The World Health Organization (WHO) recognizes that the health of individuals and communities is affected by many factors: “where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family.”^[2] Research conducted by the WHO suggests that these characteristics play a more significant role in affecting our health than any others, including having access to health care. For this reason, anthropologists who are interested in issues related to health and illness must use a broad holistic perspective that considers the influence of both biology and culture. Medical anthropology, a distinct sub-specialty within the discipline of anthropology, investigates human health and health care systems in comparative perspective, considering a wide range of bio-cultural dynamics that affect the well-being of human populations. Medical anthropologists study the perceived causes of illness as well as the techniques and treatments developed in a society to address health concerns. Using cultural relativism and a comparative approach, medical anthropologists seek to understand how ideas about health, illness, and the body are products of particular social and cultural contexts.

ETHNOMEDICINE by Sashur Henninger-Rener

Figure 1. Tibetan medicine poster.

Ethnomedicine is the comparative study of cultural ideas about wellness, illness, and healing. For the majority of our existence, human beings have depended on the resources of the natural environment and on health and healing techniques closely associated with spiritual beliefs. Many such practices, including some herbal remedies and techniques like acupuncture, have been studied scientifically and found to be effective.^[3] Others have not necessarily been proven medically effective by external scientific evidence, but continue to be embraced by communities that perceive them to be useful. When considering cultural ideas about health, an important place to start is with ethno-etiology: cultural explanations about the underlying causes of health problems.

In the United States the dominant approach to thinking about health is biomedical. Illnesses are thought to be the result of specific, identifiable agents. This can include pathogens (viruses or bacteria), malfunction of the body’s biochemical processes (conditions such as cancer), or physiological disorders (such as organ failure). In biomedicine as it is practiced in the United States (Western biomedicine), health is defined as the absence of disease or dysfunction, a perspective that notably excludes consideration of social or spiritual well-being.

The biomedical approach to health strikes many people, particularly residents of the United States, as the best or at least the most “fact-based” approach to medicine. This is largely because Western biomedicine is based on the application of insights from science, particularly biology and chemistry, to the diagnosis and treatment of medical conditions. The effectiveness of biomedical treatments is assessed through rigorous testing using the scientific method and indeed Western biomedicine has produced successful treatments for many dangerous and complex conditions: everything from antibiotics and cures for cancer to organ transplantation.

However, it is important to remember that the biomedical approach is itself embedded in a distinct cultural tradition, just like other ethno-etiologies. Biomedicine, and the scientific disciplines on which it is based, are products of Western history. The earliest Greek physicians Hippocrates (c. 406–370 BC) and Galen (c. 129–c. 200 AD) shaped the development of the biomedical perspective by providing early insights into anatomy, physiology, and the relationship between environment and health. From its origins in ancient Greece and Rome, the knowledge base that matured into contemporary Western biomedicine developed as part of the Scientific Revolution in Europe, slowly maturing into the medical profession recognized today. While the scientific method used in Western biomedicine represents a distinct and powerful “way of knowing” compared to other etiologies, the methods, procedures, and forms of reasoning used in biomedicine are products of Western culture.^[4]

Figure 2: The Taiyang bladder meridian, one of several meridians recognized in traditional Chinese medicine. From Shou Hua’s Jushikei Hakki, 1716, Tokyo.

In matters of health, as in other aspects of life, ethnocentrism predisposes people to believe that their own culture’s traditions are the most effective. People from non-North American and Western European cultures do not necessarily agree that Western biomedicine is superior to their own ethno-etiologies. “Western“ culture does not even have a monopoly on the concept of “science.” Other cultures recognize their own forms of science separate from the Western tradition and these sciences have histories dating back hundreds or even thousands of years. One example is Traditional Chinese Medicine (TCM), a set of practices developed over more than 2,500 years to address physical complaints holistically through acupuncture, exercise, and herbal remedies. The tenets of Traditional Chinese Medicine are not based on science as it is defined in Western culture, but millions of people, including a growing number of people in the United States and Europe, regard TCM as credible and effective.

Ultimately, all ethno-etiologies are rooted in shared cultural perceptions about the way the world works. Western biomedicine practitioners would correctly observe that the strength of Western biomedicine is derived from use of a scientific method that emphasizes objectively observable facts. However, this this would not be particularly persuasive to someone whose culture uses a different ethno-etiology or whose understanding of the world derives from a different tradition of “science.” From a comparative perspective, Western biomedicine may be viewed as one ethno-etiology in a world of many alternatives.

TECHNIQUES FOR HEALING by Sashur Henninger-Rener

Western biomedicine tends to conceive of the human body as a kind of biological machine. When parts of the machine are damaged, defective, or out of balance, chemical or surgical interventions are the preferred therapeutic responses. Biomedical practitioners, who can be identified by their white coats and stethoscopes, are trained to detect observable or quantifiable symptoms of disease, often through the use of advanced imaging technologies or tests of bodily fluids like blood and urine. Problems detected through these means will be addressed. Other factors known to contribute to wellness, such as the patient’s social relationships or emotional state of mind, are considered less relevant for both diagnosis and treatment. Other forms of healing, which derive from non-biomedical ethno-etiologies, reverse this formulation, giving priority to the social and spiritual.

In Traditional Chinese Medicine, the body is thought to be governed by the same forces that animate the universe itself. One of these is chi (qi), a vital life force that flows through the body and energizes the body and its organs. Disruptions in the flow or balance of chi can lead to a lack of internal harmony and ultimately to health problems so TCM practitioners use treatments designed to unblock or redirect chi, including acupuncture, dietary changes, and herbal remedies. This is an example of humoral healing, an approach to healing that seeks to treat medical ailments by achieving a balance between the forces or elements of the body.

Communal healing, a second category of medical treatment, directs the combined efforts of the community toward treating illness. In this approach, medical care is a collaboration between multiple people. Among the !Kung (Ju/’hoansi) of the Kalahari Desert in southern Africa, energy known as n/um can be channeled by members of the community during a healing ritual and directed toward individuals suffering from illness. Richard Katz, Megan Bisele, and Verna St. Davis (1982) described an example of this kind of ceremony:

The central event in this tradition is the all-night healing dance. Four times a month on the average, night signals the start of a healing dance. The women sit around the fire, singing and rhythmically clapping. The men, sometimes joined by the women, dance around the singers. As the dance intensifies, n/um, or spiritual energy, is activated by the healers, both men and women, but mostly among the dancing men. As n/um is activated in them, they begin to kia, or experience an enhancement of their consciousness. While experiencing kia, they heal all those at the dance.^[5]

While communal healing techniques often involve harnessing supernatural forces such as the num, it is also true that these rituals help strengthen social bonds between people. Having a strong social and emotional support system is an important element of health in all human cultures.

THE EXPERIENCE OF ILLNESS IN PLACE by Sashur Henninger-Rener

Social Construction of Illness

As the above examples demonstrate, cultural attitudes affect how medical conditions will be perceived and how individuals with health problems will be regarded by the wider community. There is a difference, for instance, between a disease, which is a medical condition that can be objectively identified, and an illness, which is the subjective or personal experience of feeling unwell. Illnesses may be caused by disease, but the experience of being sick encompasses more than just the symptoms caused by the disease itself. Illnesses are, at least in part, social constructions: experiences that are given meaning by the relationships between the person who is sick and others.

The course of an illness can worsen for instance, if the dominant society views the sickness as a moral failing. Obesity is an excellent example of the social construction of illness. The condition itself is a result of culturally induced habits and attitudes toward food, but despite this strong cultural component, many people regard obesity as a preventable circumstance, blaming individuals for becoming overweight. This attitude has a long cultural history. Consider for instance the religious connotations within Christianity of “gluttony” as a sin.^[6] Such socially constructed stigma influences the subjective experience of the illness. Obese women have reported avoiding visits to physicians for fear of judgment and as a result may not receive treatments necessary to help their condition.^[7] Peter Attia, a surgeon and medical researcher who delivered a TED Talk on this subject, related the story of an obese woman who had to have her foot amputated, a common result of complications from obesity and diabetes. Even though he was a physician, he judged the woman to be lazy. “If you had just tried even a little bit,” he had thought to himself before surgery.

Subsequently, new research revealed that insulin resistance, a precursor to diabetes, often develops as a result of the excess sugars used in many kinds of processed foods consumed commonly in the United States. As Attia observes, high rates of obesity in the United States are a reflection of the types of foods Americans have learned to consume as part of their cultural environment.^[8] In addition, the fact that foods that are high in sugars and fats are inexpensive and abundant, while healthier foods are expensive and unavailable in some communities, highlights the economic and social inequalities that contribute to the disease.

Figure 3: AIDS prevention art, Mozambique. The text reads “think of the consequences, change behavior, prevent HIV/AIDS”.

The HIV/AIDS virus provides another example of the way that the subjective experience of an illness can be influenced by social attitudes. Research in many countries has shown that people, including healthcare workers, make distinctions between patients who are “innocent” victims of AIDS and those who are viewed as “guilty.” People who contracted HIV through sex or intravenous drug use are seen as guilty. The same judgment applies to people who contracted HIV through same-sex relationships in places where societal disapproval of same-sex relationships exists. People who contracted HIV from blood transfusions, or as babies, are viewed as innocent. The “guilty” HIV patients often find it more difficult to access medical care and are treated with disrespect or indifference in medical settings compared with superior treatment provided to those regarded as “innocent.” In the wider community, “guilty” patients suffer from social marginalization and exclusion while “innocent” patients receive greater social acceptance and practical assistance in responding to their needs for support and care.^[9]

The stigma that applies to “guilty” patients also ignores the socioeconomic context in which HIV/AIDS spreads. For instance, in Indonesia, poor women can make considerably more money as sex workers than in many other jobs: $10 an hour as a sex worker compared to 20 cents an hour in a factory.^[10] In a similar way, poverty and a lack of other choices contribute to a decision to engage in sex work in other societies, including in sub-Saharan Africa where rates of HIV infection are among the highest in the world. Poverty itself is one of the greatest “risk factors” for HIV infection.^[11] The clear relationship between poverty, gender, and HIV infection has been the topic of a great deal of research in medical anthropology. One example is Paul Farmer’s classic book, AIDS and Accusation: Haiti and the Geography of Blame (1992), which was one of the earliest books to critically evaluate the connection between poverty, racism, stigma, and neglect that allowed HIV to infect and kill thousands of Haitians. Projects like this are critical to developing holistic views of the entire cultural, economic, and political context that affects the spread of the virus and attempts to treat the disease. Partners in Health, the non-profit medical organization Paul Farmer helped to found, continues to pursue innovative strategies to prevent and treat diseases like AIDS, strategies that recognize that poverty and social marginalization provide the environment in which the virus flourishes.

BIOMEDICAL TECHNOLOGIES by Sashur Henninger-Rener

In the history of human health, technology is an essential topic. Medical technologies have transformed human life. They have increased life expectancy rates, lowered child mortality rates, and are used to intervene in and often cure thousands of diseases. Of course, these accomplishments come with many cultural consequences. Successful efforts to intervene in the body biologically also have implications for cultural values and the social organization of communities, as demonstrated by the examples below.

Antibiotics and Immunizations

Infectious diseases caused by viruses and bacteria have taken an enormous toll on human populations for thousands of years. During recurring epidemics, tens of thousands of people have died from outbreaks of diseases like measles, the flu, or bubonic plague. The Black Death, a pandemic outbreak of plague that spread across Europe and Eurasia from 1346–1353 AD, killed as many as 200 million people, as much as a third of the European population. Penicillin, discovered in 1928 and mass produced for the first time in the early 1940s, was a turning point in the human fight against bacterial infections. Called a “wonder drug” by Time magazine, Penicillin became available at a time when bacterial infections were frequently fatal; the drug was glorified as a cure-all.^[12] An important factor to consider about the introduction of antibiotics is the change to an understanding of illness that was increasingly scientific and technical. Before science could provide cures, personalistic and naturalistic ethno-etiologies identified various root causes for sickness, but the invention of antibiotics contributed to a strengthening of the Western biomedical paradigm as well as a new era of profitability for the pharmaceutical industry.

The effects of antibiotics have not been completely positive in all parts of the world. Along with other technological advances in areas such as sanitation and access to clean water, antibiotics contributed to an epidemiological transition characterized by a sharp drop in mortality rates, particularly among children. In many countries, the immediate effect was an increase in the human population as well as a shift in the kinds of diseases that were most prevalent. In wealthy countries, for instance, chronic conditions like heart disease or cancer have replaced bacterial infections as leading causes of death and the average lifespan has lengthened. In developing countries, the outcome has been mixed. Millions of lives have been saved by the availability of antibiotics, but high poverty and lack of access to regular medical care mean that many children who now survive the immediate dangers of infection during infancy succumb later in childhood to malnutrition, dehydration, or other ailments.^[13]

Figure 4: Women and children waiting to enter a medical clinic in Somalia. The clinic is open 2 days each week and treats 400-500 people each day.

Another difficulty is the fact that many kinds of infections have become untreatable as a result of bacterial resistance. Medical anthropologists are concerned with the increase in rates of infectious diseases like tuberculosis and malaria that cannot be treated with many existing antibiotics. According to the World Health Organization, there are nearly 500,000 cases of drug resistant tuberculosis each year.^[14] New research is now focused on drug resistance, as well as the social and cultural components of this resistance such as the relationship between poverty and the spread of resistant strains of bacteria.

Immunizations that can provide immunity against viral diseases have also transformed human health. The eradication of the smallpox virus in 1977 following a concerted global effort to vaccinate a large percentage of the world’s population is one example of the success of this biotechnology. Before the development of the vaccine, the virus was killing 1–2 million people each year.^[15] Today, vaccines exist for many of the world’s most dangerous viral diseases, but providing access to vaccines remains a challenge. The polio virus has been eliminated from most of the world following several decades of near universal vaccination, but the disease has made a comeback in a handful of countries, including Afghanistan, Nigeria, and Pakistan, where weak governments, inadequate healthcare systems, or war have made vaccinating children impossible. This example highlights the global inequalities that still exist in access to basic medical care.

Because viruses have the ability to mutate and to jump between animals and people, human populations around the world also face the constant threat of new viral diseases. Influenza has been responsible for millions of deaths. In 1918, a pandemic of the H1N1 flu infected 500 million people, killing nearly 5 percent of the human population.^[16] Not all influenza strains are that deadly, but it remains a dangerous illness and one that vaccines can only partially address.^[17] Each year, the strains of the influenza virus placed in the annual “flu shot” are based on predictions about the strains that will be most common. Because the virus mutates frequently and is influenced by interactions between human and animal populations, there is always uncertainty about future forms of the virus.^[18]

Reproductive Technologies

Today, the idea of “contraception” is linked to the technology of hormone-based birth control. “The pill” as we now know it, was not available in the United States until 1960, but attempts to both prevent or bring about pregnancy through technology date back to the earliest human communities. Techniques used to control the birthrate are an important subject for medical anthropologists because they have significant cultural implications.

Many cultures use natural forms of birth control practices to influence the spacing of births. Among the !Kung, for instance, babies are breastfed for many months or even years, which hormonally suppress fertility and decrease the number of pregnancies a woman can have in her lifetime. In Enga, New Guinea, men and women do not live with one another following a birth, another practice that increases the time between pregnancies.^[19] In contrast, cultures where there are social or religious reasons for avoiding birth control, including natural birth spacing methods, have higher birth rates. In the United States, the Comstock Act passed in 1873 banned contraception and even the distribution of information about contraception.

Although the Comstock Act is a thing of the past, efforts in the United States to limit access to birth control and related medical services like abortion are ongoing. Many medical anthropologists study the ways in which access to reproductive technologies is affected by cultural values. Laury Oaks (2003) has investigated the way in which activists on both sides of the abortion debate attempt to culturally define the idea of “risk” as it relates to women’s health. She notes that in the 1990s anti-abortion activists in the United States circulated misleading medical material suggesting that abortion increases rates of breast cancer. Although this claim was medically false, it was persuasive to many people and contributed to doubts about whether abortion posed a health risk to women, a concern that strengthened efforts to limit access to the procedure.^[20]

Other forms of reproductive technology have emerged from the desire to increase fertility. The world of “assisted reproduction,” which includes technologies such as in vitro fertilization and surrogate pregnancy, has been the subject of many anthropological investigations. Marcia Inhorn, a medical anthropologist, has written several books about the growing popularity of in vitro fertilization in the Middle East. Her book, The New Arab Man (2012), explores the way in which infertility disrupts traditional notions of Arab masculinity that are based on fatherhood and she explores the ways that couples navigate conflicting cultural messages about the importance of parenthood and religious disapproval of assisted fertility.^[21]

CONCLUSION by Sashur Henninger-Rener

As the global population becomes larger, it is increasingly challenging to address the health needs of the world’s population. Today, 1 in 8 people in the world do not have access to adequate nutrition, the most basic element of good health.^[22] More than half the human population lives in an urban environment where infectious diseases can spread rapidly, sparking pandemics. Many of these cities include dense concentrations of poverty and healthcare systems that are not adequate to meet demand.^[23] Globalization, a process that connects cultures through trade, tourism, and migration, contributes to the spread of pathogens that negatively affect human health and exacerbates political and economic inequalities that make the provision of healthcare more difficult.

Human health is complex and these are daunting challenges, but medical anthropologists have a unique perspective to contribute to finding solutions. Medical anthropology offers a holistic perspective on the relationship between health and culture. As anthropologists study the ways people think about health and illness and the socioeconomic and cultural dynamics that affect the provision of health services, there is a potential to develop new methods for improving the health and quality of life for people all over the world.