Nina Brown, Thomas McIlwraith, Laura Tubelle de González

2020 American Anthropological Association 2300 Clarendon Blvd, Suite 1301 Arlington, VA 22201

ISBN Print: 978-1-931303-67-5 ISBN Digital: 978-1-931303-66-8

This book is a project of the Society for Anthropology in Community Colleges (SACC) and our parent organization, the American Anthropological Association (AAA). Please refer to the website for a complete table of contents and more information about the book.





Sashur Henninger-Rener, Pasadena City College


Learning Objectives Learning Objectives

• Define the biocultural perspective and provide examples of how interactions between biology and culture have affected human biology.

• Identify four ethno-etiologies (personalistic, naturalistic, emotionalistic, and biomedical) and describe how each differs in explain- ing the root cause of illness.

• Explain the significance of faith in healing.

• Examine the relationship between mental health and cultural factors, including stigma, that affect the way people with mental health conditions are perceived.

• Discuss examples of culture-bound syndromes.

• Evaluate the positive and negative effects of biomedical technologies.


What does it mean to be “healthy”? It may seem odd to ask the question, but health is not a universal

concept and each culture values different aspects of well-being. At the most basic level, health may be

perceived as surviving each day with enough food and water, while other definitions of health may

be based on being free of diseases or emotional troubles. Complicating things further is the fact that

that each culture has a different causal explanation for disease. For instance, in ancient Greece health

was considered to be the product of unbalanced humors or bodily fluids. The four humors included

black bile, phlegm, yellow bile, and blood. The ancient Greeks believed that interactions among these

humors explained differences not only in health, but in age, gender, and general disposition. Various




things could influence the balance of the humors in a person’s body including substances believed to be

present in the air, changes in diet, or even temperature and weather. An imbalance in the humors was

believed to cause diseases, mood problems, and mental illness.1

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 edu-

cation 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, includ-

ing 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, investi-

gates 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


ANTHROPOLOGY AND THE BIOCULTURAL PERSPECTIVE Evolutionary biology is a field of study that investigates the ways that natural processes have shaped

the development of life on Earth, producing measurable changes in populations over time. Humans,

Homo sapiens, are a special case in the discussion of evolution. We are a relatively young species that

has been on Earth for only about 195,000 years.3 Although this may sound like a long time, com-

pared with other animals, humans are newcomers and we have been subject to processes of natural

selection and adaptation for less time than many other living things. In that short time period, human

lifestyles have changed dramatically. The first humans evolved in Africa and had a foraging lifestyle,

living in small, kin-based groups. Today, millions of people live in crowded, fast-paced, and technolog-

ically advanced agricultural societies. In evolutionary terms, this change has happened rapidly. The fact

that these rapid changes were even possible reveals that human lifestyles are biocultural, products of

interactions between biology and culture. This has many implications for understanding human health.

The theory of natural selection suggests that in any species there are certain physical or behavioral

traits that are adaptive and increase the capacity of individuals to survive and reproduce. These adap-

tive traits will be passed on through generations. Many human traits contributed to the survival of

early human communities. A capacity for efficient walking and running, for instance, was important to

human survival for thousands of years. However, as cultural change led to new lifestyles, some human

characteristics became maladaptive.

One example is the obesity epidemic that has emerged all over the world. According to the Center for

Disease Control and Prevention, more than one-third of the population of the United States is obese.4

Obesity is considered to be a “disease of civilization,” meaning that it did not exist in early human popu-

lations. Taking a biocultural evolutionary approach to human health, we can ask what traits character-

istic of early human foraging populations might have encouraged an accumulation of fat in the human

body. The answer comes from the evidence of food shortages among foraging populations. In fact, 47

percent of societies that forage experience food shortages at least once per year. Another 24 percent

experience a shortage at least every two years.5 When taking this into account, the ability to retain body

fat would have been advantageous for humans in the past. Women with more body fat could give birth

to healthy babies and breastfeed them, even in periods of food scarcity. It is also possible that women




and men would have viewed body fat as a sign of health and access to resources, choosing sexual part-

ners based on this characteristic. If so, powerful biological and cultural forces would have contributed

to genetic traits that led to efficient metabolism and higher body fat.

With the development of agriculture, calories became more easily available while many people in the

population became more sedentary. Traits that were once adaptive became maladaptive. The develop-

ment of cultural preferences for foods high in fat and sugar, such as the “standard American diet” (SAD)

is directly associated with obesity. These cultural changes have had a negative impact on health in many

places. In Polynesia, for instance, obesity rates were around 15 percent in traditional farming commu-

nities, but climbed to over 35 percent as people moved to cities.6 This is an example of the biocultural

nature of many human health challenges.

Another example of this biocultural dynamic is sickle cell anemia, an inherited disease that can be

fatal. A person who inherits the sickle cell gene from both parents will have red blood cells with an usual

sickle (crescent) shape. These cells cannot carry oxygen as efficiently as normal red blood cells and they

are also more likely to form painful and dangerous blood clots. Ordinarily, genetic conditions that make

it more difficult for individuals to survive or have children, will become less common in populations

over time due to the effects of natural selection. From an evolutionary perspective, one might ask why

a deadly genetic condition has remained so common in human populations.

The cultural context is important for answering this question. The sickle cell gene is found most often

in human populations in Africa and Southeast Asia where malaria is widespread. Malaria is a mosquito-

borne illness that can be deadly to humans. People who have inherited one copy of the sickle cell anemia

trait (instead of the two copies that cause sickle cell disease) have resistance to malaria. This is a sig-

nificant adaptive trait in parts of the world where malaria is widespread. There is some evidence that

malaria became a significant threat to human health only after the invention of agriculture. The defor-

ested areas and collections of standing water that characterize agricultural communities also attract

the mosquitos that carry disease. 7 In this case, we can see biocultural dynamics in action. Because

resistance to malaria is an adaptive trait, the sickle cell gene remained common in populations where

malaria is present. In parts of West and Central Africa, up to 25 percent of the population has the sickle

cell gene. While sickle cell anemia is still a deadly disease, those who inherit a single copy of the gene

have some protection from malaria, itself a deadly threat in many places. This example illustrates the

biocultural interaction between genes, pathogens, and culture.

Infectious diseases generally do not have an adaptive function for humans like the examples above,

but many infectious diseases are influenced by human cultural systems. Because early human commu-

nities consisted of small groups with a foraging lifestyle, viruses and bacteria transmitted from per-

son to person were unlikely to result in large-scale epidemics. Healthy individuals from neighboring

groups could simply avoid coming into contact with anyone who was suffering from illness and out-

breaks would be naturally contained.8

The rapid increase in the size of human communities following the invention of agriculture changed

this pattern. Agriculture can support more people per unit of land and, at the same time, agriculturalists

need to live in permanent urban settlements in order to care for their crops. In a cyclical way, agri-

culture provides more food while also requiring that people have sizeable families to do the necessary

farm work. Over the course of several thousand years, agricultural communities became increasingly

densely populated. This had many implications for local ecology: problems disposing of waste and diffi-

culty accessing clean water. A prime example of the health effects of the transition to urban settlements

is cholera, a water-borne illness that spreads through water that has been polluted with human feces.

Cholera, which was first detected in urban populations in India, has killed tens of thousands of people




Figure 1: Traditional Tibetan Medicine Poster.

throughout history and continues to threaten populations today, particularly in developing countries,

where access to clean water is limited, and in places that have experienced natural disasters.9

From an adaptive perspective, human beings die from infectious diseases because they do not have

immunity to them. Immunity can be built up over time for some diseases, but unfortunately only after

the illness or death of many members of a population.10 When a new infectious disease reaches a pop-

ulation, it can wreak havoc on many people. Historically, several new infectious diseases are known to

have been introduced to human populations through contact with livestock. Tuberculosis and smallpox

were linked to cattle and influenza to chickens. When humans domesticated animal species, and began

to live in close proximity to them, new routes for the transmission of zoonotic disease, illnesses that can

be passed between humans and animals, were established.11 Living in cities accelerates the spread of

infectious diseases and the scale of outbreaks, but may also contribute to the natural selection of genetic

traits that confer resistance to disease. This biocultural evolutionary process has been documented in

urban populations where there are genes providing some resistance to leprosy and tuberculosis.12



Ethnomedicine is the comparative study of cultural

ideas about wellness, illness, and healing. For the major-

ity 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.13 Others

have not necessarily been proven medically effective by

external scientific evidence, but continue to be

embraced by communities that perceive them to be use-

ful. When considering cultural ideas about health, an

important place to start is with ethno-etiology: cultural

explanations about the underlying causes of health


In the United States the dominant approach to think-

ing 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. In non-Western contexts biomedical explanations are often viewed as unsatisfac-

tory. In his analysis of ideas about health and illness in non-Western cultures, George Foster (1976)

concluded that these ideas could be categorizes into two main types of ethno-etiology: personalistic and





Ethno-Etiologies: Personalistic and Naturalistic Personalistic ethno-etiologies view disease as the result of the “active, purposeful intervention of

an agent, who may be human (a witch or sorcerer), nonhuman (a ghost, an ancestor, an evil spirit), or

supernatural (a deity or other very powerful being).”15 Illness in this kind of ethno-etiology is viewed

as the result of aggression or punishment directed purposefully toward an individual; there is no acci-

dent or random chance involved. Practitioners who are consulted to provide treatment are interested

in discovering who is responsible for the illness—a ghost, an ancestor? No one is particularly interested

in discovering how the medical condition arose in terms of the anatomy or biology involved. This is

because treating the illness will require neutralizing or satisfying a person, or a supernatural entity, and

correctly identifying the being who is the root cause of the problem is essential for achieving a cure.

The Heiban Nuba people of southern Sudan provide an interesting example of a personalistic etiol-

ogy. As described by, S.F. Nadel in the 1940s, the members of this society had a strong belief that illness

and other misfortune was the result of witchcraft.

A certain magic, mysteriously appearing in individuals, causes the death or illness of anyone who eats

their grain or spills their beer. Even spectacular success, wealth too quickly won, is suspect; for it is the

work of a spirit-double, who steals grain or livestock for his human twin. This universe full of malig-

nant forces is reflected in a bewildering array of rituals, fixed and occasional, which mark almost every

activity of tribal life.16

Because sickness is thought to be caused by spiritual attacks from others in the community, people

who become sick seek supernatural solutions. The person consulted is often a shaman, a person who

specializes in contacting the world of the spirits.

In Heiban Nuba culture, as well as in other societies where shamans exist, the shaman is believed

to be capable of entering a trance-like state in order to cross between the ordinary and supernatural

realms. While in this state, the shaman can identify the individual responsible for causing the illness and

sometimes the spirits can be convinced to cure the disease itself. Shamans are common all around the

world and despite the proverbial saying that “prostitution is the oldest profession,” shamanism proba-

bly is! Shamans are religious and medical practitioners who play important social roles in their com-

munities as healers with a transcendent ability to navigate the spirit world for answers. In addition, the

often have a comprehensive knowledge of the local ecology and how to use plants medicinally. They

can address illnesses using both natural and supernatural tools.

In naturalistic ethno-etiologies, diseases are thought to be the result of natural forces such as “cold,

heat, winds, dampness, and above all, by an upset in the balance of the basic body elements.”17 The

ancient Greek idea that health results from a balance between the four humors is an example of a nat-

uralistic explanation. The concept of the yin and yang, which represent opposite but complementary

energies, is a similar idea from traditional Chinese medicine. Achieving balance or harmony between

these two forces is viewed as essential to physical and emotional health. Unlike personalistic expla-

nations, practitioners who treat illness in societies with naturalistic ethno-etiologies are interested in

understanding how the medical condition arose so that they can choose therapeutic remedies viewed

as most appropriate.

Emotional difficulties can be viewed as the cause of illness in a naturalistic ethno-etiology (an emo-

tionalistic explanation). One example of a medical problem associated with emotion is susto, an illness

recognized by the Mixe, an indigenous group who live in Oaxaca, Mexico, as well as others through-

out central America. The symptoms of susto include difficulty sleeping, lack of energy, loss of appetite

and sometimes nausea/vomiting and fever. The condition is believed to be a result of a “fright” or shock

and, in some cases at least, it is believed to begin with a shock so strong that it disengages the soul from




the body.18 The condition is usually treated with herbal remedies and barrida (sweeping) ceremonies

designed to repair the harm caused by the shock itself.19 Although physicians operating within a bio-

medical ethno-etiology have suggested that susto is a psychiatric illness that in other cultural contexts

could be labeled anxiety or depression, in fact susto is does not fit easily into any one Western biomed-

ical category. Those suffering from susto see their condition as a malady that is emotional, spiritual, and


In practice, people assess medical problems using a variety of explanations and in any given society

personalistic, naturalistic, or even biomedical explanations may all apply in different situations. It is

also important to keep in mind that the line between a medical concern and other kinds of life chal-

lenges can be blurry. An illness may be viewed as just one more instance of general misfortune such as

crop failure or disappointment in love. Among the Azande in Central Africa, witchcraft is thought to

be responsible for almost all misfortune, including illness. E.E. Evans-Pritchard, an anthropologist who

studied the Azande of north-central Africa in the 1930s, famously described this logic be describing a

situation in which a granary, a building used to store grain collapsed.

In Zandeland sometimes an old granary collapses. There is nothing remarkable in this. Every Zande

knows that termites eat the supports in course of time and that even the hardest woods decay after years

of service. Now a granary is the summerhouse of a Zande homestead and people sit beneath it in the

heat of the day and chat or play the African hole-game or work at some craft. Consequently it may hap-

pen that there are people sitting beneath the granary when it collapses and they are injured…Now why

should these particular people have been sitting under this particular granary at the particular moment

when it collapsed? That it should collapse is easily intelligible, but why should it have collapsed at the

particular moment when these particular people were sitting beneath it…The Zande knows that the

supports were undermined by termites and that people were sitting beneath the granary in order to

escape the heat of the sun. But he knows besides why these two events occurred at a precisely similar

moment in time and space. It was due to the action of witchcraft. If there had been no witchcraft peo-

ple would have been sitting under the granary and it would not have fallen on them, or it would have

collapsed but the people would not have been sheltering under it at the time. Witchcraft explains the

coincidence of these two happenings.21

According to this logic, an illness of the body is ultimately caused by the same force as the collapse

of the granary: witchcraft. In this case, an appropriate treatment may not even be focused on the body

itself. Ideas about health are often inseparable from religious beliefs and general cultural assumptions

about misfortune.22

Is Western Biomedicine An Ethno-Etiology? 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 bio-

medicine 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




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

insights into anatomy, physiology, and the relationship between environment and health. From its ori-

gins in ancient Greece and Rome, the knowledge base that matured into contemporary Western bio-

medicine 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 dis-

tinct and powerful “way of knowing” compared to other etiologies, the methods, procedures, and forms

of reasoning used in biomedicine are products of Western culture. 23

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-Western 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 Medi-

cine (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 Tradi-

tional 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 biomedi-

cine 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 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. Prob-

lems 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 num

can be channeled by members of the community during a healing ritual and directed toward individu-

als 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 clap-

ping. The men, sometimes joined by the women, dance around the singers. As the dance intensifies,

num, or spiritual energy, is activated by the healers, both men and women, but mostly among the danc-

ing men. As num is activated in them, they begin to kia, or experience an enhancement of their con-

sciousness. While experiencing kia, they heal all those at the dance.24

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.

Faith and the Placebo Effect Humoral and communal approaches to healing, which from a scientific perspective would seem to

have little potential to address the root causes of an illness, present an important question for medical

anthropologists. What role does faith play in healing? Sir William Osler, a Canadian physician who

was one of the founders of Johns Hopkins Hospital, believed that much of a physician’s healing ability

derived from his or her ability to inspire patients with a faith that they could be cured.25 Osler wrote:

Faith in the Gods or in the Saints cures one, faith in little pills another, suggestion a third, faith in

a plain common doctor a fourth…If a poor lass, paralyzed apparently, helpless, bed-ridden for years,

comes to me having worn out in mind, body, and estate a devoted family; if she in a few weeks or less by

faith in me, and faith alone, takes up her bed and walks, the Saints of old could not have done more.26

In fact, there is a considerable amount of research suggesting that there is a placebo effect involved

in many different kinds of healing treatments. A placebo effect is a response to treatment that occurs

because the person receiving the treatment believes it will work, not because the treatment itself is effec-


In Western biomedicine, the placebo effect has been observed in situations in which a patient believes

that he or she is receiving a certain drug treatment, but is actually receiving an inactive substance such

as water or sugar. 27 Research suggests that the body often responds physiologically to placebos in the

same way it would if the drug was real.28 The simple act of writing a prescription can contribute to

the successful recovery of individuals because patients trust that they are on a path that will lead to

wellness.29 If we consider the role of the placebo effect in the examples above, we should consider the

possibility that humoral and communal healing are perceived to “work” because the people who receive

these remedies have faith in them.

An interesting example of the complexity of the mind-body connection is found in studies of inter-

cessory prayer: prayers made to request healing for another person. In one well-known study,

researchers separated patients who had recently undergone heart surgery into two groups, one con-

taining people who know they would be receiving prayers for their recovery and another group who




Figure 3: A botánica store selling herbal folk medicines.

would receive prayers without being aware of it. Those patients who knew they were receiving prayers

actually had more complications and health problems in the month following surgery.30 This reflects

an interesting relationship between faith and healing. Why did the patients who knew that others were

praying for them experience more complications? Perhaps it was because the knowledge that their doc-

tors had asked others to pray for them made patients more stressed, perceiving that their health was at

greater risk.

However, it can also be a lack of faith that drives

people to look for alternative treatments. In the

United States, alternative treatments, some of

which are drawn from humoral or communal heal-

ing traditions, have become more popular among

patients who believe that Western biomedicine is

failing them. Cancer research facilities have begun

to suggest acupuncture as a treatment for the

intense nausea and fatigue caused by chemother-

apy and scientific studies suggest that acupuncture

can be effective in relieving these symptoms.31

Marijuana, a drug that has a long recorded history

of medical use starting in ancient China, Egypt,

and India, has steadily gained acceptance in the

United States as a treatment for a variety of ail-

ments ranging from anxiety to Parkinson’s dis-

ease.32 As growing numbers of people place their faith in these and other remedies, it is important to

recognize that many alternative forms of healing or medicine lack scientific evidence for their efficacy.

The results derived from these practices may owe as much to faith as medicine.

MENTAL HEALTH Unlike other kinds of illnesses, which present relatively consistent symptoms and clear biological evi-

dence, mental health disorders are experienced and treated differently cross-culturally. While the disci-

pline of psychiatry within Western biomedicine applies a disease-framework to explain mental illness,

there is a consensus in medical anthropology that mental health conditions are much more complicated

than the biological illness model suggests. These illnesses are not simply biological or chemical disor-

ders, but complex responses to the environment, including the web of social and cultural relationships

to which individuals are connected.

Medical anthropologists do not believe there are universal categories of mental illness.33 Instead,

individuals may express psychological distress through a variety of physical and emotional symptoms.

Arthur Kleinman, a medical anthropologist, has argued that every culture frames mental health con-

cerns differently. The pattern of symptoms associated with mental health conditions vary greatly

between cultures. In China, Kleinman discovered that patients suffering from depression did not

describe feelings of sadness, but instead complained of boredom, discomfort, feelings of inner pressure,

and symptoms of pain, dizziness, and fatigue.34

Mental health is closely connected with social and cultural expectations and mental illnesses can arise

as a result of pressures and challenges individuals face in particular settings. Rates of depression are

higher for refugees, immigrants, and others who have experienced dislocation and loss. A sense of pow-

erlessness also seems to play a role in triggering anxiety and depression, a phenomenon that has been




documented in groups ranging from stay-at-home mothers in England to Native Americans affected by

poverty and social marginalization.35

Schizophrenia, a condition with genetic as well as environmental components, provides another

interesting example of cross-cultural variation. Unlike anxiety or depression, there is some consistency

in the symptom patterns associated with this condition cross culturally: hallucinations, delusions, and

social withdrawal. What differs, however, is the way these symptoms are viewed by the community.

In his research in Indonesia, Robert Lemelson discovered that symptoms of schizophrenia are often

viewed by Indonesian communities as examples of communication with the spirit world, spirit posses-

sion, or the effects of traumatic memories.36 Documenting the lives of some of these individuals in a

film series, he noted that they remained integrated into their communities and had significant respon-

sibilities as members of their families and neighborhoods. People with schizophrenia were not, as often

happens in the United States, confined to institutions and many were living with their condition with-

out any biomedical treatments.

In its multi-decade study of schizophrenia in 19 countries, the World Health Organization concluded

that societies that were more culturally accepting of symptoms associated with schizophrenia inte-

grated people suffering from the condition into community life more completely. In these cultures, the

illness was less severe and people with schizophrenia had a higher quality of life.37 This finding has been

controversial, but suggests that stigma and the resulting social isolation that characterize responses to

mental illness in countries like the United States affect the subjective experience of the illness as well as

its outcomes.38


Social Construction of Illness As the above examples demonstrate, cultural attitudes affect how medical conditions will be per-

ceived 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 iden-

tified, 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 com-

ponent, 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.39 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.40 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




Figure 4: AIDS prevention art, Mozambique. The text reads “think of the consequences, change behavior, prevent HIV/AIDS.”

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.41 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.

The HIV/AIDS virus provides another example

of the way that the subjective experience of an ill-

ness can be influenced by social attitudes. Research

in many countries has shown that people, includ-

ing healthcare workers, make distinctions between

patients who are “innocent” victims of AIDS and

those who are viewed as “guilty.” People who con-

tracted 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 con-

tracted 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 sup-

port and care.42

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 fac-

tory.43 Sex work may be the only form of employment available in a patriarchal society. In a similar

way, poverty and a lack of other choices contribute to a decision to engage in sex work in other soci-

eties, 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.44 The clear relationship between

poverty, gender, and HIV infection has been the topic of a great deal of research in medical anthro-

pology. 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.

Culture-Bound Syndromes A culture-bound syndrome is an illness recognized only within a specific culture. These conditions,

which combine emotional or psychological with physical symptoms, are not the result of a disease or

any identifiable physiological dysfunction. Instead, culture-bound syndromes are somatic, meaning




they are physical manifestations of emotional pain. The existence of these conditions demonstrates the

profound influence of culture and society on the experience of illness.

Anorexia Anorexia

Anorexia is considered a culture bound syndrome because of its strong association with cultures that

place a high value on thinness as a measure of health and beauty. When we consider concepts of beauty

from cultures all over the world, a common view of beauty is one of someone with additional fat. This

may be because having additional fat in a place where food is expensive means that one is likely of a

higher status. In societies like the United States where food is abundant, it is much more difficult to

become thin than it is to become heavy. Although anorexia is a complex condition, medical anthropol-

ogists and physicians have observed that it is much more common in Western cultural contexts among

people with high socioeconomic status.45 Anorexia, as a form of self-deprivation, has deep roots in

Western culture and for centuries practices of self-denial have been associated with Christian religious

traditions. In a contemporary context, anorexia may address a similar, but secular desire to assert self-

control, particularly among teenagers.46

During her research in Fiji, Anne Becker (2004) noted that young women who were exposed to adver-

tisements and television programs from Western cultures (like the United States and Australia) became

self-conscious about their bodies and began to alter their eating habits to emulate the thin ideal they saw

on television. Anorexia, which had been unknown in Fiji, became an increasingly common problem.47

The same pattern has been observed in other societies undergoing “Westernization” through exposure

to foreign media and economic changes associated with globalization.48

Swallowing Frogs in Brazil Swallowing Frogs in Brazil

In Brazil, there are several examples of culture-bound syndromes that affect children as well as adults.

Women are particularly susceptible to these conditions, which are connected to emotional distress. In

parts of Brazil where poverty, unemployment, and poor physical health are common, there are cultural

norms that discourage the expression of strong emotions such as anger, grief, or jealousy. Of course,

people continue to experience these emotions, but cannot express them openly. Men and women deal

with this problem in different ways. Men may choose to drink alcohol heavily, or even to express their

anger physically by lashing out at others, including their wives. These are not socially acceptable behav-

iors for women who instead remark that they must suppress their feelings, an act they describe as hav-

ing to “swallow frogs” (engolir sapos).49

Nervos (nerves) is a culture-bound syndrome characterized by symptoms such as headaches, trem-

bling, dizziness, fatigue, stomach pain, tingling of the extremities and even partial paralysis. It is viewed

as a result of emotional overload: a state of constant vulnerability to shock. Unexplained wounds on the

body may be diagnosed as a different kind of illness known as “blood-boiling bruises.” Since emotion

is culturally defined as a kind of energy that flows throughout the body, many believe that too much

emotion can overwhelm the body, “boiling over” and producing symptoms. A person can become so

angry, for instance, that his or her blood spills out from under the skin, creating bruises, or so angry

that the blood rises up to create severe headaches, nausea, and dizziness. A third form of culture-bound

illness, known as peito aberto (open chest) is believed to be occur when a person, most often a woman,

is carrying too much emotional weight or suffering. In this situation, the heart expands until the chest

becomes spiritually “open.” A chest that is “open” is dangerous because rage and anger from other peo-

ple can enter and make a person sick.50




In stressful settings like the communities in impoverished areas of northeastern Brazil, it is common

for people to be afflicted with culture-bound illnesses throughout their lives. Individuals can suffer

from one condition, or a combination of several. Sufferers may consult rezadeiras/rezadores, Catholic

faith healers who will treat the condition with prayer, herbal remedies, or healing rituals. Because these

practitioners do not distinguish between illnesses of the body and mind, they treat the symptoms holis-

tically as evidence of personal turmoil. This approach to addressing these illnesses is consistent with

cultural views that it is the suppression of emotion itself that has caused the physical problems.


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 out-

breaks 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.51 An important factor to consider about the intro-

duction 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 con-

ditions 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 suc-

cumb later in childhood to malnutrition, dehydration, or other ailments.52





Figure 5: 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 bac-

terial 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.53

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.54 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 popula-

tions around the world also face the constant threat of new viral diseases. Influenza has been respon-

sible for millions of deaths. In 1918, a pandemic of the H1N1 flu infected 500 million people, killing

nearly 5 percent of the human population.55 Not all influenza strains are that deadly, but it remains

a dangerous illness and one that vaccines can only partially address.56 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.57




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.58 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.59

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 preg-

nancy, has been the subject of many anthropological investigations. Marcia Inhorn, a medical anthro-

pologist, 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 nav-

igate conflicting cultural messages about the importance of parenthood and religious disapproval of

assisted fertility.60


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.61 More than half the human population lives in an urban environ-

ment 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. 62

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 perspec-




tive on human evolutionary and biocultural adaptations as well as insights into 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.


Discussion Questions Discussion Questions

1. This chapter describes several examples of diseases that result from interactions between biology and culture such as obesity. Why is it important to consider cultural factors that contribute to illness rather than placing blame on individuals? What are some other examples of illnesses that have cultural as well as biological causes?

2. Many cultures have ethno-etiologies that provide explanations for illness that are not based in science. From a biomedical per- spective, the non-scientific medical treatments provided in these cultures have a low likelihood of success. Despite this, people tend to believe that the treatments are working. Why do you think people tend to be satisfied with the effectiveness of the treatments they receive?

3. How does poverty influence the health of populations around the world? Do you see this in your own community? Who should be responsible for addressing health care needs in impoverished communities?


Adaptive: Traits that increase the capacity of individuals to survive and reproduce.

Biocultural evolution: Describes the interactions between biology and culture that have influenced

human evolution.

Biomedical: An approach to medicine that is based on the application of insights from science, partic-

ularly biology and chemistry.

Communal healing: An approach to healing that directs the combined efforts of the community

toward treating illness.

Culture-bound syndrome: An illness recognized only within a specific culture.

Emotionalistic explanation: Suggests that illnesses are caused by strong emotions such as fright, anger,

or grief; this is an example of a naturalistic ethno-etiology.

Epidemiological transition: The sharp drop in mortality rates, particularly among children, that

occurs in a society as a result of improved sanitation and access to healthcare.

Ethno-etiology: Cultural explanations about the underlying causes of health problems.

Ethnomedicine: The comparative study of cultural ideas about wellness, illness, and healing.

Humoral healing: An approach to healing that seeks to treat medical ailments by achieving a balance

between the forces, or elements, of the body.

Maladaptive: Traits that decrease the capacity of individuals to survive and reproduce.

Medical anthropology: A distinct sub-specialty within the discipline of anthropology that investigates

human health and health care systems in comparative perspective.

Naturalistic ethno-etiology: Views disease as the result of natural forces such as cold, heat, winds, or

an upset in the balance of the basic body elements.

Personalistic ethno-etiology: Views disease as the result of the actions of human or supernatural


Placebo effect: A response to treatment that occurs because the person receiving the treatment believes

it will work, not because the treatment itself is effective.




Shaman: A person who specializes in contacting the world of the spirits.

Somatic: Symptoms that are physical manifestations of emotional pain.

Zoonotic: Diseases that have origins in animals and are transmitted to humans.


Sashur Henninger-Rener is an anthropologist with research in the fields of comparative religion and

psychological anthropology. She received a Master of Arts from Columbia University in the City of

New York in Anthropology and has since been researching and teaching. Currently, Sashur is an

instructor at Pasadena City College, teaching Cultural and Biological Anthropology. In her free time,

Sashur enjoys traveling the world, visiting archaeological and cultural sites along the way. She and her

husband are actively involved in animal rescuing, hoping to eventually found their own animal rescue

for animals that are waiting to find homes.


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27. Cara Feinberg, “The Placebo Phenomenon,” Harvard Magazine


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31. National Cancer Institute, “Acupuncture,”


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39. Collean Barry, Victoria Bresscall, Kelly D. Brownell, and Mark Schlesinger, “Obesity Metaphors: How Beliefs

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41. Peter Attia, “Is the Obesity Crisis Hiding a Bigger Problem?,” TEDMED Talks April 2013 Retrieved from

42. Anish P. Mahajan, Jennifer N. Sayles, Vishal A. Patel, Robert H. Remien, Daniel Ortiz, Greg Szekeres, and

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43. Elizabeth Pisani, “Sex, Drugs, & HIV: Let’s Get Rational,” TED Talks February 2010.





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50. Ibid., 369-371

51. Robert Bud, “Antibiotics: From Germophobia to the Carefree Life and Back Again.”

52. Nancy Scheper Hughes, Death Without Weeping: The Violence of Everyday Life in Brazil (Berkeley: University of

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53. World Health Organization, “Antimicrobial Resistance,”

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57. Suzanne Clancy, “Genetics of the Influenza Virus,” Nature Education, 1(2008): 83.

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59. Laury Oaks, “The Social Politics of Health Risk Warning: Competing Claims about the Link between Abortion

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bara Herr Harthorn and Laury Oaks (Westport, CT: Praeger, 2003).

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(Princeton, NJ: Princeton University Press, 2012).

61. Food and Agriculture Organization of the United Nations, “The Multiple Dimensions of Food Security,”

62. World Health Organization, “Urbanization and Health,” Bulletin of the World Health Organization, 88(2010):




    • Is Western Biomedicine An Ethno-Etiology?
    • Techniques for Healing
    • Faith and the Placebo Effect
    • Social Construction of Illness
    • Culture-Bound Syndromes
    • Antibiotics and Immunizations
    • Reproductive Technologies