroons
REFERENCES
Barker, D., & Spence, B. (1988). Afro-Caribbean agriculture:
A Jamaican Maroon community in transition. Geographical
Journal, 154, 198208.
Barrett, L. (1976). Healing in a balmyard: The practice of folk healing
in Jamaica, W. I. In W. D. Hand (Ed.), American folk medicine
(pp. 285300). Berkeley: University of California Press.
Besson, J. (1979). Symbolic aspects of land in the Caribbean: The tenure
and transmission of land rights among Caribbean peasantries.
In Malcolm Cross & Arnaud Marks (Eds.), Peasants, plantations
and rural communities in the Caribbean (pp. 86116). Location/
Guildford Press.
Besson, J. (1997, Fall). Caribbean common tenures and capitalism: The
Accompong Maroons of Jamaica. Plantation Societies in the
Americas, 4(2 & 3), 201232.
Bilby, K. (1994). Maroon Culture as a distinct variant of Jamaican culture. In Kofi E. Agorsah (Ed.), Maroon heritage: Archaeological,
ethnographic and historical perspectives (pp. 7285). Kingston:
Canoe Press.
Brody, E. B. (1981). Sex, contraception and motherhood in Jamaica.
Cambridge: Harvard University Press.
765
Lowe, H., Payne-Jackson, A., & Duke, J. (2001). Jamaicas ethnomedicine: Its potential in the health care system. Kingston, Jamaica:
Pelican Publishers.
Patterson, O. (1970). Slavery and revolt: A socio-historical analysis of
the First Maroon War 16551740. Social and Economic Studies,
19, 289325.
Price, R. (1979). Maroon societies: Rebel slave communities in the
Americas. Baltimore: Johns Hopkins University Press.
Robertson, D. (1988). Jamaican Herbs. Montego Bay: De Sola Pinto
Distributors.
Sheridan, R. (1986). The Maroons of Jamaica, 17301830: Livelihood,
demography and health. In Gad Heuman (Ed.), Out of bondage:
Runaways, resistance and marronage in Africa and the Americas
(pp. 152172). New York: Frank Cass Publications.
Sobo, E. (1993). One blood: The Jamaican body. Albany: State
University of New York Press.
Sobo, E. (1996). Abortion traditions in rural Jamaica. Social Science
and Medicine, 42, 495508.
Smith, M. G. (1965). Community organization in rural Jamaica. In.
M. G. Smith (Ed.), The plural society in the West Indies (pp. 176195).
Berkeley, Los Angeles: University of California Press.
Watts, D. (1987). The West Indies: Patterns of development, culture and
environmental change since 1492. Cambridge Studies in Historical
Geography, Cambridge: Cambridge University Press.
Wendenojo, W. (1989). Mothering and the practice of balm in
Jamaica. In C. S. McClain (Ed.), Women as healers: Cross-cultural
perspectives (pp. 7697.) New Brunswick: Rutgers University
Press.
Japanese
Denise Saint Arnault
ALTERNATIVE NAMES
LOCATION
AND
LINGUISTIC AFFILIATION
766
Japanese
OVERVIEW
OF THE
CULTURE
Demographics
There were 127 million Japanese in Japan in 2000 (World
Health Organization, 2002a), making it the eighth largest
population in the world (see Table 1). The annual growth
rate in 2000 was 0.3%, much lower than the 1.1% in the
United States. Twenty-three percent of the Japanese population is over 65, higher than the 16.6% in the United States.
The fertility rate is below replacement level in Japan, at 1.4
children per woman, while, in the United States, the fertility
rate is 2.0. Seventy-five percent of the Japanese live in
urban areas. In the 1930s, the Japanese household was primarily multigenerational, with around 70% of the elderly
living with their children. In 1955, about half of Japanese
households were still three generations, and by 1990, 60%
were nuclear family households and only 15% were three
generations (Feeney & Mason, 2001). The Japanese citizenry are educated and literate, with 100% of the population completing primary school since 1955, and 95%
completing secondary school during the same period. In
1996, estimates were that 31% of the population was
enrolled in tertiary education. However, a gender gap persists in higher education, with 27.2 per 1,000 women in
third level education, compared with 35.8 per 1,000 men
WHO
member states
Germany
Total
Annual
population growth
(000)
rate (%)
2000
19902000
Percentage
of population
aged 60
years
1990
Total
fertility
rate
82,017
0.3
20.4
23.2
1.4
1.3
127,096
0.3
17.4
23.2
1.6
1.4
8,842
0.3
22.8
22.4
2.0
1.4
United
Kingdom
59,415
0.3
20.9
20.6
1.8
1.7
United
States of
America
283,230
1.1
16.6
16.1
2.0
2.0
Japan
Sweden
History
The Japanese migrated to the islands in AD 470, where
they were primarily a tribal people, with heterogeneous,
regional, cultural, and social patterns. The Empress Suiko
reigned from 592628, and institutionalized several elements of Chinese civilization into Japanese social and
political life, including the adoption of the Chinese writing system, rules of rank and etiquette, the Chinese calendar, diplomatic relations with China, a highway system,
and a constitution. The Nara period (709784) institutionalized Buddhist religion and with it, Chinese images,
books, ritual devises, astronomy, and architecture. This
period also gave rise to the public bath, cremation, maps,
and an irrigation system. The Heian period (8th to 12th
century) was a period of cultural evolution, including the
development of an indigenous Japanese kana writing system, poetry, and scroll paintings. Feudal institutions, a
militaristic government, and political power struggles
resulted in the social disorder and feudal warfare that
characterized the Medieval period (12th to 16th century).
However, this period also saw the rise of Zen Buddhism,
and the development of an indigenous healing system
based on Chinese medicine. The Tokugawa period
(16031868) marked military reunification, and the
development of the bushido, or the way of the Samurai
warrior. Confucian rules of civil order, including rules of
loyalty, social hierarchy, and filial piety, were institutionalized into the society, as well as an aversion to outside
cultural influences.
The 700 years of cultural isolation during the
Medieval and Tokugawa periods (11851853) allowed not
only a richly developed cultural identity, but also an
intense nationalism. The 1847 Meiji restoration was the
official end of this international isolation, as the government centralized, deposing the feudal landholders, as well
as modernizing education, the judiciary, the military, and
their economic system (de Bary & Dykstra, 2001;
Reischauer, 1981; Vogel, 1967; Yoshino, 1992). Japans
late but rapid rise in industry and urbanization has set it
apart from other East Asian countries, and its capitalistic
economy was based on a Confucian social and political
order, creating an industrial organization very different
from most other industrialized countries.
767
Sociocultural Norms
Research shows that two opposing dynamics are central
in Japanese social interactions. One dynamic is the
768
Japanese
Percentage of
public
expenditures
Percentage of
private
expenditures
Percentage
WHO member
of GDP
state
Total
Public
Private
Social
security
Germany
10.3
75.8
24.2
91.6
8.3
29.5
52.8
7.5
78.1
21.9
89.2
10.8
1.3
77.8
Japan
Tax
Private Out-offunded insurance pocket
Sweden
7.9
83.8
16.2
0.0
United Kingdom
6.8
83.3
16.7
11.8
88.2
20.8
66.8
12.9
44.8
55.2
33.2
66.8
60.7
28.3
United States
of America
100
100
769
800
700
600
500
400
300
200
100
0
1200
1000
800
600
400
200
0
Physicians
Germany
Sweden
UK
USA
Japan
Nurses
Figure 1. Selected WHO members physicians and nurses per 100,000 around 1988
(Ministry of Health Labour and Welfare, 2002; World Health Organization, 2002a).
160
140
120
Germany
100
Sweden
80
UK
60
USA
40
Japan
20
0
Midwives
Dentists
Pharmacists
770
Japanese
160
140
140
120
120
100
100
80
80
60
60
40
40
20
20
0
ns
tio
c
fe
in
k
y
er
or tac
nc
t
at
ca cul rt a
r
ci hea
VA
y
or
ra
i
sp
r
ve
ve
ti
es
li
g
di
re
1995
1996
l
na
te
ex
VA
su
ic
de
de
ic
m
ho
1997
250
200
150
Germany
100
Sweden
UK
USA
50
Japan
A
su
icid
e
ho
mi
cid
e
MV
na
l
live
r
ex
ter
e
tiv
es
ato
r
y
dig
CV
A
res
pir
ac
k
he
art
att
ory
ce
r
ca
n
cu
lat
cir
inf
ec
tio
ns
Figure 4. Selected WHO members death rates (per 100,000): 1996 (World Health Organization,
2002a).
Medical Practitioners
771
60
50
40
30
20
10
0
All
ages
Male
75+
Female
Figure 5. Japanese 1997 suicide rates per 100,000 by sex (World Health
Organization, 2002a).
80
70
60
50
40
30
20
10
0
st
Au
ria
s
k
y
d
a
a
ia
ry
en om rica
an
on
vi
ni
ru
ar
an
an
an rati
ga
la
e
to
m
ed gd
ap Lat
m
nl
u
n
i
s
e
J
n
r
u
F
th
e
e
E
B
Sw Kin f Am
de
H
D
Li
G
o
d
Fe
te
es
an
ni
si
at
U
t
s
S
u
R
d
te
ni
U
Males
Females
Figure 6. Selected WHO members suicide rates per 100,000 by sex: 1996 (World
Health Organization, 2002b).
MEDICAL PRACTITIONERS
Japans primary medical system is western biomedicine.
The government sponsored medical scholars to study
Dutch medicine and translate German medical texts in
the 1700s. In the late 1800s, the Japanese government
772
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
The primary concept in Kampo is balance in the entire
physical, mental, social, and emotional state. Kampo
practitioners gather information about subtle aspects of
personal experience, such as cravings, warm or cold sensations, sweating, eye, nose, and mouth states such as
dryness, redness or congestion, digestive changes, energy
level, quality of sleep and the like. Causes of imbalances
include both internal and external pathogens, such as
wind, cold, heat, dampness, improper diet, or overwork.
The state or condition is then understood according to
three sets of complementary sets of indicatorshot: cold,
excess: deficiency, and internal: external. Hot and cold
refers to the experience of temperature throughout the
body, as well as under or over activity of physiological
processes. Excesses and deficiencies refer to the constitutional state of the person, including the degree of vitality, resistance to stress and imbalance, and energy level.
Finally, internal: external refers to the location of the
pathogenic processes, and attunes the practitioners to the
depth of the problem. Internal problems indicate that
pathogenic situation has existed longer and the problem
is more entrenched. In addition to these complementary
states of balance, Kampo is concerned with blood flow,
bodily fluids, and vital energy (qi). Bodily fluids and qi
Japanese
need to circulate freely and can become blocked or stagnant, causing states of illness.
Kampo treatment is indicated when multiple organs
are affected, such as in immune disorders or in the failing
health of the elderly, and when the patients condition
does not have a ready biomedical diagnosis or effective
treatment, such as is the case in psychosomatic illness or
idiosyncratic illness expressions. Finally, they are widely
used as alternative and complementary treatments to biomedicine (Long, 1987; Ohnuki-Tierney, 1984; Rister,
1999; Tsumura, 1991; Yamamura, 1987).
773
60
50
1950
1970
40
1980
30
1990
2000
20
2001
1960
10
0
Spontaneous
Artificial
Figure 7. Japan fetal death rates per 100,000 by year and cause (Ministry of
Health Labour and Welfare, 2002).
Infancy
Mothers tend to stay in the hospital for a week, but may
remain confined to the house for as long as a month.
About half of all Japanese mothers breast-feed, and women
experience a great deal of anxiety about producing
enough milk for the infant, fostering the use of therapeutic activities such as breast massage, heat applications,
and supportive nursing care. The nursing event is considered a natural, intensely personal time for the mother and
infant to connect in a nonverbal, mutually dependent way.
Fathers, and Japanese society, believe that childcare is
774
within the purview of women, and that the only one who
can truly love and nurture an infant is its mother (Miyaji &
Lock, 1994).
Maternalinfant bonding in Japan has been the subject of numerous international psychological studies
(Shwalb & Shwalb, 1996). Japanese mothers quietly and
physically reassure and interact with their baby, anticipating needs rather than waiting for the infant to signal
needs. The intense bond formed during this period is
part of the interdependent relationship pattern that will
continue throughout life. This socialization pattern fosters
individuation within an interdependent social frame.
Throughout their lives, Japanese individuals enjoy periods of refueling into the indulgence of the intimate
relationship, referred to as amae (Freeman, 1998).
Childhood
As the child enters into toddlerhood, gendered differences in
the maternalchild relationship have been noted (Freeman,
1998). Boys are rough, active, and vocal, receiving minimal
interference from the mother. When the male child is disciplined, it tends to be with a gentle encouragement to be
concerned about his role as the older brother (if appropriate) and to recognize that his behavior reflects on his family. Girls are expected to help the mother at a young age,
and are encouraged to recognize their role in the home,
and their role as a sweet, loving, polite daughter in public.
Children are rarely cared for outside of the home during their first few years. When mothers return to work, it
tends to be after their children enter school. The childs
schooldays are similar to that of adolescents, wearing
uniforms, and commuting to school by train. Visitors to
Japan are often enchanted by groups of well-groomed and
well-behaved, eager, and boisterous children on trains and
buses. Mothers are expected to prepare balanced, fresh
foods for children, be involved in school activities and to
devote their evenings to the childrens studies.
Adolescence
The Japanese school year begins in April. The average
high school day begins around 8:30 am. Since most people in Japan travel by rail, a teenager in Japan may leave
home as early as 6:30 am. At the end of the day students
are often involved in club activities. Consistent with the
tendency for people in Japanese culture to affiliate with
one primary group, Japanese students may join only one
club. These clubs may be sports or culture clubs. The
Confucian hierarchical relationship pattern of seniors and
Japanese
juniors is created and maintained during the club activities. It is the responsibility of the seniors (senpai) to
teach, initiate, and take care of the juniors (kohai). It is
the duty of the kohai to serve and defer to the senpai.
Most of the interaction the typical adolescent has is with
peers at school, on the long rides to and from school, and
through phone and e-mail contact.
Japanese students spend as many as 240 days a year at
school. In addition to this long school year, it is highly likely
that students attend after school cram schools where
approximately 60% of Japanese high school students go for
supplemental lessons. These schools operate after school
and extend into the evening, and require extra homework,
leaving the Japanese adolescent little free time during the
week. Tuition for these schools is expensive and parents
may carefully select and pay for the highest level of schools
affordable. Parents and adolescents accept this burden on
their time, effort and finances because admission to a good
university can be a primary factor in the success of a
Japanese adult, determining employment opportunities, and
future income. Students who fail an entrance examination
may feel as though they have failed their family and experience intense worries about their future, making them a
highly vulnerable sector of Japanese youth (Johnson &
Johnson, 1996; Rohlen, 1983; White, 1993).
The behavioral problems of Japanese adolescents
have risen throughout the 1980s and 1990s at an alarming
rate. Many of these problems, including truancy, rebelliousness in school and school refusal, can be seen as social
reactions to the incredible stress of life in a conformist
society, where academic success is held to be the most
important social goal. The school-refusal syndrome is
characterized by somatic complaints of headaches and
stomachaches, followed by refusal to go to school, moodiness, and sometime verbal and physical abuse of parents.
The child may then become listless, depressed, withdrawn,
and remain secluded in their rooms. These somatic symptoms, passive resistance, and retreatism are consistent with
the Japanese forms of resistance in the face of social pressure which cannot be directly changed (Lock, 1987).
Some of these behavioral changes may also be
related to the modern ambivalence toward Japanese cultural rules, and the westernization of Japanese cultural
expectations. One example is the problem of bullying
(ijime). One survey found that 31% of third-graders,
25% of fourth-graders, 13% of fifth-graders, 10% of
sixth-graders, 17% of seventh-graders, and 8% of
eighth-graders are victims of ijime (U.S. Department of
Education, 2002). One aspect of ijime is that students who
References
The Aged
The rapidly aging population has created a burden on the
health care infrastructure of Japan. Much of the distresses
related to the chronic illnesses described above are age
related. The most controversial element of the burgeoning
heath care needs of the elderly is about who should
provide their care. Japan has only recently begun to create an institutional infrastructure to accommodate these
needs (Health Statistics Division, 1999). Instead, the
Japanese government has called upon a reawakening of
the traditional structure of the Japanese family and the
Confucian ideal of filial piety among the citizenry. This
expectation leaves the burden of long term care of the
elderly to the women in Japanese society.
Another facet of the burden of care is the cultural
expectation of dependency. Japanese patients, especially
the chronically ill or elderly, are expected to remain
dependent. Western models of rehabilitation for the purpose of self-care are considered inappropriate. The concept that an elder may become bedridden, and be cared
for by family, is alive in the Japanese consciousness.
Even when an infirmed elderly person is in a facility, or
when they live with family members, all present hold no
expectation that they will resume self-care (Keifer, 1987;
Shibusawa & Mui, 2001). One example of this phenomenon is the average length of stay in Japans hospitals is
38.3 days, compared with 8 days in the United States
(Keifer, 1987; Sonoda, 1988), suggesting an expectation
of dependency.
Another aspect of the plight of the elderly and the
chronically ill in Japan, as in much of the west, is that these
conditions do not respond to technological advances. In
Japan, fortunately, there is an alternative health care system, Kampo, which specializes in chronicity and quality of
life. Kampo medicines are often paid for by the national
insurance, and it is common for the elderly to seek Kampo
(Keifer, 1987; Sonoda, 1988).
775
REFERENCES
Bachnik, J. (1994). Uchi/Soto: Challenging our conceptualizations of self,
social order, and language. In J. M. Bachnik & C. J. Quinn (Eds.),
Situated meaning: Inside and outside in Japanese self, society, and
language (pp. 337). Princeton: Princeton University Press.
Bauer, J. (2001). Demographic change, development, and economic status of women in East Asia. In A. Mason (Ed.), Population change
and economic development in East Asia (pp. 359384). Stanford:
Stanford University Press.
Befu, H. (1980). The group model of Japanese society and its alternative. Rice University Studies, 66(1), 169187.
Befu, H. (1993). Cultural nationalism in East Asia (Vol. Berkeley:
University of California Press.
Bestor, T. (1996). Forging tradition: Social life and identity in a Tokyo
neighborhood. In W. P. Zenner (Ed.), Urban life: Reading in urban
anthropology (2nd ed., pp. 524547). Prospect Heights: Waveland
Press.
Cornell, L. L. (1996). Infanticide in early modern Japan? Demography,
culture, and population growth. Journal of Asian Studies, 55(1),
2250.
de Bary, W. T., & Dykstra, Y. (2001). Sources of Japanese tradition
(2nd ed.). New York: Columbia University Press.
776
DeNoon, D., Hudson, M., McCormack, G., & Morris-Suzuki (Eds.)
(2001). Multicultural Japan: Paleolithic to postmodern. New York,
NY: Cambridge University Press.
Feeney, G., & Mason, A. (2001). Population of East Asia. In A. Mason
(Ed.), Population change and economic development in East Asia
(pp. 6195). Stanford: Stanford University Press.
Freeman, D. M. A. (1998). Emotional refueling in development,
mythology, and cosmology: The Japanese separation-individuation
experience. In S. Akhtar & S. Kramer (Eds.), The colors of childhood: Separation-individuation across cultural, racial and ethnic
differences (pp. 1760). Northvale: Jason Aronson.
Health Statistics Division. (1999). Patients and medical institutions in
Japan: Graphical review of health statistics. Tokyo: Health and
Welfare Statistics Association.
Hendry, J. (1992). Individualism and individuation: Entry into a social
world. In R. Goodman & K. Refsing (Eds.), Ideology and practice
in modern Japan (pp. 5571). New York: Routledge.
Johnson, M. L., & Johnson, J. R. (1996). Daily life in Japanese high
schools. Japan Digest, U.S.Japan Database, Indiana University.
Retrieved September 12, 2002, from http://www.indiana.edu/~japan/
digest9.html
Johnson, T. (1995). Dependency and Japanese socialization. New York:
New York University Press.
Keifer, C. W. (1987). Care for the aged in Japan. In E. Norbeck &
M. Lock (Eds.), Health, illness, and medical care in Japan:
Cultural and social dimensions (Vol. pp. 89110). Honolulu:
University of Hawaii Press.
Klass, D., & Heath, A. O. (199697). Grief and abortion: Mizuko Kuyo,
the Japanese ritual resolution. Omega, 34(1), 114.
Lebra, T. (1976). Japanese pattern of behavior. Honolulu: University of
Hawaii Press.
Lock, M. (1987). Protests of a good wife and wise mother: The medicalization of distress in Japan. In E. Norbeck & M. Lock (Eds.),
Health, illness, and medical care in Japan: Cultural and social
dimensions (pp. 130157). Honolulu: University of Hawaii Press.
Long, S. O. (1987). Health care providers: Technology, policy, and professional dominance. In E. Norbeck & M. Lock (Eds.), Health, illness, and medical care in Japan: Cultural and social dimensions
(pp. 6688). Honolulu: University of Hawaii Press.
Miller, R. A. (1972). The Japanese language. Tokyo: Zohoban.
Ministry of Health Labour and Welfare. (2002). Statistics and other data.
Retrieved September 10, 2002, from http://www.mhlw.go.jp/english/
Ministry of Public Management, Home Affairs, Posts, and Telecommunications. (2002). Statistical handbook of Japan: 2002. Retrieved
September 10, 2002, from http://www.stat.go.jp/english/data/
handbook/c13cont.htm#cha13_2
Miyaji, N. T., & Lock, M. M. (1994). Monitoring motherhood:
Sociocultural and historical aspects of maternal and child health in
Japan. Daedalus, 123(4), 87112.
Namihara, E. (1987). Pollution in the folk belief system. Current
Anthropology, 28(4), S65S74.
Ohno, S. (1970). The origin of the Japanese language. Tokyo: Kokusai
Bunka Shinkokai.
Ohnuki-Tierney, E. (1984). Illness and culture in contemporary Japan:
An anthropological view. New York: Cambridge University Press.
Ohnuki-Tierney, E. (1989). Health care in contemporary Japanese religions. In L. E. Sullivan (Ed.), Healing and restoring: Health and
medicine in the worlds religious traditions (pp. 5988). New York:
Macmillan.
Japanese
Okunishi, Y. (2001). Changing labor forces and labor markets. In
A. Mason (Ed.), Population change and economic development in
East Asia (pp. 300331). Stanford: Stanford University Press.
Pharmacia. (2001). What women want. Pharmacia and Upjohn.
Retrieved September 10, 2002, from http://www.birth
controlresources.com/results.htm
Reischauer, E. L. (1981). The Japanese. Cambridge, MA: Harvard
University Press.
Rister, R. (1999). Japanese herbal medicine: The healing art of Kampo.
Garden City Park: Avery.
Rohlen, T. P. (1983). Japans high schools. Berkeley: University of
California Press.
Rosenberger, N. R. (2001). Gambling with virtue: Japanese women and
the search for self in a changing nation. Honolulu: University of
Hawaii Press.
Saint Arnault, D. M. (2002). Help seeking and social support in
Japanese company wives. Western Journal of Nursing Research,
24(3), 295306.
Shibusawa, T., & Mui, A. (2001). Stress, coping, and depression among
Japanese American elderly. Journal of Gerontological Social Work,
36(1/2), 6382.
Shwalb, D. W., & Shwalb, B. J. (Eds.). (1996). Japanese childrearing:
Two generations of scholarship. New York: Guilford Press.
Smith, R. (1961). The Japanese rural community: Norms, sanctions and
ostracism. American Anthropologist, 61, 522533.
Sonoda, K. (1988). Health and illness in changing Japanese society.
Tokyo: University of Tokyo Press.
Steslicke, W. E. (1987). The Japanese state of health: a politicaleconomic perspective. In E. Norbeck & M. Lock (Eds.), Health,
illness, and medical care in Japan: Cultural and social dimensions
(pp. 2465). Honolulu: University of Hawaii Press.
Tsumura, A. (1991). Kampo: How the Japanese updated traditional
herbal medicine. San Francisco: Kodansha.
U.S. Department of Education. (2002, November 3, 2001). Secondary
education in the life of Japanese adolescents: Adolescents problem behaviors. Contemporary Research in the United States,
Germany, and Japan: Japan. Retrieved September 12, 2002, from
http://www.ed.gov/pubs/Research5/Japan/secondary_j3.html
United Nations. (2000). The worlds women: Trends and statistics
(Vol. 16). New York: Author.
Vogel, E. (1967). Kinship structure, migration to the city and modernization. In R. P. Dore (Ed.), Aspects of social change in modern
Japan (pp. 91111). Princeton: Princeton University Press.
White, M. (1993). The material child: Coming of age in Japan and
America. New York: The Free Press.
World Health Organization. (2002a). WHO Statistical Information
System (WHOSIS). WHO. Retrieved September 10, 2002, from
http://www3.who.int/whosis/menu.cfm
World Health Organization. (2002b, September 4). Mental health:
Global suicide rates by country, age and gender. World Health
Organization. Retrieved September 12, 2002, from http://
www5.who.int/mental_health/main.cfm?p0000000149
Yamamura, Y. (1987, August 1921). Recent advances in the pharmacology of Kampo (Japanese Herbal) medicines. Paper presented at
the 10th International conference of Pharmacology, Auckland.
Yeo, S., Felters, M., & Maeda,Y. (2000). Japanese couples childbirth experiences in Michigan: Implications for care. Birth, 27(3), 191198.
Yoshino, K. (1992). Cultural nationalism in contemporary Japan:
A sociological inquiry. New York: Routledge.
777
Jat
Sunil K. Khanna
ALTERNATIVE NAMES
The Jats constitutes one of the largest and diverse
communities living in northwestern India and Pakistan.
According to Westphal-Hellbusche and Wesphal (1964),
the Arabic equivalent of Jat is Zutt, a generic term used
for men from India. The word Jat also means bunch of
hair and the Jats themselves claim that they have
descended from the hair of lord Shiv. According to
Ibbetson (1916), Jats are of Indo-Aryan (or IndoScythian) descent. Bowles (1977) argues that the word
Jat in the Punjabi language means a grazer or herdsman, but notes Ibbetsons (1916) suggestion that a shift
from the Punjabi soft t to a hard t in some Muslim
areas means an agriculturalist.
LOCATION
AND
LINGUISTIC AFFILIATION
The Jats are distributed over a wide and diverse geographic areafrom the hot and humid regions in northwestern India to the hills and plains in southern
Pakistanpresenting extensive cultural, linguistic, and
religious diversity. Some Jat groups have also been identified in the Maldives, Russia, and Ukraine. Different Jat
groups living in India and Pakistan speak different
dialects of Hindi, Urdu, Sindhi, and Punjabi.
OVERVIEW
OF THE
CULTURE
778
Jat
MEDICAL PRACTITIONERS
midwives and/or biomedical doctors for prenatal, perinatal, and postnatal health care. Notwithstanding these
changes, health care during prenatal and perinatal periods
is primarily a responsibility of Jat women and Jat men
play little or no role in this arena.
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
In spite of the increasing use of western medicine and
technology among the Jats, traditional ideas of health, illness, and healing, generally associated with Ayurvedic,
Homeopathic, and Unani healing systems constitute the
core theories of illness. Generally, the Jats use nonbiomedical systems of healing for chronic health conditions. The non-biomedical treatments prescribed
generally involve herbal and plant medicines, seasonal
dos and donts, dietary changes, etc. Among the Jats,
non-biomedical categories hot and cold foods are
generally associated with seasons and physiologic effects
(Freed & Freed, 1993).
The Ayurvedic system of medicine adopts a holistic
approach through dietary and lifestyle changes, herbal
medicine, and exercise to cure chronic disease and maintain individual health. The Ayurvedic system of medicine
is based on the ancient knowledge contained in
Atharvaveda. It deals with the totality of individual and
social health including preventive and curative aspects. In
fact, Ayurveda is a way of life based on certain emphasis
on diet, lifestyle, and Yoga practices suitable for an individual according to his/her constitution. The constitution,
in turn, is determined on the basis of the predominance of
or loss of equilibrium in one or more of the humor, viz.
Gas (Vata), bile (Pitta), or phlegm (Kapha). Based on the
symptoms produced due to excess or deficiency of particular fault (dosha), the Ayurvedic practitioner selects
remedial measures in the form of herbs, plant medicine,
and metal salts.
The present health and healing culture among the
Jats of northwestern India and Pakistan involves an eclectic use of treatments and therapies from several distinct
healing traditions, namely, Ayurveda, Homeopathy,
Unani, and biomedicine. In addition, local healers use a
combination of ideas related to disease causation and
treatment modalities borrowed from a variety of healing
traditions and practices.
779
The Jats in north India continue to believe in numerous mother goddesses, many of whom serve as the names
of diseases, especially those of childhood. Most Jat communities identify two mother goddesses namely, Sitala and
Khasra for smallpox and skin rashes, respectively. In order
to protect children and family members from illness, evil
eyes, and harmful spirits, the Jats tie protective amulets
made of iron, gold, silver, copper, beads, cloths, and strings
on childrens wrists, ankles, and around their necks
(Freed & Freed, 1993). Beliefs associated with evil spirits
are more common among Jat women than among Jat men.
More commonly in rural Jat communities, diseases like
tetanus, diarrhea, and measles are often associated with
spirit possession and evil eye. Jat women are expected to
worship local deities and observe charms (totkas) in order
to ward off evil spirits and cure diseases among family
members, especially children (Chowdhry, 1994).
SEXUALITY
AND
REPRODUCTION
780
Jat
Infancy
A great deal of demographic, ethnographic, and health
research among northwestern peasant communities in
India, especially among the Jats, indicates sex differentials
in health and mortality during infancy and early childhood.
While several factors have been identified as causing excessive female mortality during infancy and early childhood,
culturally prescribed patterns of son preference and daughter neglect are considered important proximate determinants of gender differentials in morbidity and mortality
among the Jats. The mortality patterns among the Jats correspond with the South Asian pattern of sex differentials:
males generally have equal or slightly higher mortality rates
than females during the first month of life and lower
mortality rates than females after the first month of life.
Ethnographic research suggests that Jat parents tend
to show preferential treatment for sons, generally investing more household resources toward ensuring their survival. Infant girls are considered relatively more resistant
to disease than an infant boy. A daughter is often equated
with kikkara thorny bush that grows wild and does not
require much nurturing.
Childhood
Gender role socialization begins very early in the life of
a Jat individual, often before children are even aware of
their sexual identity. This may happen even before the
development of an internal motive for conforming to sex
role standards. Jat parents and the community play
important roles in reinforcing norms of expected behavior. Jat girls, generally socialized under strict patriarchal
control, came to understand their limited sex role options
and the rigid patterning of these options.
For the young girl discrimination in terms of nutrition and health care allocation occurs in conjunction with
a constant reinforcement of her gender identity.
The individual and additive effects of cultural and
biological factors invariably lead to lower survival rates
for Jat girls than boys, and negatively influence their
overall growth and development patterns, reproductive
health, and fertility (Khanna, 1997).
Adolescence
Son preference and daughter neglect has continued among
the Jats in spite of increased urban contact as well as access
781
782
Adulthood
Jats prefer early marriage, especially in the case of girls.
Among the Shahargaon Jats, the average age at marriage is
16 years (Khanna, 1995). Jat parents observe strict patterns
of subcaste (gotra), village, and at times, regional exogamy
while arranging marital alliances for their children. Jats practice patrilocalitya cultural practice that requires the bride
to leave her natal home after marriage in order to live with
her husbands family. The adjustment process for the
young Jat bride in her affinal home involves meeting conjugal responsibilities, often from a position of complete ignorance, and dealing with the daily demands of the household
chores. She is expected to maintain veil (purdah or ghunghat) from senior men in the family and the community.
Expectations to produce a son usually result in early
pregnancy among the Jats. Early marriage followed by
early childbearing increases the risk of obstructed labor
and reproductive morbidity. Due to increase availability
of health care in most rural and urbanizing areas of northwestern India, the Jats generally seek prenatal and perinatal health care from state-sponsored health clinics. Jat
women in the household are primarily responsible for
health care during and after pregnancy.
Among the Jats, sex and gender are contrasting concepts. Jat parents do not think of their children only in
terms of a childs sex because what concerns them most
is whether the child is a son (beta) or daughter (beti).
These terms invoke an entire set of cultural values and
behavioral norms associated with the sex of the child.
While the birth of a son is considered a good gift or an
indication of the familys good fortune, that of a daughter is considered a sign of distress and anxiety. Some
of the commonly used proverbs expressing strong son
preference among the Jats include:
The number of sons is equal to the number of sticks and the number
of sticks determines the amount of land controlled by a family (jitney
ladke utney lath, jitney lath utna kabza); and selling milk is equivalent
Jat
to selling a son (jisney gharka dudh baech diya usne apna puut
baech diya).
The Aged
Older members in the Jat community command considerable social prestige and respect. The Jats prefer to live
in joint families with older men as heads of the household. While men enjoy high status and respect in the family primarily by virtue of their gender, Jat women have to
783
REFERENCES
Bowles, G. T. (1977). The people of Asia. London: Weidenfeld and
Nicolson.
Chowdhry, P. (1994). The veiled women: Shifting gender equations in
rural Haryana 18801990. New Delhi: Oxford University Press.
Datta, N. (1999). Forming an identity: A social history of the Jats. New
Delhi: Oxford University Press.
Freed, R. S., & Freed, S. A. (1993). Ghosts: Life and death in north
India. Washington, DC: The American Museum of Natural History.
Fuchs, S. (1974). The aboriginal tribes of India. Delhi: Macmillan
India.
Ibbetson, D. (1916). Punjab castes. Lahore: India Press.
Khanna, S. K. (1995). Gender discrimination, maternal health, and
pregnancy outcomes in north India. Doctoral dissertation,
Syracuse University.
Khanna, S. K. (1997). Traditions and reproductive technology in an
urbanizing north Indian village. Social Science & Medicine, 44(2),
171180.
Khanna, S. K. (2001). Shahri Jat and dehati Jatni: The Indian peasant
community in transition. Contemporary South Asia, 10(1), 3753.
Kolenda, P. (1987). Regional differences in family structure in India.
Jaipur: Rawat Publications.
Lewis, O. (1958). Village life in northern India. Urbana: University of
Illinois Press.
Pradhan, M. C. (1966). The political system of the Jats of northern
India. Bombay: Oxford University Press.
Qanungo, K. (1982). History of the Jats: Contribution to the history of
northern India. New Delhi: Surajmal Memorial Education Society.
Westphal-Hellbusch, S., & Westphal, H. (1964). The Jat of Pakistan.
Berlin: Duncker & Humbolt.
Lijiang Naxi
Sydney Davant White
ALTERNATIVE NAMES
Currently, the Lijiang Naxi and the Yongning Naxi (or
Mosuo) are officially classified by the Peoples Republic of
China government as members of the same Naxi minority
nationality, with the Mosuo designated as a branch of the
Naxi; however, both groups see themselves as significantly
different peoples. This entry focuses on the Naxi of the
Lijiang area, specifically the Naxi of the Lijiang basin.
During the Republican Period (1912 49 CE), the contemporary Naxi of the Lijiang area of the Peoples Republic of
LOCATION
AND
LINGUISTIC AFFILIATION
784
Lijiang Naxi
OVERVIEW
OF THE
CULTURE
785
786
Therapeutic Practices
Prior to 1949, the primary therapeutic epistemology
informing basin Naxi understandings of affliction was the
medicine of systematic correspondence following Paul
Unschulds (1985) termthe classical text-based
humoral therapeutic practice associated with the
Confucian state that serves as the theoretical underpinning of the post-1949 socialist Chinese states formulation of traditional Chinese medicine (TCM). The
hegemony of this epistemology reflects both the degree
Lijiang Naxi
Medical Practitioners
787
MEDICAL PRACTITIONERS
Prior to 1949, basin Naxi practitioners of Chinese medicine (namely, the medicine of systematic correspondence
combined with Chinese herbal pharmaceuticals, acupuncture, and massage techniques) were virtually all male, and
had either acquired their knowledge as apprentices of their
fathers or other older male relatives, or through an apprenticeship with a non-related practitioner usually arranged
by their parents. They started as young boys and gradually
developed expertise over the years through learning from
their masters, reading the classic texts of Chinese medicine, and learning through personal experience.
During the Cultural Revolution, the practitioners in
the basin who were recruited to staff the brigade clinics
and to carry out the practice of integrated medicine were
generally from one of three backgrounds. Middle-aged
and younger doctors and medical technicians trained in
788
Lijiang Naxi
789
790
Lijiang Naxi
SEXUALITY
AND
REPRODUCTION
791
792
Lijiang Naxi
References
REFERENCES
Bossen, L. (2002). Chinese women and rural development: Sixty
years of change in Lu village, Yunnan. Lanham: Rowman and
Littlefield.
Chao, E. K. (1995). Depictions of difference: History, gender, ritual and
state discourse among the Naxi of Southwest China. Doctoral dissertation, University of Michigan.
Chao, E. K. (1996). Hegemony, agency, and re-presenting the past: The
invention of dongba culture among the Naxi of Southwest China.
In M. J. Brown (Ed.), Negotiating Ethnicities in China and Taiwan
(pp. 208239). Berkeley: Center for Chinese Studies and Institute
of East Asian Studies.
Chao, E. K. (1999). The Maoist shaman and the madman: Ritual bricolage, failed ritual, failed ritual theory. Cultural Anthropology,
14(4), 505534.
Croizier, R. C. (1968). Traditional medicine in modern China: Science,
nationalism, and the tensions of culture change. Cambridge, MA:
Harvard University Press.
Croizier, R. C. (1976). The ideology of medical revivalism in modern
China. In C. Leslie (Ed.), Asian Medical Systems: A comparative
study (pp. 341355). Berkeley: University of California Press.
Diamond, N. (1988, January). The Miao and poison: Interactions on
Chinas southwest frontier, Ethnology XXVII, 1, 125.
Farquhar, J. (1994). Knowing practice: The clinical encounter of
Chinese medicine. Boulder, CO: Westview Press.
Farquhar, J. (1998). Re-writing traditional medicine in Post-Maoist
China. In D. Bates (Ed.), Knowledge and the Scholarly Medical
Traditions (pp. 251276). Cambridge: Cambridge University
Press.
Furth, C. (1986). Blood, body and gender: Medical images of the female
condition in China, 16001850. Chinese Science, 7, 4366.
Furth, C. (1987). Concepts of pregnancy, childbirth, and infancy in
Ching Dynasty China. Journal of Asian Studies, 46(1), 735.
Furth, C. (1999). A flourishing Yin: Gender in Chinas medical history,
9601665. Berkeley: University of California Press.
Goullart, P. (1955). Forgotten kingdom. London: John Murray.
793
Hansen, M. H. (1999). Lessons in being Chinese: Minority education
and ethnic identity in Southwest China. Seattle: University of
Washington Press.
Harrell, S. (1995). Introduction: Civilizing projects and the reaction to
them. In S. Harrell (Ed.), Cultural Encounters on Chinas Ethnic
Frontiers (pp. 336). Seattle: University of Washington Press.
He, Z. (1994). Dui Mosuo Muxi Jiating de zai renshi (Rethinking the
Mosuo matrilineal family). In Li Xiaojiang, Zhu Hong, & Dong
Xiu Yi (Eds.), Xingbie Yu Zhongguo (Gender and China). Beijing:
Shenghuo, Du Shu, Xin Zhi (Life, Schooling, New Knowledge
Press).
He, Z. (1999). Shengcun he Wenhua de Xuanze: Mosuo Muxizhi Jiqi
Xianzai Bianqian (The choice of survival and culture: Mosuo
matrilineal system and contemporary change). Kunming, PRC:
Yunnan Educational Publishing House.
Hsu, E. (1992). Transmission of knowledge, texts, and treatment in
Chinese medicine and qigong: Three Settings in Kunming City,
P.R.C. Doctoral dissertation, Cambridge University.
Kleinman, A. (1980). Patients and healers in the context of culture: An
exploration of the borderland between anthropology, medicine,
and psychiatry. Berkeley: University of California Press.
Kleinman, A. (1986). Social origins of distress and disease: Depression,
neurasthenia, and pain in modern China. New Haven: Yale
University Press.
Kristof, N. D. (1993). China is trying to stifle scandal over reused hypodermic needles. New York Times, May 5, 1993.
Mathieu, C. (1996). Lost kingdoms and forgotten tribes: Myths, mysteries and mother-right in the history of the Naxi nationality and
the Mosuo people of Southwest China. Doctoral dissertation,
Murdoch University.
Mathieu, C. (1998). The Moso Ddaba religious specialists. In
M. Oppitz & E. Hsu (Eds.), Naxi and Moso Ethnography
(pp. 209234). Zurich: Volkerkundemuseum Zurich.
Mathieu, C. (2000). Myths of matriarchy, the Mosuo and the kingdom
of women. In C. Brewer & A.-M. Metcalf (Eds.), Researching the
fragments: Histories of women in the Asian context. Manila:
New Day.
McKhann, C. F. (1992). Fleshing out the bones: Kinship and cosmology in Naqxi religion, Volume One. Doctoral dissertation,
University of Chicago.
McKhann, C. F. (1995). The Naxi and the nationalities question. In
Stevan Harrell (Ed.), Cultural Encounters on Chinas Ethnic
Frontiers (pp. 3962). Seattle: University of Washington Press.
Mueggler, E. (1991). Money, the mountain, and the state: Power in a
Naxi village. Modern China, 17(2), 188226.
Mueggler, E. (2001). The age of wild ghosts: Memory, violence, and
place in Southwest China. Berkeley: University of California
Press.
Potter, S. H., & J. M. Potter. (1990). Chinas peasants: The anthropology of a revolution. Cambridge: Cambridge University Press.
Rees, H. (2000). Echoes of history: Naxi music in modern China.
Oxford: Oxford University Press.
The Revolutionary Health Committee of Hunan Province (RHCHP).
(1977). A barefoot doctors manual. Seattle: Cloudburst Press.
Rock, J. F. (1947). The Ancient Na-Khi kingdom of Southwest China
(Volumes 1 & 2). Cambridge: Harvard University Press.
Rock, J. F. (1963). The land and culture of the Na-khi tribe of the
ChinaTibet Borderland. Wiesbaden: Franz Steiner Verlag.
794
Malagasy
Scheid, V. (1995). Transformation of the non-substantial: Developing traditional medicine in contemporary China. Paper presented at the Lu
Gwei-djen Memorial Workshop on Innovation in Chinese Medicine.
Needham Research Institute, Cambridge, U.K., March 1995.
Shih, C.-K. (1993). The Yongning Moso: Sexual Union, household
organization, gender and ethnicity in a matrilineal duolocal society
in Southwest China. Doctoral dissertation, Stanford University.
Shih, C.-K. (1998). Mortuary rituals and symbols among the Moso. In
M. Oppitz & E. Hsu (Eds.), Naxi and Moso Ethnography
(pp. 103125). Zurich: Volkerkundemuseum Zurich.
Shih, C.-K. (2001). Genesis of marriage among the Moso. Journal of
Asian Studies, 60, 381412.
Sivin, N. (1987). Traditional medicine in contemporary China. Ann
Arbor: Center for Chinese Studies, University of Michigan.
Unschuld, P. U. (1985). Medicine in China: A history of ideas.
Berkeley: University of California Press.
Walsh, E. R. (2001a). The MosuoBeyond the myths of matriarchy:
Gender transformation and economic development. Doctoral dissertation, Temple University.
Walsh, E. R. (2001b). Living with the myth of matriarchy: The Mosuo
and tourism. In T. Chee-Beng, S. C. H. Cheung, & T. Hui (Eds.).
Anthropology, Tourism, and Chinese Society. Bankok: White Lotus
Press, 93124.
Weng, N. (1993). The Mother House: The symbolism and practice of
gender among the Naze in Southwest China. Doctoral dissertation,
University of Rochester.
Malagasy
Janice Harper
ALTERNATIVE NAMES
The people of Madagascar are known collectively as the
Malagasy. This chapter is based on fieldwork conducted
among the Malagasy living in the southeastern forests of
Madagascar who are ethnically identified as both Tanala
and Betsileo. Although treated as comparative and mutually exclusive ethnic groups, such social groupings are
misleading. Tanala (People of the Forests) is a performative identity; those who live in the forests and engage
in the forest economy are Tanala, whereas Betsileo is
an administrative division of the pre-colonial Merina
autocracy. Hence, for many living in the southeastern
forests of Madagascar, Betsileo represents ones ancestry,
while Tanala represents ones contemporary social
identity. Moreover, ethnic identification is problematic
because those so labeled do not necessarily think of
795
OVERVIEW
OF THE
CULTURE
796
Malagasy
heavily from the world market to finance poorly conceived national industries that failed to succeed, including soy and flour mills, despite the fact that the Malagasy
do not produce soy or wheat. Consequently, notwithstanding his proclaimed resistance to foreign influence,
Madagascar became the first socialist country to accept
the economic liberalization criteria of the IMF. Structural
adjustment policies included the continual devaluation of
the Malagasy franc (including by nearly half in 1987),
drastic cuts in the social sector such as health care and
education, and privatization of industry, banking, and
other financial institutions. These policies were aimed at
expanding foreign economic investment in the country,
but caused rapid inflation, severely limited access to biomedical health care, and contributed to the decline of educational standards in the rural areas (see Hewitt, 1992 on
structural adjustment in Madagascar).
Ratsirakas reign over the people collapsed following the massacre of peaceful demonstrators outside his
palace in 1991. In 1993 physician Albert Zafy was democratically elected as president, but by 1996 he was
impeached for abuse of power and Ratsiraka elected to
return to office, this time as a humanist ecologist, calling for international investment in the countrys ecological resources. The islands species diversity has led it to
be regarded as one of the worlds biodiversity hotspots,
drawing considerable international aid and attention to its
endangered flora and fauna, most notably the many
species of lemur that exist no place else on earth.
In 2001, Ratsiraka lost a bid for re-election when the
self-made millionaire mayor of Antananarivo, Marc
Ravalomanana, narrowly defeated him. When Ratsiraka
refused to concede defeat and declared martial law, mass
protests ensued, leading to an economic paralysis of the
country. A recount of the electoral results was ordered,
and Ravalomanana was sworn in as president in May of
2002. The African Union refused to accept the presidency
as legitimate and suspended Madagascar from the
African Union, leading to a new election in December of
2002. When Ravalomanana clearly won a majority of the
votes in the second election, Madagascar was reinstated
into the African Union. Ravalomanana has made reducing poverty and inequalities in the distribution of wealth
priorities of his presidency, and has continued to endorse
the goals of environmental conservation. Toward these
efforts, he has called for increasing attention to ecological
tourism as a strategy toward economic self-sufficiency
among the Malagasy.
Medical Practitioners
797
MEDICAL PRACTITIONERS
A wide spectrum of medical practitioners can be found in
Madagascar, but access to western biomedical practitioners,
798
Malagasy
SEXUALITY
AND
REPRODUCTION
799
800
Malagasy
Infancy
The new mother will stay with the child in the confines
of the home for up to 2 months, venturing outside only to
relieve herself. This period of confinement has been
growing shorter and shorter, as womens agricultural
work must be resumed and the heat of the home may
become unbearable (with little or no ventilation or light).
I heard several stories of new mothers becoming ill from
ghost sickness, requiring them to terminate their confinement early, in order to appease the ghosts.
Women try, if possible, to give birth in their natal
home. When this occurs, there will be a celebration to
mark the departure of the child and mother from the village, before their return to the womans marital residence.
Children are nursed into their second year. They are
toilet trained at a young age, often less than a year when
diapers are not available. The urine of a baby is considered benign and laughter is the usual response to a child
urinating in the home or on an adult. Although women are
the primary caretakers of children, brothers, fathers, and
grandfathers are very active caregivers, and do not hesitate to hold or watch young infants or children when the
mother is unavailable.
Children who are seriously ill or handicapped are
loved and cared for, although I did witness several
instances of serious neglect of very ill children, with considerable disagreement as to why they were neglected
(see Harper, 2002).
Measles are a grave concern for young infants, as is
possession by ghosts. Ombiasa prepare special amulets
for protection. Chronic disorders, such as scabies and respiratory problems, are so ubiquitous that they do not
cause much alarm. Indigenous medicines may or may not
be used. When pharmaceutical medicines are available,
they are used.
Childhood
Children are well loved and cared for in Malagasy societies. Among the forest farmers of the southeastern
region, childhood was a time of great joy, imaginative
play, and hard work. Children learn at an early age to care
for younger siblings, to help their parents with household
chores, to labor in the fields, and to go to school.
Learning the responsibilities and skills associated with
rural living begins early. Children are taught to use large
knives in many cases before they can even walk, and once
801
Adolescence
Boys are circumcised from the ages of about 4 to 14.
Circumcision is based more on availability of the circumciser than any culturally ascribed time period,
although this may have been otherwise in the past, or may
differ in other regions. I witnessed one circumcision
ceremony, in which all uncircumcised boys over the age
of about 4 were publicly circumcised in an unannounced
ceremony. Following circumcision, they were given
toaka gasy to drink and set down on the ground. Every
boy thus circumcised developed serious infections,
requiring the use of antibiotic creams and, in some cases,
oral antibiotics (requiring the father and the infected boy
to hike an hour and a half over the hilly terrain to the nearest hospital to get a prescription for antibiotics requiring
a substantial portion of the household income).
Adolescence is a period of increasing responsibility
and preoccupation with the opposite sex. Girls go to the
market every week, in hopes of meeting a boy from
another village. Boys also attend markets, and in many
cases, begin drinking. Alcohol use and abuse can become
a serious problem at this stage. Drinking, and sexual
promiscuity, is a concern among a number of parents who
regard these habits as new and potentially destructive to
both the family and the culture, although it is unclear how
new such habits are.
Many girls are mothers by their mid- to late-teens,
and if they are unmarried, they remain in their natal
household and receive considerable support from their
families. Nonetheless, economic hardships are common,
and adults recognize early pregnancy as increasing a
daughters economic vulnerability.
Adulthood
Domestic abuse does occur, but a woman is not expected
to endure it. Should her husband abuse her, the community will support her and the fokonolona (village-level
council) may intervene. Nonetheless, divorce may well
have significant economic repercussions, leading a
woman to endure an unhappy or abusive marriage despite
its unacceptability. Divorce means that a woman is
expected to return to her natal village. Although she will
theoretically have rights to one third of her parents land,
802
Malagasy
The Aged
Age is regarded with considerable respect, and is considered a time when ones work in the fields is expected to
give way to domestic responsibilities. Older people are
important to the household economy by caring for children, cooking, cleaning the home and compound, and
References
803
REFERENCES
Astuti, R. (1995). People of the sea: Identity and descent among the
Vezo of Madagascar. Cambridge: Cambridge University Press.
Beaujard, P. (1983). Princes et paysans: Les Tanala de lIkongo: Un
espace social du sud-est de Madagascar. Paris: Editions
LHarmattan.
Bloch, M. (1989). Ritual, history and power: Selected papers in anthropology. London and Atlantic Highlands: The Athlone Press.
Campbell, G. R. (1985). The role of the London Missionary Society in
the rise of the Merina Empire 18101861 (A contribution to the
economic history of Madagascar). Swansea: University College.
Covell, M. (1987). Madagascar: Politics, economics and society.
London and New York: Frances Pinter.
Dubois, S. J. (1938). Monographie des Betsileo (Madagascar). Paris:
Institut dEthnologie.
Hanson, P. (1997). The politics of need interpretation in Madagascars
Ranomafana National Park. Doctoral Dissertation, University of
Pennsylvania.
Harper, J. (2002). Endangered species: Health, illness and death among
Madagascars people of the forest. Durham: Carolina Academic
Press.
Hewitt, A. (1992). Madagascar. In Structural adjustment and the
African farmer. Alex Duncan & John Howell (Eds.). London:
Heinemann
Kightlinger, L. K. (1993). Mechanisms of Ascaris lumbricoides
overdispersion in human communities in the Malagasy rainforest.
Doctoral Dissertation, University of North Carolina at Chapel Hill,
North Carolina.
Kottak, C. (1971a). Cultural adaptation, kinship, and descent in
Madagascar. Southwestern Journal of Anthropology, 27(2), 129147.
Kottak, C. (1971b). Social groups and kinship calculation among the
southern Betsileo. American Anthropologists, 73, 178193.
Kottak, C. (1980). The past in the present. Ann Arbor: The University
of Michigan Press.
Larson, P. M. (1996). Desperately seeking the Merina (Central
Madagascar): Reading ethnonyms and their semantic fields in
African identity histories, Journal of Southern African Studies,
22(4), 541560.
Larson, P. M. (2000). History and memory in the age of enslavement:
Becoming Merina in highland Madagascar, 17701882.
Portsmouth, NH: Heinemann Social History of Africa Series.
Linton, R. (1933). The Tanala: A hill tribe of Madagascar. Chicago:
Field Musuem of History.
New Africa (2001). Madagascar Health and Population, available
online at: www.newafrica.com/profiles/healthpopulation
804
Malays
Malays
Ronald Provencher
ALTERNATIVE NAMES
LOCATION
AND
LINGUISTIC AFFILIATION
805
OVERVIEW
OF THE
CULTURE
806
Malays
Medical practitioners
807
MEDICAL PRACTITIONERS
There are four commonly recognized categories of traditional medical practitioners: bidan, bomoh, dukun, and
pawang. A bidan is comparable to a midwife in cosmopolitan medicine, but she is more. She helps pregnant
women prepare for giving birth, attends and directs the
birth, and deals with postpartum problems of the mother
and child. She treats childrens illnesses and female
health problems. Any bidan knows a great deal about diet
and the humoral qualities of foods. Most urban and many
rural Malay women now give birth in clinics or hospitals;
but even urban women consult with traditional bidan in
such matters as diet, bathing, and positioning the fetus for
easier birth, or preventing pregnancy after intercourse.
In southern Thailand, Malaysia and Indonesia, traditional
bidan are often incorporated into national health
programs through additional training, licensing, and
involvement in community clinics.
The dukun, who may be male or female, is a
general practitioner in terms of knowledge; but may be
recognized as a specialist (tukang) who is skillful in
particular treatmentsfor example: tukang urut (massage), tukang sunat (circumcision), tukang tulong or
tukang patah (setting broken bones). Also, a commonly
used term for a bidan (midwife) is dukun beranak
(birthing healer). In some communities, successful students of a bomoh are made dukun in a formal ceremony
led by the bomoh who instructed them. And the ritual is
attended by members of the community. Dukun is a
general term for a traditional healer of any sort.
Bomohs are more knowledgeable and powerful than
dukuns, especially in treating illnesses caused by social,
psychological, and spiritual problems. They are general
practitioners with a specialization in therapies similar to
psychiatry in cosmopolitan medicine. Most bomohs utilize a powerful theatrical therapeutic routine, main puteri
(playing the princess), which varies depending on
808
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Many aspects of traditional Malay medicine are known to
ordinary persons. Malay adolescents and adults usually
know how to stop the flow of blood from wounds and
Malays
809
810
Malays
each lime, in turn, which fall into a bowl of water that has
absorbed powerful words spoken by the bomoh. Some
slices float peel-side up and others float peel-side down.
The sequence and proportion of each of these two possibilities signals whether or not the bomoh will take the
case. The details vary, of course (Provencher, 1984;
Werner, 1986).
If the bomoh decides to take the case, she or he
usually prescribes a routine of prayer and bathing, using
bomoh-blessed water and herbs as additives to the bath
water, and the patient is given instructions concerning
diet, and scheduling of work and other activities. The
patient or a relative is delegated to purchase ingredients
(ramuan) to be used for treatment at home and for the
next session. In subsequent sessions, the bomoh will
probably: (1) administer herbal medicines that purge the
contents of stomach and bowels; (2) provide other
blessed ingredients to be added to bath water; (3) outline
a course in religious devotion; and (4), if the patient completes the course of treatment successfully, celebrate success with a small ritual feast (kenduri nasi guru) with
patient and family providing a special tray to feed any
good spirits involved and a gift/payment to the bomoh.
The beginning and ending of treatment, the divining
of whether or not the bomoh can cure the victims illness
and the payment/celebration in successful cases are standard. Details of diagnosis/treatment vary according to the
perceived cause of the illness, and according to the routines of particular bomohs. There are many different
Malay psychiatric therapies, sometimes glossed in the
literature as playing the princess (main puteri), in which
the bomoh begins to pray, goes into a trance, speaks in
another voice, collapses, revives, and magically extracts
dirty things (kotoran) from the body and soul of the
patient. The dirty extracted things vary: oddly shaped
artifacts and thorns, parts of insects, hair, dirt, and rusty
needles. And the means of extraction vary too, including:
grasping odd shaped objects and insect parts out of thin
air, collecting hundreds of red hairs by rubbing a ball of
semi-dry dough over the body of the patient, collecting
rusty needles and dirt by rubbing the body of the patient
with an unbroken raw chicken egg, and collecting dirt and
objects by rubbing the body of the patient with a previously unbroken betel nut pod. In all of these, the symbolism is that of unnatural, intrusive, or dirty things
and food. From a Malay perspective, these broken dirty
things symbolize broken and improper social relationships. Bomoh, patients relatives and friends, and even the
SEXUALITY
AND
811
REPRODUCTION
Knowledge of sexual activity is gained early and naturally in the context of familiar and relaxed back region
behavior of the Malay house, where dress, speech, and
behavior are extremely relaxed and casual. Older children, especially girls, take care of their younger siblings.
If a woman has no daughter, a son often takes the role of
mothers helper, especially in the care of babies and
infants. Malay children know the anatomy of gender and
where babies come from. Most Malay couples share
active and imaginative sex lives, and joke about the formality of what they imagine to be the standard position
for sexual intercourse in English culture. Nonetheless
adolescent girls are secluded and their virginity is protected, as much as possible, until they are married.
Pregnancy before marriage is a matter of scandal. And,
under Islamic law, a private meeting of a man and woman
who are not married to each other constitutes the crime of
khalwat (close proximity), which is punished under the
jurisdiction of the Islamic courts. Adolescent boys and
men, however, are expected to be sexually promiscuous
before, and even after marriage.
Marriages are supposed to be arranged, and sometimes they are. But beginning in the 20th century, when
Malays and most of the rest of the world began to experience rapidly increasing secularization through mass
media, individuals more frequently exercised personal
choice regarding marriage. For example, interviews in the
1960s of elderly Malay women who had migrated to
Kuala Lumpur from Indonesia in the first three decades
of the 20th century revealed that many had married more
than once and that most of their marriages had been with
men of their own choice. Nonetheless, even in the 1990s,
the ritual details of most Malay marriages were traditional and they projected images of arranged marriage.
812
Infancy
A womans first baby, female or male, receives a great
deal of attention from adult relatives, neighbors, and
friends of the family. Subsequent babies receive less
attention, depending on the spacing of births, and they are
tended by older siblings. Roles of boys and girls begin to
diverge at five or six years of age. Psychological problems in later life are more common among the eldest and
the youngest of a sibling set, perhaps because as infants
and children their experiences in the ranked relations
between siblings were less balanced, lacking deep experience either of being junior or of being senior in a society where rank is the most basic aspect of social
relationships (Provencher, 1999).
Female babies are brought symbolically into the fold
of Islam at a much earlier age and with less physical
trauma and social fanfare than males. Forty days after a
Malay baby girl is born, adult female neighbors and
relatives gather at the mothers home to celebrate the end
of the postpartum period of the new mother and to perform a ritual clitorodectomy (actually a clitoridotomy) of
the newborn baby girl (Laderman, 1987). In this Malay
ritual, unlike the equivalent ritual in some other Islamic
societies, the clitoris is not removed or even damaged.
It is barely scratched. The physiologically equivalent traditional entrance to Islam for Malay boys, circumcision
(sunat), comes at a later age and involves more physical
and psychological trauma.6
Childhood
By the mid 1960s most of the serious epidemic diseases
of childhood had been controlled or mitigated by public
health systems of the post-colonial governments of
Malays
Adolescence
Adolescence is not a clearly marked age in traditional
Malay culture. For example, most males are circumcized
after religious instruction, sometime between 9 and 13
years of age, but the range is 6 to 20 years of age.
Traditionally, the circumcision ritual and feast (kenduri
bersunat) is a public event, sometime hosted by a single
household with one or several boys and sometimes by
several households in a neighborhood. In the latter case,
an arbor or open-wall tent may be erected in an empty
space near the street to ease access for on-lookers and
guests. This also reduces costs and labor for each household, and the ritual of the feast and the actual operation
of circumcision of each boy can be viewed by all who
attend. After prayer, the circumcision expert (tukang
sunat or mudim) pulls the foreskin over the end of the
glans of the penis, clamps the foreskin with a traditional
implement, and cuts off the excess foreskin with a bamboo knife. Then he applies a medicinal compound (obat
tasak) and bandages (tali kundang). The boys, now fully
Islamic males, lie down on cots or bedding dressed only
in their sarongs, and are on public view the first day.
Night-lights are lit in their houses until the wounds heal,
Notes
813
several days later. Health problems attending circumcision are rare, although newspapers occasionally print
stories about a slip of the knife by an incompetent
tukang sunat.
There is no similar coming of age celebration for
girls. The onset of menarche does not define the beginning or ending of adolescence for Malay females.
However, a part of marriage ritual involves an exhibition
of the brides ability to read and recite the Koran; and
some female bomohs have said that this is more equivalent to male circumcision than the cutting of the clitoris,
because it is evidence of being fully Muslim. School
systems in southern Thailand, Malaysia, and Indonesia
provide another, institutional means, by which Malays
discuss the stages (darjah) between childhood and
adulthood.
The virginity of girls until their first marriage is
closely protected through modest dress and careful
chaperoning. And the possibilities of being attractive to
boys through fashionable clothes are still dampened by
the common requirement of school uniforms for public as
well as private schools in Southeast Asia. Nonetheless,
adolescents are regarded to be naturally gatal (itchy or
easily sexually aroused), flirtations occur, and girls
become pregnant. The pregnancy may lead to marriage,
an early abortion, or birth, and informal adoption of the
child by an adult relative. Adoption is not encouraged in
Islamic law, but as a traditional practice among relatives
in Malay society it is fairly common (McKinley, 1975).
Young unmarried men may be seduced or be driven
sexually mad by a woman through her feeding him
perfumed rice (nasi uap), a common diagnosis of
young men caught engaged in lewd sexual behavior in
public. Adolescent girls, too, are thought to be driven
crazy by love magic. The cure may involve ritual discovery of the real perpetrator and/or sending the victim to
live with a relative in a distant place.
Prostitution is common in towns and cities, and
venereal diseases and AIDS are serious health problems.
But these are dealt with almost entirely within the context
of the cosmopolitan health services.
Adulthood
NOTES
The Aged
The aged are revered in formal courtesy and are commonly cared for by their children in their last years. This
care of elderly parents is often given as a reason for having children. Men are viewed as more likely than women
to become senile, and women who live beyond childbearing years usually live long lives.
814
2.
3.
4.
5.
6.
REFERENCES
Andaya, B. W., & Andaya L. Y. (1982). A history of Malaysia. London:
Macmillan Publishers.
Bellwood, P. (1985). Prehistory of the Indo-Malaysian Archipelago.
North Ryde, N.S.W.: Academic Press Australia.
Endicott, K. M. (1970). An analysis of Malay magic. Oxford University
Press.
Gimlette, J. D. (1971). Malay poisons and charm cures. Kuala Lumpur:
Oxford University Press.
Golomb, L. (1985). An anthropology of curing in multiethnic Thailand.
Illinois studies in anthropology no. 15. Urbana & Chicago:
University of Illinois Press.
Hamidy, U. U. (1986). Dukun Melayu Rantau Kuantan Riau. Pekan
Baru, Riau Islands: Bagian Proyek Penelitian dan Pengkajian
Kebudayaan Melayu (Melayulogi). Departemen Pendidikan dan
Kebudayaan.
Hartog, J. (1972a). Sibling rank of Malay psychiatric patients and
juvenile delinquents. The Southeast Asian Journal of Tropical
Medicine and Public Health, 3.1, 124137.
Hartog, J. (1972b). The intervention system for mental and social
deviants in Malaysia. Social Science & Medicine, 6, 211220.
Heggenhougen, H. K. (1980). Bomohs, doctors and sinsehs-medical
pluralism in Malaysia. Social Science & Medicine, 14B, 235244.
Heggenhougen, H. K., & Navaratnam, V. (1979). A general overview on
the practices relating to the traditional treatment of drug dependents
Malays
in Malaysia. Penang: National Drug Dependence Research Centre,
Universiti Sains Malaysia.
Karim, W.-J., (1984). Malay midwives and witches. Social Science &
Medicine, 18.2, 159166.
Kasimin, A. (1995). Santau sebagai satu cabang ilmu sihir. Kuala
Lumpur: Percetakan Watan Sdn. Bhd.
Laderman, C. (1987). Wives & midwives: Childbirth and nutrition in
rural Malaysia. Berkeley: University of California Press. (first
published 1983).
Laderman, C. (1992a). Malay medicine, Malay person. In M. Nichter
(Ed.), Anthropological approaches to the study of ethnomedicine
(pp. 191205). Amsterdam: OPA.
Laderman, C. (1992b). A welcoming soil: Islamic humoralism on the
Malay Peninsula. In C. Leslie & A. Young (Eds.), Paths to Asian
medical knowledge (pp. 272288). Berkeley: University of
California Press.
McKinley, R. H. (1975). A knife cutting water: Child transfers and
siblingship among urban Malays. Doctoral dissertation in anthropology. The University of Michigan.
Provencher, R. (1971). Two Malay worlds: Interaction in urban and
rural settings. Research monograph no. 4. Berkeley: University of
California.
Provencher, R. (1979). Orality as a pattern of symbolism in Malay
psychiatry. In A. L. Becker & A. A. Yengoyan (Eds.), The imagination of reality: Essays in Southeast Asian coherence systems.
Provencher, R. (1984). Mother Needles: Lessons on inter-ethnic
psychiatry in Malaysian society. Social Science & Medicine, 18.2,
139146.
Provencher, R. (1999). Order in the Malay house: Malay kin categories,
ethnic ranks, and the unconventional behavior of toyols. In
L. W. Aragon & S. D. Russell (Eds.), Structuralisms transformations: Order and revision in Indonesian and Malaysian societies.
Tempe, AZ: Program for Southeast Asian studies monograph
series.
Provencher, R. (2001). Malaysias mad magazines: Images of females
and males in Malay culture. In J. A. Lent (Ed.), Illustrating Asia.
Honolulu: University of Hawaii Press.
Pauka, K. (1998). Theater and martial arts in West Sumatra: Randai and
silek of the Minangkabau. Monographs in international studies.
Southeast Asia series, No. 103.
Resner, G., & Hartog, J. (1970). Concepts and terminology of mental
disorder among Malays. Journal of Cross-cultural Psychology,
1.4, 369382.
Skeat, W. W. (1900). Malay magic: Being an introduction to the folklore
and popular religion of the Malay peninsula. London: Macmillan
and Co. Ltd.
Suparlan, P. (1991). The Javanese dukun. Jakarta: Peka Publications.
First published in Masyarakat Indonesia, Vol. 5, no. 2, 1978,
pp. 195216.
Werner, R. (1986). The practices and philosopies of the traditional
Malay healer. Studia Ethnologica Bernensia, No. 3. Berne: The
University of Berne, Institute of Ethnology.
815
Maori
Mason Durie
ALTERNATIVE NAMES
New Zealand Maori, Tangata Whenua o Aotearoa.
OVERVIEW
OF THE
CULTURE
816
Maori
Epidemiological Trends
Prior to European colonization of New Zealand, the
Maori population was thought to have reached a steady
state, around 150,000 to 200,000. The major life threatening diseases were associated with pneumonia, physical
injury, child birth, and gastro-intestinal disorders. In the
19th century when settlers from Europe began to arrive,
there was a dramatic epidemiological shift. Infectious
diseases, such as typhoid fever, tuberculosis, measles,
and influenza took a heavy toll. A lack of natural immunity combined with the impacts of new lifestyles and
diets led to high mortality rates (in 1854 there were over
4,000 deaths during an epidemic of measles) and depopulation. The situation was aggravated by a high number
of deaths attributable to musketsan innovation that
altered the nature and scale of tribal encounters and
battles with the British imperial troops.
As depopulation was arrested and population
increases began to occur disease patterns changed again.
Although still a major problem until the middle of the
Socio-Economic Circumstances
Collectively Maori are over-represented in lower socioeconomic groupings, but between Maori individuals there
is also considerable variation that is not immediately
obvious when comparisons between Maori and nonMaori are made. At an aggregated level the gap between
Maori and non-Maori is wide but there is also an emerging gap between Maori who are employed and well qualified and those who are unemployed with poor prospects
of employment. Health status and housing standards are
likely to be reflected in that differential. On the other
hand, it is unusual for middle class Maori to live entirely
apart from wider family networks. Each Maori family
group is inevitably represented across the social strata
(Henare, 1994). In this regard it is often difficult to separate socio-economic conditions from cultural and historical factors, even though some individuals may be
relatively well-off.
Educational achievement is probably the most significant determinant of socio-economic advancement and
although achievement levels lag behind non-Maori, there
are signs that Maori are making gains. The establishment
of alternatives such as Khanga Reo (Maori language
early childhood education centers) have provided an
incentive but within the mainstream higher Maori participation rates in early childhood education have also been
evident, growing by over 30% between 1991 and 1993.
However, despite the fact that over 40% of all Maori children under 5 years of age are enrolled in early childhood
services, the growth has failed to keep pace with the
increase in enrollments of non-Maori so that the disparity is not reducing and may even be increasing (Ministry
of Education, 1998).
Educational underachievement is directly linked to
work force participation and Maori levels of unemployment bear out the relationship. As well, and perhaps of
greater significance, Maori unemployment has mirrored
macro-economic swings and has been exacerbated by the
move toward free market policies that occurred in New
Zealand after 1984. Up until 1987 Maori were more
likely than other New Zealanders to participate in the
labor force. However, by 1988 a sudden rise in unemployment had occurred, and continued for a further
4 years reaching 27% in 1992. Non-Maori unemployment
had also increased but the rates were relatively low
(4% rising to 7%) so that the disparity was high, and
remains so (Maori unemployment is now close to 14%,
non-Maori around 5%). Of particular concern is the
relatively high youth unemployment rate; in 1996 the
overall unemployment rate was nearly 8% for all
New Zealanders but 20% for 1519 year olds and 30%
for Maori aged between 15 and 19 years (Childrens
Agenda, 1999).
Because of their dependence on employment,
income levels for Maori are significantly lower than for
non-Maori. But there are other reasons that contribute to
Maori economic disadvantage including long term unemployment, disability and sole parent households (New
Zealand Government, 1994). Maori are over-represented
in all categories of beneficiaries, have uptake rates of
more than three times the non-Maori rate for the domestic purposes benefit and are twice as likely to receive an
unemployment benefit. In 1996 one in every two Maori
women aged fifteen and over received a government benefit compared with one in five non-Maori women, and
45% of Maori women lived in households where the
817
Political Position
In 1840 the British Crown signed the Treaty of Waitangi
with Maori tribes. The Treaty guaranteed continuing
property rights and a degree of tribal autonomy. However,
it was largely ignored and by 1975 Maori discontent with
the appropriation of land, forests and fisheries, together
with concern about the erosion of Maori language and
culture, led to the establishment of the Waitangi Tribunal.
The Tribunal has the authority to investigate grievances
against the Crown for breaches of the principles of the
Treaty and is able to recommend remedial action to the
Government. Over 800 claims have been lodged. A continuing emphasis on the Treaty of Waitangi has created
irritation for many non-Maori New Zealanders but, in the
absence of a written constitution, it remains a pivotal
focus for Maori especially in defining their position in
modern New Zealand and their relationship with the government. The Treaty is included in health legislation and
imposes an obligation of government agencies to actively
address Maori health issues.
Maori have been active participants in the indigenous rights movement and are increasingly seeking
opportunities for greater autonomy, not necessarily as an
independent nation-state but in decision-making over
Maori resources, the delivery of services to Maori, and
full participation in the affairs of the nation. Progress has
been considerable. In the current parliamentary system,
out of 120 members of parliament, 17 are Maori and
seven seats are reserved for members who represent
Maori electorates. Maori are also represented in the judiciary, within the state services, in all professions, and in
the diplomatic corp.
Medical Practitioners
Traditional healing was practiced by tohunga who were
skilled in the use of rongoa (treatments derived from
plant products) and the recitation of karakia (chants used
to encourage healing through spiritual pathways). The
Tohunga Suppression Act 1907 prohibited traditional
healing methods but after the repeal of the legislation in
1964 there has been a resurgence of traditional methods
and a number of healers have established large practices.
There is a greater spirit of co-operation between medical
818
and customary approaches to healing with mutual agreement that all treatments have limitations and a combined
approach may heal mind and spirit as well as body.
Traditional healing as part of the modern health care system is now recognised by government and some contracts
have been offered for traditional healing services
(Ministry of Health, 1999a).
The earliest Maori medical practitioner was Maui
Pomare. He graduated from the American Medical
Missionary College in Chicago in 1899 and was followed
in 1904 by Te Rangi Hiroa, the first New Zealand trained
Maori doctor (Durie, 1998). There are now 198 Maori
medical practitioners, a little over two percent of the total
registered medical practitioners (Health Workforce
Advisory Committee, 2002). Important to the recruitment
of Maori doctors have been affirmative action programs,
first introduced at the University of Otago Medical School
in 1900, and continued at the University of Auckland.
Some 10 to 15 positions are reserved for Maori students
each year. To be eligible for the scheme, students are
required to demonstrate Maori descent, some involvement
with Maori communities, and support from their own tribe.
In 1999 Maori medical practitioners formed an association, Te ORA, that provides a professional focus for
Maori doctors and arranges scientific and cultural enrichment programmes. It also acts as a conduit for information relating to Maori health including opportunities for
practice within Maori communities. Maori medical practitioners occupy a range of positions in hospital and private practice. Generally their clinical skills are
indistinguishable from other practitioners but in addition
they tend to be competent in Maori language and custom
and are able to modify practice to accommodate Maori
health perspectives. Their active involvement in Maori
communities in a variety of roles inevitably confers
expectations that will provide leadership beyond the
health sector and not infrequently places demands on
them that are difficult to meet.
Maori
SEXUALITY
AND
REPRODUCTION
819
Infancy
Although the Maori infant mortality rate declined more
rapidly over the past half century than the rate for nonMaori, it remained significantly higher at 11.6 per 1000
compared with 5.3 per 1000 in 1996. Sudden infant death
syndrome (SIDS) accounted for the major difference but
there are signs that the mortality rate is falling for both
Maori and non-Maori, due mainly to a reduction in SIDS
since 1996 (Ministry of Health, 1999b). During an active
campaign to reduce SIDS a number of risk factors were
highlighted including smoking, lack of breast-feeding,
the prone position, and sleeping with the baby.
Prematurity still remains a significant problem for Maori
infants. It appears to be associated with younger mothers,
smoking, poorer antenatal care, and economic hardship.
Childhood
In Maori children under the age of fifteen years there is
an over-representation in disability statistics; 16% as
against 11%. And under the age of 5 years, Maori
children are more than twice as likely to be hospitalized,
most often because of respiratory diseases. Hearing
impairment, though less prevalent than a decade ago is
still significantly more common among Maori preschoolers, about twice as many fail hearing tests; and
hearing loss is usually detected later at about 4 years
compared to 21 months for a European child (Ministry of
Health, 1998a). Most telling, in 1994 the mortality rate
for Maori under the age of 15 years was 125 per 100,000
820
Adolescence
While mortality rates and hospital admissions tend to
be lower for youth and young Maori adults, the health
risk behaviors are high. They include smoking, alcohol
and drug misuse, motor vehicle accidents, suicide, and
attempted suicide. Between Maori and non-Maori the
risks are similar but the rates show disproportionately
high consequences for Maori, especially Maori males.
The major cause of death remains motor vehicle accidents, often associated with alcohol use. The 1997
mortality rate for all New Zealanders was 14.1 per
100,000 population (Ministry of Health, 1998b); Maori
rates, previously higher, have now converged with nonMaori. But the Maori and non-Maori rates for suicide
have moved in different directions. Suicide was rare
among Maori but over the past decade the rates for both
groups have increased. An analysis of the suicide rates for
the period 195791 showed an overall lower Maori rate;
it was not until 1987 that Maori youth suicides had
reached similar levels to non-Maori (Skegg, Cox &
Broughton, 1995). By 1990 Maori male rates had risen to
10 though non-Maori rates had risen even more to 35. But
by 1993 the differences in youth suicide between Maori
and non-Maori males had virtually disappeared, both
rates being around 33 per 100,000 (Skegg, 1997). Maori
rates have escalated even further so that in 1997 the
Maori male suicide rate (26.8 per 100,000) was 28%
higher than non-Maori while the Maori female rate (8.6
per 100,000) was almost 60% higher than for non-Maori
Maori
Adulthood
Deaths from stroke have been relatively stable for most
New Zealanders but rates for Maori have fluctuated in an
upward direction since 1988 and are now about a third as
high as for non-Maori. Diabetes occurs more frequently
amongst Maori, with a death rate of 47.4 per 100,000,
compared to 10.3 per 100,000 for the total population
(Ministry of Health, 1998b). For Maori and other New
Zealanders the main causes of death are heart disease and
cancer. While Maori mortality rates for both conditions
have improved, the disparities are still significant.
Mortality rates from ischemic heart disease are 257 per
100,000 for Maori and 150 per 100,000 for all
New Zealanders (including Maori) while the gap between
Maori and non-Maori death rates due to cancer has
actually widened since 1988 to 348 per 100,000
compared to 250 per 100,000 (Te Puni Kokiri, 1998).
Since the mid-1970s mental health problems have
emerged as a major health concern. Maori first admission
rates to psychiatric services had surpassed non-Maori
rates for all age groups by 1974. Not only are the rates
of admission different but Maori patients also have different needs, receive different diagnoses, enter hospital
through different pathways, and have higher rates of
readmission. Between 1984 and 1993 the rates for first
admissions for Maori men and women had been steady,
120 per 100,000 for women and 180 per 100,000 for
Maori men. But readmission rates increased, greatly for
men (64%) and significantly for women (28%). While
Maori women and non-Maori women had similar rates
of first admission over the decade, Maori male rates
have been consistently higher by about a quarter than
non-Maori rates.
Drug and alcohol abuse and psychosis accounted for
32% of all Maori first admissions. Admissions for
schizophrenia had increased as well and by 1993 were
two or three times higher than non-Maori rates and rates
for Pacific peoples. Schizophrenia, affective disorders,
and other psychotic disorders made up 40% of Maori
first admissions and 78% of readmissions (Te Puni Kokiri,
1996).
The Aged
Despite several generations of Western influence, Maori
society generally retains a positive view toward aging and
older people (kaumatua), affording them status and at the
same time expecting them to fulfill certain defined roles
on behalf of the whanau (family) and hapu (tribe and
community). In order to meet those obligations, however,
kaumatua must contend with a range of issues that impact
on their health and material well-being. In other words,
the cultural role cannot be isolated from the conditions in
which older Maori live.
Although the great majority of older Maori are not
in dire circumstances, there is nonetheless a relatively
high rate of disadvantage, poverty, and material hardship
levels being around three or four times those of nonMaori. This has major implications because the proportion of older Maori is going to increase quite rapidly over
the next two or three decades.
Age related disability is more likely among older
Maori than non-Maori, affecting one in three (Ministry of
Health, 1994). Major causes of death for this age group
include coronary artery disease, cancer, and respiratory
diseases, while the common reasons for hospitalization
include respiratory disease, cancer, hypertensive disease,
coronary heart disease, cataracts, stroke, and diabetes.
In a survey of 400 older Maori men and women,
821
822
REFERENCES
Childrens Agenda. (1999). Child policy briefing paper. Auckland:
New Zealand Childrens Advocacy Trust.
Davey, J. (1998). Tracking social change in New Zealand from birth to
death iv. Wellington: Institute of Policy Studies, Victoria
University.
Durie, M. (2001). Mauri Ora the dynamics of Maori health. Auckland:
Oxford University Press.
Durie, M. (1998). Whaiora Maori Health development (2nd ed.).
Auckland: Oxford University Press.
Durie, M. (1985). A Maori perspective of health. Journal of Social
Sciences and Medicine, 20(5), 483486.
Dyall, L. (1997). Maori. In Pete M. Ellis & Sunny C. D. Collings
(Eds.), Mental Health in New Zealand From a Public Health
Perspective, Public Health Report Number 3. Wellington: Ministry
of Health.
Health Workforce Advisory Committee. (2002). The New Zealand
Health Workforce A Stocktake of Issues and Capacity 2001.
Wellington: Author.
Henare, D. (1994). Social policy outcomes since the Hui Taumata. In
Kia Pmau Tonu, Proceedings of the Hui Whakapmau Maori
Development Conference. Palmerston North: Maori Studies,
Massey University.
Maori
Horwood, L. J., & Fergusson, D. M. (1998). Psychiatric disorder and
treatment seeking in a birth cohort of young adults. Wellington:
Author.
Ministry of Health. (1994). Four in ten: A profile of New Zealanders
with a disability or long-term illness. Wellington: Author.
Ministry of Health. (1997a). Primary prevention of rheumatic fever.
Wellington: Author.
Ministry of Health. (1997b). Rangatahi sexual wellbeing and reproductive health. Wellington: Author.
Ministry of Health. (1998a). Our childrens health key findings on the
health of New Zealand children. Wellington: Author.
Ministry of Health. (1998b). Progress on health outcome targets 1998.
Wellington: Author.
Ministry of Health. (1999a). Standards for traditional Maori healing.
Wellington: Author.
Ministry of Health. (1999b). Our health our future Hauora Pakari,
Koiora Roa the health of New Zealanders. Wellington: Author.
Ministry of Health. (2001). Priorities for Maori and Pacific health
evidence from epidemiology. Wellington: Author.
Ministry of Health. (2001b). Suicide trends in New Zealand 197898.
Wellington: Author.
New Zealand Government. (1994). Report submitted by the New
Zealand Government to the United Nations world summit for
social development. Wellington.
Skegg, K. (1997). Suicide and Parasuicide. In Ministry of Health (Ed.),
Mental health in New Zealand From a public health perpsective.
Wellington: Ministry of Health.
Skegg, K., Cox, B., & Broughton, J. (1995). Suicide among New
Zealand Maori: is history repeating itself? Acta Psychiatrica
Scandinavia, 106, 17.
Statistics New Zealand. (1998). New Zealand now Maori. Wellington:
Department of Statistics.
Te Awekotuku, N. (1991). Mana Wahine: selected writings on Maori
womens art, culture and politics. Auckland: New Womens Press.
Te Puni Kokiri. (1996). Ng Ia o te Oranga Hinengaro Maoritrends
in Maori mental health 19841996. Wellington: Ministry of Maori
Development.
Te Puni Kokiri. (1997). Oranga Kaumatua: the health and wellbeing of
older Maori people. Wellington: Ministry of Maori Development.
Te Puni Kokiri. (1998). Progress toward closing social and economic
gaps between Maori and Non-Maori. Wellington: Ministry of
Maori Development.
Te Puni Kokiri. (1999). Hauora o te Tinana me ona Tikanga: A guide
for the removal, retention, return and disposal of Maori body
parts, organ donation and post-mortem. Wellington: Ministry of
Maori Development.
Te Puni Kokiri, Ministry of Womens Affairs. (1999). Maori Women in
Focus Titiro Hngai Ka Mrama. Wellington: Ministries of Maori
Development and Womens Affairs.
823
Matsigenka
Carolina Izquierdo and Glenn H. Shepard Jr.
ALTERNATIVE NAMES
Machiguenga, Matsiguenka, Kogapakori, Kugapakori.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
Traditionally, the Matsigenka have lived in small, scattered, highly autonomous settlements organized around
the household and the residence group showing a strong
preference for matrilocal residence. Kinship follows a
Dravidian pattern prescribing bilateral cross-cousin marriage (Johnson & Johnson, 1975). Polygamy was common in the past but has become less frequent. The
Matsigenka continue to make important decisions within
the household and residence group. At certain historical
moments, political and economic integration under tyrannical leaders called kurakas has emerged, always in
response to outside forces (Camino, 1977; RenardCasevitz, 1991).
The Matsigenka subsist on a combination of fishing,
hunting, forest foraging, and long-fallow swidden agriculture. They grow the staples of sweet manioc, plantains,
and bananas alongside diverse other crops, medicinal
plants, and fruit trees that mature as gardens are abandoned to forest regeneration. Women spin native cotton
and weave tunic-like garments on backstrap looms.
Women spend tremendous time and effort in preparing
manioc beer (ovuiroki), the centerpiece of Matsigenka
824
Matsigenka
% Deaths
70
60
50
40
30
20
10
0
Resp.
GI
Warfare
Snake
Sorcery
Spirit
Attack
Accident Unknown
Other
Medical Practitioners
825
MEDICAL PRACTITIONERS
Shaman-healers among the Matsigenka are known as
seripigari, tobacco-intoxicated ones (Baer, 1992).
Seripigari use tobacco and psychoactive plants to enter
into a trance, communicate with spirits, and treat spiritbased illnesses (Shepard, 1998). They are usually men,
but women are sometimes mentioned. The seripigari
undergoes an apprenticeship with an experienced shaman
and gains special powers by fostering a relationship with
benevolent spirits known as Saangariite, Invisible/Pure
Ones. The seripigari sing esoteric songs to invoke spirits or call wayward souls, and use their magical breath to
locate and suck sorcery objects (spines, stones, herbs,
etc.) from the patients body. More than healers, the seripigari are ambassadors to the cosmos who negotiate with
the forces of nature to ensure the availability of game,
acquire new crop varieties, and control the elements. The
seripigari are heroes in Matsigenka mythology, however
in actual practice, they are beset by moral ambiguity. The
same powers required to cure illness can also be used to
cause it. The Matsigenka distinguish between healing
shamans and illness-causing sorcerers (matsikanari),
however any shaman may be a suspect for sorcery accusations. This inherent moral ambiguity has been fueled by
Christian missionaries denunciations of shamans as
Devil worshipers. Furthermore, shamans were ineffective in halting the devastating epidemics. The seripigari
have been apparently driven into hiding or extinction
in many communities. Recent ethnographies note that
the Matsigenka deny the existence of seripigari in their
communities (see Bennett, 1991, p. 380; Shepard, 1999a,
p. 82; Izquierdo, 2001, p. 233). Yet after years of such
denials, Shepard (1999a) discovered that seripigari were
in fact active (albeit discreetly) in several communities in
the Manu and Madre de Dios Regions.
A new breed of practitioners known as steam bath
healers (itsimpokantavagetira) has emerged in acculturated communities of the Urubamba, apparently filling
the void left by the absent (or secretive) seripigari. Like
seripigari, steam bath healers are able to remove intrusive
pathogenic objects from patients suffering sorcery and
other spirit illnesses. Unlike the seripigari, steam bath
healers do not use tobacco or psychoactive plants and
do not enter trance. Instead, they subject the patient to
a steam bath by placing scalding hot river stones in a pot of
water with special herbs layered in the bottom. The patient
stands over the pot covered in a cotton tunic as the healer
826
fans the hot steam. When the water cools, the healer
removes the contents of the pot and discovers a variety of
objects (nails, sorcery herbs, plastic containers, etc.) that
have apparently emerged from the patients body. The
healer converses in detail with the patient about the history of the illness, focusing on social conflicts and possible sorcery suspects. Multiple treatments are usually
required, and the healers charge a moderate to considerable fee. The technique of steam-bath healing is open to
men and women, is learned from a practitioner for a
large fee, and was introduced to the Matsigenka by the
neighboring Ashaninka.
Another medical treatment alternative is the government health post. Each full-scale health post (Posta de
Salud) is manned by one doctor and two nurses who
remain (in theory) for twelve-month stints as part of a
required rural service program, making trips to outlying
communities for check-ups and vaccinations. Health
posts are generally well stocked with pain relievers and
antibiotics, though they lack laboratory facilities. There
are three health posts in the Urubamba region, serving
approximately 25 communities, and two in the upper
Madre de Dios serving about 10 communities. Some
communities have small village health posts (Posta
Sanitaria) manned by regional Peruvian or resident
Matsigenka sanitarios, health care workers with basic
training who receive a small government salary and minimal medical supplies. Native health promoters (promotor de salud) work on a volunteer basis, sometimes
combining biomedical with traditional healing methods.
Health posts are largely underutilized because of the
urban-educated professionals typically paternalistic
views, begrudging attitude, and poor communication
with community members. Few complete the full twelvemonth stint, leaving lesser-trained regional nurses, sanitarios, or promotores in charge for extended periods of
time.
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Classification of Illness
The Matsigenka distinguish and classify illness according to a number of criteria: symptoms, body part/organ
Matsigenka
Theories of Illness
The Matsigenka concept of well-being is summarized in
the verb shinetagantsi, which means to be happy, productive, and well-fed as well as free of illness. Concepts
antithetical to well-being include illness (mantsigarentsi), suffering (tsipereagantsi), thinness or weight loss
(matsatagantsi), sorrow or worry (kenkisureagantsi),
anger (kisatsi), and soul loss (gasuretagantsi). Health
and well-being and, conversely, illness and malaise,
embrace physical, emotional, and spiritual states as well
as harmony (or lack thereof ) in productive, social, and
environmental interactions. In the Matsigenka cosmosas-ecosystem, illness, misfortune, and death are often
interpreted through the ecological metaphor of predation: just as humans hunt for sustenance, so also demons,
illnesses, and dangerous animal spirits look on human
beings as game animals (Shepard, 2002c).
Matsigenka theories of illness demonstrate complex
notions of etiology and efficacy that challenge Western
827
Matsigenka name
Etiology
Severity
Gastrointestinal
Intoxication, vomiting
w/ fever (Yellow fever?)
Diarrhea w/ blood
Diarrhea
Pigarontsi, kepigari
Highest
Shiarontsi
Tseritsi
High
Medium
Vomiting
Indigestion
Stomachache
Kamarankagantsi
Sametsi
Katsimotiatagantsi
Gynecological
Retained placenta
Difficult childbirth,
post-partum bleeding
Miscarriage (fetus)
Miscarriage, induced
abortion (early pregnancy)
Menstruation (painful,
excessive bleeding)
Menstruation (normal)
Terira okontetake
iranonta
Okatsitake
oananekite,
voaasetagantsi
Omechotaira ogairi
Oseriakotake
oananekite
voaasetagantsi
katsiri / kogapage
Voaasetagantsi,
seriagantsi
taboo activities
(arrow resin use)
no reason, taboo activities
(cutting bamboo)
Medium
Low
Low
Highest
High
sorcery
animal spirit, plant-induced
High
High
no reason, sorcery,
animal spirits
moon
Medium
Low
Respiratory
Bloody cough,
tuberculosis
Cold, flu
Throat abscess (tonsillitis)
Voreagantsi iraatsi
foreigners
Highest
Merentsi
Vompotsanotagantsi
Highest
High
Cough
Voreagantsi
Sore throat
Katsitsanotagantsi
Nasal congestion,
runny nose
Nosebleed
Shirinkasetagantsi
foreigners
falls from sky, mixing
foods, trauma
falls from sky, mixing
foods, foreigners
falls from sky, mixing
foods, trauma
no reason
Medium/
High
Low
Voaatagantsi iraatsi
girimashiku
mixing foods
Low
Vitantagantsi negiku
lethal illness
Highest
Kentarontsi,
kitsogirontsi
Katsinegitagantsi
Highest
High
Heart /Chest
Heart failure,
cardiac arrest
Chest pain (needle pain)
Heart pain, epigastric pain
Heart palpitations
(fear in the heart)
Fevers
Shivering, chills
(malaria)
Fever w/ chills
Fever
Tsaronegintagantsi
High
High
Mogekari, shigekari
Highest
Anatiri, janatiri
Kovaagantsi
High
Medium
828
Matsigenka
Table 1. Continued
Illness category/gloss
Body pain
Bone pain, rheumatism
Body pain, (back, knee pain)
Headache, migraine
Rib pain
Waist, kidney pain
Ear/Eye/Dental
Earache (w/ pus, abscess)
Matsigenka name
Etiology
Severity
Shinkogiitagantsi
Katsipagetagantsi,
(katsitishitagantsi,
Katsigeretotagantsi)
Katsigitotagantsi
High
Medium
Medium
hygiene, worms,
foreigners
hygiene, worms, falls
from sky
worms, food
hygiene, trauma, falls from
sky, foreigners
old age, animal spirit, trauma
Medium/
High
Medium
Katsimeretagantsi
Katsitsakitagantsi,
tsatsakirontsi
Earache (simple)
Sakempitagantsi,
sompokempitagantsi
Katsikempitagantsi
Toothache
Eye pain, infection
Tsororoaari
Skin
Wound-like
Abscess, boil
Cut, wound, (arrow wound)
Sore, leishmaniasis
Pustule, infected wound
Sompotsi
Teretsi
Tsirivaito, katsinori
Shomporentsi
Burn, blister
Scab
Saatagantsi, meregagantsi
(Teretsi)
Inflammatory
Inflammation, swelling
Nonarontsi
Hives, urtication
Kepigisetagantsi
Patsaatagantsi
Piikitagantsi,
pirikitagantsi
Kaenitagantsi, tsomiri
Patsetsi
Kutatagantsi
Medium
Medium
Medium
Medium
Medium
High
High/
Medium
Medium
Medium
Medium/Low
Medium/Low
no reason, w/ infection,
fever
plants (urticating), animal
spirits, mixing foods,
falls from sky, wounds, hygiene,
hygiene, urticating plants
High/Medium
Medium
Medium
Low/Medium
Low
Low
Medium
Medium
Kotsetsi
Patsaavagantetagantsi,
terevagantetagantsi
Kutanenetagantsi
(as kotsetsi)
Medium
Measles, Pox
Measles, smallpox
Chicken pox
Saarontsi, sarampion
Morokisetagantsi
demons, foreigners,
animal spirit (cowbird)
Highest
Medium
Maranki yatsikanti
Matsontsori
yatsikanti
Highest
High
Itching, (mycosis)
Scabies
White spots, (mycosis)
Oral (esp. in Children)
Candida, sores (thrush)
Fever blisters
Animal bite/sting
Snakebite
Jaguar bite
Medium
829
Table 1. Continued
Illness category/gloss
Matsigenka name
Etiology
Severity
Peccary bite
Spider bite
Stingray sting
Paraponera ant sting
Caterpillar sting
Shintori yatsikanti
Jetyo yoganti
Inaro ikentanti
mushi yoganti
Soromai
iporonganti
Sani yoganti
Medium
Medium
Medium
Low
Low
Low
Pugasetagantsi
Medium
Tamampegagantsi
causes gastrointestinal,
fever, skin conditions
(esp. children)
causes gastrointestinal,
fever, skin conditions
Highest
w/ severe GI illness,
trauma, falls from sky
w/ severe GI, heart illness
High
Wasp sting
Footprint sorcery
Sudden death, demon attack
Rape by demon (deer)
Matsitagantsi
Ampaseri,
gagitetagantsi
Komutagagantsi
Itsitanti kamagarine
(maniro)
Tsavitetagantsi
Amumpava
Kisanitagantsi
Kamakamatagantsi
Miscellaneous
signs/symptoms
Muscle cramps
Tsoritsi
Kitetagantsi
Shigopirentsi
Katsiriraapanatagantsi
Taratagantsi
katsitsinitagantsi,
tsomiri
Low
(except in ill, old)
Highest
Highest
Highest
Highest
High
Medium
Medium
High
High
Medium
830
Matsigenka
Gynecological
Bloody
Diarrhea
Diarrhea
Sudden
Death
Miscarriage
Gastrointestinal
Painful
Menstruation
Indigestion
Yellow Fever
Cramps
Body Pain
Rib Pain
Heart Pain
Bad dreams
(infants)
Knee Pain
Chest Pain
Tuberculosis
"Dreaming Ghost"
Headache
Snakebite
Inflammation
Ant Sting
Rashes
(infants)
Skin
Animal
Bites
Jaguar,
Peccary Bite
Micosis
Thrush
(infants)
Bloody Nose
Sorcery
Rheumatism
Arthritis
Fever
Plant/ Respiratory
Cold/Flu
Cough
Animal
Spirit
Measles
Runny Nose
Revenge
Restlessness
(infants)
"Seeing Ghost"
"Broken by Deer"
Back Pain
"Mixing Foods"
G.I. upset
(infants)
Demons,
Sorcery
Waist Pain
Abdominal Pain
Vomiting
Difficult
Childbirth
Wounds
Boils, Abscesses
Leishmaniasis
Chancre
Gonorrhea
Urinary infection
Kidney problem
Leishmaniasis
Fungus
Skin infection
Chupo
Scabies
Smallpox
Measles
831
Parasites
Conjunctivitis
Birth defects
Hemorrhage
Toothache
Knee ache
Body ache
Drowning
Snakebite
Stomachache
Falling from tree
Headache
Rheumatism
Itsavitetaka
Diarrhea Muscle spasms
Kamasantorit
Vomiting
Gastritis
Tuberculosis
Flu
Cough
Bronchitis
Fever
Malaria
Tetanus
Sorcery
Posanga
Cholera
Rabies
Stress in 2 dimensions is 0.135
Sopai
Maniro
832
encounter for three days and take numerous precautionary measures and remedies. Paralysis or sudden death in
old people is attributed to assault by the deer demon:
otingarantira maniro, broken by the deer. People who
are ill or at vulnerable junctions in the life cycle do not
eat deer meat, and some people avoid it altogether.
Whereas predatory demons, animal spirits, and
ghosts were blamed for inexplicable illnesses in the past,
sorcery is frequently invoked in Westernized communities. Footprint sorcery (gagitagantsi) is carried out by collecting dried bits of mud from the victims footprint and
boiling them with special herbs, causing the victims leg to
swell, become tingling or numb (ampasetagantsi), and
turn black as if burned (shinkogitagantsi). The Matsigenka
believe that love magic (posanga) is a kind of sorcery
brought by outsiders, causing physicalemotional symptoms in its victims (dizziness, heart palpitations, sadness,
insanity), as well as infidelity and social strife in the community. Sorcery accusations are often aimed at those same
groups of outsiders (Ashaninka, Piro, Shipibo) who
served as intermediaries for Western economic interests
throughout the 20th century. However, in increasing numbers other fellow Matsigenka are being accused and identified as sorcerers. Ethnically diverse communities and
mission towns are thought to be especially dangerous, and
Matsigenka who have lived among them are prime sorcery
suspects. Thus sorcery theories reflect Matsigenka constructions of interethnic relations and notions of culture
change (Izquierdo & Johnson, 2003).
Treatment of Illness
Treatment decisions often relate as much to social
dynamics as to the choice of the appropriate remedy, and
may involve self or family care, consultation with kin,
informal networks, local healers, and medical personnel.
The Matsigenka incorporate biomedical and local knowledge in assessing health care options. Some 300 species
of medicinal plantsmostly primary forest shrubs and
herbs but including some cultivated plants and weeds
were identified in an ethnobotanical survey of seven communities (Shepard, 1999a), and the average informant
knows 80 or more species (Izquierdo, 2001). Medicinal
plant knowledge is widely shared, though a degree of specialization is found along gender lines: women are more
knowledgeable about plants for child care and fertility
control, while men specialize in hunting medicines and
treatments for wounds and snakebite.
Matsigenka
833
SEXUALITY
AND
REPRODUCTION
834
Matsigenka
are prohibited from manufacturing arrows: cutting bamboo is thought to cause uterine hemorrhage, and sticky
arrow-fletching resin (taviri) causes retained placenta.
Parents avoid specific foods and behaviors believed to
result in unwanted physical as well as personality traits
(anger, laziness) in the developing fetus.
Traditionally, births were attended by elder female
relatives but in many communities today, midwives are
chosen based on experience and given basic training by
the medical personnel. Women give birth in a squatting
position, gripping a vertical support such as a house post.
Birthing in the health postprone and surrounded by
lights, instruments, and strangersis viewed as unattractive and frightening.
The immediate concern upon birth is the passing of
the placenta and the cutting of the umbilical cord.
Medicinal plants are used to aid in the passing of the placenta (iranonta) to avoid dangerous complications.
Traditionally, the umbilical cord is cut with a grass-like
bamboo with razor edges (tiposhi). Metal implements are
now used, though improper hygiene has been known
to cause tetanus. The cut cord is treated with arrow- fletching resin (taviri) and other umbilical cord plants
(shirimogutopini), or Western antiseptics when available.
The mother and baby are washed in warm water and herbs.
Both the placenta and later, the umbilical cord are buried
to avoid contact with carrion animals or evil spirits.
Infancy
The time between birth and the falling of the umbilical
cord is especially dangerous. Both parents remain
indoors and follow strict dietary and behavioral restrictions. Through the first few months of life, parents
maintain certain restrictions to avoid mishaps and illness
in their infants. Strong-smelling and carnivorous fish and
game are avoided because of their vengeful spirits, as are
urticating or caustic plants, thought to cause rashes in
newborns. To dispel vengeful spirits, the mother bathes
the baby daily (once or more times) in warm herbal mixtures including sedges as well as fragrant, viscous, and
colorful plants. In addition to their role in hygiene, these
practices reflect the general anxiety of parents about newborns in a setting where infant mortality is considerable.
Quickly, the couple must return to the productive
routines of daily life to provide a good example and
prevent the child from growing up lazy or inactive.
Babies are carried at all times by their mothers in a woven
cotton sling (tsagompirentsi), nursing on demand. Babies
Childhood
Diarrhea, especially when combined with vomiting,
quickly dehydrates infants and young children, and is a
frequent cause of death in this age category. Increasingly,
health workers are teaching oral rehydration therapy. The
extended abdomen visible in most children and many
adults is evidence for a moderate, practically normative
parasite load. Extreme parasite loads are known to cause
anemia and even life-threatening intestinal blockage,
especially in children. Ficus latex is a common and effective folk remedy for intestinal worms, though some
Matsigenka fear the powerful purgative properties of an
improper dose. (Matsigenka mens use of purgative and
emetic plants may also help reduce parasite loads.)
Pharmaceutical antihelminthic treatments are distributed
with increasing frequency, however without sanitation
and potable water, reinfection is rapid.
Mothers are the main care providers for small infants,
though fathers come to take on an important role in education and discipline in later childhood. Socialization of
appropriate emotions as well as competence, autonomy, and
sociability is a strong focus even in infancy. Children are
cherished and protected by an ever-present network of family members. However, once children have gained a strong
footing, they are given great freedom. Children learn from
a young age to participate in subsistence activities. Young
girls help their mothers in cooking, cleaning, childcare, and
gardening, while boys roam a bit more freely, playing at
hunting, fishing, building shelters, and making fires.
Children may be given a series of herbal treatments
to ensure fast growth, protection from illness, and positive behavioral traits (honesty, industriousness, emotional
control) in later life. Children are also taught to show
respect toward particular animals and plants, because
mocking, handling, or bothering them may provoke spirit
revenge. Children are taught to control their expressions
of pain and other negative emotions, leading to a marked
stoicism among Matsigenka adults.
835
Adolescence
By about age 15, children should be proficient in subsistence responsibilities and know right from wrong.
Adolescents who act inappropriately are publicly humiliated and punished. Stealing is considered a serious
offense. Adolescents are also punished for bullying, laziness, and overly precocious sexual behavior. Girls are
generally permitted to engage in an open sexual relationship at a somewhat younger age than boys, who must first
prove their abilities in hunting and gardening. Teenage
boys may be given a series of purgatives and eye-stinging
remedies to develop their hunting skills. They are not
allowed to touch or eat their first several kills, and are
taught to avoid bragging about or being selfish with meat,
lest they lose their stamina and aim. Teenage girls may
learn herbal remedies for learning to spin cotton, gaining
weight, having strong and durable teeth, removing pubic
hair (considered unaesthetic), or regulating fertility.
Transition into womanhood begins with first
menstruation, marked by an extended ritual of seclusion
(oantarotira, she becomes an adult) during which the
girl lives in a small hut, eats special foods, avoids the sun
and the gaze of males, receives special instructions from
close female kin, and spins and weaves cotton to produce
a tunic for her future husband. She emerges from seclusion after completing the tunic, shaving her head to mark
the transition. Her emergence is generally greeted by a
manioc beer party held in her honor, during which suitors
may express their intentions to her and her parents.
836
Matsigenka
NOTE
1. Data from three Matsigenka populations (Sotileja, Yomybato, &
Kamisea), organized from least to most acculturated, and two neighboring Panoan-speaking populations, the Yora, contacted forcefully
in 1985 and the Chitonahua, contacted forcefully in 1995. Data are
taken from extensive genealogical interviews (Shepard 1999a:
105107), except Kamisea which represents deaths occurring during
fieldwork conducted from 1996-1999 (Izquierdo, 2001).
REFERENCES
Alvarez-Lobo, R. (1996). Sepahua: Motivos para crear una misin
catlica en el Bajo Urubamba. Lima: Misioneros Dominicos/
ENOTRIA S.A. Coleccin Antisuyo Vol. 1.
Baer, G. (1992). The one intoxicated by tobacco: Matsigenka shamanism. In Matteson-Langdon, J. & G. Baer (Eds.), Portals of power:
Shamanism in South America (pp. 79100). Albuquerque:
University of New Mexico Press.
Bennett, B. Y. (1991). Illness and order: Cultural transformation among
the Machiguenga and Huachipaeri. Doctoral Dissertation, Cornell
University.
Camino, A. (1977). Trueque, correras e intercambio entre los Quechas
Andinos y los Piros y Machiguenga de la montaa Peruana.
Amazonia Peruana, 1(2), 123140.
References
Cueva, N. (1990). Un acercamiento a la situacin de salud en la provincia de ManuDepartamento de Madre de Dios (Manu: Un gran
reto en la selva). Manu: AMETRA/Centro Bartolom de las
Casas.
Gregor, T. (1985). Anxious pleasures: The sexual lives of an Amazonian
people. Chicago: University of Chicago Press.
Izquierdo, C. (1995). The illness experience: Health care choices among
the Mapuche living in Santiago. M.A. Thesis, Department of
Anthropology, University of California at Los Angeles.
Izquierdo, C. (2001). Betwixt and between: Seeking cure and meaning
among the Matsigenka of the Peruvian Amazon. Doctoral
Dissertation, Department of Anthropology, Los Angeles:
University of California.
Izquierdo, C. (In review). When health is not enough: Subjective,
societal, and biomedical indicators of well-being among the
Matsigenka of the Peruvian Amazon. Social Science and Medicine.
Izquierdo, C., & Johnson, A. (In review). Desire, envy and punishment:
Matsigenka emotion schema in illness narratives and folk stories.
Culture, Medicine and Psychiatry.
Jelliffe, D. B. (1966). Assessment of the nutritional status of the community. Geneva: World Health Organization.
Johnson, A. W. (1983). Machiguenga gardens. In R. Hames &
W. Vickers (Eds.), Adaptive responses of Native Amazonians
(pp. 2963). New York: Academic Press.
Johnson, A. W. (2003). Families of the forest: The Matsigenka Indians
of the Peruvian Amazon. University of California Press: Stanford.
Johnson, A. W., & Behrens, C. A. (1982). Nutritional criteria in Machiguenga
food production decisions. Human Ecology, 10, 167189.
Johnson, O. R. (1978). Interpersonal relations and domestic authority
among the Machiguenga of the Peruvian Amazon. Doctoral
Dissertation, Department of Anthropology, Columbia University.
Johnson, O. R. (1980). The social context of intimacy and avoidance: A
Videotape Study of Machiguenga Meals. Ethnology, 19, 353366.
Johnson, O. R., & Johnson, A.W. (1975). Male-female relations and the
organization of work in a Machiguenga community. American
Ethnologist, 2(4), 634638.
Kimerling, J. (1991). Amazon crude. New York: Natural Resources
Defense Council.
Lyon, P. J. (1984). Change in Wachipaeri marriage patterns. In
K. M. Kensinger (Ed.), Illinois Studies in Anthropology No. 14.
Marriage Practices in Lowland South America (pp. 52263).
Urbana and Chicago: University of Illinois Press.
Neel, J. V. (1974). Control of disease among Amerindians in cultural
transition. Bulletin of the Pan American Health Organization, 8(3),
205211.
Plowman, T. C., Leuchtmann, A., Blaney, C., & Clay, K. (1990).
Significance of the fungus Balansia cyperi infecting medicinal
species of Cyperus (Cyperaceae) from Amazonia. Economic
Botany, 44(4), 452462.
Renard-Casevitz, F. M. (1976). Notes sure la pharmacope des
Matsiguenga. INSERM (Les Colloques de lInstitut Nacional de la
Sant et de la Recherche Mdicinal) 63, 129144.
Renard-Casevitz, F. M. (1991). Le banquet masqu: Une mythologie de
letranger chez les Indiens. Paris: Lierre & Coudrier Distribution,
Eadiff.
Rivera, L. (1991). Territorio Indgena: El area de influencia del proyecto
gas de Camisea. Lima: Centro para el Desarrollo de Indgena
Amaznica (CEDIA). Documento de Trabajo-Libreta de Campo.
837
Shepard, G. H. Jr. (1998). Psychoactive plants and ethnopsychiatric
medicines of the Matsigenka. Journal of Psychoactive Drugs,
30(4), 321332.
Shepard, G. H. Jr. (1999a). Pharmacognosy and the senses in two
Amazonian societies. Doctoral Dissertation, Department of
Anthropology, University of California at Berkeley.
Shepard, G. H. Jr. (1999b). Shamanism and diversity: A Matsigenka
perspective. In D. A. Posey (Ed.) (pp. 9395). UNEP Global
Biodiversity Assessment Supplement 1. Cultural and Spiritual
Values of Biodiversity. London: United Nations Environmental
Programme and Intermediate Technology Publications.
Shepard, G. H. Jr. (2002a). Three days for weeping: Dreams, emotions
and death in the Peruvian Amazon. Medical Anthropology
Quarterly, 16(2), 200229.
Shepard, G. H. Jr. (2002b). Natures Madison Avenue: Sensory cues as
mnemonic devices in the transmission of medicinal plant knowledge among the Matsigenka and Yora of Peru. In J. R. Stepp,
F. S. Wyndham, & R. K. Zarger (Eds.), Ethnobiology and
Biocultural Diversity: Proceedings of the 7th International
Congress of Ethnobiology (pp. 326335). Athens, GA: University
of Georgia Press.
Shepard, G. H. Jr. (2002c). Primates in Matsigenka subsistence and
worldview. In A. Fuentes & L. Wolfe (Eds.), Primates Face to
Face: The Conservation Implications of Human and Nonhuman
Primate Interconnections (pp. 101136). Cambridge, U.K.:
Cambridge University Press.
Shepard, G. H. Jr., & Chicchon, A. (2001). Resource use and ecology
of the Matsigenka of the eastern slopes of the Cordillera
Vilcabamba. In L. E. Alonso et al. (Eds.), RAP Working Papers No.
12. Biological and Social Assessments of the Cordillera de
Vilcabamba, Peru (pp. 164174). Washington, DC.: Conservation
International.
Snell, B. E. (1998). Pequeo diccionario Machiguenga-Castellano.
Lima: Instituto Lingstico de Verano/Summer Institute of
Linguistics. Documento de Trabajo Vol. No. 32.
Snell, B. E., & Davis, H. (1976). Kenkitsatagantsi Matsiguenka.
Pucallpa: Instituto Lingstico de Verano/Summer Institute of
Linguistics. Comunidades y Culturas Peruanas.
Snell, W. W. (1964). Kinship Relations in Machiguenga. M.A. The
Hartford Seminary Foundation.
Soto, J. C. (1982). Ecologa de la salud in comunidades nativas de la
Amazonia Peruana. Amazonia Peruana, 3,1326.
Strongin, J. (1982). Machiguenga, medicine, and missionaries: The
introduction of Western health aids among a native population
of Southeastern Peru. Doctoral Dissertation, Department of
Anthropology, Columbia University.
Townsley, G. (1987). The outside overwhelms: Yaminahua dual
organization and its decline. In: H. O. Skar & F. Salomon (Eds.),
Vol. 38 (pp. 355376). Natives and Neighbors in South America:
Anthropological Essays. Goteborg: Goteborgs Etnografiska
Museum. Etnologiska Studier.
von Hassel, J. M. (1904). Los varaderos del Purs, Yura y Manu.
Boletn de la Sociedad Geogrfica de Lima, 15, 241246.
Wilbert, W. (1986). Warao Herbal Medicine: A Pneumatic Theory of
Illness and Healing. Doctoral Dissertation, Department of
Anthropology, University of California at Los Angeles.
Yu, D. W., & Shepard, G. H. (1998). Is beauty in the eye of the
beholder? Nature, 396, 321322.
838
ALTERNATIVE NAMES
None.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
839
840
Diet
The Maya peoples of Highland Chiapas have a long
tradition of swidden agriculture based primarily on corn,
beans, squash, and chili peppers. Small flocks of chickens
provide a generous quantity of eggs. Turkeys, pigs, and
cattle provide occasional meat. Some sheep are raised but
these play a very minor role in indigenous diet as their
primary value is the wool they produce for warm clothing and a few tourist items. Availability and consumption of these cultivated and domesticated species is
complemented by a rich variety of non-domesticated or
lightly managed species. In more recent times, the
non-domesticates have predominantly been of plant
origin as population pressures have virtually eliminated
the large game animals (such as deer, agouti, peccary
etc.) and restricted the number and distribution of smaller
ones (e.g., field rodents, squirrels, rabbits, gophers, and
lizards) in the region. The small edible creatures are often
opportunistically captured in traps, though a few people
may still go hunting. In a few areas, streams provide
fish, snails, and frogs on occasion. A few wild birds
are sometimes eaten. Some people still keep nests of
native bees for their honey. The rainy season provides an
abundance of wild mushrooms and there is growing cultivated mushroom production, primarily for market sales.
The period between last harvests, when agricultural
stores are lowest is also the period of greatest consumption of non-cultivars. Subsistence agriculture is so
marginal in the area that it is not terribly uncommon in
bad years for some families to run short on beans or corn
and be forced either to eat some of their seed stock or find
a means of supplementing supplies through market
purchase or exchange.
As in all such contexts of marginal resources, it is
the children who are most affected. Chronic childhood
nutritional stress is evident in the generally short stature
of the population. Those families who are most well-off
economically follow the universal pattern of short stature
and overweight for first generation adults. Continued
economic and dietary stability results in a second generation of (sometimes dramatically) increased stature.
There is also potentially a hidden danger in the
change of lifestyles that frequently accompanies economic success. These typically include a shift from traditional food, especially wild species to foods of higher
prestige such as beverages and snack foods with high
sugar, salt, and/or fat content that are low in nutrients.
Fortunately the classic shift from breast to bottle, with all
the attendant health consequences, has not become a
major problem for the highland Maya.
When peoples whose dietary problem has normally
been getting enough to eat achieve food sufficiency and
the potential for excess, the concept of restriction or balance is not operative. The usual pattern elsewhere is a
trend toward obesity and an increased prevalence of
diabetes. Such dietary consumption and nutritional health
changes may be beginning to occur in the Highland
Maya. People frequently report asukcar ( Spanish
azucar sugar) as a diagnosis. That there is no Maya
term for diabetes (although they do recognize such signs
as ants being drawn to urine) suggests that it is a relatively new problem. Based on the number of informal
reports of the disease, a systematic study and potential
early intervention program would be appropriate.
The weedy species (listed in Appendix 1) that contribute to traditional Maya diet provide high quality nutritional supplements, especially when agricultural resources
are lowest. They appear to be the primary sources for
vitamin A and thiamine and to add an important amount
of calcium to the diet. Vitamin A deficiency is a major
problem in many third world populations. It has not been
reported as a problem for this group, although the association of vitamin A deficiency with increased susceptibility to diarrhea could potentially play a role in the high
rates of diarrheal disease in this population. An early
symptom of vitamin A deficiency is poor night vision.
There appears to be no term in Maya for such a condition.
Iodine deficiency, represented by goiter and possibly
dwarfism, is often reported in populations inhabiting
mountainous regions, including Maya populations of
Highland Guatemala. For reasons that are not as yet clear,
this does not seem to represent a major health problem in
the Highlands of Chiapas. Discovering the sources of this
positive deviance in health pattern could possibly provide
a model for other highland peoples.
Recent research (Luber, 1999) suggests that protein
calorie nutrition is identified by a native term, chalam
tsots second layer of hair and studies have shown that
this is a significant health problem in the highland region
(Berlin & Berlin, 1996). In a diet based on corn and
beans, it is frequently difficult for small children to consume sufficient amounts to meet total nutritional needs.
Simple addition of a fat source is usually sufficient
to compensate for this. For both children and adults
food quantity is currently more of a problem than the
nutritional quality of the foods themselves. This has the
841
Disease1
As seen in Figure 3, gastrointestinal diseases are the
greatest cause of both morbidity and mortality. The high
frequency of gastroenteric conditions in both the
ethnoepidemiological and epidemiological data is a
reflection of the virtual universal parasitism and frequent
diarrheal episodes typical of populations living in
the socio-economic conditions characteristic of these
communities.
Respiratory infections are the second most frequent
cause of illness. Respiratory problems are surely related
to the altitude (on average 2,000 m), to cold weather and
traditional house construction which affords little protection from cold wind, as well as the smoke of cooking
fires. Respiratory problems represent the fourth most frequent reported cause of death. This would suggest that
many of these illness are more minor colds and coughs
with low mortality.
Fever or, to use a bio-medical gloss fever of
unknown origin, is mentioned as the third most frequent
842
MEDICAL PRACTITIONERS
It is more accurate to define areas of medical specialization in Maya medicine and note that aspects of one or
more of these specialties may be incorporated in any
given healers armamentarium of skills. These specialties
include diviner/healer, one who prays to the mountains,
pulse-reader, mid-wife, bone-setter, massager, and (in
Yucatan) herbalist (tsak xiu lit. herb grabber).
Diviner/healers incorporate the more traditional
shamanic healing practices. Prayers to the mountains
might best be considered as preventive medicine specialists in that they pray to the hills and in caves for the
protection of the population and for the prevention of
periodic and epidemic diseases (such as the classic childhood diseases). Pulse-readers are able to diagnose and
monitor the progress of disease based on the detection of
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
General Principles
The Maya medical system is holistic in that there is a close
relationship between the health of an individual and his/her
relationship with other people, various environmental
factors and forces and members of the spiritual realm as
well as elements of contagion. Both problems of health and
their treatments can be divided into two distinct systems
(following Foster, 1976);
843
844
SEXUALITY
AND
REPRODUCTION
845
Infancy
A new child of either sex is generally welcome, although
there may be a slight preference for boys. Prayers and
rituals are begun shortly after birth to make certain that the
ancestral spirits and deities protect the child and a variety
of preventive measures are undertaken to keep the babys
soul intact. During the first few weeks, the mother and
child avoid social contacts and stay close to home to prevent illness, especially of the infant. The infants soul is
considered to be weakly attached and various precautions
are taken to prevent the babys soul from wandering,
becoming lost, or returning to the cosmic pool. The infants
wrists and ankles may be tied with string or small bracelets
to tether the soul. An infant may wear amulets, such as
amber bracelets to prevent illness, especially from evil eye.
When mother and child begin to go out, the mother must
place branches or other items to across all paths crossing
where her pathway to guide the babys soul safely home.
Within a few months a baby is often be in the care
of older siblings who learn from a very early age to carry
a child in a shawl on their backs. Birth defects and undesirable physical and mental characteristics may result
when a pregnant woman makes fun of a person or animal
who has the particular characteristic. Sometimes just
looking at an animal, especially a dead animal, will
cause developmental problems for the child to be born.
An envious woman may disrupt a pregnancy and take the
Childhood
Childhood is a training period for adulthood. Children are
included in all aspects of life and, as their understanding
and abilities grow, they gradually assume a greater role in
daily household activities as well as special occasion
rituals. Pre-pubescent girls are initiated into the art of
tortilla making by wrapping their hands with hot tortillas
to toughen them as they begin their training in this
fundamental activity. Pre-pubescent boys begin accompanying their fathers in their agricultural duties. As they
assume the roles of adulthood, their health risks are those
of adults and these are reflected in their health patterns.
Forces of change for these patterns derive from the
increased numbers of children attending school for longer
periods, as well as increased involvement in cash-based
846
Adolescence
Perhaps because adolescents are inclined to high risk
behavior, there is an overall higher report of illness during
this period (Figure 4 above).
Adulthood
While the causes of illness are similar for men and women,
the causes of death vary considerably. Although mid-wives
seem to have a high success rate for live births, maternal
mortality is high when complications occur. Many women
still know a number of herbal formulae for birth control
reportedly that may effect temporary or permanent infertility, including Diascorea floribunda, the plant source of
the primary modern contraceptive prescribed for hormonal
suppression of female fertility. Biomedical health care
providers and well-meaning family planning programs
have discouraged the use of herbal controls. However, the
Maya are joining the alternative medicine revolution and
returning to their traditional medical formulations.
Death precipitated by accidents or violence is
reported at about equal frequency with deaths related to
obstetric/gynecological problems. Males, on the other
hand, have a disproportionate mortality due to these
causes. Over 85% of mens deaths due to accident or violence were attributed to homicide (39% for women). The
old patterns of violence toward women are changing very
slowly. It is possible that a large portion of those were due
to violence initiated by (inebriated) males, which plays a
tragic role in morbidity and mortality among the
Highland Maya.
The Aged
As can be seen in demographic data from the Highlands
of Chiapas, the elderly comprise a small percentage of the
population. The extended household appears to be common enough to accommodate those few who reach
advanced age. It is recognized that the older generations
are sources of cultural knowledge that is not being
learned by many youths. When occasions arise in which
this knowledge is attributed special value, the aged gain
in prestige. However, many of the young aspire to the
knowledge and skills of the national and international
community and their appreciation of traditional
Appendix B
847
APPENDIX A
Species Contributing Nutritional Supplements to Traditional Maya Diet
Acacia spp.
Amaranthus hypbridu
Amaranthus spinosus
Bidens pilosa, B. bicolor
Brassica campestris
Bromelia plumieri
Byrsonima crassifolia
Chenopodium ambrosioides
Cirsium horridulum
Diastacea micanthra.
Erythrina chiapasana
Eugenia acapulcensis
Eugeniatenejapensis
Galinsoga caracasana
Guazuma ulmifolia
Lantana camara
Lantana hirta
Linum nelsoni
Lycopersicon esculentum
Mangifera indica
Morus celtidifolia
Optuntia guatemalensis
Parathesis chiapensis.
Physalis gracilis
Physalis gracilis
Piper auriatum
Piper umbellatum
Portulaca oleracea
Psidium guajava
Psidium guineense
Rubus spp.
Saurauria scabrida.
Solanum nigrum
Solanum douglasii
Solanum nodiflorum
Solanum nudum
Sonchus oleraceus
Tagetes filifolia
Vitus bourgaeana
APPENDIX B
The Tzeltal-Tzotzil Cuadro Bsico of Medicinal Plant Species for use
in Treatment of the Twelve Major Classes of Health Conditions
Major illness category
(and sub-class)
Gastrointestinal conditions
general diarrhea
bloody diarrhea
Cissasmpelos pareira
Calliandra grandiflora,
C. houstoniana (Fabaceae)
Psidium guineense (Myrtaceae)
Byrsonima crassifolia (Malpighiaceae)
Sonchus oleraceus (Asteraceae)
Acacia angustissima (Fabaceae)
Crataegus pubescens (Rosaceae)
Nicotiana tabacum (Solanaceae)
antiseptic, digestive
antibiotic, antispasmodic, carminative, diaphoretic,
digestive, expectorant, hemostatis, nervine, pectoral,
sedative, stomachic, tonic, vulnerary
diuretic, emmenagogue, expectorant, stimulant
astringent
strong spasmolytic, antimicrobial, and hemostatic,
activity, cold
alexiteric, astringent,
diuretic
antibacterial, antifungal
diuretic, anodyne, anorexiac, anthelmintic,
anticonvulsive, antidote (various insect,
arachnid venom), cathartic, CNS stimulant,
cyanogenic, diaphoretic, emetic, entheogen,
expectorant, hemostatic, intoxicant, laxative,
narcotic, parasiticide, pediculicide, purgative,
sedative, stimulant
848
Major illness category
(and sub-class)
abdominal pain
epigastric pain
intestinal worms
Respiratory problems
cough, colds
croup
(whooping cough)
emollient
alopecia, warm
Rhus schiedeana
Ranunculus petiolaris (Ranuculaceae)
Wounds
due to accidents, violence
Liquidambar styraciflua
Skin Infections
skin eruptions
often with pus
Fever
Tagetes nelsonii
antimicrobial, cold
(warm)
(see above)
Eye Infections
References
849
Edema
antibiotic, anticancer
analgesic, anodyne, diuretic, hypnotic
Obgyn
antiseptic
anodyne
(see above)
NOTES
1. Data from two ethnoepidemiological surveys, conducted by
E. A. Berlin in 198788 and J. R. Stepp in 19992000, form the basis
of this report. These patterns generally fit the epidemiological
reports from health clinics of the region.
2. The original proposition of Foster and Anderson limited personalistic
illness to those directed specifically at an individual, however, it is
clear that there are other non-natural or beyond natural etiologies that
would not fit within a naturalistic classification and are therefore
included here in the personalistic category.
3. St. Elmos fire is the term used to refer to the atmospheric phenomena that produces ball-lightening that seems to shower on earth.
4. This aspect of Maya curing has been poorly studied except among
the Maya of Yucatan, where Garca, Sierra, and Baln (1996) have
made an interesting comparison between Maya and Chinese Medical
systems.
5. In at least one municipality of the Highlands of Chiapas, this classification has come to be associated with naturalistic conditions,
primarily through the influence of a local priest who has emphasized
illness and disease as coming from God but more in the nature of
things. This in the sense of Gods will be done as opposed to particular punishment or penalty for transgression.
REFERENCES
Berlin, E. A., & Berlin, B. (1998). Biodiversity of Highland Maya diet.
Annual meetings of the American Anthropological Association.
Philadelphia, December 1998.
Berlin, E. A., & Berlin, B. In press. Dietary biodiversity of the Highland
Tzeltal Maya of Chiapas, Mexico. In P. Townsend (Ed.),
Biodiversity and health. Ames, Iowa: University of Iowa Press.
Berlin, E. A., & Berlin, B. (1997). Non cultivated plant foods Of The
Highland Maya: Preliminary explorations. Paper presented at the
II International Congress of Ethnobotany, Mrida, Yucatan.
Berlin, E. A., & Berlin, B., (1996). Medical ethnobiology of the
Highland Maya of Chiapas, Mexico: The gastrointestinal diseases
(pp. 557). Princeton University Press, Princeton: NJ 557.
Berlin, B, & Berlin, E. A. (1994): Anthropological issues in medical
anthropology. In: (Ed.), Prance G. Ethnobotany and the search for
new drugs (pp. 240258). Ciba Foundation Symposium No. 185,
New York: John Wiley.
Castille, D. (1996). Psychological affliction and mental illness among
Maya Indians of Highland Chiapas, Mexico. Doctoral dissertation.
Berkeley: University of California.
Fabrega, H. & Silver, D. B. (1973). Illness and shamanistic curing in
Zinacantan. Palo Alto: Stanford University.
Foster, G. M. (1976). Disease etiologies in Nonwestern Medical
Systems. American Anthropologist, 78(4), 773782.
Garca, H., Sierra, A., & Baln, G. (1996). Medicina Maya tradicional:
Confrontacin con el Sistema Conceptual Chino. Mexico:
Educacin, Cultura y Ecologa, A. C. (EDUCE) Johnson, T.
(1998). CRC Ethnobotany Desk Reference. Boca Raton, FL, CRC
Press.
Luber, G. E. (1999). An explanatory model for the Maya Ethnomedical
Sundrome Chalam tsots. Goergia Journal of Ecological
Anthropology, 3, 1423.
Morton, J. F. (1981). Atlas of medicinal plants of Middle America:
Bahamas to Yucatan. (Two Volumes), Springfield, Illinois:
C. C. Thomas.
Stepp, J. R., & Moerman, D. E. (2001). The importance of weeds in
Ethnopharmacology. Journal of Ethnopharmacology, 75(1): 2531.
Stepp, J. R., (2001). Highland Maya medical Ethnobotany in ecological
perspective. Doctoral dissertation, Athens: University of Georgia.
(UNICEF), United Nations Children Fund (1991). The state of the
Worlds Children. London: Oxford University Press.
850
Mongolia
Mongolia
Daniel J. Hruschka and Brandon A. Kohrt
ALTERNATIVE NAMES
Mongolian, Mongol.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
Three cultural systemsCentral Asian mobile pastoralism, Tibetan Buddhist lamaism, and a Soviet model of
developmenthave profoundly shaped Mongolian society. Although it is difficult to trace the ethnic term
Mongol much farther back than Genghis Khans 13th
century confederacy of nomads (Morgan, 1996), todays
Mongolian pastoralists maintain cultural patterns that are
characteristic of many traditional Central Asian societies
(Humphrey & Sneath, 1999). Most economic activity
revolves around livestock grazing. The steppes sparse
vegetation constrains population density and requires frequent moves between pasture sites. Horses, which are the
most prized of domesticated animals, have historically
served to connect the territorys sparse human population.
To accommodate annual mobility in a rugged climate,
traditional Mongolian dwellings (the circular felt-lined
851
852
Environment
Mongolia has an extreme continental climate, with low
precipitation, long, cold winters (average January
temperature ranging from 35C in the north to 15C
in south) and short, hot summers (average June temperatures ranging from 1530C). Temperatures are generally
below freezing for 7 months out of the year (Academy of
Sciences, 1990). The countrys low population density
and cold climate have limited potential disease vectors
(humans or otherwise), and Mongolians have had only
rare encounters with a number of infectious diseases.
Cholera, for example, was first reported in Mongolia in
1996 (WHO, 1999). Similarly, Mongolia experienced
smallpox epidemics much later than did its southern
neighbors (Fisher, 1988; Serruys, 1980). At the same
time, the extremely cold, dry environment provides a
fertile bed for respiratory infections, which contribute to
nearly half of all newborn, infant, and child deaths
(Neupert, 1995; WHO, 1999). In contrast, diarrheal
diseases contribute to fewer than 15% of infant and child
deaths (WHO, 1999).
Mobile Pastoralism
Mongolias unique environmental regime has further
influenced health by constraining the populations subsistence activities. Several aspects of the climatic
regimelow precipitation, poor water supplies, and short
summersrender crop agriculture a risky venture, while
salty soils and an abundance of good feed grasses make
most of the country ideal for sustained livestock production. The general reluctance of Mongolians to cut or
disturb the earth, to fence the earth into agricultural plots,
or to eat grass likely also contributes to the reliance on
pastoral production (Williams, 1996). Although fewer
than half of Mongolians now engage in herding (NSO,
2000; Shombodon, 1996), the lifestyle continues to affect
the health of a sizeable portion of the population (Foggin
et al., 1997).
Mongolians who maintain a rural lifestyle breed and
raise different proportions of the traditional five domesticated animals (tavan hoshuu mal, horses, cattle and yak,
sheep, goats, and camels). One of the greatest health
concerns for herding populations is the threat of losing
herd animals, either to poaching, to natural predators, to
severe weather, or to infectious disease. Perhaps the most
serious threat to Mongolian herds is extremes in winter
Mongolia
Diet
Early Chinese chroniclers confirm that the Mongolian
diet has for centuries consisted of meat and dairy products, with rice, grain, and wine either traded or captured
from agricultural areas in China (Cheney, 1968; Jagchid
& Hyer, 1979). Fat is accorded special value, with sheep
bred for their fatty rumps and honored guests given the
first portion of solid white fat from a cooked sheeps tail.
Mongolians prepare numerous milk derivatives
(tsagaan idee)cream from boiled milk (orom), yogurt
(tarag), fermented milk (airag), raw milk (suu), varieties
of dried milk curd (aaruul), butter (tos), cream (tsotsgii),
dried cheese (eetsgii), and distilled sour milk (nermel).
Salted milk tea is a mainstay. Mongolians consume a
limited range of vegetables (potatoes, carrots, turnips,
cabbage, onions, and garlic), a restriction that is due
Infrastructure
The central challenge for all health systems in Mongolia
has been to equitably distribute medical knowledge and
health resources to a thin mobile population ranging over
huge areas. One grass roots solution to this problem has
been a distribution of medical knowledge whereby households maintain moderate levels of know-how concerning
local medicines and illnesses, with more experienced
traditional practitioners dispersed but common enough to
be accessible in times of need (Hruschka, 1998).
853
854
MEDICAL PRACTITIONERS
The majority of medical practitioners in Mongolia belong
to one of three major traditionsmodern Russian
medicine, Tibetan Buddhist medicine, and pre-Buddhist
traditional medicine.
Pre-Buddhist Traditional
Health Specialists
Healers, trained neither at government medical schools
nor from Tibetan Buddhist sutras, have dominated much
of Mongolias medical history and continue to participate
in healthcare today. These traditional healers specialize in
distinct, but overlapping, arenas of knowledge rather than
comprising a homogenous set of practices and theories
(Hruschka, 1998; Humphrey & Onon, 1996). Bariach
(barishi) generally perform massage and musculoskeletal
manipulation to treat maladies including concussions,
broken bones, headaches, and bone or organ displacements (Hruschka, 1998). Boo (male) and udagan
(idughan, yadgan) (female) employ ecstatic trance to
master spirits with power over maladies and misfortunes
(Humphrey & Onon, 1996). Ekh barigch (bariyachi) hold
knowledge of female birth-giving and are comparable
with traditional birth attendants. Otoch (otoshi) have had
different roles in different Mongolian contexts. Among
the Dagur Mongols of Manchuria, otoshi were charged
with female fertility and child development (Humphrey
& Onon, 1996), while in other contexts the term has signaled a general medical specialist (Kriegel, 1997; Jagchid
& Hyer, 1979) or someone skilled with medicinal plants
(Lessing, 1982). Each of these specialists is believed to
possess the power of spirits and forces related to his or
her field of knowledge, much as blacksmiths (darkhan) in
Mongolia
the same areas are believed to have access to spirits controlling metal-smithing (Hruschka, 1998; Humphrey &
Onon, 1996).
Mongolians generally feel that traditional practitioners whether they are boo, bariach, or eck barigch do
not choose to become healers, but rather are chosen by
deceased ancestors (ug) who once practiced the specialty.
An individual is usually called by the ancestors in the
form of an untreatable illness, and the only way to cure
the illness is to ritually take the ancestral talent (udam)
and begin healing (Hruschka, 1998; Humphrey & Onon,
1996). These healers were persecuted under both Tibetan
Buddhist and socialist regimes, and only since 1990 have
they begun to experience a resurgence in public practice
(Hruschka, 1998).
Buddhist Medicine
With the destruction of monasteries and the mass purging
of monks in the 1930s and 1940s, the socialist regime
effectively erased Tibetan Buddhist medicine as an
institution (Bawden, 1989). Before that time, however,
prominent Tibetan Buddhist monasteries in Mongolia
often maintained a college of medicine (mampa datsan)
where future physicians (maaramba, emch, or otoch)
trained in the diagnosis and treatment of illness (Jagchid
& Hyer, 1979). The Tibetan Buddhist medical canon in
Mongolia was a vast collection of sutras, theoretical
commentaries, and case studies compiled and revised
over centuries of practice. To become skilled in this field
of knowledge, a student was obliged to study at least
20 years in the datsan before becoming a physician
(Cheney, 1968). In recent decades, Tibetan medicine has
returned as a legal form of healing.
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
The theories and treatment of illness in Mongolia derive
primarily from three medical traditionspre-Buddhist
traditional, Tibetan Buddhist, and Russian modern.
Mongolians do not generally envision these predominant
modes of health care as mutually exclusive, coherent
wholes. Rather, individuals synthesize the basic tenets
and classificatory systems of each tradition into frameworks that fit their past and current illness experience.
Although it is impossible to completely disentangle the
original theories and treatments from these traditions,
this section will attempt to identify aspects particular to
each tradition.
Pre-Buddhist Traditions
The pre-Buddhist, or shamanic, medical tradition deals
with a broad range of misfortune ranging from inconveniences as benign as losing things to maladies as deadly as
the plague (Bawden, 1960; Humphrey & Onon, 1996).
Misfortune in its many forms (truck accidents, depression, miscarriages) is explained by recourse to a field of
powers personified as malignant humans, animals, or
ancestors (e.g., ongon, lus savdag, elriye, chidkun, tuidker, ada, eliye [Bawden, 1960; Heissig, 1980; Humphrey
& Onon, 1996]). These forces can be set in motion by
external actions, such as a curse, or by an individuals
own actions, such as the breach of a taboo.
Treatments under this system usually invoke the
powers of specific spirits. Tsagaan ovgon (the white old
man), for example, was known among the Buriats to
protect humans from poxes and various feverish illnesses
(Heissig, 1980). The task of a healer is to prevent misfortune by appealing to specific spirits or to correct (zasa-) a
855
Tibetan Medicine
Tibetan medicine in Mongolia, although predominantly
influenced by traditional Tibetan/Ayurvedic thought, has
some unique facets related to Mongolias prior theories of
illness. The three humors of Tibetan medicinekhii
(wind/air), badgan (phlegm), and shar (bile)constitute
the categorical backbone of the medical theory (Kohrt
et al., 2003a; Kriegel, 1997; Matignon, 1895). Diseases are
classified according to the interruption of flow or imbalance of these three humors (Cheney, 1968). In the
Mongolian context, these humors map onto concepts that
may have pre-dated the influx of Tibetan Buddhism.
Badgan (derived from Tibetan bad-kan) and shar
(the Mongolian word for yellow and jaundice) are
opposed according to a cold-hot (seruun-khaluun) set of
dichotomies (moon-sun, slow-fast, female-male, waterfire, and arga-bilig which is often described as yin-yang)
(Kriegel, 1997). Khii, resembling both the Tibetan humor
wind and the Chinese concept of chi, dominates the
humoral triad, and is responsible for neurological and local
idioms of distress, such as yadargaa (Kohrt et al., 2003).
Initial diagnosis involves taking a history, reading a
persons pulse, and examining the patients urine. A combination of pulse attributes reveals type of illness, location
of pathology, personal temperament, and childhood history
of disease. Urine, illuminates humoral constitution when
assessed by smell, taste, temperature, color, and foaming
potential (Cheney, 1968; Kriegel, 1997; Matignon, 1895).
Treatment depends upon the type of illness. Plant
and mineral compounds (tan) are often taken in hot water
856
Mongolia
Russian Medicine
The biomedical approach employed in Mongolia derives
from the Soviet model. Physicians currently diagnose and
treat according to the International Classification of
Disease-10 (ICD-10). Mongolian biomedicine also
emphasizes lifestyle and integrates therapies such as
cupping, acupuncture, massage, and various forms of
naturopathy. Injections (glucose, vitamin complexes, calcium chloride, and saline) are a popular form of treatment
for myriad health problems (Kohrt et al., 2002).
SEXUALITY
AND
REPRODUCTION
Sexuality
Pre-socialist Mongolia is stereotyped as having promiscuous sexual norms, and consequently high rates of venereal
disease (Bawden 1989; Cheney, 1968; Rupen, 1964;
Jagchid & Hyer 1979). During socialism sexual activity
outside of marriage was discouraged, and sex is not normally an acceptable topic in public discourse. Most education about sex and sexuality occurs through peers and
via the media. Sexual or gender forms different from a
standard heterosexual dichotomy are little understood and
treated with either confusion or disdain. Consequently little information is available on the subject. Post-socialist
Ideal Household
The ideal Mongolian household, which is captured in
socialist art and contemporary movies, is a heterosexual
857
Infancy
Infancy (balchir nas) in Mongolia, as in many other
regions of the world, is an especially risky period of the
life span. Even with the expansion of a socialist medical
system that made child health one of its primary concerns, infant mortality rates are still high, with 5060 of
every 1000 live births not surviving past the first year of
life (NSO, 2000). At this sensitive period of development,
efforts are made to protect children from all kinds of
disturbances, including states of fright or soul loss.
Among the Buriats, for example, black ash is smudged on
a childs forehead before leaving a ger at night in order to
protect the child from being frightened by wandering
spirits. This protects the child from loss of soul, a
disorder accompanied by listlessness or recurrent illness,
and if untreated, potentially death (Humphrey, 1996).
Breast-feeding is nearly universal, with over 96% of
children born in the 1990s fed with breast milk.
Mongolian mothers continue breast-feeding their infants
far longer than world standards, with a median age of cessation at 25 months. One fifth of children receive breastmilk up to three years. The median duration (8 months)
of postpartum amenorrhea is consequently quite long.
This pattern of sustained breast-feeding does not differ by
education or by residence (rural vs urban) (Dashtseren,
1999). Supplementation generally included animal milks
and boiled mutton soup (bantan) (Randall, 1993).
Rickets is widely reported in Mongolian children.
Due to concerns about cold weather, infants are rarely
taken outside in winter, and even then only when heavily
swaddled. The consequent lack of exposure to sunlight
during winter combined with depleted maternal supplies
of calcium may contribute to this problem (Randall,
1993). Respiratory illnesses are by far the largest cause of
death in both infants and children (see Environment
section).
Childhood
Childhood generally begins when a child reaches 3
Asian years of age, which overestimates years from
birth by an average of 18 months (Beall & Goldstein,
1992). In Ulaanbaatar, children (okhin refers to girls and
khuu to boys) are generally cared for by their mother
(57%) and/or grandmother (31%); fathers are caregivers
in 26% of homes (Kohrt et al., 2003b). A big step in rural
enculturation is reached when children (at about age 5)
858
Adolescence
Today Mongolians enter school at around the age of 8,
a time when children are beginning to have a sense of the
world around them, and when they would traditionally
begin to ride horseback independently and to assist in
herding large animals (horses, oxes and camels) (Cheney,
1968). Little data exists on sexual maturation among
Mongolians, but a recent study in the rural West recorded
a median age of menarche at 14 years of age (Beall &
Goldstein, 1992). There is no clear rite of passage related
to sexual maturation, but once children begin looking and
acting more like adults, they take on a set of gendered
terms different then those assigned to children (hovguun
for boys and busgui for girls).
Knowledge of sexual behavior most often comes
from friends, with surprising homogeneity of attitudes
given this horizontal mode of transmission. A number of
these attitudes engender behaviors that increase the
chance of sexually transmitted infection (STI) (Hruschka,
2001), which could partly explain the high rates of STIs
among youth aged 1525 (Purevdawa et al., 1997).
Mongolia
The Aged
Ancient Chinese chronicles noted with condescension
that the nomads to the north honor the strong and
despise the old (Jagchid & Hyer, 1979). Upon closer
inspection, however, Mongolians maintain entrenched
cultural patterns devoted to the aged. Those individuals
who live a long life (nastai khun) are treated with great
respect and often referred to with honorifics (guai, ahai,
avgai). This deference to the aged is perhaps most apparent during the Mongolian new year, Tsagaan sar, when
younger members of families and communities visit their
elders and present them with gifts. During the socialist
regime, the state provided generous pensions and state
services to the elderly. Since 1989, however, pensions
have not kept up with inflation, and the elderly must
depend on family members for support (Briller,
2000).
Adulthood
A number of criteria are associated with someone who
has come of age (Nasan hursend hun). In the past, these
criteria were related to the establishment of a householdfinding a spouse, having children, and developing
a herd. Today, they can also be associated with getting a
job. Women normally marry around 2024, and marriage
is nearly universal for women, with only 1% of women at
age 49 unmarried (Tsendjav & Marckvardt, 1999). Men
marry a few years later than women (NSO, 2001). Most
women report the end of menses around 4548 years old
(Tsendjav & Marckvardt, 1999).
Socialism
Given official statistics, the development of socialism
beginning in the 1920s seems to have improved the health
of Mongolians in profound ways. The socialist goal was
to spread the benefits of modern medical technology to
all citizens of Mongolia free of chargea plan that
mirrored the larger socialist platform of equitable distribution of economic, social, and cultural fruits of modern
development (Academy of Sciences, 1990; Farkas,
1993). Based on a rational Soviet model of strong central
planning, the system grew rapidly after World War II to
form a comprehensive hierarchy of health care. Ideally,
medical outposts staffed by a nurse practitioner catered to
residents within a 35 km radius, county clinics with 1
3 doctors (general practitioners and maternal/child health
specialists) provided primary and maternal care, and
more specialized hospitals in cities treated referrals from
859
Post-Socialism
By 1990, in step with other post-socialist countries,
Mongolia had begun a series of social and political transitions toward multi-party governance and a decentralized economy. The initial years of the transition were
difficult for Mongolians. With the subsequent loss of
Soviet subsidies (30% of its GDP prior to 1990), the state
was not able to continue funding its massive social
support system (Smith & Lannert, 1995). Inflation skyrocketed from near zero during the socialist period to
325% in 1992 (NSO, 2000). Unemployment rose as collectives and public corporations were privatized or simply ceased operations (Griffin, 1995). GDP per capita
dropped 1/5 from 1990 to 1998 (UNDP, 2000). At the end
of the 1990s, however, many of the same indicators now
suggest that Mongolians have weathered the transitional
storm (NSO, 2000). On the other hand, several disturbing
trends have continued their course. With reductions in
state expenditures in Mongolia, education and health
infrastructure continues to deteriorate (Humphrey &
Sneath, 1999; World Bank 2001), while a clearly visible
gap continues to grow between the rich and the poor
(Griffin, 1995).
Reductions in state funding have had serious consequences for the medical delivery system (Medvedeva, 1996).
860
Between 1989 and 1992, most of the MPRs maternitywaiting homes were closed, while the referral system that
had relied on jeep ambulances and planes for critical
emergencies went into disuse (Randall, 1993). There is
evidence that increased dependence on womens work
coupled with decreased state control is further leading
pastoralist women to have home births and return to work
quickly (Mongolian Ministry of Health, 1999). Rural
feldshers posts, which cost about 3 to 4 times as much
per bed as any other health unit were discontinued in
1990 (Center for Health Statistics, 1993).
Disruption of health services in the first years of the
transition has been implicated with the increase in maternal mortality from 120175 per 100,000 live births
(19851990) to a peak of 240 in 1993. With a stabilization of the health system, this rate has subsequently
declined to around 150 in 1997 and 1998 (WHO, 1999).
Nonetheless, the difference between maternal mortality
in Ulaanbaatar and the rest of the country has increased
in the last few years (WHO, 1999), suggesting increasing
disparity in access to perinatal care. An opposing trend
is that of infant and child mortality, with estimates of
infant mortality actually decreasing (NSO, 2000;
Tserendulam, 1999).
In contrast to infant and child mortality, adult
mortality rose dramatically after the end of socialism
with a 25% increase for all age groups between 15
44 years (19901993) (WHO, 1999). This increase in mortality disproportionately effected young males (1534).
Indeed the mortality of young men continued to increase
throughout the 1990s, while that for young women experienced a slight decline after an initial increase (WHO,
1999). These gender differences in mortality rate changes
are reflected in life expectancy trends, with male life
expectancy at birth having stayed around 64 since the
1980s, and female life expectancy increasing from 64 in
the 1980s to 68 years from birth in 1997 (WHO 1999).
The incidence of several infectious diseases has also
increased in the last decade. Perhaps related to the collapse of veterinary services, brucellosis and tuberculosis
incidences have both doubled (NSO, 2000; WHO, 1999),
while transitions in sexual behavior are likely implicated
in the recent increases in sexually transmitted diseases
(Purevdawa et al., 1997).
The stress of the socio-economic transition has also
had a marked impact on the mental health of many
Mongolians. For example, Mongolians who self-reported
more changes in the past decade suffered from more
Mongolia
References
REFERENCES
Aberle, D. F. (1961). Arctic Hysteria and Latah in Mongolia. In
Y. Cohen (Ed.), Social Structure and Personality: A Casebook.
New York: Holt, Rinehart and Winston.
Academy of Sciences of the Mongolian Peoples Republic. (1991).
Information Mongolia. Oxford: Pergamon Press.
Avirmed, A., & Marckwardt, A. M. (1999). Household and respondent
characteristics. In G. Altankhuyag & A. M. Marckwardt (Eds.),
Mongolia Reproductive Health Survey 1998. Ulaanbaatar:
National State Office of Mongolia.
Batbayar, B.-E. (1999). Twentieth Century Mongolia (D. Suhjargalmaa,
S. Burenbayar, H. Hulan, & N. Tuya, Trans.). Cambridge, U.K.:
The White Horse Press.
Bawden, C. R. (1960). The supernatural element in sickness and death
according to Mongol Tradition. Asia Major, 8, 215257.
Bawden, C. R. (1976). On the evils of strong drink: A Mongol tract from
the early 20th century. In W. Heissig (Ed.), Tractaca Altaica
(pp. 5979). Wiesbaden: Otto Harrassowitz.
Bawden, C. R. (1977). A note on a Mongolian burial ritual. Studia
Orientalia, 47, 2535.
Bawden, C. R. (1989). The Modern History of Mongolia ( 2nd revised
ed.). London: Kegan Paul International.
Bawden, C. R. (1994). Confronting the supernatural. Wiesbaden:
Harrassowitz.
Beall, C., & Goldstein (1992). High prevalence of excess fat and central fat patterning among Mongolian pastoral nomads. American
Journal of Human Biology, 4, 6, 1992: 747756.
Bold, B.-O. (1996). Socio-economic segmentationKhot-ail in
nomadic livestock keeping of Mongolia. Nomadic Peoples, 39,
6986.
Briller, S. H. (2000). Whom can I count on today? Contextualizing the
balance of family and government old age support for rural
pensioners in Mongolia. Unpublished Doctoral dissertation, Case
Western University, Cleveland.
Bruun, O., & Odgaard, O. (Eds.). (1996). Mongolia in transition:
New patterns, new challenges. Richmond, Surrey: Curzon
Press.
Bulag, U. (1998). Nationalism and Hybridity in Mongolia. Oxford:
Clarendon Press.
Center for Health Statistics and Information. (1993). Health Statistics
of Mongolia. Ulaanbaatar, Mongolia: Ministry of Health.
Centers for Disease Control and Prevention. (2002). Nutritional
Assessment of Children after severe WeatherMongolia, June
2001. Morbidity and Mortality Weekly Review, 51(01), 57.
Chabros, K. (1992). An East Mongolian ritual for children. In
G. Bethenfalvy (Ed.), Altaic Religious Beliefs and Practices
(pp. 5963). Budapest: Research group for Altaic Studies.
Chagnaadorj, B. (1999). Unwanted pregnancy and abortion. In
G. Altankhuyag & A. M. Marckwardt (Eds.), Mongolia
Reproductive Health Survey 1998. Ulaanbaatar: Mongolian
National Statistical Office.
861
Cheney, G. A. (1968). The Pre-revolutionary culture of Mongolia.
Bloomington, Indiana: The Mongolia Society.
Cleaves, F. W. (1954). A medical practice of the mongols in the
thirteenth century. Harvard Journal of Asiatic Studies, 17,
428444.
Dashtseren, A., & Marckwardt, A. M. (1999). Fertility Preferences. In
G. Altankhuyag & A. M. Marckwardt (Eds.), Mongolia Reproductive
Health Survey 1998. Ulaanbaatar: National Statistical Office of
Mongolia.
Dashtseren, A. (1999). Breastfeeding. In G. Altankhuyag &
A. M. Marckwardt (Eds.), Mongolia Reproductive Health Survey
1998. Ulaanbaatar: Mongolian National Statistical Office.
Farkas, O. (1993). Post-Modern health services in Mongolia: On the
integration of traditional medicine to the national health care
system. Unpublished Doctoral dissertation.
Field, M. G. (1976). The Modern Medical System: The Soviet
Variant. In C. Leslie (Ed.), Asian medical systems: A comparative
approach (pp. 82101). Berkeley: University of California
Press.
Fisher, C. T. (1988). Smallpox, Salesmen, and Sectarians. Ming Studies
(Spring), 123.
Foggin, P., Farkas, O., Shiirev-Adiya, S., & Chinbat, B. (1997). Health
status and risk factors of seminomadic pastoralists in Mongolia:
A geographical approach. Social Science and Medicine, 44(11),
16231647.
Goldstein, M., & Beall C. (1994). The Changing World of Mongolias
Nomads. Berkeley: University of California Press.
Griffin, K. (1995). Preface. In K. Griffin (Ed.), Poverty and the
Transition to a Market Economy in Mongolia (pp. viiixii).
New York: St. Martins Press.
Hiessig, W. (1953). A Mongolian source to the lamaist suppression
of shamanism in the 17th century. Anthropos, 48, 129, 493536.
Heissig, W. (1980). The Religions of Mongolia (G. Samuel, Trans.).
Berkeley, CA: University of California Press.
Heissig, W. (1986). Banishing illnesses into effigies in Mongolia. Asian
Folklore Studies, 45(1), 3344.
Hruschka, D. J. (1998, Winter). Baria Healers among the Buriats in
Eastern Mongolia. Mongolian Studies, 21.
Hruschka, D. J. (2001). The Stigma of Syphilis in Mongolia and its
Public Health Implications. Paper presented at the Central
Eurasian Studies Conference, Bloomington, Indiana, March 2001.
Hruschka, D. J., Kohrt, B. A., Kohrt, H. E., & Tsagaankhuu, G. (2001).
Yadargaa: A culturally and biologically bound illness in Mongolia.
American Journal of Human Biology, 13(1), 37.
Hu, J., & Stuart, K. (1992). Illness among the Minhe Tu, Qinghai
province: Prevention and etiology. Mongolian Studies, 15,
111135.
Humphrey, C. (1993). Avgai Khad: Theft and social trust in postcommunist Mongolia. Anthropology Today, 9(6), 1316.
Humphrey, C., & Onon, U. (1996). Shamans and elders: Experience,
knowledge, and power among the Daur Mongols. Oxford:
Clarendon Press.
Humphrey, C., & Sneath, D. (1996). Culture and environment in inner
Asia. London: Paul and Company.
Humphrey, C., & Sneath, D. (1999). The End of Nomadism? Durham,
NC: Duke University Press.
Jagchid, S., & Hyer, P. (1979). Mongolias Culture and Society.
Boulder, Colorado: Westview Press.
862
Jagchid, S. (1988). Shamanism among the Dakhur Mongols. In
S. Jagchid (Ed.), Essays in Mongolian Studies. Provo, Utah:
Brigham Young University.
Kirby, E., Oyuntugs, S., Uranchimeg, D. (2001). Smoking in Mongolia:
Prevalence, knowledge and attitudes: Results from an urban
survey, 2001. Australia: Adventist Development and Relief Agency
(ADRA) Australia.
Kler, J. (1938). Sickness, death, and burial among the Mongols of the
Ordos Desert. Primitive Man, 9, 2731.
Knaus, W. A., & Petroff, N. A. (1982). Inside Russian medicine: An
American doctors first-hand report. Boston: Beacon Press.
Kohrt, B. A., Kohrt, H. E., & Tsagaankhuu, G. (2001). Vulnerability and
stress in Mongolia: the adaptive significance of yadargaa.
American Journal of Physical Anthropology, 32 Supplement,
9192.
Kohrt, B. A., Hruschka, D. J., Kohrt, H. E., Panabianco, N. L.,
Tsagaankhuu, G. (2003a). Distribution of distress in post-socialist
Mongolia: a cultural epidemiology of yadargaa. Social Science
and Medicine. In press.
Kohrt, H. E., Kohrt, B. A., Waldman, I., Saltzman, K., & Carrion, V.
(2003b). An ecological-transactional model of significant risk factors for child psychopathology in outer Mongolia. Submitted for
publication.
Korsunkiyev, T. K. (2001). Ancient Oirat books about oriental medicine.
In Y. Bregel (Ed.), Papers on inner Asia (Vol. 36, pp. 33).
Bloomington, Indiana: Indiana University, Research Insitute for
Inner Asian Studies.
Kriegel, A. (1997). Tradition et modernity dans la medicine en mongolie. Unpublished Maitrise, Universite de Paris X, Nanterre.
Lessing, F. (1982). Mongolian-English Dictionary. Bloomington: The
Mongolian Society.
Lhagvasuren, M., Tumurtolgoi, N., & Marckwardt, A. M. (1999).
Reproductive and child health. In G. Altankhuyag &
A. M. Marckwardt (Eds.), Mongolia Reproductive Health Survey
1998. Ulaanbaatar: National Statistical Office of Mongolia.
Luvsantseren, Z. (1999). Family Planning. In G. Altankhuyag &
A. M. Marckwardt (Eds.), Mongolia Reproductive health survey
1998. Ulaanbaatar: National Statistical Office of Mongolia.
Matignon, J. J. (1895). La medicine des Mongols. Archives cliniques de
Bordeaux, 4(11), 101110.
Medvedeva, T. (1996). Medical Services and health issues in rural areas
of inner asia. In C. Humphrey & D. Sneath (Eds.), Culture and
Environment in Inner Asia. Cambridge: White Horse Press.
Mongolian Ministry of Health (1992). Health sector review. Ulaanbaatar,
Mongolia: Ministry of Health.
Mongolian Ministry of Health (1995). Contraceptive knowledge attitude
and practice survey. Ulaanbaatar: Mongolian Ministry of Health.
Montell, G. (1937). Distilling in Mongolia. Ethnos, 2(5), 321332.
Morgan, D. (1996). The Mongols. London: Blackwell Publishers.
Narsu, & Stuart, K. (1988). Insects used in Mongolian medicine.
Journal of the Anglo-Mongolian Society, 11(1), 713.
Neupert, R. F. (1995). Early-age mortality, socio-economic development and the health system. Health Transition Review, 3557.
Neupert, R. F. (1996). Population and the Pastoral Economy in
Mongolia. Asia-Pacific Population Journal, 11(4), 2746.
NSO (1997). Demographic Survey. Ulaanbaatar: National Statistical
Office of Mongolia.
Mongolia
NSO (1999). Reproductive Health Survey. Ulaanbaatar: National
Statistical Office.
NSO (2000). Mongolian Statistical Yearbook 1999. Ulaanbaatar:
National Statistical Office of Mongolia.
NSO (2001). The 2000 Population and Housing Census. Ulaanbaatar:
National Statistical Office of Mongolia.
Panday, R. N. (2002). The use of induced abortion as a contraceptive:
the case of Mongolia. Journal of Biosocial Science, 34, 91108.
Purevdawa, E., Moon, T. D., Baigalmaa, C., Davaajav, K., Smith, M. L., &
Vermund, S. H. (1997). Rise in sexually transmitted diseases during democratization and economic crisis in Mongolia. International
Journal of STD & AIDS, 8, 398401.
Randall, S. (1993). Issues in the Demography of Mongolian nomadic
pastoralism. Nomadic Peoples, 33, 209229.
Robinson, B., & Solongo, A. (2000). The gender dimension of economic
transition in Mongolia. In F. Nixson, B. Walters, B. Suvd, &
P. Luvsandorj (Eds.), The Mongolian Economy: A manual of
applied economics for a country in transition. Massachusetts:
Edward Elgar Publishing, Inc.
Roerich, G. N. (1933). La Medicine au Thibet et les lamas Gueriseurs.
LEthnographie, 27, 9798.
Rupen, R. (1964). Mongols of the twentieth century (Vol. 37).
Bloomington, Ind.: Indiana University Press.
SCRFS. (1994). Statistics of Russia. Moscow: State committee of the
russian federation on statistics.
Seidenberg, S. (1991). The horsemen of Mongolia. In P. Carmichael
(Ed.), Nomads (pp. 96125). London: Collins and Brown.
Serruys, H. (1980). Smallpox in Mongolia during the Ming and Ching
dynasties. Zentralasiatische Studien, 14(1), 4163.
Shombodon, D. (1996). The division of labor and working conditions
of herdsmen in Mongolia. In C. Humphrey & D. Sneath (Eds.),
Culture and Environment in Inner Asia. Cambridge: White Horse
Press.
Skapa, B. (1995). Mongolian women and poverty during the transition.
In K. Griffin (Ed.), Poverty and the transition to a market economy
in Mongolia (pp. 90 103). New York: St. Martins Press.
Smith, S., & Lannert, J. (1995). Human capital: The health and
well-being of the population. In K. Griffin (Ed.), Poverty and the
Transition to a Markey Economy in Mongolia (pp. 7789).
New York: St. Martins Press.
Strickland, S. S. (1993). Human nutrition in Mongolia: Maternal
mortality and rickets. Nomadic Peoples, 33, 231239.
Tianlu, Z., & Rongqing, H. (1996). Chinas population in transition and
development. Beijing: Gaodeng Jiaoyu Chubanshe Shatan Houjie.
Tsendjav, B., & Marckwardt, A. M. (1999). Other proximate determinants of fertility. In G. Altankhuyag & A. M. Marckwardt (Eds.),
Mongolian Reproductive health survey 1998. Ulaanbaatar:
Mongolian Statistical Office.
Tserendulam, T. (1999). Infant and Child Mortality. In G. Altankhuyag &
A. M. Marckwardt (Eds.), Mongolia Reproductive Health Survey
1998. Ulaanbaatar: National Statistical Office of Mongolia.
Underdown, M. (1977). The Mongols and wine (attitude to alcohol as
revealed in Mongolian literature). Journal of the Oriental Society
of Australia, 12, 11113.
UNICEF. (2001). Speaking out! voices of children and adolescents in
East Asia and the Pacific. Bangkok.
United Nations Development Programme. (2000). Human Development
Report 2000. New York.
863
The Nahua1
Brad R. Huber
ALTERNATIVE NAMES
Aztec, Nahuat, Nahuatl, Mexicano, Mexijcatl.2
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
864
they cook using a floor level hearth, sit on low stools, and
sleep on a petate (woven mat) directly on the floor or on
wood planks supported by concrete blocks. These living
conditions permit the spread of infectious diseases of the
skin, and of the respiratory and gastrointestinal systems.
Households are composed of nuclear or patrilocal
extended families whose adult members may own
arable land or have access to ejidos (government land
grants). In general, the Nahua trace descent bilaterally,
avoid marrying a blood relative or compadre (ritual
coparent), and marry within the community or municipality. Compadrazgo ties are often very important
socially and economically, and may be established on the
occasion of a birth, marriage, severe illness, or death as
well as for a first communion, confirmation, and the
acquisition of a saints image, car, or house. Fiestas that
accompany these life-cycle events have banquets in
which abundant amounts of food rich in carbohydrates,
proteins, fats, vitamins, and minerals are served. They are
also occasions for the ritual sharing of cigarettes and
alcohol. The extent to which adults are addicted to nicotine and ethanol is not known, but fiestas are occasions
during which some men and a few women become very
inebriated.
Nahua social organization is generally based upon
men agreeing to perform for little or no financial remuneration civil, political, and religious works (cargos) that
benefit the community. Cargo holders and other community authorities participate in the distribution of ejido
lands, the settlement of minor disputes, and the sponsorship and celebration of saints feast days. Community
social organization is variable with respect to the presence
and influence of a council of elders, state-level political
officials, teachers, biomedical personnel, Catholic priests,
and Protestant missionaries.
As is the case with other aspects of contemporary
Nahua culture, religious beliefs and practices are a complex blend of Native American and Spanish elements.
Pre-hispanic religious beliefs and practices can be found
in relatively unacculturated communities where native
religious practitioners celebrate rituals coinciding with
the winter-solstice, planting, and harvesting, and preside
over disease-prevention and curing rituals, ceremonies
petitioning rain, and divinations. The influence of
Spanish Catholicism is evident in more acculturated
Nahua communities where Spanish-speaking priests have
encouraged community members to observe the Catholic
liturgical calendar for nearly 500 years.
The Nahua
MEDICAL PRACTITIONERS
Nahua medical specialists are usually consulted only
when the herbal remedies and special diet recommended
by members of an individuals family (e.g., wife, mother,
grandmother) are ineffective in treating an illness. The
most common Nahua medical practitioners are the
shaman (tepahtihqui,4 tepahtiani, tlamtiquetl, pajchijquetl, curandero/a), midwife (tetejquetl, partero/a), bonesetter (texixitojquetl, huesero/a), herbalist (xiutepatique,
hierbero/a), and massager (tlatitilanki, sobador). Less
common are specialists such as curer of fallen fontanel,
spirit exorcist, prayer leader, snake bite healer, sucking
healer, injectionist, and spiritualist. The majority of medical practitioners heal on a part-time basis, devoting most
of their energy to farming, housework, child care, wage
labor, and crafts work. A small minority of medical
practitioners practice two medical specialties, and a few
undertake three or more. Nahua medical practitioners
865
866
The Nahua
SEXUALITY
AND
REPRODUCTION
867
868
The Nahua
Infancy
Babies are carried with a shawl on their mothers backs
and breast-fed on demand for the first six months of their
lives. In some parts of the Sierra Norte de Puebla, a
mother applies a bitter herb (chichicxihuit) to her nipples
to discourage a child from breast-feeding. Weaning foods
(e.g., atole, tortillas, beans) are gradually introduced until
the child is fully weaned, which occurs about the sixth
month of a womans next pregnancy (Taggart, 1997,
pp. 234235). By age 2 or 3, children eat the full repertoire of local foods, and begin to talk and walk. There is
a widespread belief that a womans children, especially
the youngest one, may become tzipititoc when she
becomes pregnant again. A child who is tzipititoc is said
to ache, lack an appetite, and cry constantly. These symptoms are attributed to the jealousy a young child feels
toward the expected baby.
Some Nahua mothers bottle-feed infants and serve
cows milk to their children. However, many Nahua children are probably lactase-deficient to some degree, and
experience diarrhea, abdominal pain, flatulence, and
bloating after consuming cows milk (Cifuentes &
Limn, 1985).
Nahua healers indicate that there are a number of
illnesses that infants are likely to suffer. Those characterized by respiratory problems include opatzmigui (oguo,
bronchitis), mitetaxis (tos ferina, whooping cough), and
pulmona (pneumonia). Others are characterized by fever
(e.g., afereca, epilepsy), and diarrhea, vomiting, and
other kinds of gastro-intestinal distress including ahuetzi
(cada de mollera, fallen fontanel), cada de cuajo (fallen
or dislocated cuajo, an organ believed to be inside the
stomach), clicos (colic), ocuiloua or chincual (worms),
mal de ojo (evil eye), and soul loss.
In a number of cases, these illnesses are attributed
to something that happened to the mother or something
the mother did while she was pregnant, for example inappropriate conduct, becoming angry frequently, eating
Childhood
Childhood begins around age 4 and lasts until the child
reaches 13 or 14 years of age. In some villages, anthropometric data suggest that 50 to 70% of preschool and
school-age children are underweight and malnourished.
Intestinal parasites are also common in children.
Biomedical practitioners treat children (and adolescents
and young adults) for acute respiratory conditions
(e.g., pneumonia, bronchitis, tuberculosis), diarrhea, and
wounds sustained in accidents that occur at home, at
school, at work, and while traveling by taxi, truck, or bus.
Males are treated for wounds at a higher rate than are
females.
Nahua healers indicate there are a number of culturebound illnesses that children suffer, including apisuilo
(tiricia, jaundice), which is characterized by yellowish
skin and eyes and attributed to a variety of causes including being reprimanded continually or being a victim of
envy. Netatil (quemadas, burns) is another culture-bound
syndrome that children as well as adult men are thought
to suffer. It is attributed to close contact with a woman
who recently gave birth, and characterized by a rash or
yellowish skin. Urinary infections (mal de orn) and eye
irritations (ixtemtoleulixli, mal de los ojos) are also
common among children.
869
870
The Aged
People are considered older adults when they are in their
late 50s and 60s. Most men and women remain active
until their deaths, and it is not unusual to see 70 or
80-year-old men farming or elderly women weaving,
cooking, and washing clothes. Men and woman expect
their children to care for them when they become elderly.
The very old (and the very young) are thought to be
relatively weak, and especially prone to illness, including
mal aire and soul loss. Sometimes, couples are faced with
the difficult decision of allocating scarce financial
resources to treat a sick elderly parent or grandparent, or
to purchase food and clothing for their children.
The Nahua
References
NOTES
1. The author would like to thank Alan R. Sandstrom (Anthropology,
Indiana University-Purdue University Fort Wayne) and James M.
Taggart (Anthropology, Franklin & Marshall College) for critically
commenting on this article. The author, of course, is solely responsible for any errors of fact or interpretation.
2. The way in which Nahua terms were rendered in the original sources
has been preserved. There is no standard orthographic system used
by all Nahua scholars.
3. Many of the Nahua, especially school-aged children, young adults,
and men speak Spanish as a second language.
4. The Nahua, Spanish, and English terms used for different types
of healers and illnesses are terms of reference rather than strict
translations.
5. To varying degrees, these principles are applicable to Nahua living
in other regions and to many other Mesoamerican groups as well.
871
6. The author thanks James M. Taggart for pointing out that tlalia
means to seat or place, and that a parallel might be drawn between
conception and the Xochitlalia ritual.
REFERENCES
lvarez Heydenreich, L. (1987). La enfermedad y la cosmovisin en
Hueyapan, Morelos. (Coleccin INI, No. 74). Mxico: Instituto
Nacional Indigenista.
lvarez Heydenreich, L. (1992). Tipos de curanderos en Hueyapan,
Morelos. In R. Campos Navarro (comp.), La antropologa mdica
en Mxico, Volume 2 (pp. 127138). Mxico, DF: Universidad
Autnoma Metropolitana.
Argueta Villamar, A., Cano Asseleih, L. M., & Rodarte, M. E. (1994).
Atlas de las plantas de la medicina tradicional mexicana.
(3 Volumes). Mxico, DF: Instituto Nacional Indigenista.
Bonfil Batalla, G. (1968). Los que trabajan con el tiempo: Notas
etnogrficas sobre los graniceros de la Sierra Nevada, Mxico.
Anales de Antropologa, 5, 99128.
Cifuentes, E., Flores, J. J., & Limn, N. E. (1985). Deficiencia de
lactasa intestinal en un pueblo Nahua: Alternativas para los programas de intervencin nutricional en la regin. La Revista de
Investigacin Clinica (Mexico), 37, 311315.
Dakin, K. (2001). Nahuatl. In D. Carrasco (Ed.), The Oxford encyclopedia of Mesoamerican cultures: The civilizations of Mexico and
Central America, Volume 2 (pp. 363365). New York: Oxford
University Press.
Dow, J. W., & Van Kemper, R. (1995). Nahua peoples. In J. W. Dow &
R. Van Kemper (Eds.), Encyclopedia of world cultures, Volume
VIII: Middle America and the Caribbean (pp. 182183). Boston:
G. K. Hall.
Emes Boronda, M., Ochurte Espinoza, C., Castaeda Silva, G., &
Peralta Gonzlez, B. et al. (1994). Flora medicinal indgena de
Mxico: Treinta y cinco monografas del Atlas de las plantas de la
medicina tradicional mexicana. (3 Volumes). Mxico, DF: Instituto
Nacional Indigenista.
Huber, B. R. (1990). The recruitment of Nahua curers: Role conflict and
gender. Ethnology, 29, 159176.
Huber, B. R., & Anderson. R. (1996). Bonesetters and curers in a
Mexican community: Conceptual models, status and gender.
Medical Anthropology, 17, 2338.
Huber, B. R., & Sandstrom, A. R. (2001). The Recruitment, training,
and practice of midwives from the United States-Mexico border to
the Gulf of Tehuantepec, In B. R. Huber & A. R. Sandstrom (Eds.),
Mesoamerican healers (pp. 139178). Austin, Texas: University of
Texas Press.
Huber, B. R., Sandstrom, A. R., & Toribio Martnez, A. (forthcoming).
Transformations in the recruitment, training, and practice of midwives in a Nahuat-speaking community of Mexico, In M. Good
Maust & M. Gmez Pineda (Eds.), Mexican midwives: Change,
continuity and controversies. Austin, Texas: University of Texas
Press.
Instituto Nacional Indigenista. (2001). Informacin bsica sobre los
pueblos indgenas de Mxico; National profile of the indigenous
peoples of Mexico; Pueblos Nahuas de la Huasteca. Mxico, D. F.
(March 19, 2001); http://www.ini.gob.mx.
872
Lewis, Oscar. (1963). Life in a Mexican village: Tepoztln restudied.
Urbana: University of Illinois Press.
Madsen, C. (1968). A Study of Change in Mexican Folk Medicine. In
M. S. Edmonson, C. Madsen, & J. F. Collier (Eds.), Contemporary
Latin American culture. Middle American Research Institute,
Publication 25 (pp. 92137). New Orleans: Tulane University.
Madsen, W. (1955). Shamanism in Mexico. Southwestern Journal of
Anthropology, 11, 4857.
Mellado Campos, V., Snchez Reyes, A., Femia, P., Navarro Magdaleno, A.,
Erosa Solana, E., Bonilla Contreras, D. M., & Domnguez
Hernndez, M. del S. (1994). La medicina tradicional de los pueblos indgenas de Mxico (3 Volumes). Mxico: DF: Instituto
Nacional Indigenista.
Mellado Campos, V., Zolla, C., & Castaeda. X. (with Antonio Tascn
Mendoza). (1989). La atencin al embarazo y el parto en el medio
rural mexicano. Mxico, D.F.: Centro Interamricano de Estudios
de Seguridad Social.
Montoya Briones, J. de J. (1964). Atla: Etnografa de un pueblo Nahuatl.
Mxico: D.F.: Instituto Nacional de Antropologa e Historia.
Nutini, H. G., & Forbes de Nutini, J. (1987). Nahualismo, control de los
elementos y hechicera en Tlaxcala rural. In S. Glantz (Ed.),
La heterodoxia recuperada en torno a Angel Palerm
(pp. 321346). Mxico, DF: Fondo de Cultura Econmica.
Nutini, H. G., & Isaac, B. L. (1974). Los pueblos de habla Nahuatl de
la regin de Tlaxcala y Puebla. Mxico, DF: Instituto Nacional
Indigenista.
Ramrez Celestino, C. (1991). Plantas de la regin Nahuatl del centro
de Guerrero. Tlalpan, Mxico: Centro de Investigaciones y
Estudios Superiores en Antropologa Social.
Redfield, M. P. (1928). Nace un nio en Tepoztln: A child is born in
Tepoztln. Mexican Folkways, 4, pp. 102108.
Redfield, R. (1930). Tepoztln, A Mexican village: A study of folk life.
Chicago: University of Chicago Press.
Robinson, D. F. (1961). Textos de medicina Nahuat. American
Indgena, 21, pp. 345353.
Sandstrom, A. R. (1978). The image of disease: Medical practices of
Nahua Indians of the Huasteca. Monographs in anthropology. no. 3.
Columbia: Dept. of Anthropology, University of MissouriColumbia.
Sandstrom, A. R. (1983). Paper dolls and symbolic sequence: An analysis of a modern Aztec curing ritual. Folklore Americano, 36,
pp. 109126.
The Nahua
Sandstrom, A. R. (1989). The face of the devil: Concepts of disease and
pollution among Nahua Indians of the southern Huasteca. In
G. Stresser-Pan & D. Michelet (Eds.), Enqutes sur lAmrique
moyenne: Mlanges offerts Guy Stresser-Pan (pp. 357372).
Mxico: Instituto Nacional de Antropologa e Historia, Consejo
Nacional para la Cultura y las Artes, & Centre dtudes mexicaines
et centramricaines.
Sandstrom, A. R. (1991). Corn is our blood: Culture and ethnic identity
in a contemporary Aztec Indian village. Norman: University of
Oklahoma Press.
Sandstrom, A. R. (1995). Nahua of the Huasteca. In J. W. Dow &
R. Van Kemper (Eds.), Encyclopedia of world cultures, volume
VIII: Middle America and the Caribbean (pp. 184187). Boston:
G. K. Hall & Co.
Sandstrom, A. R. (2000). Contemporary cultures of the Gulf Coast. In
J. D. Monaghan (Ed.), Supplement to the Handbook of Middle
American Indians. Volume 6, Ethnology (pp. 83119). Austin:
University of Texas Press.
Sandstrom, A. R., & Sandstrom, P. E. (1986). Traditional papermaking
and paper cult figures of Mexico. Norman: University of
Oklahoma Press.
Signorini, I. (1989). Los tres ejes de la vida: Almas, cuerpo, enfermedad
entre los nahuas de la Sierra de Puebla. Xalapa, Veracruz, Mexico:
Universidad Veracruzana.
Taggart, J. M. (1995). Nahuat of the Sierra de Puebla. In J. W. Dow &
R. Van Kemper (Eds.), Encyclopedia of world cultures, volume
VIII: Middle America and the Caribbean (pp. 190193). Boston:
G. K. Hall & Co.
Taggart, J. M. (1997). The Bear and his sons: Masculinity in Spanish
and Mexican folktales. Austin: University of Texas Press.
Taggart, J. M. (2001). Nahua. In D. Carrasco (Ed.), The Oxford encyclopedia of Mesoamerican cultures: The civilizations of Mexico
and Central America, Volume 2 (pp. 359363). New York: Oxford
University Press.
Unidad Regional de Acayucan. (1983). Ciclo de vida de los nahuas.
Cuadernos de Trabajo, Acayucan, No. 22. Mxico: Direccin
General de Culturas Populares.
Vexler, M. J. (1981). Chachahuantla, A blouse-making village in
Mexico: A study of the socio-economic roles of women. Doctoral
dissertation, University of California, Los Angeles, 1981.
873
Navajo
Joanne McCloskey
ALTERNATIVE NAMES
Din, means The People in Navajo, and is often
preferred throughout the Navajo Nation.
OVERVIEW
OF THE
CULTURE
Relative to the Pueblo Indians, the Navajo were latecomers, arriving in the Southwest sometime before or around
1500 ad (Brugge, 1983). Originally huntergatherers,
they adopted agriculture from the Pueblos and sheep and
horses from the Spanish. The Navajos thrived as
pastoralists and agriculturists, moving their sheep
with the changing seasons between winter camp and
summer camp where they raised corn, squash, beans, and
melons.
After their release from imprisonment at Bosque
Redondo in Ft Sumner, New Mexico in 1868, the Navajo
continued their reliance on livestock and crops until the
1930s. The initiation of livestock reduction by the
commissioner of Indian Affairs, John Collier, in 1933
sounded the death knell for the land-based economy.
Unable to support themselves with the drastically
reduced herds, Navajos had no alternative but to seek
work in the labor force. At first Navajo men worked, often
at off-reservation jobs on the railroad, ranches, in
construction and mining, and as migrant field hands.
Women stayed at home to maintain the fields and reduced
herds, while weaving rugs to sell at trading posts.
874
Navajo
MEDICAL PRACTITIONERS
Navajo medical practitioners include diagnosticians,
healers, and herbalists. Three types of traditional diagnosticians are stargazers, listeners, and hand tremblers, of
which hand tremblers are by far the most common. After
praying to Gila Monster, one of the Holy People, a hand
trembler goes into a mild trance (Milne & Howard,
2000). Hand tremblers may be either male or female, with
a predominance of females among practitioners who
function only as diagnosticians (Adair, Deuschle, &
Barnett, 1988). In addition, road men in the Native
American Church also act as diagnosticians. Although
not all road men diagnose, many use charcoal gazing, the
second most common method of diagnosis (Milne &
Howard, 2000).
Three primary types of Navajo healers are medicine
men, or singers, who conduct traditional ceremonies;
road men who lead Native American Church meetings;
and pastors of fundamentalist Christian churches who
perform faith healing. In addition, western biomedical
practitioners may be used alone or in combination with
religious forms of healing. Similar to the many years of
education required to prepare medical doctors, medicine
men undergo many years of apprenticeship to learn a single ceremony. Depending upon the apprentices other
activities and the ability to memorize hundreds of songs,
prayers, and rituals, the learning period may last as long
as 15 years (Morgan, W., 1977).
Herbalists, who use their vast knowledge of local
flora for medicinal as well as ceremonial purposes, are
usually elders. They may use their herbal remedies only
for members of their extended families or their cures may
be in demand for a wider group. As an example, an
herbalist from the Crownpoint area on the eastern portion
of the reservation uses her knowledge of plants to prevent
births, to facilitate an easy childbirth, and to treat sores,
bruises, the common cold, and broken bones.
Some Navajos seek cures from healers belonging
to other tribes. For example, on the western portion of
the reservation, Navajos may travel to Hopi Indian villages for treatment to extract objects from the patients
body that cause illness and problems (Levy, 1983;
Morgan, F., 2002).
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Classification of Illness
Etiologic agents believed to cause disease include
animals, insects, natural phenomena, mistakes made
during healing ceremonies, contact with ghosts of
deceased humans, and contact with living or dead foreigners, particularly enemies (Wyman & Kluckhohn,
1938). Among the animals and insects that cause illness,
the most frequently identified are the bear, coyote, porcupine, snake, eagle, moth, ant, long-horned grasshopper,
and camel cricket. The most commonly named natural
phenomena responsible for illness are lightning and
whirlwinds (Levy, 1983). Failure to observe the taboo
regarding abstinence from sex during or four days after a
ceremony can cause illness. Illness can result from contact with the dead or from the location where a person
died. Because pregnant women and their husbands are
particularly vulnerable, they cannot attend funerals.
These etiologic factors may lead to a variety of
symptoms and illnesses. There is no direct correlation
between a causative agent and a disease process. A single cause may produce any of several symptoms and conversely, a single symptom may be caused by any of
several etiologic agents. Likewise, No Navajo disease
is known by the symptoms it produces, or by the part of
the body it is thought to affect (Levy, 1983, p. 132). For
instance, bear sickness and porcupine sickness have been
caused by contact with these animals. The time frame for
symptoms to appear after exposure may loosely be sooner
or later. For example, a diagnostician may find that an
adults health problem originated during gestation
because either parent came in contact with lightning or a
dead person.
Theories of Illness
The ultimate source of illness is a lack of harmony
between an individual and the natural or supernatural
world. To restore health, evil must be driven out and
replaced with good (Adair, Deuschle, & Barnett, 1988;
Reichard, 1974). Rather than treating the physical symptoms of an illness, a ceremony focuses on exorcising the
intrusive factors (Wyman, 1983). Purification rites, such
875
Treatment of Illness
Three types of Navajo healing, traditional ceremonies,
Native American Church, and Christian faith healing,
together with western biomedicine make up the contemporary Navajo health care system (Csordas, 2000).
Traditional Navajo healing employs a didactic approach
through rituals, songs based on stories of obstacles overcome by the Holy People, and prayer that immerses the
patient in the contextualization of life experience within
a cosmological and physical home, the Navajo land and
people (Csordas, 2002, p. 167). Crucial to the successful performance of ceremonies is the perfect recitation of
prayers. Themes found in prayers, songs, and sandpaintings include the directions, colors, jewels, and simple
numbers like four and its multiples (Reichard, 1944).
Besides reciting prayers and songs and performing or
directing the ceremonial rituals, medicine men talk to
patients, emphasizing the positive (Carrese & Rhodes,
2000). As one man told how a medicine man had helped
him, They dont just sing. They also talk to you
(McCloskey, 1998b, p. 22). All participants in the hogan
pray with corn pollen by taking a pinch, then putting
some in their mouths, some on top of their head, and
trailing the remainder in an upward gesture. Knowledge
of the Navajo language is pivotal to understand and
appreciate the progression of events during an all-night
ceremony. One participant stated that he was too
absorbed in the beauty of whats going on even to think
about sleep (Csordas, 2002, p. 168).
876
Navajo
877
Theories of Efficacy
From a western perspective, three main theories of
efficacy attempt to explain the success of Navajo healing.
These theories interpret Navajo healing as psychotherapy,
as social acts, or as cultural performances. As a form of
native psychotherapy, Navajo healing relies on a powerful practitioner. A medicine man is an imposing figure
who becomes the epitome of success, spiritual harmony,
and culturally appropriate behavior (Topper, 1987,
p. 221). He is respected as someone who, like a grandparent, can resolve conflict. Psychotherapeutic elements
of healing such as confession, therapeutic alliance, transference, suggestion, and the manipulation of symbols
unite to effect a cure (Topper, 1987).
The social dimension of Navajo healing offers a
second explanation of efficacy. The presence and support
of extended family, clan members, and friends act as
powerful affirmation of belonging in a support network,
identifying the patient as a significant link in a web of
relationships. When an individual suffers a crisis that
indicates a disruption of harmony, the family rallies to
make arrangements for a ceremony. Enlisting aid from
family and friends acknowledges the patients importance
to the group. The patient becomes the center of supportive attention (Spickard, 1991, p. 201). The Navajo
educator, Ruth Roessel (1981), also emphasizes the social
support integral to a ceremony in her discussion of the
Kinaald, the Navajo girls puberty ceremony. The planning, gathering of items to be used such as the grass brush
and cornmeal, cooking meals for guests, tending the fire
while the corncake cooks, and participating in the allnight ceremony require the cooperation of many helping
hands.
The third explanation for the efficacy of Navajo
ceremonies is that they are cultural performances, a reenaction of cultural values and beliefs. The role of sandpaintings in ceremonies dramatically portrays their
performative nature. A ceremony tells the story of a specific adventure of the Holy People, which is retold in the
songs and prayers as well as in the sandpaintings. When a
patient sits on a sandpainting, he or she identifies with the
Holy People who have been attracted by their likenesses
in colored sands. It is too little to say that for the person,
this identification must be a very significant event (Gill,
1987, p. 55). The healing power of the supernaturals
absorbs the sickness and restores the health of the patient
seated on the sandpainting (Griffin-Pierce, 1992).
878
SEXUALITY
Navajo
AND
REPRODUCTION
Infancy
When an infants umbilical cord dries and falls off,
parents save it for burial in a nearby location related to
traditional economic pursuits and appropriate to the sex
of the child. A boys umbilical cord is buried near a corral
to promote his successful work with livestock while a
girls umbilical cord is buried close to a loom to assure
her future success as a weaver.
A babys first laugh marks him or her as a social
being and is celebrated with a gathering of family and
friends. The person who made the baby laugh provides
the sheep to be butchered. The baby, sitting on the
mothers lap, hands out small gifts to guests, including
salt. Distributing these gifts assures that a child will grow
up to be a generous adult.
Many infants spend much of their first year of life in
the protective and comforting environment of a cradleboard, which in Navajo means baby diaper. In his study
of Navajo infancy, Chisholm (1983) found that infants are
quieter and less irritable at birth than white babies.
Childhood
The traditional attitude toward children equated them with
wealth. Not only were children important sources of labor
in the land-based economy, but also they were looked to
as companions and sources of help in old age. Although
children now spend their childhood years in school, they
nevertheless are viewed as blessings and as evidence of
the sacred process of increase (Farella, 1984). Despite the
trend toward nuclear family households, children often
benefit from the influence of grandparents, who may care
for children for extended periods during childhood while
parents complete their education or work in an urban area.
Approaches to discipline vary, but the ideal continues to
be talking to children, calmly explaining the difference
between right and wrong.
A major health concern among Navajo children is
the increasing tendency toward obesity. This secular trend
is a culmination of changes in diet and activity level, with
traditional foods and high levels of physical activity
replaced with foods high in fat and calories and a sedentary lifestyle. The trend toward obesity constitutes a risk
factor for future health problems. Findings from a nutritional survey carried out in 1989 (Sugarman, White, &
Gilbert, 1990) contrasts markedly with earlier studies.
Earlier studies in 1955 and 1968 found some cases of
malnutrition among Navajo children but few cases of
879
Adolescence
For Navajo girls menarche is a notable event, celebrated
by family, kin, clan relatives, and friends with a Kinaald,
the Navajo puberty ceremony. Acknowledging her ability
to bear children and ushering in her status as a woman, a
girls Kinaald is a 4-day event. Major events are running
to the east at dawn; grinding corn for the alkaan, or corncake, to be distributed to guests; and participating in the
all-night ceremony conducted by a medicine man. In the
words of Mary Shepardson, One cannot overestimate
the importance of this rite in creating a positive selfimage in a young girl (1995, p. 164). The Kinaald reenacts the first Kinaald held for Changing Woman, the
beloved Navajo deity and model for Navajo womanhood
(Frisbie, 1993). The ceremony continues to thrive today,
sometimes being arranged by mothers who themselves
did not have one when they were students away from
home at boarding school (Frisbie, 1993; McCloskey,
1998a). Compared to the Kinaald held for Navajo girls,
the performance of a ceremony for boys at puberty is rare.
880
Navajo
Adulthood
The Aged
References
881
REFERENCES
Aberle, D. F. (1983a). Navajo Economic Development. In Alfonso Ortiz
(Ed.), Southwest (pp. 641658). Vol. 10, Handbook of North
American Indians. Washington: Smithsonian Institution.
Aberle, D. F. (1983b). Peyote Religion among the Navajo. In Alfonso
Ortiz (Ed.), Southwest (pp. 558569). Vol. 10, Handbook of North
American Indians. Washington: Smithsonian Institution.
Adair, J., Deuschle, K. W., & Barnett, C. R. (1988). The peoples health:
Anthropology and medicine in a Navajo community. Revised and
Expanded Edition. Albuquerque: University of New Mexico Press.
Bailey, F. L. (1948). Suggested techniques for inducing Navaho women
to accept hospitalization during childbirth and for implementing
health education. American Journal of Public Health, 38,
14181423.
Bailey, F. L. (1950). Some sex beliefs and practices in a Navaho community with comparative material from other Navaho areas.
Papers of the Peabody Museum of American Archaeology and
Ethnology, Harvard University, Vol. XL, No. 2. Cambridge,
Massachusetts: Peabody Museum.
Bailey, G., & Bailey, R. G. (1986). A history of the Navajos: The reservation years. Santa Fe, New Mexico: School of American
Research Press.
Ballew, C., White, L. L., Strauss, K. F., Benson, L. J., Mendlein, J. M., &
Mokdad, A. H. (1997). Intake of nutrients and food sources of
nutrients among the Navajo: Findings from the Navajo health and
nutrition survey. The Journal of Nutrition, 127, 2085S2093S.
Boyce, W. T., Schaefer, C., Harrison, H. R., Haffner, W. J. H.,
Lewis, M., & Wright, A. L. (1986). Social and cultural factors in
pregnancy complications among Navajo women. American
Journal of Epidemiology, 124, 242253.
Broudy, D. W., & May, P. A. (1983). Demographic and epidemiologic
transition among the Navajo Indians. Social Biology, 30, 116.
Brugge, D. M. (1983). Navajo prehistory and history to 1850. In
Alfonso Ortiz (Ed.), Southwest (pp. 489501). Vol. 10, Handbook
of North American Indians. Washington: Smithsonian Institution.
Byers, T., & Hubbard, J. (1997). The Navajo health and nutrition survey: Research that can make a difference. The Journal of Nutrition,
127, 2075S2077S.
Carrese, J. A., & Rhodes, L. A. (2000). Bridging cultural differences in
medical practice: The case of discussing negative information with
Navajo patients. Journal of General Internal Medicine, 15, 9296.
Chisholm, J. S. (1983). Navajo infancy:An ethological study of child
development. NY: Aldine Publishing Company.
Choudhary, T. (2001). 20002001 Comprehensive Economic
Development Strategy. Support Services Department, Division of
Economic Development, The Navajo Nation. Window Rock, AZ:
Navajo Nation.
882
Choudhary, T. (2003). Data from Census 2000. Support Sciences
Department, The Navajo Nation. Window Rock, AZ: Navajo
Nation.
Conners, J. L., & Donnellan, A. M. (1998). Walk in beauty: Western
perspectives on disability and Navajo family/cultural resilience.
In H. I. McCubbin, E. A. Thompson, A. I. Thompson, &
J. E. Fromer (Eds.), Resiliency in Native American and immigrant
families (pp. 159182). Thousand Oaks: Sage Publications.
Csordas, T. J. (2002). Body/Meaning/Healing. NY: Palgrave Macmillan.
Csordas, T. J. (2000). The Navajo healing project. Medical
Anthropology Quarterly, 14, 463475.
Davies, Wade. (2001). Healing ways: Navajo health care in the twentieth century. Albuquerque: University of New Mexico Press.
Farella, J. R. (1984). The main stalk: A synthesis of Navajo philosophy.
Tucson, AZ: The University of Arizona Press.
Freedman, D. S., Serdula, M. K., Percy, C. A., Ballew, C., & White, L.
(1997). Obesity, levels of lipids and glucose, and smoking among
Navajo adolescents. The Journal of Nutrition, 127, 2120S2127S.
Frisbie, C. J. (1987). Navajo medicine bundles or Jish:Acquisition,
transmission, and disposition in the past and present.
Albuquerque: University of New Mexico Press.
Frisbie, C. J. (1993). Kinaald: A study of the Navaho girls puberty
ceremony. Salt Lake City:University of Utah Press.
Gill, S. (1987). Native American religious action: A performance
approach to religion. Columbia, South Carolina:University of
South Carolina Press.
Griffin-Pierce, T. (1992). Earth is my mother, sky is my father: Space, time,
and astronomy in Navajo sandpainting. Albuquerque:University of
New Mexico Press.
Hartle-Schutte, M. (1988). Contemporary usage of the Blessingway
ceremony for Navajo births (Master of Arts thesis, University of
Arizona, 1988). Ann Arbor, Michigan: University Microfilms
International.
Joe, J. (1982). Cultural influences on Navajo mothers with disabled
children. American Indian Quarterly, 6, 170190.
Kim, C., McHugh, C., Kwok, Y., & Smith, A. (1999). Type 2 Diabetes
mellitus in Navajo adolescents. The Western Journal of Medicine,
170, 210 213.
Kunitz, S. J., & Levy, J. E. (2000). Drinking, conduct disorder, and
social change: Navajo experiences. NY: Oxford University
Press.
Kunitz, S. J., & Levy, J. E. (1991). Navajo aging: The transition from
family to institutional support. Tucson, AZ: The University of
Arizona Press.
Levy, J. E. (1978). Changing burial practices of the western Navajo:
A consideration of the relationship between attitudes and behavior.
American Indian Quarterly, 4, 397405.
Levy, J. E. (1983). Traditional Navajo health beliefs and practices. In
S. J. Kunitz (Ed.), Disease change and the role of medicine: The
Navajo experience (pp. 118145). Berkeley, CA: University of
California Press.
Lewton, E. L., & Bydone, V. (2000). Identity and healing in three
Navajo religious traditions: Saah Naagh Bikeh Hzh. Medical
Anthropology Quarterly, 14, 476497.
Linford, L. D. (2000). Navajo places: History, legend, landscape. Salt
Lake City: University of Utah Press.
McCloskey, J. (1998a). Three generations of Navajo women:
Negotiating life course strategies in the eastern Navajo agency.
American Indian Culture and Research Journal, 22, 103129.
Navajo
McCloskey, J. E. (1998b). Traditional components of treatment for
Navajo alcohol abusers: Ethnographic case studies. Report for the
Din Center for Substance Abuse Treatment and the Navajo
Nation. Center for Alcoholism, Substance Abuse, and Addictions,
University of New Mexico.
Mendlein, J. M., Freedman, D. S., Peter, D. G., Allen, B., Percy, C. A.,
Ballew, C. et al. (1997). Risk factors for coronary heart disease
among Navajo Indians: Findings from the Navajo health and nutrition survey. The Journal of Nutrition, 127, 2099S2105S.
Mercer, S. O. (1996). Navajo elderly people in a reservation nursing
home: Admission predictors and culture care practices. Social
Work, 41, 181189.
Milligan, B. C. (1984). Nursing care and beliefs of expectant Navajo
women (Part 1). American Indian Quarterly, 8, 83102.
Milne, D., & Howard, W. (2000). Rethinking the role of diagnosis in Navajo
religious healing. Medical Anthropology Quarterly, 14, 543570.
Mingo, C., Herman, C. J., & Jasperse, M. (2000). Womens stories: Ethnic
variations in womens attitudes and experiences of menopause, hysterectomy, and Hormone Replacement Therapy. Journal of Womens
Health & Gender-Based Medicine, 9, S27S38.
Mitchell, R. (2001). Tall woman: The life story of Rose Mitchell, A
Navajo woman, c. 18741977. C. J. Frisbie (Ed.). Albuquerque:
University of New Mexico Press.
Morgan, F. (2002). Personal Communication. December 28, 2002.
Morgan, W. (1977). Navajo treatment of sickness: Diagnosticians. In
David Landy (Ed.), Culture, disease, and healing: Studies in medical
anthropology (pp. 163169). NY: Macmillan Publishing Co.
Navajo Area Indian Health Service. (2000). 2000 Navajo Middle School
Youth Risk Behavior Survey. Shiprock, New Mexico: Navajo Area
Indian Health Service.
Navajo Area Indian Health Service. (2002). Health Profile. Office of
Program Planning and Evaluation. Window Rock: AZ.
Office of Navajo Government Development. (1998). Navajo Nation
Government (4th ed.). Window Rock, Arizona: Navajo Nation.
Percy, C., Freedman, D. S., Gilbert, T. J., White, L., Ballew, C., &
Mokdad, A. (1997). Prevalence of hypertension among Navajo
Indians: Findings from the Navajo health and nutrition survey. The
Journal of Nutrition, 127, 2114S2119S.
Quintero, G. A. (1995). Gender, discord, and illness: Navajo philosophy
and healing in the Native American Church. Journal of
Anthropological Research, 51, 6989.
Reichard, G. A. (1944). Prayer: The compulsive word. American
Ethnological Society Monograph, 7. Seattle: University of
Washington Press.
Reichard, G. A. (1974). Navaho religion: A study of symbolism. NY:
Bollingen Foundation Inc., 1950. Reprint, NY: Bollingen Series
XVIII, Princeton University Press.
Roessel, R. (1981). Women in Navajo society. Rough Rock, AZ: Navajo
Resource Center, Rough Rock Demonstration School.
Schwarz, M. T. (1997). Molded in the image of Changing Woman:
Navajo views on the human body and personhood. Tucson, AZ:
The University of Arizona Press.
Servilla, M. J. (1997). Describing the health-related quality of life of
former Navajo uranium miners with spirometry abnormalities.
Masters of Science thesis, University of New Mexico.
Shepardson, M. (1978). Changes in Navajo mortuary practices and
beliefs. American Indian Quarterly, 4, 383395.
Shepardson, M. (1995). The Gender Status of Navajo Women. In
L. F. Klein & L. A. Ackerman (Eds.), Women and Power in Native
883
Findings from the Navajo health and nutrition survey. The Journal
of Nutrition, 127, 2106S2113S.
Willging, C. E. (2002). Clanship and K: The relatedness of clinicians
and patients in a Navajo counseling center. Transcultural
Psychiatry, 39, 532.
Witherspoon, G. (1983). Navajo social organization. In Alfonso Ortiz
(Ed.), Southwest (pp. 524535). Vol. 10, Handbook of North
American Indians. Washington: Smithsonian Institution.
Wright, A. L., Bauer, M., Clark C., Morgan, F., & Begishe, K.
(1993). Cultural interpretations and intracultural variability in
Navajo beliefs about breastfeeding. American Ethnologist,
20, 781796.
Wyman, L. C. (1983). Navajo ceremonial system. In Alfonso Ortiz
(Ed.), Southwest (pp. 536577). Vol. 10, Handbook of North
American Indians. Washington: Smithsonian Institution.
Wyman, L. C., & Clyde Kluckhohn. (1938). Navajo classification of
their song ceremonials. Memoirs, 50. Menasha, Wisconsin:
American Anthropological Association.
Young, R. W. (1961). The Navajo yearbook: 19511961, A Decade of
Progress. Window Rock, Arizona: Navajo Agency, Bureau of
Indian Affairs.
Nepal
Gregory G. Maskarinec
OVERVIEW
OF THE
CULTURE
The modern state of Nepal emerged in the late 18th century as the king of one local hill principality, Gorkha,
884
Nepal
Medical Practitioners
885
MEDICAL PRACTITIONERS
His Majestys Government of Nepal (HMG) officially
acknowledges four systems of medicine: allopathy,
Ayurveda, homeopathy, and Unami as being practiced in
Nepal, although the latter two are not widespread.
Ayurvedic practices tend to be localized in Kathmandu or
the areas adjacent to India. Locally, Ayurveda is considered most efficacious in the treatment of hepatitis. HMG
reports that there is one biomedically trained physician
for approximately 19,000 persons and one nurse per
5,000 persons, but these numbers, bad as they are, are
severely misleading unless it is concurrently noted that
nearly all physicians and nurses are to be found in urban
areas, leaving the rest of the country either to poorly
trained health workers or to traditional practitioners.
Nepal has one 40-bed acute care hospital for the mentally
ill, and 13 trained psychiatrists, all in Kathmandu. Even
in urban areas, health care delivery is systematically
biased in favor of the wealthy and the middle class, while
the poor are denied services both because of the cost and
the structure of the traditional society. Although Nepal is
a signatory to the 1978 Alma Ata Declaration and despite
the rhetorical commitment of successive governments
toward committing resources for better health, improved
health care remains a low priority in Nepal, as it would
necessarily require a more equitable social system.
Outside the Kathmandu Valley, drug therapy is
almost inevitably mismanaged. Nevertheless, injections
and capsules have acquired a nearly magical status, so that
villagers who do consult a modern medical practitioner,
even if it is only the lowest paid health post peon who may
lack even a high school education let alone any medical
training, expect their treatment to include these.
Unrealistic expectations of biomedical efficacy coupled
with poor patient education contributes to many villagers
disillusionment with the governments promotion of
Western medicine. Self medication is common, as medical halls (drug stores) that lack trained pharmacists
supply pharmaceuticals on demand. In rural areas, these
medications are often expired stock from India.
Traditional practitioners, a diverse group including
oracles, shamans, spirit mediums, Buddhist lamas,
Tantrics, astrologers, wandering ascetics, and herbal
healers, all remain more familiar, less frightening and less
intrusive than is Western-style medicine. Traditional
practitioners are less condescending and far easier to
886
Nepal
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Nepalis tend to be extremely fatalistic, observing that in
this Age of Darkness (Kali Yuga), inevitable deterioration
of the world, at all levels, personal, social, and cosmic, is
all that can be expected. All concepts of life, death, and
suffering are permeated by the theory of Karma, with its
cycles of rebirth that connect morality with retribution
and reward. Ones caste and gender, for example, are generally recognized as reaping what has been sown in ones
previous lives. Karma, then, is ultimately responsible for
all illness and affliction. Nevertheless, Nepalis distinguish proximate causes to their illnesses, and most accept
SEXUALITY
AND
REPRODUCTION
887
888
Infancy
As soon as possible after a birth, an astrologer is consulted, to calculate the childs future and to choose an
auspicious name, which is based on the time of birth. The
most serious of astrological disturbances is that of mul,
which occurs when certain planets of both the child and
Nepal
Childhood
Nepals last major smallpox epidemic was in 196364.
Official eradication of smallpox by 1974 is concrete evidence of what a well-focused public health campaign
might do for the six vaccine preventable diseases of
childhooddiphtheria, whooping cough, tetanus,
poliomyelitis, tuberculosis, and measlesall of which
contribute significantly to childhood morbidity and
mortality.
For high caste, twice-born, males, the most important childhood ceremony is to receive the sacred thread.
Brahman boys usually receive this at age seven or nine,
while Chetris may wait until their teens. Once invested
with a thread, a boy has many new ritual responsibilities
and privileges, such as now being allowed to eat in
the company of adults. There is no parallel ceremony
for girls.
Children are, in general, treated with considerable
affection and are rarely disciplined. They are gradually
integrated into the familys daily chores. Older children
assume responsibility for caring for their younger
siblings.
Adolescence
As most Nepalis are married by their mid-teens, there is
no real adolescence in Nepal, just a quick transition
from childhood to adulthood.
Adulthood
First menstruation marks the beginning of adulthood for
women. No special ceremonies are performed, but in
some communities the woman is secluded for 15 days,
during which time she may not be seen by males.
Menstruation is considered ritually unclean, and there are
many rules that a menstruating woman must follow. She
is treated as an untouchable, even for other women, and
should maintain physical isolation for the first four days
of her period; she must not cook nor fetch water; she may
not perform any religious rite.
The Aged
In all cultures of Nepal, to reach an old age is a guarantee of respect. A special ceremony is held to honor a
person who reaches the age of 84. Elderly persons
continue to contribute to household labor and childcare,
to the extent of their abilities, and take major roles in
family decision-making. Care for the elderly is regarded
as a responsibility of the extended family.
The major medical problems of the elderly in Nepal
are not significantly different than those found throughout the world.
889
890
REFERENCES
Ali, Almas. (1991). Status of health in Nepal. Kathmandu: Resource
Center for Primary Health Care, Nepal and SouthSouth
Solidarity, India.
Bista, Dor Bahadur. (1972). People of Nepal (2nd ed.). Kathmandu:
Ratna Pustak Bhandar.
Dixit, Hemang. (1999). The quest for health: The health services of
Nepal (2nd ed.). Kathmandu: Educational Enterprise.
Maskarinec, Gregory G. (1995). The rulings of the night. An ethnography of Nepalese shaman oral texts. Madison: University of
Wisconsin Press.
Pradhan, Ajit et. al. (1997). Nepal family health survey 1996.
Kathmandu: New Era.
Sigdel, Shailendra. (1998). Primary health care provision in Nepal.
Kathmandu: GTZ/Primary Health Care Project.
Tausig, Mark & Sree Subedi. (1997, August). The modern mental health
system in Nepal: Organizational persistence in the absence of
legitimating myths. Social Science & Medicine, 45(3), 441447.
Worth, Robert M. & Narayan N. K. (1969). Nepal health survey
19651966. Honolulu: University of Hawaii Press.
ALTERNATIVE NAMES
The Northwest Coast is the standard name for the culture
area. The main constituent cultures are from north to
south, Eyak, Tlingit, Haida, Tsimshian, Haisla, Haihais,
Heiltsuk (formerly Bella Bella), Nuxalk (formerly Bella
Coola), Oowekeeno, Kwakwakawakw (formerly
Kwakiutl), Coast Salish, Nuu-chah-nulth (formerly
Nootka), Makah, Quileute/Chemakum, Chinookans,
Takelma, Alsean, Siuslaw, Coos, and Athapaskans.
LOCATION
AND
LINGUISTIC AFFILIATION
891
OVERVIEW
OF THE
CULTURE
892
Social Organization
Aside from their linguistic diversity, the ideas of family,
ancestry, descent, and kinship differed greatly, though
there are similarities across cultural boundaries. Small,
localized groups of people formed the principle unit of
production and consumption organized around a core of
kin defined according to the local rules of kinship.
Ownership of resources typically resided with the kin
group, whose members associated themselves with
specific localities and village sites. Traditional village life
included permanent winter villages, which often grew in
population size through the winter feasting and ceremonial season to include hundreds of people. In the summer,
families often dispersed to annual settlement camps to
collect shellfish, fish and hunt.
Among the Eyak, Tlingit, Haida, Tsimshian, and
neighboring Kwakwakawakw-speaking Haisla on the
northern coast, autonomous matrilineal households or
lineages formed the basic units of a village. Typically
towns were comprised of one or more matrilineal lineages. Each lineage was represented by a hereditary chief
who acted as trustee of the lineage properties while house
chiefs managed the affairs of their own individual houses.
With the possible exception of the Tsimshian, these
northern groups divided their societies into moieties, as a
means of organizing relationships between individuals,
families, and lineage groups. According to Halpin and
Seguin (1990), traditional Tsimshian society at the village
level was a moiety, like that found among the Eyak,
Tlingit, and Haida, and not the four-fold structure commonly reported. The basic social unit was the corporate
matrilineage called a house whose members, together
with affines, children belonging to other lineages, and
slaves, occupied one or more dwellings.
The Eyak represent the northernmost Northwest
Coast group, and are linguistically related to the
Athapaskan family and more remotely to the Tlingit.
Within the historical period, the neighboring Tlingit were
to exert considerable cultural influence on this group
893
894
illnesses. Measles, influenza, whooping cough, tuberculosis, and scarlet fever reached epidemic proportions
among an increasingly weakened and vulnerable native
community throughout the 1800s. In the case of the
Haida, the Nuu-chah-nulth, and many others, a lethal
combination of disease, warfare, dislocation, and stress
worked to destroy many family groups with weakened or
remnant groups joining more powerful neighbors to create new political structures (Acheson, 1998; Arima and
Dewhirst, 1990). For small-scale societies everywhere,
catastrophic population losses required, if they were to
survive, new social, economic and political alignments.
The concept of composite bands and tribes as a
product of the merging of various like bands due to the
initial shock, depopulation, relocation, and distribution
of the early contact period is certainly not new. Among
the Nuu-chah-nulth, for example, declining populations
and extended warfare throughout the late 1700s and early
1800s worked toward creating or maintaining tribes and
confederacies (Drucker, 1951).
The move away from matrilineal kinship toward
more patrilineal oriented descent observed among the
Haida, for example, can in part be attributed to severe
population fluctuations. The need to restructure social
groupings as a result of population decline, coupled with
the growth of a market economy, increasing economic
cooperation between father and son, and the growing
advantages of politically important rank in a father,
conspired to break down the matrilineal descent group.
The implications of these trends are equally significant to traditional native experiences with illnesses and
medicinal practices, the role of shamans, and religious
practices. Shamans occupied an ambiguous position
within the community in their role as both caregiver and
a potentially malevolent force that possessed unique
supernatural curing, divining, or witchcraft capabilities.
They also had an extensive practical knowledge of pharmacologically active plants and herbs. The introduction
of new, destructive illnesses not readily understood,
placed shamans in a particularly precarious position. The
discrediting of their role and diminishing value placed on
traditional healing practices, and even the outright loss of
such cultural knowledge, created a vacuum that gave rise
to the messianic movements of the 1800s and enabled the
missionary movement to make significant inroads by the
late 1800s. The emergence of revitalization or nativistic movements, such as the Prophet Dance and Shaker
religion among a number of coastal groups, underscores
appears to have been stable from 3500 BC to the postcontact period (Cybulski, 1994). Mortality rates, on the
other hand, underwent an unprecedented increase with
the introduction of a suite of highly infectious diseases
following contact.
Described as the most terrible single calamity to
strike the Aboriginal community (Duff, 1964), smallpox
was a reoccurring pandemic resulting in the progressive
and catastrophic decline in population from the outset of
culture contact. Following in the wake of the major smallpox epidemics of the late 1700s, 183738, and 186263,
were a host of other diseases, including measles, influenza,
whooping cough, tuberculosis, and scarlet fever, that
reached epidemic proportions among an unsuspecting and
highly susceptible native community (Table 1). Lingering
diseases such as influenza, scrofula, and syphilis, observed
among later native populations, can also be inferred for the
early contact period.
By far the deadliest of all the virgin soil epidemics
to strike the Northwest Coast was smallpox, which
appeared in cycles as a result of contact with outside
carriers and a sufficiently large enough population of
non-immunes for the disease to take hold and spread. The
disease afflicted people of all ages, and not just successive generations of children, which had the effect of
fragmenting families and dissolving kin groups. Caring
for the ill was thus made much more difficult and mortality rates soared.
Historical accounts provide indisputable evidence of
smallpox on the coast by the 1770s, appearing among the
Haida, Ditidaht (Nuu-chah-nulth), the Coast Salish, and
the Chinookan. It struck the Tsimshian in 1795 and the
Coast Salish again a few years later. Though the severity
of these early outbreaks can only be inferred in the
absence of detailed population records for this period, it
is reasonable to expect a catastrophic population decline
equal to (if not greater than) the population losses of the
late 1800s. Trade, warfare, and even attempts to escape an
outbreak spread the virus rapidly. For the period 1835 to
1890 the number of lives lost on the coast is estimated to
be in the realm of 62%, and possibly as great as 90%
(Boyd, 1985, 1990, 1994) (Tables 1 and 2).
Within the first quarter of the 19th century another
epidemic, variously identified as smallpox, measles, or
simply the mortality, was reported among the
Cowichan on southern Vancouver Island (British
Colonist, 1862). On the North coast, smallpox reappeared
among the Tsimshian at Fort Simpson in the early autumn
895
3,100
17,400
9,300
900
8,600
7,500
4,000
14,000
24,399
780
11,990
8,640
2,700
1,200
4,500
1,400
4,500
6,000
8,000
14,500
3,000
19,000
8,000
10,000
5,500
14,820
14,500
1780
(Mooney
1928)
3,000
5,500
1829
(Green
1915)
5,025
1,940
8,500
7,500
1,628a
1,225
1835
(Tolmie
n.d.)
8,216
3,291 (3,285c)
1,086
2,316
409
1,834 (2,871b; 1,628c;
1,250)
509
32,460a (40,998d)
7,093a
1,429
1,615 (1,625)
2,815 (2,827b; 2,495c)
9,880
183641 HBC
Census
(Douglas n.d.)
2,500
2,352
2,500
1858
(Duncan
n.d.)
285
364
481
426
233
662
1,012
5,899
491
378
2,252
1,900
3,593 (3,613e) 3,093
445
726
1,869
1,462
284
1889
315
1881 Canada
Census
8,522
868
5,364
204
1,797
3,084
292
392
415
438
1,119
2,075
1890
(Canada
1891)
813
5,309
340
2,853
2,834
229
393
578
364
1,087
1,333
1895
(Canada
1896)
770
4,640
340
1,639
2,750
244
377
533
354
782
1,364
1,071
1896
(Canada
1897)
567
3,658
288
1,257
2,159
852
599
814
1,383
1,130
1906
(Mooney
1928)
4,462
1930
Some discrepancies in the figures exist due to differences in identification and ethnolinguistic grouping as well as calculation errors in some of the original tables. Entries prior to the mid-1830 are estimates only.
a
Douglas, 1856; b Kane, 1859; c Martin, 1848; d Curtis, 1915; e Dominion of Canada 1882: 164.
NUXALK
KWAKWAKAWAKW
NUU-CHAH-NULTH
COAST SALISH
Northern
Central
Southern/Southwest
CHEMAKUAN
PENUTIAN SPEAKERS
ATHAPASKAN (Lower
Columbia; Oregon)
Bands not visited
TLINGIT
TSIMSHIAN
Nishga
Coast Tsimshian
Gitksan
Southern Tsimshian
HAIDA
Massett
West Coast
Skidegate
HAISLA
HEILTSUK
Pre-contact
projection
(Boyd
1990)
Medical Practitioners
897
Group
Pre-epidemic
population
Post-epidemic
population
Total loss
Tlingit
Nishga
9,980
2,423
7,255
1,615
2,725
808
27
33
MEDICAL PRACTITIONERS
The practice of medicine embodied an array of ideas
and concepts along with highly practical and effective
remedies and treatment. Alongside the skillful practical
treatment of injuries such as fractures and wounds, there
is a long history on the Northwest Coast of shamanic
practices, which invoke the spiritual both as the cause and
in the treatment of the suffering.
Shamans
Shamans act as a medium for the supernatural, possessing unique curing, divining, or witchcraft capabilities
acquired through birth, visionary experiences, contact
with some form of supernatural force and, in some cases,
through vocational training. Among most Northwest
Coast groups a person who received healing powers had
to apprentice with an established shaman in order to learn
to control his newfound powers. The period of apprenticeship varied, but normally ended with a major healing
performance. Illnesses cured by shamans were (and are)
of essentially three types: soul loss, spirit disease, and
spirit or object intrusion. Shamanic practice is now much
reduced, but elements of it can be found in many groups,
Traditional Ethno-Biological
Knowledge: Herbalists
Shamans also possessed an extensive knowledge of
pharmacologically active plants and herbs. Herbal healing
is seen, however, as somewhat distinct though not entirely
separate from the magical or supernatural healing practices by shamans. This distinction between ritualists and
herbalists is near universal in the region. Certain plants
were considered personal property while other medicines, such as the cascara bark laxative, were universally
known (Bouchard and Turner, 1976). The Green or Indian
hellebore of the Lily Family (Veratrum viride), for example, had widespread use in North America for curing
wounds and alleviating toothaches (Vogel, 1970). An
extremely poisonous plant due to a combination of toxic
alkaloids, hellebore was widely known to coastal peoples
for its medicinal properties as a blistering agent, local
anaesthetic and decongestant, and internally as a physic
(Turner, 1978). The effectiveness of many herbal medicines, however, was dependent on a level of secrecy about
the type of plant used and its application, and in practice
most treatments combined herbal use with shamanism.
As privately held secret knowledge, plant remedies
retain potency and also secure some respect and power
for those who maintain the knowledge. Much of this practical knowledge was lost over generations confronting
severe depopulation from waves of epidemic diseases like
smallpox, tuberculosis, influenza, and pneumonia.
Confidence in shamans to be able to deal with these
terrible epidemics has also meant a loss of knowledge in
dealing with psychological anguish.
Today, many people with plant knowledge confront
a difficult ethical dilemma; if they choose to share
their knowledge the plants upon which they depend
may become desirable commercial commodities and
be overharvested (as happened with Pacific Yew in the
treatment for breast cancer). Losing control over
traditional knowledge therefore may not benefit local
people and may harm their environment. Yet local indigenous people often wish to assist a wider humanity with
their knowledge. As well, the efficacy of teas and decoctions may vary greatly between locally prepared and
ritually administered herbs and synthesized commercial
preparations.
898
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
The treatment of externally caused injuries, such as fractures, dislocations, wounds, skin irritations, and the like
was highly practical and effective. The use of splints to
set fractures, for example, was universal and included the
steps of straightening and use of pain-allaying medicine.
Evidence of the cauterization of teeth to alleviate severe
periodontal disease and trephination in accordance with
the surgical principle of fracture decompression, is cited
for pre-contact populations. Drawing on the affected part
effectively treated snakebites and the cleaning of wounds.
Such a practice extended to the treatment of internal
ailments attributed to supernatural agencies or spirit
intrusion.
Generally, disease was the result of either a human
or supernatural agent, though natural causes could be
considered. Acts such as sorcery, taboo violation, diseaseobject intrusion, spirit intrusion, and soul loss called for
culturally prescribed treatment by a shaman. Confession
often forms part of the treatment, serving as a powerful
catharsis in helping to alleviate sickness due to broken
taboos.
Soul loss is often associated with what could be
glossed as depression, possibly including a degenerative
disease as well. Although soul loss does not kill its victims
immediately, it can be lethal if the soul is not retrieved in
a reasonable period of time. Only the most experienced
shamans treated (and continue to treat) soul loss. In traditional ceremonies the shaman, or his spirit helper,
retrieves the lost soul. Often the shaman brings the soul
back to the person in a bed of eagle down; he may also
have to struggle against many hostile spirits to return the
soul to the person. In our experience soul loss is often
associated with people whose close friends and relatives
have recently died in a sudden and unexpected manner
indeed, the departed may wish the individual to come and
live with them in the realm of the dead. Spirit diseases are
generally associated with ritual impurity and the afflicted
individual may either become possessed by the spirit
itself, contract a fatal disease, or become contaminated by
the spirit. Although some shamans have claimed to be able
to treat spirit illnesses, most appear to have regarded them
as terminal. Spirit and object intrusion is associated with
belief in witchcraft: malevolent spirits or shamans hired
by others or acting on their own can send illness producing objects (bone slivers, etc.) into a persons body. The
shaman, in a dramatic performance, removes these
objects. This kind of classic shamanic performance transforms a person from the subject of hatred by unknown
spirits or people into the object of community concern
and assistance. It is in essence restorative whereby sick
individuals become the focus of family and community
concern.
Aside from, though often combined with these
practices, is the widespread medicinal use of plants and
plant products. Commonly utilized plant medicines
throughout the region include various rejuvenating teas
made from aquatic plants that grow in streams; treatments
for relief of pain obtained from tree bark (willow, as the
source of aspirin is known) or especially Devils Club
root (Turner, 1982). Diuretics created from stinging nettle teas are widely used. Bark preparations taken from a
wide variety of trees are also used for respiratory, digestive, gynecological, and dermatological ailments
throughout the area. Tree barks have also been used to
treat fevers, diabetes, kidney problems, sore eyes, and
hemorrhaging, and also as general tonics. In most cases,
infusions or decoctions of barks are used. The medicines are drunk or applied externally as a wash and are
particularly well described for Coast Salish people on
Vancouver Island (Turner, 1990).
As well, at least 20 species in Ranunculaceae, the
buttercup family, are reported as having been used medicinally by 19 different groups of native peoples in British
Columbia and adjacent areas. These species are known to
contain the skin-irritating, blister-causing compound,
protoanemonin, in their fresh state and it is probably the
active principle involved in many of these medicinal
applications. Most groups utilized the plants as external
poultices for boils, cuts, abrasions, and other skin sores.
Other disorders treated with anunculaceous species
include: muscular aches, colds, and other respiratory ailments (Turner, 1984). The slime from slugs, which
numbs skin surfaces and serves to protect the animal from
predation, also appears to have been widely used as a
topical anesthetic.
Many plants or plant products used on the
Northwest Coast have made their way into Western
medicine, and include a variety of laxative, diurectic,
emetic, and febrifuge drugs (Vogel, 1970). Examples
include sarsaparilla (Aralia nudicaulis) used by the
Nuxalk and the Kwakwakawakw for stomach pains.
899
Adolescence
Seclusion of girls at puberty accompanied by dietary
restrictions is traditional and premarital sex has long been
frowned upon throughout the region. In many areas
where potlatch ceremonies and feasting continues, a
major public ceremony for the daughters of high status
chiefs may take place announcing their changed status as
a mature woman, ready for marriage. Boys throughout
the region did not have a traditional feast to announce
their arrival at manhood but often went on quests to
obtain a guardian spirit. This practice made them vulnerable to potentially dangerous supernatural powers. Some
features of this quest still survive throughout the region
and include ritual bathing in the sea during the early
morning. Visits to hot springs and arduous hikes or canoe
trips are also relatively commonplace along with travel to
cities, or distant relatives, and friends. Elevated causes of
external death among young people throughout the
region include motor vehicle road accidents, suicide,
900
The Aged
The aged are widely respected for their knowledge, and
if they are especially wise and known for their rectitude
they are designated as elders throughout the region.
Because early mortality is commonplace, and the Native
population bears a young profile due to high birth rates,
there are not a large number of elderly people in the
Native population of the region. However, serious degenerative illness is commonplace among those seniors who
survive into old age, and it increasingly centers on Non
Insulin Dependant Diabetes Melitus (NIDDM), and all its
sequalae, including limb loss, organ damage, heart
disease, and blindness (Heffernan, 1995). Rates of
autoimmune diseases are also elevated for Native populations on the Northwest Coast, especially rheumatoid
arthritis and systemic lupus erythmatosis.
also especially high, as are neoplasms of the female reproductive system, and blood/lymph. Premature death from
Ischemic heart disease, cerbrovascular strokes, and cardiomyopathies are also higher than for base populations
throughout British Columbia. Mortality from infectious
diseases, especially those affecting the respiratory system
are uncommonly high and affect many age groups; these
include: pneumonia, influenza, asthma, pulmonary fibrosis, and tuberculosis. Septicemia and viral hepatitis rates
are also elevated, as are HIV infections, especially in
urban areas such as Vancouver (Foster et al., 1995). No
systematic comparative epidemiological or vital statistics
data appear to have been published for American jurisdictions, where socialized medicine is not available, and
statistical data are not comprehensively compiled.
Traditional belief emphasizes that death is associated with dangerous ghosts, whose powers include those
which may make the living seriously ill. The great
epidemics of the past, and current high mortality from
many causes, have certainly provided a steady supply of
ghostly spirits for over a century. Throughout the region
the dead were traditionally disposed of in myriad ways:
by suspension in trees, in mortuary boxes set atop memorial poles, in caves or in canoes suspended on scaffolds,
or by cremation. After the creation of missions, cemeteries were widely used and stand in sad testimonial to the
loss of young lives during the waves of epidemic diseases
that struck many Native villages throughout the region.
Many gravestones are those of children. Today, both
burial and cremation are commonplace, along with a
major memorial ceremony for high status and chiefly
persons where the title is passed on and where the participants receive gifts of food and clothing.
The last half of the 20th century also witnessed a
massive migration into cities throughout the region and
consequently Anchorage, Vancouver, Victoria, Seattle,
Prince Rupert, Bellingham, and Portland all have large
populations of Native People. These populations come
from the Northwest indigenous groups but are also
migrants from other areas including the interior plateau,
the Arctic, the Canadian prairies, American Middle West
and the Southwest. The traumasphysical and psychologicalassociated with epidemic diseases, residential
institutions, urbanization, and poverty are also deeply
connected to a loss of traditional lands and water. The
destruction of forests, salmon streams, pollution from
mining and paper mills, and a great reduction in marine
resources have all contributed to widespread despair,
References
REFERENCES
Acheson, S. (1998). In the wake of the yaaats xaatgaay [Iron
People]: A study of changing settlement strategies among the
Kunghit Haida. BAR International Series 711, Unpublished
dissertation, University of Oxford.
Arima, E. & Dewhirst, J. (1990). Nootkans of Vancouver Island. In
W. Suttles (Ed.), Handbook of North American Indians: Northwest
Coast (Vol. 7, pp. 391411). Washington, DC: Smithsonian
Institution.
Benoit, C. & Carroll, D. (1995). Aboriginal midwifery in British
Columbia: A narrative untold. In P. H. Stephenson, S. J. Elliott,
L. T. Foster & J. Harris (Eds.), A persistent spirit: Towards understanding aboriginal health in British Columbia (pp. 223248).
Victoria: University of Victoria, Western Geographical Press.
Boas, F. (1932). Current beliefs of the Kwakwakawakw Indians,
Journal of American Folk-Lore, 14 (176), 177260.
Bouchard, R. T., and Turner, N. J. (1976). Ethnobotany of the Squamish
Indian People of British Columbia. Unpublished manuscript,
British Columbia Indian Language Project, Victoria.
Boyd, R. (1985). The introduction of infectious diseases among the
Indians of the Pacific Northwest, 17741874. Unpublished Doctoral
dissertation, Pullman, Washington: University of Washington.
Boyd, R. (1990). Demographic history, 17741874. In W. Suttles (Ed.),
Handbook of North American Indians: Northwest Coast, (Vol. 7,
pp. 135148). Washington, DC: Smithsonian Institution.
Boyd, R. (1994, Spring). Smallpox in the Pacific Northwest: The first
epidemics. BC Studies, 101, 540.
British Colonist 12/9/1862, British Columbia Archives and Records
Service, Victoria.
Canada. (n.d.) Federal Census Returns, 1881. Microfilm copy, British
Columbia Archives and Records Service, Victoria.
Canada, Dominion of. (1882). Annual Report of the Department of
Indian Affairs for the year ended 31st December, 1881. Sessional
Papers No. 6. Ottawa: MacLean, Roger.
Canada, Dominion of. (1886). Annual Report of the Department of
Indian Affairs for the year ended 31st December, 1885. Sessional
Papers No. 4. Ottawa: MacLean, Roger.
Canada, Dominion of. (1891). Annual report of the Department of
Indian Affairs for the year ended 31st December, 1890. Sessional
Papers No. 18. Ottawa: Brown Chamberlin.
901
Canada, Dominion of. (1896). Annual Report of the Department of
Indian Affairs for the year ended 30th June, 1895. Sessional Papers
No. 14. Ottawa: S.E. Dawson.
Canada, Dominion of. (1897). Annual Report of the Department of
Indian Affairs for the year ended 30th June, 1896. Sessional Papers
No. 14. Ottawa: S.E. Dawson.
Canada, Dominion of. (1882). Annual Report of the Department of
Indian Affairs for the year ended 31st December, 1881. Sessional
Papers No. 6. Ottawa: MacLean, Roger & Co.
Codere, H. (1990). Kwakiutl: Traditional culture. In W. Suttles (Ed.),
Handbook of North American Indians: Northwest Coast (Vol. 7,
pp. 359377). Washington, DC: Smithsonian Institution.
Cooper, M. (1995). Aboriginal suicide rates: Indicators of needy communities. In P. H. Stephenson, S. J. Elliott, L. T. Foster, &
J. Harris (Eds.), A persistent spirit: Towards understanding
aboriginal health in British Columbia (pp. 207221). Victoria:
University of Victoria, Western Geographical Press.
Curtis, E. S. (1915). North American Indian (Vol. 10). New York:
Johnson Reprint Corporation [reprinted 1970].
Cybulski, J. (1990). Human Biology. In W. Suttles (Ed.), Handbook of
North American Indians: Northwest Coast (Vol. 7, pp. 5259).
Washington, DC: Smithsonian Institution.
Cybulski, J. (1994). Culture change, demographic history, and health
and disease on the Northwest Coast. In C. S. Larsen (Ed.), In the
wake of contact: Biological responses to conquest, (pp. 7585).
New York: Wiley-Liss, Inc.
de Laguna, F. (1990). Tlingit. In W. Suttles (Ed.), Handbook of North
American Indians: Northwest Coast (Vol. 7, pp. 203228).
Washington, DC: Smithsonian Institution.
Donald, L. (1997). Aboriginal slavery on the Northwest Coast of North
America. Berkeley: University of California.
Douglas, J. (nd). Private papers, second series 1853. A/B/40/D75.4,
British Columbia Archives and Records Service, Victoria.
Douglas, J. (nd). Indian Population Vancouvers Island 1856. Enclosure
No. 1 in Governor Douglas Dispatch No. 24 of the 20th October
1856, Colonial Office 305/7, Microfilm 393A, British Columbia
Archives and Records Service, Victoria.
Drucker, P. (1951). The Northern and Central Nootkan tribes. Bureau of
American Ethnology Bulletin, 144. Washington.
Drucker, P. (1965). Cultures of the North Pacific Coast. Scranton,
Pennsylvania: Chandler.
Drucker, P. (1983). Ecology and political organization on the
Northwest Coast of America. In E. Tooker (Ed.), The development
of political organization in Native North America, Proceedings
of the American Ethnological Society, 1979. New York:
J. J. Augustin.
Duff, W. (1964). The impact of the White Man: The Indian history of
British Columbia, Anthropology in British Columbia, Memoir
No. 5, Victoria.
Foster, L., Macdonald, J., Tuk, T. A., Uh, S. H., & Talbot, D. (1995).
Native Health In British Columbia: A vital statistics perspective.
In P. H. Stephenson, S. J. Elliott, L. T. Foster, & J. Harris (Eds.),
A persistent spirit: Towards understanding aboriginal health in
British Columbia (pp. 4394). Victoria: University of Victoria,
Western Geographical Press.
Halpin, M. M. & Seguin, M. (1990). Tsimshian peoples: Southern
Tsimshian, Coast Tsimshian, Nishga, and Gitksan. In W. Suttles
902
(Ed.), Handbook of North American Indians: Northwest Coast,
(Vol. 7, pp. 267284). Washington, DC: Smithsonian Institution.
Hamori-Torok, C. (1990). Haisla. In W. Suttles (Ed.), Handbook of
North American Indians: Northwest Coast (Vol. 7, pp. 306311).
Washington, DC: Smithsonian Institution.
Harris, J. (1995). Rebuilding: Listen with the ears of our eyes. In
P. H. Stephenson, S. J. Elliott, L. T. Foster & J. Harris (Eds.),
A persistent spirit: Towards understanding aboriginal health in
British Columbia (pp. 357385). Victoria: University of Victoria,
Western Geographical Press.
Hawthorn, H. B. (1965) Introduction. Cultures Of The North Pacific
Coast. Scranton, Pennsylvania: Chandler.
Heffernan, M. C. (1995). Diabetes and aboriginal peoples: The Haida
Gwaii diabetes project in a global perspective. In P. H. Stephenson,
S. J. Elliott, L. T. Foster & J. Harris (Eds.), A persistent spirit:
Towards understanding aboriginal health in British Columbia
(pp. 261269). Victoria: University of Victoria, Western
Geographical Press.
Hilton, S. F. (1990). Haihais, Bella Bella, and Oowekeeno. In W. Suttles
(Ed.), Handbook of North American Indians: Northwest Coast,
(Vol. 7, pp. 312322). Washington, DC: Smithsonian Institution.
Hopkinson, J., Stephenson, P. H., & Turner, N. J. (1995). Changing traditional diet and nutrition in aboriginal peoples of Coastal British
Columbia. In P. H. Stephenson, S. J. Elliott, L. T. Foster & J. Harris
(Eds.), A persistent spirit: Towards understanding aboriginal
health in British Columbia (pp. 129166). Victoria: University of
Victoria, Western Geographical Press.
Kane, P. (1859). Wanderings of an artist among the Indians of North
American from Canada to Vancouvers Island and Oregon through
the Hudsons Bay Companys territory and back again. London:
Longman, Brown, Green, Longmans, and Roberts.
Kennedy, D., & Bouchard, R. (1990). Bella Coola. In W. Suttles (Ed.),
Handbook of North American Indians: Northwest Coast (Vol. 7,
pp. 323339). Washington, DC: Smithsonian Institution.
Martin, R. M. (1848). The Hudson Bay Territories and Vancouvers
Island. London: T. Brettell.
McIlwraith, T. F. (1948). The Bella Coola Indians. 2 vols. Toronto:
University of Toronto.
Modeste, D., Elliott., D., Gendron, C., Greenwell, B., Johnny, D.,
Payne, H. (1995). Shuliutl Quwutsun/The spirit of Cowichan:
A journey through the Tsewultun Health Centre/Huy Tseep Qu Nu
Siiyeyu Kwuns I M I Ewuu Tuna Tsewultun. In P. H.
Stephenson, S. J. Elliott, L. T. Foster & J. Harris (Eds.),
A Persistent Spirit: Towards understanding aboriginal health in
British Columbia (pp. 331356). Victoria: University of Victoria,
Western Geographical Press.
Read, S. (1995). Issues in health mangement promoting First
Nations wellness in times of change. In P. H. Stephenson,
S. J. Elliott, L. T. Foster & J. Harris (Eds.), A persistent
903
Ojibwa
Linda C. Garro
ALTERNATIVE NAMES
Anishinaabe; Ojibway, Ojibwe; Chippewa (U.S.);
Mississauga or Southeastern Ojibwa (southern, central
Ontario), Nipissing, Algonquin, Plains Ojibwa (sometimes
known as Bungi); Northern Ojibwa; Saulteaux or Saulteurs
(Manitoba); Ojicree or Oji-Cree, Southwestern Chippewa
(based on Goddard, 1978, p. 583 cited in Brown, 1997).
Geographically, this entry primarily concerns present-day
Canada, particularly Manitoba and Ontario. Anishinaabe
(plural Anishinaabeg) is the preferred ethnonym in
Manitoba and Ontario (Peers, 1994, p. xvii).
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
904
Ojibwa
905
906
Ojibwa
907
peoples and the wider society (see Garro, 1993 for a more
extended discussion). Like Grassy Narrows, the traditional resource base of other communities has been
eroded with the resulting dependence on governmentsponsored welfare programs and other forms of economic
assistance (see also Waldram, 1985). In addition, separating children from their families and removing them to
off-reserve locations has increased the feelings of demoralization and hopelessness. Exposure to mercury poisoning and forced relocations, often because of flooding of
land by hydroelectric dams, has occurred with other communities. Many First Nations communities, like Grassy
Narrows, have in recent years worked toward achieving a
greater degree of self-determination which involves
greater involvement in such institutions as education,
child welfare, health care, and the justice system. Actions
directed at regaining control over a land resource base,
through settling land claims or by other means, are
another important part of this ongoing process (see Garro,
1993). The struggle for self-determination, for resource
rights and lands rights, is also a struggle for better health
(Culhane Speck, 1989, p. 90).
908
MEDICAL PRACTITIONERS
Outside of urban centers, few communities have resident
physicians. The health center was staffed by visiting
physicians approximately three afternoons a week with
other physicians and hospitals located in towns approximately an hours drive distance. All expenses of biomedical care, including transportation costs and prescription
drugs, are either covered by universal health insurance or
the federal government. Public health nurses and community health workers (residents of the community who
have participated in training courses and whose work is
supervised by nurses) focus on public health, health
education, and prevention. They also make home visits to
Ojibwa
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Illness Treatment Decisions
Patterns of care-seeking are diverse and complex (Garro,
1998). During the course of fieldwork, thirteen separate
visits were made to 61 randomly selected families over a
six to eight month period. The total number of illness case
histories is 468. Of these, 189 (40%) were cared for at
home without recourse to any other source of care.
Among the remaining 279 cases, 225 (81%) were seen by
a physician, 98 (35%) were seen by medicine persons
who were consulted as mediators with other-than-human
persons, 21 (8%) sought remedies from a herbalist, and
10 (4%) consulted another type of practitioner (nonAnishinaabe herbalist, chiropractor, acupuncturist,
psychologist). The percentages add up to more than
100% because some cases involved multiple treatment
alternatives outside the home. Of the 225 cases seen by a
physician, 66 (29%) also consulted a medicine person.
909
910
Ojibwa
911
912
Infancy
The health center encourages breast-feeding through
home visits. This is seen as an important public health
concern for the Canadian Aboriginal population because
of the potential impact on elevated morbidity rates for
infectious diseases (Martens & Young, 1997) and rates of
breast-feeding for Aboriginal women in Manitoba are
considerably lower than non-Aboriginal women (HildesRipstein, 1998). Another activity to which health center
staff devote considerable effort is a vaccination program
for infants and children. A yearly, and popular, baby show
is sponsored by the health center with the judging based
on vaccination records, breast-feeding, and other health
promoting activities.
When infants cry and cannot be comforted a number
of possible reasons may be consideredteething, a temperature, or simply a child just born that way. One oftenconsidered possibility for the fussiness of a colicky
infant is that this signals the need for the child to be given
an Anishinaabe name. An Anishinaabe name confers some
protection on the infant and serves to establish relationships between the child and other-than-human persons.
The power to bestow names is a gift given to some individuals in the community. A feast for those invited is given
at the time that the name is bestowed and commemorative
feasts are given in subsequent years.
Childhood
A central goal for Ojibwa individuals is not to be controlled by ones environment including other people
with acts that are attempts to control others ... negatively
evaluated (Black, 1977, p. 145). Even in childhood,
autonomy is respected and parents tend not to interfere
with what children choose to do. Children are allowed
considerable scope to discover the world for themselves
and learn from mishaps. Providing food and shelter for
children is the responsibility of the parents, but bedtimes,
Ojibwa
Adolescence
Suicide, alcohol, the use of drugs, sniffing (solvents, glue,
and gasoline), break-ins, and vandalism among adolescents are significant concerns for community members.
Living in a community with a high level of unemployment and low incomes dependent on social assistance,
many youth do not see the future as having much to offer.
Manitoba has the lowest rate of school attendance among
Aboriginal youth of any province or territory in Canada.
At the time of the 1996 census, only 44.1% of those aged
1524 reported attending school either full or part-time,
with a considerable gap in school attendance between
Aboriginal and non-Aboriginal youth (Hallett, 2000).
Many of the youths who do not attend school are also not
employed (37.5% of Aboriginal youths) and Aboriginal
youths in Manitoba are 3.5 times more likely to be unemployed as non-Aboriginal youths. Aboriginal youths are
over-represented in correctional facilities and in urban
gangs (Hallett, 2000). Teen births also occur at a rate
three times higher for status Indians than for others in
the province.
Adulthood
National figures show Aboriginal women having fewer
children, steadily declining from an average of 5.7 births
References
The Aged
Elders are treated with respect and are often consulted for
advice. For example, as part of the transfer of control
process, the health centers director and staff decided to
consult with a group of elders on a regular basis and especially before implementing any changes in their services
or policy. Although being a respected elder is a matter of
recognition rather than something achieved simply by
913
age, a party given for elders invited everyone over the age
of 55. At the same time, an increasing number of elders
are living on their own, although if grown children are
still living in the community they are often nearby and
visit often. Increasingly, the long-term consequences of
diabetes are evidentincluding blindness, renal failure,
and amputations.
REFERENCES
Bishop, C. A. (1999). Ojibwa. In J. H. Marsh (Ed.), The Canadian
Encyclopedia 2000 (p. 1702).Toronto: McClelland & Stewart.
Black, M. B. (1977a). Ojibwa power belief system. In R. D. Fogelson &
R. N. Adams (Eds.), The anthropology of power: Ethnographic
studies from Asia, Oceania, and the New World (pp. 141151).
New York: Academic Press.
Black, M. B. (1977b). Ojibwa taxonomy and percept ambiguity. Ethos,
5, 90118.
Black-Rogers, M. (1989). Dan Raincloud: Keeping our Indian Way.
In J. Clifton (Ed.), Being and Becoming Indian: Biographical
Sketches of North American Frontiers (pp. 226248). Dorsey
Press: Chicago.
914
Brown, J. S. H. (1997). Ojibwa, cultural summary. Human Relation
Area Files. Yale University.
Culhane Speck, D. (1989). The Indian health transfer policy: A step in
the right direction or revenge of the hidden agenda. Native Studies
Review, 5, 187213.
Fontaine, Phil. (1991). Health for First Nations in the 1990s. Manitoba
Medicine, 61, 2122.
Garro, Linda C. (1988). Explaining high blood pressure: Variation in
knowledge about illness. American Ethnologist, 15, 98119.
Garro, Linda C. (1990). Continuity and change: The interpretation of illness in an Anishinaabe (Ojibway) community. Culture, Medicine &
Psychiatry, 14, 417454.
Garro, Linda C. (1993). Perspectives on the health and health care of
Canadas first peoples. Culture, Medicine & Psychiatry, 17,
145157.
Garro, Linda C. (1995). Individual or societal responsibility?
Explanations of diabetes in an Anishinaabe (Ojibway) community.
Social Science and Medicine, 40, 3746.
Garro, Linda C. (1996). Intracultural variation in causal accounts of
diabetes: A comparison of three Canadian Anishinaabe (Ojibway)
communities. Culture, Medicine and Psychiatry, 20, 381420.
Garro, Linda C. (1998). On the rationality of decision making studies:
Part 1: Decision models of treatment choice. Medical
Anthropology Quarterly, 12, 319340.
Garro, Linda C. (2000a). Remembering what one knows and the
construction of the past: A comparison of cultural consensus theory and cultural schema theory. Ethos, 28, 275319.
Garro, Linda C. (2000b). Cultural meaning, explanations of illness, and
the development of comparative frameworks. Ethnology, 39,
305334.
Garro, Linda C. (2001). The remembered past in a culturally meaningful life: Remembering as cultural, social and cognitive process.
In H. Mathews & C. Moore (Eds.), The psychology of cultural
experience (pp. 105147). Cambridge: Cambridge University
Press.
Garro, Linda C. (2002). Hallowells challenge: Explanations of illness
and cross-cultural research. Anthropological Theory, 2, 7797.
Goddard, Ives. (1978). Central Algonquian languages. In B. Trigger
(Ed.), Handbook of North American Indians (Vol. 15, Northeast
pp. 583587). Washington, DC: Smithsonian Institution.
Hallett, Bruce. (2000). Aboriginal people in Manitoba 2000. Winnipeg,
MB: Human Resources Development Canada & Manitoba
Aboriginal Affairs Secretariat.
Hallowell, A. Irving. (1936). The passing of the Midewiwin in the Lake
Winnipeg region. American Anthropologist, 38, 3251.
Hallowell, A. Irving. (1942). The role of conjuring in Saulteaux Society.
Philadelphia: University of Pennsylvania Press.
Hallowell, A. Irving. (1955). Culture and experience. Philadelphia:
University of Pennsylvania Press.
Hallowell, A. Irving. (1960). Ojibwa ontology, behavior and world view
In S. Diamond (Ed.), Culture in history: Essays in honor of Paul
Radin. New York: Columbia University Press. (Reprinted in
Hallowell, A. I. (1976). Contributions to Anthropology
[pp. 357390]. Chicago: University of Chicago Press.)
Hallowell, A. Irving. (1976). Contributions to anthropology: Selected
papers of A. Irving Hallowell. Chicago: University of Chicago
Press.
Ojibwa
Hallowell, A. Irving. (1992). The Ojibwa of Berens River, Manitoba:
Ethnography into history. J. S. H. Brown (Ed.) (and author of
Preface and Afterword). Fort Worth, TX: Harcourt Brace.
Hildes-Ripstein, E. (1988). Infant care practices in First Nations
Peoples of Manitoba: Are there any modifiable risk factors for
SIDS. M.Sc. Thesis, University of Manitoba, 1988.
Holzkamm, T. E., Lytwyn, V. P., & Waisberg L. G. (1988). Rainy River
Sturgeon: An Ojibway resource in the fur trade economy. The
Canadian Geographer, 32, 194205.
Howard, J. (1965). The Plains Ojibwa or Bungi. Vermilion: University
of South Dakota, Anthropological Papers No. 1.
Martens, P. J., & Young T. K. (1997). Determinants of breastfeeding in
four Canadian Ojibwa communities: A decision-making model.
American Journal of Human Biology, 9, 579593.
Mithun, M. (1999). The languages of North America. Cambridge:
Cambridge University Press.
ONeil, J. (1988). Referrals to traditional healers: The role of medical
interpreters. In D. Young (Ed.), Health care issues in the Canadian
North (pp. 2938). Edmonton: Boreal Institute for Northern
Studies, University of Alberta.
Peers, Laura. (1994). The Ojibwa of Western Canada, 1780 to 1870.
Winnipeg: University of Manitoba Press.
Pettipas, Katherine. (1994). Severing the ties that bind: Government
repression of indigenous religious ceremonies on the Prairies.
Winnipeg: University of Manitoba Press.
Pettipas, Katherine Autumn. (1977). Ojibwa pharmacopoeia. Manitoba
Nature, 1219.
Ray, A. J. (1974). Indians in the fur trade: Their role as hunters,
trappers, and middlemen in the lands southwest of Hudson Bay,
16801870. Toronto: University of Toronto Press.
Reading, J. (1999). An examination of residential schools and elder
health. In First Nations and Inuit Regional Health Survey. Ottawa:
First Nations and Inuit Regional Health Survey Steering Committee.
Rhodes, R. A. & Todd, E. M. (1981). Subarctic Algonkian languages.
In June Helm (Ed.), Handbook of North American Indians (Vol. 6,
Subarctic pp. 5266). Washington, DC: Smithsonian Institution.
Rogers, E. S. (1969). Natural environmentsocial organization-witchcraft: Cree versus OjibwaA test case. In David Damas (Ed.),
Contributions to Anthropology: Ecological Essays (pp. 2439).
Bulletin No. 230, Anthropological Series No. 86, Ottawa: National
Museums of Canada.
Rogers, E. S. (1978). Southeastern Ojibwa. In B. Trigger (Ed.),
Handbook of North American Indians (Vol. 15, Northeast
pp. 760771). Washington, DC: Smithsonian Institution.
Shkilnyk, A. M. (1985). A poison stronger than love: The destruction of
an Ojibwa community. New Haven & London: Yale University
Press.
Steinbring, J. H. (1981). Saulteaux of Lake Winnipeg. In June Helm
(Ed.), Handbook of North American Indians (Vol. 6, Subarctic
pp. 244255). Washington, DC: Smithsonian Institution.
Thornton, Russell. (2000). Population history of Native North
Americans. In M. R. Haines & R. H. Stecke (Eds.). A Population
History of North America (pp. 950) Cambridge: Cambridge
University Press.
Ubelaker, D. H. (1988). North American Indian population size,
AD 1500 to 1985. American Journal of Physical Anthropology, 77,
289294.
915
Waldram, J. B. (1985). Hydroelectric development and dietary delocalization in northern Manitoba, Canada. Human Organization, 44,
4149.
Waldram, J. B., Herring, D. A., & Young T. K. (1995). Aboriginal health
in Canada: Historical, cultural, and epidemiological perspectives.
Toronto: University of Toronto Press.
Young, T. K. (1988). Health care and cultural change: The Indian
experience in the central Subarctic. Toronto: University of Toronto
Press.
Oklahoma Choctaw
Joseph Neil Henderson and Linda Carson Henderson
ALTERNATIVE NAMES
The official name for the tribe is the Choctaw Nation of
Oklahoma. Other terms that are locally used include
Choctaws, and sometimes Chocs. The linguistically
correct name is Chattah. This is occasionally used by
native speakers in oral discourse and for some official
occasions such as tribal ceremonies and, on occasion, at
political speeches.
The two largest Federally recognized Choctaw
tribes are the Oklahoma Choctaw and the Mississippi
Choctaw who live on a Federal reservation north of
Jackson, Mississippi. They are descendants of families
that were not removed to Indian Territory. These Choctaw
tribes are not politically affiliated with each other,
although there are friendly relations between the two.
916
OVERVIEW
Oklahoma Choctaw
OF THE
CULTURE
Medical Practitioners
917
MEDICAL PRACTITIONERS
Since about 1955 when the Indian Health Service (IHS)
was established, most tribes have had allopathic physicians providing basic primary care at modest clinics and
hospitals on tribal lands. In recent years, many tribes have
918
Oklahoma Choctaw
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
The Oklahoma Choctaw have experienced generations of
contemporary American education and life experience.
Most of the Choctaw population are subscribers to the
biomedical model and are participants in it via the health
care services provided by the Indian Health Service or the
tribal health care operations staffed by conventionally
trained personnel. However, medical pluralism is present
as indicated by the use of culturally derived healers, as
reported herein.
The contemporary Oklahoma Choctaws have a
cultural history imbued with multiple explanatory models
for health and disease. Although many of the old ways
are shielded from outsiders, there are reported instances of
practices derived from diseaseobject intrusion theory. For
example, a report of shoulder pain was treated with superficial skin incisions over the site of pain, direct application
of the mouth to the incisions, sucking of the incision site,
and showing the diseaseobject (a spider-like mass) to
the patient. Also, a type of soul loss is known to the tribal
members, although no current reports of an instance of this
have been reported. An entity known as impashilup
(literally, eater [of the] spirit) would enter the body and
consume the soul. Prevention was to abstain from destructive or morose thoughts. Cure is not currently known.
919
920
Oklahoma Choctaw
SEXUALITY
AND
REPRODUCTION
Infancy
The exposure to American educational institutions and the
biomedical model via the Indian Health Service has lead
to a Choctaw model of infancy that is largely based on contemporary American patterns. However, there is sufficient
concern for some motherinfant pairs regarding nutrition
and parenting that a strong WomenInfantChildren
program is available throughout the tribal area. Mothers
will come to one of ten Field Offices operated by the
Choctaw Nation. These Field Offices typically are brick
buildings with about 1,000 square feet of space. They have
a common room for meals and meetings as well as offices
for project coordinators who administer nutrition projects,
family resources (e.g., parenting, domestic abuse) assistance, and Community Health Representatives. The infants
can be brought to these locations for basic anthropometric
measurements to screen for developmental indicators. The
mothers also receive health education information from
the staff and by print materials. They can also obtain
nutritional supplements for the infant.
Childhood
All children receive education in the local public schools.
There are Head Start programs that are well attended and
to which tribally owned buses transport the children from
remote rural locations. However, there is a problem with
proper childhood nutrition that many believe results in
adult onset diabetes mellitus, and an increasing concern
about a rising incidence of Type II diabetes in childhood.
The Choctaw Nation is currently expanding its diabetes
education base to include elementary school children
because primary prevention strategies are of utmost
importance to diabetes control.
921
Adulthood
Nutrition, exercise, and substance abuse are the main
health issues of adulthood. The health care program of
the tribe has aggressively responded to these in the last
several years. As with other non-Indian programs responding to these matters, it has proven difficult to have a total
success with these health problems.
Substance abuse is a problem of sufficient magnitude
that special programs have been developed. A special
inpatient facility has been operated by the tribe for years
and serves members of all tribes. This includes alcohol
abuse as well as other substances. One component of the
substance abuse program integrates the use of sweat
lodges with the more conventional treatment protocols.
It is considered to offer spiritual, mental, and physical
purification.
The Choctaw Nation hospital has made strides to
respond to adult onset diabetes (Type II) by operating a
Diabetes Wellness Center. This center is staffed by
endocrinologists, diabetes educators, specially trained
nurses, and podiatrists. The center takes a family model
approach to intervention and conducts family education
for the prevention and treatment of diabetes.
Aged
Adolescence
Choctaw adolescents attend local public middle and high
schools where they are exposed to a typical American curriculum regarding the sciences and health. There is a significant problem with smoking rates that is compounded
by Oklahomas dubious distinction as the state with the
highest use of tobacco products. Moreover, there is some
cultural impetus for tobacco use that relates to tobacco as
a sacred substance. Many advertisements in American
Indian newspapers advocate Traditional Use, Not
Abuse. However, adolescent tobacco use remains high.
922
Oklahoma Choctaw
REFERENCES
Acton, K. J., Shields, R., Rith-Najaran, S., Tolbert, B., Kelly, J., Moore, K.
et al. (2001). Applying the diabetes quality improvement project
indicators in the Indian Health Service primary care setting.
Diabetes Care, 24, 2226.
American Diabetes Association. (2002). Diabetes among Native
Americans. March 12, 2002. Available online at, http://www.
diabetes.org
923
Henderson, J. N., Crook, R., Crook, J., Hardy, J., Onstead, L., CarsonHenderson, L. et al. (2002). Apolipoprotein E4 and tau allele
frequencies among Choctaw Indians. Neuroscience Letters, 324,
7779.
Indian Health Service. (2000). Trends in Indian health: 19981999.
Rockville: Indian Health Service.
McKee, J. O. (1989). The Choctaw. New York: Chelsea.
Swanton, J. (1946). The Indians of the Southeastern United States.
Bureau of American Ethnology Bulletin 137. Washington, DC:
U.S. Government Printing Office.
ALTERNATIVE NAMES
The Roma name is one that has become common currency
today, replacing the designation Gypsy which has negative
connotations. Since many Roma use the term Gypsy with
outsiders, and there are contexts in which Gypsy is the
broader term, its use is still applicable in certain contexts
and certainly appears in the literature as well as Internet
search engines. In Europe and the British Isles, terms such
as Romanies, Travelers or Tinkers are also used. Many
different groups form the Roma population based on a
common sense of belonging although they may have very
different characteristics and use different names.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
924
MEDICAL PRACTITIONERS
The Roma in the United States seek medical help both
from American doctors and their own drabnari, literally
meaning older women who have knowledge of medicines.
They are very assertive in seeking medical care from the
medical system. Many are on welfare and have medicaid
cards and therefore have access to good medical care.
They have an unusual ability, given that most are illiterate,
to understand our complex medical system and to get
attention from medical personnel (Sutherland, 1992a). On
the other hand, their insufficient knowledge of biology
and medicine as well as their rudimentary vocabulary in
English puts them at risk. They often do not practice preventative medicine or understand the full implications of
doctors instructions. While they may demand specific
famous doctors or treatment they have heard about, they
ignore preventative and long-term treatment. They have
been known to share pills with each other, request specific
colored pills and prefer older, physically bigger doctors
over younger, thinner ones (Sutherland, 1992a,b). When a
family member is sick, large numbers of relatives congregate at the hospital, sometimes camp on hospital grounds,
and create confusion among medical personnel. However,
they respect authority and are eager to learn about the best
treatments and are supported by a huge network of relatives. One study in the United States concluded that Roma
receive better medical care than other urban minorities
because they are so effective at utilizing medical services
(Salloway, 1973). These generalizations are not applicable
to Balkan and Eastern European Roma where the
discrimination is so much more severe, and where many
Roma are denied access to medical care.
Some older women are medical practitioners for
diseases they consider under the purview of their own
group. These women may supervise treatments for the
patient in addition to those ordered by the doctor. Their
treatments deal with diseases they classify as Gypsy diseases which include convulsions based on possession by
the Devil (the cure is the Devils own dung or Asafetida);
infection by a spirit called Mamioro which means little
grandmother (the cure is her vomit prepared into
tablets). Older women acting as midwives also attend
childbirth to help the mother have an easier birth
(a Selaginella plant, called St. Marys Hand, is placed in
water to open the wombalso at the deathbed to make
sure the spirit leaves the room) (Sutherland, 1992a).
925
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
The Roma view health and illness in the larger context of
social order. Good health and good fortune (many
children, money) are consequences of individual diligence in following purity rules. Conversely illness, bad
luck, and impurity are also closely associated with being
ritually unclean (marime). To be ritually clean, the Roma
must follow a large number of rules about washing, eating, separation of parts of the body, separation of male
and female, and separation from the polluting influences
of non-Roma who do not follow these rules (Sutherland,
1986). They make a distinction between illnesses caused
by contact with non-Roma and their own Gypsy
illnesses. For the former they go to the American
medical system, and for the later they consult their own
drabarni. Gypsy illnesses include those caused by
Mamioro, a spirit who visits places that are unclean and
brings illness, tosca, a disease they translate as nerves
is caused by the devil, as are convulsions which are a sign
that the devil has entered the body of the individual.
Other illnesses and bad luck are caused by mule, the
ghosts or spirits of dead relatives. Mule are not necessarily harmful, but relatives of the dead who do not properly
observe pomani (death rituals) could be made ill by them.
Mental illness is rare, although virtually every Roma
person I knew who was tested by a psychiatrist was
diagnosed with borderline personality disorder, that is, in
relation to the American view of a healthy personality
(Sutherland, 1986). The cure for mental illness is for a
person to follow the purity rules and other social customs
such as getting married. All drabarni carry a bag of
medicines that may include Asafetida, johai (literally
meaning, ghost) which are baked pieces of the vomit of
Mamioro (most likely is a slime mold called
Fuligo septica) and other herbal medicines such as a
fungus called the spoon, a special herb called drarnego,
garlic, black pepper, gold coins, and pieces of the aprons
of ancestors who were drabnari. Johai is the most valuable medicine a drabnari carries in her medicine bag. It
cures fear of ghosts, hemorrhages, influenza, pneumonia,
cholera, and epileptic convulsions and is administered in
addition to medicines prescribed by a doctor (Sutherland,
1992a).
926
SEXUALITY
AND
REPRODUCTION
Infancy
In the first 6 weeks, an infant is viewed as highly vulnerable. At birth the baby is tightly swaddled and handled
only by the mother. If the mother nurses, she is told to
avoid certain foods considered to produce colic (green
vegetables and tomatoes). Many women choose to bottlefeed. In the first weeks of life the mother and baby are
isolated from all other family members, and the windows
and door to her room are kept shut to keep out a spirit of
death that may come to harm the baby. Another danger to
the baby is the evil eye which causes the baby to fuss and
become ill. The giver of the evil eye is then asked to make
a cross with spittle on the forehead of the baby to counter
it. The dangers of infancy are ameliorated when the baby
is baptized at about 6 weeks of age. If a baby dies, it is
considered prikaza (a polluting misfortune) for the parents who must avoid the body of the baby (Sutherland,
1992a, 1996).
Childhood
A child is protected from illness when he or she is
baptized and considered free of pollution from birth
substances. Children are much loved and enjoy freedom
from the restricting rules of cleanliness. They are not
Adolescence
A major change occurs at adolescence for both boys and
girls. Adolescents are introduced to the notion of personal
shame. Their bodies and their behavior are suddenly
judged in terms of their control of polluting substances
(menstrual blood, semen) and shameful actions (sexual
contact). Girls in particular have to keep clean and
observe the washing, dressing, cooking, and eating codes
of women. Womens clothes are washed separately from
those of men and children, and they cannot cook food for
others during menstruation unless they avoid touching
menstrual blood. Some girls fast during menstruation
(Sutherland, 1986). Adolescents are expected to behave
much like adults and to marry as early as possible.
Those who experiment with drugs or sex are considered
to have a social or mental problem for which marriage is
a cure. Alcohol and smoking are not discouraged.
Adulthood
Married women are expected to support their husbands
family and their own children. Mens income can be spent
on themselves or their children. Women must serve food
to their in-laws and show respect to men by not passing
in front of them (unless they have a baby in their arms) or
allowing their skirts to touch men. They must show modesty by wearing more traditional Roma clothes, and, if
married, a head scarf (diklo). Adult women and men soon
develop health problems such as obesity, diabetes, high
cholesterol, and hypertension leading to an untimely
death in many cases. At menopause or when they cease
sexual relations, men and women become pure again
and the cleanliness rules are eased. To encourage good
health, they eat pepper, salt, vinegar, garlic, and onions
(Sutherland, 1992a).
927
The Aged
Old people are highly regarded for their knowledge and
special status as pure because menstruation and sexual
relations are assumed to have ceased. The aged are politically powerful and exert a great deal of influence over
the younger members of the extended family group. They
are consulted on everything including arranging the marriages of their offspring and all political decisions by the
group. Usually a younger person will not agree to medical procedures without the approval of their oldest relatives who often arrange the medical treatment and act as
a mediator with the doctors. In the hospital an older
authority figure must be involved in all decisions, and the
older women may also treat the patient. The aged are surrounded by their family and cared for at home until death.
They may not travel much because of illnesses, but they
are at the center of all social and political life. Showing
proper respect for the old is the best way of ensuring that
their spirit will not carry a grudge to the grave and plague
the relatives left behind. Even before a person dies their
good deeds begin to take on a mythological stance, and
the bad deeds are never mentioned (Sutherland, 1986).
928
REFERENCES
Braham, M. (1993). The untouchables: A survey of the Roma People of
central and eastern Europe. Geneva: UNHCR.
Cilla, G., Perez-Trallero, E., Marimon, J. M., Erdozain, S., & Gutierrez, C.
(1995). Prevalence of hepatitis A antibody among disadvantaged
gypsy people in northern Spain. Epidemiology and Infection, 115,
157161.
Gresham, D. et al. (2001). Origins and divergence of the Roma
(Gypsies). American Journal of Human Genetics, 69, 13141331.
Hajioff, S., & McKee, M. (2000). The health of the Roma people:
A review of the published literature. Journal of Epidemiology and
Community Health, Nov 54(11), 864869.
Lehti, A., & Mattson, B. (2001). Attitude to care and pattern of
attendance among gypsy womena general practice perspective.
Family Practice, 18, 445448.
Nemenyi, M. (1999). Gypsy mothers and the Hungarian health care
system. Patrin Web Journal, Jan 6.
929
Sutherland, A. (1992b, September). Gypsies and health care. Cross-cultural medicine (Special Issue). Western Journal of Medicine, 157,
276280.
Thomas, J. (1985). Gypsies and American medical care. Annals of
Internal Medicine, 102, 842845.
Thomas, J. (1987 August, 15). Disease, lifestyle and consanguinity in
58 American Gypsies. Lancet, 377379.
Zoon, I. (2001). On the margins, Roma public services in Romania,
Bulgaria and Macedonia. New York: Open Society Institute.
Samoa
James R. Bindon
OVERVIEW
OF THE
CULTURE
Population
Demographers agree that there were no reliable estimates
of population in the Samoan Islands until the 1920s.
Reports of missionaries and administrators during the
19th century vary widely in quality, and supply widely
varying population counts. Commodore Wilkes based his
1839 estimate of the population on reports from local
missionaries to come up with a total of about 57,000. This
early figure is viewed as the least reliable of the 19th century. The first reasonably reliable census yielded a total of
about 34,000 in 1853. The discrepancy between these two
censuses led to speculation about severe depopulation
after European contact. However, most demographers
930
History
Voyagers of the Lapita culture settled in the FijiTonga-Samoa area between about 1500 and 1000 BC.
Contacts between Samoa, Tonga, and Fiji were maintained
throughout prehistory and, later, relations were maintained
with other Polynesian groups including Tokelau, Wallis,
and Futuna. Significant European contact and acculturation began in 1830 when John Williams of the London
Missionary Society (LMS) arrived and established his
church through fortuitous political circumstances.
There was conflict for colonial control between
Germany, Great Britain, and the United States until 1900
when the four islands in the west became a German
colony and the five islands in the east were claimed as the
Territory of American Samoa by the United States. As a
result of the League of Nations actions during World
War I, New Zealand assumed administration of the
German colony from 1914 to 1962. Independence from
New Zealand as a constitutional monarchy came in 1962
with the founding of the Independent State of Western
Samoa, later changed to the Independent State of Samoa
(commonly Samoa) in 1997. The eastern islands remain
a United States territory, administered by the Office of
Insular Affairs, U.S. Department of the Interior. The
territory elected its first Samoan governor in 1977.
Economy
The traditional economy of the archipelago was based
on root and tree crop farming supplemented by fishing. The economic development of the two Samoas
Samoa
Social Organization
The fundamental unit of social organization in Samoa is
the aiga which can mean the household, the nuclear family, or the extended family. As an extended family, each
aiga is headed by a title holder or matai. Traditionally
each aiga had a specific compound with several related
families living under its matai. Communities or villages
(nuu) consist of several aiga with long-term associations. Nuu are governed by councils or fono in which all
matai have a voice. The matai titles are divided into two
general types, chiefs or alii and talking chiefs or tulafale,
and ranked within each of these divisions from lowest to
highest. The nuu are independent political units but they
group together into regional alliances for some purposes.
This community level of organization is still important in
the ISS and American Samoa, although residence has
become increasingly based on the nuclear family rather
than the aiga.
Religion
There is little remnant of traditional religion other than
generalized beliefs in ancestral spirits (aitu). Today
Samoans are overwhelmingly Christian. In ISS 99.7% of
the population adheres to Christianity, about half of which
belongs to the LMS derived Christian Congregationalist
Church of Samoa (CCCS). The rest are Roman Catholics,
Methodists, Latter-Day Saints, and Seventh-Day
931
THE CONTEXT
OF
HEALTH
Health Indicators
Many 19th-century sojourners remarked on the general
good health of the Samoan population (MacPherson &
MacPherson, 1990). The well being of the Samoans has
been attributed to a hospitable environment, an excellent
vegetable- and marine-based diet, limited opportunity for
infectious disease exposure from outsiders, and a high
standard of personal hygiene, including frequent bathing.
This good health notwithstanding, the early visitors to
Samoa heard of an epidemic illness introduced by sailing
gods long before the arrival of Europeans. This epidemic
is said by one observer to resemble cholera. Other than
this relatively isolated prehistoric episode, Samoans
appear to have enjoyed a long, stable period of good health
prior to European exposure in the 19th century. Kramer
(1903/1995), because of his medical training and extended
stay in Samoa, provides the best early description of
medical conditions. He notes the absence of malaria and
comments on the occasional presence of leprosy, the frequent occurrence of respiratory ailments (much of which
he classifies as consumption or tuberculosis), and the
widespread incidence of elephantiasis (filariasis), which
he estimates as afflicting 5% to 10% of the population.
Many other 19th-century visitors commented on the presence of elephantiasis which manifests as extreme swelling
of the legs, scrotum, or breasts. While the high visibility
of this disease (it was not uncommon to see Samoans with
the signature swollen legs and ankles in the 1970s)
accounts for some of the remarks, it is clear that this was
a significant pre- or early-contact disease.
A seminal event separating the health history of ISS
and American Samoa occurred in 1918. An epidemic
outbreak of influenza (the Spanish flu pandemic) arrived
in Apia aboard the New Zealand ship Talune in
November 1918. The official death rate in ISS was
recorded as 22% (20% among Samoans, 33% among
part-Samoans, and 2% among Europeans) although the
impact was much greater as many deaths occurred in the
ISS
American Samoa
75.3
4.1
10.4
Rank
#1
#3
#2
#4
#5
1995 sources: American Samoa (WHO, 1999a), ISS (WHO, 1999b). 2001
sources: American Samoa (CIA, 2001a), ISS (CIA, 2001b).
932
Health Infrastructure
Prior to contact there was a limited set of personal
practices and healers ( fofo) available for the relatively
few native health problems. Most medical consultation
occurred within the village context where different healers were responsible for specific conditions. By the
1860s, there were trained physicians ( fomai) in Apia,
brought in by the LMS and German companies. The
German Navy established a hospital in Apia in the 1890s,
but there was no Western medical attention paid to the
eastern islands until 1900 (Gray, 1960). As the U.S. Navy
began administration of American Samoa, plans were
made for a dispensary near Pago Pago which turned into
the local hospital and served until it was replaced by the
current L.B.J. Tropical Medical Center in Fagaalu in
the 1970s. In ISS, the genesis of the public health system
of outreach dates to the experience with the Spanish flu.
The New Zealand administration established womens
committees (komiti tumama) in the villages to promote
health and hygiene. By the 1940s there was a well established system of primary health care available throughout
ISS, and many village hospitals were built.
MEDICAL PRACTITIONERS
Prior to contact individuals offered their own prayers for
ailments or they consulted one of the healers or fofo near
Samoa
Table 2. 1996 Healthcare Workforce in the Independent
State of Samoa and American Samoa
ISS
Doctors
Dentists
Pharmacists
Nurses
Midwives
American Samoa
Number
Per 10,000
Number
Per 10,000
57
6
6
257
60
3.44
0.40
0.40
15.50
3.60
16
N/R
N/R
146
N/R
2.90
N/R
N/R
26.20
N/R
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Precontact paradigm
Prior to the arrival of Europeans, Samoans attributed
illness to the displeasure of the gods or to the work of
spirits (aitu). Stair, who visited Samoa in the 1840s,
classified the gods into four categories, the third of which
was the aitu who were responsible for much of the
mischief and illness that befell Samoans (Stair, 1897).
These beliefs resulted in treatments that focused on
identifying the act that caused the displeasure or the aitu
responsible for the malady and prescribing behaviors to
assuage the god or aitu. There are many prayers that are
933
Contemporary paradigm
Other prayers and offerings were made once a specific god or aitu was identified as being responsible for
an illness:
In a case of sickness, a cup of kava [ava, beverage made from the root
of Piper methysticum] was made and poured on the ground outside the
house as a drink-offering, and the god [Salevao] called by name to come
and accept of it and heal the sick. (Turner, 1884, p. 51)
and
In another place [Taisumalie] was incarnate in an old man who acted as
the doctor of the family. His principal remedy was to rub the affected
part with oil, and then shout out at the top of his voice five times the word
Taisumalie, and five times also call him to come and heal. This being
done, the patient was dismissed to wait recovery. On recovery the family had a feast over it, poured out on the ground a cup of kava to the god,
thanked for healing and health, and prayed that he might continue to turn
his back towards them for protection, and set his face against all the
enemies of the family. (Turner, 1884, p. 59, emphasis in the original)
934
Samoa
Mental Health
Few cultures have had as much written about mental
health as have the Samoans, beginning with Meads characterization of a people with few neuroses and little maladjustment (Mead, 1928) and accelerating to a fever pitch
with Freemans depiction of aggressive and suicidal
Samoans (Freeman, 1983). Several volumes have since
dealt with this controversy (see Caton, 1990; Holmes,
1987; Orans, 1996). Neither extreme viewpoint is likely
to have much merit and a better characterization of
Samoan mental health would lie somewhere between the
two. A psychiatrist working in American Samoa in the
1970s hypothesized that the underreporting of mental
illness by biomedical standards in American Samoa was
a result of the social system, which provides a means of
curing emotional disorder by family group process and
ritual, by making the disorder less disruptive, and by
absolving the affected individual of personal guilt
(Walters, 1977). Thus, much of what would be diagnosed
and treated as deviant under the biomedical paradigm is
informally handled within Samoan families.
SEXUALITY
AND
REPRODUCTION
Infancy
After children were born they were lovingly cared for. For
the first 3 days, attention was paid to shaping the head by
laying the child on its back and surrounding the head with
flat stones. The hand was used to press the forehead and
the nose to produce the desired shape (Turner, 1884). The
mothers milk was examined by a woman every day for up
to a week to determine if it were ready for the infant.
During this time the infant was fed on the juice of the
coconut, after which breast-feeding and supplementation
with pre-masticated vegetables were started (Stair, 1897).
Contemporary infants are primarily breast-fed, but
this varies between American Samoa and ISS. In
American Samoa, where employment opportunities are
better, women tend to wean their infants early to return to
work. In ISS, breast-feeding is likely to continue longer.
In both areas, infants grow very rapidly during the first
6 months of life after which time the infants in ISS, especially from remote rural areas, tend to slow in rate of
growth (Bindon & Zansky, 1986). Bindon and CabreraMereb (1990) found infants in American Samoa to be
quite healthy, with respiratory complaints being the most
common illness. They also found that exclusively breastfed infants tended to be healthier at 3 through 9 months
than infants who were at least partially bottle-fed.
Childhood
Stair (1897) describes child rearing as alternating
between overly severe punishment for minor infractions
and over-indulgence. Holmes and Holmes (1992) also
note severe punishment in Manua in 1954. Similar discipline continues to be the norm, and is the source of
some difficulties with child welfare organizations outside
the islands. By 3 or 4, the gender roles are being shaped
among the children and girls begin to assume household
roles. By 5 or 6 a young girl may be baby-sitting and
935
caring for her next younger sibling. Boys have more freedom during early childhood, although they may have to
feed the chickens, fetch water, and accompany their
mother in gathering food on the reef. By 7 or 8, both boys
and girls have assumed an active role in the genderappropriate tasks of the household. An exception to this
training may occur in a family where a mother has no
young daughters and cannot adopt a young girl to help
with the housework. In such a case, a son may be
recruited by the mother to fill the role of a young girl in
helping the mother manage the household. In such cases,
when the boy continues to adopt the female gender role
into adolescence and perhaps adulthood, the name
faafafine is applied. A faafafine may marry and have
children but continue to play a female role in the family
and the village. Since the institution of formalized
schooling, the patterns of training and household assistance by children have been dramatically altered. Preschool child care is more likely to be done by the elderly
while school-age siblings are in class, and everyone
shares in the household chores once done by the children.
Adolescence
Male circumcision is the norm in Samoa. At about 9 or 10,
two boys arrange to go to a specialist to perform the surgery. They bring him a gift of food and tapa. The operation involves a single longitudinal incision on the foreskin
which peels back and after healing looks as if the foreskin
has been removed (Holmes & Holmes, 1992). There is no
other ceremony associated with this milestone. No such
female operations are conducted.
A young man joins the aumaga (society of untitled
men) with the sponsorship of his matai at around 14 or 15
or, today, after he graduates from school. The aumaga
serves the village at the direction of the fono. Adolescent
girls used to join the aualuma (unmarried women) and
sleep in a separate house serving as a court to the taupou
(village princess). Today the group comes together only
on special ceremonial occasions, frequently for dancing
and singing.
Adulthood
Turner (1884) says that adulthood was marked for men
by tattooing. Males spend their adulthood seeking a
matai title and their wives support this attempt as their
status is also enhanced. Today upward mobility through
936
The Aged
Old age has traditionally been identified in Samoa as the
best time of life. The elderly, over about age 50, are
treated with respect, they have minimal demands on their
time and energy, and one can rely on the support of ones
children and relatives. Many of these attitudes persist
today, although times are changing. Since the 1970s,
homes for the aged have been opened in both ISS and
American Samoa, a result of the emigration of younger
Samoans and the occasional failure of family resources
to provide for the elderly who remain in the islands
(Holmes & Holmes, 1992). A number of elderly Samoans
suffer the depredations of diabetes, blindness being one
of the most visible symptoms.
Samoa
REFERENCES
Bindon, J. R. (1988). Taro or rice, plantation or market: Dietary choice
in American Samoa. Food and Foodways, 3, 5978.
Bindon, J. R. (1995). Polynesian responses to modernization:
Overweight and obesity in the South Pacific. In I. de Garine &
N. J. Pollock (Eds.), Social aspects of obesity (pp. 227251).
London: Gordon and Breach.
Bindon, J. R. (1997). Coming of age of human adaptation studies in
Samoa. In S. J. Ulijaszek & R. A. Huss-Ashmore (Eds.), Human
adaptability: Past, present, and future (pp. 126156). Oxford:
Oxford University Press.
Bindon, J. R., & Baker, P. T. (1997). Bergmanns rule and the thrifty
genotype. American Journal of Physical Anthropology, 104,
201210.
Bindon, J. R., & Cabrera-Mereb, C. C. (1990). The health status of
infants in American Samoa during the first year of life. American
Journal of Human Biology, 2, 511519.
Bindon, J. R., & Zansky, S. M. (1986). Growth and morphology. In
P. T. Baker, T. S. Baker, & J. M. Hanna (Eds.), The changing
Samoans (pp. 222253). New York: Oxford University Press.
Caton, H. (1990). The Samoa reader: Anthropologists take stock.
Lanham, MD: University Press of America.
CIA. The World FactbookAmerican Samoa. (2001a). Washington, DC
(January 1, 2001); Available online at, http://www.cia.gov/cia/
publications/factbook/geos/aq.html.
CIA. The World FactbookSamoa. (2001b). Washington, DC
(January 1, 2001); Available online at, http://www.cia.gov/cia/
publications/factbook/geos/ws.html.
Freeman, D. (1983). Margaret Mead and Samoa: The making and
unmaking of an anthropological myth. Cambridge, MA: Harvard
University Press.
Gray, J. A. C. (1960). Amerika Samoa: A history of American Samoa
and its United States Naval Administration. Annapolis: United
States Naval Institute.
937
Saraguros
Ruthbeth Finerman
ALTERNATIVE NAMES
The word Saraguro translates from the Quichua
language as Land of Corn. The indigenous community
self-identifies as Saraguros, indgenas, or more rarely, as
runas (people). Non-indigenous residents may speak of
Saraguros with the pejorative indio or chinita. Saraguros
occasionally make derogatory reference to acculturated
individuals as leichos or gente acomodado.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
938
Production
Like most Andean peasants, Saraguros are agropastoralists (Gade, 1999; Wilson, 1999). Bullock-pulled plows
are used to plant maize, potatoes, beans, wheat, and
barley. Cattle herding yields major capital, and families
also raise sheep, guinea pigs, swine, chickens, and rabbits. Wool from sheep is handspun and woven to fashion
traditional Colonial-period garments. Crafts, including
beadwork, embroidery, and weavings are also manufactured for personal use and for sale.
Social Organization
Strong differences in wealth and status exist among
Saraguros, and between indigenous and non-indigenous
residents (Belote, 1978). Status also differs somewhat by
gender, as males enjoy a higher public profile. However,
Saraguro women can garner recognition by sponsoring
religious festivals and, as in other parts of Ecuador, they
wield ample power over household resources, decisionmaking, and family comportment, particularly as they
Saraguros
Religion
While evangelical movements have made some inroads in
the region, Catholic doctrine dominates religious life. Yet,
as in much of the Andes (Allen, 1997; Dover, Seibold, &
McDowell, 1992; MacCormack, 1991), Saraguro beliefs
and practices retain many elements of pre-Conquest cosmology, including animistic reverence for the sun, moon,
wind, rivers, and rainbows. Such spirits are also linked to
personalistic illnesses.
Environmental Factors
The natural ecosystem presents a mixed bag of health risks
and benefits. The high altitude and cold temperatures
produce several deaths each year from hypothermia. The
climatic phenomenon El Nio produces devastating rains
that wipe out crops and wash out roads, cutting off access
to medical care. Wildlifemainly venomous snakes and
spidersposes some threat, particularly since most children and older adults walk barefoot. Domesticated animals
expose their owners to zoonoses including tuberculosis,
rabies, flea and tick infestations, and a host of parasitic
diseases. Nevertheless, the rich ecosystem also supports
a diverse food supply and a vast array of medicinal plant
species that are routinely exploited for health promotion in
Saraguro and throughout the Andes (Bastien, 1987;
Naranjo & Escaleras, 1995; Wilson, 1999).
Household ecology also yields risks, although these
have shifted over time. Most old homes have dirt floors,
and kin tend to share beds in one room, facilitating contact with contaminants and the spread of communicable
disease. Recent home renovations and new homes invariably boast plank flooring and separate sleeping quarters,
yet these upgrades mainly reflect the crowding of large
extended families into a single home. Prior to 1990, most
Saraguros cooked on open hearths fueled by firewood,
risking burns and respiratory irritation. However, depletion of firewood supplies has since forced a shift to use of
cooking gas. This has reduced hearth fire hazards, but
poses a danger should gas cylinders rupture and explode.
During the same period, most homes gained access to
water pipelines, but the unpurified water continues to
spread disease. The community also lacks effective
sewage and waste disposal, but many homes now feature
outdoor latrines and showers, slightly reducing waste
levels indoors. Still, some Saraguros continue to collect
urine in the home (for use in dye vats), and most residents
come into contact with solid waste and contaminated soil
and water when cultivating fields.
939
Social Factors
Saraguros associate social and economic productivity
with health, thus disability, inactivity, or unemployment
is considered both unhealthy and antisocial. Pressure to
remain productive has fostered migration, particularly of
unemployed males, forcing many women and young
children to take charge over households, crops, and herds.
Worse still, the migrants frequently return from the
lowlands and cities carrying a host of new diseases (e.g.,
malaria, cholera) that spread through the community.
Interpersonal harmony is also viewed as fundamental to health, and some illnesses are attributed to anger,
envy, despair, or discord. Thus, social cohesion is characterized as essential to well-being, and gossip stands as
a powerful social control mechanism. Women here are
concerned to avoid gossip should their children appear ill
or malnourished and they take special pride when told
that their children look robust. These women retain the
primary social role in managing family health, and skillful healers gain substantial power in both the household
and community (Finerman, 1995). Females are socialized
into the family healer role during childhood, when they
begin to assist their own mothers in preparing remedies
for younger siblings. As they age and establish their own
families, women continue to consult their mothers and
female friends for health care advice.
940
MEDICAL PRACTITIONERS
Indigenous Saraguro curing specialists include herbalists,
midwives, and shamans. Herbalists provide medicinal
plant preparations and advice on diet for a range of ailments. Midwives advise women on fertility, prenatal and
postpartum care, and may assist in labor and delivery,
employing massage, baths, herbal remedies, and dietary
guidance. Curanderos specialize in intractable conditions, particularly illnesses suspected of being caused by
supernatural agents. Nevertheless, Saraguros make minimal use of these practitioners, treating almost all illnesses
with home remedies (remedios casseros). Not surprisingly, only a few of these specialists practice here, and
those who do are more likely to be patronized by nonindigenous town residents.
In addition to traditional curers, the town supports a
few private physicians and dentists, and a hospital staffed
by medical and nursing interns and community health
workers. Several private pharmacies also operate, typically selling products without prescription. But, as with
traditional healers, Saraguros have proven unlikely to
consult biomedical providers unless all home treatment
efforts are exhausted.
Home-based health care combines preventive activities involving hygiene, dress, dietary laws, and personal
comportment, plus an extensive repertoire of herbal
remedies. Women view their healing role as a natural
extension of their duties in bathing, clothing, feeding, and
generally nurturing kin. They invariably argue that they
are the first to spot the signs of illness (e.g., appetite or
sleep loss, pain, lethargy) and they usually possess years
of healing experience. Most also reason that other practitioners could never match a mothers concern for her own
familys welfare.
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Etiology
Saraguro views of illness concern the actions of both
naturalistic and personalistic agents. One of the most
pervasive beliefs here and throughout Latin America is
that of humoral opposition (Foster, 1998). Specifically,
Saraguros
Treatment
As noted, Saraguros usually rely on their mothers or
wives to manage health, despite access to various
professional curers. This popular or informal sector
of family-based care predominates cross-culturally
(Kleinman, 1980); in southern Ecuador Saraguros enjoy
a degree of fame for their expertise in herbal medicine.
Indigenous women here possess curing knowledge
that is at once highly complex and syncretic, blending traditional curing elements with biomedicine. The richness
of their knowledge derives from a lifetime of experience
in treating sick kin and from continual expansion of their
curing arsenal. Saraguro women routinely consult their
own mothers and female friends for advice, and they gain
fresh curing insights from health specialists. Women usually accompany spouses and children to practitioners, and
providers tend to direct treatment instructions to these
women. In the process, they learn new concepts and
therapies that help them upgrade their curing routines.
By contrast, specialists such as curanderos, midwives,
and physicians almost never share insights among one
941
942
SEXUALITY
Saraguros
AND
REPRODUCTION
Sexual Activity
Despite strong affiliation with Catholicism, Saraguros
demonstrate only weak adherence to religious mores
regarding sex. In particular, premarital sex is only mildly
discouraged, and births outside wedlock are both
common and readily accepted. Indeed, such births are a
positive indicator of a females fecundity and can
enhance her prospects for marriage, though aspirations
decrease with subsequent pregnancies. Extramarital
affairs incur slightly more social disapproval, yet most
residents profess tolerance, particularly in cases of absent
spouses (e.g., wives of migrant workers, or abandoned
spouses). Homosexuality is criticized, but almost never
discussed. Greater censure is reserved for incest, which is
called immoral and unhealthy. Local folklore claims that
incestuous couples gradually transform into dogs, manifesting new canine attributes after each transgression. For
the most part, however, locals regard sex as both normal
and healthy, but also a private matter. Women follow
select rules of sexual decorum; in particular, they cover
their mouths when smiling and laughing, as showing
teeth is vulgar. However, men and women are equally
fond of sexual jokes and innuendo.
Fertility
In the indigenous community, the social transition from
childhood to adulthood is not marked by initiation into
sexual activity or, in the case of females, by menarche.
Instead, childbirth is the main marker of maturity. Females
retain the title girl (nia) or child (hija) even after
marriage, until their first birth. Males also lose the moniker
nio or hijo only after they have children. Childbearing is
significant in most peasant societies; offspring are critical
to expand a familys labor pool and provide care for aging
parents; households also procure support through fictive
kin networks (Mitchell, 1991, pp. 4751).
Fertility itself is a sign of good health and humoral
equilibrium. A woman who readily conceives and bears
children is robust and warm; infertility and miscarriage
may arise from various problems, including a cold
metabolism, witchcraft, and envy. Barren women are also
considered prone to weakness (debilidad) and heart failure.
Saraguro understandings of conception shifted
in recent generations. Accounts from the 1960s cite
Fertility Control
Ideal family size also evolved over the last half of the
20th century. Historically, Saraguro couples hoped to
have many children to expand production and care for
their aging parents. Yet, by the 1950s competition for land
intensified and youths deserted Saraguro in search of
acreage and wages. More couples also found that larger
families could not afford to educate all of their children.
By the 1970s, family planning campaigns began to
actively promote the benefits of smaller families. Today,
families with just one son and one daughter are the ideal.
Even so, Saraguros face multiple barriers to effective
contraception.
Church representatives in Saraguro condemn birth
control, and many men fear that contraception facilitates
adultery by women. Such antagonisms make discussion
of the topic both sensitive and infrequent. Yet, most in
the indigenous community regard pregnancy prevention
as a womans privilege, and as her burden. A majority
of women rely on herbal teas to prevent or terminate
a pregnancy, though such preparations are unreliable.
Occasionally, women seeking abortion consult curanderos,
or travel to larger cities to purchase contraception. Few see
local physicians or druggists, fearing gossip. A small number have taken drastic steps to induce miscarriage, pounding their belly, falling down hillsides, or ingesting irritants
such as wood ashes. Still, few attempt to terminate
unwanted pregnancies; almost all reconcile themselves
to the condition as Gods will (lo que Dios quiere).
Nevertheless, they frequently bemoan their large families
and extol the good fortune of women with few children.
943
Infancy
Indigenous parents profess no gender preference among
offspring. Both sexes retain their parents names, and
both can inherit. Twin births seem to cause no concern,
but are extremely rare in this population. It is possible
that, in the past, such births precipitated higher maternal
mortality, leaving a population that is genetically less
prone to multiple pregnancy. Birth defects and deformities do incite shame and are interpreted as a punishment
from God. However, the child faces minimal risk for
active or passive infanticide, since religious doctrine
effectively prohibits such recourse. Still, a few families
have hidden such offspring at home, so that their disgrace
is less public.
Saraguros rightly regard newborns as especially
vulnerable to illness and death; fears are understandable
given that, prior to the 1960s, infant mortality at times
reached 40%. Waves of measles, chicken pox, and
whooping cough decimated families before immunization campaigns intensified. Infants still face substantial
risk of diarrhea and dehydration, respiratory infection,
and communicable disease, and are considered highly
prone to evil airs, magical fright, soul loss, envy sickness,
and witchcraft.
Here and elsewhere in Latin America, infants and
children who die before their First Communion are said to
become angels or angelitos (Lillo, 1942). The dead child
is adorned with a paper crown and wings, and seated on a
decorated altar in their home. Their death is marked by an
extended period of feasting and dancing; the tradition
helps parents to better cope with the loss of a child.
While such deaths are celebrated, Saraguros take
pains to forestall the loss of offspring. Newborns are
kept in virtual isolation for the first 40 days of life.
Saraguro mothers breast-feed infants on demand, rather
than on a schedule. Mothers customarily breast-feed for
one year, or until the mother becomes pregnant again.
944
Childhood
The transition from infancy to childhood in Saraguro is
gradual, marked mainly by enhanced mobility, communication, and autonomy. Once offspring begin to walk, talk,
and play independently, they are given more responsibilities and tasks. By five years of age children begin to help
with younger siblings, keep watch over sheep and cattle,
and fetch items for their mothers. Daughters assist mothers in meal preparation, sibling care, housework, and
preparation of medicinal remedies. Parents rarely discipline offspring, although they may threaten spankings
or a thrashing with nettles. More often, parents simply
assign more chores, reasoning that work keeps children
too busy to cause trouble.
In Saraguro, children must be fully vaccinated to
register for school. Nonetheless, sickness rates increase
for students, as contagious and parasitic diseases spread
and children suffer more accidental injury. Parents also
Saraguros
Adolescence
Puberty and adolescence receive almost no recognition in
this population. Typically, daughters quietly inform their
mothers of the onset of menarche, but they receive little
instruction and face few restrictions other than minor
dietary taboos (e.g., consumption of avocado) and perhaps
admonishment to avoid pregnancy. Adolescent sons garner
still less attention, but may gain greater freedom; young
Saraguro males frequently stay out all night attending
fiestas or drinking with male companions. Such behavior
risks few penalties other than mild parental rebuke. Youths
are said to face few health risks, other than unplanned
pregnancy or injury precipitated by intoxication.
Adulthood
Most Saraguro adults describe their lifestyle as exceptionally healthy (sano), comprising vigorous labor, and
a balanced diet. Nevertheless, a majority report chronic,
albeit minor complaints like muscle aches, fatigue, and
eye strain, plus a range of acute respiratory and intestinal
disorders. Other common concerns include pregnancy,
physical trauma (usually related to work or alcohol intoxication), alcoholism, animal bites, and tuberculosis.
Adults claim to suffer fewer traditional ailments like
magical fright and soul loss, yet nervios is pervasive
among adults (especially women), and mal aire strikes
most adults who take cattle to pastures in the windy and
wet high elevation paramos.
The Aged
Aging, like other social transitions, is a subtle process in
this population. This is largely because there is no designated age for retirement or social security benefits;
Most Saraguros remain economically productive
throughout their lives, and provide supplemental aid with
family care and curing expertise. Also, Saraguros show
few signs of aging; hair tends to remain black until
945
(but hold these over their heads out of respect for the sun)
and recite final prayers. Saraguros assert that open graves
emit dangerous airs and the essence of ghosts. Thus,
mourners (especially those who handled the corpse, held
vigil, or prepared the grave) return home immediately
after the ceremony and bathe to remove any residue of
death. Most also pour cologne in their hands and cup it to
their face, rubbing it in and inhaling deeply as a treatment
for supernatural illness.
Soon after mass and burial, family and friends strip
the home of all possessions; these are carried to a local
river, where all goods (e.g., clothing, bedding, and even
furniture) are meticulously washed to purge the residue of
death. The walls and floor of the house are also scrubbed,
and doors and windows are left open for several hours to
expel any lingering malevolent airs or spirits.
Rites may be interrupted if cause of death is in doubt
(Finerman, 1984). Until recently, physicians performed
autopsies in the cemetery just prior to burial, in full view
of the mourners. Since proper instruments and lab analysis were not available onsite, results were unreliable at
best. Worse still, this act delayed burial for hours and subjected mourners to the sight of a loved ones dissection
(for which kin were billed). Today, bodies are usually
autopsied at the hospital, then released for vigil, mass,
and interment.
Death
Saraguros exhibit both respect for and fear of the dead.
With the exception of children honored as angelitos, the
deceased seem to be regarded in vaguely malevolent
terms. Survivors are loath to speak of the dead by their
Christian name; more often, the deceased is referred to
obliquely as el cadver or el difunto. Mourners view
corpses as corrupted flesh that pollutes the home and
threatens corpse sickness (aire grande), which can
rob the living of their souls and even their lives.
Consequently, indigenous funerary customs venerate the
memory of the dead, but also operate to protect the health
and well-being of the family and community.
Soon after death, the body is bathed, dressed for burial, and laid out at home. A rosary is placed in the hands,
and candles encircle the bier. Mourners accompany the
corpse on an all-night vigil and pray for their soul. As the
night progresses, attendants may consume alcohol to
toast the dead and pass the hours. The coffin is then carried to church for funeral mass, and then up a hill to the
local cemetery. At graveside, mourners remove their hats
946
REFERENCES
Allen, C. (1997). When pebbles move mountains: Iconicity and
symbolism in Quechua ritual. In R. Howard-Malverde (Ed.),
Creating context in Andean cultures (pp. 7384). New York:
Oxford University.
Argello, S., & Sanhuenza, R. (Eds.) (1996). La medicina tradicional
Ecuatoriana. Quito: Banco Central.
Barreto, R., Barrera, A., Unda, M., & Carrin, A. (1996). Ciudades y
Pueblos Saludables. Quito: OPS/OMS (PAHO/WHO).
Bastien, J. (1987). Healers of the Andes. Salt Lake: University of Utah.
Belote, L. (1978). Prejudice and pride: Indian-White relations in
Saraguro, Ecuador (Ph.D. Dissertation). Urbana: University of
Illinois.
Bolton, R., & Bolton, C. (1978). Concepcion, embarazo y alumbramiento en una aldea Qolla. Antropologia Andina, 12, 5874.
Saraguros
Cosminsky, S. (1976). Cross-cultural perspectives on midwifery. In
X. Francis, S. Grollig, & H. Haley (Eds.), Medical anthropology
(pp. 229248). The Hague: Mouton.
Dover, R., Seibold, K., & McDowell, J. (Eds.). (1992). Andean
cosmologies through time. Bloomington: Indiana University.
Finerman, R. (1982). Pregnancy and childbirth in Saraguro:
Implications for health care change. Medical Anthropology,
6, 269277.
Finerman, R. (1984). A matter of life and death: Health care change
in an Andean community. Social Science & Medicine, 18,
329334.
Finerman, R. (1987). Inside-out: Womens world view and family health
in an Ecuadorian Indian community. Social Science & Medicine,
25, 11571162.
Finerman, R. (1988). The price of power: Gender roles and stressinduced depression in Andean Ecuador. In P. Whelehan (Ed.), The
anthropology of women in health (pp. 153169). Granby, MA:
Bergin & Garvey.
Finerman, R. (1989). Tracing home-based health care change in an
Andean Indian community. Medical Anthropology Quarterly,
3, 162174.
Finerman, R. (1995). Parental incompetence and selective neglect:
Blaming the victim in child survival. Social Science & Medicine,
40, 513.
Finerman, R. (1998). Saraguro: Medical choices, medical changes.
In M. Ember, C. Ember, & D. Levinson (Eds.), Portraits of culture:
Ethnographic originals (pp. 5983). Upper Saddle River, NJ:
Prentice-Hall.
Foster, G. (1998). How to stay well in Tzintzuntzan. Reprinted in
M. Whiteford & S. Whiteford (Eds.), Crossing currents:
Continuity and change in Latin America (pp. 290304). Upper
Saddle River, NJ: Prentice Hall.
Gade, D. (1999). Nature and culture in the Andes. Madison: University
of Wisconsin.
Harrison, R. (1989). Signs, songs and memory in the Andes: Translating
Quechua language and culture. Austin: University of Texas.
Kleinman, A. (1980). Patients and healers in the context of culture.
Berkeley: University of California.
Kroeger, A., & Barbira-Freedmann, F. (1992). La lucha por la salud en
el Alto amazonas y en los Andes. Quito: Abya-Yala.
Lillo, B. (1942). El angelito. In Relatos Populares (pp. 219234).
Santiago, Chile: Nascimento.
Macas, F. (1995). Los Saraguros. In J. Vinneza (Ed.), Identidades
Indias en el Ecuador contemporaneo (pp. 339369). Quito:
Abya-Yala.
MacCormack, S. (1991). Religion in the Andes. Princeton: Princeton
University.
McKee, L., & Argello, S. (Eds.). (1988). Nuevas investigaciones
antropologicas Ecuatorianas. Quito: Abya-Yala.
Mitchell, W. (1991). Peasants on the edge: Crop, cult and crisis in the
Andes. Austin: University of Texas.
Naranjo, P., & Escaleras, R. (Eds.). (1995). La medicina tradicional en
el Ecuador. Quito: Universidad Andina.
Pan American Health Organization. (2000). Health statistics from the
Americas. Washington, DC: PAHO.
Tousignant, M. (1988). La teora quechua de las emociones: Un ejemplo
de la Provincia de Bolvar, Ecuador. In L. McKee & S. Argello
947
Shipibo
Warren M. Hern
ALTERNATIVE NAMES
Shipibo, Conibo, Chama.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
948
Shipibo
949
recovery with population growth rates that exceeded precontact rates. In fact, it appears that the most rapid population growth of the Shipibo population occurred in the
years immediately following World War II.
At the same time, there has been an aggressive
immigration of other Peruvians into the upper Peruvian
Amazon. The town of Pucallpa, which was principally a
Shipibo settlement in the mid- to late 19th century, contained a Peruvian MestizoCriollo population of about
3,500 in 1944. The Trans-Andean highway reached
Pucallpa at about that time, and immigration from the
Andes and the Peruvian coastal cities began, as did
increased commercial activities in logging, petroleum
exploration, fishing, cattle ranching, and agriculture. The
Shipibo were increasingly exposed to sources of rapid
cultural change, and they also found themselves competing increasingly with other groups and immigrant
populations for the same resources.
Rapid cultural change in the region was enhanced
by the establishment in the late 1940s of the Summer
Institute of Linguistics, an evangelical Christian group
dedicated to translating the Bible into native languages.
Their base was built on the shore of Lake Yarinacocha
and included a landing strip for the use of the missionary
planes as well as establishing a fleet of float planes
capable of landing on the waterways and lakes. The
missionaries also provided excellent medical care, both
preventive and therapeutic, to all indigenous groups with
whom they had contact.
Another important influence on both cultural change
and the health of the Shipibo was the establishment in
1960 of the Hospital Amazonico (Albert Schweitzer) by
Dr. Theodor Binder, a German physician who was dedicated to helping the indigenous people of the Peruvian
Amazon. The hospital, located on a high bank overlooking Yarinacocha and near the village of Puerto Callao,
was several kilometers upstream from the Summer
Institute of Linguistics. This area was separated from
Pucallpa by approximately five kilometers of canopy rain
forest and an overgrown cacao plantation.
Dr. Binder found the Shipibo in the 1950s to be
suffering from a wide variety of infectious and parasitic
diseases, with tuberculosis as a major epidemic which
was killing many adults. He established the hospital to
treat the Shipibo and other indigenous people for free. He
also employed Shipibo men in the agriculture and animal
husbandry projects that provided the hospital staff and
patients with food.
950
Shipibo
Medical Practitioners
951
MEDICAL PRACTITIONERS
Several kinds of traditional medical practitioners are
recognized among the Shipibo, although the highest and
most authentic status is accorded the muraia, or seer.
The muraia is usually a man who, in addition to his normal activities of fishing, hunting, and tending his chacra,
practices the traditional Shipibo healing arts. A principal
component of the muraias method of combating illness
is oni, otherwise known widely as aya huasca, or dead
mans vine. Oni is the Shipibo preparation of banisteria
caapi, a hallucinogenic drug known and used in different
forms throughout the Amazon. It is derived from a certain
vine that is harvested, cut up into small pieces, and boiled
for 810 h in order to decoct the alkaloid that is the active
hallucinogen. The practitioner takes large gulps of this
liquid while entering a healing session ( jonibensuate)
with one or more patients. The songs he sings under the
influence of the oni help him go into the underworld to
fight off the yushin, or evil spirit trying to kill both the
patient and the muraia, and help him summon the ani
yushin, or great spirit. The ani yushin tells the muraia
which songs (huihua) to sing to heal the patient and
where to look for the right herbal remedies.
In addition to singing the healing songs (jonibensuatehuihua), the muraia talks to the patient, sounding
very much like a Western psychotherapist, blows smoke
over the patients body, and rustles bundles of dried
plants over the affected area. These sessions go on for
hours.
Another medical practitioner may be a curiosa,
(Spanish term), or birth attendant who is not trained
formally as a midwife. Another Spanish term for such a
person is parteira, or someone who attends partos
(births). The Shipibo do not seem to have a word of their
952
Shipibo
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
The Shipibo are practical people who live in a complex,
dynamic, and potentially hazardous environment in
which injuries and death can and often do occur quickly.
Traumatic injuries such as snakebite, puncture wounds,
fractures, burns, lacerations, sting ray wounds, bites by
carnivorous fish and alligators, insect stings, accidental
gunshot, and allergic contact with known poisonous
plants are obvious sources of suffering and death for the
Shipibo. They have innumerable herbal remedies (rao)
for these injuries, and some of them work amazingly
well. The Shipibo are generally, it seems, incredibly
resistant to a wide variety of pathogens that would fell the
average person of European descent almost instantly.
The Shipibo have a certain working knowledge of
what Europeans would call comparative anatomy and
physiology since they dissect animals of all kinds in the
process of food preparation. They know, for example, that
there are embryos and fetuses in the uteri of various
female animals that they kill such as tapirs, wild boars,
and monkeys and that these features are not found in male
animals.
On the other hand, internal illnesses and conditions
without obvious origins such as fevers, paralysis, birth
defects, and difficult deliveries are traditionally ascribed
to conditions in the spirit world. In particular, the condition of cupia is widely attributed as a cause for various
ailments, and the term for experiencing a variety of cupia
is cutipado. The first term may be an original Shipibo
word, but the latter is the grammatically Spanish past participle of the verb, cutipar, which may be a Spanish adaptation of a Shipibo concept. It is a widely used expression
throughout the Peruvian Amazon. In any case, cutipado
roughly corresponds to bewitched in English, and
cupia is a kind of instant explanation for an otherwise
inscrutable condition or illness experience. A child
who is albino or who is exceptionally light-skinned,
but normal in all other respects, may be said to be
cutipado. This characterization is also a useful deflection
of potentially inconvenient questions about why the individual looks so different from his or her siblings or
cousins.
If, for example, a woman is pregnant, there are
certain foods she may or may not eat and certain acts she
may not commit at certain times such as sexual intercourse. If she violates these restrictions, she may experience cupia or said to be cutipado, (Alvarez, 1990) a part
of which is the process of being visited by and having
sexual intercourse with a river porpoise or dolphin during
the night. This state becomes the obvious post-hoc explanation for a difficult delivery, a stillbirth, delivery of a
deformed child, death of the woman during childbirth,
hemorrhage following childbirth, lack of breast milk, etc.
If a man kills a cayman (Caiman sclerops, variety of
alligator found on the Ucayali), dolphin, or certain other
animals, or if he cuts down a tree such as a lupuna that is
sacred, he also may be cutipado, which is the obvious
explanation for his prolonged inexplicable illness in
which he experiences severe abdominal pain, headache,
malaise, convulsions, or jaundice and dies an agonizing
death. It could also be that he simply offended someone,
who arranged for him to be cutipado.
A young woman who is cutipado may experience a
dissociative, hysterical episode during which she is obviously out of control, having seizures, screaming, shaking,
clenching her teeth, sweating, moaning, and beyond any
social interaction. These episodes, which are uncommon,
may go on for long periods of time up to an hour. In such
a case, she has clearly been cutipado by an enemy,
perhaps a social or sexual rival, with the help of
someone who practices brujeria (Spanish for witchcraft).
The person who practices black magic (magica negra)
casts a spell (cupia) on the person who then experiences
the dissociative state, which does not in any way resemble what is known in Western medicine as an epileptic
seizure. I have observed these behaviors (with similar
explanations) in other indigenous societies in Latin
America.
SEXUALITY
AND
REPRODUCTION
The Shipibo like sex and are sometimes quite open about
it, particularly in joking relationships. They love obscene
and intimate sexual humor, especially when there is a
cover of darkness to obscure the speaker (even though
everyone knows from the voice who is speaking).
Whether it is under the influence of Christian missionaries or reflects traditional Shipibo custom, sexuality is not
flaunted or openly recognized during the day and in the
midst of communal activities. Young people court and
disappear into the bush. Although there is no formal
953
954
Shipibo
Infancy
Newborn infants are not given a name until one or more
months of age. The Shipibo name ( janecon, true name)
is given first, although a Spanish name with paternal and
maternal surnames may be given for birth registry. The
reason for the delay in naming is the recognition of a high
probability of neonatal death.
Newborn infants are traditionally painted with huito,
a black vegetable dye (Genipa sp.), with their faces painted
in a typical geometric Shipibo design. The explanation for
the face painting is that the design wards off the yushin, or
evil spirit that causes illness and death. It also looks nice.
There is no distinction between painting a thing or person
with designs to protect it from evil spirits or just for fun.
Shipibo children are engulfed in love from their first
moments and are highly indulged by both parents.
Children are breast-fed for at least 6 months, and
complete weaning may not occur for several years.
Childhood
Young children up to the age of 1012 are given great
freedom to play with their peers and to explore the area
around the house and village. They frequently accompany their parents or other adults on excursions such as
going to the garden to cultivate or gather food, or, in the
case of boys, to hunt and fish with their fathers.
Shipibo children begin learning the complex family
relationships including kinship terms and avoidance
patterns at a very early age (Abelove, 1978). A Shipibo
childs social success is highly correlated with its
mothers pattern of interactions with others.
Child abandonment is almost unknown. It is inconceivable to the Shipibo. Only mestizos abandon their
children. Discipline is gentle and consists principally of
quiet talking and persuasion. Once in a while, a parent
will spank a young child. A parent may gently scold or,
rarely, have an angry exchange with an ill-behaved older
child, but it does not appear that the physical abuse of
children occurs among the Shipibo.
Sick children are given round-the-clock nursing
care, and those with chronic illnesses are given special
955
Adolescence
Although traditional patterns are changing rapidly with
the introduction of formal schools through the high
school level, Shipibo adolescents still assume many adult
responsibilities that include subsistence activities and
mating. Informal trial marriages occur with an adolescent
couple cohabiting in the girls parents house, and these
are generally regarded as temporary arrangements. If the
girl becomes pregnant, however, a more stable relationship is likely to emerge.
Adulthood
In the absence of formal Western schools, Shipibo girls
entered permanent sexual relationships at the age of 13 or
14 and immediately began having children. They were
considered adults from that point on. Currently, girls are
encouraged to attend school at least through grade school
and beyond if possible. Sexual encounters occur, but
adolescent cohabitation in the traditional patterns occurs
much less than it did before the introduction of schools.
Once a nuclear family is established, the young
husband builds a house for his own family, typically in
the family compound or immediately adjacent to the
home of the womans parents. A separate structure containing the hearth and eating area is usually a few meters
from the house. In the case of polygynous marriages,
each woman may have her own house and hearth.
People over 40 years of age are considered old
since life expectancy is under 50 for women and not
much past 50 for men.
The Aged
People who are very oldthose who reach the age of 70 or
80are treated with great respect and veneration. An
elderly adult woman suffering from tuberculosis, for
example, is given her own hut next to the main family
house, and young children are assigned to help her in
every way. Her food is brought to her and she is accompanied to the lake or river for bathing.
Tuberculosis is a major killer of mature and elderly
adults among the Shipibothose who have the most
knowledge of the ancient traditions, songs, and secrets of
956
Shipibo
longer think about the things that are so sad they make
us cry.
REFERENCES
Alvarez, J. A. (1990). Diccionario de Peruanismos. Lima: Libreria
Studium Ediciones, p. 164.
Arevalo, V. J. (1994). Medicina Indigena: Las plantas medicinales y
su beneficio en la salud Shipibo-Conibo. Lima: Ediciones
AIDESEP.
Abelove, J. M. (1978). Pre-verbal learning of kinship behavior among
Shipibo infants of Eastern Peru. Doctoral dissertation, City
University of New York. Ann Arbor, Michigan: University
Microfilms International.
Bergman, R. W. (1980). Amazon economics: The simplicity of Shipibo
Indian wealth. Doctoral dissertation, Syracuse University. Ann
Arbor, Michigan: University Microfilms International.
Eakin, L., Lauriault, E., & Boonstra, H. (1980). Bosquejo Etnografico
de los Shipibo-Conibo Del Ucayali. Lima: Ignacio Prado Pastor
Editorial.
Foller, M. (1990). Environmental changes and human health: A study of
the Shipibo-Conibo in Eastern Peru. Goteborg: University of
Goteborg.
Hern, W. M. (1971). Community health, fertility trends, and ecocultural
change in a Peruvian Amazon Indian village, 19641969.
M.P.H. thesis, Department of Epidemiology, University of North
Carolina School of Public Health.
Hern, W. M. (1976). Knowledge and use of herbal contraceptives in a
Peruvian Amazon village. Human Organization, 35, 919.
Hern, W. M. (1977). High fertility in a Peruvian Amazon Indian village.
Human Ecology, 5(4):355368.
Hern, W. M. (1988). Polygyny and fertility among the Shipibo: An
epidemiologic test of an ethnographic hypothesis. Doctoral dissertation, Department of Epidemiology, University of North Carolina.
Ann Arbor, Michigan: University Microfilms International.
Hern, W. M. (1990). Individual fertility rate: A new individual fertility
measure for small populations. Social Biology, 37:102109.
Hern, W. M. (1992a). Polygyny and fertility among the Shipibo of the
Peruvian Amazon. Population Studies, 46:5364.
Hern, W. M. (1992b). Shipibo polygyny and patrilocality. American
Ethnologist, 19(3):501522.
Hodge, L. G., & Dufour, D. L. (1991). Cross-sectional growth of young
Shipibo Indian children in eastern Peru. American Journal of
Physical Anthropology, 84(1):3541.
Myers, T. P. (1988). El efecto de las pestes sobre las poblaciones de la
Amazonia alta. Amazonia Peruana, 8(15):6181
Myers, T. P. (1990). Sarayacu: Ethnohistorical and archeological
investigations of a nineteenth-century Franciscan mission in the
Peruvian Montana. Lincoln: University of Nebraska.
Roe, P. G. (1982). The cosmic zygote: Cosmology in the Amazon basin.
New Brunswick: Rutgers University Press.
Samanez Y Ocampo, J. B. (1980). Exploracion de los rios Peruanos
Apurimac, Eni, Tambo, Ucayali y Urubamba Hecho por Jose
B. Samanez Y Ocampo En 1883 y 1884: Diario de la expedicion y
anexos. Lima: Consuelo Samanez Ocampo de Samanez e hijas.
957
Sotho
Nancy Romero-Daza and David Himmelgreen
ALTERNATIVE NAMES
Basotho, Basuto, Southern-Sotho.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
958
Sotho
MEDICAL PRACTITIONERS
Basotho traditional healers can be categorized depending
on the healing methods they use and the type of training
received. Two of the major categories include herbalists
and Bible readers (Romero-Daza, 1994a). Herbalists
specialize in the treatment of diseases through the use of
herbs and roots, while Bible readers usually belong to a
specific church and treat their patients almost exclusively
with blessed water and prayers. Depending on the
959
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
While the biomedical paradigm is readily accepted by
most of the Basotho, traditional beliefs regarding the
cause of illness and disease are still commonly found
among this population. Prominent among these is the
belief that diseases are caused by the breech of taboo. For
example, a person who has sexual relations while still
mourning the death of his/her spouse may be afflicted by
mashoa or mahae which roughly correspond to genital warts. According to traditional beliefs, as the body of
the deceased decomposes, so do the sexual organs of the
surviving spouse (Hall & Malahleha, 1989). Another
common cause of disease is the use of witchcraft. For
example, a person can cause another to become sick by
placing a special magical substance (usually water containing powerful medicines) on the path to be traveled by
his/her enemy (Romero-Daza, 1994a). Finally, disease
960
Sotho
SEXUALITY
AND
REPRODUCTION
Infancy
During the first two or three months after the birth of a
baby, mother and infant are secluded in a house whose
entrance is marked with reeds projecting from the thatch
right above the door. These reeds serve to warn strangers
as well as men who are not immediate relatives to stay
away (Gay, 1980). It is believed that this protects the new
baby from evil that can be caused by the bad conduct
of adults (Sechefo, nd). The new mother must remain
inside as much as possible, but if she needs to come out,
she must cover herself with a special blanket or shawl.
Both mother and child receive direct care from the
mothers female relatives, thus exposing the baby from
the beginning of its life to direct interaction with many
mothers. Special ceremonies to end childbirth pollution
are conducted when the baby loses the remains of the
umbilical cord. These include the shaving of the babys
head and the washing of clothing and bedding. At this
point, the babys father is allowed for the first time to
enter the house where his wife and child are (Gay, 1980).
Among Basotho, there is a strict taboo against sexual
relations during the post-partum period and especially
during the breast-feeding period, which may extend for up
to two years. Engaging in sexual activity during the lactation period is believed to result in the contamination of the
breast milk by the semen, which causes serious health
problems to the infant (Romero-Daza, 1994a). Senyeha
as the disease is called, is characterized by rapid weight
loss, severe diarrhea, loss of appetite, and failure to thrive,
and may be fatal to the infant. Weaning informally marks
the end of the period of infancy, and signals that the
mother is ready to resume sexual activity (Gay, 1980).
961
Childhood
The beginning of the weaning period, when the child is
around two years of age, coincides with the expansion of
the number of caretakers a child has. At this time, the
child begins to spend much more time under the care of
other female relatives, including very young girls, and
starts the active process of socialization into the prescribed gender roles. Young girls spend most of their time
in the family compound and begin contributing to domestic chores such as the collection of dry dung to be used
for fire, or the collection of wild vegetables. Young boys,
on the other hand, spend most of their time taking care of
the animals. In fact, with the absence of adult men for
most of the year, even very young boys often spend
extended periods of time away from their homes while
taking care of the familys animals. This early division of
labor translates onto marked differences in school attendance. Unlike girls in many other developing countries,
Basotho girls have a higher school attendance rates and
higher overall literacy rates than do boys (Ministry of
Planning, 1991).
Although minor corporal punishment as a disciplinary measure is not uncommon among the Basotho, the
culture rejects the use of excessive force that may result
in injuries (Ministry of Planning, 1991). Among Basotho
children, the most common health problems are waterborne diseases such as diarrhea and typhoid, nutritional
deficiencies such as kwashiorkor and marasmus, acute
respiratory infections, and skin problems such as scabies
and fungal infections (Gish, 1982; Himmelgreen, 1994;
Ministry of Planning, 1991; WHO, 2002). Rates of HIV
infection among Basotho children are increasing rapidly.
With prevalence rates among pregnant women reaching
up to 24%, many HIV positive children are being born.
Even those who are not infected are experiencing the
indirect consequences of the epidemic, as they often lose
one or both of their parents to the epidemic. More and
more, orphaned children are being forced to take the
responsibility for younger siblings if they do not have
grandparents or other relatives who can support them
when their parents die.
Adolescence
In Basotho society, the end of childhood is traditionally
marked by participation in initiation schools. Although the
practice is diminishing in frequency, it still constitutes a
962
major rite of passage for many young Basotho. During initiation school, groups of adolescents spend a period of up
to several months in isolated areas of the country. During
this time, which is surrounded by secrecy, teenagers learn
about their traditions, their culture, and about what it
means to be Basotho. At the end of the initiation school,
boys are circumcised, and special ceremonial feasts are
conducted to mark their entrance into adulthood and their
new status as full members of the group. Young girls are
not required to undergo any genital operation.
Basotho discourage the practice of premarital sex
and encourage marriage at an early age. Traditionally,
there existed taboos to regulate the sexuality of adolescents. For example, young women were not allowed to eat
eggs, since these were believed to increase the adolescent
girls sexual needs and to make them more fertile than
necessary. Nevertheless, premarital sex is on the rise, as is
the number of children born out of wedlock (Ministry of
Planning, 1991). Teenagers are also exhibiting increasing
numbers of Sexually Transmitted Infections, and of
HIV/AIDS. As of 1993, teens accounted for 9.4% of all
individuals seeking outpatient care for STIs in public hospitals and clinics (Family Health International, 1997). One
factor that contributes to the spread of STIs and undermines the efficiency of prevention programs is the cultural
tradition that prohibits the open discussion of sexual
matters before marriage (Romero-Daza, 1994a, 1994b).
Adulthood
The most common health problems among Basotho adults
include high blood pressure, alcoholism, respiratory tract
diseases, cardiovascular disease, skin conditions, STI
(especially gonorrhea, syphilis, and AIDS), and injuries
(Gay & Hall, 1994; Schumacher et al., 1990). Among
women, reproductive problems and STIs including gonorrhea, syphilis, trichomonal vaginalis, and candida moniliasis account for most outpatient visits to health facilities
throughout the country (Gay & Hall, 1994). Women
accounted for more than half of the HIV infection cases in
the country as of 2000 (Family Health International, 2001).
The rate of infection for pregnant women who seek prenatal care has been increasing considerably in both urban and
rural areas of the country, and ranges from 12.3% in the
isolated mountainous areas of Mokhotlong to 42.2 % in the
capital city of Maseru (Family Health International, 2001).
Among men, the major causes of morbidity and
mortality are associated with their occupation as miners.
Sotho
The Aged
Among the Basotho, the elderly are afforded special status
and respect as pillars of the society. Traditionally, children
and grandchildren offer a source of material and social
support for their elders. However, as in many places in
Africa, with the explosion of the AIDS pandemic, the
traditional roles are rapidly changing, and the elderly
are being forced to care for their younger relatives.
Specifically, as adults of reproductive age become ill, their
parents become the main care providers, who are also burdened with the responsibility of finding financial resources
for the treatment of the diseased. As the younger generation dies, the elderly find themselves being responsible for
the upbringing of any of their young grandchildren left
orphaned (Romero-Daza & Himmelgreen, 1998).
References
REFERENCES
Ambrose, D. (1976). The guide to Lesotho. Johannesburg, South Africa:
Winchester Press.
963
Central Intelligence Agency (CIA) (n.d.) The World Factbook,
Lesotho. Available online at, http://www.odci.gov/cia/publications/
factbook/geos/lt.html
Family Health International. (2001). Lesotho and Swaziland,
HIV/AIDS risk assessments at cross-border and migrant sites in
Southern Africa. Available online at, http:// www.fhi.org /en/aids/
impact/impactpdfs/lesothoandswaziland.pdf
Gay, J. S. (1980). Basotho womens options. A study of marital careers
in rural Lesotho. Doctoral dissertation, University of Cambridge,
Lucy Cavendish College, London.
Gay, J. S. (1982). Women and development in Lesotho. Maseru,
Lesotho: USAID.
Gay, J. S., Gill, D., Green, T., Hall, D., Mhlanga, M., & Mohapi, M.
(1991). Poverty in Lesotho, a mapping exercise, Phase II report.
Maseru, Lesotho: European Community Aid Counterpart.
Gay, J. S., & Hall, D. (1994). Poverty in Lesotho, 1994. A mapping
exercise. Maseru, Lesotho: Secheba Consultants Publishers.
Gish, O. (1982). Economic dependency, health services, and health: The
case of Lesotho. Journal of Health Politics, Policy, and Law, 64,
762779.
Global Policy Network. (2001). Highlights of current labor
market conditions in Lesotho. Available online at, http://
globalpolicynetwork.org
Hall, D., & Malaheleha, M. (1989). Health and family planning services in Lesotho: The peoples perspective. Maseru, Lesotho: World
Bank for Lesotho Government Ministry of Health.
Himmelgreen, D. (1994). Coping in a highly seasonal environment:
A household study of changing nutritional status, health, and diet
among women and children from highland Lesotho. Doctoral dissertation, State University of New York at Buffalo, Amherst, New York.
Himmelgreen, D., & Romero-Daza, N. (1994). Changes in body weight
in Basotho women: Seasonal coping in households with different
socioeconomic conditions. American Journal of Human Biology,
6(5), 599612.
Huss-Ashmore, R., & Goodman, J. L. (1988). Seasonality of work,
weight, and body composition for women in highland Lesotho. In R.
Huss-Ashmore, J. J. Curry, & R. K. Hitchcock (Eds.), Coping with
seasonal constraints (Vol. 5, pp. 2944). Philadelphia, MASCA.
Ikuska website (nd). Sotho. Available online at, http://www.ikuska.com/
Africa/Etnologia/Pueblos/pueblos_fram.htm
Ministry of Planning. (1991). The situation of women and children in
Lesotho. Maseru, Lesotho: Ministry of Planning, Economic and
Manpower Development.
Murray, C. (1981). Families divide: The impact of migrant labor in
Lesotho. Cambridge: Cambridge University Press.
Romero-Daza, N. (1994a). Migrant labor, multiple sexual partners, and
STDs. Doctoral dissertation, State University of New York at
Buffalo, Amherst, N.Y.
Romero-Daza, N. (1994b). Multiple sexual partners, migrant labor, and
sexually transmitted diseases, the makings for an epidemic.
Knowledge and beliefs about AIDS among women in highland
Lesotho. Human Organization, 53, 192205.
Romero-Daza, N., & Himmelgreen D. (1998). More than money for
your labor. Migration and the political economy of AIDS in
Lesotho. In M. Singer (Ed.), The political economy of AIDS,
Critical Approaches in Health Social Sciences Series. New York:
Baywood Press: 185204.
964
Sudanese
Sudanese
Rogaia Mustafa Abusharaf
ALTERNATIVE NAMES
None.
LOCATION
AND
LINGUISTIC AFFILIATION
965
OVERVIEW
OF THE
CULTURE
966
MEDICAL PRACTITIONERS
Medical practitioners in the Sudan include physicians,
physician assistants, midwives, nurses, traditional birth
attendants, traditional healers, zar sheiks and sheikhas (the
Sheikhas are the women who officiate in zar or spirit possession ceremonies), and diviners among others. Modern
medicine in the Sudan was officially introduced by the
Anglo-Egyptian regime (18981956), a process that was
thoroughly chronicled by historian Heather Bell (1999).
During the colonial period, different sectors of Sudans
health care were developed including the introduction of
modern midwifery training. Reliance on biomedical
versus traditional healers varies vastly by education,
residence, and gender differences. For instance urban
dwellers are more likely to go to hospitals as opposed to
rural populations who rely heavily on traditional or folk
cures. Also significant are gender differences, where
women seek the advice of religious leaders or zar sheikhas
more than their male counterparts who often dismiss the
importance of folk healing.
Sudanese
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Illness, physical or psychological, is subject to scrupulous
theorization. Consequently, ways of dealing with illness
are not confined to biomedicine. Instead, reliance on
traditional healing is especially obvious. In fact, throughout Sudanese provinces and villages, traditional healing is
the single mode of curing that is readily available for the
community. According to Sudanese gynecologist Osman
Modawi, modern medicine is commonly thought of as the
last resort (1982). The term traditional medicine encompasses a variety of methods of protecting and restoring
health that existed before the appearance of modern
medicine. On the whole, traditional medicine refers to
acupuncture, traditional birth attendants, mental healers,
and herbal medicine (WHO Fact Sheet, 1999).
In the Sudan, one of the most important theories of
illness is derived from the overwhelming belief in the
power of the evil spirits. The spirits are thought to inflict
injury as well as undermine ones health through the
notion of Ammal, or the foul act. Ammal is typically
inflicted through witchcraft causing substantial impairment and damage. Treatment is at all times sought through
the counsel of shamans or witch doctors who alone have
the God-given gift of counteracting the callous act. The
shaman, who listens carefully to the symptoms of illness,
performs a series of steps to identify types of spirits and
methods for the cure. The Azande for instance, believe that
witchcraft can be inherited and that a person can be a
witch, causing others impairment, without realizing
his/her power. Because of this threat, effective resources of
diagnosing witchcraft are very important. One method is
through the use by oracles, of benge, a poison, which is fed
to little chickens. The chickens death or survival provides
the oracles answer. Azande also use benge as proof to substantiate ones guilt before a court of law (Evans Pritchard,
1976). Notwithstanding the changing cultural life of
Azande people and their forced displacement as a result of
war, their beliefs on illness and adversity continue to hold
witchcraft as the most important threat to someones
health and well-being. In an interview I conducted with
Thomas, a 43-year-old Azande, who resides in ElSalam
camp for the internally displaced, he stressed that Kuguor
still run rampant. People cannot forget everything about
their lives at home before they came to this place.
967
SEXUALITY
AND
REPRODUCTION
Sexuality
Attitudes toward sexuality and reproduction are positioned at the heart of significant cultural and religious
beliefs amongst the Sudanese. Open discussion of matters pertaining to sexuality is extremely proscribed by
these beliefs. To a great extent, this interdiction is intimately linked to how society views sexuality in the first
place. Largely seen as an ominous threat that looms
largely over ones purity and morality if left unchecked,
social and physical regulation is aggressively pursued.
This view is of special relevance to female sexuality.
One of the most important vehicles for dulling womens
sexuality is achieved through female circumcision.
The origins of this practice are very mystifying and
obscure. In exploring its ideology, we find varied oral
accounts describing mythological rather than documented origins. Although the majority attributed the
diffusion of the practice to pharaonic Egypt, some analysts argued that the custom might have originated from
the Red Sea People who introduced it to neighboring peoples. Writers such as Abdalla Eltayeb (1964), a noted
Sudanese linguist, see female circumcision as a legacy of
the Arabization of the Sudanese people. What is important to remember is that female circumcision is not a universal practice in the Sudan, which is not surprising
because the peoples and cultures of the country are very
heterogeneous. According to Sudan Demographic &
Health Survey the prevalence of the practice is as follows:
northern Sudan, 98.7%, eastern Sudan, 86.5%, western
Sudan, 95.5%. Because of the important link between
female circumcision and sexuality, it is necessary to elaborate its ideological underpinnings. Understanding ideology is a step toward understanding strategies for its
eradication. Indeed, Habermas (1971) argues that the
only knowledge that can orient action is knowledge that
frees itself from mere human interests and is based on
ideas. The reasons for female circumcision and the age at
which it is performed differ across Sudan by regional,
ethnic, and class differences. As far as the operations
among northerners are concerned, they have been practiced for a variety of cosmetic, religious, medical, and
968
Fertility
Fertility and fecundity figure prominently in the cultural
constructions of gender identities and conceptions of
womanhood and manhood amongst the Sudanese.
Conversely, fear of infertility prompts individuals and
communities to invent effective measures to counteract
the prospects of childlessness. In the Nuba Mountains,
Modawi (1982, p. 81) described the effort of one community of dealing with infertility: In the Nuba Mountains
there is a small hill which looks like the male genital
organs. Infertile women visit this hill to perform certain
rituals to treat their infertility. In some of the other rituals
a toy boy with prominent genitalia and made of hina is
thrown into water. It is also thought that eating the male
genitals of animals corrects infertility. The scarcer the animal, such as crocodile, the more potent the cure.
Sudanese
Infancy
In the Sudan infants are most warmly welcomed through
an exciting assortment of rituals and rites celebrating
their arrival in the world. One of these celebratory occasions is the Simaya, or the naming ceremony. In northern
Sudan, and elsewhere this ritual has attracted the attention of anthropologists for its zestfully symbolic content.
The symbolism of this ceremony is brilliantly captured
by Fadwa El-Guindi, who argued, A function of such a
969
970
Childhood
Children are seen as a source of security and spiritual
immortality (Deng, 1972). Childhood is also a phase in
which intensive efforts at gender bending and conditioning gets underway. For example, in many parts of the
Sudan Sudanese boys and girls are circumcised during
this period. Rites of passages that signify the acquisition
of new identities are also observed during this time.
However, children, like the rest of the Sudanese population are experiencing insurmountable problems relating
to health, political conflict, economic insecurity, and
social unrest. This situation is particularly clear in a
UNICEF report (2001) on the situation of children in
Sudan. The report provides detailed analysis of the
impact of the civil war, internal displacement, landmines,
economic exploitation, and abductions, on children.
Contagious diseases and illnesses that infringe upon childrens health in the Sudan are wide-ranging, including
malaria, diarrheal and acute respiratory infections. Lack
of drugs and inadequate medical care combine to affect
the health of Sudanese children dramatically.
Adolescence
In the Sudan, the onset of adolescence is managed
through culturally proscribed means and strategies. In
fact, the socioeconomic circumstances prompt many
parents and caregivers to entrust adolescents with responsibilities and obligations that are far beyond their years.
Hence, social maturity is not measured by ones age as
such, but by their productivity and contribution to the
familys economics.
Sudanese
The Aged
Compassion and empathy toward the elderly population
is one of the most important values for Sudanese people
irrespective of region, ethnicity, or religion. Children and
grandchildren view their relationship to aging parents as
one of obligation and debt. Hardly ever do aging family
members get sent to nursing homes.
Aging does not only mean a longed-for release from
physical work, but it also means greater authority especially for post-menopausal women. Age frees women
considerably from some of the most arduous tasks and
societal expectations that they had had to adhere to during their reproductive years. It follows that menopause is
looked at as a phase in life that is increasingly empowering, and is rarely discussed as a medical problem.
A woman in her fifties recalled that when her mother was
experiencing menopause and had all the symptoms associated with the condition such as hot flashes, her physician never explained to her that she was experiencing
menopause. She added that in the Sudan women never
talk about menopause. This observation is corroborated
by the fact that literature on fertility in the Sudan has
rarely touched on attitudes toward menopause.
Adulthood
Achieving an adult status in the Sudan is contingent
upon fulfillment of crucial steps in the social ladder such
as marriage, attainment of employment, and property
ownership. Adulthood, however, does not presuppose
total individuality or independence from extended
family networks. It is very common for adult children
married or unmarriedto continue to reside with their
parents.
971
REFERENCES
Abdel Rahim, M. (1973). Arabism, Africanism, and self-identification
in the Sudan. In D. Wai (Ed.), The Southern Sudan: The problem
of national integration (pp. 2947). London: Frank Cass.
Bell, H. (1999). Frontiers of Medicine in the Anglo-Egyptian Sudan
18991940. Oxford: Clarendon.
Deng, F. (1972). The Dinka of the Sudan. Prospect Heights, IL:
Waveland Press.
Eltayeb, A. (1964). The changing customs of the Riverain Sudan. Sudan
Notes & Records, 45, 1227.
Evans-Pritchard, E. (1976). Witchcraft, oracles, and magic among the
Azande. Oxford: Clarendon.
Faris, J. (1972). Nuba personal art. London: Duckworth.
Habermas, J. (1971). Knowledge and human interest. Boston: Beacon
Press.
Inter Press Service. (1997). Sudan health: UN issues call for emergency
aid. Feb. 18th. (Doc. No. 970218)
Kenyon, S. (1991). Five women of Sennar: Culture and change in
central Sudan. Oxford: Clarendon.
El-Guindi, F. (1996). El Soubu: Egyptian celebration of life. Film Study
Guide. Los Angeles: El Nil Research.
Thai
Chris Lyttleton
ALTERNATIVE NAMES
OVERVIEW
LOCATION
AND
LINGUISTIC AFFILIATION
OF THE
CULTURE
972
Thai
973
974
Health Infrastructure
Health services infrastructures in Thailand include
government, non-government organizations (NGOs),
and private sector clinics and institutions. Over the past
30 years the government has allocated slightly less than
5% of its annual budget to the Ministry of Public Health
(MOPH). Since the onset of the Five-Year Development
Plans in the early 1960s, the highly bureaucratized network of State health facilities has been extended across
Thai
Medical Practitioners
MEDICAL PRACTITIONERS
The Thai practice pluralistic preventive and curative
strategies engaging a range of health practitioners. The
medical system in Thailand was oriented to traditional
Thai health regimens until the late 18th century. Over the
past 100 years, Western medical practice has become dominant in terms of government support and local patronage.
Health practitioners trained in (cosmopolitan) biomedicine
are therefore the most prominent in Thai society.
In 1998, there were 19,500 practicing doctors (a ratio
of 1 : 3,136 people, with a disproportionate number in the
urban sector). Between 1971 and 1995, the percent of these
doctors working in the public sector declined from 93.3%
to 76.3% reflecting a move into the more financially
rewarding private hospital sector (in 1998 there were 957
public and 473 private hospitals, some of which have
become famous worldwide for cosmetic surgery). Since
the economic crash this trend has been reversed. In 1998,
there were 56,366 professional nurses (1 : 1,073) with the
vast majority (roughly 90%) working in the public sector.
A large number of government doctors (and sometimes nurses in rural areas) also run private clinics during
out-of-work hours. Here they offer a range of services
from general practice to specialist medical services. It is
estimated that as high as 69% of practicing specialists
have not been certified by the Thai Medical Council. The
medical doctors (and nurses) are able to increase their
975
976
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Strongly influenced by the Ayurvedic system of medicine
in India, traditional Thai medicine classifies forty-two
bodily elements into four groupsfire, wind, water and
earth. Disease comes from changes in the balance of elements of fire, wind, and waterearth is very stable and
seldom causes diseaseand correspondingly illness is
classified as a disease of either bile, wind, or mucus
(Mulholland, 1979). Historic Thai medical texts report
wind illness as the most common affliction which, following the Indian humoral theories of medicine, denotes
any illness affecting the quality or faculties of movement,
including such diseases as leprosy or epilepsy. In practice, it is highly likely that over the centuries a synthesis
Thai
SEXUALITY
AND
REPRODUCTION
977
978
Thai
Infancy
Traditional postpartum confinement rites wherein the
mother would lie by a fire in her house for 5 to 9 days, have
largely disappeared. Coupled with specific food restrictions
geared to restoring humoral balance, this was believed to
restore and strengthen her body and soul and complete a
first-time mothers transition into mature womanhood
(Hanks, 1963, p. 71). Such practices have been dispersed by
changing beliefs as to the nature of recuperation, practical
issues such as lack of fireplaces in modern houses, lack of
time, and the recommendations of doctors who discourage
it especially after Cesareans and/or tubal ligations.
Lying by the fire was based on beliefs that females
are soft natured/souled and spiritually vulnerable after
birth. Such beliefs also apply to the child, and ritual specialists still typically perform soul protection ceremonies
shortly after the child is born.
Breast-feeding has declined in favor of bottle and
formula feeding in sync with the large presence of many
young mothers in the workforce. Public health campaigns
have recently advocated breast-feeding as the most desirable option for new mothers. Infants and young children
are typically cared for by extended family members and
older siblings, as it is common that both parents work.
National rates of young children (ages 35) enrolled in
nurseries and pre-school childcare rose from 39.3% in
1992 to 79.5% in 1998. On the other hand, child abandonment has also increased. A survey of abandoned
infants at 40 health facilities showed a rising rate from
90/100,000 to 120/100,000 in 1998.
Childhood
In the past young rural Thai boys and girls would begin to
work the fields at around the age of 11 or 12. From some
parts of Thailand, teenage girls were sent into the sex
industry shortly after reaching puberty. These days such
practices are illegal and prosecuted as child abuse. Six
years of state-sponsored secondary school education has
recently become available nationwide ensuring a later
entry into the workforce. Gender roles still strongly influence models of socialization with male qualities believed
to be best nurtured through avoidance of strict discipline
whereas girls are required to carefully observe parental
rules. In early childhood, it is not uncommon for the young
boys genitals to be an item of attention ( joking and tickling), young girls on the other hand are generally taught to
be modest and compliant from an early age. Pneumonia is
Adolescence
The major health problems of youth (1019 yrs20% of
population) are linked to social behaviors including substance abuse, teenage pregnancy, sexually related health
problems (STDs), and mental health issues such as violence and suicide. Maternal mortality is highest in the
1519 age group often resulting from unsafe and illegal
abortions. Thai adolescents face large risks from STDs, in
particular HIV/AIDS47% of STD patients are between
the ages of 15 and 24and in the first decade of HIV
spread from 1984 to 1996 single females under 24 years of
age were the highest risk group for infection, largely
through commercial sex (Pimpawun et al., 2000). Nowadays, for many Thai safe sex is as much an issue of who
one has sex with as it is of using a condom or not. As sexual relations between Thai adolescents take place more
commonly, and condom use is not prevalent as these relations are seen as safe because they are not commercial sex.
Genital operations, the insertion of small round objects
(pearls) under the foreskin, are found amongst a small
number of Thai males but it is unclear whether this contributes to the spread of disease. Substance abuse, in particular of methamphetamines (ATS), has also increased
dramatically amongst Thai youth. Over 6 months in
1995/96 a nationwide survey conducted a urine analysis of
118,375 students from primary through university level. Of
the 79,671 secondary students sampled, 1.1% tested
positive to methamphetamine use and 3.8% of the 17,082
vocational students tested positive (Vichai et al., 2001).
979
The Aged
In accordance with Buddhist ideology the elderly generally have high status within the household; in rural
areas they have traditionally resided with the youngest
daughter and her husband. Home care is typical for most
manageable forms of illness. The most common diseases
of the elderly are muscular, tendon and skeletal disorders,
followed by peptic ulcers, hypertension, and heart disease. Primary causes of mortality are cardio-pulmonary
disease, cancer, diabetes, liver, and kidney disease. A
1995 survey (Chantaphen, 1995) of both rural and urban
elderly showed 82.8% of those between 50 and 59 still
worked which dropped to 42% for those 60 and over. The
most common diagnosed ailment was back pain and
29.1% had been hospitalized in the previous year. Fortytwo percent exercised regularly and 57% meditated daily.
Illiteracy is high amongst this group and self-medication,
especially analgesics and vitamins, by far the most
common form of health-seeking treatment.
Adulthood
980
Thai
remains are subsequently exhumed and crematedto prevent similar misfortune befalling kin. These beliefs are no
longer widespread. There is usually no change to the living
arrangements of the remaining spouse with the existing kin.
REFERENCES
Amara Pongsapich et al. (2001). Current status of civil society organizations in health sector in Thailand, unpublished report, Social
Research Institute, Chulalongkorn University, Bangkok.
Bamber, Scott. nd. Lom: A term in association with Illness in traditional
Thai medicine, unpublished paper.
Chantaphen Chupraphawan et al. (1995). Health survey of Thai over
50 years of age (in Thai). Bangkok: Health Research Institute.
Cohen, Paul. (1989). The politics of primary health care in Thailand,
with special reference to nongovernment organizations. In
P. Cohen & J. Purcal (Eds.), The political economy of primary
health care in southeast asia (pp. 159176). Canberra: Australian
Development Studies Network.
Gray, Alan., & Sureeporn, Punpuing. (1999). Gender, sexuality and
reproductive health in Thailand. Institute for Population and Social
Research, Mahidol University, Thailand.
Guest, Philip., & Tan, Jooean. (1994). Transformation of marriage patterns in Thailand, Institute for Population and Social Research,
Mahidol University, Thailand.
Hanks, Jane. (1963). Maternity and its Rituals in Bang Chan. New York:
Cornell University Press.
Komatra, Chuengsatiensup et al. (2000). Community drug use in
Thailand, unpublished report, Faculty of Pharmacy, Chiang Mai
University.
Kritiya, Archawanichakul et al. (2001). Domestic violence against
women: The scale of the problem, its impact and solutions, (in
Thai). Research Report, Institute for Population and Social
Research, Mahidol University, Thailand.
Lyttleton, Chris. (1996). Health and development: Knowledge systems
and local practice, Health Transition Review, 6, 2548.
Tongans
Barbara Burns McGrath
ALTERNATIVE NAMES
LOCATION
AND
LINGUISTIC AFFILIATION
981
OVERVIEW
OF THE
CULTURE
Tonga is a relatively homogenous society (most of its population of approximately 105,000 are Polynesian) with a
highly stratified social structure headed by the monarch at
the national level, and by chiefs and chiefly lineages at the
local level (Marcus, 1978). The first ruler, Tui Tonga
reigned during the late 9th century. He was the son of
Tangaloa, the god of the sky, and Vaepopua, an earthly
mother. Succeeding holders of the title of Tui Tonga
descend from Tangaloa and form the top of the pyramidshaped social organization, the base of which is made up of
commoners. In 1643, the Dutch explorer Abel Tasman
noted the long-established peace and stability of the islands,
which he felt were due to the system of reciprocal relations
that existed between the chiefs and commoners. In 1845,
Tupou I united the islands that were ruled by a number of
competing chiefdoms (Campbell, 2001; Latwkefu, 1974).
Much of the early history of Tonga is recorded in
oral tradition with genealogies providing a chronology of
events. They continue to be used to evaluate rank, seniority, and status, and are called upon to mediate disputes
involving land allocation and title succession (Herda,
1990). Poetry and dance are another means used to record
both culture and history. These often link events to specific localities of the Tongan landscape emphasizing the
connection between the people and their environment.
This ecology-centered concept of culture and history
(tala-e-fonua) is being explored by contemporary Tongan
scholars to examine past events from a new perspective
(Hauofa, 2000; Mahina, 1993).
Despite a long history of European contact, Tonga is
the only island group in the Pacific to avoid colonization.
It became a constitutional monarchy in 1875 and a British
protectorate in 1900. Tonga acquired its independence in
1970 and became a member of the Commonwealth of
Nations. The government reflects the hierarchical social
structure with decisions being made primarily by the
monarch (King Taufaahau Tupou IV), the nobility, and a
982
Tongans
Medical Practitioners
MEDICAL PRACTITIONERS
Health care providers in Tonga may be divided roughly
into two types: traditional healers ( faitoo fakatonga) who
prescribe herbal cures, set bones, and use therapeutic
massage, and biomedical practitioners (physicians and
registered nurses) who are located in the hospitals and
clinics.
Traditional Healers
Both men and women can be healers, though there appear
to be more women. Entry into the profession varies, but
most individuals are young adults when they begin to
practice. Recruitment is informal with a tendency to
choose a relative. The person who is selected may be one
who showed an early interest or aptitude, or one the
healer decides is appropriate to receive the skill. When it
is time for a healer to retire, he or she will transfer the
knowledge and skill to the successor. This ritual has a
name, fanofano, but may be as simple a saying a few
words, I give you my faitoo. Other healers learn of
their ability by accident or are told about it in a dream. If
they are able to effect cures in people previously labeled
as incurable, they are described as having mana. Healers
live ordinary lives, receiving minimal material benefits.
They receive gifts from patients, but these are more
tokens of gratitude than payment. These can be as small
as a few cigarettes or as valuable as woven mats or bark
cloth for a particularly impressive cure. During the treatment, kava or food is often shared. Because the healer is
merely the vaka (vessel) for the healing power of God,
abuse of this divine gift will result in the healer losing the
ability to cure. The sins of greed or pride put the healer
at risk for possession by the very spirit being fought
(Cowling, 1990).
Healers tend to be specialists, not general practitioners, and those who claim to have cure-alls have little
credibility (Parsons, 1985). As in the past, infusions
983
Biomedical Practitioners
Following the influenza epidemic of 1918 that took the
lives of 8% of the population, Queen Salote established a
Department of Health with free medical care for all. Most
practitioners studied medicine in Fiji, and later in Samoa
(Wood-Ellem, 2001). Today there are approximately
70 physicians, most of whom trained in Fiji,
New Zealand, or Australia, and 340 nurses (Young Leslie,
personal communication, 2002). Nurses attend the
nursing school in Tonga for their basic education and
study abroad for advanced training.
The oldest and largest hospital is on the main island
of Tongatapu with 200 beds, running at 5060% occupancy. The average adult duration of stay is 10.1 days. The
reasons for hospitalization match the recorded leading
causes of mortality in Tonga: diseases of the circulatory
system, neoplasm, intestinal infectious disease, respiratory disease, and digestive disease.
When a person is admitted to the hospital, it is
assumed that a relative will be available for personal care
such as bathing and feeding. The caretakers of the
patients create an informal system within the institution.
Physicians and nurses receive respect as individuals who
have gifts for healing, however, many people view the
hospital with a mixture of relief and fear. Relief that
Tonga now has a modern facility to care for its citizens,
and fear because it seems that everyone who is admitted
dies there. The hospital is referred to as fale mahaki,
house of sickness. The medical response to the fear of
death is that statistics do not confirm this perception, but
what does happen is that people wait so long before coming in that it is too late to save them, and the mortality
rates are higher than they need be. For their part, health
care workers express ambivalence toward traditional
practice. One would be hard-pressed to find an individual
who has not experienced the therapeutic effects of massage when skillfully administered, but traditional methods are also described as dangerous, and should not be
984
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
The concepts of mana and tapu are central to an understanding of health and illness. Mana refers to the degree
to which objects and persons are endowed with supernatural powers. Having mana offers some protection against
misfortune and bad luck, and it is the force that allows
healers to act as a vessel for the healing power of God.
Tapu is also a complex concept that combines a number
of distinct notions (Radcliffe-Brown, 1952). Tapu is
sacred, and describes a connection with the gods. It also
describes those things that are forbidden or prohibited
(the English word taboo is derived from this Tongan
term). It is in this sense that the early Tongan chiefs and
objects touched by them were tapu. These two dimensions of social control also have cosmic consequences,
so that breaking a tapu or misusing mana may result
in misfortune through the agency of spirits (Levy, 1973;
Shore, 1989).
Illness is talked about in a number of different ways.
One system distinguishes Western illnesses from indigenous ones. Conditions thought to be introduced by
Europeans, or at least best treated with Western therapies,
are mahaki faka Palangi (European sickness). The
category mahaki fakatonga includes everything else
(Parsons, 1985). Another classification that is used
describes those misfortunes caused by natural events as
mahaki pe or puke pe (just sick), as opposed to problems
caused by spirits. The latter are mahaki (or puke) faka
tevolo (McGrath, 2000).
The word tevolo is a complex term, most often
glossed as devil, but more accurately refers to ancestral
and nameless spirits (the older term for tevolo is
faahikehe, other side (Kaili, personal communication,
2002). Puke faka tevolo implies supernatural agency. The
Tongans
985
986
SEXUALITY
Tongans
AND
REPRODUCTION
following Sunday wearing ritual fine mats. Most marriages occur when the couple are in their 20s, and they
often live, at least temporarily, with parents of one side or
the other. A young wife who lives with her husbands
family faces challenges as she is of lower status than her
affines, especially her husbands sisters.
Having children is very important and fertility is valued as an expression of femininity. Although infertility is
cause for concern, adopting a child can moderate the
social stigma. Fertility rates vary, with some rural families having six or more children; in the city two or three
children is more common. Overall the fertility rate is
gradually decreasing. The government and a few of the
churches promote family planning, but because of feelings of modesty about sexuality, and personal religious
beliefs, few couples use contraceptives. Children are
viewed as future providers for the family, and blessings
from God, so there is pressure to have a large family. This
presents a conflict for the increasing number of families
with both parents working outside the home.
Infancy
Traditional practices, such as burying the placenta near
the home, are followed to a varying degree throughout
the islands. The Tongan term for placenta, land, and grave
are the same, fonua, signifying the cyclical nature of life,
and a connection between person and place (Mahina,
1999). After childbirth, the mother and infant return
home for a period of rest and seclusion. Ideally, female
relatives will appear and provide help for the household.
The Christening, which occurs at three months, marks the
end of the seclusion, acknowledges the childs membership within the kainga, and is accompanied by gift
exchanges. Naming the child is an honor often given to a
person of rank or a relative of high status, such as the
mehekitanga.
During the first few years of life, the baby receives
almost constant attention from both men and women of
the household, and sleeps next to the mother at night
(Spillius [Bott], 1960). Breast-feeding is the norm, and
lasts until the baby is about 8 months old. Babies are frequently massaged with scented or herbed coconut oil to
prevent ailments or deformities, or to treat fussiness or
fever. This massage is done by the mother or other female
relatives. Massage of the skull soon after birth is done by
a faitoo to ensure the fontanel closes properly. The first
birthday is cause for great celebration with an elaborate
feast attended by the kainga, the minister, and neighbors
in the village.
Childhood
Most of the following data on childhood and adolescence
in Tonga are from Helen Morton (1996). Children, both
boys and girls, are highly valued and bring meaning to
life and to social institutions such as marriage. Early
childhood is marked by love and affection from indulgent
adults. It is the responsibility of the mother to teach her
children to act properly, but as the child grows, all adults
of the community, as well as older sibling and relatives,
act in parental ways. As they get older, boys have more
freedom to wander, whereas girls are expected to stay at
home and do chores, be better behaved, and act more
responsibly.
Adolescence
The whole span of childhood and adolescence is regarded
as a time for molding behavior to become a fully adult
person. The importance of kinship relations and the values of love (ofa), respect (fakaapaapa), and obedience
(talangofua) are described by many Tongans as the key to
987
988
Tongans
REFERENCES
Bathgate, M., Donnell, A. Mitikulena, A. et al. (1994). The health of
Pacific Islands people in New Zealand. Analysis and monitoring
report 2. Wellington: Public Health Commission.
Beaglehole, E., & Beaglehole, P. (1941). Pangai, village in Tonga.
Wellington, NZ: The Polynesian Society.
Besnier, N. (1996). Polynesian gender liminality through time and
space. In G. H. Herdt (Ed.), Third sex, third gender: Beyond sexual dimorphism in culture and history (1st pbk ed., pp. 285328).
New York: Zone Books, Distributed by MIT Press.
Bloomfield, S. F. (1986). It is health we want. Fiji: University of the
South Pacific, Suva.
Bott, E., Salote, T., & Tavi. (1982). Tongan society at the time of
Captain Cooks visits: Discussions with Her Majesty Queen
Salote Tupou. Wellington: Polynesian Society.
Campbell, I. C. (1994). The doctrine of accountability and the unchanging
locus of power in Tonga. Journal of Pacific History, 29(1), 8194.
Campbell, I. C. (2001). Island kingdom:Tonga ancient and modern
(2nd rev. ed.). Christchurch, NZ: Canterbury University Press.
Collins, V. R., Dowse, G. K., Toelupe, P. M., Imo, T. T., Aloaina, F. L.,
Spark, R. A., & Zimmet, P. Z. (1994). Increasing prevalence of
NIDDM in the Pacific island population of Western Samoa over a
13-year period. Diabetes Care, 17(4), 288296.
References
Collocott, E. E. V. (1923). Sickness, ghosts, and medicine in Tonga.
The Journal of the Polynesian Society, 22, 136142.
Cowling, W. A. (1990). Eclectic elements in Tongan folk belief and healing practice. Paper presented at the Tongan Culture and History,
Canberra.
Crews, D. E., & MacKeen, P. C. (1982). Mortality related to cardiovascular disease and diabetes mellitus in a modernizing population.
Social Science Medicine, 16(2), 175181.
Englberger, L., Halavatau, V., Yasuda, Y., & Yamazaki, R. (1999). The
Tonga health weight loss program, 19951997. Pacific Health
Dialog, 6(2), 153159.
Evans, M., Sinclair, R. C., Fusimalohi, C., & Liavaa, V. (2001).
Globalization, diet, and health: An example from Tonga. Bulletin
of the World Health Organization, 79(9), 856862.
Ferdon, E. (1987). Early Tonga. Tucson: University of Arizona Press.
Filihia, M. (2001). Men are from Maama, women are from Pulotu:
Femals status in Tongan society. Journal of Polynesian Society,
110(4), 377390.
Finau, S. (1981). Traditional medicine in Pacific health services. Pacific
Perspective, 9(2), 9298.
Foliaki, S. (1999). Mental health among Tongan migrants. Pacific
Health Dialog, 6(2), 288294.
Gailey, C. (1992). A good man is hard to find: Overseas migration and the
decentered family in the Tongan Islands. Critique of Anthropology,
12(1), 4774.
Gifford, E. W. (1929). Tongan society. Honolulu: Bishop Museum.
Gordon, T. (1996). They loved her too much: Interpreting spirit possession in Tonga. In J. Mageo and A. Howard (Eds.), Spirits in culture, history and mind. New York: Routledge.
Hauofa, E. (2000). Epilogue: Pasts to emember. In R. Borofsky (Ed.),
Remembrance of Pacific Pasts: An invitation to remake history.
Honolulu: University of Hawaii Press.
Herda, P. S. (1990). Genealogy in the Tongan construction of the past.
Paper presented at the Tongan Culture and History, Canberra.
James, K. E. (1990). Gender relations in Tonga: A paradigm shift. Paper
presented at the Tongan Culture and History, Canberra.
James, K. E. (1991). Migration and remittance: A Tongan village
perspective. Pacific Viewpoint, 32(1), 123.
Kaeppler, A. (1993). Poetics and politics of Tongan laments and
eulogies. American Ethnologist, 20(3), 474501.
Latukefu, S. (1974). Church and state in Tonga: The Wesleyan Methodist
missionaries and political development, 18221875. Honolulu:
University of Hawaii Press.
Levy, R. (1973). Tahitians: Mind and experience in the Society Islands.
Chicago: University of Chicago Press.
Macpherson, C., & Macpherson, L. A. (1990). Samoan medical belief
and practice. Auckland New York: Auckland University Press,
Distributed outside New Zealand by Oxford University Press.
Mageo, J. M. (1998). Theorizing self in Samoa: Emotions, genders, and
sexualities. Ann Arbor: University of Michigan Press.
Mahina, O. (1993). The poetics of Tongan traditional history, tala-efonuaAn ecology-centered concept of culture and history.
Journal of Pacific History, 28(1), 109121.
Mahina, O. (1999). Food meakai and body sino in traditional Tongan
society: Their theoretical and practical implications for health
policy. Pacific Health Dialog, 6(2), 276287.
Marcus, G. E. (1978). Nobility and the chiefly tradition in the modern
Kingdom of Tonga. Journal of the Polynesian Society, 87(2), 74120.
989
Mariner, W., & Martin, J. (1981). Tonga Islands: William Mariners
account: an account of the natives of the Tonga Islands in the
South Pacific Ocean, with an original grammar and vocabulary of
their language (4th ed.). Neiafu, Vavau, Tonga, Southwest Pacific
(P.O. Box 83, Neiafu): Vavau Press.
McDade, T. (2002). Status incongruity in Samoan youth: A biocultural
analysis of culture change, stress, and immune function. Medical
Anthropology Quarterly, 16(2), 123150.
McGrath, B. B. (2000). Swimming from island to island: Healing practice in Tonga. Medical Anthropology Quarterly, 13(4), 483505.
McGrath, B. B. (2002). Seattle faa Samoa. The Contemporary Pacific,
14(2), 307340.
McGrath, B. B. (2003). A view from the other side: Place of spirits in
the Tongan social field. Culture, Medicine and Psychiatry, 27,
2948.
Moengangongo, M. (1988). Tonga. In T. Tongamoa (Ed.),
Pacific women: Roles and status of women in Pacific societies.
Suva: Institute of Pacific Studies of the University of the South
Pacific.
Morton, H. (1996). Becoming Tongan: An ethnography of childhood.
Honolulu: University of Hawaii Press.
Morton, H. (2002). From mauli to motivator: Transformations in reproductive health care in Tonga. In M. J. Vicki Lukere (Ed.), Birthing
in the Pacific (pp. 3155). Honolulu: University of Hawaii Press.
Parsons, C. D. F. (1985). Healing practices in the South Pacific. Laie,
Hawaii Honolulu, Hawaii: Institute for Polynesian Studies,
University of Hawaii Press distributor.
Poltorak, M. (2002). Aspersions of agency: Ghosts, love and sickness in
Tonga. Unpublished dissertation, University College, London.
Puloka, M. H. A. (1999). Avanga: Tongan concepts of mental illness.
Pacific Health Dialog, 6(2), 268275.
Radcliffe-Brown, A. R. (1952). Structure and function in primitive society, essays and addresses. London: Cohen & West.
Rogers, G. (1977). The fathers sister is black: A consideration of
female rank and power in Tonga. Journal of the Polynesian Society,
86(2), 157182.
Schoeffel, P. (1978). Gender, status and power in Samoa. Canberra
Anthropology, 1(2), 6981.
Shineberg, D. (1978). He can but die: Missionary medicine in preChristian Tonga. In N. Gunson (Ed.), The changing Pacific: Essays
in honour of H. E. Maude (pp. 285296). Melbourne: Oxford
University Press.
Shore, B. (1989). Mana and tapu. In R. B. Alan Howard (Ed.),
Developments in Polynesian ethnology. Honolulu: University of
Hawaii Press.
Simmons, D. (1997). Diabetes and its complications among Pacific
people in New Zealand. Pacific Health Dialog, 4(2), 7579.
Sinoue, S. a. P. Z. (2000). The Asia-Pacific perspective: Redefining
obesity and its treatment. Melbourne: International Diabetes
Institute, Regional Office for the Western Pacific, World Health
Organization.
Small, C. A. (1997). Voyages: From Tongan villages to American suburbs. Ithaca: Cornell University Press.
Spillius [Bott], E. (1960). Report on brief study of motherchild relationships in Tonga. Geneva: World Health Organization.
Teilat-Fisk, J. (1990). Tongan grave art. In F. A. H. a. L. Hanson (Ed.),
Art and identity in Oceania (pp. 222243). Honolulu: University
of Hawaii Press.
990
Trobriand
Trobriand
Jay Bouton Crain, Allan Clifford Darrah, and Linus Silipolakapulapola DigimRina
ALTERNATIVE NAMES
Bweyowa, Kiriwinia, Kilivila, Bowoya, Trobrianders,
Trobriand Islanders.
LOCATION
OVERVIEW
AND
LINGUISTIC AFFILIATION
OF THE
CULTURE
991
992
Trobriand
MEDICAL PRACTITIONERS
The literature makes no note of specialized traditional
positions or offices for medical practitioners. However,
there are individuals in each village who have knowledge
of curative spells and magic-producing materials.
Malinowski noted that magic to prevent dangers in childbirth, to cause abortion, treat genital discharge, swellings
of the limbs, and toothache was controlled by women, but
men also possess spells to control various aspects of
reproduction (Malinowski, 1929).
Noting that Trobrianders lack a tradition of local midwives, Pschl and Pschl (1985) called for the training of
female birth attendants. Lepani (2001) indicates that 126
women have been trained as Village Birth Attendants.
There is also a health center in Losuia and more than a
dozen local aid posts, with the actual count of functioning
sites varying due to staffing problems.
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Classifications of Illness
Bweyowa notions of the body, the beginning and ending
of life, the nature of disease, and the various stages of life
993
Theories of Illness
The natural state of a person is health. Theoretically
people die from old age; however, usually one of the
above agencies is blamed. Weiner has argued that magic
comes to the forefront, not because of risk, as Malinowski
suggested, but rather when the outcome of an exchange is
imperative. In Weiners view, magic is about controlling
men through exchanges rather than control of nature;
control over natural forces, such as the wind and rain, is
proof that one has the power to dominate others (Weiner,
1987). Weiners starting point is different from that of
Weber, who places the source of meaning in the crises of
illness. Weiners perspective does not focus on misfortune or its remediation, and tends to ignore revenge, the
other half of reciprocity. It is also a top-down view of
society given that magic is such a limited resource, a prerogative of rank, while suffering is the great common
denominator.
Both illness and senescence are associated with
blackening and also with heat/fire. Malinowski observed
that magic which affects health comes in paired sets of
spells, called vivisa for therapeutic magic and silami for
magic of affliction (Malinowski, 1916). A sorcerer without the perceived capacity to heal would be deemed
incompetent. Vivisa refers to the defensive or healing
994
Trobriand
Treatment of Illness
Bloodletting is an important therapeutic practice in the
Massim (Baldwin, 1937; see also Munn, 1986; Senft,
1986; Villeminot, 1967). Blood, produced by eating
heavy kaula, is itself heavy, and its removal has the effect
of lightening a person in terms of both color and weight.
Gawan dancers are bled to lighten themselves. In the
Trobriands, cuts or scratches are made with a sharp stone
in order to remove blood or relieve pain, headaches, lassitude, chills, hematoma, and bruises (Villeminot, 1967).
Bruises which produce a discoloration, likened to those
suffered by pigs when clubbed to death, are lacerated to
remove the blackness. Blood, once released from the
body, is dangerous to matrilineal kin, but can be a gift that
can establish exchange relationships. Gawan fathers put
blood on their children to inaugurate exchanges of betel
and other edibles with them (Munn, 1986).
SEXUALITY
AND
REPRODUCTION
995
996
Infancy
Children are generally welcome additions to the family,
however, both Austen (193435) and Lepani (2001)
indicate that abortions, by both herbal and mechanical
means, are also an option. Lepani also reports that pregnancy often results in marriage, an outcome that is far
more frequent these days than 30 years ago. Powell
(1980) mentions the use of traditional forms of contraceptives, called kaikariga [kai- is a prefix for wood and
kariga is death].
Bellamy (Black, 1957), Assistant Resident
Magistrate and doctor in the Trobriands, from 1906 to
1915, reports that female infanticide may have been practiced; however, Malinowski rejected this possibility (1929).
Montague (1985) reports that Kaduwagans deny practicing infanticide even though it is within a mothers rights
up until she has fed her child. A newborn, prior to its first
meal, is the property of the woman who did the work of
growing it, just as yams are the property of the man who
raised them. A genetrix can elect to feed a neonate, give
the child to someone else to feed, or the infant can just
disappear, without ever entering the kinship system. Once
the neonate has been fed, it is human rather than property,
and its kinship ties, which follow milk rather than blood,
are to the person whose dietary history it shares
(Montague, 2001). All newborns have the same kind of
undifferentiated blood. It is only when a child drinks
milk, which incorporates the nurses unique dietary history, that it becomes related through these shared differentiations. Weiner notes that wet nurses are given axe
blades [beku] as repayment for their milk and to reclaim
the infant for its natal dala.6
From the third month of her pregnancy through the
first month after parturition, a prima para must eat hard
dry foods [kaula], which produce blood and milk. If
she eats soft and wet foods, the baby will suffer from a
nonspecific disease called gwemata (Pschl & Pschl,
1985). Gwemata means cold and damp (Baldwin, 1937).
As late as the1970s, women were encouraged to refrain
from conjugal relations until their children entered the
toddler stage in order to protect the quality of their milk.
During postpartum seclusion, a major concern is to protect the mothers milk by keeping it warm. Cold or
reheated foods are also avoided to prevent damaging fluctuations to the mothers internal temperature. Women also
cover their heads at night out of fear that they will lose
body heat, thereby cooling their milk (Montague, 1985).
Trobriand
Childhood
Children enjoy considerable independence. Malinowski
(1929) reports that parents are more likely to request
favors of their children, sometimes accompanied by
threats, than they are to give them commands. They rely
on the childs sense of fairness and obligation, which is
instilled at a very early age. By age four, the child moves
into the village play group and increasingly avoids
parental discipline and oversight in a process of emancipation which Malinowski (1929) judged to be gradual
and pleasant. At a point roughly coinciding with menarche, young girls are given a short red skirt symbolic of
their capacity to evoke desire from others.
Adolescence
As a child ages it is expected to explore its sexuality
and may receive adult approval and encouragement in
Adulthood
The emphases on white symbolism, in prima para rituals,
is best viewed in the broader context of Trobriand
997
998
Trobriand
References
NOTES
1. Montague has collected oral histories that indicate that there was
a severe population decline during the early 19th century due to
post-contact diseases (personal communication).
2. The major ethnographers of the Trobriand and related Massim
cultures include: C. G. Seligman, Bronislaw Malinowski, Henry
Powell, Annette Weiner, Shirley Campbell, Ann Chowning
(Fergusson), Debbora Battaglia (Port Moresby and Sabarl),
Fredrick Damon (Woodlark Island), Linus DigmRina (Trobriands
and Fergusson), Reo Fortune (Fergusson and Dobu), Edwin
Hutchins, Susanne Kuehling (Dobu), Jerry Leach, Maria Lepowsky
(Sudest), Luciana Lussu, Martha Macintyre, Susan Montague,
Nancy Munn (Gawa), Giancarlo Scoditti, Carl Thune (Normanby),
Karin Grossman, Stuart Berde (Panaeiti), and Michael Young.
Medically trained observers include: R. L. Bellamy,
R. H. Black, R. Pschl and U. Pschl, Wolf Schiefenhvel, and
S. Lindeburg.
Other relevant views of Trobriand life have been written by:
TomTavala, John Kasaipwalova, Chief Naributal, Juta Malnic
(photographer and author), Leo Austen (Magistrate), Rev. Ralph
Lawton (missionary-linguist), Father Bernard Baldwin (missionary), Kenneth Costigan (architect), and Ellis Silas (artist).
3. This work employed the DEPTH Database, a compilation of 8,000
pages of digital texts on Massim cultures, which is a greatly expanded
version of the HRAF Trobriand Collection (www.csus.edu/anth/
trobriand/depth). The authors wish to acknowledge the assistance of
Caroline Gardner, Andy Connelly, Erin Caddy, and Sebastian
Barbosa of the DEPTH team.
4. For magic to live in the belly, it must continually be retrieved by
sub-vocalization; thus, spells recorded by anthropologists are no
longer active. The usual expression for a man who has completely
learned all of his fathers magical knowledge would be Your father
(his name) died empty handed, you have completely taken all of his
stomachs contents. This is a direct reference to the mans magical
knowledge and its transmission, whilst adding praise for the competence of the heir.
5. DigimRina notes that even though the benefits of hammering
have been frequently cited in the literature, the idea is foreign to him.
999
6. It should be noted that Weiner (1976) views dala as a kinship
category equivalent to a matrilineage, with membership being
determined by shared blood. Montague, on the other hand, says that
people are grouped into a dala based on shared mental capabilities
which are determined by an individuals dietary history.
7. People are said to resemble their fathers rather than their mothers
or other matrilineal kin. It is a grave insult to say that blood
relatives resemble each other. In this passage, beauty refers to the
brothers daughter.
REFERENCES
Austen, Leo. (193435). Procreation among the Trobriand Islanders.
Oceania, 5, 102113.
Austen, Leo. (1945). Cultural changes in Kiriwina. Oceania, 16, 1560.
Baldwin, B. (1937). The vocabulary of Biga Boyowa. Unpublished
manuscript, Pacific Manuscript Bureau, Reel 63.
Baldwin, B. (1945). Usituma! Song of Heaven. Oceania, 15, 201238.
Black, R. H. (1957). Dr. Bellamy of Papua. Medical Journal of
Australia, 2, 189197, 232238, 279284.
Bickler, Simon H. (1998). Eating stone and dying: Archaeological survey on Woodlark Island, Milne Bay Province, Papua New Guinea
(Doctoral dissertation, University of Virginia, 1998).
Brindley, Marianne. (1984). The symbolic role of women in Trobriand
gardening. Miscellania anthropologica, 5. Pretoria: University of
South Africa.
Burenhult, G. (2000). The archaeology of the Trobriand Islands, Milne
Bay Province, Papua New Guinea. BAR International Series 1080.
Oxford: Archaeopress.
Campbell, Shirley. (1984). The art of Kula (Doctoral Dissertation,
Australian National University, 1984).
Capell, A. (1976). General picture of Austronesian languages, New
Guinea area. In S. J. Wurm (Ed.), Austronesian languagesNew
Guinea area languages and language study (Vol. 2, Pacific
Linguistics, Series C, No. 39, pp. 552). Canberra: Australian
National University.
Darrah, Allan C. (1972). Ancestors in Trobriand ritual. Manuscript,
Northwestern University.
DigimRina, Linus. (1998). An updated effect of the dreadful drought:
The Trobriand experience. APFT Briefing Note, Brussels.
Fortune, Reo F. (1932). Sorcerers of Dobu. London: Routledge &
Kegan Paul.
Egloff, Brain. (1978). The Kula before Malinowski: A changing configuration. Mankind, 11, 429435.
Hipsley, E., & Clements, F. (1950). Report on the New Guinea Nutrition
Survey Expedition 1947. Canberra: Department of External
Territories.
Knauft, Bruce. (1999). From primitive to postcolonial in Melanesia and
anthropology. Ann Arbor: University of Michigan Press.
Lawton, R. (1993). Topics in the description of Kiriwina (Pacific
Linguistics Series D-84), Malcom Ross & Janet Ezard (Eds.).
Australian National University: Research School of Pacific
Studies.
Leach, Edmund R. (1966). Virgin birth. Proceedings of the Royal
Anthropological Institute (pp. 3949).
1000
Leach, Edmund R. (1968). Virgin birth: Correspondence. Man, 3,
651656.
Lepani, Katherine. (2001). Negotiating open space: The importance of
cultural context in HIV/AIDS communication modelsA qualitative study of gender, sexuality, and reproduction in the Trobriand
Islands of Papua New Guinea. Masters thesis, University of
Queensland.
Lindeberg, S. et al. (1994). Cardiovascular risk factors in a Melanesian
population apparently free from stroke and ischaemic heart disease: The Kitava study. Journal of Internal Medicine, 236,
331340.
Malinowski, Bronislaw K. (1916). Baloma: Spirits of the dead in the
Trobriand Islands. Journal of the Royal Anthropological Institute,
46, 353430.
Malinowski, Bronislaw. (1929). The sexual life of savages in NorthWestern Melanesia: An ethnographic account of courtship, marriage and family life among the natives of the Trobriand Islands,
British New Guinea. London: G. Routledge & Sons, Ltd.
Malinowski, Bronislaw. (1935). Coral gardens and their magic: A study
of the methods of tilling the soil and of agricultural rites in the
Trobriand Islands. (Vol. I); The description of gardening (Vol. II);
The Language of Magic and Gardening London: George Allan &
Unwin.
Malnic, Jutta. (1998). Kula: Myth and magic in the Trobriand Islands.
Wahroonga, NSW: Cowrie Books.
Milke, W. (1965). Comparative notes on the Australian languages of
New Guinea. Lingua, 14, 330348.
Montague, Susan. (1971). Trobriand kinship and the virgin birth controversy. Man, 6, 353368.
Montague, Susan. (1973). Copulation in Kaduwaga. Man, 8, 304305.
Montague, Susan. (1974). The Trobriand society (Doctoral dissertation,
University of Chicago, 1974).
Montague, Susan. (1985). Infant feeding and health care in Kaduwaga
village. In Leslie Marshall (Ed.), Infant care and feeding in South
Pacific. New York: Gordon & Breach.
Montague, Susan. (1989). To eat for the dead. In F. H. Damon &
R. Wagner (Eds.), Death rituals and life in the societies of the Kula
ring (pp. 2345). DeKalb: Northern Illinois University Press.
Montague, Susan. (2001) The Trobriand kinship classification and
Scheniders cultural relativism. In R. Feinberg & M. Ottenheimer
(Eds.), The cultural analysis of kinship: The legacy of David M.
Schneider (pp. 168186). Champaign: University of Illinois Press.
Munn, Nancy. (1986). The fame of Gawa: A symbolic study of value
transformation in a Massim (Papua New Guinea) society.
Cambridge: Cambridge University Press.
Nutrition Monitoring Group. (1980). Report of the Nutrition Monitoring
Group. Provincial Health Office, Division of Health, Alotau,
Milne Bay Province, Papua New Guinea.
Pschl, R., & Pschl, U. (1985). Childbirth on Kiriwina, Trobriand
Islands, Milne Bay Province, Papua New Guinea. Papua New
Guinea Medical Journal, 28, 137145.
Trobriand
Powell, Harry A. (1968). Correspondence: Virgin Birth. Man (N.S.),
651653.
Powell, Harry A. (1969). Genealogy, residence and kinship in Kiriwina.
Man (N.S.), 4, 177202.
Powell, Harry A. (1980). Review: Woman of value by A. Weiner.
American Anthropologist, 700702.
Schiefenhvel, S., & Schiefenhvel, W. (1996). Am evolutionaren
Modell -Stillen und fruhe sexualization bei den Trobriandern (Erin
Caddy, Trans.). In Christine E. Gottschaulk-Batschkus & Judith
Sculer (Eds.), Ethnomedizinische Perpectiven zur fruhen Kindheit
Curare im Autfrag der Arbeitsgemeinschaft Ethnomedizin.
Scoditti, Giancarlo. (1996). Kitawa oral poetry: An example from
Melanesia (Pacific Linguistics Series D 87). Canberra: Australian
National University Department of Linguistics.
Seligmann, C. G. (1910). The Melanesians of British New Guinea.
Cambridge: Cambridge University Press.
Senft, Gunter. (1986). Kilivila: The language of the Trobriand
Islanders. Berlin: Mouton de Gruyter.
Silas, Ellis. (1926). A primitive Arcadia: Being the impressions of an
artist in Papua. London: T. Fisher Unwin.
Spiro, Melford. (1968). Virgin birth, parthenogenesis, and physiological paternity: An essay on cultural interpretation. Man, 3, 242261.
Spiro, Melford. (1972). Correspondence: Reply to Montague. Man, 7, 315.
Spiro, Melford. (1973). Copulation in Kaduwaga. Man, 8, 631.
Stocking, George. (1977). Contradicting the doctor: Billy Hancock and
the problem of the Baloma. History of Anthropology Newsletter,
4(1), 1112.
Tambiah, S. J. (1968). The magical power of words. Man, 3, 175208.
Tambiah, S. J. (1983). On flying witches and flying canoes: The coding
of male and female values. In J. W. Leach & E. R. Leach (Eds.),
The Kula: New perspectives on Massim exchange (pp. 249276).
Cambridge: Cambridge University Press.
Villeminot, Jacques et Paule. (1967). Les Seigneurs des Mers du Sud.
La vie ancestrale et paradsique de habitants de iles Trobriand.
Paris: P. Laffont.
Wayne, Helena. (Ed.). (1995). The story of a marriage: Volume I. The
letters of Bronislaw Malinowski and Elsie Masson. London:
Routledge.
Weiner, Annette B. (1976). Women of value, men of renown: New perspective on Trobriand exchange. Austin: University of Texas Press.
Weiner, Annette. (1987). The Trobriand Islanders of Papua New
Guinea. New York: Holt, Rinehart and Winston.
Young, Michael. (1983). The Massim: An introduction. The Journal of
Pacific History, 18, 410.
Young, Michael. (1986). The Worst Disease: The cultural definition
of hunger in Kalauna. In L. Manderson (Ed.), Shared wealth and
symbol: Food, culture and society in Oceania and Southeast Asia
(pp. 111126). Cambridge: Cambridge University Press.
1001
Tuareg
Susan J. Rasmussen
ALTERNATIVE NAMES
Kel Tamajaq (People who speak Tamajaq); Kel
Tagelmust (People of the Veil); Targui; Touareg; and
also names designating groups from the different regions
and confederations, for example, Kel Air (People of the
Air region); Kel Ewey (People of the Bull, a political
confederation), descent groups or clans (Kel Nabarro;
Kel Tafidet), and the pre-colonial social strata, for
example, Imajeghen (designating the aristocracy); Inaden
(smith-artisans); and Imghad (tributaries).
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
History
A number of sourcesoral traditions recorded by Rodd
(1926), Bernus (1981), and Nicolaisen & Nicolaisen
(1997), Saharan rock art, and Arab chroniclesrelate
the early origins and migrations of various Tuareg
1002
origins tended to be underrepresented in the new occupations of the governmental and urban infrastructures.
Recently, however, attitudes toward education have been
more favorable.
Most Tuareg today practice a mixed economy of
livestock herding, oasis gardening, caravan and other itinerant trading expeditions, and labor migration. A series of
recurrent droughts, however, has diminished the livestock
of many herders, pressuring them toward greater sedentarization and more intensive gardening. In addition,
there are more specialized artisan activities traditionally
performed by smiths, an endogamous, hereditary occupational social stratum. Recently, some Tuareg have also
become active in tourism.
Tuareg
Religion
The local pre-Islamic or popular Islamic belief system
interweaves with more official Islamic beliefs and
practices. Tuareg converted to Islam under the influence
of Sufism and Almoravid marabouts between the 7th and
1003
1004
Tuareg
MEDICAL PRACTITIONERS
Types of traditional medical practitioners in Tuareg society include herbalists; bone-setters; Islamic scholars or
marabouts; diviners; and spirit possession ritual exorcism
specialists. Some of these specializations overlap, many
practitioners refer patients to each other, and many
patients consult more than one practitioner for a given illness. Herbalists are predominantly though not exclusively
women; many are called medicine women (tinesmegelen). Many inherit their profession in clans and apprentice with an older female relative. These practitioners do
diagnostic, healing, and referral work and cure mostly
stomach afflictions with leaves, barks, and roots and also,
sometimes, with medicines purchased in markets or
brought into the region by trade. They diagnose through
massage with special focus upon the stomach. Herbalists
also practice some psycho-social, particularly marital,
counseling and, along with Islamic scholars/marabouts,
are often consulted to treat womens fertility problems.
Many herbal medicine women emphasize their complementary, rather than competitive relationship to Islamic
scholars/marabouts in healing, describing these healers
as being like husband and wife, and referring some
patients to marabouts (Rasmussen, 1998b). Some herbal
medicine women perform non-Quranic divination,
through dreaming; this specialty is called asawad,
denoting to look or see, and its practitioners called
imaswaden (sing. amaswad or amanai, fem. tamaswad or
tamanai) (Rasmussen, 2001). Some herbalists also know
bone-setting, while other practitioners set bones, but do
not practice herbal medicine: they are called imadasen
(sing. amadas, fem. tamadas). Other non-Quranic diviners are called by the Hausa-derived term bokaye (sing.
boka); these diviners tend to be male and practice more
often in the towns, whereas the herbalist/diviners tend to
be female and practice more often in the countryside.
Bokaye diviners work with plants as well, but supplement
them with scents (usually perfumes, but also some herbal
medicines inhaled through the nose) and other ritual paraphernalia such as cowrie shells. They are believed to
work with a tutelary spirit, in a pact with the Kel Essuf
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Despite some influence of hospitals and clinics, particularly in the towns, Tuareg cultural understandings concerning illness, particularly in the countryside, include
many alternatives to the biomedical paradigm. Fundamental to the local paradigm is a continuum, rather than
rigid opposition, between body and mind and between
organic and non-organic illnesses. Much Tuareg medicine
features counteractive theories of balance and harmony,
1005
for example, hot versus cold states of the body and diseases caused by imbalance of these forces. These states are
gender-linked; for example, women should ideally be cool,
and men should ideally be warm, but these states should
not become too pronounced or intensified, for example, a
man can become too hot and ill (Figueiredo
in Claudot-Hawad, 1996, pp. 113137). Too intense cold
or heat, or conversely, accumulation of the opposite of the
ideally-dominant quality brings illness, and requires
a cure. These conditions of hot/cold and associated
afflictions are sometimes literal, sometimes non-literal or
metaphorical in connotations, for example, hot illnesses
(tuksi) are believed to be caused by too much heat, from
hot foods (dates, tomatoes), sunlight, or moon-beams
(these latter may cause illness from direct contact, as in
sun-stroke, or, alternately, by sitting on warm mats or from
their reflections inside doorways). Tuksi may also result
from anger and other strong sentiments. These require
counteractive treatments with herbal medicines, ritual precautions, or dietary remedies (such as cold foods, e.g.,
millet). Many of these illnesses include stomach ailments.
Cold illnesses (tessmat) are the counterpart of hot illnesses. These include urinary tract problems and STDs.
Treatment is sought from herbalists, who often prescribe
plant remedies and ritual bathing (Rasmussen, 1998b).
Other diseases may be caused by the wind and aromas;
covering the bodily orifices is important to prevent them.
There are additional conditions that defy neat classification into organic and non-organic, and have only
approximate, rather than exact, translations into the
English language and Euro-American established biomedical paradigms: for example, anoughou refers to a
condition caused by a sudden change in routine with subsequent deprivation of the usual nourishment or habit;
tamazai refers to a condition approximating depression, in
which one suffers from a long-term hidden wish or resentment that cannot be directly expressed. This latter relates
to important Tuareg cultural values that discourage direct
or explicit speech and encourage indirect expression by
allusion. Sometimes, many residents believe, this condition results from unrequited love or other love problems
(tarama). It often provokes goumaten spirit possession. A
stomach ailment called karambaza, usually diarrhea, is
believed to be caused by the mystic ritual powers of
smith/artisans (tezma or ettama), activated automatically
when they are refused a present or denied a request.
Karambaza attacks children or livestock of the offending
party, often a noble patron. Its remedies involve seeing an
1006
Tuareg
SEXUALITY
AND
REPRODUCTION
Infancy
In the countryside, infant mortality is approximately
60%. Spirits are believed to sometimes mistake babies for
goat-hide water-bags, and pull them back into the spirit
world. Efforts are made to keep newborns in the world of
humans. The firstborn male wears a tuft of hair on top of
the head in order to be pulled by the Prophet up into paradise in the event of death. If a baby is stillborn, no condolence or nameday rituals are held; if a baby dies after
crying, a condolence ritual is held as for deceased adults.
Babies are often called stranger until they are 1 week
old, then are given several names, Quranic by the father
and marabout, and non-Quranic by the maternal grandmother, at the nameday ritual. The marabout writes
Quranic verses in vegetal ink for the babys mother to
drink, to protect from malevolent spirits and humans.
Special names are given to babies when a previouslyborn sibling died, in order to distract the spirits, for
1007
Childhood
Children are encouraged to assist with adult chores. In some
regions, toddlers are given chickens to raise as pets to practice for future herding of their parents livestock. Small children are encouraged to explore their physical environment
freely, and corporal punishment is rare, although adults in
rural communities keep a watchful eye on childrens activities. Toddlers begin to wear protective religious amulets
around weaning age. At around eight years, young girls
begin to assist their mothers in cooking and fetching water.
At this age, boys traditionally start to accompany their
fathers on caravan trading expeditions, help in the oasis
gardens, and smith/artisan boys begin apprenticeships at the
forge with an older male relative. Children of both sexes
herd livestock. Nowadays, more girls and boys of diverse
social origins go to both Quranic and secular schools.
Adolescence
Despite childrens full participation in adult tasks, Tuareg
recognize adolescence as a distinct phase, and a Tamajaq
term designates an adolescent: ekabkab (fem. tekabkab).
Local concepts of the life course are, nonetheless, not
strictly linear, chronological, or biological, but rather these
phases are socially and ritually defined (Rasmussen, 1997).
For example, females are considered to become women
at marriage, rather than upon menstruation; males are considered marriageable upon taking up the mens face-veil, at
approximately 1820 years of age. Adolescents of either
sex, but particularly women, are believed to be vulnerable
to jealousy of spirits and humans at life transitions.
1008
The Aged
Aged persons are ideally respected. Children are supposed to care for ailing parents. Elderly persons of either
sex reside next door to children, and participate prominently in Islamic and pre-Islamic rituals. Many elderly
persons continue to work (herding, caravanning, and gardening) as long as their health and energy permit,
although more arduous labor (fetching well water and
firewood) is usually performed by younger relatives.
Physical problems of older women are attributed to
aging processes in general, rather than specifically from
the cessation of menstruation (Rasmussen, 2000, pp.
91116). Herbal medical specialists and other women
report few symptoms associated with the menopause
model in western established bio-medicine. Postchildbearing womens ritual and social roles apparently
compensate for any perceived physical problems, and
many such problems merge with other age-related problems in local medicine.
Tuareg
1009
REFERENCES
Bernus, E. (1981). Touaregs Nigeriens: Unite dun peuple pasteur.
Paris: Editions de lOffice de la Recherche Scientifique et technique de lOutre-Mer.
Casajus, D. (2000). Gens de Parole: Langage, poesie et politique en pays
touareg. Paris: Editions la decouverte textes a lappui/anthropologie.
Claudot-Hawad, H. (1993). Touareg: Portrait en fragments. Aix-enProvence: Edisud.
Claudot-Hawad, H. (1996). Touareg et Autres Sahariens entre Plusieurs
Mondes. Aix-en-Provence: Edisud.
Decalo, S. (1996). Historical dictionary of Niger. Lanham, MD,
London: The Scarecrow Press.
Figueiredo, C. (1996). Identite et concitoyennete. La reelaboration des relations entre hommes et femmes aux marges de la societe Kel Adagh
(Mali). In H. Claudot-Hawad (Ed.), Touareg et Autres Sahariens entre
Plusieurs Mondes (pp. 113137). Aix-en-Provence: Edisud.
Keenan, J. (1976). Tuareg: People of Ahaggar. New York: St. Martins
Press.
Murphy, R. (1964). Social distance and the veil. American Anthropologist,
66, 12571274.
Murphy, R. (1967). Tuareg kinship. American Anthropologist, 69,
163170.
Nicolaisen, J. (1961). Essaie sur la religion et la magie touaregues. Folk,
3, 113160.
Nicolaisen, I. and Nicolaisen, J. (1997). The pastoral Tuareg. Rhodos,
Copenhagen: The Carlsberg Foundation.
Norris, H. T. (1975). The Tuareg: Their Islamic legacy and its Diffusion
in the Sahel. Wilts, England: Aris and Phillips.
Norris, H. T. (1990). Sufi mystics of the Niger desert. Oxford: Clarendon
Press.
Porch, D. (1984). The Conquest of the Sahara. New York: Knopf
(Random House).
Rasmussen, S. (1991). Lack of prayer: Ritual restrictions, social experience, and the anthropology of menstruation among the Tuareg.
American Ethnologist, 18, 751769.
Wape
William E. Mitchell
ALTERNATIVE NAMES
Wapei, Wapi.
LOCATION
AND
LINGUISTIC AFFILIATION
1010
Wape
OVERVIEW
OF THE
CULTURE
1011
1012
MEDICAL PRACTITIONERS
Indigenous
The Wape recognize three types of part-time indigenous
practitioners who diagnose and/or treat sicknesses, none
of which use trance or an altered state of consciousness
(Mitchell, 1990). A numoin (Olo), the most feared and
powerful, is a male shaman-witch who receives his healing prowess by magically killing persons whose ghosts
give him his healing powers. In Tok Pisin he is called a
sangumaman and is found in other parts of New Guinea
as well as among some of the Australian aborigines.
A sangumaman supposedly can fly and make himself
invisible and his services are used only when a person is
seriously ill. If the patient recovers, the sangumaman
receives the credit. If not, further treatment is sought.
Today there are few, if any, sangumaman practitioners
among the Wape, but the less contacted groups to the
south still have them and they are sometimes resorted to.
A wobif (Olo) does not have the supernatural powers of a sangumaman and is not feared by villagers. He
learns his healing skills from an another wobif and is
given a small fee or gift for his services. The third type of
practitioner is a glasman (Tok Pisin) whose skills were
brought into the area by men returning from contract
labor work on the coastal plantations. He is solely a diagnostician and does not offer treatment. As a clairvoyant
he determines the cause of the illness by looking into
his patient and asking questions. Having specified the
cause on the basis of an indigenous differential diagnosis
he then prescribes an appropriate treatment that may
include consulting a wobif or sangumaman. He too
receives a small fee or gift for his services.
Introduced
The grassroots practitioner of modern medicine is the
aide post orderly or doktaboi (Tok Pisin). These men have
Wape
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
Although many Wape have a rudimentary understanding
of the biomedical theory of sickness in terms of, for
example, a penicillin injections attack on invading bacteria, it is seldom persuasive. It is the theories of their own
culture intimately conveyed in myth, ceremonial, and
everyday events that offer a more satisfying understanding of sickness and dying. The Wape believe in a complex
set of unseen spirit forces that affect them in both positive and negative ways (Mitchell, 1987; Waisi, 1982).
While these can, for example, cause an earthquake or
inflict illness and death, with the proper rituals they can
enhance life as well.
1013
1014
Wape
SEXUALITY
AND
REPRODUCTION
Infancy
The mean weight of the Wape baby at birth, 2.40 kg, is
one of the lowest on record (Malcolm, 1973). Malaria is
holoendemic and one of the main causes of high infant
mortality. From birth until about a year old, an infant subsists on its mothers milk and premasticated sago paste.
Nursing babies usually double their birth weight within
3 months and treble it just over a year. From between
about 8 months and 1 year, infants may be offered premasticated taro and a green shoot when seasonally available. However green vegetables in the form of boiled
Gnetum gnemon leaves are not offered until a child is
walking and completely toilet trained, about 2 years old.
As a result, by the age of 6 months, a baby is most likely
deficient in both caloric and protein intake. After a year,
more solids are occasionally added to the diet including
sago grubs and breadfruit providing additional protein.
As the Wape also have little access to meat, and fresh fish
is taboo to babies, malnutrition is not an uncommon
problem among babies and toddlers.
Although a mother has the main responsibility for
her infant, the father will remain in the village with the
baby in a sling on his body when his wife is in the forest
making sago flour. If a baby cries to nurse, it is not
unusual for a father to offer his own breast as a pacifier.
Other children and relatives also carry the baby from time
to time; until it can crawl it is in almost constant physical
contact with one attentive caregiver or another. Weaning
is a gradual process with the toddler returning occasionally to the breast until it is dry.
Childhood
Unless there is a school in the village or close by, children are left much on their own to play with their age
mates in the central plaza or shadow the activities of their
parents. Boys, more than girls, go into the forest and forage for small game and other food. Children sleep in the
same house as their parents and take their meals there too.
Dining is a private family affair. Overt signs of malnutrition are not as common among children as they are
among toddlers and infants. Parents are affectionate to
both their male and female children and to viciously
strike or whip a child is almost unheard of.
1015
Adolescence
Chronic undernutrition appears to be a factor in the
comparatively late onset of secondary sexual characteristics. One study (Wark & Malcolm, 1969) notes the onset
of menarche in girls at 18.4 years. The onset of puberty
in boys including the lowering of the voice is correspondingly delayed in comparison to European populations. Unlike some New Guinea societies, the Wape have
no special ceremonies marking puberty. While toddlers
and younger children play together, adolescent boys and
girls tend to separate into gender-determined groups.
Girls take an important role in helping their mothers in
the familys food quest, but the small birds and animals
obtained by boys are usually reserved for themselves.
Adulthood
Premature aging has been observed in many New Guinea
societies and the Wape are no exception. Measurements
of adults show a marked decline in height with age from
2 to 3 cm and there is a concomitant loss of weight. The
average age of death for both men and women is the midforties. With physical maturity coming late and death
coming early, Wape adulthood is of limited duration
for many.
The Aged
There are few aged in Wape society. It is an exception for
an adolescent to have grandparents. An old person usually lives with her or his sons family. The elderly help
1016
Wape
REFERENCES
Briggs, E. A. (1928). New Guinealand of the devil devil. Australian
Museum Magazine, 3, 265273.
Briggs, E. A. (1929). The black heart of New Guinea. Australian
Geographer, 1, 3840.
Foley, W. A. (1986). The Papuan languages of New Guinea. Cambridge:
Cambridge University Press.
Laycock, D. C. (1975). The Torricelli phylum. In S. A. Wurm (Ed.),
Papuan languages and the New Guinea linguistic scene, 1, 767780.
Malcolm, L. A. (1973). Growth and development patterns and human
differentiation in Papua New Guinean communities. Prepared for
the IXth International Congress of Anthropological and
Ethnological Sciences, AugustSeptember 1973, at Chicago, IL.
Marshall, A. J. (1938). The men and birds of paradise: Journeys through
equatorial New Guinea. London: William Heinemann.
McGregor, D. E. (1982). The fish and the cross (2nd ed.). Goroko:
Melanesian Institute.
McGregor, D. E., & McGregor, A. R. F. (1982). Olo language materials. Canberra: Australian National University (Pacific Linguistics,
Series D, No. 42).
Mihalic, F. (1971). The Jacaranda dictionary and grammar of
Melanesian Pidgin. Brisbane: Jacaranda Press.
Mitchell, J. (1973). Life and birth in New Guinea. Ms. Magazine,
1(11), 2123.
Mitchell, W. E. (1973). A new weapon stirs up old ghosts. Natural
History, 82, 7484.
Mitchell, W. E. (1978). On keeping equal: Polity and reciprocity among
the New Guinea Wape. Anthropological Quarterly, 51, 515.
Mitchell, W. E. (1987). The bamboo fire: Fieldwork with the
New Guinea Wape (2nd ed.). Prospect Heights, IL: Waveland Press.
Mitchell, W. E. (1988). The defeat of hierarchy: Gambling as exchange
in a Sepik society. American Ethnologist, 15, 638657.
Mitchell, W. E. (1990). Therapeutic systems of the Taute Wape. In
N. Lutkehaus, C. Kaufmann, W. E. Mitchell, D. Newton,
L. Osmundsen, & M. Schuster (Eds.), Sepik heritage: Tradition and
change in Papua New Guinea (pp. 428438). Durham: Carolina
Academic Press.
Mitchell, W. E. (1999). Why Wape men dont beat their wives:
Constraints toward domestic tranquility in a New Guinea society.
In D. A. Counts, J. K. Brown, & J. C. Campbell (Eds.), To have
and to hit: Cultural perspectives on wife beating (pp. 100109).
Urbana, IL: University of Illinois Press.
Taru, L. (1977). Causes of lack of development in the Lumi
Sub-Province of the West Sepik Province between 1945 and 1955.
Yagl-Ambu, 4, 314328.
1017
Waisi, P. (1982). The Laufis world-view: An attempt to locate its metaphysical base. A sub-thesis submitted to the University of Papua
New Guinea as a partial requirement for the Bachelor of Arts
Honours Degree in Philosophy. Papua New Guinea: Waigani.
Yanomam
Jennifer Kuzara and Raymond Hames
ALTERNATIVE NAMES
Yanomami, Waika, Waica, Guaica, Shori, Yanoama,
Yanomama, Shiriana, Xiriana, Shidishana, and Guajaribo.
The names Sanema, Sanum, and Sanima are auto denominations of Yanomam people to the north and east of the
main tribal distribution. They are culturally and genetically very closely related to the larger Yanomam groups
and their dialect is partially intelligible.
The name Yanomam means person, individual, or
human. Alternative names such as Shamatari or Waica
(Waika) are relative terms used by some Yanomam to
refer to other Yanomam living to the south or north,
respectively.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
1018
Yanomam
Patterns of Disease
There has been a considerable amount of biomedical and
epidemiological research done on the Yanomam since
1966 that we cannot hope to effectively detail here.
Elsewhere (Hames & Kuzara, in press) we present a
much more complete review of this research, especially
as it relates to the complexities of disease processes, origins, interactions, epidemiology, genetic susceptibilities,
and the role of contact and acculturation. The pattern of
diseases that affects the Yanomam has been changing
rapidly since first contact with Europeans and others.
It is difficult to know with certainty what the disease
pressures acting on the Yanomam prior to contact would
have been; it is likely that many of the infectious diseases
affecting the Yanomam today were absent before the last
century. Presently, in addition to introduced infectious
diseases, the Yanomam suffer widely from macroparasite infections. The humoral immune defenses that are
most effective against macroparasites preclude the T-cell
driven immune defenses that would be of most aid against
many introduced diseases, such as tuberculosis. Thus, the
matrix of both diseases to which the Yanomam have
been exposed since before their first contact, exacerbated
by the conditions of sedentism in which many Yanomam
now find themselves, and those to which they are newly
exposed, is complex. Because first contact occurred so
recently, many diseases which have been introduced can
be traced to their original source or point of introduction.
Others, however, seem to have preceded actual contact
with Europeans, either through contacts between the
Yanomam and other Amerindians of the area, or through
infected animal vectors.
One of the most serious parasitic diseases now
afflicting the Yanomam is malaria, a serious infection
that can result in high fevers, hemolytic anemia, and
potentially dangerous enlargement of the spleen and liver.
Of the two species of Plasmodium, P. vivax is the most
common species, while P. falciparum results in the most
severe infection. In Yanomam territories, P. falciparum
accounts for most infections (68.6%, Torres, Magris,
Villegas, Torres, & Dominguez, 2000; 57.1%, Mato, 1998).
1019
1020
Yanomam
1021
tested for HDV, all six of them were positive for the
presence of anti-delta antigens, showing that this particularly severe form of hepatitis was present among the
Yanomam prior even to its description in the medical
literature. However, these results may not be representative of the entire population, as the samples from 1975
were collected from individuals who showed some sign of
liver disease.
Hepatitis poses a severe health risk for the
Yanomam who engage in many practices that make the
wide and rapid spread of this blood- and saliva-borne disease likely. Breast-feeding, which can last 23 years, the
premastication of childrens food, the sharing of instruments used to pierce the body, the sharing of chewed
tobacco, and the early onset of sexual activity are only
some of the examples of this.
Venereal disease has been present among the
Yanomam since the 1960s, and gained greater prevalence
since then (Peters, 1998, p. 247). HIV is also a concern, as
Boa Vista, one of the larger settlements in close proximity
to the Yanomam, has one of the highest rates of HIV in
Brazil.
Another kind of virus with long-term effects that is
now a concern for the Yanomam is the polyoma virus.
Working in the field in 1969, James Neel and Arthur
Bloom showed high rates among the Yanomam of cytogenetic damage similar to that caused by SV40, the simian
polyoma virus. The polyoma virus is a type of papova
virus, or DNA tumor virus, a class of viruses which have
been implicated in carcinogenesis. These viruses can also
produce kidney, neurological, and lymphoid disease. A
study by Major and Neel (1998) showed that among individuals from 33 villages, 43.06% had significant titers of
antibody to JCV polyoma virus, and 40.65% had significant titers of antibody to BKV polyoma virus. The distribution and heterogeneity suggested that the viruses were
of recent introduction to the Yanomam, and that there
were probably two points of entry of the virus into the
group, with introduction from the eastern (Brazilian) portion of their territory more significant than that from the
western (Venezuelan) side. Other studies have shown
unexpected chromosomal damage among the Yanomam
(Neel, 1971). The Yanomam were chosen for a study of
chromosomal damage as an example of a population who
had been exposed to minimum levels of toxic agents in
the environment. The results were surprising, showing
that compared to the controls (members of the expedition) and a group of Japanese examined in a similar study,
1022
Yanomam
Medical Practitioners
1023
MEDICAL PRACTITIONERS
Shamans (shabori) are the major medical practitioners
among the Yanomam. Young men who wish to become
shamans are apprenticed by an experienced shaman who
is usually a senior agnate (Taylor, 1976). They are taught
appropriate chants to call spirits (or hekura, who are
causes and cures for illnesses and exist in the form of tiny
humanoids) and supernatural lore. The training is
demanding often lasting more than a year and during this
1024
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
The Yanomam believe that nearly all illness (and most
misfortunes) are caused by either spirits (hekura) or the
ghosts (bore) of deceased Yanomam. The Yanomam
have a complex conception of the soul. One of these, the
mamo, can be attacked or lured out of the body by hekura
sent by a malevolent shaman (Chagnon, 1997, p. 113). If
counter magic is not preformed by a curing shaman, death
will ensue.
There are two kinds of spirits that can cause illness:
bore or sprits of dead Yanomam and hekura. A bore is that
part of the soul that travels to a distant area of forest when
a person dies. If a kinsman offended the deceased during
his lifetime, the ghost may avenge himself by causing sickness. An important offense is an improper mortuary ceremony which includes, among other things, destruction of
Yanomam
SEXUALITY
AND
REPRODUCTION
Infancy
Infanticide occurs for all the reasons listed above for abortion and, in addition, if the child has a congenital defect.
Preferential female infanticide is widely reported for the
Yanomam. The Yanomam show a decided preference for
males (as in the case of twin births described above) and in
many villages there is an infantile and juvenile sex ratio
strongly skewed towards boys. To some extent, this skewing is a consequence of preferential female infanticide.
Early and Peters (2000, pp. 210212) in a careful analysis
of infanticide for Brazilian Yanomam show that 8% of all
births results in infanticide and of these 32% are preferential female infanticides. However, in nearly all cases the
decision to kill a child is made prior to birth.
During an infants first 6 months of life, it is in the
exclusive care of his mother or a close female relative
when the mother is indisposed. During this time fathers
are believed to lack the competence to care for infants.
Mothers are expected to provide attentive care for the
child and nurse on demand. Throughout most of the day
1025
Childhood
During the first 3 years of life children are seldom disciplined. However, if discipline is meted out, it can be very
severe. If the child cries or becomes upset, it is given the
breast or its genitals are gently rubbed, or it is pacified in
other ways. Between the ages of 4 and 8 children roam
immediately about the village in mixed age and sex
groups. However, during this time boys and girls begin to
segregate in same-sex groups with boys having more
freedom to range further from the village and the girls
are encouraged to help their mothers or care for younger
siblings.
Adolescence
During this period boys and girls begin to take on labor
activities that ultimately mirror adults patterns. Girls
begin this process much earlier. By the time they are 9
years of age, they help carry firewood, fetch water, and
prepare food. By the time they are 1213, they have mastered the rudiments of nearly all of a womans tasks.
Throughout this period they are expected to avoid boys
and young men when they are bathing or otherwise out of
sight of their parents. At the sign of their first menses,
1026
Adulthood
There are few Yanomam women who do not bear the
scars of their husbands violence. Women may be jabbed
in the buttocks or thigh by arrow points, burned with firewood, or cracked across the head with firewood splitting
the skin on the skull. Sometimes these injuries lead to
significant disability or death. There are probably no
Yanomam men who do not bear injuries from dueling or
warfare. Most injuries are on the head in the form of split
skin. In fact, the men will shave their tonsure to show
these dueling injuries. Death through violence accounts
for 530% of all adult male mortality (Hames, 2001).
The Aged
The aged are treated well especially if they are surrounded by numerous kin and can still make economic
contributions to families with whom they are associated.
Common ailments include arthritis and old injuries that
limit mobility.
Yanomam
References
1027
REFERENCES
Basanez, M. G., Yarzabal, L., Takaoka, H., Suzuki, H., Noda, S., &
Tada, I. (1988). The vectoral role of several blackfly species
Diptera simuliidae in relation to human onchocerciasis in the
Sierra Parima and Upper Orinoco regions of Venezuela. Annals of
Tropical Medicine and Parasitology, 82, 597612.
Beckerman, S., Lizzaralde, R., Ballew, C., Sissel, S., Fingelto, C.,
Garrison, A., & Smith, H. (1998). The Bari partible paternity project: Preliminary results. Current Anthropology, 39, 164167.
Chagnon, N. (1997). Yanomam (5th ed.). New York: Harcourt Brace
Jovanovich.
Confalonieri, U. E., Araujo, A. J., & Ferreira, L. F. (1989). Intestinal
parasites among Yanomami indians. Memorias do Instituto
Oswaldo Cruz, 84, 111114.
Crews, D. E., & Mancilha, C. J. J. (1991). Correlates of blood pressure
in Yanomami indians of northwestern Brazil. Ethnicity and
Disease, 3, 362371.
Donnelly, C., Thomson, L., Stiles, H., Brewer, C., Neel, J. V., &
Brunelle, J. (1977). Plaque, caries, periodontal diseases, and
acculturation among Yanomam Indians, Venezuela. Community
Denistry and Oral Epidemiology, 5, 3039.
Early, J., & Peters, J. (2000). The Xiliana Yanomami of the Amazon.
Gainesville, FL: University Press of Florida.
Eveland, W., Oliver, C. W. J., & Neel, J. V. (1971). Characteristics of
Escherichia coli serotypes in the Yanomamma, a primitive Indian
tribe of South America. Infection and Immunity, 4, 753756.
Franco, M. H. L. P., Brennan, S. O., Chua, E. K. M., Kragh, H. U.,
Callegari, J. S. M., Bezerra, M. Z. P. J., & Salzano, F. M. (1999).
Albumin genetic variability in South America: Population distribution and molecular studies. American Journal of Human
Biology, 11, 359366.
Franco, R. F., Araujo, A. G., Zago, M. A., Guerreiro, J. F., &
Figueiredo, M. S. (1997). Factor IX gene haplotypes in
Amerindians. Human Biology, 69, 19.
Freeman, J., Laserson, K. F., Petralanda, I., & Spielman, A. (1999, May).
Effect of chemotherapy on malaria transmission among Yanomami
Amerindians: Simulated consequences of placebo treatment.
American Journal of Tropical Medicine and Hygiene, 60, 774780.
Gershowitz, H., & Neel, J. V. (1978). The immunoglobulin allotypes
(Gm and Km) of twelve Indian tribes of Central and South
America. American Journal of Physical Anthropology, 49,
289301, maps, table.
Godoy, G. A., Volcan, G. S., Medrano, C., & Guevara, R. (1989).
Onchocerciasis endemic in the state of Bolivar Venezuela. Annals
of Tropical Medicine and Parasitology, 83, 405410.
Greenberg, J. (1960). The general classification of Central and South
American languages. In Men and cultures. Selected papers of the
Fifth Internation Congress of Anthropological and Ethnological
Sciences, Philadelphia, 1956 (pp. 791794). Philadelphia.
Grillet, M. E., Basanez, M. G., Vivas, M. S., Villamizar, N., Frontado, H.,
Cortez, J., Coronel, P., & Botto, C. (2001, July). Human onchocerciasis
1028
in the Amazonian area of Southern Venezuela: Spatial and temporal
variations in biting and parity rates of black fly (Diptera: Simuliidae)
vectors. Journal of Medical Entomology, [print] 38, 520530.
Hagen, E., Hames, R. , Craig, N., Lauer, M., & Price, M. (2001). Parental
investment and child health in a Yanomam village suffering shortterm food stress. Journal of Biosocial Science, 99, 133.
Hames, R. (1979). A comparison of the efficiencies of the shotgun and
bow in neotropical forest hunting. Human Ecology, 7, 219252.
Hames, R. (1989). Time, efficiency, and fitness in the Amazonian protein quest. Research in Economic Anthropology, 11, 4385.
Hames, R. (1996). Costs and benefits of monogamy and polygyny for
Yanomam women. Ethology and Sociobiology, 17, 181199.
Hames, R. (1999). Reciprocal altruism in Yanomam food exchange.
In L. Cronk, N. Chagnon, & W. Irons (Eds.), Human behavior and
adaptation: An anthropological Perspective (pp. 226252).
New York: Aldine de Gruyter.
Hames, R., & Kuzara, J. (in press). The nexus of Yanomam growth,
health, and demography. In Francisco Salzano & Magdalena
Hurtado (Eds.), Lost Paradises and the Ethics of Research and
Publication. Oxford University Press.
Hurtado, M., Hill, K., Kaplan, H., & Lancaster, J. (2001, June). The
epidemiology of infectious diseases among South American
Indians: A call for guidelines for ethical research. Current
Anthropology, [print] 42, 425432.
Intersalt, C. R. G. (1988). Intersalt: An international study of electrolyte
excretion and blood pressure results for 24 hour urinary sodium
and potassium excretion. British Medical Journal, 297, 319328.
Jansson, B. (1990). Dietary total body and intracellular potassium to
sodium ratios and their influence on cancer. Cancer Detection and
Prevention, 14, 563566.
Laserson, K. F., Petralanda, I., Almera, R., Barker, Jr., R. H., Spielman,
A., Maguire, J. H., & Wirth, D. F. (1999a, December). Genetic
characterization of an epidemic of Plasmodium falciparum malaria
among Yanomami Amerindians. Journal of Infectious Diseases,
180, 20812085.
Laserson, K. F., Wypij, D., Petralanda, I., Spielman, A., & Maguire, J. H.
(1999b, May). Differential perpetuation of malaria species among
Amazonian Yanomami Amerindians. American Journal of
Tropical Medicine and Hygiene, 60, 767773.
Lawrence, D. N., Neel, J. V., Abadi, S. H., Moore, L., Adams, G.,
Healy, G., & Kagan, I. (1980). Epidemiologic studies among
Amerindian populations of Amazonia. III intestinal parasitoses in
newly contacted and acculturating villages. American Journal of
Tropical Medicine and Hygiene, 29, 530537.
Lizot, J. (1977). Population, resources, et Guerre chez les Yanomami.
Libre, 2, 111145.
Major, E. O., & Neel, J. V. (1998). The JC and BK human polyoma viruses
appear to be recent introductions to some South American Indian
tribes: There is no serological evidence of cross-reactivity with the
simian polyoma virus SV40. Proceedings of the National Academy
of Sciences of the United States of America, 95, 1552515530.
Mancilha-Carvalho,. J. J., & Crews, D. E. 1990. Lipid profiles of
Yanomam Indians of Brazil. Preventive Medicine, 19, 6675.
Melancon, T. (1982). Marriage and reproduction among the Yanomam
of Venezuela. Thesis, Pennsylvania State University.
Migliazza, E. (1972). Yanomam grammar and intelligibility. Doctoral,
Indiana.
Milliken, W., & Albert, B. (1996). The use of medicinal plants by the
Yanomami Indians of Brazil. Economic Botany, 50, 1025.
Yanomam
Neel, J. V. (1971). Genetic aspects of the ecology of disease in the
American Indian. In F. M. Salzano (Ed.), The ongoing evolution of
Latin American populations (pp. 561590). Springfield, IL: Thomas.
Neel, J. V., Centerwall, W., Chagnon, N., & Casey, H. (1970). Notes
on the effect of measles and measles vaccine in a virgin soil
population of South American Indians. American Journal of
Epidemiology, 91, 418429.
Oliver, W. J., Cohen, E. L., & Neel, J. V. (1975). Blood pressure, sodium
intake, and sodium related hormones in the Yanomam Indians, a
no-salt culture. Circulation, 52, 146151.
Perez, M. S. (1998). Anemia and malaria in a Yanomami Amerindian
population from the southern Venezuelan Amazon. American
Journal of Tropical Medicine and Hygiene, 59, 9981001.
Peters, J. F. (1980). The Shirishana of the Yanomami Brazil a demographic study. Social Biology, 27, 272285.
Peters, J. F. (2000). Life among the Yanomami. Peterborough, Ontario,
Canada: Broadview Press.
Ramos, A. R. (1995a). Papel poltico das epidemias o caso Yanomami.
Ya No Hay Lugar para Cazadores, 5589.
Ramos, A. R. (1995b). Sanuma memories. Madison, WI: University of
Wisconsin Press.
Rassi, E., Laurda, B., & Giuaimaraes, J. (1976). Study of the area
affected by onchocerciasis in Brazil: Survey of local residents.
Bulletin of the Pan American Health Organization, 10, 3345.
Saffirio, G., & Hames, R. (1983). In K. Kensinger & J. Clay (Eds.), The
Forest and the Highway. Working Papers on South American
Indians #6 and Cultural Survival Occasional Paper #11 ( joint
publication) (pp. 152). Cambridge, MA: Cultural Survival.
Service, E. (1975). Origins of the state and civilization. New York:
W. W. Norton.
Sousa, A. O., Salem, J. I., Lee, F. K., Vercosa, M. C., Cruaud, P.,
Bloom, B. R., Lagrange, P. H., & David, H. L. (1997). An epidemic
of tuberculosis with a high rate of tuberculin anergy among a population previously unexposed to tuberculosis, the Yanomami Indians
of the Brazilian Amazon. Proceedings of the National Academy of
Sciences of the United States of America, 94, 1322713232.
Spielman, R. S. (1979). The evolutionary relationships of two populations: A study of the Guaym and the Yanomama. Current
Anthropology, 20, 377388.
Taylor, K. (1976). Body and spirit among the Sanuma (Yanoama)
of North Brazil. In F. Grollig & H. Haley (Eds.), Medical
Anthropology (pp. 2748). The Hague: Mouton.
Torres, J. R., & Mondolfi, A. (1991). Protracted outbreak of severe delta
hepatitis experience in an isolated Amerindian population of the
Upper Orinoco Basin Venezuela. Reviews of Infectious Diseases,
13, 5255.
Torres, R. J., Noya, G. O., Mondolfi, G. A., Peceno, C., & Botto, A. C.
(1988). Hyperreactive malarial splenomegaly in Venezuela.
American Journal of Tropical Medicine and Hygiene, 39, 1114.
Torres, R. J. R., Magris, M., Villegas, L., Torres, V. M. A., & Dominguez,
G. (2000). Spur cell anaemia and acute haemolysis in patients with
hyperreactive malarious splenomegaly. Experience in an isolated
Yanomam population of Venezuela. Acta Tropica, [print] 77,
257262.
Vivas, M. S., Basanez, M. G., Botto, C., Rojas, S., Garcia, M.,
Pacheco, M., & Curtis, C. F. (2000, November). Amazonian onchocerciasis: Parasitological profiles by host-age, sex, and endemicity in
southern Venezuela. Parasitology, [print] 121, 513525.
1029
Yoruba
Norma H. Wolff
Alternative Names
In the past the Yoruba have been identified by outsiders
as the Anago, Olukumi, and Aku (Adediran, 1998) Major
subgroups include the Egba, Egbado, Ekiti, Igbomina,
Ijebu, Ijesa, Ife, Kabba, Ondo, Owo, and Oyo.
LOCATION
AND
LINGUISTIC AFFILIATION
OVERVIEW
OF THE
CULTURE
1030
Yoruba
dysentery, pneumonia, measles, tuberculosis, gastroenteritis, and gonorrhea. Water-borne diseases such as
cholera, diarrhoea, and other enteric infections are common due to the lack of reliable water supplies. Piped
water is available only in urban areas. Villages depend on
streams, wells, and rainwater stored in pots and drums for
their water. Such water is often polluted. Another major
factor in determining health status is diet. Ecological conditions are such that the major crops raised are high carbohydrate foods. They include cassava, yam, and maize.
Protein sources are scarce and expensive to acquire.
Children are fed a high carbohydrate diet, particularly eko
or ogi (cornmeal pap). Malnutrition based on inadequate
consumption of proteins and enteric infections caused by
bad water and contaminated food, stored and cooked
under unsanitary conditions, are common (Iyun, 1994).
Aspects of the built environment also contribute to health
problems. Particularly in the urban areas, overcrowding
and inadequate public services contribute to deplorable
sanitation and outbreaks of diseases in low income
neighborhoods.
It is estimated that half of Nigerias children die
before the age of 6 from such causes as measles, gastroenteritis, malaria, tetanus, meningitis, pneumonia,
diarrhoea, whooping cough, polio and tuberculosis
(Osunwole, 1997; Oyeneye, 1991). In parts of Yorubaland,
infant mortality rates remain high, 78 out of 1,000 children dying before the age of 3 (Folasade, 2000). The most
common nonfatal chronic diseases are malaria and guinea
worm infestation. In 1987, the World Health Organization
estimated that Nigeria had the highest number of guinea
worm cases (140 million) in the world. Complications of
guinea worm infestation are the major cause of work and
school absenteeism. At the end of the 20th century,
epidemics of infectious diseases included cholera, yellow
fever, cerebrospinal meningitis, and AIDS, as well as continuing chronic infections of malaria, guinea worm, and
high rates of malnutrition (Metz, 1992). A newer trend
that is affecting higher income groups is the prevalence of
noninfectious social-stress diseases. Hypertension is a
leading cause of illness of Yoruba adults over the age of
30 treated in hospitals in Ibadan, Yorubalands largest city,
with males over the age of 45 bearing the greatest risks of
developing cardiac disease (Iyun, 1994, 1995). Upper
income males are most likely to suffer from hypertension
and myocarditis, while women run the risk of rheumatic
and pulmonary heart disease (Iyun, 1995). The increase in
heart disease in urban Westernized Africans has been
1031
1032
available to all, improve nutrition, promote health education, develop a family health program, promote family
planning, introduce improved therapy for childhood diarrheal diseases, and implement vaccination campaigns
against major childhood diseases (Metz, 1992). In the
early 1990s, challenges remained, including continuing
disparities between ruralurban availability of healthcare facilities and personnel. These problems persist in
the 21st century due to continuing economic tensions and
lack of foreign exchange limiting the availability of medical supplies, drugs, and equipment.
MEDICAL PRACTITIONERS
Yorubas have a wide variety of options in seeking health
care. Choices are determined by the nature and history
of the illness and the availability of services. Treatment
often starts in the family with herbal remedies made
with recipes passed through generations or after consulting locally printed indigenous medical formula
books (Maclean, 1971). Indigenous practitioners who
tap natures unseen powers to treat a full range of human
misfortunes and illnesses are often the next recourse.
Onisegun are herbalist-healers who heal illness and
combat misfortune. Oloogun are more likely to both
cure and cause illness and misfortune (Wolff, 1979,
2000). When supernatural causation of illness is suspected, the close ties between the medical and religious
systems draw the afflicted to babalawo, divination
priest-healers of Ifa, or olorisa, priests of deities.
Additional specialists include midwives, bone setters,
circumcisers who cut tribal marks and incisions for
medicines placed under the skins, and specialists in the
treatment of mental illnesses.
Gender is not a problem to practicing indigenous
medicine. Women practitioners (iya isegun) specialize in
womens and childrens health, as well as treatment of
conditions such as asthma, diabetes, jaundice, hypertension, and fractures (Osunwole, 1997). As midwives,
female practitioners manage childbirth and gynecological
problems that affect fertility. Women favor female healers
because of the bonds of similar experience and their
expertise on childrens diseases, including whooping
cough, measles, neo-natal tetanus, tuberculosis, and polio.
Women do not treat mental illnesses and other conditions
that necessitate using powerful supernaturally charged
medicines for fear that exposure to such forces causes
Yoruba
infertility or birthing of deformed children by the practitioner. Because of the importance placed on women treating women in indigenous context, there is a modern focus
on training Traditional Birth Attendants (TBAs) who
combine indigenous and biomedical practices to oversee
pregnancies and act as educators on womens and childrens health. TBAs provide both pre- and postnatal care
and take an active role in Primary Health Care programs
including family planning and safe mother programs.
They give advice on curing infertility, preventing
unwanted pregnancies, and consult with pregnant women
on diet, activity levels, and sexual relations during pregnancy. As midwives, they provide indigenous herbal therapies to speed birth, stop postpartum bleeding and
stimulate breast milk, as well as perform childbirth rituals
(Osunwole, 1997; Oyeneye, 1991).
In the urban areas, health-care options are evidence
of the contemporary indigenous and biomedical mix.
Clinics and hospitals provide access to biomedical specialists, including doctors with a wide range of specialties,
nurses, interns, midwives, and other medical workers. On
the streets and in the markets, every sort of pharmaceutical drug is for sale, specialists offer indigenous medicinal
ingredients including plants, animal parts, and minerals;
peddlers hawk patent medicines and home remedies, and
injectionists provide shots for every ailment. Contemporary religious beliefs also play a part in urban healing
practices. Christian faith healers of the syncretic churches,
such as Aladura, cure and drive out harmful spirits with
prayers and holy water. Muslim scholar-healers cure
with Islamic medicines and charms and the power of the
holy word.
Biomedical doctors in Yorubaland have found that
cooperation with indigenous healers is feasible, costeffective, and welcomed by patients, particularly in the
rural areas. Blending indigenous with scientific medical
practices makes them more acceptable and sustainable in
the Yoruba worldview. Adeoye Lambo, a Western-trained
Yoruba psychiatrist who served as the head of the World
Health Organization, was a pioneer in this effort. As
director of Aro Psychiatric Hospital in southwestern
Nigeria, Lambo found that Yoruba mental patients recovered more quickly when indigenous practitioners were
involved in their treatment. He developed the therapeutic
village approach where the mentally ill and their relatives
live together in a nearby settlement where the patient
receives treatment from both hospital and indigenous
practitioners.
CLASSIFICATION OF ILLNESS,
THEORIES OF ILLNESS, AND
TREATMENT OF ILLNESS
The Yoruba take a holistic approach to health or alafia
(lit. peace), a philosophy of life, health, and death tied
to the indigenous religion. Alafia encompasses physical,
social, emotional, psychological, and spiritual well-being
in the total environmental setting (Ademuwagun, 1978).
Physical health (ilera), a prerequisite to achieving life
goals, is negatively impacted by aisan, minor illnesses,
such as fevers, headaches, diarrhoea, and vomiting that
interfere with daily activities, and arun, which includes
serious pathological conditions, communicable diseases
such as smallpox and venereal diseases, infirmities,
chronic tiredness, debilitating mental illnesses, and
unexplained misfortunes (Ademuwagun, 1978; Warren,
Egunjobi, & Wahab, 1997a).
The indigenous medical system takes into account
both natural and supernatural causation of illness and
misfortune (Awolalu, 1979; Odebiyi, 1989). It is a personalistic medical system where causation includes
super-sensory forces directed toward afflicted individuals
in acts of active purposeful intervention by human or
nonhuman beings (Foster, 1976). Giving offense to
potentially dangerous human beings such as witches (aje)
or sorcerers (osho) and to entities such as evil spirits
(anjonu), deities (orisha), and ancestors (egungun) is an
ever-present danger. The belief that misfortunes of all
kinds result from power attacks directed by malevolent
beings is firmly entrenched in Yoruba thought. Every
stage of life is fraught with possibilities of supernatural
intervention that negatively affect advancement. Medicines
or oogun are designed to combat these forces.
Oogun takes tangible or intangible form to either
cure, cause, or counter illness and misfortune. In medicines, ashe, a potent universal power that the creator god
put into all nature, is focused and energized for good or
evil purposes through the combination of ingredients,
preparation procedures, and incantations or words
(Abiodun, 1994). To make medicine is to transform the
raw materials of nature such as leaves, roots, fruits,
woods, bird and animal parts, minerals and soils, and
sometimes artifacts, into power objects according to
specific formulas. The potential danger in the powers
incorporated into medicines necessitates taboos and precautions in the making. Osanyin, the deity of medicine, is
1033
1034
Yoruba
SEXUALITY
AND
REPRODUCTION
1035
1036
Infancy
Male and female circumcision is performed a few days
after birth, although the Egba and Ijebu sub-groups do
not practice female excision (Caldwell, Orubuloye, &
Caldwell, 1997). Men report that circumcision enhances
sexual performance and reproductive potential, as well as
reduces the female libido and promiscuity. Women support the practice of female circumcision by claiming that
it makes child delivery easier (Osunwole, 1997). There is
also a belief that the clitoris tip is charged with dangerous power that can kill the birthing child if it touches
its head (Caldwell et al., 1997). It is only recently with
global campaigns condemning female circumcision that
Yoruba women identified the practice as an act of male
domination to reduce female sexuality. In a 1997 survey,
male circumcision remained universal while female circumcision, still prevalent in the rural areas (98%), had
slightly declined in the urban areas (94%). Education,
religion, and socioeconomic status were significant factors in the decline. Only 87% of girls born to mothers
with secondary school education were circumcised.
Christians were less likely than Muslims to circumcise
females, and there was a decrease in families where
fathers were in professional, managerial, or clerical occupations. The most significant change has been the medicalization of circumcision beginning in the 1970s. With
involvement by biomedical professionals, circumcisionrelated deaths are rarely reported, and there has been a
Yoruba
major shift from excision to clitoridectomy in female circumcisions (Caldwell et al., 1997).
Infants are carried on the mothers back and breastfed on demand. From birth breastmilk is supplemented
with herbal infusions (agbo) thought to guard against a
variety of ailments and ward off evil influences. Solid
food in the form of cornstarch pap is introduced as early
as 2 months. While seen as health-enhancing, these practices increase the likelihood of death-threatening diarrhea
and other illnesses. Malnutrition is also a strong possibility if breast-feeding is not continued, because pap is a
poor source of protein and kwashiorkor may develop
(Davies-Adetugbo, 1997). In addition, the tonic purgatives (agbo) given to infant early each morning in the first
6 months and to older children whenever they fall sick
may be detrimental to health as ingredients, including
cow urine, are variable and unregulated (Maclean, 1971).
Some infants are singled out for special treatment.
Tied to high infant mortality rates is the belief in abiku
(born-to-die) children, troublesome spirits that die
before adulthood and return again and again to the same
mother. Such children are treated with special medicines
and given names such as Malomo (Do not go again)
(Maclean, 1971).
Childhood
There are many safeguards to ensure the health of children and protect them from evil influences and accidents.
Home remedies are used to treat minor illnesses and
indigenous and biomedical healers are consulted for more
serious ailments. From birth, children wear charms and
have imposed food proscriptions associated with attracting the favor of deities. However, children born with physical and mental defects are stigmatized. Congenital
malformations in children are perceived as supernatural
punishment for the parents and can be grounds for
a husband to desert his wife (Odebiyi & TogonuBickersteth, 1987). There is little tolerance for individuals
with physical abnormalities, despite the indigenous belief
that they are favored children of Obatala (Orisha-nla), the
sculptor-divinity who shapes children in the womb.
Albinos (afin), dwarfs (irara), hunchbacks (abuke), cripples (aro), and the dumb (odi), for example, are sacred to
Obatala (Awolalu, 1979). In the real world, handicapped
children are ridiculed and avoided and often exhibit withdrawal behavior. For example, in studies of attitudes
toward deaf children, no efforts were made at home
Adolescence
While there are no elaborate prolonged puberty rituals, the
importance of womens childbearing role is marked by
special ceremonies with sacrifices to the deities to thank
them when a girl reaches menarche (Togonu-Bichersteth,
1988).
Adulthood
The Yoruba have no ritual acknowledgment of adulthood.
Adulthood is recognized by taking on the expected male
and female roles defined by the division of labor. Men take
up economic activities, such as farming and craft production, and women become childbearers and rearers. It is
marriage and parenthood that fully identify individuals as
adults. Men marry between ages 25 and 30 and women
between 17 and 25. An integral part of marriage negotiations between families is investigations to reveal any family history of undesirable characteristics such as the
presence of leprosy, insanity, epilepsy, barrenness, birth
anomalies, or social digressions. It is expected that the
bride be in good health and be able to bear strong healthy
children. While expectations of virginity have altered in
contemporary context, the unquestioned health of wife
and future children is imperative (Eades, 1980; Olusanya,
1969).
The Aged
Yoruba old age occurs when the person can no longer
effectively carry out primary gender roles associated with
the division of labor. For men, the critical sign is
decreased stamina, so that active farming and labor
become difficult and economic productivity dwindles.
The critical indicator for women is menopause when
childbearing ceases. Three major factors contribute to a
sense of well-being and happiness in old age. These are
having good health, responsible children nearby, and sufficient money. Security for the elderly comes from within
the family where adult children, particularly sons, provide for aged parents economic and emotional needs.
1037
1038
REFERENCES
Abiodun, R. (1994). Understanding Yoruba art and aesthetics: The concept of ase. African Arts, XXVII(3), 6878.
Abraham, R. C. (1958). Dictionary of Modern Yoruba. London:
University of London Press.
Adebayo, A., & Adamchak, D. J. (1991). Ethnic affiliation and fertility
attitudes of Nigerian university students. College Student Journal,
1, 470477.
Adediran, B. (1998). Yorubaland up to the emergence of the states. In
A. D. Ogunremi & B. Adediran (Eds.), Culture and society in
Yorubaland (pp. 114). Ibadan: Rex Charles Publication in association with Connel Publications.
Adelowo, E. D. (1988). A comparative look at the phenomena of death
(iku), burial and funerary rites (isinku) in Yorubaland. Odu, 33,
163188.
Ademuwagun, Z. A. (1978). Alafiathe Yoruba concept of health:
Implications for health education. International Journal of Health
Education, XXI(2), 8997.
Akinkugbe, O. O. (1995). Lifestyle and cardiovascular diseases:
Emerging problems of health development in the Third World.
In B. F. Iyun, Y. Verhasselt, & J. A. Hellen (Eds.), The health of
nations: Medicine, disease and development in the Third World
(pp. 177183). Aldershot: Avebury.
Awolalu, J. O. (1979). Yoruba beliefs and sacrificial rites. London:
Longman.
Bascom, W. (1969). The Yoruba of southwestern Nigeria. New York:
Holt, Rinehart & Winston.
Buckley, A. D. (1985). Yoruba medicines. Oxford: Clarendon Press.
Caldwell, J. C., Orubuloye, I. O., & Caldwell, P. (1997). Male and
female circumcision in Africa from a regional to a specific
Nigerian examination. Social Science and Medicine, 44,
11811193.
Davies-Adetugbo, A. A. (1997). Sociocultural factors and the promotion of exclusive breast-feeding in rural Yoruba communities of
Osun, State, Nigeria. Social Science and Medicine, 45, 113125.
Eades, J. S. (1980). The Yoruba today. Cambridge: Cambridge
University Press.
Yoruba
Falola, T. (1999). The history of Nigeria. Westport, CN, London:
Greenwood Press.
Folasade, I. B. ( 2000). Environmental factors, situation of women and
child mortality in southwestern Nigeria. Social Science and
Medicine, 51, 14731189.
Foreign Area Studies (FAS) of The American University. (1972). Area
handbook for Nigeria. Washington, DC: U.S. Government Printing
Office.
Foster, G. M. (1976). Disease etiologies in non-western medical systems. American Anthropologist, 78, 773782.
Iyun, B. F. (1994). Health problems in Ibadan region. In M. O. Filani,
F. O. Akintola, & C. O. Ikporukpo (Eds.), Ibadan region (pp.
256268). Ibadan: Rex Charles.
Iyun, B. F. (1995). Cardiac morbidity in Nigerian society: Trends and
inter-relationships. In B. F. Iyun, Y. Verhasselt, & J. A. Hellen
(Eds.), The health of nations: Medicine, disease and development
in the Third World (pp. 139151). Aldershot: Avebury.
Lawoyin, T. O., & Onadeko, M. O. (1997). Fertility and childbearing
practices in a rural African community. West African Journal of
Medicine, 16, 204207.
Leroy, F., Olaleye-Oruene, T., Koeppen-Schomerus, G., & Bryan, E.
(2002). Yoruba customs and beliefs pertaining to twins. Twin
Research: The Official Journal of the International Society for
Twin Studies, 5, 132136.
Maclean, U. (1971). Magical medicine: A Nigerian case-study. London:
Allan Lane, The Penguin Press.
Metz, H. C. (Ed.). (1992). Nigeria: A country study. (5th ed.).
Washington, DC: Federal Research Division, Library of Congress.
Odebiyi, A. I. (1989). Food taboos in maternal and child health: The
views of traditional healers in Ile-Ife, Nigeria. Social Science and
Medicine, 28, 985996.
Odebiyi, A. I., & Togonu-Bickersteth, F. (1987). Concepts and management of deafness in the Yoruba medical system: A case study
of traditional healers in Ile-Ife, Nigeria. Social Science and
Medicine, 24, 645649.
Olusanya, P. O. (1969). Nigeria: Cultural barriers to family planning
among the Yorubas. Studies in Family Planning, 37, 317.
Osunwole, S. A. (1997). The role of women in traditional Yoruba medicine. In D. M. Warren, L. Egunjobi, & B. Wahab (Eds.), Studies
of the Yoruba therapeutic system in Nigeria (pp. 118128). Ames:
Iowa State University, Center for Indigenous Knowledge for
Agriculture and Rural Development. Studies in Technology and
Social Change, No. 28.
Oyeneye, O. Y. (1991). Family health in Nigeria. International Journal
of Sociology of the Family, 21, 18999.
Prince, R. (1961). Indigenous Yoruba psychiatry. In A. Kiev (Ed.),
Magic, faith, and healing: Studies in primitive psychiatry today
(pp. 84120). New York: Free Press of Glencoe.
Renne, E. P. (1993). Gender ideology and fertility strategies in an Ekiti
Yoruba village. Studies in Family Planning, 24, 343353.
Renne, E. P. (1997). Local and institutional interpretations of IUDs
in southwestern Nigeria. Social Science and Medicine, 44,
11411148.
Renne, E., & Bastian, M. L. (2001). Reviewing twinship in Africa.
Ethnology, 40, 111.
Riedmann, A. (1993). Science that colonizes: A critique of fertility
studies in Africa. Philadelphia: Temple University Press.
References
Togonu-Bichersteth, F. (1988). Perception of old age among Yoruba
aged. Journal of Comparative Family Studies, 19, 113122.
Udegbe, I. B. (1995). Current adjustment patterns of elderly Yoruba
women and their health implications. In B. Iyun, B. Folasade,
U. Verhasselt, & J. A. Hellen (Eds.), The health of nations:
Medicine, disease and development in the Third World
(pp. 217223). Aldershot, England: Avebury.
Verger, P. F. (1995). Ewe: The use of plants in Yoruba society. Sao Paulo:
Copmpanhia das Letras.
Warren, D. M., Egunjobi, L., & Wahab, B. (1996). The Yoruba concept
of health and well-being: Implications for Nigerian national
health policy. In F. Fairfax III, B. W. Wahab, L. Egunjobi, &
D. M. Warren (Eds.), Alaafia: Studies of Yoruba concepts of health
and well-being in Nigeria (pp. 49). Ames: Iowa State University
Center for Indigenous Knowledge for Agriculture and Rural
Development. Studies in Technology and Social Change, No. 25.
Warren, D. M., Egunjobi, L., & Wahab, B. (Eds.). (1997a). Studies of
the Yoruba therapeutic system in Nigeria. Ames: Iowa State
University Center for Indigenous Knowledge for Agriculture and
Rural Development. Studies in Technology and Social Change,
No. 28.
1039
Warren, D. M., Osunwole, S. A., & Wolff, N. H. (1997b). Yoruba lexicon for therapeutics. In D. M. Warren, L. Egunjobi, & B. Wahab
(Eds.), Studies of the Yoruba therapeutic system in Nigeria
(pp. 4472). Ames: Iowa State University Center for Indigenous
Knowledge for Agriculture and Rural Development. Studies in
Technology and Social Change, No. 28.
Wolff, N. H. (1979). Concepts of causation and treatment in the
Yoruba medical system: The special case of barrenness. In
Z. A. Ademuwagun, J. A. A. Ayoade, I. E. Harrison, & D. M. Warren
(Eds.), African therapeutic systems (pp. 125131). Waltham:
Crossroads Press.
Wolff, N. H. (2000). The use of human images in Yoruba medicines.
Ethnology, 39, 205224.
Zeitlin, M. F., & Babatunde, E. D. (1995). The Yoruba family:
Kinship, socialization, and child development. In M. F. Zeitlin,
R. Megawangi, E. M. Kramer, N. D. Colletta, E. D. Babatunde, &
D. Garman (Eds.), Strengthening the family: Implications for
international development (pp. 142181). Tokyo, NY, Paris:
United Nations University Press.
Subject Index
Hmong, 739740
Iroquois, 749
Jamaican Maroons, 762763
Japanese, 774775
Jat, 781782
Malagasy, 801, 801802
Malays, 847848
Maori, 809
Matsigenka, 824
Maya of Highland Mexico, 835
Mongolia, 858
Nahua, 869870
Navajo, 879880
Nepal, 889
Northwest Coast, 899900
Ojibwa, 912
Oklahoma Choctaw, 921
Roma of the United States and Europe, 927
Samoa, 935
Saraguros, 944
Shipibo, 955
Sotho, 961962
Sudanese, 970
Thai, 979
Tongans, 987
Trobriand, 996997
Tuareg, 1007
Wape, 1015
Yanomam, 10251026
Yoruba, 1037
Adrenoleukodystrophy (ALD), genetic disease, 412413
Adulthood
African-Americans, 554
Amish, 562563
Argentine Toba, 570
Badaga, 577
Baliem Valley Dani, 597598
Bangladeshis, 586587
British, 604605
Burmese, 612613
Cree, 620621
Datoga, 636637
Fore, 645
Fulani, 662
1041
1042
Garhwali, 671
Garifuna, 678
Greeks, 687
Hadza, 694
Han, 716
Hausa, 726727
Hmong, 740
Iroquois, 749750
Jamaican Maroons, 763764
Jat, 782
Malays, 848
Maori, 809810
Matsigenka, 824825
Maya of Highland Mexico, 835
Mongolia, 858
Nahua, 869870
Navajo, 880
Nepal, 889
Ojibwa, 912913
Oklahoma Choctaw, 921
Roma of the United States and Europe, 927
Samoa, 935936
Saraguros, 944
Shipibo, 955
Sotho, 962
Sudanese, 970
Thai, 979
Tuareg, 1008
Wape, 1015
Yanomam, 1026
Yoruba, 1037
Agammaglobulinemia, genetic disease, 413
Age studies, phenomenology, 131132
Aged
African-Americans, 554555
Amish, 563
Argentine Toba, 570
Badaga, 578
Bangladeshis, 587
British, 605
Burmese, 613
Cree, 621
Fore, 645
French, 654655
Fulani, 662663
Garhwali, 671672
Garifuna, 678
Greeks, 687
Hadza, 694695
Han, 716717
Hausa, 727
Hmong, 740
Iroquois, 750
Jamaican Maroons, 764
Japanese, 775
Jat, 782783
Malagasy, 802
Malays, 848
Subject Index
Maori, 810
Maya of Highland Mexico, 835
Mongolia, 858
Nahua, 870
Navajo, 880881
Nepal, 889
Northwest Coast, 900
Ojibwa, 913
Oklahoma Choctaw, 921922
Roma of the United States and Europe, 927
Samoa, 936
Saraguros, 944945
Shipibo, 955956
Sotho, 962
Sudanese, 970
Thai, 979
Tuareg, 1008
Wape, 10151016
Yanomam, 1026
Yoruba, 1038
Agency for International Development (USAID), 166
Aging, 217223
AD, 314315
anthropological perspectives, 312
anthropology of, 217
chronic diseases of, 311318
cultural construction, 218
and disease, 311
elderhood, 217218
gender and, 219
global context, 220221
identifying, 218
impact, population health, 311312
longevity, 435
Matsigenka, 824825
menopause, 219
old age, 217218
societal transformation, 220
status, 219220
witchcraft, 220
see also Population aging
AIDS see HIV/AIDS
AIS see Androgen insensitivity syndrome
Akaptonuria, genetic disease, 414
Albinism, genetic disease, 409, 413414
Alcohol use, 293301
AA, 20, 298
alcohol abuse, 296
alcoholic personality, 295
alternatives, 298299
anthropology and alcohol studies, 294296
anthropologys contribution to understanding, 300
culture window, 295296
Datoga, 636
discourse, universalizing, 299300
education as prevention, 298
epidemiology, 297298
Han, 706
Subject Index
milestones, 297
Mongolia, 853854
practical implications, 296300
problems, related, 296
public policies, 297298
ritual setting hypothesis, 378
treatment, 298299
trends, 296300
WHO, 297, 299300
see also Drug use
Alcoholics anonymous (AA), 298
illness narratives, 20
Alcoholism, Native Americans, 202
ALD see Adrenoleukodystrophy
ALS see Amyotrophic lateral sclerosis, familial
Altered states of consciousness (ASC), shamanism, 146148
Alzheimers disease (AD), 314315
African-Americans, 554555
cross-cultural distribution, 314315
genetic disease, 414415
prevention, 315
risk factors, 314315
sociocultural studies, 315
treatment, 315
Ambiguous genitalia, genetic disease, 415
American Academy of Pediatrics, breast milk substitutes, 234
American Association of Mental Retardation (AAMR), 494495
Amok, Malaysia, 324
Amuk, Malays, 844845
Amyotrophic lateral sclerosis, familial (FALS), genetic disease, 415
Androgen insensitivity syndrome (AIS), genetic disease, 415
Angelman syndrome (AS), genetic disease, 416
Anishinaabe sickness, Ojibwa, 910911
Anosmia, genetic disease, 416
Anthropological health research, history, 45
Anthropological interviewing, psychoanalysis, 6364
Anthropological research, comparative nature, 158159
Anticipation, genetic disease, 397398
Applied issues, cross-cultural health research, 311
AS see Angelman syndrome
ASC see Altered states of consciousness
Asthma, genetic disease, 416
Ataxia telangiectasia (A-TI), genetic disease, 416
Australia, refugee health, 194195
Autism, genetic disease, 408, 417
Autosomal inheritance, genetic disease, 395397
Ayurvedic system, Jat, 779
Balneology, Czechs, 626627
Bariba, birth, 227
Beginning-of-life decision-making, bioethics, 7778
Behavior disability/difference, 360363
Behavioral intervention, HIV/AIDS, 465469
Benefits, breast-feeding, 231
Benin, birth, 227
Beta thalassemia, Greeks, 683
Biafra, post-colonial development and health, 186
Bilateral donors, economic development, 166
1043
Biocultural models, child growth, 236237
Bioethics, 7386
anthropology importance, 73
applied anthropological work, 7980
beginning-of-life decision-making, 7778
cultural diversity, 7980
cultural domain of inquiry, 7578
cultural process, 7578
death, 7576
defining, 74
EBM, 81
end-of-life care, 77
ethics consultation, 7980
ethno-ethnic traditions, 7879
future research areas, 8081
genetic disease, 404405
genetics, 78
historical development, 7374
identity, 78
identity, bioethicists, 79
informed consent, 80
justice, 8081
cf. medical ethics, 74
organ transplantation/donation, 76
prognosis disclosure, 7677
public health, 8081
race, 78
reproductive ethics, 78
research ethics, 80
terminal diagnosis disclosure, 7677
theoretical issues, 75
topical issues, 7578
truth-telling, 7677
Biological warfare, population control, 277
Biomedical practitioners, Tongans, 983984
Biomedical technologies, 8695
contraceptives, 8789
organ transplantation/donation, 9192
pharmaceuticals, 8788
reproductive technologies, 8991, 102
Biomedicine, 95109
anthropology and, 9697
childbirth, 104
disease construction, 101
early studies, 9596
and humanism, 99
knowledge, 9799
Local Biology, 99100
practice, 9799
principle of separation, 98
realities, 99101
social stratification, 200201
stance of practice, 103
translating, 104105
trends, 101103
worldview, 9799
Yoruba, 1032
Biomedicine cultures, emerging infectious diseases, 388389
1044
Biopolitics, death/dying, 248249
Biosocial traits, childhood, 239240
Biotechnology, genetic disease, 399405
Bipolar affective disorder, genetic disease, 417
Birth, 224230
African-Americans, 552
Amish, 561
anthropology of, 225226
Argentine Toba, 567568
authoritative knowledge, 228229
Badaga, 575576
Baliem Valley Dani, 595596
Bangladeshis, 585
Bariba, 227
Benin, 227
biomedicine, 104
British, 603
Burmese, 611
contextualising birthing systems, 226228
Cree, 619
cross-cultural analysis, 225226
cultural patterning, 225226
Czechs, 628
Datoga, 634635
early ethnographies, 224225
early surveys, 224225
Fore, 644
French, 653
Fulani, 660
Garhwali, 669670
Garifuna, 677678
global perspectives, 226228, 229
Greeks, 685686
Hadza, 693
Han, 715716
Hausa, 725
Hmong, 737738
Iroquois, 748
Jamaican Maroons, 762
Japanese, 773
Jat, 780
local perspectives, 226228, 229
Malagasy, 800
Malays, 846847
Malaysia, 227
Maori, 808
Matsigenka, 823
Maya of Highland Mexico, 834
midwifery, 225226
Mongolia, 857
multiple births, 438439
Nahua, 867868
Navajo, 878
Nepal, 888
Northwest Coast, 899
Ojibwa, 911912
Oklahoma Choctaw, 920
placenta disposal, 224225
Subject Index
Roma of the United States and Europe, 926
Samoa, 934935
Saraguros, 942943
Shipibo, 954
Sierra Leone, 227228
Sotho, 960961
Sudanese, 969
Thai, 978
Tongans, 986
Trobriand, 995
Tuareg, 10061007
Wape, 10141015
western, anthropology of, 228
witchcraft, 227
Yanomam, 10241025
Yoruba, 1036
see also Midwifery
Birth control
abortion as, 278
population control, 273274, 278
see also Contraceptives; Family planning
BL see Burkitt lymphoma
Black Death see Bubonic plague
Blindness, disability/difference, 363
Blood pressure
cultural consonance, 333334
differences, societies, 328330
stress, 333334
Bloom syndrome, genetic disease, 417
BMD see Bone mineral density
Body disability/difference, 360363
Bolivian altiplano, medical pluralism, 112113
Bombay phenotype, genetic disease, 417
Bone diseases
OA, 56
osteoporosis, 312314
Bone infections, paleopathology, 5354
Bone mineral density (BMD), 312313
Bone tumours, paleopathology, 5657
Bones, illness of, Datoga, 632
Bonesetters
Jamaican Maroons, 756
Nahua, 865
Bovine Spongiform Encephalitis (BSE), 390
Brain-death, 248249
organ transplantation/donation, 9293
Brazil
cholera, 308
HIV/AIDS, 469
possession and trance, 140
psychoanalytic movements, 6566
sufferer experience, 28
Breast cancer
African-Americans, 551
demographic transition, 399400
genetic disease, 408, 417418
illness narratives, 2021
Breast-feeding, 230235
Subject Index
benefits, 231
costs, 231232
cross species perspective, 230232
cultural practices, 232233
disease protection, 231
evolutionary perspective, 230232
health benefits, 231232
immunologic protection, 231
initiation, 232233
La Leche League, 234235
maintenance, 232233
oxytocin, 231
physiological perspective, 230232
prolactin, 231
substitutes, 234235
supplementation, 233234
weaning, 233234
western practices, 234235
BSE see Bovine Spongiform Encephalitis
Bubonic plague
paleopathology, 54
population control, 270
Buddhist medicine, Mongolia, 854
pre-Buddhist Traditions, Mongolia, 854, 855
Burial, Jamaican Maroons, 764
Burkitt lymphoma (BL), genetic disease, 418
CAH see Congenital adrenal hyperplasia
California, holistic/new age healing center, 114
CAM see Complementary and alternative medicine
Cancer, paleopathology, 5657
Cannabis, drug use, 378379
Cannibalism, Fore, 640
Cardiovascular disease, 328335
African-Americans, 553
blood pressure, 328330
Caries, paleopathology, 57
Case studies
disasters, 160162
medical pluralism, 111114
Cattle, Fulani, 656
CCR5 gene mutation see Chemokine (C-C) receptor 5
CDC see Centers for Disease Control and Prevention
CDD see Chronic degenerative disease
Centers for Disease Control and Prevention (CDC), 27
CGH see Hypertrichosis, congenital generalized
Chagas disease, epidemiology, 479481
Charcot-Marie-Tooth disease 1A (CMT1), genetic disease, 418
Chemokine (C-C) receptor 5 (CCR5), genetic disease, 408, 418419
Chiapas area, Maya of Highland Mexico, 828829
Child abuse/neglect, 242, 301305
breaking the cycle, 303304
categories, 301302
consequences, 304
cross-cultural perspective, 303
definitions, 301302
demographics, 302303
etiology, 303
1045
incidence, 302303
intervention, 304
prevention, 304
Child care practices, SIDS, 510511
Child growth, 235244
biocultural models, 236237
continuity, 239
cross-cultural examples, 240241
DNA regulation, 236237
events/duration, 237239
life history theory, 237239
medical anthropology, 236
plasticity, 239
pygmies, 241
reasons, 239
risks, 241242
study reasons, 235236
Childbirth see Birth
Childhood
African-Americans, 552553
Amish, 562
Argentine Toba, 569
Badaga, 577
Baliem Valley Dani, 596
Bangladeshis, 586
biosocial traits, 239240
British, 604
Burmese, 612
Cree, 620
Czechs, 628629
Datoga, 636
Fore, 644
French, 654
Fulani, 661662
Garhwali, 671
Garifuna, 678
Greeks, 687
growth events/duration, 237239
Hadza, 693694
Han, 716
Hausa, 725726
Hmong, 739
Iroquois, 749
Jamaican Maroons, 762763
Japanese, 774
Jat, 781
Malagasy, 800801
Malays, 847
Maori, 808809
Matsigenka, 824
Maya of Highland Mexico, 835
Mongolia, 857858
Nahua, 869
Navajo, 879
Nepal, 888
Ojibwa, 912
Oklahoma Choctaw, 921
Roma of the United States and Europe, 926927
1046
Samoa, 935
Saraguros, 944
Shipibo, 955
Sotho, 961
Sudanese, 970
Thai, 978979
themes, 239240
Tongans, 987
Trobriand, 996
Tuareg, 1007
Wape, 1015
Yanomam, 1025
Yoruba, 1037
Childrens Vaccine Initiative (CVI), 263
China
abortion, 278
diabetes mellitus, 343344
family planning, 89
psychoanalytic movements, 6566
Chinese Medicine, Traditional (TCM), Lijiang Naxi, 786787
Cholera, 305311
Brazil, 308
history, 305306
prevalence, 306
Chromosomal mutations, genetic disease, 394395
Chronic degenerative disease (CDD), 34
Chronic diseases of aging, 311318
AD, 314315
osteoporosis, 312314
CHRs see Community Health Representatives
Circulatory abnormalities, paleopathology, 56
Circumcision, female see Female genital cutting
CJD see Creutzfeldt-Jakob disease
CKN1 see Cockayne syndrome type 1
Class, social stratification, 203
Clinical medicine, illness narratives in, 4546
Cloning, stem cell, 403
CMA see Critical medical anthropology
CMT1 see Charcot-Marie-Tooth disease 1A
Cockayne syndrome type 1 (CKN1), genetic disease, 419
Cognitive-ethnographic studies, illness treatment decisions, 1618
Cognitive medical anthropology, 1223
Colon cancer, genetic disease, 419
Colonial era, Haitians, 699
Colonialism see Post-colonial development and health
Color blindness, genetic disease, 419420
Community-based interventions, diabetes mellitus, 347
Community context, Ojibwa, 907908
Community Health Representatives (CHRs), Oklahoma Choctaw, 918
Complementary and alternative medicine (CAM)
Amish, 560
Czechs, 626
Conditions, medicalized, 120121
Congenital adrenal hyperplasia (CAH), genetic disease, 408, 420
Congenital defects, paleopathology, 5152
Congo, post-colonial development and health, 186
Consent, informed see Informed consent
Contact, Northwest Coast, 893894
Subject Index
Contagions, Northwest Coast, 893894
Contemporary paradigm, Samoa, 933934
Contraception
and abortion, 8889
biographies, 8788
biomedical technologies, 8789
Hmong, 737
Jamaican Maroons, 761762
population control, 274
reproductive health, 283284
social aspects, 283284
Contragestin, population control, 274
Contranatals, population control, 274275
Controversies, cross-cultural health research, 311
Conventional medicine, cf. vernacular medicine, 8
Costs, breast-feeding, 231232
Cot death see Sudden infant death syndrome
Counseling, genetic disease, 403404
Creutzfeldt-Jakob disease (CJD), 390, 399, 401402, 409410
genetic disease, 420
cf. kuru, 401
Cri-du-chat syndrome, genetic disease, 420
Critical medical anthropology (CMA), 2330, 102
critical perspective, 2425
disease, defining, 26
health, defining, 26
impact, 2930
key concepts, 2629
medical hegemony, 2829
medical pluralism, 29, 111
medicalization, 28
origin, 2526
sufferer experience, 2728
tobacco, 525527
Critical perspective, health social sciences, 2425
Crohn disease, genetic disease, 421
Cross-cultural distribution
AD, 314315
osteoporosis, 313
Cross-cultural health research
controversies, 311
key concepts, 311
vs. mono-cultural health research, 89
theoretical issues, 311
Cross-cultural medical systems, 68
Cross-cultural perspectives
child abuse/neglect, 303
shamanism, 146
Cross-cultural research, schizophrenia, 489491
Cross-cultural review, disability/difference, 360363, 366367
Cross species perspective, breast-feeding, 230232
Cultural consensus theory, 1415
Cultural consonance, blood pressure, 333334
Cultural diversity, bioethics, 7980
Cultural expression
neuroses, 6263
psychoses, 6263
Cultural factors, Malays, 840842
Subject Index
Cultural history, African-Americans, 547548
Cultural knowledge, comparing, 1516
Cultural models, illness narratives, 1821
Cultural settings, variability, 1415
Cultural variation, evolutionary theory, 35
Culture and environment, Northwest Coast, 891892
Culture-bound syndromes, 319327
amok, 324
defining, 319321
Japan, 320321
koro, 320, 323324
kuru, 324325
latah, 325
Malaysia, 320, 323324
nerves, 320, 322
social change, 325326
susto, 322323
types, 321322
Culture, defining, 12
Culture of poverty, urban poor, 210
Culture overview
African-Americans, 545546
Amish, 557558
Argentine Toba, 564565
Badaga, 572573
Baliem Valley Dani, 591592
Bangladeshis, 579580
British, 599600
Burmese, 607609
Cree, 615616
Czechs, 622623
Datoga, 629630
Fore, 638641
French, 646647
Fulani, 656657
Garhwali, 665
Garifuna, 673674
Greeks, 681682
Hadza, 689690
Haitians, 696699
Han, 703704
Hausa, 718719
Hmong, 729731
Iroquois, 744745
Jamaican Maroons, 754755
Japanese, 766768
Jat, 777778
Lijiang Naxi, 784785
Malagasy, 795796
Malays, 840
Maori, 804805
Matsigenka, 812
Maya of Highland Mexico, 828
Mongolia, 850851
Nahua, 863864
Navajo, 873
Nepal, 883884
Northwest Coast, 891894
1047
Ojibwa, 903905
Oklahoma Choctaw, 916
Roma of the United States and Europe, 923924
Samoa, 929931
Saraguros, 937938
Shipibo, 947948
Sotho, 957958
Sudanese, 965
Thai, 971972
Tongans, 981982
Trobriand, 990991
Tuareg, 10011003
Wape, 10101011
Yanomam, 10171018
Yoruba, 10301031
Culture shock, psychoanalysis, 59, 6465
Culture window, alcohol use, 295296
Current era, Haitians, 699700
Curses, Datoga, 632
CVI see Childrens Vaccine Initiative
Cystic fibrosis, genetic disease, 421
Cytogenic conditions, genetic disease, 394395
DALY see Disability Life Years
Dancers, Jamaican Maroons, 756
Darwin, Charles
genetic disease, 393
population control, 269
Deafness, genetic disease, 421
Death control, population control, 272273
Death/dying, 244252
bioethics, 7576
biopolitics problem, 248249
brain-death, 9293, 248249
critique and innovation, 246
defining, 7576, 9293, 248249
experience, 246248
hospice movement, 247248
organ transplantation/donation, 9293
as problem of life, 248249
process, 246248
religious studies, 245246
ritual studies, 245246
social inequality, disease distribution, 249
social studies, 245246
studies, 246248
Uniform Determination of Death Act (1981), 248
violent death, 249251
see also Sudden infant death syndrome
Death/dying, Jamaican Maroons, 764
Death/rebirth, shamanism, 147148
Decision-making, cognitive-ethnographic studies, 1618
Degenerative disease, paleopathology, 56
Demographic data, Czechs, 623624
Demographic transition, genetic disease, 399400
Demographics
Japanese, 766
Saraguros, 937938
1048
Demographics, child abuse/neglect, 302303
Demography
Haitians, 696697, 699
population control, 270271
transition theory, 271
Demonic forces, Greeks, 683
Dengue fever, 306
epidemiology, 479481
Dental paleopathology, 57
Depression
genetic disease, 422
mental disorder, 488489
DGS see DiGeorge syndrome
DI see Diego blood group
Diabetes insipidus, genetic disease, 422
Diabetes mellitus, 335353
African-Americans, 344, 346
China, 343344
community-based interventions, 347
complications, 336337
definitions, 335336
diagnostic criteria, 336
dietary transitions, 341343
educational interventions, 347
epidemiology, 337338
evolution, 340341
genetic disease, 422423
genetic thriftiness, 340341
Hispanic traditional medicine, 345
IDF, 337
India, 343344
Iroquois, 751
Korea, 343344
Latino traditional medicine, 345
lifestyle factors, 341343
Maya of Highland Mexico, 829830
medical anthropology, 339
Native Americans, 342, 345, 346
obesity, 335, 336, 338, 341
Oklahoma Choctaw, 919920
patient-provider interactions, 346
Pima Indians, 342
populations studied, 338339
prevalence, 337338
risk factors, 335, 336, 338, 341
traditional healthcare beliefs, 343345
type 1;, 335, 422
type 2;, 335, 341, 343345, 422423
Diachronicity, disasters, 158
Diarrhea, 353360
biomedical diagnosis, 354355
biomedical perspectives, 353
cause, 355
classification, 353355
diagnostic categories, 353354
environmental relationships, 357
epidemiologic cycles, 355357
ethnomedical care/treatment, 357
Subject Index
ethnomedical classes, 353354
ethnomedical perspectives, 353
ethnomedical transmission, 355
implications, theoretical/applied, 358359
Mexico, 359
pathogens, 356357
transmission routes, 355357
treatment, 357358
treatment, home, 357358
treatment, plants, 359
urban poor, 209
web sites, 359360
Diego blood group (DI), genetic disease, 423
Diet
Czechs, 624625
Hadza, 690691
Han, 704705, 713
Malagasy, 797
Maya of Highland Mexico, 829830, 836
Mongolia, 852853
Trobriand, 992
Yanomam, 1023
Dietary transitions, diabetes mellitus, 341343
Diffusing medical systems, 7
Diffusion of Innovations Theory (DIT), HIV/AIDS,
467468
DiGeorge syndrome (DGS), genetic disease, 423
Disability, 103
Disability/difference, 360373
anthropology of, 366369
behavior, 360363
blindness, 363
body, 360363
cross-cultural review, 360363, 366367
defining, 368
illness and, 368369
neurofibromatosis, 363
research review/critique, 363366
responses, 360363
theory review/critique, 363366
WHO, 368
Disability Life Years (DALY), depression, 488
Disaccharide intolerance, genetic disease, 423424
Disasters, 157164
adaptation, 158
anthropology perspectives, 158159
case study, 160162
classifying, 157
defining, 158
diachronicity, 158
earthquake case study, 160162
ethnography, 160
history of research, 157158
research methodologies, 159160
resilience, 159
social aspects, 157
stress, 157
vulnerability, 159
Subject Index
Disease
and aging process, 311
anthropological perspectives, 307308
classification, paleopathologic, 51
CMA, 26
construction, 101
defining, 34, 26
ecological/evolutionary perspective, 307
ecology, 3133, 36
emerging infectious, 383391
equilibrium and change, 32
evolution, 3132, 3336
genetic see Genetic disease
insect vector see Vector-borne diseases
Interpretive perspective, 308
natural selection, 307
political/economic perspective, 307
vector-borne see Vector-borne diseases
water-borne, 305311
Disease distribution, social inequality, 249
Disease patterns, Yanomam, 10181023
Disease protection, breast-feeding, 231
DIT see Diffusion of Innovations Theory
Divorce
Hadza, 694
Hmong, 736737
DM see Myotonic dystrophy
DMD see Muscular dystrophy Duchenne type
DNA
child growth regulation, 236237
mutations, 395
Domestic abuse
Czechs, 625626
Datoga, 637
Malagasy, 801802
Double-Y syndrome, 395
genetic disease, 424
Down syndrome, genetic disease, 394, 409, 424425
Drug use, 374382
after 1960, 378379
anthropology of, 375
background, 374377
cannabis, 378379
consequences, 378
contributions, 380381
early accounts, 375
ethnography, street drug use, 379
hazards, 376
history, 374377
HIV/AIDS, 379380
impact, 380381
methods, 377380
models, 377380
prohibition, 376377
western moralism, 376
see also Alcohol use
Dwarfism, genetic disease, 408, 425, 431432
Dying/death
1049
African-Americans, 555
Amish, 563
Argentine Toba, 570571
Badaga, 578
Baliem Valley Dani, 598
Bangladeshis, 587588
British, 605606
Burmese, 613614
Cree, 621
Czechs, 629
Datoga, 637
Fore, 645
French, 655
Fulani, 663
Garhwali, 672
Garifuna, 679
Greeks, 687688
Hadza, 694
Han, 717
Hausa, 727728
Hmong, 740
Iroquois, 750
Japanese, 775
Jat, 783
Malagasy, 802803
Malays, 848
Maori, 810811
Matsigenka, 825
Maya of Highland Mexico, 835836
Mongolia, 858
Nahua, 870
Navajo, 881
Nepal, 889
Ojibwa, 913
Oklahoma Choctaw, 922
Roma of the United States and Europe, 927928
Samoa, 936
Saraguros, 945
Sotho, 962963
Sudanese, 970
Thai, 979980
Tongans, 987988
Trobriand, 998999
Tuareg, 1008
Wape, 1016
Yanomam, 1026
Yoruba, 1038
Dyslexia, genetic disease, 425
Earthquake case study, disasters, 160162
EBM see Evidence-based medicine
Ebola, 389
Ecological/evolutionary perspective, disease, 307
Ecological perspectives, 3137
controversies, 33
reproductive ecology, 33
Economic development, 164170
bilateral donors, 166
1050
defining, 164165
international agencies, 165166
medical anthropologists in, 167168
private foundations, 166167
United Nations, 165
USAID, 166
WHO, 165166
World Bank, 165166
Economic factors
African-Americans, 546548
Amish, 558560
Argentine Toba, 565566
Badaga, 573
Baliem Valley Dani, 592593
Bangladeshis, 580581
British, 600601
Burmese, 609610
Cree, 616617
Czechs, 623626
Datoga, 630631
Fore, 641643
French, 647
Fulani, 657658
Garhwali, 665666
Garifuna, 675
Hadza, 690691
Haitians, 699700
Han, 704707
Hausa, 719720
Iroquois, 745746
Japanese, 768771
Jat, 778
Lijiang Naxi, 785787
Malagasy, 796797
Malays, 840842
Maori, 805807
Matsigenka, 812814
Maya of Highland Mexico, 828831
Mongolia, 851854
Nahua, 864
Navajo, 874
Nepal, 885
Northwest Coast, 894897
Ojibwa, 905908
Oklahoma Choctaw, 916917
Roma of the United States and Europe, 924
Saraguros, 938939
Shipibo, 948951
Sotho, 958959
Sudanese, 965966
Thai, 972975
Tongans, 982983
Trobriand, 991992
Tuareg, 10031004
Wape, 10111012
Yanomam, 10181023
Yoruba, 10311032
Economy
Subject Index
Czechs, 623
Datoga, 630
Haitians, 697698
Hmong, 730
Japanese, 767
Samoa, 930
Tuareg, 10011002
Ectodermal dysplasia, anhidrotic (EDA), genetic disease, 426
EDS see Energy dispersive spectrometer
Educational interventions, diabetes mellitus, 347
Edward syndrome, 395
genetic disease, 426
Efficacy theories, Navajo, 877
Elderhood, aging, 217218
Emerging infectious diseases, 383391
biomedicine cultures, 388389
culture, 386387
epidemiology, 386387
examples, 383384
future directions, 390
molecular biology, 387388
social change, 387388
study methods, 386388
theoretical heritage, 384386
Emphysema, congenital, genetic disease, 426
End-of-life care, bioethics, 77
Energy dispersive spectrometer (EDS), forensic anthropology, 39
Enteritis necroticans, Fore, 641642
Environmental factors
African-Americans, 546548
Amish, 558560
Argentine Toba, 565566
Badaga, 573
Baliem Valley Dani, 592593
Bangladeshis, 580581
British, 600601
Burmese, 609610
Cree, 616617
Czechs, 623626
Datoga, 630631
Fore, 641643
French, 647
Fulani, 657658
Garhwali, 665666
Garifuna, 674675
Greeks, 682683
Hadza, 690691
Haitians, 699700
Han, 704707
Hausa, 719720
Iroquois, 745746
Japanese, 768771
Jat, 778
Lijiang Naxi, 785787
Malagasy, 796797
Malays, 840842
Maori, 805807
Matsigenka, 812814
Subject Index
Maya of Highland Mexico, 828831
Mongolia, 851854
Nahua, 864
Navajo, 874
Nepal, 885
Northwest Coast, 894897
Ojibwa, 905908
Oklahoma Choctaw, 916917
Roma of the United States and Europe, 924
Saraguros, 938939
Shipibo, 948951
Sotho, 958959
Sudanese, 965966
Thai, 972975
Tongans, 982983
Trobriand, 991992
Tuareg, 10031004
Wape, 10111012
Yanomam, 10181023
Yoruba, 10311032
Environmental factors, mental retardation, 498500
Environmental relationships, diarrhea, 357
EPI see Expanded Program on Immunization
Epidemics see Emerging infectious diseases
Epidemiology
alcohol use, 297298
emerging infectious diseases, 386387
genetic, 407409
mental retardation, 496498
SIDS, 507509
trends, Maori, 805
vector-borne diseases, 479481
Epilepsy, progressive myoclonic 2 (EPM2A), genetic disease, 426
EPM2A see Epilepsy, progressive myoclonic 2
Erythroblastosis fetalis, genetic disease, 426
Essential tremor (ETM1), genetic disease, 426
Ethics see Bioethics; Medical ethics
Ethnic identity, Garifuna, 673674
Ethnicity, social stratification, 201202
Ethnographic research vs. ethnological research, 89
Ethnography, disasters, 160
Ethnological research vs. ethnographic research, 89
Ethnomedical studies, vector-borne diseases, 481482
Etiologies
Hmong, 733735
Jamaican Maroons, 758759
ETM1 see Essential tremor
Eugenics
genetic disease, 393394
population control, 277278
Evidence-based medicine (EBM), bioethics, 81
Evil eye
Datoga, 632
Garhwali, 667668
Greeks, 684
Evolutionary perspectives, 3137
breast-feeding, 230232
controversies, 35
1051
cultural variation, 35
disease, 3132, 3336
see also Paleopathology
Exorcism, possession and trance, 142
Expanded Program on Immunization (EPI), 263
Externalizing illness, 67
Extrusion illness, 7
Factor V Leiden thrombophilia, genetic disease, 426
FALS see Amyotrophic lateral sclerosis, familial
Familial fatal insomnia (FF1), genetic disease, 426427
Family and kinship
Czechs, 623
Datoga, 630
Haitians, 698
Japanese, 767
Tuareg, 1002
Family planning, 8889
population control, 279
Family, Saraguros, 938
FAP see Adenomatous polyposis, familial
Fatalism, Nepal, 886887
Female genital cutting (FGC), 252262
elimination strategies, 257260
Islam, 256
medicalization, 259
Prevention of Discrimination and the Protection of Minorities,
254, 258
Sierra Leone, 255
Special Report, 254, 258
Sudan, 255
trivialization of culture, 253257
Female pollution, Fore, 639640
Fertility
Han, 714715
Mongolia, 856
Saraguros, 942
Sudanese, 968969
Fertility enhancement, reproductive health, 285
Fertility regulation, reproductive health, 283284
Fetal hemoglobin, hereditary persistence, heterocellular (HPFH),
genetic disease, 427
Fever, Datoga, 632
FF1 see Familial fatal insomnia
FGC see Female genital cutting
FHC see Hypercholesterolemia, familial
Fires of life, Trobriand, 994
Five Elements, Han, 708709
FMF see Mediterranean fever, familial
Food
homelessness, 172173
see also Nutritional anthropology
Food therapy, Han, 713
Forensic anthropology, 3742
applications, 40
definitions, 37
EDS, 39
goals, 3839
1052
history, 3738
methodology, 39
related disciplines, interface with, 4041
SEM, 39
techniques, new, 3940
training, 38
Fractures, paleopathology, 5253
Fragile X syndrome (FRAX), genetic disease, 427
Fructose intolerance, genetic disease, 427
Funerals, psychoanalysis, 6061
Future directions
emerging infectious diseases, 390
HIV/AIDS, 473474
mental disorders, 491
tuberculosis, 536537
Future research areas, bioethics, 8081
G6PD deficiency, Greeks, 683
Galactosemia, genetic disease, 428
Garrod, Archibald Edward, 393
Gastronomy, French, 649650
Gaucher disease, genetic disease, 428
Gender
aging and, 219
social stratification, 203204
Gender relations, Fore, 639
Gender research, vector-borne diseases, 483
Gendered body, phenomenology, 130
Genetic disease, 391462
achromatopsia, 408
albinism, 409
anticipation, 397398
antiquity, 392393
autism, 408
autosomal inheritance, 395397
bioethics, 404405
biotechnology, 399405
breast cancer, 408
CCR5 gene mutation, 408
CJD, 390, 399, 401402, 409410
congenital adrenal hyperplasia, 408
cytogenic conditions, 394395
Darwin, Charles, 393
demographic transition, 399400
distributions, 409453
Down syndrome, 394, 409
dwarfism, 408
etiology facets, 392
eugenics, 393394
foundation, genetics, 393
gene therapy, 403404
genetic counseling, 403404
genetic epidemiology, 407409
genomic imprinting, 397398
Herodotus, 392
history, 391394
Human Genome Project, 400401
inborn errors of metabolism, 393
Subject Index
kuru, 409
lactose persistence, 408
MCAs, 394395
maple syrup urine disease, 408
Maupertuis, 392
mechanisms, 394395
Mendel, Gregor, 393
mitochondrial inheritance, 397
modes of inheritance, Mendelian, 395397
modes of inheritance, non-Mendelian, 397399
molecular genetic conditions, 395
molecular genetics, 394
monogenic factors, 397
multifactorial disorders, 398399
mutations, chromosomal, 394395
mutations, DNA, 395
New World syndrome, 409
phenocopies, 399
polydactyly, 408
polygenic factors, 398399
porphyria variegata, 408
SCD, 392, 408
sex-linked inheritance, 397
sources, current information, 399
stem cell research/cloning, 403
synopsis, syndromes, 411453
Tay-Sachs disease, 408, 409
uniparental disomy, 397398
web sites, 399
Weissmann, August, 393
X-linked inheritance, 392, 397
Y-linked inheritance, 397
see also Named diseases
Geneticenvironmental interactions, mental retardation, 501502
Genetic factors, mental retardation, 498
Genetic thriftiness, diabetes mellitus, 340341
Genetics, bioethics, 78
Genitalia, ambiguous, genetic disease, 415
Genomic imprinting, genetic disease, 397398
Germs, Jamaican Maroons, 757758
Gerstmann-Straussler-Sheinker disease (GSSD), genetic disease, 428
GGM see Glucosegalactose malabsorption
Ghettos see Urban poor
Gilles de la Tourette syndrome (GTS), genetic disease, 429
Glaucoma, genetic disease, 429
Global context, aging, 220221
Global immunization efforts, 263
Global perspectives
birth, 226228, 229
urban poor, 211
Glucose-6-phosphate dehydrogenase (G6PD) deficiency, genetic
disease, 429
Glucosegalactose malabsorption (GGM), genetic disease, 429
Glycogen storage disease, genetic disease, 429
Government, Czechs, 623
Growth see Child growth
GSSD see Gerstmann-Straussler-Sheinker disease
GTS see Gilles de la Tourette syndrome
Subject Index
Guatemala earthquake, case study, 160162
Guevedoces, genetic disease, 430
Gusii practices, weaning, 233234
Haiti, medical pluralism, 113
HBM see Health Belief Model
HCV see Hepatitis C virus
HD see Huntington disease
HDN see Hemolytic disease of the newborn
Healers
Hausa, 720722
Hmong, 732733
Tongans, 983
Healers, shamanism, 148149
Healing
and possession/trance, 141142
shamanism, 152153
Healing behaviors, evolution, 3435
Health
African-Americans, 550
CMA, 26
defining, 34, 26
homelessness and, 174175
Health Belief Model (HBM), HIV/AIDS, 466467
Health care system, Japanese, 768769
Health conditions
Hmong, 731732
Maya of Highland Mexico, 836838
Health context, Jamaican Maroons, 755756
Health development, 164170
medical anthropologists in, 167168
see also Economic development
Health, historical context, Ojibwa, 906907
Health indicators, Samoa, 931932
Health infrastructure
Czechs, 625
Haitians, 700
Samoa, 932
Thai, 974975
Health insurance, Czechs, 625
Health patterns
Argentine Toba, 571
Badaga, 578
Bangladeshis, 588
Fulani, 663
Garhwali, 672
Garifuna, 679680
Greeks, 687688
Hadza, 694
Iroquois, 750752
Maya of Highland Mexico, 836
Mongolia, 858861
Nahua, 870871
Nepal, 889890
Northwest Coast, 900901
Oklahoma Choctaw, 922
Roma of the United States and Europe, 928
Saraguros, 945946
1053
Sudanese, 970
Tongans, 988
Tuareg, 1008
Wape, 1016
Yanomam, 10261027
Yoruba, 1038
Health profile, Saraguros, 938939
Health research, history, 45
Health-seeking process, 56
Health situation, Argentine Toba, 566
Health social sciences, critical perspective, 2425
Hegemony, medical see Medical hegemony
Hemochromatosis, hereditary (HH), genetic disease, 430
Hemoglobin (Hb) alleles, genetic disease, 430
Hemolytic disease of the newborn (HDN), genetic disease, 431
Hemophilia, genetic disease, 431
Hepatitis C virus (HCV), 383, 389
Hepatitis, Yanomam, 1021
Herbal practitioners, Han, 707708
Herbal treatments, Han, 711714
Herbalists
Hmong, 732
Jamaican Maroons, 756
Navajo, 874
Northwest Coast, 897
Hermansky-Pudlak syndrome (HPS), genetic disease, 431
Hermaphroditism, genetic disease, 431
Herodotus, genetic disease, 392
HGP see Human Genome Project
HH see Hemochromatosis, hereditary
Hispanic traditional medicine, diabetes mellitus, 345
History
Czechs, 622623
Haitians, 697
Hmong, 729730
Japanese, 766767
Samoa, 930
Saraguros, 937938
Tuareg, 1001
History, anthropological health research, 45
HIV/AIDS, 383, 386387, 389
Baliem Valley Dani, 593
Bangladeshis, 588
behavioral intervention, 465469
behavioral research, anthropology in, 469473
Brazil, 469
condom use, 465
DIT, 467468
drug use, 379380
epidemiological features, 464465
ethnography and, 470472
future directions, 473474
Han, 705706
HBM, 466467
illness narratives, 20
immune system effects, 464465
Lijiang Naxi, 791
Malagasy, 799
1054
medical features, 464465
morbidity, 463
mortality, 463
Nepal, 889890
post-colonial development and health, 189
prevention, 462479
Puerto Rico, 469
reproductive health, 286
research, 462479
research methods, 472473
sexuality and, 286
social stratification, 202203
Sotho, 958959
syndemics, 27
Thai, 977978, 979
TRA, 467
transmission, 464
treatment, 465
urban poor, 208, 209
Holistic/new age healing center, California, 114
Homelessness, 170177
daytime respites, 176
defining, 170171
doubling-up, 174
ending, 175176
food, 172173
health and, 174175
leadership, 176
mental illness, 174175
methodologies, study, 171
panhandling, 172
physical health, 174
skid row studies, 171172
street life, 172
substance abuse, 175
supportive housing, 176
survival strategies, 171174
theories, 170171
transitional housing, 176
tuberculosis, 174
urban poor, 208
Homeopathic practitioners, Bangladeshis, 582
Homeopathy, French, 651652
Hormone replacement therapy (HRT), 605
British, 605
Hospice movement, 247248
Hospitals, Hausa, 722723
HPFH see Fetal hemoglobin, hereditary persistence, heterocellular
HPS see Hermansky-Pudlak syndrome
HRAFs see Human Relations Area Files
HRT see Hormone replacement therapy
HTC2 see Hypertrichosis, congenital generalized
Human Genome Project (HGP), 98, 399
genetic disease, 400401
Human Relations Area Files (HRAFs), 9
Humanism, and biomedicine, 99
Humoral pathology, Greeks, 683684
Hunter syndrome, genetic disease, 432
Subject Index
Huntington disease (HD), genetic disease, 432
Hurler syndrome, 432
Hydrops fetalis, genetic disease, 432
Hypercholesterolemia, familial (FHC), genetic disease, 432
Hyperlipoproteinemia, genetic disease, 432433
Hypertrichosis, congenital generalized (CGH) (HTC2), genetic
disease, 433
Hypophosphatasia, familial, genetic disease, 433
IBD see Inflammatory bowel disease
Ideal household, Mongolia, 856857
Identities, medicalized, 120121
Identity, bioethics, 78
Identity, Fulani, 657
IDF see International Diabetes Federation
IHS see Indian Health Service
Illness
defining, 34
disability/difference and, 368369
externalizing, 67
extrusion, 7
internalizing, 67
intrusion, 7
Illness classification
African-Americans, 550551
Amish, 560
Argentine Toba, 566567
Badaga, 574575
Baliem Valley Dani, 594
Bangladeshis, 582583
British, 602
Burmese, 610611
Cree, 618619
Czechs, 627628
Datoga, 631632
Fore, 643
French, 648652
Fulani, 658659
Garhwali, 666669
Garifuna, 676677
Greeks, 683684
Hadza, 692
Haitians, 700701
Han, 709710
Hausa, 723724
Hmong, 733736
Iroquois, 747748
Jamaican Maroons, 757760
Japanese, 772773
Jat, 779
Lijiang Naxi, 788791
Malagasy, 798799
Malays, 843846
Maori, 807
Matsigenka, 815822
Maya of Highland Mexico, 832833
Mongolia, 855856
Nahua, 865867
Subject Index
Navajo, 875
Nepal, 886887
Northwest Coast, 898899
Ojibwa, 909911
Oklahoma Choctaw, 919920
Roma of the United States and Europe, 925
Samoa, 932934
Saraguros, 940941
Shipibo, 952953
Sotho, 959960
Sudanese, 966967
Thai, 976977
Tongans, 984985
Trobriand, 992993
Tuareg, 10051006
Wape, 10121014
Yanomam, 1024
Yoruba, 10331035
Illness concept, Han, 709
Illness defined, African-Americans, 550
Illness diagnosis, Han, 710
Illness narratives, 4249
in anthropology, 4445
in clinical medicine, 4546
cultural models, 1821
illness autobiography, 4243
narratologists, 4647
Illness theories
African-Americans, 550551
Amish, 560
Argentine Toba, 566567
Badaga, 574575
Baliem Valley Dani, 594
Bangladeshis, 582583
British, 602
Burmese, 610611
Cree, 610611
Czechs, 627628
Datoga, 631632
Fore, 643
French, 648652
Fulani, 658659
Garhwali, 666669
Garifuna, 676677
Greeks, 683684
Hadza, 692
Haitians, 700701
Han, 708709
Hausa, 723724
Hmong, 733736
Iroquois, 747748
Jamaican Maroons, 757760
Japanese, 772773
Jat, 779
Lijiang Naxi, 788791
Malagasy, 798799
Malays, 843846
Maori, 807
1055
Matsigenka, 815822
Maya of Highland Mexico, 832833
Mongolia, 855856
Nahua, 865867
Navajo, 875
Nepal, 886887
Northwest Coast, 898899
Ojibwa, 909911
Oklahoma Choctaw, 919920
Roma of the United States and Europe, 925
Samoa, 932934
Saraguros, 940941
Shipibo, 952953
Sotho, 959960
Sudanese, 966967
Thai, 976977
Tongans, 984985
Trobriand, 993994
Tuareg, 10051006
Wape, 10121014
Yanomam, 1024
Yoruba, 10331035
Illness treatment
African-Americans, 550551
Amish, 560
Argentine Toba, 566567
Badaga, 574575
Baliem Valley Dani, 594
Bangladeshis, 582583
British, 602
Burmese, 610611
Cree, 610611
Czechs, 627628
Datoga, 631632
Fore, 643
French, 648652
Fulani, 658659
Garhwali, 666669
Garifuna, 676677
Greeks, 683684
Hadza, 692
Haitians, 700701
Han, 710711
Hausa, 723724
Hmong, 733736
Iroquois, 747748
Jamaican Maroons, 757760
Japanese, 772773
Jat, 779
Lijiang Naxi, 788791
Malagasy, 798799
Malays, 843846
Maori, 807
Matsigenka, 815822
Maya of Highland Mexico, 832833
Mongolia, 855856
Nahua, 865867
Navajo, 875877
1056
Nepal, 886887
Northwest Coast, 898899
Ojibwa, 909911
Oklahoma Choctaw, 919920
Roma of the United States and Europe, 925
Samoa, 932934
Saraguros, 940941
Shipibo, 952953
Sotho, 959960
Sudanese, 966967
Thai, 976977
Tongans, 984985
Trobriand, 994
Tuareg, 10051006
Wape, 10121014
Yanomam, 1024
Yoruba, 10331035
Illness treatment decisions, cognitiveethnographic studies, 1618
Immigration, population control, 276
Immunization, 262268
acceptance, 265266
barriers, 265
British, 603604
CVI, 263
demand, 265266
EPI, 263
global efforts, 263
history, 262263
Jamaican Maroons, 763
media reports, 267
Netherlands, 266
Philippines, 266267
resistance, 266267
vaccination programs, 264265
Immunologic diseases, paleopathology, 56
Immunologic protection, breast-feeding, 231
In vitro fertilization (IVF), 91
Inborn errors of metabolism, genetic disease, 393
India
diabetes mellitus, 343344
medical pluralism, 111
psychoanalytic movements, 6566
Indian Act (1876), Ojibwa, 905
Indian Health Service (IHS), Oklahoma Choctaw, 917919
Indonesia, post-colonial development and health, 185187, 189
Industrial development, Han, 704
Infancy
African-Americans, 552
Amish, 561562
Argentine Toba, 568
Badaga, 576577
Baliem Valley Dani, 596
Bangladeshis, 585586
British, 603604
Burmese, 612
Cree, 619620
Czechs, 628
Datoga, 635636
Subject Index
Fore, 644
French, 653654
Fulani, 660661
Garhwali, 670671
Garifuna, 678
Greeks, 686687
growth events/duration, 237239
Hadza, 693
Han, 716
Hausa, 725
Hmong, 738739
Iroquois, 748749
Jamaican Maroons, 762
Japanese, 773774
Jat, 781
Malagasy, 800
Malays, 847
Maori, 808
Matsigenka, 823824
Maya of Highland Mexico, 834835
Mongolia, 857
Nahua, 868869
Navajo, 878879
Nepal, 888
Ojibwa, 912
Oklahoma Choctaw, 921
Roma of the United States and Europe, 926
Samoa, 935
Saraguros, 943944
Shipibo, 954955
Sotho, 961
Sudanese, 969970
Thai, 978
Tongans, 986987
Trobriand, 996
Tuareg, 1007
Wape, 1015
Yanomam, 1025
Yoruba, 10361037
Infectious disease
paleopathology, 5354
urban poor, 209
Infectious diseases, emerging see Emerging infectious diseases
Infertility
reproductive health, 285
reproductive technologies, 8991, 102
Inflammatory bowel disease (IBD), genetic disease, 433434
Informed consent, bioethics, 80
Infrastructure
Han, 706707
Mongolia, 853
Inherited disease see Genetic disease
Inner-cities see Urban poor
Insect vector diseases see Vector-borne diseases
Internalizing illness, 67
International Diabetes Federation (IDF), 337
International relations, Haitians, 698
Internet sites see Web sites
Subject Index
Interpretive perspective, disease, 308
Interviewing, anthropological see Anthropological interviewing
Intrusion illness, 7
Iran
family planning, 89
menstruation, 282
Islam, FGC, 256
IVF see In vitro fertilization
Japan
culture-bound syndromes, 320321
family planning, 89
medical pluralism, 113
psychoanalytic movements, 6566
Justice, bioethics, 8081
Juvenile stage, growth events/duration, 237239
Key concepts, cross-cultural health research, 311
Kinship, Saraguros, 938
Klinefelter syndrome, genetic disease, 434
Korea, diabetes mellitus, 343344
Koro, culture-bound syndrome, 320, 323324
KRAS see Ras oncogene
Kuru
cf. CJD, 401
culture-bound syndrome, 324325, 386, 387
genetic disease, 399, 409, 434
Kuru, Fore, 642643
La Leche League, breast-feeding, 234235
Lactose persistence, genetic disease, 408
Language of Wider Communication (LWC), African-Americans, 545
Laos, Hmong in, 731732
Latah, culture-bound syndrome, 325
Latah, Malays, 844845
Latino traditional medicine, diabetes mellitus, 345
Lebers hereditary optic neuropathy (LHON), genetic disease,
434435
Legislation
Uniform Determination of Death Act (1981), 248
violent death, 249251
Leprosy, paleopathology, 54
Lesch-Nyhan syndrome, genetic disease, 435
LHON see Lebers hereditary optic neuropathy
Life cycle, growth events/duration, 237239
Life cycle, health through, Lijiang Naxi, 792793
Life history theory
child growth, 237239
principles, 237239
trade-offs, 237239
Lifestyle factors, diabetes mellitus, 341343
Linguistic affiliation
African-Americans, 545
Amish, 557
Argentine Toba, 564
Badaga, 572
Baliem Valley Dani, 591
Bangladeshis, 579
1057
British, 599
Burmese, 607
Cree, 614615
Czechs, 622
Datoga, 629
Fore, 638
French, 646
Fulani, 656
Garhwali, 665
Garifuna, 673
Greeks, 681
Hadza, 689
Haitians, 696
Han, 703
Hausa, 718
Hmong, 729
Iroquois, 743744
Jamaican Maroons, 754
Japanese, 765766
Jat, 777
Lijiang Naxi, 783784
Malagasy, 794795
Malays, 839840
Maori, 804
Maya of Highland Mexico, 827828
Mongolia, 850
Nahua, 863
Navajo, 873
Nepal, 883
Northwest Coast, 890891
Ojibwa, 903
Oklahoma Choctaw, 915
Roma of the United States and Europe, 923
Samoa, 929
Saraguros, 937
Shipibo, 947
Sotho, 957
Sudanese, 964965
Thai, 971
Tongans, 980981
Trobriand, 990
Tuareg, 1001
Wape, 10091010
Yanomam, 1017
Yoruba, 10291030
Local Biology, biomedicine, 99100
Local perspectives
birth, 226228, 229
urban poor, 211
Location
African-Americans, 545
Amish, 557
Argentine Toba, 564
Badaga, 572
Baliem Valley Dani, 591
Bangladeshis, 579
British, 599
Burmese, 607
1058
Cree, 614615
Czechs, 622
Datoga, 629
Fore, 638
French, 646
Fulani, 656
Garhwali, 665
Garifuna, 673
Greeks, 681
Hadza, 689
Haitians, 696
Han, 703
Hausa, 718
Hmong, 729
Iroquois, 743744
Jamaican Maroons, 754
Japanese, 765766
Jat, 777
Lijiang Naxi, 783784
Malagasy, 794795
Malays, 839840
Maori, 804
Matsigenka, 812
Maya of Highland Mexico, 827828
Mongolia, 850
Nahua, 863
Navajo, 873
Nepal, 883
Northwest Coast, 890891
Ojibwa, 903
Oklahoma Choctaw, 915
Roma of the United States and Europe, 923
Samoa, 929
Saraguros, 937
Shipibo, 947
Sotho, 957
Sudanese, 964965
Thai, 971
Tongans, 980981
Trobriand, 990
Tuareg, 1001
Wape, 10091010
Yanomam, 1017
Yoruba, 10291030
Long-QT syndrome (LQT), genetic disease, 435
Longevity, 435
see also Aging
Low-income countries, nutritional anthropology, 181182
LQT see Long-QT syndrome
LWC see Language of Wider Communication
Lymphatic filariasis, epidemiology, 479481
MCAs see Major chromosome anomalies
MAD1 see Major affective disorder 1
Magical healers, Hmong, 732733
Major affective disorder 1 (MAD1), genetic disease, 436
Major chromosome anomalies (MCAs), 394395
genetic disease, 419
Subject Index
Malaria, 479485
Baliem Valley Dani, 593
Bangladeshis, 588
epidemiology, 479481
Greeks, 683
Yanomam, 10181019
see also Vector-borne diseases
Malaysia
amok, 324
birth, 227
culture-bound syndromes, 320, 323324, 325
family planning, 89
koro, 320, 323324
latah, 325
Male initiation, Fore, 640
Malnutrition, 241242
Baliem Valley Dani, 592593
low-income countries, 181182
Malagasy, 797
urban poor, 208209
Malthus, Thomas Robert, population control, 269, 272
MAOA see Monoamine oxidase A deficiency
Maple syrup urine disease, genetic disease, 408, 436
Marfan syndrome, genetic disease, 436
Marriage, Saraguros, 938
Maupertuis, genetic disease, 392
MDRTB see Multi-drug-resistant tuberculosis
MDS see Multidimensional scaling
Measles, Yanomam, 1022
Media reports, immunization, 267
Medical anthropologists, in economic development, 167168
Medical anthropology
child growth, 236
diabetes mellitus, 339
Medical decision making, Hmong, 735736
Medical ethics
cf. bioethics, 74
defining, 74
Medical expenses, Czechs, 625
Medical hegemony, CMA, 2829
Medical pluralism, 109116
Bolivian altiplano, 112113
case studies, 111114
CMA, 29, 111
conceptions, 110111
Haiti, 113
India, 111
Japan, 113
power relations, 114115
United States, 113114
Zaire, 111112
Medical pluralism, post-socialist, Mongolia, 860861
Medical practitioners
African-Americans, 548550
Amish, 560
Argentine Toba, 566
Badaga, 573577
Baliem Valley Dani, 593594
Subject Index
Bangladeshis, 581582
British, 601602
Czechs, 626627
Datoga, 631
Fore, 643
French, 647648
Fulani, 658
Garhwali, 666
Garifuna, 676
Greeks, 683
Hadza, 692
Haitians, 700
Han, 707708
Hausa, 720723
Hmong, 732733
Iroquois, 746747
Jamaican Maroons, 756757
Japanese, 771772
Jat, 778779
Lijiang Naxi, 787788
Malagasy, 797798
Malays, 842843
Maori, 807
Matsigenka, 814815
Maya of Highland Mexico, 832
Mongolia, 854855
Nahua, 864865
Navajo, 874
Nepal, 885886
Northwest Coast, 897
Ojibwa, 908909
Oklahoma Choctaw, 917919
Roma of the United States and Europe, 925
Samoa, 932
Saraguros, 940
Shipibo, 951952
Sotho, 959
Sudanese, 966
Thai, 975976
Tongans, 983984
Trobriand, 992
Tuareg, 10041005
Wape, 1012
Yanomam, 10231024
Yoruba, 10321033
Medicalization
CMA, 28
conditions, 120121
critique, 118120
FGC, 259
identities, 120121
menopause, 122
modernization, 116118
naturalization of social control, 116125
reproduction, 119
risk as self-governance, 122123
social stratification, 200201
wellness, 121122
1059
womens responses, 118119
Medicinal drugs, Czechs, 627
Medicinal plants, Maya of Highland Mexico, 836838
Medicine classification, Han, 711714
Mediterranean fever, familial (FMF) (MEF), genetic disease, 436437
Melanoma, malignant, genetic disease, 437
MELAS see Mitochondrial encephalopathy lactic acidosis syndrome
Memory, embodied, phenomenology, 131132
Mendel, Gregor, genetic disease, 393
Menkes syndrome, genetic disease, 437
Menopause, 282
aging and, 219
Greeks, 687
medicalization, 122
Menstruation
Iran, 282
reproductive health, 281282
Mental disorders, 486493
background, 486487
culture-specifics, 487488
defining, 486
depression, 488489
future directions, 491
kinds of disorders, 488491
schizophrenia, 489491
universals, 487488
Mental health
Greeks, 684
Samoa, 934
Mental illness
Czechs, 627628
homelessness, 174175
Japanese, 771
Mental retardation, 493505
AAMR, 494495
background, 493494
cultural factors, 499500
defining, 494496
diagnosis, 494496
environmental factors, 498500
epidemiological data, 498499
epidemiology, 496498
etiology, 497
family supports, 500501
future perspectives, 502503
genetic-environmental interactions, 501502
genetic factors, 498
international data, 501
intervention issues, 500502
population differences, 497
services issues, 500502
X-linked non-specific, 437
Metabolic disorders, paleopathology, 55
Methicillin-resistant staphylococciae (MRSA), 383, 389
Mexico, diarrhea treatment, 359
Middle-age, Tuareg, 1008
Midwifery, 225226
Jamaican Maroons, 756
1060
Nahua, 865, 867868
Netherlands, 228229
see also Birth
Migration, population control, 276
Mineral water, French, 650
Miscarriage, Datoga, 634
Mitochondrial encephalopathy lactic acidosis syndrome (MELAS),
genetic disease, 437
Mitochondrial inheritance, genetic disease, 397
Mitochondrial myopathies, genetic disease, 437
Mobile pastoralism, Mongolia, 852
Modernization, medicalization, 116118
Molecular biology, emerging infectious diseases, 387388
Mono-cultural health research, vs. cross-cultural health
research, 89
Monoamine oxidase A deficiency (MAOA), genetic disease, 438
Morality, possession and trance, 140
Morbidity
Japanese, 769771
Maya of Highland Mexico, 830831
Mortality
Japanese, 769771
Matsigenka, 813
Maya of Highland Mexico, 830831
Mosaicism, chromosomal, genetic disease, 438
Mourning, psychoanalysis, 6061
Moxibustion, Han, 714
MPS1/2 see Mucopolysaccharidosis type 1/2
MRSA see Methicillin-resistant staphylococciae
MTb see Mycobacterium tuberculosis
Mucopolysaccharidosis type 1/2 (MPS1/2), 438
Multi-drug-resistant tuberculosis (MDRTB), 387388, 389
Multidimensional scaling (MDS), 1314
Multifactorial disorders, genetic disease, 398399
Multiple births, 438439
Mummification, paleopathology, 4950
Muscular dystrophy Duchenne type (DMD), genetic disease, 439
Mutations, chromosomal, 394395
Mutations, DNA, 395
Mycobacterium tuberculosis (MTb), syndemics, 27
Myopia 2 (MYP2), genetic disease, 439
Myotonic dystrophy (DM), genetic disease, 439
Narratives, illness see Illness narratives
National Health Service (NHS), British, 601, 605
National Strategies for Sustainable Development (NSSD), population
control, 272
Native Americans
alcoholism, 202
diabetes mellitus, 342, 345, 346
Natural causes, illness, Garhwali, 667
Natural selection, disease, 307
Naturalistic health problems, Maya of Highland Mexico, 832833
Naturalistic medicine, 7
Naturalization of social control, medicalization, 116125
Nerves, culture-bound syndrome, 320, 322
Netherlands
Subject Index
immunization, 266
midwifery, 228229
Neurofibromatosis
disability/difference, 363
genetic disease, 440
Neuroses, cultural expression, 6263
New Guinea, kuru, 324325, 386, 387
New reproductive technologies (NRTs), 8991, 102
New World syndrome, genetic disease, 409, 440
NHS see National Health Service
NRTs see New reproductive technologies
NSSD see National Strategies for Sustainable Development
Nutrition
Han, 704705, 713
Yanomam, 1023
Nutritional anthropology, 178184
history, 179
low-income countries, 181182
methods, 179180
themes, 181183
theoretical orientations, 179180
todays health, 182183
Nutritional disorders
overnutrition, 242
paleopathology, 55
undernutrition, 241242
see also Malnutrition
Obesity
African-Americans, 553
diabetes mellitus, 335, 336, 338, 341
genetic disease, 440
Navajo, 880
Tongans, 985
Occupations
Czechs, 623
Datoga, 630
Haitians, 697698
Japanese, 767
Tuareg, 10011002
Ombiasa, shamanism, 797798
Onchocerciasis, epidemiology, 479481
Onchocerciasis, Yanomam, 1019
Oral rehydration salts (ORS), 88
Organ transplantation/donation
bioethics, 76
biomedical technologies, 9192
brain-death, 9293
exploitation, 9293
ORS see Oral rehydration salts
Osteoarthritis (OA), paleopathology, 56
Osteogenesis imperfecta, genetic disease, 440441
Osteoporosis, 312314
cross-cultural distribution, 313
diagnosis, 312313
prevention, 313314
risk factors, 313
Subject Index
treatment, 313314
WHO, 313
Osteoporosis, French, 648
Oxytocin, breast-feeding, 231
P53 tumor suppressor protein (TP53), genetic disease, 441
Paleopathology, 4958
bone tumours, 5657
cancer, 5657
circulatory abnormalities, 56
congenital defects, 5152
degenerative disease, 56
dental, 57
disease classification, 51
findings, 5157
history, 50
immunologic diseases, 56
infectious disease, 5354
metabolic disorders, 55
mummification, 4950
nutritional disorders, 55
osteoarthritis (OA), 56
pneumoconiosis, 55
rheumatoid arthritis, 56
technical considerations, 5051
traumatic injury, 5253
vitamin abnormalities, 55
see also Evolutionary perspectives
Parasitic infections, Yanomam, 10191020
Parkinson disease, genetic disease, 441
Pastoralism, Fulani, 656
Patau syndrome, 395
genetic disease, 441
Pendred syndrome, genetic disease, 441
Penicillin-resistant neisseriae gonorrhoea (PRNG), 383
Periodontal disease, paleopathology, 57
Personal symbols, psychoanalysis, 61
Personalistic health problems, Maya of Highland Mexico, 833
Personalistic medicine, 7
Pharmaceuticals
biographies, 8788
biomedical technologies, 8788
Phenocopies, genetic disease, 399
Phenomenology, 125136
age studies, 131132
of the body, 127128
body, ethnographic uses, 128129
body in distress, 129130
body of difference, 130131
gendered body, 130
memory, embodied, 131132
methodological perspectives, 126127
suffering, politics of, 132
theoretical perspectives, 126127
Phenylketonuria, genetic disease, 441442
Philadelphia chromosome, 395
genetic disease, 442443
1061
Philippines, immunization, 266267
Philosophical underpinnings, Japanese, 767
Phocomelia, genetic disease, 443
Physical handicaps, Datoga, 632
Pigbel, Fore, 641642
Pill, 8889
social aspects, 283284
Pima Indians, diabetes mellitus, 342
PKD1 see Polycystic kidney disease, adult
Placenta, disposal, 224225
Pneumoconiosis, paleopathology, 55
Polio, paleopathology, 54
Political conditions
Datoga, 630
Haitians, 698
Tuareg, 1002
Political/economic perspective, disease, 307
Political factors
African-Americans, 546548
Amish, 558560
Argentine Toba, 565566
Badaga, 573
Baliem Valley Dani, 592593
Bangladeshis, 580581
British, 600601
Burmese, 609610
Cree, 616617
Czechs, 623626
Datoga, 630631
Fore, 641643
French, 647
Fulani, 657658
Garhwali, 665666
Garifuna, 676
Greeks, 682683
Hadza, 690691
Haitians, 699700
Han, 704707
Hausa, 719720
Iroquois, 745746
Japanese, 768771
Jat, 778
Lijiang Naxi, 785787
Malagasy, 796797
Malays, 840842
Maori, 805807
Matsigenka, 812814
Maya of Highland Mexico, 828831
Mongolia, 851854
Nahua, 864
Navajo, 874
Nepal, 885
Northwest Coast, 894897
Ojibwa, 905908
Oklahoma Choctaw, 916917
Roma of the United States and Europe, 924
Saraguros, 938939
1062
Shipibo, 948951
Sotho, 958959
Sudanese, 965966
Thai, 972975
Tongans, 982983
Trobriand, 991992
Tuareg, 10031004
Wape, 10111012
Yanomam, 10181023
Yoruba, 10311032
Political identity, Garifuna, 673674
Political organization
Fore, 639
Hmong, 730
Political position, Maori, 806
Pollution, environmental, Czechs, 624
Polycystic kidney disease, adult (PKD1), genetic disease, 443
Polydactyly, genetic disease, 408, 443
Polygenic factors, genetic disease, 398399
Polyoma virus, Yanomam, 10211022
Polyposis of colon, familial, genetic disease, 443
Poor, urban see Urban poor
Population
Czechs, 622
Datoga, 629630
Samoa, 929930
Population aging
health impact, 311312
United Nations, 221
see also Aging
Population control, 269280
biological warfare, 277
birth control, 273274
bubonic plague, 270
contraceptives, 274
contragestin, 274
contranatals, 274275
controversies, 275279
cultural revolution, 269270
Darwin, 269
death control, 272273
demography, 270271
ecological models, 271272
eugenics, 277278
family planning, 279
historical background, 269270
immigration, 276
issues, 275279
Malthus, 269, 272
medicine developments, 272275
methods, 270275
migration, 276
NSSD, 272
organizations, governmental/private, 275
other species, 279
overconsumption, 275276
overpopulation, 275
responses, 269270
Subject Index
responsibilities, procreative/reproductive, 279
rights, procreative/reproductive, 279
sterilization programs, 277278
theories, 270275
warfare, 276277
ZPG, 275
Population differences, mental retardation, 497
Population distribution, Han, 704
Population history, Northwest Coast, 894897
Population statistics, African-Americans, 546
Populations studied, diabetes mellitus, 338339
Porphyria variegata, genetic disease, 408, 443444
Possession and trance, 137145
behavioral manifestations, 137138
belief sources, 137
belief types, 137
Brazil, 140
exorcism, 142
geographic distributions, 138139
and healing, 141142
morality, 140
religions, 140, 142143
sociocultural correlates, 138139
western thought, 139140
women, 140
Post-colonial development and health, 184191
Postcolonial era, Haitians, 699
Prader-Willi syndrome (PWS), genetic disease, 444
Pre-contact paradigm, Samoa, 932933
Pregnancy
African-Americans, 552
Amish, 561
Argentine Toba, 567568
Badaga, 575576
Baliem Valley Dani, 595596
Bangladeshis, 585
British, 603
Burmese, 611
Cree, 619
Czechs, 628
Datoga, 633635
Fore, 644
French, 653
Fulani, 660
Garhwali, 669670
Garifuna, 677678
Greeks, 685686
growth events/duration, 237239
Hadza, 693
Han, 715716
Hausa, 725
Hmong, 737738
Iroquois, 748
Jamaican Maroons, 762
Japanese, 773
Jat, 780
Malagasy, 800
Malays, 846847
Subject Index
Maori, 808
Matsigenka, 823
Maya of Highland Mexico, 834
Mongolia, 857
Nahua, 867868
Navajo, 878
Nepal, 888
Northwest Coast, 899
Ojibwa, 911912
Oklahoma Choctaw, 920
outcomes, 284285
Roma of the United States and Europe, 926
Samoa, 934935
Saraguros, 942943
Shipibo, 954
Sotho, 960961
Sudanese, 969
Thai, 978
Tongans, 986
Trobriand, 995
Tuareg, 10061007
Wape, 10141015
Yanomam, 10241025
Yoruba, 1036
see also Reproductive health
Preventive measures, Czechs, 628
Principle of separation, biomedicine, 98
Prion protein (PRNP)
genetic disease, 444
see also Creutzfeldt-Jakob disease; Familial fatal insomnia;
Gerstmann-Straussler-Sheinker disease; Kuru
Private foundations, economic development, 166167
PRNG see Penicillin-resistant neisseriae gonorrhoea
PRNP see Prion protein
Production, Saraguros, 938
Progerias, genetic disease, 444
Prognosis disclosure, bioethics, 7677
Prolactin, breast-feeding, 231
Prophylaxis, psychoanalysis, 6061
Prostate cancer, British, 605
Proteomics, 98
Proteus syndrome, genetic disease, 444445
Pseudohermaphroditism, genetic disease, 445
Psychoanalysis, 5869
anthropological interviewing, 6364
culture shock, 59, 6465
funerals, 6061
mourning, 6061
personal symbols, 61
prophylaxis, 6061
psychoanalytic movements, 6566
psychoses, 6263
ritual treatments, 5961
shamanism, 5961
Psychoanalytic movements, Brazil, 6566
Psychoses
cultural expression, 6263
treatment, 62
1063
PTC tasting, genetic disease, 445
Public health, bioethics, 8081
Public health infrastructure, Lijiang Naxi, 786
Public policies, alcohol use, 297298
Puerto Rico
family planning, 89
HIV/AIDS, 469
Pulaaku, Fulani, 657
PWS see Prader-Willi syndrome
Pygmies, 241
see also Dwarfism
Qigong, Han, 713
Quadratic Assignment Program, 15, 16
Race, bioethics, 78
Ras oncogene (KRAS), genetic disease, 445446
RB1 see Retinoblastoma
Refugee health, 191198
healthcare provision, 195196
implications, conflict/displacement, 193194
third country resettlement, 194195
Religions
African-Americans, 548, 549550
Burmese, 608609
Czechs, 623
Datoga, 630
FGC, 256
Fulani, 657
Greeks, 682
Haitians, 698699, 701
Han, 707
Hmong, 730731
Islam, 256
possession and trance, 140, 142143
Samoa, 930931
Saraguros, 938
Tongans, 981
Tuareg, 10021003
Religious beliefs, Yoruba, 1031
Religious healing, Greeks, 684
Religious ideology, Jamaican Maroons, 759760
Religious studies, death/dying, 245246
Religious traditions, Japanese, 767
Reproduction
Amish, 560561
Argentine Toba, 567
Badaga, 575
Baliem Valley Dani, 595
Bangladeshis, 583584
British, 602603
Burmese, 611
Czechs, 628
Datoga, 632633
Fore, 643644
French, 652653
Fulani, 659660
Garhwali, 669
1064
Garifuna, 677
Greeks, 684685
Hadza, 692693
Haitians, 701702
Han, 714715
Hausa, 724
Hmong, 736737
Iroquois, 748
Jamaican Maroons, 760762
Japanese, 772773
Jat, 779780
Lijiang Naxi, 791792
Malagasy, 799
Malays, 846
Maori, 808
Matsigenka, 822823
Maya of Highland Mexico, 834
medicalization, 119
Mongolia, 856, 857
Nahua, 867
Navajo, 878
Nepal, 887
Oklahoma Choctaw, 920
Roma of the United States and Europe, 926
Samoa, 934
Saraguros, 942
Shipibo, 953954
Sotho, 960
Sudanese, 967969
Thai, 977978
Tongans, 986
Trobriand, 994995
Tuareg, 1006
Wape, 1014
Yanomam, 1024
Yoruba, 10351036
Reproductive ecology, 33
Reproductive ethics, bioethics, 78
Reproductive health, 280290
fertility enhancement, 285
fertility regulation, 282284
HIV/AIDS, 286
infections, 285286
infertility, 285
menstruation, 281282
pregnancy outcomes, 284285
reproductive life cycle, 281282
STDs, 285286
see also Pregnancy
Reproductive technologies, 8991, 102
Research ethics, bioethics, 80
Research interests, 910
Reservations, Iroquois, 743744
Resilience, disasters, 159
Resort patterns, health-seeking process, 56
Retinoblastoma (RB1), genetic disease, 446
Rett syndrome (RTT), genetic disease, 446
Rhesus isoimmunization, genetic disease, 446447
Subject Index
Rheumatoid arthritis, paleopathology, 56
Risk as self-governance, medicalization, 122123
Risk factors
AD, 314315
diabetes mellitus, 335, 336, 338, 341
osteoporosis, 313
SIDS, 507509
stress, 331333
Risks, child growth, 241242
Ritual studies, death/dying, 245246
Ritual treatments, psychoanalysis, 5961
RNA viruses, 385
RTT see Rett syndrome
Russia
MDRTB, 387388, 389
psychoanalytic movements, 6566
Russian modernist traditions, Mongolia, 854855, 856
St. Lucia, stress, 332
Samoan community, stress, 332333
Scanning electron microscope (SEM), forensic anthropology, 39
SCD see Sickle cell disease
Schizophrenia (SCZD)
cross-cultural research, 489491
genetic disease, 447
mental disorder, 489491
Science men, Jamaican Maroons, 756757
Self-care, African-Americans, 551
Self-governance, risk as, 122123
SEM see Scanning electron microscope
Seripigari, Matsigenka, 814815
Severe combined immunodeficiency disease, X-linked (XSCID),
genetic disease, 447
Sex-determining region of the Y chromosome (SRY), genetic
disease, 448
Sex-linked inheritance, genetic disease, 397
Sexual orientation, social stratification, 202203
Sexual pleasure, Hmong, 737
Sexuality
Amish, 560561
Argentine Toba, 567
Badaga, 575
Baliem Valley Dani, 595
Bangladeshis, 583584
British, 602603
Burmese, 611
Czechs, 628
Datoga, 632633
Fore, 643644
French, 652653
Fulani, 659660
Garhwali, 669
Garifuna, 677
Greeks, 684685
Hadza, 692693
Haitians, 701702
Han, 714715
Hausa, 724
Subject Index
Hmong, 736737
Iroquois, 748
Jamaican Maroons, 760762
Japanese, 772773
Jat, 779780
Lijiang Naxi, 791792
Malagasy, 799
Malays, 846
Maori, 808
Matsigenka, 822823
Maya of Highland Mexico, 834
Mongolia, 856
Nahua, 867
Navajo, 878
Nepal, 887
Oklahoma Choctaw, 920
Roma of the United States and Europe, 926
Samoa, 934
Saraguros, 942
Shipibo, 953954
Sotho, 960
Sudanese, 967969
Thai, 977978
Tongans, 986
Trobriand, 994995
Tuareg, 1006
Wape, 1014
Yanomam, 1024
Yoruba, 10351036
Sexuality, HIV/AIDS and, 286
Sexually transmitted diseases (STDs), 285286
Shamanism, 145154
animism, 151152
ASC, 146148
ASC bases, therapeutic processes, 149150
ASC, psychobiological structures, 148149
community relations, 150
contemporary, 152153
cross-cultural perspective, 146
death and rebirth, 147148
Han, 707
healers, 148149
healing, contemporary, 152153
Hmong, 732, 734
illness, contemporary, 152153
Malagasy, 797798
Matsigenka, 814815
meaning and emotions, 150151
Nahua, 865, 866
Nepal, 885886, 887
Northwest Coast, 897
ombiasa, 797798
psychoanalysis, 5961
role-taking, 152
soul journey, 147
soul loss, 148
spirit, 151152
therapeutic processes, 148, 149152
1065
universals, 146148
Yanomam, 10231024
Sickle cell disease (SCD), 392, 408
genetic disease, 448449
Sickness, defining, 34
SIDS see Sudden infant death syndrome
Sierra Leone
birth, 227228
FGC, 255
Situs invertus viscerum, genetic disease, 449
Sleep physiology research, SIDS, 509510
Slums see Urban poor
SMA see Society for Medical Anthropology
Smallpox, Northwest Coast, 895, 897
Social change
culture-bound syndromes, 325326
emerging infectious diseases, 387388
Social conditions
Datoga, 630
Haitians, 698
Tuareg, 1002
Social factors
African-Americans, 546548
Amish, 558560
Argentine Toba, 565566
Badaga, 573
Baliem Valley Dani, 592593
Bangladeshis, 580581
British, 600601
Burmese, 609610
Cree, 616617
Czechs, 623626
Datoga, 630631
Fore, 641643
French, 647
Fulani, 657658
Garhwali, 665666
Garifuna, 675
Greeks, 682683
Hadza, 690691
Haitians, 699700
Han, 704707
Hausa, 719720
Iroquois, 745746
Japanese, 768771
Jat, 778
Lijiang Naxi, 785787
Malagasy, 796797
Malays, 840842
Maori, 805807
Matsigenka, 812814
Maya of Highland Mexico, 828831
Mongolia, 851854
Nahua, 864
Navajo, 874
Nepal, 885
Northwest Coast, 894897
Ojibwa, 905908
1066
Oklahoma Choctaw, 916917
Roma of the United States and Europe, 924
Saraguros, 938939
Shipibo, 948951
Sotho, 958959
Sudanese, 965966
Thai, 972975
Tongans, 982983
Trobriand, 991992
Tuareg, 10031004
Wape, 10111012
Yanomam, 10181023
Yoruba, 10311032
Social inequality, disease distribution, 249
Social organization
Fore, 639
Fulani, 656657
Hmong, 730
Northwest Coast, 892893
Samoa, 930
Saraguros, 938
Social sciences, health see Health social sciences
Social stratification, 198206
biomedicine, 200201
class, 203
constructing hierarchy, 201204
defining, 198200
ethnicity, 201202
gender, 203204
health and, 200
HIV/AIDS, 202203
medicalization, 200201
negotiating health, 201
sexual orientation, 202203
western context, 198206
Social studies, death/dying, 245246
Socialism, Mongolia, 859
post-socialism, Mongolia, 859861
Society for Medical Anthropology (SMA), 45
Socio-economic circumstances, Maori, 805806
Sociocultural norms, Japanese, 767768
Sorcery
Fore, 640641
Garhwali, 667668
Hmong, 734
Matsigenka, 814815
Trobriand, 993
Wape, 10131014
Soul loss, shamanism, 148
Souls, Hmong, 734
Spasmophilia, French, 648
Spirits
Hmong, 734
Trobriand, 993
Spiritual intervention, Jamaican Maroons, 759760
Spiritual life, Garifuna, 674
Spirituality, African-Americans, 548, 549550
Spoken Soul, African-Americans, 545
Subject Index
Squatter settlements see Urban poor
SRY see Sex-determining region of the Y chromosome
STDs see Sexually transmitted diseases
Stem cell research/cloning, genetic disease, 403
Sterilization programs, population control, 277278
Stigma
tuberculosis, 533534
vector-borne diseases, 483
Stress, 328335
blood pressure, 328330, 333334
disasters, 157
models, 331333
risk factors, 331333
St. Lucia, 332
Samoan community, 332333
Substance abuse, homelessness, 175
Sudan, FGC, 255
Sudden infant death syndrome (SIDS), 506518
child care practices, 510511
epidemiology, 507509
history, 507509
prevention, 513515
rates across cultures, 511513
risk factors, 507509
sleep physiology research, 509510
Sufferer experience, Brazil, 28
Sufferer experience, CMA, 2728
Suicide, Japanese, 771
Supernatural causes, illness, Garhwali, 667668
Supplementation, breast-feeding, 233234
Susto, culture-bound syndrome, 322323
Symbols, personal, psychoanalysis, 61
Syndemics
CMA, 2627
urban poor, 211
Syphilis, paleopathology, 54
Taboos, Garhwali, 668
Tauvau, Trobriand, 993
Tay-Sachs disease (TSD), genetic disease, 408, 409, 449
TCM see Traditional Chinese Medicine
Temporomandibular joint (TMJ), illness narratives, 20
Terminal diagnosis disclosure, bioethics, 7677
Testicular feminization (TF), genetic disease, 449
Thalassemia, alpha, genetic disease, 449450
Thalassemia, beta, genetic disease, 450
Thalassemia, beta, Greeks, 683
Theoretical issues, cross-cultural health research, 311
Theory of Reasoned Action (TRA), HIV/AIDS, 467
Therapeutic practices, Lijiang Naxi, 786787
Tibetan Buddhist medicine, Mongolia, 858859
Tibetan medicine, Mongolia, 855856
TMJ see Temporomandibular joint
Tobacco, 518528
anthropological studies, 522523
CMA, 525527
and the Colonies, 521
as a critical commodity, 521522
Subject Index
cultural studies, 523525
Han, 706
and health, 518519
impact on Europe, 520521
Mongolia, 853854
New World origins, 519520
social history, 519521
Tourette syndrome see Gilles de la Tourette syndrome
TP53 see P53 tumor suppressor protein
TRA see Theory of Reasoned Action
Traditional Chinese Medicine (TCM), Lijiang Naxi, 786787
Trance see Possession and trance
Transforming liquids, Trobriand, 997998
Traumatic injury
illness narratives, 43
paleopathology, 5253
Treatment decisions, cognitive-ethnographic studies, 1618
Trends
alcohol use, 296300
biomedicine, 101103
Triplo-X syndrome, 395
genetic disease, 450
TSD see Tay-Sachs disease
Tuberculosis, 383
adherence issues, 532533
care-seeking behaviours, 531532
control, 528542
cultural research, 531535, 536537
current approaches, 535536
current tools, 535536
diagnosis, 529530
epidemiological features, 529
future directions, 536537
history, 530531
homelessness, 174
MDRTB, 387388, 389
medical features, 529
MTb, 27
program structure, 535
provider behavior, 534535
research, 528542
service delivery, 534535
social research, 531535, 536537
stigma, 533534
treatment, 529530
Yanomam, 10221023
Tuina, Han, 713
Tuina, Han, 713714
Turner syndrome, genetic disease, 450451
Tuskegee experiment, African-Americans, 547548
Twins/twinning, 451
see also Multiple births
Tyrosinemia, genetic disease, 451
UNHCR see United Nations High Commissioner for Refugees
UNICEF, breast milk substitutes, 234235
Uniform Determination of Death Act (1981), 248
Uniparental disomy, genetic disease, 397398
1067
United Nations
economic development, 165
population aging, 221
refugee health, 191193
UNHCR, 191193, 195
United Nations High Commissioner for Refugees (UNHCR),
191193, 195
United States
abortion, 278, 284
diabetes mellitus, 344346
Hmong in, 731732, 733
medical pluralism, 113114
Urban poor, 207213
culture of poverty, 210
diarrhea, 209
global perspectives, 211
HIV/AIDS, 209
homelessness, 208
infectious disease, 209
local perspectives, 211
malnutrition, 208209
representing, 209210
structural violence, 211
syndemics, 211
threats to health, 207209
violence, 208
USAID see Agency for International Development
Vaccination see Immunization
Vancomycin-resistant enterococciae (VRE), 383, 389
Variability, measuring, 1415
Vector-borne diseases, 479485
community participation, health programs, 482483
ecological studies, 480481
epidemiology, 479481
ethnomedical studies, 481482
gender research, 483
health programs, 482483
stigma, 483
Vernacular medicine, cf. conventional medicine, 8
Violence, urban poor, 208
Violent death, 249251
Vitamin abnormalities, paleopathology, 55
Voodoo
African-Americans, 550
Haitians, 700
VRE see Vancomycin-resistant enterococciae
Vulnerability, disasters, 159
Waardenburg syndrome (WS1), genetic disease, 451
Warfare
biological, 277
population control, 276277
Water-borne diseases, 305311
anthropological contributions to study of, 306309
anthropological perspectives, 307308
cholera, 305311
dengue fever, 306
1068
determinants, 309
typology, 306
water insecurity, 308309
web sites, 309310
Water therapies, French, 650
Weaning, 233234
Gusii practices, 233234
see also Breast-feeding
Web sites
diarrhea, 359360
genetic disease, 399
water-borne diseases, 309310
Weissmann, August, genetic disease, 393
Werner syndrome (WRN), genetic disease, 451
West Nile Virus, 385, 389
Western medicine, Han, 708
White mans sickness, Ojibwa, 910
WHO see World Health Organization
Wilson disease (WND), genetic disease, 452
Witchcraft
aging and, 220
birth, 227
Datoga, 632
Garhwali, 667668
Hausa, 721
WND see Wilson disease
Women, possession and trance, 140
Womens responses, medicalization, 118119
World Bank, economic development, 165166
Subject Index
World Health Organization (WHO)
alcohol use, 297, 299300
breast milk substitutes, 234235
cholera, 305
disability/difference, 368
economic development, 165166
health, defining, 26
osteoporosis, 313
Worm infections, paleopathology, 5455
Worm infections, Yanomam, 10191020
WRN see Werner syndrome
WS1 see Waardenburg syndrome
X-linked inheritance, genetic disease, 392, 397
Xeroderma pigmentosum (XP), genetic disease, 452
XSCID see Severe combined immunodeficiency disease,
X-linked
XX male syndrome, genetic disease, 452
XY female syndrome, genetic disease, 452
Y-linked inheritance, genetic disease, 397
Yangsheng, Han, 713
Yunani system, Bangladeshis, 582
Zaire
medical pluralism, 111112
post-colonial development and health, 185, 188
Zellweger syndrome, genetic disease, 452
Zero Population Growth (ZPG), 275
1069
1070
Haisla see Northwest Coast
Hati see Haitians
Haitians, 696702
Hatien see Haitians
Han, 703717
Han-ren see Han
Hatsa see Hadza
Hausa, 718729
Hausa-Fulani see Hausa
Haytian see Haitians
Heiltsuk see Northwest Coast
Hli-khin see Lijiang Naxi
Hmong, 729743
Hodnosaunee see Iroquois
Hua-ren see Han
Ife see Yoruba
Igbomina see Yoruba
Ijebu see Yoruba
Ijesa see Yoruba
Imajeghen see Tuareg
Imghad see Tuareg
Inaden see Tuareg
Iroquois, 743754
Jamaican Maroons, 754765
Japanese, 765776
Jat, 777783
Kabba see Yoruba
Kangeju see Hadza
Kel Air see Tuareg
Kel Ewey see Tuareg
Kel Nabarro see Tuareg
Kel Tafidet see Tuareg
Kel Tagelmust see Tuareg
Kel Tamajaq see Tuareg
Kilivilan see Trobriand
Kiriwinian see Trobriand
Kogapakori see Matsigenka
Kugapakori see Matsigenka
Kwakiutl see Northwest Coast
Kwakwakawakw see Northwest Coast
Leeward Maroons see Jamaican Maroons
Lesotho see Sotho
Lijiang Naxi, 783794
Machiguenga see Matsigenka
Madagascar see Malagasy
Makah see Northwest Coast
Malagasy, 794804
Malays, 839849
Mangati see Datoga
Maori, 804811
Maroons see Jamaican Maroons
Matsigenka, 812827
Matsiguenka see Matsigenka
1071
Thai, 971980
Tindiga see Hadza
Tinkers see Roma of the United States and Europe
Tlingit see Northwest Coast
Toba see Argentine Toba
Tongans, 980990
Touareg see Tuareg
Travelers see Roma of the United States and Europe
Trobriand, 9901000
Trobriand Islanders see Trobriand
Trobrianders see Trobriand
Tsimshian see Northwest Coast
Tuareg, 10011009
Tuscarora see Iroquois
Union of Myanmar see Burmese
United Kingdom see British
Waica see Yanomam
Waika see Yanomam
Wakindiga see Hadza
Wales see British
Wape, 10091017
Wapei see Wape
Wapi see Wape
Watindiga see Hadza
Windward Maroons see Jamaican Maroons
Xiriana see Yanomam
Yamato see Japanese
Yanoama see Yanomam
Yanomama see Yanomam
Yanomami see Yanomam
Yanomam, 10171029
Yindunixiya Huaren see Han
Yongning Naxi see Lijiang Naxi
Yoruba, 10291039
Zhong Huar Re Min Gong He Guo see Han
Zhongguo-ren see Han
Zutt see Jat