Coming To Our Senses:Appreciating The Sensorial in Medical Anthropology

transcultural psychiatry
June 2008
ARTICLE
Coming to Our Senses: Appreciating the Sensorial in Medical Anthropology

MARK NICHTER
University of Arizona
Abstract This article supports the call for the sensorially engaged anthropological study of healing modalities, popular health culture, dietary practices, drug foods and pharmaceuticals, and idioms of distress. Six concepts are of central importance to sensorial anthropology: embodiment, the mindful body, mimesis, local biology, somatic idioms of distress, and the work of culture. Fieldwork in South and Southeast Asia and North America illustrates how cultural interpretations associate bodily sensations with passions (strong emotions) and anxiety states, and bodily communication about social relations. Lay interpretations of bodily sensations inform and are informed by local understanding of ethnophysiology, health, illness, and the way medicines act in the body. Bodily states are manipulated by the ingestion of substances ranging from drug foods (e.g., sources of caffeine, nicotine, dietary supplements) to pharmaceuticals that stimulate or suppress sensations concordant with cultural values, work demands, and health concerns. Social relations are articulated at the site of the body through somatic modes of attention that index bodily ways of knowing learned through socialization, bodily memories, and the ability to relate to how another is likely to be feeling in a particular context. Sensorial anthropology can contribute to the study of transformative healing and trajectories of healthcare seeking and patterns of referral in pluralistic healthcare arenas. Key words body memory healing sensorial anthropology somatic idioms of distress trauma
Vol 45(2): 163197 DOI: 10.1177/1363461508089764 www.sagepublications.com Copyright 2008 McGill University
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Transcultural Psychiatry 45(2)
Sensorial Anthropology: Six Central Concepts

Anthropologists have coined the term sensorial anthropology to describe the study of cultural responses to the perceptual output of sense modalities (e.g., touch, taste, smell, sight, and sound) as well as sensations such as dizziness, shortness of breath, chest and heart pain, indigestion, states of hot and cold, and shifts in energy that conjoin mental and/or emotional states with a physical condition (Hinton & Hinton, 2002). Included in the purview of sensorial anthropology are the study of sensations that evoke and are triggered by embodied memories, and the study of how the spaces and places in which bodies are situated predispose perceptions of sensation that are associated with feelings of fear and vulnerability, well-being and protection. Six inter-related concepts employed within medical anthropology are particularly useful to sensorial anthropology: embodiment (Bourdieu, 1977; Csordas, 1990, 1993; Merleau-Ponty, 1964), the mindful body (Scheper-Hughes & Lock, 1987), mimesis (Bourdieu, 1977; Lyon, 2002), local biology (Lock, 1993, 2005; Lock & Kaufert, 2001), somatic idioms of distress (Mark Nichter, 1981), and the work of culture (Hollan, 1994; Obeyesekere, 1985, 1990). Embodiment refers to ones lived experience of ones body as well as ones experience of life mediated through the body as this is inuenced by its physical, psychological, social, political, economic, and cultural environments. As noted by Kirmayer (2003), the essential insight of embodiment is that the body has a life of its own and that social worlds become inscribed on, or sedimented in, bodily physiology, habitus, and experience (p. 285). Csordas (1990: 12) adds that embodiment involves ones perceptual experience and mode of presence and engagement in the world. Embodiment is prereexive, but not precultural (Csordas, 1990). It is inuenced by ones ongoing socialization (class and caste, position and habitus) as reected in such things as taste preferences and diet, aesthetics and style, body projects, and so on (Appadurai, 1981; Bourdieu, 1984; Khare, 1992; Pinard, 1991; Prasad, 2006). Embodiment is a dynamic process and a form of contextual and historical engagement that results in ones memories becoming embedded in associational elds composed of images as well as sensations. Within these associational elds, experiences of the past, present, and future inuence one another.1 Given that perceptions are transformed (objectied) into objects and words, they come to symbolize, symbols in turn can evoke experiences, memories, and sensations (Merleau-Ponty, 1962). We inhabit embodied spaces rich in symbols and cues that trigger this two-way process (Basso, 1996; Cartwright, 2007; Casey, 1996, 1997; Low, 2003). The mindful body is the nexus of ones phenomenological, social, and body politic.2 Within ones mindful body the sensorial, the cognitive, and
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Nichter: Coming to Our Senses
the emotional dimensions of our being in the world are coextensive and exist in dynamic relationship. Mimesis refers to the process whereby social and visceral correspondences come to mirror each other as copies or resonances through such processes as iconic association.3 Relevant to the study of sensations, the process of mimesis contributes to bodily memory in terms of both what Bourdieu (1977, 1990) has described as durable bodily dispositions associated with habitus (associated with familiar sensational states) and the bodily memory of traumatic events. Traumatic events become embodied through ontological resonances within a semantic network that Kleinman (Kleinman & Becker, 1998; Kleinman & Kleinman, 1985) has termed their sociosomatic reticulum a concept akin to semantic illness networks (Good, 1977). Hagengimana and Hinton (in press) have called for a study of trauma-somatics that examines why trauma results in particular sets of symptoms in different cultures. This entails a consideration of the extent to which experiences of trauma are associated with bodily processes as locally understood and experienced, as well as social and cultural values, and organizational principles. Important to note, an appreciation of mimesis and the sociosomatic reticulum leads one to view somatization as a normal bodily mode of experiencing personal, social, and political distress, not a more primitive or lessadaptive substitution for verbal articulation (Kleinman, 1995; Mark Nichter, 1981). Mimesis also provides us with a good platform from which to examine the appeal of drug foods, pharmaceuticals, and recreational drugs in as much as they (a) produce bodily states in step with social and work-related routines and desired states, (b) are useful in dealing with negative affect and states such as boredom, and (c) provide psychosocial and psychological release. As noted by Lyon (2002), mimesis speaks to the interlocking of bodily, sociocultural, and psychological processes, as well as bodily agency when it comes to understanding why particular substances associated with different sensational states are favored. The concept of local biologies (Lock, 1993, 2005) acknowledges the importance of the biological body as an active agent and the dynamic inter-relationship between culture and biology such that biological difference can inuence individual experience as well as cultural interpretations of that experience (Lock, 1993). Lock bases most of her writing on local biology on research carried out on the sensorial experience of menopause in Japan in comparison with womens experience of menopause in the USA. Many other domains of health-related experience are worth exploring in terms of local biologies, such as the impact of different staple diets on the bodies and lived sensorial experience of different populations across the life course and at times of illness and distress. Local biologies need to be examined in relation to local phenomenologies, which
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Halliburton (2002) describes as constituted by both local analytic theories of experience and lived experience itself and assumes these inuence one another to some degree (p. 1126). Somatic idioms of distress refer to the ways in which visceral responses to distress communicate angst to signicant others. Somatic sensations resonate within ones social universe whether consciously acknowledged or not. Somatic distress can also constitute an expression of collective ills (Frankenberg, 1986) when experienced as a form of somatic response to forms of oppression.4 In some cases, this visceral expression can serve as a form of protest, a weapon of the weak (Scott, 1985), albeit a protest easily medicalized (Frankenberg, 1986; Scheper-Hughes, 1991). Attentiveness to visceral expressions of distress can also serve as an idiom of concern at the site of the body. The work of culture (Obeyesekere, 1985, 1990) refers to the process whereby distressful states, perceived risk and motives, negative affects, and sensations are transformed into publicly accepted sets of meanings and symbols that can be manipulated, or dealt with in some culturally salient manner. Importantly, Obeyesekere notes that where subjective experience is often articulated through the medium of cultural symbols, cultural symbols are only ever imbued with signicance once they are internalized and integrated into the context of an individuals emotional and motivational concerns (see Throop, 2003, p. 112). Obeyesekere further observes that personal experience is organized in the context of cultural images to the extent that cultural templates may actually help to shape the individuals experience of reality (Throop, 2003, p. 114). Healthcare seeking in pluralistic healthcare arenas may well involve the matching of personal experience and personal symbols to healthcare modalities that make sense and resonate in visceral as well as cognitive ways.5 Sensorial anthropology explores how sensations are experienced phenomenologically, interpreted culturally, and responded to socially. This entails examining which sensations are treated as important/relatively unimportant in particular sociocultural contexts by both the primary party experiencing them and signicant others. It requires an appreciation of those sensations deemed normative and to be expected, positive, and culturally valued (e.g., age markers); and negative and devalued, yet salient. It also demands investigation of the social relations of sensorial experience recognizing that the sensorial is not just experienced individually, but dividually. I use the term dividual as a heuristic to emphasize that ones experience of sensations is often dynamic and transactional.6 In cultures where social enmeshment fosters close interpersonal as well as intrapersonal bodily monitoring, ones experience of sensations is rarely solitary. This may be the case even if one adopts a stoic posture and does not verbally
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articulate what one is feeling. Sensations resonate within ones social network among those attentive to uctuations in each others somatic state. The work of culture is often described as involving the symbolic transformation of painful affects through ritual or narrative. It also involves bodily feedback on appropriate ways to handle or deal with sensorial states in culturally appropriate ways. An example might be the visceral as well as verbal feedback a woman receives from other women about how to handle the pain of childbirth. Another example might involve the feedback one receives on how to handle sensations associated with performing a particular occupational task, or handling a traumatic event.
Ayurveda as a Formative Experience: Participant Observation at the Site of the Body

Thirty years ago I arrived in south India with the ambitious plan of studying the popular health culture of a south Indian community and how the local population made use of diverse healing traditions within their pluralistic healthcare arena. One of the rst healing traditions I was drawn to was Ayurvedic medicine. I had read about Ayurveda in preparation for my eldwork and had a passing familiarity with its basic principles. At least that is what I thought until I encountered an Ayurvedic practitioner who eventually became one of my key informants and teachers. Ishwara came from a family of Ayurvedic practitioners and in addition to learning at home from his elders, attended a renowned college of integrated Ayurvedic medicine in Madras. There he studied both Ayurveda and the biosciences in the 1940s. When I rst met him, Ishwara was lukewarm about teaching me Ayurveda. While he was willing to discuss Ayurvedic principles with me, he made it clear that learning Ayurveda required far more than the study of books. It required an understanding of cosmology and ecology as well as knowledge of my own body gained through adhering to a dietary regimen. He had heard from a relative who had visited the USA that Americans had no routine diet and ate when and whatever they pleased. Without a routine diet, he asked, how could I know my body and its constitution? Without knowing my body and its constitution how would I in turn be able to evaluate the properties of foods and medicines? And how could I diagnose my own humoral imbalances let alone those of others? Your body, he said, must be your rst teacher. You must learn to use your senses and not just your mind. Gradually, I won Ishwaras trust and he began to teach me, but not in the way I had imagined. To an observer, he was a scholar whose house was stacked with books on Ayurveda and other Vedic sciences, textbooks on physics, chemistry, and botany, and books on agriculture ranging from the
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mundane to the teachings of Rudolf Steiner on planting according to the phases of the moon. I do not exactly remember what I said to Ishwara about anthropology that caught his attention, but I do remember his fascination with the notion of participant observation. This participant observation, he said, is a method used by our rishis to gain knowledge by observing how different ways of living (diet, work, play, etc.) affected their bodies, desires, and mind. This participant observation, he joked, does not sound very British, and yet you say are a student at a British university. Ishwara had been a keen observer of the British and had much to say about their rule in India. He admired the British who colonized India as great collectors and organizers of information. Their district gazetteers contained detailed maps and census data as well as neatly catalogued information on subjects ranging from the districts ora and fauna to its archeological and pilgrimage sites, its history to its caste distribution, hierarchy, and language dialects. This is how the British ruled India, Ishwara noted, namely, through knowledge, the creation of maps, rules and measures, and a bureaucracy that came to administer many areas of Indian civic life. But, he paused, the British never truly settled in this place. They were great explorers and clever administrators, but they did not become one with the land, and they did not adapt to the diet of this place. And do you know why? he asked me one day as we were eating roasted jackfruit during a heavy rain. Within a moment, he provided the response: because this would render them less British. With a gleam in his eye, Ishwara noted that the British collected information on almost every subject except one. They did not collect recipes or compile cookbooks. Because they did not adopt our diet, Ishwara sighed, they never truly understood our system of medicine. I had no idea whether Ishwaras observations about the diet of colonial ofcials in India were accurate, but I did get the gist of his message as it pertained to me.7 Ishwara was asking me if I was ready to alter my diet and in doing so adapt to local biology (Lock, 1993), an experience that would provide me with a profound personal transformation in the name of participant observation. I later came to understand why my embodying, not just learning, Ayurvedic principles, was so important to him. Late one afternoon, after talking to me about the relationship between the microcosm and macrocosm, Ishwaras favorite subject, he asked me a rhetorical question: What do you think about the way the Indian government treated Ayurveda? During this conversation it became clear to me that Ishwara saw Ayurvedas decline in prestige as a direct outcome of the Indian elite adopting British ideas about Ayurveda being less scientic than bioscience. The reason the British did not respect Ayurveda more,
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Ishwara emphasized, was because they did not appreciate Ayurvedas keen observations of bodily processes expressed in humoral terms. How could they, without experiencing the body as we know it? As Ishwara saw it, it was essential to Ayurvedas future that its empirical base be validated. I got the impression that Ishwara saw me not just as a graduate student, but as a representative of the west.8 It was important to him that I learn about the ow of bodily humors at the site of my own body so that I would experience the teachings of Ayurveda as empirically grounded.9 If you really want to understand Ayurveda as a participant observer, Ishwara stated, the place to begin is your stomach. Like many of the Ayurvedic scholars I met, Ishwara often spoke using analogies. In this case, he likened my adapting to the staple diet of South Kanara to a plant learning to adapt to the soil of a new place. But his comparison of parboiled (double boiled) rice to the soil of South Kanara was meant as far more than an analogy. Ishwara encouraged me to literally take in the essence of the land through the consumption of locally grown rice, vegetables, fruits, and herbs, the water from local wells, and the milk of local cows. He saw this internalization and embodiment of place as something essential for my transformation (transplantation).10 Ishwara emphasized that Ayurveda must be understood and practiced in relation to time, place, climate, local food, and the type of work different kinds of people perform. Ayurveda is an applied science, he often repeated. The wisdom of the ages needs to be applied to meet the conditions of the present. You cannot assume that medicines that work well with one person or population in south India will work equally as well as in north India or North America because the way of life is different and peoples staple diet and climate are different. You must learn to adjust your practice according to the principles you are being taught. And you must be able to read the body to adjust well. Otherwise, he warned, you will become a catalogue practitioner prescribing out of the catalogues of medicine companies that list medicines for different sets of symptoms. As an Ayurvedic vaidya (practitioner), Ishwara assumed that my bodily transformation would not be easy and would result in discomfort for some time. However, it was a necessary rst step to both my becoming habituated to place, and attentive to bodily sensations that I would learn to read as signs of humoral change. To make a long story short, my rst months learning about Ayurveda involved my own digestive system. Understand digestion, Ishwara told me over and over again, and you will be able to understand Ayurveda. And so my wife Mimi and I adopted a simple south Indian Brahmin vegetarian diet for two years. We came not only to relish it, but found within Brahmanic folk dietetics the application of Ayurvedic science in everyday life. Our local biologies and sense of taste
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did alter and we were able to understand and participate in a daily running commentary on foods and bodily sensations in a visceral way a way described by Schechner (2001) as involving snout to belly to bowel rasaesthetics. Ishwara watched me practice social anthropology with both interest and some amusement. When I arrived in India, folk dietetics was one of the rst subjects I decided to study as early interviews led me to believe that the most basic form of self-care involved dietary change more commonly food restrictions than food proscriptions. Initially, I attempted to catalogue the properties of foods based on their hot/cold and humoral qualities following procedures already used by anthropologists in Latin America and India (B. Beck, 1969) in the 1970s. I attempted to investigate both consensus and intracultural variation in the classication of foods and local perceptions of their effect on the body (Mark Nichter, 1986). This led me to discuss what sensations different people felt after eating different types of foods. Ishwara considered my surveying of individuals about their impressions of food qualities to be supercial, although he believed that asking what sensations they experienced after eating particular foods was a good diagnostic indicator of their constitutions. You are lumping the experiences of different kinds of people together, and counting similarities and differences by caste, he observed, but what does that tell you? He believed that in order to understand responses to foods one must examine more than an individuals caste, although food differences among castes were clearly important to consider. He encouraged me to think further in terms of informants body constitution and humoral disposition, their state of health, season, and occupation.11 Your anthropology skims the surface of the sea and does not take into account its currents, the wind, or tide, he stated. To understand the sea you must sail the sea and to understand the qualities of food you must use your own senses and consume foods alone or only with rice (a staple baseline diet) and see their effect on your constitution. Ishwara was keen that I personalize this learning experience. He emphasized that it was essential for me to learn to trust my body and read sensations as signs of interaction between the properties of substances and the state of my body. It is for this knowledge, Ishwara stated, that patients consult Ayurvedic vaidya and ask what foods they should or should not eat when they are ill. They already have a general idea of what they should or should not eat during illness, but they look to us for more specic advice based on our expert assessment of their state of humoral imbalance and how this will be affected by foods and medicines. We speak from the knowledge of experience, knowledge grounded in our own experience as well as that learned from those we have observed closely in our practice.
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Our patients bodies teach us about the ow of humors (dosha) if we are attentive. And so I spent months eating foods and sampling medicinal plants and reporting to Ishwara what sensations I felt after consuming them. Ishwara often baited me. He would not tell me the name of a plant until I had tasted it and commented on the sensations I felt after consuming it. He pushed me further and asked me to learn about my body constitution by examining why I desired certain tastes and why I had an aversion to other tastes when healthy or when ill. Trying to read my bodys hungers (desires) was the most difcult challenge I faced. I was presented with a basic dilemma: was my body desiring some taste because that is what was needed to achieve balance (the way an animal knows to eat a particular plant when ill), or was it my illness (bodily imbalance) that produced a desire as a sign of imbalance? Ishwara repeated his fathers favorite saying to me often: Disease is a hunger and medicine a food for that hunger. Appetite is necessary for life, he often remarked, but uncontrolled appetites, physical as well as all forms of desire and greed are the root causes of most hunger. This was a principle Ishwara saw as basic to understanding not only Ayurveda, but also other healing modalities such as exorcism and sorcery. The physical and mental attributes of hungers, Ishwara emphasized, were mirror images of each other. This enabled vaidya to refer patients to exorcists (mantravaidya) with diagnoses that involved a form of code switching, humoral states, and types of sensations corresponding to the attributes of particular types of spirits and celestial bodies. Gradually, I learned about common humoral disorders and how they could manifest as different sets of symptoms. Each time my wife or I became ill or even experienced physical changes such as cracks on the soles of our feet or at the sides of our lips (and so on), we were told this was a good opportunity to learn about bodily imbalances. I also observed vaidyapatient interactions at the homes and clinics of several other practitioners and took notes on what questions they asked patients about their body. These questions typically addressed sensations they experienced related to taste, indigestion, hot and cold feelings in different parts of the body, sleep, defecation, tingling sensations in the hands and feet, feelings of heaviness, lack of strength, lightheadedness, dizziness, and so on. Over time, I came to better understand why such questions were being asked and I learned to use my own senses to diagnose aspects of an individuals constitution and humoral imbalance. I learned to touch a persons skin to see if it was oily or dry signs of wind (i.e., vata) or phlegm (kapha) humoral predominance and to distinguish different pulse rhythms (although I never became good at this). All of these empirical observations
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enable vaidya to discern patterns of sensations as signs and symptoms of humoral predominance and imbalance. Ayurvedic vaidya gather sensorial data and then lter it through a humoral knowledge grid that yields patterns of associations that suggest diagnostic possibilities. Practitioners of experience near ethnomedical traditions like Ayurveda learn to be attentive to the body sensations of their patients as well as to use their own body as an instrument of diagnosis.12 Learning Ayurveda requires vaidya to know and calibrate their own bodies through routine bodily regimens involving diet and lifestyle. I have presented my own experience as a foreign novice engaged in participant observation that required me to adopt (adapt to) the local biology of my informants in order to understand both the way illnesses were being thought about (and diagnosed) by experts, and how sensations were being responded to by a lay population exposed to Ayurvedic ideas in a very diluted way. This experience changed the way I do ethnography, for it led me to be far more attentive to the sensorial.
Popular Health Culture: Being Attentive to the Sensorial

Learning how those in other cultures understand their bodies entails an understanding of ethnophysiology. Beyond knowledge of parts and organs are local perceptions of bodily processes often understood in terms of analogical frames of reference involving: (a) cosmology and principles that are assumed to pervade the macrocosm and microcosm, rendering the bodylanduniverse coextensive; (b) ecological relationships observed in nature (e.g., sun/wind/rain inter-relationships), symbiotic relationships assumed to exist between man and other species of life, and knowledge gleaned from studying plant and animal behavior; (c) ows and blockages (uid, wind, energy hydraulics and pneumatics); and (d) processes of transformation (e.g., digestion viewed in terms of cooking, churning), organization (e.g., mechanical systems), and communication (e.g., computer models driving ideas about immune responses). Analogical and metaphorical understanding of bodily processes inuences local biology and bodily experiences. As pointed out by many anthropologists, popular ideas about bodily processes, illness etiology, and pathology may also be coextensive with dominant ideologies in society at a particular point in time.13 In such cases, ethnophysiology is biopolitical to the extent that it naturalizes perceptions of the order of things and contributes to governmentality. Bodily sensations experienced when one is healthy or ill are commonly interpreted in relation to bodily processes and how they are thought to be impeded. Let me cite a few examples of how sensations inform and are
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informed by notions of bodily processes as well as cultural health concerns. My rst example involves digestion, a process that in south India is associated with a process of both cooking and churning, the owing in of food, and the owing out of wastes. Hunger, digestion, and defecation are the most basic parameters of health and well-being for the vast majority of the Indian population. Rural agriculturalists can literally tell the time of day by their hunger cycles and taking untimely meals is considered a serious impediment to health, rendering one vulnerable to a host of problems. In many ways, ones digestive cycle is like an internal clock calibrated to sensations associated with food-transit time (hunger, defecation patterns) and activity patterns. One of the most common discussions I had with informants in India was about their digestive tracts, foods, and their effect on the body. Common signs of ill health associated with digestion included the inability to eat as much as one was accustomed to, burning sensations in the stomach or upon defecation, low energy and lack of strength, abdominal pain while working or bending, lack of taste or a lingering bitter or sour taste in the mouth, gas, and the feeling that one needs to defecate but could not do so. These signs prompted actions that varied from fasting and shifts in what one would or would not eat to the taking of medicines to increase digestive capacity (there are many home remedies and Ayurvedic medicines for this), purge the body of wastes, or purify the blood of wastes now circulating within the body. In some cases, infected wounds were thought to be evidence that the blood was impure, especially if the pus that exuded had a noxious odor. Many different types of bodily sensations and psychological states (lethargy, dullness, lack of interest) led people to think that their digestion or the ow of wastes out of the body was not correct. These sensations were taken seriously and guided the most basic forms of self-care. In the case of young children, bodily sensations associated with the movement of worms in the body proved to be very important. In southwestern Karnataka state, India, the term givana da hulla (worms of life) refers to worms one inherits from ones mother via the breast milk. These worms are thought to both churn foods in the stomach (much as earthworms churn soil) and consume waste in the stomach bag (much as snails might clean the inside of a sh tank). A limited number of worms are considered necessary for life, but too many are thought to cause problems. For this reason, home-care practices are undertaken to control both the number and activity of worms in the gut, lest worms migrate and cause mischief evident when worms are seen exuding from a childs anus or nose. It is beyond the scope of this article to examine cultural notions of worms and their symbiotic relationship with humans in great depth (see
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Geissler, 1998 for a good case study in Kenya). The point I want to make here is that many bodily sensations experienced by babies and young children that are expressed nonverbally are linked by mothers to worm activity because of notions of ethnophysiology that guide subjunctive what if thinking. For example, there is a tendency for mothers to think that worms are responsible for a baby or young child crying. It is imagined that the worms are hungry and restless and are demanding food. When the worms are not fed it is perceived that they begin to eat at the esh of the child. And if a baby vomits up breast milk or does not take to the breast, it is the worms that may be rejecting the mothers milk. In such cases, a mother may be encouraged to feed the child rice water (or glucose solution). Breast milk will be introduced gradually so the worms can become accustomed to it. I once asked Ishwara about mothers perceptions of worm activity, and his answer integrated Ayurvedic principles with local notions of ethnophysiology. He noted that if ones body humors were in balance, their body did not accumulate wastes (Sanskrit: mala) and worm problems would not occur. However, when digestion was not correct, wastes accumulated and worms multiplied and sometimes migrated. Ishwara did not discount mothers perceptions of worm activity, but he perceived worm activity to be a sign of a more fundamental humoral imbalance that would not simply be rectied by calming worms. He was attentive to mothers observations of worm activity, but his reading of worm activity as a vaidya differed markedly. When children do not yet have a vocabulary to express the sensations they feel, it is mothers who have to interpret what is troubling a child using their common sense as well as their own senses. Mothers monitor the health of their children through touch, smell, sight, and sound. This became clear to me while conducting research related to respiratory disease in both India and the Philippines. I was commonly told by mothers that they knew when their children were becoming ill by changes in how they sucked breast milk (felt by mothers at the site of the breast when the breast became engorged with milk due to poor sucking), the sound of their breathing, the movement of their stomach and chest when breathing was labored, the amount and smell of their sweat, their urine color and stool consistency, their gaze, and their activity level. In coastal Karnataka, Indian mothers spoke of their children having inside fever (Kannada: ole jwara), discernible to their touch at different parts of the body, although not necessarily registered by a thermometer in the usual locations temperature is taken. In some cases, internal fever was associated with other heatrelated symptoms such as skin rashes that were noted along with other body sensations like a childs thirst or even the cracking of the childs feet (a place heat was thought to escape).
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In the Philippines, when a child suffered from labored breathing or a deep cough, I observed that many mothers became concerned about pilay hangin. This is a condition that can occur when a child falls or is held too tightly, resulting in bodily dislocations that can impede breathing and cause or complicate respiratory illness (Mark Nichter & Nichter, 1994). Most mothers do not feel that they have the ability or sensitivity to diagnose pilay and take their children to native practitioners for diagnosis. These practitioners are thought to have heightened sensitivity that allows them to be able to touch the childs back and identify dislocations, which are then treated by massage and herbal preparations. Filipino mothers often suspected that their childs illness was climate induced, but still checked for pilay. In addition to the sound of a childs labored breathing, bodily movements and other sensations mothers observed as unusual raised an alarm that the problem might not simply be associated with the lungs. They wanted to check for pilay as a just in case precaution before they spent money on a doctors visit or allopathic medicines as bodily dislocations were thought to render doctors treatments ineffective (Mark Nichter & Nichter, 1994). A sense of vulnerability and local perceptions of illness as latent or cumulative can lead people to be hypervigilant to bodily sensations. Let me cite two examples. When HIV rst received press in India in the early 1990s, I encountered several men who tested seronegative for HIV in Kerala and Karnataka state, yet suffered from AIDS-related phobia (Chandra & Ravi, 1995; Jacob & John, 1989). Similar to men whom I had studied during the 1970s who had experienced semen-loss (dhat) syndrome, many of these men suffered from anxiety and guilt associated with having had sex with a prostitute.14 In some cases, this event had occurred recently, while in other cases the event had occurred several years before. During interviews with these men, a wide range of sensations was reported as perceived signs of HIV. These included feelings of weakness, inability to concentrate or control ones emotions, loss of appetite, feeling of heat inside the body (inside fever), paresthesia in the hands or feet, tingling or burning sensation in the genitals when they urinated, skin rashes, palpitations, or a racing heartbeat, and in one case an increased sensitivity to the smell of menstrual blood. Many of these symptoms have been reported globally as biological signs of anxiety, but some had particular cultural salience. They t a cultural pattern of symptoms that were all thought to manifest as a result of uncontrolled heat in the body. One informant described HIV to me as a heat-related disorder that manifested internally rst and then gradually worked its way to the surface, resulting in skin rashes and then open sores, heat-related indigestion, diarrhea and weight loss, and tuberculosis.15 Every time he experienced heat-related sensations, he was sure that his HIV was about to manifest. He interpreted
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an HIV diagnostic-test message asking people to come in for an AIDS test three months after risky sex to mean that seeds of AIDS could lie dormant in the body for months, if not years, before growing large enough to be seen. He kept returning to the clinic to check for AIDS when he felt heatrelated sensations, fearing this was an indication that the seeds of the disease had now germinated. In some cases, men may attempt to hasten or trigger the symptoms of an illness they believe is latent in their body due to the feeling of bodily sensations like heat or tingling sensations. An example of this was in Thailand: while working on a sexually transmitted infection (STI) study, I ran across men who were concerned about transmitting an STI to their wives following a sexual encounter with another woman. Many of these men were working far from home as migrant laborers. Several of these men had become hypervigilant near the time they were due to travel home. They worried about burning sensations they experienced while urinating and monitored the pressure of their urine stream, as well as the color and smell of their urine. In only one case did a man go to a clinic and ask for a diagnostic test (the test was for HIV although he had sex within the past month). Some of the other men immediately took combination medicines (Thai: yaa chud) following the experience of unsual bodily sensations. Packets of yaa chud medicines are sold at drug shops (although illegal) and often contain a combination of antibiotics and diuretics. Other men attempted to hasten the manifestation of latent illness so they could see if they were ill. A variety of food thought to trigger symptoms (fermented sh paste dishes, specic fruits and vegtables) was eaten and the person then waited to see what would happen. If symptoms or unsual sensations manifested or were exacerbated, they sought treatment.
Sensorial Anthropology and the Study of Pharmaceutical Practice

Bodily sensations experienced after taking medications inuence whether medications are considered effective/ineffective or compatable/ incompatabile. Notions about ethnophysiology, illness etiology, and how a medication is thought to act in the body inuence whether sensations experienced after taking a medicine are judged in a positive or negative light (Etkin, 1992; Mark Nichter, 1989; Mark Nichter & Nichter, 1996). For example, in India I have encountered people who have experienced diarrhea, a burning sensation, or colored urine after taking a medicine and viewed this as an anticipated part of the healing process associated with the removal of toxins or heat from the body. I have documented other people in the same community negatively evaluating these sensations as
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well as such sensations as a bad taste in the mouth, dry mouth, light sensitivity, and so on. Cultural interpretations of medications are an important issue to consider when trying to understand both nonadherence and a populations propensity to complain or not complain about the sensations they feel as side effects of medication. In some instances, sensations that one might think of as negative side effects are valued. For example, I have been told by many people in India that the experience of a burning sensation felt in the body following taking a medicine is a measure of the medicines strength. Other anthropologists have made similar observations. For example, in Malawi, women infrequently complain about the side effects of chloroquine because they feel these symptoms indicate the drug is working (Helitzer-Allen, 1989). This is a case of a side effect being interpreted as a demonstration of efcacy. Van der Geest (1982) has reported that the side effects of a medicine are valued in a region in Ghana where spurious drugs are commonly found in the market. In many regions of the world, informants feel they know they were taking the real drug by its tell-tale signs in the body. Other social scientists have corroborated this proof function of side effects in markets that are ever more polluted by poor quality and bogus drugs (Cockburn, Newton, Kyeremateng Agyarko, Akunyili, & White, 2005).16 Cultural perceptions of compatibility also play an important role in how people determine the suitability of particular types of medication for their personal use. Compatibility the t between medication and the bodily constitution of an individual is used to explain why a medication proves efcacious for one person and not another, given a similar type of complaint. Described most extensively in research in the Philippines as a concept guiding pharmaceutical use (Hardon, 1987, 1991, 1994; Tan, 1994, 1996), I have encountered variations of the concept in Indonesia and Thailand, and Craig (2002) has described the importance of the concept in Vietnam. The perception of a medicine being compatible is important for at least four reasons: (a) people may use a drug deemed compatible as self-treatment for a wide variety of complaints; (b) drug effectiveness may be misjudged after a short time if expectations of a drug are unmet, leading the user to think the medicine is incompatible; (c) side effects may be seen as a sign of drugs incompatibility;17 and (d) noncompliance with medication prescribed may be justied on the basis of a medicine not being compatible (Mark Nichter, 2002). Little research has been conducted on how medicines are evaluated in respect to compatibility. My own research suggests this to be determined as much by how sensations associated with medicine use are interpreted as by immediate relief from symptoms, especially when there is a concern that the medicine will impact on important bodily functions (such as digestion and defecation) and ones capacity to work. A cultural consideration of
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popular and unpopular regimens used to treat a particular illness needs to take stock of local perceptions of sensations associated with taking specic drugs.18 Sensorially engaged research also needs to explore two other areas of pharmaceutical experience. In what contexts and to what extent do sensations related to the progression of an illness become conated with the sensations caused by the medications used to treat or manage the illness? In the case of an asymptomatic condition like hypertension, I have come across patients in North America who have conated the side effects of medications (and warnings about side effects on labels) with the condition itself. In some cases, people become hypervigilant about these sensations, interpreting them as an escalation or are-up of the condition. A second area of research called for is a sensorially engaged ethnographic assessment of the pharmaceutical management of emotional and psychological states, and the production of neurochemical selves (Chatterjee, 2004; Martin, 2006; Rose, 2003). How do medicated states of being affect the experience of different types and ranges of sensation, attentiveness, and perceptions of what social and work environments are tolerable? Also begging consideration is how the cultural interpretation and salience of particular emotional states inuence the popularity of pharmaceuticals such as antidepressants (Kirmayer, 2002).
Sensorial Anthropology and the Study of Tobacco, Drug Foods, and Dietary Supplements
A sensorial approach to ethnography also provides valuable insights into the use of drug foods such as tobacco, caffeinated beverages, dietary supplements, and so on. Mimi Nichter and I have paid close attention to the sensorial in our research on tobacco use in South and Southeast Asia and the USA, and areca nut use in India (Mark Nichter for the Project QTI Group, 2006; Mimi Nichter, Nichter, & Van Sickle, 2004). In the Philippines and Indonesia, people overtly describe searching for brands of cigarettes that are compatible with their body, believing that the right cigarette will not harm their body and even be a useful form of selfmedication. Their evaluation of compatibility is based on the presence of positive sensations such as relaxation or reducing stres, as well as the absence of negative sensations smoking not affecting their appetite or causing unpleasant sensation in the throat or lungs. In Indonesia, cigarettes are specically smoked to reduce unpleasant thoughts and bodily sensations associated with stress (Mark Nichter for the Project QTI Group, 2006; Mark Nichter, Nichter, Padmawati, Thresia, & the Project QTI Group, forthcoming). Cigarettes are explicitly marketed as a good means to do so with advertisements portraying stressful situations in life
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(from problems with a girlfriend or a boss to worries about the cost of living or unemployment), with the invitation to just smoke and enjoy (Mimi Nichter, 2006). Control of the emotions among Javanese men is culturally condoned and cigarettes are positioned as a substance that will assist one to manage negative affect as well as to engage in positive social interactions. In the USA, we have studied smoking initiation among youth and found differences in the way sensations of early smoking episodes are experienced (Acosta et al., 2008). For some youth the common experience of dizziness following ones rst few cigarettes was experienced negatively, whereas for others the experience was talked about in more positive terms such as a high or a buzz. Do such different responses help predict who goes on to become a routine or heavy smoker? Another area of tobacco use we have been examining among college students is party smoking. Beyond issues of social identity, afliation, and peer inuence we are investigating other forms of utility associated with smoking. Some students smoke to moderate the effects of alcohol (Mimi Nichter et al., 2006). While some smokers boost a high from alcohol by smoking, others speak of regulating a high by smoking and putting them back in a steadier bodily state, when they feel they are getting too drunk (or intoxicated from another drug). In India, our research on betel nut (areca nut) use taught us to look at not just positive and negative sensations, but also states where lack of sensation is marked. One of the most common reasons people cited for chewing areca nut was to reduce the experience of tastelessness in the mouth (Tulu/Kannada language: chappe). Curiously, this sensation of chappe was described both at times of hunger and after nishing a meal. In other contexts chappe is complained about by those with negative affect and one vaidya described the state to me as having no taste for life a condition caused by poor digestion. Other reasons areca and tobacco are consumed are to warm the body when working in the rain, or to give a work boost, as areca has a mild stimulant effect. Sensorial anthropological research has much to contribute to studies of the social utility and popularity of other drug foods ranging from those having a stimulant to a sedative effect, especially at specic junctures of history among particular groups of people. Anthropologists and historians have documented the signicant role that drug foods such as sugar, tea, coffee, tobacco, and alcohol played in the expansion of the world market system during the fteenth and sixteenth centuries (Bradburd & Jankowiak, 2003; Jankowiak & Bradburd, 1996; Mintz, 1996; Schivelbusch, 1992). To increase production in an emerging capitalist economy, the use of stimulants was fostered to enhance physical performance by increasing endurance, concentration, and the intensity of physical work. Drug foods
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were also used for the relief of physical pain associated with hard labor and to suppress negative emotional states, allowing colonial workers to tune out the wretchedness of life in conditions that might have otherwise been intolerable (Bradburd & Jankowiak, 2003). In present-day society, drug foods and dietary supplements are also being used to keep people in step with the production process (E. P. Thompson, 1967), the dictates of a fast-paced hyperstimulated society (a condition that Vuckovic, 1999, 2000 has described as time famine), and the boredom and restlessness experienced as a side effect of a hyperstimulated state (Stromberg, Nichter, & Nichter, 2007). We need sensorial ethnographies of how people use drug foods and drugs (vitamins, dietary supplements, stimulants, sleeping medications, and so on) to help them cope with the demands of the world in which they live. Recently, Jennifer Thompson and I have been investigating not only when and why people use dietary supplements, but how they determine how much of a herbal supplement to use based on the sensations they feel in their bodies, perceptions of bodily constitution, and sensitivity to medicines (Mark Nichter & Thompson, 2006; J. J. Thompson & Nichter, 2007).
Sensorial Anthropology and the Study of Somatic Idioms of Distress and Concern
As one gains perspective into how visceral states and sensorial experience are interpreted in different cultural contexts, somatic modes of attention and inattention became more apparent. Csordas (1993) has spoken of somatic states of attention as culturally elaborated ways of attending to and with ones body in surroundings that include the embodied presence of others. The individual body is coextensive with that of other agents inhabiting the same social environment. Their biorhythms and consumption patterns, tastes, and desires are known by signicant others. For this reason, research on idioms of distress calls for close examination of both somatic states of attention and mimesis, where the bodily states resonate with affective states. In south India, common ways of experiencing and expressing distress at the site of the body include shifts in food consumption recognized by family members as well as physical complaints such as the sensations of having a ball or mass (Kannada: gulma) in the stomach, making it difcult to eat or digest food, a phenomenon associated with both humoral imbalance (Ayurvedic diagnosis of ama) as well as sorcery. Other complaints take on social salience when expressed verbally or nonverbally through the act of taking medications or the seeking of practitioners. Common complaints include constipation (blockage in ows), burning sensations (uncontrolled heat), dizziness (imbalance), the feeling
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of toxicity (Kananada: nanju), tastelessness, dullness, lack of strength, semen loss, menstrual complaints and complaints of white discharge (leucorrhea), nerve troubles (Kannada: nara dosha), and more recently BP or pressure. BP is becoming increasingly common as a medical diagnosis and many pharmaceutical products have appeared on the market to address this complaint. Local understanding of BP associates the complaint with too much thinking (cascades of negative thoughts and circular thinking), mental worries, and negative affective states, as well as inappropriate diet, poor blood quality, and heat in the body. All of the aforementioned complaints speak to break down, imbalance, powerlessness, and blockage in social as well as bodily processes. And as Kirmayer and Young (1998) have noted, these somatic states may be indicative of any combination of seven things: an index of a disease or disorder, a symbolic expression of intrapsychic conict, an indication of specic psychopathology, a culturally salient idiom of distress, a metaphor for experience, an act of positioning within a local world, or a form of social commentary or protest.19 I have argued earlier (Mark Nichter, 1981) that in order to understand how and when idioms of distress available in particular cultural contexts (from the somatic to sorcery or spirit possession) are engaged, it is important to know what feedback is received from signicant others. It is also important to study how practitioners interpret and treat manifestations of distress while engaging in the work of culture. In the case of indigestion, a common idiom of distress that I have written about at some length (Mark Nichter, 2001), Ayurvedic vaidya treat humoral imbalance as the root cause of many problems we would tend to see as psychological or psychosomatic, believing that once balance is achieved and rhythms reestablished in the body/mind, then social solutions may be possible to discern or act upon. Beyond treating a patients humoral state and reinstating bodily rhythms, Ayurvedic treatment may have a variety of social impacts. It could be argued that in some cases this treatment medicalizes what is essentially a psychosocial problem by focusing on an individuals humoral imbalance instead of family dynamics, provides the patient some form of secondary gain by directing attention to them by family members, provides the patient with a way of focusing on themselves or thinking about their problems in a new way, or provides them with an ally or strong protector (more common in the case of exorcists mantravaidi) who looks after their well-being and is attentive to their concerns, needs, and fears. The act of receiving Ayurveda treatment at home or in a clinic may also provide an aesthetically pleasing sensual environment associated with positive memories and sensations triggered by smells, tastes, visual cues (images of deities, etc.) and being touched (Farquhar, 1994; Halliburton, 2003). A positive placebo response may be triggered by associations with
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past treatment experiences encoded as positively charged embodied memories associated with particular affective and sensory states. Sensations associated with the smell of a herbal decoction boiling may evoke associations not only with a particular medicine, but with the experience of being cared for by a particular healing modality or a particular person (practitioner, signicant other, etc.). The way of administering medications (or treatment) and the performing of particular types of rituals in conjunction with giving medication may evoke further positive sensations and constitute an idiom of concern. Just as trauma is embodied and triggered by cues (objects, symbols, spaces, times, etc.), so too positive memories and affective and sensorial states are embodied and may be evoked by healing modalities. Two recent trends that inuence somatic idioms of distress and concern are worth highlighting. The rst is the current propensity to mask and medicalize sensations that once served as somatic idioms of distress. I began noticing this trend in India in the late 1970s during the heyday of Indias family planning campaigns. When women who had received family planning operations at sterilization camps experienced feelings of distress and complained about bodily sensations associated with weakness, dizziness, and heat in the body, they were given diazepam by doctors who did not know how to manage these vague sets of sensations. Over the past 15 years I have witnessed more and more households taking family members complaining of culturally salient somatic symptoms to doctors (general practitioners), where they are given pharmaceutical xes in the form of an ever-increasing array of psychoactive drugs. I have also observed the rising use of drugs like diazepam (under the brand name Calmpose) by the general public purchased over the counter although a scheduled drug especially in urban areas. Pharmaceutical xes for psychosocial problems are becoming more widely accepted. Ecks (2005) has noted that presentday advertising for anti-depressant medication in India portrays people (especially the urban middle class) as unmarked by depressive illness as a result of taking pharmaceuticals that allow the aficted individual to reenter social life, rendering them de-marginalized (Ecks, 2005). These drugs are depicted as both blocking negative sensational states and enhancing social interaction. The popularity of such drugs as technical xes for psychosocial, emotional, and mental health problems is also being fostered by the psychiatry profession, which is predisposed to offer medicines to patients as a prestigious rst line of treatment now in keeping with patient expectations (Nunley, 1996). The commercial Ayurvedic drug industry has also responded with products specically designed for states of negative affect associated with both life cycle events for women and sensations associated with negative affect. Some mantravaidi I have followed over the years have also begun
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incorporating psychoactive drugs in the sacred ash (bhasma) or turmeric powder preparations they give to patients to ingest during ritual cures.20 What impact does this pharmaceuticalization of negative sensational states associated with social problems have on somatic idioms of distress, healing modalities, and self-care? This is an important area for future research. A second trend in India is the rising popularity of diagnostic tests (scans) as a measure of quality of care by patients. Getting a scan is also being used as both an idiom of concern by family members who want to demonstrate that they are doing everything possible to address a health problem, and as an idiom of distress by patients. Testing technology (CT scans, MRIs, sonograms, etc.) is readily available to the public and increasingly more affordable in urban areas to even the lower middle class. It is a protable enterprise for practitioners and testing centers alike, who in some cases offer walk-in services to patients without a referral or to patients referred by indigenous practitioners (Mark Nichter & Van Sickle, 2002). This has opened up a new space for the expression of distress and concern. Sensations associated with anxiety states are often the focus of a scan. And receiving a scan is enough to legitimate the aficteds sense of angst to family members and for them to be seen as at risk, if not ill, with a specic diagnosis. In many cases, the aficted are still treated by practitioners after receiving negative test results and told that tests may have to be repeated in the future, or that their case is not serious, but needs to be watched. After being told this, some patients become hypervigilant and associate all manner of sensations with heart problems, pressure, nerves, and so on. A related trend, beginning in the late 1980s, has been for families to directly take (without a referral) those aficted with sensations associated with anxiety states to neurologists and neurosurgeons to rst rule out nerve disorders and to get tested. One popular neurosurgeon I interviewed in the city of Mangalore in 1990 estimated that more than one-third of his rst-time patients fell into this category. He was able to refer some of these patients to psychiatrists, but many wanted to be treated directly with medications after some form of test was administered. They wished to receive treatment for nerve-related problems, not mental problems, which are stigmatized. We know little about how social response and interpretation of sensations commonly associated with states of depression, anxiety, and so forth are changing in cultural contexts exposed to new types of medication, forms of medical technology, and healing modalities, and the advertising that accompanies their introduction. In North America, how does the growing presence of complementary and alternative healing modalities and forms of diagnosis inuence how bodily sensations are
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talked about, framed, and responded to by different segments of the population?
Sensorial Anthropology and the Study of Transformative Healing and Trajectories of Healthcare Seeking
There are many things we know little about related to healing modalities and the management and release of sensations associated with pathological states, negative affective states, and embodied memories. How do healing modalities attend to deeply embedded and re-emergent sensations associated with embodied traumatic events lodged in particular spaces of the body (Casey, 1987) and triggered by environmental and cultural cues, psychological states such as fear, sadness, anger, and feelings of vulnerability? Strong emotional states and states of anxiety are often re-experienced as a cascade of embodied sensations associated with evocative memories, triggered by particular spaces, times, breaches in social relations, states of uncertainty and threats to the future (the hallmark of anxiety) or sudden shocks (of any type). What sensations commonly accompany these states, which ones become amplied or are dwelled upon because of their particular cultural or personal valence? And how do different healing modalities release painful sensations through forms of body work, energetic healing, ritual, prayer, the use of pharmacopoeia (adopting different therapeutic strategies), and so on? I have recently joined a team of multidisciplinary researchers attempting to look at the process of whole-person healing interventions in the USA associated with complementary and alternative medicine treatment (Ritenbaugh, Verhoef, Fleishman, Boon, & Leis, 2003). The focus of the group is to better understand trajectories of change from states of stuckness (chronic unhealthy repetitive patterns often marked by negative states of sensation such as chronic pain) to the process of transformation through which healing takes place and well-being of bodymindspirit and social relations emerges (Koithan et al., 2007). The group is attentive to shifts in sensational states associated with movement in this process, which range from the way in which one experiences the sensations of pain or levels of energy to shifts in the acuity of ones senses, such as changes in taste or ones ability to touch or feel touch. Under investigation are both shifts in sensational states as makers, turning points, or resonances of other associated changes and how different healing modalities catalyze if not directly effect such changes. Sensorially engaged anthropology can also contribute to the study of how healing modalities treating negative states of affect and associated bodily sensations function over time, providing us insights into trajectories
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of care. Of key importance, although little studied by anthropologists, is how long the effectiveness of treatments and the reframing of distressful experiences last before they need to be recharged, and when healing leads to long-lasting if not permanent transformation and release of negative bodily memories.21 Victor Turners research into the meaning of symbols in ritual is relevant to processual studies of healing as works of culture. Turner pointed out that symbols are inherently unstable and that in order to maintain their salience they must routinely be recharged by performative acts that produce resonance between a symbols two poles: one pole evoking cognitive representations related to some social and moral order and the other pole sensory, evoking visceral states and embodied feelings.22 A related issue demanding consideration is how sets of practitioners work together or engage in referral to deal with different aspects of a patients illness experience and process of healing. When I was rst conducting eldwork in south India in the 1970s, it was common for wellestablished Ayurvedic vaidya, astrologers, and exorcists to refer patients to one another. An Ayurvedic vaidya would deal with negatively experienced bodily sensations, humoral imbalances, and the re-establishment of healthy bodily rhythms. An exorcist or astrologer (many had combined practices) offered patients protection when they felt a heightened sense of vulnerablity and experienced states of anxiety associated with spirits or sorcery (acts of a strong enemy) through acts of propitiating and appeasing offending spirits, emplacing them, or imprisoning them through ritual acts (Tarabout, 2000). Ayurvedic vaidya, astrologers (jyothisni), and mantravaidi recognized that excessive passions anger, desire, grief disrupted the body/mind of the aficted, and each did their part to reduce feelings of vulnerability, enhance the persons strength, and reestablish balance. Today such referral patterns still exist, but appear to be becoming less common in the area of south India where I have been conducting long-term eldwork. We know little about patterns of referral in North America between biomedical practitioners and complementary and alternative medicine practitioners at a time when complementary and alternative medicine is being used or experimented with by a signicant percentage of the population, and more and more practitioners are becoming interested in integrated medicine (Institute of Medicine, 2005). When and to whom are these biomedical practitioners referring patients who complain of illness experiences and sets of sensations (such as manifestations of chronic pain) for which a biomedical diagnosis and treatment is problematic? How are such bodily states being managed in the short- and long-term by complementary and alternative medicine practitioners? Does management involve behavior or life style change beyond being directed at symptoms?
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Conclusion
In this article I have highlighted ways in which sensorially engaged anthropology can contribute to the study of ethnomedicine and medical anthropological studies of popular health culture, pharmaceutical practice, drug food and substance use, idioms of distress and concern, transformative healing, and healthcare seeking. The meanings and experience of bodily sensations are biosocial and need to be studied in the context of social change. We are living at a time when thresholds of tolerance to discomfort are decreasing (Barsky, 1988; Barsky & Borus, 1995) and the number and variety of pharmaceutical xes for all manner of symptoms of malaise are increasing. Manifestations of chronic pain are becoming more prevalent in North America (Csordas & Clark, 1992), and advancements in risk assessment and proling (and a robust risk-assessment industry) are leading to shifts in risk subjectivities (Lupton, 1999). More and more people today are adopting risk roles as one feature of biomedicalization (Clark, Mamo, Fishman, Shim, & Fosket, 2003) and in the course of doing so are giving new meaning to bodily sensations they now associate with the warning signs of diseases. Environmental risk and perceptions of such risk are also inuencing individuals interpretations of somatic experience and intuitive toxicology (Kraus, Malmfors, & Slovic, 1992; MacGregor & Fleming, 1996).23 This is also a time of increased medicalization of suffering (Misbach & Stam, 2006) and the pharmaceutical management of emotional states, in part driven by the pharmaceutical industry, and simultaneously a time when more and more biomedically trained doctors are willing to refer patients to practitioners of complementary and alternative medicine for states of ill health they are unable to diagnose and treat effectively. It is a time when complementary and alternative medicine modalities are ourishing and an increasing number of people are willing to try these modalities to promote health, as well as attend to negative sensations associated with emotional states, embodied memories, the stress of living in a fast-paced high-pressure world, environmental and occupational health problems, and so on. A next generation of sensorial anthropology will need to be attentive to these and other trends such as heightened sensation-seeking among youth, given a faster pace of life and technology that enables round-the-clock access to sources of stimulation, social engagement, and enthrallment.24 We will have much to learn from an anthropology that comes to its senses.
Notes
1. Casey (1987) draws a distinction between body memory and memory of the body. Both are involved in linking the past to the present and future. Body 186
Nichter: Coming to Our Senses memory is intrinsic to the body, to its own ways of remembering: how we remember in and by and through the body . . . the way the body itself, in its sinews and on its surface, remembers its own activity (Casey, 1987, p. 147). Body memory occurs when one experiences sensations in the present similar to those they have experienced in the past, such that memories, fears, etc. inuence the present experience. In memory of the body, the body is the object of recollection in the mind. Memory of the body involves how individuals remember and narrate bodily events. At issue is the extent to which changes in memory of the body may affect changes in body memory such as the release of traumatic bodily memories and their associated sensations. Three perspectives from which the body may be viewed are: (a) as a phenomenally experienced individual body-self; (b) as a social body, a natural symbol for thinking about relationships among nature, society, and culture; and (c) as a body politic, an artifact of social and political control (Scheper-Hughes & Lock, 1987). I nd it more useful to think of mimesis in terms of resonance between mindemotionsbody than mindbody mirroring. Mimesis is one way of understanding both the metaphoric (similarity) and metonymic (contiguity) contexture and interlinking of cognitive, affective, and bodily experience. See Kirmayer (1992, 1993) on how metaphor links bodily, persona, and social experience and the need to study metaphor in relation to praxis and not just cognition. My use of the term resonance draws upon the phenomena of string resonance (sympathetic vibration) in music and applies it to the bodymind continuum. I view mimesis as one means through which humans organize experiences across domains through iconic relations, homologies, and perceptions of common processes often elaborated in healing systems and ritual. Sickness, in these contexts, can be read as bodily idioms for registering protest and for negotiating power relations (Scheper-Hughes, 1991, p. 56). Personal symbols according to Obeyesekere (1981) are: cultural symbols whose primary signicance and meaning lie in the personal life and experience of individuals (p. 44). In a culture replete with symbols like south India with its complex local and pan-Indian cosmology and pluralist healthcare arena, different people assign different levels of signicance to various symbols depending on the degree to which they have been rendered personal and internalized. Personal ties to symbols may be cognitive, emotional, sensorial, or afliational (associated with social formations of the living and deceased) with the most powerful symbols producing an embodied as well as a cognitive response. As Halliburton (2004) has noted, pluralistic healthcare systems afford the aficted a greater pool of resources to draw upon and a greater opportunity to nd a t between patient and modality. This may inuence outcome studies for mental health in societies with fewer and greater variety of healing modalities. Marriott (1990) has argued that in India a nonwestern sense of the self as dividual contrasts with the western notion of individuality and autonomy as the foundational aspects of identity. Western conceptions of self or 187
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Transcultural Psychiatry 45(2) personhood tend to be bounded, stable, enduring, and impermeable. Dividuality is a transactional conceptualization of selfhood based on the idea of a permeable self and dynamic interchange within ones environment that alters ones very being. I use the term here as a useful heuristic and am not endorsing broad application of Marriotts rather Brahmanic (textual) interpretation of perceptions of self in India. The relationship between diet and the domestication of imperialism in British India is actually quite complex (see Appadurai, 1988; Procida, 2003; Zlotnick, 1996). For a similar observation on how the ethnographer is addressed as a representative of the west at some points of an interview see Trawick (1992). See Engler (2003) on struggles to claim legitimacy for Ayurveda through the valorization of empirical observations. See Zimmerman (1987) for a discussion of the biogeographic and topological aspects of Ayurvedic medicine and the ways in which bodily constitution and local ecology interact such that one takes on qualities of ones environment. Zimmerman notes how the plants and animals of particular places concentrate the essences of that place, and how these essences are in turn passed on to humans through the processes of eating and subsequent humoral transformation (cooking). To some extent ones identity is environmentally constituted (Brennan, 2002). On the importance of constitution and disposition in Ayurveda see Singh (2007). I am not claiming that the only way healers come to know the experiential state of their clients is through the use of their bodies. Indeed, some healing traditions call for a healer to dissociate themselves from their own bodies in order to feel the presence/consciousness/spirit of those who are the subjects of divination. Moreover, what constitutes the boundaries of the body varies by healing tradition and may well include a sense of being that extends beyond the skin. Some mantravaidi, for example, accord signicance to the direction from which the aficted individual approaches their house, the time of consultation, qualities of the earth taken from the house of the aficted, social interactions between members of the party representing the aficted, and so on. See, for example, Sivin (1995) and Unschuld (1985) on the relationship between Confucianism and Chinese medicine or Martin (1987, 1990, 1994) on how biomedicine and popular health culture in North America reect both Fordist and exible accumulation as well as gender ideology. Dhat syndrome (Bhatia & Malik, 1991; Edwards, 1983; Mark Nichter, 1981; Ranjith & Mohan, 2006) is often associated with masturbation as well as with having visited a prostitute and typically involves complaints of weakness, inability to concentrate, having a penis that hangs to the right or left, and fear of impotence, as well as inability to maintain an erection with a woman. I did not come across anyone suffering from pseudo-AIDS who associated this disease with masturbation and only one who associated it with homosexuality. I came across several men who suffered from this syndrome after 188
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13.
14.
Nichter: Coming to Our Senses having mixed (had intercourse) with women while working in the gulf as migrant workers. Tuberculosis is thought to be predisposed, if not caused, by many things in India (Mark Nichter, 2008) including excessive states of bodily heat associated with excessive sex, alcohol consumption, or smoking. Drug counterfeiting has reached epidemic proportions and constitutes a major challenge for global health. The World Health Organization (WHO) estimates that at least 10% of the global drugs market consist of counterfeits (Kelesidis, Kelesidis, Rafailidis, & Falagas, 2007; Newton et al., 2006; WHO, 2006). A study conducted in WHOs Southeast Asia Region in 2001 revealed that 38% of 104 antimalarial drugs on sale in pharmacies did not contain any active ingredients (Aldhous, 2005). A drugs negative side effects may go unreported in a population if people feel the medicine has not worked for them due to incompatibility. The perception is that the drug might be compatible for others. In a similar vein, drug resistance is often thought about in individual rather than populationbased terms. For example, in a study of peoples evaluations of leprosy-treatment regimens in Thailand, Boonmongkon (1995) found that patients viewed multidrug therapy positively, reporting that they experienced a sensation of lightness, which is locally associated with good health. By contrast, a mono-drug therapy was considered by many people to produce an unhealthy feeling of heaviness. Disciplines like epidemiology need to take the cultural meaning of symptom and sensation states seriously when developing syndromic management plans. See, for example, Trollope-Kumars (2001) review of the research on the meaning of leucorrhea among South Asian women. This review validates observations I made about this bodily state being used as an idiom of distress (Mark Nichter, 1981). Prior to their use of modern drugs, some exorcists used herbal drugs that have psychoactive pharmaceutical properties like Rauwola serpentina. My use of the term reframing does not specically relate to cognitive reframing. As noted by Kirmayer (2003), healing does not necessarily reframe meaning in a cognitive sense, it can also reframe experience on a sensorial, emotional, and bodily level. Although outside the scope of this article, the study of how ritual works clearly requires an assessment of the sensorial experience of ritual and how associative states are experienced by the mindful bodies of participants in sociosomatic terms that translate social experiences into embodied responses (Kirmayer, 1993, 2004; Kleinman & Becker, 1998). For example, sensory states associated with particular types of spirit possession in the area of southwestern India where I have conducted eldwork (Tulunadu) are induced through the distinctive smell of areca nut inorescence (singara). Although the symbol of areca inorescence is cognitively evocative and polysemous, it is the distinct smell of singara that is a potent trigger of associations in ritual contexts further marked by the smell, sight, and sound of other ritual items. 189
15.
16.
17.
18.
19.
20. 21.
22.
Transcultural Psychiatry 45(2) 23. Kraus et al. (1992) describe humans as intuitive toxicologists relying on their senses of sight, taste, and smell to detect harmful or unsafe food, water, and air. In our current risk society (U. Beck, 1992, 1996; Giddens, 1990) people living in industrialized countries increasingly feel vulnerable to risks from technology, and doubt that government regulations and agencies protect them adequately from chemical risks due to the political and economic power of corporate interest groups. In such a climate, argue MacGregor and Fleming (1996), somatic sensations associated with psychological states ranging from stress to depression may be attributed to environmental pollutants, and apprehension about occupational and environmental risks may make people hypersensitive to sensory cues associated with a range of experiences. 24. There is a need to study not just the desire for particular sensations, but the seeking of sensations as arousal, and boredom as a state of nonarousal and nonengagement and how this is responded to by youth (Stromberg et al., 2007).
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Nichter: Coming to Our Senses Van der Geest, S. (1982). The illegal distribution of western medicines in developing countries: Pharmacists, drug peddlers, injection doctors and others. A bibliographic exploration. Medical Anthropology, 6(4), 197219. Vuckovic, N. (1999). Fast relief: Buying time with medications. Medical Anthropology Quarterly, 13(1), 5168. Vuckovic, N. (2000). Effect of time famine on womens self-care and household health care. Permanente Journal, 4(3), 1319. World Health Organization. (2006). Counterfeit medicines. Fact Sheet No. 275. http://www.who.int/medicacentre/factsheets/fs275/en/. Zimmerman, F. (1987). The jungle and the aroma of meats (J. Lloyd, Trans.). Berkeley, CA: University of California Press. (Reprinted 1999, Motalil Banarsidass, Delhi.) Zlotnick, S. (1996). Domesticating imperialism: Curry and cookbooks in Victorian England. Frontiers: A Journal of Women Studies, 16(2/3), 5168. Mark Nichter, PhD (University of Edinburgh, 1977) and MPH (Johns Hopkins University, 1978), is Regents Professor of Anthropology, Family Medicine, and Public Health at the University of Arizona, Tucson. He coordinates the graduate medical anthropology training program in the Department of Anthropology. His interests include the anthropology of the body, health and illness; risk and harm reduction; global health; clinically applied anthropology; political ecology; the process of healing and ethnomedicine. He has conducted signicant ethnographic eldwork in South and South East Asia as well as the USA and has been a social science advisor for the International Network of Clinical Epidemiology for over two decades. He is currently involved in research on tobacco in the USA, Indonesia and India. Among his publications stand the following books: Global Health: Why Cultural Perceptions, Social Representations, and Biopolitics Matter (2008); with Margaret Lock (eds., 2002) New Horizons in Medical Anthropology; with Mimi Nichter (1996) Anthropology and International Health: Asian Case Studies; and Anthropological Approaches to the Study of Ethnomedicine (ed., 1992). Professor Nichter has published over 70 articles and book chapters related to medical anthropology. Address: Haury Building, University of Arizona, Tucson, AZ 85721, USA. [E-mail: Mnichter@u.arizona.edu]
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transcultural psychiatry

Coming to Our Senses: Appreciating the Sensorial in Medical Anthropology

Transcultural Psychiatry 45(2)

Sensorial Anthropology: Six Central Concepts

Nichter: Coming to Our Senses

Transcultural Psychiatry 45(2)

Nichter: Coming to Our Senses

Ayurveda as a Formative Experience: Participant Observation at the Site of the Body

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Transcultural Psychiatry 45(2)

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Popular Health Culture: Being Attentive to the Sensorial

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Transcultural Psychiatry 45(2)

Sensorial Anthropology and the Study of Pharmaceutical Practice

Nichter: Coming to Our Senses

Transcultural Psychiatry 45(2)

Nichter: Coming to Our Senses

Transcultural Psychiatry 45(2)

Nichter: Coming to Our Senses

Transcultural Psychiatry 45(2)

Nichter: Coming to Our Senses

Transcultural Psychiatry 45(2)

talked about, framed, and responded to by different segments of the population?

Nichter: Coming to Our Senses

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